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Resumption of conduction requires an appropriately timed escape beat effective 100mg kamagra oral jelly free sample erectile dysfunction pills, premature beat (sinus or ectopic) relative to Phase 4 depolarization causing the block purchase cheap kamagra oral jelly on line erectile dysfunction penile injections. Value of Intracardiac Studies in the Evaluation of A-V Conduction Disturbances Several specific points are discussed in this section to emphasize the value of intracardiac studies in the diagnosis and management of A-V conduction disturbances kamagra oral jelly 100mg generic impotence beta blockers. Although it has been suggested that His bundle extrasystoles reflect a diseased His bundle and may not differ greatly from His bundle block in their prognostic 12 significance order on line kamagra oral jelly impotence curse, we believe that therapy should initially be directed at suppressing automaticity rather than at failing conduction. The atrium is paced at a cycle length of 700 msec with stable conduction intervals. Ventricular depolarization results from the fifth paced atrial complex and demonstrates no change in A-H or H-V intervals. Bottom: Ventricular pacing during complete antegrade A-V block demonstrates 1:1 V-A conduction. A retrograde His is seen following the ventricular electrogram during ventricular pacing because conduction proceeds up the left bundle branch. The “blocked” P wave in the surface leads has an atrial activation sequence identical to sinus rhythm. The intracardiac recordings demonstrate a junctional (His bundle) depolarization that fails to propagate antegradely but produces retrograde concealed conduction in the atrioventricular node, which is the cause of the blocked P wave. Increased automaticity in the His bundle rather than impaired conduction is responsible for this phenomenon. The observation of typical Type I block in the same patient, however, suggests that the site of block is the A-V node. Because high-grade block can occur anywhere in the A-V conduction system, an intracardiac study is essential for accurate localization when the site of block cannot be really determined. In the presence of third-degree block, the rate of the escape pacemaker also provides only limited information 18 about the site of block because of considerable overlap (Fig. If the rate is greater than 50 bpm, however, the escape pacemaker is likely to be located high in the A-V junction, and the site of block is likely to be in the A-V node. Combined A-V nodal and infra-His block has been described as the mechanism in alternate- 28 beat Type I block. Atrial pacing or the introduction of premature stimuli may precipitate latent prolongation or failure of conduction. Note that the range of rates in each site is rather broad although the means clearly differ. Only when the escape rhythm is very slow (<28 bpm) or relatively rapid (>50 bpm) can the rate be diagnostically useful information be deduced. The rhythm is sinus, and there is a gradual prolongation of A-V nodal conduction (A-H interval) until the fourth atrial depolarization A is not followed by a His bundle deflection H or by ventricular depolarization V. Following the next (fifth) atrial depolarization, the A-H interval shortens to 250 msec; that is, typical Type I second-degree A-V nodal block occurs. Presence of block may not be the sole cause of symptoms (see subsequent paragraphs on Therapeutic Considerations). This is particularly true in the presence of organic heart disease where ventricular tachycardia is the cause of syncope. When a pacemaker is to be implanted for assumed or proven intra- or infra-His block, V-A conduction may be intact. Recognition of these potential problems helps the physician choose the appropriate pacemaker and programming to prevent their occurrence. Atrial pacing process five-to-four A-V nodal Wenckebah (open arrow) and two-to-one block below the His H. The mechanism for suppression of conduction in His–Purkinje tissue appears to be a cumulative, rate-related depression of amplitude and excitability of Purkinje fibers that persists following 29 cessation of pacing. The ability to conduct retrogradely at rapid rates may be a requisite to this phenomenon. Most recent studies suggest that the block site might be the Purkinje–myocardial junction and that retrograde 29 conduction to the Purkinje system is not necessary. I do not favor this explanation because it seems unlikely that all Purkinje–myocardial junctions would be affected similarly and simultaneously. We have seen this phenomenon occasionally; it has always occurred in the presence of a pre-existent intraventricular and A-V conduction disturbance. In such patients single ventricular premature depolarization or ventricular pacing can produce higher 30 degree of heart block, which usually resolves in seconds. Wald and Waxman have shown that both rate and duration can affect the duration of block. The ability of single ventricular premature depolarization as well as ventricular pacing to induce this phenomenon is more compatible with earlier reports of requiring penetration into already diseased His–Purkinje system (Fig. Of note, all of our cases demonstrated concealed retrograde conduction (see Chapter 6). A second mechanism of perpetuation of this A-V disturbance is Phase 4 block (see 31 Paroxysmal A-V Block above). Therapeutic Considerations Artificial permanent pacing via the epicardial or transvenous route is so far the only practical therapy for A-V conduction disorders. Patients considered for pacemaker therapy of a bradyarrhythmia can be generally placed in one of four groups: (a) those with sustained or documented bradyarrhythmia sufficient to precipitate hemodynamic deterioration and symptoms, (b) those with symptoms and suspected, but not documented paroxysmal bradyarrhythmia, (c) those with bradycardia-induced tachycardias, and (d) those who are asymptomatic but whose electrophysiologic findings place them at high risk for paroxysmal and potentially dangerous high-grade block and bradycardia (Table 4-5). The decision to place a pacemaker in the first group (those with documented bradyarrhythmia and concomitant symptoms) is straightforward, regardless of the site of block. In the second group (those with symptoms of a suspected bradyarrhythmic origin), one needs to weigh the chance of the symptomatology being cardiac against the evidence for an electrophysiologic substrate likely to cause paroxysmal block. Hence, the patient with paroxysmal syncope and no evidence of neurologic disease who has first-degree or second-degree intra-His or infra-His block appears to be a good candidate for a pacemaker despite the lack of direct correlation of bradyarrhytmia and the symptom. While the use of external event recorders may be useful in correlating symptoms with bradyarrhythmias, the relative infrequency of symptoms may make this impractical. Recently, an implantable loop recorder that can be interrogated like a pacemaker has been approved as a “syncope monitor” (Reveal(tm) Medtronics, Inc. Whether this monitor will be more cost effective than 32 33 implanting a pacemaker, with its own monitoring capabilities, is uncertain. Data from our laboratory , and 34 35 others , have demonstrated that electrophysiology study may provide useful information in many of these patients, particularly when overt organic heart disease is present. In such instances, ventricular tachyarrhythmias 33 35 can be induced, which are probably responsible for syncope. Many of these patients will still require pacemakers because antiarrhythmic agents required to suppress ventricular tachycardia increase third-degree A-V block. The decision to place a pacemaker in patients in the group of asymptomatic patients with alarming electrophysiologic findings is the most difficult and controversial one. In our experience, “first-degree” infra-His block with H-V intervals exceeding 100 msec, alternating bundle branch block with changing H-V intervals (see Chapter 5), as well as second- or third- degree intra-His or infra-His block, is so apt to result in severe paroxysmal symptoms that we recommend pacemaker therapy for all these patients, regardless of the absence of symptoms. The conducted complexes show a left bundle branch block, left anterior hemiblock configuration, and have a markedly prolonged H-V interval of ≈ 120 msec. Lidocaine (100 mg) produced complete intra-His block with no escape for more than a minute. Full electrophysiologic studies are of value in patients with syncope (recurrent) and heart disease. The presence of A-V conduction defects may merely represent unrelated manifestations of the same or different disease process. Thus, in such cases, pacemaker therapy should not be undertaken in the absence of a complete electrophysiologic evaluation. During pacemaker implantation for second-degree or third-degree A-V block, lidocaine or similar local 36 anesthetics may increase A-V block and depress escape pacemakers (Fig. The sensitivity of the His– Purkinje system to lidocaine can be readily evaluated safely in the laboratory. In addition to aiding the decision on whether or not to pace, the electrophysiology study may help in choosing the mode of pacing. As noted, V-A conduction may be intact in some patients with complete infra-His block. Site of conduction delay and electrophysiologic significance of first-degree atrioventricular block in children with heart disease. Time dependent changes in the functional properties of the atrioventricular conduction system in man. Pseudo A-V block secondary to premature nonpropagated His bundle depolarizations: documentation by His bundle electrocardiography. Clinical, electrocardiographic, electrophysiological, and follow-up studies on 16 patients. Conduction intervals and conduction velocity in the human cardiac conduction system. Two-to-one A-V block with four-to-three A-V nodal wenckebach, a form of spontaneous multilevel block. Paroxysmal complete heart block due to bradycardia-dependent “phase 4” fascicular block in a patient with sinus node dysfunction and bifascicular block. Electrophysiologic evaluation and follow-up characteristics of patients with recurrent unexplained syncope and presyncope. Electrophysiologic testing in the evaluation of patients with syncope of undetermined origin. Long-term follow-up of patients with recurrent unexplained syncope evaluated by electrophysiologic testing. Effect of local lidocaine anesthesia on ventricular escape intervals during permanent pacemaker implantation in patients with complete heart block. Chapter 5 Intraventricular Conduction Disturbances Intraventricular conduction disturbances are the result of abnormal activation of the ventricles. Normal ventricular activation requires the synchronized participation of the distal components of the atrioventricular (A-V) conducting system, that is, the main bundle branches and their ramifications. In addition, abnormalities of local myocardial activation can further alter the specific pattern of activation in that ventricle. In the last chapter, I discussed the entire infra-His system as a unit as a site of prolonged, intermittent, or failed conduction.

Note that lower lid is affixed to the inner aspect of the lateral orbital rim Lower Eyelid Blepharoplasty 769 Fig kamagra oral jelly 100mg otc short term erectile dysfunction causes. In cases of a negative vector generic 100 mg kamagra oral jelly with amex circumcision causes erectile dysfunction, the globe is essen- conjunctival surface along the lateral lower lid buy kamagra oral jelly with mastercard erectile dysfunction va disability compensation. Such is the case in patients Mersilene or Prolene double-armed horizontal mattress with prominent eyes or a recessed malar area [11] discount kamagra oral jelly 100mg visa erectile dysfunction relationship. By con- suture is placed through the tarsal plate, through the nicked trast, patients with deep set eyes or a prominent bony orbit conjunctiva and back out anteriorly. Those with a negative vector are pre- placed at a 90° angle to this through a portion of the tarsus disposed to downward displacement of the lid following lower and around the canthopexy suture as a locking stitch to pre- lid blepharoplasty. Placing the canthoplasty slightly higher vent cheese wiring of the Prolene through the tarsal plate. The two arms of the canthopexy suture are then placed along If supraplacement of the canthoplasty stitch fails to ade- the inner aspect of the lateral orbital rim periosteum. By quately elevate the lid level, insertion of a spacer graft may passing the sutures deep to superficial the canthus is pulled be necessary. Following canthoplasty placement, the lower posteriorly and superiorly, avoiding a bowstring type defor- lid retractors and conjunctiva are divided with the Bovie, mity. The distance between the two arms of the suture should below the level of the inferior arcade usually 4 mm inferior correspond to the width of the tarsal plate. The spacer material is then sewn along the arms should correct lid laxity and maintain a lower lid posi- posterior lamella to physically elevate the lid margin. If tied too tightly, Materials used can include Enduragen, Alloderm, or autog- clotheslining of the lid below the globe can occur; this is enous ear cartilage. The spacer material is cut to the desired corrected by loosening the suture and stretching the lid supe- height needed for support of the cut lid margin. The freed lid margin is held against the lateral lateral vector to smooth the infraorbital skin. Straight excess at the lateral extent is conservatively marked as a tri- sharp scissors are used to perform a full thickness excision of angle (Fig. The area of redundancy is deepithelialized to the redundant lid, usually measuring 2–4 mm. The same create a lateral pennant of orbicularis muscle that can be double-armed 4-0 Mersilene or Prolene is passed inferiorly anchored to the lateral orbital rim and provide solid suture to superiorly along the cut edge of the tarsal plate. Once fixation of the lower lid during the postoperative healing again, each arm of the suture is passed from deep to superfi- phase (Fig. A suture is placed through the muscle and cial along the lateral orbital rim periosteum at the level of the then tacked to the periosteum along the anterior aspect of the midpupillary line and tied to reestablish lid fixation. Any excess muscle is fast absorbing plain is then used to tack the anterior aspect of trimmed. This recreates the natural concavity in the lateral the lower lid gray line to the posterior aspect of the upper lid lid region and acts as an additional means to counteract the gray line in an effort to recreate a sharp lateral canthal angle. Any skin muscle excess along the lid margin itself is of the anterior globe to the inferior orbital rim should be taken also excised with curved sharp scissors, taking care to avoid 770 K. A running 5-0 Prolene is used to close the subciliary and lateral canthotomy incisions. Typically this includes artificial tears during the day, and a steroid/antibiotic ophthalmic combination ointment at night. Oral steroids, cool compresses, and head elevation are useful to minimize swelling. In addition to the aes- and conservative skin excision minimize complication risk, thetic deformity, these positional changes can lead to dry several other factors alone or in combination can predispose eyes and exposure keratitis. These factors include failure Lower Eyelid Blepharoplasty 771 of the lateral canthal suture fixation, excessive edema or contribute to postoperative lid malposition. A drill hole cantho- proptosis or midface hypoplasia predisposes a patient to this plasty may be necessary. Drill holes are created along the lateral problem due to the inherent imbalance of lower lid support orbital rim and the tarsal plate suture needles may be passed mechanisms. The combination of globe prominence coupled through these for fixation to the bony orbit. With the exception of an expanding hematoma, In cases of lid malposition, a majority of patients will these do not usually require reoperation and can be managed respond to conservative treatment initiated in the early postop- with warm compresses to promote liquefaction and resorp- erative period. Stretching the lower lid hemorrhage is rare with an incidence less than 1 %, but early superiorly against the curve of the globe can also be helpful. Immediate operative inter- quate lid support is essential when performing transcutaneous vention is necessary. Both canthopexy and canthoplasty techniques removal, lateral canthotomy and cantholysis, and control of fix the lateral lid to the periosteum along the inner aspect of active hemorrhage. Orbital bony decompression is a last the lateral orbital rim in an attempt to stabilize lid position. Lateral canthal fixation has proven useful to not only prevent Chemosis refers to a condition in which the conjunctiva lower lid problems but to also correct them when they occur. The edematous conjunctiva prevents Therefore, in cases where lateral canthal fixation was not ini- adequate tear dispersion and a dellen, or corneal dry spot, tially performed or technical failure of the suture is suspected, occurs. The etiology is likely lymphatic drainage obstruction, lateral canthoplasty should be performed. If recognized intraoperatively, leads to skin shortage which can overcome even solid tarso- the conjunctiva can be snipped to decompress the edema. Anterior lamellar postoperative treatment regimen focuses on ocular lubrication deficiency from aggressive skin resection can be identified with a combination of artificial tears and ointment. If severe or cases respond to stretching exercises, but those that do not persistent, the globe can be anesthetized with topical anesthetic will usually require skin grafting. The presentation of erythema and malposition is not limited to the lateral canthal region and tenderness in the initial weeks following blepharoplasty will includes the central portion of the lower lid. Treatment the scarred structures need to be completely released and the lid with a 7–10 day course of oral antibiotics is appropriate. To maintain adequate support to the lower lid and cor- usually the result of more atypical organisms, namely myco- rect vertical lamellar deficiency, a spacer graft must be inserted bacteria. Use of material such as a human be initiated, though clinical resolution can be rather protracted. The presence of redness with will ultimately translate into 1 mm of corrected vertical height. Quality Medical distinction to those cases attributable to an infectious etiology. As is often the case in plastic surgery, the best surgical out- Quality Medical Publishing, St. Plast Reconstr Surg 121(1):241–250 show, and ectropion bear both functional and aesthetic con- 9. Plast Reconstr Surg 92: lize lid position in the setting of lower lid blepharoplasty are 1068–1072 essential to minimizing postoperative complication risk. Plast Reconstr Surg 125(1): 384–392 Blepharoplasty: Minimally Invasive Approach Nicolò Scuderi and Luca A. Dessy 1 Introduction 2 Preoperative Evaluation The orbit and the surrounding tissues constitute the emo- It is always necessary that patients undergo ophthalmic eval- tional and expressive part of the human face. During the ophthalmology visit, it is impor- erative evaluation allows to safely obtain satisfying results. Afterwards, tear secretion is evalu- development of less invasive techniques that offer the advan- ated through the Shirmer’s test and finally the presence of tage of being easier and faster and that allow to reduce the local infections (blepharitis, chalazion) is ruled out. These minimally invasive techniques allow to to choose the most appropriate technique, the surgeon should obtain natural, effective, long-lasting results with a decrease then evaluate the following characteristics: in risk of complications [1, 2]. This chapter presents the minimally invasive techniques • Quantity and characteristics of palpebral skin: It is of lower blepharoplasty that, when appropriately selected, important to evaluate the skin excess when the patients produce significant and effective results reducing the risk of look upwards. The following approaches are described: the the surgeon an idea of how much skin excess is present. If preseptal and retroseptal transconjunctival approach to the the evaluation of the skin excess is performed only with lower eyelid, the treatment of lower eyelid skin excess by the patient looking frontally or downwards, after the skin pinch technique or other ancillary treatments. In this kind of surgical procedure, indeed, the pretarsal presence of pseudoherniation. This evaluation is also bet- portion of the orbicularis oculi muscle is not touched so as to ter performed with the patient looking upwards. In order preserve the shape and function of the eyelid and reduce the to distinguish the fat herniation from the oedema, a light onset of lower eyelid malposition. The herniated fat becomes more promi- nent with pressure, whereas in case of palpebral oedema no change is noticed. Dessy between the lower eyelid and the inferior limbus while the fat protruding in the palpebral bags is eliminated or reposi- patient is looking forward. In normal conditions, there tioned through a direct access route that must not pierce the should be no scleral show below the limbus. The distance between the corneal light subjects: young patients with periorbital fat herniation reflex and the lower eyelid is normally 5. In case of slight skin excess, skin rejuvenation indication on how much skin is needed to correct the should be performed by chemical peeling or laser resur- ectropion caused by the deficit of the anterior lamella. In case of heavy skin excess, it is necessary to • Presence of a hypertrophic orbicularis oculi muscle: A associate its removal with a cutaneous flap by the ‘pinch hypertrophic muscle can appear as an evident strip in the blepharoplasty’ or the traditional transcutaneous lower eyelid. This access can also be indicated in patients come back to the normal position is measured. Less than with a high risk of dischromic, hypertrophic or keloid one second (without blinking) is normal. Usually, transconjunctival inferior blepharoplasty is per- • Negative vector: The relationship between the cornea and formed under local anaesthesia. A few drops of topical the inferior orbital margin is evaluated from the lateral anaesthetic (ossibuprocaine) are instilled into the inferior view.

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Plastic Surgery in Massive Weight Loss Patients 431 Delayed Healing: Due to the high tension closure through transfusions from volunteer-donated blood from the hos- subcutaneous tissue generic 100mg kamagra oral jelly with visa erectile dysfunction after prostate surgery, wound disruption or delayed wound pital blood bank buy kamagra oral jelly cheap best erectile dysfunction doctor. Our anesthesi- would require debridement (removal of dead tissue) in the ologist offers normovolemic hemodilution order kamagra oral jelly canada impotence at 17, whereby sev- office purchase kamagra oral jelly 100 mg with mastercard erectile dysfunction bipolar medication, frequent dressing changes, or further surgery to eral units of blood are removed from you after starting remove the non-healed tissue. The wounds may be your operation with immediate replacement with intrave- encouraged to heal in over weeks or be closed with sutures nous fluids. Do not take any aspirin or anti- General Risks of Surgery inflammatory medications for ten days before surgery, as Healing Issues: Certain medical conditions, dietary supple- this will increase the risk of bleeding. Nonprescription ments, and medications may delay and interfere with heal- “herbs” and dietary supplements can also increase the risk ing. We will provide the supplements problem that could result in the incisions coming apart, that you need for optimum healing. To reduce these risks, you must follow directions on Should a serious infection occur, treatment including our dietary supplements. Patients with diabetes or those intravenous antibiotics or additional surgery to remove taking medications such as steroids on an extended basis dead tissue and drain abscesses may be necessary. Smoking will cause a wound infections accompanied by exposed and “spitting” delay in the healing process. Patients with significant skin sutures are common and are usually easily dealt with by laxity (patients seeking facelifts, breast lifts, abdomino- limited debridement and dressing care. There is a greater plasty, and body lifts) will continue to have the same lax risk of infection when multiple body contouring proce- skin after surgery. The quality or elasticity of skin will not dures are combined instead of single operations. Dehiscence: In most areas your skin closure is in two lay- There are nerve endings that may become involved with ers. Separation of the superficial, deep, and/or both lay- healing scars during surgery such as suction-assisted ers may occur any time during your first postoperative lipectomy, abdominoplasty, facelifts, body lifts, and month. While major nerve injury is unlikely, through, too much movement or bending, and skin small nerve endings during the healing period may become necrosis cause dehiscence. Broken superficial skin too active producing a painful or oversensitive area due to sutures may be urgently replaced. Often massage and early nonsur- require return to the operating room for closure under gical intervention resolves this. While Open wounds may take weeks to heal or secondary clo- always unwelcome, at times swelling can be massive. Wounds allowed to heal on offer a variety of new modalities to reduce swelling, their own usually benefit from later scar revision. For prolonged firmness and pain in the to collect leakage of injected and body fluids. The smooth tissues, we offer the MedX Phototherapy System to silicone drains are removed with usually minimal pain in deliver highly effective and efficient protocol of superlu- about ten days when the drainage is less than 50 cc each minous diode and low-level laser therapy. Nevertheless, sometimes serum accumulations occur deep massage therapies are also provided in our nearby underneath the skin. If the seroma fluid returns, a new is possible that you will lose enough blood to warrant drain is placed in the seroma cavity. Agha-Mohammadi Change in Skin Sensation: Postoperative diminished (or loss difficult to control medical problems, a presurgical consul- of) skin sensation (numbness, pins and needles sensation, tation with a Magee Women’s Hospital anesthesia repre- burning, or itching) and/or pain in the lower torso and sentative should be scheduled. Additional Surgery Asymmetrical fullness, bulges, and depression may be Recognition of Dr. Hurwitz, scar appearance and healing ten- rience, improvement in your condition with low morbid- sions are not fully predictable. Nevertheless, there is no guarantee or excessively wide, and asymmetrical and/or out of opti- warranty expressed or implied on the results that may be mum position. Even though risks and complications occur scarring are uncommon and sometimes unsightly scars infrequently, the complications associated with abdomi- may result. Scars may be asymmetric and hyperpig- noplasty, upper body lift, and medial thighplasty are addi- mented. The more operations performed at a single session, necessary to treat excessive scarring. The Allergic Reactions to Medications: Serious adverse reactions practice of medicine and surgery is not an exact science, may occur to drugs used during surgery and later pre- so I am still learning how to apply the optimal combina- scription medicines. Should complications or breathing difficulties as those may be signs of serious occur, or aesthetic expectations be unmet, additional pro- complications. Allergic reactions may require additional cedures or other treatments are likely to be recommended. Hurwitz is prepared to provide mutually agreed upon Pulmonary Complications: Pulmonary complications may follow-up corrective surgery at a reasonable cost. Our occur secondarily to blood clots (pulmonary emboli), doctor-patient relationship continues well beyond your pneumonia, or partial collapse of the lungs after general initial complex operation. Should either of these complications occur, plan and accepting the risks as presented in this document you may require hospitalization and additional treatment. Should you choose to continue care with another Long-Term Effects: Subsequent alterations in body contour plastic surgeon, Dr. Hurwitz will facilitate the transfer of may occur as the result of aging, weight loss or gain, information to that doctor, but Dr. Hurwitz accepts no pregnancy, or other circumstances unrelated to the above responsibility for the planning, arrangements, or costs of procedures. Since sutures are used to tighten abdominal subsequent care by another plastic surgeon. Therefore, unwanted postoperative abdom- Health Insurance inal fullness may occur. Most health insurance companies exclude coverage for cos- Pain: Chronic pain occurs infrequently from nerves becom- metic operations such as abdominoplasty, lower body lift, ing trapped in scar tissue. Your insurance company may Poor Aesthetics: You may be disappointed with your postop- not pay for complications that might occur from surgery. Undertreatment with residual laxity Payment is anticipated if you suffer postoperatively from a and looseness or overtreatment with excessive tightness of medical condition, such as cardiac arrhythmia, pneumonia, skin can occur with flattening of regional contours and wid- urinary tract infection, etc. If your remains because torso skin laxity also occurs in the vertical hanging panniculus is symptomatic for recurring chronic direction, which is not fully treated. Considerable judg- rash or infections or chronic disabling back ache, then our ment is used to achieve the optimum shape and skin turgor, office is likely to help you obtain some financial relief. At times, Financial Responsibilities it is desirable to perform additional procedures to improve The cost of surgery involves several charges for the services your appearance which may increase your costs. Hurwitz, Complications of Anesthesia: Both local and general anesthe- the hospital, anesthesia, laboratory tests, and possible sia involve risk, which will be discussed by your anesthe- outpatient hospital charges, depending on where the sur- siologist on the day of surgery. Depending on whether the cost of Plastic Surgery in Massive Weight Loss Patients 433 surgery is covered by an insurance plan, you will be 4. I acknowledge that no guarantee has been given by anyone responsible for necessary co-payments, deductibles, and as to the results that may be obtained. I consent to the photographing or televising of the complications develop from the surgery. Secondary sur- operation(s) or procedure(s) to be performed, including gery or hospital day-surgery charges involved with revi- appropriate portions of my body, for medical, scientific, sionary surgery would also be your responsibility. For purposes of advancing medical education, I consent to Informed consent documents are used to communicate informa- the admittance of observers to the operating room. I consent to the disposal of any tissue, medical devices, or condition along with disclosure of risks and alternative forms body parts which may be removed. I authorize the release of my Social Security number to define principles of risk disclosure that should generally appropriate agencies for legal reporting and medical meet the needs of most patients in most circumstances. It has been explained to me in a way that I understand: sidered all inclusive in defining other methods of care and a. There may be alternative procedures or methods of additional or different information which is based on all treatment. Informed consent documents are not intended I consent to the procedures and the above listed items to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are sub- ject to change as scientific knowledge and technology References advance and as practice patterns evolve. American Society of Plastic Surgeons Procedural statistics (2006) It is important that you read the above information care- Body contouring after massive weight loss, www. National Institutes of Health (1998) Clinical guidelines on the iden- tification, evaluation, and treatment of overweight and obesity in I have received, read, and given ample opportunity to adults: the evidence report. I recognize that during the course of the operation and (2008) Will all Americans become overweight or obese? Data obtained from American Society for Metabolic and Bariatric ered necessary or advisable. Ann Plast Surg 21(5):472–479 band placement: influence of time, weight loss, and comorbidities. Int J condition and quality of life in patients with morbid obesity before Adipose Tiss 1:5–11 and after surgical weight loss. Plast Reconstr Surg 82(2):299–304 weight loss and mortality in the severely obese. Pitanguy I (1971) Surgical reduction of the abdomen, thigh, and 1028–1033 buttocks. In: Peter Rubin abdominal laxity after massive weight loss: reverse abdominoplasty J, Alan M (eds) Aesthetic surgery after massive weight lost.

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Fodor P (1995) Wetting solutions in aspirative lipoplasty: a plea for safety in liposuction discount kamagra oral jelly 100mg line erectile dysfunction ultrasound protocol. Rohrich R buy kamagra oral jelly 100 mg with mastercard erectile dysfunction psychological treatment, Beran S cheap kamagra oral jelly 100 mg fast delivery erectile dysfunction blog, Fodor P (1997) The role of subcutaneous infil- tration in suction-assisted lipoplasty: a review cheap 100 mg kamagra oral jelly otc erectile dysfunction premature ejaculation treatment. Fodor P, Watson J (1998) Personal experience with ultrasound-assisted lipoplasty: a pilot study comparing ultrasound-assisted lipoplasty with traditional lipoplasty. Schrudde J (1980) Lipexeresis as a means of eliminating local adi- suction-assisted lipoplasty and 3rd-generation internal ultrasound- posity. Plast Reconstr Surg 105(7):2604–2607 Evolution of Lipoplasty Then, Now, and the Future 355 38. Fodor P, Apfelberg D et al (1994) Progress report on multicenter Reconstr Surg 2(3):424–432 study of laser-assisted liposuction. Plast and monoethylglycinexylidide in liposuction: a microdialysis Reconstr Surg 86(1):84–93 study. Fodor P, Cimino W (2005) Suction-assisted lipoplasty: physics, Plast Surg 23:379–385 optimization and clinical verification. Oper Tech Plast Reconst Noninvasive body contouring by focused ultrasound; safety and Surg 8(1):23–37 efficacy of the contour 1 device in a multicenter, controlled, clinical 48. Plast Reconstr Surg 110(3):912–922; dis- Plastic Surgery Products, 16–17, Anthem Media, Los Angeles. Michelangelo In liposculpture, shapes are hidden in the body of patients, In my opinion liposuction requests maximal humbleness, and it’s up to plastic surgeons to unveil them. Liposculpture is an important surgical operation, even if it is often considered minor by patients and by some surgeons. The aim of patients is now not only a simple fat 1 Introduction removal, but a total body reshaping, a “remise en forme” requiring fat removal from multiple areas. Also, the procedures frequently involve performed by Schrudde, Fischer, Meyer, and Kesserling [1] both sides that are often asymmetric. Truly, the first documented use of cannulas • It is a “closed” operation: it is based on the ability of the to remove fat for aesthetic purposes was performed by surgeon to “feel” the result. Dujarier, who used a gynecological curette to remove fat • Differently from abdominoplasties or mammoplasties, from the legs of a famous dancer. If too much is suctioned, it dramatic because of vascular damage ultimately leading to will be very hard to correct later on. In 1964, Pitanguy reported an innovation for trochanteric lipodystrophy, where scars were limited to areas After many years, I have now realized that liposculpture covered by underwear. In 1980, Schrudde used a curette con- must be perfect just after surgery, because the sentence “time nected to an aspiration system. They surgeons doing liposculpture the rate of unhappy patients first described in 1983 the use of a smooth cannula connected following the procedure is rapidly growing. The term “liposculpture” was tion is now one of the most “dangerous” operations in aes- introduced by Fournier who began in the 1980s fat aspiration thetic surgery for legal claims. Liposculpture has become a fashionable term, but the original meaning has been forgotten. Unfortunately, the false simplic- ity of the technique created during the years some confusion This is a very important moment. The patient should be seen especially in beginners, who thought that any type of skin in a bright place, with a big mirror down to the ground. The patient should undress and body asymmetries (hips, As any technique, liposuction has limits in indications. The patient should be aware of For example, in treating the abdomen, it is always necessary postural defects, degree of skin laxity, and so on. This can ori- should be obtained in order to demonstrate what surgery can ent the surgeon towards liposuction in patients with tight truly achieve. Although incredible results concerning the skin and muscles or toward a mini/full abdominoplasty in profile are possible with liposculpture, it will not be possible situations of muscle/skin laxity. Patients for inner thigh treatment, orienting surgeons toward a lipo or often do not notice these points before surgery, they do after, inner thigh lift, or in the aging neck, where sometimes pure or their spouse or friend might. On the contrary, when fat depos- despite diet and exercise in patients age 45 years or younger. In selected cases other techniques will be Thickness of subcutaneous fat is measured with the pinch associated. Usually, the abdomen, flanks, and hips should have Superficial tridimensional liposculpture has allowed the more than 3 cm of thickness to get the real benefit from extension of this technique to difficult areas (intergluteal and liposuction. Other areas where pinch test is lower than 2 cm, infragluteal folds, trunk) and to patients over 45 years old like heels, will rarely benefit from this procedure. The surgeon should understand, how- The degree of skin laxity is also very important in patient ever, that the degree of skin retraction is maximal in the tro- selection. Tissue laxity on flanks, gluteal regions, and thighs is chanteric areas and on the lateral thorax and flanks, while it evaluated by tractioning the skin over the iliac bones and look- is moderate on the inner thighs and arms, and on the abdomi- ing at modifications on the lateral thigh and gluteus. Usually nal wall, except when skin laxity is associated to multiple irregularities will disappear with this maneuver in most stretch marks. If in adjunct even the volume excess on the Tridimensional Liposculpture 359 trochanteric region is reduced just with skin traction, then this Aesthetic surgery is not a cheap surgery, and should not is probably due only to laxity than to fat excess. Severe skin laxity is defined when the examiner is able to At the end of the consultation, we usually give the patient advance skin more than 8 cm over the lateral thigh and flank the informed consent that explains thoroughly the surgery, and more than 6 cm in the inner thigh. The very last step is done by the secretaries and abdominal skin in a vertical fashion, and should it be more involves all the expenses for surgery: it should be precise and than 6 cm, a mini/full abdominoplasty is indicated, espe- mention also possible touch-ups. It is utmostly important to show the patient her pictures also from the back and in the three-quarter view, to point out 4 Evaluation of the Volume asymmetries and defects. We prefer to correct pictures with to Be Aspirated a marker instead of morphing as a default, to avoid unrealis- tic expectations. Usually, we use morphing only when we Once the surgeon has established that the patient is a candi- deal with responsible patients. Instead, when we deal with date for liposuction, determination of how much fat to be obsessive or compulsive patients or people who ask too removed will be made. The technical evolution in surgery many questions, we do think that morphing could be contra- and instruments, together with the reduced blood losses, has indicated and lead to legal problems. This is defined as a suction over The first medical examination should include a thorough 5,000 cc per surgery. According to the international litera- explanation on indications of surgery, on consequences ture, there are no available data regarding the maximum vol- (scars, recovery), on limits, and, most importantly, on thera- ume to aspirate with safety. This will allow the patient to undergo complications increases treating wider areas and greater vol- surgery confident and prepared to what she thinks is the best umes. The medical examination will consequences of fat loss should be always considered, to include preoperative exams to be evaluated by the anesthetist allow a proportional volume loss to physical conditions of some days before surgery, in order to rule out if the patient is the patient. It is important to highlight the difference between on anticoagulants, hormones, and so on and to understand if total fat removal and fluid aspiration, which is defined as the she will need some postoperative pain therapy. Before con- combination between fat and fluids removed during liposuc- cluding the examination, we evaluate the superficial and tion. A well-experienced surgeon will be able to predict more deep venous system with color duplex scanning. The sur- or less the volume to be aspirated: this will be extremely geon should explain all the possible therapeutic options, with important, even in the preoperatory phase, where one should benefits, costs, and risks and alternatives for each procedure. When dealing with These factors, together with pain and different recovery large areas, even with small volumes to be aspirated, caution times, might influence the patient to undergo minor or major must be very high. The surgeon should conclude his consultation than 6,000 cc of pure fat, in a single session, even with an having a firm approval for the operation. I usually advice the overnight stay for more relatives of the patient at the consultation is a good idea; they than 2,500 cc to be aspirated. During the consultation, the patient will be informed 5 Why a Tridimensional Liposculpture? Complications should be pointed out, without frightening The Webster dictionary defines sculpture as “the art of recre- the patient, but clearly and sincerely. A thorough understanding of fat deposits and their anesthesia needs time for pharmacological catabolism. It is very risky to operate under unsafe liposculpture goes beyond traditional liposuction, i. The surgeon “sculptor” should create and cele- other cosmetic operations such as face lift and so on, but for brate the beauty of the human body. From this position, it sure, you can always get to a surgical layer where tissue ele- was easy for me to decide to become a plastic surgeon. On the other hand, when the sur- I first observed a liposuction, over 30 years ago, this tech- geon gets too close to the dermis, scissors will encounter nique appeared to me as an “assault to holy areas. The same happens with 3D liposcu- lines, with rough instruments as those large cannulas of the lpture. Why should we limit our work to molding that the goal of this operation shoudn’t have been only suc- fat, without considering its case, i. Other points we started thinking of skin retraction as an allied force to came with time: why should I remove only the deep layer of have optimal results. With massive tissue thinning, skin fat when the deformity usually includes also the superficial retraction capacities are best utilized (Fig. Why should I limit the use of cannulas to an aspira- erative garments which support skin retraction (i. In other words, I often compare liposuction with rhi- ticularly when patients are not very young.