E. Magnus Ohman, MD, FRCPI

• Professor of Medicine
• Associate Director, Duke Heart Center?ardiology Clinics
• Director, Program for Advanced Coronary Disease
• Duke Clinical Research Institute
• Duke University Medical Center
• Durham, North Carolina

Bilateral paramedian incisions are made in the periosteum 1 cm lateral to the midline anxiety symptoms 7 year old generic serpina 60 caps otc, and periosteal elevation is initiated in a subperiosteal plane with a Joseph periosteal elevator anxiety symptoms and treatment purchase discount serpina on line. Thus anxiety symptoms head pressure trusted serpina 60 caps, a 2-cm central strip of periosteum remains attached to the mandible; this is said to reduce the risk of mandible resorbing secondary to pressure from the implant anxiety hierarchy order serpina 60caps mastercard. A blunt Freer elevator is placed in the pocket anxiety disorder key symptoms cheap 60caps serpina mastercard, and the periosteum is manually elevated anxiety symptoms similar to heart attack cheap serpina online master card, taking care not to dissect superiorly in the region of the mental nerve, nor to detach the periosteum off of the inferior border of the mandible. The left hand is used to palpate the location of the elevator, ensuring that it is precisely parallel to the inferior border of the mandible. Following the development of the pockets, the site is irrigated with Bacitracin solution to reduce bacterial load and prevent infection of the implant. The implant is then folded acutely and the contralateral phalange of the implant is guided into the contralateral pocket. A second stabilizing suture of 4-0 Surgipro or Nylon is used to secure the implant in the midline inferiorly along the inferior border of the mentum. The ideal position of the implant should correspond to the inferior border of the mandible. The lateral aspects of the implant are palpated to ensure that the implant is not folded or curled upon itself, and the surgical site is again irrigated with Bacitracin solution. Submental liposuction is an effective procedure to address localized adipose collection and can be performed as an isolated procedure or combined with complementary surgery. Extraction of fatty deposits in this region, when performed on ideal candidates, can result in marked improvement in neck contour. Good candidates for submental liposuction include patients of normal general body habitus, with elastic skin, well-defined mandible, high and posterior hyoid position, and well-defined, localized collections of subcutaneous fat (Table 25. Liposuction was developed in the 1970s with the use of rigid cannula and suction device. Illouz (1983) described a modification of the technique, which included the use of tumescence to expand the surgical plane and reduce bleeding. Over the years, refinements in technique and equipment have allowed for more accurate fat removal with a reduction in the incidence of complications. The principle of surgical liposuction is based on contouring submental fatty deposits by precise reduction of adipocytes in the region. Following suction-assisted avulsion of fat cells, recontouring relies on redrapage of the overlying skin envelope and subdermal contraction. Surgical Technique Prior to the procedure, the patient is marked in the upright position. The extent of the fatty accumulations is palpated with the fingers, and the borders of the maximal submental collection are marked. The majority of the Chapter 25: Aesthetic Surgery of the Neck and Submental Region Table 25. Factor Body habitus Skeletal features Hyoid position Muscular features Adipose tissue Skin tone Good candidate Normal Anterior, strong mentum, and well-defined mandible High and posterior Taut platysma Well-defined, localized collection Elastic Poor candidate Large with excess generalized adipose tissue Posterior, weak chin position, and poorly defined mandible Low and anterior Lax platysma Diffuse distribution Lax 283 submental fat is localized centrally in the submental area, and thus, liposuction is generally focused in this region with feathering into the surrounding tissues to create a smooth transition. Access to the submental fat deposit is via a small submental incision, wide enough to allow for smooth passage of a cannula. Care should be taken to avoid a large incision to maintain adequate suction during the procedure. Conversely, an incision that is too small will restrict cannula motion and result in excessive friction and tissue trauma. When treatment of the jowls is indicated, the approach is via an infralobular incision. Fine cannulas must be used to avoid nerve injury and contour irregularity in this sensitive region. Cervicofacial liposuction can be performed under local anesthesia, intravenous sedation, or general anesthesia. The authors use a partial tumescent technique, infiltrating the treatment region with a 1:1 mixture of 0. Excessive infiltration is avoided to preserve the anatomic landmarks and to prevent distortion of the preplanned treatment regions. The incision is undermined for a distance of 1 cm with Stevens tenotomy scissors to develop a subdermal plane, which will allow for insertion of the cannula. If jowl liposuction is to be performed, similar incisions are made in the infralobular crease. Fine cannulas must be used for cervicofacial liposuction to prevent excessive removal of fat and to avoid injury to neurovascular structures. In general, the authors prefer to use a 3- or 4-mm cannula in the submental region and a 2- or 3-mm cannula in the jowl region. Prior to applying suction, the cannulas are used to create tunnels in a deep subcutaneous plane. Once pretunneling is completed, negative pressure suction is applied via a commercially available electric liposuction pump or manually with a handheld syringe. With the nondominant hand supporting (but not pinching) the fat accumulation externally, the dominant hand is used to aspirate the adipose tissue with long, radial passes of the cannula in a fan-shaped pattern. The aperture of the suction cannula is directed away from the skin flap to avoid dermal injury leading to contour irregularities, and care is taken to sculpt the region in a smooth and even manner. Extraction volumes vary for each patient, but in general, the total volume of fat extracted ranges from 10 to 100 cc. To prevent postoperative hematoma or seroma collection, a pressure dressing is applied to the submental region and removed on the second postoperative day. A pressure garment may be recommended for use at night for a further 2 weeks to aid in redraping of the skin envelope. Ideal candidates for the procedure have normal body habitus and strong skeletal structure with a well-defined mandible, anterior chin position, and high and posterior hyoid bone. Anteriorly, dehiscence and laxity of the platysma present as vertical banding of the neck. While facelift is covered elsewhere in this text, a description of platysmaplasty is outlined below. Options include contouring localized adipose collections in the neck, augmenting the skeletal structure of the mandible, and tightening the muscular sling. Commonly, a combination of these procedures is necessary for comprehensive treatment of the lower neck region. Incidence of cervical branch injury with "marginal mandibular nerve pseudo-paralysis" in patients undergoing face lift. Advanced considerations determining procedure selection in cervicoplasty; part one: anatomy and aesthetics. Defining the facial extent of the platysma muscle: a review of 71 consecutive face-lifts. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Surgical Technique the amount of submental adipose tissue is first assessed and treated via liposuction prior to platysmaplasty. Any excess central adipose collection is excised directly between the medial borders of the platysma, taking care to avoid excessive fat resection, which can result in contour irregularities. Meticulous hemostasis using bipolar cautery is vital to prevent postoperative hematoma. The two anterior borders of the muscle are then brought together in the midline with a central corset technique. Horizontal mattress 3-0 Vicryl sutures are used for this purpose to approximate the muscle borders in the midline creating a tight midline sling. Partial platysmal resection or platysmal transection at the level of the hyoid bone may need to be performed in a small proportion of patients. For the majority of patients, the platysma will be further tightened laterally and redundant skin excised via a postauricular incision, which is commonly combined with a facelift procedure. Correction of Lids (Blepharoplasty) Don Julian De Silva, Brett Kotlus 26 Chapter Overview 26. The traditional transcutaneous technique results in a scar in the skin and a higher risk of lower eyelid retraction. The more contemporary transconjunctival technique avoids a skin scar and has a lower risk of eyelid retraction. Blepharoplasty is commonly used to describe a number of eyelid procedures including upper blepharoplasty, lower blepharoplasty, and Asian blepharoplasty. Cosmetic blepharoplasty is one of the most popular 286 Section 2: Facial Plastics esthetic surgeries. The forehead, brows, midface, and cheek have intimate relationship with the eyelids and need to be considered in evaluation of the eyelids. The frontalis is a weak elevator of the upper eyelid; however, it has an important role in upper eyelid as the activity of the frontalis muscle impacts the shape of the eyebrow and eyelid sulcus. Preaponeurotic fat lies immediately behind the septum and with facial aging the fat may prolapse anteriorly resulting in a bulge in the upper eyelid. There are two components to the fat, medial fat that is pale in color and central fat that is darker yellow. Laterally in the eyelid is the lacrimal gland and caution must be observed in this area as surgical reduction of the gland can result in marked hemorrhage and dry eye. A branch of the palpebral artery lays posterior to the medial fat pad and caution is required to avoid injury to this vessel to avoid hemorrhage. Common facial aging in the upper eyelid includes excess skin, photoaging, and rhytidosis, fullness of the upper eyelid with fat prolapsing anteriorly, and atrophy of the sub-brow fat pad. The surface anatomy of the upper eyelid includes the eyebrow, the eyelid crease, and the eyelid itself; the space between the eyebrow and the eyelid crease is termed the eyelid sulcus. The eyelid consists of three principal layers: anterior lamellar (skin, subcutaneous tissue, and orbicularis oculi muscle), middle lamellar (orbital septum), and the posterior lamellar (tarsal plates, striated and smooth muscles, and conjunctiva). A common sign of facial aging is laxity in the upper eyelid skin that can droop over the upper eyelid (termed dermatochalasis). It is divided into two principal parts: the innermost palpebral part that is present in the eyelids and an outer orbital part. The muscle is innervated by the facial nerve from temporal and zygomatic branches on the deep surface and is not denervated or injured by transcutaneous eyelid surgery. The septum lies posterior to the medial palpebral ligament and anterior to the lateral palpebral ligament, and blends with the levator aponeurosis above the superior tarsal border. The orbital septum provides an important functional barrier in the eyelid that protects the spread of infection from superficial skin tissues to the orbital cavity. Although the normal male eyebrow is considered at the superior orbital rim and the female brow above the orbital rim, there is considerable variability in the position of the eyebrow and many patients have low eyebrows in youth. The normal distance between the upper and lower eyelids (palpebral distance) is 9 mm (however this is not necessarily an accurate measurement of eyelid position as the measurement is reliant on the position of the lower eyelid). The skin crease is the distance from the upper eyelid margin to the supratarsal crease. The lateral palpebral arteries are derived from the lacrimal artery and the medial palpebral arteries from the ophthalmic artery. The lymphatic drainage of the medial one-third of the upper eyelid is to the submandibular lymph nodes and from the lateral two-thirds to the superficial parotid (periauricular) lymph nodes (Nerad, 2010). The lower eyelid is pulled away from the globe (termed lower eyelid distraction), if the eyelid can be pulled 8 mm away from the globe this is defined as severe lower eyelid laxity. In evaluating the snap back test, the speed at which the lower eyelid returns to its normal position is also evaluated. Orbicularis oculi muscle is present immediately beneath the thin lower eyelid skin as a ring around the eye attaching to the periorbital skin. The skin and orbicularis oculi muscle comprise the outer or anterior lamellar of the eyelid. Orbital septum is a fibrous membrane that compartmentalizes the orbital fat, provides an important barrier for preventing infection from the superficial eyelids to the deeper orbit. The orbital fat is separated between the medial and central fat pads by the inferior oblique muscle and caution is required during surgery to avoid damage to this muscle (Harley, et al. If the lateral canthus is lower than the medial canthus, the lower eyelid should be evaluated for laxity. In the snapback test, the lower eyelid is stretched away from the eye and time for the eyelid to return to its normal position is observed without blinking, laxity is defined by a slow return to the normal eyelid position. Globe protrusion is the relative position of the globe to the orbital rim (>15 mm). There is considerable ethnic variability in relative globe protrusion; however, in patients with considerable globe protrusion, ophthalmology assessment is indicated to exclude orbital pathology including thyroid eye disease and neoplasia. Orbitomalar ligament attaches the orbicularis oculi to the inferior orbital rim (also termed the orbicularis-retaining ligament). In youth, there is a smooth continuity between the lower eyelid and cheek, with facial aging there can be distension of the ligament that gives rise to appearance of ring beneath the lower eyelid. Common facial aging of the lower eyelid includes fat prolapsing anteriorly that is seen as lower eyelid bags, loss of subcutaneous eyelid, and cheek fat that can accentuate the nasojugal hollows. Laxity and actinic changes of the lower eyelid skin can be seen as lines and wrinkles.

A two-channel setup is commonly used so that both horizontal and vertical eye movements are represented anxiety xanax benzodiazepines cheapest serpina. This is possible even when the patient is in complete darkness owing to the infrared light that is used anxiety 300 order serpina 60 caps amex. Though helpful anxiety zinc cheap serpina, the potential for error is high when the interpretation provided by the software is used indiscriminately anxiety 12 signs purchase serpina toronto. Consequently anxiety 4 hereford bull order generic serpina online, it is essential that administers of the test receive adequate training to maintain a level of quality control over the resulting report anxiety symptoms last all day 60 caps serpina free shipping. As with all tests of vestibular function, results should be clinically correlated. Interpretation is based on the peak velocity, latency, and accuracy of the generated saccades when compared to normative data. Dysmetria is an abnormal pattern of saccadic eye movement where the patient briefly overshoots (hyperme tria) or undershoots (hypometria) the target on a consistent basis. Saccadic slowing may also be observed, resulting in saccades that have a rounded appearance on the resultant tracing (Barber and Stockwell, 1980). Delayed saccadic latencies are of particular clinical relevance when the delay is unilateral. If gaze-evoked or congenital nystagmus is present, it will often be superimposed on the generated saccades. As is the case for all oculomotor tests, true saccadic abnormalities must be distinguished from confounding factors. Poor attention or incomprehension of the task can result in misinterpretation of the test results. When pursuit is normal, the patient will be able to follow the path of the target precisely, with few or no corrections. Saccadic pursuit occurs when the patient is unable to maintain the target on the fovea as it moves. Abnormal pursuit may be observed unilaterally or in both directions and is suggestive of a central lesion. As with saccades, gaze-evoked and congenital nystagmus may be overlaid on a smooth pursuit tracing. Saccades Saccades are fast and precise conjugate eye movements that optimize the clarity of the intended fixation target on the fovea. The assessment of saccadic eye movement is accomplished by instructing the patient to fixate on a target that moves suddenly in a direction specified by the examiner. The saccade test uses a peripheral light Gaze Stability Test For the gaze stability test, the patient is asked to maintain primary or eccentric gaze positions to the left, right, up, Chapter 6: Vestibular Testing of the Patient with Dizziness/Balance Problems and down. The gaze test begins in primary position, with gaze returning to center after each eccentric gaze position is complete. The sequence may be repeated without a fixation point (eyes closed or with goggle cover on). If the test is attempted using something other than a computergenerated target. The purpose of testing gaze stability is to detect persistent nystagmus in any of the eccentric gaze positions. When nystagmus is observed, the direction of the fast phase and the intensity of the nystagmus should be noted for all applicable gaze positions. The nystagmus can be categorized based on the presence and intensity of the nystagmus in the various gaze positions: present during gaze in the direction of the fast phase of the nystagmus only (first degree), present in primary gaze, as well as in the direction of the fast phase where it is more intense (second degree), present in all gaze positions, greatest in direction of fast phase (third degree). The presence of rebound nystagmus, which is seen when the nystagmus changes direction upon returning to primary position, is a central finding. The presence of vertical nystagmus (upbeat or downbeat) with fixation can also indicate a central lesion. Unfortunately, the results from such tests have limited utility as they are essentially evaluating the pursuit system. When a full-field arrangement is available, the visual pursuit system can be further minimized by asking the patient to count the number of targets that appear, rather than asking the patient to follow each target until it disappears. Spontaneous Nystagmus Test To evaluate whether spontaneous nystagmus is present, the patient typically completes an alerting task while the eye movements are recorded for at least 30 seconds with vision denied (eyes closed or goggle cover on) and the head at rest. When spontaneous nystagmus is caused by asymmetric inputs resulting from a peripheral lesion, the fast phase of the nystagmus will typically beat away from the side of the lesion. Spontaneous nystagmus should be largely suppressed with fixation when caused by a peripheral lesion. Optokinetic nystagmus can be easily suppressed when the patient does not closely attend to the moving visual field. A body roll is an option for patients who are not able to achieve sufficient head rotation. The presence of spontaneous nystagmus should be considered when interpreting the positional tests. If nystagmus is observed with positional changes but does not change in intensity and direction from the spontaneous nystagmus, true positional nystagmus is not present. A "positive" (abnormal) head-shake test is identified when robust nystagmus is present following the head shake. A positive head-shake test is most commonly considered an indication of a peripheral lesion. In its most classic presentation, a peripheral lesion produces post-headshake nystagmus beating in the direction opposite to the side of lesion. It is not uncommon for the nystagmus to change direction (phase) as the response decays. Post-head-shake nystagmus resulting from a peripheral lesion should not persist beyond approximately 20 seconds; when it does, a central cause should be suspected. The presence of vertical nystagmus post-headshake, known as "cross-coupling," is also an indication of central pathology. The maneuver is accomplished by first asking the patient to sit in an upright position. The eyes are observed for the presence of nystagmus, which is usually torsional in nature and may have a delayed onset. When the patient is returned to the upright position, the direction of the nystagmus should be observed for signs of reversal, which is commonly seen. Patients with injuries or problems involving the neck or back, as well as elderly patients may not be able to tolerate the Dix-Hallpike test. In the years since, the caloric test has become a widely used technique for detecting unilateral vestibular dysfunction, as well as being a source of considerable controversy. During the caloric test, water or air is used to irrigate the external auditory canal at a temperature that differs significantly from body temperature. The direction of the nystagmus that is produced is predictable based on the temperature of the stimulus. The responses from the left and right labyrinths are compared for the purpose of identifying a unilateral weakness or overall hypofunction. The resultant cupular deflections change the neural firing rate from the lateral labyrinth of the test ear, causing nystagmus. This was proven incorrect in 1986 when caloric nystagmus was successfully produced in space where performing the test in the presence of microgravity mitigated the convection component of the proposed mechanism (Scherer, et al. To date, a definitive mechanism does not yet exist to explain the nystagmus produced from caloric testing. A detailed otoscopic examination is essential for maximizing the validity of the test. Any evidence of prior surgery or trauma should be noted, as well as any other factors that could potentially impact the test results. Even nonoccluding cerumen can negatively impact the accuracy of the test results by altering the passage of the stimulus during irrigation. Since it is impossible to determine the level of occlusion needed to impact the flow of the stimulus, it is advisable to clear the canals of any debris prior to testing. When necessary, the testing procedure should be modified to ensure patient safety. For example, air (and not water) must be used as the stimulus when a tympanic membrane perforation is present. Caloric test results from a perforated eardrum can be misleading (see interpretation). The patient should be provided with detailed instructions regarding the test procedure. This step can be helpful in alleviating fears and concerns a patient might have about the test. It is not uncommon for patient to believe that calorics will make them vomit or be unable to function for the remainder of the day. This elicits both excitatory (warm stimulus) and inhibitory (cool stimulus) responses from both canals. The irrigations occur one at a time in succession with a short waiting period in between to allow for the cessation of the nystagmus. Closed-loop systems, which use a water-filled balloon to achieve caloric stimulation without direct water stimulation, are no longer manufactured but may still exist in some testing centers. It is generally accepted that air calorics require more technical skill to perform than water because the stream of air can more readily be directed toward the ear canal wall rather than the intended tympanic membrane (newer air caloric irrigators have an otoscope-like viewing lens to assist with aiming the flow of air). However, air calorics do not involve water, which can leak over the patient and equipment, and can be performed even when a tympanic membrane perforation is present. The patient should be given alerting tasks to ensure that the nystagmus is not being suppressed. Once the nystagmus reaches its peak and begins to subside (approximately 30 seconds postirrigation), the patient is asked to fixate on a target for approximately 10 seconds. Once the nystagmus has completely subsided and the patient is willing, the tester continues with the same temperature in the opposite ear, eventually completing the irrigations with cool water as well. There is no absolute consensus in the literature regarding the ideal order of irrigations for the caloric test. This is well within normal limits (the cutoff for "normal" is typically set between 20% and 30%). In this example, the patient has an 82% unilateral weakness, often referred to as a canal paresis. If the examiner is unable to obtain a measureable response using warm and cool water, an additional irrigation may be completed using water mixed with ice, though some patients have difficulty tolerating the stimulus largely because of the intense cold on the skin of their ear canal during irrigation. In some cases, the more intense stimulus will be effective in eliciting nystagmus that was absent using the other temperatures. Many patients with unilaterally absent function will also have a spontaneous nystagmus beating away from the affected side. Chapter 6: Vestibular Testing of the Patient with Dizziness/Balance Problems being tested. One solution is to roll the patient into the prone position (head lowered slightly from horizontal) or to have them sit up partway through the test. It is possible but less common for patients to have bilaterally absent caloric responses. Head impulse testing, a technique discussed later in the chapter, should be completed along with other tests in order to confirm total canal paresis bilaterally. Caloric responses that are bilaterally present but at reduced velocities are also considered significant. Otoscopy should be repeated to rule out a tympanic membrane perforation as the cause of the hyperactive response. Directional preponderance (%) may be used to indicate that a certain direction of nystagmus (left-beating nystagmus or right-beating nystagmus) is more prevalent in the results. However, it is thought to have little clinical significance, as it is nonlocalizing. Abnormal values, typically above 50%, can be indicative of a central lesion and should be noted. Practical considerations and limitations: Caloric testing requires considerable training and attention to detail in order to be completed and, thus, interpreted accurately. The results from patients presenting with ear pathology can be particularly challenging. For example, in the case of a unilateral tympanic membrane perforation, the lateral canal is more exposed and receives intensified stimulation. An enhanced response on the perforated side can easily be misidentified as a caloric reduction on the intact side. Caloric testing results for a unilateral tympanic membrane perforation, therefore, have limited use unless the response is reduced on the perforated side. As with all other tests of vestibular function, it is vital to interpret results in the context of the clinical presentation. Technical sources should be ruled out before accepting unusual or inconsistent findings. As the reader can surmise from reading this section, the literature contains little consensus regarding the delivery of caloric testing. Owing to inconsistencies in the literature, the normative values used clinically are variable. Both otolith organs are sensitive to intense acoustic stimulation and have connections with motor nuclei.

The double blind anxiety nos discount serpina online american express, placebo-controlled study used sodium fluoride to treat active disease anxiety zone discount serpina 60caps without a prescription, at a dose of 20 mg/day (enteric coated capsule) combined with 500 mg calcium gluconate and 400 units of vitamin D anxiety symptoms headaches purchase generic serpina canada. The author recommends this regimen anxiety emoji buy serpina master card, given its experimental backing (Bretlau anxiety 13 year old serpina 60caps for sale, Salomon and Johnsen anxiety symptoms 60 caps serpina with amex, 1989). X-linked Hereditary Deafness this syndrome causes a congenital mixed hearing loss, so it would be uncommon for it to present in adulthood. There is also dilation of the lateral end of the internal auditory canal, and deficiency of the modiolus. Other anomalies may also be present, including in carrier females (Saylisoy, et al. Stapedotomy may be necessary to bypass the fixation and prevent recurrence (Tos, 2000). Both mobilization of the stapes and stapedotomy are said to be associated with a higher rate of sensorineural hearing loss than otospongiosis. Osteogenesis Imperfecta Osteogenesis imperfect occurs in several forms, with type I ("osteogenesis imperfecta tarda") being of most relevance. It is an autosomal dominant disease of the skeleton and connective tissue, with the hearing loss usually beginning in the teens and twenties (Tos, 2000). If osteogenesis imperfecta is diagnosed, it is recommended that these patients be considered for nonsurgical rehabilitation. A surgeon with considerable experience in difficult stapedectomy should be consulted before any decision to operate. It is important to warn such patients beforehand that they will still have a hearing loss postoperatively, and indeed may still be a candidate for hearing aid fitting. However, the improved hearing will mean a lower-powered hearing aid can be used, with less battery consumption, less risk of feedback, and less need for a tight fitting ear mold. The patient will also cope better in situations where they cannot usually wear a hearing aid. Tympanosclerosis of the oval window varies from small deposits to obliteration of the niche. The plaques may affect the stapedius tendon, stapes superstructure, and/or the footplate. These features imply the problems faced with surgery may be much greater than with otospongiosis, and the risks of failure higher. Simple mobilization by removal of plaques is often insufficient as they may reform with reappearance of the hearing loss. Plaque removal, therefore, needs to be radical and any attic or tympanic membrane disease needs to Chapter 13: Surgical Management of the Patient with Hearing Loss Bretlau, P. A double-blind, placebo-controlled study on sodium fluoride treatment in otospongiosis. Computed tomographic findings of X-linked deafness: a spectrum from child to mother, from young to old, from boy to girl, from mixed to sudden hearing loss. Surgical solutions for conductive hearing loss (Volume 4 of the Manual of Middle Ear Surgery). Note: If this were a real patient, a vestibular schwannoma affecting the left ear should be considered. The surgeon will be pleased the operation was successful, but the patient will probably not feel much better off. In such cases, surgery may be declined on the grounds that the predicted benefit (minimal) may not be worth the risks. If this were a real patient, unless there was an explanation for the asymmetry, a vestibular schwannoma on the side of the poorer hearing ear would need exclusion. It is uncommon as a presenting symptom in the otolaryngology clinic, but can be extremely disabling for patients. The infrequency with which tinnitus is seen in the clinic may therefore reflect reluctance by the patient or primary doctor to refer, believing incorrectly "nothing can be done about it". Most people, for example, will hear tinnitus in a soundproof room, and temporary tinnitus after exposure to loud noise is very common. The British national survey of hearing estimated that the prevalence of tinnitus in the adult population was as follows: 10% report prolonged spontaneous tinnitus, 1% severe annoyance, and 0. No less than 7% reported prolonged tinnitus but no hearing loss (Vesterager, 1997). Tinnitus can be divided into physiological (tinnitus heard by normal people in quiet), objective (the sound exists and can be detected by an observer), and subjective (the sound is a perception only and cannot be detected). Objective tinnitus is uncommon; it includes audible bruits from vascular lesions, sounds of muscular origin, and sounds generated within the cochlea (rare)-Table 14. The recognition and management of objective tinnitus will be covered later in this chapter. Patients may present with tinnitus and virtually any disease anywhere in the auditory pathway; other patients may have disabling tinnitus with normal hearing and no discoverable cause. Care should be taken, therefore, in saying that subjective tinnitus is "caused" by any given condition; it is more logical to use the term "associated with" the majority of patients pre. Many comparative terms can be used: whistling, machinery, insects, roaring, steam escaping, and so on. It is important to ask if the patient has noticed the tinnitus is asymmetrical or pulsatile, as these patients may need further investigation. For the assessment and management of patients with objective tinnitus, please see the section at the end of this chapter. The clinician looking after tinnitus patients needs a model explaining how and why some patients with tinnitus develop problems and others do not. This model needs to be plausible, backed by research and explainable to patients to gain their understanding and compliance with treatment (Goodey, 2007). This chapter follows the neurophysiological model of tinnitus as outlined by Jastreboff (2007). Subjective tinnitus is perception of neural activity within the auditory pathways. Neural plasticity causes tinnitus-related activity to spread to structures in the brain not involved in hearing such as the limbic system and sympathetic autonomic nervous system. It is these central components that cause the "suffering" experienced by patients. Some individuals develop a central component (postulate 2) and present with disability from tinnitus (postulate 3). It follows, therefore, that managing the central component of disabling tinnitus is crucial. Evidence that these postulates are likely to be correct is provided by psychoacoustical tests, in which patients with tinnitus are asked to match their tinnitus for volume and pitch with an external sound source (such as a signal from an audiometer). The amount of volume needed to match the tinnitus is no greater in those patients with disability than those without. It is, therefore, not the perception of tinnitus that causes disability; it is the reaction of the central nervous system to that perception. Many processes have been suggested as leading to abnormal neural activity in the auditory system, which can then be perceived as tinnitus. Detailed discussion on this topic is beyond the scope of a symptom-based textbook, and the interested reader is referred to Jastreboff (2007). The majority of patients who develop permanent tinnitus learn to tolerate the sensation. The brain interprets this as a neutral (nonthreatening) stimulus and the tinnitus is usually blocked from reaching conscious perception (adaptation to the tinnitus). These patients will state that they can hear their tinnitus if they pay attention, but under most circumstances they are completely unaware of it. The brain interprets this as a threatening/unpleasant stimulus and the limbic and sympathetic nervous systems become activated. The tinnitus then becomes an impossible to ignore stimulus (failure of adaptation). Activation of the limbic and autonomic nervous system follows, with the development of vicious spirals at both conscious and unconscious levels. The model postulates that this is especially likely to happen if the tinnitus is first noticed at a time when the patient is undergoing a distressing life event, such as bereavement and loss of employment. At such times the patient will be in a state of psychological arousal, and particularly aware of any potentially threatening new event, such as the onset of tinnitus. Alternative models have been developed since Jastreboff (2007), although further discussion is beyond the scope of a problem-orientated textbook. The nature of the tinnitus, including whether it is asymmetrical, onset and time course, and the disability. The time course of the tinnitus must also be asked: is it continuous, pulsatile, fluttering, or popping. If the patient answers "yes" to any of these questions, they have marked disability from their tinnitus. More sophisticated measures such as the tinnitus handicap inventory are appropriate for more specialized settings than the general otolaryngology clinic: 2. Any history of migraine or migraine symptoms such as phonophobia, photophobia, and headache 5. Any history of head/ear trauma, drug therapy, systemic disease, and other potential causes (Table 14. The examination must include otomicroscopy, examination of the cranial nerves, and examination of the head and neck with auscultation (of the ear canal, parotid region, mastoid region, and neck). Examination of the temporal arteries is included, as is examination of the muscles of the scalp and, looking for evidence of muscle tension disorder. Avoid clearing the ear canal with suction during the otomicroscopy, and as a last step check to see if the patient reports temporary reduction of tinnitus following 60 seconds of exposure to an 18G suction held just inside the entrance to the external ear canal. Instruct the patient to report immediately if they find the noise of the suction distressing, in which case abandon this test. Full testing must be insisted on in patients even if they believe their hearing is normal. Specific tests for tinnitus, such as matching the tinnitus against pure tones or other acoustic stimuli, are more appropriate for the specialized tinnitus clinic. Patients with a discoverable cause will need investigation and management as appropriate for the underlying condition. Patients requiring further investigation: a list of reasons why tinnitus patients may require this is given in Table 14. Patients with normal or symmetrical hearing and no discoverable cause should proceed directly to tinnitus management as described below, and do not need imaging unless there are suspicious features not covered in this description. The majority of tinnitus patients will not have suspicious features and are in this category (the blue area in Flowchart 14. Briefer, intermittent periods of asymmetrical tinnitus probably do not warrant investigation. Feature Asymmetrical tinnitus and/or asymmetrical hearing loss Pulsatile tinnitus Pulsatile tinnitus, no lesion found Possible conductive hearing loss Miscellaneous Possible cause(s) Vestibular schwannoma Vascular or neoplastic-see Table 14. Up to 4% of patients with vestibular schwannoma may present with unilateral tinnitus (Dawes and Basiouny, 1999). It is important to remember than even if the patient has a discoverable cause, disability from tinnitus may persist after appropriate management. These patients will include those with no suspicious features, and those who have been investigated and treated for other conditions, and who present with ongoing disability from tinnitus. The majority of these patients will respond to simple treatment measures (top half of Flowchart 14. If the patient has a significant hearing loss, recommend that the patient have this rehabilitated with hearing aids. Regardless of the method of intervention, the patient must be informed that improvement is likely but will take time and compliance with treatment. This includes avoiding (if possible) factors known to aggravate tinnitus such as loud noise, sleep disturbance (which can both aggravate and be caused by tinnitus), caffeine, drugs such as aspirin, bruxism, and stress. Associated conditions: It is important that factors triggering or exacerbating tinnitus should be treated. Migraine should be managed aggressively as the phonophobia, hyperacusis, and headache-not to mention hours spent lying down in a quiet room with nothing but the tinnitus to listen to-are potential major aggravating factors for tinnitus. The clinician should refer these patients for further, more specialized management. Transcranial magnetic stimulation has been suggested as a potential treatment for tinnitus but good evidence of efficacy is not yet available. A useful analogy to suggest to the patient is that a flash of light is perceived readily in a dark room, but not at all in a snowfield in sunlight. Most patients will have also noticed that their tinnitus is less noticeable when they can hear the sound of rain outside. If tinnitus is associated with a conditioned reflex as suggested by Jastreboff, then making the stimulus (tinnitus) less perceptible will encourage extinction of the reflex. Since tinnitus is readily perceived in quiet, some extra sound should be provided in this situation-usually the bedroom for most patients. This sound has to be background, of a relaxing quality, contain nothing that might distract the patient and prevent sleep, and should be loud enough to hear clearly but not so loud as to prevent sleeping. The time frame for improvement is similar to that for hearing aids, and it must be stressed that the sound enrichment must be used consistently.

Sufficient energy must be delivered within this time to achieve tissue vaporization anxiety leg pain discount serpina online american express. Early low power systems (<1000 W) required longer on-times anxiety treatment without medication purchase serpina 60caps online, with the potential of causing deeper thermal damage and resulting in scarring frequently anxiety symptoms even on medication purchase serpina 60caps amex. It has been calculated that the necessary fluence to achieve pulsed-laser ablation of skin tissue is 5 J/cm2 anxiety symptoms muscle tension discount serpina 60 caps mastercard. The result is little heat damage to deeper structures and char-free tissue removal anxiety uti order serpina with visa. One pass may be enough for mild rhytids or sun damage anxiety symptoms worksheet discount 60caps serpina overnight delivery, but three passes are needed to effectively reduce wrinkles and scars in moderate-tosevere cases. The only exception is in the eyelids where no more than two passes should be used. Gentle wiping of the desiccated debris in between passes is important, as any water remaining on the skin may absorb laser energy and block it targeting the dermal tissue. Clinical end point is reached when yellow chamois-looking skin is seen, signifying reticular dermis. Re-epithelialization starts from the undamaged epithelial cells lining the adnexal structures of the skin. Most reports have shown significant improvement in photoaged skin regardless of the system used. Emitting a wavelength of 2940 nm, it is near the largest absorption peak by the water molecule and has a higher affinity for water. This makes it more capable of removing extremely thin layer of tissue, with scant thermal damage. However, as there is smaller depth of penetration, less collagen shortening is stimulated. However, the results are superficial, with limited success in removing deep winkles (Kauvar and Hruza, 2005). It also has poorer hemostasis, as penetration is not deep enough for blood vessel coagulation. Oral antihistamine can be prescribed if there is no evidence of fungal colonization. Infection Patients may develop bacterial (Staphylococcus aureus, Pseudomonas), fungal (Candida), or viral (herpes simplex) infection. Most infections are temporary and can be managed by appropriate topical or systemic treatment. Permanent scarring Mainly occurs as a result of infection, or when the depth of ablation is too deep. Special caution with a reduced number of passes or reduced fluence should be used in the treatment of specific areas like the eyes or the neck. Post-treatment erythema and edema are minimal, resolve within hours, with the patients able to return to normal daily activities immediately. The drawback is that it induces dermal changes only, with limited benefit for those who have both epidermal and dermal changes secondary to photoaging. The improvement is mild and nonspecific, with multiple treatments required to provide minimal incremental improvement. Treatment Options Pulsed-Dye Laser Using the principles of selective photothermolysis, the main chromophore in vascular lesions is oxyhemoglobin. Hemoglobin has absorption peaks at 418, 542, and 577 nm for oxy-, deoxy-, and methemoglobin, respectively. The strongest peak is at 418 nm (blue), but strong absorption by melanin and its limited penetration depth preclude the use of this wavelength. Argon laser (blue-green light 488 and 514 nm) is preferentially absorbed by oxyhemoglobin in the ectatic dermal vessels, but the long exposure time means heat can diffuse and cause injury to surrounding structures. Clinically, this produces a high incidence of scarring, atrophy, and hypopigmentation (Kauvar and Hruza, 2005). Pulsed dye laser has a wavelength of 577 or 585 nm, providing increased depth of clearance. The treatment produces intravascular thrombosis without epidermal or dermal damage. The exposure time or pulse duration must be chosen to match the diameter of the blood vessel being treated. Fractional Resurfacing Fractional photothermolysis is the latest technology in laser skin resurfacing. The concept behind this approach is to thermally alter a fraction of the skin, leaving intervening areas of normal skin. The uninjured tissue that surrounds these columns then serves to repopulate the ablated columns by fibroblast activity and neocollagenesis as in ablative laser resurfacing. The advantages of fractional laser lie in the fact that it causes lower epidermal and dermal thermal damage. There is preservation of the overlying stratum corneum, with coagulation of dermal blood vessels. However, the improvement in rhytids and photodamage is not as significant as with ablative resurfacing, and multiple sessions spaced at 1- to 4-week intervals maybe needed. With increasing age, the lesions grow with the child, and change their color from pink to purple. Immediate skin whitening this occurs as a consequence of epidermal damage due to overly aggressive laser parameters or poor skin-cooling techniques. When graying or whitening occurs, the skin should be cooled immediately, with topical antibiotic ointment used to prevent crusting. Judicious use of sunscreen and active skin-cooling techniques can decrease the incidence of hyperpigmentation. Hypopigmentation this indicates the use of aggressive laser parameters, improper skin cooling, or treatment of sun-tanned skin. Typically, they undergo a period of rapidly enlargement by cellular proliferation, followed by involution after the first year of life. As involution is not always complete, 50% of the patients may be left with telangiectasia, epidermal atrophy, and redundant fibrofatty tissue. There is some evidence to suggest that lesions that involute slowly are more likely to leave a residuum, whereas those that involute rapidly are likely to achieve complete involution. Treatment is normally carried out during the proliferative phase of superficial hemangioma, where the laser can minimize or even halt the superficial growth. It is also useful in treating complications such as ulcers associated with superficial hemangiomas. Laser therapy can also be used to treat residual telangiectasia and atrophic scarring, which can happen after involution of a hemangioma. Proliferating hemangioma can cause destruction to the papillary dermis, leading to atrophy. Interstitial laser therapy, originally developed for treating malignant tumors, has since been adapted for treating deep vascular lesions. The epidermis and papillary dermis can be protected from thermal damage by active skin cooling. On the face, telangiectasia develops secondary to genetic predisposition, chronic actinic damage, collagen vascular disorders, or vascular regulation disorder such as acne rosacea. It can affect both males and females and can be further subdivided into congenital and acquired, as well as localized and generalized forms. Other causes include metabolic conditions (porphyrias, internal malignancies), medications (minoxidil, cyclosporine, and phenytoin), and rarely tumors or malformations. Excess androgens can be endogenous (polycystic ovarian syndrome, congenital adrenal hyperplasia, or adrenal tumors) or from exogenous sources. The acceptable amount of facial and body hair is very dependent on culture and society. Excess hair on the face or certain body parts such as the forearms and legs can be distressing to some people. Treatment Options For telangiectasia in the lower extremities, sclerotherapy remains the gold standard. This approach has come to rival electrolysis in successful treatment of small hair-bearing areas. To be successful in treating unwanted facial hair with lasers, one must understand the mechanism of hair growth and how lasers work to target the hair follicle. The infundibulum is the hair follicle orifice on the skin surface to the entrance of the sebaceous duct. The isthmus is the short middle section from the entrance of the sebaceous duct to where the arrector pili muscle attaches. The inferior segment lies below the arrector pili muscle attachment and includes the hair bulb and dermal papilla. Melanin is produced by melanocytes within the bulb and transferred to matrix cells. The hair shaft is a cornified structure that protrudes above the surface of the skin. The phases of hair follicle are anagen (active synthesis), catagen (intermediary regression), telogen (rest), and exogen (shedding). During transition from anagen to catagen, there is cessation of melanin production and apoptosis of melanocytes, an important fact in laser hair removal. Although laser hair removal is based again on the principles of selective photothermolysis, the difference here is that the target chromophore (melanin) is different to the clinical target (hair matrix and the stem cells). These follicular stem cells are located in the outer root sheet, in an area called the bulge, near the attachment of the arrector pili muscle, approximately 1. Because the depth and pigmentation of the bulb are dependent on the stage of the hair cycle, it is possible that the cycle influences the susceptibility to laser injury. In the majority of patients, permanent hair reduction is achieved, with only one or two sessions being required annually for maintenance. However, there is a caveat: melanin in the epidermis presents a competing site for absorption of the light energy, causing epidermal injury. To destroy the nonpigmented stem cells, heat must diffuse from the pigmented area (hair) to the target. Thus, the clinical target is destroyed by heat diffusion rather than by direct heating, a theory different to selective thermolysis. Melanin absorbs photons of light, becomes activated, and then releases the extra energy in the form of heat to the target tissue, in this case the hair follicle. Color contrast between epidermis and the hair shaft (and bulb) are paramount in determining the optimal wavelength. For high contrast (fair skin and dark hair), shorter wavelengths such as the Ruby laser 694 nm and Alexandrite laser 755 nm can be used. Laser does not destroy hair in the resting stage of the cycle; therefore, repeated sessions are required for maximum treatment efficacy. Even in the best candidates with dark hair and fair skin, permanent hair removal is not possible. However, the bulb damage results in induction of catagen and telogen, with subsequent hair growth becoming 22. The common pigmentations seen include solar lentigos (age spots), ephelides (freckles), seborrheic keratoses, pigmented nevi, melasma, and birth marks. Care must be taken to evaluate these and differentiate them from a malignant process. The primary advantage of light-based treatments is that most hyperpigmented lesions can be removed completely in one or two treatments. Darker lesions and lesions in the deeper layer of the dermis would require more number of treatments. The localization of the pigment target is a key determinant for the selection of the appropriate therapeutic wavelength. In Q-switched lasers, energy is stored in the laser medium during its off interval. This enables the delivery of pulses with extremely high-peak power in nanoseconds, resulting in deeper dermal penetration. It is thought that laser helps to remove pigment within the scar by inducing capillary destruction. Two to six treatment sessions are necessary, with improvement seen in scar color, height, texture, and pliability. The future trend sees us marching toward less invasive technologies and using combining treatments. Fractional resurfacing is gaining more popularity due to its remarkably short recovery time. Research is also being carried out on combining fractional laser with photodynamic therapy, as the ablative columns created by fractional resurfacing facilitate the delivery of phototherapy agent.

When this is not available anxiety obsessive thoughts buy discount serpina line, the author prefers porcine collagen sheet because it is (a) easily available anxiety symptoms out of the blue cheap serpina 60 caps amex, (b) ready to use from the packet anxiety 38 weeks pregnant purchase serpina 60 caps, (c) the architecture is very close to human tissue anxiety symptoms 8 months purchase 60caps serpina with amex, (d) it is acellular and hence nonimmunogenic anxiety 4 weeks pregnant discount serpina online visa, (e) there is no additional donor site morbidity anxiety while pregnant buy generic serpina 60caps on line, and (f) it is resistant to collagenase enzymes. The upper lateral cartilages are then sutured back to the dorsal border of the septal cartilage. If the septal support is weak, the septal framework is reconstructed using conchal or rib cartilage graft in the usual manner. If the perforation is large and the edges of the perforation are not coming together without tension after mobilizing the flaps, a reduction rhinoplasty is performed to reduce the height of the dorsum. Sometimes, the internal nasal valve angle may appear narrow after the flaps are sutured and the nasal cavity may appear smaller as the inferior flaps have been lifted off the floor of the nasal cavity. A-perforation margins of right flap, B-perforation margins of left flap, C-perforation margins of septal cartilage. A-nasal floor, B-inferior mucosal flap raised form nasal floor, C-maxillary crest. A-inferior margin of septal perforation, B-superior margin of septal perforation, C-reverse cutting needle during vertical mattress suture. Nasal septum perforation repair using differently designed, bilateral intranasal flaps, with nonopposing suture lines. Endoscopic repair of nasal septal perforation with acellular human dermal allograft and an inferior turbinate flap. Radial forearm free flap for repair of a large nasal septal perforation: a report of a case in a child. Upper lateral cartilage inner mucoperichondrial flap technique for the repair of nasal septal perforation. Endonasal repair of septal perforations using a rotational mucosal flap and acellular dermal interposition graft. Repair of large nasal septal perforation with titanium membrane: report of 10 cases. Repairing large perforation of nasal septum with titanium membrane and local pedicled mucoperiosteum flap. Surgical management of septal perforation: an alternative to closure of perforation. Ottaviano F large nasal septal perforation repair by closed endoscopically assisted approach. Prosthetic rehabilitation of large nasal septal defect with an intranasal stent: a clinical report. Clinical utility of the inferior turbinate flaps in the reconstruction of the nasal septum and skull base. Endoscopic repairment of septal perforation with using a unilateral nasal mucosal flap. Pedicled local mucosal flap and autogenous graft for the closure of nasoseptal perforations. Temperature and humidity profile of the anterior nasal airways of patients with nasal septal perforation. Intranasal temperature and humidity profile in patients with nasal septal perforations before and after surgical closure. Endoscopic repair of nasal septal perforation with acellular dermal matrix and pedicled mucoperichondrial flap. Repair of a large septal perforation with a radial forearm free flap: brief report of a case. Nasal septal perforation repair using open septoplasty and unilateral bipedicled flaps. The results of septal button insertion in the management of nasal septal perforation. Numerical simulation of airflow patterns and air temperature distribution during inspiration in a nose model with septal perforation. Two piece nasal septum prosthesis for a large nasal septum perforation: a clinical report. Technical advances in the correction of septal perforation associated with closed rhinoplasty. Vascularized mucoperiosteal pull through flap for closure of large septal perforation: a new technique. Septal perforation repairing with combination of mucosal flaps and auricular interpositional grafts in revision patients. Experiences with a new surgical technique for closure of large perforations of the nasal septum in 55 patients. Repair of nasal septal perforation using a simple unilateral inferior meatal mucosal flap. Repair of nasal septal perforations using local mucosal flaps and a composite cartilage graft. Endoscope-assisted repair of large nasal septal perforation using a complex mucoperichondrial flap and free tissue graft. Make the patients aware of these asymmetries and the consequent limitations they impose on achieving desirable results preoperatively. Patients seeking aesthetic treatments to satisfy external motivations are poor candidates for aesthetic treatments. Even though these changes affect the whole body, they leave their mark on the face, which is the most exposed and noticed part of the body, more evidently than elsewhere in the body. The attitude of our society has changed over the last few decades, gradually accepting "youth" as the desired outlook. Social stigma and reluctance associated with aesthetic surgery has virtually disappeared and surgery to look younger has become much more acceptable. Management of aging has also evolved over the years by incorporating both surgical and nonsurgical options with equal footing. Aging of the face is known to affect every constituent part of the facial structure. The behavior of skin, fat, muscles, salivary glands, and the underlying bony skeleton with aging involve both anatomic and physiological dynamics. An aesthetic facial plastic surgeon has to address changes affecting each layer of the facial tissues to achieve a long-lasting and natural appearing result. Some of the important external influences contributing to skin aging include excessive exposure to sun or other sources of ultraviolet radiation, toxins such as smoking, hormonal changes (Leung and Harvey, 2002), and sleeping position (Sarifakioglu, et al. Damage to collagen and elastic fibers as well as the reduction in cross-links between collagen fibers causes reduced skin thickness along with low elasticity and skin recoil. Patients may present seeking correction of these or prominent melolabial fold and groove, marionette lines, or tear trough deformities. Aging is accompanied by appearance of age spots and an increase in the size of skin pores (Zimbler, Kokoska and Thomas, 2001). A loss of tone and bulk brings about gross variation in the profile that is accentuated by the appearance of rhytids. The activity of muscles of expression leads to the development of dynamic rhytids, which later becomes static rhytids. With age there is loss of subcutaneous fat, reduction in volume of fat pads, and redistribution of fat. Lipoatrophy contributes to a loss of the normal convex facial contour (Ascher, et al. In addition, it causes increased hollowness of periorbital area, brow, forehead, cheek, mental, perioral, and temple areas. The osseocutaneous ligaments holding the fat pads in their normal position become attenuated with age leading to soft tissue ptosis. Bony margins such as the orbital margins become prominent due to a change in fat orientation. All these changes lead to ill-defined jawline and cervicomental angle, prominent melolabial folds, and deep melolabial grooves. These changes lead to gradual change in shape of the young "V" shaped face to an inverted "V" configuration seen later in life. There may be retro-orbicularis oculi fat ptosis, laxity of orbicularis oculi muscle, and laxity of upper lid skin leading to brow ptosis and dermatochalasis. Pseudoherniation of orbital fat leads to prominent medial and central fat pads in the upper lid. Similarly eye bags may form in the low lid area due to pseudoherniation of medial, central, and lateral fat pads. Jowls are created by the downward pull and ptosis of facial portion of platysma (Zimbler, Kokoska and Thomas, 2001). Other contributing factors include ptosis of midface soft tissues, laxity of mandibular cutaneous and masseteric cutaneous ligaments, and loss of definition of chin and jawline. A reduction in height and overall size of the facial skeleton fails to support the overlying soft tissue envelope, giving the appearance of sagging and drooping. The floor of the orbits sinks resulting in lateral bowing of the lower lid and increased scleral show. The periorbital soft tissues of youth are shallow in a narrow orbit, described as being an unbroken convex line from the lower eyelid to the cheek (Hamra, 1996). With progressive aging, those dimensions become wider and deeper as skeletonization of the orbit occurs, beginning in the fourth decade. Resorption of mandible and maxilla along with loss of dentition causes a loss of support to the labial and mental tissues, producing an appearance of excess soft tissue and wrinkles. Position of the eyebrow steadily Chapter 20: Analysis of Aging Face descends from well above the supraorbital rim to a point at or below it. Loss of eyebrow volume is partly a result of bony absorption in the supraorbital region. The expectations of the patient are assessed and a picture of what is realistically achievable by the surgeon is conveyed to the patient. At the end of consultation, if the surgeon has any doubts about the expectations of the patient, he or she must be referred for a psychological assessment. Most patients requesting rhytidectomy are in their fourth to sixth decade and may have multiple medical problems, and taking various medications. History of smoking is significant as this is one of the commonest causes of postoperative skin necrosis. Uncontrolled diabetes mellitus and previous radiotherapy to the face can also affect tissue vascularity. Psychosocial history is important to identify clinically depressed patients who seek aesthetic surgery. It is essential to set up a photographic lab in the clinic for uniformity and ease of serial documentation. With the advent of increased international travel and medical tourism, the likelihood of a facial plastic surgeon encountering patients from different ethnic backgrounds is high. It is essential to know the interethnic variations in facial morphology in order to provide tailor-made surgical plans for the consulting patient. Forehead height, interocular distance, and nasal width show much variation among various ethnic groups. The least amount of variability is found in the ear height and upper, middle, and lower facial widths (Fang, Clapham and Chung, 2011). Delayed midface aging has been noticed among Asian and Afro-Caribbean races as well as delay in aging among Caucasians with prominent cheek bones (Hamra, 1996). The submandibular glands subluxate, causing swelling in the submandibular region, which sometimes persists even after a facelift procedure. Subluxation of the lacrimal glands adds fullness to the lateral part of the upper eyelids. As in any aesthetic surgery, patients considering surgical treatment of the aging face should be scrutinized thoroughly to identify the appropriate candidate. The surgeon must understand the aesthetic flaw that concerns the patient before offering a management plan. Motivation of the patient must be assessed, seeking to know if it is internal motivation or external motivation driving him/her toward the treatment. The essential questions to pose during the interview include the reason for contemplating treatment, the timing behind the decision, and any prior attempts at therapy. Not being satisfied with previous results and going for revision to correct minor or perceived anomalies may be due to a body dysmorphic disorder. Spending time listening to the patient and reaching an understanding on the expectations and the final outcomes, go a long way in avoiding patient and surgeon dissatisfaction, legal hassles, and expensive suits. It also helps the surgeon to educate the patient on normal anatomy, facial aesthetics, and enhancements that are possible given his or her unique facial characteristics. Facial asymmetry, such as hemifacial atrophy, may become more noticeable with age. Clinically visual inspection of the entire face, palpation to differentiate soft tissue from bony 210 Section 2: Facial Plastics defects, comparison of the dental midline with the facial midline, and dentomandibular variations are noted. It is important to note that the fat pad density around the cheek on the hemiatrophic side needs to be altered to allow for appropriate correction of the underlying mandibulomaxillary deformities (Zufferey, 2005; Cheong and Lo, 2011). Upper Third of Face the most prominent parameters to assess in the upper third of the face are the height of the forehead, position of the hairline, and glabellar and forehead rhytids. The vertical rhytids in the glabella are secondary to the corrugator supercilii over action, while the horizontal rhytids are due to procerus muscle activity. It is important to assess whether the rhytids are hyperfunctional lines noticeable only on muscle contraction (dynamic) or present at rest secondary to actinic changes (static). Palpation of the forehead lightly with patient alternately contracting and relaxing his/her forehead musculature helps delineate the frontalis distribution. Scars and pigmentary changes should be noted and the patient informed accordingly. The wrinkle units may also be measured by objective profilometric ratios for better standardization in reviewing the results (Hatzis, 2004).

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