One of the most difficult aspects in rhinoplasty is resolving and preventing functional compromise of the nasal valve area reliably. The nasal valves are crucial for the individual breathing competence of the nose. Structural and functional elements contribute to this complex system: the nasolabial angle, the configuration and stability of the alae, the function of the internal nasal valve, the anterior septum symmetrically separating the bilateral airways and giving structural and functional support to the alar cartilage complex and to their junction with the upper lateral cartilages, the scroll area. Subsequently, the open angle between septum and sidewalls is important for sufficient airflow as well as the position and function of the head of the turbinates. The clinical examination of these elements is described. Surgical techniques are more or less well known and demonstrated with patient examples and drawings: anterior septoplasty, reconstruction of tip and dorsum support by septal extension grafts and septal replacement, tip suspension and lateral crural sliding technique, spreader grafts and suture techniques, splay grafts, alar batten grafts, lateral crural extension grafts, and lateral alar suspension. The numerous literature is reviewed.
Fingolimod-related bradycardia is usually asymptomatic, reaches its nadir within 6 hours post-dose and recovers spontaneously. Here we report the case of a 30-year-old MS patient with vagotonia who developed symptomatic bradycardia with 33 beats per minute at nadir 39 hours after a single dose of fingolimod. Bradycardia was responsive to atropine, but returned within 2 hours. Overall, it took a week until the patient recovered. Extended monitoring is advised in patients with symptomatic bradycardia.
This article is focused on technical details for successfully reconstructing the nasal skin cover in parts or totally. Nasal reconstruction is based on the successful reconstruction of the inner lining and the nasal framework in three-layer defects. The details to be considered include planning the flap, subunit reconstruction and outline of margins, dealing with hair-bearing forehead skin, sequence of stages, intermediate debulking, details of pedicle dissection, brow reconstruction, forehead closure, forehead expansion, and complication management.
To our knowledge, our study is the largest series published to date and the first one to compare the prevalence of forehead flap necrosis in the 2- versus the 3-stage technique for paramedian forehead flaps. We found no evidence that the use of a 3-stage forehead flap lowers the prevalence of necrosis. Until larger multicenter studies or meta-analyses can be conducted, smaller yet well-conducted studies such as the present one provide critical data and represent an important contribution to the field. Future research should investigate whether the 3-stage technique produces better aesthetic results than the 2-stage technique.
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