Twin Alar Rims: A Rare Type of Alar Rim Deformity and Its Correction Using "SAIL" Technique.

The beauty and golden proportions of a face are largely determined by the shape and size of the nose one inherits. When the subunits of the nasal structure are considered, the width and structure of Ala and Alar rims determine to a large extent the beauty of the nose itself. Various classifications exist to evaluate the alar rim deformities that are inherited as well as iatrogenic, but occurrence of twin alar rims as a deformity has rarely been reported. This article reports the deformities of drooping tip, hanging columella, and asymmetry of alar rims along with twin alar rims. All the problems were addressed with an open rhinoplasty approach and combining the alar incision with the sail technique to achieve the correction of twin alar rim.

The Utility of Screening for Coccidioidomycosis in Recipients of Inhibitors of Tumor Necrosis Factor α.

BACKGROUND: Tumor necrosis factor α inhibitors (TNFi) are commonly used to treat immune-mediated disorders, but they are associated with an increased risk of mycobacterial and fungal infections. We compared the outcomes of TNFi recipients screened for asymptomatic coccidioidomycosis with those of unscreened patients to compare the development of symptomatic coccidioidomycosis and to describe its outcomes for patients with abnormal coccidioidal screenings. METHODS: We searched electronic health records from 4 September 2010 through 26 September 2016 for all patients receiving a TNFi for dermatologic, rheumatologic, or gastroenterologic diagnoses, then categorized patients by whether or not they had undergone coccidioidal serologic testing for screening or diagnostic purposes. RESULTS: A total of 2793 patients had a TNFi prescribed. Of those, 1951 met the inclusion criteria: 1025/1951 (52.5%) never had coccidioidal screening; 925/1951 (47.4%) had serologic screening either before beginning TNFi therapy or annually, or both after beginning a TNFi. Symptomatic coccidioidomycosis developed in 35/1025 (3.4%) unscreened patients. Of those screened, 861/925 (93.1%) had negative serologic tests, of which 11/861 (1.3%) subsequently developed symptomatic coccidioidomycosis; 36/925 (3.9%) had coccidioidomycosis at screening (7, probable infection; 11, possible infection; 18, asymptomatic seropositive result); and 17 had only positive findings for immunoglobulin M antibodies and did not meet the definition for coccidioidomycosis. The unscreened cohort was more likely to have symptomatic coccidioidomycosis than the screened cohort (35/1025 vs 11/861, P < .01). CONCLUSIONS: Screening for asymptomatic coccidioidomycosis within a Coccidioides-endemic area allowed for identifying and managing asymptomatic coccidioidomycosis before patients began TNFi therapy. Less symptomatic infection developed in the screened than the unscreened cohort.

Coronal/Hemicoronal Approach - A Gateway to Craniomaxillofacial Region.

AIMS: The coronal incision with its various modifications provides the most versatile approach to various areas in the craniomaxillofacial region coupled with excellent exposure. The aesthetic advantage of a hidden scar in the hairline, accounts for its continued popularity. The aim of this study was to review the surgical anatomy, technique and problems of post-operative morbidity pertinent to coronal approach in various clinical situations such as craniofacial trauma, tumour resections and reconstructive craniofacial procedures. MATERIALS AND METHODS: In this study, ten patients who presented to Oral and maxillofacial surgery department with various craniofacial problems requiring the use of coronal and hemicoronal approach for treatment were evaluated over a period of two years. Five patients needed coronal approach and another five underwent the surgical procedures through hemicoronal approach. This was an observational study. RESULTS: It was observed that a well-planned and carefully designed coronal/hemicoronal incision with strict adherence to surgical principles posed minimal complication during surgery as well as post-operatively. None of the patients developed infection or heamatoma in the postoperative period. Sensory nerve deficits along the distribution of supraorbital nerve was observed in four patients of bicoronal approach and three patients of hemicoronal approach which completely resolved at the end of six months. Motor nerve weakness was observed in four patients in immediate postoperative period which gradually improved. But it persisted in one patient even after six months who had pathology of temporo-orbital region. All the patients had transient alopecia along the line of incision which improved at the end of six months. No other significant disadvantages or complications were noted. CONCLUSION: This approach offers widest accessibility and visibility to the entire upper and middle one third of the face in less than twenty minutes as observed in our study. The postoperative complications are minimal, minor and outweigh the advantages for surgical treatment in any given clinical situation as observed in this study. This proves the brilliance of coronal approach in solving an array of surgical problems pertinent to craniomaxillofacial region with superior aesthetic outcomes. ABBREVIATIONS: ZMC-Zygomatico maxillary complex, NOE-Nasoethmoidal complex, LF-Lefort, ORIF-open reduction internal fixation.