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A virus buster discount zyvox 600 mg on line, the bilayer graft is harvested as one graft, leaving the mucosa attached to the septum. B, the contralateral septum must be preserved with no perforations to prevent a septal perforation. B, A chondromucosal graft has been sutured to the skin flap with quilting sutures. Care is taken to incise only the mucosa and the cartilage and to spare the mucosa on the contralateral side. The strip should include the nasal mucosa and the cartilage; it should not penetrate the nasal mucosa on the opposite side of the cartilage to avoid septal perforation. After the initial incision, the cartilage can be grasped and dissected free from the opposing nasal mucous membrane with a blunt dissector. B, A swivel blade scalpel is used to make the superior cut and to create the graft. D, the usual shape and consistency of nasal septal cartilage in a mucosal graft are shown. The cartilage is trimmed to approximately half of its original width and thickness. The graft is sutured into place with interrupted 4-0 chromic sutures; the surgeon must make certain that the mucosal side is in proper alignment. For milder cases, homologous tissue Chapter 4 · Periorbital Reconstructive Tissue Grafts 119 such as Enduragen or alloplastic materials may be considered. For more severe scarring and contracture, we recommend the use of autologous material. B, Rib cartilage that has been shaved and fanned is used as a spacer for the left lower lid to correct retraction. C, the same patient is seen after the placement of the rib cartilage graft and the repair of left lower lid, with a skin graft applied to the upper lid. A 4 cm incision is made in the inframammary crease in a female or just under the origin of the pectoralis major overlying the rib cartilage in a male. The overlying fascia and muscle are divided with electrocautery to expose the perichondrium of the rib cage. Bookend flaps are made through the perichondrium to expose the cartilage and to facilitate closure. Care should be taken to preserve the bony cartilaginous junction by making the incision medial to this point. A scalpel can be used to make a tangential excision approximately 1 cm thick and 2 cm in vertical height. If the entire thickness is desired, a thoracic rib cartilage periosteal elevator can be used to isolate the rib from the underlying perichondrium.
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Preseptal-Preperiosteal Undermining of the Skin-Muscle Flap To extend the lower lid blepharoplasty antibiotic lupin 500 zyvox 600 mg buy, the skin-muscle flap over the malar area is undermined, releasing the arcus marginalis. The orbitomalar ligament-the osteocutaneous ligament stretching from the orbital rim to the malar skin-is divided at its insertions to the periosteum, slightly inferior to the inferior orbital rim. Greater mobility of the orbicularis oculi muscle is achieved by releasing the orbitomalar ligament, a procedure that will make future repositioning easier. The orbital fat is normally separated by two thin layers: the septum and the orbitomalar ligament. B, Additional preperiosteal undermining is performed in the area for fat transposition over the tear trough. When performing this step, it is helpful to have the protective contact lens in place. Between the central and nasal fat pockets, care is required to prevent damaging the inferior oblique muscle. The fat is grasped with forceps, brought outward, and excised with the Bovie coagulation needle. Chapter 8 · Lower Lid Blepharoplasty 297 the lateral fat pocket is removed, if necessary, after the lateral canthoplasty procedure has been completed, because its tension will cause additional lateral fat herniation. The lateral fat is grasped with Adson forceps, then trimmed with a Bovie cutting needle; the edges are cauterized. The arcuate extension of the Lockwood ligament laterally is preserved to prevent recurrence of the lateral fat prolapse. However, simulating fat removal with retropulsion of the fat superomedial to the tear trough clearly defines the anatomy of the defect. The defect can be defined as a depression within the border of the inferior medial orbicularis oculi muscle medial to the levator alaeque nasi and the levator labii superioris. The orbitomalar ligament is initially released, and the preperiosteal dissection is carried along the semicircle of the infraorbital rim, from the lateral canthus to the level of the infraorbital nerve. Additional dissection in the tear trough area is required to transpose the central and medial fat pads into the nasojugal groove. An insulated Desmarres retractor is used to expose the medial orbital rim to the level of the anterior nasolacrimal crest. Dissection continues for 5 mm to the muscular triangle of the tear trough deformity, where a pocket for fat transposition will be created. The ligamentous attachments of the anterior lamella overlying the tear trough are released. Dissection should be limited to prevent injury to the buccal branch of the facial nerve, which is medial to the tear trough at the level of the angular artery. The levator labii superioris alaeque nasi muscle is stimulated with electrocautery.
Chapter 8 · Lower Lid Blepharoplasty 287 Canthoplasty Technique In patients for whom canthopexy does not reduce the laxity or the ability to distract the lower lid intraoperatively antibiotics for sinus infection webmd zyvox 600 mg buy mastercard, canthoplasty is required. B, A method of suture insertion in the edge of the lid for fixation to the orbital rim, showing a closeup of the realigned lateral canthal angle. The gray line of the upper and lower lid and the lash margins must be properly aligned to prevent blunting or webbing of the lateral canthal angle. D, A lateral cantholysis of the lateral retinaculum is performed to free the lower lid for elevation for canthoplasty. The amount of lower lid resection needed is determined by placing the edge of the lower lid against the lateral periosteum and assessing redundancy. The lid is shortened by full-thickness excision of the redundant lateral lower lid. This suture is then placed in the inner lateral orbital periosteum at the horizontal pupillary line. The margins of the upper and lower lids at the canthus are precisely aligned with a 5-0 or 6-0 buried Vicryl suture to ensure symmetrical lid alignment at the gray line and of the lashes. This method ensures that the relationship of the upper and lower lid re-creates the "vest-over-pants" anatomy. The lateral scleral triangle is larger and more pointed than the nasal scleral triangle and varies much more with changes in lateral canthal anchoring; these changes are more effective in the overall context of the lower lid position and eye prominence. A prominent or a deep-set eye-particularly when associated with a positive or negative vector, such as a recessed or prominent malar area-can also influence eye fissure shape, depending on the final position of the canthal anchoring. In patients with a recessed malar area, or a negative vector, the tendency is toward a downward clotheslining of the lower lid postoperatively; in patients with a prominent malar area, or a positive vector, the tendency is toward an upward clotheslining of the lower lid postoperatively. The standard positioning of canthal anchoring is at the center of the pupil and the position is inside the orbital rim. B, With a deep-set eye, the lower lid will clothesline upward, an effect that occurs with superior placement of canthal anchoring at the superior pupil. Altering the point of canthal anchoring to a more downward and inward fixation point inside the orbital rim at the level of the inferior pupil will prevent this problem. C, With a prominent eye, the lower lid will clothesline downward with placement at the standard position and with overtightening. Canthal anchoring placed at the superior pupil with avoidance of overtightening the suture, even leaving an "air knot," can prevent this in mild cases. Each is chosen according to eye prominence to produce a normal-shaped eye fissure.
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Angar, 47 years: We commonly undermine the fornix conjunctiva to cover exposed spacer material when wider spacers are used.
Delazar, 61 years: A cutting Bovie needle or a Beaver blade is used to cut parallel incisions opposite the ones in the lacrimal sac.
Redge, 40 years: With this tension applied, the grayish capsulopalpebral fascia is dissected from the underlying conjunctiva, starting inferior to the tarsal plate and inferior arcade.
Connor, 21 years: A and B, Unusual appearance of chordoma with tumor cells showing extensively vacuolated cytoplasms resembling fat.
Ningal, 56 years: This type of contouring can be accomplished with a single strand of suspensory material configured in a pentagonal manner.
Charles, 50 years: B, the enucleated eye with traction sutures and the desired margin of the optic nerve, particularly for a malignancy of the eye.
Deckard, 48 years: An endoscopic forceps can be used as an insulated cautery to cauterize the muscle before removal and also to achieve hemostasis if bleeding occurs.
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