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Most postoperative medications are prescribed according to a standard protocol (see example protocol in table 9 cheap viagra jelly uk erectile dysfunction pump in india. Cardiac surgical patients are commonly on numerous medica- tions some of which must be continued into the postoperative period and others which should be stopped generic viagra jelly 100 mg overnight delivery erectile dysfunction with normal testosterone levels. Antibiotic prophylaxis • Prophylaxis against surgical site infection is routinely continued into the postoperative period. Stress ulcer prophylaxis • Prophylaxis is essential in patients mechanically ventilated for >48 hours. Electrolytes • hypokalaemia and hypomagnesaemia are common in the postoperative period and put patients at i risk of arrhythmia. Glucose control • hyperglycaemia is common after cardiac surgery and associated with i mortality and complications in patients both with and without diabetes mellitus. Perioperative blood glucose control after cardiac surgery reduces mortality: • Caution: avoid hypoglycaemia. Arrhythmia (atrial fbrillation) prophylaxis • early postoperative administration of β-blockers in patients without contraindications is standard therapy to reduce the incidence and/or clinical sequelae of atrial fbrillation. Prevention of coronary graft spasm • radial artery grafts are particularly prone to spasm therefore vasodilators are commonly used: • e. Subcutaneous apomorphine or topical preparations of rotigotine (Neupro®) are available for patients in whom the oral route is contraindicated. Myasthenia gravis • Careful management of anticholinesterase medication is essential to avoid myasthenic crisis and respiratory failure postoperatively. Drugs for respiratory diseases Inhaled bronchodilators and steroids should be continued in the intubated patient via nebulizer or metered dose inhaler attachment to the ventilator circuit. Corticosteroids Patients taking chronic glucocorticoid therapy require perioperative supple- mentation due to suppression of the hypothalamic–pituitary–adrenal axis. Restarting preoperative medications Cardiovascular drugs β-blockers, aCe inhibitors, and statins should be recommenced in patients with ischaemic heart disease (see b Secondary prevention, p. Drugs for psychiatric disorders Can generally be restarted on postoperative day . Most human errors are not the result of poor technical knowledge or ability but are due instead to ‘non-technical’ aspects of performance such as communication. Within a multidisciplinary team and between diferent tiers of a clinical team efective communication can be problematic, with difering commu- nication styles complicated by hierarchical, ethnic, and gender infuences. Within an intensive care environment a single patient’s care may be ‘handed over’ within the multidisciplinary team over 5 times within any single 24-hour period. Missing or incomplete information during admission or subsequent hand- over is a common cause of error and patient harm. During the handover of information distractions or interruptions increase cognitive demands leading to inefciency and an i risk of error. Good situation awareness and efective role and task allocation start with efective communication. Written and verbal communication can work hand in hand to allow such communication and care planning. By taking a short period of time to think about how we all handover information at each stage of the patient’s journey we have the potential to ensure that the patient’s safety is paramount and optimal and timely care is delivered. It consists of: • the mitral valve, forming the inlet to the ventricle • the conical apical portion, containing fne trabeculations • the outfow tract leading to the aortic valve. Myocardial contractility is spiral, producing radial contractility and longitudi- nal shortening. In addition, regional wall-motion abnormalities can be defned and culprit vessels identifed. In addition, identifcation and management of reversible causes including myocardial ischaemia are described. Contractility: pharmacological support Chapter 27 on circulatory support details the pharmacological actions of diferent classes of inotropes together with their indications. Contractility: mechanical support Chapter 27 on circulatory support goes on to describe the indications and use of mechanical and extracorporeal life support. It consists of: • the sinus (infow) below the tricuspid valve • the free wall (providing contractility) which is thin walled • the infundibulum (outfow) leading to the pulmonary valve. Pulmonary artery foatation catheter • the only way to directly measure right heart pressures. Optimize preload • If uncertain, 00mL crystalloid fuid challenge and assess response. Reduce afterload • pulmonary vasodilators such as inhaled nitric oxide, or nebulized iloprost. Contractility: pharmacological support there is no evidence for the best inotrope regimen to use in right heart fail- ure. Key point an exit strategy should always be identifed before embarking on any form of mechanical support. Afterload reduction Pulmonary hypertension • Mean pulmonary artery pressure ≥25mmHg at rest or >30mmHg on exercise. Reversible causes Reversible causes should be identifed and treated once initial management is underway. Caution not to overlook posterior changes (St depression in V–3 with dominant R-wave pattern). Pulmonary hypertension—acquired, mitral valve disease • Severe mitral stenosis (valve area <. Supportive measures may be required in the immediate postoperative phase after mitral valve replacement. Pulmonary hypertension—acquired, thromboembolic disease • although rare in the immediate postoperative period in cardiac surgery, pulmonary embolism (pe) may be seen in long-term patients and those admitted for non-surgical care. If there are no features of shock (tachycardia or hypotension) then anticoagulation with heparin is sufcient. If the patient is haemodynamically compromised by pe then the clot should be dispersed. Some may present because of rheumatic heart disease and may have other valve involvement. In a young person there should be a high index of suspicion of a con- genitally abnormal valve, e. Natural history there is a long latent period in the development of aS where patients remain asymptomatic and the risk of sudden death is low. In addition, the hypertrophied myocardium requires a high perfusion pressure to maintain endocardial perfusion and may require vasopressors. Subaortic obstruction Subaortic stenosis may present as a fxed or dynamic obstruction below the level of the aortic valve. Subaortic obstruction occurs in the form with high septal hypertrophy or a sigmoid septum. Aortic regurgitation—chronic Aetiology Chronic aortic regurgitation (aR) most commonly presents in the elderly as a degenerative disease. Aortic regurgitation—acute Aetiology acute aR is most commonly associated with bacterial endocarditis and aor- tic dissection. Natural history Death due to pulmonary oedema, ventricular arrhythmias, electromechanical dissociation, or circulatory collapse is common in acute severe aR, even with intensive medical management.

Immediate management includes restricting oral intake proven viagra jelly 100 mg impotence of organic origin, monitoring fluid and electrolyte balance discount viagra jelly online master card erectile dysfunction reversible, and pain control. The pancreatitis sometimes may be so severe as to produce hemorrhage into the pancreas or pulmonary injury. Be able to describe the anatomy of the pancreas and its relations to the duode- num and spleen 2. The gland is anatomically divided into head, neck, body, and tail regions and is diagonally placed across the posterior abdominal wall (Figure 22-1). The head of the pancreas lies within the curve of the second and third parts of the duodenum, and its infe- rior portion forms a hooklike uncinate process that lies posterior to the superior mesenteric vessels. The neck lies at the L1 vertebral level, with the pylorus of the stomach immediately superior. The body of the gland passes superiorly to the left, with the tortuous splenic artery along its superior border. The short tail of the pancreas lies within the splenorenal ligament and may contact the hilum of the spleen (Table 22-1). The exocrine pancreas is drained by a main pancreatic duct, which begins in the tail and passes to the right through the body, neck, and inferior portion of the head. The duct pierces the wall of the second part of the duodenum in close association with the common bile duct, with which it typically unites to form the hepatopan- creatic ampulla, which, in turn, opens through the major duodenal papilla. Several smooth muscle sphincters surround these ducts, which may enter the duodenum separately at the papilla. The superior portion of the head is drained by an acces- sory pancreatic duct that usually joins the main duct but may drain separately into the duodenum at the minor duodenal papilla. The head of the pancreas receives Common hepatic artery Celiac artery Short gastric arteries and Left gastric artery veins Portal vein Gastroduodenal artery Splenic artery Spleen Superior duodenal and vein artery Posterosuperior pan- creaticoduodenal artery Left gastroepiploic Anterosuperior pan- artery and creaticoduodenal vein artery Pancreas Transverse Duodenum pancreatic artery Inferior mesenteric vein Jejunum Right gastroepiploic Middle colic artery and vein artery and vein Gastroduodenal vein Right colic artery and vein figure 22-1. The duodenum is the first, shortest, widest, and least mobile portion of the small intestine. It is anatomically subdivided into four parts, and its C-shaped configu- ration is intimately related to the pancreas. The superior or first part is the pos- teriorly directed continuation of the pylorus of the stomach, and it lies at the L1 vertebral level. Its first portion or ampulla (clinically, the duodenal cap) is intra- peritoneal, within the hepatoduodenal ligament. The descending or second part is retroperitoneal, lies opposite L1 through L3, and receives the pancreatic and bile ducts (hepatopancreatic ampulla) at the major duo- denal papilla on its posteromedial wall. The horizontal or third part is also retroperi- toneal, passes to the left, and crosses L3. The ascending or fourth part lies on the left side of the L3 and L2 vertebrae and is retroperitoneal, except perhaps for the last few millimeters as it becomes continuous with the jejunum at the duodenojejunal junction, indicated anatomically by the suspensory ligament of Treitz. The spleen is the largest lymph organ of the body and functions as if it were a lymph node for the circulatory system. It is intraperitoneal, suspended in the left upper quadrant by the gastrosplenic and splenorenal ligaments (subdivisions of the greater omentum). It has a convex diaphragmatic surface and concave hilum, where the ligaments attach. The splenic artery (a major branch of the celiac artery) enters, and the splenic vein exits the spleen through the hilum and is within the splenorenal liga- ment, in addition to the tail of the pancreas. You note an artery and vein passing anteriorly to the uncinate process of the pancreas and the third portion of the duodenum. He is brought into the emergency room and is noted to have a hematoma involving the pancreas. The portal vein is formed by the union of the superior mesenteric and splenic veins posterior to the neck of the pancreas. The splenic artery, the most tortuous artery of the body, is located along the superior border of the pancreas as it passes to the left toward the spleen. Abdominal and pelvic blunt-force trauma such as a motor vehicle accident is commonly associated with retroperitoneal hematoma, such as involving the pancreas. The pancreas is located in the retroperitoneal space, and hematomas are typically in the midline. For several months, he has noticed that his abdomen has been growing larger and that his skin has turned yellow. Cirrhosis results in severe fibrotic scarring of the liver, which decreases blood flow through the organ. Hypertension in the portal venous system is the result, with collateral venous flow, especially in organs having venous drainage by the portal and vena caval systems, such as the abdominal surface, and the esophagus. The spleen is frequently enlarged, and the ascites, fluid within the peritoneal cavity, is due to liver insufficiency. Death may ensue as a result of bleeding from esophageal varices or bacterial peritonitis of the ascitic fluid. The liver is covered with visceral peritoneum over most of its surface and is sus- pended by several mesenteric structures called ligaments. The falciform ligament (with the round ligament of the liver, the adult remnant of the umbilical vein, in its free margin) is reflected onto the anterior abdominal wall and divides the liver into apparent right and left anatomical lobes. As the falciform ligament passes onto the superior surface of the liver, the two layers of peritoneum diverge to the right and to the left, creating the anterior layers of the coronary ligaments. These pass to the right and to the left to the extremes of the superior liver surface, turn back on themselves (creating the triangular ligaments), and turn posteriorly to form the posterior layers of the coronary ligaments. In this manner, an area devoid of visceral peritoneum is created, the bare area of the liver. The posterior layers of the coro- nary ligaments converge to form the lesser omentum, which passes from the visceral surface of the liver to the lesser curvature of the stomach (hepatogastric ligament) and the first part of the duodenum (hepatoduodenal ligament). The liver is divided anatomically into four lobes by external landmarks and is delineated on the visceral surface by fissures and fossae, which form the letter H (see Figure 23-1). The left side of the H is formed by the fissure for the round ligament and the ligamentum venosum (adult remnant of the ductus venosus); the left lobe is to the left of this fissure. The crossbar of the H is the porta hepatis, through which the hepatic artery, portal vein, and nerves enter the liver and the bile ducts and lymphatics exit. Appendix fibrosa Inferior vena cava Esophageal impression Bare area of the liver Caudate lobe Coronary ligament Gastric impression Portal vein Suprarenal impression Hepatic artery Renal impression Porta hepatis Common hepatic duct Cystic duct Edge of lesser omentum Duodenal impression Quadrate lobe Round ligament Colic impression Gallbladder figure 23-1. The left portal lobe is the left anatomical lobe, quadrate lobe, and the remainder of the caudate lobe. The portal lobes are supplied by lobar branches of the hepatic artery, portal vein, and bile ducts. Although lacking external landmarks, the portal lobes are further divided functionally into hepatic segments. The liver receives a dual blood supply; approximately 30 percent of the blood entering the organ is from the hepatic artery, and 70 percent is from the portal vein. The proper hepatic artery is a branch of the common hepatic artery, one of the three major branches of the celiac artery. As it approaches the liver, it divides into right and left hepatic branches that enter the liver and divide into lobar, seg- mental, and smaller branches. Eventually, blood reaches the arterioles in the portal areas at the periphery of the hepatic lobules and, after providing oxygen and nutri- ents to the parenchyma, drains into the hepatic sinusoids.

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All patients were reported to have an improvement in their subjective nasal valve obstruc- tion and a widening of the nasal valve discount viagra jelly online amex erectile dysfunction drugs in australia. The authors have also claimed that flap mobilization could create a mild cephalic alar rotation that could further improve the airflow cheap viagra jelly 100 mg visa impotence yoga poses. Suspension Sutures this case, they are dissected free from the surrounding soft tis- sues, cut just lateral to the dome, reversed, and sutured back to Suspension sutures are used to widen the nasal angle by sus- their beds again. A modification of this technique is to suture the ipsilateral, medial infraorbital rim. The suture is anchored they can be freed from the investing soft tissues and can be to the bone by a periosteal stitch or by a screw. The linear axis of the Lateral Crural Dissection and Repositioning pocket should be designed for maximum support of the lateral This method can be applied in two different ways. These grafts are usually obtained from the crura can be inwardly concave with a pinched appearance. To open the external valve and obtain a more natural tip shape, the lateral crus can be dissected free of the underlying skin, divided vertically near the dome, flipped over, and sutured to its bed again. They are placed into the pockets under the lateral crura and collapse or supra-alar pinching. In case of malpositioned been reported for the correction of both internal and external lateral crura, alar retraction, and severe cases of alar collapse, a nasal valve collapse. It was also noted that larger grafts could be used in patients with severe collapse or thicker skin. My preference is usually to use larger grafts Alar Battens placed in a tight pocket whose tail usually exceeds the piriform Alar batten grafts are curvilinear cartilage grafts that are placed aperture. Regardless of the approach, I also prefer suturing into a precise pocket at the point of maximal lateral wall them to the lateral crura for fixation. When these grafts are 209 Functional Nasal Surgery used for external valves, which is the case on many occasions, they are usually placed on and under the lateral half or two- thirds of the lateral crura. Porous polyethylene implants have been used as alar battens,32 but sometimes with a rather high extrusion rate. Four of these patients have undergone surgery for the treatment of a collapsed alar rim, and five more as a supportive measure against thick and sebaceous skin. Instead of cutting and turning in the medial two- thirds of the lateral crura, a partial linear cut was done along the horizontal axis of the lateral crus leaving a 7-mm caudal segment. By this method, it was aimed to support the lateral crus on all parts and to have a splinting effect throughout the remaining lateral crus. It really worked well in dealing with concave lateral crura when the lateral crura were thick and strong enough to counter opposing forces applied to each other obtained by turning in and suturing in a sandwich fashion. But when the lateral crura were weak, it solely acted as an additional support to the remaining cartilage. After the sixth case, I made one more modification to support both external and internal valves at the same time. After injecting lidocaine with 1:100,000 adrenaline under the lateral crus for hydro-dis- section, a pocket was created under the lateral crus starting near the dome cephalically. While opening this pocket along the lateral crus, a 2-mm caudal part was not detached and the scroll area was not disturbed (i. The prerequisite is to have a complete strip of the lower lateral cartilages, and the height of the lateral crus must be at least 12mm. Alar Rim Grafts Alar rim grafts are thin, soft cartilage grafts that measure s-12 Fig. The cephalically trimmed piece of cartilage is folded inward to create a double layer of cartilage like a sandwich and sutured. It is claimed that it pro- vides superolateral rotation of the lateral crura, increasing the cross-sectional area, and an additional support for the lateral wall of the nasal vestibule. An alar batten implant of high-density porous polyethylene has been used for reinforcement in case of Fig. Especially within the past two decades, many techniques have been presented to overcome the problems around the nasal valves. To perform functional rhinoplasty, a surgeon Other Methods should give attention to the nasal valves and do his or her best In the lateral crus pull-up technique, a permanent submu-cosal to reconstitute the nasal valve function by using one or some of spanning suture is put between the piriform aperture and the the techniques described in this article. In this particular case, (e) lateral crural turn-in flaps, (f) butterfly graft, alar battens, and alar rim grafts are all used. He can breathe better through his nose, and he is satisfied with the aesthetic out- come as well. Analysis of outcomes after functional rhinoplasty using a disease- References specific quality-of-life instrument. Plast Reconstr Surg 2007; 119: 1903–1910 nasal valve collapse: technique for repair using autologous cartilage. Aesthetic Plast Surg 1998; 22: internal nasal valve: modified splaygraft techniquewith endonasal approach. Use of the spring graft for prevention of midvault complica- implants to correct nasal valve collapse. Turn-in folding of the cephalic portion of the lateral Laryngoscope 2002; 112: 1917–1925 crus to support the alar rim in rhinoplasty. An adjustable, butterfly-design, titanium-expanded polytetra- cartilage in aesthetic rhinoplasty using a cephalic turn-in flap. The flaring suture to augment the repair of the dysfunctional nasal que, and outcomes. Arch Facial Plast Surg 2006; 8: Arch Facial Plast Surg 2008; 10: 164–168 293–299 214 Functional Rhinoplasty: Treatment of the Dysfunctional Nasal Sidewall 27 Functional Rhinoplasty: Treatm ent of the Dysfunctional Nasal Sidew all John A. The compliance of the nasal valve is a function of disease-specific quality of life. The cross-sectional area, on the other hand, is directly tion, which may be post-traumatic, idiopathic, congenital, and related to the unique anatomy of the nose. Khosh and lapse, emphasizing an accurate evaluation of the epicenter of colleagues studied the cause and anatomical site of nasal valve collapse and the specific surgical correction of the underlying dysfunction in a series of 53 patients presenting for surgical dysfunction. The vast majority (79%) of patients fell into the iatrogenic group, suffering from obstruc- tion secondary to previous rhinoplasties. In this study, A thorough understanding of nasal anatomy is essential in the the most common site of obstruction was felt to be the internal evaluation and treatment of nasal valve collapse. Since it was first described, the concept of the nasal valve falls that have been cited include overzealous resection of lower has been further characterized and the internal and external lateral cartilages, uncorrected septal deformities, infracture of nasal valves have been distinguished. The internal nasal valve is the lateral nasal wall, and scarring within the internal valve defined as the area between the caudal border of the upper lat- angle. Perhaps the most critical region of the sidewall is the inter- ing cause is essential in appropriating the correct treatment valve area. The subjective assessment should include the onset, lateral crus, induding the fibrofatty tissue, which extends to the history of trauma (including surgery), duration, exacerbating bony piriform aperture. The small sesamoid cartilages are occa- and relieving factors, impact on daily life, and very importantly, sionally found in this area, perhaps representing an attempt to laterality. The intervalve area lies immediately cative of ventilatory performance as venous congestion will deep to the supra-alar crease; deep, pinched creases here often increase the volume of the erectile tissue in the turbinates and anterior septum. These areas should Bridger relates the nasal valve to a Starling resistor, which con- be evaluated in their natural resting state and during inspira- sists of a semirigid tube with a collapsible segment anteriorly.

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Sequential lowering of the anatomic components under direct vision will allow restoration of dorsal cosmesis when the pollybeak is cartilaginous purchase viagra jelly 100mg free shipping erectile dysfunction cleveland clinic. A columellar strut may be required for added support discount viagra jelly generic erectile dysfunction doctors northern virginia, and it is our standard practice to place such a graft after an external approach. Soft tissue pollybeaks are more troublesome, and scar tissue may need to be excised at revision surgery followed by interval steroid (triamcinolone) injections. It is important not to disrupt the subdermal plexus when resecting soft tissue, and a simple but effective technique is to use a multitoothed Brown-Adson forceps to remove excess tissue without undue force. Saddle Nose Overresection of the cartilaginous middle third can create either a saddle nose deformity or inverted-V deformity. Recommendations are made for preservation of at least 10mm of dorsal and caudal septal cartilage to maintain support in this area. This should be regarded as absolute mini- mum and particularly where septal surgery is required for function as well as cosmesis. Layered onlay grafting in a small pocket as previously described will adequately correct such a problem in many cases. The usually cartilaginous graft’s edges are beveled and smoothed to avoid being visible, something that is of particular importance in the thin-skinned individual. Covering with other soft tissue such as temporalis fascia, perichondrium, or acellular dermis (AlloDerm) may help with the camouflage. The addition of a columellar support strut is also advocated to maintain a strong tip projection. Inverted-V Deformity The inverted-V deformity is a consequence of either excessive resection of or collapse of the upper lateral cartilages inferome- Fig. The nose displays a “washed-out” appearance with 414 Revision Rhinoplasty: An Overview of Deformities and Techniques Fig. There may be associated internal nasal valve collapse giving rise to nasal obstruction. Spreader grafts are an effective way of resolving this deformity and can improve nasal valve dysfunction. These are cartilaginous strips placed longitudinally between the upper lateral cartilage and septum. Based on Sheen’s original work,28 the mucosa is left intact and spreader grafts are placed extramucosally. The functional improvement has been difficult to quantify objectively, but sub- jective improvement is to be anticipated. Placement via an external approach allows for accurate visualization and fixation but when required can be equally well-placed endonasally29 into tight submucoperichondrial pockets and held with tissue glue or with percutaneous transseptal sutures if needed. Unilat- eral placement of spreader grafts may also correct asymmetries of the dorsum. Overall overresection of the dorsum may be a failure of rec- ognition of the anatomic basis to the hump and its overlying skin and soft tissue envelope. The revision rhinoplasty surgeon should recognize the bony and cartilaginous contributions of the dorsum and the fact that the skin and soft tissue thickness varies along it, being thicker in the nasofrontal region and in the supratip and at its thinnest overlying the rhinion. Preoperative assessment should define what spe- cific anomalies are present and the ideals for correction. Problems encountered may be conveniently thought of as being due to underrotation or overrotation, underprojection or overprojection, width problems, or intrinsic tip deformities. Rotation Deformities The poorly rotated nose after primary surgery is often a conse- quence of loss in tip support mechanisms due to the original incisions. The conjoint medial crura represent one aspect of the tripod, the other two being the individual lateral crura. Most of the techniques rely on knowledge of the tripod theory of the nasal tip (▶ Fig. Under this theory, the conjoint medial crura are considered as one part of the tripod with each lateral crura representing a separate lateral limb. Manipulation of any part of the tripod model can be used to predict changes in the projection and rotation of the nasal tip. Lateral crural steal techniques with recruit- ment of the lateral crura medially using domal suturing can also be usefully employed. Plumping grafts and columellar struts can be used to create an illusion of rotation. The middle third of the nose was infratip area will give an illusion of counterrotation and excessively narrowed and the nasal tip asymmetric and under- increased length of the nose. Correction involved insertion of spreader grafts, paranasal extreme cases, a composite graft may be needed in the space onlay grafts, a columellar strut, and a shield graft. Division and overlap of the medial crura is another option, although this does also deproject the tip. Projection Deformities Maintenance of projection of the nasal tip is often desirable in rhinoplasty surgery. Reasons why it occurs after primary rhinoplasty were described under rotation deformities. Options to restore tip projection once again are many and include grafting of the tip, lateral cru- ral steal procedures, vertical dome division, and suturing tech- niques. Lack of deprojection of the tension nose is also a frequently encountered problem in revision surgery. This area may well have been neglected due to inexperience with the somewhat complex and often multiple steps required. A full transfixion incision will divide a major tip support mechanism and is an easy initial step in correcting this deformity. This may need to be combined with division and overlay of the medial, lateral, or both crura, depending on the rotation requirements. Correction was by a cartilaginous caudal age of this method is the rigidity and lack of mobility such a septal graft and septal cartilage dorsal onlay. The revision surgeon may thus encounter a patient dissatis- fied with alar width who previously had an overly projected nose that was corrected. This can lead to flaring of the nasal width and, if noted, correction with alar base resection is ideal during the primary procedure. It is beyond the scope of this chapter to describe the procedures in detail, but correction should reflect whether there is excess alar flare, nostril size, or a combination of these and is detailed elsewhere. The inexperienced rhinoplasty surgeon may not be aware of the triad of thin skin, strong alar cartilages, and bifid- ity of the tip, which together predispose to their formation when there is an excess cephalic strip reduction and inadequate nar- rowing of the domes. Controversy surrounds the predisposition of vertical dome division techniques to formation of bosses, and distinguished authors have both suggested35 and refuted36 this possibility. Treatment options include trimming or resection of the knuckled areas with suture reconstruction of the lower lateral cartilages. Covering the area with a camouflage graft may also help correct any minor residual deformity. Alar Retraction Overzealous cephalic strip resection can lead to alar retraction due to the visoring effect caused by contraction as healing occurs.