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Individuals who have marked defcits in social communication discount npxl 30caps mastercard, but whose symptoms do not otherwise meet criteria for autism spectrum disorder order npxl master card, should be evaluated for social (pragmatic) communication disorder cheap npxl 30 caps otc. Specify if: z With or without accompanying intellectual impairment z With or without accompanying language impairment z Associated with a known medical or genetic condition or environmental factor z Associated with another neurodevelopmental, mental, or behavioral disorder. With early diagnosis, improved care, Management of abnormal behavior (behavior modif- and intensive behavioral therapy, the proportion of sub- cation). For details, See factors operating before pregnancy, during pregnancy, Chapter 23 (Intrauterine Infections). Tese dis- tions, over criticism, discrimination, unfavorable compari- orders are relatively stable, internalized and difcult to son, over or under discipline, dominance by the parents, treat than the adjustment reactions, but less than neurosis marital disharmony, etc. Common examples of this category are failure to attend to the normal needs of the child, unfavorable nail biting, thumb sucking, somnambulism and enuresis. Parents z Scholistic problems: Reading, writing or mathematical disability, z Misinterpreted behavior repeated failures, absenteeism, truancy, school phobia, aggres- z Mismatched expectations siveness. Even in frank cases, parents are 103 child, a stepchild, a mentally or physically handicapped reluctant to consult a psychiatrist due to social taboos. He is unlikely to Not infrequently, parental attitudes may well be a cocktail fulfll this function completely and earnestly without the of overprotection and rejection at diferent times, depending knowledge of fundamentals of child psychiatry. Etiology: It lies in disturbed relationship with parents/ It is a useful intervention for many behavioral dis- caregivers and non-stimulating environments. Clinical features: Two types are recognized: To be of real beneft, the change should be learned and 1. Pathologic: In infants with mental retardation (usu- ior is often imposed on children and/or parents. Te hallmark of rumination is malnutrition, weight Secondly, while counseling for a change in behavior, any loss and growth delay. Generally speaking, mothers are expected to Treatment: Reinforcing correct eating behavior. However, it is desirable that the father too take interest and responsibility in this pursuit. Te term, pica (Latin: magpie), refers to eating of substanc- Counseling should also aim at difusing the guilt feeling es other than food (non-edible/non-nutritive items), e. Pica as a manifestation of inclination for mouthing other parents with similar problems and providing and tasting in the absence of any associated problem may guidelines for coping with them. Etiology: An association of pica with mental retarda- Te feld of child psychiatry primarily deals with tion is a category per se. Here we are largely concerned identifcation and handling of the emotional, behavioral with pica in otherwise normal children. Its knowledge situation, pica usually occurs in children from the lower in case of a pediatrician is of particular importance, at least strata of society with suggestions of parental neglect and for two reasons. Asso- First, his frst contact with the child and his parents ciated malnutrition with worm infestation and vitamin and the subsequent contacts uniquely contribute to and mineral defciencies is common. Whether these are evaluating the development of the child and advising the cause or efect of pica remains unclear. Intes- but also for seeking psychiatric consultations as and tinal parasitic infestations are generally associated. Besides, there is a disorders are subtle and are likely to be passed of risk of chronic lead poisoning which can be dangerous. Te subject consumes a large amount of food in a which becomes palpable as a big lump in the upper abdo- short amount of time followed by an attempt to rid himself men (trichobezoar), particularly after meals. Purging is attained by Te perverted appetite in such children is generally self-induced vomiting, taking a laxative or diuretic, fasting a manifestation of psychologic cause which should be and/or excessive exercise. Etiology: Tere is an extensive concern for body Treatment: In view of the common association weight. Many individuals with bulimia nervosa also between pica and worm infestation plus vitamin and have an additional psychiatric disorder. Psychotherapy (especially behavior modifcation) is of Family histories of alcohol and substance abuse, value in cases where pica is associated with psychosomatic mood and eating disorders may be present. Treatment: It revolves around psychotherapy along with antidepressant and antipsychotic agents. It is quite a common problem, Intense fear of gaining weight, causing anxiety to parents. A distorted perception of body weight and body image, Etiology: Factors contributing it include overindul- and gence by parents who may well be themselves fussy Amenorrhea in postmenarcheal girls. Teenagers with anorexia nervosa place a high value on Management: It revolves around such behavioral controlling their weight and shape, using extreme eforts strategies as: (restricting diet and indulgence in too much exercise) that z A pleasant, conducive atmosphere at main meal tend to signifcantly interfere with activities in their lives. Restrictive: The patient not only severely restricts z A pleasant presentation of foods the amount of food intake, but also controls calorie z Offering small to moderate serving at a time intake by vomiting after eating or by misusing z Avoiding eating energy foods in between main meals laxatives, diet aids, diuretics or enemas. They may z Parents and other family members setting exam- also try to lose weight by exercising excessively. Non-restrictive: The patient with anorexia binges ments about the food being served. Tis is the time to begin toilet training in Accompanying manifestations include anxiety, depres- the form of simple instructions given in a holistic manner. Frequently induced vomiting and abuse of diuretics In no case, parents should use force or pressurize him. For sev- 3 months for training though they are likely to need some erely malnourished subjects, nutritional rehabilitation, help for washing/cleansing body part up to 5 years of age preferably in a health facility, is essential. Te term, enuresis, denotes normal urinary bladder empty- z Chronological age is at least 5 years of age (or equivalent develop- mental level). A proportion of children Specifc types: Nocturnal (night-time) only, diurnal (day-time) only, nocturnal and diurnal. Types Diagnosis Four types are recognized based on day-time symptoms: Tis should include a detailed interview with the parents as 1. Type I: Monosymptomatic nocturnal enuresis well as the child to fnd the etiologic or, at least, associated 2. Clinical Features An X-ray of lumbosacral spine, ultrasonography, voiding Two clinical types are recognized—(1) primary (persistent) cystourethrogram and urodynamic studies are often and (2) secondary. In the primary (persistent) enuresis, the child has Treatment never been dry at night. It is usually the result of erratic bladder training either by parents who are overanxious A prompt treatment is essential or the child may continue for prompt control, or those who are not reasonably to have enuresis plus added emotional problems in ado- close to the child’s needs, or chronic psychological lescence. Treatment is, as a rule, not required before 6 stress not related to bladder training. Secondary (regressive) enuresis is characterized by If the underlying disease is detected it should be treated. In fact, they should offer special pat and Te causes of enuresis are: even reward on occasions when the child does not Psychologic enuresis may be a manifestation of family wet the bed. Parents need to spend at least half an hour In both types (primary and secondary), an organic of quality time with the child. Dysuria, Bladder-strengthening exercises: Tis includes emp- frequency, straining, dribbling, gait disturbances and poor tying the bladder before sleeping, drinking large quan- bowel control suggest an underlying organic cause. Using an electric alarm (buzzer) device: Te buzzer is (Infantile Syncope) designed in such a way that the child wakes up as soon Tis common situational disorder is characterized by the as he is about to wet the bed.

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Morphine and hydromorphone undergo conjugation with glucuronic acid to form discount 30 caps npxl visa, in the former case purchase npxl with paypal, morphine 3-glucuronide and morphine 6-glucuronide npxl 30 caps mastercard, and in the latter case, hydromorphone 3-glucuronide. Meperidine is N-demethylated to normeperidine, an active metabolite associ- ated with seizure activity, particularly after very large meperidine doses. The small volume of distribution (V ) d of alfentanil results in a short elimination half-life of 1. Remifentanil has an ester group that is hydro- lyzed by esterase hydrolysis, so its elimination half-life is less than 10 minutes with no cumulative effects even in prolonged infusions. Excretion: The end products of morphine and meperidine biotransformation are eliminated by the kidneys, with less than 10% undergoing biliary excretion. Morphine administration in patients with renal failure has been associated with prolonged narcosis and ventilatory depression. Renal dysfunction increases the chance of toxic effects from normeperidine accumulation. Drug interactions: Meperidine administered with monamine oxidase can result in hypertension, hypoten- sion, hyperpyrexia, coma, or respiratory arrest. Barbiturates, benzodiazepines, and other central nervous system depressants can have synergistic cardiovascular, respiratory, and sedative effects with opioids. The biotransformation of alfentanil after treatment with erythromycin may lead to prolonged sedation and respira- tory depression. All opioids stimulate the medullary chemoreceptor trigger zone to cause nausea and vomiting. Meperidine may induce seizures, especially in end-stage renal disease due to metabolite normeperidine. Cardiovascular effects: Meperidine increases heart rate; all others cause vagal-mediated bradycardia. Meperidine and morphine release histamine, which can cause profound hypotension; this is minimized by infusing opioids slowly or by pretreatment with histamine antagonists. Arterial blood pressure often falls as a result of bradycardia, venodilation, and decreased sympathetic reflexes. Intraoperative hypertension during opioid anesthesia may signal inadequate anesthetic depth. Gastrointestinal: Opioids slow gastrointestinal motility by binding to opioid receptors in the gut and reducing peristalsis, which can lead to severe constipation. Endocrine: Opioids block the secretion of catecholamines, antidiuretic hormone, and cortisol to surgical stimulation. For example, pentazocine is an antagonist at µ receptors, a partial agonist at κ receptors, and an agonist at σ receptors. The irreversible nature of its inhibition underlies the nearly 1-week duration of its clinical effects (e. Respiratory effects: Aspirin overdose has complex effects on acid–base balance and respiration. Acetaminophen abuse or overdosage is one of the most common causes of fulminant hepatic failure resulting in hepatic transplantation in Western societies. Each neuromuscular junction contains approximately 5 million of these receptors, but activation of only about 500,000 receptors is required for nor- mal muscle contraction. Neuromuscular blocking agents are divided into two classes: depolarizing and nondepolarizing. Most commonly they are used for tetany (a sustained stimulus of 50–100 Hz) and train-of-four (a series of four twitches in 2 s). Fade, a gradual diminution of evoked response during prolonged or repeated nerve stimulation, is indicative of a nondepolarizing block. Phase I depolarization block does not exhibit fade during tetanus or train-of-four, and it does not demon- strate posttetanic potentiation. Mechanism of termination of action: Diffuses from neuromuscular junction, metabolized by pseudocholin- esterase. Prolonged by: Hypothermia (slightly prolonged); reduced pseudocholinesterase levels as found in pregnancy, liver disease, renal failure (2–20 minutes); abnormal pseudocholinesterase enzyme (heterozygous for atypical pseudocholinesterase results in 20 to 30-minute block, homozygous for atypical pseudocholinesterase results in 4- to 5-hour block). Clinical note: Dibucaine inhibits normal pseudocholinesterase enzyme by 80% (the dibucaine number) and atypical pseudocholinesterase by 20%. Contraindications: Routine use of succinylcholine is relatively contraindicated in children because of the risk of hyperkalemia, rhabdomyolysis, and cardiac arrest from undiagnosed myopathies. Bradycardia occurs most frequently in children but can occur in adults after a second dose. Hyperkalemia: Normal muscle releases potassium with succinylcholine elevating the plasma potassium by 0. This can be life threatening with preexisting hyperkalemia or in patients who have suffered burn injury, massive trauma, or other conditions. Muscle pains are sometimes noted postoperatively after succinylcholine administration. Elevation of intracranial, intragastric, and intraocular pressures have been reported. Prolonged action (discussed on front side of card) Malignant hyperthermia can be triggered in susceptible patients by succinylcholine. Maintaining neuromuscular blockade can be done by administering intermittent boluses or by continuous infusion but should be guided by a nerve stimulator and clinical signs. Potentiation can occur by volatile anesthetics (10%–15% dose reduction) and by adding other nondepolariz- ing neuromuscular blockers (more than additive). Additionally, hypothermia, respiratory acidosis, hypoka- lemia, hypocalcemia, and hypermagnesemia can prolong a nondepolarizing block. In general, the diaphragm, jaw, larynx, and facial muscles (orbicularis oculi) respond to and recover from muscle relaxation sooner than the thumb. Side effects include histamine release and autonomic effects, depending on the drug. Renal excretion is significant in clearing doxacurium, pancuronium, vecuronium, and pipecuronium. Side effects: Histamine release (hypotension, tachycardia, bronchospasm), laudanosine toxicity (breakdown product of Hofmann elimination that can cause central nervous system excitation and is metabolized by liver), prolonged action (at abnormal pH and temperature). Cisatracurium (benzylisoquinoline; stereoisomer of atracurium) Metabolism and excretion: Same as atracurium. Side effects: Laudanosine toxicity (significantly lower levels than with atracurium), prolonged action (at abnormal pH and temperature). Vecuronium (steroidal) Metabolism and excretion: Excretion is primarily biliary and secondarily renal (25%); limited liver metabolism. Gantacurium (chlorofumarate) Metabolism and excretion: Cysteine adduction and ester hydrolysis. Nondepolarizing muscle relaxants: Neuromuscular transmission is blocked by nondepolarizing muscle relaxants that bind to postsynaptic nicotinic cholinergic receptors. Reversal of Nondepolarizing Muscle Relaxants Spontaneous reversal: Occurs with gradual diffusion, redistribution, metabolism, and excretion of nonde- polarizing muscle relaxants. Pharmacologic reversal: Occurs with the administration of specific reversal agents.

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The accuracy of the report was 58% when calculated manually from the paper version discount 30caps npxl overnight delivery, compared with 100% accuracy when electronically calculated buy npxl 30caps without a prescription. In addition purchase npxl without a prescription, the handheld electronic diary was preferred by 81% of patients over the paper diary with reasons given such as “saves time” and “easier to complete. However, it is recognized that a definitive study in order to test this electronic diary equivalence is required, particularly noting that younger people are more likely to adopt such approaches more readily than the elderly. An electronically based adaptation of a paper- based diary must be shown to produce data that are of at least equivalent or higher reliability. However, all parameters are extremely variable so actually defining what is considered “normal” presents challenges [23–25]. There is also considerable overlap in the range of what may be considered “normal limits” between asymptomatic patients and symptomatic patients [24,26,27]. For example, an older woman of 70 years old is likely to have a higher 426 frequency and smaller volume/void than a 20-year-old woman. In addition to this, independent of age, there is a positive relationship between maximum volume voided during the day (functional bladder capacity) and the total 24 hour volume. Here, a woman who voids a large amount over 24 hours is likely to have a higher frequency and larger volume per void than a woman of similar age who only voids a smaller amount over 24 hours. One hypothesis is that this may be an adaptation to keep the voiding frequency relatively constant by adjusting the bladder capacity to compensate for changes in fluid intake. Nevertheless, these relationships have implications for the clinical interpretation of bladder diaries. As might be expected, even after adjustment, the voiding frequency still increases with both age and voided volume over 24 hours. However, it is reported to reduce the variability of the frequency and functional bladder capacity by about 25% and 50%, respectively. This usually includes some assessment of the impact on the quality of life, as well as the perceived severity of symptoms as reported by the patient. A scoring scheme for each question provides some quantification of the severity of symptoms and may also be used to evaluate the effectiveness of any management strategy at a later stage [14,29]. Despite this, an audit by the Royal College of Physicians [5] found that over a quarter of acute care patients did not have their urinary symptoms recorded. An assessment of the impact of incontinence on the quality of life was recorded in only 69% of primary care and 25% of acute care patients. However, it is acknowledged that there is likely to be the potential for bias introduced by the interviewer [33] and the agreement between patients and clinicians regarding satisfaction with treatment outcomes is known to be poor [34]. There is also a direct relationship between patient satisfaction and the fulfillment of treatment expectations [35]. For this reason, the emphasis in current clinical practice is capturing the patients’ lived experience rather than from the clinicians’ perspective. It is important that the choice of questionnaire is appropriate to the intended use. Section 2 covers the variety of questionnaires that are available and provides some guidance as to the content covered by the available questionnaires in clinical use. The most recent research suggests optimum diary duration of 3 or 4 days in order to strike balance between capturing the necessary information and not placing any unnecessary burden upon the patient. Electronic diaries are showing promise but still require full psychometric evaluation. Normative values calculated from bladder diaries are extremely variable, but recent research has reduced this uncertainty by providing parameter-adjusted reference tables. Frequency-volume chart: The minimum number of days required to obtain reliable results. Urinary diaries: Evidence for the development and validation of diary content, format and duration. The standardisation of terminology of lower urinary tract function: Report from the Standardisation Sub-committee of the International Continence Society. Voiding diary for the evaluation of urinary incontinence and lower urinary tract symptoms: Prospective assessment of patient compliance and burden. A systematic review of the reliability of frequency-volume charts in urological research and its implications for the optimum chart duration. Developing and validating the International Consultation on Incontinence Questionnaire Bladder Diary. Development of two electronic bladder diaries: A patient and healthcare professionals pilot study. Parameters of bladder function in pre-, peri-, and postmenopausal continent women without detrusor overactivity. The 24-h frequency-volume chart in adults reporting no voiding complaints: Defining reference values and analysing variables. Bladder diary measurements in asymptomatic females: Functional bladder capacity, frequency and 24 hour volume. The frequency/volume chart as a differential diagnostic tool in female urinary incontinence. The role of the frequency-volume chart in the differential diagnostic of female urinary incontinence. Comparison of the Danish Prostatic Symptom Score with the International Prostatic Symptom Score, the Madsen-Iversen and Boyarsky symptom indexes. Patient-reported outcomes in overactive bladder: The influence of perception of condition and expectation for treatment benefit. Health Measurement Scales: A Practical Guide to Their Development and Use, 3rd ed. This was achieved using a pair of elongated electrodes embedded within the absorbent layer of a diaper, which contained dry electrolytes. Following urine loss, the moisture between electrodes resulted in a change in electrical conductivity that could be detected and recorded. The pad test as we know it today was originally simultaneously described by Sutherst et al. It consists of the use of a perineal pad to document urinary incontinence and quantify its severity quantitatively, under natural conditions. The amount of loss is calculated by subtracting the weight of the pad before the test from its weight after the end of the test. The temperature-sensitive device uses a diode temperature sensor imbedded in the outermost layer of a pad, which records a change in voltage across the diode when urine (warmer than the perineum) is lost. These two methods are devised to detect urine leakage during ambulatory urodynamic studies without the bulk of the Urilos but are unable to quantify loss. The clinical use of these devices has never been evaluated and their accuracy was disputed.

This distance is usually less in the area of the sternal notch sively to reach a maximum at the level of the hyoid bone discount npxl 30 caps mastercard. A good quan- and increases as we reach the level of the hyoid bone after which it tity of tissue should be incorporated in each bite to minimise the risk of reduces progressively up to the mental symphysis where it is solidly tearing the muscular fibres purchase npxl overnight delivery. On completion of the sutures some irregularities may be visible on stop the suture at approx buy npxl 30 caps line. We old patient with considerable quantities of skin excess in the anterior and consider corsetplasty as a very useful manoeuvre in many cases but we lateral neck, chin-subhyoid platysmal bands and loss of cervico- have to remember that it is based on a lateral to medial traction. After the corsetplasty, there is a marked improvement technique to be effective in remodelling the lateral contour of the man- in the neck. To include this structure, we have to penetrate to a as the muscle in this area is already sufficiently mobile for depth of approximately 1 cm in patients with an average this kind of traction. On the other hand, when we apply quantity of fat tissue; this depth can be varied according to vertical suspension then the muscle has to be mobilised the thickness of the preauricular tissue. In a patient with sig- extensively to optimise the movement of tissue volumes nificant adipose tissue, we will undoubtedly have to pene- from the inframandibular to a more cranial position. An 82-year-old patient with considerable skin excess, long traction of the muscle. This technique is particularly suited in cases of platysma bands, loss of mandibular angle and irregularities in the man- significant muscle and skin excess and mandibular-clavicular bands; it dibular contour. Obviously, in a thin face, the suture will be placed more quately mobilised the platysma, we place a suture on Lorè’s fascia. There is depth of the bite can vary according to the quantity of adipose tissue pres- little risk of lesion to the facial nerve if the suture is not placed too deep Fig. The suture should not only include fat but also effect of the sutures some of the muscular tissue. Given that the facial nerve is found at a depth greater a solid anchorage point without placing the sutures too an than 2 cm in a thin face and at a depth of even 3 cm in a fat excessive depth (Figs. After performing a certain number of operations, we decided After tying the sutures, excess tissue (muscle-adipose- to proceed without dissecting the fascia as this same manoeu- aponeurotic) in the infraauricular region creates a bulge in vre could, in some way, damage or weaken this structure. If a certain quantity of excess not search for this structure but just ensure to fix the suture to a dipose tissue is still visible despite this manoeuvre, then 946 M. A second suture similar to the pre- bulge in the infraauricular area and to reinforce the overall stability of vious is added to ensure greater stability to this anchorage. The lower the fixation part of the flap is sutured to the mastoid fascia to avoid any unpleasant this can be “thinned” by diathermic cautery or excised by When the mastoid area is used for anchorage many scissors, paying attention not to cut the previously placed patients report painful sensation for a few weeks; oppositely, sutures. We can add a third central area of suspension which can parameters are not met then we can frequently witness a pre- also play an important role in the definition of the neck and cocious recurrence of the laxity in the cervical area. The presence of any irregular- is the reason why if we want to pull the platysma in a vertical ity in the contour could jeopardise the final results, especially vector in the anterior facial area we have to apply this trac- in thin-skinned patients. Surgical Treatment of Ageing in the Neck 947 We believe that the action of the platysma is not limited to The deep fat reaches its maximum thickness at the mid- the neck only but is also present in the face. Its continual line and thins out as it extends laterally to cover the subman- contraction creates a downward pull on the tissue in the sub- dibular gland. This, together with the effect of gravity and the Obviously, there are differences both in volume and dis- other factors involved in the ageing process, tends to dislo- tribution between thin and fat faces. In fat faces, the deep cate the tissue of the lower third of the face in a caudal direc- adipose tissue can extend beyond the lateral borders of the tion. This phenomenon is usually counteracted by applying platysma, whereas usually in thin faces the fat extends plication or imbrication techniques or in specific cases, by laterally no further than 2 cm from the midline. A good solution to the anterior bellies of the digastric muscles and is also called interrupt this continuity and obviate the downward pull of the “intradigastric fat”. In other cases, the superficial and the deep fat layers are in contact, but separated by a thin lamina of connective tissue in the entire area where the two 5 The Deep Adipose Tissue muscles run separately. Each individual had a different fat distribution between Going from the surface to the depth of the neck, the fourth the two compartments; a fat neck is characterised by accu- layer is constituted by the deep adipose tissue. Underlying mulations of fat in both compartments, normally with preva- the platysma in the anterior region of the neck is a fat layer lence in one or the other. Many surgeons important to distinguish between the superficial and deep fat, refer to the term “interplatysmal” which, in our opinion and both from a diagnostic and therapeutic point of view. For example, in the case of low decussation of the platysma, the greater part of this fat is • A static visual examination: the deep fat is localised and found in a sub- and not in an interplatysmal plane. Superficial fat is usually more ated either beneath the mandible or superior to the digastric diffuse and often shows irregularities in its thickness, muscle and so it is imprecise to define this as being “interpla- especially in the vicinity of the hyoid bone. The deep fat is very similar to lipomatose tissue, • Palpation: the deep fat is decidedly less mobile than the even if it is never encapsulated as happens in a mature superficial fat. When examining the face, it is important to evaluate the • D ynamic examination: the subplatysmal fat moves visi- quantity of the adipose tissue and its localisation in the neck bly when swallowing whereas superficial fat does not. The thickness of the superficial more visible whereas the deep fat, located under the pla- fat can vary from a few millimetres to three centimetres or tysma, becomes less visible. This last manoeuvre is more more; its distribution in the various sectors of the face is effective in patients with a low decussating platysma. Contrarily, both the localisation and the but the thickness of each of them may vary. In a neck with quantity of subplatysmal fat layer vary less and similarly to considerable quantities of superficial fat, it not always easy the buccal fat pad (or Bichat’s fat pad); it remains fairly stable to quantify the presence of deep fat; in these cases, the defin- in time and is influenced marginally by any weight change. Ceravolo • Closed liposuction is often performed to avoid undermining the anterior neck region. The surgeon, in order to obtain a good cervico-mandibular angle, may voluntarily or involun- tarily deepen the cannula to remove deep fat without associ- ating any further treatment of the platysma. In these cases, and particularly so in the case of a high decussating pla- tysma, there is a risk of creating a midline depression. We use scissors or termocautery to dissect and remove, step by step and conservatively the adipose mass which is generally in the form of a triangle. The first is lateral to medial applied via an anterior removed progressively, evaluating step by step the results to plication at the midline; the second is medial to lateral applied via avoid an overly-aggressive lipectomy. An aggressive removal of this portion of fat could create a clear cut depres- sion which may have to be treated through a plication of the In treating this type of inaesthetism, the key element is to digastric muscles. After removing the fat from the suprahyoid preserve an adequate layer of subdermal superficial fat. We frequently In practice, in the case of considerable excess fat in the encounter some bulges below the lower end of the plication anterior neck, we prefer to perform a moderate, closed lipo- which is due to the presence of fat of the middle lower neck suction followed by a subplatysmal lipectomy under direct region. Contrarily, any irregularity caused by excessive removal The thinner the cutis, the thicker the adipose layer which should of deep fat is less visible and normally easier to treat by tak- be conserved. We believe that a deep lipectomy should never be ing advantage of the overlying layers. This is due to the • It is technically difficult to assess whether the cannula is fact that the platysma is open at the midline. This is a tempo- removing fat from the deep layer or from the superficial rary phenomenon and normally disappears when the anterior one and we may easily risk to carry out an inappropriate plication of the platysma is completed. The overzealous removal of superficial or deep fat should • The deep fat layer is more vascularised than the superfi- always be avoided.

F. Kor-Shach. Christendom College.

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