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By W. Berek. New England Institute of Technology.

No osteotomies were used buy discount extra super levitra 100mg, ● Onlay mid-third 7 and bilateral spreader grafts were inserted discount 100 mg extra super levitra visa. An angled columella ● Plumping 4 strut was sutured between the medial and middle crura and an ● Caudal extension 2 interdomal suture placed extra super levitra 100 mg free shipping. Overdeveloped anterior nasal spine/posterior septal angle with dorsal hump and extrinsic tip overprojection buy 100 mg extra super levitra fast delivery. The lateral crura were trimmed by 3mm strut helped maintain tip projection after deprojection, and the leaving 8-mm continuous strips. A septal cartilage on lay lateral spreader grafts help maintain middle third support and prevent crural strut graft22 was sutured to the right lateral crus to counter an inverted-V deformity. The case illustrates deal- ing with the lateral crural convexity using cartilage grafts to 68. The depressor septi nasi muscle was that a better balancing of the dorsal line rather than excess dor- divided and a small hump reduced by rasping the bone and sal reduction would make the nose appear smaller. An open 540 Special Considerations in Northern European Primary Aesthetic Rhinoplasty Fig. The upper laterals were separated from ing curve in nasal analysis informed by intraoperative findings the quadrilateral cartilage, and a composite lowering of the dor- and postoperative review of the preoperative images. The cartilage was shaved and the bone planning is performed repeatedly by the authors at various rasped. The first time is during the initial consultation, with osteotomies narrowed the base of the nose. Bilateral spreader image manipulation an integral part of agreeing on aims and grafts were inserted. A second, more detailed surgi- and bilateral domal sutures and an interdomal suture to dimin- cal planning session is performed postconsultation. Immediately prior to operating, the authors advise a 10-minute session free from interruptions to focus on the upcoming sur- 68. This emphasizes that rhinoplasty is tail- Analysis helps the surgeon recognize pitfalls to be avoided as ored specifically for each case rather than being the application well as deformities to be improved. The following Skin will shrink-wrap more in these patients, and, as in all clinicoanatomic groups represent findings in our patient group. Excess bony reduction in these patients will emphasize the the Overprojected Tip tip-dorsum imbalance, which may be exacerbated by a soft- Female Northern European patients very frequently request tissue “polly beak,” the supratip area being the site of least skin hump reduction and a smaller nose. We prefer to be conservative with dorsal reduction and a hump aggressively lowered, the nose will look excessively and tip retro-projection in our overprojected patients with concave and unnatural with a ‘‘ski-jump’’ appearance in the lat- dorsal humps. We aim for ideal shape and tip dorsum balance eral view and a washed out, flattened appearance in the middle but leaving a slightly larger nose. This will particularly be of concern in the to a normal position, particularly using interrupted strip 542 Special Considerations in Northern European Primary Aesthetic Rhinoplasty Fig. This will subdivided into the columella labial, columella lobular, and col- produce an amorphous nose lacking definition. Over- smaller nose can be achieved, but it is rarely as much a reduc- development of the anterior nasal spine and/or the posterior tion as the patient would like and may be offset by increased septal angle will increase the angle and create the illusion of an width and loss of definition in the nasal tip. Finding the ideal position of the subnasale29 will help to determine whether these two anatomic structures are overdeveloped or whether the nose is short. Such a reduction would be incorrect if the tip is intrinsically overrotated due to Muscle excessively long medial crura or extrinsically overrotated Daniel uses the tip angle as a measure of tip rotation. In our experience with the North the angle of the tangent in the lateral profile from the vertical European female nose, the posterior septal angle is often 543 Ethnic Rhinoplasty Fig. The anterior nasal These deformities are characterized by overdevelopment of the spine and posterior septal angle will not be abnormally palpa- septal cartilage in both dorsal and caudal directions. They may ble, and the angle will be decreased with smiling as the tip is be associated with enlargement of the anterior nasal spine (26% pulled inferiorly. The upper lip will also be elevated and may in our series) and short nasal bones with therefore long upper wrinkle in the columella labial junction. As the cartilaginous hump is large in these when necessary via a 3- to 4-mm incision on the lateral border cases, its removal will invariably separate the long upper of the columella at the posterior edge of the medial crus of the laterals from the quadrilateral cartilage. This also helps maintain upper Crushed cartilage is useful as small onlay grafts, especially lateral cartilage support. Extra attention should be given tive at first to avoid overresection of the medial margins of the to the smoothness of the dorsum if the skin is thin, as often is upper laterals. Further hump reduction usually involves pre- the case with Northern European tension nose patients. It is rare in the authors’ experience for the large, North Euro- Once the dorsum is reduced and the upper lateral cartilages pean female nasal tip to be a problem solely of excess volume are no longer contiguous with the septal cartilage, the mid- or vertical lateral crural surface area. This is exacerbated by short alone is insufficient and when relied upon in excess to narrow nasal bones. The nose is at risk of inverted-V deformity, a the bulbous tip will greatly increase the risks of bossae develop- chance increased by osteotomies. Auto- lateral crus with a vertically orientated axis of curvature, or spreader grafts32 are an alternative to septal cartilage spreader ‘‘tunnel tip,’’ that may when severe be mistaken for a malposi- grafts. Using dome creation/dome spanning sutures23 to ing the dorsal and caudal septum to relocate the anterior septal improve definition in these characteristic tip deformities will angle will allow tip retroprojection. Reduction of the anterior narrow the domes and to a slight degree diminish lateral crural nasal spine may also be necessary as described above. Interrupted strip techniques26 to set back us to use alar contour grafts and lateral crural strut grafts with the nasal tip, particularly if performed before septal cartilagi- tip sutures. The curvature will be made worse by domal sutures, hence domal sutures should be avoided. External facial dimensions and minimum nasal cross- The physical principles of rhinoplasty are relevant to all ethni- sectional area. Am J nasal and facial analysis and precise operative planning based Phys Anthropol 1991; 85: 419–427 on this analysis. International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg 2005; 16: possibilities are, what the limitations are, and what the pitfalls 615–646 are. Facial Plastic and dorsal hump with an overprojected tip, (2) the enlarged ante- Reconstructive Surgery. The tension nose: open structure rhinoplasty and (4) the bulbous nasal tip with lateral crura recurvature. Lateral crural strut graft: technique and clinical reduction rhinoplasty plan is applied to all such patients applications in rhinoplasty. Plast Reconstr Surg 1997; 99: 943–952, discus- sion 953–955 requesting a smaller nose. The correction of angular deformities of the nose by a subcutaneous [25] Guyuron B. The overprojecting nose: anatomic component Plast Surg 1988; 12: 203–206 analysis and repair. Plast Reconstr Surg 2002; 109: 2495– 159–168 2505, discussion 2506–2508 546 The Surgical Approach to the Mediterranean Nose 69 The Surgical Approach to the editerranean Nose Armando Boccieri As a channel of rapid exchange for culture and trade, the Medi- element is an open nasolabial angle with good rotation and terranean was a cradle of civilization in ancient times, bringing projection of the nasal tip. The same journey can be made different racial groups into contact and giving birth to a sharply through the centuries in search of an ideal model of female defined race whose characteristics are still present today. Examination of all these one another were the Romans, Greeks, Spanish, Jews, Turks, famous faces again reveals a nose of some length with a straight Phoenicians and Egyptians. Anthropometric studies performed profile, good projection, and a fairly open nasolabial angle. The in different periods have identified some somatic features of latter parameter appears to be the element most constantly the face common to the Mediterranean race. These typical traits present in the most beautiful Mediterranean faces, endowing include dark coloring of the eyes and skin, black hair, a low- the possessor with immediate appeal and setting off the lips medium brow, strongly marked lineaments, and a prominent and the other facial features. The tip is often ptotic obtuse and not particularly pronounced angles best exemplified and the skin somewhat thick. An overly prominent conformation of the nose can there- ments of the nasal pyramid distancing the patient from the fore attract attention and impair this particular expressiveness models of beauty of the past and present familiar to us all. Conversely, an insufficiently pronounced nasal conformation, such as saddle nose deformity, can also lead to a mournful expression that is equally out of keeping with the Mediterranean face. Rhinoplasty must not be confined in such cases to correcting the deformity in question but should seek above all to restore the harmony of the nose in the context of the face in accordance with the canons of Mediterranean ethnic beauty.

The renal fascia fuses with the fascia of the psoas muscle posteriorly and with the adventitia of the renal vessels anteriorly cheap extra super levitra 100mg overnight delivery. Within the renal fascia is an accumulation of fat known as perirenal fat discount extra super levitra 100mg mastercard, which is continuous with the fat within the renal sinus order extra super levitra 100mg without prescription. Pararenal fat is thick posterior to the kidney order extra super levitra in united states online, but it is thin anteriorly between the renal fascia and parietal peritoneum. Inferior vena cava Suprarenal gland Aorta Left renal artery Separate suprarenal fascia Left renal vein Fusion of renal fascia True kidney capsule Peritoneum Space of Gerota Descending colon Perirenal fat Prerenal fascia Peritoneum Colon Perirenal fat Pararenal fat Retrorenal fascia Renal pelvis figure 25-1. As each artery nears the renal pelvis, it typically divides into five segmental arteries that enter the hilum to supply segments of renal tissue. The right renal artery is the longer artery, and both renal arteries lie posterior to the renal veins when entering the hilum. The renal veins exit the hilum anterior to the arter- ies, and the left vein is longer and crosses the midline. On examination, she has acne, abnormal male pattern bald- ing, and enlargement of her clitoris. Blood tests show normal serum testosterone levels but a markedly elevated level of dihydroepiandrostenedione sulfate, an adrenal androgen. The testosterone level is normal, and the level of dihydroepiandrostenedione sulfate is markedly elevated. She also has virilism, or the effects of androgens on the skin, voice, and clitoris. The hyperandrogenism seems to be of acute onset, which is consistent with an androgen-secreting tumor. The two possibilities include an ovarian tumor, usually Sertoli-Leydig cell tumor, or an adrenal tumor. Because the pelvic examination and testosterone levels are normal, an ovarian etiology is less likely. Moreover, the high level of dihydroepiandrostenedione sulfate almost establishes the supra- renal (adrenal) gland as the cause. Another cause of hirsutism is polycystic ovarian syndrome, which includes hirsutism, obesity, anovulation, and irregular menses. Cushing syndrome or disease presents strong cortisol effects, such as buffalo hump, abdominal striae, easy bruising, and central obesity. Each gland sits on the superior pole of each kidney, enclosed within the renal fascia, and, hence, embedded in the perirenal fat. The left gland is shaped like a comma and related to the spleen, pancreas, stomach, and diaphragm. The suprarenal glands receive their blood supply from multiple small branches that arise from the inferior phrenic, aorta, and renal arteries. The lymphatic drainage of the abdomen is diagrammatically summarized in Figure 26-1. In general, the lymphatic drainage of abdominal organs reversely fol- lows their arterial blood supply. If a “final common pathway” for lymph drainage in the abdomen could be named, it would be the lumbar (aortic) lymph nodes, and lymph from these nodes drains to the cisterna chyli and thoracic duct. Figure 26-1 shows that the lymphatics from the gonads also drain to the upper lumbar nodes as the gonadal vessels arise in the upper abdomen (reflect- ing the site of their embryologic origin). Note also that the pectinate line in the anal canal is a watershed with regard to lymphatic drainage. The lymph from the anal canal and rectum superior to this line drains to iliac nodes; inferior to this line, lymph drains to inguinal nodes. The lymph of nodes located along the several arteries that supply the stom- ach will drain to the celiac nodes. Remember that the arteries that supply the stomach are all branches of the celiac artery. Tumor cells from either gonad that metastasize through the lymphatics will metastasize to the lumbar (aortic) lymph group. She relates that she had a similar mass about 1 year ago that required minor surgery. On physical examination, she is afebrile, and inspection of the perineum shows a 3 × 2-cm fluctuant mass at the five-o’clock position of the vestibule. The patient is afebrile and has a 3 × 2-cm fluctuant, inflamed mass at the five-o’clock position of the vestibule. These findings are very consistent with a greater vestibular (Bartholin) gland infection. The greater vestibular glands are located at the five- and seven- o’clock positions of the vulva. If the ducts of the glands become obstructed, the glands may enlarge and become infected, usually with multiple organisms other than those responsible for sexually transmitted diseases. Treatment for this patient is to create a fistulous tract to decrease the incidence of recurrence; the two most common methods are incision and drainage with a catheter left in place for several weeks and marsupial- ization of the cyst wall, which is suturing the inner lining of the cyst wall to the epi- thelium around the periphery of the cyst. Biopsy is typically not required in a young patient, but for vulvar masses or abnormalities in women older than 40 years it is required to rule out malignancy. It is bounded bilaterally by the pubic symphysis (anterior), ischiopubic ramus (anterolateral), ischial tuberosity (lateral), sacrotu- berous ligament (posterolateral), and the coccyx (posterior). A line between the ischial tuberosities divides the perineum into anterior and posterior urogenital and anal triangles, respectively. Deep to the skin is the fatty layer of superficial fascia, a continuation of a similar layer in the abdomen (Camper fascia). In the abdomen, deep to the fatty layer is the membranous layer of superficial fascia (Scarpa fascia) that continues into the perineum, where it is called Colles fascia. In the perineum, Colles fascia is attached laterally to the fascia lata of the thigh and to the posterior border of the perineal membrane and the perineal body. The perineal membrane is a thin but strong fascial sheet attached to the ischiopubic rami, thus stretching across the urogenital triangle. The potential space between the deep layer of the superficial (Colles) fascia and the perineal membrane is the superficial perineal pouch (space). Attached to the superior surface of the perineal membrane are the deep transverse perineal and sphincter urethrae muscles within the deep perineal pouch (space). The perineal body attaches to the posterior edge of the membrane at its midpoint (Figures 27-1 and 27-2). Superficial to the perineal membrane, the pudendum or vulva (external geni- talia) includes the mons pubis and labia majora, labia minora, vaginal vestibule, bulbs of the vestibule, greater vestibular (Bartholin) glands, clitoris, and the asso- ciated ischiocavernosus and bulbospongiosus muscles. The mons pubis is a rounded, hair-covered elevation anterior to the pubic symphysis formed by a mass of the fatty layer of the superficial fascia. Fat-filled posterior extensions of the mons form the hair-covered labia majora, which are united by anterior and posterior commissures. Mons pubis Labium majus External urethral Glans clitoris orifice Vestibule Labium minus Hymen Vaginal Fossa navicularis orifice Perineal body Anus figure 27-1. Medial to each labia majora are the thin, fat-free, hairless labia minora that are filled with erectile tissue and surround the vestibule of the vagina, which contains the urethral and vaginal ori- fices. The labia minora are united posteriorly by the frenulum of the labia minora or fourchette. Anteriorly, the two labia minora are united by extensions that pass anterior and posterior to the glans of the clitoris as the prepuce and frenulum of the clitoris, respectively. The clitoris is composed of paired cylinders of erectile tis- sue or corpora cavernosa attached to the ischiopubic rami as the two crura and are surrounded by the ischiocavernosus muscles. The corpora cavernosa converge toward the pubic symphysis to form the body, which is sharply flexed inferiorly and terminates as the glans anterior to the urethral orifice. Superior (deep) to the labia majora and minora, at the margins of the vestibule, are the paired bulbs of the vestibule. At the posterior ends of the bulbs and partially embedded in them are the paired greater vestibular (Bartholin) glands. A superficial transverse perineal muscle lies along the posterior edge of the perineal membrane and attaches laterally to the ischial tuberosity and medially to the perineal body. The components of the clitoris, bulb of the vestibule, greater vestibular gland, and the bulbospongiosus and ischiocav- ernosus muscles are encased in the deep perineal or investing (Gallaudet) fascia.

Type D lesions: Type D lesions have poor results with endovascular treatment order extra super levitra 100mg, therefore open surgery is the primary treatment order extra super levitra 100 mg amex. T h e pat ient is a diabet ic and t akes an oral hypoglycemic agent order genuine extra super levitra, a long-acting β-blocker buy extra super levitra pills in toronto, and a statin. O n examination, he has normal pulses in the right leg but no pulse in the left groin and leg. H e returns 8 months later with worsening calf pain with minimal exertion and a non- healing ulcer at the tip of his left fourth toe. Left iliac artery angioplasty and stent placement followed by left femoral popliteal artery bypass D. Left iliac artery angioplasty and left superficial femoral artery angioplasty and stent placement E. T his woman is severely debilit ated by her dement ia and st roke to t he point where she is now con fin ed t o h er bed in a lon g-t er m car e facilit y. H er ph ysical exam in at ion reveals diminished femoral pulses bilaterally, diminished popliteal pulse on the right and absent popliteal pulse on the left, and no palpable pedal pulses bilaterally. H er left first and second toes are gangrenous and she has extensive cellu lit is involvin g h er left foot an d dist al t h ir d of h er lower leg. O btain aortography with run-off of the left lower extremity to identify obstructive sites and treat those with angioplasty and stent placement, followed by t oe amput at ion s an d ant ibiot ic t reat ment B. Obtain aortography with run-off of the left lower extremity to identify the obstructive sites then perform open bypass to revascularize the left lower leg, followed by t oe amput at ions and ant ibiot ic t reat ment D. H e states that he was in his usual state of good health until 4 hours ago when he develop sudden onset of right foot and leg pain. H is physical examination reveals irregu- larly irregular h eart beat 120 beat s/ minut e, blood pressure 130/ 78 mm H g, and respiratory rate 24 breat hs/ minute. The cardiac monitor shows irregu- larly, irregular rhyt h m wit h the absence of p-waves. H is right lower ext rem- it y is cool t o the t ouch and h as a bluish discolorat ion below the mid-t h igh. His aort ic pulse is normal, t he femoral pulses are normal bilaterally, t he left pop- lit eal and pedal pulses are normal, and the right poplit eal and pedal pulses are absent. Syst em ic h ep ar in iz at io n, an gio gr ap h y, an d p lacem en t of r igh t su p er ficial femoral ar t er y st ent C. Occlusion of his left iliac artery would most likely be the cause of his sympt oms and absence of pulse in his femoral art ery and dist ally. It is likely that t h ere h as been progression of the art erial occlusive process in h is left lower ext remit y. This patient has ischemic, gangrenous changes in the left, first and sec- ond toes. H er vascular examination suggests that she had occlusive disease at mult iple levels above and below t he inguinal ligament. O pt ions A and C are appropriate if our goal of care is to establish blood flow to her left lower ext remit y t o allow the local amput at ions t o h eal in h er t oes. T h e most import ant det ails regarding t his pat ient’s case are t hat she has severe demen- tia, neurologic deficits from a prior stroke, and she is nonambulatory and bed bound. Revascularization of the ischemic extremity is not justifiable and not beneficial for a patient who is bed bound and nonambulatory; therefore, below the knee amputation is the best option for her. Systemic heparinization and femoral artery embolectomy is the most appropriate choice for this pat ient without history of chronic arterial occlu- sive disease sympt oms present ing wit h new onset at rial fibrillat ion, and acut e right femoral artery occlusion. Most likely, this patient has suffered from an acut e embolizat ion to t hat art ery. The pat ient has ischemic sympt oms wit h some fin d in gs of advan ced isch em ia ( blu ish d iscolor at ion wit h m ot or an d sen sor y neuropathy). Surgical embolectomy and catheter-directed thrombolytic therapy are all options that would help revascularize the right leg. The surgi- cal appr oach is mor e likely t o r e-est ablish p er fu sion fast er t h an t h r ombolyt ic therapy and is a preferable option for him. Prior to this time, the patient has had an uncomplicated course,and was in the process of receiving her in st ru ct io n s fo r d isch a rg e fro m the h o sp it a l. Du rin g yo u r a sse ssm e n t, sh e a p p e a rs anxious and complains that she is unable to “catch her breath. Sh e is re ce ivin g O b y n a s a l c a n n u la w it h a n 2 O saturation of 96% by p ulse oximetry. Despite her O saturation, the p atient is 2 2 complaining that she is having difficulties with her breathing. He r lu n g s are cle ar wit h slig h t ly d im in ish e d b re at h so u n d s at both bases. Her legs are mildly edematous bilaterally and her left calf is mildly tender to palpation. H er ph ysical exam in at ion oes n ot i ent ify any sign ificant abn or malit ies other than calf ten erness. Since all of these possible iagnoses are potentially lethal if not i ent ifie an t reat e in a t imely fash ion, t he clinician must be prepare t o inves- tigate an a ress the patient’s symptoms imme iately. Her physical examination is essent ially normal wit h t he except ion of calf t en erness an nonspecific imin- ishe breat h soun s at bot h lung bases. We know t hat at this time, the patient has a history of colon cancer an a postoperative course that ha been unremarkable up until this time. The fact that she has ha an unremarkable recov- ery from her colect omy re uces our suspicion for acut e lung injury; t his compli- cat ion is com m on ly cau se by an int r a-ab om in al in fect iou s pr ocess in pat ient s following int est in al surger y. O nce t his is init iat e wit h appropriat e support ive care, we can obt ain the necessary confirmat ory st u ies. This mo ality is very useful for evaluations of the upper an the lower extremities. Its accuracy is reporte at 96%, an more importantly, pulmonary angiography has a low false-negative rate (0. The a vant age of pulmonary angiography is that, cat h et er ir ect e t r eat ment s can be eliver e t o issolve the clot s in the pu lm on ar y arteries. The raw-backs of this technique inclu e elays in preparat ion for this st u y an proce ure-relat e major complicat ions in 1. Recent major surgery (within 10 ays) an / or recent traumatic brain injuries are con si er e con t r ain icat ion s t o syst em ic t h r omb olyt ic t h er apy. T h e assessment t akes in t o accou n t r isk fact or s an recent events (eg, trauma, surgery, long plane ri es, an cancer). Elevation of d - imers suggests that there is thrombus formation an egra ation that is ongoing. The problem is that d- imer elevations are not specific an also occur with sepsis, recent myocar ial infarct ion, st rokes, trauma, an surgery. A number of genetic risk factors for V T E h as been i en - tifie, which inclu e Factor V Lei en, protein C eficiency, protein S eficiency, an ant i-t hrombin eficiency. Similarly, there are a number of acquired risk fac- tors (aging, cancer, obesity, congestive heart failure, stroke, an anti-phospholipi ant ibo ies) an transiently acquired risk factors (immobility, trauma, hospitaliza- tion, pregnancy, central venous catheters, oral contraceptives, an hormonal ther- apy). For most patient s, prophylaxis consist s of mechanical an / or pharmacologic measures. Pat ient s wit h major t rau- matic injuries, spinal cor injuries, as well as orthope ic surgery patients un er- goin g join t r eplacem en t s are am on g the h igh est r isk p op u lat ion s for V T E. Pat ient wit h score less t han 2 are classifie as low suspicion; pat ient s wit h scores of 2 to 6 are mo erate risk, an patients with scores > 6 are high risk (see Table 51– 2). In a it ion, risk st rat ificat ion can also help eliminat e unnecessary imaging st u ies in some pat ient s. O nce init ial ant icoagulat ion is est ablishe, most patients are then transitione to oral warfarin therapy. Some pat ient s wit h long-t er m ant i- coagu lat ion n ee s are bein g maint ain e on n ewer or al agent s that in clu e ir ect thrombin inhibitor ( ibigatran), an factor Xa inhibitors (rivaroxaban, apixaban). Several clinical trials have verifie that these newer agents are not inferior in com- parison to warfarin. Patients with unpro- vok e V T E oft en r eq u ir e 1 2 m o n t h s o r lo n ger p er io s of syst em ic an t ico agu lat io n. Retrievable filtere are being applie increasingly to re uce the rate of filter-relate complicat ion s. Determine d - imer level, an obtain a pulmonary angiogram if this valu e is elevat e E.

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