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Fasciculoventricular bypass tract (no reentrant tachycardias) Electrophysiologic Manifestations Electrocardiographic and electrophysiologic characteristics of decrementally conducting bypass tracts depend on the sites of insertion: either the atrium or the A-V node and the site of insertion in the ventricle erectile dysfunction doctor san jose generic super viagra 160 mg with visa. Those pathways that arise in the atrium more closely resemble a typical A-V bypass tract erectile dysfunction 21 years old super viagra 160 mg on-line. Both atriofascicular and slowly conducting atrioventricular pathways demonstrate greater preexcitation when atrial stimulation is performed closer to the bypass tract erectile dysfunction operations super viagra 160 mg purchase fast delivery, whereas the degree of preexcitation observed over bypass tracts that arise from the A-V node is not influenced by the site of atrial stimulation erectile dysfunction prevalence purchase discount super viagra online. The conduction velocity down the bypass tract is an additional critical determinant of the degree of preexcitation erectile dysfunction medication names safe 160 mg super viagra. If the conduction time over the bypass tract to the ventricle (by whatever route) approximates that of the normal conduction system, little or no preexcitation may be present in the basal state (Fig. Any perturbation – such as changing autonomic tone, or electrical or pharmacologic maneuvers that prolong conduction to the ventricles over the normal A-V normal conducting system (primarily the A-V node) to a greater degree than in the slowly conducting accessory pathway – will increase the degree of preexcitation. Since all of these accessory pathways exhibit decremental conduction, the P-delta (or P-R) will increase in response to atrial pacing. During sinus rhythm (left), the degree of preexcitation depends on the relative conduction time down the decrementally conducting bypass tract and conduction time down the normal conducting system below the “takeoff” of the bypass tract. The increase in P-delta interval is due to conduction delay above the site of the takeoff. Electrophysiologic studies are critical to document the presence and type of these slowly conducting accessory pathways and their participation in clinical arrhythmias. The H-V interval may be normal or decreased, depending on whether any evidence of preexcitation exists. Normalization of the H-V by His bundle pacing proves that the takeoff is from the node or the atrium and excludes a fasciculoventricular pathway (see below). Electrophysiologic studies have demonstrated that the vast majority (probably greater than 90%) of these decrementally conducting accessory pathways are atriofascicular or long atrioventricular pathways. Slowly conducting short atrioventricular pathways are a distant second with pathways arising in the A-V node being least common. Sites of 34 atriofascicular or long atrioventricular and 9 short atrioventricular pathways that I have studied are shown in Figure 10-110. Atriofascicular and Long Atrioventricular Bypass Tracts As shown in Figure 10-113, atriofascicular and/or long atrioventricular pathways have their atrial insertion at the 22 48 49 149 150 free wall of the right atrium. In the baseline state minimal or no preexcitation may be present; thus, the H-V interval may be normal (∼60%) or short. The A-H interval will show a greater degree of prolongation than the A-V interval regardless of the morphology. The fixed V-H interval, despite shorter atrial paced cycle lengths and/or coupling intervals (Fig. In my opinion, whenever the V-H is <20 msec insertion into the right bundle branch is likely. Long atrioventricular bypass tracts inserting 20 near the right bundle branch have been described by Haissaguerre et al. In my experience and that of others, most of these 18 20 21 22 48 49 149 150 153 long fibers are consistent with slowly conducting atriofascicular tracts. Decrementally conducting atriofascicular and long atrioventricular pathways are located along the anterior and lateral free wall of the right ventricle (solid line, 35 patients). Short atrioventricular pathways are more variably located (dots, 12 at the right free wall and 3 at a left lateral site). The first is a normal sinus complex with no evidence of conduction over the atriofascicular tract. In the third and fourth complexes, conduction over the atriofascicular tract is present, and there is a reversal of activation sequences, with the right bundle potential occurring before the His bundle potential. This suggests that the atriofascicular bypass tract inserts into the right bundle branch and conducts retrogradely to the His bundle. Careful mapping of the tricuspid annulus and the anterior free wall of the right ventricle has demonstrated discrete potentials with complexes comparable to those recorded P. It is recorded as a single long structure, analogous to the right bundle branch, which in most cases appears to join the distal right bundle branch at the insertion of the moderator band at the apical third of the free wall (Fig. In essence, it functions as an auxiliary conducting system in parallel to the normal conduction system. During preexcitation propagation is traced anterogradely over the accessory pathway and retrogradely up the right bundle branch to the His bundle to give rise to the short V-H interval (Fig. In this instance, the His bundle is activated prior to the proximal right bundle branch, with anterograde conduction down the right bundle branch to the site of block. This is the mechanism of long and short V-H tachycardias (see subsequent discussion). The onset of ventricular activation always occurs at the apical third of the right ventricular free wall regardless of the route of retrograde activation. Atrial pacing at a cycle length of 800 msec produces the progressive development of preexcitation over an atriofascicular bypass tract. A fixed A-H with a short, retrograde V-H during atrial pacing is characteristic of an atriofascicular bypass tract. A and B: Atrial pacing at a drive cycle length of 500 msec is shown with progressively premature atrial extrastimuli. The increasing P-R interval with a fixed V-H and a constant degree of preexcitation provides supporting evidence of a decrementally conducting bypass tract that inserts in the right bundle branch. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Three panels show the effect of atrial pacing at cycle lengths of 600, 370, and 340 msec. Absence of the H when anterograde block in the atriofascicular pathway occurs confirms that the H is dependent on conduction through the atriofascicular pathway; i. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Supraventricular tachycardia with anterograde conduction over an atriofascicular pathway and retrograde conduction over the A-V node is present for the first four complexes. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Dual A-V nodal pathways are more readily appreciated using ventricular stimulation. During rapid ventricular pacing and ventricular extrastimuli, the retrograde conduction time is usually fast, compatible with conduction over a fast A-V nodal pathway. Initiation of tachyarrhythmias by ventricular stimulation (which we have observed in 85% of our patients) is virtually always associated with conduction up a relatively fast retrograde pathway followed by conduction down an antegrade slow pathway that is associated with preexcitation. The anterograde slow pathway can either be the accessory pathway or the slow A-V nodal pathway, in which case the accessory pathway acts as an innocent bystander during typical A-V nodal reentry. We have documented dual A-V nodal pathways (described in more detail later) in the majority of patients with atriofascicular pathways. In my opinion, the sudden appearance of preexcitation associated with a “jump” from fast to slow A-V nodal pathways with a His inscribed before ventricular activation or with a V-H ≤−10 msec (i. While one cannot exclude a slowly conducting atriofascicular tract that becomes manifest with a jump to the slow A-V nodal pathway, a consistent pattern of dual-pathway dependence and an “H-V” relationship too short to be retrograde from the distal right bundle branch would be fortuitous. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Analysis of the retrograde atrial activation sequence and response to programmed stimulation during the tachycardia usually are sufficient to document the presence of an additional A-V bypass tract, as described earlier (see Chapter 8). Each sinus beat on the right hand part of the tracing conducts over a fast and slow atriofascicular pathway to give rise to a 1 to 2 tachycardia. Short Slowly Conducting Atrioventricular Bypass Tracts These bypass tracts are less common than the atriofascicular or long atrioventricular pathways. They are analogous to decrementally conducting concealed bypass tracts (see Chapter 8) anatomically in that they bridge 48 the A-V rings. As with other anterogradely decremental pathways, retrograde conduction is not seen. The amount of preexcitation is related to the relative conduction times over the A-V node and bypass tract. Retrograde conduction to the His bundle is only seen during antidromic tachycardias or following A-V block. Although these pathways demonstrate decremental conduction and Wenckebach-type block in response to rapid atrial pacing (Fig. Nodofascicular and Nodoventricular Bypass Tracts Bypass tracts that originate in the A-V node are rare. Their presence is suggested if antidromic tachycardia is present with A-V dissociation. During atrial pacing at 600 msec the stimulus to delta is 195 msec, demonstrating slow conduction over this right free wall accessory pathway. The absence of changes in preexcitation suggests marked A-V nodal conduction delay or block at baseline. Tachycardias Associated with Atriofascicular, Slowly Conducting A-V, Nodofascicular, and Nodoventricular Bypass Tracts Virtually all patients with nodofascicular, decrementally conducting atriofascicular or A-V tracts, or true nodoventricular bypass tracts present with arrhythmias. The role of the nodofascicular or nodoventricular fiber in initiating and maintaining the tachycardia requires detailed study, because the fibers can act as innocent bystanders during A-V nodal reentry or an obligatory component 15 18 19 87 155 156 157 158 (antegrade limb of a macro-reentrant circuit). During ventricular stimulation, if rapid and fixed V-A conduction is present, one must always exclude the presence of a separate A-V bypass tract. Analysis of the retrograde atrial activation sequence and response to programmed atrial and ventricular stimulation during the tachycardia usually is sufficient to document the presence of an additional A-V bypass tract, as described earlier. Tachycardias associated with atriofascicular and nodofascicular or nodoventricular or slowly conducting A-V bypass tracts can be divided into those with short and long V-H intervals. The types of arrhythmias theoretically possible with nodofascicular and nodoventricular pathways are schematically shown in Figure 10-129. Short V-H tachycardias may be due to A-V nodal reentry or use of an atriofascicular or nodofascicular bypass tract inserting into the right bundle branch. The difference in the retrograde activation patterns between short and long V-H tachycardias is shown in Figure 10-130. There is no a priori reason why an individual cannot have more than one of these mechanisms operative. In all of our patients with short V-H tachycardias, we have documented dual A-V nodal pathways antegradely or retrogradely. This has led some investigators to consider all short V-H tachycardias as being due to A-V nodal 150 reentry, with the atrio- or nodofascicular or long atrioventricular bypass tract acting as an innocent bystander. Although dual A-V nodal pathways have been present in almost all such patients whom we have studied, the clinical rhythms have been due to both A-V nodal reentry incorporating an innocent bystander atrio- or nodofascicular or long atrioventricular bypass tract and reentry using one of these bypass tracts as the antegrade P. These mechanisms can be very difficult to distinguish, and both may be present in individual patients. In patients with A-V nodal reentry, induction by atrial extrastimuli is always associated with a dual-pathway response, which may not be seen if the impulse traverses the atrio- or nodofascicular or long atrioventricular bypass tract antegradely and captures the His bundle retrogradely before it is antegradely activated by the impulse traversing the slow pathway. This is analogous to 1:2 conduction initiating preexcited tachycardias over an A-V bypass tract (see Fig. In this instance, the first complex and all subsequent complexes are due to conduction over an atriofascicular or long atrioventricular bypass tract such that the impulse reaches the ventricle before the same impulse reaches the His bundle over the slow pathway. This results in ventricular activation over the bypass tract and atrial activation as a result of an A-V nodal echo. The process repeats, and sustained A-V nodal reentry is associated with a maximally preexcited tachycardia with a left bundle configuration. This mechanism is similar to that described previously in this chapter, with 1:2 conduction initiating orthodromic tachycardia or, more analogously, antidromic tachycardia. Anterograde conduction down the atriofascicular pathway is shorter due to the longer cycle length of the tachycardia. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. As demonstrated by the case shown in Figure 10- 29, A-V nodal reentry can be associated with a “long V-H” or a “short V-H” tachycardia. No fusion is seen during the long V-H tachycardia, because the ventricles will be refractory to any activation over the normal pathway. Initiation by ventricular extrastimuli more readily affords one the opportunity to assess whether or not the decrementally conducting bypass tract is an innocent bystander. The rapid V-A conduction over the His–Purkinje with turnaround down the slow pathway documents the presence of dual pathways. The question arises whether the nodofascicular bypass tract is an innocent bystander or is participating in the tachycardia. One of the important methods used to distinguish the two is by comparing the H- A interval during initiation of the tachycardia by ventricular extrastimuli or during ventricular pacing with the H-A interval during the tachycardia. If an atriofascicular, nodofascicular, or decremental atrioventricular bypass tract were used as the anterograde limb of the circuit, the H-A interval during ventricular pacing or the ventricular extrastimulus initiating it (particularly at comparable coupling intervals as the cycle length of the tachycardia) should have the same H-A interval as that observed during the tachycardia. If the V-H interval during the tachycardia is significantly less than the H-V interval (i. Thus, in my opinion, a true nodoventricular or slowly conducting short atrioventricular fiber can never be obligatorily involved in a short V-H tachycardia. Atrial or ventricular extrastimuli can sometimes reveal that a short V-H tachycardia is due to A-V nodal reentry. The presence of a short V-H tachycardia in such instances should suggest A-V nodal reentry with an innocent bystander bypass tract. The impulse turns around in the A-V node and conducts antegradely down the slow pathway from which the nodofascicular bypass tract takes off to excite the ventricles. At this time, perpetuation of the tachycardia is seen with retrograde conduction over the fast pathway and antegrade conduction over the slow pathway. On cessation of pacing, in the middle of the panel, the return cycle is also 300 msec, with the V-H remaining fixed and short. The ability to entrain the tachycardia with a fixed V-H interval during pacing that is identical to that during the first unpaced tachycardia supports the diagnosis of an atriofascicular bypass tract participating in the circuit. Tachycardias due to atriofascicular bypass tracts may be very difficult to distinguish from those due to nodofascicular bypass tracts. While V-A block or V-A dissociation excludes the participation of a slowly 18 155 156 157 158 conducting atriofascicular bypass tract, this is a rare finding.

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To date erectile dysfunction doctor in atlanta buy cheap super viagra 160 mg, the only woman who has ever claimed traumatic memories associated with labial elongation in my experience has been one chronically ill erectile dysfunction pump on nhs super viagra 160 mg on-line, illegal immigrant undergoing medical evaluation pursuant to an asylum seeking application to the U erectile dysfunction treatment in bangladesh 160 mg super viagra purchase with amex. Sylvia Tamale erectile dysfunction on molly super viagra 160 mg line, feminist erectile dysfunction pills images discount super viagra 160 mg with mastercard, human rights activist, and law professor in Uganda, who argues that elongation enhances female sexual pleasure and is not a human rights violation. Tamale published Eroticism, Sensuality, and “Women’s Secrets” among the Baganda: A Critical Analysis [37]. Western researchers lent further academic credibility to the female empowerment and reported benefits of labial elongation in a 2008 peer-reviewed community survey of Rwandan women [38]. Waxing of pubic hair and Internet access to genital images appear to have contributed to the rise in numbers of women in industrialized nations seeking modification of their own genitalia to match what they subsequently believe to be “normal” [39]. Grassroots movement to address this genital conundrum exist in online galleries of vulvar images such ® as “The Labia Library”; Kotex online platform for teens that reinforces “Well, there is no ‘normal’ looking vagina; just like your face is different to almost everyone in the world so is your vagina”; and the U. Regardless of the wide range of normal genital anatomy, women continue to seek modification. Physicians addressing such concerns have no meaningful resources in standard medical texts with which to create a reference point for the patient, and for themselves, as most anatomy illustrations of genitalia offer just one morphological image, lacking any acknowledgment or illustration of the wide 1713 variations in normal genital architecture [43]. What data exist on genital morphology variability show that normal clitoral size, labial measurements, vaginal, perineal, and clitoral–urethra length vary widely, with no association to age, parity, ethnicity, hormone, or sexual activity status [44]. In addition to cosmetic appearance and body image concerns, client/patient motivations also include chafing, interference with sexual and sporting activities, discomfort in clothing, and improvement in sexual friction and sexual satisfaction. In one recent cohort study, 1/3 of women seeking labiaplasty reported being teased about the appearance of their genitals compared to 3% in the control group. The labiaplasty group did not have higher rates of childhood abuse nor any difference on validated measurements of disgust or general appearance compared to controls not seeking labiaplasty [46]. They did not rate higher for anxiety or depression but were more likely to report poor sexual and body image satisfaction and to demonstrate avoidance behaviors regarding these concerns [47]. In a recent prospective comparative trial of women undergoing labiaplasty compared to controls, 91% showed postoperative improvement in long-term follow-up of 11–42 months, and four meeting preoperative criteria for body dysmorphic disorder related to their labia no longer met criteria for this diagnosis post-op (although one did continue to meet criteria, but for her nose, as her vulvar dysmorphia was ameliorated by the labiaplasty operation) [48]. Among peripubertal girls, motivation for labiaplasty is often related to marked asymmetry of the labia minora, anatomic comparison to other girls, normal genital changes associated with puberty, and images on the Internet and in anatomy books [49]. Technical skill is of paramount importance but having an artist’s eye is of equal value” [50]. Others literally own websites containing the phrases “labiaplasty revision” and “botched labia” in the website domain names, which contain web pages titled “Labiaplasties gone wrong” and “Labiaplasty nightmares,” an unprecedented predatory medical marketing phenomenon [51–53]. Labiaplasty While labiaplasty is most notorious for associated cosmetic goals, many teen and adult women seeking the operation do so for function reasons, particularly if there is catching and pinching of labia during vigorous sporting activities and/or if there is marked asymmetry of the labia minora, or robust, redundant or hypertrophied labia minora that distort body contour in tight clothing or beachwear [4,44,45,54]. The most commonly illustrated of these are anterior and posterior colporrhaphy and perineorrhaphy. Women undergoing anterior and posterior compartment repairs undergone for vaginoplasty to rejuvenate the vagina report 90%–100% satisfaction rates, with 0%–4% regret, and a low rate of complications including wound dehiscence, dyspareunia, rectoperineal fistula, post-op bleeding, and surgical site infection [54]. Hymen Restoration Hymenoplasty involves careful reconnection of the hymen remnants to recreate a pseudo-virginal state, most commonly requested by women from cultures that place high social significance on virginity and gaining popularity in Europe and the United States from women seeking virginity certificates or hymen restoration surgery [55]. This procedure is under scrutiny due to the inherent cross-cultural and socioethical issues involved. Domestic violence was found with high prevalence in 1 Swiss study of 80 women seeking “revirgination. A second Swiss survey of 100 public hospitals addressed this issue present in Switzerland’s immigrant communities, most frequently Turkey and Arab nations. Most of the clinics responding revealed that they usually or always provide revirgination hymenoplasty to immigrant women [57]. Another crosssectional survey of Lebanese university students revealed that physical harm and death are considered strongest justification for undergoing hymen restoration, although the majority of students did not endorse revirgination on ethical grounds of honesty between married couples, with no difference in this opinion related to the participants’ gender or religious background [58]. A Swedish survey of clinicians showed that while a majority of clinicians would provide virginity certificates or hymen reconstruction to young women undergoing honor-related threat, the remainder have engaged the international zero tolerance policy toward such requests [59]. One Indian website offers a revirgination that guarantees bleeding at first coitus by including prerequisite vaginal tightening, because with hymen reconstruction only “… most patients do not bleed and their husbands complained that vagina was loose. One should go for vaginal tightening of muscles (in addition to hymenoplasty)” [60]. A 2010 British Broadcasting Company article investigated hymen reconstruction services available in Paris, performed most often for Arab immigrant women facing ostracism, death, or suicide as the price paid for entering marriage without intact virgin status. The profiled French physician, who performs two to three hymen restorations per week, states “I believe we as doctors have no right to decide for her or judge her” [61]. In the United States, revirgination motives include a desire to improve one’s sex life and “the ultimate wedding anniversary gift” for clients’ husbands. In one online article, a woman from New York City explains “If a woman isn’t a virgin when she gets married, a man can always put her down for that” [62]. Containing a red dye, it further promises the appearance of virginal blood on the sheets, “… not too much but just the right amount. Labia The goal is to preserve/create symmetry while reducing dependent labial length. Wedge technique involve both central (pie slice) and posterior (anterior edge sewn to incised perineal surface) options [54]. Deepithelialization labiaplasty: The skin overlying the majora is excised in an elliptical dissection, without removing underlying fibromuscular or fat pad structures. The skin edges are reapproximated vertically to achieve smoother labia majora skin, less dependent bulk when standing, and increased dermal turgor [65]. Labial augmentation with injectable filler: Cosmetic fillers include autologous fat and 1718 synthetics, including hydroxyapatite, polyacrylamide gel, hyaluronic acid, and bovine collagen. Similar to oral labial bulking through injected filler material, cosmetic surgeons now offer injection of filler to restore a youthful fullness and turgor to wrinkled, deflated labia majora. Marketing claims include statements such as “Sagging labia majora can impact your confidence and hinder your sense of youthfulness. Cosmetic fillers may be complicated by injection site bruising, temporary swelling, uneven lumpiness of injected material, bacterial wound infection with symptomatic lesions at 5 years (most commonly due to Staphylococcus epidermidis and Propionibacterium acnes), migratory nodules, granulation, and chronic inflammation [66–68]. Technique details in published interviews in the lay-press disclose that the laser is used to make all incisions and that recovery takes 4–6 weeks [70]. The marketing language emphasizes restoration of coital friction to improve both female and male sexual satisfaction. Descriptions state that incisions are made with the laser with recuperation lasting 4–6 weeks. The founder’s research data of “… a pilot study (in ® which) 87% of women surveyed after receiving the G-shot reported enhanced sexual arousal/gratification” cannot be verified on literature search of peer-reviewed journals [75]. The existence and function of the G-spot as an anatomic entity continues to spur debate since first described by Grafenberg in 1950. In a 2004 study of genital and sexual function in women, the anterior vaginal wall was not described as an area of erogenous stimulation, though other vaginal parameters, such as depth, did correlate to sexual sensitivity and orgasm intensity [73]. The O-shot website contains further claims of cure of coincident urinary incontinence. Is a Canadian woman with a facelift and breast augmentation (both considered unacceptable and absurd in most developing nations) who requests a “Barbie labiaplasty” under any less disturbing social influences than a Masai woman undergoing ritual genital cutting? Do either one require international monitoring of their genital management issues? Is traditional genital cutting always traumatic, mutilating, and utterly without personal reward? Is the marketing of standard colporrhaphy techniques as “vaginal rejuvenation” a semantic trick to increase financial yield, or is it a new framework within which women opt to forego the geriatric “prolapse” label for the more youthful concept of “rejuvenation” instead? Perhaps the answer lies in labial elongation, the only do-it-yourself option with enticing alleged benefits and minimal apparent risk. Ottawa: Society of Obstetricians and Gynaecologists of Canada; 2013 December [cited June 2, 2014]. Genital beautification: A concept that offers more than reduction of the labia minora. Is elective vulvar plastic surgery ever warranted, and what screening should be conducted preoperatively? London: Rwandan women view the elongation of their labia as positive; February 15, 2008 [cited July 2, 2014]. Female genital cutting/mutilation in Africa deserves special concern: An overview. Personal communications with colleagues and patients, Somaliland (Edna Adan Ismael multiple conversations 2012– 2015), Rwanda (colleagues who prefer to remain anonymous 2013–2014), Ethiopia (Dr. Mulu Muleta, Gondar University, multiple conversations 2012), Senegal (Professor Serigne Magueye, L’Hopital de Grand Yoff, Dakar multiple conversations 2011–2015). The effectiveness of community-based program on abandoning female genital mutilation/cutting in Senegal. Government working together for the abandonment of female genital mutilation/cutting. The term female genital mutilation violates the rights of Bondo/Sande women and girls in Sierra Leone [Internet]. Freetown: This Is Sierra Leone; March 2014 [cited July 3, 2014] Available from: http://www. Kampala: Observer; June 16, 2010 [cited June 25, 2014] Available from: http://www. Kampala: Eimieeza Lobby Live Lets Talk Uganda; May 21, 2012 [cited June 25, 2014] Available from: http://www. Capetown: Africa Gender Institute, University of Cape Town, Feminist Africa Web; issue 5, 2005; cited [June 25, 2014] Available from: http://agi. Rwandan female genital modification: Elongation of the labia minora and the use of local botanical species. A comparison of risk factors for women seeking labiaplasty compared to those not seeking labiaplasty. Laguna Beach: Alinson Institute for Aesthetic Vulvovaginal Surgery; [cited July 3, 2014] Available from: http://urogyn. Beverly Hills: Labiaplasty Revision Surgeon; [cited June 28, 2014] Available from: www. Atlanta: Laser Vaginal Rejuvenation Atlanta; [cited July 5, 2013] Available from: http://www. Honour-related threats and human rights: A qualitative study of Swedish healthcare providers’ attitudes towards young women requesting a virginity certificate or hymen reconstruction. Backgrounds of women applying for hymen reconstruction, the effects of counseling on myths and misunderstandings about virginity, and the results of hymen reconstruction. Restoration of virginity: Women’s demand and health care providers’ response in Switzerland. Crosssectional study of Swedish physicians’ attitudes towards young females requesting virginity certificates or hymen restoration. Delhi, Bangalore, Mumba: Hymenoplasty; [cited July 3, 2014] Available from http://hymenoplasty. Bacterial infection as a likely cause of adverse reaction to polyacrylamide hydrogel fillers in cosmetic surgery. Woodland Hills: MakeHeal November 25, 2009 [cited June 25, 2014] Available from: http://news. Self-assessment of genital anatomy, sexual sensitivity and function in women: Implications for genitoplasty. A randomized, double-blind, placebo and active-controlled, half-head study to evaluate the effects of platelet-rich plasma on alopecia areata. Increased survival of human free fat grafts with variable densities of human adipose-derived stem cells and platelet rich plasma. Depressed facial scars successfully treated with autologous platelet rich plasma and light- emitting diode phototherapy at 830 nm. However, controversy and debate over the subject remain the most discussed issue in this area, not the in-depth surgical techniques. The line between cosmetic and medically indicated surgical procedures is a gray area, and procedures are performed for both purposes. In the current chapter, we will review the background and history of these procedures, the available data to support them, and the techniques and complications of these procedures. Finally, we will also attempt to shed light on what is myth and what is science in this relatively new field of elective genital vaginal surgery for sexual function and cosmesis of the female vagina and vulva. The current chapter is divided into two sections, the first covering vaginal rejuvenation procedures and the second covering external vaginal/vulvar cosmetic surgery. Many use the term “vaginal rejuvenation” to encompass all elective vaginal/vulvar surgery; however, we feel that it should be used only to refer to functional procedures of the internal vaginal canal and introitus that are designed to enhance sexual function, which includes ensuring adequate support of the pelvic floor and then internal vaginal canal repairs and repair of the introitus. Similarly, cosmetic vaginal surgery to many just means labiaplasty or labial minora reduction; however, one will see in the second section of the chapter that it is much more comprehensive than this. Therefore, we have defined “cosmetic vaginal/vulvar surgery” as cosmetic or aesthetic procedures of the outside of the vagina and/or vulva, including labiaplasty, labia minora reduction, excess or redundant clitoral prepuce reduction, labia majora reduction or augmentation, labia majora divergence repair, perineal skin reduction, and mons pubis reduction. In most instances, to achieve the outcome desired by the woman, a combination of these external cosmetic procedures needs to be done, truly bringing in the “art” of aesthetic surgery. The purpose of these procedures is not to correct pelvic floor defects, but they are modifications of traditional colporrhaphy designed to repair the damage from childbirth and are frequently performed concomitantly with reconstructive procedures for pelvic organ prolapse. These procedures involve vaginal reconstructive techniques to anatomically modify the vaginal caliber by decreasing the diameter of the vaginal canal while reconstructing the perineal body and the vaginal introitus in an attempt to enhance sexual gratification for the woman [2–4]. However, the implication of this definition is to actually give credence to women’s complaints of altered sexual function secondary to vaginal relaxation/looseness (Figure 116. Many women who are candidates for vaginal rejuvenation have symptoms and clinical findings of prolapse. Therefore, a proper repair must involve restoring the foundation of pelvic floor support and encompass some of the newer concepts of vaginal rejuvenation in the repair. Prolapse and vaginal relaxation occurring after vaginal childbirth is not a new concept. We have clear evidence that vaginal delivery increases the risk of vaginal support problems, vaginal relaxation, prolapse, and incontinence.

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After 3 months of treatment erectile dysfunction support groups purchase generic super viagra on line, participants were fitted and treated with the other type of pessary erectile dysfunction 20 order super viagra online from canada. The primary outcome was change in prolapse symptoms erectile dysfunction cream super viagra 160 mg buy without a prescription, assessed using validated questionnaires where to buy erectile dysfunction pump generic super viagra 160 mg online. The percentage of participants who successfully fit with at least one pessary is 92% erectile dysfunction statistics cdc cheap super viagra 160 mg buy on-line, and 60% continued the pessary therapy for 3 months (there were no differences seen between pessary types). About 75% of patients were successfully fit with a pessary, and 43%– 56% continued use through 4–12 months follow-up [10,11,13,14]. In one study, prolapse symptom improvement (assessed using a validated questionnaire) best predicted pessary continuation [11]. All three studies found overall improved prolapse and urinary symptoms after pessary treatment. However, among women without urinary symptoms at baseline, 21% developed new stress incontinence symptoms, which was associated with treatment dissatisfaction. Of 246 patients who chose pessary treatment, 187 retained the pessary at the 4 weeks follow-up visit and were entered into follow-up. Finally, two recent observational studies provide some information about treatment outcomes in patients choosing pessary treatment compared to surgery. The majority of pessary users wore ring pessaries (83%), and 95% of the prolapse surgeries were vaginal-approach native tissue repairs. At 1-year follow-up, both groups had significant improvements in prolapse, urinary, bowel, and sexual symptoms. The extent of symptom improvement was similar in the pessary and surgery groups when controlled for age. However, the study had significant loss to follow- up (32% of the pessary group and 45% of the surgery group). This loss to follow-up and the observational study design limit the impact of these results. Bottom row: (left) Marland; (middle) donut; (right) cube (All three by courtesy of Milex, Inc. Both patient groups had similar characteristics at baseline, and both treatment groups improved 3 months after treatment. The development of new stress incontinence occurs in a minority of patients, but it is associated with pessary discontinuation. Most women interested in pessary treatment can be successfully fitted with a pessary, and 40%–60% will continue its use for greater than 6–12 months. More studies are needed to compare outcomes after pessary treatment versus surgery before conclusions can be reached regarding comparative effectiveness. Pessary Fitting Rates of successful pessary fitting in the literature range from 41% to 92%, with variable definitions used for success [9,10,14,18,19]. Often, more than one visit and the use of two or more pessaries are required for fitting. Half of the patients required two or more visits for fitting and a median of two pessaries was tried. Thirty percent of patients required two visits and on average two pessaries were tried per visit to achieve a successful fit. Patient characteristics that predict a successful pessary fitting are inconsistent across studies [10,14,18–20]. In several studies, prior hysterectomy and prior reconstructive surgery were more common in those with pessary fitting failure [10,18,19]. Possible anatomic predictors include a wide introitus (>4 fingerbreadths), short vaginal length (<7 cm), and larger genital-hiatus-to-vaginal-length ratio [14,20]. Among postmenopausal women, use of vaginal estrogen therapy may increase fitting success rates [19]. Many pessary providers report tailoring their choice of pessary to specific support defects [3], but this practice is based on limited evidence. Many published protocols use the ring or ring with support pessary as a first choice pessary in all patients because of its ease of use and reserve other pessary types (most often Gellhorn, donut, or cube pessaries) for women unable to retain or to be comfortably fitted with a ring [10,14,22,23]. Iowa Pessary Protocol Given the few published studies on pessary treatment, the literature cannot guide clinicians in choosing pessary management strategies. Therefore, much of clinical pessary practice is based on clinical experience and expert opinion. Here, we present the pessary protocol used at the University of Iowa Urogynecology Clinic. Prior to fitting a pessary, we treat most women that demonstrate vaginal atrophy for 6 weeks with vaginal estrogen therapy, as this may increase the likelihood of a successful pessary fitting [19]. Similar to other reported protocols [10,14,22], we begin by trying to fit a ring or ring with support pessary as these are easy for providers to fit and for patients to self-manage. If unable to fit either a ring or Gellhorn pessary, other types (commonly a donut or cube) are tried. An appropriately fitting pessary should fill the vagina, but allow the clinician’s finger to easily sweep between the pessary and the vaginal wall. After finding a pessary with a good fit, we instruct women to do vigorous activity in the clinic area (such as brisk walking and straining) to ensure that the pessary is retained in the vagina and is comfortable. We also ask that women attempt to void with the pessary in place before leaving the office. In postmenopausal patients without contraindications to hormonal therapy, low-dose vaginal estrogen is often prescribed. In most cases, patients are scheduled for an initial follow-up appointment within 2 weeks. Women fitted with a cube pessary are asked to return sooner (within 1 week) because of an increased risk of vaginal erosions [22], which in our experience may occur rapidly. At each subsequent pessary appointment, patients are first examined with the pessary in place to ensure correct fit and placement in the vagina. We recommend turning the speculum 90° to visualize the anterior and posterior surfaces carefully. After an initial 2-week and 3-month check, we examine women who manage their own pessary yearly. In contrast to reports from some centers [14,22], we find the majority of women can be instructed to remove and replace their pessaries at home. We recommend women remove the pessary once or twice weekly, leave it out overnight, and then reinsert it in the morning. Women rarely encounter excessive or malodorous vaginal discharge using this approach. If women are unable or unwilling to remove the pessary at home, they are seen at regular intervals in the office for pessary removal and examination. In these patients, we gradually increase the office visit interval after the initial follow-up visit to a maximum interval of 3 months. Women who develop increasing vaginal discharge or erosions over shorter intervals will need more frequent follow- up. Visiting nurses can be an invaluable resource for women unable to care for the pessary on their own. They are often able to visit the woman at home, remove the pessary in the evening, and return in the morning to replace it. Excessive or foul-smelling discharge, increased discomfort, or vaginal bleeding signals a need to arrange medical follow-up. Pessaries used to treat incontinence frequently have 679 a knob that is placed under the urethra (Figure 44. Some of the most commonly used incontinence pessaries include the incontinence dish (with or without support) and the incontinence ring with knob (with or without support) (inset, Figure 44. Flow rates did not decrease, and voided and postvoid volumes were unchanged with the pessary, suggesting that urethral obstruction did not occur. At urodynamics, maximal urethral closure pressures did not increase (as seen in previous studies), but functional urethral length did increase. Contrary to prior findings [24], 680 maximal flow rates decreased and detrusor pressures increased, suggesting increased urethral resistance, although postvoid volumes were not elevated. Increasing urethral resistance and elevation of the bladder neck may also help restore continence. Effectiveness Few controlled trials have been published evaluating the use of incontinence pessaries. Both devices significantly decreased urine loss (measured with a pad test) during exercise when compared to the control session. Better outcomes were seen with both devices in women who had milder urine loss [27]. In total, 450 participants with stress- predominant urinary incontinence were randomized to incontinence pessary, behavioral therapy with pelvic muscle training, or a combined treatment arm. In two retrospective studies (including 100 and 190 patients), about 60% chose to undergo a pessary fitting for stress or mixed urinary incontinence, and 85%–90% were successfully fit [29,30]. Of those successfully fit with a pessary, 55%–60% continued using the pessary (median duration of follow-up 11–13 months). In contrast to these findings, in a small prospective study, only 16% of 38 women fit with an incontinence ring with support pessary chose to continue use out to 1 year [31]. In the few that continued the use, the pessary resulted in fewer leaking episodes and 9 (24%) were subjectively “dry. Placement of a menstrual tampon has similar moderate levels of success (57% continent during use) in treating exercise-induced incontinence [27]. In a small study (32 women), a novel bell-shaped self-positioning incontinence pessary (Uresta, EastMed, Inc. One reusable device available in Australia and Europe (Contiform International, Blacktown, New South Wales, Australia) is shaped like a large hollow tampon [35]. The device, designed to be fitted and self-managed by patients, can be reused for 30–60 days. In a small study of this device, 54% of women who completed the treatment period were dry. The Contrelle Activgard (Codan, Kobenhavn, Denmark) is a polyurethane foam tampon. In the 50 women who completed the 4-week trial, 92% were subjectively continent [37]. Urethral inserts and external urethral occlusive devices function as mechanical barriers to prevent urinary leakage. These devices require highly motivated and manually dexterous patients as the devices must be removed to urinate and then replaced after each void. Studies suggest they have lower overall success rates than seen for some of the vaginal devices, partly because of higher dropout rates [38]. Urethral inserts are sterile, single-use devices placed into the urethra by the patient and held in place by an inflated balloon at the bladder neck. Such inserts are appropriate for women with no history of recurrent urinary tract infections and no serious contraindications to bacteriuria (e. Multicenter studies demonstrate high rates of continence with urethral inserts in place (80%–95%) and high rates of satisfaction in women who continue use, but overall results are limited by high withdrawal rates and frequent adverse events [39,40]. External urethral occlusive devices fit over the external urethral meatus and are held in place by adhesive or suction. These devices have fewer reported side effects than the urethral inserts, but reported continence rates are lower (40%–50%) [41,42]. Patient acceptability of this type of device, similar to urethral inserts, appears to be limited. Several types have been marketed in the United States in the past, but none are currently commercially available. In a 5-year prospective study, 12% of pessary users experienced minor complications (including pain or discomfort, vaginal excoriation or bleeding, and constipation) [15]. Vaginal discharge, odor, and vaginal infections may also occur in pessary users, but these are infrequent reasons for discontinuing the use [22,29]. Erosions may be more common in women with hypoestrogenic vaginal changes and in those using a cube pessary. In one case series, erosions developed in 5 of 6 women using cube pessaries, but in only 3 of 101 women using ring pessaries [22]. Vaginal erosions due to pessary use typically can be managed by removing the pessary more frequently, suspending use entirely for some period of time (e. If erosions recur, a change to a different size or type of pessary may be necessary. Symptomatic vaginal discharge associated with pessary use may be treated with antibiotics and vaginal estrogen treatment or by suspending pessary use until symptoms resolve. Some clinicians routinely recommend the regular use of vaginal products for vaginal acidification or lubrication to decrease vaginal discharge or odor symptoms in pessary users, but minimal evidence exists to support or refute this practice. More serious complications related to pessaries can also occur, such as erosion or impaction into 682 surrounding structures or organs, but these appear to be rare and typically are seen in patients with a “neglected” pessary [44]. A 2008 literature review identified 39 cases of major complications, including 8 vesicovaginal fistulas, 5 other urological complications, 4 rectovaginal fistulas, 3 other bowel complications, and 19 impacted pessaries [44]. Only 2 of the 39 occurred in women who received appropriate clinical follow-up, again supporting the importance of careful pessary management by providers and patients. In a 4-week trial of a disposable vaginal device, 52% of patients reported adverse events (most often discomfort and spotting) in week 1 compared to 5% in week 4 of device use [37]. Urethral devices, especially urethral inserts, have higher rates of adverse events than the vaginal devices. The most commonly reported complications include urinary tract infections, hematuria, and urethral and/or bladder irritation and discomfort [39,40]. Urethral inserts and occlusive devices are also effective, but their use is limited because of more frequent adverse effects and the intensive patient effort required for use.

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However impotence kegel exercises generic super viagra 160 mg with mastercard, deep creases and skin excess are best dealt As with much of aesthetic surgery erectile dysfunction endovascular treatment 160 mg super viagra order, the aims in rejuvenative with surgically by means of browlift impotence kidney stones trusted super viagra 160 mg, with or without dener- procedures for the brow are simple erectile dysfunction doctors kansas city super viagra 160 mg purchase amex, and the difficulty lies in vation of the muscles of the brow and resection of the pro- their implementation erectile dysfunction pills gnc generic 160 mg super viagra overnight delivery. While the use of chemical youthful appearance to the brow region, without “overplay- denervation with Botox and soft tissue augmentation with ing the hand” and conveying an overly lifted appearance. As non-autologous fillers will not be discussed in further detail Barton states in his book, while the depressed brow in unaes- here, the reader is referred to an excellent article on the topic thetic, it is natural. The goal is to elevate the elements of the brow smoothly with long-term results, and detail the limited situations in and to the correct extent. Because of the power of the brow typically needs to be lifted more than the remainder of endoscopic lift, and the well-hidden scars, coronal incisions the brow. In lifting and redraping the brow, transverse lines should be softened, and if necessary autologous or off-the- 9 Operative Technique shelf fillers can be employed to fill deeper creases. Hair fol- licle concentration and thickness should be preserved, and In the senior author’s clinical cases, the results of this ana- the hairline location should be either preserved or lifted to a tomical study of the ligamentous attachment positions are minor extent. If indicated, an upper blepharoplasty should be applied to preserve them with both open and endoscopic performed to excise excess upper eyelid skin prior to redrap- approaches. Whenever possible, the tenets detailed above rior to the hairline, dissection is performed inferiorly in the for the aesthetic brow should be the goal. Care is however, the appearance of the row and upper lids can vary taken to preserve the medial brow retaining structures. The lateral retinacular ligament is released lateral to the supraorbital nerve, avoiding any trac- tion on the nerve. Adequate exposure for resection of the 8 Approaches medial corrugators and procerus muscles is obtained by dis- secting a central tunnel between the two superomedial retain- 1962 Gonzales-Ulloa Coronal incision for forehead/browlift [3 ] ing structures. Preserving these medial retaining structures 1978 Ortiz-Monasterio Combined rhytidectomy and coronal allows the surgeon to control the position of the lateral brow browlift procedures [25 ] while helping to prevent over-elevation or lateral spreading 1994 Vasconez Endoscopic approach to browlift [26 ] of the medial brow in both endoscopic and open procedures. Gonzales-Ulloa first described the coronal approach in Once the dissection is completed, the process of brow an isolated procedure for elevation of the forehead and elevation and suspension can begin. Ortiz-Monasterio then incorporated this as an ele- ated with a small drill, which provide strong cleats through ment of his rhytidectomy technique in 1974, and many which to pass the suture. Two variations on this long coronal such as screws, posts, or anchors which could become pal- incision have become commonplace, the standard coronal pable are avoided. The suspensory sutures consist of per- incision with curvilinear deviations such that the incision manent (4-0) nylon sutures in the deep dermal plane. Three is always 6–7 cm posterior to the hairline and a modified passes of the suture are made through the deep dermis, anterior hairline incision. This modified anterior hairline aponeurotic tissues, and galea for each point of fixation. This incision is the senior author’s knot will not slip as subsequent throws are placed. Care preference in those patients with a relatively high hairline must be taken to avoid placing too much tension on these or anteriorly thinning hair. The next major advance in surgical approaches arrived with the advent of endoscopy in plastic surgery. Knize fur- 10 Closure ther refined these approaches with a limited scar technique for brow, temporal, and upper eyelid rejuvenation. These The closure of the endoscopic or limited-length incisions minimally invasive techniques are, in most cases, equally within the hair is accomplished with a skin stapler. These potent in terms of brow elevation versus the coronal incisions are everted properly, and the scars heal well with approach, with a reduced incidence of scalp paresthesias or the advantages of ease of removal and without the need to alopecia. Though fewer surgeons are relying on the coronal tie or remove sutures among the hair follicles. Incisions approach, it is still the technique used by most plastic sur- that must be located nearer to the hairline, and in thinner geons despite these shortcomings. We present the senior hair by necessity, are closed with running 5-0 nylon sutures author’s preferred approach to endoscopic brow rejuvenation, and W-plasty for camouflage of the healed scar. The medial retaining ligamentous attachments were left intact to control the position of the medial brow b e c Forehead and Brow Rejuvenation 873 11 Peri- and Postoperative Care 2. Postoperative care of the patient begins on the operating Plast Reconstr Surg 29:658–673 table after the browlift procedure. Lippincott Williams & Wilkins, Philadelphia between the surgeon and anesthesiologist, and without 6. With intraoperative the frontal branch of the facial nerve: the significance of the tempo- careful attention to hemostasis and postoperative strict ral fat pad. Plast Reconstr Surg 83(2):265–271 adherence to activity instructions, the incidence of hema- 7. Agthong S, Huanmanop T, Chentanez V (2005) Anatomical varia- tions of the supraorbital, infraorbital, and mental foramina related toma should be rare. J Oral Maxillofac Surg 63(6):800–804 be instructed to sleep with their head elevated and their neck 8. The senior author also instructs his patients Plast Reconstr Surg 96:323 to place a wedge beneath the head when sleeping. Plast Reconstr Surg and anticoagulants should be held for at least a week after 97:928–937 brow rejuvenation. Aesthetic Plast Surg 13:217–237 Complication rates for brow rejuvenative procedures are simi- 13. Plast Reconstr Surg 99:1808–1816 The complications, though infrequent, should be recognized 16. Plast Reconstr Surg 124(2): is treated with intravenous antibiotic coverage for skin flora 615–623 and drainage if necessary. Lastly, importance of the retaining ligamentous attachments of the fore- head for selective eyebrow reshaping and forehead rejuvenation. Fagien S (1999) Botox for the treatment of dynamic and hyperki- 13 Results/Cases netic facial lines and furrows: adjunctive use in facial aesthetic sur- gery. Plast Reconstr Surg 116(5):1479–1487 neck rejuvenation was also performed with upper lid blepha- 23. This It is important to differentiate plication from suspension: happens regarding any situation: pain, tumors, laxity and, plication sutures neighboring structures; suspension anchors indeed, vanity. Concerning facelift surgical techniques, in structures that are far one from another. Suspension is stron- the past two decades plastic surgeons have looked for more ger, modifying a vector of traction. Since a good result in natural results, less invasive surgeries, suitable recovery, low rhytidoplasty is essentially the final effect of traction vectors, stigma, shorter scars, and low risk; besides which, patients it makes all the difference. In this technique the surgeon defines the more than a pleasant appearance; they feel happy with the points that will limit the whole area where the suspension will simple comment that they are looking good for their age. As the front or below the ear, leaving the muscles free to stabilize in a respected surgeon Thomas Biggs used to say, it is time to final and natural situation, and the superior and posterior portion have “the most for the least. This dynamic accommodation will preserve the tively new options in the plastic surgeon’s arsenal, although patients’ own facial expressions. How much different facelift history would have diseases, since it is a quick procedure that respects the been if the paper by Virenque [2] could have been dissemi- integrity of most anatomical structures. The relevant points perceived since that time are the is carried out, it acts by repositioning the facial volume in a compact loop suture, elevating en-bloc the fallen struc- tures of the face such as jowls and malar fat pads, and even improving the neck contour. The first one is anchored to the periosteum of the zygoma and extending to the platysma muscle, at the mandibular angle. Over time, the incision changes to an inverted “Ω” (omega) around the ear and small undermining [6] in the open technique (the closed technique consists of one incision at the sideburn and a small one behind the ear). Two include the deep temporal fascia; a second purse-string suspension purse-string sutures are performed: the first one suture will be performed, ahead and parallel to the first. With a finger the surgeon slides the facial skin toward the ear, simulating the intended result. Repeating this maneuver four or five times a dotted line is drawn around the ear, deter- A third purse-string suture may be executed, beginning at mining the minimum undermining to achieve the result. The inci- mental region and neck, using a 3-mm incision behind the sions of the skin will vary according the intended traction chin. On completion, an inverted-omega incision is made contouring the ear, starting with a zigzag beveled inci- sion about 3 mm above the border of the sideburn, in order to 2. Marchac reported U-shaped incision in the temporal area and The previously-marked area is undermined at the subcu- surrounding the ear. Next, the risorius-masseter zone is exposed, in addition to the cranial portion and the mandibular insertion of the platysma muscle. Regardless of the technique used there will be an overlapping of muscles in this area; it is indeed convenient to restore volume. At this time the purse-string suture is performed; it is eas- ier to begin from behind the ear toward the neck and face. In the mastoid fascia there will be no tissue lifting, since it is a strong and fixed area. The traction begins to raise the tissues as soon as the platysma muscle is reached. The bites must not be close to one another; it is important to leave a 2-cm space between them to permit imbrication of tissues. A 45° insertion of the needle will provide a stronger and safer suture, hence assuring a better traction. At this moment the surgeon must pull up this semicircular suture to assure that the intended result is being achieved, and that an effective vertical volume reposition has been obtained (Fig. Once the ideal path is realized, the needle is passed deeply, entering the anterior limit of the sideburn incision and directed toward the limit of the retroauricular incision. After arriving in the posterior area, the thread is passed through the needle hole (Figs. Only then is muscular action along the stitch so as to offer a natural the knot complete (Figs. The purse-string suture expression to the patient, with a smooth and progressive is then performed (Fig. It is desirable to leave this suture without addi- For those who may be afraid of using the needle described, tional stitches in its anterior area, so that the facial muscles it is perfectly feasible to achieve the same results by per- may act in a dynamic fashion and adapt to the movements of forming a two- or three-step suture in the hairy area. Sometimes it is necessary to perform a superficial dissec- tion with a cannula to treat some dips. It may be also neces- sary at the sideburn and preauricular area to reseat a triangle of skin to promote an adjustment. Some excess skin will remain ahead of the ear and earlobe, which will settle in 2 or 3 weeks. Stocchero Case 2 Preoperatively and 3 years postoperatively Suspension Techniques in Aesthetic Surgery of the Face 885 886 I. Stocchero 5 Complications 7 Pearls and Pitfalls After having performed more than 400 facelifts with this technique, only one major complication was seen: a superfi- Pearls cial skin necrosis in a patient who was a smoker and had a Performing judicious marking and paying attention to previous car accident with injury of the facial artery on the the well-known dangerous zones is the most important same side. The quality of the result will depend on the good Expressive bruising was the most common complication, choice of traction points. The final Ear lobe swelling occurred in 3 % of cases, consequent to loop, after tied, will tend to resemble the shape of a a very tightened suture near the ear. In patients with a specific point of laxity, it may be necessary to perform additional braces to correct certain folds and undertractioned areas. By using a blunt Hagerdon Bayonet Modified Needle, it is 6 Informed Consent possible to achieve a desired point for pulling the insufficiently treated area, performing a maneuver Usually, consent is given in Portuguese and consists of three described as “fish and tie”: the needle is passed and a different printed forms: thread is pulled, fixing the desired area in the parotid fascia. General Orientation: Discusses what may occur in any tysma to the fascia of Loré [17], therefore acting as a plastic surgery procedure; for example, scars, asymmetry, cervical brace. It is recommended that all additional surgery limits, false expectations, and medicine braces be placed before the Roundblock stitch, hence interactions allowing free adaptation of tissues according to 2. Rhytidoplasty Surgery Orientation: Discusses specific Pitfalls topics regarding the surgery, what is expected, what to Care must be taken with the distance from the ear to take to hospital, preoperative and postoperative restric- prevent a “strangulation” of the auricular pavilion that tions. Regarding suspension facelift the patient is made will promote pain and distortion. Tonnard P, Verpaele A (2002) Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg 121:677–680 International Symposium of Plastic Surgery, Buenos Aires, 17 Aug 2. Marchac D (2009) Évaluation de 50 liftings cervicofaciaux monob- Reconstr Surg 83:11–16 loc avec suspension. Plast Reconstr Surg 117:2001–7 Rejuvenation of the Midface Brunno Ristow 1 Introduction Frequently, and for many years, I examine lovely faces and think: “How can we (surgically) achieve this? Approaches I use benefited from ideas with reverence for the resilience or delicacy of tissues, will expressed by colleagues; however, personally, I trace the make the surgeon the one that at the end, checkmates the beginning of a major departure from the accepted standards – aging face. His suspension of the fascia above the fat pocket of Bichat set me on a journey which is one of the pillars of what I came to use 2 General Considerations [2 – 4]. Much followed with the identification of the superficial In the midface, there are two consequential fascias. Although for a decade I continued my anatomical system known as the superficial musculo- evolution, Skoog’s suspension remained constant. This structure of substance lowing decade, I was influenced by Connell [5], and finally, can be separated from the far more delicate second fascia, I evolved into a synergistic link of these concepts [6 – 8 ]. Lovely, natural, long-lasting results that I found myself working mostly alone in my professional please and delight patients are anchored on the ability and career. This partially offered me the opportunity to study the skill of the surgeon to master these maneuvers. Of the two basic methods of progress, the first being experimentation that leads ultimately to conclusions sometimes unknown or the 3 Anatomical Issues second having intuition of an outcome and applying that thought to the anatomy, personally I fit on the last group. To surgeons, the understanding of the position of the fat in a young face, its distribution and the consequence this has on the surface contours of the face is essential. That the skin over achieve results that are natural, contours that the patient had the midface remains relatively static with aging but the fat when younger, with no alteration of the fundamental param- shifts has been elegantly demonstrated [10 ]. In fact, that connect it to the skin, severely compromise the blood if one studies the contours of beautiful women in their 30s it supply, and likely achieve a combination of short-lived artifi- is not unusual to see a subtle concavity of the contours of the cial and unnatural results. Very young twenty-first century may seem out of touch with our develop- women in their teens usually have more overall facial fat.

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Zero pressure and reference height are concepts that are often confused in urodynamics doctor for erectile dysfunction in ahmedabad buy super viagra 160 mg on-line, for example erectile dysfunction medications and drugs buy 160 mg super viagra fast delivery, by use of the misleading term “zero reference height erectile dysfunction treatment michigan cheap super viagra 160 mg amex. Zero pressure is the value recorded when a transducer is open to the environment when disconnected from any tubes or catheters erectile dysfunction treatment at home discount 160 mg super viagra overnight delivery, or when the open end of a connected erectile dysfunction viagra 160 mg super viagra, fluid-filled tube is at the same vertical level as the transducer. The reference height is the level at which the transducers must be placed so that all urodynamic pressures have the same hydrostatic component. It is often argued that it does not make a difference for the most relevant parameter, pdet, if the same error is introduced to pves and pabd, as they tend to cancel each other out. The hydrostatic pressure is real and important, and 1837 inevitably plays a role in any intracorporeal pressure recording. Also, it is only meaningful to subtract one pressure from the other— for example, (pves ‒ pabd = pdet)—when both are recorded to the same reference level. Pressure Transducers Urodynamic techniques are developed using external pressure transducers connected to the patient with fluid-filled lines, allowing easier compliance with the standards of correct zero and reference height. Catheter-mounted pressure transducers, so-called microtip transducer catheters, have become popular due to their apparent higher accuracy, better dynamic resolution, and their apparent independence from hydrostatic pressure. A catheter-mounted pressure transducer is an advantage for dynamic recordings of urethral pressures during coughing (stress profiles) as well as for ambulatory urodynamics in mobile patients. Here, only the application of catheter-mounted pressure transducers for intravesical and pabd recordings will be discussed as urethral pressures are dealt with in a separate report [4]. All aspects of urodynamic pressure recording outlined in the preceding section are valid and independent of transducer type. It is impossible to define the precise position of an intravesical and a rectal catheter-mounted pressure transducer as to place them at any common level, and impossible to position them at the standard level of the upper border of the symphysis pubis. It has become popular to circumvent this problem by setting the catheter-mounted pressure transducer to zero pressure when inside the body at the start of pressure recording. This, however, means that both the standard zero pressure as well the reference level are ignored, so that such recorded pressure cannot be compared between patients or centers. The fact is that the initial intravesical and abdominal resting pressures are real, are different between patients, and depend significantly on the patient’s position. Thus, there are significant potential errors: By ignoring the correct atmospheric zero pressure, an error of up to 50 cmH O can occur, and as the reference height of catheter-mounted pressure transducers is usually2 undetermined, another potential error of 10 cmH O is possible for a full bladder. In addition, when a2 study starts with zero pabd, then the commonly observed pabd decrease at pelvic floor relaxation during voiding will result in negative pabd values, and thus in pdet being higher than pves. The same problem of apparent independence from the existing hydrostatic pressure also applies to air-filled catheters and/or connection tubings. Due to the absence of a water column between the balloon-covered opening on the catheter and the external transducer, the reference height in an air-filled system will refer to the position of the sensing balloon on the catheter and not to the external transducer. It is recommended that external transducers connected to fluid-filled tubings and catheters be used for intravesical and pabd recording. If microtip or air-filled catheters are used, any deviation from standard zero and reference level should be minimized and taken into account at the time of data analysis. Urodynamic Catheters Comparison between patients and urodynamic studies performed in different centers would be facilitated by the use of standard catheters. It is recommended that for the measurement of intravesical pressure and for bladder filling, the standard catheter for routine urodynamics is a transurethral double- lumen catheter. Only in small children and patients with severe constrictive obstruction (stricture) does suprapubic pressure recording have clear advantages. Intraurethral catheters should be as thin as possible, limited only by the practicality of insertion and by internal lumen sizes, which should be sufficiently large to avoid excessive damping of pressure transmission and to achieve the desired filling rate with standard pumps. The major advantage of a double-lumen catheter is that the fill/void sequence can be repeated without the need for recatheterization. Note that the use of a 6 Fr double-lumen catheter can limit the infusion rate during cystometry to 20–30 mL/min, as a typical roller pump may not manage to transport a higher perfusion rate through such a small lumen. This can result in an incorrect filling volume being indicated by the machine when the filling volume is calculated from the pump setting. For example, with a filling rate set at 60 mL/min and an actual filling rate of 30 mL/min, the machine will show double the filling 1838 volume. With some equipment, higher filling rates are possible; it is essential that any system should be critically tested to (1) measure the maximum filling rate that can be achieved by a particular catheter attached to an individual pump and (2) correct or calibrate the indicated infused volume. Removing the larger filling tube for voiding may appear to be an advantage because only a single small tube is left in the urethra. However, there are no data to suggest that, for example, in a compressive obstruction such as benign prostatic obstruction, a 6 Fr catheter has a detrimental influence on the pressure or flow data. There are, however, data suggesting that results from a single study may be misleading. A double-lumen catheter facilitates a second fill/void study to establish reproducibility. Reintroduction of the separate filling tube for a repeated study is more invasive and complicated. Although there are various methods for the successful recording of pabd, a flaccid, air-free balloon in the rectal ampulla gives a suitable signal for pabd to determine a meaningful pdet when pves is measured synchronously (pdet = pves – pabd). In females, vaginal recording may be more acceptable and provides comparable results. The role of the balloon is to maintain a small fluid volume at the catheter opening and to avoid fecal blockage, which can prevent or impair pressure transmission to the transducer. Additionally, as the rectal ampulla and the vagina are not homogeneously fluid-filled spaces, the balloon prevents pressure artifacts arising from contact between the catheter opening and the wall tissue. The balloon serves this function best when it is filled to only 10%–20% of its unstretched capacity. Overfilling and elastic distension of the balloon is the most common mistake in pabd recording. The resultant high balloon (not abdominal) pressure will produce a misleading pressure reading. Such an artificially elevated balloon distention pressure can be avoided by making a small hole in the balloon, although this is unnecessary if the balloon is filled properly as described earlier. It is also possible to record reliable pabd with a very slowly perfused (<2 mL/min) open-ended catheter. Equipment Recommendations The minimum recommended requirements for a urodynamic system are as follows: Three measurement channels—two for pressure and one for flow. Meaningful plausibility assessment and quality control are possible only when the measured and derived signals are displayed continuously as curves over time, without delay (in real time), as the examination proceeds. The following sequential position of tracings is 1839 suggested: pabd at the top, then pves, pdet, and Q (Figures F. The following minimum technical specifications are recommended: Minimum accuracy should be ±1 cmH O for pressure and ±5% full scale for flow and volume. The scalings should be kept unchanged as much as possible, because urodynamic data quality control is based on pattern recognition, and the recognition of patterns depend on scaling. Therefore, it is recommended that during recording and for analysis, minimum scaling for pressure should be of 50 cmH O/cm, for flow 10 mL/s/cm, and for the time axis 1 min/cm or 5 s/mm during filling and 2 s/mm2 during voiding. To enable a retrospective judgment of the curves, urodynamic measurements should be documented as curves over time with comments and explanations. It is usually insufficient to document urodynamic measurements by a few numerical values alone. The same amplitude of scaling should be used for all documentation, although the time axis may be compressed. For a printout, maximum full-scale deflections of 200 cmH O, 50 mL/s, and 1000 mL are sufficient2 for pressure, flow, and volume, respectively. In most cases, half the maximum full scale will be sufficient to show all relevant parts of curves. Calibration of Equipment The need to calibrate pressure transducers, flowmeters, and pumps cannot be stated simply as “yes” if there is a need or “no” if there is not. Two aspects must be considered: the intended accuracy of the system and the investigator’s experience with the system. If a new system is installed or new transducers are being used, it is recommended that regular calibration be carried out. However, calibration should2 not be ignored and good urodynamic equipment makes it technically possible to perform a calibration. Calibration should not be confused with simple “zero balancing,” which is only one part of calibration. In addition to setting the zero, it must be possible to check and adjust the amplitudes of all measurement channels, that is, to calibrate all signals. Calibration of a flowmeter can be achieved by pouring a precisely measured volume at a constant flow into the flowmeter, typically 400 mL in 20–30 seconds (at 15–20 mL/s), and checking the recorded volume. Similarly, one can test a pump by measuring the time to deliver a known volume (e. It is recommended that pump calibration be performed with the filling catheter connected. Such a pump calibration can only be as good as the cylinder used, which needs to have good resolution and be accurate. Pressure Signal Quality Control: Qualitative and Quantitative Plausibility It is very important to observe and to test signals carefully and to correct any problems before starting 1840 the urodynamic study. If the signals are perfect at the beginning of the study, they usually remain so without the need for major intervention. If a quality problem does not disappear at once, when filling commences, it will usually deteriorate further during the study. Conscientious observation of the patient and of the signals, in particular pdet, during all parts of the study, together with continuous signal testing, are the keys to high-quality urodynamics. The first aim is to avoid artifacts and the second to correct the source of all artifacts immediately they occur. The following three criteria form the minimum recommendations for ensuring quality control of pressure recordings: 1. Resting values for abdominal, intravesical, and detrusor pressure are in a typical range (see in the following text). The abdominal and intravesical pressure signals are “live,” with minor variations caused by breathing or talking being similar for both signals; these variations should not appear in pdet. Coughs are used (every 1 minute or, for example, 50 mL filled volume) to ensure that the abdominal and intravesical pressure signals respond equally. Coughs immediately before voiding and immediately after voiding should be included. When standards are followed, that is, with the transducer zeros set to atmospheric pressure and the transducers placed at the level of the upper edge of the symphysis, the typical ranges for initial resting pressure values for pves and pabd are as follows (Schäfer, unpublished communications): Supine 5–20 cmH O2 Sitting 15–40 cmH O2 Standing 30–50 cmH O2 Usually both recorded pressures are almost identical, so that the initial pdet is zero, or close to zero, that is, 0–6 cmH O in 80% of cases and in rare cases up to 10 cmH O [2 2 5]. All initial pressure values should be verified and the patient’s position should be documented on the urodynamics trace. All negative pressure values, except when caused by rectal activity, should be corrected immediately. It should always be kept in mind that pabd is recorded not in order to ascertain the actual rectal pressure but to eliminate the impact of (abdominal) pressure changes on pves. The principal aim is to determine the pdet, which is the pressure in the bladder without the influence of pabd. By talking to the patient during the study, the proper dynamic response in the pressure signals can be observed and is “automatically” documented (Figures F. Problem Solving If either detrusor or rectal contractions occur, the recorded pressures in pves and pabd will be different. Such changes can be identified and interpreted with sufficient accuracy and reliability only when the patient is observed and the relation between signal changes and patient sensation/activity are checked for plausibility and documented. Any pressure change caused by smooth muscle contractions will show a “smooth” pattern (Figures F. If pressures increase or decrease stepwise, or with a constant slope over a long period of time, a nonphysiologic cause, such as catheter movement, should be considered. If a sudden drop or increase occurs in either the pves or the pabd signal, the usual cause is the movement, blockage (Figure F. When the patient changes position, sudden changes in resting values occur and are seen equally in both pressure signals. If pves (without change in pabd) increases slowly—as is typical for a low-compliance bladder—it is important to test for any other possible cause for a slow pressure increase. One cause could be a problem with the intravesical catheter measurement; for example, the hole for the pressure conducting lumen is slowly moving into the bladder neck region. This should be assessed by asking the patient to cough, if there is 1841 no other apparent artifact. Furthermore, it is recommended that bladder filling is stopped if the filling rate is above a physiological limit of 10 mL/min. If the value of pves drops after filling is stopped, it is likely that “low compliance” was, at least in part, related to fast filling. There are several common problems that must be solved before the study is started or when observed during a study: Problem: Initial resting pdet is negative, for example, −5 cmH O. If not, gently reposition the rectal balloon and/or make a small hole in the balloon. It is very important to flush slowly while observing the pressure signal because pressures above 300 cmH O may damage the transducer. If this does not solve the2 problem, add some more volume to the bladder via the filling lumen. If resistance to filling is high and it does not drain easily when opened, it will be necessary to check the catheter position, and to reposition the catheter, if necessary. The situation is different from the clear statement that “p2 det cannot be negative” as we do not have a definite upper limit for the normal maximum “resting” value for pdet. Thus, we can only follow the present guidelines that, in most tests in an empty bladder, pdet is between 0 and 5 cmH O, and in some 90%, it is between 0 and 10 cmH O. If the patient has no detrusor overactivity, a pdet of 15 cmH O is unlikely to be valid and there may be a signal problem.

Testimonials:

Candela, 58 years: It is more common in older patients with dehydration, poor oral hygiene, malnutrition, oral neoplasms, liver cirrhosis, and diabetes mellitus. The theory is supported by typical concomitant features such as an elongated sigmoid colon, a mobile mesorectum, lax lateral ligaments, and pelvic floor weakness. Such 15 facilitation, which has been shown to require simultaneous atrial activation, more likely results from summation, 6 as suggested by Zipes et al.

Baldar, 31 years: Clinical manifestations: Muscle wasting, weakness, osteoporosis, central obesity, abdominal striae, hyperten- sion, mental status changes Anesthetic considerations: Correct volume overload and hypokalemic metabolic alkalosis preoperatively. Hypersensitive Pelvic Floor Hypertonus of the pelvic floor musculature accounts for some of the concerns of female patients who present for evaluation of sexual health concerns. The gunshot wounds to the fetus were atypical due to the intermediate tar- gets including the mother, uteroplacental unit, and amniotic fuid.

Hassan, 47 years: Improvements in the symptoms of manual evacuation was noted in 36%–63% [22,64,67] with a de novo rate of 7% in one study [22]. Clinical and Urodynamic Features Voiding symptoms are variable among these patients. The reported incidence for cystocele is around 9 per 100 woman-years, 6 per 100 woman-years for rectocele, and 1.

Thorald, 37 years: In all instances, we use full heparinization with 5,000 to 10,000 U as a bolus and 1,200 to 3,000 U/h drip, adjusted to maintain an activated clotting time of 250 to 350 seconds. Much like graciloplasty and artificial bowel sphincter procedures, a circumferential tunnel is created around the anal canal with sharp and blunt dissection. If the condition the middle finger, the flexor pollicis brevis muscle is is not treated surgically, it may be exacerbated by con- beneath the ring finger, and the transverse head of the tracture of the capsule in the adjacent finger joints.

Folleck, 41 years: While the Amid classification was useful for past mesh devices, nearly all contemporary products are characterized as type I rendering this characterization ineffective for distinguishing products. More recent reports of laparoscopic techniques that have become available have been presented, including laparoscopic Davidov, Vecchietti, and balloon vaginoplasty procedures [57–59]. Since diagnosis in a large majority of cases is clinical, Leaving the clinically suspected case untreated for a empirical therapy is strongly recommended.

Innostian, 24 years: Catheter tips differ in order to facilitate insertion and drainage of the bladder for a variety of clinical scenarios (see Figure 45. Ablation of such tachycardias is not only difficult, but is virtually never curative since these patients typically have large infarctions and multiple arrhythmias. This is in contrast to the induction of sustained monomorphic tachycardia by routine or even aggressive stimulation techniques, which in my opinion remains highly specific, occurring only in those populations of patients who have had sustained monomorphic tachycardia; symptoms compatible with this arrhythmia (e.

Emet, 60 years: New onset vesicovaginal fistula after transurethral collagen injection in women who underwent cystectomy and orthotopic neobladder creation: Presentation and definitive treatment. Note the orbital contusion to her left eye, which is a recessed area of her face and not usually associated with a fall while striking a fat surface. Suggested criteria for a staged closure include intragastric or intravesical pressure above 20 cm H O, peak inspiratory pressure above 35 cm H O, or an end-tidal carbon dioxide above 50 mm Hg.

Snorre, 57 years: If we use this as the percentage for all adults 65 years old and older living in the United States, what is the probability that among 65 adults chosen at random more than 25 percent will have been told by their doctor or some other health care provider that they have cancer? Ryall and Marshall [29] suggested that the reduction is maximum urinary flow rate caused by the fine (diameter = 2 mm) urethral catheter used in their study of 147 symptomatic men was of the order of several mL/sec. Any history of multiple sclerosis, parkinsonism, spinal cord injury, stroke, or spina bifida should be recorded.

Miguel, 51 years: Most innovators are constantly changing their surgical practice in search of refinements, which make procedures easier, quicker, cheaper, less morbid, or more effective. Lef ventricular thickness is bacterial, fungal, parasitic, autoimmune, and hypersensi- best measured approximately 2 cm below the mitral valve tivity, can present as sudden death. Vital general rules in pediatric practical In case of anterolateral aspect of thigh, needle should Box 49.

Ramirez, 40 years: Incorrect attachment on right is in the form of only nipple in infant’s narrowly-open mouth with lower lip not turned outward and chin not touching the breast. Another similarly characteristic skin lesion of kwashiorkor is crazy-pavement dermatosis. Characteristics of initiation and termination of catecholamine-induced triggered activity in atrial fibers of the coronary sinus.

Gamal, 30 years: Resetting response patterns during sustained ventricular tachycardia: relationship to the excitable gap. On the other hand, a very early atrial extrastimulus may block in the bypass tract closest to the stimulus site and conduct over a bypass tract at a more distant site (see Fig. Comparison of Burch and lyodura sling procedures for repair of unsuccessful incontinence surgery.

Ines, 27 years: In the rare instance of a midureteral or proximal ureteral transection, ureteroureterostomy would be preferred, but only if the anastomosis can be widely spatulated and tension-free. Left bundle branch block is either Pulmonary vascularityis indicated by intrapulmonary congenital or secondary to cardiomyopathy. Ferrous succinate 23 On the basis of biochemical and hematological changes Ferrous lactate 19 iron defciency is graded into 3 Stages (Box 32.

Peer, 55 years: Fluoroscopic guidance is used to plan the insertion point and assess the depth of the lead. It is often said that the 30° laparoscope should be reserved for use by the “professional” laparoscopic surgeon, while the 0° laparoscope is the best choice for the “amateur” laparoscopic surgeon. Tis is in marked Chest X-ray shows enlarged heart without any contrast to the fxed narrow orifce in the case of valvular evidence of structural abnormality (Fig.

Ugo, 26 years: At the molecular level, post transcriptional regula- 19–85 years, showed a steady, linear increase in oxidative tion might represent a putative mechanism to modulate indi- events throughout adult life and in particular that the capac- vidual efficiency in the activation of cellular stress response. We suggest that vesicoscopy has an earlier role to play, if after a reasonable attempt of conservative management the problem persists. If we did, one could theoretically separate reentry from triggered activity, or automaticity, based on the response of the tachycardia to the drug and P.

Fedor, 28 years: Patching should be avoided, as it may mask a more Patients present with proptosis, excessive pain, eyelid swell- serious complication, such as an orbital hemorrhage. Such morbidities are usually minor and include pain at implant site, seroma, excessive tingling in the vaginal region, and superficial wound infection [62]. In view of the fact that the rate of administration can markedly influence the hemodynamic response, we recommend that Class 3 studies always be determined on chronic oral doses of various agents.

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