They also noted that surgeons placing vaginal mesh should undergo training specific to each device and have experience with reconstructive surgical procedures and a thorough understanding of pelvic anatomy order lyrica 75mg otc. Prior to considering treating the anterior vaginal prolapse with graft or mesh lyrica 150 mg low price, patients should undergo a thorough informed consent process including discussion of risks purchase lyrica 150mg on line, benefits discount lyrica 75mg with visa, and both surgical and nonsurgical alternative treatments. Many surgeons would not consider the use of mesh in a patient who has had a previous mesh complication. Mesh augmentations should not be used in pregnant women or women who are contemplating future pregnancy, as the vaginal mesh does not stretch significantly. In patients who have had pelvic radiation, mesh placement is not recommended because of the risk of poor wound healing. Similarly, preexisting local or systemic infection is a contraindication for vaginal mesh placement, particularly nonabsorbable synthetic mesh. Many surgeons would not recommend the use of nonabsorbable synthetic mesh if colorectal surgery is being performed concurrently. Chronic steroid use, smoking, uncontrolled diabetes mellitus, or other causes of a compromised immune system can impair wound healing, and many would consider these conditions to be relative contraindications to vaginal mesh placement. Pelvic pain syndromes such as endometriosis, vulvodynia, interstitial cystitis, fibromyalgia, and dyspareunia should be evaluated preoperatively to allow for comprehensive counseling as to the best surgical and nonsurgical form of treatment. Currently, there are three general categories of transvaginal mesh or graft placement options for the management of anterior vaginal prolapse: (1) self-tailored mesh, (2) commercially available trocar- 1256 guided mesh kits that use a transobturator approach, and (3) commercially available mesh kits that use a transvaginal fixation method rather than a trocar (nontrocar kits). The initial incision for anterior vaginal mesh placement usually involves significant hydrodissection and a deeper colpotomy incision than usually performed for a traditional native-tissue anterior colporrhaphy so that the perivesical space is entered. Despite the lack of evidence that any one placement technique is best in managing a patient’s symptoms, most experts would agree on some basic perioperative tenets: The bladder should be drained with a transurethral catheter. Inset: preferential support of the bladder neck when compared to the bladder base. The correct space for dissection is found using a “loss of resistance” technique similar to that used by an anesthesiologist placing an epidural. A wheal or blanching illustrates incorrect intraepithelial placement of the fluid. Hydrodissection in the correct plane will create a fluid bubble in the avascular vesicovaginal and rectovaginal spaces. It is vital that the surgeon perform a full-thickness dissection deep into the vesicovaginal and rectovaginal spaces to avoid erosion of the mesh postoperatively. Proper hydrodissection, as described earlier, facilitates the identification of the proper dissection plane. Allow enough room for Mayo scissors to be easily placed between the mesh and the vagina. Also, ensuring that the mesh is placed flat and with minimal tension will improve fibroblast growth and minimize complications of pain or erosion. The colpotomy incision is closed utilizing a nonlocking continuous absorbable suture. Self-Tailored Mesh Placement Self-tailored mesh can be customized by the surgeon to match the size and shape of each patient’s individual pelvic anatomy. This type of surgery requires a strong set of vaginal surgical skills as it involves dissections similar to sacrospinous ligament fixation, iliococcygeus suspension, uterosacral suspension, and vaginal paravaginal defect repair. No studies have compared standard repair techniques using self- tailored mesh with other mesh placement techniques. Trocar-Based Mesh Kits Trocar-guided devices can be used to suspend mesh by passing needles through the transobturator and/or ischiorectal fossa. While these three products are no longer marketed by their respective companies in the United States, some trocar-based kits are still available in the United States and worldwide. First, a weighted speculum, self-retaining retractor, or Deaver retractors are placed in the vagina. Allis clamps are positioned at the urethrovesical junction for traction and 1 cm distal to the vaginal apex. As opposed to an anterior colporrhaphy in which the vaginal epithelium and muscularis are split for plication, the mesh is placed underneath the muscularis to maintain a thickened vascularized epithelium in order to minimize mesh exposure or erosion. To enter this potential space, the surgeon injects a dilute vasopressin solution or 0. Irrigation may help during the dissection, as the defect is a glistening white line. A sagittal colpotomy incision is made between the Allis clamps long enough to admit two fingers comfortably. Next, countertraction along the entire incision line is achieved with either the serial Allis clamps or a self-retaining retractor. The vaginal epithelium and full-thickness muscularis are dissected away from the bladder defect. Sharp and blunt dissection of the bladder is then performed while keeping the muscularis and epithelium on the vaginal flaps. A number of different trocar types are available including helical-shaped trocars similar to those for transobturator slings and flexible straight trocars. Cutaneous incisions that are 4–7 mm in length are made over the appropriate locations for the obturator 1258 foramen and/or gluteus trocars. When placing multiple mesh arms through the transobturator space, the superior and inferior puncture sites should be at least 3 cm apart so the mesh can lay flat. Two fingers placed into the vagina can retract the colon, elevate the bladder, and minimize deviation of the trocar tip with direct palpation. If the surgeon conserves the uterus, then permanent sutures can be placed into the cervical stroma to stabilize the mesh. Cystoscopic and rectal examinations before, during, and after each portion of the surgery can be helpful. Once adequate hemostasis is obtained, the vaginal epithelium is closed with a continuous nonlocking stitch of delayed absorbable suture. Placing a lubricated vaginal pack may minimize bleeding and keep the mesh flat during healing. After desired tensioning, all ends of the mesh arms should be trimmed below the surface of the skin and the incisions closed. Concurrent procedures, such as a midurethral sling, should be done through a separate vaginal incision at this time. Nontrocar Mesh Kits The nontrocar or “single-incision” mesh kits have become increasingly popular and largely replaced trocar-based kits. The products avoid the potential complications associated with blind trocar passage through the transobturator space and ischiorectal fossa and allow mesh fixation via direct visualization. Additionally, most currently available nontrocar kits provide apical fixation to the sacrospinous ligaments bilaterally as well as anterior vaginal support. The technique for the nontrocar kits begins similarly to the technique for trocar-guided kit placement. For apical fixation, the surgeon palpates the location of interest then identifies the sacrospinous ligament at least 2 cm medial to the ischial spine. The mesh arms are slowly and individually adjusted to a loose tension, and then the mesh is sutured flat. Cystoscopy with visualization of ureteral flow is performed to ensure integrity of the bladder and ureters. Retropubic surgeries such as the Burch colposuspension are discussed in Chapter __. The preparation for vaginal paravaginal repair begins as for an anterior colporrhaphy. Marking sutures are placed on the anterior vaginal wall on each side of the urethrovesical junction, identified by the location of the Foley balloon after gentle traction is placed on the catheter (Figure 82. In patients who have had a hysterectomy, marking sutures are also placed at the vaginal apex. If a culdeplasty or apical suspension procedure is being performed, the stitches are placed but not tied until completion of the paravaginal repair and closure of the anterior vaginal wall. As for anterior colporrhaphy, vaginal flaps are developed by incising the vagina in the midline and dissecting the vaginal muscularis laterally. The dissection is performed bilaterally until a space is developed between the vaginal wall and retropubic space. Blunt dissection using the surgeon’s index finger is used to extend the space anteriorly along the ischiopubic rami, medially to the pubic symphysis, and laterally toward the ischial spine. If the defect is present and dissection is occurring in the appropriate plane, one should easily enter the retropubic space, visualizing retropubic, and paravaginal adipose tissue.

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Int J Cancer comes in aesthetic and reconstructive breast surgery using triple 118:998–1003 antibiotic breast irrigation: six-year prospective clinical study order lyrica 75 mg with visa. Deapen D generic lyrica 75mg on line, Hamilton A order 75mg lyrica otc, Bernstein L et al (2000) Breast cancer stage Reconstr Surg 117:30–36 at diagnosis and survival among patients with prior breast implants buy discount lyrica 150 mg. Handel N (2007) The effect of silicone implants on the diagnosis, ple technique using alloderm to convert subglandular breast prognosis, and treatment of breast cancer. Ann Plast Surg vertical scar breast reduction with glandular transposition of the nip- 59:250–255 ple-areola in breast asymmetry. Plast Reconstr Surg 104:771–781; discussion 782–784 incision, implant, and pocket plane. When we talk about tuberous breasts we enter into a This type of malformation carries great psychological vast realm of different definitions, anatomical characteris- impact and severe relationship implications because these tics, and correction techniques. Among the numerous defini- breast deformities sometimes present a grotesque appear- tions used to describe these malformations are tuberous ance and can seriously influence the fundamental perception breast, tubular breast, hypoplasia of the inferior pole, con- of patients’ femininity. This is the main reason why patients stricted inferior pole, snoopy breast, domed nipple, and affected by these malformations seek surgical help at a very intra-areolar herniation [1 ]. As a consequence, these cases the possible psychological damage that could there is an unclear embryological explanation and some con- negatively influence the psychological and emotional growth fusion concerning the possible surgical choices, which are of these young patients should be taken into consideration. To Crucially, in my experience to date I have never seen an obtain a correct diagnosis of the deformity, it is necessary to improvement of tuberous breast deformity as the patient have the following: ages; on the contrary, I have always noticed a worsening of the condition. This includes a general clini- cal evaluation, a local morphological evaluation, and, last but These questions will help the surgeon to better understand not least, an understanding of the patient’s expectations patient’s expectations, for example: “how do you imagine obtained through “clarifying questions. All clinical and social history has to be nects the deep surface of the gland with the fascia of the considered to rule out any long-term effect on tissue struc- pectoral muscle and with the muscle of the anterior ser- ture and dystrophy. Two thin layers of the superficial fascia are united above the superior border of the breast into a single thin layer, which then continues above the clavicle with the A patient in less than perfect health is a good candidate superficial cervical fascial muscle aponeurotic system for postoperative complications. The superficial and deep layers of the abdominal fascia are connected by a system called the suspension ligaments, 2. Some authors describe it as a “fibrotic constricting quite often the expectations in young patients are “very ring” at the periphery of the areola, more dense in the infe- high,” not having clearly in their mind the difficulties their rior half of the breast. Therefore, the surgeon must main- In both cases, the expansion of the gland into the infe- tain the proper balance between the duty to explain the dif- rior pole is prevented, and for this reason it projects itself ficulty of the case but without causing any anxiety or panic in forward, concentrating behind the areola, thus projecting the patient. The gland is In the presence of a confused patient with a psychiatric pushed forward, herniating into the areola, which becomes condition, it is advisable for the surgeon to decline or enlarged and expands, sometimes completely, around the postpone surgery. The procedure is completed by placing the criteria the simplest clear and synthetic technique to face this mammary prosthesis and performing cutaneous synthesis. This typical, seemingly insignificant, deformity is enhanced by the white line contouring the profile of Fig. This is a central inferior glandular flap with an inferior pedi- cle based on the superficial vascular net. The size and shape of the flap will vary from • Thickness of the tissue covering the thorax case to case, according to the quantity of gland herniating • Major or minor evidence of the mammary profile deformity into the areola. The flap is incised at full thickness from the surface up to Thus, we can distinguish: the muscular thoracic plane. One then proceeds to under- mine the residual gland from the deep plane and the soft tis- 1. This flap is created through Characteristics a small inferior periareolar incision; by doing so I tackle the “glandular protrusion” undermining it from the areolar skin, (a) Moderately hypoplastic or normoplastic breast just enough to sculpt the flap, leaving it pedicled to the glan- (b) Tubular morphological appearance dular surface. This small and relatively simple flap is capable of producing surprising improvement in the mammary profile and symmetrization with the contralateral breast. With such a flap the superior border of the in a 23-Year-Old Patient areola is flattened, and by transposing such a flap inferiorly, softening of the inferior protrusion with improvement in the mammary profile is achieved. The flap can have a lateral or medial pedi- cle, which is transposed inferiorly and caudally to the inferior border of the retro-areolar protrusion where deep glandular incisions on the mammary base were previously performed. Careful evaluation is done through palpation of the quantity of gland that will form the flap, and quantity of skin to be excised to flatten the areolar enlargement and increase the conization of the mammary apex Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 265 j l Fig. At this stage, through the existing cutaneous incisions, the prosthetic pocket is prepared and the prosthesis is implanted, the retro- k areolar glandular plane is sutured, and the cutaneous plane is closed, which will result in a periareolar scar devoid of any tension and a short vertical scar Result of Case 1 m F i g. A Second More Severe Example of Tuberous c Breast Type I Severe tuberous deformity in a 17-year-old patient, which presents all the morphological anomalies described in Case 1 but in a more extreme manner. This could demonstrate the absence of the superficial layer of the fascia of Scarpa and the absence of Cooper’s ligament at the level of the areola. In this projection, also evident are the fibrotic ring that completely surrounds the small mammary footprint on the tho- rax and its extreme lateralization with a very wide, totally flat inter- F i g. The mammary gland devoid of the dermis is incised at the level of the areola inferior border, perpendicularly up to the tho- F i g. Scarring is also satisfactory, although a few inferior periareolar striae still remain Case 3. This type of malforma- tion represents a double challenge because it sums up the difficulty of the tuberous deformity with the added difficulty of the breast asymmetry. As we are dealing with young patients, we must aim for good results that will be stable and long-lasting. Therefore, we take into consideration the factor defined in Plastic Surgery as the “fourth dimension,” namely, the passage of time, with its effect on body morphology and changes such as pregnancies and mere aging. It is fairly evident that a prosthetic breast will not undergo the same modifications as the natural breast; my motto, therefore, in cases of mammary asymmetry where one breast requires a mammary implant, is: “To reduce the bigger breast to the size of the smaller one, in order to use two equal pros- theses when this option is possible. This oblique projection shows a satisfactory breast shape with an adequate volume and ade- least two similar situations on both breasts, not only in regard quate areolar projection into the inferior pole to dimensions but also the shape. This procedure requires a very careful preopera- tive observation and palpation of the breasts with the patient in a standing position to discern the appropriate site and the correct quantity of gland that needs to be excised, thus reduc- ing the bigger breast to the shape and volume of the smaller one. When this approach is not possible, we must attempt to symmetrize both breasts with two different prostheses. However, the inferior pole still appears slightly flat and tense while in the areola infe- rior half we can observe a glandular, though small protrusion, which can be released through a small inferior periareolar cutaneous incision h Resezione ghiandolare sottocutanea F i g. On the skin of the infe- m rior pole is marked the subcutaneous site that will involve the small fla p j F i g. There is good symmetriza- tion, and the excessive lateralization of the breasts is sufficiently dis- guised by the filling of the mammary space q F i g. The right breast is severely hypoplastic while the left breast can be considered slightly or moderately hypoplastic. Volume asymmetry is such to allow, in my opinion, the application of my basic concept of adjusting the bigger F i g. Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 277 d F i g. These lines are pole, which will correspond to the point of its maximum protuberance On the left breast are marked the lines for mastopexy using the vertical technique with reduction of the areola, and f markings for the periareolar de-epithelialization of the infe- rior pole. This flap allows us to achieve two goals: the opening and relaxation of the mammary base, and the thickening of the g inferior pole. This technique, with few variations, has been described by Benelli [7, 8], Botti [3] (who calls it “mammary expan- sion”), and Persichetti et al. In some cases two flaps cans also be utilized, one laterally and one medially to the areola, leaving untouched the area under the subareolar region in order to maintain its projection. Tuberous Breast Variant of Type I: A Peculiar Case We may consider this as a variant of type I. Clearly evident is extreme breast lateral- ization with a pedicle that starts laterally from the anterior pillar of the axilla. This characteristic, together with the cutaneous areolar expansion, which has lost its contour in its inferior half of the de-epithelialization area in the inferior pole, represents the particular difficulty of this case Fig. This can be attained through mobilizing and transferring the glandular flaps from the lateral region to fill the medial region and then positioning the mammary implants at the center of the mammary cone. The flap in this peculiar case, unlike other flaps so far described, is created with a lateral pedicle, which allows the dragging of the greater part of the gland toward the medial quadrants. The de-epithelialization is performed according to relaxation of the gland that will constitute the lateral inferior quadrant preoperative skin markings. The dermis of the inferior pole is under- (Q3) and portion of Q4; and the medial flap (3), formed by the “open- mined from the glandular surface up to the inferior border of the ing” of the gland of the medial inferior quadrant. The lateral flap (2) is, as much as possible, pulled medially to form part of the inferior pole, which will cover the prosthesis. The dermal flap is repositioned on the gland at the center of fixed on the thoracic surface and, as much as possible, medially under the inferior pole, after which the skin incisions are sutured the medial flap (mf) (Muti E. The areolas are still some- areolas are still laterally positioned, but the medial quadrants are fuller what large, due to the redistribution of most of the peripheral periareo- and appear more normal, and the defect is disguised lar skin in order to reduce the vertical scar and perform a small refinement at the submammary sulcus k F i g.

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Prophylactic treatment with steroids and H blockers such as ranitidine and diphenhydramine may be indicated purchase 150 mg lyrica visa. External pressure can compromise blood flow discount 75mg lyrica amex, result- ing in edema purchase lyrica 75 mg with mastercard, ischemia order 75mg lyrica overnight delivery, and necrosis. When a nerve passes through a closed compartment or has a superficial course, it is more susceptible to injury. Risk factors for lower extremity neuropathy include prolonged lithotomy posi- tioning, hypotension, thin body habitus, increased age, vascular disease, diabetes, and cigarette smoking. Intraoperative Management Use of axillary roll with lateral decubitus position decreases the risk of brachial plexus injury. Consultation with a neurologist may be indicated for nerve conduction and electromyography testing. Before discharge, the patient notes she has numbness in her left leg and has difficulty walking. Common peroneal nerve The common peroneal nerve is the most commonly injured nerve in the lower extremity because of the super- ficial course it takes around the fibular head. The patient was placed in stirrups for the procedure, which likely caused compression of the nerve. Her vital signs on admission are heart rate, 47 beats/min; blood pres- sure, 80/50 mm Hg; respiratory rate, 18 breaths/min; oxygen saturation, 97%; and temperature, 36. Phenylephrine would increase her blood pressure but may exacerbate her slow heart rate by causing reflex bradycardia. Of course, the pulse rate can always be determined by palpation of peripheral arteries or auscultation of heart sounds. Treatment: If the patient is stable with normal mentation, blood pressure, and oxygen saturation, then obser- vation is appropriate. Note that hypoglycemia no longer included in Hs but nonetheless should still be included in the differential diagnosis. Better outcomes are associated with early chest compressions, quality of chest compressions (sternal depression of 1½–2 in (4–5 cm) in adults or 1–1½ in (2–4 cm) in children and then allowing for full reexpansion of the chest wall) and decreased time between intervals in chest compres- sions. If the provider is alone, he or she should give 30 compressions for every 2 breaths. If an advanced airway or bag-mask is used with another rescuer assisting, respirations should target 10 to 12 breaths/min. A pulse check and analysis of rhythm should be performed after 5 cycles of 30:2 compressions to breaths. The resulting rhythm and presence or absence of pulse will determine the next step in care. After the defibrillator pads are attached to the chest, the initial shock (120–200 J) is given. This cycle is repeated until another rhythm is identified or efforts have been exhausted. During the code, the Hs and Ts should be discussed, and treatment should be instituted (e. Clinical manifestations: Rapid heart rate with or without hemodynamic instability. Rate-related signs and symptoms can occur at many rates but infrequently at less than 150 beats/min. His postoperative pain is being treated with hydromorphone patient-controlled analgesia. At shift change, the nursing staff finds him unresponsive without a pulse, and a code is called. Because this has already been started, the next intervention should be to defibrillate. The airway can be secured after the initial shock because time to defibrillation is an important predictor of survival. Emergence from General Anesthesia Problems such as airway obstruction, shivering, agitation, delirium, pain, nausea and vomiting, hypother- mia, and autonomic labiality are frequently encountered. Delayed emergence The most frequent cause of delayed emergence (when the patient fails to regain consciousness 30–60 min after general anesthesia) is residual anesthetic, sedative, and analgesic drug effect. Nerve stimulator used to exclude significant neuromuscular blockade in patients on a mechanical ventila- tor who have inadequate spontaneous tidal volumes. Less common causes of delayed emergence include hypothermia, marked metabolic disturbances, and perioperative stroke. Supplemental oxygen should be administered during transport to patients at risk for hypoxemia. Rescue single-shot, continuous nerve blocks, or continuous epidural analgesia are used when moderate to severe postoperative pain is present or oral analgesia is not possible. Differential diagnosis of postoperative agitation includes serious systemic disturbances (e. Transdermal scopolamine is effective but associated with side effects such as sedation, dysphoria, blurred vision, dry mouth, urinary retention, and exacerbation of glaucoma, particularly in elderly patients. Shivering and Hypothermia The most important cause of hypothermia is a redistribution of heat from the body core to the peripheral compartments. Differential diagnosis for shivering includes nonspecific neurologic signs (posturing, clonus, or Babinski sign), bacteremia, sepsis, drug allergy, or transfusion reaction. These 2 physiological effects are poorly tolerated by patients with preexisting cardiac or pulmonary impairment. Hypothermia has been associated with an increased incidence of myocardial ischemia, arrhythmias, increased transfusion requirements caused by coagulopathy, and increased duration of muscle relaxant effects. Patients should have been observed for respiratory depression for at least 20 to 30 minutes after the last dose of parenteral opioid. Minimum discharge criteria for patients recovering from general anesthesia include: Easy arousability Full orientation The ability to maintain and protect the airway Stable vital signs for at least 15 to 30 minutes The ability to call for help if necessary No obvious surgical complications (such as active bleeding). Postanesthetic Aldrete Recovery Score Ideally, the patient should be discharged when the total score is 10, but a minimum of 9 is required. Treatment includes jaw-thrust maneuvers, small dose of succinylcholine (10–20 mg) and temporary positive-pressure ventilation with 100% oxygen to prevent severe hypoxemia or negative-pressure pulmonary edema. Glottic edema after airway instrumentation is an important cause of airway obstruction in infants and young children. Treatment Obtundation, circulatory depression, and severe acidosis (arterial blood pH <7. Large doses of naloxone in sudden pain and marked increase in sympathetic tone, which can precipitate a hypertensive crisis, pulmonary edema, and myocardial ischemia or infarction. Hypoxemia Most common cause of hypoxemia after general anesthesia: Increased intrapulmonary shunting from a decreased functional residual capacity relative to closing capacity Treatment: Oxygen therapy with or without positive airway pressure is the cornerstone of treatment. Routine administration of 30% to 60% oxygen is usually enough to prevent hypoxemia with even moder- ate hypoventilation and hypercapnia. Significant hypotension, defined as a 20% to 30% reduction of blood pressure below the patient’s baseline level, requires correction. Treatment Increase in blood pressure after a fluid bolus (250–500 mL crystalloid or 100–250 mL colloid) confirms hypovolemia. Hypertension Most commonly caused by noxious stimulation from incisional pain, endotracheal intubation, or bladder distention Marked hypertension can precipitate postoperative bleeding, myocardial ischemia, heart failure, or intracranial hemorrhage. Elevations in blood pressure greater than 20% to 30% of the patient’s baseline and those associated with adverse effects such as myocardial ischemia, heart failure, or bleeding should be treated. Hydralazine and sublingual nifedipine may cause reflex tachycardia and have been associated with myocardial isch- emia and infarction. Bradycardia often represents the residual effects of cholinesterase inhibitors, opioids, or β-adrenergic blockers. Premature atrial and ventricular beats often represent hypokalemia, hypomagnesemia, increased sympa- thetic tone, or (less commonly) myocardial ischemia. The body of the mask functions as both a reservoir for oxygen and expired carbon dioxide; therefore, a minimum oxygen flow of 5 L/min is required to avoid rebreathing. The basic difference is the reservoir being filled “partially” with the patient’s expired tidal volume versus a nonrebreather, which uses a flap-type valve between the bag and the reservoir.

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V. Mine-Boss. Duke University.