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In these cases 20mg tadacip amex, surgical therapy in the period generally needed for rheumatic activity to the form of valve replacement with prosthetic valve subside discount tadacip online visa. In the absence of carditis purchase genuine tadacip line, Treatment of chorea: Reassure the parents that it is there is no need for restricting the salt generic tadacip 20 mg with visa. Consider using drugs if the Anti-infammatory drug therapy: Anti-infammatory symptoms are severe. Te drugs used are phenobarbi- agents are the mainstay in the management of acute tone, chlorpromazine, diazepam and haloperidol. Tese agents are required to suppress with phenobarbitone and consider using other drugs the ongoing infammation and provide symptomatic as required. Tis is to eradicate the z Rheumatic fever with carditis: For 10 years after the last attack, streptococcal infection. Alternatively use oral penicillin 4 lakh units (250 mg), every 4–6 hourly for 10 days. Te mitral prophylaxis every 21 days with benzathine penicillin regurgitation may spontaneously disappear over a period of 1. Ideal is to prevent occurrence of rheumatic fever with early diagnosis and treatment. It is the most common acquired heart the acquisition of group A streptococcal infection disease in children. Te disease is basically valvular heart (through implementing actions and measures that disease afecting the heart valves either in isolation or in target environmental, economic, social and behavioral combination. Mitral valve is the commonly involved fol- conditions, cultural patterns of living) and adequate lowed by aortic valves. In practice, primary Mitral Regurgitation prophylaxis focuses on identifcation and treatment of streptococcal sore throat with penicillin therapy. Mitral regurgitation is the most common and earliest mani- Beside penicillin therapy, primary prophylaxis requires festation of rheumatic carditis. Varying degree of mitral educating the public on the dangers of streptococcal regurgitation occur in almost all cases of acute carditis. Ten full days therapy is a must, high volume overload results in enlargement of the left especially when oral drugs are used. Te mitral regurgitation that occurs once in every 21 days for 27 kg weight and more, and during acute rheumatic fever usually subsides by about a 0. Most often the mitral regurgitation is mild to prophylaxis, include penicillin V, 250 mg twice daily, moderate and remains asymptomatic for a longer time. Ideally, the secondary prophylaxis should be continued Clinical Features lifelong. However, some experts recommend it till 40 years Clinical manifestations are dependent on the severity. In patients with no residual lesion, one Patients with moderate to severe regurgitation develop may consider giving secondary prophylaxis for a limited easy fatigability and dyspnea on exertion. Appropriate prophylaxis against infective endocarditis is On examination, heart is enlarged; apex is displaced very much essential. Te frst heart Prognosis sound is normal, second heart sound is accentuated Prognosis depends upon the severity of the disease, with augmented pulmonary component, a pansystolic especially the carditis. Children with severe carditis are at murmur is heard at the apex with radiation to the left axilla increased risk of chronic sequelae in the form of rheumatic (Fig. Mortality rate is high in patients indicating increased early rapid flling of the left ventricle. Infective endocarditis can complicate In severe mitral regurgitation, diastolic murmur may be describe rapid occurrence of mitral stenosis in children, 489 occur rapidly within few years after the carditis. It is more common in children in South Indian, Sri Lanka and some other parts in Asia. Mitral stenosis result from fbrosis of the mitral ring, commissural adhesions, contractures of the valve heard at apex due to large blood fow from left atrium leafets, chordae tendineae and papillary muscles. Te diastolic murmur is of shorter resultant reduction in valvular orifce causes an increased duration and ends in mid-diastole. It may be associated pressure and volume load on the left atrium, resulting with diastolic thrill. Persistent high pressure leads to pulmonary venous hypertension followed by pulmonary Diagnosis arterial hypertension, right atrial and right ventricular Chest X-ray shows left ventricular enlargement, left enlargement. Electrocardiogram is normal in mild and asympto- Te development of mitral stenosis usually takes more than matic cases with normal axis. It may also show the orifce size is reduced to 25% or less of the expected arrhythmic changes. Children with mild stenosis are asymptomatic or Echocardiogram shows enlarged left atrium and the present with mild symptoms like tiredness and dyspnea. Patients with severe mitral stenosis present with progressive Doppler echo shows the severity of mitral regurgitation. Hemoptysis Differential Diagnosis can occur due to rupture of bronchial or bronchiolar Beside rheumatic etiology, various other causes of mitral veins. Blood streaked sputum may be seen in patients regurgitation in children include septum primum type who develop pulmonary edema. Arrhythmias aggravate the left ventricular fbroelastosis and septum secundum type symptoms of mitral stenosis. Afterload of tricuspid regurgitation and systolic pulsation of reducing agents are useful in the long-term management. Precordium reveals normal sized heart in Surgical treatment is indicated for severe mitral mild mitral stenosis. But in moderate to severe mitral regurgitation resulting in recurrent heart failure, stenosis, there will be moderate to huge cardiomegaly. Te surgical measures include prosthetic Parasternal right ventricular type of lift may be present mitral valve replacement mainly. Te absence of presystolic accentuation of the murmur is against Mitral Stenosis the diagnosis of mitral stenosis. Second heart sound Rheumatic mitral stenosis is less common in pediatric is loud in the presence of pulmonary hypertension. Unlike mitral regurgitation, mitral stenosis A pansystolic murmur of low intensity may be heard develops late in children. Pathophysiology and Hemodynamics Te aortic valvular disease occurs due to sclerosis of aortic valves, leading to shortening, distortion and retraction of the cusps, which causes inadequate closure during diastole. Regurgitation of the blood through the incompetent aortic valve results in increased left ventricular volume load. Te dilatation of the left ventricle is directly proportionate to the degree of aortic leak. Te regurgitation of blood results in impaired systemic blood fow (decreased cardiac output). X-ray of chestshows enlarged left atrium, right ventricle, However, the signifcant aortic regurgitation results in low cardiac output. Tis result in wide peripheral pulse plethoric pulmonary feld and prominent pulmonary pressure, and it can be identifed as exaggerated arterial artery. Progressive left ventricular dilation results in and right atrium in severe cases. Mild to moderate aortic regurgitation with good ventric- Management ular function does not give rise to symptoms. Others include exercise intolerance and Surgical treatment is indicated in subjects with severe exertional dyspnea and paroxysmal dyspnea. Other peripheral signs of aortic regurgi- z Closed mitral valvotomy is done to relieve the tation have been listed below (Table 27. Hence, it is less useful in patients with when the limb is elevated from supine position above the level more of subvalvar fusion. Application of pressure proximally produces After the mitral valve, the cardiac valve most often involved systolic murmur and pressure distal to the chest piece produces in rheumatic heart disease is the aortic valves. Pulsations may be seen over the uvula, tip of aortic stenosis does not occur in pediatric patients. Precordial examination shows left ventricular type Clinical Features 491 of cardiac enlargement with heaving apical impulse and Tere is no specifc symptomatology due to tricuspid seesaw movements of the chest in severe cases. Occasionally patient may complain of right heart sound is soft and aortic component of second sound hypochondrial pain due to congested liver. A diastolic include ‘V’ waves on the jugular venous pulse, systolic thrill may be felt. Te typical aortic regurgitation murmur pulsation of the liver and blowing holosystolic murmur, is a diastolic murmur, begins immediately after the second best heard along the left lower sternal border.

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If the attacks are prolonged discount tadacip 20mg with mastercard, discomfort order tadacip 20mg otc, fatigue and malnutrition may side buy tadacip 20mg online, presenting with a well transilluminated scrotal swell- develop order tadacip 20mg fast delivery. It usually disappears nostril, orbital pressure, carotid sinus pressure, induction spontaneously by 6 months of age. In case of its persis- of vomiting and therapy with drugs such as chlorpromazine tence beyond one year of age, herniotomy is needed. Nonretractable Prepuce Nasolacrimal Duct Blockade (Physiological Phimosis) A proportion (2%) of the newborn may have persistent Many male newborns may have a prepuce that is adherent watery discharge and even conjunctivitis (usually unilat- to the underlying glans. Te condition should be consid- the nasolacrimal duct and clears spontaneously by 1–3 ered pathological only if the difculty in retracting the pre- months. All that is needed is frequent wash of the eye with puce over the glans is persistent beyond 3 years of age and a moist sterile swab and gentle massage of the skin over causes bulging of the foreskin on passing urine. In the presence of an infection, antimi- Mothers need to be advised not to attempt to forcibly crobial eye drops may be indicated. Hymenal Tags About 60% of normal baby girls show mucosal tags at the Umbilical Hernia (Fig. Such a baby measures 46 cm or less z Buccal pad of fat is prominent in length (crown-heel) and has head circumference of 32 cm z Excessive lanugo hair present all over the body or less. Bright light is supposed to z Retinopathy of prematurity (earlier termed retrolental fbropla- act by producing chemically excited state and generating sias) (Fig. Ponderal and thin, skin losing its normal elasticity and hanging in index* is below 2 against the normal of over 2. An artist’s depiction labia minora and clitoris are edematous so that labia majora are widely of the condition developing in a premature infant’s eye as a result of placed and not covering labia minora. Maternal malnutrition, heart disease, tuberculosis, renal disease and bronchial pregnancy-induced hypertension and other diseases asthma, etc. Since cell population is reduced, adverse infuence early during gestation, reducing growth potential is considerably afected, resulting in both cell number and cell size. Incidence of accompanying congenital malformations Twin pregnancy: After 35 weeks of gestation, the is high. Te early in embryonic life causing hypoplastic type of magnitude of infants in developing world is enormous. Out of a total of 22 million such infants in the world, 21 Placental dysfunction:Maternal problems such as toxe- million belong to the developing countries. India’s share mias of pregnancy and hypertension may be responsi- is quite substantial—7–10 million. Birth (perinatal) asphyxia as a result of cerebral anoxia Hypothermia Prevention Hypoglycemia Female literacy and formal education:A well-informed, Polycythemia from chronic hypoxia educated mother is likely to have better health before and Food intolerance during pregnancy, avoid harmful agents and infuences Permanent retardation in linear growth and psycho- during pregnancy and show better reproductive perfor- motor development. Management is dictated by Maternal infections: Malaria, urinary tract infection this decision. Early feeding not only prevents hypoglycemia, but also To prevent hypothermia in the neonates. Prognosis Prompt and systematic resuscitation whenever indi- Intrauterine growth retardation infants are easy to feed cated. Clean hands: Hand hygiene, using sterile gloves z Detailed examination done and recorded. Clean cord tie: Clean and sterile ties/clamp passing urine 6–8 times/24 hours and sleeping well for 2–3 hours 4. Care in First Few Hours z Health education to mothers—proper mother care techniques like feeding, bathing, infection and prevention measures, etc. Warm chain z Proper discharge slip has been prepared and handed over to Exclusive breastfeeding, initiated within half-one hour parents. Before discharge, certain criteria Management of common problems of neonates must be met (Box 17. Early detection of high-risk cases and management Follow-up Safe and suitable referral to special care/intensive care centers. First follow-up visit—normal at 6 weeks when check-up as well as immunization can be given. Tis has a bearing on management, including tion is supine position rather than prone position. Since the dates z Rooming-in (bedding-in): Mother should be of last menstruation are frequently not forthcoming from encouraged to indulge in rooming-in, i. Yet another method umbilical stump is shed and the local area becomes of determining the gestational age is fetal ultrasonographic clean. Te expanded new Ballard scoring system (that in- sponging may be given after 24 hour of birth. Female: Widely separated labia majora with exposed labia minora and clitoris Discharge and Follow-up z Breast nodule: Less than 5 mm diameter All normal newborns need to stay in the hospital for a z Ear cartilage: Defcient with poor elastic recoil z Scalp hair: Wooly (fne) or fuzzy (fufy). Creases over 40–50 mm: –1 crease transverse 2/3 entire sole <40 mm: –2 crease only Breast Imperceptible Barely Flat areola–no Stripped areola, Raised areola, Full areola, perceptible bud 1-2 mm bud 3-4 mm bud 5-10 mm bud Eye/ear Lids fused Lids open, Slightly curved Well-curved Formed and Thick cartilage, loosely (–1), pinna fat, stays pinna; soft; slow pinna, soft but frm, instant ear stif tightly (–2) folded recoil ready recoil recoil Genitals, male Scrotum fat, Scrotum empty, Testes in upper Testes descend- Testes down, Testes pendu- smooth faint rugae canal, rare rugae ing, few rugae good rugae lous, deep rugae Genitals, Clitoris Prominent Prominent Majora and Majora large, Majora cover female prominent, clitoris, small clitoris, enlarging minora equally minora small clitoris and labia fat labia minora minora prominent minora Table 17. Presence of one or more of these As a rule, his ideal body temperature (axillary) should signs is an indication for prompt evaluation. Warm labor/delivery room with a minimal temperature of 25°C z Of color and lethargy 2. Delayed bathing—best postponed to end of frst week by which time the cord has fallen Pulmonary 7. Appropriate clothing; wrapping in several layers of warm, but z Tachypnea ( respiratory rate >60/min) light clothes rather than a single layer of thick cloth z Chest retractions/indrawing 8. Professional alertness—well-trained and sensitized healthcare Gastrointestinal providers z True diarrhea 10. Failure to pass urine by 48 hours Skin Clinical Features z Umbilical sepsis Low body temperature (35–30°C or even less), cold z Pyoderma skin with or without acrocyanosis (from peripheral z Sclerema. Te standard method of measuring Tachypnea and respiratory distress (from high pulmo- newborn’s body temperature is axillary thermometer. It is further categorized as: cally-controlled heated mattress) Cold stress: 36–36. Etiopathology Sclerema should arouse suspicion of: Cold injury Gram-negative septicemia Fig. Histologic changes include broadening around mother’s waist may assist in keeping the baby in position. Better growth Protection against infection Clinical Features Reduction in frequency of apneic spells Te overlying skin becomes hard and stretched and cannot Better mother-infant bonding. With the involvement of the thorax, respiratory Neonate-related difculty (shallow and rapid breathing) and cyanosis may z The neonates should have no medical problem. Treatment Mother-centric z The mother should be healthy, willing and coop- Terapy is directed at the underlying cause together with erative. Recovery occurs, despite aggres- sive treatment, only in a small proportion of cases. Kangaroo Mother Care is a very efective method of Appropriate clothing is employed to hold the baby in providing nursing and warmth through skin to skin contact position. Tis assists in keeping the baby warm Sanabria and Prof Martinez of the University of Colombia, all times. Bagota, Latin America in 1979 in response to shortage of He is made to feed at the breast on demand (minimal incubators and severe hospital infections. Maintenance of infant’s temperature Else, the baby may be wrapped in woolen clothing. A modern incubator, available in most specialized A severe form of hyperthermia develops in neonates nurseries, is an excellent device to maintain temperature and infants who are warmly dressed for the low outdoor and humidity according to baby’s requirements. Te incubator temperature should be such as the neonate contributes to development of fever with a will maintain the axillary temperature of the baby temperature as high as 41–44°C. Manifestations include fushing, apathy, dry and warm A low reading rectal thermometer, graduated for skin. Later, stupor, grayish pallor, coma, seizures and 20–40° range, is a must for accurate recording of the hemorrhagic shock may follow. Fluid and electrolyte imbalance, if present, should also be Tis enables accurate observations of his general corrected. Once oxygenation and temperature is maintained, breast- feeding should be started within half to one hour. It is not only species specifc, but Tis is an economic alternative for the expensive incubator also baby specifc.

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The rate of open laparoscopy among Dutch gynecologists was only 2% and was reserved for those with previous laparotomy best 20mg tadacip, those with suspected adhesions quality 20 mg tadacip, and the very obese or thin order generic tadacip on line. An alternative message is that gynecologists should not perform procedures that they perform 1510 rarely in patients at high risk of complications purchase tadacip online. In our own tertiary referral urogynecology practice, the open technique is used exclusively. In a recent Cochrane review comparing open and closed access for laparoscopic entry, 17 trials evaluated 3040 individuals. Overall, there was no advantage in using any single technique in preventing major complications. Extraperitoneal insufflations and failed entry were both less frequent in the open technique compared to the closed approach [16]. It has been demonstrated that 50% of women with previous midline vertical incisions and 20% with low transverse incisions have some degree of periumbilical adhesions [17]. When there is concern regarding the safety of blindly introducing the insufflating needle at the umbilicus, an alternative site of placement is the left upper quadrant 3 cm below the costal margin in the midclavicular line (Palmer’s point, Figure 102. In retrospective audits, no significant complications have been reported with this approach [18,19]. Trocar-Associated Complications In an attempt to minimize the risk associated with accessing the abdominal cavity, increased attention has been focused on trocar design. The cutting blade retracts into the plastic sleeve after the abdominal wall has been penetrated. The incidence of major vascular injuries from trocars and Veress needle averages around 0. They concluded that despite the blade retracting soon after entry into the peritoneum, the momentary presence of the blade in the abdominal cavity as seen in Figure 102. They dilate the fascia and muscular tissues, thus decreasing the potential trauma as it enters the abdominal cavity. Conical tips require a greater entry force to the abdomen than sharper pyramidal [24] and leave a defect approximately 50% narrower than the sharper pyramidal [25]. Leibl, in a nonrandomized study, demonstrated that the reduced wound defect following the use of conical trocars was clinically relevant, with incisional hernia being reported 10 times more frequently after the pyramidal as compared to the conical trocar [26]. In a further study, there were no reported injuries to blood vessels of the anterior abdominal wall in the conical group as compared to 0. Munro and Tarnay [29] recently demonstrated that the fascial and muscular defect from a 12 mm blunt trocar resulted in a similar fascial defect to the 8 mm pyramidal trocar and suggested that the fascial defects from 12 mm blunt trocars do not need closing, a view supported by others [27,30]. Optical access trocars are designed to decrease the injury to vessels and viscera by allowing the surgeon to identify each layer of the abdominal wall and avoiding inadvertent injuries during entry due to a lack of vision. In a single randomized comparison, direct optical was quicker to perform than both the open [31] and closed [32] approaches without any difference in bleeding or vascular or bowel injuries. While the superiority of optical access approach compared to alternative entry techniques has been demonstrated, further validation of these outcomes outside of the single research group is required. An important advantage of laparoscopy over laparotomy is the lower rate of wound complications and hernias. In one study, the incidence of wound infection after open colposuspension was 11% as compared to 1% after the laparoscopic approach [34]. Magrina has estimated that the incidence of trocar hernias after laparoscopic gynecology surgery was 10–100 times lower than laparotomy [35]. The incidence of incisional hernia increases to 3% with the use of 12 mm trocars [36]. It is largely accepted that while 5 mm trocars do not require fascial closure, when bladed trocars 10 mm or greater are utilized, the defects should be closed to minimize the risk of bowel entrapment or incisional hernia. The bowel was able to be reduced with traction from bowel forceps with the bowel mucosa being viable. Following this complication, we utilize a trocar site closure device for all 10 mm trocars. Preliminary studies have demonstrated that the blunt trocars will significantly reduce the incidence of trocar site hernia [26], and many believe they do not need to be closed [29,30]. Secondary Trocars 1513 Secondary trocars are required for operative pelvic floor surgery. The correct positioning of these trocars is vital to minimize damage to the vasculature of the anterior abdominal wall (Figure 102. A thorough knowledge of the vasculature of the anterior abdominal wall is required to minimize and treat perforation of the vessels. The inferior epigastric artery arises from the external iliac artery, passes superior to the inguinal ligament, and travels superiorly and medially to the lateral edge of the rectus muscle. Its position deep to the rectus muscle and superficial to the peritoneum allows for relatively easy localization laparoscopically (Figure 102. The superficial epigastric artery arises from the femoral artery near the inguinal ring and courses medially above the rectus muscle toward the midline. The smallest branch of the femoral artery, the superficial circumflex iliac artery, runs laterally to supply the skin and superficial fascia. Perforation of the inferior epigastric artery will produce retroperitoneal or intraperitoneal bleeding. Perforation of the superficial epigastric artery will result in intramuscular or subcutaneous bleeding. The deep circumflex iliac artery arises from the external iliac artery opposite the inferior epigastric artery and runs posterior to the inguinal canal to the anterior superior iliac spine where it anastomoses with a variety of vessels. The surgeon can use transillumination for locating superficial abdominal wall vessels, but intraperitoneal identification is required for the inferior epigastric artery. When the inferior epigastric artery is difficult to visualize, intra-abdominal landmarks can be helpful. It usually arises from the inguinal canal medial to the round ligament and travels cranially lateral to the obliterated umbilical arteries. If further trocars are required, they can be sited in the midline suprapubically or at the level of the umbilicus lateral to the edge of the rectus muscle. If a 10 mm trocar or greater is required for introducing mesh, the harmonic scalpel, or the removal of pathology, this is placed either on the side of the surgeon or at the suprapubic site, if utilized. Even after all these preventive measures are employed, experienced laparoscopic surgeons may still be faced with arterial bleeding from the inferior epigastric artery. The offending trocar should not be removed as this denotes the location of the artery that may become difficult to visualize as the hematoma spreads. If the bleeding is recognized early and the inferior epigastric artery can be identified, both ends of the transected vessel can be diathermied with bipolar forceps (Figure 102. The trocar is then removed over the catheter and firm traction, secured with an umbilical cord clamp overnight (Figure 102. This is very similar to the technique utilized for closing large trocar defects in Video 102. Approximately one-half of these injuries occur during entry [3,8,38], and the large and small bowel are equally involved [4,39]. As there appears to be no significant difference in the rate of bowel injuries with either the closed or open approach, little can be done to minimize the occurrence of the injury except that the damage may be more readily detected intraoperatively with the open technique [40]. After reviewing the literature, Magrina calculated that only 43% of bowel injuries at laparoscopic surgery were diagnosed intraoperatively [35]. The mortality rate from bowel injuries in gynecological laparoscopy ranges from 2. Direct Injuries If there is a recognized Veress injury to the bowel at the time of surgery and there is no associated fecal spill, it is likely that the injury can be managed expectantly. Although no clear guidelines exist in nine cases of Veress injuries to the bowel treated expectantly, there were no complications [1,8,38]. Trocar 1515 damage to the small bowel mandates careful inspection of the whole bowel to ensure no through-and- through injuries have occurred. Simple small injuries to the small and large bowel should be repaired in one or two layers of interrupted sutures, the pelvis irrigated, and antibiotics commenced. We carefully checked to ensure a through-and- through injury had not occurred and the small bowel was repaired in two layers of interrupted 3.

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These mouth must preserve its functions at all times purchase 20mg tadacip free shipping, especially as purchase tadacip line, procedures must be based on the strong aesthetic sense of the like the eyelids proven 20 mg tadacip, it guards a ‘place of identity’ of psychologi- surgeon and his perfect knowledge of the surgical anatomy cal importance linked to the subconscious self-identification and the microscopic structure of the lips cheap tadacip 20mg without prescription, keeping in mind of the individual. Corrections of any kind must respect the functions of evaluate the impact of his work on the physiology of the lips the lips. Any surgical correction must consider the age of the The demand for aesthetic correction of the lips has patient and the future consequences that these corrections increased over the years, mainly with regard to increasing may have. Doctors must not yield to abnormal requests; a patient has The injection of filling materials is a relatively easy the right to express his wishes, the surgeon has the obligation method to use and gives immediate results which have made to safeguard the patient and if necessary dissuade him. Complications with irreversible outcomes, resulting from The corrective efficacy of the fillers has reduced the indica- the excessive injection of fillers, of sometimes even inappro- tion for aesthetic surgery procedures. At the same time, there priate materials, or incorrect surgical indications, are becom- has been an increasing demand for corrective surgery follow- ing more and more frequent. Unaesthetic features of the lips may have congenital ori- gin or be acquired later in life; in the latter case, ageing and traumas are the most common causes (Fig. The anterior part of each lip is made up of a cutaneous e xternal covering, defined by a F. By means of the fornix of the vestibule the rear part continues into the gums and is delimited by the mucus-gum line. The mucosa of the fornix of the vestibule medially join together creating a triangular fold attached to the gum, known as frenulum of the lips which is always more devel- oped in the upper lip. The line of contact of the closed lips, the rima of the mouth, is situated slightly above the cutting edge of the upper incisors. Small dips, the labial commissures, mark the corners of the mouth on both sides and are located distally at the first premolar. The upper lip e xtends upward to the nostrils and is delimited on both sides by the nasola- bial folds. The median cutaneous part appears concave, creating the subnasal sulcus under the nose or philtrum , and F i g. The philtrum is separated from the lateral labio-mental fold, 10 contour, 11 rima of the lips, C – C′, labial portio by the crests which converge upwards, from the commissures contour to the base of the columella. The vermilion in the 3 Structure median porzio, corresponding to the tubercle on the upper lip, is slightly concave and the lateral porzios are flat or ten- The corrective operations on the lips act on the individual dentially convex (Fig. In-depth knowledge of the The shape, dimension and volume may vary according to structure of the lips as well as their morphology is essen- race, and genetic features also have individual characteris- tial. Not many papers have been published on this topic: milion and any kind of corrective operation will modify it Sawyer, See and Nduka have made an objective, 3D stereo- in some way. The laxness of these strata is at the root of the oedema, with possible stretching and deformation of the lips in the case of inflammation or local- ized irritation (Fig. The orbicular muscle of the mouth , the only one with an occlusive sphincter function of the rima of the mouth, makes up the greater part of the mouth and is an almost elliptic shape. The orbicular muscle surrounds the opening of the mouth with the upper and lower extremities meeting at the commis- sure of the lips. It is divided into two parts: the superficial labial part, made up of scattered and lax muscular bundles with dermic insertion and the deep marginal part, made up of F i g. The deep marginal part makes up sebaceous glands, 8 sudoriporous glands, 9 epithelium of the skin, 10 the greater part of the muscle. This means that the surgeon has to the nasal ala, the elevators of the upper lip and the minor work with great care during any corrective operation as it zygomatic muscles; for the lower lip – the depressor mus- cannot be replaced. It is made up of a membrane of dry cles of the lower lip and the tranversal muscles of the mucosa and contains almost no glands, which allows the chin; the greater zygomatic muscles, the elevator muscles underlying blood bed to show through, giving the vermil- of the corners of the mouth, the depressor muscles of the ion its characteristic red colour. It may be darker in tone corners of the mouth, the pursing muscles and risorius due to the greater presence of melanin, common in people muscles for the lip commissures. It has a dense net of sensitive nerve endings and an like irregular, small, hard, protuberant nodules on the ves- extensive superficial plexiform venous net. In the adult male the contour of the lips is surrounded by Most of the blood vessels and sensitive nerve endings are a beard (Fig. Lower lip: orbicular muscle of the mouth (1), depressor muscles of the lower lip (5 ), moves lower lip down, turning it inside out; mental muscle (6 ) and transverse muscles, raise and pucker the skin of the chin. Commissures of the lips: greater zygomatic muscles and elevator muscles of the corner of the mouth (7 ), move the lip fissure upwards, back and lift lip fissures up; depressor muscles of the mouth (9 ), buccinator muscles (10 ), move lip fissures backwards and make the cheeks and the lips adhere to the dental arches; risorius muscle (8 ), move the lip fissures back 3. This fact explains one of the most serious complications that can arise from a prop- The venous drainage follows the passage of arterial vascu- agation of inflammatory/infective processes of the face, larisation and the tributary veins converge below the facial namely, the infection and thrombosis of the cavernous and submentum veins. Pass through the corresponding foramens and go cutaneous drainage of the median part of the lower lip, 3, 4 mucosa towards the lips, 3 facial nerve branch drainage of the lower lip, 5 cutaneous drainage of the lower lip, which cross over the median line and go to the submandibular lymph nodes of the opposite side which spread over the whole surface of the lips. The lymphatic vessels of the upper lip surround the labial Motor innervation i s provided by the facial nerve commissures and together with the ones on both sides of the through its zygomatic, buccal and marginal mandibular lower lip drain into the sub-mandibular lymph nodes. Some of the more medial vessels may cross the median line unifying the drain- age system of the two sides. There may be some small buccal 5 Classification lymph nodes in the passage from the lower lip and the chin. The sub-mandibular and sub-mental lymph nodes drain into The unaesthetic feature of the lips may be congenital , pres- the deep cervical lymph nodes such as the pre-tracheal or ent in the youth as a genetic characteristic, and/or acquired, jugular-omohyoid (Fig. They can be worsened by various factors: genetic, such as the hyperactiv- ity of facial mime; environment, such as exposure to the sun; 4. Both, the young and the old may acquire an alteration due to accidental or iatrogenous Sensitive innervation for the upper lip is mainly provided by trauma. The features may manifest themselves singly or the infra-orbital nerve (branch of the maxillary nerve) and combined. The most frequent are: hypoplasia/hypotrophy, by the mental nerve for the lower lip. These nerves pass insufficient projection of the lip contour and the philtra through the corresponding foramens and make their way crests, long upper lip, perioral wrinkles and the results of towards the lips where they form small fan-like branches former treatments (Table 1 ). The wishes and comments of the patient, gical procedure, as the shape and volume of the lips may be best expressed in front of a mirror, are very important and altered making any kind of intervention unfeasible. The shape, ticular anatomical area lends itself to trunkal anaesthesia volume, consistency, length of upper lip, perioral wrinkles which needs to be supported by a local anaesthetic which and any static and/or dynamic asymmetry must be observed also serves a haemostatic purpose. One millilitre of The patient must be told what is feasible and what is not; he anaesthetic is infiltrated per side, close to where the infra must be informed of the kind of correction that he is under- orbital nerves e merge for the upper lip and the mental nerves going and the post-operative course. In addition, 2 ml are infiltrated in each lip lips may swell up considerably, due to their intrinsic ana- locally distributing the solution between the vestibule and tomical structure and the type of operation. To distribute Corrections may be performed singly or combined with the local anaesthetic evenly, the lip should be massaged others and essentially consist in the use of different proce- while the adrenalin takes effect. This method allows a com- dures: filling, lifting of the upper lip, eversion/inversion of plete analgesia and good vaso-constriction with a minimum the vermilion and can be separated into two groups: additive change in the volume and shape making the corrective opera- chieloplastic or reductive chieloplastics. In additive chieloplastics some filling materials The local anaesthetic can be combined with vigilant seda- may be introduced by means of injection (fillers) and others tion advisable for excitable patients or when operating on as a graft or implant inserted with a surgical procedure both lips at the same time. Cheiloplastics 1053 8 Additive Cheiloplastics The laser, used in the correction of the wrinkles around the mouth and the improvement of the cutaneous quality, 8. The advent of ‘fillers’ and the ‘laser’ has greatly reduced the indication of surgical correction of the lips. Fillers introduced by means of injections are more ver- makes this treatment more complex and in the long term satile, and permit a focused volume correction with more results do not always compensate unaesthetic features, the predictable and immediate results (Fig. The Though the operation is relatively simple, nevertheless it use of autologous tissues such as derma and fat is the sur- requires rigorous and meticulous preparation by the doctor. The use of other tissue samples such as The type of or excessive and at times inappropriate use of the temporal fascia and the orbicular muscle may be consid- injected filler materials can result in complications that may ered convenient harvests when they can be obtained during be difficult to solve with sometimes irreversible results and other operations. Experience shows that prosthesis is then inserted into the subcutaneous of the ver- the derma is more stable and is obtained from a strip of skin million between the transition line and the contour b y means without epithelium with adhering adipose tissue. The volume depends on the number of should preferably be harvested from an area that is not too strands (Fig. It may also be obtained during another the transition line and a cannula needle of about 5 mm is surgical procedure with exeresis of the skin. With the passing introduced at a subcutaneous level, in the space between the of time, dermic cysts may appear in the grafted area, though transition line and the lip contour. The size of the cannula needle able as a 1–2 mm thick lamina, from which a lip-length depends on the method chosen to treat the fat (a) washed, ellipse is obtained. This according to Coleman; in the former, the needle size is Cheiloplastics 1055 a b Fig.