Role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion cheap 7.5mg meloxicam overnight delivery. Microlaparoscopic left upper quadrant entry in patients at high risk of periumbilical adhesions purchase generic meloxicam. Major vascular injury as a complication of laparoscopic surgery: A report of 3 cases and a review of the literature purchase meloxicam with visa. An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the department of defence. Influence of different trocar tips on abdominal wall penetration during laparoscopy. Laparoscopic surgery complications associated with trocar tip design: Review of literature and own results. A randomized prospective study of radially expanding trocars in laparoscopic surgery. Randomized double-masked comparison of radially expanding access device and conventional cutting tip trocar in laparoscopy. The impact of trocar-cannula design and simulated operative manipulation on incisional characteristics: A randomized trial. Laparoscopic port sites do not require fascial closure when nonbladed trocars are used. Abdominal access in gynaecologic laparoscopy: A comparison between direct optical and open access. Abdominal access in gynaecological laparoscopy: A comparison between direct optical and blind closed access by Verres needle. Bladeless direct optical trocar insertion in laparoscopic procedures on the obese patient. Laparoscopic Burch colposuspension: A minimum 2-year follow-up and comparison with open colposuspension. Serious trocar accidents in laparoscopic surgery: A french survey of 103,852 operations. Use of computed tomography in the diagnosis of bowel complications after gynecologic surgery. Burden of adhesions in abdominal and pelvic surgery: Systematic review and met-analysis. Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: A prospective randomized study. Promontofixation coelioscopique: Resultats a court terme et complications chez 83 patientes. La promonto-fixation sous coelioscopie: Une voie d’abord seduisante pour la cure des prolapsus. Laparoscopic promontory sacral colpopexy: Is the posterior, recto-vaginal, mesh mandatory? Intraoperative and postoperative gastrointestinal complications associated with laparoscopic sacrocolpopexy. Gastrointestinal complications following abdominal sacrocolpopexy for advanced pelvic organ prolapse. Robotic compared with laparoscopic sacrocolpopexy: A randomized controlled trial [article]. Abdominal sacrocolpopexy for vault prolapse without burial of mesh: A case series. Laparoscopic sacrocolpopexy for female genital organ prolapse: Establishment of a learning curve. Implementation of laparoscopic sacrocolpopexy: Establishment of a learning curve and short-term outcomes. The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Uretral catheter placement for prevention of ureteral injury during laparoscopic hysterectomy. Complications of pelvic organ prolapse surgery and methods of prevention Int Urogynecol J 2013;24:1859–1872. Lumbosacral osteomyelitis after robot-assisted total laparoscopic hysterectomy and sacral colpopexy. The development of robotic surgery was aided by the Defense Advanced Research Projects Agency, who funded research into the possibility of a remote surgery program for ® battlefield triage. In Europe, it has full regulatory clearance and has the Conformité Européenne mark since 1999 [1]. The benefits for the surgeon include the potential for greater precision, lower error rates, shorter learning curves, and superior ergonomics than conventional laparoscopy. By December 2012, there were 2,585 da Vinci Surgical Systems installed in approximately 2,025 hospitals worldwide with approximately 450,000 robot-assisted procedures performed in 2012, an increase of approximately 25% compared to 2011 [6]. The general definition of technology assessment used was “a comprehensive form of policy research that examines the short- and long-term social consequences of the application or use of technology. This makes them an ideal tool and reference point for systematic reviews of new technology. Equally, the analysis must be transparent and deal with issues of quality-adjusted life-years and cost–benefit analysis as appropriate to the geographical area served. They are a valuable tool for health care policy making and decision making by governments. They concluded that based on the evidence available, the robot-assisted surgery may have a significant impact on many clinical outcomes in patients undergoing hysterectomy. In general, robotic surgery can have an impact on reducing hospitalization costs, but the investment made in acquiring this technology is significant, and institutions that choose to adopt it should make efforts to monitor its costs and outcomes in order to maximize cost-effectiveness within their own center. To decrease costs, centers should maximize caseloads, consider keeping the robot operational for longer durations if possible, and use the technology for multiple indications, particularly those with greater potential 1524 impact on important patient outcomes and savings on institutional costs. One of the key advantages of using robotic technology for gynecological procedures is the reduction in surgeon fatigue and the ability to perform complex surgery with a minimal invasive technique. The system consists of three main components: the console from where the surgeon controls the operation, the patient side cart with four interactive robotic arms to which the ® operating instruments are attached, and the vision system (Figure 103. The EndoWrist instruments used during surgery combines 7 degrees of freedom, with 90 degrees of articulation to provide a range of motion superior to the human hand. It also combines intuitive motion and fingertip control with motion scaling and tremor reduction technology to provide instruments with greater capabilities, and improved surgical dexterity. The principle of robotic surgery is that the surgeon operates unscrubbed while seated at the console, from which they are able to view the operating field in three dimensions through a stereoscopic viewer. It is associated with success rates of 74%–98%, a low recurrence rate, and reduced dyspareunia [14] when compared with vaginal sacrospinous fixation. Laparoscopic sacrocolpopexy has been shown to have similar outcomes with reoperation rates of approximately 6%–7% and a mesh erosion rate of 3% [15]. Furthermore, the conversion rates reduced with increased operator experience [15]. A study by Akladios assessing learning curves in robotic surgery highlighted that once the learning curve is complete, the 1-year cure 1525 rate was 98%; however, there was a 20% de novo dyspareunia rate [16].

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Left views: Preoperative discount 7.5mg meloxicam fast delivery, and Right views : postoperative views purchase meloxicam visa, demonstrating upper midface widening 15mg meloxicam with amex. This can pro- preoperative, right: is 1 year postoperative using Terino extra large duce a sunken, tired, older look. Bottom: A 50-year-old female prominence in a type 2 or type 3 face, a large malar shell placed in with aging midfacial atrophy. Left: preoperative, right : is 1 year post- the submalar region restores a youthful fullness to the face. Top : A operative following placement of Terino extra large malar shell placed 32-year- old female with hereditary midface submalar deficiency. Left: in submalar zone 5 3D Facial Volumization with Anatomic Alloplastic Implants 1001 Fig. Utilization of a large malar Preoperative, and right views : 1 year postoperative shell into the submalar space creates the illusion of a round, full apple 1002 E. This helps to correct a flat or “dish-face” appearance age and may produce irregularities or result in negligible A type 6 midface deficiency exists in the perinasal pre- improvement. Volume deficiency or the appearance of Over the past 5 years, there has been strong interest in a retrusiveness in this aspect of the skeleton is common in cer- subperiosteal elevation of all soft tissue layers from the tain ethnic groups, especially Asians and Western Indians in maxilla followed by a suspension of them in an upward the Americas. It also exists as a congenital hereditary trait, direction to provide greater volume filling in the inferior which can be mild or severe and which may require compli- orbital rim area. This midface suspension can be accompa- cated orthognathic surgery using maxillary LeForte relation- nied by inferior orbital fat rearrangement over the inferior ships. Alloplastic augmen- rupted along the entire orbital rim to create a space for the tation is permanent. Type 6 peripyriform and premaxillary intraorbital fat to be transposed and sutured into (Figs. They are usually of lesser S ubperiosteal midfacial suspension alone without the magnitude than the greater volume/mass interrelationships addition of alloplastic implants is a technique, which is still of the malar–midface, jawline, and nose. Therefore, they do new enough to require the test of time to evaluate long-term not command as much attention during an initial aesthetic persistence of volume correction and three-dimensional facial contour consultation unless the patients are focused improvement of the suborbital hollow appearance and on their deficiency themselves and request treatment by the malar–submalar shape. This also adds support to the lower eyelid to elevate it to a more attractive horizontal position Today’s men emulate the lean, athletic, and muscular con- 12 Chin–Jawline Augmentation figuration typified by the Greco-Roman statues of the ancient world. Therefore, liposuction currently leads the list of aes- Historically, a masculine image has been characterized by thetic operative procedures performed on men (and also qualities of strength, courage, boldness, and aggressiveness. Unwanted fat deposits are eliminated from the male Masculine images that impress us since youth include those torso with relative ease. The increasing popularity of cosmetic surgery has Traditional nasal contour changes and chin augmenta- resulted in increasing demands on the part of men as well. Currently, men comprise Present images of masculine facial structure, which are being at least 20 % and perhaps 30 % of an aesthetic surgery prac- sought by today’s male patients derive in part from the 1940s tice. Their greatest desires are to attain the masculine ideal and 1950s comic strip heroes. Green Lantern, the Lone Ranger, Batman, and dozens of 3D Facial Volumization with Anatomic Alloplastic Implants 1005 Fig. Both patients demonstrate successful improve- siderably improves a type 5 deficiency. Autogenous tissue transplants of ment of the suborbital hollow, tired look using this implant (arrows) Extent of midface subperiosteal space dissection Masseter m. Preoperative photos are on the left Example of two patients in whom premaxillary retrusive contour defor- others possessed jutting jawlines, massive cheek bones, and Within this liberal climate, men are paying more attention straight, strong nasal profiles (Fig. Today’s modern health and fitness characteristics assisted greatly in the success of such promi- movement has created a new era of athletic endeavor, which nent actors as Kirk Douglas, Gregory Peck, Charlton Heston, again, emulates the ideal Greco-Roman image. Nasal contouring and chin along with a revival of Superman, Dick Tracy, and others. Now, how- Schwartzenegger, Robert Redford, Tom Selleck, Mel Gibson, ever, males are adventuring into facial and jawline changes. Over the last two decades, there has also been an increas- ing emphasis and attention on male adornment. Mother Nature has delegated the male of any species to be the most 13 Zonal Anatomy colorful, by virtue of both genetic endowment and behav- of the Premandible Space ioral manifestation. Society further glorifies the male image through high-fashion wardrobes, hairstyles, and accessories, Techniques for chin augmentation have been amplified by which today include even jewelry through the ear lobes, extending the shape and size of the traditional, centrally nose, and other more private anatomical parts. Oval chin implants have traditionally ously augmented, creates significant changes in the shape been placed between the mental foramina. This only into this central segment often produce an abnormal and region can be configured into four functional anatomic zones unattractive, round, central protuberance (Fig. This is particularly accentuated in a patient tral mentum, creates a chin–jawline contour that is anatomi- who possesses an inherited round, globular, and protuberant cally natural (Fig. It becomes even more unde- “extended anatomic contour” implants designed by the sirable aesthetically if, in the process of aging, he or she author [13 ]. Augmentation within the midlateral zone, and develops an adjacent lateral soft tissue sulcus between the even further into the more posterior part of the mandible, central chin mound and the sagging, more lateral jowl ele- creates broadening and definition of the mid and posterior ments. This zone includes the posterior one- 3D Facial Volumization with Anatomic Alloplastic Implants 1009 Fig. This often produces a nonattractive central abnormal, rounded protuberance third of the horizontal ramus extending back from the These must be completely released to expand the space oblique line and includes the gonion of the mandible and the around the bony borders of the mandibular angle. Its boundaries are as release is necessary to allow the curved borders of the com- follows: mercially available angle implants to extend around the infe- rior and ascending posterior mandible margins to secure 1. The roof is the overlying muscle matic dissection when releasing the masseter muscle from 3. The posterior and inferior borders are limited by strong, veins or anterior facial vein and artery are harmed. When fibrofascial insertions of the masseter muscle damaged, these vessels can bleed profusely. Lower Extending the posterior mandible down creates a less obtuse, and more acute posterior mandibular angle, which gives the Premandible space lower mandibular border more horizontal definition. This zone is defined as “that region in the lower facial jawline/mandible aesthetic segment where volume–mass alloplastic alterations will produce variable lengthening of the vertical dimension of the face. Traditional alloplastic chin implants do not and cannot increase the vertical height to lengthen the lower third aes- thetic segment. Osteotomies with interpositional bone graft- ing with autologous fat transplants techniques are currently methods chosen by most plastic surgeons to accomplish this Fig. For the novice and ordinarily that can be augmented to correct specific regional contours for the trained plastic surgeon, orthognatic genioplasties are techni- lower esthetic mandibular facial segment cally complicated, imprecise, and have significant complica- tions (5–10 %), such as nerve damage, asymmetries, and Variable augmentation of the angle can be produced to “step-off” irregularities. Implants are available commer- author in 1986 to wrap around the inferior bony margin of the cially that either widen this posterolateral segment in a lateral mandible and increase the vertical distance from the lower lip 3D Facial Volumization with Anatomic Alloplastic Implants 1011 Fig.

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They do however go far beyond the simple traditional posterior repairs and perineoplasty of old purchase meloxicam in india. The focus of these older procedures is simply to restore and reduce the bulge buy meloxicam cheap, whereas the focus of vaginal rejuvenation is to restore the caliber of the vagina and genital hiatus back to prechildbirth state from the introitus all the way up to the apex order meloxicam 15mg amex. No drop-offs or dips should be felt and there should be no tension placed on the levators that causes lateral banding of the vagina. Additionally, the cosmetic appearance of the introitus and perineal body is also taken into account and requires intricate dissection and repair to not only restore function of the introitus but also obtain an appearance that the woman desires. That look typically is one of the vaginal opening being closed, not gaping or wide open with a normal length perineal body that does not bulge out following the repair. This look is sometimes difficult to obtain, without making the introitus too tight, which will cause pain with intercourse. Posterior Wall, Introitus, and Rejuvenation The posterior vaginal wall is the focus of any vaginal rejuvenation procedure. In a woman with a mild cystocele or mild relaxation of the anterior vaginal wall, a small anterior colporrhaphy can be completed to take care of this prior to repair of the posterior wall. However, one needs to be very careful with this as if the repair of the anterior wall is too aggressive, it will lead to lateral banding and constriction of the vagina, before the posterior wall is even started. An incision is made at the introitus, typically in trapezoid pattern, that will also be used in the perineoplasty portion of the procedure (Figure 116. A small incision is then made in a vertical fashion on the posterior wall, and the vaginal epithelium is dissected off the underlying rectovaginal fascia all the way laterally out to the levators (Figure 116. The dissection must be taken all the way up to the apex of the vagina, as the repair needs to incorporate the entire posterior wall to restore the caliber of the full length of the vagina (Figure 116. The dissection of the vaginal epithelium may be completed with a laser, as championed by Dr. David Matlock, or completed utilizing more standard techniques with sharp scissors or electrocautery. Care of course needs to be taken with any electrical energy source near the rectum. If a rectocele is present, the fascia is repaired in a site-specific fashion with delayed absorbable suture for the first layer of the repair. This may be a lateral repair of the defects, a midline placation, or a combination (Figure 116. The caliber of the vagina is then addressed by plication of the rectovaginal fascia in the midline with delayed absorbable sutures. Levator plication is avoided; however, the diameter of the vagina is constantly measured, and several layers of plication may be needed to reduce the genital hiatus and reduce the caliber of the vagina to an appropriate level (Figure 116. A small amount of vaginal epithelium is then excised and the incision closed in a running fashion. A perineoplasty is then completed, involving a very meticulous and detailed dissection out laterally to obtain the lacerated edges of the deep and superficial transverse perineal muscles and bringing them back together in the midline to achieve uniformity at the same level of the posterior wall repair. The inferior edges of the labia majora that will make up the posterior forchette of the vaginal opening must be marked at the beginning of the procedure so that these edges match up during the closure to form the vaginal opening. An appropriate amount of skin must also be excised from the perineum and introitus to result in a cosmetically pleasing appearance of the opening of the vagina for the patient. A multilayer (typically this may involve four or five layers) is completed at the perineum and introitus (Figure 1737 116. When a repair is primarily for vaginal relaxation for sexual function, it becomes a much more meticulous dissection and repair as the surgeon has to constantly be judging and measuring vaginal caliber to try to restore the entire vaginal length to its prechildbirth state. If this is not done, then the results will be poor and the patients’ sexual function may not change or they will be worse secondary to pain, vaginal shortening, scar tissue formation, and/or constrictions. Postoperative Care Routine postoperative care is given to patients undergoing vaginal surgery. Many of the procedures are undertaken on an outpatient basis, and the surgery is completed under spinal or general anesthesia. A pudendal block may also be completed prior to or during the procedure to help decrease postoperative pain. Vaginal packing is left in for a short period of time and removed prior to the patient being discharged. Routine instructions for vaginal surgery are given to the patient and she is seen in follow-up at 4 weeks postoperatively. The vaginal introitus and caliber are assessed, and if felt necessary, the patient will begin perineal massage in warm water bath for 1–2 weeks prior to resuming sexual relations. Conclusion Vaginal rejuvenation surgery is one of the latest trends in elective vaginal surgery for women. It is a repair of the vaginal caliber in women who suffer from decreased vaginal sensation or of feelings of a loose or wide vagina that affects their sexual life. In many instances, women who present with these symptoms are found to have other pelvic pathologies such as prolapse that must also be addressed during any repair contemplated. Sexual dysfunction or decreased sexual sensation may be the first symptoms that women suffer from in the progression of prolapse, and therefore, a proper exam is vital prior to any repair. We have ample evidence that prolapse and vaginal relaxation can create sexual dysfunction and that repair may reverse these changes in many women. It is important to note that when dealing with sexual dysfunction due to vaginal laxity alone, the surgical repair must be very meticulous and exact in order to enhance sensation and function and not impair it. However, little research exists on the relationship between a woman’s genital image and her sexual function. Realizing one’s genital image is part of one’s body image; it is easy to understand how many women might feel sexually inhibited if they are not comfortable with the appearance of their vagina, vulva, or external genitalia. A survey of 3627 women found that women with positive body images reported more sexual activity, initiation of sexual activity, orgasm, sex with lights on, and greater comfort undressing in front of their partners, trying new sexual behaviors, and pleasing their partner [43]. Cosmetic vaginal surgery is currently steamrolling its way into mainstream culture. There have been many negative comments and editorials written suggesting that both the doctors and the patients should not be pursuing cosmetic vaginal surgery [44–46]. Many of those who imposingly opine are often ignorant of the patient and their disposition as well as their medical conditions and their associated symptoms [47]. Physical symptoms are usually associated with wearing certain types of clothing; engaging in activities such as walking, jogging, exercise, and bicycling; and finally intercourse. Yet, other patients are afflicted with emotional problems such as embarrassment, anxiety, and a loss of self-esteem. Cosmetic vaginal surgery does not always begin and end with labia minora reduction surgery, i. There are many different techniques that can be applied to enhance a woman’s genital cosmetic image. To understand the techniques, a basic understanding of the external genitalia is essential before undertaking surgical procedures.

Furthermore order 15mg meloxicam mastercard, the retroglandular recommended; in this way the dynamic distortion is reduced position poses no problems in terms of breast distortion dur- and a wider expansion of the inferior pole of the gland is ing the contraction of the pectoralis muscle; this point has to obtained cheap 15mg meloxicam. Actually 15 mg meloxicam overnight delivery, the complete release of the inferior inser- be adequately explained to the woman. The optimal expan- ralis fascia is elevated together with the deep layer of the super- sion of the inferior pole of the breast may need additional ficial fascia, including the perimysium, the results are different. According to the classic tech- positive effect on the capsular contracture and a lesser degree nique, the pectoralis muscle insertions to the overlying breast of visibility of the implant edges has been advocated. It must be utilized More recently a technique of selective release of the every time tissue thickness over the implant seems question- pectoralis muscle, tailored to the patient’s anatomy, has able, being aware that aging will worsen the problem of tis- been popularized and is widely used. This decision has to be taken also considering “dual plane” pectoralis detachment minimizes the dynamic two unfavorable aspects of this position, such as the move- forces of the pectoralis contraction, offering at the same ment related distortion of the breast and the more painful and time the best possible tissue coverage for the implants in long postoperative course. The term “dual plane” is of the implant are invaluable, particularly considering related to the fact that dissection is partly performed in the patients in which the device becomes palpable and visible. Distortion of the breast while the pectoralis major contracts Dissection is performed not only behind the pectoralis can be very fastidious for the patient, particularly when no major, but also directly over it, detaching the muscle from manipulation or release of the medial and inferior muscular the gland for a variable distance, according to the required insertions has been done. In this case the muscular contrac- degree of expansion of the inferior pole as well as to the tion pulls the implant superiorly and laterally, leading with level of the ptosis. Included in the technique is also the time to the permanent displacement of the device. The pectoralis muscle retracts upwards the potential expansion of the inferior half of the gland and at different levels, covering only the superior tract of the implant. The dissection over the pectoralis muscle is extended up to Table 1 Implant position the level of the superior border of the areola, in order to cor- rect the ptosis; in this way the implant can fill the lower pole Retroglandular position of the breast and obtain as much as possible of the pseudo-lift Increased incidence of fibrosis effect. Visibility/palpability of the superior border of the implant Rippling The retracted pectoralis flap should be sutured again to the Unfit for thin tissues; breast parenchyma; this maneuver has to be performed after Increased evidence of spherical contracture the positioning of the implant with the patient seated, in order Suitable for correction of minimal ptosis to adequately verify the level of replacement. Greater motility A modified dual plane technique is characterized by a No dynamic distortion during pectoralis muscle contraction horizontal section of the pectoralis muscle 2 cm distally to Subpectoral position the superior limit of the glandular dissection. This will cre- Low degree of pericapsular fibrosis ate a smaller flap, with still a useful weakening of the infer- Reduced evidence of incidental fibrosis olateral border of the muscle, allowing to eventually Less suitable in case of ptosis disguise any glandular defect evidenced by the muscular Dynamic distortion during pectoralis muscle contraction contraction. Exerting a light pressure on the inferior and Implant Selection pole of the gland, the superior limit that has to be filled up is marked (Fig. This measured These complex formulas have been of great help in the value identifies in most of the patients the width of the implant comprehension of the dimensions concept, caring after to be utilized, as the device definitely needs to be completely previously omitted details; nevertheless these algorithms can covered by the breast tissues (Fig. The main point is that the edges of the device are not quately select breast implant size are listed here: visible nor palpable either medially or laterally under the thinned tissues. This mea- sure is written down by the manufacturer on the implant Medial and lateral contour. The under tension measure approximately reflects medial and lateral parenchymal boundaries are marked, the postoperative condition, when tissues are distended by pushing slightly the gland inwards and outwards, in order to the new volume; its value gives an indication on the degree make the gland boundaries more evident (Fig. The inframammary ridge is marked while tractioning the Nipple-ridge distance with elevated arm. Abducting the arm This line is temporarily considered the potential new mam- of 90°, the nipple will be positioned approximately in the mary ridge. That measure will approximately correspond to the radius of the implant base, whose value has to be compared with the Table 2 Implant selection already measured transverse diameter. Width: breast width minus tissue thickness The position of the new ridge has to be checked. The Height: distance between the expected position of the inframammary nipple-ridge distance on the median line of the body has to ridge and the superior boundary of the area to be filled up correspond to the sum of the implant radius and the tissue Shape: if the two measures are identical, a round or anatomical thickness of about 1–1. The position of the implant with a round base can be positioned; if the transverse diameter is longer than the vertical one, an anatomical implant with ridge can be pushed down; obviously, it is necessary to be oval base is preferred. Using an anatomical implant with oval base, sure that the ridge is not too tiny and that it can be lowered we can change the shape into an improved aesthetic result without any deformation or double contour. In thin Projection: any base size has 3–4 different projections patients, the lowering of the ridge often involves an inad- a c b d Fig. If under tension the nipple-ridge distance stretches about 1 cm, the compliance is low; if the stretch reaches 3 cm, it is possible – and appropriate – to select a more projecting implant. If under tension the nipple-ridge distance is superior to 8 cm, the patients have a ptosis of the breast that will be corrected with great diffi- culty by the implant. Anatomic implants, also called drop devices, have been on the market since many years, with a great variety of shapes and projections; many authors consider them of the greatest importance to obtain in the woman a natural, non-operated look. The main difference between these implants and the round ones resides in the superior pole, which is thinner and can be positioned at different heights with respect to Fig. The implant surface has to capability of receiving the new volume, and thus to their permanently adhere to the patient’s tissues. This patient shows a low superior pole with high oblique view (3/4) postop Augmentation Mastoplasty 137 a b d c Fig. Low texturization items create no • Retroglandular implants are more often palpable, with adherence between the implant and the tissues and do not visible margins. The surgical table in the operating room must have adjustable segments, in order to maintain the patient in the sitting position during the procedure and to evaluate the cor- rect and symmetric positioning of the implants. These reference points are useful while dissecting the implant pocket with the patient lying on Fig. Augmentation Mastoplasty 139 13 Surgical Access dislocation and malrotation of the implant, leading to an obvious alteration of the gland shape. At the moment, the most frequently utilized surgical accesses The dissection of the retroglandular space is rather sim- are the axillary, the periareolar and the inframammary ridge ple, as this plane is easily detachable from the pectoralis fas- routes. The axillary route is favored because the scars are hid- cia and shows a limited vascularization. The dissection is den in the axillary pit, posteriorly to the anterior pillar and thus precisely limited within the marked boundaries. The access site If a retrofascial dissection is needed, it is better to use a is far from the gland, but with adequate surgical instruments it periareolar access or to make the incision in the inframam- is possible to prepare a retroglandular pocket; but if the implant mary ridge. The dissection of the inferior pole can begin in has to be positioned in the retromuscolar plane, the use of the retroglandular space, to become later on retrofascial once endoscopic equipment is mandatory, as it greatly aids the con- the nipple has been reached and subsequently proceed in the trol of the inferomedial corner of the pocket. In this way the axillary access greatly influences implant selection, as it is visibility of the superior margin of the implant is reduced in easy to position either empty implants, which can be filled up patients showing limited thickness of soft tissues at this with saline later on after their introduction into the pocket, or level. Electrocautery is utilized for dissection, leaving the round implants; on the contrary, the utilization of large ana- corresponding muscular fibers exposed; the perimysium is tomic devices filled with cohesive gel is a rather complex pro- detached as well. In case of reoperative surgery, the axillary route is the tion of the muscular fibers; a traction applied on the pectora- least practical of the various options and invariably forces to lis muscle can make the procedure easier. Whatever access is selected in order to create a subpecto- The periareolar access is positioned in the center of the ral space, the free margin of the pectoralis major has to be breast and allows the operator to easily master the surgical searched for and detached from the costal plane, interrupting field while choosing the implant site and during the introduc- all the inferior costal inscriptions as well as the inferior ster- tion of the anatomic implants. If the scar shows a normal nal ones for a 2/3 cm tract; this way the inferior pole of the evolution, it is hardly visible, as it rests exactly between the gland expands more easily. In unusual conditions, when dissection is the most widely utilized and also the most artic- the diameter of the areola is extremely short, inferior to two ulated one.

The limited medium-term results suggest a higher efficacy than Burch but with more urgency and voiding problems purchase meloxicam 15mg online. After going through a stepwise process of cellular destruction and sterilization buy meloxicam on line, these materials essentially provide a framework of collagen cheap meloxicam 15 mg visa, which lends itself to invasion with fibroblasts and new blood vessels. Whether the tissues become completely replaced by host fibrous tissue or remain intact remains unclear. Of the available xenografts materials, more has been written about porcine dermis. Xenoderm was a dried preparation requiring preliminary soaking before implantation, while Pelvicol is a prewetted dermal graft that handles much like a piece of autologous fascia. Case series presenting early outcomes from Pelvicol implantation [133] promised encouraging efficacy, but longer-term studies have shown unacceptable failure rates. The material was awkward to handle and was withdrawn from the market by the manufacturers in the mid-1990s. Small intestinal submucosa has also been used for urethral support as well as many other uses. There have been conflicting reports on the extent of tissue reaction related to the use of this tissue [140,141]. Synthetics As aforementioned, the long-term durability of these procedures with graft materials has been questioned, with reports of graft failure and declining success rates over time [5]. As such, the midurethral synthetic sling was developed, replacing the pubovaginal sling as the gold standard for stress incontinence, and thus, polypropylene mesh is worth mentioning here as a graft material though it is discussed at length in another chapter [142]. Nonetheless, patients are not necessarily aware of these differences and should be counseled appropriately prior to any surgical intervention, especially when voicing concerns about mesh placement [144]. As such, patients should be informed that synthetic slings are considered a first-line treatment option for stress incontinence. Attempts to improve this coaptation effect through minimally invasive injection techniques have challenged clinicians for over 50 years. The mechanics of urethral bulking seem to be that by increasing the passive resistance of the urethra, leakage is diminished. The ideal injection material should be nonimmunogenic, thus causing no localized inflammatory reaction; stable chemically; nondegradable so that its bulking effect remains; and easy to inject to minimize the difficulties of surgery. Since most of these agents consist of particles suspended in a carrier gel or fluid, it is also important that the particles are large enough not to be absorbed and risk migration, and for as little carrier gel as possible to be absorbed, which results in reduction in efficacy. The first injection techniques to be tried and reported were by Murless in 1938 [146]. He used sclerosing agent, sodium morrhuate, in 20 women and achieved continence in 17 of them, presumably through the effect of scarring and contracture of the vaginal wall. Quakels in 1955 used paraffin to achieve the same effect, but reports of pulmonary embolism stopped the technique [147]. The speed of this procedure and its apparent efficacy, even if this was lower than conventional surgery, appeared to offer a truly minimally invasive alternative to surgery for women who wanted to avoid the risk of morbidity. However, reports of serious complications began to emerge including periurethral abscess [152,153] pulmonary granulomata [154,155], and obstructive uropathy [156], and long-term outcomes were observed to deteriorate from 80% initial response to 27% at 3 years [157] and to 33% at 5 years [158]. Gonzales de Garibay, in 1989, reported an alternative bulking agent that utilized autologous fat cells obtained by microliposuction and reinjected into the periurethral tissues [159]. This had the major advantage of being autologous tissue with no immunogenicity problems, cheapness, and ease of use. However, the initial results were disappointing with only 23% of women improved at 12 months [160] and none in another study [161] though Palma achieved 64% cure at 12 months by means of repeated injections [162]. Of the 68 women enrolled, 35 received fat and 33 received saline injections of whom 22% and 20%, respectively, were improved at three months. Much further research and clinical development has continued into the modern era using a variety of injectable materials. In brief, recently developed injectables such as silicon particles and calcium hydroxylapatite can result in an improvement in incontinence, but patients may not necessarily achieve dryness. According to the 2012 Cochrane Review on injection therapy for urinary incontinence, there is insufficient evidence in the use of bulking agents to guide clinical practice, and this is discussed in detail in another chapter [164]. Nevertheless, understanding these procedures is paramount as our current surgical treatment options are based on these fundamental surgical principles. The continued use of what some would regard as archaic may be defensible in experienced hands, where the outcomes are well monitored and known to surgeon and patient alike. Thus, scrutiny of surgical technique and materials is becoming commonplace, ultimately providing better patient care, which is the ultimate goal. Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5- year follow up. Structural support of the urethra as it relates to stress urinary incontinence: The hammock hypothesis. Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. A randomised controlled trial comparing two autologous fascial sling techniques for the treatment of stress urinary incontinence in women: Short, medium and long-term follow-up. Anterior colporrhaphy plus inside-out tension-free vaginal tape for associated stress urinary incontinence and cystocele. Primary stress urinary incontinence and pelvic relaxation: Prospective randomized comparison of three different operations. Three surgical procedures for genuine stress incontinence: Five-year follow-up of a prospective randomized study. A randomized trial of burch retropubic urethropexy and anterior colporrhaphy for stress urinary incontinence. Randomised comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapse. Four-corner bladder and urethral retropubic suspension versus anterior colporrhaphy in the correction of stress urinary incontinence with urethrocystocele 3–4. A prospective, randomized and controlled trial for the treatment of anterior vaginal wall prolapse: Medium-term follow-up. Evaluation of long-term results of surgical correction of stress urinary incontinence. The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension. Comparison of the anterior colporrhaphy procedure and the Marshall– Marchetti–Krantz operation in the treatment of stress urinary incontinence among women. Ten-year results of Marshall–Marchetti–Krantz and anterior colporraphy procedures. Surgical treatment of stress urinary incontinence: A comparison of the Kelly plication, Marshall–Marchetti–Krantz, and Pereyra procedures. Retropubic cystourethropexy: A review of two operative procedures with long-term follow-up. Paravaginal repair of lateral vaginal wall defects by fixation to the ischial periosteum and obturator membrane. A randomized comparison of Burch colposuspension and abdominal paravaginal defect repair for female stress urinary incontinence.

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Disopyramide reversal of induced hypotension-bradycardia in neurally-mediated syncope buy meloxicam from india. Electrophysiological studies in screening of the “mixed type” of carotid sinus syncope 7.5mg meloxicam visa. Sinus node electrogram in patients with the hypersensitive carotid sinus syndrome buy meloxicam us. Relevance of diagnostic atrial stimulation for pacemaker treatment in sinoatrial disease. Electrophysiologic testing in patients with sinus pauses and/or sinoatrial exit block. The human sinus nodal electrogram: techniques and clinical results of intra-atrial recordings in patients with and without sick sinus syndrome. Significance of pacemaker recovery time after the Mustard operation for transposition of the great arteries. Chapter 4 Atrioventricular Conduction The usefulness of intracardiac recording and stimulation techniques in humans was first realized during its application to patients with disorders of atrioventricular (A-V) conduction. The A-V block has been traditionally classified by criteria combining implications about anatomic site, mechanism, and prognosis. Because intracardiac studies can provide much of this information directly, a classification of A-V block that is applicable to the A-V conduction system as a whole or to any of its components is preferred (Table 4-1). Thus, in our laboratory, we prefer to consider first-degree, second-degree, and third-degree A-V block as prolonged conduction, intermittent conduction, and no conduction, respectively, because it more accurately defines the underlying physiology. For example, in the presence of first-degree block, impulse transmission (output/input) is 1:1 (hence the inappropriateness of the term block), although conduction through the whole A-V conduction system, or any of its parts, is prolonged; in the presence of second-degree block, impulse transmission is less than 1:1; and in the presence of third-degree block, no impulse transmission occurs. Type I second-degree block, to which the eponym Wenckebach block is often applied, is characterized by progressive prolongation in A-V conduction time preceding the nonconducted time in the conducted beat following the blocked impulse. However, careful measurement of intra-His conduction times with stable plunge wire electrodes revealed minimal (1- to 2-msec) increments before the blocked beat, a range that usually falls within the error of measurement of the recording techniques commonly used in humans. Thus, the subdivision of second-degree A-V block into two distinct types may not be sound from a mechanistic viewpoint. Nevertheless, from a practical viewpoint it is worth noting that intermittent conduction (second-degree A-V block) associated with no (or undetectable) preceding increment is a behavior characteristic of the His–Purkinje system. Therefore, block greater than second-degree A-V block includes 2:1 A-V block, high-degree A-V block (≥2 consecutive blocked P waves of intermittent conduction), and complete A-V block with evidence. Theoretically, abnormalities of A-V conduction may result from conduction disturbances in any region of the heart, although certain patterns of block can be localized to specific sites (Table 4-2). In the case of a prolonged P-R interval, intracardiac measurements may show normal intracardiac conduction (e. Hence, precise localization of a conduction disturbance may aid the clinician in planning the therapeutic approach. Because of the lack of complete data, these questions are often answered on subjective rather than objective grounds; nevertheless, the following paragraphs present P. Although there are no anatomic data supporting the presence of specific internodal tracts (anterior, middle, or posterior) that 3 facilitate internodal conduction, preferential pathways of atrial conduction exist, but they appear to be related to the spatial and geometric arrangement of atrial fibers rather than to specialized “tracts. Of interest is the fact that a majority of dogs develop complete A-V block and a junctional rhythm if all three internodal tracts (found in dogs) are sectioned. On the other hand, prolonged A-V conduction (first-degree block) that is due to atrial conduction delay is not uncommon in humans. In all instances, however, delayed activation to the lateral left atrium is present. The assessment of intra-atrial conduction demands the reproducible and accurate timing of local 5 electrocardiograms from specific anatomic sites in the atria. While high-density mapping may be useful to ascertain local atrial defects, fewer points are needed to demonstrate the cause of P-wave abnormalities (in a general way). For the reasons given in Chapter 2, simple measurement of the P-A interval is inadequate for the assessment of intra-atrial conduction. These latter two procedures are not really justified unless a left atrial tachycardia is suspected. For accuracy and consistency, the principles of measurement described in Chapter 2 must be followed strictly. Accuracy is further enhanced by the use of rapid recording speeds (200 mm/sec or greater). A single catheter may be used to map more than one location as long as the rhythm (usually sinus) remains constant, and a reproducible reference electrogram is chosen (e. The mean activation time in a group of 24 patients with normal P waves and the mean values in a group of 15 patients with electrocardiographic left atrial enlargement are shown in Figure 4-2A, B, respectively. Obviously detailed atrial activation mapping using the Carto electroanatomic system is most accurate and is necessary for ablation of left atrial tachyarrhythmias. Normal activation is shown in Figure 4-3 in which activation of the left atrium occurs over Bachmann bundle, with additional conduits through the interatrial septum and coronary sinus (and potentially via interatrial bridges). In this patient, delayed activation of the left atrium (P to coronary sinus) and normal intra- right atrium conduction are shown by the atrial map. Intra-atrial delay involving only the right atrium is far less common, but it is seen in the presence of congenital 6 7 heart disease, particularly the endocardial cushion defects and Ebstein anomaly of the tricuspid valve. The prolonged intra-right atrial conduction time was probably due to longer time necessary to traverse the abnormally large right atrium. The demonstration that intra-atrial conduction delay is responsible for prolonged A-V conduction (first-degree A-V block) may alleviate concern that A-V nodal delay, intra-His delay, or infra-His delay is responsible. The vertical line marks the reference point for measurement and is the earliest evidence of atrial electrical activity. Activation times are plotted from various standard sites in the atria, with mean activation time shown with a bar and number. It occasionally occurs spontaneously as Type I second-degree exit block from an automatic atrial focus in the setting of digitalis toxicity (Fig. A similar phenomenon can be precipitated in the laboratory by rapid atrial pacing, which results in progressive increments in the stimulus-to-A 9 interval until the stimulus is not propagated, at which time the process repeats itself. Such types of intra-atrial delays appear to be substrates for intra-atrial reentry (Chapters 8, 9). Interatrial and intra-atrial dissociation have been observed during atrial tachyarrhythmias, particularly atrial flutter and fibrillation. In such instances, all or some part of the atrium manifests one rhythm while the remainder is activated differently. Atrioventricular Node The A-V node accounts for the major component of time in normal A-V transmission. The range of normal A-H time during sinus rhythm is broad (60 to 125 msec), and it can be profoundly influenced by changes in autonomic tone. Thus, 11 measurements of A-V nodal function over periods of time may not be reproducible. Delay in the A-V node is by far the most common source of prolonged A-V conduction (first-degree A-V block) 12 (Fig. From another viewpoint, most patients (≥95%) with a total P-R interval greater than 300 msec have some degree of A-V nodal delay. It is worth reemphasizing that A-V conduction can vary greatly with changes in the P.

The earlier activation at this site suggests two retrograde atrial breakthrough sites and two bypass tracts purchase meloxicam 7.5 mg online. Fusion is seen in the second and seventh complexes buy cheap meloxicam 7.5 mg line, and total preexcitation over the anterior paraseptal bypass tract is seen in the fourth through sixth complexes order 15 mg meloxicam amex. Note the difference in V-A intervals associated with different H-V intervals with various degrees of fusion. The change in V- A intervals is due to the relative activation of the ventricles over the bypass tract and the time that the normal conducting system activates the ventricles. Patients with multiple bypass tracts have been associated with a higher incidence of ventricular fibrillation according to some investigators, a higher incidence of preexcited tachycardias, and clearly, more complicated anatomy for catheter-based or surgical ablation. Thus, it is imperative that one make every effort to detect their presence during electrophysiologic studies. In the presence of multiple bypass tracts the complexity and number of the potential tachycardia circuits is large (Fig. If one considers the fact that a given patient may have more than two A-V bypass tracts (20% of our patients with multiple bypass have three or more tracts), enhanced A-V nodal conduction, P. In nearly 10% of patients with preexcitation, A-V nodal reentry is present, and in some it is the only arrhythmia (Fig. During the preexcited tachycardia, anterograde conduction occurs over a left lateral bypass tract, and retrograde conduction occurs over a second slowly conducting posterior paraseptal bypass tract. A ventricular stimulus delivered when the His is refractory preexcites the atrium with a shorter V-A interval than during the first three complexes; thus, producing a paradoxical premature capture. This earlier retrograde atrial activation sequence results in subsequent delay of antegrade conduction through the A-V node. This delay allows for retrograde activation over a left lateral bypass tract to be manifested. This left lateral bypass tract was previously concealed by antegrade penetration into it by atrial activation that initiated over the right anterior bypass tract. Schematically shown are six potential mechanisms of arrhythmias with two functioning atrioventricular bypass tracts. Atriald extrastimuli only induced typical A-V nodal tachycardia; orthodromic tachycardia was never observed. Although the authors initially ascribed this syndrome to the presence of an A-V nodal bypass tract, the pathophysiologic basis and clinical significance of the syndrome was clarified in the 1980s through the use of intracardiac recordings and programmed stimulation. A short P-R interval may have many mechanisms including a variant of normal, enhanced sympathetic tone, an anatomically small A-V node, ectopic atrial rhythm with differential input into the A-V node, or isoarrhythmic A-V dissociation. The syndrome, as initially described, requires the presence of paroxysmal arrhythmias in addition to the short P-R interval. Most investigators believe that enhanced A-V nodal conduction (perhaps using 13 14 135 136 137 138 139 140 specialized intranodal fibers) is responsible for the majority of cases , , , , , , , while a minority 3 5 139 140 141 are associated with atrio-His connections. In the latter instance, atrial flutter and fibrillation with rapid ventricular responses are the clinical problem. Controversy still exists concerning the functional significance and the anatomic existence of the posterior intranodal tracts 9 described by James, which are the third possibility. Although there is no anatomic correlate of a specialized intranodal pathway, the complex structure of the A-V node, with areas of tightly packed, longitudinally arranged transitional fibers on the periphery of the node, and a lattice network of more loosely connected fibers around densely packed nodal tissue can provide an anatomic substrate for relatively fast and relatively slow conduction. Electrophysiologic Properties The hallmark of patients with the so-called Lown–Ganong–Levine syndrome is enhanced or accelerated A-V conduction, which more than 90% of the time is due to accelerated conduction through the A-V 135 136 137 138 139 140 141 node. The His bundle in this instance is retrogradely activated from the site of distal His insertion. The short H-V is due to the difference in conduction time from the site of insertion in the distal His bundle to the ventricle and to the conduction time from the site of insertion in the distal His bundle to the proximal His bundle. One must distinguish this “short H-V” from the recording of a distal right bundle branch potential, an anatomically shortened posterior division, or premature insertion of normal-sized bundle branch to the ventricular muscle. Block in the bypass tract can usually be achieved through the use of antiarrhythmic agents or occasionally by the induction of atrial fibrillation. Intra-atrial conduction delays and/or H-V prolongation can produce a normal P-R interval without influencing A-V nodal conduction. In the same vein, the presence of bundle branch block in no way signifies an alteration in A-V nodal conduction. Typical of patients with short P-R intervals (110 msec), A-V nodal conduction time is short (A-H interval, 35 msec), and the H-V interval is normal (H-V = 45 msec). A and B: Atrial pacing does not affect the P-R interval, which remains fixed at 100 msec. C: Proof of that appears during atrial fibrillation in which block in the atrio-His bypass tract occurs and conduction proceeds over the normal pathways. It is imperative to identify the mechanism and characteristics of the type of accelerated A-V conduction since the mechanism of enhanced A-V conduction determines the type of the spontaneous arrhythmias. This can be done by analyzing the response of the A-V conducting system to programmed stimulation and/or drug interventions. If accelerated conduction is due to enhanced A-V nodal conduction, patients should respond to such perturbations qualitatively similar to, but perhaps quantitatively less than, the normal A-V node. In contrast, if accelerated A-V conduction is due to an atrio-His bypass tract, responses characteristic of nodal tissue should not be present. The electrophysiologic characteristics of patients with enhanced A-V conduction are discussed in subsequent paragraphs. The atrial paced cycle length is shown on the abscissa, and the resultant A-H interval is on the ordinate. The response of patients with normal P-R intervals to atrial pacing is shown by the stippled area. Three patterns of response to atrial pacing are observed in patients with short P-R intervals: (1) no A-V nodal delay, characteristic of an atrio-His bypass tract (circles); (2) a dual-pathway response, characteristic of a preferential intranodal pathway (dashed line); and (3) a response qualitatively similar to normal but with a lesser degree of A- H prolongation, compatible with a partial A-V nodal bypass tract, a small A-V node, or an extremely rapid intranodal pathway (solid line). Atrial Pacing 135 136 137 138 139 140 141 142 Several types of responses to atrial pacing have been reported (Fig. This usually takes the form of a smooth, continuous, but blunted prolongation of the A-H interval, or of an initial blunted small increase in A-H interval followed by a significant jump at a critical cycle length, typical of dual A-V 13 14 143 144 nodal pathways. In patients with such blunted responses, the 136 A-H interval is rarely >200 msec, and in the study by Benditt et al. These numbers may vary somewhat, depending on patient selection and adrenergic tone in the laboratory. It is of interest, however, that in both groups the maximum A-H before Wenckebach was similar. In a second type of response, a small increase is followed by a jump in the A-H at a critical paced cycle length with a subsequent gradual increase while maintaining 1:1 conduction at cycle lengths of <300 msec. In such patients, the maximum A-H interval can exceed 200 msec, and the maximum increment in A-H interval will exceed 100 msec because conduction at shortest paced cycle lengths during 1:1 conduction is through the slow A-V nodal pathway.

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