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Sinus tracts form (which can become draining fistulas) in the apocrine gland body 3 pulse pressure explained discount 0.25 mg lanoxin with visa. Microsurgical approach is preferable tissue with healing by secondary intention i arterial occlusion buy generic lanoxin 0.25 mg online. Antibiotics: Tetracycline and erythromycin may be helpful long-term catheter for bladder drainage ii arrhythmia high blood pressure discount lanoxin 0.25 mg without a prescription. Subtotal penile loss: release penile suspensory ligament blood pressure homeostasis trusted lanoxin 0.25mg, recess scrotum and suprapubic skin, apply skin graft to remaining stump 2. Can be done in one-stage procedure, sensation may be restored, better appearance, competent urethra, may have adequate rigidity (fibula) d. Infection begins at skin, urinary tract, rectum and spreads to penis, scrotum, perineum, abdomen, thighs, and flanks in the Dartos, Scarpa’s, and Colles fascia c. Handbook of Plastic the surgical treatment of hand problems is a specialized area of interest in plastic surgery. It must function with precision, as in writing, as well as with strength, Surgery 6th Edition. Chest reconstruction: Anterior and anterolateral chest wall and wounds affecting respiratory function. Chest reconstruction: Regional reconstruction of chest wall wounds that do not affect respiratory function (axilla, posterolateral chest, and posterior trunk). Wrist – a large number of tendons, nerves and vessels pass through a very small space, 3. Motor branch of median nerve; test palmar abduction of thumb against resistance d. Motor branch of ulnar nerve; ask patient to fully extend fingers, then spread fingers or cross fingers. Color – nailbed should be pink, blanch with pressure, and show capillary refill 6. Temperature – finger or hand should be similar in temperature to uninjured parts 8. If a hand surgeon is not available, clean and suture the skin wound, splint the examination and treatment. An awake patient will tolerate a tourniquet for 15-30 min hand, and refer as soon as possible for delayed primary repair. If bleeding is a problem, apply direct pressure and elevate until definitive care done within 10 days available 9. Reduce fractures and dislocations, apply internal or external fixation if needed a. Splinting should be in safe position when possible, but alternative positioning 3. Position where collateral ligaments are at maximum stretch, so motion can be extension, and dorsal blocking splint for flexor tendon repairs regained with least effort Fig. Proper splinting prevents further injury, prevents vessel obstruction, prevents further tendon retraction 4. All flexor tendon, nerve and vascular injuries, open fractures, and complex injuries are managed in the operating room 5. Wrap part in gauze moistened in saline, place in clean plastic bag or specimen cup, seal c. Don’t immerse part directly in ice water or pack directly in ice – it may freeze 3. Evaluate blood supply circumferential full thickness burns may require escharotomy c. Pressure from edema and pus in a closed space can produce necrosis of tendons, nerves, blood vessels, and joints in a few hours. Paronychia infection of the lateral nail fold Treatment: if early, elevation of skin a. Nail can be cleaned and replaced as a splint, or silastic sheet used as splint to b. Pressure of abcess may impair blood supply prevent adhesion of the eponychial fold to the nailbed c. Have high index of suspicion – patients are often unwilling to admit being in a 2. Most common site over a knuckle ulnar collateral ligament, might need operative repair) b. Treatment can range from gentle protective motion if Minimally displaced to closed reduction and cast to open reduction and internal fixation b. If involved finger overlaps another, there is rotation at the fracture site which must be reduced. Unstable fractures require internal or percutaneous fixation Duplication of 5th finger is common autosomal dominant trait in African-Americans. Joint surfaces should be anatomically reduced Thumb duplication often requires reconstructive surgery 3. Most can be treated with closed reduction; open reduction can be necessary if supporting structures prevent the reduction. Rheumatoid arthritis – synovial hypertrophy can lead to nerve compressions (carpal tunnel syndrome), joint destruction. Nerve compressions – compression of nerve by overlying muscle, ligament or fascia 1. Not all ulcers of the lower extremity will require the plastic and reconstructive surgeon is often called upon to treat many wound problems of the surgical intervention when appropriate management is pursued. These include leg ulcers of various etiologies, trauma with extensive soft tissue ulcers is wound hygiene, correction of the underlying problem, and specific surgical loss or exposed bone, vascular or neural structures, and lymphedema. The plastic surgeon is an integral member of the treatment team from the onset of the problem. If so, the treatment must address both An ulcer is an erosion in an epithelial surface. Pentoxifylline therapy in combination or as substitute for compression therapy if 2. Surgical treatment requires excision of the entire area of the ulcer, scar tissue, and b. Usually more distal on the foot than venous stasis ulcers surrounding area of increased pigmentation (hemosiderin deposition). Most often found on the lateral aspects of the great and fifth toes, and the dorsum ligation of venous perforators is also performed of the foot i. Usually located on plantar surface of foot over metatarsal heads or heel hypertension, diabetes, etc. If possible, it is best to perform bypass surgery first, and then healing of the ulcer a. Failure to heal is usually due to compromised area of the ulcer, scar tissue, and by any means will be easier surrounding blood supply and an unstable scar f. Usually occurs over bony prominence proximal amputation may be required if revascularization is not possible c. Debride necrotic tissue and use topical and systemic antibiotics to control the. Be conservative in care; early amputation is detrimental since many patients will a. Frequently associated with arthritis and/or inflammatory bowel disease or an have life-threatening infections in the other leg within a few years underlying carcinoma c. After control of bacterial contamination, small ulcers may be excised and closed b. Clinical diagnosis microscopic appearance non-specific primarily; larger ulcers may require flap coverage 70 71 d. The medial and lateral heads of the gastrocnemius muscle are most often utilized. Rule out proximal arterial occlusion and improve arterial inflow when needed to cover an open knee joint f. Lower Leg Patient education in caring for and examining their feet is extremely important a.

Characteristics of ether include: • Low boiling point 34oC Magnet • High saturated vapour pressure 56 blood pressure chart cdc discount lanoxin 0.25mg. It has cloth wicks which still • Sympathomimetic contain 200mls of ether when the level indicator is empty hypertension 40 mg order lanoxin 0.25 mg fast delivery. It has a temperature indicator which is • Some analgesic efect at low doses red when above 30oC blood pressure medication in the morning or at night buy 0.25 mg lanoxin, aluminium at less than 10oC and black • Potentiates the efect of muscle relaxants at the optimal working temperature 10oC to blood pressure video purchase lanoxin 0.25mg line 30oC. It produces • Tends to increase blood glucose concentration, and to relax very accurate concentrations with variable fow rates but loses uterine muscle precision with continuous fow and with extremely low fow rates. Increase the concentration by 1% every 6-8 breaths omV up to 10% and then increase it by 2. Tere is a risk of explosion which is No minimised when using only air as the carrier gas and in remote keyed locations diathermy is rarely available. If diathermy is being flling used a safe distance of 20cm between the expired port and the diathermy should be maintained. It has a metal wick and is not thermally compensated but only thermally bufered with an ethylene glycol jacket. In the original design the downstream vaporiser was flled Temperature with trichloroethylene. The calibration scale can be detached indicator allowing use of diferent inhalational agents, most commonly Level indicator halothane. It is accurate with variable fow rates but this Port for flling accuracy drops of in the continuous fow mode. As it is only the vaporiser thermally bufered, with prolonged and high gas fows the concentration decreases as the temperature decreases and you will see condensation appear on the outer surface. It is thermally As such high concentrations are required to maintain compensated with a bimetallic strip. In recent years this system has been incorporated into a more typical anaesthesia machine, the Glostavent • Total ventilation • Oxygen fow rate • Size of the reservoir tubing upstream of the vaporiser. The respiratory rate and inspiration/expiration ratio have much less infuence on the inspired oxygen concentration. If the reservoir tubing is short, with a volume of 104ml, then a high inspired oxygen concentration is impossible whatever fow rate is used. With a reservoir tubing of at least one metre in length and 415ml volume an inspired oxygen concentration (FiO) of 30% can be achieved with a fow rate 1L. Tere was a paediatric Oxford infating bellows and The portable Diamedica drawover system has overcome the a pedivalve instead of the standard Ambu E valve. Another way to use drawover in children is to convert it to Standard drawover systems have to be adapted for use in small a “manual continuous fow”. This sucks a fow of air and oxygen across the vaporiser and The other issue in paediatrics is the performance of the flls the bag on the T-piece which is used to ventilate the vaporiser. The compression of the bellows has to be constant and be efcient at small tidal volumes as their output is afected continue in both spontaneous and assisted ventilation. With all similar efect can be achieved with a self-infating bag but as the vaporisers except the recently designed ones, there is a by its nature a self-infating bag reinfates automatically with noticeable loss of output with continuous fow. It is important not to over compress the self-infating bag as this will be transmitted to the baby’s lungs Merucry and may cause overinfation. This “manual continuous fow” sphygmomanometer mimics adult drawover but the output of the vaporisers is not as expected. You will usually need to dial up a higher inspired concentration and is therefore less economical. It can be used when there is no oxygen or electricity but it is very labour Farman’s intensive as one hand is pumping the bellows and the other entrainer ventilating with the Ayre’s T-piece. This can make it difcult at induction especially if there is no assistance to the anaesthetic provider. Another way of using the drawover apparatus in small infants Oxygen supply is to convert it to simple continuous fow. This can be done using a Farman’s entrainer: • Fits into the distal end of any drawover vaporiser. Farman’s entrainer in use with the emo • Acts as a venturi entraining air as oxygen fows through at 1 1 Figure 5. You may prefer to insert a paediatric selffor their valves: this is still a low pressure system and fow could infating bag instead. With halothane it is much safer if vaporisers markedly lose their accuracy: drawover vaporisers oxygen can be added to air using reservoir tubing at least 1 were designed for intermittent gas fow. Adjust the fow of oxygen until the minimal equipment, the drawover system can provide a safe, manometer reads 100mmHg which is supposed to ensure robust, portable and cost efective system for anaesthetising a total fow of 10-12L. You can also produce continuous fow by simply attaching Key points: the oxygen supply directly onto the vaporiser and putting an • <5kg assist ventilation for all cases Ayre’s T-piece on the outlet of the vaporiser. This needs a high fow of oxygen and a one way valve between the vaporiser and • 5-10kg spontaneous ventilation for short cases, assisted the T-piece to prevent backfow and ensure flling of the bag ventilation if longer than 20 minutes on the T-piece. As with the Farman’s entrainer the vaporiser • >10kg spontaneous ventilation unless muscle relaxation will deliver signifcantly lower concentrations than expected. In the newer designed systems with a reservoir bag attached to the inlet of the vaporiser, you can connect a T-piece with reFerenceS a one way valve directly to the vaporiser outlet or substitute a 1. In situations where there is a lack of paediatric equipment it is safe to use the adult drawover equipment. Minimum oxygen requirements during anaesthesia with the Triservice all babies under 5kg body weight however short the procedure. You may allow 5-10kg infants to breathe spontaneously for short cases but use assisted ventilation for the longer cases. If only the Oxford infating bellows is in use then you must remember Figure 1 and 6 courtesy of Dr Iain Wilson. Many conditions afect multiple • Prominent epicanthic folds, upwardly systems, so it is important for the anaesthetist to slanting palpebral fssures. This article will consider Summary Down syndrome and other congenital syndromes of • Single transverse palmar crease and wide 1st and 2nd toe gap. Where history or examination reveals pulmonary infections, hypoventilation due to muscle hypotonia, and any signs or symptoms suspicious of cervical cord compression, obstructive sleep apnoea. It is recommended that all newborns with elective surgery should be postponed and specialist referral made. Morbidity position or difcult laryngoscopy is anticipated, it is recommended and mortality for uncorrected lesions is high. Surgical correction of that radiological evidence of cervical spine stability be obtained. Central Nervous System Conduction defects can occur following surgical repair of defects. Musculoskeletal Screening for thyroid disease should be undertaken at birth, 6 • Craniocervical instability, months and yearly thereafter. Asymptomatic atlantoaxial dislocation • Acute lymphoblastic leukaemia, acute myeloid leukaemia, occurs in 12 to 20%, however spinal cord compression is rare. Lateral fexion, extension and odontoid preoperative evaluation of a child with down cervical spine radiographs are poorly predictive of cord compression. Appropriately-sized oro/naso-pharyngeal airways and laryngeal mask airway must be You must assess the airway and evaluate for features of craniocervical immediately available to rescue a potentially difcult airway. Tere is also a higher incidence of airway obstruction on emergence and an increased incidence of post-extubation stridor (1. During other children with developmental delay and associated behavioural procedures such as laryngoscopy, rigid bronchoscopy and disorders, careful preoperative preparation is essential, enlisting oesophagoscopy, attempt to maintain the neck in a neutral position the help of parents, in order to try to gain the child’s trust and avoiding excessive extension or fexion. Preoperatively the child and parent should be given the not appear to be at high risk with neck rotation up to 60 degrees. Antacid premedication The use of regional anaesthetic techniques may be challenging in may be benefcial in those with gastro-oesophageal refux disease. Hypotonia may afect the ability to maintain the airway, fact be benefcial for several reasons including the higher 4 which may require simple airway manoeuvres (head tilt, chin lift or reported incidence of bradycardia on induction of anaesthesia, jaw thrust) or positioning the child in the lateral position to maintain the chronotropic efects in the presence of low plasma 7 airway patency. Where craniocervical instability is suspected or catecholamine concentrations and for its antisialogogue efects. Use of intraoperative considerations in down syndrome airway adjuncts (oropharyngeal or nasopharyngeal airway) may be Routine monitoring should be used as for any other case. Postoperative agitation incidence of airway obstruction on induction and the occurrence can be problematic, occasionally requiring sedation to prevent of severe bradycardia on induction. This may be limited by the presence of parents or carers in infection and all invasive lines should be inserted under full aseptic combination with efective analgesia.

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The tip of the corneal image aligns with a scale reading representing its distance from the orbital rim blood pressure young female lanoxin 0.25 mg without a prescription. The distance between the two measuring devices is adjusted so that each aligns with and abuts against its corresponding orbital rim blood pressure 50 over 30 order lanoxin 0.25 mg. To allow reproducibility for repeat measurements in the future ocular hypertension cheap lanoxin 0.25mg on line, the distance between the two devices is recorded from an additional scale on the horizontal bar blood pressure medication yeast infections lanoxin 0.25mg sale. Using the first mirror scale, the patient’s right eye position is measured as it fixates on the examiner’s left eye. This abnormal forward protrusion of the eye can be produced by any significant increase in orbital mass, because of the fixed size of the bony orbital cavity. As with any form of ophthalmoscopy, a dilated pupil and clear ocular media provide the most optimal view. One of the most common applications is disk photography, used in the evaluation for glaucoma. Since the slow progression of glaucomatous optic nerve damage may be evident only by subtle alteration of the disk’s appearance over time (see Chapter 11), precise documentation of its morphology is needed. By slightly shifting the camera angle on two consecutive shots, a “stereo” pair of slides can be produced that will provide a three-dimensional image when studied through a stereoscopic slide viewer. Stereo disk photography thus provides the most sensitive means of detecting increases in glaucomatous cupping. The dye highlights vascular and anatomic details of the fundus, making fluorescein angiography invaluable in the diagnosis and evaluation of many retinal conditions. Because it can so precisely delineate areas of abnormality, it is an essential guide for planning laser treatment of retinal vascular disease. After a small amount of fluorescein is injected into a vein in the arm, it circulates throughout the body before eventually being excreted by the kidneys. As the dye passes through the retinal and choroidal circulation, it can be visualized and photographed because of its properties of fluorescence. A blue “excitatory” filter bombards the fluorescein molecules with blue light from the camera flash, causing them to emit a green light. The “barrier” filter allows only this emitted green light to reach the photographic film, blocking out all other wavelengths of light. A digital black and white photograph results, in which only the fluorescein image is seen. Because the fluorescein molecules do not diffuse out of normal retinal vessels, the latter are highlighted photographically by the dye (Figure 2–28). The diffuse background “ground glass” appearance results from fluorescein filling of the separate underlying choroidal circulation. The choroidal and retinal circulations are anatomically separated by a thin, homogeneous monolayer of pigmented cell—the “retinal pigment epithelium. In contrast, focal atrophy of the pigment epithelium causes an abnormal increase in visibility of the background fluorescence (Figure 2–29). The photo has been taken after the dye (appearing white) has already sequentially filled the choroidal circulation (seen as a diffuse, mottled, whitish background), the arterioles, and the veins. The macula appears dark due to heavier pigmentation, which obscures the underlying choroidal fluorescence that is visible everywhere 118 else. Abnormal fluorescein angiogram in which dye-stained fluid originating from the choroid has pooled beneath the macula. This is one type of abnormality associated with age-related macular degeneration (see Chapter 10). Secondary atrophy of the overlying retinal pigment epithelium in this area causes heightened, unobscured visibility of this increased fluorescence. A fluorescein study or “angiogram” therefore consists of multiple sequential black and white photos of the fundi taken at different times following dye injection (Figure 2–30). Early-phase photos document the dye’s initial rapid, sequential perfusion of the choroid, the retinal arteries, and the retinal veins. Later-phase photos may, for example, demonstrate the gradual, delayed leakage of dye from abnormal vessels. This extravascular dye-stained edema fluid will persist long after the intravascular fluorescein has exited the eye. A: Right eye showing poorly defined (edematous) macula (unfilled arrow) with scanty exudates and multiple large dark blot hemorrhages (filled arrows) suggesting retinal ischemia. B: Left eye neovascularization (abnormal new vessels) on the disk (unfilled arrow). C: Right eye arteriovenous phase when fluorescein (seen as white) has filled the arterioles (unfilled arrows) and almost completely filled the veins (filled arrows). D: Left eye late phase showing extensive retinal nonperfusion (hypofluorescence) (arrows). E: Right eye late phase showing enlargement of the foveal avascular (nonfluorescent) zone (filled arrow) and leakage of 120 fluorescein (edema) in the surrounding retina (unfilled arrows). F: Left eye later phase showing increasing leakage of fluorescein (arrow) from the new vessels on the optic disk. Changes in blood flow such as ischemia and vascular occlusion are seen as an interruption of the normal perfusion pattern. Abnormal vascular permeability is seen as a leaking cloud of dye-stained edema fluid increasing over time. Hemorrhage does not stain with dye but rather appears as a dark, sharply demarcated void. This is due to blockage and obscuration of the underlying background fluorescence. Indocyanine green angiography is superior for imaging the choroidal circulation, particularly when there is surrounding or overlying blood, exudate, or serous fluid. As opposed to fluorescein, indocyanine green is a larger molecule that binds completely to plasma proteins, causing it to remain in the choroidal vessels. Unique photochemical properties allow the dye to be transmitted better through melanin (eg, in the retinal pigment epithelium), blood, exudate, and serous fluid. This technique may serve as a useful adjunct to fluorescein angiography for imaging occult choroidal neovascularization. Microscopic changes in the macula, such as edema (Figure 2–31), can be imaged and measured. Imaging of the optic disk and the peripapillary retinal nerve fiber layer, with comparison to data from normal individuals and from prior examinations, facilitates early detection and monitoring of optic nerve damage (Figure 2–32). Optical coherence tomography cross-section image of a normal macula (A) and a macula with pigment epithelial detachment showing fluid beneath the retinal pigment epithelium (B). Retinal nerve fiber layer optical coherence tomography scans showing borderline thinning in one eye (A), predominantly temporal thinning in both eyes (B), and global thinning in both eyes (C). This can provide high125 resolution images and measurements of the cornea, iris, and intraocular devices and lenses. Fundus autofluorescence depends on the autofluorescence of lipofuscin, which is a naturally occurring byproduct of phagocytosis of photoreceptor outer segments, but abnormalities of its distribution and concentration are useful indicators of retinal damage (Figure 2–33). Fundus autofluorescence with sharply demarcated area of 126 hypofluorescence in the left eye (arrow) due to laser burn. Highfrequency sound waves are emitted from a special transmitter toward the target tissue. As the sound waves bounce back off the various tissue components, they are collected by a receiver that amplifies and displays them on an oscilloscope screen. A single probe that contains both the transmitter and receiver is placed against the eye and used to aim the beam of sound (Figure 2–34). Various structures in its path will reflect separate echoes (which arrive at different times) back toward the probe. Those derived from the most distal structures arrive last, having traveled the farthest. Each returning echo is displayed as a spike whose amplitude is dependent on the density of the reflecting tissue. The spikes are arranged in temporal sequence, with the latency of each signal’s arrival correlating with that structure’s distance from the probe (Figure 2–35).

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Techniques in which these concepts are promoted have been shown to hypertension complications discount lanoxin 0.25 mg otc produce the most acceptable results in the long-term arteria genus purchase lanoxin 0.25 mg online. In reality define pulse pressure quizlet buy generic lanoxin 0.25 mg on-line, given even the most favourable circumstances blood pressure explained discount lanoxin 0.25 mg on-line, secondary surgery may be required and a return to the basic principles employed in primary surgery rather than modifying the existing state is necessary. However, there are other surgical procedures that are required as the child grows older. Where problems with speech exist, that cannot be resolved by therapy alone, velopharyngeal surgery may be necessary. Following assessment, this includes revision palatoplasty, palatal lengthening or pharyngoplasty. Later, in clefts involving the alveolus, bone grafting is carried out usually between the ages of 7 and 11 years. When growth is complete orthognathic surgery to correct abnormal facial bone development, in particular an under-developed maxilla, may be needed. Finally, there may be residual deformities of the nose and rhinoplasty will be required. Ultimately, the adherence to an agreed protocol working in a fully equipped and co-ordinated setting with a full complement of concerned professionals and the facility for collection of data such that problems can be identified and corrected at the earliest possible opportunity, will enable the surgeon to ensure the best outcome. Craniofacial Surgery Craniofacial surgery is concerned with the management of patients presenting with congenital or acquired conditions, affecting the hard and soft tissues of the head and face. The Department of Health approves and funds designated centres for the management of craniofacial conditions including: Craniosynostoses Craniofacial dysostoses Orbital dysostosis Encephalocoeles Craniofacial clefts these conditions are evident early in life and most patients are children under the age of 2. Patients referred to designated units are assessed and investigated by a multidisciplinary team and treatment combines the principles of maxillofacial reconstruction with neurosurgery. The surgical techniques employed in congenital conditions can also be applied to good effect in the treatment of skull base tumours and craniofacial trauma. Premature fusion of one or more skull sutures (craniosynostosis) occurs in 1 in 2,000 of the population. Syndromic craniosynostoses, such as Crouzon and Apert syndromes occur in 1 in 10,000 and 1 in 150,000 live births respectively. Historically, patients underwent numerous procedures performed by various clinicians from different surgical specialties. Results were generally poor and associated with high morbidity and even mortality. Many patients with severe deformity were denied surgery, because of the risks involved. The surgery is major, often protracted and associated with significant blood loss in the small child. Intensive care is needed for the more complex cases, or where the airway is compromised. Some children require more than one procedure as growth and dental development influence facial form and function. However, with an active, established team and utilising contemporary techniques, such as distraction osteogenesis, it is possible to perform fewer, more extensive procedures. The craniofacial principles of wide surgical exposure, primary bone grafting and internal fixation should be applied to the management of complex craniofacial trauma. Severely injured patients of all ages can be stabilised and offered early definitive treatment using these techniques. Morbidity is reduced and hospital stay shortened and there is an overall improvement in outcome. These surgical approaches can also be used to access intracranial and skull base lesions. By drawing on expertise gained in the management of trauma, tumour and congenital disease of the soft and hard tissues of the face, the maxillofacial surgeon plays a key role in craniofacial surgery. Skull Base Surgery the base of the skull is a complex and relatively inaccessible region. Pathology in this area may arise from either within the skull itself or from adjacent areas such as the paranasal sinuses, the orbit and the face. Conventional approaches to skull base lesions frequently require prolonged retraction of the brain and/or the resection of uninvolved structures to improve exposure. The resultant morbidity of such techniques, in terms of both cerebral function and facial appearance were often considerable with the result that many deep-seated skull based tumours were considered inoperable. The limited access also made adequate reconstruction of defects difficult and, in some cases, impossible. Recent developments in surgical approaches to the skull base are based on the temporary disarticulation or dismantling of the skeleton of the face and the skull to varying degrees. These bone segments are mobilised either as free bone segments, completely detached from the soft tissues, or pedicled to the soft tissues to retain their blood supply. In most cases the so-called "access osteotomy" is combined with a conventional craniotomy. Facial incisions are avoided wherever possible the coronal scalp flap and intraoral incisions providing adequate exposure in many cases. If facial incisions are necessary, these are carefully sited and will usually heal with an imperceptible scar. Maxillofacial Surgeons, by virtue of their training in surgery of the facial bones and soft tissues, have contributed significantly to the development of the surgical access techniques now in common practice. Sophisticated imaging techniques accurately identify both the position and dimensions of lesions and, in some cases, correctly diagnosing their nature. Interventional radiologists can reduce the blood supply of tumours and vascular abnormalities further decreasing the potential morbidity of surgery, which at times allows surgeons to treat previously inoperable lesions. The recent development of "navigation" systems enables surgeons to pinpoint their position in three dimensions at the time of surgery, which is of particular value where the pathology has destroyed the usual anatomical landmarks. The selective use of minimally invasive techniques and focused radiosurgery will also become more common as the limits of such techniques are appreciated. Notwithstanding these developments, adequate access to skull base pathology will remain an essential requirement for successful surgical treatment. The data drives a laser over a bath of photosensitive resin which produces a series of stacked slices, and an accurate three-dimensional industrial prototype or model. These so-called bio-models can be extremely useful in a number of particular clinical situations involving bony facial deformities, as this process allows the accurate visualisation of the facial skeleton. It is an invaluable aid to both the diagnosis and treatment planning of congenital, developmental and post-traumatic conditions affecting the facial region. In particular, it allows the maxillofacial surgeon to appreciate spatial displacements in all three dimensions and to make accurate measurement of the deformity. The correction of post-traumatic or development facial asymmetry has always been difficult. Great accuracy is required to achieve a successful surgical result, due to the fact that facial deformity and asymmetry is often the result of relatively small magnitudes of bony displacement or deformity. The surgeon is then able to practice the surgery on the model, thereby allowing full appreciation of the osteotomy bone cuts required to achieve the desired results, together with any areas which may require augmentation with bone grafts. Valuable theatre time can be saved, by allowing the pre-operative of bone plates to be used for fixation on the "post-operative" bio-model that demonstrates the planned realignment of the facial bones. This technique also ensures there is surgical accuracy in achieving the planned outcome for the patient. Stereolithographic bio-models can also allow the measurement of volume estimation of both bony structures for possible implantation and of bony cavities for reconstructive purposes. Stereolithography has been used in maxillofacial surgery in the following situations: the diagnosis of and planning of corrective surgery for congenital facial deformities Late reconstruction of complex bony facial trauma Orbital volume estimation, for the correction of post-traumatic enophthalmos Orbital reconstruction, following ablative surgery for malignancy Evaluation of bone availability for the placement of osteo-integrated implants, both extra and intra oral the pre-operative adaptation of temporomandibular joint prostheses for the treatment of advanced, degenerative joint disease, or posttraumatic bony ankylosis Facial Aesthetic Surgery Facial appearance is of the utmost social and psychological importance. There tend to be fairly standard ideals of what constitutes a "normal" or beautiful/handsome face and many attempts have been made to quantify the proportions of the face and the produce the "ideal" face as a guide to artists and surgeons. Variations from the "norm" are often perceived as imperfections, or even outright ugliness by individuals who seek surgical correction. They are often self-conscious, lack confidence and may even be psychologically disturbed by their appearance. Other people may suffer an exaggerated ageing appearance which can be accelerated and accentuated by excess ultra-violet irradiation (photo-ageing), smoking, excess alcohol, diet or a combination of all four. Finally, and probably most importantly, faces can be disfigured as a result of facial injury or as a result of surgery for malignancy. Facial aesthetic surgery is part of the training programme for higher surgical trainees in oral & maxillofacial surgery and as a specialty we have extensive knowledge of the growth, development, anatomy, function and inter-relationships of all components of the face and jaws. The commonest procedures undertaken are: Rhinoplasty, to alter the shape/size of the nose and to improve nasal function Pinnaplasty, to correct the fairly common deformity of "bat ears" Genioplasty, to correct deformity of the chin the ageing face, where the muscles start to sag, causing the over-lying skin to sag also.

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