Reconstruction in open anterior skull base surgery: A review and algorithmic approach.

PURPOSE: Defects resulting from open resection of anterior skull base neoplasms are difficult to reconstruct. Our objective was to review the literature and describe an evidence-based algorithm that can guide surgeons reconstructing anterior skull base defects. METHODS: A research librarian designed database search strategies. Two investigators independently reviewed the resulting abstracts and full text articles. Studies on reconstruction after open anterior skull base resection were included. Studies of lateral and posterior skull base reconstruction, endoscopic endonasal surgery, traumatic and congenital reconstruction were excluded. Based on the review, a reconstructive algorithm was proposed. RESULTS: The search strategy identified 603 unique abstracts. 53 articles were included. Adjacent subsites resected, defect size, radiotherapy history, and contraindications to free tissue transfer were identified as key factors influencing decision making and were used to develop the algorithm. Discussion of the reconstructive ladder as it applies to skull base reconstruction and consideration of patient specific factors are reviewed. Patients with a prior history of radiotherapy or with simultaneous resection of multiple anatomic subsites adjacent to the anterior skull base will likely benefit from free tissue transfer. CONCLUSIONS: Reconstruction of anterior skull base defects requires knowledge of the available reconstructive techniques and consideration of defect-specific and patient-specific factors.

Adverse events in facial plastic surgery: Data-driven insights into systems, standards, and self-assessment.

PURPOSE: Complications in facial plastic surgery can lead to pain, suffering, and permanent harm. Yet, the etiology and outcomes of adverse events are understudied. This study aims to determine the etiology and outcomes of adverse events reported in aesthetic facial plastic surgery and identify quality improvement opportunities. MATERIAL AND METHODS: A cross-sectional survey analysis was conducted using an anonymous 22-item questionnaire distributed to members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Participants were queried on demographics, practice type, and adverse events related to aesthetic facial surgeries. RESULTS: Two hundred fifty-three individuals participated; nearly half of respondents (49.0%) held membership in both AAO-HNS and AAFPRS. Of these, 40.8% of respondents reported at least one adverse event within the past 12 months of practice. A total of 194 adverse events were reported, most commonly related to facelift (n = 59/194, 30.4%), rhinoplasty (n = 55/194, 28.4%), and injection procedures (n = 38/194, 19.6%), with hematoma or seroma being the most commonly described. Most adverse events were self-limited, but approximately 68% resulted in further procedures. Surgeon error or poor judgement (n = 42) and patient non-adherence (n = 18) were the most commonly ascribed reasons for adverse events; 37.1% of participants reported a change in clinical practice after the incident. CONCLUSIONS: Adverse events were not infrequent in facial plastic surgery. Understanding these adverse events can provide impetus for tracking outcomes, standardization, and engagement with lifelong learning, self-assessment, and evaluation of practice performance.

Factors associated with skin graft take in fibula and radial forearm free flap donor sites.

LEARNING OBJECTIVES: Identify factors associated with skin graft take in fibula free flaps (FFF) and radial forearm free flaps (RFFF) donor sites. STUDY OBJECTIVES: To determine which factors are associated with decreased skin graft take at the donor site in FFF and RFFF in head and neck patients. DESIGN: Retrospective Chart Review Case Series. SETTING: Multicenter Tertiary Care. METHODS: A multicenter retrospective review was performed at three institutions identifying patients who underwent free tissue transfer, specifically either FFF or RFFF, between 2007 and 2017. Patient demographics, medical history, and social history were examined including age, gender, BMI, smoking status, diabetes and preoperative anticoagulation use. Preoperative, intraoperative data, and postoperative data were also examined including tourniquet use, type of flap, area of skin graft, if the skin graft had a donor site or if it was taken from the flap, wound NPWT use, cast use, use of physical therapy, DVT prophylaxis, limb ischemia, heparin drip, and postoperative aspirin use. Statistical analysis was used to determine which factors were significantly associated with skin graft take. RESULTS: 1415 patients underwent a forearm or fibula flap and 938 patients underwent split-thickness skin graft. Of these, 592 patients had sufficient information and were included in the final analysis. There were 371 males and 220 females. The average age was 55.7. Complete skin graft take was seen in 480 patients (81.1%). On univariate analysis, patients with diabetes (p = .003), type of flap (fibula p < .001), skin graft area (p = .006), tourniquet use (p = .003), DVT prophylaxis (p = .008) and casting (p = .003) were significantly associated with decreased skin graft take rate. In a multivariate analysis, diabetes (OR 2.17 (95%CI 1.16-3.98)), fibula flaps (OR 2.86 (95%CI 1.79-4.76)), an increase in skin graft area (OR 1.01 (95%CI 1.01-1.01)), post-operative aspirin (OR 2.63 (95%CI 1.15-5.88), and casting (OR 2.94 (95%CI 1.22-7.14)) were associated with poor rates of skin graft take. CONCLUSION: Several factors affect skin graft take rate and should be considered when performing a skin graft for a donor site defect.

Tourniquet use and factors associated with hematoma formation in free tissue transfer.

PURPOSE: Our objective was to understand which variables are associated with hematoma formation at both the donor and recipient sites in head and neck free tissue transfer and if hematoma rates are affected by tourniquet use. METHODS: Patients were identified who underwent free tissue transfer at three institutions, specifically either a radial forearm free flap (RFFF) or a fibula free flap (FFF), between 2007 and 2017. Variables including use of tourniquet, anticoagulation, treatment factors, demographics, and post-operative factors were examined to see if they influenced hematoma formation at either the free tissue donor or recipient site. RESULTS: 1410 patients at three institutions were included in the analysis. There were 692 (49.1%) RFFF and 718 (50.9%) FFF. Tourniquets were used in 764 (54.1%) cases. There were 121 (8.5%) hematomas. Heparin drips (p < .001) and DVT prophylaxis (p = .03) were significantly associated with hematoma formation (OR 95% CI 12.23 (4.98-30.07), 3.46 (1.15-10.44) respectively) on multivariable analysis. CONCLUSIONS: Heparin Drips and DVT prophylaxis significantly increased hematoma rates in free flap patients while tourniquets did not affect rates of hematoma.

Management of Large Facial Defects.

There is considerable variation in the surgical management of patients with large facial defects after excision of skin malignancy. The surrounding facial subunits as well as local, regional, and distant soft-tissue flaps can be considered in more complicated facial defects. We place an emphasis on the versatility of adjacent tissue advancement and transposition flaps in the treatment of these defects. We also focus on the secondary reconstructive efforts necessary to achieve the best functional and aesthetic outcomes for patients.

An Algorithm for the Prevention and Treatment of Pain Complications of the Radial Forearm Free Flap Donor Site.

BACKGROUND: The radial forearm free flap (RFFF) is a staple of microsurgical reconstruction. Significant attention has been paid to donor-site morbidity, particularly vascular and aesthetic consequences. Relatively few authors have discussed peripheral nerve morbidity such as persistent hypoesthesia, hyperesthesia, or allodynia in the hand and wrist or neuroma formation in the wrist and forearm. Here, we present a diagnostic and therapeutic algorithm for painful neurologic complications of the RFFF donor site. MATERIALS AND METHODS: The peripheral nerves that can be involved with the RFFF are reviewed with respect to the manner in which they may be involved in postoperative pain manifestations. A method for prevention and for treatment of each of these possibilities is also presented. RESULTS: Nerves from the forearm that can be harvested with the RFFF will have the most likelihood for injury and these include the lateral antebrachial cutaneous nerve, the radial sensory nerve, and the medial antebrachial cutaneous nerve. A nerve that may be injured at the distal juncture of the skin graft to the forearm is the palmar cutaneous branch of the median nerve. The "prevention" portion of the algorithm suggests that each nerve divided to become a recipient nerve should have its proximal end implanted into a muscle to prevent painful neuroma. The "treatment" portion of the algorithm suggests that if a neuroma does form, it should be resected, not neurolysed, and the proximal portion should be implanted into an adjacent muscle. The diagnostic role of nerve block is emphasized. CONCLUSION: Neurological complications following RFFF can be prevented by an appropriate algorithm as described by devoting attention to the proximal end of recipient nerves. Neurological complications, once present, can be difficult to diagnose accurately. Nerve blocks are critical in this regard and are employed in the treatment algorithm presented.

Treatment for lymphedema following head and neck cancer therapy: A systematic review.

OBJECTIVE: To perform the first systematic review evaluating all established treatment modalities of head and neck lymphedema resulting from head and neck cancer therapy. Since craniofacial lymphedema treatment represents unique challenges not addressed by extremity lymphedema therapies, a systematic review and evaluation of treatment modalities specific to this area is needed to guide clinical management and further research. DATA SOURCES: Four electronic databases were searches from inception to September 2018. These included Scopus (Embase), PubMed (Medline), Clinicaltrials.gov, and Cochrane Databases. REVIEW METHODS: A search string was developed, and all databases queried for keywords on three subjects: head and neck cancer, lymphedema, and therapy. Results were uploaded to an EndNote database where relevant items were identified by hand-searching all titles and abstracts. Subsequently results were combined, duplicates removed, and full papers screened according to eligibility criteria. RESULTS: Of a total 492 search results, twenty-six items met eligibility criteria for this review. These included fourteen cohort studies, seven case reports, two randomized controlled trials, two systematic reviews, and one narrative review totaling 1018 study subjects. The manual lymph drainage group had the largest number of studies and participants, with fewer studies investigating selenium, liposuction, and lymphaticovenular anastomosis. CONCLUSION: Evidence for the efficacy of all types of lymphedema therapy is limited by paucity of large randomized controlled trials. While manual lymph drainage is best studied, liposuction and surgical treatments have also been effective in a small number of patients.

Nasal Alar Schwannoma: An Unusual Case Report.

PURPOSE: To present the second known case of nasal alar schwannoma, first since 1973, with important considerations for surgical management. CASE REPORT: We present the case of a 25-year-old male with a 5-year history of progressively enlarging, non-tender, right alar mass with resultant ipsilateral nasal congestion and dyspnea secondary to nasal valve collapse. The mass was located cephalic to the mid-lateral aspect of the lower lateral crural cartilage, which extended to the pyriform aperture. The mass was removed in an en bloc fashion using an endonasal rhinoplasty approach with placement of an alar batten graft for valve stabilization. The surgical pathology of the mass was consistent with schwannoma. CONCLUSION: Regardless of the rarity, schwannoma should remain on the list of possible etiologies for a nasal alar mass. Depending on the size and concurrent mass effect, the external nasal valve may be compromised requiring careful evaluation and operative stabilization for optimal postsurgical outcome. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Successful facial artery pseudoaneurysm coiling and pedicle preservation following free tissue transfer.

Patients undergoing free tissue reconstruction are at risk for development of an anastomotic pseudoaneurysm, which may present as delayed neck hemorrhage or a pulsatile neck mass. Diagnosis may be achieved by noninvasive imaging, angiography, and exploration. Management strategies for head and neck pseudoaneurysms have included open vessel ligation, open direct vessel repair, endovascular parent vessel embolization, and, most recently, endovascular pseudoaneurysm embolization. In patients with anastomotic pseudoaneurysms where adequate flap inosculation is doubted, endovascular pseudoaneurysm embolization with pedicle preservation may be an appropriate primary treatment approach. We discuss the successful endovascular coiling of an external carotid artery branch anastomotic pseudoaneurysm in a patient one month after free tissue reconstruction of a total laryngopharyngectomy and partial glossectomy defect.

Microvascular Flaps in Nasal Reconstruction.

Nasal reconstruction for subtotal and total rhinectomy defects is a challenging endeavor, which requires technical finesse, a keen artistic eye, and the ability to anticipate long-term changes that accompany postoperative healing. While local and regional flaps have traditionally been utilized to reconstitute missing nasal elements, certain situations may not provide sufficient or acceptable tissue for optimal reconstruction. In these situations, the three major components of the nose-lining, structural support, and external skin-may require reconstruction with tissues harvested from distant sites through microvascular free tissue transfer. Our objective in this article is to discuss the general approach to nasal reconstruction and present the considerations for free tissue transfer with regard to each nasal component. The virtues of free flap transfer as well as its shortcomings and potential complications are discussed.

Endoscopic keel placement to treat and prevent anterior glottic webs.

We performed a retrospective chart review to examine and describe our clinical experience of use of the Lichtenberger technique to place silicone elastomer keels after lysis of existing webs or for prevention of webs following anterior commissure surgery in adults. Twenty-two patients were identified for inclusion, ranging in age from 24 to 80 years. For 18 patients with existing glottic webs,the surgical procedure involved laryngoscopy with complete lysis of the anterior glottic web by laser or sharp technique, followed by placement of a square of silicone elastomer that is sutured in place with the Lichtenberger needle holder and left in place for 3 to 5 weeks. The procedure was well tolerated, and successfully corrected the web in all but 2 cases. For 4 patients, the procedure was performed prophylactically at the time of anterior commissure surgery considered high-risk for web formation. The procedure does not require a tracheotomy, and patients can maintain a normal diet and have functional phonation while the keel is in place. This approach to treating anterior glottic webs offers several advantages over traditional open thyrotomy with keel placement and should be considered to treat or prevent anterior glottic webs.

Divided nevus of the eyelid: review of embryology, pathology and treatment.

Divided nevus, which is also known as "kissing nevus," "split ocular nevus" and "panda nevus" is a rare congenital dermatological abnormality that occurs on opposing margins of upper and lower eyelids. There is a paucity of literature on this rare anomaly, with most knowledge from this disease process derived from isolated case reports and series. The purpose of this study is to report a new case of divided nevus of the eyelid and to discuss the unique embryology, pathology, and potential treatment options for this rare entity. A systematic review of literature was performed of the English literature on PubMed and Medline with just under 150 cases reported in the literature. The vast majority of the divided nevi seen in this review were medium sized and of the melanocytic intradermal type. There were no described cases of malignant transformation in any of the documented cases. Numerous methods for reconstruction were described including the entire reconstructive ladder with both one and two staged approaches. In this review, we present basic guidelines to the reconstruction of these complicated defects, although ultimate treatment should be individualized and dependent on surgeon comfort.

Anatomical evidence of microbial biofilms in an alloplastic nasal implant.

UNLABELLED: Recently, bacterial biofilms have been proposed as a potential cause of the extreme resistance to antibiotics and impaired host responses in potentially infected facial implants. As opposed to the bacteria in a free-floating or planktonic state, biofilms exist in a sessile form, adherent to a solid or liquid interface and become embedded in a complex matrix that is oftentimes impenetrable to modern day antibiotics. This can lead to chronic infection of implants which ultimately necessitates their removal in a majority of cases. In this novel case report, we show the histomorphological appearance of biofilm formation in a patient with an alloplastic nasal implant that was persistently infected and had to be removed. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Facial Artery Musculomucosal Flap Operative Techniques.

SUMMARY: Regional flaps are an important component of the reconstructive ladder and represent a versatile option in reconstructing various oral cavity defects. An axial buccal flap based on the facial artery, the facial artery musculomucosal flap, was first described by Pribaz et al. and has been shown to have good functional outcomes with minimal morbidity. Indeed, other surgeons have praised its favorable arc of rotation, reliability, and role as an alternative to free tissue transfer, with shorter duration of general anesthesia and allowance for earlier postoperative mobilization. The facial artery musculomucosal flap has significant versatility, as it can be superiorly or inferiorly based and can be performed in either single- or two-stage fashion. It is of particular advantage for reconstruction of the oral cavity (retromolar trigone, hard palate, alveolar ridge, lip, tongue, and floor of mouth), oropharynx (tongue base, lateral pharynx, and soft palate), and sinonasal structures. Despite its advantages, its widespread use has been limited by a lack of familiarity and difficulty in safely raising a reliable flap consistently. The senior author (S.C.D.) has successfully utilized a high volume of facial artery musculomucosal flaps with a low complication rate in a broad array of oral cavity and oropharyngeal defects. In this article, the authors share technical details on how to harvest and inset this flap by incorporating key landmarks in a reliable fashion.

Predictors of Free Flap Volume Loss in Nonosseous Reconstruction of Head and Neck Oncologic Defects.

OBJECTIVES: Free tissue reconstruction of the head and neck must be initially overcorrected due to expected postoperative free flap volume loss, which can be accelerated by adjuvant radiation therapy. In this study, we aim to identify patient and treatment-specific factors that may significantly contribute to this phenomenon and translate these characteristics into a predictive model for expected percent free flap volume loss in a given patient. METHODS: Patients with a history of oral cavity and/or oropharyngeal cancer who underwent nonosseous free flap reconstruction were reviewed between January 2009 and November 2018 at a tertiary care center. Demographics/characteristics, total radiation dose, radiation fractionation (RF), and pre/postradiation free flap volume as evaluated by computed tomography imaging were collected. Free flap volume was measured by a fellowship-trained neuroradiologist in all cases. Only patients receiving adjuvant radiotherapy with available pre/postradiation imaging were included. Multivariable linear regression modeling for prediction of free flap volume loss was performed with optimization via stepwise elimination. RESULTS: Thirty patients were included for analysis. Mean flap volume loss was 42.7% ± 17.4%. The model predicted flap volume loss in a significant fashion (P = .004, R2 = 0.49) with a mean magnitude of error of 9.8% ± 7.5%. Age (ß = 0.01, P = .003) and RF (ß = -0.01, P = .009) were individual predictors of flap volume loss. CONCLUSIONS: Our model predicts percent free flap volume loss in a significant fashion. Age and RF are individual predictors of free flap volume loss, the latter being a novel finding that is also modifiable through hyperfractionation radiotherapy schedules.

Interfacility Transfer Guidelines for Isolated Facial Trauma: A Multidisciplinary Expert Consensus.

BACKGROUND: The objective of this study was to develop guidelines for the transfer of patients with isolated craniomaxillofacial trauma. METHODS: A national, multidisciplinary expert panel was assembled from leadership in national organizations and contributors to published literature on facial reconstruction. The final panel consisted of five plastic surgeons, four otolaryngologist-head and neck surgeons, and four oral and maxillofacial surgeons. The expert panelists' opinions on transfer guidelines were collected using the modified Delphi process. Consensus was predefined as 90 percent or greater agreement per statement. RESULTS: After four Delphi consensus building rounds, 13 transfer guidelines were established, including statements on fractures of the frontal sinus, orbit, midface, and mandible, as well as soft-tissue injuries. Twelve guidelines reached consensus. CONCLUSIONS: The decision to transfer a patient with craniomaxillofacial trauma to another facility is complex and multifactorial. While a percentage of overtriage is acceptable to promote safe disposition of trauma patients, unnecessarily high rates of secondary overtriage divert emergency medical services, increase costs, delay care, overload tertiary trauma centers, and result in tertiary hospital staff providing primary emergency coverage for referring hospitals. These craniomaxillofacial transfer guidelines were designed to serve as a tool to improve and streamline the care of facial trauma patients. Such efforts may decrease the additional health care expenditures associated with secondary overtriage while decompressing emergency medical systems and tertiary emergency departments.

Odor identification ability and self-reported upper respiratory symptoms in workers at the post-9/11 World Trade Center site.

UNLABELLED: Following the World Trade Center (WTC) collapse on September 11, 2001, more than 40,000 people were exposed to a complex mixture of inhalable nanoparticles and toxic chemicals. While many developed chronic respiratory symptoms, to what degree olfaction was compromised is unclear. A previous WTC Medical Monitoring and Treatment Program study found that olfactory and nasal trigeminal thresholds were altered by the toxic exposure, but not scores on a 20-odor smell identification test. OBJECTIVES: To employ a well-validated 40-item smell identification test to definitively establish whether the ability to identify odors is compromised in a cohort of WTC-exposed individuals and, if so, whether the degree of compromise is associated with self-reported severity of rhinitic symptoms. METHODS: The University of Pennsylvania Smell Identification Test (UPSIT) was administered to 99 WTC-exposed persons and 99 matched normal controls. The Sino-Nasal Outcomes Test (SNOT-20) was administered to the 99 WTC-exposed persons and compared to the UPSIT scores. RESULTS: The mean (SD) UPSIT scores were lower in the WTC-exposed group than in age-, sex-, and smoking history-matched controls [respective scores: 30.05 (5.08) vs 35.94 (3.76); p = 0.003], an effect present in a subgroup of 19 subjects additionally matched on occupation (p < 0.001). Fifteen percent of the exposed subjects had severe microsmia, but only 3% anosmia. SNOT-20 scores were unrelated to UPSIT scores (r = 0.20; p = 0.11). CONCLUSION: Exposure to WTC air pollution was associated with a decrement in the ability to identify odors, implying that such exposure had a greater influence on smell function than previously realized.

Resurgence of regional flaps for head and neck reconstruction.

PURPOSE OF REVIEW: The strain on healthcare resources in light of the COVID-19 pandemic has forced many head and neck surgeons to explore reconstructive options that may decrease length of stay. Here, we review three common and versatile regional flaps used in head and neck reconstruction that are comparable alternatives to free tissue transfer. RECENT FINDINGS: Initial anatomic descriptions of the facial artery musculocutaneous (FAMM) flap, the supraclavicular artery island flap and the submental artery island flap were published decades ago. Since then, many have proposed modifications to these descriptions to improve technical ease and patient outcomes. Benefits of regional flaps include ease of harvest, comparable outcomes to free tissue microvascular flaps, shorter operative time and hospital length of stay. Drawbacks to regional flaps include limitations to size and reach, partial necrosis, wound dehiscence and surgeon experience. The integrity of the vascular pedicle is also contingent upon vessel preservation during the cancer ablation. SUMMARY: Although a resurgence of regional flaps began well before the COVID-19 pandemic, many institutions began looking for alternatives to free flap reconstruction to conserve healthcare resources and minimize patient hospitalization time in the past year. There has been a revival of regional flaps such as the FAMM, supraclavicular and submental flaps that are valuable reconstructive options for many defects of the head and neck.

Free Functional Gracilis Flaps for Facial Reanimation in Elderly Patients.

Importance: The free functional gracilis flap (FFGF) is a versatile procedure in reanimating the paralyzed face, yet its application in seniors is limited by perceptions of morbidity and inefficacy. Objective: The study objective was to compare the morbidity and effectiveness of FFGF reanimation among senior and younger patients. Design, Setting, and Participants: A retrospective chart review was performed on 20 consecutive patients aged 60 years and above (seniors) and 35 patients aged 40 years and below (juniors) who underwent FFGF for facial reanimation. Among this group, 16 senior and 22 junior patients with available long-term follow-up data were analyzed for functional outcomes. Main Outcomes and Measures: The length of postoperative stay and postoperative complications were compared with assess immediate results. A second analysis for functional outcomes was assessed by resting and smile facial asymmetry index (FAI), as well as maxillary dental display to compare facial tone and lip excursion. Results: The average age of seniors was 67 ± 5 years and that of juniors was 27 ± 10 years. Mean lengths of postoperative stay were 4 ± 2 versus 3 ± 1 days in seniors versus Juniors, respectively (p = 0.16). There were no intraoperative complications and postoperative complications in one (5%) senior and four (11%) juniors (p = 0.64). There was functional muscle recovery in all cases, with more pronounced correction of both resting (Δ3.0 mm vs. Δ2.4 mm, p = 0.66) and dynamic (Δ5.2 mm vs. Δ4.2 mm, p = 0.37) FAI in seniors than in juniors. Among patients who underwent a multivector FGFF, there was an additional three versus one visualized maxillary teeth (p = 0.03) in seniors versus juniors, respectively. Conclusions and Relevance: The FFGF is effective for facial reanimation among seniors and can be performed with minimal morbidity. Age alone should not preclude the application of the FFGF in seniors with a preference for more dynamic options.

Simultaneous Septal Perforation and Deviation Repair with a Chondromucosal Transposition Flap.

Nasal septal perforations can cause issues of epistaxis, whistling, crusting, saddle deformity, and obstruction, which motivate patients to seek surgical repair. Numerous methods of septal perforation repair have been described, with surgical success rates ranging from 52% to 100%, but few studies address situations with concomitant septal deviation. In treating patients with septal perforation and deviation, both issues should be addressed for optimal outcomes. While routine septoplasty involves the removal of septal cartilage, septal perforation repair involves the addition of interposition grafts. The composite chondromucosal septal rotation flap harmoniously combines these seemingly conflicting goals as an effective and efficient technique for septal perforation repair. We present 3 patients successfully treated for their septal perforation and septal deviation concurrently with this technique.