By P. Rufus. Syracuse University.

Enzyme-inducing drugs such as carbamazepine purchase penegra 50 mg otc, phe- ible causes for reduced fertility rates among people with epilepsy order penegra 100mg mastercard. In a cross-sec- epilepsy or risks to the fetus incurred by seizures or the drug treat- tional study buy cheap penegra, monotherapy with carbamazepine was associated with ment best 50mg penegra. However, some studies suggest that concurrent disabilities and ment in doses of at least 900 mg/day was associated with similar en- comorbidities (e. Fertility rates among people with epilepsy in 12 out of 21 men treated with valproic acid for generalized or were essentially normal in two population-based studies from focal seizures [6]. No diference was observed in linear growth ment [11], whereas a cross-sectional study of men and women with and sexual maturation [18]. When 41 girls on valproic acid were epilepsy found no diference in levels of reproductive hormones compared with 54 healthy controls, hyperandrogenism was ob- between those taking levetiracetam, carbamazepine or lamotrigine served more frequently among the valproic acid-exposed girls, but [12]. A long-term follow-up of these cohorts revealed normal endo- esis or sperm function. A small cross-sectional study As suggested in a recent comprehensive review, women with epi- of men with epilepsy suggested that all investigated drugs, carba- lepsy should be monitored for signs and symptoms of reproductive mazepine, oxcarbazepine and valproic acid, were associated with an dysfunction in conjunction with their clinical visits. This includes increase in abnormal sperm morphology [10], although the clinical assessment of menstrual cycles, occurrence of hirsutism, acne, relevance of these fndings remains to be shown. In addition to the com- mental factors can contribute to the development of this syndrome. In these studies, 30–40% of patients treated and an increased frequency of unplanned pregnancies [21]. However, whether this dose is 26 years (44% and 23%) but was similar if treatment was started at sufcient is uncertain. Taken to- Estradiol-containing oral contraceptives induce the elimination of gether, these observations confrm that valproic acid can indeed lamotrigine. This can lead as important as reported in the initial cross-sectional studies from to breakthrough seizures unless the lamotrigine dosage is adjusted. Tese changes occur rapidly and hence lamotrigine levels rise during Withdrawal of carbamazepine in seizure-free male and female the pill-free week if sequential pills are used [23]. This may induce patients has also been associated with normalization (increase) toxic symptoms. Preliminary data suggest that estradiol can have a of serum testosterone and free androgen index [17]. Pure proges- sectional studies assessed endocrine function in a younger female tagen-containing pills do not seem to afect lamotrigine serum con- population with epilepsy [18,19]. A cohort of 77 girls, 8–18 years centrations, and concomitant use of valproic acid appears to block of age, under treatment with valproic acid (n 40), carbamazepine the estradiol-induced efects on lamotrigine kinetics [24]. Howev- (n = 19) or oxcarbazepine (n = 18) were compared with 49 healthy er, as lamotrigine can reduce the bioavailability of gestagens [25], Reproductive Aspects of Epilepsy Treatment 313 Table 23. Drugs in which the clearance is Drugs that increase the clearance Drugs that do not affect the induced by estradiol-containing of oral contraceptives clearance of oral contraceptives oral contraceptives Carbamazepine Ethosuxumide Lamotrigine Eslicarbazepine acetate Gabapentin Valproic acid Felbamate Lacosamide Lamotriginea Levetiracetam Oxcarbazepine Pregabalin Phenobarbital Retigabine Perampanel Tiagabine Primidone Valproic acid Phenytoin Vigabatrin Rufnimide Zonisamide Topiramate (at dosages >200 mg/day) a Lamotrigine does not affect estradiol concentrations but has a modest effect (18% reduction in plasma concentration) on the norgestrel component of the combined oral contraceptive. It has therefore been suggested that for women taking lamo- a few such reports have been published. In contrast, prolonged sei- trigine, the combined contraceptive pill can be used with tricycling zure activity, such as status epilepticus, may be a serious threat to or continuous use to avoid fuctuations in lamotrigine serum con- the fetus as well as to the woman. Given the choice of two drugs similar in all other women with status epilepticus (12 of whom were convulsive) [28]. The possibility of using com- nancy are not associated with an increased risk of birth defects. Generalized tonic–clonic seizures during labour can cause fetal Pregnancy in women with epilepsy asphyxia. Focal seizures that impair consciousness may also impose In the treatment of epilepsy during pregnancy, maternal and fetal risks because the mother’s ability to cooperate during the delivery risks associated with uncontrolled seizures need to be weighed is lost. Nevertheless, Effects of maternal seizures on the fetus there is a general consensus among physicians that generalized ton- Epileptic seizures in a pregnant woman may have adverse efects ic–clonic seizures in particular should be avoided during pregnancy on the fetus, in addition to risks for the woman. With respect to for the sake of the well-being of the fetus as well as the mother. Maternal risks with uncontrolled seizures Tonic–clonic seizures are associated with transient lactic acidosis, Epilepsy is a serious condition and uncontrolled seizures occasion- which is likely to be transferred to the fetus. This concern appears to be fetal heart rate, which is a common response to acidosis, has been particularly relevant during pregnancy. Fourteen deaths were epilepsy-related, of which afects uterine blood fow and thus the fetus. An estimated 1 in ternal abdominal trauma could also, theoretically, cause injury to 1000 women with epilepsy died during or shortly afer pregnancy the fetus or placental abruption. Despite these efects, intrauterine compared with 1 in 10 000 in the general population. This appears to be mainly because of a decrease Seizure control during pregnancy and delivery in drug binding to plasma proteins and/or an increase in drug me- The largest prospective study of seizure control in pregnancy to tabolism and elimination. A decrease in protein binding will result date reported that 59% of 1736 women remained seizure-free in lower total drug levels but leave unchanged the unbound, active throughout pregnancy [27]. Earlier studies, mainly from special- concentration of the drug, which is the relevant concentration in ized epilepsy centres, indicated that approximately one-third of the treated mother as well as for exposure to the fetus. Prospective studies of fewer selected women with phenobarbital decline by up to 50% [34]. Total concentrations of epilepsy suggest that the proportion of women who deteriorate is carbamazepine decline to a lesser extent and the changes in un- smaller [26]. Some of the observed changes in seizure frequency bound concentrations are insignifcant [28]. Marked decreases in are likely to be explained by the normal spontaneous fuctuations total phenytoin concentrations to about 40% of prepregnancy levels in seizure occurrence, but it appears that some periods of pregnan- have been reported [34], whereas free concentrations decreased to cy are associated with a signifcant increase in seizures. For valproic acid, no signifcant changes were alized tonic–clonic seizure occurs during labour in about 1–2% noted in unbound concentrations despite a fairly marked decrease of pregnancies of women with epilepsy and within 24 hours afer in total concentrations [34]. Taking all seizure types together, such as valproic acid and phenytoin, total plasma concentrations roughly 5% of women with epilepsy will experience seizures during can be misleading during pregnancy, underestimating the pharma- labour, delivery or immediately thereafer. In some patients, serum concentrations decline in late carbamazepine, lamotrigine, phenobarbital or valproate [32]. Of pregnancy to 30% of prepregnancy levels, with normalization all cases, 67% remained seizure-free throughout pregnancy. Such alterations in serum con- eralized tonic–clonic seizures occurred in 15% of the pregnancies. Recent data suggest a similar decline in likely to remain seizure-free (74%) than women with focal epilep- serum concentrations of the active moiety of oxcarbazepine [28] sy (60%). Worsening in seizure control from the frst to second or and a fall in serum concentrations of levetiracetam of up to 50% third trimesters occurred in 16% of pregnancies. The fgures quoted represent average changes for groups of pa- Status epilepticus occurs in less than 1% of all pregnancies of tients, while the efect of pregnancy varies among individuals. The women with epilepsy and does not seem to occur more frequently decline in plasma concentration is insignifcant in some patients during pregnancy than in other periods of life. A single drug level is of limited value cated that poor compliance with the drug treatment, ofen because because the optimal concentration difers in diferent individuals. If seizures occur for the frst time during the last The literature on rates of obstetric complications in pregnant wom- 20 weeks of pregnancy, eclampsia needs to be excluded. Earlier studies suggest cerebral venous thrombosis also occur at a higher frequency during that induction of labour and instrumental deliveries are more fre- pregnancy. This may be a consequence of fear of treatment also apply for women in pregnancy, although treatment seizures and unfamiliarity with epilepsy among obstetricians rath- is ofen withheld during the frst trimester unless the risk is high for er than a refection of an increased rate of obstetric complications. Caesarean section might be needed if frequent seizures greatly im- pair cooperation in the forthcoming labour and delivery or if a gen- Pharmacokinetics of antiepileptic drugs during eralized tonic–clonic seizure occurs during labour [26]. For these pregnancy reasons, pregnant women with epilepsy should be counselled by The pharmacokinetics of many drugs changes signifcantly during obstetricians who are familiar with epilepsy-related problems and pregnancy, and this can have consequences for maternal seizure delivery should take place in well-equipped obstetric units. Reproductive Aspects of Epilepsy Treatment 315 While some studies suggest that, with modern management, controls and criteria for malformations can account for the varia- there is no signifcant increase in common obstetric complications tion in outcome [34]. However, the prevalence Although the pathogenesis is likely to be multifactorial, including of malformations among children exposed to carbamazepine is genetic predisposition, socioeconomic circumstances, seizures and consistently fairly low (2. Secondly, it appears that malformation rates are higher in association with valproic acid Major congenital malformations than with carbamazepine or lamotrigine, and that the risk of ma- A large number of retrospective and prospective cohort studies jor malformations with lamotrigine is similar to that of carbamaz- have confrmed an increased frequency of major malformations epine.

In foc- the time required for the formation of a precipitate varies culation best penegra 50mg, soluble antigen–antibody complexes form in anti- with the system and contrasts with the rapidity of antigen gen as well as in antibody excess regions buy penegra american express. Generally order penegra 50mg line, it depends on the ratio reaction purchase 100 mg penegra overnight delivery, precipitate is developed with even minute quanti- of antigen to antibody and is more rapid at the equivalence ties of antigen, causing the curve to pass through the origin zone. Roitt and associ- bodies require longer times for precipitation (for example, ates demonstrated that one human antiserum to thyroglobu- gelatin–antigelatin system requires 10 d). Other factors such as the storage or serum, volumes, washing of the complexes, use of diluents, presence of active enzymes Although no satisfactory explanation has yet been offered for in serum, and state of aggregation of antigen may affect the the focculation curve, it may be attributable in part to such vari- course of the precipitation reaction. Flocculation is a variant of the preciptin reaction in which Different antigenic determinants may be involved in foccula- soluble antigens interact with antibody to produce precipi- tion and precipitation. The addition of toxin to the homologous tation over a relatively narrow range of antigen to antibody antitoxin in several fractions with appropriate time intervals ratios. Flocculation differs from the classic precipitin reac- between them results in a greater toxicity of the mixture than tion in that insoluble aggregates are not formed until a greater would occur if all the samples of toxin were added at once. If the antibody (or total ization if the toxin is added in divided doses than if all toxin protein) precipitated vs. In focculation reactions, given quantity of antitoxin if all toxin is added at one time than excess antibody as well as excess antigen inhibits precipita- if it is added in divided doses with time intervals between. Precipitation occurs only over a narrow range of anti- form of reaction has been called the Danysz phenomenon or body to antigen ratios. Neutralization in the above instances is tested are formed in both antigen and antibody excess. This phenomenon is attributed to the combination of other biological materials through the formation of a precipi- toxin and antitoxin in multiple proportions. The fraction of toxin to excess antitoxin leads to maximal binding of assay depends on the turbidity or cloudiness of a suspension. When a second fraction of toxin It is based on determination of the degree to which light is is added, insuffcient antitoxin is available to bring about neu- scattered when a helium–neon laser beam is directed through tralization. Equilibrium is reached after an appropriate time a standard curve devised from the light scatter produced by interval. The interaction between toxin and antitoxin is consid- solutions of known antigen concentration. This method is ered to occur in two steps: (1) rapid combination of toxin and used by many clinical immunology laboratories for the quan- antitoxin and (2) slower aggregation of the molecules. These tifcation of complement components and immunoglobulins reactions are outlined in the steps shown above. Antigen–Antibody Interactions 301 Antigens Antigens 1,2,3 1,2,3 Plain 3 Bands of 3 Bands of gel medium precipitation Antiserum precipitation formed by formed by containing Antiserum Ag-Ab Ag-Ab anti-1,2,3 containing interaction interaction antibodies anti-1,2,3 antibodies Single Diffusion in One Dimension Double Diffusion in One Dimension figure 8. This implies that the antigen preparations in adjacent overlaid with a mixture of the homologous antigens, and a peripheral wells are identical (reaction of identity); they have distinct band for each resulted. This constitutes a diffusion in two dimensions was developed by Ouchterlony reaction of nonidentity (Figure 8. Agar is poured on a fat glass surface such as a microscope slice, glass plate, or Petri It implies that the antigenic determinants are different in dish. Wells or troughs are cut in the agar and these are flled each of the two sample of antigen. Multiple reaction of partial identity occurs when two antigen prepa- component systems may be analyzed by use of this method rations that are related but not the same are placed in separate and cross-reactivities detected. Double diffusion in agar is adjacent wells with an antibody preparation that cross-reacts a useful method to demonstrate similarity among structur- with both of them placed in a central well (Figure 8. Antigen is placed in one well, the precipitation lines between each antigen– antibody antiserum in an adjacent well, and the plates are observed system converge, but a spur or extension of one of the pre- the following day for a precipitation line where antigen and cipitation lines occurs. This reaction of partial identity with antibody have migrated toward one another and reached spur formation implies that the antigen preparations are equivalent concentrations. A single line implies a single similar but that one has an antigenic determinant not pres- antigen–antibody system. A reaction of identity and nonidentity may tral well with others cut equidistant from it at the periphery be observed simultaneously, implying that two separate anti- are employed, a reaction of identity may be demonstrated by gen preparations have both common and different antigenic placing antibody in the central well and the homologous anti- determinants. A spur is an extension of a precipitation line observed in a two-dimensional double-immunodiffusion assay such as the Ouchterlony test. It represents a reaction of partial identity anti-y between two antigens that cross-react with the antibody. Mancini, in 1965, developed a quantitative technique employ- ing single radial diffusion to quantify antigens. Plates are Reaction of identity: Double immunodiffusion in two poured in which specifc antibody is incorporated into agar. The antigen is permitted to diffuse into the agar contain- cent wells and permitted to diffuse toward a specifc anti- ing antibody and produce a ring of precipitation where they body diffusing from a third well that forms a triangle with interact (Figure 8. The precipitation ring encloses an area the other two, a continuous arc of precipitation is formed. Standard curves are employed using known antigen standards, and the antigen concentration as Reaction of nonidentity: Double immunodiffusion in two refected by the diameter of the ring ascertained. The Mancini dimensions in gel can show that two antigen solutions are technique can detect as little as 1 to 3 µm/ml of antigen. If each antigen solution is depos- ited into separate but adjacent wells and permitted to diffuse Radial immunodiffusion is a technique used to ascertain toward a combination of antibodies specifc for each antigen the relative concentration of an antigen. Antigen is placed diffusing from a third well that forms a triangle with the in a well and permitted to diffuse into agar containing an other two, the lines of precipitation form independently of appropriate dilution of an antibody. This ring that encircles the well in the equivalence region is pro- reaction reveals a lack of identity with no epitopes shared portional to the antigen concentration. Diffusion coeffcient is a mathematical representation of Reaction of partial identity: Double immunodiffusion in a protein’s diffusion rate in gel. The diffusion coeffcient is two dimensions in gel can show that two antigen solutions useful in determining antigen molecular weight. This demonstrates trolyte, such as erythrocytes, latex particles bearing antigen, 20 12 11 1 15 10 2 9 3 49 66 93 146 185 8 4 mg/100 ml 7 5 10 6 5 0 50 100 150 200 mg/100 ml figure 8. Antigen–Antibody Interactions 303 1:240 dilution, the antibody titer is said to be 240. Thus, the serum would contain approximately 240 units of antibody per milliliter of antiserum. For absolute amounts of antibody, quantita- tive precipitation or other methods must be employed. Clusters of Free Antibodies Aggulated bacteria bacteria (agglutinin) bacteria Agglutination inhibition is diminished clumping of particles (agglutination) in vitro bearing antigen on their surface by the addition of soluble anti- (agglutinogen) gen that interacts with and blocks the agglutinating antibody. Bacterial agglutination is antibody-mediated aggregation or bacterial cells to form an aggregate which may be viewed of bacteria. This technique has been used for a century in either microscopically or macroscopically (Figure 8. If the diagnosis of bacterial diseases through the detection of antibody is linked to insoluble beads or particles, they may an antibody specifc for a particular microorganism or for the be agglutinated by soluble antigen by reverse agglutination. To carry out an agglutina- on the surface of particles such as erythrocytes, bacteria, tion reaction, serial dilutions of antibody are prepared and or latex cubes to cause their aggregation or agglutination in a constant quantity of particulate antigen is added to each an aqueous environment containing electrolyte. Red blood cells may serve as carriers for other than agglutinin antibody that cause agglutination or adsorbed antigen, e. Like precipitation, agglutination is a second- hemagglutinating viruses and lectins. As specifc antibody cross-links particulate antigens, aggregates form An agglutinogen is an antigen on the surface of particles that become macroscopically visible and settle out of suspen- such as red blood cells that react with the antibody known sion. Thus, the agglutination reaction has a sensitivity 10 to as agglutinin to produce aggregation or agglutination. The bentonite focculation test is an assay in which benton- ite particles were used as carriers to adsorb antigens. These However, massive agglutination may occur without immuni- antigen-coated bentonite particles were then agglutinated by zation. Antibodies alone are not enough and phagocytes must the addition of a specifc antibody. Titer is the quantity of a substance required to produce a Passive hemagglutination is the aggregation by antibodies reaction with a given volume of another substance. An agglutination titer is the highest dilution of a serum which causes clumping of particles such as bacteria.

Surgical implications of bronchopulmonary dysplasia buy penegra 50mg otc, Pediatr Surg 22:1132- 19S7;1136 penegra 100mg visa. A comparison of nebulized budesonide buy penegra 50 mg without prescription, intramuscular dexamethasone buy penegra 50 mg low price, and placebo for moderately severe croup, N Engl Med 1998;339:498-503. Blunt pediatric laryngotracheal trauma: case reports and review of the literature, Am J Emerg Med 1994;12:207-11. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials, Pediatrics 1989;83:683-93. Pericardial fl”p,aor- topexy: an ea~and sate technique In the treatment of tracheomalacia. Retropharyngeal abscess management in children: current practices, Otolaryngol Head Neck Surg 1999;121:398-405. Effectiveness of continuous positive airway pressure in the treatnent of bronchomalacia in infants: A bronchoscopic documentation, Crit Care Med 1986;14:125-27. Tracheobronchial abnormalities in infants with bronchopulmonary dysplasia, Pediatr 111:779. Epiglottis: Incidence of extraepiglottis and pneumonia: Report of 72 cases and review of the literature, Pediatrics J 1976;58:526-31. Topical mitomycin as an adjunct to choanal atresia repair, Arch Otolaryngol Head Neck Surg 2002;12S:39S-400. Central vocal cord paralysis and paresis presenting as laryngeal stridor in children, Laryngoscope 1990;100:10-13. Dexamethasone in the prevention of postextubation stridor in children, J Pediatr 1991;118:289-94. Aryepiglottoplasty for laryngomalacia: 100 consecutive cases, Laryngology Otology 2001;115:35-3S. Prospective randomized double blind stuby comparing L-epinephrine and racenic epinephrine aerosols in treatment of Laryngotracheitis (croup). A randomized comparison of helium-oxygen mixture (Heliox) and racemic epineph rine for the treatment of moderate to severe croup, Pediatrics 2001;107:E96. Sudden fatal cardiac arrest in a child with an unrecognized anterior mediastinal mass, Resuscitation 1990;19:175-77. Incidence of vocal fold paralysis in infants undergoing ligation of patent ductus arteriosus, Ann Thorac Surg 1996;61:814-16. Laryngoscopy and intubation are potent physiologic stimuli that are associated with severe discomfort, profound cardiovascular and cerebrovascular changes and increased airway reactivity. The chapter focuses on basic physiology and anatomy of airway and describes the techniques and adjuncts used in airway management and treatment of respiratory failure. How pediatric airway is different from adult airway with their clinical consequences? The pediatric airway differs from the adult airway in several important anatomic and physiologic ways. By 6 months, dimensions of the nares have nearly doubled, but they are still easily occluded by edema, secretions or external pressure. The airway of the infant or child is much smaller in diameter and shorter in length than the airway of the adult. This reduction in diameter markedly increases resistance to airflow and therefore work of breathing. The infant larynx is high in the neck at birth, with the epiglottis at the level of the first cervical vertebra. By 6 months the epiglottis has moved to about the level of the third cervical vertebra. It continues to descend to its adult position at about the fifth or sixth cervical vertebra. The high position of the larynx makes the angle between the base of the tongue and glottic opening more acute. As a result, straight laryngoscope blades are often more useful than curved blades for creating a direct visual plane from the mouth to the glottis. The epiglottis in infants and toddlers is long, floppy, narrow and angled away from the long axis of the trachea. This problem can be overcome by using a straight laryngoscope blade and by directly lifting the epiglottis. While intubating a child the tracheal tube may become caught at the anterior commissure of the vocal cords. In children younger than 10 years, the narrowest portion of the airway is below the vocal cords at the level of the non distensible cricoid cartilage and the larynx is funnel shaped. In teenagers and adults the narrowest portion of the airway is at the glottic inlet and the larynx is cylinder shaped. Tracheal tube size must be based on the size of the cricoid ring rather than the size of the glottic opening. In the infant and young child, the subglottic airway is smaller and more compliant and the supporting cartilage less developed than in the adult. The subglottic airway tends to collapse or narrow if there is upper airway obstruction. Under normal conditions the glossopharyngeal muscles maintain the tone of pharyngeal airway. This approximation of structures in combination with large tongue, small mandible and inadequate glossopharyngeal muscle tone (especially in a child with altered level of consciousness) contributes to the vulnerability to airway obstruction in infants. In virtually any settings where respiratory difficulty is suspected, oxygen should be administered. Any patient who is unable to maintain airway develop respiratory failure or require therapeutic hyperventilation (increased intracranial pressure) a functional airway should be established and ventilated. Alternative airways Oxygen Administration Administer oxygen to all seriously ill or injured patients with respiratory insufficiency, shock, or trauma. During cardiac arrest a number of factors contribute to severe progressive tissue hypoxia and the need for supplemental oxygen administration. At best, mouth-to-mouth ventilation provides 16 to 17% oxygen with a maximal alveolar oxygen tension of 80 mm Hg. Even optimal external chest compressions provide only a fraction of the normal cardiac output, so that blood flow and therefore delivery of oxygen to tissues are markedly diminished. The combination of low blood flow and usually low oxygenation leads to metabolic acidosis and organ failure. Oxygen should be administered to children demonstratingcardiopulmonary arrest2 or compromise to maximize arterial oxygen content even if measured arterial oxygen tension is high, becauseoxygen delivery to tissues may still be compromised by a low cardiac output. Whenever possible, humidify administered oxygen to prevent drying and thickening of pulmonary secretions; dried secretions may contribute to obstruction of natural or artificial airways. The concentration of oxygen delivered depends on the oxygen flow rate and the patient’s minute ventilation. If the inspiratory flow rate exceeds the oxygen flow rate, air is entrained, reducing the oxygen concentration delivered. Masks If the patient demonstrates effective spontaneous ventilation, use a simple face mask to provide oxygen at a concentration of 30 to 50%. To provide a consistent concentration of oxygen, the mask of appropriate size should provide an airtight seal without pressure on the eyes. If the mask has an inflatable rim, the rim can mold to the contours of the child’s face to minimize air leak. This low-flow device delivers varying inspired oxygen concentrations, depending on the child’s respiratory rate and effort and the size of the child. Nasal cannulas are often better tolerated than a face mask and are suitable to use in children who require modest oxygen supplementation. Nasal cannula flow rates >4 L/min for prolonged periods are often poorly toleratedbecause of the drying effect on the nasal mucosa. Do not use an oropharyngeal airway in the conscious child because it may induce vomiting. An improperly sized oropharyngeal airway may fail to keep the tongue separated from the back of the pharynx or may actually cause airway obstruction. To select the proper size (length) of oropharyngeal airway from flange to distal tip, choose one equal to the distance from the central incisors to the angle of the jaw. They may be useful in children with a diminishedlevel of consciousness or in neurologically impaired childrenwho have poor pharyngeal tone leading to upper airway obstruction. In very young patients, airway secretions and debris readily obstruct small nasopharyngeal airways, making them unreliable.

During the initial consultation discount penegra 100 mg with amex, the procedure is the ideal candidate for a suture lift has mild ptosis explained in detail and all potential risks and of brow purchase 100mg penegra overnight delivery, lateral canthus buy penegra 50 mg online, malar fat pad purchase penegra without a prescription, jowls, or neck. An instruction leafet is Even mild ptosis in these areas can produce a sad provided (Table 34. Smoking reduces blood circulation, slows down healing, and may increase complications 2. Aspirin affects your blood’s ability to clot and could increase your tendency to bleed during surgery or during the postoperative period 3. They may increase your risk of bleeding and bruising during and following surgery 4. It is minimally invasive, requiring a small incision or puncture, often placed behind the hairline. Suitability for a Suture Lift You will be assessed thoroughly beforehand to determine if you are suitable or not. Typically, patients who are suitable have mild drooping or sagging of cheeks, jowls, neck, or brow and are otherwise in good physical and mental health. If you have more severe sagging, a suture lift might not be appropriate, and you will be advised on alternatives. Then a small incision is placed, usually behind the hairline where it is out of sight, and a stitch is passed under the skin in the fat or under muscle or fascia (layer above muscle). Special precautions You should not proceed with this procedure if you are pregnant or breast feeding, or if you are allergic to local anesthetic agents. If you have medical conditions or are on certain medications, such as aspirin, steroids or warfarin, treatment may be deferred, so you need to give your doctor your complete medical history. You should avoid taking vitamins and herbal supplements such as Ginko Billoba and St John’s W ort for 2 weeks before treatment. Potential risks and com plications of a Suture Lift procedure A small cannula (like a needle) is passed under your skin. As such, there is always a small risk of damage to structures under the skin, including the facial nerve, other nerves and blood vessels, causing facial weakness, numbness or bleeding. Numbness usually resolves or improves over time You may experience some swelling, bruising, and pain following the procedure. As with any injectable or invasive procedure, you may develop an infection, though the chance is low. You will receive a course of prophylactic antibiotics for 1 week following your treatment. Benefts and outcom es of treatm ent It is usual to notice immediate lifting of the treatment area. There is a small possibility that the procedure will fail if the suture cuts through the fat and tissue under the skin. Benefts of a suture lift will last a variable period of time, depending on the individual, and no guarantee of results or longevity of results is given It is usually possible to reverse or repeat the procedure if required. Alternatives to a Suture Lift procedure Alternatives to a suture Lift procedure include noninvasive skin tightening using infrared light or radiofrequency, other suture lift procedures, a surgical face lift procedure, or indeed no treatment at all. Yes No If yes, specify:________________________ Are you currently taking any of the following medications: warfarin, aspirin, palvix, steroids? Yes No Have you previously completed a New Patient Data Form at Venus M edical Beauty? Yes No Please state if you have any other medical conditions, allergies, or are taking any medications not previously outlined in the New Patient Data Form: 34 Suture Lifting Techniques 395 Table 34. I consent to being photographed prior to treatment and understand that this photograph will remain the property of Venus M edical Beauty and may be used for educational or academic purposes. I have outlined the expected benefts of treatment, as well as any potential risks, complications and side-effects of treatment. I have given the patient the opportunity to read the literature pertaining to this treatment and clarifed any further questions and queries where they existed. The author uses absorbable nonbarbed sutures refects the origins of suture lifting. Some of the early suture lifts used nylon or ten- preceptor courses are available internationally [16]. The func- lifting techniques are made of nonabsorbable material tion of the barbs is to grasp tissue, distribute forces such as polypropylene and polytetrafuoroethylene, along the length of the barbed portion of the suture, or absorbable material including polydioxanone and and elevate or compress tissue in the direction of the polycaproamide. Sulamanidze invented barbed spread use today, although newer designs such as coned sutures for facial rejuvenation in 1998. Nonbarbed suture lifts, such as those using lengths and sizes that are inserted subcutaneously braided absorbable polycaproamide, may cut through through an 18-gauge spinal needle. Happy Lift Double Needle ough knowledge of facial anatomy to ensure appropri- sutures (Promoitalia International Srl, Rome, Italy) ate lifting without injury to underlying nerves. A are also polypropylene sutures with bidirectional classifcation for suture lifting techniques is presented barbs, but with straight needles swaged to either end. Although a number of techniques are This obviates the need for a spinal needle for place- available, there is a lack of evidence that one technique ment. The barbs on these sutures are forked, presum- or system is superior to the others. Happy Lift™ Ancorage (Promoitalia Int Srl, Rome, Italy) Nonbarbed suture lifts Subcutaneous lift 1. The smooth central press tissues to create volume and a lift that is perpendicular to portion suspends the malar fat. These described that elevate soft tissues and anchor them to polypropylene sutures have unidirectional barbs that lift stable temporalis or mastoid fascia [17]. Although Contour Threads are no Isse [18] and Contour Threads (Surgical Specialties longer in distribution, they were used widely [20–22]. For mid- Contour Threads, although there is a greater barb density face rejuvenation, Sasaki describes his technique using on the Italian sutures and the barbs are forked. Serdev improved upon Guillemain’s original and M endez-Florez’s revised curl lift techniques by using slowly absorbable nonbarbed semi-elastic polycapro- 34. Using curved suture-passing needles of vari- cosmetic enhancement in 1956 using a strip of nylon to ous lengths, the braided antimicrobial sutures are elevate a ptotic buccolabial fold [12]. Erol and Hernandez-Perez described sim- held in place by anchoring the proximal ends of the plifed suture suspension techniques to lift the brow sutures to the deep temporal fascia, periosteum, or using nylon and polypropylene, respectively [23, 24]. There are certain advantages Although these procedures are quick and simple, results of Serdev’s techniques. Other nonbarbed sutures used to lift braided sutures also yield to movement due to their 398 P. The procedure is performed through tiny the rationale for using cones instead of the commonly stab incisions only without the need for skin closure. Secondly, the tensions applied to barbs are procedures are likely as the aging process continues. Finally, the cones incite an infam- matory response around the sutures, anchoring them in 34. These coned sutures are currently marketed as the Silhouette Isse developed a polypropylene suture with regularly Suture (Silhouette Lift; Kolster M ethods Inc. A newer 34 Suture Lifting Techniques 399 blue dyed Silhouette suture with six cones is now available. Dyed sutures are easy to fnd if attempts are made to retighten the suture by opening the old inci- sion site in the scalp. In appropriately selected patients, these sutures elevate the malar fat pad, jowls, and neck through minimal incisions under infltrative local anes- thesia and allow a quick return to normal activities. Elevating the midface, in particular, provides notice- able rejuvenation by restoring the beauty triangle 34. The closed suture lifting techniques described here require passage of straight needles swaged to sutures or curved suture- Fig. This danger zone (red) extends from the infe- Semi-sharp needles are passed blindly in the subcutane- rior border of the zygomatic arch to a line above the bony lateral canthus. Important anatomical the facial nerve is vulnerable to injury where it passes superf- considerations for suture lifting include the following: cially in the superfcial temporal fascia 1. This variation exists of the facial nerve, and frontal branch of the super- in the forehead, parotid, zygomatic, and infraorbital fcial temporal artery. The temporal medial to the nasolabial fold, in the upper and lower branch of facial nerve is usually described as hav- lips.

This danger zone (red) extends from the infe- Semi-sharp needles are passed blindly in the subcutane- rior border of the zygomatic arch to a line above the bony lateral canthus order penegra on line. Important anatomical the facial nerve is vulnerable to injury where it passes superf- considerations for suture lifting include the following: cially in the superfcial temporal fascia 1 generic 100mg penegra with mastercard. This variation exists of the facial nerve cheap 100 mg penegra amex, and frontal branch of the super- in the forehead generic penegra 50mg with mastercard, parotid, zygomatic, and infraorbital fcial temporal artery. The temporal medial to the nasolabial fold, in the upper and lower branch of facial nerve is usually described as hav- lips. M ore ing skin and has an important role in transmitting accurately, the nerve can be found between 2. The materials and instruments required depend on the tech- nique and sutures employed. Lifting the mid and lower face using Silhouette sutures (Silhouette Lift; Kolster M ethods Inc. The greater auricular nerve is prone to injury as it M onopolar diathermy, skin retractors, and instruments passes through this danger zone behind the border of platysma for suturing and skin closure are useful for suture lift- ing techniques that require incisions and dissection in be grasped using curved needles at the level of the the scalp. A list of materials required for suture lifting zygomatic arch close to the external acoustic using coned Silhouette sutures is provided in Table 34. During brow suture lifts, the needle should stay For techniques using nonbarbed sutures, the entire superfcial to avoid the deep branch of the supraor- procedure can be performed through stab incisions bital nerve as it courses medial to the temporal crest only without the need for skin closure. The medial brow lies in a danger zone where required for suture suspension using polycaproamide the supraorbital and supratrochlear nerves exit their sutures are listed in Table 34. The method described here employs absorb- canal, the greater auricular nerve can be found half able bidirectional barbed sutures to elevate the dermis way between the posterior and anterior borders of of the lateral brow with anchorage under the galea at sternocleidomastoid [31]. A danger zone can be considered as an oblong, 2 cm wide and 6 cm long, with its centre on a point 6. Suture suspension the suture lifting techniques described here use sub- of the platysma for neck lifting should avoid this cutaneously inserted coned or barbed sutures and area. For brow line vertically with the lateral limbus or just lateral to elevation, the author uses absorbable barbed sutures. To make a preoperative assessment, place the Coned sutures placed in the thin tissues of the fore- thumb 1 cm above the lateral third of the brow and lift head are more likely to be visible or palpable and lift- 0. In older patients with derma- ing the galea superiorly using nonbarbed sutures does tochalasis, manual elevation of the brow may cause not provide satisfactory elevation of the brow. These patients may require blepharoplasty or a A bidirectional convergent barbed polydioxanone forehead lift. Two weeks prior to brow suture lifting, suture (Happy Lift Revitalizing, Promoitalia, Srl, chemodenervation of lateral fbers of orbicularis oculi Rome, Italy) with a smooth central portion and two with botulinum toxin should be performed to alleviate needles swaged to either end is used for the brow lift the depressor action of this muscle on the lateral brow (Fig. The needle is pulled through so that the central smooth Needle, Promoitalia Srl, Rome, Italy). The portion of the suture is situated in the brow between the two punc- brow is elevated manually to determine the appropriate amount of tures. The barbs on the created allows easier passage of the needle in the superfcial subcu- sutures grasp the subcutaneous tissues and hold the brow in an taneous plane. The suture lifts the dermis of the brow and suspends it via the anchored convergent barbs to the galea aponeurotica above the hairline to the lateral third of the brow. About 10 mL of lidocaine with epinephrine (1:200,000) diluted with 10 mL of normal saline is drawn into a 20 mL syringe and infltrated subcutaneously along the path of the marked lines and in the lateral brow. Although anes- thesia of this area could be achieved with supraor- bital nerve blocks, the hydrotomy achieved with infltrative anesthesia allows easier passage of the needle in the subcutaneous tissues. In the scalp, at the proposed point of anchorage of the suture, infl- tration is made deep to the galea to the level of the periosteum. Two stab incisions are made in the scalp in line with the desired vector for lifting the lateral brow. Using a 16-gauge needle, a puncture is made through the skin at the tail of the brow and in the hair of the Fig. The frst needle, with suture should be pulled inferiorly when the patient is asked to force- attached, is passed from the tail of the brow, intrad- fully close the eyes, but should not rise when the patient is asked ermally, to exit at medial puncture. This avoids inadvertently denervating central portion of the suture will come to lie in the fbers of frontalis, which act to elevate the brow. One or more injections can be made in the orbicularis 2 weeks before a brow dermis of the brow. Placement below the dermis in lift to alleviate the depressor action of this muscle the subcutaneous tissue has a propensity to cut 406 P. Stab incisions dle then re-enters the medial puncture and passes using a #11 blade are made at the marked points. The subcutaneously along the marked path to exit from curved needle is passed from the upper medial inci- the incision in the scalp. The second needle passes sion to the lower medial incision, under the superf- from the tail of the brow, subcutaneously to exit the cial temporal fascia but above the deep temporal incision in the scalp. To fnd this plane, lift a tuft of hair above the the superfcial tissues above the lateral brow to avoid path of the needle and pass the needle deeply. The needles should be a thick layer of tissue covering the needle are cut from the sutures so that two barbed suture following passage, but it should not be so deep that ends exit from the scalp incisions. However, anchor- passed through the eye of the needle and the needle is age of the proximal cut ends of the suture under the withdrawn. Next, the needle is passed in the superf- galea further secures the lift and prevents slippage. A cial subcutaneous plane from the lower lateral inci- curved suture-passing needle is passed deep to the sion to the lower medial incision and the suture end is galea from one incision to the other and the suture threaded through the needle’s eye and brought to the ends are brought through the same incision and tied. Finally the needle is passed into the upper medial incision, taking a bite of periosteum and deep Suture lifting in the temporal area provides a subtle temporal fascia along the superior temporal fusion but important rejuvenation in the upper face by lifting line, and exits from the upper lateral incision. The the tail of the eyebrow, the lateral canthus, and the suture is brought from this incision to the upper upper cheek (Fig. In the periorbital area, ele- medial one so that both ends exit from the same inci- vation of soft tissues by 2–3 mm provides noticeable sion. The frst is along a line drawn perpen- the hairline, and elevate the tail of the brow and upper dicular to the tail of the eyebrow, just behind the tem- face. A second point is made just behind the inverted or tethered down, are released using the tip hairline 4–5 cm inferior to the frst point. The incisions heal quickly by second- points are made above the frst points in line with the ary intention. One of these points should be along is usual along the hairline but this contracts and the superior temporal crest line where the deep tem- disappears in 1–2 weeks. After skin preparation and sterile draping, local anes- thesia using lidocaine 1–2% with 1:200,000 adrena- 34. The inferior points mark the exit sites for 34 Suture Lifting Techniques 407 a c Fig. One of the superior incisions (b) is made along the the deep temporal fascia, and the needle receives the suture end superior temporal crest line (red dots). The suture is cut and buried by through the eye of the needle and the suture is brought back applying traction to the puncture site with the tip of an artery from point A to B. Some physicians pass the needle below the superfcial temporal fascia frst, and then redirect the needle to come superfcially into the subcutaneous plane at the level of the temporal hairline. However, it is easier to start the needle passage in the correct plane above the superfcial temporal fascia under direct vision at the temporal incision and continue into the malar fat pad in the same plane. As the needle is passed along its course, the nondominant hand gently grasps the tissues over the needle as it passes through the tem- ple and then malar fat pad. A blunt trocar, provided by the suture company, can be used to facilitate atraumatic passage of the needle through the tissues before emerg- ing from the skin. If the suture passes too superfcially it may catch the dermis and lead to irregularities. At this point, one the points should not be made below a line drawn from or more cones can be cut from the suture as outlined the lobule of the ear to the modiolus. Sutures passing above, making sure not to pull through any cones that below this line could disrupt with movement of the are to remain on the suture.

The rib will be identified as a hyperechoic curvilinear line with an acoustic shadow beneath it order 50mg penegra with amex. The three layers of intercostal muscle cheap 50mg penegra with mastercard, the external buy 100mg penegra with amex, internal order penegra 50mg fast delivery, and innermost, will be identified in the intercostal space between the adjacent ribs (Fig. Color Doppler will help identify beneath the adjacent intercostal artery and vein (Fig. This space between adjacent ribs provides an excellent acoustic window which allows easy identification of the intercostal space and the pleura beneath it. Adjacent ribs with the intercostal space in between have been described as having the appearance of a flying bat (Fig. Longitudinal ultrasound image demonstrating adjacent ribs, the intercostal muscles, and pleura with the lung beneath. Longitudinal ultrasound view demonstrating the external, internal, and innermost intercostal muscles and the pleura and lung beneath them. The clinician should then identify the pleura which appears as a bright hyperechoic line known as the bright sunset pleural line due to its resemblance to the bright line that appears on the horizon as the point at which the sun sinks below the horizon (Figs. In health the pleura and adjacent lung should be seen to slide back and forth on one another during normal respiration. A,B: the ultrasound appearance of adjacent ribs and intercostal space between has been described as having the appearance of a “flying bat. Longitudinal lung scan with low-frequency curvilinear ultrasound transducer: two adjacent ribs and the echogenic pleural line between and below them. Visualization of the flying bat sign is useful for detection of the pleural line, and should be the first step in lung evaluation. Once these sonographic anatomic landmarks are clearly identified, the clinician can then proceed with ultrasound evaluation for pathology of the pleura and underlying lung. Ultrasound evaluation for pneumothorax is carried out with the patient in the sitting or semisupine position based on patient comfort. Since almost 100% of clinically significant pneumothoraces will have an anterior and/or inferior component when the patient is placed in the semisupine position, a linear high-frequency ultrasound transducer is then placed in the longitudinal plane with the superior aspect of the ultrasound transducer rotated approximately 15 degrees laterally on the anterior chest wall and an ultrasound survey scan is obtained (Figs. Since nearly all clinically significant pneumothoraces have an anterior and/or inferior component when the patient is placed in the semisupine position, a linear high-frequency ultrasound transducer is placed in the longitudinal plane with the superior aspect of the ultrasound transducer rotated approximately 15 degrees laterally on the anterior chest wall. After the pleura is identified, the next step is to ascertain if the pleura and adjacent lung are sliding back and forth with respiration. The sliding of the bright line of the pleura and underlying lung is known as the sliding lung sign and if present, always precludes pneumothorax in the anatomic area being imaged (Fig. It is important to note that while the presence of a sliding lung sign excludes the diagnosis of pneumothorax in the area being imaged, the converse is not true. The absence of a sliding lung sign, while highly suggestive of the diagnosis of pneumothorax, is also observed in the absence of pneumothorax in some patients who are posttotal pneumonectomy or who are suffering from acute respiratory failure, apnea, pleural adhesions, massive atelectasis, severe pulmonary fibrosis, phrenic nerve palsy, rapid mechanical ventilation with small tidal volumes, and cardiopulmonary arrest. In this setting the clinician should next turn his or her attention to the lung just adjacent to the pleura and image this area of lung using M-mode ultrasound. If no pneumothorax is present, the pleura and the lung beneath it have been described as having the appearance of “waves on a sandy beach” (Figs. The waves on a sandy beach pattern is caused by the reflection of ultrasound waves by the bright white line of the pleura which lies between the waves created by the relatively motionless chest wall, the sand beneath the white line which is created by the evenly moving lung below. M-mode ultrasound will also aid in the identification of the lack of lung sliding by demonstrating the stratosphere sign as the lines look similar to the contrail vapor trails left by a jet flying at high altitude (Fig. A: Oblique scan of an intercostal space, showing the pleural line and some horizontal repetition artifacts called A-lines. B: M mode is useful to objectify the lung sliding by visualization of the seashore sign. The pleural line is between waves (the motionless thorax wall, above) and sand (the respiratory moving lung, below). However, between two ribs, strictly half a centimeter below in the adult, the pleural “bright sunset” line is located. The horizontal A-lines that arise from the pleural line have clinical implications. A flagrant difference in the pattern which appears on either side of the pleural line. A: M-mode ultrasound will demonstrate the stratosphere sign in the presence of pneumothorax due to the absence of the motion of lung sliding on pleura. Exclusively horizontal lines are displayed, indicating complete absence of dynamics at the level of, and below, the pleural line (arrowheads), a pattern called the stratosphere sign. A: If a pneumothorax is present, the lung just adjacent to the pleura will have the appearance of “ripples on a pond” due to the artifact produced by the perturbation of the ultrasound waves caused discontinuity of the parietal and visceral pleura as the visceral pleura which closely adheres to the lung pulls away from the parietal pleura, which is attached to the chest wall. The sonogram of the highest point of the thorax in supine position shows a sector of reverberation artifacts that resemble ripples on a pond. This point is known as the “lung point” and it is identified by moving the ultrasound transducer from the anterior point at which the ripples on the pond sign is identified until the lateral margin of the anterior pneumothorax is reached (Fig. The normal waves on a sandy beach sign may alternate with the abnormal ripples on a pond sign when the patient is asked to take a deep breath as the area of lung which has pulled away from the chest wall moves back and forth under the ultrasound transducer as the chest wall expands and contracts with respiration (Fig. The location of the lung point has an added advantage when placing a chest tube as the clinician can avoid placing the tube into an area of normal lung. Clinical experience has shown that the presence of a lung point only in anterior position is indicative of a small to moderate pneumothorax and the more lateral and posterior the lung point is identified, the larger and more clinically significant the pneumothorax. Obviously, if there is a complete pneumothorax, the lung point will not be identifiable. On the right (time–motion), a sudden change is visible at the precise location where the collapsed lung, subject to a slight increase in volume during inspiration, reaches the wall. The “sandy” pattern generated by lung sliding instantaneously replaces a pattern formed by horizontal lines (arrow). A probe placed at a point slightly anterior to the lung level will display a pneumothorax pattern. B: At inspiration, we must imagine that the lung volume slightly increases, therefore increasing the surface of the lung in contact with the wall. The probe remaining at the same location will immediately display fleeting lung patterns. The B-line is an easily seen artifact that always arises from the bright sunset line of the pleura and spreads out as it moves deeper into the lung without disappearing or fading in intensity. The B-line has the appearance of a comet tail and erases the horizontal A-lines as it moves deeper into the lung (Fig. A-lines are simply reverberation artifacts from the pleura and are characterized by the fact that they are parallel with the bright-line pleural sunset line and do not move (Fig. The presence of single or multiple B-lines essentially rules out the presence of pneumothorax in the area being imaged (Fig. Multiple B-lines, which are also called lung rockets because they have the appearance of a rocket at liftoff, are artifacts caused by fluid-filled interlobar fissures have been associated with lung disease that has as part of its pathophysiology increased extravascular lung fluid (Fig. These lung rockets are analogous to the Kerley B-lines seen on plain radiographs and are associated with a variety of interstitial lung diseases including pulmonary edema, mycoplasma 646 pneumonia, viral pneumonia, sarcoidosis, and interstitial pulmonary fibrosis (Figs. With significant extravascular lung fluid, there can be a merging of multiple B-lines that have been termed the shining lung sign (Fig. On both sides, the upper and lower ribs of the intercostal space are recognized by their acoustic shadow. Only one arises at a distance from the pleural line, which is the critical distance between the probe head and the pleural line. Four or five comet-tail artifacts are visible fanning out from the pleural line, vertically oriented, well-defined, laser-beam–like, erasing A-lines, and spreading up to the edge of the screen without fading, that is, ultrasound B-lines. Several B-lines visible in a single view are suggestive of a rocket at liftoff, hence the label “lung rockets. This lateral scan did not show the alveolar lesion, but multiple B-lines are often detected in the thoracic areas surrounding it (pneumonia of the posterior right lobe). Real-time lung ultrasound for the diagnosis of alveolar consolidation and interstitial syndrome in the emergency department. These vertical comet-tail artifacts have the specific peculiarities of strictly arising from the pleural line, being well defined and laser-like, moving with the lung sliding, spreading to the edge of the screen without fading, and erasing normal A-lines. A: Ultrasound diffuse positive pattern: Comet-tail artifacts (or B-lines) are multiple (at least three) in each scan and diffuse in all the eight anterior and lateral scans (four per side).