김포공항 발렛주차는 편도대여가 가능한가요?
편도대여가 가능한가요 가족용 차량을 직접 운전하는 경우나 여행 시 특수 장비를 갖춘 장애인 차량이 필요한 경우 김포공항의 발레파킹 서비스를 이용하면 터미널까지 편리하게 이동할 수 있습니다. 아래 글에서는 비용, 김포공항 발레파킹 주차장 위치, 예약 전 알아두어야 할 사항에 대해 필요한 모...
Male revision rhinoplasty surgery is the most difficult and challenging procedure performed by facial plastic surgeons. Perfecting three-dimensional nose surgery takes years to improve and perhaps master. In rhinoplasty surgery, the minor rhinoplasty maneuvers we do today can lead to significant postoperative deformities within three years. Many of us are taught that aggressive cartilage removal is a thing of the past. Today’s concept is “less is more”. Less cartilage excision, cartilage repositioning, camouflage techniques, structural grafts, and suturing techniques are taught in most residencies and fellowships and at our national meetings. When primary rhinoplasties are performed, the need for future revision rhinoplasty is becoming more common. In general, revision rhinoplasty in men is more complex than in women because men may have higher or unrealistic expectations and often thick nasal skin, which is more difficult to re-support the nasal tip than in thin nasal skin.
In male primary rhinoplasty surgery, the key to preventing complications is prior diagnosis of possible anatomical and functional abnormalities. For example, a patient desires a dorsal hump reduction and you identify short nasal bones, thick skin, and a long median vault. Your thorough evaluation will alert you that this patient is at risk for subluxation of the upper lateral cartilage of the nasal bones (inverted V deformity) and internal valve collapse after osteotomies.
For male revision rhinoplasty patients, initially perform a detailed anatomical and functional evaluation of the nose followed by documentation of any postoperative nasal deformities that are present and sites of nasal obstruction. After identifying problems and potential complications, create an overall surgical plan while reviewing the preoperative photographs and be prepared to use the full surgical armamentarium, as your preoperative plans for revision nasal surgery will often change during surgery.
Below is my algorithm for a revision rhinoplasty consultation. When the appointment is made, the patient is asked to bring a copy of their medical records and operative reports from their rhinoplasty surgery(s), as well as photographs of their native nose. Review the notes and photos as the prospective patient discusses the surgery with their patient care coordinator. This will give you a head start in identifying problems, assuming there is a problem. A detailed history is then taken while the patient’s wishes are carefully listened to. Do you have realistic expectations? This is by far the most important detail the astute surgeon needs to glean from the story. What is the patient unhappy with: a pinched tip or a chicken beak deformity?
Also, listen to the patient and see if negative comments are made or if the patient seeks litigation against the previous surgeon. If this is the scenario, you may want to think twice before performing revision rhinoplasty on this patient. If the male patient is not happy with the results of the surgery you performed on him, he is very likely to say nasty words about you in the surgeon’s office later. Do you fit the SIMON profile (Single, Immature, Masculine, Obsessive and Narcissistic)? If so, be careful as these patients are very difficult to please and are litigious. Within the first five minutes of his history, the astute surgeon must know if the patient is a good candidate for revision surgery. Poor patient selection can lead to a dissatisfied patient and surgeon.
Another important detail is to know if the patient has nasal obstruction. The incidence of postoperative nasal obstruction after primary rhinoplasty is approximately 10%.1 Determine if nasal obstruction was present prior to the operation. If the obstruction is the result of surgery, it is necessary to answer a series of questions. Has the patient had a reduction rhinoplasty surgery? Have the patient point to where the obstruction is. Is it static or dynamic? Does it present with normal or deep inspiration? What relieves and worsens nasal obstruction? What are the characteristics of nasal obstruction? Was septal surgery performed? Follow the physical exam.
For the physical exam, I use a detailed nasal analysis worksheet. I perform a detailed visual and tactile assessment of the nose. Use a bare finger to palpate the nose. Examine the skeletal and cartilaginous skeleton, tip, and skin and soft tissue sheath features in frontal, oblique, lateral, and base views. For the bony back, examine for osteotomies, the presence of open-roof deformity or rocker deformity, and over- or under-resection of the hump. If inadequate hump reduction is in question, first look for a deep base and/or underprojecting ptotic nasal tip and microgenia.
Look for midvault abnormalities such as a narrow medianvault, inverted-V deformity, or underresection of the cartilaginous dorsum (chicken-beak deformity). For the tip, examine tip projection, rotation, support, alar and columellar retraction, overly aggressive alar base reduction, and lower lateral crura characteristics such as overresection, cephalic orientation, or formation of bumps. Excessive resection of the lower lateral cartilage complex in men with a dense sebaceous covering of skin and soft tissue can cause tip ptosis and subsequent nasal obstruction. A deviated cartilaginous back and tip may signify a deviated septum. This is only a partial list of the anatomical problems that the surgeon must identify in the nasal analysis.
For male patients with nasal obstruction, observe him taking a normal, deep inspiration in frontal and basal views. Often the diagnosis is easily identifiable as supraalar, alar, and/or rim collapse (slit-like nostrils) during static or dynamic states. External valve collapse (inferior lateral cartilage pathology) can be assessed with the soft end of a cotton swab while plugging the contralateral nostril. The cotton swab elevates the area of obstruction, either the alar rim, the lower lateral crus, or the supraalar region. See if nasal obstruction is relieved by elevating the nasal tip in patients with ptosis of the nasal tip. Perform the Cottle maneuver (pulling the cheek laterally) to check for internal valve collapse. Although this test is usually non-specific, it can diagnose internal nasal valve pathology caused by supraalar impingement or a narrow angle between the upper lateral cartilage and the septum. In the basal view, examine the feet of the medial crura to identify whether they are compressing the nasal airways.
After a thorough external nasal evaluation, the endonasal examination is performed. At a minimum, perform an anterior rhinoscopy with and without topical decongestion. In certain cases, nasal endoscopy and rhinomanometry may be helpful. Evaluate the nasal septum for perforations, persistent deviations, and any remaining cartilaginous remnants that will be used for grafting. Other causes of nasal obstruction to identify are: hypertrophic inferior turbinates, synechiae between the lateral nasal wall and the septum, nasal masses, and anomalies in the middle turbinates (concha bullosa).
While examining the patient, create a list of mental problems with solutions followed by documentation on your nasal analysis sheet, such as: 1. External valve collapse secondary to overremoval of the lower lateral crus with an open rhinoplasty plan with bone grafts. alar slat using conchal cartilage, 2. collapse of the internal nasal valve secondary to a tight median and supraalar pinch with moderate inspiration with a plan of bilateral extensor grafts and supraalar slat grafts using conchal cartilage, and 3. alar retraction bilateral with a plan of grafts composed of shell. If a structural graft is necessary, she decides what material can be used. A thorough understanding of autologous (septal, conchal, costal cartilage, deep temporal fascia, and cranial vault) or alloplastic graft types, as well as harvesting techniques, is needed.
This is just an initial plan as you are creating your algorithm. Guaranteed, it will change as you get closer to surgery. Computer transformation can be extremely helpful if patients are advised that the final image is not a guarantee of results. However, despite proper notification and consent, there have been reports of lawsuits filed by patients for results that are different from those generated by the computer imaging camera. Computer imaging can give clues about the patient’s expectations. Unrealistic expectations can be identified when the surgeon creates a conservative picture and the patient wants radical change. Therefore, computer imaging can be a powerful tool in the evaluation of patients for surgery. I cannot count the number of times I have turned away male patients for primary and secondary revision surgery because they had unrealistic expectations and were only identified by computer transformation. An additional use of the computer image is to use it as a target in surgery. Take preoperative and computer imaging photographs to the operating room.
편도대여가 가능한가요 가족용 차량을 직접 운전하는 경우나 여행 시 특수 장비를 갖춘 장애인 차량이 필요한 경우 김포공항의 발레파킹 서비스를 이용하면 터미널까지 편리하게 이동할 수 있습니다. 아래 글에서는 비용, 김포공항 발레파킹 주차장 위치, 예약 전 알아두어야 할 사항에 대해 필요한 모...
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