The Quantification of Surgical Changes in Nasal Tip Support
Mark M. Beaty, MD;
Wallace K. Dyer II, MD;
Matthew W. Shawl, MD
Arch Facial Plast Surg. 2002;4:82-91.
ABSTRACT
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Objectives To quantify the changes in the strength of nasal tip support associated
with various surgical modifications and to identify the procedures that best
maintain or augment tip support.
Design Case study in 2 phases. Phase 1 included 10 patients undergoing primary
rhinoplasty, 5 undergoing secondary rhinoplasty, and 5 control patients. Fresh
cadavers were used in phase 2. A purpose-built instrument (Beaty Tensegrometer;
G. M. Tooling, Chamblee, Ga) was used to measure nasal tip support before
and after surgical modifications.
Results In the patients who underwent primary rhinoplasty, there was a 25% decrease
in tip support when the ligamentous attachments between the lateral crura
were divided. Reconstruction of these attachments increased tip support over
baseline by 35%. With a columellar strut and ligament reconstruction, tip
support was increased by 44%. In the secondary rhinoplasty group, reconstruction
with the dynamic adjustable rotation tip-tensioning technique increased nasal
tip support over baseline by 70%. In cadavers, intercartilaginous incisions
and delivery of the lower lateral cartilages caused a loss of tip support,
while raising the skin–soft tissue envelope with the open technique
did not. Extensive resection of the lower lateral cartilages caused a loss
of tip support.
Conclusions This study demonstrates that nasal tip support can be reliably quantified
in a reproducible manner. Use of the open approach, reconstruction of the
attachments between the lateral crura, conservative resection of the lower
lateral cartilages, and the dynamic adjustable rotation tip-tensioning technique
for secondary rhinoplasty best preserve nasal tip support.
INTRODUCTION
SURGICAL MODIFICATION of the complex architecture of the nasal tip is
the most challenging aspect of rhinoplasty. Numerous clinical descriptions
of nasal tip support and surgical methods for tip modification have been proposed.
Surgical modifications that reshape the nasal tip affect the strength of its
architecture. Maintenance or augmentation of the architectural strength of
the nasal tip is necessary to achieve desired aesthetic and functional results.
Clinical evaluation of nasal tip support by finger palpation of its
resistance to deformation is a routine part of the diagnostic workup for rhinoplasty.
In Rhinoplasty: The Art and the Science, Tardy1 states that "pressure applied to the tip with the
index finger will be helpful in determining the resistance to tip retrodisplacement
and the degree of ‘recoil' and forward thrust of which that particular
tip is capable." Surgeons may subjectively evaluate preoperative and postoperative
nasal tip support with finger palpation. However, to our knowledge, objective
changes in nasal tip support after surgical modification have never been quantified
in the literature.
Our goal was to quantify changes in nasal tip support before and after
common rhinoplasty modifications. Objective quantification of these changes
will provide valuable information to guide modification of the nasal tip.
NASAL TIP SUPPORT
Tardy2 described nasal tip support mechanisms
in major and minor groups (Table 1).
These designations were determined by clinical experience and are currently
accepted as the determinants of nasal tip support. Surgical alteration of
these tip support mechanisms produces changes in the shape and function of
the nasal tip. Selection of the appropriate surgical modification is determined
by the desired effect, such as a change in tip rotation, projection, or width.
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Table 1. Nasal Tip Support Mechanisms
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Anderson3 compared the nasal tip architecture
to a tripod in 1969. According to his analogy, the medial crura of the lower
lateral cartilages (LLCs) together form the central limb of the tripod. Each
lateral crus independently forms a lateral limb. Anderson's4
description of nasal tip support mechanisms emphasizes the importance of the
extensive ligamentous attachments between the crural cartilages. Tardy's description
emphasizes the importance of the interdomal portion of these ligamentous attachments.
NASAL TIP MODIFICATION
Anderson and Ries5 described nasal tip
modification by altering the components of the tripod: "Tip projection can
be decreased by destroying the supports of the tripod or by shortening its
legs. The main supports are destroyed by interrupting the ‘ligaments'
connecting the medial ends of the lateral crura, by lowering the projection
of the septal dorsum, and by excising cartilage from the region of the inferior
septal angle." Anderson3 also believed that
reconstitution of the ligamentous attachments between the lateral and intermediate
crura was necessary to restore the strength of the nasal architecture.
Many surgeons prudently believe that conservative surgery is essential
to successful modification of the nasal tip. The open rhinoplasty approach,
popularized by Anderson and Johnson and Toriumi,6
advocates wide exposure of the nasal tip architecture, with minimal violation
of tip support mechanisms. This approach contrasts with the closed or delivery
approach, in which exposure of the cartilage framework is limited and incisions
violate significant tip support mechanisms.
Conservative methods of LLC modification using the open approach have
been described. Kridel and Konior7 introduced
the lateral crural overlay to achieve cephalic rotation of the tip without
permanent division of the lateral crus. They also advocated conservative removal
of cephalic strips to narrow and cephalically rotate the nasal tip. Kridel
and Konior8-9 described the "lateral
crural steal" for management of the underprojected nasal tip8
and the "domal truncation procedure" for management of the overprojected tip.9 Suture support of the domes has also been advocated
by Tardy,1 McCollough and English,10 Tebbetts,11 Baker,12 and Perkins et al.13
The common thread of their techniques is conservation of nasal tip support.
Johnson and Toriumi6 emphasize both surgical
conservation and augmentation of nasal tip support in Open
Structure Rhinoplasty. They advocate placing a columellar strut between
the medial crura for increased nasal tip projection and support. This strut
is routinely fashioned from septal cartilage and is often combined with a
shieldlike tip graft to project and refine the nasal tip.
We also advocate the concepts of conservatism and augmentation of support
for tip rhinoplasty. In cases of primary rhinoplasty, we use the open approach
to obtain maximal exposure and minimal interruption of tip support. Refinement
of the nasal supratip is accomplished by excising conservative cephalic strips
and reconstituting the ligamentous attachments between the medial and lateral
crura (the intercrural ligament)14 (Figure 1). Reestablishment of the intercrural
ligament significantly augments nasal tip support. If additional tip projection
or support is necessary, a columellar strut is placed.
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Figure 1. Intercrural ligament.
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The cartilage and supportive ligaments of patients undergoing secondary
rhinoplasty have often been severely weakened. The lateral crura and scrolls
are frequently overresected or absent, and the domes are often malpositioned
by scar contracture. This type of injury typically results in decreased tip
projection, cephalic overrotation, and associated nasal valve collapse. This
triad of findings has been termed a porcine deformity15 and presents a significant reconstructive challenge.
Dyer and Yune15 describe the dynamic, adjustable,
rotation tip-tensioning (DARTT) technique, a method of nasal reconstruction
that reestablishes tensile support of the damaged nasal architecture. The
DARTT technique allows precise selection of nasal tip projection, rotation,
and correction of nasal valve collapse.
MATERIALS AND METHODS
One of us (M.M.B.) designed a device (Beaty Tensegrometer; G. M. Tooling,
Chamblee, Ga) that is capable of measuring the resistance of the nasal tip
to deformation in multiple vectors (Figure
2). This measure of resistance to deformity is a quantification
of the subjective finger palpation that was advocated by Tardy.1
Instrument calibration was performed at 1-month intervals to ensure that no
fatiguing of the springs had occurred. No significant changes in calibration
were found during the study period. During calibration trials, each data point
was independently measured 3 different times to evaluate the projected intertrial
error of the device. Intertrial variation in these measurements was less than
3%.
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Figure 2. The purpose-built instrument (Beaty
Tensegrometer) that was used to measure nasal tip resistance to deformation
in 3 vectors.
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Tightening of the thumbscrew at the crown of the gantry increased compression
on a spring, applying pressure to the nasal tip along the chosen vector. Deflection
of the tip was measured in millimeters along the attached scale at the side
of the gantry. The compression necessary (in grams) to deflect the nasal tip
by 1, 2, or 3 mm in each vector was recorded (Table 2). Compression of the tip beyond 3 mm resulted in the crural
architecture pushing against the nasal septum, with further measurement reflecting
resistance of the septal cartilage.
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Table 2. Compression Necessary (in Grams) to Deflect the Nasal Tip
in Each Vector
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The device was stabilized on the upper lip and malar eminence, with
the measurement gantry centered over the nasal tip. The measurement gantry
was oriented along the vector to be evaluated. Three vectors were evaluated:
(1) along the columella, (2) along the nasal dorsum, and (3) along the plane
of the lateral crura. Measurements were taken before, during (directly on
the cartilaginous tip framework), and immediately after surgery.
The study comprised 2 phases. In phase 1, tip support was measured in
live patients; in phase 2, cadavers were studied. The results were statistically
analyzed with a commercially available software package (Excel; Microsoft
Corp, Redmond, Wash) by comparing group means using 1-way analysis of variance
or paired t test, as appropriate.
PHASE 1
The first phase of the study included 5 nonsurgical control patients
and 15 surgical patients. Of the 15 surgical patients, 10 underwent primary
nasal surgery and 5 underwent secondary rhinoplasty. All tip modifications
were performed through an open approach.
During phase 1, measurements were taken before and after the following
procedures: surgical incisions (marginal and transcolumellar), opening of
the skin–soft tissue envelope (S-STE), placement of a columellar strut,
reconstitution of the intercrural ligament, and performance of the DARTT technique.
Preoperative and postoperative measurements were taken with the S-STE intact,
and intraoperative measurements were taken directly on the cartilaginous framework.
PHASE 2
In the second phase of the investigation, 15 fresh cadavers were studied.
Each cadaver was inspected to ensure that no significant nasal damage was
present. They were divided into groups of 5 for evaluation of different surgical
modifications. Cadavers were used for more than 1 evaluation when appropriate.
For example, noses used to measure the effects of open technique exposure
were also used to evaluate the effect of suture reconstitution of the intercrural
ligament.
During phase 2, measurements were taken before and after the following
procedures: surgical incisions (intercartilaginous, transfixion, marginal,
and transcolumellar), opening of the S-STE, crural modifications, placement
of a columellar strut, and reconstitution of the intercrural ligament.
Differences between the open and closed approaches to the nasal tip
were analyzed for changes in support. Two different methods for lateral crural
modification were evaluated. First, cephalic strips of crural cartilage were
resected from medial to lateral (Figure 3). Second, cartilage was resected from lateral to medial, progressively
truncating the crus (Figure 4).
Twenty percent of the volume of the lateral crus was resected at a time before
each measurement. Data were recorded on the effect of suture reconstitution
of the midline intercrural ligament (Figure
5). Effects of each surgical modification were measured along the
3 vectors previously described.
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Figure 3. Technique of cephalic strip resection.
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Figure 4. Technique of lateral crural truncation.
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Figure 5. Intercrural suture technique.
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RESULTS
PHASE 1
Fifteen patients who underwent rhinoplasty (10 primary, 5 secondary)
were evaluated for nasal tip support before, during, and immediately after
surgery. Each procedure was tailored to the needs of that specific patient
and performed through an open approach. Three vectors were evaluated: (1)
along the columella, (2) along the nasal dorsum, and (3) along the plane of
the lateral crura. The vector along the plane of the lateral crura was chosen
as the representative measure of tip support because it combines components
of both projection and rotation. The following results are based on measurements
that were taken along that vector, except where noted.
Preoperative Measurements
Measurements of nasal tip support in 5 control patients compared with
preoperative patients undergoing primary or secondary rhinoplasty revealed
no significant differences in any vector. In all groups, there was slightly
greater tip support in the vector along the columella, compared with the other
2 vectors. This finding may indicate that there was slightly greater support
along the vector of the paired medial crura. Mean values for each group are
summarized in Table 2.
Elevating the S-STE
In all cases, elevating the S-STE reduced tip support. Paired t tests showed significant differences in nasal tip support
before and after elevation of the S-STE in both primary and secondary rhinoplasty
groups (P<.05).
In patients undergoing primary open rhinoplasty, the mean nasal tip
support was reduced by 20%, 26%, and 20% at 1, 2, and 3 mm of deflection,
respectively, by elevating the S-STE (P<.05).
Patients undergoing secondary open rhinoplasty had even greater losses in
tip support when the S-STE was opened, with mean reductions of 64%, 61%, and
52% at 1, 2, and 3 mm of deflection, respectively (P<.05).
Reconstructing the Intercrural Ligament
In primary open rhinoplasty, elevating the S-STE in a bloodless plane
above the crural cartilages disrupted the intercrural ligament from the domes
to the septal angle (25% loss of support). Reconstituting the intercrural
ligament (Figure 5) provided an
increase in tip support over baseline of 35%, 24%, and 24% at 1, 2, and 3
mm of deflection, respectively (P<.05).
Columellar Strut
Patients in the primary open rhinoplasty group were evaluated for changes
in tip support after columellar strut placement. Placement of a columellar
strut alone provided a 40% increase in nasal tip support in the vector along
the columella (P<.05). In the vectors along the
nasal dorsum and along the plane of the lateral crura, however, no significant
difference was found (P = .15). Also, when intercrural
fixation sutures were used in combination with a columellar strut (4 patients),
the increase in support was even more pronounced (27%, 42%, and 44%, respectively)
(P<.05).
DARTT Technique
Reconstruction in patients undergoing secondary rhinoplasty was performed
using the DARTT technique described by Dyer and Yune15
(Figure 6). These patients had a
statistically significant increase in the strength of the cartilagenous nasal
tip architecture after reconstruction (P<.01).
Mean increases of 364%, 208%, and 213% were seen at 1, 2, and 3 mm of deflection,
respectively. These measurements were taken intraoperatively, directly on
the cartilaginous architecture before the S-STE was redraped.
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Figure 6. Diagram of dynamic adjustable
rotation tip-tensioning technique.
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Postoperative Measurements
Finally, all patients were evaluated for changes in tip support from
the preoperative to the immediate postoperative state with the S-STE replaced.
In the primary rhinoplasty group, nasal tip support was increased 30% over
baseline in all 3 vectors. In the secondary rhinoplasty group, the tip support
was increased 70% over baseline in all 3 vectors. All these changes were statistically
significant (P<.05). A summary of preoperative
vs postoperative tip support is provided in Table 3.
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Table 3. Percentage Increase in Nasal Tip Support After Procedure*
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PHASE 2
Elevating the S-STE
The effect of the open rhinoplasty technique on tip support was measured
on cadavers. Tip support was measured after marginal and transcolumellar incisions
were made and the S-STE was elevated. During phase 2, care was taken to preserve
the intercrural ligament as the S-STE was elevated. Support measurements were
taken with the S-STE elevated and the intercrural ligament intact. Elevation
of the S-STE caused no significant change in tip support (P = .11).
Closed Approach Incisions
The effect of the closed (transnostril) approach on tip support in cadavers
was then evaluated. Placement of marginal and transfixion incisions had no
effect on tip support. After intercartilaginous incisions, tip support decreased
25% in all 3 vectors. The LLCs were delivered and then replaced in their native
position with no further modification. Delivery of the LLCs resulted in a
10% further loss of tip support (35% total) in vectors along the plane of
the lateral crura and along the columella. A 42% loss of support was seen
in the vector along the nasal dorsum. All these differences were statistically
significant (P<.05) and are summarized in Table 4.
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Table 4. Percentage Decrease in Nasal Tip Support After Procedure*
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Intercrural Ligament Reconstruction
In 5 noses, after the closed technique with delivery of the LLCs was
used (alone resulting in a 35% loss in tip support), a transcolumellar incision
was made and the S-STE was elevated. This effectively converted the procedure
into a "standard" open rhinoplasty approach. The intercrural ligament was
then reconstructed with sutures, and tip support was measured. Tip support
increased 25% in the vector along the plane of the lateral crura compared
with preoperative measurements (P<.05). Tip support
was equivalent to the preoperative levels in the vectors along the columella
and nasal dorsum.
Crural Modifications
Cephalic strips were taken from medial to lateral in 5 noses through
a closed approach. Serial measurements were taken after resection of increments
of 20% from the total width of the lateral crus. Tip support did not change
beyond that imposed by delivery of the crura (35% loss) until 80% of the lateral
crural width was resected (Figure 3).
With 80% of the LLC resected, a further 35% loss of tip support was seen in
all 3 vectors.
Progressive resections of LLC were taken in 5 additional noses in a
lateral to medial direction (Figure 4).
In these specimens, an open approach was used, and the intercrural ligament
was preserved. There was no significant change in nasal tip support until
80% of the width of the LLC was resected (P>.60).
At 80% or greater resection, a 25% loss of tip support in all vectors was
measured.
COMMENT
Most surgical procedures that alter nasal tip structure decrease tip
support. An important goal of tip modification should be to maintain or augment
nasal tip support. A nasal tip with adequate support can better withstand
the compressive forces of the weight of the overlying S-STE and inevitable
scar contracture. A purpose-built device (Beaty Tensegrometer) was designed
to measure the changes in nasal tip support before and after common rhinoplasty
procedures. Measurements were taken on live patients during phase 1 and on
cadavers during phase 2.
PHASE 1
There was no difference between the preoperative measurements of tip
support of the control patients and the preoperative measurements of the patients
undergoing either primary or secondary rhinoplasty. The patients undergoing
primary rhinoplasty were expected to have tip support measurements that were
similar to those of the control patients. Those undergoing secondary procedures
had deformed nasal tips manifest by deprojection, cephalic overrotation, and
nasal valve collapse and were expected to have decreased tip support. This
was not the case. The equivalent resistance to nasal tip deformation in these
patients compared with controls is likely attributable to support from the
nasal septum and scar tissue. Though having the same resistance to deformation
as the noses of the control patients, their noses were collapsed and severely
compromised both aesthetically and functionally.
In live patients, opening the S-STE reduced tip support. During primary
rhinoplasty, the S-STE is usually opened directly over the LLCs in a "bloodless"
tissue plane. During this procedure, the intercrural ligament is routinely
divided from the dome to the anterior septal angle. Separation of this ligamentous
support between the 2 lateral crura, from the anterior septal angle to the
domes, resulted in a 25% loss of tip support. Intercrural fixation sutures
that are placed to reconstruct the ligament achieved a 35% increase (over
baseline) in nasal tip support.
In the primary rhinoplasty group, measurements of changes in tip support
for several surgical modifications were recorded. Placement of a columellar
strut provided a statistically significant increase in tip support of 40%
along the vector of the columella. There was no significant increase in support
along the other vectors. A columellar strut alone is only capable of providing
substantial tip support along its long axis. Because a columellar strut does
not prevent tip rotation, loss of support of the lateral crura can cause cephalic
rotation of the nasal tip.
After cephalic strip resection, the medial edges of the lateral crura
were reapproximated from the anterior septal angle to the domes, eliminating
dead space and increasing tip support. These sutures alone produced a 35%
net increase in nasal tip support over baseline when measured directly on
the cartilaginous framework during surgery. The intercrural ligament is essential
to support of the nasal tip and should be considered a major tip support mechanism.
Also, when intercrural fixation sutures are used along with a columellar strut,
the increase in support is even greater, measuring a mean increase of 44%.
All patients undergoing secondary rhinoplasty had significant compromise
of the cartilaginous architecture of the nasal tip. Three patients had near
total resection of the lateral crura. One patient had multiple vertical divisions
of the lateral crura, and one had a crushed nasal septum that appeared to
have been morselized.
Despite similar preoperative values in resistance to deformation, the
patients undergoing secondary rhinoplasty lost more tip support than those
undergoing primary rhinoplasty on elevation of the S-STE (60% vs 25%). In
the secondary rhinoplasty group, the S-STE was opened and the supportive scar
tissue was separated from the remnants of the weakened LLC. This separation
resulted in a decompression that caused the larger measured loss of tip support.
Patients in the secondary rhinoplasty group underwent the DARTT reconstruction
as described by Dyer and Yune.15 A columellar
strut affixed to the medial crura is joined as an integrated structure with
septocolumellar interposition grafts. The entire structure is then placed
on tension using a double-pronged hook beneath the domes. The nasal tip is
held in the desired position (rotation and projection) while the torsionally
stable septocolumellar interposition grafts are sutured to the nasal septum.
Nasal tip support measured directly on the cartilaginous framework is approximately
tripled after the DARTT technique is used.
After closure of the S-STE in patients undergoing a DARTT technique,
a mean increase of 70% over baseline in nasal tip support was seen. The technique
provides renewed support and allows adjustability and precision in placement
of the nasal tip.
PHASE 2
Cadavers were used to evaluate surgical techniques that are not generally
used in our practice, many of which are associated with the closed approach
to the nasal tip. Marginal and transfixion incisions had no significant effect
on nasal tip support. These findings are in agreement with the conclusion
of Tebbetts11 that "soft tissue incisions were
the scapegoat for the real culprit—destructive tip shaping techniques."
Placement of intercartilaginous incisions produced a 25% loss in tip support
in all vectors. These incisions divide the scrolled attachment of the lower
lateral and upper lateral cartilages as well as transecting the intercrural
ligament from the septal angle to the dome. Delivery of the LLCs completes
the division of the ligamentous binding between the domes and medial crura
and further weakens the nasal tip (total, 35%).
In contrast to the outcome in live surgical patients, in cadavers the
ligamentous attachments between the LLCs were preserved when the S-STE was
elevated. Freeing the S-STE, while preserving the intercrural ligament, was
shown to have no significant effect on support of the nasal tip. The intercrural
ligament is a major tip support mechanism, and its division significantly
weakens tip support. When the intercrural ligament is reconstructed, nasal
tip support returns to preoperative levels or greater.
Resection of portions of the LLCs had no significant effect on nasal
tip support until 80% of the cartilage had been excised. This held true whether
cephalic strips were taken from medial to lateral or whether crural truncation
was performed from lateral to medial. These surprising findings suggest that
the maintenance of the intercrural ligament may be more critical to nasal
tip support than the bulk of the lateral crural cartilage itself. Although
the intercrural ligament is a major tip support mechanism, large resections
of the LLC can still produce significant nasal tip deformities and functional
compromise owing to the inevitability of scar contracture.
CONCLUSIONS
This study demonstrates that nasal tip support can be reliably quantified
in a reproducible manner. Based on the findings of this study, the intercrural
ligament (ligamentous attachments between the lateral, domal, and medial crura)
is a major tip support mechanism. When the intercrural ligament alone is completely
divided, nasal tip support decreases by 35%. Therefore, a full one third of
the support of the nasal tip is attributable to the midline binding of the
intercrural ligament. During rhinoplasty, suture reconstitution of the intercrural
ligament increases tip support by 35% over peroperative measurements. The
open approach to rhinoplasty is less damaging to nasal tip support than the
closed approach. This observation was confirmed by measuring tip support before
and after each approach.
We advocate the concepts of surgical conservatism and augmentation of
nasal tip support during rhinoplasty. After nasal tip rhinoplasty, a well-supported
nasal tip is better able to withstand the compressive forces of the inherent
weight of the S-STE and the inevitability of scar contracture.
In primary rhinoplasty, we use the open approach to obtain maximal exposure
and minimal interruption of tip support. Refinement of the nasal supratip
is accomplished by excising conservative cephalic strips and reconstituting
the intercrural ligament. If additional tip projection or support is necessary,
a columellar strut is placed. Using these guidelines, nasal tip support will
increase between 35% and 44% over baseline (Figure 7). In secondary rhinoplasty, we advocate an open approach
and the DARTT technique, which increases tip support by an average of 70%
(Figure 8).
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Figure 7. Preoperative (A, C, and E) and
postoperative (B, D, and F) photographs of a patient who underwent primary
rhinoplasty with intercrural fixation.
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Figure 8. Preoperative (A and C) and postoperative
(B and D) photographs of a patient who underwent dynamic adjustable rotation
tip-tensioning technique.
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Although the quantification of nasal tip support is in its infancy,
it has great potential to guide facial plastic surgeons toward predictable
and structurally stable results. Selecting the methods of tip modification
that best preserve or augment the architectural integrity of the nasal tip
will ultimately benefit all our patients.
AUTHOR INFORMATION
Accepted for publication August 15, 2001.
Corresponding author and reprints: Mark M. Beaty, MD, Milton Hall
Plastic Surgery, 2365 Old Milton Pkwy, Alpharetta, GA 30004 (e-mail: mmbeaty{at}earthlink.net).
From Milton Hall Plastic Surgery, Alpharetta, Ga (Dr Beaty), and Buckhead
Facial Plastic Surgery (Drs Dyer and Shawl).
REFERENCES
1. Tardy ME. Rhinoplasty: The Art and the Science. Philadelphia, Pa: WB Saunders Co; 1997.
2. Tardy ME. Rhinoplasty. In: Cummings CW, ed. Otolaryngology Head and Neck
Surgery. St Louis, Mo: Mosby–Year Book Inc; 1993:807-856.
3. Anderson JR. The dynamics of rhinoplasty. In: Proceedings of the Ninth International Congress
of Otolaryngology. Amsterdam, the Netherlands: Excerpta Medica; 1969:708-710.
Excerpta Medica: International Congress. Series, No. 206.
4. Anderson JR. A reasoned approach t | 
