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The most important question is the invasion of this artery by tumour and if so, to what extent. The cement is the bone-like, rigid connective tissue covering the root of the tooth. Advances in both surgical technology and surgical techniques have increased the predictability of pre-implant surgery and have also reduced the morbidity of such surgery. For example, the horizontal orientation of a running W-plasty might not suit this area as well as a wavy line excision to recreate the philtral column. The sural nerve, the small saphenous vein and artery are within the subcutaneous tissues of the lateral leg and are superior to the fascia of the posterior tibialis muscle. The fibula head and lateral malleolus (as constant anatomical landmarks) are identified and marked. Spina bifida occulta occurs in vertebra L5 or S1 in approximately 10% of otherwise normal people. The sensory nerve supply is via the auriculotemporal, the lesser occipital and the greater auricular nerves, and the concha also receives sensory innervation via the vagus nerve. In reality, surgeons have been dissecting benign tumours to some extent in an extracapsular plane ever since the conservative parotidectomy technique was conceived. At approximately 3 months, the valve of the oval foramen fuses with the septum secundum, forming the oval fossa (fossa ovalis). Have a low threshold for abandoning the procedure and seeking radiological guidance. Complications the greatest risk with this operation is the development of an orocutaneous fistula. Where the lateral capsule has to be sacrificed, a flap from the deep layer of temporal fascia may be rotated down over the lateral side of the joint to form a pseudocapsule. The general efferent fibers are distributed to the otic ganglion from which postsynaptic fibers pass to the parotid and posterior lingual glands. Long cords have a tendency to prolapse through the cervix or to coil around the fetus. Vertical releasing incisions to increase exposure to the surgical site can be made distal to the canines and should extend from the mesial buccal or distobuccal line angles of the teeth to minimize loss of the dental papilla or formation of a double papilla, which can be unsightly. The lateral compartment of the lower leg (lateral to the fibula itself) is formed by peroneus longus and brevis muscles (the latter muscle arising from the fibula more distally). In these situations, the supple nature of full thickness abdominal skin grafts, for example on the radial aspect of the forearm, are proving advantageous over split skin where primary closure is difficult. The subcutaneous tissues are then closed with interrupted vicryl to bring the wound edges together, and the skin is brought together with 6/0 monofilament. Implantation of a blastocyst can be detected by ultrasonography at the end of the second week. The transinguinal approach involves identification and retraction of either the spermatic cord or round ligament and dissection through the transversus abdominus to expose the external iliac vessels. Success depends on the entire surface being held in contact with the bone by firm even pressure. Entry through the joint capsule With the condyle distracted inferiorly, pointed scissors are used to bluntly enter the superior joint space and it is opened to reveal the superior surface of the articular disc. However, not all patients vomit and the difficulty therefore lies in deciding who should have their airway secured as a precaution. The tensor tympani, the muscle attached to the malleus, is derived from the mesenchyme in the first pharyngeal arch, and the stapedius muscle is derived from the second pharyngeal arch. The primary tumour is seen as a large shadow, while a sentinel node is seen as a smaller shadow. Soon the intervening regions of mesenchyme undergo apoptosis (programmed cell death), forming notches between the digital rays. B, Transverse section of the metencephalon (developing pons and cerebellum) showing the derivatives of the alar and basal plates. Antiviral prophylaxis (famciclovir, valacyclovir) should be instituted in this group of patients.

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Identification of the anterior border of the septum, subperichondrial undermining of the nasal septum and release of ala cartilage from the vestibular skin. The displacement of the pattern enables the software to compute an accurate three-dimensional model. The expelled secondary oocyte is surrounded by the zona pellucida, an acellular glycoprotein coat, and one or more layers of follicular cells, which are radially arranged to form the corona radiata and cumulus oophorus. The radiographic evaluation of craniosynostosis is used to quantitatively define aberrant anatomy, plan surgical procedures and to provide a means to demonstrate to parents the difference between stenosed and nonstenosed sutures. In this respect, functional outcome needs to be considered before embarking on major palliative surgery. Allow the patient to rinse the mouth with saline several times to remove any salivary contamination. This approximates to the surface markings of the pedicle; the thoracoacromial vessels. The primary survey is usually carried out by the frontline team in the accident and emergency department, while maxillofacial surgeons will require to undertake a secondary survey prior to the definitive management of maxillofacial injuries. From medial to lateral, they are: Myelencephalon Neuroblasts from the alar plates in the myelencephalon migrate into the marginal zone and form isolated areas of gray matter: the gracile nuclei medially and the cuneate nuclei laterally. Prophylactic antibiotics are recommended according to the American Association of Orthopedics guidelines for invasive dental procedures for the two years following prosthetic insertion. Patients undergoing maxillary impaction may require the removal of the inferior turbinates to provide needed space and to reduce nasal airway obstruction. Similarly, a forehead that is sloped too acutely will also present special challenges during an endoscopic brow lift. As the dissection proceeds medially to the ilium the overlying internal and external oblique muscles will need to be incised to the medial end of the ilio-inguinal ligament. Operation 783 (d)i (d)ii (d)iii (d)iv (d)v (d)vi (e)i (e)ii (e)iii (e)iv (e)v (e)vi 784 Post-traumatic rhinoplasty unicortical calvarial bone is problematic and resection on the septum condemned. Once the bone graft has been harvested, it should be stored in saline and kept moist until the time of grafting. Palatoglossus muscle runs from the velar aponeurosis to the posterior superior parts of the tongue. When the defect is tumour free, it may be closed with flaps or in some sites allowed to granulate. However, although some flap thinning can be easily undertaken at the margins of the flap, reduction of the entire flap to say 50 per cent would not be recommended, particularly to surgeons new to this technique. Their axons are distributed to the muscles derived from the head myotomes (preotic and occipital). The umbilical cord usually drops off 7 to 8 days after birth, the end of the early neonatal period. Arterial patency is indicated by well-dilated vessels demonstrating either pulsatile elongation or expansile pulsation. Distraction osteogenesis device selection is based on available bone stock, ease of application, distance of distraction osteogenesis and ability to adjust the distraction vector post device placement. It is the appropriate reduction of bone on the palatal side that makes this procedure a less attractive alternative. There is a shallow pit in the glans penis at the usual site of the urethral orifice. Schweckendiek popularized this two-stage procedure in many cleft centres worldwide when he published excellent long-term results in 1978. As development proceeds, differential growth shifts the origin of the right subclavian artery cranially, until it comes to lie close to the origin of the left subclavian artery. Nevertheless, it is an important surgical tool in the armamentarium of a transplant surgeon. It is also important that the light is administered at a right angle to the surface to ensure equal dose symmetry of the light across the treatment field.

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Once at the zygomatic arch, the dissection is carried out to the potential superior joint space. The streak diminishes in relative size and becomes an insignificant structure in the sacrococcygeal region of the embryo. After complete separation, the function of the obturator nerve segment included in the graft should also be checked with the nerve tester after placing the graft on a moist adductor longus muscle pulled upward ligated branches to the adductor longus muscle Dissection of the muscle to identify individual muscular units. Growth of the chorionic sac is extremely rapid between the 5th and 10th weeks of development. The graft is placed on the recipient site with the point of entry of the vascular pedicle and the nerve on the undersurface of the muscle. The upper facial half can be divided into an upper unit (comprising the frontal bone and a maxillofacial unit). Only one pair of membranes contributes to the formation of adult structures; the first membrane becomes the tympanic membrane. If recipient sites are to be created in the frontal hairline, bilateral supraorbital nerve blocks would be adequate. Some congenital cataracts are caused by teratogenic agents-particularly the rubella virus (see Chapter 19. The dental occlusion may not be easily attained if there is a pre-existing abnormal bite and/or missing teeth. Although some sinuses and cysts are remnants of the first pharyngeal groove, others represent ectodermal folds sequestered during formation of the auricle from the auricular hillocks (swellings that contribute to the auricle). Early assessment of dental arch development in repaired unilateral cleft and unilateral cleft lip and palate vs. Debate over this has been intense over the last decade with two consensus conferences and a recent prospective randomized multicentre study. Moreover, if the optic vesicle is removed and placed in association with surface ectoderm that is not usually involved in eye development, lens formation can be induced. B, Transverse section of the embryo showing expansion of the peritoneal cavity (arrows). Some free tissue free flap harvest sites may require skin cover, but this is outside the head and neck, for example to cover a radial forearm flap harvest. The vellus hair gives clues as to the true natural hair direction that the transplant must simulate in order to achieve a natural result. Finally, the craniotomy segment may be repositioned taking care not to compress the pericranial graft and trying to position any subsequent space in the bone cuts to give the most cosmetically acceptable result. Although birth trauma is commonly considered a cause of congenital torticollis, this may also result from malpositioning in utero. Dirt should be thoroughly removed from wounds to prevent skin tattooing and a sterile nail brush should be used with dilute chlorhexidine solution to thoroughly remove any such debris, followed by copious irrigation with sterile normal saline. Hair shaft diameter is an important determinant in how much hair is moved in a graft. Interventional sialography has developed methods for treating both eventualities using ideas taken from other areas of intervention. The cells in the equatorial zone are cuboidal; as they elongate, they lose their nuclei and become secondary lens fibers. To maintain blood supply to the osteotomized inner and outer segments, the periostium is left attached to the bone. A subplatysma dissection is made in a cephalic direction elevating the skin, subcutaneous tissue and platysma superiorly to the level of the mandible. Ten per cent of salivary tumours arise in the minor glands and about 50 per cent of these will be malignant. It is important that the surgeon is comfortable, usually sitting with adequate support of the arms. New hair growth will only be seen after 12 weeks and should grow at approximately 1 cm per month. Prior to injection, ice application is used to minimize bruising as the injection is made subcutaneously.

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The surgical and radiotherapeutic options are quite morbid for these patients who have synchronous dysplastic areas in their oral cavity which may extend over large areas. It is important to keep the dissection on the anterior surface of the orbital rim since this minimizes herniation of periorbital fat. The distal portion of the flap is at risk for ischaemia because kinking of the small vessels typically occurs at the fold area. The arrows in C show the pathway taken by the neuroblasts from the alar plates to form the olivary nuclei. Accessory hepatic ducts are present in approximately 5% of the population, and awareness of their possible presence is of importance in surgery. Pulling the gastrostomy into position the endoscopist ties the tapered end of the gastrostomy tube to the insertion thread at the mouth and the assistant then pulls the abdominal end of the thread until the attached tube abuts the cannula (which can be felt as the thread stops running freely). Recent systematic reviews have examined the efficacy of therapeutic interventions undertaken to reduce the incidence of alveolar osteitis after oral surgery. Hence, a definite diagnosis may not be possible on the frozen sections, but the pathological process can be correctly determined in most cases. Again, stab perforations or meshing of the graft helps to prevent haematoma formation. Bone grafting procedures include onlay grafts, inlay grafts into the floor of the maxillary antrum and Le Fort I maxillary osteotomy with advancement and downgrafting techniques. The unilateral cleft lip and palate cases were more asymmetric than the unilateral cleft lip cases. The infraorbital nerve immediately branches into up to ten branches at the foramen. Inadequate blood supply and scarred host bed can lead to recurrence or larger perforations. Following tooth loss, the blood supply of the edentulous mandible differs from that of the dentate mandible. This septum divides the cranial part of the foregut into a ventral part, the laryngotracheal tube (primordium of the larynx, trachea, bronchi, and lungs), and a dorsal part (primordium of the oropharynx and esophagus). The tip of the cone 412 Thyroidectomy, cysts of the thyroglossal duct tract and ectopic thyroid should lie just below the foramen caecum at the base of the tongue. In order to mobilize the lip completely, the muscles are also freed from the underlying maxillary bone in a subperiosteal manner. Prosthetic maintenance is ongoing, particularly in the first year, where soft tissue changes can be extensive. Complications Aesthetic blunting and vertical discrepancies of the medial canthal tendon are best dealt with through a combination of 530 Craniofacial trauma, including management of frontal sinus and nasoethmoidal injuries retrospective review. Some cases of microcephaly appear to be genetic (autosomal recessive); others are caused by environmental factors such as cytomegalovirus infection in utero (see Chapter 19). Access osteotomies are useful for posterior tongue, some soft palate and pharyngeal/parapharyngeal tumours, as well as for those in the infra-temporal fossa. Mandibular endosseous implants and autogenous bone grafting in irradiated tissue: A 10-year retrospective study. Crossing these lines produces a broad ugly scar Undermining of the tissues should be in the subcutaneous level and only about 1 cm distance. Electrocautery of the small vessels is not recommended in order to avoid thermal damage to the main pedicle. It is recommended, if possible, to obtain a panorex film prior to placement of the screws in order to evaluate the root morphology. However, imaging will confirm that the tumour 402 Extracapsular dissection is indeed superficial and may reveal other hidden neoplasms in the deep lobe or elsewhere.

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The hypoglossal nerve and the motor nerve supply to the masseter muscle have also been used as a source of innervation to a muscle graft, but could not achieve the degree of symmetry that the facial nerve provides. The volume required may be large and, in some instances, iliac crest grafts may have to be utilized rather than morcelized calvarial grafts. The epiglottis develops from the caudal part of the hypopharyngeal eminence, a prominence produced by the proliferation of the mesenchyme in the ventral ends of the third and fourth pharyngeal arches (see Chapter 10. The base of the lateral crura on the cleft side is released from the pyriform margin. Eventually, rupture of vessel walls follows, and blood seeps into the surrounding connective tissue. The high septal defect resulted from abnormal absorption of the sinus venosus into the right atrium. The dilator pupillae and sphincter pupillae muscles of the iris are derived from the neuroectoderm of the optic cup. The cuts can be made with an oscillating saw on a sterile table, and completed with an osteotome. Ultimately, anastamotic patency can be assessed by a return of colour and capillary refill to the revascularized tissue. C, Similar section of an adult head and neck, showing the path taken by the thyroid gland during its embryonic descent (indicated by the former tract of the thyroglossal duct). The Kent modification of this approach described in the first edition of this book reduces the stretching, while providing excellent access to the ramus. The injury can be observed with scapular flap harvest because of patient positioning. E, Transverse section at the level shown in D after disappearance of the mesentery of the ascending and descending colon. Again, wide subperiosteal undermining should be utilized to facilitate this process. Specimens placed in saline and alcohols are often useless for histological assessment and biopsy should be delayed if adequate fixative is unavailable. Watson reported the first successful microvascular transfer of a free latissimus flap in 1979, and exploited a wide variety of applications for head and neck reconstruction. Development involves many changes that transform a single cell, the zygote, into a multicellular human being. The first is in the management of a ranula and the other is when a tumour is present. The defect is often in the squamous part of the occipital bone and may include the posterior part of the foramen magnum. Closure Following removal of the parotid, the blood pressure is returned to normal and the head-up tilt returned to horizontal. The lateral wall and roof are stronger and, as a result, fractures of these walls are generally rare. The periosteum provides the most physiologic and effective barrier membrane in all bone grafting situations. After several mitotic cell divisions, the sperms grow and undergo gradual changes that transform them into primary spermatocytes-the largest germ cells in the seminiferous tubules. To harvest the follicles from these strips, the author uses the 15C blade for monografts and a Persanna size 10 blade in the multi-bladed knife between the spacers. Traditionally, a small curved anterior incision is made on one side of the septum. When Furlow presented some very encouraging results in 1986, the method gained popularity and is nowadays a very well-established procedure in many cleft centres around the world. Failure to reinnervate the muscle may occur if the cross-face nerve graft has too few actively regenerating axons. B and C, Note that the metanephric tubules, the primordia of the nephrons, become connect with the collecting tubules to form uriniferous tubules. Bone within the mouth in the maxillary and palatal regions can be sufficiently vascular to accept direct grafting. Also, wide undermining of the pedicle and surrounding tissue may be undertaken; however, extensive undermining may disrupt vascular perforators.

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The rectus abdominis myocutaneous flap is very suitable for the extensive defects resulting from radical maxillectomy with zagoma because of its large soft tissue volume. In some situations, consideration is given to removing teeth adjacent to the unerupted tooth to be removed for surgical access. Prolonged intubation to secure the airway and blood transfusions may be necessary. Care must be taken not to disrupt the soft tissue overlying the car- tilage of the constructed ear. A great amount and variety of soft tissues are available for restoring complex defects involved in the skull base, orbit and midface. For this reason, flaps which do not involve the gingival margin or gingival papilla are increasingly utilized (Table 2. These demonstrated that mouth washing with chlorhexidine pre-operatively and then for 7 days post-operatively has the most significant preventative effect, while antibiotic prescription does not appear to prevent its occurrence. The models of the pectoral girdle and upper limb bones appear slightly before those of the pelvic girdle and lower limb bones. Mobilize the face to the planned position and temporarily wire together the maxillary and mandibular teeth. In cases of severe rupture of the sinus membrane, the exposed sinus is sealed with a cortical plate bone stabilized with a microplate. A temperature probe should be inserted and the infant has to be kept warm throughout the procedure. The use of appropriate access osteotomies may facilitate cerebral protection by minimizing brain retraction, while maintaining a wide corridor of access to the pathology. Closure begins with placement of a 4/0 clear nylon suture at the canthal region to tack the lid subcutaneous tissue to the rim periosteum. The proximal stump of the submandibular duct should be loosely sutured to the oral mucosa at the back of the operation site. Development of Urinary Bladder 11 For descriptive purposes, the urogenital sinus is divided into three parts. Post-operative care includes careful eye observations to include visual acuity, pupil reactions, ocular movements and most importantly increasing pain. For more predictable and precise osteotomies, a transcutaneous approach, lateral to the nasofacial groove, with a 2 mm osteotome, leaving no visible scar, is preferred. Occasionally, spasm of the facial artery occurs, which can be released by carefully applying papaverine to the end of the facial artery. The gland is arbitrarily divided into superficial and deep lobes by the facial nerve, but this structure cannot be identified with ultrasound. The proximal opening of the thyroglossal duct persists as a small pit- the foramen cecum in the dorsum of the tongue. Loud tracheal breath sounds may indicate partial obstruction of the airway that may be followed by a complete cessation of sounds when total obstruction occurs. A flap is developed forwards by blunt dissection with periosteal elevator exposing the root of the zygomatic arch. Appropriate local anaesthetic blocks and infiltration is performed to establish anaesthesia and haemostasis. In very difficult situations, the assistance of an interventional radiologist may be required to identify the disrupted vessel or consider translumenal methods of haemorrhage control. Cells of the anterior wall of the hypophyseal diverticulum proliferate and give rise to the pars anterior of the pituitary gland. Enlargement of the vestibular aqueduct and endolymphatic duct is the most common congenital ear defect in children with hearing loss. The importance of the retaining ligamentous attachments of the forehead for selective eyebrow reshaping and forehead rejuvenation. The central parts of these buds break down, forming tonsillar crypts (pit-like depressions). Skin and oral mucosa substitutes prevent donor site morbidity, provide more therapeutic options and accomplish better outcomes than conventional therapies in reconstructive surgery.

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The majority of road trauma and interpersonal violence cases are associated with maxillofacial head injuries to a greater or lesser extent and it is important therefore that these injuries are treated practically and without mystique. Dissection progresses inferiorly into the preauricular region below the level of the superior temporal line keeping close to the underling temporal fascia. It is imperative to prepare patients for this possibility at the time of primary repair. Rarely, intraocular tumours extend transclerally and invade the periocular tissues and the orbit. If this is not possible, the leading edge of the avulsion should be excised sharply to promote full thickness healing with suture approximation. Patients with slow-flow lesions adjacent to bone can have skeletal deformity treated. This principle is often extended to the premolar region, and the number of plates used depends very much on the fracture configurations. The laryngotracheal diverticulum soon separates from the primordial pharynx, but it maintains communication with it through the primordial laryngeal inlet. If an abnormally large oval foramen develops as a result of defective development of the septum secundum, a normal septum primum does not close the abnormal oval foramen at birth. Most fractures occur following blunt injury to the face, commonly following interpersonal violence in many countries. In isolated dextrocardia, the abnormal position of the heart is not accompanied by displacement of other viscera. Blind biopsies are also useful (for example of the tongue base and posterior nasal space), particularly in patients with an unknown primary tumour. Some muscles, such as the intercostal muscles, remain segmentally arranged like the somites, but most myoblasts migrate away from the myotome and form nonsegmented muscles. Apart from availability, a number of other factors must be considered when selecting recipient vessels. Cross-facial nerve grafts and microneurovascular free muscle transfer for long established facial palsy. Even these procedures do not enable the entire mass of the muscle to be used, because most of the muscle acts as the pedicle. The increasing use of ultrasound means that the incidentally detected thyroid nodule is a significant problem; ultrasound will detect nodules in between 50 to 70 per cent of females over the age of 50 years. Fat injected into the lips disappears rapidly and is not the ideal choice as a filler for the lips. Thus, if required, the incision is extended superiorly across the hair line and inferiorly around the mandibular angle into the submandibular area. At the time of ovulation, the amount of cervical mucus increases and becomes less viscid (sticky), making it more favorable for sperm transport. In addition, lower facial asymmetries, anterior open bites and post-traumatic malocclusions can be rectified. The defects are usually classified according to developmental criteria, with the incisive fossa and papilla used as reference landmarks. Vascular assessment of the infratemporal fossa may require magnetic resonance angiography to determine the extent of involvement of the great vessels. Top tips Planning of treatment is best undertaken in a multidisciplinary team setting. Ambulation is helpful for hastening the resolution of ileus, heralded by the return of bowel sounds. The skin of the nasal floor is then repaired with 5/0 vicryl starting posteriorly to within a few millimetres of the nasal sill. As small pieces of the endometrium detach and pass into the uterine cavity, the torn ends of the spiral arteries bleed into the uterine cavity, resulting in an accumulated loss of 20 to 80 ml of blood. Musculus uvulae are a paramedian pair of muscles running from the posterior nasal spine to the tip of the uvula. E, Pelvic kidney or discoid kidney, resulting from fusion of the kidneys while they were in the pelvis. The most common primary malignant intraocular tumour in adults is uveal melanoma, whereas in children it is retinoblastoma.

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The axons of the olfactory cells are collected into 18 to 20 bundles around which the cribriform plate of the ethmoid bone develops. The free ends of the lateral crura are reconstructed into a continuous strip by suturing the ends with 5/0 resorbable sutures to maintain the strength of the tip tripod. It enters the axilla from behind the axillary vessels and then descends with the thoracodorsal artery and vein to the neurovascular hilum. This rotation and growth explains why the left vagus nerve supplies the anterior wall of the adult stomach, and the right vagus nerve innervates its posterior wall. The muscle is attached by a flat tendon into the lateral lip of the intertubercular sulcus of the humerus. Neural tube formation is a complex cellular and multifactorial process involving genes and extrinsic and mechanical factors (see Chapter 16). This operation is much easier to perform as no orbital structures need to be preserved. When a skin paddle has been harvested, the defect is closed with either a full thickness or split thickness skin graft. The width of the muscle segment that is used for facial reanimation commonly occupies half of the width of the muscle belly, so that the anterior half of the muscle is divided for harvesting. The preauricular aspect of the incision is marked from the posterior aspect of the temporal incision inferiorly following a natural skin crease anterior to the ear to just above the tragus. Under the influence of various embryonic growth factors, including bone morphogenetic protein signaling, epiblast cells migrate through the primitive groove to become endoderm and mesoderm. Fetal Monitoring Continuous fetal heart rate monitoring in high-risk pregnancies is routine and provides information about the oxygenation of the fetus. The same is true for those patients who receive posterior retrodiscal scarification procedures to treat slightly dislocated discs. The arrows indicate the dorsal growth of the neural tube and the simultaneous dorsolateral movement of the somite remnant, leaving behind a trail of sclerotomal cells. No attempt is made to free the lateral crura of the ala cartilages from the overlying skin. In such cases, a limited external approach to enable lower mandibular border fixation may be required. In cases of obvious bony orbital tumour involvement, the orbit with the adjacent An essential part of the decision-making process is reconstruction and rehabilitation of the exenterated orbital socket. The sural nerve is easily harvested by a 2-cm curvilinear incision one finger breadth distal and superior to the lateral malleolus of the ankle. Repair may also require reestablishment of the canalicular and nasolacrimal ducts. Mid columellar incision and bilateral infracartilaginous incision extending towards the inferior turbinate. The nerve fibers of the dorsal nerve root are derived from neural crest cells that migrate to the dorsolateral aspect of the spinal cord, where they differentiate into the cells of the spinal ganglion. The greatest danger Giving detailed information and obtaining informed consent apex inferior border of angle superior border of angle lateral epicanthal line 11. Facial nerve injury Facial nerve palsies are common post-operatively, particularly in the temporal branch and especially following revision surgery. Subsequently, a subperiosteal pocket is created using a small Joseph periosteal elevator. In the region of the anterior lacrimal crest, the lacrimal sac is reflected laterally with the orbital contents when the periosteum is separated from the nasal wall. During early development, the duodenal lumen is completely occluded by epithelial cells. The relative indications include: 358 Tumours of the skull base previous adjuvant radiotherapy/operation complex defects (jugum resected) coverage non-vascularized dural flaps failure of a loco-regional flap. Lastly, alloplastic materials are at risk for foreign body reaction, with significant inflammation and increased risk of infection. Rupture of the membrane before division of the cloaca by the urorectal septum leads to exstrophy of the cloaca, resulting in exposure of both the bladder and hindgut.