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His head has to be positioned and draped in a way that allows turning of the head and provides access to both parotid areas arteria supraorbitalis buy cheap diovan, as well as visual control of perioral and periorbital muscles blood pressure 60 year old purchase diovan line. Good visualization is mandatory for safe exposure and reliable identification of the individual nerve branches, as well as microsurgical coaptation between the branches and the sural nerve graft later on. Thus, if required, the incision is extended superiorly across the hair line and inferiorly around the mandibular angle into the submandibular area. Despite a rather long incision line, the resulting scar is less conspicious than the vertical cheek incisions that are otherwise recommended for direct access to the nerve branches. When the anterior edge of the parotid gland is reached, dissection is continued along the fascia into the fat tissue where the branches leave the gland. Redundance of innervation is mandatory for those functions that are provided by the branches selected for coaptation with the cross-face nerve graft to avoid loss of function on the non-paretic side. Thin rubber ropes are used to mark these branches and the dissection is carried on in the subcutaneous plane anteriorly to the nasolabial crease. The pathway for the nerve graft to the opposite side of the face runs through a subcutaneous tunnel in the upper lip. This tunnel is dissected from bilateral curved incisions at the alar base and a contralateral preauricular incision. The latter incision is placed in a facelift-like fashion and the parotid area is exposed by extracapsular dissection after elevation of a facial skin flap. When the subcutaneous tunnel is finished, a thin and curved long forceps is inserted from the paretic to the non-paretic side. The proximal end of the nerve graft is grasped and guided through the tunnel to the paralyzed side. In this way, coaptation of the facial nerve branches is not inadvertently done to fascicles that run into side branches that have been divided or torn during harvest. The nerve is placed high in the upper lip immediately underneath the collumella and the alar base in order to avoid interference with the dissection during muscle transfer lateron. Nerve testing to prove redundance of nerve supply in the buccal and zygomatic region. Operation 245 bilateral curved incision around alar base for tunneling of the upper lip planned position of the commissure at rest is registered on the paralyzed side with a ruler. The extent of movement of the commissure during smile on the non-paralyzed side is also measured directly using the ruler and the direction of movement is marked on the skin with an arrow. These marks will have to be renewed after facial skin disinfection and draping immediately before the operation starts. The required length of the muscle graft can be estimated from the distance between the zygomatic bone prominence and the position of the modiolus at rest. It will not be possible to connect all fascicles of the nerve graft to the small facial nerve branches, but it is important to make sure that the fascicles of the facial nerve branches are securely connected to individual fascicles of the sural nerve graft. Suction drainage with one 10 gauge drain on either side and skin closure in layers end the operation. It is important to make sure that the drain is not located in the vicinity of the coapted nerve branches, to avoid inadvertent damage during drain removal. The facial skin on the paralyzed side is elevated from the perauricular incision, which is extended to the submandibular area. Subcutaenous dissection is carried on to the lower border of the mandible where the facial vessels are identified and exposed to be used as recipient vessels for the muscle graft. Elevation of the skin is continued medially until the oral commissure and the malar prominence are reached. The traction points will have to be modified slightly and the procedure repeated until a satisfactory smile shape results. Commonly, one or two more traction points are needed to produce a movement and shape that mimics that of the normal side. The additional points are commonly found slightly more medial to the commissure in the upper lip and below the central point in the lateral portion of the lower lip. In order to achieve a symmetric smile it is important pre-operatively to: define the desired position of the modiolus at rest with the patient sitting in an upright position; identify the vector and the extent of movement of the commissure during smiling.

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Calculi in the intraglandular part of the duct are usually located at the junction of the main duct and the first order tributaries 4 arteria aorta order diovan 80 mg with mastercard, the stone mimicking a stag horn calculus as seen in the renal pelvis (see also Chapter 5 blood pressure normal reading order cheapest diovan. The overwhelming majority present as slowgrowing painless masses within the parotid capsule. Of these tumours, 85 per cent will be benign, mostly pleomorphic salivary adenomas. When skin fixation, ulceration or fungation, facial nerve weakness or lymphatic metastasis is present, the tumour is clearly malignant. The majority of malignant parotid tumours are clinically indistinguishable from benign tumours. Rupture, either at biopsy or at the time of surgery, leads to widespread spillage of clumps of cells resulting in multiple recurrences which may be very difficult to control. If the tumour remains intrinsic within the parotid at the time of surgery, the exact histological diagnosis is unlikely to influence the definitive surgical procedure. However, if the tumour is obviously malignant and has extended beyond the anatomical boundaries of the parotid, open surgical biopsy is indicated. Fine needle aspiration biopsy has been widely advocated in the pre-operative diagnosis of parotid masses. Although it is safe, oral pathologists find it difficult to make a definitive diagnosis based on a few aspirated clumps of cells because the architecture of the tumour is lost and many parotid tumours are heterogenous in appearance and the aspirated sample may not be representative. The newer technique of fine needle core biopsy, particularly when performed using ultrasound guidance, offers hope of more accurate diagnosis. The post-stimulation emptying film is most valuable as it is a good measure of function and will often determine if surgical excision is indicated. Both techniques give a good anatomical image of the region, but neither can reliably demonstrate the plane of the facial nerve nor distinguish intrinsic malignant tumours from benign. This results in the formation of a funnellike opening of the duct on to the cheek and avoids subsequent stricture formation. Some anaesthetists are willing to moderately lower the blood pressure, which reduces arteriolar and capillary bleeding. The hair in front of the ear is either shaved or gathered into a tuft which can be taped down on to the skin of the cheek. The area is infiltrated with conventional dental local anaesthetic containing 2 per cent lignocaine hydrochloride and 1:80 000 epinephrine (adrenaline). The external auditory meatus is plugged with a small piece of vaseline-impregnated tulle to prevent blood entering the meatus and irritating the drum. The surface markings of the parotid duct are marked on the skin of the face at the start of the operation and can be readily transposed to the surface of the parotid fascia once the flap has been raised. A line is drawn from the lowest point of the alar cartilage to the angle of the mouth. This line is bisected and the midpoint is joined with a straight line to the most posterior point of the tragus. The incision then follows the pre-auricular attachment of the pinna skimming across the free edge of the tragus, following the attachment of the lobe posteriorly and then swinging gently down into a neck crease. The patient is positioned supine with moderate neck extension and the head turned away from the operative side. This variation results in a less visible scar, but surgical access to the parotid region is slightly more difficult. The branch of the facial nerve supplying the upper lip runs parallel with the duct either on its surface or a few millimetres superior to the duct. At the superior and anterior margins of the parotid gland, great care must be taken not to damage branches of the facial nerve which in these areas become very superficial. The flap is held forwards by suturing the flap to the head drapes with mattress sutures. Identification of the parotid duct the duct is identified where it emerges from the anterior border of the parotid.

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The accuracy of diagnosis increases with gestational age arrhythmia atrial tachycardia diovan 40mg without prescription, and it depends on the experience of the sonographer arteria pudenda interna discount 80 mg diovan with visa, equipment, the position of the fetus, and the amount of amniotic fluid. A, Schematic drawing of a sagittal section of the caudal region of an 8-week female embryo. C, Similar section at a more caudal level illustrating fusion of the paramesonephric ducts. D, Similar section showing the uterovaginal primordium, broad ligament, and pouches in the pelvic cavity. Development of Male External Genitalia Masculinization of the indifferent external genitalia is induced by dihydrotestosterone that is produced peripherally by 5-reductase conversion of testosterone from the testicular Leydig cells. As the primordial phallus enlarges and elongates to become the penis, the urogenital folds form the lateral walls of the urethral groove on the ventral surface of the penis. The urethral folds fuse with each other along the ventral surface of the penis to form the spongy urethra. The surface ectoderm fuses in the median plane of the penis, forming the penile raphe and enclosing the spongy urethra within the penis. At the tip of the glans penis, an ectodermal ingrowth forms a cellular ectodermal cord, which extends toward the root of the penis to meet the spongy urethra. This juncture completes the terminal part of the urethra and moves the external urethral orifice to the tip of the glans penis. During the 12th week, a circular ingrowth of ectoderm occurs at the periphery of the glans penis. The corpora cavernosa and corpus spongiosum develop from mesenchyme in the phallus. A and B, Diagrams illustrating appearance of the genitalia during the indifferent stage (fourth to seventh weeks). C, E, and G, Stages in the development of the male external genitalia at 9, 11, and 12 weeks, respectively. To the left are schematic transverse sections of the developing penis illustrating formation of the spongy urethra and scrotum. D, F, and H, Stages in the development of the female external genitalia at 9, 11, and 12 weeks, respectively. The clitoris develops in a similar way to the penis, except that the urogenital folds do not fuse, except posteriorly, where they join to form the frenulum of labia minora. The labioscrotal folds fuse posteriorly to form the posterior labial com missure and anteriorly to form the anterior labial com missure and the mons pubis. Most parts of the labioscrotal folds remain unfused and form two large folds of skin, the labia majora. The new classification avoids using the term "hermaphrodite" and instead uses the term "intersex. The external and internal genitalia are variable, owing to differing degrees of development. The phenotype may be male or female, but the external genitalia are always ambiguous. The external genitalia are female, but the vagina usually ends in a blind pouch and the uterus and uterine tubes are absent or rudimentary. At puberty, there is normal development of breasts and female characteristics, but menstruation does not occur and pubic hair is scanty or absent. The failure of masculinization results from a resistance to the action of testosterone at the cellular level in the genital tubercle and the labioscrotal and urogenital folds. There is no ovarian abnormality, but the excessive production of androgens by the fetal suprarenal glands causes masculiniza tion of the external genitalia, varying from enlargement of the clitoris to almost masculine genitalia. Commonly, clitoral hypertrophy, partial fusion of the labia majora, and a persistent urogenital sinus are noted. Hypo spadias is the most frequent anomaly involving the penis and is found in 1 in 125 male infants. In glanular hypospadias, the external urethral orifice is on the ventral surface of the glans penis.

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This flap is most commonly used for orbital-maxillary defects pulse pressure determinants discount diovan online visa, skull base reconstruction and glossectomy defects arteria plantaris medialis 80mg diovan with mastercard. Glossectomy defects reconstruction As a myocutaneous flap, it is particularly suitable for reconstructing total glossectomy defects. Fat volume is well preserved in a denervated free myocutaneous flap, but it loses muscular bulk with time. The upper vessel is the superior epigastric artery, one of the two terminal branches of the internal mammary artery. The rectus abdominis muscle is enclosed in the rectus sheath, which consists of an anterior and posterior lamina. The anterior sheath should never be harvested below the arcuate line where there is no posterior sheath. This is particularly important in the restoration of abdominal wall integrity after raising the rectus abdominis muscle or musculocutaneous flap. The commonly used inferior rectus abdominis flap is a musculocutaneous flap based on the deep inferior epigastric artery and vein and terminal musculocutaneous perforators. These vessels arise from the external iliac artery and vein and course superomedially to run along the deep lateral aspect of the muscle. The deep inferior epigastric vein is frequently found to be a system of paired venae comitantes running with the artery. Just proximal to the external iliac vein, this system often forms one dominant vein. The rectus abdominis myocutaneous flap is very suitable for the extensive defects resulting from radical maxillectomy with zagoma because of its large soft tissue volume. Skull base reconstruction the rectus abdominis flap is also commonly applied for the reconstruction of skull base defects in which a large volume of conformable, vascularized muscle is required to obliterate a skull base defect and bolster a dural closure. In these cases, the flap is harvested without a cutaneous paddle unless skin closure of a palatal defect is required. The operating field is prepped between lower rib arch, posterior axillary line and upper thigh. Depending on tissue requirements, the skin paddle can be designed vertically, totally overlying the rectus muscle, or obliquely, along an axis between the umbilicus and the tip of the scapula with much of the skin paddle lateral to the linea semilunaris. This latter orientation is possible because of an axial blood flow pattern from the portion of skin overlying the muscle in the periumbilical area parallel along this axis. When designed in this manner, the lateral aspect of the flap is much thinner than the portion overlying the muscle and can be useful when the defect requires soft tissue of varying thickness. Operative technique Flap design Draw linea alba, linea semilunaris, inguinal ligament, symphysis, costal margin and approximate position of arcuate line at level of anterior iliac spine. Landmarks are palpated, which include the ribcage, pubis and anterior superior iliac spine. The defect size is measured or estimated, and a flap that is slightly larger than the defect is designed. Use caution when working with the rectus muscle because musculocutaneous perforators may be violated. Placing tacking sutures from the skin to the anterior sheath can preserve the viability of the perforators. The inferior incision is placed above the arcuate line in order to facilitate closure without the use of mesh. Post-operative care 207 deep inferior epigastric artery and vein deep inferior epigastric artery and vein 3. The medial fascial incision is made in proximity to the linea alba, again taking care to preserve perforating vessels with dissection. As this dissection is carried inferiorly, the vascular pedicle will be identified in the area of the arcuate line. When the flap is ready for transfer, the vessels are clamped and the pedicle is divided. Proper and careful closure of the anterior sheath is important to prevent a hernia.

Diseases

• Heterotaxy, visceral, X-linked
• Juvenile gastrointestinal polyposis
• Frontometaphyseal dysplasia
• Neurocysticercosis
• Congenital amputation
• Epidermolysis bullosa simplex, Ogna type
• Meningoencephalocele-arthrogryposis-hypoplastic thumb
• Amelogenesis imperfecta

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B blood pressure chart low purchase diovan 80 mg amex, Transverse section of the embryo showing the position of the intermediate mesenchyme before lateral folding occurs blood pressure medication by class discount diovan 80mg online. C, Transverse section of the embryo after the commencement of folding, showing the nephrogenic cords. D, Transverse section of the embryo, showing the lateral folds meeting each other ventrally. The pronephroi soon degenerate; however, most parts of the pronephric ducts persist and are used by the second set of kidneys. Mesonephroi these large, elongated excretory organs appear late in the fourth week, caudal to the pronephroi. The mesonephric kidneys consist of approximately 40 glo meruli with mesonephric tubules. The mesonephroi create urine between weeks 6 to 10, until the permanent kidneys begin to function. The mesonephroi degenerate toward the end of the first trimester (3 months); however, their tubules become the efferent ductules of the testes. Metanephroi the metanephroi-primordia of the permanent kidneys- begin to develop early in the fifth week. The urine is excreted into the amniotic cavity and forms a portion of the amniotic fluid. The mesonephric tubules are pulled laterally; their normal position is shown in A. B, Transverse section of the embryo showing the nephrogenic cords from which the mesonephric tubules develop. C to F, Successive stages in the development of mesonephric tubules between the 5th and 11th weeks. The expanded medial end of the mesonephric tubule is invaginated by blood vessels to form a glomerular capsule. A, Lateral view of a 5-week embryo showing the ureteric bud, the primordium of the metanephros. B to E, Successive stages in the development of the ureteric bud (fifth to eighth weeks). Observe the development of the kidney: ureter, renal pelvis, calices, and collecting tubules. The ureteric bud is the primordium of the ureter, renal pelvis, calices (subdivisions of the renal pelvis), and collecting tubules. The elongating bud penetrates the metanephrogenic blastema-a mass of cells derived from the nephrogenic cord-that forms the nephrons. The stalk of the ureteric bud becomes the ureter, and the cranial part of the diverticulum undergoes repetitive branching. The straight collecting tubules undergo repeated branching, forming successive generations of collecting tubules. The first four generations of tubules enlarge and coalesce to form the major calices. The end of each arched collecting tubule induces clusters of mesenchymal cells in the metanephrogenic blastema to form small metanephric vesicles. The renal corpuscle (glomerulus and its capsule) and its proximal convoluted tubule, the nephron loop (Henle loop), and the distal convoluted tubule constitute a nephron. Branching of the metanephric diverticulum depends on an inductive signal from the metanephric mesoderm- differentiation of the nephrons depends on induction by the collecting tubules. The lobulation usually disappears during infancy as the nephrons increase in size. Nephron formation is complete by approximately week 36-each kidney contains approxi mately 2 million nephrons. Positional Changes of Kidneys the developing metanephric kidneys lie close to each 11 other in the pelvis. As the abdomen and pelvis grow, the kidneys gradually relocate to the abdomen and move farther apart. B and C, Note that the metanephric tubules, the primordia of the nephrons, become connect with the collecting tubules to form uriniferous tubules. D, Observe that nephrons are derived from the metanephric blastema and the collecting tubules are derived from the ureteric bud.

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This should be assessed promptly in the primary survey of the trauma Repair of lacerations Uncomplicated lacerations in cooperative adults and older children are usually treated well and promptly under local analgesia heart attack lyrics demi cheap diovan 160mg visa. The use of general anaesthesia may be necessary for complex lacerations heart attack songs videos buy discount diovan 80 mg online, particularly where there is skin loss, or simple lacerations in young uncooperative children. The wound should first be carefully examined to enable the removal of foreign bodies (soft tissue radiographs may help to locate radio-opaque material). Tissue with poor viability may require clean excision, but a most conservative approach must be taken in the facial region, where every effort should be made to conserve soft tissue. Dirt should be thoroughly removed from wounds to prevent skin tattooing and a sterile nail brush should be used with dilute chlorhexidine solution to thoroughly remove any such debris, followed by copious irrigation with sterile normal saline. Haemostasis should be obtained by electrocoagulation for small vessel bleeds and ties used for bleeds from larger vessels. The cleansed wound is first loosely assembled, in order that an assessment of any tissue loss can be made. If the wound can be brought together with only moderate tension after wide undermining of the adjacent tissue if necessary, then primary closure should be carried out. If an aesthetic and functional primary closure is not possible, consideration of grafting procedures or flap development should be considered, and this is likely to be scheduled as a further elective procedure. This may involve the use of split or fullthickness skin grafts, local rotation flaps, distant pedicled flaps or free flaps with microvascular anastomosis. In these instances, temporary closure of a wound will reduce the possibility of infection or haemorrhage, while arrangements for definitive treatment are made. Maxillofacial fractures 449 patient, and can be rectified either by attempting to draw the posteriorly impacted bony complex forward by finger pressure around the hard palate and tuberosities, or by prompt tracheostomy. Fractures of the middle third of the facial skeleton should be considered as a combination of the major lamella displacements described by Le Fort, and of damage to the specialized bony complexes which we recognize as the dentoalveolar, midmaxillary, malar, nasal and orbital complexes. Fractures at more than one Le Fort level or at different levels on separate sides are common. Mandibular fractures are notated by site, as condylar, ramus, angle, body or parasymphaseal fractures. The combination of parasymphaseal and angle fracture occurs most commonly, and it is wise always to look for more than one mandibular fracture. Fractures of the maxilla and mandible occur in numerous combinations, often with comminution and, whilst rarely compound in the maxilla, are invariably so in the mandible, along the roots of the teeth into the mouth. Circumorbital and subjunctival ecchymosis may be present, with limitation of eye movements where there has been muscle trapping, often the inferior rectus in fractures of the floor of the orbit. A step defect is usually palpable in the inferior rim of the orbit and there is frequently numbness over the distribution of the inferior orbital nerve ipsilaterally. There may be diplopia, often owing to oedema or displacement of the orbital complex, but sometimes owing to detachment of suspensory ligaments of the globe. The globe should be examined by an ophthalmologist to rule out internal derangement. Malar complex fractures and those of the orbit are frequently associated with subconjunctival Assessment A clinical assessment for fractures of the facial skeleton is usually best carried out systematically from above downwards, starting with a careful examination and palpation of the cranium, gently probing through any lacerations, where present, for underlying bony damage. Next, the orbital rims are examined with the nasal skeleton, malar bodies and zygomatic arches. Tenderness and step deformities or swellings will usually betray underlying fractures. When the facial skeleton from the front has been viewed, a further examination should be made by the physician standing behind the seated patient: looking down on the facial skeleton from above can be revealing. It is always wise to question the patient with regard to previous nasal fractures that can otherwise be deceptive. The dentition and alveolus must be carefully checked for fractured or missing teeth and radiographs of lacerated soft tissue or chest and abdominal films used to reveal the presence of avulsed teeth or dental prostheses. The mandible is carefully examined by palpation, feeling for step defects; intraorally the occlusion is examined for discontinuity. The patient will be able to perceive any small disruption in the occlusion accurately.

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A formed thyroglossal duct is rarely seen and an arbitrary zone of tissue is removed blood pressure chart normal blood pressure range diovan 160mg cheap. This dissection can be facilitated by placing the finger of the surgeon or assistant into the vallecula to press the base of tongue forward pulse pressure change during exercise generic diovan 80 mg without a prescription. If a perforation into the pharynx occurs, it is closed in a watertight fashion with a resorbable suture. Closure the tongue musculature then closed upon itself with a resorbable suture after haemostasis has been achieved. Complications Recurrence of a thyroglossal duct cyst occurs at up to 3 per cent after the Sistrunk operation. Surgery for recurrent thyroglossal ducts cysts should involve resection of a wide zone of tissue throughout the path of the thryoglossal duct. Like thyroidectomy, an arterial-fed haematoma has the potential to produce emergent airway obstruction. Resection of the central cylinder of tongue tissue may damage the hypoglossal, and less likely, the lingual nerves. Sublingual and laryngotracheal, or intratracheal ectopic thyroid, are exceedingly rare with only ten reported cases of laryngeal thyroglossal tissue. Other sites of ectopic thyroid that are rarely encountered include mediastinal locations, such as the heart and lungs, the pancreas and the adrenal glands. Congenital lingual thyroid may be associated with otherwise normal descent of the gland into the neck or may be the only functioning thyroid present. In neonates, this can present as an airway-obstructing mass in the base of the tongue. Treatment for this condition is based on the level of symptoms with surgical reduction or excision of the base of tongue mass reserved for relief of obstruction. Lingual thyroid tissue can present in the neonate or infant with swallowing difficulties or partial airway obstruction. Smaller deposits of lingual thyroid tissue may be identified later in life as an incidental finding on routine examination. The need for resection of lingual thyroid is based upon symptoms and not on the mere presence of the mass. Malignancy in lingual thyroid has been reported with follicular carcinoma identified among two of 12 cases in the series of Kamat et al. This can be done transorally in edentulous patients and among those that can open the mouth widely. Through either approach, the glossotomy is performed with electrocautery through the midline raphe of the tongue, Procedure Lingual thyroid tissue in young children as well as in some older patients can be removed via a transoral route. A bite block is positioned to maintain an open mouth position and bilateral traction sutures of 2/0 silk are placed on the dorsal surface of the tongue, at the junction of the anterior and posterior halves of the oral tongue. The lingual thyroid is grasped with a DeBakey or other forceps and electrocautery is used to resect the ectopic thyroid tissue. The resulting defect is either closed with resorbable suture or left open to heal by granulation. The ventral surface of the tongue is divided between the sublingual plica, taking care to preserve the submandibular duct orifices. The lingual thyroid is excised and the tongue is closed utilizing multiple deep resorbable sutures, as well as standard mucosal closure. The actual defect of the lingual thyroid may be left to granulate if it cannot be closed. Complications Post-operative haemorrhage usually requires a return to surgery for control. Top tips Thyroidectomy It is advisable to document normal vocal cord mobility prior to thyroidectomy, either via direct fibre-optic examination or by indirect mirror laryngoscopy. Avoid violation of the thyroid capsule during dissection, as this will encourage bleeding. Access to a bulky goitre or large thyroid tumour may require high, horizontal division of the strap muscles. Removal of a bulky goitre or tumour can be facilitated by initial removal of the isthmus.

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The lateral part of the marginal incision is placed along the caudal margin of the lateral crura pulse pressure under 25 order diovan 160mg without a prescription. The back of the scalpel is used to palpate the edge of the cartilage to identify the correct position for the lateral incision hypertensive encephalopathy purchase discount diovan on-line. Then the hook is placed between the lateral portion of the marginal incision and the columellar portion, with simultaneous traction on the nasal skin with a single hook to make the connecting incision, respecting the facet or soft triangle of Converse, which should be preserved; incisions too close to the nostril rim can result in alar notching or distortion of the facet. By using three-point Alar base surgery Aesthetic narrowing of the nasal skeleton and tip must be balanced by concomitant reduction of the alar base. Alar lobule excision at the nostril floor and sill results in reduction of flare as well as in slight reduction of the alar bulk, and provides medial alar repositioning. In reduction of overprojecting tips, alar wedge excisions reduce the overall length of the alar sidewalls. Reduction of the volume, curve and flare will result, the extent of each dependent on the angulation of the excision. Flap elevation is carried laterally to the point of attachement of the lateral crura with soft tissue. At the rhinion, the remainder of the dissection of the nasal bones is performed subperiosteally, using sharp dissection. For septoplasty and cartilage harvesting for later grafting a hemitransfixion incision is used. In difficult septoplasties or in asymmetric tips, the interdomal ligament is cut and the medial crura separated. Incisions are made in the cartilaginous septum at 1 cm parallel to the caudal septum and dorsum, leaving in an inverted L-shape support, allowing the maximal amount of cartilage to be harvested. Routinely, the author prefers to address the osseocartilaginous vault before the tip and lower third with alar base correction as the last step. Under direct visualization, reduction of the cartilagenous dorsum is performed with a No. Sharpened Rubin osteotomes are used to resect the bony hump to nasion in continuity with the cartilaginous resection. In the glabellar area, the hump is sharply separated from the attaching soft tissues, before being removed and preserved together with the harvested cartilage in a physiologic solution. Irregularities are removed with sharp resection to avoid disruption of the osseous-cartilagenous junction. Closure of the open roof deformity is through the use of osteotomies, under direct vision using a 3 mm microosteotome, creating a laterally fading line for controlled back-fracture created by the lateral osteotomies. If these are especially thick then triangular wedges are removed along the medial osteotomy. No infiltration, stab incision or periosteal raising is carried out to prepare the lateral osteotomies. The osteotome is initially engaged in a plane perpendicular to the pyriform aperture. Once a triangle of bone is preserved at Websters area, the osteotome is directed up the lateral bony wall under finger control. Just below the level of the medial canthus, the cut is directed more anteriorly to meet the medial osteotomy when required. The back fracture is completed with rotation of the osteotome and finger pressure. The inward fractures can be performed with greater accuracy and precision transcutaneously at the lateral mid portion of the osteotomy and through the glabella if necessary with a 2 mm microosteotome and without stab incision. The mobility of the nasal bones can be palpated through the skin and controlled under direct vision.

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