This lecture discusses the management of saddle nose deformities. The speaker classifies saddle nose deformities into 5 types from mild to severe. For mild cases, the goal is to "finish the job" by minimally reducing the hump. For moderate cases, a balanced approach of reducing bone and using it as an onlay graft is recommended. More severe cases may require rib or ear cartilage grafts. The most severe cases require total reconstruction using rib grafts to build a new nasal scaffold. Sharp instruments, conservative grafting, and considering vascularization are important for successful reconstruction of saddle nose deformities.
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
El Derecho de la Informática ha sido considerado por algunos autores, como “el conjunto de normas que regulan las acciones, procesos, productos y relaciones jurídicas surgidas en torno a la informática y sus aplicaciones”.
Otros autores lo definen como “conjunto de leyes, normas y principios aplicables a los hechos y actos derivadas de la informática”
El Derecho de la Informática ha sido considerado por algunos autores, como “el conjunto de normas que regulan las acciones, procesos, productos y relaciones jurídicas surgidas en torno a la informática y sus aplicaciones”.
Otros autores lo definen como “conjunto de leyes, normas y principios aplicables a los hechos y actos derivadas de la informática”
Derechos fundamentales en el derecho de la informaciónJohaquin Bartra
Los Derechos Fundamentales son aplicables a todas las materias no solo del derecho sino a todas aquellas que se encuentran vinculadas de alguna manera y otra con la sociedad y específicamente con las personas, por tanto el Derecho a la Información no se encuentra ajeno a la necesidad de regularlo de acuerdo a los Derechos Fundamentales planteados inicialmente, para ello es necesario cuestionarnos cuál es la fuente de información activa más potente, barata y útil, no es necesario realizar un exhaustivo análisis para concluir que es el internet, un medio de información que ha demostrado a lo largo de los últimos años que es efectivo y además necesario por las exigencias actuales de adaptarse a la modernidad, por tanto iniciaremos con definir específicamente qué es el internet, viene a ser un conjunto descentralizado de redes de comunicación interconectadas que utilizan la familia de protocolos TCP/IP, lo cual garantiza que las redes físicas heterogéneas que la componen como una red lógica única de alcance mundial estableciendo un intercambio de información constante entre diversos usuarios en un tiempo reducido, si bien es cierto, Internet ya no es un fenómeno nuevo, ha revolucionado el mundo tal y como se conocía hace 30 años. Es un fenómeno global, vinculado estrechamente con la comunicación, pero que influye en gran medida sobre casi todos los ámbitos de la sociedad. Poco podían imaginar sus creadores que en apenas 20 años sería un invento tan imprescindible como el teléfono o la televisión.
This video explains Lumbar Microsurgical Minimally Invasive Decompression in Detail. When degenerative disc disease begins to affect the spine this is called degenerative disc disease. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Lumbar Disc Replacement feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
From Jubilee Hospital, Trivandrum, Kerala, South India.
Here I present few of my Rhinoplasty (Pre and Post Op Pictures) done in Jubilee Hospital Trivandrum, Kerala in South India. The Jubilee Hospital is a Christian Mission Hospital in the city of Trivandrum giving affordable treatment to everyone. Please note, the pictures are taken after the sutures are removed after 7 days and long term follow up is not practical in this part of the world.
HyProCure is an extra-osseous talotarsal stabilization device. Like any other implantable device there situations that arise that may need to be corrected.
Maintaining and Restoring Your Youthful Experience | Keller Plastic Surgerydrkellersurgery
Maintaining our appearance is important. Having an appealing persona is valuable in a work environment or in our personal lives, no matter what our age. We feel better if we like our look.
As we mature, the structures of our face fall and we lose our facial volume. The end result is a "mad", "tired", or "sad" appearance. We are not projecting the happy persona that we really feel.
Our approach is not to simply "do a facelift", but to work at restoring the natural, beautiful or handsome persona that resides within each of us.
Description of 13 years of orthopaedic practice in a prison, without facilities under desperate situations. During this time not only were 14000 patients treated, many startling orthopaedic discoveries were made. This is an award winning talk by Dr L.Prakash
This is a surgeons experience in prison, living under difficult situations, treating desperate patients, who had no where else to go. The studies conducted, discoveries made and new modalities invented.
Facial trauma is without doubt a most challenging area within the specialty of oral and maxillofacial surgery. Trauma with all its aspects has great importance, being the main cause of morbidity and mortality with rising frequency worldwide, especially in recent decades. Traumatic facial injuries are often associated with high mortality and varying degrees of physical, functional, psychological damage, cosmetic disfigurement, and concomitant injuries to other organs that may be added complicating factors. Road traffic accidents represent the main cause of facial trauma. According to WHO, Egypt leads the Middle East when it comes to road accidents, with an average of 12,000 people killed annually. Interpersonal violence is the second most prevalent etiologic factor. Our society is progressively becoming more and more violent and impatient, perhaps due to overcrowding, so the frequency of patients reporting in emergency with facial bones fracture is increasing.
During the last three decades, significant advances have occurred in the methods of fixation used for facial bone fractures, resulting in improved functional and aesthetic outcomes. Surgical techniques have been moving away from delayed closed reduction with internal wires suspension to early open reduction and internal plate fixation. The transition from wire osteosynthesis to rigid internal fixation in facial bone fractures using different micro or mini-plates and screw systems is regarded as one of the greatest advances in the field of maxillofacial surgery. I hope this book reflects the latest trends, concepts and innovations in the care of patients with facial trauma.
For convenience, the text is divided into 3 sections. Section 1 deals with primary care of the patients. Section 2 is concerned with midface fractures. In section 3 management of trauma to the lower face is discussed. Upper face injuries are not included and the reader could find the subject elsewhere under the topic of craniofacial traumatology. From the basic to the most complex, readers will find that each chapter is sequentially organized to provide a concise, and practical description of the operative details. The goal was to provide the reader with a fully comprehensive, yet highly illustrated text on the subject of facial trauma.
Ximena CarrilloSON 310010113Why SonographyIt was exactl.docxericbrooks84875
Ximena Carrillo
SON 3100
10/1/13
Why Sonography
It was exactly one year ago that I became interests in Sonography, when unfortunately, my sister in law passed away in Ecuador. She had pain in her stomach for a long time, she went to the doctor several times and they couldn’t find anything wrong with her and kept saying she was fine. She then started to notice bleeding every time she used the bathroom, so my mother in law decided to take her to a different doctor, only to find out she had cancer. Not long after that, they found a tumor in her head and after two weeks, she became unconscious and passed away. This made me realize that the medicine world in my country is not as advanced as here in United States, and I would love to take this advancement in medicine and technology there where we could save a lot of lives.
There are a lot of qualities that makes up a good sonographer, for me one of the most important is to be emotionally stable. We need to have empathy for others, feel their pain; but it is very important that we know how to contain ourselves when it is a hard time for a patient so that we give them strength. Another quality for a sonographer will be having good communication skills. This is important because we are going to have to communicate with other doctors as well as with patients, explaining imaging procedures, so that they understand what they are about to go through. Having technical skills is a good quality for a sonographer as well, since we are going to be operating imaging equipment. We need to follow instructions and pay close attention to our images to help doctors properly diagnose and treat patients.
My responsibility as a sonographer student is related to the responsibility of the faculty and clinical preceptors and in turn to my success in sonography, in the fact that I need to act and behave as if I am already a sonographer. I have to be responsible with all my assignments and be on time everyday for class. I also have to follow all clinical procedures and be careful with my classmates just like I will with my patients. I also have to follow all the teacher’s instructions and close pay attention to everything I am doing. All of these will definitely help me with my success as a sonographer student.
Before this class started, I wasn’t expecting having all these labs. I thought this class was going to be just like a “take note” class with a textbook. I am very thankful for these labs because they definitely helped me determine that sonography is a good fit for me and that this is what I really want to do. The labs gave us a good feeling of what this career is about, and it helped me understand better what I m going to be doing for the rest of my life. It wasn’t easy for me to locate the different organs at the beginning, but in our final lab exam I did pretty good and that just proves that with practice you just get better at it.
If I end up having doubts about sonography in the future, my next choice of inter.
Similar to Saddle nose transcribed_lecture_2012 (20)
Ximena CarrilloSON 310010113Why SonographyIt was exactl.docx
Saddle nose transcribed_lecture_2012
1. LECTURE 1: MANAGEMENT OF THE SADDLE NOSE
Management of Saddle Nose Deformity
Daniel G. Becker MD FACS
Clinical Professor
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology-Head and Neck Surgery
University of Pennsylvania
Thank you for inviting me to the Multispecialty Course in Plastic Surgery here at the Bellagio in
Las Vegas to discuss the management of the saddle nose.
2. This is my first visit to Las Vegas, and I must say, it is quite a place! I would like to thank Dr
Waldman from Kentucky, Dr Paul Nassif from Beverly Hills in Los Angeles California, and the
other course organizers. This is really a wonderful course both professionally and also socially.
It has been nice to see friends from around the world in this festive setting. Last night we
enjoyed a 50th
birthday celebration, and also I have had some nice re-unions with a former
resident of mine from the University of Pennsylvania, and also a college classmate from
Harvard College, who is a prominent dermatologist in New York, someone I haven’t seen in 25
years. And, I’ve made a few new friends while I’ve been here. So, this meeting has been a
delight.
In this 20 minute lecture, my goals are to discuss the cause, the evaluation, and the treatment
options for a saddle nose deformity. In the course of a lecture, we can only cover a limited
amount of material. With that in mind, I would like to direct you to the website,
www.RhinoplastyArchive.com for more information and further study.
Dr Pietro Palma of Milano, Italy and I are the editors of this website, the world’s first free, online
surgical textbook. I encourage you to go there for more detailed information. On the subject of
the Saddle Nose – the subject of this lecture, this free on-line medical textbook has three
individual chapters on the saddle nose deformity. There are also hundreds of videos, including
video of ear cartilage harvest, rib cartilage harvest, and other subjects pertinent to treatment of
the Saddle Nose.
The saddle nose deformity is characterized by a distinctive scooped-out appearance of the
nasal bridge that resembles a horse saddle.
3. The shape represents a collapse of the intrinsic cartilaginous and/or bony support structures of
the nose. Characteristics include a loss of dorsal height, middle vault and dorsal depression, a
loss of tip support and definition, columellar retrusion, shortened vertical length, tip-over
rotation, and retrusion of the nasal and caudal spine.
The causes are numerous. The most common is traumatic. Also, surgery can be a cause.
There are also vascular causes such as the use of drugs like cocaine or Afrin. In this situation,
damage to the septum causes a septal perforation, loss of the L-strut support, and collapse – a
saddle nose. Systemic disorders such as Wegener's disease and sarcoid can also cause
saddle nose. Cancers such as inverted papilloma and squamous cell cancer can lead to saddle
nose deformity as well, and also there are infectious causes like syphilis, leprosy, or bacterial
infection leading to a septal abscess.
There are a number of classification schemes to describe saddle nose deformities. I like the
one described by Daniel and Brenner in "Facial Plastic Surgery Clinics of North America," in
2006. In their classification scheme, it goes from type 0 to type 5, with type 0 being what you
might call a pseudo-saddle nose, a very minor depression, type 5 being the most catastrophic,
requiring a major reconstruction. And, of course, types 1 through 4 are the stages in between.
4. What I propose to do in this lecture is, using this classification scheme as a template, to go from
the most mild to most severe and just outline what my personal treatment algorithm is.
Here, you see this first patient has a very mild saddle nose deformity from a trauma, I believe it
was a softball injury. You see here the before photo, and the photo after surgery by me.
5. My treatment for this kind of problem is what you might call, "to finish the job." This patient told
me in the office that she had a little bump to begin with, she never really liked it, and the softball
injury made it worse. She doesn’t like the bump and she just wants it gone. As you can see on
the before picture, the saddle nose injury has created a mild bump, the cartilaginous portion of
the nose has dropped making the overall bump appear worse than in her pre-injured codition.
And so what I typically have done surgically in this kind of case is to do a closed, or endonasal
approach, simply take down the rest of the bump. This is really what she wants, she wants me
to “finish the job” that the softball started!. She wants a smaller nose and so you might say that
the softball did the first half of the operation and I did the other, and so this tends to be a
relatively straightforward surgery, with a closed approach, minor hump take-down, osteotomies.
Here is the frontal view, before and one year postoperative.
You can see in the before picture how the saddle nose creates a flattened appearance of the
middle vault region, and then one year after, that flattened look is gone, and she has nice clean
nasal lines after surgery. Here are the angled (oblique) view and the base view photos before
and after.
6. Some helpful hints for hump take-down, I recommend an anatomic approach, breaking it down
in your mind mentally into the various components. I like to draw out the intended reduction on
the skin before injection.
Also, it is really critical that you use very sharp instruments, and we will talk about that in
another lecture. But, the short version – for those of you who use osteotomes to take down the
bony nasal bump, they dull quickly and should be discarded after a few uses. Sharpening them
with a sharpening stone or even having them sharpened by your surgical center does not seem
to be sufficient. A picture is worth 1000 words: here is an electron microscopy photo of an
osteotome before use, and after 9 uses.
7. If you were having your hump taken down, which one of these two osteotomes would you want
used on you?!
I hope this photo is persuasive.
New osteotome……9 uses
When you use the osteotome, a gentle 2-tap technique is really helpful in guiding the osteotome
along the desired line, and then final refinements can be made with a rasp. I prefer a powered
rasp.
This next patient has a slightly greater deformity, and in cases like this a balanced approach is
my preference.
8.
9. In his case, what I did was to take down the bony bump, and then I used it as an onlay graft to
build up the depression. What that creates is sort of a nice compromise, a nice balance. Pre-
operatively, the upper third of the nose is too high and the middle third is too low, and so by
balancing those we get a nice result. Indeed, that is what I did in this gentleman, with a very
happy outcome as you can see.
Here is a fellow, he was a motocross competitor and suffered an injury.
10. As you can see, he had a substantial saddle nose deformity. I repaired this with a double-layer
ear cartilage graft, and because he had thin skin we wanted to create a little bit of a cushion,
and so I used AlloDerm. I wrapped the double-layer graft in AlloDerm and inserted that, and in
his case we used an open approach. I think you can see, as well, when you look at the side
view, that when you put on an onlay graft it ends up lengthening the nose. In the before picture,
you see as if the nose has been lifted, and simply by rebuilding that bridge it can tend to push
the tip down and lengthen it in a very favorable way.
This woman has an isolated substantial middle vault depression.
In her case, I did a closed rhinoplasty with a triple-layer onlay graft. This is a 5-year
postoperative result; she got a wonderful result.
11. And this is a woman who suffered a trauma to her nose and has a similar severe saddle nose
deformity, perhaps more severe.
12. In her case, she had a large septal perforation and was not interested in cartilage harvest from
her ears or rib, and so we discussed irradiated rib.
Irradiated rib is well-described as a good option for rhinoplasty. A number of reports in the
literature describe very good long-term success. And as you can see from the early
postoperative picture shown here, she had a beautiful early result.
Here is the intraoperative photo, the irradiated rib that I then carved to the proper size.
13. I made little limited marginal incisions bilaterally to make a precise pocket, and I simply inserted
the graft.
14. However, there is a valuable lesson to be learned here. The patient came back six months after
surgery; look at these photos from before and after irradiated rib graft, she is slightly better but
has had significant partial resorption.
15. Here is the lesson to be learned. First of all, it was a very large graft in a poorly vascularized
area, so I think it was asking a lot for that entire graft, a graft of that thickness, to live. if it is a
poorly vascularized bed you have to be more cautious, less ambitious. I think in a case like this,
if you are overly ambitious and you start the reabsorption cascade in motion, then you end up
getting more reabsorption than you bargain for, so I think that if you err on the side of
conservatism when you are using irradiated rib, you are better off.
I think it is just like if you are working in a garden, if you have bad soil it is hard to really expect
your transplanted plant to survive. You are going to lose some of the leaves, and maybe even
the whole plant, if you are not careful. So you have to keep in mind the bed you are putting it in,
it has to be well fertilized – or a well-vascularized bed, in the case of a patient.
And so, in this patient we did a revision, and in this case we did use her ear cartilage, a double-
layer graft with soft tissue. We left the postauricular soft tissue on it, which facilitated the
transplanting of it. For a video of my surgical technique of ear cartilage harvest, go to
www.RhinoplastyArchive.com.
16. This is a nice six-month postoperative result, and I think you can see that we were, in fact, able
to restore a nice profile for her. Time will tell if this will be a lasting result, but I have heard from
the patient (she lives at a distance) and she tells me she is doing well still, over a year since her
surgery.
Now, this is a gentleman with a much more severe deformity. He has a very complicated
deformity.
17. In addition to the saddle nose that you see here, where the upper portion was really over-
resected, the lower portion was under-resected. So he has a little bit of an over-projection of his
tip, a pollybeak deformity, and also an over-resected bridge. What complicates this further is
that his bridge is uneven. It was unevenly over-resected, so there is a depression on the right
side compared to the left.
In his case, we did a complex reconstruction with ear cartilage for reconstructive grafting.
Surgery included takedown of the lower nasal bridge, and placement of a unilateral spreader
18. graft. In the prior patient earlier in this lecture, I took down the upper part of the bridge and used
that tissue to build up the lower portion. in this case the resected bridge was nusable, and so we
took down the lower portion and then used ear cartilage to build up the upper portion to create
balance. I think you can see with this nearly three-year result, really a beautiful result in his
case.
This next patient represents the class 5 deformity, major reconstruction needed.
19. You can see from before and after she needs a total reconstruction, and in her case we used
irradiated rib, shown below.
This is a gentleman who has a similar sort of problem, and we did use his own rib.
20. See www.RhinoplastyArchive.com for more information including video, more information on rib
harvest. I think that for these kinds of reconstructions, probably autogenous rib is preferable,
although I think that either autogenous or irradiated rib are good options.
21. Here you see a picture of his rib harvest.
Basically, in these sorts of situations you build an entire new architecture of the nose, a new
scaffolding over what exists, because the whole nose is collapsed. You need to build a whole
new structure on top of it.
This is what it looks like on the inside,
22. and then this is the one-year postoperative result.
Well, I see from the clock that I am on time, but my time is up. I hope you found this lecture
useful. Thank you