Salll Naficy

~"'~Mosby

Shan R. Baker, MD Sam Naficy, MD Professor and Chief, Facial Plastic and Reconstructive Surgery Department of Otolaryngology

Facial Plastic Surgery & Laser Center Kirkland, Washington

University of Michigan Medical Center Ann Arbor, Michigan

With contributions by Brian Jewel, MD Division of Facial Plastic and Reconstructive Surgery

Department of Otolaryngology/Head and Neck Surgery University of Miami School of Medicine

Shayne Davidson Medical fll ustrator

Jaye Schlessinger Medical fllustrator

~T,1Mosby An Imprint of ElsevIer Science

St. Louis London Philadelphia Sydney Toronto

PART I Fundamentals CHAPTER 1 History of Nasal

Reconstruction Early Nasal Reconstruction, 2 The Italian Method, 3 The Indian Method, 3 Internal Lining, 5 Nasal Framework, 9 Skin Coverage, 9 Recent Developments, 10 Conclusion, 10

CHAPTER 2 Anatomic Considerations Topographic Analysis, 13 Aesthetic Units, 14 External Nasal Anatomy, 16 Nasal Skeletal Anatomy, 18 Internal Nasal Anatomy, 21

1

2

13

CHAPTER 3 Preparation of the Patient 25 Preoperative Consultation, 25 Anesthesia, 28 Local Anesthesia, 29 Postoperative Care and Supplies, 29 Hospitalization, 30

CHAPTER 4 Internal Lining 31 Primary Closure, 32 Full-Thickness Skin Grafts, 32 Bipedicle Vestibular Skin Advancement Flap, 33 Septal Mucoperichondrial Hinge Flap, 34 Composite Septal Chondromucosal Pivotal Flap, 36 Turbinate Flaps, 41 Forehead Flap, 45 Microsurgical Flaps, 46

CHAPTER 5 Structural Support 47 Restorative Grafts, 47 Structural Grafts, 49 Contour Grafts, 54

CHAPTER 6 External Covering 58 Preparation of the Defect, 58 Primary Closure, 62 Healing by Secondary Intention, 62 Delayed Skin Grafting, 62 Skin Graft, 65 Perichondrocutaneous Graft, 65 Composite Graft, 66

Nasal Cutaneous Flaps, 66 Interpolated Melolabial Flap, 66 Interpolated Paramedian Forehead Flap, 66 Radial Forearm Microsurgical Flap, 70

_=_~T~e~ch~nique

CHAPTER 7 Cartilage Grafts Auricular Cartilage Graft, 72 Septal Cartilage Graft, 76 Rib Cartilage Graft, 77 Alar Cal1ilage Graft, 79 Contouring Grafts, 79

CHAPTER 8 Bone Grafts Cranial Bone Graft, 83 Rib Bone Graft, 85 Septal Bone Graft, 86 Sculpting and Fixation of Bone Grafts, 87

71

72

83

CHAPTER 9 Skin and Composite Grafts 89 Skin Grafts, 89 Split-Thickness Skin Graft, 90 Full-Thickness Skin Graft, 90 Composite Chondrocutaneous Grafts, 95 Other Composite Grafts, 98

CHAPTER 10 Nasal Cutaneous Flaps 103 Technique, 104 Single Lobe Transposition Flap, 106 Rotation Flap, 106 V to Y Island Pedicle Advancement Flap, 106 Dorsal Nasal Flap, 107 Bilobe Flap, 112 Complications, 119

CHAPTER 11 Intranasal Flaps 121 Skin Grafts, 121 Bipedicle Vestibular Skin Advancement Flap, 122 Ipsilateral Septal Mucoperichondrial Hinge Flap, 124 Contralateral Caudally Based Septal Mucoperichondrial Hinge Flap, 130 Bilateral Caudally Based Septal Mucoperichondrial Hinge Flaps, 132 Contralateral Dorsal Septal Mucoperichondrial Hinge Flap, 132 Septal Composite Chondromucosal Pivotal Flap for the Tip and Columella, 133 Septal Composite Chondromucosal Pivotal Flap for the Dorsum, 137

xi

XII Contents

Septal Composite Chondromucosal Pivotal Flap for the Tip, Columella, and Dorsum, 140 Tubinate Mucoperiosteal Flap, 140 Postoperative Nasal Care, 141

CHAPTER 12 Subcutaneous Hinge Cheek Flaps 144

Lateral Alar Defect, 147 Nasal Sidewall Defect, 151 Combined Ala and Sidewall Defect, 152 Complications, 152

CHAPTER 13 Interpolated Cheek Flaps: Reconstruction of the Alar and Columellar Units 153

Reconstruction of the Ala, 153 Technique: Interpolated Subcutaneous Pedicled Cheek Flap, 154 Technique: Interpolated Cutaneous Pedicled Cheek Flap, 164 Cheek Versus Forehead Flap, 165 Complications, 166 Reconstruction of the Columella, 167 Technique: Interpolated Subcutaneous Pedicled Cheek Flap, 169

CHAPTER 14 Interpolated Paramedian Forehead Flaps 171

Paramedian Forehead Flap, 174 Surgical Technique, 177 Special Case, 190 Forehead Expansion , 191 Complications, 192 Advantages, 192

CHAPTER 15 Refinement Techniques 196 Contou ring of Flaps, 196 Interpolated Paramedian Forehead Flaps, 196 Interpolated Cheek Flaps, 197 Nasal Cutaneous Flaps, 198 Secondary Contouring, 198 Alar Base Reduction, 199 Correction of A lar Notching, 201 Contour Grafting, 202 Hair Removal, 202 Concurrent Rhinoplasty, 202 Scar Revision , 207 Dermabrasion, 207 Eyebrow Repositioning, 209 Correcting Facial Asymmetry, 209 Correcting Contour Deformity, 209

CHAPTER 16 Complications 212 Hemorrhage, 212 Infection, 213 PartialThickness Flap Necrosis, 213 FullThickness Flap Necrosis, 213 Skin Graft Necrosis, 214 Alar Retraction, 214 Excessive Scarring, 217 Cutaneous Changes, 217

PART III Representative Cases 223 SECTION A Partial Thickness Defects 224

CHAPTER 17 Reconstruction of Lateral Tip: Two Methods of Repair 224

Discussion , 225

CHAPTER 18 Reconstruction of Central Tip: Three Methods of Repair 23 1

First Case, 231 Second Case, 23 1 Third Case, 232 Discussion, 233

CHAPTER 19 Reconstruction of Tip, Dorsum, Sidewalls, and Ala 237

Discussion, 239

CHAPTER 20 Sequential Paramedian Forehead Flaps 244

Discussion, 246

SECTION B Full-Thickness Defects 250

CHAPTER 21 Reconstruction of Nasal Facet 250

Discussion , 251

CHAPTER 22 Reconstruction of Ala and Lateral Tip 257

Discussion, 260

CHAPTER 23 Bilateral Paramedian Forehead Flaps 263

Discussion, 265

CHAPTER 24 Reconstruction of Nasal Sidewall and Dorsum 269

Discussion , 273

CHAPTER 25 NearTotal Nasal Reconstruction

Discussion, 281

CHAPTER 26 Reconstruction of Ala,

275

Cheek, and Upper Lip 284 Discussion , 287

CHAPTER 27 Reconstruction of Nasal Dorsum, Sidewall, Cheek and Medial Orbit 289

Discussion, 292 Index 297

IS or asa

eeons rue Ion

Brian S. Jewett

disease states.

njulY and disfigurement of the nose have been well described. Nasal deformity has been attributed to self-infliction, mutila-tion as a form of punishment, and various

The first recorded account of mutilation as a form of punishment was in 1500 BC when, in India, Prince Lakshmana deliberately amputated the nose of Lady Surpunakha. King Ravana arranged for the reconstruc-tion of Lady Surpunakha's nose by his physicians, docu-menting one of the earliest accounts of nasal recon-struction. ' During the 9th centUlY, Danes slit the noses of Irishmen who could not pay their taxes, and Sixtus Quintus of Rome mandated the amputation of the noses of thieves during the 16th centulY.' In 1769, the Ghoorka King of India ordered the amputation 01 the nose and lips 01 all 865 male inhabitants 01 the cap-tured city of Kil1ipoor, Nepal. The king changed the name of the city to Naskatapoor, which means "city without noses."3 Traumatic amputation 01 the nose has been established in history as a form of humiliation to such an extent that the practice has insinuated itself into the language of many cultures in the form of idio-matic expressions. For example, in English, the phrase to lose face suggests humiliation or embarrassment. In Urdu and Punjabi, the phrase mera nce kart gaya is a common expression connoting "you have hurt my feel-ings," but it literally means "you have cut off my nose."'

The repair of nasal defects is the oldest form of facial

2

reconstructive surgery,' and the Indian art 01 total nasal reconstruction represents the first, il not the most im-portant, chapter in the history of plastic surgery.'

Early Nasal Reconstruction

The earliest descriptions of total nasal reconstruction come from ancient India during the Vedic period, ap-proximately 3000 BC.' The first detailed description of nasal reconstruction is found in the Indian medical treatise Sushruta Samhita (700 BC). The operative proce-dure described was a cheek flap, and it was performed by members of a caste of potters known as Koomas' Vagbhat, a 4th centUlY Indian physician, recounts in greater detail the technique of cheek flap rhinoplasty. He describes the use of topical hemostatic agents, intra-nasal splints, and leaves. He emphasizes cutting with accuracy, protecting the pedicle, and approximating the edges of the wound carefully.' Most of the reconstruc-tions were performed by potters and bricklayers, and advances were made as the tradition was passed down among family members. Surgical equipment included special cements, cotton suture, and ant heads to close wounds'

The first European to record techniques of repairing delects of the nose, lips, and ears by using adjacent

tissues was Celsus during the 1st century AD.' Paulus Aegineta, a 7th centUlY Greek physician, helped to inte-grate Eastern medical and surgical practices into West-ern civilization. He summarized contemporalY medical practices in a seven-volume compendium. In the sixth book of the set, he desclibes the treatment of facial defects by the rearrangement of adjacent healthy tissue:'

The Italian Method

In 14th centUlY Italy, Branca de Branca performed a procedure similar to that described in Sushruta Sam-hita. 8. 9 His son, Antonius Branca, went on to describe a new method of nasal reconstruction: the Italian method. This procedure involved transferri ng a piece of tissue from the arm to the nose in a staged fashion. The operation was tedious, requ ired six stages, and re-mained a secret within the Branca family. The only contemporary medical text with an accurate report of Branca's procedure is the Buch del' Buendth-Ertznei (The Book of Bandage Treatment) , written in 1460 by Hein-rich von Pfolspeundt, a knight of the Teutonic Order. The book remained unknown for more than 400 years, hidden in manuscript form in the libralY of Erfurt Uni-versity. In the second half of the 19th centUlY, Haeser and Middledorpf discovered it and had it publishedlO

Alessandro Benedetti, professor of anatomy and sur-gery at Padua Universi ty in Italy, was the first to publish results using the Italian method (Fig. I- I). His publica-tion appeared before Haeser and Middfedorpf's book containing the original description by Antonius Branca. Benedetti rebelled against the Greek traditions of teach-ing anatomy as a blend of science and magic and emphasized teaching through direct observation of facts, with independence of judgment. Benedetti pub-lished an eight-volume text on anatomy in 1493. In volume IV, chapter 39, he describes the Italian method of nasal reconstruction 11:

At present ingenious men have indicated how to correct nasal deformities. Their method consists in cu tting a little piece of flesh from the patient's arm, in the shape of a nose and applying it to the stump. For this they cut the top layer of skin on the arm with a scalpeL Having made a scalification in the nose, if this is needed, or if the nose has been recently cut off, they bind the arm to the head, so that raw surface adheres to raw surface. When the wounds have conglutinated together they take from the arm with a scalpel as much as is needed for the restoration. Blood vessels of the nose supply nourish-ment to the flap, and finally a covering is obtained, with hairs sometimes growing there after the nature of the arm.

History of Nasal Reconstruction CHAPTER 1

_ Figure 1-1. Portrait of Alessandro Benedetti. Legnago, Italy.

3

More than 100 years later, in 1597, Tagliacozzi pub-lished De Cuytorum Chiyurgia pey Insitionem, which de-scribed in detail the Italian method of nasal reconstruc-tion (Fig. 1-2). This was the first text dedicated solely to the subject of plastic surgery. Tagliacozzi reproduced Benedetti's passage in volume I, chapter 19, of his work. 12

The Indian Method

The origin of using a forehead flap for nasal reconstruc-tion is unclear in history, but the procedure has been performed since 1440 AD by the Mahrattas of Kumar, some Nepalese families, and the Kanghiara family of Kangra, India. The procedure was practiced in secrecy, shared among family members, and it became known as the Indian method.!. s

The first account of the midline forehead flap is found in the Madras Gazelle, a journal published in Bombay during the 1700s. The article was later repro-duced in English in London's Gentleman 's Magazine ( 1794), and it fostered the renaissance of nasal recon-structive surgery in Europe.' The article describes the fate of Cowasjee, a bullock driver with the English army

4 CHAPTER 1 History of Nasal Reconstruction

_ Figure 1-2. The Italian Method. (From Nichter LS. Morgan RF. Nichter MA: The impact of Indion methods for total nasal reconstruction. Clin Plast Surg 10:635-647, 1983)

in the War of 1792. Cowasjee had been captured by Tipu Sultan, ruler of Mysore, who violently opposed British involvement in southern India. Tipu Sultan cut off food and supplies to the English troops under the command of Cornwall is by attacking the Maharatta bul-lock drivers who transpOlted needed grains to the Brit-ish. The Sultan gave rewards for each nose or ear brought back after a raid. Cowasjee lost his hand and nose, and the article describes the operation to restore his nose. The a.ticle is signed "B.L.: but the author is assumed to be an English surgeon named Cully Lyon Lucas (Fig. 1- 3). The operation was described as fol-lows:

A thin plate of wax is fitted to the stump of the nose, so as to make it a nose of good appearance. It is then flattened and laid on the forehead. A line is drawn around the wax, and the operator then dissects off as much skin as it covered, leaving undivided a small slit between the eyes. This slit preserves the circulation until

a union has taken place between the new and old parts . . . . Skin is now brought down from the forehead and, being twisted half round, its edge is inserted into the incision, so that a nose is formed with a double hold above, and with its alae and septum below fixed in the incision. A little Terra Japonica is softened with water, and being spread on slips of cloth, five or six of these are placed over each other, to secure the joining. No other dressing but this cement is used for four days . ... The connecting slips of skin are divided about the twenty-fifth day . ... The artificial nose is secure and looks nearly as well as the natural one; nor is the scar on the forehead very obselVable after a length of time.

The English surgeon Carpue learned the procedure and published a book in 1816 called An Account of Two Successful Operations for Restoring a Lost Nose from Integuments of the Forehead. His detai led descrip-

, , ~,I.

/ ,

"

_ Figure 1-3. English bullock driver after total nasal recon-struction, as shown in Letter to Editor. London's Gentlemans Magazine. 1794. (From Nichter LS, Morgan RF. Nichter MA: The impact of Indian methods for total nasal reconstruction. Clin Plast Surg 10:635-647, 1983)

tion states that the procedure was performed wi th "an old razor: and lasted about an hour and a half (Fig. 1-4)13 As Carpue's book circulated throughout Europe, the operation came to be more widely accepted'4 In :818, the first book devoted solely to rhinoplasty, Rhino-piastik, was published by Carl von Graefe. The book listed 55 articles and books on the subject of rhino-plasty and included Carpue's work.' Waren was the first to perform the forehead flap operation in America, and he published his account in the Boston Medical and Surgical Journal in 1837'5

Internal Lining

As the use of the midline forehead flap became more "idespread, it became apparent that the results of re-constructing full-thickness defects without supplying an internal lin ing were poor. The shape of the nose often became distorted because the skin flap used for recon-stJuction contracted during the healing process because of the exposed undersurface. Tissues suggested to pro-\ide internal l inings included skin grafts, nasal mucosa, local flaps, and folding the forehead flap on itsel!. '

During the 19th centUlY, Ernst Blasius, chief of oph-Ihalmologic surgery of Berlin , Johann Friedereich Dief-

_ Figure 1-4. Joseph Carpue (1764-1 840), the first European ~ perform the Indian Method of nasal reconstruction. (From ' ... ::tIter LS. Morgan RF. Nichter MA: The impact of Indian -~s for total nasal reconstruction. Clin Plast Surg 10:635-

1983)

History of Nasal Reconstruction CHAPTEr.! 1 5

fen back, chief of surgelY at Munich Hospital, and Na-tale Petrali of Milan advocated folding the midline forehead flap on itself to provide both external cover-age and internal lining. All three surgeons claimed precedence in succeeding with this method of total nasal reconstruction. Based on the date of the first op-eration to use a folded forehead flap for total nasal reconstruction , the honor goes to Blasius, who per-formed the procedure in 1838 (Fig. 1- 5). Petrali was the first to actually publish an account of this method of reconstruction, in 1842. However, the idea of folding a forehead flap on itself when restorin g the lower pa,t of the nose was first suggested by Pierre August Labat of Paris who, in 1834, described using a trilobed fore-head flap and turning it inward . Because these sur-geons were associated with large teaching hospitals in Europe, the use of mid forehead flaps grew in popular-ity.S. 17- 19

Using a forehead flap to supply l issue for the internal lining increased the size of the flap required for recon-struction. As flaps increased in size, it became more difficult to pivot the flap 180 degrees in the midline. The awkward but necessary twisting of the flap often compromised the flap's blood supply and made it diffi-cult for the flap to reach the columella. In addition, taking more forehead tissue left large donor-site scars that were unSightly. In 1850, Auvert suggested slanting the flap in an oblique fashion, diagonally across the forehead toward the temporal area. Th is design pro-vided sufficient length to reach the columella whi le still allowing the flap to fold on itself. In 1935, Gillies pro-posed using a design called the up-and-down flap. The pedicle ascended from the origin of the supraorbi tal vessels on one side and extended to the hair-bearing scalp. The flap then turned downward in an arc to the contralateral supraorbital vessels (Fig. 1- 6). Converse, in 1942, described a scalping flap wi th a longer pedicle that reached to the hair-bearing scalp. This flap left the patient with a hailY pedicle across the eye for weeks prior to division. Ultimately, these flaps caused the pa-tient to live with a large donor'site scar. Patients also experienced sign ificant nasal obstruction secondary to the bulkiness of the tissue, once the forehead flap was folded on itself to provide the lining for the noses

Other modifications in the design of forehead flaps included extending one limb of the incision inferior to the other, as described by Lisfranc in 1827. Labat curved his incisions proximally, centering the flap over the medial brow and canthus on one side. Both of these modified designs reduced the twist of the pedicle base and brought the flap closer to the recipient site' During the 1930s, Kazanjian was the first to delineate the primary blood supply 01 the midline forehead flap. He described a precise midline forehead flap that facili-tated primary closure of the donor-site wound. This was a major advance in the field , given concerns about the forehead scar that developed after the healing of the

6 CHAPTER 1

, , , , , , , ,

History of Nasal Reconstruction

, ,

, , , , , , , , , J' , ,

, , ,

--

, , , , , , , , , -------

, , , , , , , ,

, -, --, ,

--

_ Figure 1-5. Blasius procedure (1848) for total nasal reconstruction with oval folded flap technique (after Nelaton and Ombredanne, 1904),

si te by secondal}' intention.20 Kazanjian and Converse illustrated that a gap exists between the paired frontalis muscles, so no compromise of forehead musculature occurs with harvesting of the midline forehead flap.'! In the I 960s, Millard designed the seagull flap, with lateral extensions for reconstruction of the alae. The exten-sions were designed to follow the natural creases of forehead wrinkle lines, Incisions for the flap extended below the level of the supraorbital rims to gain extra length and ease of pivoting." - "

While some surgeons were experimenting with larger forehead flaps that could be folded to provide lining, others were exploring the use of adjacent facial tissue as a source for internal lining, In 1874 , Volkmann de-scribed turning inward portions of residual nasal skin adjacent to the defect to provide internal lining (Fig, I -T). Thiersch , in 1879, described the transfer of cheek flaps to the nose for internal lining (Fig, 1-8). In 1898, Lossen first applied skin grafts to line the forehead flap. The grafts were placed under the forehead musculature, allowed to heal , and then transferred to the nose as a composite flap, Millard advocated bilateral, superiorly based, hinge melolabial flaps to line the alae and colu-mella Converse and Casson, in 1969, used a forehead flap for the internal lining and flaps from other donor sites to cover the external nose," Despite the use of adjacent tissue and skin grafts for lining, patients con-

tinued to have difficulty with nasal obstruction. This was due to scar contracture and failure to provide suffi-cient structural suppOl1 to the nose, Attempts were made to use cartilage grafts to replace missing nasal framework at the time of forehead flap transfer, but these procedures were often complicated by extrusion or necrosis of the grafts, fnsertion of carti lage grafts secondarily was also problematic and often provided little improvement in nasal contour because of ~ontracture of the covering flap,

Surgeons looked to the native nasal mucosa for inter-nal lining, In 1902, de Quervain first used the septum to provide lining and support for the lateral wall of the nose," Kazanjian described a septal flap based on the dorsurn. The flap consisted of contralateral mucoperi-chondrium and was used to line the ala,2! Gillies de-scribed a mucoperichondrial flap based on the caudal septum," Millard described a superiorly based septal flap that was used to reconstruct sidewall defects in amputated, saddle, cleft-lip, and flat noses," and an anteroinferior ipsilateral septal flap for alar lining." Na sal mucosa provided thin, nonobstructive internal lin-ing, The pliability of these lining flaps minimized distor-tion of the overlying nasal skin, A source of lining tissue independent of the forehead facilitated the de-sign of smaller forehead flaps because they were used solely for external covering.

/,--"---

~

! ' LJ

,

I

,

-' _ .. _, ad

"

- - .1 ;~':'~:":':",~':~~': "" .... _ "::::"~:'~ ____ ,* __ _ .. '_ .. _ ___ 0.. .._

I

~:=~~;.~~. __ c l E __ "'-_' __ "'~ .....0 _

--, .. _. _ .. En ...... _.

., lil'! "lljjl"IJI'!'fjl"j''''tl';I'1 '1H

'I'IlII-I:il!'n

If' "

'1 :1' 'I II 'I'fll 11-

!, ' '1

I.""

I'l' _

I.

~ l:J

. "'!f I

It .. ___ J .

a .1~le

I

~1,j1fd ~il_l!I'

I i;llil!i!'II;II('I'ifii~i!I:I'lt'l:il~ll-lii li!II'I-l!llj';j'j'II,lil .>:;tl~

~'. I

:1i:i-"

11

....

~~1.!!11l,l! I

~'11 I 1!1~!I;:!i!!!f'i!!il!!I!illllill!!i{I!I:iil!!ili!ilii!II

!111!;:ll"'ljll:'III'lf' It,ll!i!!!: IJiliUi,!!;l!

1,1' f .'J

'Il!' I

;11 .lII, hll,1I1hlth:IrH

I I I -! o - "'II-Ill IE!':'ll"l!l

'1'1

;lljJI;l Ii

~ll:

! I,.. d

.I.Il ,II, l!! ,'I .. j"

t

_.

'UHI'IH li,llj'iijIHj"I'I'1 ll!';,'il'l'll!lj;t

Ij' I H~I

. .]~.!

l: .

. ! .. ~ i

1 . t

2; "-I

j

I' "J'l' 1-i!.jU

!!l;;' "

./ ,,~Ii ...

I ..

,lij!.ld hiI;l;lllt!

_ , .. _

. _,

lUI!!!!l. i11:!liJ!p:,1 U ;'h;lrl!~ll I j!! ! '!J

j 'h1tolid'!im

i,I,h!J . IIm

l.! 11. . II! ,llll 1,

j liill' 'ilt If;!\ IH'tim

tl ~WII!iUt111Ii ;'il it:~

1.!I'jl !~I'l':

lll!'!!II'I;!,I.jl.I.I. II,,!, 'lll-

.-r-l'" , '1

1"1

'j' I

lil,I'l-ll'l l'li'lll_l.!!1 I --,

-o

-

J i Hlii,J'l(li ;11 !Jl1IW

u!d!Ni!{flil; 'j'iiIW

I! Jin hlllii, fill!illlfal1l! ai i!n! m

!!~;ll:, l.lh

_ .......... _...,,-" U._DF ,',0,

... Coo, "'"

. __ ""' .... _, lOW __ ~

.. ..-. .... _ .... _---"'--..... _ _ cno ........ __ .. ", ... "" ........ _-..0:. .. , :

, .-..". - If' '" "" _..- .. _ ""~~ --,-.- ........... -~-- ,._--- ,_ .... _- .... _ ..... ., -.... ".,.,." ' ... u,..,.._,., .. , ,' __ a .... _ ... _ .... _ .. _.,

.... - ..... ".,' .... -" T 0, Do e_ -... ... '. __ --,,.,

:~=c, ;.=-,,,.~:-=.,11 =' a '" - ---..... '.,., .... ~-;:-===:::: -

,---*--",,_e>r a ... , _"",'

II

"" ..... ,"" " ..... ~--"' ....... '--,-. , ,.,.. ,,,. ,.. ~ "'" :~~~~",,=~.= - _.-, .... ' ..... ""' '1

" .. _ u _. "" .. '" , ___ ' .. __ - ...... ,"'-:'~'~_: 1_ ... _ OO!C:"' ___ , _ ' .... 1 ......... " '.,"._ " _",_ ... _wr ... ~. __ _ __ ,",, ' ! "'-'---- ........ _' .... -... c-.. ... ..- till. -.. '" .. d ... _ ... _ .. - ',.' ......... - ..... ' .... '''. om. "- ..... '" ..... ='L+ II. _ < "- "- ....... _ _ .-.. __ 77.'_ ..... -.. - Loo,. _",,- _ ... _ ex:. _" Do __ " .... " ___ _ _ .... - ... -..,-.

"'_00' _ _ .... ' .. .. _oc._"...... . ....... _ _ .... _,..,,.' .... "','-" _oc. ....... " ..... _ ... _ ... _ _ ... _-----",,...,.,,,_. .' "''''._''--_ ......... -.......... .. - ,,-

2

Anatomic Considerations

-.... ;,,"' 10' .... 01 ........ 100\)'

10 _"" 10 -.: '001""'" ,,, ..... "" -. ' ''' ' .U

7

' ",,0.."'111

_ _ , _, 004"

,CO "'_0""" ,"11 ,,,, ....... ' OU

ell , ------.q;

"

..., ..,"""'" __ "';,Ion ....... _ DO ... "..., .......,." .. """ ____ ThL .. _, pooc .. .-".

""""', 'ON";; __ ....... ,"" _ 0/ ""'h _ 0/ "" " .... .

1'"1 ".!!IIII'; llil!! W

J'i!lll"it" l!lWP

It" ;. -111111;11-

'I l~!IJ' ,!!!!,',!;lll!' j'lll1111111 oj

IJII!lll II!J. 1:11':II:,lll!II,:!I,!,llll Il!llI1

,l

! ",

"'1'1

l' 1 'II

I, '11'1

i ." I

' ~iJH .. H

H

~ u

.~]

Jd

~1..,1

,hH

HL

! H

IHIe

IH'lII

~

1 1111"

l!1I"

't""U

H! litH

' lH

'!I'!WI'

I

-. ..n,t -"1

I H~

~.li>I u

... p

h ~

~'l!'

f tl 'i '"'' "'i'" .01 ...... ....... " _.,501 "'

" , 7 C 7._

--...... - -- ._-"-

" , ,.. .

to ' ........... 1 ' bd" ",7: .... """ ond ... _.-. ,....-.,... ........... '" ' ..... -~ ... ,,$ .. _ ..... 7 ....... ... ........ , ....... , ', .... - .... _'F' ':."_'" .. w ...... 5 I ... _'U ' ...... -.-'" .-, 'Al. _ '" ,oM! "'" 7 ,.. ... ! 7 = IL\1 bo,_._ .. ooc .... _ ...... uxL._ w ........ : ,,",,' .... """" .......... ;u .. ..... ... ... _ c-.,. ond ...... ,,"'- _.....,., ... ...

.::::.:,. =

. , -,.,. ".-..-"'->-~-"'--""'"-

....., " ........ ""'""'""" 01 b. """'" I&t< ...

" ._m

;::."' .. .".,. .. ""-,=! ..... -_ ..... _, 4' ... _.....,.."n ""_ .....

lO19fOI _ Pc " '0"

..... - .... .. too _ """"" ._-_1M, 100,_, __ , __ "- , _ _ ",_"cd.,. ,_ M i.' , ""'" -... - -- ........... ...., "" _ID __ ......... _ ..... _

-_ ..... __ .. ~--

..... _..,." " 1';" __ .;;.~,_~ of ... -..;. "'" .. 7 ,,,. _ ...

,ltl>o "",. P'''' .. "''''Y

"

The __ -' ....... " ... U' .2._""" _ _ l>y tho -... "'" ,,,. aOO!oI _ of ...,

--,,\0,--_ ............ ---_ .. ~-

.... ' ~ .. """ ;, ...... "'_ .... "'" 'WOO" .,..>1 "" ..... _ .... "'"1 bo ""' .. . nlS ". _ oc. _." ______ T>oo _ or ------......... -

3

Preparation of the Patient

I In , "'~ .. "*'" _ ~ _.,... '.H' :.: _ ... """" "'" """"" '" ~ ... "'_ lo """'" .,. oj t " ,..1" """ ...... '""'."""" ..... ~"""l' The ~ '" tho _ n>O)' .,-... ... """"'" '" '""""""'" _"""'. r .. __ """'J'OO _ _ ;'" """" """"" __ ",,"""c.., pub", &!rio 0"",,, durioc tho"' ....... vi ~ In ......, on ;,.., I' ' '.... ' ..... """'. The "-_

............ '" "" .... ..., _"'-' __ .. _ioIy, ..... __ .L ...... "' ... __ ........ ... __ '" ..... W" .d .- "'" .... _""-. _lIopo.h_OO __ ,,. , ... ...,. ... _ _ ,.,.,.IN_ .... .,_ ... P" .... -.. """""""" """_ ...... _". _>no!,~ "1".1., '"*, ..... "'_ ..... _ : ':'L", Fot-"'~-+I __ .... ", , J Iopo, """"""'" II< -. ..... ~ .. ' .", -:

"--"''''''~''''''''-''' IOIoe , .'.,......,"" __ b_ "'" __ "' ........... "",...,..- br_ ....... _ .... , ... _ 1'fIo'' -.._

..- ...... ""'~IO_"''cO,r''''_'' I ' ,. ,," ...... . _ ~ ..... up ... 3 _ _ .. ...,y ""Iuo.!< .... , .d.,_ ..,. .tn.,. "'" _ r. "PI""~'''' (T ..... 3-j). Cuoomool .. """"" ... ",' ..... 3 OJ ! '. A "" ...... or n....r ........ ,,~, .. ...,.->

_ _ 'r' " .... , ' , .. , - -- ,

, tvAaoo ___ "'_"' ___

,-..,-~,,---, .. ..,,-.-. """'~' " Q. _ .... "Jo

_ ,_or " _",._ .,.,' ""' __ """"'''IPI1. ,,, " '"""" ""'...., - ""'"'. """"-~-, -... 7 "' ______ G,

"on ___ .~."''''''' . o ' . ""'0 """, .. , _. "'"" __ 9J.oI""", .. on ...., " 2'5 '" Xl o.a-. 6 W. ""'" ........ o,.ct Th-J ""'" ... """" .. - -. '""""oo .......

" ............ .. " .. ... -~ . .. M, ..

",. "", 'III' , ... 01 """" __ ~ _ .. _ "-r't'- __ '" ..... .....,_ """ """'") ........ ',' ... _____ 1_",_ ..... -. ' ... ' .. _-, .... ..... -"""'--_ .. _ .... -- ___ .... ____ " So __ pM ,._ , __ ... _ .. _ ", ....... __ " .... cq., ' .... ~ ... _ n.. _.al __ .......... ' ... " .. _ .......... "" "'"' _ ... _ ., "tot .... ... _ "'"" ino''' II , ,"' ..... __ ;, .."..,,_ '"' ..... ,.--"""""" (110. ... _.11.,.. _ .. '"'" __ '!'>I ........ "''I .w..,. , .;,. __

~ OM)''' """"I", P"'''' -.. _to _. ~~ .... __ I __ ..... I ._

'"' ... -, ....... _ .. " by _ ......

'''P*'''''''''_ .. .. , "

LlI)(UJIOl

._ .. _ ......... -,""'_ .. _ .. ---~.

Cor. and

....-. , . ... , .. h. ___ ..,.., 2 '"' _.-,,_l.-S) ... P ,",0 foo' =_ .... __ ... ' , ",,",,,",01_,..,,1'

-,-~ ...... antibiooi< 01_. p"...,,, ... i,"""",""., _ n..')' Mb"8. '-'

'lljl!I!lrllll'llllll'l 1'lll!'II: 1"ltl'll"'I,!I,.,g'li !/.lJill.! J!llj'ljll 'lllll, ~;.!!

0)

!HllH!i!!!mm !~f!' l~l~ I HI!!

'1I"i'fl,

e .~

1,'" 1i!i!_, e

.HI"III!jl

.-i"!1l."1

I, --'

i 7

. H

}< H~

Hh

-0

l e ~ Q

) +

-e

HI J 1.; J # i ! :1 II !. n

.... -8n1~1~n

1'1

-,,1','

II : 111!~!i! , -Ii fj.;.;J!H

,

"I'l'l"l' I I , . I-It"

' .

! ',11111;" l!,h

'j:;llil 1 lll'ji II!!!' ~

~~ i'

t!!1': je

',Jl

I ; 'll'} rll'

01 llllll.11

-,I

'" ~ ..

f!l --"

! I ~!l!

HI!

! ' ., .1 ,;11

/HH

t; j'P

l!l rllllli

"I.! ,1

!

.. 1"1>

":l'li .. 1'thI1

i!""l!;~rl .

",.~iI

~h:,;>. ~

I ljl'd1;'lrll , !!h

fl,;i ~ ~ ~ t! ~.j . ~ t j til' ~ !l1".J!i",ll

~ 'l'il!".'ll!l

~ l~l~!J~!lj]~~j ','m

ll!l!'ll ~ph~"'l~JL~ i

p ~ lIH l"U;

liU,ljl!lh

'j' 'J"

1 1 "II

; in j

1.1 j};:o

',111'!1,,1-"1 H

1

) ~,d:iH

""I ',","'" _ ............ !>tIMip .......... _"' ....... 10 ... .. __ tot _ bI' ..... 10 s'_ ... _ .... "' ... __ ...... _ ..... _ ...... _-, ., _ .... - .' ..... ...,.,....--_~_W"e6 .... _an

........... 110 .... oM ~ __ .~. booo_'

...- ' ''''''' '. 1Iop ....... .......",.,---

.""" ...... - (j '''''. "" -- ..... _ (j oM l100011 _ ..... ..,.;cwo. ..- .... ...... P ~ ;I ................. ""...- (j __ < .... '"""r ....

---

, - _ .... ,,~,, __ .. ',_ ._ ...... - "d" , "'...., ........... """""" .... __ ... ""'" """' .... -"' ... .-..., ""'" - """'- "' ....... ...., ........... , --,- ' .,......., _-...""'..... ......-...... _. _ ',,--,.---... ,. .. "'..- ... ..-

...,..,... 1 ""', "' .... """'" """" or ... -..., ..... """', OJ to ... .- ....... , .... _.OX-! ... '-' ___ "" .... "" or .... """"" -...,_ ............ " ... ,.... ...... C ~ 00 "'" """""-"'" _. ,',_'."_ ........ _.-~ O,A ....... __ .... ..-_ .... .....,_.

., ..., """ __ ., '" .... "" ... 0.- ~

,. --

.... ,,' wow' ....... '- __ ""...,. "'~ to, ....,. =, ". .. " : ! ... ...,...,... .............. - '" "" -. """ ... -_ ~ _ ... """"'_, _ ... OJ,. flop, ..." ... _ !wIooo ..... .......,..,.. _ ........ __ 120"4 ,..;, ...... codioft s "hod,-. ...... 10< rio! _II-. .. _tt, \_0>.,0 ........... """ .1_ ' 5 . ..... _01""' _ _ TIM !lop _ 10< U ",d' II , Iooo~ ...", .... _01 .... == I.: kl .. _ ... " ._""--_ .. ... ................. _ 7....,. ....... _' .... ... ,,,,,".04 __

\I ,01 """'" _,I ' , 101 toqo __ _

"" '''-"''f"'I'''''''' "' ... ",>" .. ~ ... .....,....,.. bo_ ., 1 .......... "" ....... OlIO __ _ "' """"' ... .,. ..." """" __ I ....... """"" ~, ........... "'" Tho", "'" _ "" tho -_ .. _ ......... _ ..... _ ... ..... ' .. __ .......... ., ..... -d.,. _ -r-. .. -. .. __ holt' Ia at ' '; __ bop' : ' ........ r .." I __ (lie ,-5)

AlII.". .... ""'" r : _, '001 ........ _00"'''-'' __ ,_ '. ...,p, 10 ... I "" 01, . ... ..",..,. ... -' __ _ , 'j"""'" 1.,."1 .~< .. _ .... __ 00., 1l ~ ',Ea or,,,,,,,,,,,,,,"", ' __ """'" .,........,... _ l.O",,_ Iop l l: ,.., .,_ ............. ....... ..... __IF ... _1) ........ __

-- "

"" ... '" , ."'.-..... ud>I ...-. or Iho p;o.>Itd fIo9 t.oc , ... "'" ",,, .. ,1,,,,,,,,,,, ,0

---

,

--,

, _ _ ._. w" .... D. "'" 0" 7 5, _ """" "" ~:! ... ""'" "" ... "'-.-_. "'0 ~ ___ ... O~. "'...-g"'''''_''''''_'''''''_ ...... _,,,': .....,,,: 0 '" :" "' ... _ ""'" """' ... """"'" W 7 0' __ , : 0 ... ,.""'.,. ... 0:- __ """" ""'-__ "-',, ____ """"'" _ ...... __ """ .. " ... ,,,, 00" _~ __ '. "'"........ "",,,,,,-,,,,,0 "",,,"'~'"'''' "...,.

1

"

,

_ _ .... "- ... ""'" _ .... _ a ........ _...-, ___ "' ...... ' -.."" _ """"" .. ...-0"'. n. _~ __ ... """_ ..... __ ~ ,..-,"""'"_ .. ~ ... _"_ ........... -., .... ' ...... ""A_"'''"_''_ "",...- ... ~ .. _ G'_' __ . " .. __ ~"' ..... """"'" ~. __ ....,. '" """""".."... .... ,p .... , ""._ ... ........ _ """'-" ........ _ '"" n __ to """"'" 0"*""' .... "'"".., c. "'-__ _ ..... '_, """-" ....... _'"_"' .... _" ... -.._ D .... _ ..... " _ __ a_b,. ,~ . ...... .-"", ............ _ ......... _"" ...... '_,"' ... 0> , ,, __ ..... ..-"""'""..- "'''''_'' ~ , '''' . .,,, ... _'"-..- ...... ,~ , . ' _ ---..I brideo ~ ~ lM'c .... y b< .. ppbo>J with """"""'" ~ flop 2,0 '" 15

" --

_ _ ,. ~, .... _ ... . >1 "" a ....... _ no ..... __ "' ...... booo, ..... -.. " ,""",, ............. , '._d .. "~' ,, __ .... ___ or .... __ ._""'....,.'" .........,.,.,.... .... '.'''.0.- .............. _""""*U ...... _"" , 7 '""_"''''-''' ........... -.

- -I J !

II!!! I " hill old' l.ll! 'h

'l Ill"

,lim

! -11!1!'I"I'!!l'!!l:l!:' I

'If;t~lillhiilii!;! h

it 'lIlli,

',' ii';i'::I.:liflil'fl-rij":jCil'

-""I'f

.,--,-'" ,>

I ~tt~

t ~

.'!~qt~~!~b.!~jl

-i;il!III;1111!~!I!I!I!i;; lll'!! ':11-I

' ll!J' Illi II' ~

~ ~

!b~~~ ~~

_. I~

ilIIl~lljil; lllll,!!I!l! ,i

III ' .J j-j 'I '

-.. ~

I-I _

1, . , ~ ,no ~

J'lt ....

, !-t 1 -

i 1 ~ ,,,

; !Ii !!'!:!!rll!l!lllllJJ'!'II'I:ljl;I'~I: llil"ll;!:tl'll,lllj,I"!I.l,I,!I.!, .n

ll/!' '1'< 'J II I

j1 "u-~'''I'' "~I; , I 't II',) 'lIlt ... Ili!,I""

I' 11 "

-I,..

I'-! ""l'I"11

~ tl_!~~~'i]'~~~~fl~!t!~I~ j!_ ~~

{ I-~

-',~""

.-.-

-,

. '

11 ;1'1 !~~!i~fi~~~~~t~i~~l]l~

~~!~! ]j

c!,

o .:lilll;.t,!lllaiH

dIa/lJdhll1 i

--

, "".. '"" on --

._-

, _ """_'.Y " a_ooo ', ' .", ... , ' _d ... , "--

oj It.. -.- '""" .... -..l .ot.w .. , n.. .. _ .. d.tJ",1< ., '"PI""' priroo;y fr._ FOlIo wImt

--__ ... ;, ",.. """ ... ""'" "'" .. t ho ..... "",of"".- .. , __ ,"" '''i'PO'''''' W". H ___ tho '''' .. flop _ I>< .Jrb .Qj ..... _ ..

""" """"'" .... _ I """'" of ... m""" .... , -. ..... ~ e __

A " < loI-... '"" n..., ~ ....... IAItu\t in ~ ., _do .., *_ ~.toc. " ... .-I J '. The _ """ 11M . 000--.0 .... , I' ., ... _ ~ ..........

... _ "" m tIoo.le """"". ""'.,....,. flop'"

... """"'- 01 ,.. 01 lit ...... . " ~ ....... _II, """ . ""e pt

t.r.I

t o 0.. 0.. ::J if

)

-o ~ ::J +

-o ::J ~ +

-if

)

! l

11

"110

!,! I'

l'U!

'I'" u

1 '!5~! 1

;!!. o

,,~i'!5

;; ~ ,I'll

! -"I ~ I! . ~ 'In

i , I' I ~f

.d ~ Ii . H

H

1: rH!~

-11 i,;,l

, ,1 f Ull'-._! H

.I lUI!

'lilll'lI'_fl f

lHil~!'!lii!lI'i '!5p

i"f ~:!llli ~ !,!!l!lil l

;,!l 1!""lh

i~!lH

.. "'''''to, .... " ., __ . , __ .. _.tw. __ ", _. ',.".

=

__ I ," , _. .. ---- '.0:.": I ---- -, - - - -... - .,.- --

L"'r; - ... 1 re , - -- - ' -- -- - . -- -- -_ ,_ . - 0; '" ." "'_ ...... _ .. .... _ ..... , uoo __ ..... _ _ __ _ .uoo ____ ..... _ _____ , -, ' ", ... . ... "'.

""""' ... - :: , b

lbo.lil, _"'_'1" I ... _b .... po;nod _ " z ." _ ..... hooI. 11>0 __ $I .. _ ..... _ .... -, ...... ..... ..... ........ _ ... , , ... -"_ .. "" .. ... __ .,.n,

w.Io;' , , __ ......... - 11>0 fIqo ...... od...-"e- .. ,."......,. ........... _ '" "" .. ood ,"UM _ '" tho __ ,rr .! __ '" ..,...

"""_ '""" tI>o _ conchol """"- t-o...- T). Tho _ ;, -=-' ... .,--.. _ ~ ....... oW '- ""', ! .G ~n '"_ IOeo ..... , ",."" -.u, . ... "oft ~ ... ""'"" to ... """""" ""'"'" 0/ ....... .,.,..... ... ....... ., tI>o ...,.,. with Iieu_ 5.0 pcbi' h" ."",.. ( ... f'Ii. 1-. 1'10- 5_6). Tho onto. ..... ...-""""' un'< ;, _ '" ... _!y 0/ """". 'n "- ;nIW>c ... _ lI'oft ......... '" __ ...

...... d.....", fn>rn .... "-., ........ """ """''''. -. ... .......... r' WIion, ... "oft .. """"'" "' ... _ (Ioc~ tho ~) 0/ 11>< ""'" .., ....... _ ...... C

" .... t .... " t "

. _".~ "." ...... ---., """"" -... _ ..... --..., "-"'-""

.,. ";"""""'11 .... _ ""'. , .., ........ j .. ... ... , ~ .. ,I tho ....... co. on tho ""_..,,.....,. "- ...... DO .' ........ ..."...., ... oW ""' ..... """''--'- .... _ .. m-b

"

_ _ ' 4,,0'""" _" do- ~ ___

----~--.. 0: _ ., ___ e< _,_.e.' t ., ,", "'" ', .... "" ..-. 0. ~ "'" ~ __ .

f. "- """"" ....

-_ .. ,._-- ......... -_ .. "_ ...... " : _0 ' - __ _ "_" 2 .... _ .. ----......... _'000, G --. .., .... ~ -... ,.,. ... ". -_ ... -..,. '" ........... , ....... AItrut ... ...,._ ... _ ..

,,' .. 1Joo< ...". ... 100_ ,,' ,~ ...... _ .......... -, ; ..... _ ... --~ .. " .. , ..... -'. 010 .... "" ... _I , .... , .. ... 60

,,"" ..... ' I '1

_ ..... ' ,,_ ........ _ . ....., _ ~I"l 0 "",:'ood~ "'" .. ""'''''" _m '" """""I ,,, ... i ... uI ,I>. rWJI. ,:.:Ii. A""" ...... '" "" ....... ~ -, ...... _'" 0< ,_IIf, Lor ,""",,"Lo:I:!' """""'.-. "'., WI-""" ...... 1...., .. ,,,,,,,0.1 ""'" .-.1...,. ~ _ ... _",,_ ... _oi ... __ """""'-M:nn _ ".. '''- -..: _ ..... _ ..nctod

_If __ oi "'1'-

_ _ .... ,., _. "'''''''"'' c-_ .. ' .,_--._._ .. ""'" ---,,---~ .... -'" """"'"" > "- ...., "" - -- .. '" ,..000_'" c .... ..-.-"'_ " ... "'--"' ..... ...

"'"' .... ,

__ ""'~_"_"'_"'" ... . -,..,,,, .... "'_ ... , ........ '. __ ... . .. """,_.....,.or __ ,,,_ .. __ -__ ..... 0.0.,.. ..

i-"'': ........ p" ...... . . "..... " ... ..... _._d.n.. ....

... ".,. ....... t4 0 __ '*"

, "'" ........ too ...,....,. _ 1.0 td)c' ',., "'" ... """ .- """"'" ... ~_ ... l/>Ol _ tho __ ....... ,,' ,. 0",oIo\I ~, .... thKkJ LLL .,., __ .. ~'r : ' ... """"' ... 100 .... _ ..... o,",~ ..... _If. A .... ' potIIcO ........ _ ______ .-M,_'"

, w, _. _ poo::Ioo ;, _ In .. 21ft __ !!It .. _ .... ,.' '",.,oom and._," P',_.Ld ..... 'oIj~_ .. ' ..... . _ n..,.",.._ ... ., ',d _ I.~ .... , ....... '" dwolloC ... -..

0nI0y .... .,.,. ., 0. pIo

6

External Covering

--' 2 [ ,~ __ ... IIapoO!"""M .. ~ ... ... ,., ,""" " .-..1>1 .. hi _ .... _ .. ...... "' ....... , \ ' ... _ ........... -_boo, ........ .-. .... _ ...

_ _ H A.a ' ".-or",,,,,,"_

""'...-. ..... -- """'" "'- ... .. ...... ..,'. ---~---......... ~_on .... ._. 7 ...... "' ...... _ ........... -..c ..... ..... ..- """" .... , ... - ....... "'-_ __ ' 00' __ o __ ~ __ E_ , . ......., ........ _o.oO.Con7

., --

_ ,_0-,. '.a " .0' .... get! - """"'" """'" '" ,..-_ C""'D,T..,. ., __ '" _,_, .... _.F_,."., ..., ""'--""" _ ....... """" ""'...-__ .... ~o . '''"O,I'd . _ """" ""'""" _. F."", .. , 7 .-

!11111:1!I!ll!:I;~i ill"

,.1.1.

-jl'l' l.lt I !. I'}

: ll,lll!I'l!!l!;.;! I , "il'!}

li!l'l!" ,iiflilli~!!'!lillll Ilil:ll!!ll,llllll:

II P'IIHuIH

;; '!iflf

lOll

,.11 II

It Ii' .iih::hf'i Ip!fH

I

u!lWt!il~';jj Ifll!'jii!;ij'i'i , l,1I L

l'i ll'! llllllll!.i!j, I

'"JIll!!': 'J' 'Illl U

'JI' 1 m I f! It; 'I' ,Pi"

U .. 'J

I,"

,I! ,1

01

' i.I I i til'

I ,,!.I!,.I. 'I'l! 1

1~~!iJis ~~I~ ~ , i!ltJ:ti ,'i!ifi:~ 'if!)

Idt !l' .. ,,-.,,:!' j'llf" Iii j-if! 'tip!' ,n

' II .lm

iiH;!j'jlW

lt.: Illr.lhll.MIIlJ!h.1l

....... ',Ill

ilmi!l " .,

1:"!'1 l lll' 'J.

; Jtj f

H'I' I,

l !h'iH

."H !

Hllll!! 'iP

! B

Ii ~ h 'II' ! Ii',', Ax]

'5

I!I~i! 11' .-..,.. 01 "" P""'-- ,_ .. _". __ wo"' x _ ...... tho Wn pi .. "...-. ., odd_ . ... ..yo "' ... """,", ... _ ..... 01 ...

.... -"" ...... "" """'" ~ ... ~,...,.

........ A IuWOc_ .. in .-It ......-.. _ .. .".

.. ..... _ """'" "" .. "' ...... OR top oj ... ....,..1OIioo

....... ..., t. ! 7 ,,., ..... IWI

... Ieoo 10kfly .. ""_ .ok'o p.'. """ _ _ """'. I",",,,, ...... of .. _ "",n. onJ bon< "'I rr->"'" ond '"_'r _ oIiJ. 1'''''' _ Is '""'" on .,,,_0," ~ b ...,.., "

.. _. -----r , --,

- - --, , -

_ _ .... ~ f . """"'"'" "'..-.. """""" "'-.-~

Tlw """'-,~ ... _...,. .. tho""'-_ 01 Pf0 '" ".,. ""' .... _. """ .............. _ 01 IhIo .....,...., twO! """"'"".

f ... ...,...,,.,., I\apo -. ... _ '" ,.,.... ..... .., .-", 01 .... ""'" . ... thW 01 o!M ox- ..... ...,., 01 .......... " __ ODd rnOLoW p..t;uo 01 ......... _

Paramedian

. ......... ~ ,,~,' '''O:A-.ot -- ""'""" -,.,. ---_ ...... "" .. __ .......,.~ot~ " .... ..

.-. ...... ot",,_ C. W~ __

... "'--, ...... ~.

.... ' , .. c.-.., "

..

_ __ o.-~ '" , ...... """""'""_ "' .. _ _ '1'. H .... '.- e. _ '''or C. _ ... e _'D, __ ,''', ..

- _ ... ~I~.'~"",,,= '-." ... __ ..... _.-. ........ ,n ".r:

_.

" .M>,...:II .. 011 " po.t;oos 01 "'" tip, I>llo "",kricoI...-.... 01 "'" _. Tho. _ ,.100- podd ....... ~d __ tho ."........, 1oId", ,oclp;to. _ in .... 'PPO< ... d , Tho n.,,;, amu"r t 'j'...!"""

7

Cartilage Grafts

--O .. 01 "'* - .", '>0" -., ""'" .'..,..,. '" ... ..,.. .. , ........ "'. """""..,.""" ~ .... "" ~".,. "' .... .at. _ ,.. r .. fIo_

.... _ OMOI .- c.-.. _ ,*",,"p ,.. ~ ................... _ r ....... ............. ' , ..... __ .. ,,-_ .. __ .. 7 .... '''01 ...... _ ..... ___ , LIO 575 ..

.. or , '-"'--'" ... _ ... _ .. _ ..... _ ..... - ....... _-_10t 5 Ofd _ "'" _ '" 7 I IofaIIoM oj lilt _01 ........ _~ .... _ .. .... __ ........ "'0';''''_ CO'" ......... a ....... ' ~ ...

~- .. ...- .. -----, .~ .. 5;._. ____ .. _ ""' ...... " "

" " I i , f

tl'f'iilil;ji;l'ill!!i"f~il:lill .!. "I,.lltl .I,I"jl.,.

- 11

II -I .-,--_ .

.. d,,"

,/L..:lw_

-~"

-

'lm1mum !Ilil! !llfi !~m; 'j

1111;lii!III;I:'III!~;;;;!!I!ll !'d~.l!k'ill jflli';'l, ,!l ,,]i~~I~ll~~jlli~

~~-~!I

"stl

I

Hiltl ''''j

!111 ' ,jll.

! g

'!.H,

I l!' h '1-', il

_ ..... )_~ T--.,. ............ """'r .. "',--- ,~""' .. ..., ,"',."",.,. '"'" co ... W 7 .. _ c ~...-.

"" oN! ~ _ 'tOt: -..... b\It --"",,--~ "'" -.J _II. ~ IIot> io cle l ...... .....,.. """"_ ~ ... ...... ... ., "'" ... -.1 1oId ('111. ' -'J-~ ' ",0-",.ichondr.ol dim :lb ......,.,.0 ....... , -- .:: - ....... ____ ..-- '" _ (to.oo ""'" ..". __ - ,..,_=_c. '-"""""_..-.",,,,,,", -..... , 'd" .... -...O'_"'_

_ ".,.,"',1ro 01 ~_ ~ .._ Lhtf>p)-. p.o ."' ... lnI

Ilmlj'!

m~ ,

, I!'

,I f!mill!

I f I

'l'l:l"l}!l"lll'j

t 1 ,,1,11'1" I

-. 1 'I

';" ,l'(J .. .

IU"l' ... .

l lil~';" il~l!;'l

. Illl.) I lfl. III t. J flnfhl

IlitHHlHmnm !

I II

~.

I ~ f\

\ Ii Ii II ) 'II !h

~'!i III

! ill !Ij

. 'I i I

! hI J Iii I" ! t"'l"lll

l ~f"Utl

I, : Iliiill!I;;

"

-.....,

, """"" _ ... rib OM 7 e ... __ ...... --' fa ...... ..,t>oao ... ,. 7 ", _1_",",,-,_ .. _'7 : 55 ....... _< ........ ,'""- ... -5 : OIl, _ ...... Ior _____ d ... _ _ .. Groll FbcDllon .....,.. _ '" ~ FO .. "'" -... _ .~ 10" ,_ , __ ... '"" ... "" ... ~""""" I-. I", ond _ c-. .- ., """'".... tilt _ ........... Tho ___ .......... , .. , ., ........ ' ..

_ _ ,_, e.. ..... , ..... ,.-" -,- ,,,,' ,. ntoinod ""'"'" -"' 0- 01 l' .. _ Tho .... ~ tied ..... ".~ , ......... , "" .-...oJ """".""' ......... .

"''hen ooconotruct>nt _ "' ......... -","1M ".,..... t>oot .. p

l f , I

i I

i " "''1.1 11.\ 'H

"'ll'l" lll}!'

II' I

"jp

t .,,!

I II , -1

' I

! ~!.llll! l:U

a"j.! Ii!!ll

1'1 ~ !

~i'ii'!" ,W .. hdl .;1:11,

. !

,0J"I'! JI!!II'! !' li l-.

I 111'1 '! ,:11' 101.'

;!l~; "

"'Jlll" I".' 1 '. 10

I d !

i'I!!' ll",!iit'l'lll;} "l'/;t i ",

11

'11 -'-

"!

II" "j

'hi

f; Il ,l,'ll;iit~ Ii . ' lijl'l. !!li';

hi fli.l!dh~!filIIHdli!lj!U '!h !J 'H

""'ll!,"l i

't,!'!'l .,l!. !

Ii, 'oll'''o

p

il '.II',)l'j'll'l:,

I I

( !, . I,

:1" l,i

"jl I

'11llll111111, II

, ", J"I'1'

II llilH

Ii'; ; f

,

HHl i;!:lh1j !II

I 'll:]!'! !!t ',,

" ~"., ,;j!~f

11 iU

uH

h'U

il~

I~R II "

PART II

Technique

00

:HIU

1H: H

! I: I n

j, ';j1lllllIO

~ ~ jr!U~5~1

1.~'jl~~ l~~ ~

lit ~J~~fL~i~Hl!

Jii!!!: 1.H!h~~h

J"l1'1""i'I' Iii 1'''I!'

~j J'l"l~:!! ~ ~ ~~fl~~n: ..,1~~1

'" 1 -e

~ .. i!'~ !l

P

! 01>1 1 .... ,00 oOOoe"", ___ TWo "-"'" pI

" _. , ,

. \' ... ." .... _ ... " .. "., ..... _."' ..... : '- ,-_ : ,_"'u .... ' ....... t' " _ or- pIoood __ E LL'+O, __ _ '_...,_~. -, ... , ' ..... _---, .......................... .. ...... -.... ' "..,. ... ..." fIw _ =' .... _ ..... ...,. .... ...,od

.., .... "" __ ........... hi _ tie _ ',. ldoyo_. ' ... __ _._--,' ' .... - .,

''0

ThoOlll __ iAA ...... ! oI'r':'" .".. ,rl",,1IQIOI

II'-'l'"!"'!" ~ t~lIliij~~i 1~{tfI f~ ~11~~ ! HI1IHHlr tlH!H'~';'

f1il!'II,II,l.lfIJ'1111'jt! ~

1~~~ }"!~

l_~ 1 " ~ s

. !!. 'I'

I!ll' >I, 11

I .d

:1

1 III jlll -."

. "

I

I 'I I l j~~!I~i~I'I,,~'~:i~}!)l:!

I

d"

'"

.

I. "'I'"!'"

.llll,! li j";!'!'III'"

ii'l! '! iii! l!i" 1 ,,1 II! 'Ii! ~ '; gill lu

H

"Il"

!l ~lli'l'!:l l'

i ~

t ~ Jl

i l41J~f~~

!l

'f l' "",' '

, ,j '1' i'i,l! JI

l~ ~~

, ~.~~~i_~!t~

~

I'll!! 11 ''l!o

.

t "1

1I'H

i'j 'lq~!1.. i

r !-"~

1!J4l

p~.~

,-It l!!l;u

,t'h:l!;lW

1!

" _.

' ........ _ .... ,." :"_ioF' ,odb' __ .... _____ .... io _

... - .. -.-~.' ..... _-

......... _ ... "... '.""" (FIt ,-. )~ ---",,,--,,.- , ...... r" ... _ ......,.ID~_ ..... __ ,,,~ I , ....... ad _ colo! ...,., wto.\ ....

- _ ... ""'_. J'I"'."I

_ _ o-""~M ' .,..-..-"' ... -_.~ ___ o.o-..... _-_ ..... -_ .

.. --'"-,,"'-

doom con_ doetom>Oy ttu.t...,. .. n .... _ ~ of ",. ....." ...,. ... ", ..... .., " ... _ ... ;, _ ... n. .... ~ "'" _ 0/ .,. _ ...

...... _ ........ _"'00. ",. """"" mo, ... ,... _ ... _ ............. _ . ocoJpol

~ .. ; ',. ;. ...... 01 ... ~ ... "" uotIloIolii tho --...,. 01 ... _ "",, "'~ .,.,..". ood _ . "",,"," ... a'do 'CPOI "'" -. ~ "", ... ..,. !Np< ~ 01

., BIH

i H

ili I

I n

-I

, II

I,

j 11

1-

! tl

l~'

I ',

!ll

I f"

I!1

; I ! I

Illi1j

l:l lJ

iJl!I

!!I!

I!!I

}il!

l!lll

lll!I

IIII

!lfl

l!fi

ll!JI

)

l~ l'

{~

2.~

~1

~g !~l~]i

J $

5 It

~~~,.I

'. --

,l

'J ll

fl .

iL '

I;,'

! WI!

ll

" .

'"

-.

111

!1 .1

!1.l

,i!.

C111

!lj

l;l!

I I

'll' 1

III

;11 J

llll

fl,.

,jll

llll

liII

I'.

,111

.!.l!I

IIII

I.III

; II

,tlll

, 11

.11 1

_. ....... c

_ _ ... , .. ~. 7

'" - '-. .. _-__ 7 _.'" __ .... _ .. _-.~- .. ,,.., --_ ............ -_._ .... _ .... '*"'" ,--.... _...... . ' Uo

"" C, .... "'- _ .... ____ t00, -" lor.,... .... ..... __ "'" "",,'loo U opt"," '" ' .. 00 11"". " ....... -"",~ , ......... """ .,.".. ......

5

; "

_. "

_ _ ", AA", T" "'*" . - "''''"--... ""' ....... _-..... ""'-- ..... -............ q".,..-_ .. ',,,, ............ ........ _ C,", Fo1, _ .. _.! , .. -....

,o.. ..... ----... - '" ... ....... .". -..,.,.. '" -.. .. ...... ,,' ..... lbio .RO"", '" pit __ boo ... ....." 01 ~ ... ""'" ...... t .. ",_, ... .." .... tho , ............ bo' """'A"",,,,_ _ ..... ...- .... _.. ...-_"" 5 "4 .

.. _. , -

TectWque ._..........,11 .. _" " , ! w .... ..., ""' ... 01 coowoo' ..... "' .. .".. .......... '"

..

--~'''''''' '"

---

_ ,_ " C ..... ~ ......... _--'" .-riO _, _ -' Show ' ,""'''''' "" ...

"" 01 p

--" , "''''''' " ..... ... ... ""- ...... ' ,,----_ .... '" ,+'--''''''''''''''' ,::":~=.,, JO, ..... __ ~ """""""..-. _"" _ ........ _._-",." ... ,' ....

"'.~ ...... -'" .... ,. "

11'III'l Illjlll;lllll'!!!!I:'j' I 1,1'1,1

1 lr' 'III lilll!!!I!j,l

U)

1111111 11111 lllllli"ltii"'! Q

.!II

I' ! 1,(1111'1 !11,.!!i'l! 0

Illllll!,I!ll,llll!!!III;I;jllll ~

LL

U

)

~

::!!i11'111:IIJI'llil"li!!:=i1ij 0

11.111 ill'll 'JII'I:I!J'.illll'l

~

~I

l !!Ill'l,l', III .j'l,l: ,!!I,;I!,

c ,

0 l

+-~

U

~;~~i~r!~;ljili! :;jli9i~ili~ill~ ~

li!l;llf~'lll'l; ll;t!~liif!l!'" 0 U)

~_t .. ll.!

e~~

~~ ~~I_ .. ~~

0 II~i;II~IIIIII!i ii1ii=

j'ii1j'jl. z

~~ ~!

~ ~~I

~~1 ~-J f I

."" ,. I

!j """'llllle,l!ll!'ll!

if;,

! ! l , ! )

-

I Iii lp III 'I' IJ ,I I' '

. III I' !I, I hi !,-,I! I It WI H

II'

I

I "1'1' l'j!ll'l"l!l!1 '111" It.

'.'

! li'.'lo till!!

.~-I,! Jtl~._~g~l

; .. '

~~ ~~~~

}

1 i"'1 "'I"

'lil"!"

-'-',

I

ill -" "'. I'!lll

ill'llt ill!'II!!!!I!l' ii.'! II !1:';I'ill!",:III'III! 1'!!I'l-lli.II:IIII';~i""" .11,ilj"I:.ll1 ; -II,IIlllli'

~!fv Zw~i.~R

, !v~li

. ~"]

i'llltll!lll:;!:!I!ll!!1 I t?: Ii flfj: 1m' tll'll!!

i ~~JI

~ I~ 1 li~1

:~~rtl~_

ir,'l h I 'j.d

, hl!

111-"'11

, ,jI",I'I! -, .,....

-.Il!' 111111

" l~l~li~lii~~j

~~1 t~~~i

..,. --

l'I"l' !'lllt'''11'~ 11'j F

! 11

"1'1

1' [!H

!'lll d]; lj . "l,fI"'l

IH! H

't'!!!q'",t;,

;j",liljl!l i!I!!!!, ~. ;1:jill,}!lj!lhiiilil!1!I'!

~ ]~...

It I!

i ... i -~

I i!

Q~::, -::-:~

'ii' 9

. ~

, ""

. 0

., lj /"'1' 'Ii'" , , IJ U~!H;~!;j~Hl"lU

!~ l~~hhll'~~ i!i ~~jHh1-~

11!11'lllli1Ill!II'1 .~

II:l?,ll!';lllllll !'!";!' l!ji!.! h

I ;1!.',

>

"iI!" :1'!!/I~'hlll!l

, t

1~~~

e -iJII -

*a ~~

, ll~ ir1 -

' ~_l

!f\I!!I,,'!jl:lllll'~ Ijl~i;l!il'!llf!I!'II;lll

1!l~I,tli 1

"'I'I'IIIIIII'll'II'II!' 1':ll'l':

, !l {

'I"l!

'bO" ""1

'II !

I iI!'llih

I l.i,I!!I:!I.; !

!:I;I!!~;IIII!,.li:I;!'.II.: li.il I 'II' ,Ii I!-

2 11>-''1"

"Ilil!' ft

,'1"11

1 i 'I!!L

!-.l

'1].II,ejlfl,11 1"

IUi ,"

I

'"'

I flap

Tho ........ _ fI'I' .... ' ... __ of ..... ......... ..,. ... 1""""'1 r..p "'" c ... be -.l ........ _ ........ of .... _, or, _ ond _ 'iii-"'" .- .... ......". .... to_ ,.., ........ .... r-

_ n- ..... '"d .... __ ... ' ...... .... 10e ... _", .... ..... to> and .co .. _ .. ..., too' "'" _. , "Y .... 01 ....... _I00< " - ""'......,. ..... _ ...

........ "' .... ~ Is Imp100 ,0 di ... _ """"""my ..... fIoo _ -.. ... ....,.., ..,.. (",..... nthuo), Tho

_ e"_",, __

n. -

, _ _ .... Coo .. c. ... U .-~ ..... ,-~ .. or. """ ond 11'1 ...... 0

--- ! ! I I

I, :\ !, )1 I

1 '~'!I'jll 1'1"1' 'II

,-j,

.

",-',1 '1'111"

ill iliJl!!ii;'I',"j'! ~ -i.o;m

1 , ... ~

:11!!l~:II'll!'I! IW

lIHH

;lfLt

h:i1 iJ ~llil !I,1t I I 'll "

"!l{9I,! .Ii

~lS~ ~

~.

!fjl~!~I':l

l~

.X!:tlSl~!~

,III !li!!L!~lii !j"

, ,I,.!.,lll

~~JI1.~!~H~ilS~1 ~

1!'I"'l"!"'!l'" ~

! i~

~lS]' '1St

I!l 111!lltl!II!! ~"".:i: qjlX'l! ~~ ~ ~ ~"'l i 'J'lll 11' 1111l;1 I,IH'~lJi1jri:

-- .-

- " Co i ,

~ _ ... _01 _ WOOD"'" ...... '" J ""' .... t...- ooIy'" _ < ___ ~ "", .. -.."' ........ """"'--, ... __ ... _ ...... _ "'" _ .. .., 5 n _' __ , ! '._"',w< It _ o .. !' "" 11>0 _ ''''''''''' .......... . "' .. _-, ...... _ .. _-btIot,"tIy _ ..,...", ... In ~l

, ..

,

_ _ ~ . . ....

-"- '"

-- ----

,

_ _ ..... 0 ...,

111"1"'111'1 "I'll

~-~ ... --'"

,

.;to ...... ""'" _ ""'- ""', ... ~ ",,- _""'Y;' _ ..... , ....... """ .1,' '" t'" ..... '!"X"'. Tho ...,...., ""'" ;, ~._, ........ '" .. ...,.. ~.., """ "" '"""' wIti>-'"" ~ ;n th< """'" _ '" ....... _. " ... __ " tho _ .",. ;, ...... than ... """"

'" ... -., tt", ............. '" t ... ""'" _ ... ........... ....., ........... cO ...... ,,,, .. , ow

'" 0-0.'0

R ' +...,.. , ...... 0

V)

Q.

0 L

L

-I

, I I

0 V) ,

I

0 l

fill' llw

mU

!UJII

c .lljll

'l'111'lf j'{ 0 ~

l

",!

1 ~H~;!

lWll

1" 1

.i lill. Tho iIIIor I10p "'")' ........... ".bod tII>O the ,--.IorlO)' ...... IUpoo\-""l' _ IIIp 10 "'" 01< ... _ .. "". 01 "'- 7 ~tic jW'I

.... _01 .... """""""" ..... ~ _. """_ *'" ~. ' '!ho n.., .,.,. _ .......... ......... ___ .. , -",'-Th.~._ ooIy .. -.. '" ...... '" _ .... "'" .. 001 luI-

......- ..., "'" .., --~ '" '" ... --. .... _ io

Ililifml 1'!I!T " ;l,,1

. t ~illlii :

11' I~I!' , 'l"'i'-I

W"'-

~ -fl~i--i

_ III H

I.!!! .j r 1, !i'i

P'P!!!ll! I

! 1"1

IIlJl !h II !!jl.'iI

jl~~]'dJli

.,,1:. 111'1 ' i' it. H

l!;H~J 0

!mill !!!! I

, T

" f' 'Jl! ,

','1-" !

! !,J ill

l ,

f 'U

1"I!O "'""" ... """'"' "","" ................. .-"""" '"'''''' ,...,.,-. ......... m ... ~ t ..,.,. ..... _ .... Uo< __ '" :to<

_ _ tOo. "._, _ .... _

d''',.'.' .~","_._ ... .., .... . ,... . ....,- ......... ..-........ . 1.,,,, ,~""" _ . ~ ........, """'d_ .... ""' ......... ", 1 __ _

e""''':A ..... _ ..... .., .. _

-~-

OIl .... ...,. '" d!'Io1lop, "'" _.1 _ "''''' """'" ., ...,. bo ,.--.... .,., ........ .., _ ... _

oJ... K "'" ~ ....... ," ....... ..., bo ...... OU)" to>._ .. , ~ldIIkro" _ .... "" __ "oil)-' (eurow". "",,";'1 .. oW< on .... dO .... " o ',bOo' 0"""0,_ b""""'"pl\Ihod ...... ,,_ ""'" '" "'" _od, The .-,. .......... .. _ ,.;th ~ ..,~'" ""_ ..... 'oo ......... _ 5() ~ "'.... The d_ !lop .. ,"""", .................. dI'>l ........ '" ....... .. , ' _ 5() ....,...,.., ............. ,_ ...... 1eaI ,,, ........ _____ A """" _ ....

-... ~.... ...... "'"'II'''' '" ... kp ..... .... 'I ........... " ~ ..,,_ ..... 011, .. "'" 5() or ~ " ... _ ""0 ... Mx:""",'" ........

. - ...

~ .. .. ' .... -.... pt

-

A

, '-

.If'!iijllillilljliiliiil[1 ii,lflff!: "'I

. iI:

ih ~~ll

,~Ih

'Ill"

~

,1:1, J~f:

~ t !S

Ii.el'!!,;~ J:'l!j .. :~L"~li

i!t.~ _!"

, .-1

1"

Illli=i:IliliiA.j 1I-i~I'!t

II !!mlill!h!!ili!tJi;.!! ;1!J!u!

Hliiij:Pii1jiIF'ii!;i U;ijW

!I' 1 !!!;il.jrll;illljj{"til III Ill! It 1 liil.il,!!ll . iii :111!iI 1j:!!lii.: ! 'I"

li'!l"! "1

""'1'1

1"" "'I'

I LrlA

IJ ," "

i,li! J't II' ",

. ",I'!' ltl! 1 11 - '1 1"; i,l'lj j"

I I '1"'1111' , ,J "'fl' ;j'

.tr.l 1 JIIII:

jll' "J"'illjfi.1 11 'II'! "

'"

1.1 14 1--,

I l

11 I ,',,'l'j I'j "'I!I'III!'

II ,Ill. l~,,1i]i

S~t .t~;. ~j~~t I~!!l I "

11 '1'" 11

1"1

0", 11 1,'1,1"

I I j.II!I!lllllij!lll;illl.!ll,ltill

iilil! Ilun milh il'hh I hh2

- - ,,_. ""'oM ... . __ ... "'-'''' 'W' """ _ ." ....... C." .oJ ...- ........ '" - - """ ... '" "" _.......- .. "'""" - ... ~ ... --_ ........ ""'"" gat. --- """'" "-"-_ .... '" __ .,. '" n "" ....... _ .......... ".,""_ .... _"'*"'" , ___ ,,"" nc~ .. _,. , . ..,"" ......

, .. , :t t'~"",.: . """ ... ", ... _ .... ""-"", and "'" Do.

- -,:0-,. "', .. "_n' . __ ""'''-__ 10.='' ._-. v-.. .... ___ .,..."..,.,_

,Uriot>Iy -.... .. """" _ 01 ... _ ,1oId Thto ..,""'Mtt) to I)-pka!ly ,.", .... ,od b\' , .. eM-Iti 01 u,. III'""" ~ of 11M 1oId. Tho "'fI!'.II'OdIy OM)' boo ,,,, ,,,,10 ........ ...... -._Ioo .... L ... _ .~ ...." ., ... ....... "'" no;, """'" ...,. ..... ... boI'!tood ..... ,k ,"" """" _ ....... _ OM _10............ - """ ...,. - ... =-- .......

... __ Lt ,.." "'" _ of P< ..... """"" "''' ... _. Tlot ,_ ~ _ "'" Irnpoir ""

.... '" '1' """"'" ""~ ...,. '" ~ .. "'" 1*_'_ "'"t. = In -... _...-....-._ /1>.1" ... ...".. I,..,.,. " "" __ '" t ... -' pnloo ... "'""- - ---- ...... "'- -.,.....,.. "- ............ - -...,.,. ....,. """I-' _ ,.,. ___ 0ri.tJ ... "" __ '" tho _ ............ flOP. w< ... ... ... _ "'....., tho __ ...... "' ... " .. """"' .. . ... '""~ Of tho .... In "....,... ....., _. """

'" """ ".... Of "" ....... ""I)'.

_ _ ,,_. _""ao_r . _ .""""'pO> ",., .. 00 __ _ ,_""a.-_

. ....... , ..... ....,~--"'"' ,_,,, ." r __ _ ,~-

C:::'CE~~ plicatlons .... ' ""'1l0 !lop 010"- ""M"lIII "'" """ __ ond .... M

Ilill'llj'I""ll'l l'II/"III!I'!"l; :'l'llll!l'!llllll! i"

l>l.t!lt~,;, I' Jil

[I JI il, 1'11,1 ,jll"

I' '"

ill III III :11 . Ill!,l; .,'l!;1

1'11 II!!' I

-Itll, "1

j

1 !"ll!11 If II j"'j"'I'-

'jl h

1

. -l-h6:1Hn~

.. '~ H~ 1lff . l'l!~

hU

h

~~,g! ~

"1

''''1'

'. 1 1'l'l

Illip",,;jlij,/l

l~ "-!I~,II';.1i~

.Ii S

j~;lH~f.aj-~~"'!l'

ll,lill;nh!Jihl!!Jhl~illlitmHlI! iUml:H!im

;!!! , I j'W

I!!il :'l'llljlHlW

tj P'i'!'iH

iW!

0 llj'lll

:E n

1:~!!~i'jil;t~~~~~I!i:l!:~i!~!!~i:ijlli~;~j! .11 ~~1~!~1

l IP: Ii jl;P'j' ill.'11 liii!; i! i"!; j' it: :j!i'

U1 I h t' i I

"lhi,;t;l LIH;il{ll.ilwf' ! 1~;lnHhi;h I!J I ihl If

.. ~- ""' ...........

_._A'~'_' I') ...... '-co -.-.. , M,_",, __ , "" __

_ ".,_ .. _0 '11 __ .... IM"m, ,~

,Co ....... ___ "I " __ __ ., I"" 1_" - ... --"-_ .. _., --... --Li. ,_ .... f_ '"' __ n. ,_ ..... ,., _.

.. _-------

II. ~_"." "-, ,. ...... , ., >G .......... _"",.. L,_"-",,,._. "'--' ... ,. ... " , .. , ... - --' :". _, .'. ___ " ___ ", ... , .... ,.". Z>'" """"""-'",,, , ....... '+._ .... __ .. , _,."..a:.-.

14

Interpolated Paramedian Forehead Flaps

. ~

Iii !!mH

tHIW

!illlm HJl!IllHlfHW

lIU :!l!l H

J f!l-l f~ ~ J ~I! ~)1 ~f! 1~:J1It 1III ~~1~jtl~f

"i-"

j l!

tll'l 1I"II!"!'!l'!!III" I I,"!

,111"!';!!.II!lj j'!IIli!II"r;-I!,.ljljl I. '-I!':'I.l-1

~ ~t

3 ~

" ~

s~ --.

l ~

l~ ]

. b

1

_ i

tl mr-! H,.I,! III .Ill h hlllli 11Ill! h III I H

ll ! 1.l,llUll

! 'jl,IIIIIIII'II!'JII"'11 1'1 'l'III'j'I'llll "11111-~

t $-"jlH

,!'1'!'~;!I!'~H!!}

,1!.j,Q.p

!!1, ~ii el!ii~

I l~j. 1Ii

.,~ .~. 1

!lf __ ~ vlji

.l~~ ll~~

.!~8.1I 11

J IIJ. ~l~

.:! _

j,1i _ P

h

:t!_ .

j

H

l! .... ]h~

jipj-sh

.lif

I~ ~_I~~h)~' L.ho."~

iHl

" "

. !

",h

l .1-,1 Ii' _

_

" 1'-il"

'OI!:II!llllllj:'ii,j!i'j',':"lllll"

;-'-!'-.;IIII ~11I!I .. illh,;i!!H

:m"hlllll

l!"wH

Mt liJih

.!

" -< ! I I II J I

I

1"1 11111 1,\11: 'j .!,llj! I h ! ",il.l!'!!'l Ii III ,llLl

!l~t.pu ..

j 1 .. 'H

! j Ill'" ,

I -

I'l-1,1 ild'~ 'I' tu

"

, ii/nIl

I'. '111 1 hit !f; Il'l";j I ll,ll!,' H

J dl~' ~

I J'II Il'll

" 1,j;'1

!ili .Il, ilt' ; itl! I;ll II Jl i'll jill

i ~

p fi'

l"! I

hlll!lll

'"

_ ..... , . - . _'"", ........... ","...ruotuo _ "

-,,~- .... _--_. " ! _t'o _v-.o ___ .....-_,,_

---""',""~'-g- "''''''-''' _ ............ , Pao .... cjion for.head Flop

.... - ...... "" ... -_ ... -~"...., p.uo--, """" "'" -, mooy .......... ","", "..,..., ., ... ....... _ .. n.", b .,,,,,,,,,,-, ____ om...,..,_ ~ - .......... p.!'~ .........., nap ....., "" ~ "'"....ochlw ....y ... ...-.. .... _'"" IoIood ",POly, 0.,,,,10:1"* .... ......,,~"" oj "'""'" _ l>co eII .rdk-.0I0u0Ir coulori>od

_al ... ....- .... _al .... /Iap._ bo _,_ ,_ ... " th .. f' '''M -",'_ ".,-....... ,iuo,,",,., -. "'" IW.. Tho".". "... , r' , ...,. .............. _ ""'_ """" .... ~ _ kaI." d. ' , ., ""'_ ...tth "' ._.~ _ ... ..... """ " ' ..... _ "" """ pI.&o>o ..;"", ............ 01 _. ".., .. k>

'" ... ", .'1'" ,,, ,."'_""" ...,. .... _.t 11OIIIbIo by ....ooInII .... ."' .... ' "" ... _'" ","""" .... _., .... _ ", ... oc..y ....... rinL Tho , ... Iie .. ~..- on'" __ .. _ ~ .... ,."'- .... ,,, .. . "'""" ... """--_oono_ ~ '" t""~ "' _ OJ """""" """ to" ... "",." ..... W ... _;.........,. '" ..... - In'IjIO ., .... 1Jop, __ __ ., _""'" -" ... n.p Ouon ... _ __ -.", ... .......,... ... - ., ....... -" ... .....-... (1';" "_~). _ .... _ iII _

'" .... .....- OM< 'flop;, '-""\' "..,...,... k.o _ fIopo '" _ "'"" S ao ill ..... .... _ Po. fI.,..! em '" _. ""' ....... oj .... " _

tho .....u _"'" 01 ... """""" m,y "'-~ ~ .... ...,....... ""'" Owl """,oily ~ ....... ....... ",., ...... "'-~ ..... -..,j ~ ......

_ _ U ->. A',",' __ "_ --.....,.,.,. ... __ ..... """" _. ____ to ""'*'_ ...., .... -- ~ ~ .. "'. ,., """" ... __ c_a.'~ __ Q ... ~-..- .... ,.- .. .....-.. , ................. -.,',.'" ..

oj ... mol '"'""'" oj .., .,...,.".. "" ... olorIor __ n. ... no". ~ ......... , "" ... ......" ..-" ... ,," . ,;""...,.... _ .... ~ In "" oI>tI< ........, ___ tbo ...... u/ ....... alb b' ...dI .. _ Ill .......... tbo __ ...

.... , .... ~ ~oj ........ - ..... "' .... ooJ_ "' ........ """,,", ~ 11o ... u , we

.... -. ~ .. k..-m.. --..... .tin

....... '" ""......,._ Met)' bIri ",,",",,"'" ........ """""- _ .. " ....... < """'I' _ ....... .. _ ., ... """ _ .... , ..... "'C .... ""''''''' 10 --I~, .... p. "''''n k_.h" ..... "'" boool r.." ...... "'" ........ " _ "' .......... """'" .. OIlY< , .. " ..... , ~,...... 01 "'" -. oM "".oId .... ,,,,,, oj ... _ :.n,th ,.." _ '" .,,11>9, ........... "~"'''' __ 01 ... """" '"'" """" .. o< "'" II rtquftd. Th< _ II _ ....... "" ... op

178 ~"

,

_ ...... to_. " _ "' .... ~ 0. "", : ",'" "~cm_ """ ,,_ ....... _'" ox- .... "....-, -""" """ "" """ ....... ~ _.

," ",""-...-" :-.. .

,

, ,

' .. .... . '"

... ,',---,,_ ......... ..-_"'_ ... _... . '''-'' ..". ........ ... ~ ____ ....-_ ... " 4 , ... ___ .... ~0&>0.0 ............. _ .... ______ ''''_'_'''''''''' ' ' ,-. :0, ____ 0 .. , ,.,, ... e--.J ...... ,C~. "'_,"_ .... __ , ~ __ " ... , .. -.. ... ~""""' ... ___ ~_ . " ... -.... ~. '''-

'" !' ........... ', ...... '-

_ _ , .. ,e"" .... 1-' . , .... . "'-OJ ...... -.._ ..

.... , .... '" .... -.. ,' " .... "'" -- '"

_ __ " .... "'" """-of.--.. ""'"'" .. .. _"...... - --.. '"'-'-"""''''-. " ....... ....,." ....... __ """""'_"""'~ C_'" --... .... -

e" ,_ ... -... ......

,u "'n'_" ' .... ", r .. ,' ''-

-be "''' ..... , t.o Po' : .., ...... ~

Th ..... ; '", .. -' " .- tho "'" ....... "" "'" """'''' okIn ',_ Y,.. l< - TlT Tho _ 0I1ht .... pIoOo".,..' : wI..,.....;m') ~""_"N _ ....... '-- ... __ dlho ..... - .. I >1 .... ____ ""

_ _ "'0 COo. "'Ht " oj _._,. ~-_ ..... _ " .. - .. --.. ~ "'''!lop II " 57 d lot ....... 01 5._ .. _ ......... , _ ..... _oI ... _~iE' I'''e_ "_," ___ 1.', __ _ ....... ' _", ... __ 00

............... ,,,- ,,,,j j '- '" 01 ""'rqli ... .,. ""'ioI -. _ ..... __ ."." "'" _ 01 tho _ ""'*" '" '" .".,.,.....,.., ~ _ _ 1, mL 01 ..... 10< __ . The '"'" ..",. .... ",tit< Iefc!h 01 .... _Oat n", .. _ ,,_ 10> ......... '" the ..... r " ... ""'""0 .... __ ,Ion " ....., '" _ '*'" 01 ob ..... .ico,~ ..... tr.. __ 01 .... "0'_ 'I"'''''' .... _ , __ The ... ,,_ io , __ ... .,0< ...... ,.U .", by thinnino'" -... _. Thio _ ... ....... ....,... 01 ... .....,10 .... ..,. oj ... ......

'I

. t:" '1'1;:'11

!' i ]J~ 11~~IJ t

J ~.:~~:~il

J~_H-

! II HlI!

. 1 ;I!I!I!!I!!I:l!l}:II~!.II", tll,h;. "slul,hI'!l hl'lU

Ili ,,,I' I ;1111;;!!111!!~1!"!!11:'1 jll':I!! . 1:,"II'!I"!~I;lltr!l!I'i' ",1,1"-

~.~--, .I'i~~~!

I-~ t

~!_,~ .i~u_

m~

ii' xII 'II, ".-'-I"

"," Q~~];iJisI11~J'~~~~~

~!!_]tJ

.-'II'li-1,,'l"ll !.~. ~t=:s::i~~~:~

i~il~~ ~~it~i~ II !l'I!ll11111"!I'lli!'II;I! Illlilil ~I Jtil! III .iufdH

hilHil,l!llll!!

1111 Illh !!PI l! I, !lilt! ~

""L;

Ii 'oH. Il'1o -.. '"" _... . J _ ...... "'hi I '1 ... 00 .... """' .. . I I_ I -..... -- ,"-_ . ...., d"dd ..... .......,. __ oII ...

" __ ......... ow ...... .. , I .... _ ' I,.bt, 1 .. _ Ii .... -..~_I' ~ .... _"'_ ..... _ It.- 'I I 1' ... _ .. ". .. .....,._1_ 1- . I ,,,,J . ..,,'" _ 1 __ .... ""....,. '" """ .... """"""' ...." _roinc "" """"' ... .... , r.- ON .- '" ...., thdr .,.,1 i 0 'I (110 li-f), _ .. ,..,.,.,. _ .... """ .... II '., ~.oD" ... ___ -" :_ 107 on, , ... _ ON _ ..... bItt "" . I"". OJ.I _ .................. _ .......... _ ..... _ ..... __. _ 0""_"" a'" .. _)o4t_ .. .. _oI .. V I ....... .. _ _ ..... q,_ .... _-(- ... "-10). __ .... ,*00." ',." ... .... _ .... _ ..,., ...... , 111. .. , '. ........ .-. __ .... -""' .. ... ~ .. 5 ~_., .. -..... ..... lbo

..-.-.. .... "'" -- ...................... .. - "' __ .... _ - , ..... roo""" . k .. Ioon _ .. .-. _01 ... ...". cor.! ~, L _. " ...... 0" ... lOq""" tho ..... ...... , 50 . ...... __ ...... ___ ...

_ ........ _ 01" .""", t ODO _ 0 _ "'" ..... 01 ... VI. '"'" __ "... -"--": , ... ""-----"' ... ..._ ___ 4:0, ",_ _ ........ __ 1:

, ..

, , -- ", ... ... -""~-.,-

_l4 189

_ _ , . ", .. _ ..... ,,_ .. ~ '''0'''''''''''''''''0'''' , .. _>=, .. _. _"''' """_ '._.w .. , ........ : .. _. __ .. ___ ar_ .... ..- ,- b . .. _""""'...................... , Cc " .... _ .. _""'." ___ ... ,, '.oJ" _ .... _ ~ ... " .. O ........ "'""'" _ ....... '"'"" " _'"" _'W , . .. "'" .w,' .-..""' __ .. _-.... 0._'

-........ _.""'". ~ .... --.... ... _ H

.. ..,..,... ... .,., ...... ,"'''' I"...

"-_ _ -,.""...:101 c~ The Poromedion FOIeheod Flop os 0

Unlng Flop

""''''" I j "' ... """'" 'Wi ,d Io;w ....., .... """"""--'d .' .. " _". ........ --... .... "-"""-_ ... ",I", ... Io;w thio """""' ....... _.., .. .....,. ," _ . ' ''''''''. in _ '" ~..-_ .... _ ... ..- ........... .......,. .... _ to ""'" """"'" '" .... A "",,,,,,,.pc" .... '" .... +0, ... ;"" ...,.. .. "'" ""'.,. '" _ -.... .""". """''''' -..- ..... tin . ....-__ 01 "'" ............. , __ /Jo;>o. On< "'- ....,. .- ......., ..,..... .,., "" ""'" PO"'- ....-"""'" (l\f. .. ->2). _ ..................... ,;uti-....... _ rib ",.undo ....... "" ,""" .. " ... "'" ...... '" ,...,.;.;. """"""'" b,",~,,",,- A t ..... ploet .... ~ .... wi! [M -lin IndoIon ~ ............. """""""_ .. _ orow>d tho pai ,a. '" k ..... dtIttl __ " ,,""' .... """'_' "' ..,.. .... boo>< '" .... !too-tot PO"""''' "' ...... rlIoo. n, ........... ..,.,.. "" .. ,ocl" .. boo>< ... 11> "" .. _ """"'" '" .... """'" '""*- The _ -.a ... pai ",,,, ~ _",II-_ '" PO"'''' bp '" -... The ."." .... ""'lI'''' ... .......- '" ... _ 01 ... bel ,,' '",,"OJ "'" _.w "' ....... ,."" ... , .. ~ "."., !lo .. I"b . .. ......., ..., ~ '" _"'" ~~ lot .... """" .. . ... ...-__ A _, boo>< .... .. _ .., ... _ ... _ .......... 01 ... ,-_ ..... __

... """"'" "'"

"' ........ "' ... ".,- .... '" "'" pINed '0 .... .... uoJ" _ "' .... IinOnQ rkp, ~ ~ tho """""" ...... .-I "" ..... .""... .. u.~ ... ',,001., The ....... boo .. ""' .... __ q lap ... ~ '0 ... ~"II iIo.po.."..ooI "" .-...Iari.o-' '''' """'"' I """"""-'< ,.,., con be ..,._.

_ ...,.- ... _ b" ..... It" .. :. -.g ~ " __ ONI ... _001 be< ,odo , .. _ . Thor ....... _ .. .,.....,. d_ ..- "'" ",- ... k .. ""' .. , ,",,_Loo,'" -...""" .. -- ' ..... ..,.., . -, .. ~ ,--'" --___ ......., ,_i...-. __ " __ _ ... _ ... """"'''' ..... bloc>. ~ , II. __ , ................. ri .. (UOO,(((] """'""""'J. No ""'_ ...,-., .. _ '" .... ..".,.,... ~ on. __ 3 , .. _.., ... tu.id\Do '" ... .-_

Olon ..-,. Tho ...,.... '" Ihe ""'...., ~ ...

""""" '" .........- """ ... '""'"' '" ... - '" the _ ........ A _"..." """""' ~ , ... ..., ... ","", d-.c ....... "" tile .... , .on ..., .......... _ " "'" _ .... uodo. The _ "","Id be ..... .. "-'" .... ,""~ k>'" ..... " ... ~ 000y __ No ",',_"_...,. '" _.., .. ""',.. ,_ oeM,>"""" to _ .... -P';"Il'" .... ,~ ... Tho pox ... ;. .'it ,,,,,,,.001,,,,,,,,,,,,,,,,,,,,.,,"";bi-_. A 2SI)L Ie. 25IJ.rnL _l .......... .... _ ...00001 """"'" " ''''''''''''''''tIy _ ..... _ ~ "'" _ ",",!wo, The _;, , _

;. ~ "' .. ........,... --., ---- ""'" tho _ N'Id "'" .... ~~2_ ..... _"' ... ...

....-. ....... ~ ........ "" .... _ ... aIoo-

"'" _ ....... ;. "*-'''''-' 'K """"""" '" ... inio< ___ ,~", ""'" _,"-.hl "'. so.r..c ""' __ ..... "'" '" ;'j .... _ .. tile _ ......... ,.,." """"" " ....... ~ ,ho ..... _ .... "'" ...au .. '" _ .... "'L. oot p,."'_ ....... ""' ...... --."" ... , .... -.. ... -.ud be __ .... ...,.. _ ", ~ 0 ........

io tile ok'" ~ .... ox_. Sol ... ...,..., "-... ""I>dn.wn ....... _", ' " 'n._, ,_ ....... " ...... ",. .... ,~ !ocIor. ~

2; k> .lO ..... '" "" ... ,m ... __ """ ~ __ ............. 00. -..,. .. _ Tho ......... ,

! '11!111"'~11'1"1' tO

O'l'"

I "' . 'II!I "il' 111'111!

!0!:;11111l!il!.i! i"!jl!l! ll'll/II,I!:!lll"l 1;' ill

oJII!iJE I"; II

i J!!l,! i'll'}ll Ill!I,I' '!'f!

I! "!I'!"I' "I' ., II! '/1

' i"'li:l oi"l!!l l'!lll.'

Ill'll til-llljl}l 'j;f!lijl t11

i,i .. ih,lh

l.11

ill-! t .111 U

I

I "II l'!"ll!l! Ill'l'lll "'11"11':11'1' 1

jft 'j!i~!I~!I~I~ I!~l~ :~: l!i:;~t~J!I~

-~ ..

-~ ~i

Ii

1 I

~ t

II

f -"

...

-,:-~1I{i~.

~ t~~

~l'~ t

$ ~l

~-jI

-~1~iL

8 U

~~ll

II 1~~Jii

~ ~

Glj1!; 1!~~;!~i:jll~I;~j;!ll1,.i:lll:~,:~~1)e~ .1 il.lIl'lhH

i:U%

III 1114ih,llmhll! I

... ..-P. 11", .. ' '_ '" .".. ....- ";nnod ... ",. ......,. 01 _"'. Jw. _ ... in .. ____ 01 .... flop .- '"

...... "'" .. ' , , .... Tho ""'"' .,.. ooaonwd .. an

""' ......... -".., ............... - ~ "' . "'"

--,-

....... "' ....... 01 ... __ .....".. _ _ .,., _Mol _""" """"-' ..... ...-01 .... d ......... """on \ ............. ...,..-." ..... ~"'" -"",001'" ~ .....

-'""_ ......... _ ... _ ... _ .. ------......... -1_a_" ___ ... ,"W'., .... ___ .... ,.' ._,,"" .. _,,___ IL'--- c -- ,"~~ ... -.-

~~=_. __ "" .. nz " 7 ~- .. _._ .. _ .... _----

_ _ ' ''''''' ~~ .... c- _"' _ __ ,_ oFg __ _ - .... ""... . .. -...---, "'" ..... --... ,--,~.-. -... " ... -, _. " _".==:.~" -..... - too ro4 .... -. - ....... -"'"'11 Ii_ . . _. - ..... -,---- " .. ,-" "'"" _ .. _- ' '''_'''_.' a.' __ _ .. __ ..... _--........ -., _ ..... _II. ___ ...... _J __ ......... .....0.". __ .......... -

',~' ...... _ .. --_ ..... _--.. __ ..... _- ... -.-. ... -,,-..,-_ ........ .-_-.. -.'" ,,_ ..... ~~~---.- ....... -.--". . . , .... ,.. .. LI. _""-_

.. ~W .. ~ , " , ..... IM

--......... ".' "' ... ,", "' .... -1-'-,""

" -,,:._ ...... __ ....... __ . ---... " .. -.. _ 0._ -_ .. _ ... - , ....... _-

w' , ... ___ """ ..... -.... ' .. "" ,,. :~.:'~_::._ ...... III ........ _ ... "'_ .. ", ... ,.,,. -

15

Refinement Techniques

~-

[N j-' ~ bell'''' """ , ........ 01 -.. '" __ ond "''''''''''' "",",. '" "- 01 "'" ...-, __ o.p.n.;t;"i '"' ..., ....... '" "" dc'''''' ..., ... .,...

0/ 1Iop .....t . ..,.,. """"'" 01 KUIpoq 01 ... "''''' .... '- _ 01 1M ~ 1Iop ko ......,. _....,.

"', .. ""''-' ..... """'" on,"'d __ ;. ~ ..... _ II"","", n- _ ...... ,

".

," ___ "",,,'1" ..",. _at'" ."., ,

Inlefpoloted Paramedian For.heod f lop$

co ,_' J ............. , ""'"'-'"... """" ., .. ....,...,. _ 01 ... ....I tip and dcnu .. _

, --, ..... '" ... _"'''''''-, ._.

,"-",,_,A

~"" ...

. , '"

Tho -.., ~_ ......... ___ " cr-t IIopo ....... _._ ..... ,,"7 ,-- , , , lop. _ p , ute.. ':0 .*w-, .. _::... .... _ .. _. , ~no,. __

~ _100_",_",,,,,, ... -. .. "~",,", -""""-------__ no,._ .. ...--_ .. ""_.-... ..... - ...... ... _ ....... r-ft:;_t,) Tho_ .. """." .. .... "' ... _10, I _""~ 01 ... _ ....... ' ..... 05:0' ..... _'._1 6, _ .. ,_ ... _ ,- 1""_ ....... r..- ..... _'" ...... _-",' '."-,,,--,., ....... "':0_ .. ', " .. .-___ I ' .... , ... , , ... _ , ,. __ ,_ . " FLi .t.:.. t! '_ .... '5~_ln __ ......", I\opo _ dl"""", ... '"""" ~"..." '" .. 10 __ ..... ,, ;., "'"' _ ~ -..".." po,._ do: .j ___ a 1ft , ,' .... '5.'}

... .. Flaps

~I n.". .,. o-.J .,. tilt .., and 00II .- .... """ "' tilt

;1 !lliill'j:'!!II' !1!=llill;II'I!!II!!11 " fi::. U

!h ,~ ;l't''';l'h

,ih''!,l

I " ,

-! !!'~

~

~~ ..

]! ~

Il~ i

~ ~~-

~~ ~_..

--)

, d

", "'!.H

i,' ,!~l I'L!i

] ! ~ ~i i~ J! ilf~l ~] IltHj ~Ihl ~ j t; ;~~i~F

~ll'l! ll! II III iI' III hi ,;! I fi,m

ll Ii!

1 1"'j';rl"

~1~J!hJ .d

fl'r~

~~~.blij1

g 11';j!.lllj.

'I ,il "!J

I

I . 'J'l .

IIj Il,:;:i' 1'/1

'1'-,-',

~

.!~l *~t

11 s:~,/!

I ! I\:"!'I!;I '{'l'i"!'"

U .. ~~h

ul

, ' 1_ '; ...

_ _ " -~ c-",_ ..-",1

_ _ , ... """ .. - ._ G .... """'_

- --- ....... , , .............. ""*'-____ -.._d -Alar Nalching

..... ~ '" .... """" __ """" -. oW ......... ""_ '" ..... of """""" -. ...... .,..... U>e

'''jj'''U Ii'"

1'1 t'"l'''

H'"

'j'!I!!,I't'I'j 'l!j!,W

'j ;;ill ;111!J!lW

"H

ll; i;i!i1:lli!lli: .1'li;;l!.

jlll1 1 1, !1'I!l!;

I ;i!ll Ili;,I!l]I!!I!1 ".J' 'If I li!.l ,l!llill III

I 1111' ._-

, ___ _1 ~'!'!"

,I -I' ,,','1'\"1

1' 1 ~

"'ll l';I'j)j'11,!,I,!",!,

~

... .JIg ~

1i ..Ii

__ ~t&

'II.

,1~,!j I

I:

~ ;!!liH

!!HlliH

lllWlilfilii U

ImW

mm

liiiH;J

ll!i: IW

Hij'

ilj;;wm

lllaJ ;'H~WiH 1

1,jI!jlt

.1 .h

,l,,, .",

1.!

f ','I i :?

i~ 1'1 i

-....

.. ~

'E

~ '"

-~ -

...

'W'

~ lul"

I ~.! lIt!!!', '1,1

HlI'I'l

11

, i I!' .. "I"

ILl! -t'!

I '-I 1,1 ~!il

'Il;d!

hm

m

Uh

f t ud

ui H

,,;!.l H

,,~"'" ~ IUlt!uIIy ......, ","" -", -...... _". '''' 'r)" W pIoO:y ....,. _ t.. ,.... _ ... ~ '" ".,... oeooooo_ Tho """'" >WCtioo _ """"" MY cotO't>'_ 0/ "'!Ii

"",a

""" __ .. .Ibod tJ\rir -..J .".

1"""'" "" ~"t'" '" ~ ... 11> "'_ ,... qu_, "'" ."". _ plio on..,.,., tho .-.1 - ___ .,. tho ~ pox"""'" n..,. ... "t'''''' ., .....,..." tho ......... .- ...... '" ., ..-, nanow _,. , .... lI'II. lS _6). """'" ...oopool

.......... "'-""'" """-__ ., _00\1)0 ~""''''!h.m'''""",,-.... pIoc ....... Tho __ ....... 011_ ... ~ - -.ny. - - .....- .. "' ... of ~ p:oIrd;"" " .. M""""_" no.. _ ....,..." bulb ........... "'" ~ " .... __ t-a.. ..... ~Tbot __ ~ __ _

..... "' .. ~ oj !.i

f 1 I ~

l!ll i mlW

I!Jl: I I

'I!II I ilhlilliH

!

' L

111'11' I

I '!It

. ~

-te

,_

t

ill!!' ,iWdlh:

! utIlItil

I HlHlWIHli

II '!j. \

HliiiHHHu "

~\

11;:i1111! ,'=I':'IIII'I'III'lllj'

1111,ii !; 1111!!I!;.I!I,ltll11,!,1 'j"

h:iP

: ~2~r~:~I'1 I .JPM~-~h i!l 11~~'

'!I ~j~

~ 1 ~ ~~

~51i t~

"I'j"-'

I' 11' -j

" I' !.

11.I.lijiJ ;!'I'!I!!-!'I',II~lll:l!ill I~llll'-!! 111.1'! I jl ,l'!l!:.,' 11~EZ~!!I~

II 1

iil ~sl:!iJ -a

:r~l el~~j~il~~'~ti~'!I~~I~iR!M;ltlll1R~~

...... ' . -""', ,."'''' ,,,~ ' ........ .... _",.- ,_" 'Itc"' ... __ "'",."" ~'l'I .... M""" ,wPpodic .... ,.". _ , ~ ..... _ .. N,.""... ~ .. "" ' .... '" d "".'" (_ ,_ l4). _ No """"' ..... .. ,_ ... " .. -"' .. __ .. "...". , d __ "" .......... ,. __ eo .. "' .. _ " .. "' ... 4_" '" ._

-N

0...,.,.."., "'- rfIO)' too .......... _ , ..... "". It:)i OIl ".,. ......tot '" ........ '" ;;,; ..po:. "'to ..., , flop CO ... .- ".". -ro _" _"'b" . __ ....:_01. _ _ , .. outto .. , , " _.dot-

_ _ ,'''" . ""'_ n .. _

-'-"

, ... , "'_ ... "."

...- """""" _ ~ tru>II ~ fkp

~I

,

'" c j,

0 .-+-O

il

~ l

IllUj

~ HHI!

0 u

m!h [l U

I1fl

. q~ ,

"'''''''';'''''''''' "" _ ............... _--..,. .. ""' ........... '" -~ -- -,..,... Infection

The _ .. POly '" tho "-' "'" _ on~ ; .. "'" 0'" C _ '" _ ........ .,_"'" ..-do_ "'-or. Suffi0_.

I "ill" liIll!

F"pr I: I If ' 'I'

II ~i~

~~~ f

~ 1~

lli ,l~ o

loljl II!'

" ~ 'IIi'

~ l'l:iit Ill! 11

o ~

-~

" !!

~

'!5

,I :

jnjh

I!

.; !i l,'!

i!!lJlj ,1,1 li 0

( ~4~~

Ij ~~~~II'

t i/.

.".

'Ii" I

.1'1 'I" Ai' :1,

" r fli; ~

.I IH

I m!, U

h!

'I l!llljl"1

'"II'll'!IIIIII";"( Ii

"J !

"1-,,1 '"

I'll

~i~~ ~!~ a ~flil ,! ',!!,!~

I

Ii I

'OJ 'l'lji'l,jif'I}''';''Hq

i

"" II 1'!5

-L

HIII~.

f "-J

'11111:lI'."" !,.!!!ll.I'j'j'

! /" "

Ifill 'I" "'j

.I,j

, II ' _l! dn.

_~. ~'~

s ~

i ~'..

' ~i

. .

i ,

~;i~V~-n"'~!

-~

f ' L;~' ~~i -Il"

-;-.q-!!~pu.!~ "I

.! ,!l!lli,1i 1jl,t"illi';!';;li't

_ ....... , .... "- c..u..oo... 0000ct " .... ,-,,; ... -,,_..-.. _.-_w" .... _ ... ,U> _ _ '" """' ..... "'''_,

'" , , , -

_ _ , .... * ......... __ ......" "."", ___ ~",::"",,,o;'"'OO_,,,,,",,"7. _ _ O;OOOO ........ ~ ,~. ; __ .. _ ......... _._ ...... G ___ ~,_." .. __ D_..., __ ...... ~_"'_ :.' ..... =", _w 2 __ ,,_, .',,, '_' 7.. .....-... "'" I

._-s.- _ 01 ..., _""" 10"""" .tum, ......... 2 .. '-... ... _ .. ' OJ! ,~ ... _.-", _._ .......... ,p.-,.., ~ ""_ .... , ,,,'" ..... boO 01..,... t ..... ""_ ... ,lop ................... _ II' tho

'I' 'S

' N

-~!"'~

.:U.

-1 I ,!J! 'j'l

! I ill t

;'"

~ ~ip

. >'! 1

1j

!in,~ ii ~il

11'111111'~'1111

i ~l~a!11~I~J~1 a~

~ ~~li:l!rl:B;!114

.~

~ ir!J~ilJliilt;1j.

~I lillllfi!I!~Nili; !

;111;!!;!!!!lllli 'J

'llillll;liillj'l I !.II fli!.'l!l,

:jii~!!l;ilni: ';iJI~ &

;,Jj1fi11hdi !I:m 2 >ili!.!j!!"

'!' lih'! v

hf!!h~tHJi .. r He

~ p

iihF

'j'l'l i 'I f,lhj"hf;;l'!} n'l--l i u

111'11i~~ll

P~i;,p ,6

II' I

Ili'jl,f'" :lll Jihhli iilla

fl i 'j'll!1

'1111jllll!II~lllll lj',li,1 1III';!1 -ItJ~1 I i~1~~t;lli;113~llt . r~~~~l i~~~I~~1

lilil!l llj! 'I ~~ .. ~

~-.~

_ ~l~~~~~,

~l 2

-E

. j!jtl~

ji

~1

!-

~-~

~~~

..~

_., lt~!;

e.J~~.~~ j~~~

~~f~tlI1, 1' ~

." C 57 ,

......, ... ~ "'_ ""'" .. "' ......... !\ql...t ~ ~ >lIo\. ~ IP>O """"'" otI

-;.:.;=~

....... _ ~_t. _ 1>1'< ............. 1IIIf"'" OJ ........... : ,I __ Hypo. :'; r.",......, .. : ,d .. dwflb. .... ..- 2~ ....... ~(fIIt 1~_UI)._ ... ....... J " ."," ~ ""'" ,e.. 7 """'"""'" ......... 1' ,d inoII"-s'" -... _ """ ............. _'>C. It> .... iIrt ' ' ....... "' ....... .... ~ --...,...... "'"""""' ..... -.. ~_~F"""""""."""'-_ .1d ..... ""II'It< _.oc_ btu .... 01 .... ,. ..

.. 5 ..... ~ '''"S ",iu ill ...... .-"Ao'.l-b Ibolo-p'_ I'" .. 5 .)loolOpi-

c _, ,

""'" -,,,,,, , ; *' , -""" - "'"""'''''' .. -, ~, . " ". ,,,,.",,_doo t __

.. .... _ "'"'~ .ro. 00I0o ... , '" ... .."......""..,., ""'......." "",,_!I_ (_ n, ,i_1\). no;, hoo ...... fIOO'!~"'" ~_ -._ _ -. -.. _ ",...-'" roPov .............. .. """' tho , "he __ f,,:too __

....... J tho """....... : ' ....... 'Kod _ "'oc.o=J>,_. "'., h' Pu' ,Sop ..... _" ,, __ en!)' ..... , ... , "J.lnd '...... ... .... _ ___ ..... ,,,-,,0.' , __ rn" ....... < ...... ""'_ .. \ _ ...... -00..... '" ... ",..' "4.,,, "

--- '" flop ... y "" ...... ,,""' ., ~ the.-. [)C'" 't

PART III

Representative Cases

--~~~-"~l~ilt~ln

;P1

P:l'1

0

. lilt. 'r!"lf

UjliiiW

--o

"'J 'h

i 0

f-~

'lilt' , 'Ii 't --

Jl 1,. -_ -0

111 ,lll,f"'!!

a -.

~o.

" 1 lj'H

! 'fir ~ ~;Hiph~

~ O

lOl

~Pi!liid!'j l o

Q::

~ tiJPlql! llin

.! 1

j!'IYll

--'

'I-

1,'1

If' , '1

-0

"l~" H

l ~

o:i:hl1jl!.l-j lfiild;l,

c ~ O

V)

... -~

~ ~~

.or:-

I h illH

till!>

,I.!" ,;/.

cD

'"

, o

i I

00

1 !'ll

111~~~j2'2:i~1:~i'j~

t ' ,

hl!''!5'_~'!ili-:!,,! .. ~

~---

..c lbl

0 +

-+

-

Q.

o Ol

iHi!;llHlHU!Hh

<

hI' ef I 8

22

s

~1 ;;~~

~ ~ I!o!il

+-

!J Il 0

V)o

()

; ~

.. -

~Ji'f.-~

3

ifl . II'lt-

lj;-I'!ll "I

ii, O

f-

I';' '1'!"jlll!-ll [3;]1

Ol !j

11~ 1

II l~~ -"

1]

Q::

ilhillil il, I;llhhl~

, .. ..-~ _Is .-

-' ... , N __ 11-1) -. .......... ....

Illl Iii! Ii, 11'1

II i

1-,I!!I

, ! I I I 1 , ! I " ! " "

""!! 'lflll"'I".I"l 1 111'1

;"'1

1: If"

J

' 'j' I ~ '''1

Il!p

llll'

IIIll! '11!lj'!'!:ll-!' I 1IIIll.;.I; ~~

~~ !Cl~~~~~~ If I

~!~i~t~~~w~J~ dll ll'li1ti,

'I!'l' liij!lll-jll!i.lil:!llll'lil 1111,1 !llllli';lij'jlr'illll!llll;l! i ",'I."1

11

,,!'ll. l.,II!!!j'll

~l:.s!~~;l]~

11'~I~~lil~I~~~IIJ, i

lliliW !lhlU

lliil! pi !ll!;li IIll

.~ iiI;l!!

II d,liH

]tHh~

'Ill';'; I~H

Jh;!/

! I ! i ! I " 11 II h

--, ....... _' ----, ... _ .. _---- -- .-.. " .. =.--..,.. __ .,." """ __ ... """' 1)1Il.k:

_ _ IJ.>. A.,C '0' n ___ .. __

_ __ " ... A~ ... "'"" ... ,_,,_ .. _

..... - -,~ . ".-- .. -~. _ . .,._ .. a .... ... _.' 1L .-., .. --

,. "

--- .. "" ......... -_ ...... ..