By D. Angir. University of Georgia.

Whether poor tip support is congenital or the metric lobule with flared and retracted nostrils and excessive result of surgical reductions in septal height or septal length or columellar show (▶ Fig buy eriacta 100mg free shipping. The resulting look is both both generic eriacta 100mg otc, inadequate (septal) tip support leads to additional side- unnatural and strongly suggestive of previous surgical interven- wall laxity and more severe sidewall distortion order eriacta 100mg without a prescription. Overrotation tion—two features that contemporary rhinoplasty consumers and excessive deprojection of the tip are common manifesta- regard as highly unacceptable. Sadly, such stereotypical tip tions of inadequate septal support, which adds to stigmatic deformities are regularly seen in the expanding population of patients seeking revision rhinoplasty. Moreover, due to their widespread prevalence, the general public often mistakenly regards these deformities as synonymous with state-of-the-art cosmetic nasal surgery. In fact, many prominent rhinoplasty surgeons have now altered their rhino- plasty technique to preserve greater volumes of lateral crural cartilage, or if possible, to avoid crural resection altogether. Anatomically, the oversized or bulbous tip results from pronounced lateral crural convexity and/or excessive sep- aration of the nasal domes. Whether crural convexity is medial to lateral, cephalic to caudal, or a combination of both, effective tip refinement mandates elimination of convexity from the lat- Fig. However, until recently, nonexcisional techniques to flatten the lateral crus have been lacking. Because the natural thickness diminished sidewall support, it should be reserved only for noses of the lateral crus averages only 0. Although the mass effect is not may prove necessary is overprojection of the medialmost cepha- always clinically relevant, potential problems with nasal airway lic margin of the lateral crus. This region of the cephalic margin, impingement, overgrafting, or limited donor material may limit which lies medial to the nasal scroll, has been designated the the utility of sidewall augmentation grafts in some patients. Judicious excision of an overprojecting para- suture placement to reshape and reposition the lateral aura, domal segment can eliminate excessive supratip fullness and can also eliminate aural convexity and achieve elegant tip create a natural and attractive transition between the dorsal refinement. In most cases, difficult or impossible to reverse, suture-based techniques are excision of only a small crescent of aural cartilage will produce a adjustable and potentially reversible, providing a controlled and noticeable improvement in profile contour. Because aggres- useful following the lateral aural “steal” technique in which a sive excision of the crural cartilage is avoided, suture modifica- pollybeak-type fullness may result as increasingly wider seg- tion of the lateral crus also preserves natural sidewall support ments of crural cartilage are advanced toward the midline. When desired, mattress sutures can also be placed between the Hence, suture-based techniques foster precision, predictability, nasal septum and the lateralmost cut margin of the paradomal and finesse in tip refinement relative to the haphazard and segment to reduce supratip width and further enhance tip unpredictable consequences of excessive cartilage excision. However, because excision of the para- Although conservative cartilage resection and/or aural augmen- domal margin preserves the entire vertical and horizontal alar tation grafting may still prove necessary in stubborn noses, buttress, as well as the entire nasal scroll, natural support to the suture-based techniques have virtually eliminated the need for lower nasal sidewall and alar margin remains largely unaltered. As stated above, conservative resection of lateral crural carti- lage is sometimes unavoidable in the difficult nose. Frequently the residual convexity is caused by the reduplicated layers of Surgical restoration of the overresected nasal tip is one of the thick cartilage present within the nasal scroll. In addition tion of both the upper and lower lateral cartilage creates four to proper alignment and symmetry, the restored tip must also layers of stacked cartilage within the nasal scroll, the mass effect appear natural and attractive, integrating harmoniously with of thick cartilage often creates undesirable width in the lower the surrounding face while maintaining adequate functional nose. Although excision of the reduplicated carti- operative aesthetic analysis and a thorough nasal examination. Note preservation of the nasal scroll and both the horizontal and vertical alar buttresses. Perhaps the most important of these steps is a systematic approach for exposure, repositioning, stabilization, tensioning of the lax nasal sidewall. Because ing the sagging lateral crural remnants by moving the nasal maximum surgical exposure is required to execute many of the domes downward (counterrotating) and/or forward (increasing essential maneuvers in tip restoration, the external rhinoplasty projection) as permitted by cosmetic tolerances. The cosmetic impact of sidewall ten- tip is to deconstruct the residual skeletal framework so that sioning is a reduction or elimination of lobular pinching and a components can be reassembled in a more attractive three- simultaneous reduction in alar retraction. Using the external rhinoplasty the secure fixation point provided by the buttressed septal approach, tedious and painstaking dissection is first used to extension graft (or its equivalent), sidewall tensioning is virtu- deglove the alar cartilage remnants, and care is taken not to ally impossible. On the other hand, as long as a secure fixation violate the inner or outer epithelial lining. Initially, all cartilage point is available, tensioning can be performed in virtually any elements are preserved in situ pending a final diagnostic nose, including the overprojected tip once the lateral crura have assessment before tissues are modified. Even noses dam- preserve the entire soft tissue envelop en bloc by dissecting aged by near-total resection of the lateral crura can be closely to the cartilage remnants. The membranous septum is improved with crural tensioning, often eliminating the need for then separated to expose the anterior septal angle, and both bulky sidewall grafts. In addition, by partial-thickness relaxing incisions in the submucosa to stretching both the lateral crural remnant and the surrounding “unravel” the internal lining and permit mobilization of the vestibular skin, sidewall tone is dramatically increased, and the malpositioned cartilage elements. Typically, contracture of the cross-sectional dimension of the internal nasal valve is often nasal lining is most severe in areas of previous cephalic resec- substantially enlarged. Owing to the increased resting tone of tion between the upper and lower lateral cartilages. Judicious the lower nasal sidewall, the threshold for dynamic nasal valve excision of fibrotic soft tissues from the undersurface of the collapse is also markedly increased. Moreover, because tension- skin flap may also be necessary in cases of severe soft tissue fib- ing frequently circumvents the need for sidewall grafting, rosis or inelasticity. Thinning the flap is a risky maneuver that encroachment of the internal nasal valve by bulky structural may devitalize the skin if the subdermal plexus is compromised grafts is avoided, a slender and more delicate nose is possible or if closing tension is excessive, but excision of fibrotic subcu- without limiting function, and satisfactory tip reconstruction is taneous fibromuscular tissues can also serve to increase skin often accomplished with far less graft material. Because the typical overresected tip is retraction may require onlay grafts, underlay grafts, or compo- pinched, underprojected, and overrotated, substantial increases site grafts for adequate stabilization of the alar margin against in nasal length and nasal projection are usually required. However, in many instances, alar haps the most important objective in secondary tip rhinoplasty rim grafts provide effective stabilization of the alar margin is to immobilize the nasal tip complex after proper reposition- without the bulk or weight typical of most sidewall grafts. Secure stabilization of the newly repositioned tip is critical These small, thin, and lightweight grafts are placed along the because an overly tight skin envelop or progressive shrink-wrap nostril rim adding both additional structural support and con- may substantially alter the unsupported nasal tip. In specific circumstan- eral nasal airway obstruction and associated nocturnal mouth- ces, a tongue-in-groove maneuver or a traditional columellar breathing, dry mouth, and frequent sleep disruption.

In this third edition of Case Files®: Anatomy discount eriacta online american express, the basic format of the book has been retained order eriacta 100 mg with mastercard. New cases include hydrocephalus cheap eriacta american express, knee injury, peritoneal irritation, rotator cuff injury, and thoracic outlet syndrome. We reviewed the clinical scenarios with the intent of improving them; however, their “real-life” presentations patterned after actual clinical experience were accurate and instructive. Through this third edition, we hope that the reader will continue to enjoy learning diagnosis and management through the simulated clinical cases. It certainly is a privilege to be teachers for so many students, and it is with humility that we present this edition. The Authors ix acknowLedgments The inspiration for this basic science series occurred at an educational retreat led by Dr. Buja served as Dean of the University of Texas Medical School at Houston from 1995 to 2003 before being appointed Executive Vice President for Academic Affairs. Lawrence Ross, who is a brilliant anato- mist and teacher, and my new scientist author Dr. Sitting side by side during the writing process as they precisely described the anatomical structures was academically fulfilling, but more so, made me a better surgeon. Cristo Papasakelariou, a dear friend, scientist, leader, and the fin- est gynecological laparoscopic surgeon I know. I would like to thank McGraw-Hill for believing in the concept of teaching by clinical cases. I owe a great debt to Catherine Johnson, who has been a fantastically encouraging and enthusiastic edi- tor. It has been amazing to work together with my daughter Allison, who is a senior nursing student at the Scott and White School of Nursing; she is an astute manu- script reviewer and already early in her career she has a good clinical acumen and a clear writing style. Ross would like to acknowledge the figure drawings from the University of Texas Medical School at Houston originally published in Philo et al. Joseph Medical Center, I would like to recognize our outstanding administrators: Pat Mathews and Paula Efird. Konrad Harms, Priti Schachel, Gizelle Brooks-Carter, John McBride, and Russell Edwards, this manuscript could not have been written. Most importantly, I am humbled by the love, affection, and encour- agement from my lovely wife, Terri, and our children, Andy and his wife Anna, Michael, Allison, and Christina. Toy xi intRoduction Mastering the diverse knowledge within a field such as anatomy is a formidable task. It is even more difficult to draw on that knowledge, relate it to a clinical setting, and apply it to the context of the individual patient. To gain these skills, the student learns best with good anatomical models or a well-dissected cadaver, at the labo- ratory bench, guided and instructed by experienced teachers, and inspired toward self-directed, diligent reading. Even with accurate knowledge of the basic science, the application of that knowledge is not always easy. Thus, this collection of patient cases is designed to simulate the clinical approach and stress the clinical relevance to the anatomical sciences. Most importantly, the explanations for the cases emphasize the mechanisms and structure–function principles rather than merely rote questions and answers. This book is organized for versatility to allow the student “in a rush” to go quickly through the scenarios and check the corresponding answers or to consider the thought- provoking explanations. The answers are arranged from simple to complex: the bare answers, a clinical correlation of the case, an approach to the pertinent topic includ- ing objectives and definitions, a comprehension test at the end, anatomical pearls for emphasis, and a list of references for further reading. The clinical vignettes are listed by region to allow for a more synthetic approach to the material. We intentionally used open-ended questions in the case scenarios to encourage the student to think through relations and mechanisms. Approach to Learning Learning anatomy consists not only in memorization but also in visualization of the relations between the various structures of the body and understanding their corresponding functions. Instead, the student should approach an anatomical structure by trying to correlate its purpose with its design. Structures that are close together should be related not only spatially but also functionally. The student should also try to project clinical significance to the anatomical findings. For example, if two nerves travel close together down the arm, one could speculate that a tumor, laceration, or isch- emic injury might affect both nerves; the next step would be to describe the deficits expected on physical examination. The student must approach the subject in a systematic manner, by studying the skeletal relations of a certain region of the body, the joints, the muscular system, the cardiovascular system (including arterial perfusion and venous drainage), the nervous system (such as sensory and motor neural innervations), and the skin. Each bone or muscle is unique and has advantages due to its structure and limi- tions or perhaps vulnerability to specific injuries. The student is encouraged to read through the description of the anatomical relation in a certain region, correlate illustrations of the same structures, and then try to envision the anatomy in three dimensions. For instance, if the anatomical drawings are in the coronal plane, the student may want to draw the same region in the sagittal or cross-sectional plane as an exercise to visualize the anatomy more clearly. Basic Terminology Anatomical position: The basis of all descriptions in the anatomical sciences, with the head, eyes, and toes pointing forward; the upper limbs by the side with the palms facing forward; and the lower limbs together. Anatomical planes: A section through the body, one of four commonly described planes. The median plane is a single vertically oriented plane dividing the body into right and left halves, whereas the sagittal planes are oriented parallel to the median plane but not necessarily in the midline. Coronal planes are perpendicular to the median plane and divide the body into anterior (front) and posterior (back) portions. Transverse, axial, or cross-sectional planes pass through the body per- pendicular to the median and coronal planes and divide the body into upper and lower parts. Directionality: Superior (cranial) is toward the head, whereas inferior (caudal) is toward the feet; medial is toward the midline, whereas lateral is away from the midline. Proximal is toward the trunk or attachment, whereas distal is away from the trunk or attachment. Motion: Adduction is movement toward the midline, whereas abduction is move- ment away from the midline. Extension is straightening a part of the body, whereas flexion is bending the structure. Approach to Reading The student should read with a purpose and not merely to memorize facts. Reading with the goal of comprehending the relation between structure and function is one of the keys to understanding anatomy. Also, the ability to relate the anatomical sci- ences to the clinical picture is critical. The following seven key questions are help- ful in ensuring the effective application of basic science information to the clinical setting. Given the importance of a certain required function, which anatomical struc- ture provides the ability to perform that function? Which lymph nodes are most likely to be affected by cancer at a particular location? If an injury occurs to one part of the body, what is the expected clinical manifestation?

Cimetidine (a drug for peptic ulcer disease) can inhibit renal excretion of pramipexole best 100 mg eriacta, thereby increasing its blood level cheap eriacta american express. Ropinirole [Requip] buy eriacta 100 mg visa, a nonergot dopamine agonist, is similar to pramipexole with respect to receptor specificity, mechanism of action, indications, and adverse effects. In contrast to pramipexole, which is eliminated entirely by renal excretion, ropinirole is eliminated by hepatic metabolism. When ropinirole is used alone, the most common effects are nausea, dizziness, somnolence, and hallucinations. When ropinirole is combined with levodopa, the most important side effects are dyskinesias, hallucinations, and postural hypotension. Note that these occur less frequently than when pramipexole is combined with levodopa. Like pramipexole, ropinirole can promote compulsive gambling, shopping, eating, and hypersexuality. Rotigotine [Neupro] is a nonergot dopamine agonist that is specific for selected dopamine receptors. Although the exact mechanism of action is unknown, it is believed that rotigotine improves dopamine transmission by activating postsynaptic dopamine receptors in the substantia nigra. Because first-pass metabolism of rotigotine is extensive, oral formulations are not manufactured. The time from application to peak is typically 15 to 18 hours but may range from 4 to 27 hours. These include a variety of sleep disorders, dizziness, headache, dose-related hallucinations, and dose-related dyskinesia. Some patients develop skin reactions at the site of application, and hyperhidrosis (excessive perspiration) may occur. Apomorphine is a derivative of morphine but is devoid of typical opioid effects (e. Apomorphine is highly lipophilic but undergoes extensive first-pass metabolism and hence is ineffective when taken orally. After subcutaneous (subQ) injection, the drug undergoes rapid, complete absorption. The most common adverse effects are injection-site reactions, hallucinations, yawning, drowsiness, dyskinesias, rhinorrhea, and nausea and vomiting. During clinical trials, there was a 4% incidence of serious cardiovascular events: angina, myocardial infarction, cardiac arrest, or sudden death. In addition, apomorphine can promote hypersexuality and enhanced erections (the drug is used in Europe to treat erectile dysfunction). Rarely, apomorphine causes priapism (sustained, painful erection), possibly requiring surgical intervention. To prevent nausea and vomiting during clinical trials, nearly all patients were treated with an antiemetic, starting 3 days before the first dose of apomorphine. About half the trial participants discontinued the antiemetic at some point but continued taking apomorphine. The side-effect profile of the ergot derivatives differs from that of the nonergot agents because, in addition to activating dopamine receptors, the ergot drugs cause mild blockade of serotonergic and alpha-adrenergic receptors. Bromocriptine [Cycloset, Parlodel], a derivative of ergot, is a direct-acting dopamine agonist. When combined with levodopa, bromocriptine can prolong therapeutic responses and reduce motor fluctuations. In addition, because bromocriptine allows the dosage of levodopa to be reduced, the incidence of levodopa-induced dyskinesias may be reduced too. The most common dose-limiting effects are psychological reactions (confusion, nightmares, agitation, hallucinations, paranoid delusions). Rarely, bromocriptine causes retroperitoneal fibrosis, pulmonary infiltrates, a Raynaud-like phenomenon, and erythromelalgia (vasodilation in the feet, and sometimes hands, resulting in swelling, redness, warmth, and burning pain). In addition, the ergot derivatives have been associated with valvular heart disease. Consequently, cabergoline is rarely used unless other management attempts have failed. A more concerning adverse effect is the development of cardiac valve regurgitation and subsequent development of heart failure. With both drugs, benefits derive from inhibiting metabolism of levodopa in the periphery; these drugs have no direct therapeutic effects of their own. Like carbidopa, entacapone inhibits metabolism of levodopa in the intestine and peripheral tissues. In clinical trials, entacapone increased the half-life of levodopa by 50% to 75% and thereby caused levodopa blood levels to be more stable and sustained. Pharmacokinetics Entacapone is rapidly absorbed and reaches peak levels in 2 hours. Elimination is by hepatic metabolism followed by excretion in the feces and urine. Adverse Effects Most adverse effects result from increasing levodopa levels, although some are caused by entacapone itself. By increasing levodopa levels, entacapone can cause dyskinesias, orthostatic hypotension, nausea, hallucinations, sleep disturbances, and impulse control disorders (see “Pramipexole”). The most common are vomiting, diarrhea, constipation, and yellow-orange discoloration of the urine. In addition to levodopa, these include methyldopa (an antihypertensive agent), dobutamine (an adrenergic agonist), and isoproterenol (a beta-adrenergic agonist). If entacapone is combined with these drugs, a reduction in their dosages may be needed. As with entacapone, benefits derive from inhibiting levodopa metabolism in the periphery, which prolongs levodopa availability. When given to patients taking levodopa, tolcapone improves motor function and may allow a reduction in levodopa dosage. For many patients, the drug reduces the “wearing-off” effect that can occur with levodopa, thereby extending levodopa “on” times by as much as 2. Unfortunately, although tolcapone is effective, it is also potentially dangerous: deaths from liver failure have occurred. Because it carries a serious risk, tolcapone should be reserved for patients who cannot be treated, or treated adequately, with safer drugs. When tolcapone is used, treatment should be limited to 3 weeks in the absence of a beneficial response. They also should be informed about signs of emergent liver dysfunction (persistent nausea, fatigue, lethargy, anorexia, jaundice, dark urine) and instructed to report these immediately. If liver injury is diagnosed, tolcapone should be discontinued and never used again.