Robert B. Devlin, PhD

• Senior Scientist
• Human Studies Division
• National Health and Environmental Effects Research Laboratory
• U.S. Environmental Protection Agency
• Research Triangle Park, North Carolina

This was possible because of the use of newer; biocompatible materials developed in the pacemaker industry erectile dysfunction epocrates order nizagara 100 mg with amex. His initial device was a five-wire electrode grounded through the footplate of the stapes impotence liver disease best 100mg nizagara. Creating a hermetically sealed device was a major challenge for early investigators impotence natural buy nizagara with mastercard. Graeme Clark and colleagues in Melbourne (1974) melted glass on to wires that exited a Kovar steel container that housed the circuitry (24) icd 9 erectile dysfunction nos generic nizagara 100 mg with mastercard. Kratochivil at Telectronics erectile dysfunction nutritional treatment discount nizagara 50mg with visa, a pacemaker company in Australia muse erectile dysfunction wiki effective nizagara 100 mg, discovered that when a blend of ceramics was sintered, it would bond to both wires and the metallic container to produce an impermeable seal. For Cochlear Corp in Australia, this technology when used in combination with a titanium package for strength produced the hermetically sealed device that is in use today. However, this construct required moving the data transmission antenna to a remote site. After implanting their initial multichannel prototype device in 1978, great strides were made in the 1980s demonstrating the superiority of these place-coding devices over the single-channel implants of House (25-29). From this time forward, place coding using multiple electrodes situated longitudinally along the course of scala tympani to stimulate the tonotopic organization of the cochlear nerve became the preferred approach (30-32). With the help of Ingeborg and Erwin Hochmair in Vienna, Austria, Kurt Burian implanted a multichannel device in 1977. Unfortunately, ceramic was more brittle and susceptible to cracks in response to external trauma. The welding of ceramic to the metal header also created a relative weak point for the hermetic seal. Over the last 30 years, electrode and speech processor developments have produced more effective stimulation strategies associated with successively higher performance levels. Further miniaturization of components has resulted in small, behind-the-ear speech processors and very thin, atraumatic electrodes that preserve intracochlear structures. In the early 2000s, bilateral cochlear implantation as well as implantation with preservation of significant acoustic residual hearing has broadened the indications for these devices. Moreover, combining acoustic stimulation with that of the electrical signal provided by the cochlear implant has begun to produce results for patients that had previously not been considered possible (33-36). Today, sound localization, hearing in noise, and even music appreciation are becoming possible. In 2005, a totally implantable cochlear implant was developed in Sydney and implanted in Melbourne, Australia, as a part of a research project conducted by Cochlear Ltd and the University of Melbourne (37). This was the first cochlear implant system capable of functioning for sustained periods with no external components. Because this device used a subcutaneous microphone, significant attenuation of the signal and interference with bodily noise limited wide-scale application. Nonetheless, the stage has now been set for a fully implantable cochlear implant With further advances, it seems probable that one day, normal hearing might be restored through combinations of technology without the need for visible external hardware. In the 1960s and 1970s, considerable opposition arose within the scientific community regarding the possibility of speech understanding by patients with cochlear implants. Over time, combining considerable improvements in technology, indications, and results with the fact that most deaf children are born to two hearing parents who want their child to communicate in an auditory-oral way has made this opposition to cochlear implants lessen. Today, cochlear implants are widely regarded as an accepted and efficacious choice for patients who are deaf or significantly hearing-impaired. The internal and external device Chapter 163: Cochlear Implants and Other Implantable Auditory Prostheses 2627 antennas are aligned for transmission by integrated magnets. The processor includes a series of filter banks that use fast-Fourier transforms to partition the acoustic signal into the respective frequency bands and decodes the information into an electrical signal. The signal is processed according to a predefined strategy, amplified, and compressed to match the narrow, electric dynamic range of the ear and sent through the intact sldn to the implanted receiver-stimulator. The electrode array that is inserted within the cochlear lumen is hardwired to the receiver-stimulator package. The longitudinal arrangement of the cochlea along a frequency spectrum (basal~apical corresponds to high pitch~low pitch regions) allows for frequency-to-place mapping. Inside the cochlea, electric impulses at the electrodes stimulate neural elements, bypassing the nonfunctioning hair cells. Thus, high-frequency information is converted to frequency pulses that are delivered to basal electrodes, while progressively lower-frequency information is relayed to more apical locations. Today, combinations of temporal and place coding account for most of the stimulation strategies in use. Temporal coding is only beginning to be implemented in newer Hilbert transformation paradigms. Coding Strategies the earliest speech-coding strategy used by the House-3M single-channel device employed amplitude modulation of a 16-kHz sinusoid by the bandpass-filtered audio input signal. The incoming signal needed to be compressed to cope with the limited dynamic range for electrical stimulation of the auditory nerve. Even though most of the original temporospectral information of the analog signal was preserved, the signal transfer to the auditory nerve was limited by the maximal firing frequency of the nerve in response to the electrical stimulation at a single site within the cochlea. High synchronization of nerve fibers and the neural refractory period only allowed for frequency transmission up to 1 kHz via pure temporal coding. For higher frequencies, the spectral information could not be sufficiently transferred. While these single-channel devices provided sound awareness and enhancement of lipreading. The earliest multichannel place-coding devices used bandpass filters to separate frequency bands and compression to reduce the needed acoustic dynamic range in to the electrical stimulation range of the cochlear nerve (-20 dB). However, these devices remained limited by current spread and channel interaction, thereby limiting spectral resolution. Poor spectral resolution probably contributed to significant spectral mismatch between the frequency allocation to a given electrode and the perceptual consequences of stimulation. Attempts to improve this spectral mismatch have included moving the site of electrode activation closer to the neural elements by creating modiolar conforming arrays, intraneural electrodes, light stimulation, or neurotrophic factors (40-42). Another approach has been to use multiple electrode activation at differing times. Today all of the modern strategies use some variation of pulsatile (on-off), interleaved stimulation of the multiple electrodes within the array in an effort to achieve specific stimulation while avoiding channel interaction, thereby improving frequency selectivity. That is, spatially separate electrodes are activated at different times to account for neural refractory times, current spread, and electrical field interaction. HiRes augments the envelope with temporal information by allowing higher-frequency components through the envelope detector. Although some patients can clearly perform better with one strategy than another, average speech scores across populations of patients do not clearly demonstrate superiority of a particular strategy (43). Pathologic Basis for Success Cochlear implantation usually results in a loss of residual acoustic hearing, presumably from intracochlear trauma induced through cochleostomy or electrode insertion, disruption of the endocochlear potential, or delayed reaction to the foreign body. A variety of evidence has demonstrated traumatic disruption of the cochlear endosteum, spiral ligament, stria vascularis, basilar membrane. Trauma and bone dust may also induce further changes in the inner ear including fibrosis and osteoneogenesis. Such intracochlear changes can potentially increase impedance values and stimulation requirements and alter psychophysical percepts. These changes might also reduce future abilities to reimplant the cochlea or the patients to consider other biologic therapies (50-55). A variety of investigations support the site of stimulation to be the spiral ganglion cell body. Moreover, most evidence demonstrates little correlation between spiral ganglion cell number and speech perception abilities using a cochlear implant Most recently, new tissue formation in the cochlea has been associated with the degree of neurosensory element loss. The devices from each implant manufacturer and some of the various differences among them are outline in the Table 163. Comparative data between the various devices are sparse or completely laddng making efficacy claims regarding technological superiority theoretical. As these comparative data are lacking, patients are left to choose technology based on factors other than performance including reliability, aesthetics, operational characteristics, surgeon and center preference, and word-of-mouth communication amongst users. Patient Selection Absolute contraindications to cochlear implantation include those patients without either a cochlea (Michel aplasia) or a cochlear nerve. Relative contraindication might include those patients with active middle ear disease, severe anesthetic risk, and too much residual hearing or those who are unwilling to tolerate the surgical risks. There are dearly patients who may require adjustment of expectations through more detailed counseling prior to considering surgery as their prognosis for attaining highlevel open-set speech perception might be more limited. Central nervous system disorders that might adversely affect normal brain function and thus performance with the implant could include previous stroke, degenerative diseases such as multiple sclerosis, dementia, tumors, or infections. With these caveats in mind, it is critical to recognize that setting appropriate expectations for potentially lower levels of performance are not contraindications to surgery. Rather, restoration of audition through cochlear implantation can result in dramatic improvements in quality oflife and daily function for these individuals but should be undertaken following appropriate counseling of expectations. In general, adults (~18 years) are required to have a moderate-to-profound hearing loss without medical contraindications and the desire to be a part of the hearing world. The results for aided speech perception testing vary by manufacturer and payer and are listed in Table 163. Prelingual children can be as young as 12 months of age, gain limited benefit from amplification, while being enrolled in an early intervention program. Older children with some degree of speech perception should also have specific speech perception testing results that are obtained while wearing appropriate amplification (Table 163. The reader should always seek up-to-date, detailed information on a case-by-case basis prior to considering candidacy. For young children, it remains critically important to recognize the importance of early intervention in the form of appropriately fit amplification and/or cochlear implantation in the development of speech perception, speech production, and spoken language (5). While these studies clearly document the fact that earlier is better, this must be balanced against the reality that cochlear implants, in their current format. With this in mind, it remains important to defer cochlear implantation until the age where developmentally appropriate behavioral audiometric results are valid (usually 7 to 9 months of age for visual reinforcement audiometry). One clear indication for very early implantation might include a history of meningitis with ongoing ossification. Irrespective of the type of intervention, early diagnostic and therapeutic auditorybased speech therapy is critical in assessing progress in spoken language development this single factor remains of paramount importance in deciding whether to proceed with implantation in the very young. Temporal Bone Imaging in Cochlear Implantation Diagnostic imaging of the temporal bone and brain is critical in patients considering cochlear implantation to (a) identify the etiology of hearing loss, (b) define surgical anatomy and the potential for complications or sequelae from surgery, and (c) identify factors that negatively impact upon prognosis for performance using the device. Cochlear obstruction can occur following previous cochlear inflammation in the setting of meningitis and the degree of labyrinthine obstruction that is due to ossification. Surgery for Cochlear Implantation Setup Cochlear implant swgay is performed under general anesthesia and typically takes between land 2 hours to complete. Patients with significant medical comorbidity should have a prior anesthetic risk assessment. A first-generation cephalosporin is sufficient as ear pathogens such as StreptDcoccus pneumoniae, Haemophilw infiuenme, and Pseudomonas aeruginosa should be unwual in routine cases. Receiver-Stimulator Placement and Fixation Following a skin incision, a subperiosteal pocket is created in the proposed region for the inte:rnal receiver-stimulator that is bounded inferiorly by the lambdoid suture and is Preparation the patient is situated in a supine position with the head turned to expose the postauricular region. Locating the receiver-stimulator too close to the pinna can result in unwanted interaction between the magnetic headpiece and the speech. Moreove:t placement too close to the mastoid can be problematic if skin retraction in to the mastoid results in unwanted device exposure. The use of manufacwrer-specific device templates prior to the incision can help locate the proper position. Focal injection of methylene blue through the skin and on to the bone allows for identification of the bony position for the internal device after skin elevation. Locating the device relative to the mastoid cavity following bony exposure can be ineffec:tive since mastoid size varies considerably among individual of all ages. The:final position of the receiverstimulator usually is significantly superior and posterior to the pinna. The long axis of the device creates roughly a 45-degree incline from the horizontal through the zygomatic arch. Chapter 163: Cochlear Implants and Other Implantable Auditory Prostheses 2633 strictly sized for the device being implanted (69). A bony depression can be created according to the device templates and the device fixed to bone by any one of a variety of methods (70). For adults, nearly all techniques are sufficient, while for children, simple suturing of the periosteum provides rigid fixation to bone and avoids intra- or transcortical drill holes or screws that might put the underlying dura or venous sinuses at risk (71). Electrode Insertion A smooth, resistance-free insertion of the proposed electrode array in to patent scala tympani is the goal of most implantations. The reader is referred to the individual surgical manuals for details regarding usage of the various devices. The facial recess is opened maximally using the horizontal semicircular canal, fossa incudis, chorda tym pan~ and facial nerve as landmarks. The round window niche overhang is initially identified as a bony, rounded ridge located inferior to the oval window niche and anterior-inferior to the stapedius tendon. The niche is always located posterior to Jacobson nerve on the cochlear promontory and 1 to 2 mm inferior to the oval window. It is very important to recognize that limited opening of the facial recess can result in an inferior view towards the hypotympanum with a resulting look at the air cell system rather than the promontory and round window region. Cochleostomy When describing the surgical technique for cochleostomy creation, one should keep the basic objectives in mind: open scala tympani (and not scala vestibuli), minimize collateral trauma to physiologically relevant intracochlear structures, and provide a relatively straight insertion trajectory along the longitudinal axis ofthe basal turn in an effort to allow for buckle-free electrode insertion. Currently, a variety of differing cochleostomy techniques exist that can be adapted to the clinical situation depending on the following: the electrode array to be used, the cochlear morphology, and the desire for hearing preservation (72).

The dorsal strut must maintain stable:fixation at the superior bony-cartilaginous junction (the key area of the dorswn) to prevent saddling of the middle nasal vault erectile dysfunction or cheating generic nizagara 100 mg visa. Deviated cartilage is either removed orrecontoured by scoring the concave side of the deviation with a scalpel impotence and diabetes order 50 mg nizagara free shipping. These partial thickness cuts can weaken the septum in a manner that facilitates repositioning toward the midline erectile dysfunction books buy nizagara 100mg with mastercard. Spreader grafts can also help correct deviations of the donal septum (see section on correction of middle third) erectile dysfunction pills viagra order nizagara 50 mg without prescription. Caudal deviations can be corrected with vettical scoring on the concave side of the septum erectile dysfunction related to prostate generic nizagara 50mg amex. Retrograde soft tissue dissection behind the medial aura must be done to create a central pocket in the membranous septum erectile dysfunction drugs market discount 100 mg nizagara mastercard. It is impottant to leave a small portion of the dorsal canilage in the keystone area (area where the septum atticulates with the nasal bones) to provide a point of suture fixation to prevent postoperative collapse of the dorsal septum. The use of a polydio:xanone sheet to stabilize the canilage grafts has been reponed to facilitate the emacorporeal technique (7). If turbinate hypertrophy is present and causing obstruction of nual airflow, a submucous resection is performed. The upper Image Is that of a low-low osteotomies, where the osteotomy Is doser to the maxilla (low) throughout Its route. The middle Image Is that of an osteotomy that starts low and ends high (doser to 1he dorsum). The bottom Image Is that of a high-low-high route, which Is the most commonly used type of osteotomy route. The first option is to mobilize the superior aspect of the septum with perrutaneous medial osteotomies using a 2-mm chisel, taking care not to extend the fracture into the cribriform plate. The cur:ved osteotome cuts across the nasal root to the conttalateral side to mobilize the central portion of the upper third. With either the percutaneous transverse or the cross-root osteotomy, the entire upper third should be easily mobilized from side to side once the lateral osteotomies have been completed. Asymmetry of the upper third of the nose is caused by deviation of the upper bony nasal framework. The nasal bones atticulate with the frontal bones superiorly and the ascending process of the maxilla laterally. They are thickest at the nasion superiorly and taper to become thinner as they approach. Asy:mmetcy of the upper bony nasal dorsum is often associated with high deviations of the septum. While small deviations can be amenable to rasp reduction or small onlay grafts, osteotomies are typically needed to correct most deviations of the upper third (8). The three primcu:y goals of osteotomies are to sttaighten a deviated nasal dorsum. This is accomplished by using small osteotomes and elevating a small tunnel of periosteum along the lateral osteotomy site prior to creation of the osteotomy. Another option for the crooked upper nasal third is to camouflage the deviation with bony reduction on the convex side and onlay cartilage grafting on the con~ side. Inkriorly, the upper lateral cartilages articulate with the lower lateral cartilages via the scroll Superiorly, both the upper lateral cartilages and the septum articulate with the nasal bones. Standardseptoplastytechniques emphasize correcting deviations along the inferior aspect of the septum. Deviations along the doiSum may require separating the upper lateral cartilage from the dorsal septum, vertical scoring of the doiSal cartilage. The spreader graft is a cartilage graft that is placed between the upper lateral cartilage and the septum. The two spreader grafts may be of unequal thickness to correct for deviations of the nasal dorsum. A vertical cut is made through the redundant upper lateral cartilage 2 to 3 mm from the medial margin (preserving the mucosa) and turned inward as an auto-spreader graft 12, 13). Using the redundant upper lateral cartilage saves precious septal grafting material for other parts of the nose. For noses that require dorsal augmentation and widening of the middle nasal vault. The onlay spreader is a trapezoid-shaped graft that is placed over the doiSal septum and between the upper lateral cartilages (14). The graft is 4 mm wide superiorly, 5 to 6 mm wide inferiorly, and approximately 2 an in length and running the length of the doiSal septum. At least one mattress suture ls pl&ald to malntaln the posltlon of 1fle spreader grafts ln open external rtllnoplasty. It is important to avoid excising upper lateral cartilage until absolutely necessary. If the upper lateral cartilages are cut before the deviation is fixed, there may be a lack of upper lateral cartilage on the side of the deviation once the nose is shifted to the midline. Deviations of the middle third of the nose can also be due to dislocation of the upper lateral cartilages from the caudal margin of the nasal bones. The surgeon can sometimes reapproximate the cartilages back to their anatomic position and suture-fixate them to the periosteum; otherwise, camouflage grafts can be utilized. Deviations can also be caused by depressions due to a collapse of an osteotomized or ttaumatically fractured lateral nasal wall. If the size of the depression is small and is not affecting the internal nasal valve, a small onlay graft of crushed or precisely contoured septal cartilage suffices. If the depression is small and the nasal valves narrow, spreader grafts are preferred since they improve the airway as well as correct the depression. Thc:~ septum Is dc:~prCilssed Into the left nasal c:avfty, which causes deviation of the middle third. Disarticulating the septum from the maxillary crest allows the surgeon to rotate the septum upward to lnCfCilase dorsal hc:~lght. This acts to reduce the saddle deprei~sslon and also places thc:~ septum betwMn the medial crura of the lower lateral cartilages. The cartilage is aushed just enough to create a soft pliable layer that can be draped over the area of deficiency. It is best to place such grafts at the end of the case when the incisions are nearly closed so that the grafts do not get displaced. Anatomically, the lower third of the nose consists of the paired lom:r lateral artilages, the caudal nasal septwn, and the nasal spine. Deviations of the lower third are often due to deflections of the caudal septum or deviation of the lower lateral cartilage H~ at times, the 10Wii7 lateral cartilages are asymmetrically malformed causing deviation of the nasal tip. Asymmetry of the lower lateral cartilage can be due to congenital variation, aggressive iattogenic resection, or traumatic alterations. Correction of the lower lateral cartilages to achieve symmetry can be petfonned with a number of methods. Many surgeons prefer the external approach for severe lower third asymmetries since the asymmetries are easier to visualize in vitro. Endonasal approaches can equally address the issue found in the crooked nasal deformity. Lower lateral cartilages that are severely distorted and asymmetric should be mobilized by releasing scar tissue and the vestibular mucosa. Some grafts such as the columellar strut and alar batten grafts (or lateral aural strut grafts) provide structural support. Suture shaping techniques, whereby a swgeon shapes the cartilages using mattress sutures, is a safe and effective way to shape the lower lateral cartilages without the risk of iaevocably damaging the cartilages if the attempt fails (15). The longer medial or lateral crura may require shortening or the shorter sides lengthening. Dividing the longer crura and suturing the A- New donor graft harvest site B- Previously removed c r~. The upper third was stralglmlned using bilateral medial and bilateral low-high-low osteotomies. To straighten her middle third, bllat:eral spR~ader grafts were placed, along with a left dorsal onlay graft to account for the conca"llfty of the upper lat:eral cartilage. Her collapsed septum was also elevated as In Case One (blade wrved arrows), but to a lesser degree. To straighten her lower 1flird, a combination of suture techniques were used along with a left alar batten graft and columellar strut. Septal splinting may be helpful in maintaining a sttaight septum and preventing blood or serum collections, which can result in areas with increased thickness. It cannot be used to sttaighten a nose that is crooked at the end of the operation. Patients are instructed to apply gentle pressure to the lateral nasal walls using the sides of the index finger while the palms of the hand are facing outward. Influence of polydioxanone foil on growing septal cartilage after surgery in an animal model: new aspects of cartilage healing and regeneration (preliminary results). Camouflage is best for smaller asymmetries or depressions, and deconstructive/ reconstructive strategy is best for more severe deviations. In posttraumatic or postswgical cases, releasing scar tissue and the vestibular mucosa may be necessary to improve the asymmeuy. Davis Cosmetic nasal surgery remains one of the most effective and long-lasting procedures in the cosmetic surgery arsenal. A successful rhinoplasty not only creates a more attractive nose, it diverts attention to the eyes, making for a more harmonious and thus a far more beautiful face. Without question, the delicate and complex three-dimensional nature of nasal anatomy, the precise and unforgiving tolerances of the nasal airway, and the lofty expectations of the typical rhinoplasty consumer make cosmetic rhinoplasty an extremely challenging surgical procedure. Moreover, the profound psychological importance of the face makes rhinoplasty a tremendously high-stakes emotional endeavor in which even dramatic cosmetic improvements may sometimes fail to meet patient expectations. Nevertheless, despite the inherent technical challenges and emotional risks, the lure of a more attractive face is a powerful motivating force that is likely to ensure the popularity of cosmetic nasal surgery indefinitely. Unfortunately, the growing popularity of cosmetic nasal surgery has also created a corresponding increase in the number of substandard rhinoplasty outcomes. While a failed rhinoplasty may occasionally result entirely from adverse tissue responses to a well-executed surgical procedure, failed surgeries are far more often the result of technical errors such as faulty cosmetic analysis, poor artistic judgment, overzealous tissue removal, and/or gross surgical ineptitude. And while primary (first-time) rhinoplasty is widely regarded as among the most challenging of all elective cosmetic procedures, treatment of a failed rhinoplasty. Moreovet; while the primary rhinoplasty patient is typically upbeat and excited about the prospect of a more attractive nose, the revision rhinoplasty patient is frequently burdened by apprehension, anxiety, and skepticism. Hence both the technical and psychological challenges of revision rhinoplasty are often formidable. Without question, complex revision rhinoplasty ranks among the most technically demanding of all cosmetic surgeries and is best reserved for the revision rhinoplasty specialist. Indeed, even for the most gifted cosmetic surgeon, a near-singular devotion to nasal surgery is often necessary to develop proficiency in this extremely challenging surgical niche. And while the technical demands of revision rhinoplasty are considerable, exceptional technical skills alone are not sufficient for a successful practice. The truly effective revision surgeon must also possess a discerning, yet compassionate listening ear and a willingness to confront the myriad emotional issues that typically accompany a failed rhinoplasty. And since the emotional consequences of a failed rhinoplasty are often so profound, the importance of revision rhinoplasty cannot be overstated. Without question, complex revision rhinoplasty is an emotionally charged and technically demanding procedure that requires expertise, sensitivity. And while perfect restoration of the devastated nose is seldom possible, a carefully conceived and well-executed surgical treatment plan is often rewarded with considerable cosmetic and functional improvement. However, devising an effective surgical treatment plan is itself a complex and difficult undertaking. The surgeon must first correctly 2989 2990 Section X: Facial Plastic and Reconstn. Care must be taken not to trivialize the surgical risla and generate a false sense of security; yet at the same time, equal care must be taken to avoid overemphasizing the surgical risb and needlessly alarming the already worried patient. Fortunately, for the majority of patienu a single operation in competent hands results in a satisfactory, albeit slightly imperfect restoration of nasal function and beauty. For the surgeon, successful restoration of the devastated nose is more than a technical triumph; it is an immensely rewan:ling endeavor in which the emotional benefiu to the patient can be truly life changing. Indeed, few other elective cosmetic procedures can impact a patient so profoundly, and the heartfelt appreciation of these individuals is extremely gratifying. And technical challenges are most severe when major anatomic deficiencies are coupled with genetically unfavorable wound-healing characteristics. Although some patients may present with only mild cosmetic or functional impairment, the complex revision rhinoplasty patient presents with moderate to severe cosmetic deformity, often complicated by concurrent nasal airway dysfunction. Sadly, a growing number of patienu are presenting with profound cosmetic deformities following multiple misguided attempts at revision swgery. In many instances, tissue limitations, such as the cumulative effects of:fibrosis, conttacture, and vascular impairment. Although young healthy individuals can sometimes tolerate repeated nasal surgeries and still retain effective healing responses, revision rhinoplasty becomes progressively more difficult with each successive surgery, and all noses will eventually reach a point of surgical intolerance at some time. Determining whether or not a given nose can safely tolerate further swgery is a difficult and imprecise undertaking, and each patient must be approached cautiously in the context of potential surgical intolerance In deciding whether or not to pursue further surgery, a thorough physical examination of the nose is paramount. Direct physical examination is the only available means of assessing the anatomic. Adverse physical findings such as a severely collapsed nasal framework, scarred and inelastic nasal skin, signs of borderline tissue perfusion, or dense cicatricial stenoses of the vestibular skin are the hallmarks of pending surgical intolerance, and these:findings should prompt a sober reassessment of the need for further surgical treatment.

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Eyelid scisson are used to perform a lateral canthotom:y and inferior cantholysis xyrem erectile dysfunction order nizagara 25mg on line. The tarsal strip is then sutured to the periosteum of the medial aspect of the lateral Oibital rim in a posterosuperior position with a 5-0 clear polypropylene suture erectile dysfunction cleveland clinic nizagara 50mg without prescription. The orbirularis is then suspended to the periosteum of the lateral o:rbital rim at the tubercle with constipation causes erectile dysfunction order 25 mg nizagara with mastercard. While a complete discussion of lower eyelid resurfacing is beyond the scope of this chapter erectile dysfunction medication patents discount nizagara 25 mg on-line, it is sufficient to say that resurfacing procedures are characterized as superficial erectile dysfunction treatment houston purchase 25mg nizagara amex, medium erectile dysfunction treatment prostate cancer buy cheap nizagara 50 mg, or deep. A superficial depth of resurfacing can be achieved with superficial laser treatments. The best outcomes are usually achieved with prompt recognition and early treatment. Unfortunately, dry eye symptoms can become chronic, requiring indefinite use of lubrication or adjunctive procedures. LaJge studies have found the incidence to range from less than 1% to 12% (11) of patients following blepharoplasty 12,13). Although the exact cause of chemosis is unknown, disruption of the lower eyelid lymphatics (particularly in the region of the lateral canthus) and conjunctival exposure from lagophthalmos are thought to be contributing factors. Conservative treatment consists of aggressive lubrication, supportive lid taping, nighttime eye patching, and limiting sodium consumption. Topical steroid drops and rarely swgical procedures, such as drainage conjunctivotomy or temporary tarsorrhaphy, are also occasionally indicated. The risk of symptomatic malposition is greater in patients with preexisting lid laxity, leading some to advocate routine canthal support in the form of canthope:x:y or canthoplasty during blepharoplasty (13). Steroid injections can also be performed to oppose the forces of contracture, particularly if a scar band is palpated. When symptomatic retraction or ectropion develop, swgical management is usually indicated. When scarring of the anterior or posterior lamella is noted, spacer graful are usually employed. This complication can often be prevmted with meticulous intraoperative hemostasia. Treatment consists of opening of incisions, decompression, and cautery of any offending vessels. Symptoms of retroo:rbital hematoma usually present within the fust 24 hows after swge:ry. Patients will complain of pain and pressure Signs include increased intraocular pressure, eyelid ecchymosis, and a tense orbit Treatment should consist of immediate decompression by opening all incisions with exploration to identify and cauterize any offending vessel. Although exttemely rare, infections have been reported, including methicillin-resistant Staphylococcus aureus, mycobacterial, Lower eyelid blepharoplasty is a detail-oriented procedure. It requires diligence in preoperative planning, intraoperative technique, and postoperative management. Brown at the Indiana University School of Medicine for his medical illustrations in this chapter. Lower blepharoplasty using bony anatomical landmarks to identify and avoid injury to the inferior oblique muscle. Primary transcutaneous lower blepharoplasty with routine lateral canthal support: a comprehensive 10-year review. Visual loss after blepharoplasty: inddence, management, and preventative measures. Blepharoplasty does not correct abnormal skin pigmentation, fine rhytids, or large malar bags/ edema. Performing blepharoplasty in patients with lid laxity requires lid-supporting adjunctive procedures (canthopexy or canthoplasty). Kridel Zahi Abou Chacra the principal role of rhytidectomy is to elevate facial tissues that have descended with the aging process. Although skin excision is performed in a face-lifting procedure, contrary to the once predominant common belief, it is often not the dominant or sole goal one should try to achieve. The authors are witness to a steady evolution of technical and anatomical advances producing a new generation of facelifts. These patients have a well-developed self-image and do not want to look different. Rather they desire a natural-appearing result that turns back the hands of time to a more youthful version of themselves. For the surgeon, the goal is to determine what physical characteristics of the face are contributing to the impression of aging, which stigmata are reversible, and by what means. Ideally, the surgeon brings to this consultation a thorough understanding of the processes that lead to an aged appearance and is familiar with a wide variety of medical and surgical interventions appropriate for addressing the clinical problem. The patient who presents with an interest in face-lift who also has brow ptosis and four-quadrant dermatochalasis can be poorly served if the incongruity is not discussed prior to proceeding with the surgery. Moreover, oftentimes these patients will be left with more stigmata of a lifted appearance should they only address the lower face due to this incongruity. For these reasons, in addition to the face-lift, it is important to discuss the potential benefits of browlift, blepharoplasty. These are adjunctive procedures that complement face-lifting surgery and address the general theme of facial rejuvenation, which sometimes face-lifting cannot achieve alone. A recent paradigm shift among many authors is volume preservation and restoration in the aging face, rather than just resuspension of deep tissues. This paradigm shift is partly demonstrated by the increasing use of biologic and synthetic injectable fillers in facial plastic surgery. Other commonly used volume-augmenting strategies for facial rejuvenation include fat injections and alloplastic implants. Proponents of such techniques argue that fat and tissue atrophy happen along with gravitational changes. Lambros (1) compared pictures taken up to 50 years apart and studied the effect of aging on the midface and periorbital complex. He concluded that there was little ptosis at the lid-cheek junction and that the aged appearance was partly due to volume loss. In another of his papers, he proposed how the addition of volume may give better results than traditional surgical methods (2). He emphasized that a face that has enough tissue volume is the best predictor of a face-lift outcome. It is our opinion and the one of many other surgeons that volume restoration is an important adjunct but does not replace the need for a surgical lift. The authors do, however, recognize that for some patients with volume loss as well as tissue descent. To lift the upper third of the face, for instance, one should rely on a forehead lift. In his recent publication, McCollough stresses that the term face-lift is often inadequately used. He describes five progressive stages of aging and proposes a classification that helps matching the specific aging stage with the appropriate rejuvenation treatment (3). His system describes procedures based on anatomic locations such as temple lift, forehead lift. This article focuses only on the anatomy and clinical considerations of the present-day rhytidectomy procedure. In general, the aging face presents five landmarks that are points of interest to patients and surgeons alike. Separate from the described underlying soft tissue changes, the surgeon must note the cumulative effects of the inherent aging process coupled with the effects of environmental exposure on the skin itself. In this regard it is convenient to think of skin aging in terms of extrinsic and intrinsic factors, affecting both the epidermis and the dermis (6). Extrinsic factors refer to environmental insults such as sun-induced damage (photodamage). Intrinsic aging refers to the natural effects of time and is generally characterized by tissue atrophy and descent and reduction in skin cellular and protein components. In fact, chronologically aged skin has reduced epidermal thickness, flattening of the dermal-epidermal junction, atrophy of the dermis, and a general decline in a variety of cell populations including melanocytes and Langerhans cells (7). This epidermal thinning then makes the skin more susceptible to damage from shearing-type forces (6). Moreover, Yousif and Mendelson (8) showed how habitual facial expressions lead to coarse skin wrinkling and deep folds. He noted that instead there is a configumtional change that results from mechanical stress acting on lax. On the other hand, photoaged epidermis is characterized by striking variability: in its thickness, with alternating areas of atrophy and hyperplasia; in pigmentation, with alternating lentigines and depigmented areas; in the degree of nuclear atypia; and in orderliness of keratinocytes maturation (10). In the past, sun-damaged epidermis was thought to be characterized by a reduction in structural elements, leading to skin wrinkling. In fact, the most striking feature of photodamaged skin is the presence of large quantities of thickened, poorly organized degraded elastic fibers, which degenerate into an amorphous mass, better known as elastosis. This loss of elastin decreases skin elasticity, defined as the loss of the ability of the skin to recoil and redmpe once pulled away from the deep tissues (11). The result is aged skin, which does not retain moisture and which loosens and hangs. The ground substance component of the dermal connective tissue matrix is greatly increased. In the dermal cell population, photodamaged skin shows numerous, hyperplastic fibroblasts and abundant, partially degranulated mast cells, which result in a chronic low-grade inflammation termed heliodermatitis. Finally, photodamaged skin shows extensive changes in the microcirculation, which can affect flap viability. Along with skin changes, atrophy of underlying soft tissue and fat have also been described. Skeletal changes pertaining to both bone loss and bone remodeling also occur with aging. Overall the aging face can be viewed as a coupling of redistributed ptotic underlying soft tissue with overlying skin changes. Together, these changes combine to contribute to the overall impression of the aging face. For most aging face patients, this means that facial rejuvenation will necessitate the surgeon concentrating on five points of interest: (a) the jowl, (b) the deepened melolabial and nasolabial folds, (c) the neck, (d) the malar region, and (e) the skin itself. These new advances have largely come about through better anatomical understanding as well as an understanding of how the aging process alters these anatomical components throughout the face and neck. Specifically, the superficial temporal artery, facial artery, tnmsverse facial artery, and infraorbital artery anastomose with one another in the subdermal plexus. The internal carotid artery also contributes to the facial skin centered around the radix and the glabella through branches of the ophthalmic artery. The elevated subcutaneous flap is based solely on the subdermal plexus, which is supplied by muscular cutaneous arteries arising from branches ofthe facial and infraoroital arteries. Moreove~; in this function it maintains consistent relationship8 with the facial nerve and major vessels within the facial region. For the operating surgeon, mastery of these relationship8 and planes of dissection are therefore critical (13). Specific:ally, four ligaments support the soft tissues of the cheek: (a) the parotidomassete:ric ligament, (b) the platysmal auricular ligament, (c) the zygomatic ligament (McGregor patch), and (d) the mandibular ligament (F"tg. Although not true ligaments, these fascial condensations are especially important in the deep plane and composite rhytidectomy (16). Release of these ligaments is important and will allow the surgeon to achieve a better pull to redrape the tissue. Ho~ this task must be undertaken with extreme caution as branches of the facial nerve are in dose proximity. The relationship of the superficial and deep facial fascias: relevanat to rhyidectomy and aging. Reports of face-lifting attempts date back to the ver:y fu:st yean of the 20th century and consisted primarily of skin excision and direct closure. This technique was utilized for aver 50 years before the first major contribution to advance face-lifting was provided by Skoog. Skoog subsequently followed this with his description in 1974 of his technique of superficial mytidectom:y of the face and neck based on a subfascial dissection. In 1990 and 1992, Hamra (24) published his techniques on deep plane face-lift and composite face-lift, respectively (25). Hamra innovates on the Skoog technique by adding a superolateral elevation of the malar fat pad. The composite lift added dissection and resuspension of the orbicularis oculi muscle superomedially, thus effacing what the author has termed as the malar crescent, in an effort to rejuvenate the periocular complex: and better create harmony with the lower parts of the face. These less invasive procedures have the advantages of decreasing associated complications and substantially minimizing patient recovery time. However, in most cases their indications are limited to patients with limited signs of aging, and results from such techniques may be shortlived or less than ideal. Webster had explored short flap face-lifting in 1983, which many later abandoned (26).

Tissue expansion is a technique used by plastic and reconstructive surgeons to cause the body to grow additional ski~ bone erectile dysfunction cream buy discount nizagara 25mg. It can occur as a normal physiologic process-the most classic example is pregnancy erectile dysfunction etiology order nizagara 25 mg online. TtsSue expansion is also seen in more mainstream culture with the popularity of body art and piercings impotence treatment purchase nizagara american express. In 1957 impotence because of diabetes nizagara 100mg with amex, Neumann provided the first report of expanding the skin using an inflatable balloon icd-9-cm code for erectile dysfunction cheap nizagara 50mg fast delivery, used in the setting to reconstruct a helical defect (2) erectile dysfunction doctors in colorado purchase nizagara with visa. Radovan popularized tissue expansion for postmastectomy breast reconstruction (3). In the 1980s, studies investigating the histologic effects of tissue expansion elucidated the biology and physiology behind this emerging reconstructive technique (4,5). Argenta reported the first description of tissue expansion in the pediatric population in 1981 (6). Tissue expansion became a widely accepted technique in the 1980s and has continued to be a useful technique in the armamentarium of the reconstructive surgeon. The advantages and disadvantages of tissue expansion are outlined below (Table 175. The ability to bring skin with near-perfect match in color and texture is a significant benefit when compared with skin grafts and pedicled or free flaps, which often transfer tissue that is not similar in texture. There is also minimal or no donor site morbidity because no secondary defect occurs. Tissue expanders are also able to incorporate tissue with specialized function or adnexal characteristics. For example, tissue expansion in the setting of breast expansion is able to preserve superior sensation in the skin flaps. One major disadvantage of tissue expansion is that it does involve multiple surgeries and/or office visits. A key understanding of the physical properties of the skin is needed to understand the changes in skin biomechanics during tissue expansion. Tension is a function of the elastic fiber network and varies with location and age. Extensibility is the response of skin Both authors have no conflict of interest and adhere to ethical guidelines. Creep is defined as a gain in skin surface area that results when a constant load is applied. In other words, it is the tendency of a solid material to slowly move or deform permanently under the influence of stresses. Biologic and mechanical creeps correspond to conventional long-term expansion and rapid intraoperative expansion, respectivdy (Thble 175. It takes weeks to months to achieve and relies on physiologic and histologic changes in the tissue (9,10). The underlying mechanism that occurs during rapid intraoperative tissue expansion is mechanical creep. There is rapid cyclical stretching of the tissue, which is performed often in a single setting, and results in only mechanical changes in the tissue (10,11). The epidermis is the uppermost layer and contains five sublayers (in order from superficial to deep): stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and stratum basale. The main cells found in the epidermal layer are Merkel cells, keratinocytes, melanocytes, and Langerhans cells. The dermis is the middle layer and consists of a superficial papillary region and a deep reticular region. The papillary region contains loose areolar connective tissue, and the reticular region contains dense concentrations of collagen, elastic, and reticular fibers. The dennis contains many hair follicles, sweat glands, sebaceous glands, apocrine glands, lymphatics, and blood vessels. The subcutaneous tissue is the deepest layer of the skin and connects the dennis with the underlying bone or muscle-it supplies the underlying tissue with blood vessels and nerves. With conventional long-term tissue expansion, biologic creep occurs at all levels of the skin. The thickness either stays the same or is slightly increased, and the stratified structure is preserved (10,12, 13). The changes are temporary, and the microscopic appearance of the skin returns to normal within a year or two after the conclusion of expansion. In the dennis, there is significant thinning of approximately 30% to 50% (10,14,15). There is increased metabolic activity in the fibroblasts and melanocytes with enhanced collagen synthesis and melanin production, respectively. The number of hair follicles and the pattern of hair growth remain the same, but the density of hair follicles decreases. Individual follicles may be separated by a factor of two without producing noticeable hair thinning. Given normal hair density, the scalp can be expanded by two to three times its original surface area before a change in hair amount is evident. In the subcutaneous tissue, adipose tissue thins approximately 50% with loss of adipocytes (14,15). Vascular proliferation occurs with the growth of capillaries, venules, and arterioles (16). Nerves lengthen with conventional tissue expansion, but their function is impaired (17). A dense fibrous capsule forms around the expander and contributes to the vascularity. The capsule also contributes to contracture and shrinkage of the flap after the expander is removed (18). The expander capsule thickness does not correlate with expander volume, location, or patient age (10). In the head and neck, common applications include use in posttraumatic or postoperative alopecia, male pattern baldness, expansion prior to major reconstruction, congenital microtia, and large or giant melanocytic nevi (19-21). Tissue expanders have been used in the scalp, forehead, ear, nose, cheek, and neck. The measurement of expanded flap width is measured across the base of the expander. Ttssue expansion works best in locations where there is solid bony support under the expander balloon device, such as the scalp and forehead. Approximately 50% of the scalp can be reconstructed with the use of tissue expansion (24). Use of tissue expandm for auricular defects is limited by the lack ofadequate non-hair-bearing soft tissue in the adjacent area. H~ some surgeons do use tissue expanders in the forehead prior to elevating and transposing a forehead flap. In the cheek and neck, the skin is relatively thin and there is potential for damage to the facial nerve and Wlderlying musculature with tissue expansion. Smaller volume expandm and longer-term expansion can be used to minimize complications. The arguments for extmlal ports are that they require less dissection, have painless port access, and allow for earlier detection of leaks. Tissue expanders can also be classified by twodimensional or three-dimensional expansion. Twodimensional linear skin sttetchm consist of a Dacron strip with hooks on both ends that are prestretched and placed under the previously elevated skin:Oaps-a. Two-dimensional expansion creates forces by pulling the perimeter away from the centtal portion of skin being stretched (10). Rectangular-shaped expanders are able to achieve a gain of 38% in tissue surface area. Crescent-shaped expanders are able to achieve a gain of 32% in tissue surface area (25). Tissue expanders vacy in size &om 1 to 1,000 mL, with head and neck tissue expanders usually varying from 1 to 250 mL. The stages of the tissue expansion process include selecting the ideal expander, inserting the expanda;. In selecting the most ideal expander for the patient, it is important to consider the size ofthe defect, location of the defect. General Chapter 175: Tissue Expanders principles include using the hugest possible expand~ and often more than one expander may be needed for large defects. A single l;uge expander is preferred over multiple smaller expand~ because this will give the greatest gain in tissue per volume of expansion and limit the number of operative sites. The incision for the placement should be as far from the expander as possible to prevent dehiscence during expansion and exposure of the device A small V- or U-shaped incision placed radially (perpendicularly) related to the direction of expansion is ideal (29). In the forehead, the tissue expander should be placed deep to the frontalis muscle In the face, the tissue expander should be placed superficial to the superficial muscular aponeurotic system. In the neck, the tissue expander should be placed superficial to the platysma muscle (30). The expander pocket should be dissected wider than the base of the expander in a blunt fdshion to presave the longitudinal bloody supply (4). Furthermore, the expander pocket must be large enough to allow the expander to lie completely flat without any folding, budding, or distortion. The expansion phase is often the most burdensome for the patient-both physically and emotionally. The interval and volume of expansion may vary by region and wound type Typially, 2 weeks are allowed for the wounds to heal after expander placement before the expansion phase begins. Expansion should be continued until the extended flap is approximately 20% lcuger than the size of the defect to account for tissue recoil during advancement. Inspection of the skin color (blanching), capillary refill, and direct palpation are routine when evaluating for further expansion. The final step in the process involves removal of the tillsue expander device and simultaneous reconstruction with the expanded flap. Case2 A 38-year-old woman with a neck scar from a bum injw:y as a child who had Wldergone previous revision and laser treatment with p~istent scar deformity. An incision is made in the right posterior scalp, and a subgaleal pocket was created. A large owl-shaped 1issue expander was selected to fill the planned defect site (A). The phases are the same-selecting the ideal expander, inserting the expander, expanding the expander, and removing the expander with reconstruction. There are no physiologic or metabolic changes that are seen in the setting of conventional long-term tissue expansion. A gain of 1 to 3 em of flap length can be achieved, depending on the site of expansion. Critics of this technique have claimed that rapid intraoperative tissue expansion is simply augmented Wldermining and tissue rearrangement (35,36). These complications include expander exposure or extrusion, skin necrosis or ischemia, numbness or weakness, infection, bone resorption, hematoma or seroma. Most authors would advocate that exposed expanders can be watched, with cessation of interval expansion. Ho~ it is often recommended that extrusion should be an indication for prompt removal If there is evidence of skin necrosis or infection, the tissue expander should be removed. Careful antiseptic techniques should be observed to minimize infection around the devices. It can provide additional skin with similar characteristics and aroid Winecessary donor site morbidity. The more traditional and commonplace conventional longterm tissue expansion relies on biologic creep and results in important physiologic changes at the epidermis, dermis, and subcutaneous tissue. Conventional long-term tissue expansion can be a lengthy process for both the patient and swgeon. The area over the hairy navus was shaved, and markings were made around the lesion site (A). The 1issue expander was dissected from the fibrous capsule, deflated, and removed (C). The expanded scalp tissue was advanced to the defect size-the incision dosed primarily laterallyand a small cantral area was left to granulate (D). The same patient during the expansion phase on frontal view (A) and side view (B). The tissue expander was dissected from the fibrous capsule, deflated, and removed (B). The expanded neck tissue was advanced to the defect size, and the incision was do9ed primarily (C). Intraoperative sustained limited expansion as an immediate reconstructive technique. Important physiologic changes in conventional expansion include increased mitotic activity and vascular proliferation. The scalp and forehead are optimal sites for reconstruction with tissue expanders. Stages of tissue expansion include insertion, expansion, and expander removal with simultaneous reconstruction. Complications occur in approximately 10% of cases, with the most common of being expander extrusion or exposure. The expansion of an area of skin by progressive distension of a subcutaneous balloon. Clinical and experimental evaluation of intermittent intraoperative short-term expansion. Quantitativi: analysis of the thickness of human skin and subcutaneous tissue following controlled expansion with a silioone implant Plast Reconstr Surg 1988;81:516-523.