This cadaver study evaluated the use of a piezoelectric-based scalpel for performing lateral osteotomies of the nasal wall during rhinoplasty procedures. 20 osteotomies were performed on 10 cadaver noses using the piezoelectric scalpel. Examiners found that the scalpel allowed for precise osteotomies along the planned path with no tearing of the nasal mucosa. The osteotomies resulted in intact lateral nasal walls with small irregularities but no comminuted fractures. This suggests the piezoelectric scalpel is a useful tool that allows for precise osteotomies of the nasal wall with minimal soft tissue damage compared to other techniques.
Sinus Lift and Immediate Implant PlacementDental Evo
Sinus Lift and Immediate Implant Placement, using LAS kit and TS3 implants.
Presentation by Dr Nicola Baldini DDS
http://www.dentalevo.it/dentistry-materials/sinus-lift-big-buccal-window/
http://www.dentalevo.it/dentistry-materials/sinus-lift-small-buccal-window/
Sinus Lift and Immediate Implant PlacementDental Evo
Sinus Lift and Immediate Implant Placement, using LAS kit and TS3 implants.
Presentation by Dr Nicola Baldini DDS
http://www.dentalevo.it/dentistry-materials/sinus-lift-big-buccal-window/
http://www.dentalevo.it/dentistry-materials/sinus-lift-small-buccal-window/
“Perio-Implant surgery: Expanding the Horizons”- Three lectures on “Sinus lifts- Alternative techniques and Strategies”, “Preparing PRF- What to do, what not to do” and “When not to use regenerative materials” organized by the Society of Periodontists and Implantologists of Kerala” at Kochi, India on 24/07/2016.
“Sinus lifts- Alternative techniques and Strategies” and “When not to use regenerative materials”- Guest lecture as a part of Dr NTRUHS Zonal CDE programme in G Pulla Reddy Dental College and Hospital, Kurnool, India on 07/10/2016.
Modified osteotome sinus floor elevation by using combination PRF membrane, b...Dr. Anuj S Parihar
The osteotome technique is more predictable with simultaneous implant placement when there is less than 5 to 7 mm of pre-existing alveolar bone height beneath sinus. Proper combination of PRF membrane, MFDBA and autogenous bone has been recommended for this situation. The purpose of this article is to describe the proper method and materials which can grow more than 10 mm bone with osteotome technique and grafting materials where the edentulous posterior maxilla radiographically showed less bone between the alveolar crest and sinus floor.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Sinus lift with dental implants Placement.(with Clinical Photographs) Dr. ...All Good Things
Hi. This is Dr. Amit T. Suryawanshi. Oral & Maxillofacial surgeon from Pune, India. I am here on slideshare.com to share some of my own presentations presented at various levels in the field of OMFS. Hope this would somehow be helpful to you making your presentations. All the best & your replies are welcomed!
Complications of lower anterior implants| Complications of Dental Implants by...Dr. Rajat Sachdeva
Implants are tooth-root like structure place beneath the jaw-bone.
although it is best replacement of natural teeth, complications are still there, surgical complications like hemorrhage and hematoma neurosensory disturbance and damages of adjacent teeth which occurs due to in-proficient surgical exercise.
Biologic complication like inflammation dehiscence and recession periimplantitis and bone loss occurs due to patient's ignorance of hygiene.
Technical Complication like implants fracture, screw loosening, prosthesis fracture.
and some miscellaneous complication, which occurs and should care as soon as possible.
An impeccable procedure is needed to perform a perfect Implants procedure.
For more details, go to our links:-Google link:
https://business.google.com/dashboard/l/04970356233769420071
Facebook link for Dental Courses:
https://www.facebook.com/dentalcoursesdelhi/
Facebook link for Dental Treatments:
https://www.facebook.com/sachdevadental/
You tube Link:
https://www.youtube.com/user/drrajatsachdeva
Linkedin link:
https://www.linkedin.com/in/drrajatsachdeva/
Slideshare:
https://www.slideshare.net/drrajatsachdeva
Twitter Page :
https://twitter.com/drrajatsachdeva
Call us to know more:- +919818894041,01142464041
#rajatsachdeva #dentistdelhi #dentaldelhi #smiledelhi #dentalclinicindelhi #dentistinashokvihar #dentalimplantologist #dentalimplantsclinic #dentalimplantcost #dentalimplanttreatment #dentalimplantprocedure #dentalimplantspecialist
“Perio-Implant surgery: Expanding the Horizons”- Three lectures on “Sinus lifts- Alternative techniques and Strategies”, “Preparing PRF- What to do, what not to do” and “When not to use regenerative materials” organized by the Society of Periodontists and Implantologists of Kerala” at Kochi, India on 24/07/2016.
“Sinus lifts- Alternative techniques and Strategies” and “When not to use regenerative materials”- Guest lecture as a part of Dr NTRUHS Zonal CDE programme in G Pulla Reddy Dental College and Hospital, Kurnool, India on 07/10/2016.
Modified osteotome sinus floor elevation by using combination PRF membrane, b...Dr. Anuj S Parihar
The osteotome technique is more predictable with simultaneous implant placement when there is less than 5 to 7 mm of pre-existing alveolar bone height beneath sinus. Proper combination of PRF membrane, MFDBA and autogenous bone has been recommended for this situation. The purpose of this article is to describe the proper method and materials which can grow more than 10 mm bone with osteotome technique and grafting materials where the edentulous posterior maxilla radiographically showed less bone between the alveolar crest and sinus floor.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Sinus lift with dental implants Placement.(with Clinical Photographs) Dr. ...All Good Things
Hi. This is Dr. Amit T. Suryawanshi. Oral & Maxillofacial surgeon from Pune, India. I am here on slideshare.com to share some of my own presentations presented at various levels in the field of OMFS. Hope this would somehow be helpful to you making your presentations. All the best & your replies are welcomed!
Complications of lower anterior implants| Complications of Dental Implants by...Dr. Rajat Sachdeva
Implants are tooth-root like structure place beneath the jaw-bone.
although it is best replacement of natural teeth, complications are still there, surgical complications like hemorrhage and hematoma neurosensory disturbance and damages of adjacent teeth which occurs due to in-proficient surgical exercise.
Biologic complication like inflammation dehiscence and recession periimplantitis and bone loss occurs due to patient's ignorance of hygiene.
Technical Complication like implants fracture, screw loosening, prosthesis fracture.
and some miscellaneous complication, which occurs and should care as soon as possible.
An impeccable procedure is needed to perform a perfect Implants procedure.
For more details, go to our links:-Google link:
https://business.google.com/dashboard/l/04970356233769420071
Facebook link for Dental Courses:
https://www.facebook.com/dentalcoursesdelhi/
Facebook link for Dental Treatments:
https://www.facebook.com/sachdevadental/
You tube Link:
https://www.youtube.com/user/drrajatsachdeva
Linkedin link:
https://www.linkedin.com/in/drrajatsachdeva/
Slideshare:
https://www.slideshare.net/drrajatsachdeva
Twitter Page :
https://twitter.com/drrajatsachdeva
Call us to know more:- +919818894041,01142464041
#rajatsachdeva #dentistdelhi #dentaldelhi #smiledelhi #dentalclinicindelhi #dentistinashokvihar #dentalimplantologist #dentalimplantsclinic #dentalimplantcost #dentalimplanttreatment #dentalimplantprocedure #dentalimplantspecialist
Title: Otoplasty: New Modification of the Mustardé technique
Author: Mohamed A.S.M. El-Rouby, MD,
Assistant Professor of Plastic surgery, Ain Shams University, Cairo, Egypt.
Abstract
Background: one of the most established techniques for management of protruding ears is the Mustardé technique (1). Many modifications had been published for this technique; however, all these modifications started by retro-auricular incision. We modify the Mustardé technique using three retroauricular microincisions to correct several deformities of the auricular cartilage in protruding ears.
Patients and Methods: 46 patients (7unilateral, 39 bilateral) (85 ears) who were candidates for this technique, their age (25 ± 2.8 years), 38 males, 8 females. The operation time, steps, follow up sessions (2 weeks, 3, 6 and 18 months) data was recorded. Preoperative and postoperative (1,18 months) photos were compared and analyzed by custom made computer program the evaluated the results.
Results: 42 patients achieve a natural appearance. extrusion of threads occurred in 8 ears. Asymmetrical ears were noticed in 4 patients and recurrence in 11 patients. These patients were revised by Mustardé technique with retro-auricular incisions. None of the patients developed retro-auricular scars.
Conclusion: this versatile modification allows for better asthenic results of otoplasty and minimizes complications of skin incision unless cartilage and/or skin resection is needed.
Reconstruction of a facial defect is a complex modality either surgically or prosthetically, depending on the site, size, etiology, severity, age, and the patient’s expectation. The loss of an auricle, in the presence of an auditory canal, affects hearing, because the auricle gathers sound and directs it into the canal.
Surgical reconstruction is preferable but prosthetic approach may be necessary in some circumstances such as the presence of complex or large defects, requirement of the recurrence control, local or general contraindications of surgery, damaged neighboring tissues due to the radiotherapy, general poor health, failed reconstructive attempts previously made, refusal of the surgery by the patient, high esthetic demands, the desire for a quick recovery and palliatively operated patients.
Nowadays, craniofacial implants are used to support and retain such prostheses. Studies have shown successful retention and stability of auricular prostheses anchored to the temporal bone with titanium implants.
[Dr. Suh's thesis in International journal SCI]
“A Novel technique for short nose correction”
The nominated thesis is about A Novel technique for short nose correction; Hybrid septal extension graft that have acquired the favorable reputation internationally based on the advanced clinical experiences.
A Novel Technique of Asian Tip Plasty by Dr. Man Koon, Suh from JW Plastic Su...JW Plastic Surgery
Background
The columellar strut graft is one of the most commonly used invisible grafts in tip plasty techniques for nasal tip projection. However, the columellar strut graft induces cephalic rotation of the dome with nasal tip projection. This is an effective change in Western people with a long nose; however, this change should be avoided in Asians who have a relatively short nose and visible nostrils. We designed a more convenient and effective technique using a rein-shaped columellar strut graft that can prevent cephalic rotation of the dome.
Methods
A total of 32 patients underwent surgery with a rein-shaped columellar strut graft with a septal cartilage. The projection and location of the nasal tip, nasal length, and nasolabial angle were measured after taking a photograph of the lateral view, and the preoperative and postoperative results were compared.
Results
There were statistically significant differences between the preoperative and postoperative values of the nasal tip projection ratio and nasal tip location ratio. There were no revision surgeries and no direct complications associated with the use of the columellar strut graft.
Conclusion
We performed tip plasty with a modified columellar strut graft—the rein-shaped columellar strut graft. In most cases of using this method, the tip projection was increased and the cephalic rotation of the tip was prevented. This surgical procedure can also be used for lengthening (rotating caudally) of the nose in some cases, as well as for the purpose of preventing the cephalic rotation of the tip.
This is a power point presentation on sinus floor elevation, describing the various techniques, biological aspects and clinical outcomes from a periodontist point of view. It also includes a brief review on the anatomy of maxillary sinus and management of complications.
orthognathic surgery is very intresting and well knowing branch in oral surgery ....this presentation is dealing with jaw correction surgery in upper jaw.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
1. CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY
Osteotomy of the Nasal Wall Using a Newly
Designed Piezo Scalpel—A Cadaver Study
Alireza Ghassemi, MD, DDS, PhD,* Andreas Prescher, MD, PhD,y
Mohammad Talebzadeh, DDS,z Frank H€olzle, MD, DDS, PhD,x and
Ali Modabber, MD, DDS, PhDk
Purpose: Achieving the desired outcome in rhinoplasty depends on many factors. Osteotomy and
adjustment of the lateral nasal wall are important steps that necessitate careful planning and execution.
A cadaver study was performed to evaluate the osteotomy result obtained with a newly designed
piezoelectric-based scalpel.
Materials and Methods: Twenty lateral osteotomies of the nasal wall were performed in 10 human
cadaver noses. The osteotomies were conducted in 6 female and 4 male cadavers (age range, 65 to 83
yr; mean age, 74.8 yr). A specially designed Piezosurgery-based scalpel was used endonasally to perform
the lateral osteotomy. Cutting of the bony nasal wall was performed subperiostally along the planned
osteotomy route under tactile control. Digital infracturing was accomplished by applying gentle pressure.
After completing the osteotomy, the osteotomy line and nasal mucosa were examined endoscopically. The
skin cover was removed to examine the lateral bony nasal wall for the shape and amount of bone
fragments, the osteotomy path, and mucosa involvement.
Results: Using the Piezosurgery-based scalpel required a learning curve, but the handling was easy.
It allowed an exact performance of the osteotomy and caused no mucosal tearing. If excessive force
was used, the piezo tip stopped working. There was no comminuted fracture pattern and the lateral nasal
wall remained in 1 piece. The duration of the osteotomy was 5 to 10 minutes on each side.
Conclusion: The piezoelectric-based scalpel is a useful tool, which can be used to perform osteotomy of
the nasal wall. In addition, this specifically designed tool tip allows an endonasal approach, is easy to han-
dle, and allows effective irrigation of the osteotomy region.
Ó 2013 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg -:e1-e6, 2013
A significant yet difficult contributor to operative suc-
cess in rhinoplasty is shaping the underlying nasal
bony structures.1,2
Depending on the deformities
presented, different osteotomy techniques—lateral,
medial, and transverse—can be indicated to achieve
the desired esthetic and functional outcome.3
Two dif-
ferent approaches—endonasal and percutaneous—
with corresponding instruments have been developed
tomakethissteppredictable,less traumatic,easy toper-
form, and controllable.2,4-7
Nevertheless, every tech-
nique has its advantages and disadvantages, and
osteotomy can cause soft tissue injury, irregularity of
the bony lateral wall, a comminuted fracture pattern,
and, as sequels, prolonged postoperative edema and
ecchymosis and functional nasal obstruction with an
undesired esthetic and functional outcome.2,5-7
Soft
*Assistant Professor, Department of Oral, Maxillofacial, and
Plastic Facial Surgery, University Hospital RWTH-Aachen, Aachen,
Germany.
yAssistant Professor, Institute of Anatomy, Medical Faculty of
RWTH-Aachen, Aachen, Germany.
zResident, Department of Oral, Maxillofacial, and Plastic Facial
Surgery, University Hospital RWTH-Aachen, Aachen, Germany.
xHead and Chairman, Department of Oral, Maxillofacial, and
Plastic Facial Surgery, University Hospital RWTH-Aachen, Aachen,
Germany.
kSenior Resident, Department of Oral, Maxillofacial, and Plastic
Facial Surgery, University Hospital RWTH-Aachen, Aachen, Germany.
Address correspondence and reprint requests to Dr Ghassemi:
Pauwelsstr 30, 52074 Aachen, Germany; e-mail: aghassemi@
ukaachen.de
Received June 18 2013
Accepted July 26 2013
Ó 2013 American Association of Oral and Maxillofacial Surgeons
0278-2391/13/00939-7$36.00/0
http://dx.doi.org/10.1016/j.joms.2013.07.028
e1
2. tissue trauma may contribute to destabilization,
hemorrhage, and prolonged postoperative ecchymosis
and edema. The nasal skin is very thin and any nasal
wall irregularity from a comminuted fracture and
irregular-shaped bony fragments will be apparent.8,9
Horton et al10,11
introduced piezo surgery in alveolar
bone surgery in 1975, using the piezoelectric ultrasonic
vibration for gentle cutting of the bone. They reported
better bone healing of the bony fragments when using
piezo surgery. Subsequently, additional uses were
introduced, such as cutting a bony window in the
maxillary sinus wall to perform sinus augmentation or
to perform orthognathic surgery.10-16
In 2007,
Robiony et al17
suggested this technique for nasal os-
teotomy. This device cuts the bone micrometrically us-
ing ultrasonic piezoelectric vibration, and it can be
adjusted by changing the frequency and cutting power.
It has proved a useful tool for cutting thin bone with
precision, causing minimal damage to soft tissue and
avoiding osteonecrosis.18
Since then, the technique
has improved rapidly and has extended its indication.12
This anatomic study was undertaken to perform
osteotomy of the nasal wall with a newly designed
piezo scalpel. The degree of difficulty of performing
osteotomy was evaluated using this scalpel through
an endonasal approach. In addition, the effectiveness
of the cooling capacity, the condition of the osteotomy
path, the amount and shape of bony fragments, and
mucosal injuries were examined.
Materials and Methods
Ten human cadaver heads were used for performing
lateral osteotomy (age range, 65 to 83 yr; mean age,
74.8 yr; gender distribution, 4 male and 6 female).
One experienced rhinoplasty surgeon, who was famil-
iar in applying the Piezosurgery device (Mectron Med-
ical Technology, Carasco, Italy), performed the
osteotomies through an endonasal approach. A spe-
cially designed piezo scalpel was used to dissect a tun-
nel and to perform the osteotomy (Figs 1, 2). In
addition, irrigation with internal cooling and a flow
of 40 mL/min was used to avoid heating the bone.
The coolant was transferred to the osteotomy area
through a hole at the end of the tool tip (Fig 2).
The mucosa was incised along the lower edge of the
pyriform aperture for about 3 mm to access the bony
lateral wall. A special tool tip was used as a periosteal
elevator to create a subperiosteal tunnel around the
pyriform aperture along the planned osteotomy
path, as marked on the skin (Fig 3). The piezo scalpel
was inserted into this tunnel and the osteotomy was
performed along the osteotomy path under digital con-
trol. After accomplishing the endonasal cutting of the
bony lateral nasal wall, 3 independent examiners (ex-
cluding the surgeons) who were blinded to the tech-
nique inspected the intranasal cavities of all cadavers
on each side with a 4-mm 30
rigid endoscope (Karl
Storz GmbH Co KG, Tuttlingen; Germany). They
looked for lacerations of the nasal mucosa. Then, the
nasal pyramid was infractured digitally on each ca-
daver. The soft tissue envelope was removed after in-
fracturing to evaluate the condition of the osteotomy
line and the size, shape, and amount of the bony frag-
ments. Special inspection was performed for contour
irregularities, bony spur or spicules generated, and
greenstick infracture characteristics. This step was fol-
lowed by an intranasal examination to explore the
nasal mucosa.
Results
Altogether, 20 lateral osteotomies were performed
in human cadaver specimens. The osteotomy path
was marked on the skin (Fig 3). It was easy to cut
through the bony wall all the way along the osteotomy
line by digitally controlling the piezo inset (Figs 1, 2).
Because of the learning curve, 10 minutes was re-
quired for the first nose and 7 minutes was required
for the second nose. For the next 8 noses, approxi-
mately 5 minutes was required. For continuous cut-
ting, the scalpel should be moved along the bone
FIGURE 1. Working insert for soft periosteal elevation. The cooling hole (arrow) is in the shaft near the handle.
Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral Maxillofac Surg 2013.
e2 PIEZO SURGERY FOR OSTEOTOMY OF NASAL WALL
3. surface by applying gentle pressure. This is sufficient
to cut partly or completely through the bone, as indi-
cated. As soon as any extensive force was exerted,
the piezo stopped working. Near the nasal root, cut-
ting the bone required more time. At the end of piezo
surgery, digital infracturing could be performed by ap-
plying gentle pressure and no forceful manipulation
was necessary.
All examiners independently recorded identical
findings from their separate endoscopic examinations
FIGURE 2. The cutting working tip with the hole close to the tip. The cooling hole (arrow) and the pathway along the shaft, where the irrigation
has to flow to reach the tip (2-headed arrow), are depicted.
Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral Maxillofac Surg 2013.
FIGURE 3. Osteotomy course marked on the skin of the cadaver
nose. This was used continuously to control the tip of the piezo scal-
pel while performing the osteotomy.
Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral
Maxillofac Surg 2013.
FIGURE 4. Endoscopic inspection of nasal mucosa after osteot-
omy. No injury to the mucosa is observed.
Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral
Maxillofac Surg 2013.
GHASSEMI ET AL e3
4. and from the condition of the lateral nasal wall. None
of the cadavers exhibited perforation of the nasal mu-
cosa (Fig 4). The examiners recorded 1 complete nasal
wall on each side, with small irregularities resembling
the tooth of the piezo scalpel. There was minimal loss
of bone material along the osteotomy line (Fig 5).
Discussion
Successful rhinoplasty is the result of controlled
changes in the nasal framework and its soft tissue cover.
Alterations and shaping of the nasal bony structure pres-
ent an ongoing challenge in esthetic and reconstructive
surgery.1
Numerous lateral osteotomy techniques
evolved in the previous century, incorporating the use
of different instruments from the saw to the chisel to
the diamond.2-7,19-21
Various modifications of available
techniques have been introduced to rhinoplasty
surgery to increase ease of performance, precision,
controllability, and reliability, on the one hand, and
reproducibility with low morbidity, on the other.
Despite the many previously described methods, it
remains difficult to perform osteotomies in such
a way as to provide esthetically pleasing and reliable re-
sults.Lateralosteotomyis associated with an increase in
hemorrhage, edema, and ecchymosis. This has been
substantiated byother studiesandcancontribute signif-
icantly to postoperative morbidity after rhinoplasty.2,5-9
Perforated lateral osteotomy preserves the support of
the periosteum and is supposed to decrease lateral
nasal wall collapse and minimize hemorrhages and
edema.5-7
However, this method is suspected of
causing comminuted fractures with irregular bony
fragments, which can cause postoperative esthetic
deformity.4
The perforating technique is reliable only
inthehandsofanexperiencedsurgeon,becauseitisdif-
ficult to direct and may need repeated passes.2,9
Murakami and Larrabee4
found more irregular osteoto-
mies and more soft tissue trauma when using the per-
cutaneous approach, and they preferred building
a subperiosteal tunnel and using an adequate technique
to ensure proper stability. In a cadaver study, Kuran
et al19
evaluated fracture line and mucosal injuries.
They found that a wide osteotome causes significantly
more mucosal injuries.
The piezo scalpel allows the cutting of a bony win-
dow into the maxilla without any laceration of the del-
icate mucosa of the maxillary sinus.13
Robiony et al17
introduced the piezo technique in rhinoplasty and em-
phasized the advantages of this method. They used an
external approach to insert the piezo scalpel. Although
soft tissue probably will not be lacerated by slight
touches, continuous irrigation would be difficult using
this approach. Robiony et al reported decreased bleed-
ing during surgery, minor edema, and periorbital ec-
chymosis immediately after surgery. The Piezosurgery
device offers effortless handling and requires very little
manual pressure.22
Moreover, it is an optimal tech-
nique for selectively cutting mineralized tissue.10
It al-
lows the exact placement and control of the tool tip
to cut along the desired path using micrometric move-
ment, and the piezo scalpel is armed with a peristaltic
pump for irrigation.14,16,22
Although this instrument
was originally developed for augmentation surgery in
the dentoalveolar field, there are different working
tips for currently available indications.11-17,22
The main purpose of this cadaver study was to
evaluate the quality of osteotomy when using the Pie-
zosurgery device. The newly designed piezo scalpel
allowed the osteotomy from an endonasal approach
and irrigation of the bone through a hole close to
the tip of the scalpel (Fig 2). Lateral osteotomy was
performed in 10 human cadaver noses (20 lateral
walls) according to the technique described earlier.
A 3-mm incision in the mobile mucosa of the pyri-
form aperture and narrow exposure of the osteotomy
site were sufficient to easily access the lateral nasal
wall. A short learning curve was necessary to become
familiar with the procedure. The exposure of bone
FIGURE 5. Osteotomy course after removal of soft tissue cover. A
very tiny tooth mark along the osteotomy path, caused by the tip
of the piezo scalpel, is depicted. The osteotomy course is regular,
which corresponds exactly to the path marked on the skin. There
is only 1 bony fragment without any comminuted fracture pattern.
Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral
Maxillofac Surg 2013.
e4 PIEZO SURGERY FOR OSTEOTOMY OF NASAL WALL
5. surface at the osteotomy site was less extensive than
with other methods. The line of osteotomy, which
had been marked on the skin along the nasofacial
crease, could be palpated and followed exactly
through the skin (Fig 3). The hand piece stopped
moving if any excessive force was used.22
It should
just be guided over the bone gently, as in piezo sur-
gery generally. It does not involve the risk of acciden-
tal dislocation of the osteotome and the course of
osteotomy can always be followed exactly as
planned.22
The sound of the cutting also can help
as acoustic feedback to guide the applied force.
The infracturing of the bony lateral wall can be ac-
complished with gentle pressure. The endoscopic ex-
amination along the osteotomy line showed a bone
ridge with spikes, similar to the tip of the scalpel,
but no major irregularity or comminuted fracture
(Fig 5). No tear of nasal mucosa was apparent
(Fig 4). The average time for incision and preparation
was 5 minutes after a learning curve in the first 2 os-
teotomies. No residual deformity, such as a bony
spur, was observed. The lateral nasal wall was ob-
served as a whole bone fragment, with some irregu-
larities of the bone edge caused by the tooth of the
piezo tool tip. The osteotomy part of the bone
showed signs of adequate irrigation and no sign of
heat development. The irrigation flowed through
the shaft of the scalpel to the tip. This had an addi-
tional cooling effect on the surrounding soft tissue
coverage (Fig 2). In some noses, the osteotomy
path was osteotomized incompletely. Nevertheless,
the infracturing could be performed easily. The re-
sulting osteotomy gap was approximately 0.5 mm.22
Because the use of piezo surgery does not cause any
soft tissue injury, minimal hemorrhage and ecchymosis
are expected postoperatively, as was shown clinically
by Robiony et al.17
The dissection of a narrow subper-
iosteal tunnel, combined with healthy and unlacerated
nasal mucosa, will hinder the collapse of the osteotom-
ized lateral nasal wall and thus decrease postoperative
edema and swelling.9
A precise and reproducible lateral
osteotomy can be performed, which is the requirement
for successful rhinoplasty. It can be controlled transcu-
taneouslytoperform theosteotomy inanexact planned
course. It makes this step easier to perform and more
controllable, with a predictable and consistent result.
This promotes faster healing and shortens postopera-
tive hospital stay.9
Because the bone thickness does
not exceed 3 mm at any point on the osteotomy lines,
piezo surgery is optimal for this procedure.19,23
In
addition, there is no need to cut through the entire
thickness of the nasal bone to infracture the nasal wall.
All kinds of osteotomies, such as transverse, median,
paramedian, and hump removal, also can be performed
as required. Although there is limited scarring from the
percutaneous approach, the concept of an external
incision conjures debate when an internal option
exists.2
Thisspeciallydesignedpiezoscalpelallowsanen-
donasal approach and thus avoids any risk of possible
scar formation.
The optimal technique for osteotomy should be safe,
precise, and reproducible, with minimal postoperative
ecchymosis and edema, and deliver a predictable re-
sult. The piezo scalpel is easy to handle and does not
cause any mucosa laceration; the osteotomy can be
performed exactly in the planned osteotomy track
and does not result in any comminuted fractures. It is
a nontraumatic and controllable alternative to known
osteotomy techniques. A learning curve may be neces-
sary, but it is a straightforward method to learn.
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e6 PIEZO SURGERY FOR OSTEOTOMY OF NASAL WALL