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Revision septal surgery may prove difficult if large areas of cartilage were excised in the original surgery generic 12.5mg metoprolol mastercard arrhythmia qt prolongation, and the risk of 53 buy generic metoprolol 50mg line arrhythmia medication. It is our own policy to crush and replace any unused cartilage after harvesting during primary surgery order 25 mg metoprolol blood pressure phobia. This Preoperative skin and soft tissue evaluation is important, as prevents scarring after apposition of the mucoperichondrial deformities are not always correctable. Accurate documentation flaps, thus facilitating easier revision surgery and harvesting if of specific areas is critical because perioperative injection of required. The risk of a septal perforation is reduced, and in any local anesthesia may mask such deformities. Dissection in cor- case it may provide additional support to the cartilaginous skel- rect surgical planes, both during primary and revision rhino- eton. Judicious resection of such irregu- revision rhinoplasty surgery is the unpredictability of the find- larities during revision rhinoplasty may be required, but cau- ings during surgery. Soft tissue contractures and scarring may tion is advised as skin and soft-tissue envelope changes are mimic underlying structural deformity, and even with meticu- largely permanent and correction can prove troublesome. Of lous planning, the surgeon must remain able to adapt or even particular concern are the erythematous changes over the dor- change the planned techniques to suit the discovered anomaly. Patients with rosacea are particularly prone to such be considered as being required to help correct such unforeseen changes. Correction may require treatment with a laser or deformities when formulating the preoperative plan. The use of postoperative steroid (triamci- ence in a variety of techniques is naturally a prerequisite to nolone) injections to reduce the risk of soft tissue pollybeak for- undertaking this sort of procedure due to the very nature of mation is discussed later. Upper-Third Deformities Deformities of the upper third of the nose after primary surgery 53. Options may be limited by prior surgery, and the option of the autogenous costal cartilage Underresection is always considered. Alloplastic materials are reserved for cases where there is minimal residual cartilage available, and the This is relatively easy to correct with resection of the bony dor- risks associated with infection and possible extrusion should be sum with an osteotome, rasp, or powered instrumentation,16,17 discussed with the patient preoperatively. Dorsal bony irregularities temporalis fascia may be used as an excellent soft tissue cover may be minimized by careful palpation with a wet finger after to camouflage minor irregularities, although acellular dermis final bony reduction with a fine rasp. The former two are easily A potential pitfall of external-approach rhinoplasty is diffi- removable in the presence of complications. Polyethylene pro- culty predicting outcome of the nasal dorsum due to the lack of motes significant tissue ingrowth, which may be advantageous, traction of the soft tissues prior to dosure of the columella inci- but equally it has the distinct disadvantage of potentially caus- sion. Irra- area, but it can prove similarly difficult to assess the bony dor- diated autogenous rib cartilage has also been advocated but sum. Final assessment of these areas should thus be made after risks long-term absorption and the possibility of warping. Corrective osteotomies may be were taken too high into thick frontal bone, causing the supe- required to mobilize a greenstick type fracture, to correct asym- rior part of the nasal bone to “rock” laterally when infractured. Should this be the case, an inter- measures can be adequately managed by insertion of a spreader mediate osteotomy may be required. Similarly, when the bony dorsum is markedly deviated, sequential osteotomies are recommended. These have been lik- ened to opening the pages of a book20 and comprise initial mobi- lization of the nasal bone opposite to the deviation followed by the bony septum and then finally the other nasal bone. Overresection If the bony dorsum has been overresected, the deep nasofrontal angle gives an apparent shortening of the nose. Correction is with cartilaginous and perhaps bony grafting at the nasion, although grafts in this area may show with time, and camou- flaging with additional soft tissue cover may be required.

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It vested cartilage is immersed in water for 30 minutes (to allow is important to distinguish between the unsupported nose the warping to occur) prior to carving generic 25 mg metoprolol overnight delivery blood pressure pills kidney failure. Alternatively discount 12.5mg metoprolol visa hypertensive urgency guidelines, the carti- that requires structural support versus those that merely lage can be stabilized with rigid fixation order metoprolol 25 mg with amex blood pressure 4 year old child, and warping can be need additional volume. The operative plan is approach, the ninth rib, which is the first floating rib, is har- written down and diagrammed in great detail. In contrast to vested using a retrograde supraperiosteal dissection back to the primary operations where the operative plan is followed bony junction. Next, a large cartilaginous portion of eighth rib with minimal changes, secondary cases demand total flexi- is easily harvested through the same incision. It is typically fused with the caudal border of the seventh rib, which makes for a tedious dissection. The superior aspect of the An aesthetically pleasing dorsum can be achieved in revision rib perichondrium can also be harvested as a possible graft for rhinoplasty cases using a variety of techniques. Technique Alternatively, superficial temporalis fascia is too thin, and ten- sor fascia lata leaves a visible scar. It is then inserted precisely into areas that need as well as less pliable, which can result in postoperative thick- augmentation using a spatula-shaped instrument. Overgrafting should In primary and secondary rhinoplasty cases where the underly- be avoided. In addition, fascia can prevent for structural grafting in major functional or aesthetic recon- “shrink wrappage” of the skin against the underlying osseocar- struction. The graft is guided into the recipient pocket using 4–0 plain catgut sutures placed at the cephalic end of the graft. Next, the caudal end is sutured in Application place near the anterior nasal angle. This technique can be used to correct the deficiency or hypopla- sia of the radix, or as a precise limited dorsal augmentation. Problems Technique There are few problems with either harvesting or using fascia grafts. Donor site problems such as scar formation and hema- A piece of fascia (2×2cm) is folded and guided with sutures toma are minimal. The fascia is then elevated with Aufricht the early phase (3 to 6 weeks postoperative) should be retractor. The patient can compress the dorsum and overnight that has been stripped of periosteum to allow better fusion taping is encouraged. Complications such as used in patients who present requesting a subtle “natural” cor- infection, displacement, or visibility are exceedingly rare. The rection of their dorsum, which is overresected, thereby creating real risk is to use fascia for augmentation when in reality it is the classic “surgical appearance. The cartilage is sharply cut to small pieces less Overcorrection should be avoided in both areas. In addition, when dissecting the radix, one which would lead to unpredictable survival. Experimental stud- should avoid dissecting the pocket too laterally, which can ies comparing the viability of dicing as opposed to crushing of result in a bulge in that region. The graft is constructed on the back table from does not “overgraft” as there is no absorption postoperatively. Long-term histological studies have hide bifidity and on the sides of dorsal rib grafts. The shape was made as identical as possible, but slightly higher (8mm) at the patient’s request.

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High prevalence of When dealing with a dissatisfied patient of their own buy metoprolol 12.5 mg low cost pulse jet pressure, the personality abnormalities in patients seeking rhinoplasty buy metoprolol 25 mg with mastercard blood pressure 4060. Five-year follow-up of cosmetic reflexively agree to a revision surgery for the sole purpose of rhinoplasty purchase 25 mg metoprolol amex blood pressure medication karvezide. Functional and aesthetic concerns of patients seek- even if marginally indicated, will more times than not result in ing revision rhinoplasty. J concerns are unfounded will only serve to further antagonize Otolaryngol 2007; 36: 130–134 the situation. J Dermatol Surg Oncol 1984; 10: 389–395 to avoid the appearance of apathy and neglect, which is often [17] Fattahi T. Recognition and management of the patient unsuitable for aes- result should be truthful with him- or herself despite the diffi- thetic surgery. If so, do I have the 1987; 113: 724–727 knowledge and skills to correct or improve the result? Facial Plast answer to either of these questions is no, the surgeon is encour- Surg 2010; 26: 333–338 aged to consider referring the patient to a colleague for a sec- [22] Moore & Jefferson. Davis and Michael Bublik The failed rhinoplasty may be loosely defined as the unhappy or come, the surgeon should encourage the patient to endorse dissatisfied patient after surgery. A wide variety of problems treatment strategies that substantially reduce surgical risk, par- can lead to patient dissatisfaction, but not all stem from techni- ticularly when the associated cosmetic outcome is likely to be cal errors. Important alternative causes of the “failed” rhino- similar or only slightly less attractive than those of riskier and plasty include grandiose patient expectations or psychiatric dis- more complex treatment strategies. Establishing a realistic sur- orders that may prevent patient contentment regardless of how gical goal that reflects the patient’s cosmetic preferences, while spectacular the cosmetic outcome. In both instances, the making allowances for preexisting anatomic or technical limita- patient may deem the outcome a complete failure despite a tions, is a critical step in avoiding a failed rhinoplasty. Cookbook technically well-executed surgical procedure with clearly approaches, in which the same ritualistic steps are applied demonstrable cosmetic improvement. Nevertheless, although indiscriminately to all patients regardless of the presenting unrealistic patient expectations are occasionally responsible for nasal contour, are seldom successful and should be condemned. Without question, the most common cause of the failed rhi- Once the cosmetic challenges have been properly analyzed noplasty is the (technical) inability to achieve the jointly held and the objectives are clearly defined, the surgeon must cosmetic objective. Although the causes are many, technical devise an anatomically effective surgical game plan. Because shortcomings are often rooted in an erroneous cosmetic analy- rhinoplasty is a dynamic operation in which unforeseen sec- sis of the nose. Recognizing an unattractive or disharmonious ondary and tertiary effects are common, a fluid game plan nose is easy even for the average individual, but underderstand- that can be adapted to changing circumstances is essential. Without an shapen nose is an great challenge that requires a sophisticated accurate and correct aesthetic analysis, misinterpretation of understanding of the surgical anatomy and the healing forces at the surgical anatomy ultimately produces systematic judg- play.. The cosmetic objective must also take into full account ment errors that are often compounded by serial misappli- the limitations of the starting nasal anatomy and the existing cations of surgical technique. For the surgical out- Hence, the first step in avoiding technical rhinoplasty failures come to appear “natural” and nonsurgical in appearance, the is to achieve a proper aesthetic understanding of the nose. The prudent rhino- takes many forms and is not relegated to one single shape or plasty surgeon must also seek to identify and disclose all preex- size, there is a spectrum of acceptable options from which to isting cosmetic imperfections that typically resist or defy surgi- choose, and the wise surgeon will elicit input from the patient cal correction. Facial asymmetry, misalignment of the piriform when seeking to pinpoint the ultimate cosmetic objective.