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By D. Sigmor. Salem State College. 2019.

Although the causes are many buy naproxen 250 mg otc, technical devise an anatomically effective surgical game plan purchase 500 mg naproxen visa. Because shortcomings are often rooted in an erroneous cosmetic analy- rhinoplasty is a dynamic operation in which unforeseen sec- sis of the nose cheap 250 mg naproxen mastercard. Recognizing an unattractive or disharmonious ondary and tertiary effects are common, a fluid game plan nose is easy even for the average individual, but underderstand- that can be adapted to changing circumstances is essential. Without an shapen nose is an great challenge that requires a sophisticated accurate and correct aesthetic analysis, misinterpretation of understanding of the surgical anatomy and the healing forces at the surgical anatomy ultimately produces systematic judg- play.. The cosmetic objective must also take into full account ment errors that are often compounded by serial misappli- the limitations of the starting nasal anatomy and the existing cations of surgical technique. For the surgical out- Hence, the first step in avoiding technical rhinoplasty failures come to appear “natural” and nonsurgical in appearance, the is to achieve a proper aesthetic understanding of the nose. The prudent rhino- takes many forms and is not relegated to one single shape or plasty surgeon must also seek to identify and disclose all preex- size, there is a spectrum of acceptable options from which to isting cosmetic imperfections that typically resist or defy surgi- choose, and the wise surgeon will elicit input from the patient cal correction. Facial asymmetry, misalignment of the piriform when seeking to pinpoint the ultimate cosmetic objective. The ultimate goal is to eliminate the cosmetic deform- with computer-morphing software, patients are able to “pre- ity and create an aesthetically pleasing, symmetric, and prop- view” various cosmetic changes to confirm their ideal cosmetic erly aligned nasal appendage, while minimizing skeletal desta- objective. Not only does computer imaging provide a mutually bilization and surgical morbidity. The accomplished nasal sur- agreeable and unambiguous cosmetic goal, it also affords the geon will possess an extensive “toolbox” of surgical techniques, surgeon an opportunity to visibly demonstrate the anticipated refined by experience and dependability, which will effectively limits of surgical intervention. Although potentially subject to address each cosmetic challenge within a given nose. Choosing exaggeration, an honest and realistic computer morph is reas- the right surgical techniques, correctly sequencing the imple- suring to the patient and provides the surgeon with a targeted mentation of these techniques, and flawlessly executing each nasal contour from which to blueprint the surgical game plan. And although the finished product must generated simulations correspond closely to the actual surgical be both attractive and harmonious, it must also possess suffi- outcome, making the technology both reliable and accurate. It is perhaps this final objective that erly conceived treatment plan is difficult to execute to perfec- proves most challenging, because long-term stability is often tion. The following section covers many of the 385 Revision Rhinoplasty technical errors that are commonly associated with the failed appearing nasal bridge from the frontal view, and a weak, rhinoplasty. Often, this is accompanied by a residual gap separating the cen- tral ethmoid complex and the nasal sidewall—the “open roof” 50. In thin-skinned individuals, the open roof deformity typically gives rise to unsightly surface indentations and corre- the Nasal Bridge sponding longitudinal shadows, further exacerbating the cos- Perhaps the most common cosmetic deformity prompting cos- metic deformity. A prominent pro- However, even the savvy rhinoplasty surgeon who recognizes file convexity of the nasal dorsum is a common morphological the need for conservative bony hump removal may have diffi- variant in both men and women, particularly those of Mediter- culty removing a thin sliver of dorsal bone. In humans, the typical dorsal hump is nasal hump, the overprojected bone is a rounded plate of dense seldom more than one-third bone and is usually comprised membranous bone connected to three underlying bony plates: mostly of cartilage. Usually this stems from requires splitting or cleaving the membranous plate along the the misimpression that the dorsal hump is actually much larger path of greatest resistance. Underprojection of the surrounding commonly performed with a Rubin osteotome using blunt force skeletal structures, namely an underprojected nasal tip or an technique, a smooth and precise cut may be difficult to achieve. It is also a commonly held misimpression path of lesser resistance, either deep to, or superficial to, the among novice surgeons that a dorsal hump is comprised largely desired plane of cleavage. Because a bony hump taller than 4mm is actually quite underresection of the bony hump, respectively. In addition, rare, and because the hump is comprised mostly of nasal carti- with the use of blunt force technique, occult heterogeneities in lage, removal of large portions of nasal bone is a common tech- bone density may produce inadvertent fractures of the nasal nical error that leads to immediate cosmetic morbidity and that bones, leading to destabilization and/or unwanted contour may also lead to subsequent (compounding) technical errors irregularities of the bony vault. Consequently, it is the preference of the senior ridgeline and the corresponding soft, closely space sidewall author to remove all bony humps with an electric sagittal bone shadows are both eliminated, giving rise to an overly broad and saw using the external rhinoplasty approach. The result is an overly broad and washed-out such as sharp edges or minor asymmetries. Consequently, consistently natural-appearing and attractive surgical results are difficult to achieve with any single method. Presently, autologous onlay grafts fashioned from solid rib or auricular cartilage or synthetic implants used in lieu of autologous materials are probably the most commonly used methods of dorsal augmentation. However, in each case, precise adaptation of the implant or graft to the underlying skeletal topography is essential, yet difficult to achieve. The result is often a conspicuous and unsightly delineation between the nasal bridge and the augmentation graft material, especially in thin-skinned patients. Grafts or implants that don’t closely dovetail with the underlying nasal framework may also shift or move when subjected to the forces of healing, and autologous cartilage grafts are also prone to contour imperfec- tions resulting from delayed alterations in shape. The polly beak deformity is one of the most common compli- Unlike the overprojected nasal dorsum, the naturally under- cations of cosmetic rhinoplasty. Typically, these patients are managed by deformity include overgrowth of the anterior dorsal septum augmenting the nasal dorsum to simultaneously create both a and/or overly wide and bulbous lateral crura. The iatrogenic narrower and taller nasal bridge, thereby improving nasal aes- causes include inadequate resection of supra-tip skeletal struc- thetics from both the frontal and profile views, respectively. When this deformity is due to excess soft tissue or effective means of achieving dorsal augmentation. This prob- postoperative scar formation, injection with low-dose triamci- ably stems from the present lack of a universally reliable surgi- nolone acetonide is often an effective treatment. In patients with a naturally wide cartilaginous vault, narrowing of the dor- sal septum from hump reduction may produce an appropriate and desirable reduction in middle vault width. Similarly, patients with long slender noses, preexisting septal deformities, and/or short nasal bones are also particularly sus- ceptible to pinching, asymmetry, and/or deviation of the middle nasal vault following hump reduction, because long, thin, and pliable middle vault cartilages are more vulnerable to distortion and collapse. Because these problems are often easy to antici- pate, anatomic risk factors like short nasal bones, tall dorsal humps, weak dorsal cartilage, or preexisting deformities of the Fig. Note unnatural dorsal septum should be carefully sought during the preopera- contour and poor blending of graft edges. Secondary treatment of the inverted V shadow at the bony-cartilaginous junction. Forma- deformity in the absence of an overresected dorsum is accom- tion of the bony-cartilaginous step-off results from either plished by physically narrowing the bony vault (to close an excessive width of the nasal bone remnants, pinching of the open roof deformity) and/or by placing cartilaginous augmenta- tion grafts to eliminate pinching of the middle vault (i.

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The drug can increase serum adalimumab (40 mg) is administered every other week as a levels of hepatic enzymes and increase the risk of hepato- subcutaneous injection order naproxen 250 mg with visa. During adalimumab treatment generic naproxen 250 mg without a prescription, toxicity when it is used in combination with methotrexate buy generic naproxen 500 mg online. Lefunomide additional benefts by increasing the frequency of adalim- is teratogenic, so its use is contraindicated in pregnancy. The recommended dose of anakinra is 100 mg/ Diet Purines Nucleic acids day administered daily by subcutaneous injection. Hypoxanthine Abatacept is a selective co-stimulation modulator and inhibits T-cell activation by binding to cell surface markers Allopurinol Xanthine oxidase (proteins) on leukocytes. Allopurinol and febuxostat act sulfasalazine was developed and is a formulation combining by inhibiting xanthine oxidase. Pegloticase and rasburicase administration an antiinfammatory drug, 5-amino salicylic acid, with an provides a recombinant uricase enzyme that converts uric acid to allantoin, antibacterial drug, sulfapyridine. Because sulfasalazine is a sulfa drug, people who are allergic to sulfa compounds should not take it. Treatment should begin with a low 3 months to manifest; however, if no effect is seen in a year, dose, and the dosage should be gradually increased until an it should be stopped. High doses of Gout attacks can be prevented by lowering the serum con- salicylates inhibit uric acid reabsorption and exert a urico- centration of uric acid. Low doses of salicylates, however, inhibit uric accomplish this goal by increasing the excretion of uric acid, acid secretion by renal tubules and thereby increase serum whereas allopurinol and other agents do so by inhibiting the concentrations of uric acid. A third class of agents provides cata- Sulfnpyrazone is another uricosuric agent that com- bolic enzymes to reverse hyperuricemia. Uric acid metabo- petitively inhibits the active reabsorption of urate at the lism and sites of drug action are depicted in Figure 30-5. As with probenecid, it increases the urinary excretion of uric acid and lowers serum urate con- Uricosuric Drugs centrations. Its administration by the intravenous route Xanthine Oxidase Inhibitors carries the same risks of allergic reactions as pegloticase. Allopurinol is used to prevent gout attacks in persons who overproduce uric acid, as indicated by a 24-hour uric Drugs for Treating Gout Attacks acid excretion that is greater than 800 mg. It is also some- Indomethacin times used to prevent hyperuricemia and gout in persons In patients with acute gout, a potent antiinfammatory drug who are having cancer chemotherapy and whose rate of is given for the rapid relief of pain. If these Allopurinol and its active metabolite, oxypurinol (also drugs do not provide relief or cannot be tolerated by the called alloxanthine), decrease the production of uric acid by patient, colchicine can be given orally or parenterally. In con- Colchicine was traditionally used to treat acute gout, but it trast to uricosuric drugs, allopurinol causes a decrease in uric is less frequently used today because of its unpleasant side acid excretion and a corresponding increase in the urinary effects, which include nausea, vomiting, diarrhea, and excretion of hypoxanthine. The drug is believed to act by disrupting reutilization of hypoxanthine and xanthine for nucleotide microtubules and inhibiting the motility of infammatory and nucleic acid synthesis via inhibition of hypoxanthine- leukocytes and thereby blocking their ability to cause urate guanine phosphoribosyltransferase. Colchicine is rapidly nucleotide concentration leads to increased feedback inhibi- absorbed after oral administration. By lowering both serum in the liver, and the drug and its metabolites are excreted by and urine concentrations of uric acid below its solubility the biliary and fecal route. If colchicine treatment causes the limits, allopurinol prevents or decreases urate deposition, adverse effects noted previously, treatment should be stopped thereby preventing the occurrence or progression of both to avoid more serious toxicity. Oxypurinol has a half-life of about 20 hours; most of this metabolite is excreted unchanged in the urine. The drugs exhibit varying because of its adverse effects, which include nausea, vomit- degrees of analgesic, antiinfammatory, and antipyretic ing, hepatitis, skin rashes, and other forms of hypersen- activity. It is also a competitive inhibitor of xanthine agents in this group can cause gastric irritation and oxidase but has the advantage of once-a-day administration bleeding, and their long-term use can lead to peptic and greater effcacy than allopurinol. Adverse effects are minor and rare but agent, but it lacks signifcant antiinfammatory and include liver enzyme elevations, nausea, arthralgia, and rash. This quinone Catabolic Enzyme Preparations metabolite is normally inactivated by conjugation with An intravenous infusion formulation of pegloticase was glutathione, but toxic doses of acetaminophen can recently approved for the patients with refractory chronic deplete glutathione and cause fatal liver failure. Pegloticase is recombinant uricase and achieves its • Acetylcysteine, a sulfhydryl compound that conjugates therapeutic effect by catalyzing the oxidation of uric acid and inactivates the quinone metabolite of aceta- to allantoin, thereby lowering serum uric acid. Allantoin is minophen, is used as an antidote for acetaminophen an inert and water-soluble purine metabolite readily elimi- hepatotoxicity. Pegloticase must be administered • Low doses of aspirin have potent antiplatelet effects in the clinic with supportive measures available nearby, as because they acetylate and irreversibly inhibit platelet there is the risk of life-threatening allergic reactions. Low doses of aspirin also produce analgesic and A similar recombinant uricase enzyme, rasburicase, is antipyretic effects, but higher doses are needed to indicated only for the initial management of plasma uric acid counteract infammation. In cases of 326 Section V y Pharmacology of the Respiratory and Other Systems severe aspirin toxicity, sodium bicarbonate can be 2. Which of the following reasons • Ibuprofen, ketoprofen, and naproxen are potent explains this unique aspect of acetaminophen? Ketorolac is a potent peripheral sites of infammation analgesic that can be given orally or parenterally. It is also used to cause closure of the (E) acetaminophen undergoes signifcant frst-pass ductus arteriosus in infants. With respect to antigout therapy, inhibition of tubulin have a slow onset of action and can cause consider- polymerization into microtubules is important given the able toxicity. It is generally well tolerated (E) plasma binding of uric acid and can be used effectively for many years. Anakinra blocks the biologic activity ing agents is the best treatment for his condition? Thromboxane A2 produces leukocytes and thereby prevents their migration into vasoconstriction and promotes the formation of clots; joints and their ability to cause urate crystal–induced therefore aspirin can prevent clot formation and coronary joint infammation. Answer B, treating gout are to increase the excretion of uric acid lefunomide, is an immunosuppressive drug that inhibits with a uricosuric agent (probenecid or sulfnpyrazone) or mononuclear and T-cell proliferation. Answer C, etaner- decrease the production of uric acid by inhibiting xan- cept, is a protein formed by recombining human p75 thine oxidase with allopurinol. The secretion of anterior pituitary hormones is controlled Anterior Pituitary Hormones and by several hormone-releasing and hormone-inhibiting Releasing Hormones factors that are formed in the hypothalamus. Evidence also • Octreotide (Sandostatin) suggests the presence of one or more prolactin-releasing • Lanreotide acetate (Somatuline Depot) factors. The various hypothalamic hormones are secreted by • Pegvisomant (Somavert) the arcuate and other hypothalamic nuclei, and they are transported to the anterior pituitary via the hypophysio- Gonadotropins and Related Drugs portal circulation. In the target • Choriogonadotropin alfa (Ovidrel) organs, they stimulate growth, development, and the secre- • Follitropin alfa (Gonal-F) tion of other hormones, which both activate specifc • Follitropin beta (Follistim) functions in various organs and exert negative feedback • Lutropin alfa (Luveris) inhibition of the corresponding hypothalamic and pituitary a • Leuprolide (Lupron) hormones. Posterior tant neuroendocrine system that regulates growth, reproduc- pituitary hormones are used therapeutically to regulate spe- tion, metabolic rates, and other critical body functions.

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Nonetheless 500mg naproxen amex, current guidelines suggest trying selegiline in newly diagnosed patients buy naproxen 500 mg line, just in case the drug does confer some protection order naproxen 500 mg with mastercard. First, when used as an adjunct to levodopa, selegiline can suppress destruction of dopamine derived from levodopa. By helping preserve dopamine, selegiline can prolong the effects of levodopa and can thereby decrease fluctuations in motor control. This may reflect a delay in the progression of the disease, or it may simply reflect direct symptomatic relief from selegiline itself. These metabolites, which do not appear to have therapeutic effects, can be harmful. As a result, bioavailability is higher than with tablets and capsules, and hence doses can be lower. Insomnia can be minimized by administering the last daily dose no later than noon. Accordingly, patients should be instructed to avoid these foods and drugs, both while taking selegiline and for 2 weeks after stopping it. B l a c k B o x Wa r n i n g : S e l e g i l i n e [ E l d e p r y l, E m s a m, Z e l a p a r ] Antidepressants are associated with an increased risk for suicide in patients younger than 24 years. Selegiline carries an increased risk for hypertensive crisis in younger patients and is contraindicated for children younger than 12 years. When used with levodopa, selegiline can intensify adverse responses to levodopa-derived dopamine. These reactions—orthostatic hypotension, dyskinesias, and psychological disturbances (hallucinations, confusion)—can be reduced by decreasing the dosage of levodopa. The drugs differ primarily in that rasagiline is not converted to amphetamine or methamphetamine. In contrast to selegiline, rasagiline is not metabolized to amphetamine derivatives. The most common side effects are headache, arthralgia, dyspepsia, depression, and flu-like symptoms. The most common additional reactions are dyskinesias, accidental injury, nausea, orthostatic hypotension, constipation, weight loss, and hallucinations. Rasagiline may increase the risk for malignant melanoma, a potentially deadly cancer of the skin. Drug and Food Interactions Rasagiline has the potential to interact adversely with multiple drugs. Like selegiline, rasagiline can intensify adverse responses to levodopa-derived dopamine. If the patient develops dopaminergic side effects, including dyskinesias or hallucinations, reducing the dosage of levodopa, not rasagiline, should be considered. Combining rasagiline with meperidine, methadone, or tramadol may pose a risk for serious reactions, including coma, respiratory depression, convulsions, hypertension, hypotension, and even death. Combining rasagiline with dextromethorphan may pose a risk for brief episodes of psychosis and bizarre behavior. This drug is structurally related to the tricyclic antidepressants, so it should be avoided. Responses develop rapidly—often within 2 to 3 days—but are much less profound than with levodopa or the dopamine agonists. Patients taking amantadine for 1 month or longer often develop livedo reticularis, a condition characterized by mottled discoloration of the skin. If effects diminish, they can be restored by increasing the dosage or by interrupting treatment for several weeks. These drugs alleviate symptoms by blocking muscarinic receptors in the striatum, thereby improving the balance between dopamine and acetylcholine. Anticholinergic drugs can reduce tremor and possibly rigidity, but not bradykinesia. These drugs are less effective than levodopa or the dopamine agonists but are better tolerated. As a result, they can cause dry mouth, blurred vision, photophobia, urinary retention, constipation, and tachycardia. Blockade of cholinergic receptors in the eye may precipitate or aggravate glaucoma. The anticholinergic agents used most often are benztropine [Cogentin] and trihexyphenidyl, formerly available as Artane. Providers need to be aware that if anticholinergic drugs are discontinued abruptly, symptoms of parkinsonism may be intensified. Autonomic Symptoms Disruption of autonomic function can produce a variety of symptoms, including constipation, urinary incontinence, drooling, orthostatic hypotension, cold intolerance, and erectile dysfunction. The intensity of these symptoms increases in parallel with the intensity of motor symptoms. Erectile function can be managed with sildenafil [Viagra] and other inhibitors of type 5 phosphodiesterase (see Chapter 51). Orthostatic hypotension can be improved by increasing intake of salt and fluid, and possibly by taking fludrocortisone, a mineralocorticoid. Urinary incontinence may improve with oxybutynin and other peripherally acting anticholinergic drugs (see Chapter 12). Constipation can be managed by getting regular exercise and maintaining adequate intake of fluid and fiber. Melatonin helps by making people feel they are sleeping better, even though objective measures of sleep quality may not improve. Unfortunately, amitriptyline, a tricyclic antidepressant, has anticholinergic effects that can exacerbate dementia and antiadrenergic effects that can exacerbate orthostatic hypotension. Both drugs are cholinesterase inhibitors developed for Alzheimer disease (see Chapter 18). Most of these drugs—levodopa, dopamine agonists, amantadine, and anticholinergic drugs—can cause hallucinations. Therefore, if psychosis develops, dopamine agonists, amantadine, and anticholinergic drugs should be withdrawn, and the dosage of levodopa should be reduced to the lowest effective amount. If antipsychotic medication is needed, first-generation antipsychotics should be avoided because all of these drugs block receptors for dopamine and hence can intensify motor symptoms. The guidelines recommend against routine use of olanzapine, another second-generation agent. Baseline Data Assess motor symptoms—bradykinesia, akinesia, postural instability, tremor, rigidity—and the extent to which they interfere with activities of daily living (e.

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Whether the surgeon choo- alterations of the cartilage can weaken its inherent structural ses an endonasal or an open approach cheap naproxen 250mg amex, we recommend a sys- support and lead to further instability naproxen 500 mg amex. Partial stabilization of the septum is provided by external For the purpose of this chapter naproxen 250mg fast delivery, we are going to discuss only septal fixation once the intraoperative reconstruction is complete. In the past, external fixation dal septum was originally described by Metzenbaum,34 who used devices such as nasal splints, nasal packs, or taping methods have theswinging-doortechniquetorepositionthenasalseptum. But the surgeon who relies on splints and sutures But many authors have subsequently modified that techni- to provide long-term stabilization will often be disappointed. For example, Pastorek and Becker35 described a modifica- cess hinges on the release and correction of the underlying injury. Another modification involves translocation of the accounts for the warping of cartilage back to its preoperative state after a septoplasty—one of the reasons for recurrence of deformities and deviations. Warping of cartilage, unfortunately, is not always under the control of the surgeon. This complication of septo- plasty particularly affects younger patients: the overall inci- dence of septal overcorrection is 2%, but the incidence for patients under the age of 20 is 7. The central quadrangular cartilage in younger patients may have a high level of metabolic activity, cell replica- tion, and proliferative capacity, all of which decline with age. The anterior free end of the cartilage, however, retains a high level of metabolic activity, cell replication, and proliferative capacity throughout the aging process. Our recommendation is to dis- cern whether or not younger patients have attained more than 90% of their adult stature relative to their family. Often, in patients with a twisted nose, septal displacement along the maxillary crest results in deformities affecting the lower two-thirds of the nose. Such displacement may be easily identified on basal view as a caudal septal deflec- tion. Most surgical techniques addressing the caudal septum involve cartilage reshaping, septal reconstruction maneu- vers, or a combination of both. When treating the caudal septum by resection, the surgeon may inadvertently violate the L-strut Fig. Arch Facial Plast Surg 2000; translates into a crooked dorsum with nasal valve compromise. In addition, a series of incisions can be made with the objective of weakening the car- tilage to facilitate its straightening and repositioning to midline. Still another modification is the use of 5–0 Prolene sutures with a Mustarde technique,38 which are placed to make the cartilage more vertical after it is scored. Most authors reserve modifica- tions of the Metzenbaum technique for patients with mild cau- dal deviations, given concern about long-term outcome. In numerous instances, correcting the caudal septum alone will also correct the dorsal asymmetry and will open the nasal valves, obviating the need for more intervention. But if a proper septoplasty fails to address dorsal deviation, further treatment with sequential release of the septal connections is necessary. The surgeon, however, should not rely your hand to hold the upper lateral cartilage as you pass the stitch. Also, additional spreader grafts may be placed to fill the concavity, straighten- contour. Their length can reset the anterior septal in a more ing the dorsum while providing functional improvement. When adequate release of the septal deviation prevents formation of precise pockets, the grafts should be secured one at a time with suture fixation. We use a bulldog clamp rather than sharp needles to stabilize the grafts for suturing. On occasion, graft extension to the anterior septal angle is beneficial to help support caudal deflection and the nasal tip. She had dorsal and tip reduction with butterfly and spreader grafts for improved support. To create the necessary structural support, a variety of fied in size and used to aid in the transition between the lower grafts based on the location of greatest collapse are employed. The nomenclature and positioning for the variety of grafts can Still another alternative is the splay graft. The cartilage is often harvested from crural strut grafts, alar spanning grafts, alar composite grafts, the concha. The usual sources of alar batten grafts adjusted to repair asymmetry of the dorsum, in the same man- are septal or conchal cartilage and, less commonly, costal carti- ner as an onlay graft, constituting a useful tool for repairing a lage. Eight patients had minor synechial bands all grafts usually can extend more medially, to provide some addi- repaired under local anesthesia. A precise vestibular mucosal pocket is elevated first, 229 Functional Nasal Surgery Fig. The locations of lateral structural grafts are positioned depending upon areas of weakness and poor contour. This also provides Alar rim grafts are another option surgeons utilize to correct added tip support by strengthening the lateral legs of the tri- mild alar collapse. They are, however, most com- helpful after caudal repositioning of the lateral crura, because monly used to address alar retraction or asymmetry. The gentle of the alar rims, as seen on a basal view, should be identified convexity of the lateral crus is better maintained when signifi- and be considered for repair. The surgeon can confirm this diag- cant asymmetries of the tip do not need to be addressed nosis on a physical exam by palpating and pinching the alar. The softest, most 230 Surgical Approach to Nasal Valves and the Midvault compressible point is typically found at the junction of the alar and the nasal tip subunits. Rim grafts are ideally placed in a precise subcutaneous pocket immediately above the existing alar rim. A double hook is used to elevate the alar rim and pro- vide counter tension while preparing the subcutaneous pocket and placing the graft. A pair of sharp curved scissors is utilized to create a precise pocket laterally 1 to 2 mm cephalic and paral- lel to the rim. It is very important to stay in the subcutaneous plane on the ala to ensure the scissors do not become superficial, risking skin perforation.