Apcalis SX

By J. Treslott. Pennsylvania College of Technology. 2019.

Breast shells cheap 20mg apcalis sx with visa, worn prenatally buy apcalis sx 20mg on line, assist in solving the problem of fat or inverted nipples cheap 20 mg apcalis sx with visa. Current recommendations are exclusive breastfeeding for the frst six months of life buy apcalis sx 20 mg with amex, appropriate complementary foods thereafter and continuing breastfeeding as long as possible. Once a nutritionally adequate and safe diet without breast milk can be provided, breastfeeding may be discontinued. Writing Committee, Infant and Young Child Subspeciality Chapter of Indian Academy of Pediatrics/Human Milk Banking Association. T e efects are of the highest order in the resource- Stunting 51% 45% limited countries such as India. T ese substandard survivors are likely to sufer from consequences such as poor quality of life (QoL), low cognitive development and learning skills over and above other handicaps. Considerable morbidity and (at times mortality) accom- panies nutritional anemias and other micronutrient and vitamin defciencies, directly or indirectly. Secondary: It is due to systemic diseases such as tuber- Undernutrition means a state of poor nutritional status culosis or malabsorption. Underweight means low weight for age; it is a com- bined indicator of both acute and chronic under- Bad Economy nutriton. With the further pressure on the meager known for the highest prevalence of underweight children. Prevalence of and entertainment, during modern times, still more undernutrition is higher in rural than in urban population. It is cus- Food insecurity may not always be the cause of primary tomary to consider it as: undernutrition. Despite availability of food, the child may 198 develop undernutrition as a consequence of factors such Working Mother as ignorance, erratic feeding practices, irrational beliefs It is a common observation that a higher proportion of the and superstitions and poor access to health facility, etc. Faulty Food Habits and Feeding More often than not, mothering is done by an elder sibling. Many deep-rooted beliefs, customs, practices, superstitions, food taboos and ignorance join hands to cause malnutrition. He is difcult introduced early enough, when the infant is about six months to feed and is vulnerable to infections. Tey wish to wait until the infant begins to approach the malnourished mothers, such infants have high mortality. Decline in the good practice of breastfeeding just Secondary Malnutrition because ignorant mothers wish to ape the sophisticated Te causes are diseases such as intestinal malabsorption city women, leading to the widespread practice of artifcial (say celiac disease, tropical sprue, cystic fbrosis, etc. Mismanage- Great reliance on milk, which may be awfully diluted, ment of diarrhea with starvation therapy or hypocaloric continues to dominate the scene even in educated and diet (still a common practice in developing countries) is well to do families. Most parents would withhold all foods other than Virtually all organs are afected in malnutrition (Box 13. Tough frank cases of kwashiorkor and marasmus cause Yet another limiting factor in adequate nutrition is little difculty in their identifcation, assessment of the belief that certain foods are not given to the baby just nutritional status may be rather difcult, especially in because they are said to be hot or cold in nature. Furthermore, assessment of nutritional Medical Reasons status concerns: Infections and disorders such as diarrhea, malaria or Individual levels as in hospital/health facility measles may prove major contributory factors in the Large groups and segments of child population, e. Te overall criteria employed for assessment of nutri- At the same time, there may result more catabolism to tional status are listed in Box 13. Intestinal parasitic infestations may either deprive the Adverse efect of malnutrition on systems/ host of nutrients or lead to malnutrition by reducing appe- Box 13. It has been convincingly demonstrated that fattening of papillae; mucosa atrophic and shiny; small intestinal malnutrition is much higher among children of birth order villous atrophy of variable magnitude depending on severity of fourth and higher than in the frst three children of a sibling malnutrition; reduced disaccharides level in brush border; rectal ship. Te brunt of the z Liver: Fatty in edematous malnutrition (kwashiorkor and sufering falls on the preschool children and the mother. Tere is an evidence that when pregnancies occur rapidly, z Endocrines: Adrenals atrophied; thyroid involution and fbrosis; perhaps every year, or every other year, incidence of high growth hormone level malnutrition is much higher. Ideally, there should be at z Lymphoreticular system: Lymphocytic depletion; thymus least three years gap between the two pregnancies. Major criteria for assessment of nutritional Age-independent indices for assessment of 199 Box 13. Dietary History Actual weight × 100 Te assessment must begin with the dietary history. Details Percentage weight for height = Expected weight for actual height about intake of cereals, vegetables, pulses, fruits, eggs Nabarrow’s thinners chart, based on weight for and meat, etc. A rough idea Te child is made to stand against the chart which about the adequacy of vitamins and minerals in the diet bears the expected weight for height. Tis is because of replacements of the baby fat be due to vitamin A defciency, may also be a feature of with muscle tissue. For exact fgures regarding mid- Age-dependent Indices arm circumference at various ages see Table 3. Also, what is more important is the serial record of child’s Triceps skin fold thickness is measured by a standard weight periodically on a growth chart. A measurement Its value lies in detecting chronic malnutrition and between 6 and 10 mm points to mild and moderate stunting. Chest/head circumference ratio less than one after Age-independent Indices frst year of life indicates malnutrition. Since, it is often difcult to fnd true age of the child in the Mid-upper arm/height ratio of less than 0. The instrument consists of a stick graduated with fgures for mid-upper arm circumference in relation to height. For this test, maximum left-upper arm circum- ference (the arm hanging by the side of the body) is recorded. From the graduations in the stick, his nutritional status in terms of 50, 60, 70 or 80% of the standard can be easily read (Fig. Shakir tape method is a simple and age-independent tool for assessing malnutrition. Tis special tape has colored zones—red, yellow and green, corresponding to less than 12. Bangle method, another method not needing age and useful in preschool children, consists of slipping a bangle with a diameter of 4 cm up the forearm. Rao’s weight/height ratio is expressed as: Weight (g) Rao’s ratio = 2 × 100 Height (cm) Normal value is above 0. In gross Hydroxyproline assay kit is suitable for hydroxypro- 201 malnutrition, it is less than 0. Salivary protein, salivary ferritin and free D-amino nitrogen in leukocyte are reduced in malnutrition. Investigations Skeletal radiographs may reveal some retardation of Laboratory investigations include complete blood bone age, osteoporosis or classical signs of nutritional picture especially, hemoglobin, erythrocyte sedimen- rickets or scurvy. While assessing the nutritional status, one must ascertain Special biochemical tests may detect subclinical mal- for evidence of intestinal parasitic infestations, malab- nutrition that could not be revealed by anthropometry. Hydroxyproline is the most Vital Health Statistics commonly used among the amino acids. Hydroxypro- For evaluation of the nutritional status of a community, line levels are an indicator of collagen content. Con- the above measures should be supported by vital statistics ditions that increase collagen turnover can elevate se- such as under fve mortality, infant mortality, neonatal rum and urine hydroxyproline levels. Urine and serum mortality, perinatal mortality, stillbirth rate and life hydroxyproline levels can be used as a marker for bone expectancy as also the ecological background. Understandably, it is important to obtain ecologic z Amino acid pattern is measured by comparing concentrations of two groups of amino acids using per chromatography as shown: information on factors such as: Glycine + serine + glutamine + taurine Food consumption by the community. Ratio = Valine + leucine + isoleucine + methionine Socioeconomic factors such as knowledge, attitudes, z Mean ratio in normal children is 1. Its main faw is that it varies considerably with countries, are energy and proteins, usually more of the age. Almost always it appears to be due to poor creatinine output of the average normal child of the same height: intake of food (energy) as such. Else, if his energy child of the same height consumption is poor, whatever proteins he takes are likely In kwashiorkor and marasmic kwashiorkor, value varies bet-ween to be consumed to provide energy rather than to build the 0. Normal children and those having fully recovered from malnutrition show an index of around unity. With beginning inadequacy of different principles of food, of nutritional rehabilitation, values speedily return to normal. According to his postu- lation, the so called adaptation hypothesis, marasmus is an extreme degree of adaptation to prolonged inadequacy of proteins and energy in the diet. Kwashiorkor is a stage of adaptation failure or dysadaptation which may follow two situations: 1. Sudden precipitation or aggravation by a fulminant infection such as measles, pertussis, bronchopneumonia or acute diarrheal episode. Gopalan feels that whereas nutritional marasmus may be the result of extreme degree of adaptation and the kwashiorkor the result of dysadaptation, relatively mild efect of adaptation may be responsible for nutri- tional dwarfng. Since, according to Gopalan’s hypoth- esis, kwashiorkor follows occurrence of dysadaptation in Fig. Kwashiorkor is said to result from gross defciency of tamination of food may well be an important factor in the proteins though energy defciency is also present. Nutritional marasmus, on the other hand, results from gross defciency of energy though protein defciency Golden’s Hypothesis of Free Radicals also accompanies. According to Golden’s hypothesis of free radical damage, Tus, it is clear that there is defciency of both, proteins kwashiorkor results from overproduction of free radicals and energy, in both the states. Te predominance of the (because of infection, toxins, iron, etc) and breakdown defciency determines whether it is going to be kwashiorkor of protective mechanism (provided by vitamin A and E, or nutritional marasmus. Many malnourished children show overlap in the clinical picture, demonstrating features of both the Jellife’s Hypothesis of Interactions and Sequelae defciency states at a time. It is often quite appropriate to According to Jellife, kwashiorkor is an intrinsically nutri- label them as marasmic kwashiorkor. A vast majority of of a mixture of interactions and sequelae of dietary imbal- the children sufering from mild to moderate forms of ances and/or defciency, infections, parasitosis, emotional it remain hidden in the community for one or another trauma from maternal deprivation due to abrupt weaning reason. Te two types of this subclinical malnutrition are— from breasts, toxins like afatoxin or ochratoxin. Tis Growth failure and poor tissue repair (due to protein lack) is quite understandable if we recall that the disease is and energy shortage (due to calorie defciency) are com- characterized by profound disturbances of water and elec- mon to all forms. A positive correlation exists between the magni- and energy lack-exist in both the syndromes. Zinc defciency may play an important of the body and reduction in the adipose tissue is role in the etiology of the syndrome of growth retarda- not clearly understood. A noteworthy point is that tion with short stature, hypogonadism, hepatospleno- despite increased body water, a malnourished child is megaly and anemia in boys. Tis paradoxical observation is ascribed to the zinc to such boys results in a dramatic improvement. Sometime, within three weeks of initiating treatment, Potassium: Tere is a defnite reduction in the total signifcant gain in weight and acceleration of sexual body potassium by as much as 25%.

They concluded that complete removal of mesh may improve outcomes and decrease persistent symptoms cheap apcalis sx 20 mg online, although significant morbidity can occur generic apcalis sx 20mg online. The goal is to create as much distance as possible between the closed vaginal cuff and the cut edge of the mesh (see insert) buy discount apcalis sx 20 mg line. These benefits must be weighed against potential complications purchase 20 mg apcalis sx with mastercard, which include vaginal mesh erosion or extrusion, pelvic pain, and dyspareunia [22]. Also reported, albeit very rarely, are bladder and bowel perforation and/or injury. A complete history and examination of all patients with suspected mesh-related complications should be completed. On pelvic examination, one should attempt to identify urogenital atrophy, palpation/visualization of any exposed mesh, mesh under tension, location of mesh arms, pain with palpation of the mesh (note location), bunching of mesh or palpable abnormalities beneath the epithelium, pain with palpation of pelvic floor musculature, or evidence of fistula. Rectal exam should be performed and cystoscopy and proctoscopy may be indicated in select cases. In patients with urogenital atrophy, the authors prefer to aggressively treat patients with local estrogen cream prior to any surgical intervention. Common presenting symptoms of women with vaginal extrusion include vaginal drainage/bleeding, pelvic pain, and dyspareunia. On examination, pain with palpation of the mesh, visible mesh exposure, and vaginal shortening/tightening may also be seen. Published rates for mesh extrusion range from 3% to over 30% with large review articles suggesting overall rates between 10% and 15% [23,24]. Risk factors include concomitant hysterectomy, smoking, total mesh volume, young patient age, early resumption of sexual activity, diabetes mellitus, and surgeon experience. Local injection with lidocaine plus epinephrine at the time of mesh placement has not been shown to increase the risk of mesh extrusion [25]. Conservative management with topical estrogen and/or topical antibiotics can be attempted; however, little evidence of success exists with this treatment. Office-based excision should be reserved for those with small exposures (usually <1 cm), adequate access to the exposed mesh, and healthy vaginal tissues. Similar to the description of office-based management of synthetic midurethral sling exposure, local anesthetic is injected around the extrusion and the adjacent vaginal epithelium is mobilized. The mesh can be excised and the vaginal epithelium brought together in a tension-free fashion with interrupted sutures. The operating room affords the surgeon improved visibility, better patient anesthesia, and a wider array of instrumentation for managing meshes’ extrusions. There seems to be a balance, with an increased risk of repeat surgery for mesh excision when partial excision is undertaken and an increased risk of recurrent prolapse as well as more intraoperative morbidity with complete excision [27]. For extrusions that are small and straightforward, mobilization of the surrounding epithelium to cover the mesh or simple excision of a small amount of mesh and closing the epithelium is usually all that is needed. If pain and a large-scale extrusion are noted, then more aggressive resection is usually performed. Techniques for surgical excision revolve around dissection of the overlying vaginal epithelium away from the mesh, followed by the dissection of the mesh away from the adjacent organ (bladder or rectum) (Figure 91. Many mesh kits consist of a body of mesh and with arms used for anchoring the mesh. After implantation and incorporation of the mesh, these arms may become vascularized. When a more complete excision is desired and the mesh body has 1401 been mobilized satisfactorily, the authors advocate for clamping and tying of the mesh arms prior to transection to decrease the risk of bleeding. After mesh removal, when possible, midline plication of underlying connective tissue is performed to help resupport the prolapsed tissue and possibly decrease the risk of recurrent prolapse. Also, if appropriate, a native tissue suture suspension of the vaginal apex to the uterosacral ligaments or sacrospinous ligaments can be performed. It acts as a scaffold and encourages host response to mediate the healing process. Biodesign will ultimately convert to normal skin in the majority of cases assuming a good blood supply is maintained (Figure 91. Vulvar skin flaps may also be used in instances where large defects are present after mesh removal. In a systematic review, the overall incidence of new-onset dyspareunia after vaginal mesh placement was 9. Pelvic muscle spasm/pelvic floor tension myalgia can present as chronic pelvic pain and may be confused with mesh-related pain. Though they may be difficult to distinguish from each other, both may improve with nonsurgical treatments such as pelvic floor physical therapy [31]. The authors recommend exhausting nonsurgical measures for the treatment of pelvic pain possibly related to mesh placement since patients undergoing surgical excision often have persistent pain [32]. Of all mesh-related complications, pain remains the symptom most resistant to medical and surgical treatment. Thus, counseling patients prior to surgery about risks associated with mesh removal is paramount. These include bleeding, infection, injury to adjacent organs, new/persistent pain, and recurrent prolapse. El-Nashar and Trabuco [32] performed an early excision of vaginal mesh, 11 days after implantation. This was performed for severe vaginal pain and urinary urgency/frequency, which began immediately after vaginal mesh placement. Complete excision, including mesh arms, was performed and the patient had resolution of all symptoms. The implanting surgeon was not the referring provider in the case earlier, and this is consistent with findings by Blandon and colleagues. In their study, only 14% of patients with mesh-related complications were referred by the surgeon who placed the mesh; about half were referred by a different physician/health-care provider and the remainder were self-referred. Visceral Injury Albeit rare, injury to the bladder and bowel can occur during placement of vaginal mesh. Significant emphasis has been placed on the concept that mesh placement requires a deeper dissection plane, i. However, the surgeon must also go to great lengths to avoid an inadvertent proctotomy or cystotomy and to avoid placing the mesh too deep (i. If a bladder or bowel injury were to occur during dissection of the vaginal epithelium, the authors would recommend aborting mesh placement and proceeding with a native tissue suture repair. When performing a trocar-based mesh procedure, rectal exam and cystoscopy should routinely be performed with the trocars in place (prior to passage of arms) to assure no visceral penetration had occurred. In the rare situation where mesh is found postoperatively in the bladder or rectum, usually a major surgical procedure will be required to remove the mesh. If mesh is found in the rectum, a diverting colostomy may be necessary prior to attempting mesh removal. Gauging the true incidence of these complications is difficult, because there is no good source for how many total procedures are being done and the frequency with which mesh augmentation is being used. As new procedures to correct pelvic floor disorders continue to evolve, open discussions among surgeons on how best to manage new and/or unforeseen complications are important. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. A three-incision approach to treat persistent vaginal exposure and sinus tract formation related to ObTape mesh insertion. Classification of biomaterials and their related complications in abdominal wall hernia surgery. Changing attitudes on the surgical treatment of urogenital prolapse: Birth of the tension-free vaginal mesh. Complications requiring reoperation following vaginal mesh kit procedures for prolapse. Factors associated with exposure of transvaginally placed polypropylene mesh for pelvic organ prolapse. Mesh erosion following abdominal sacral colpopexy in the absence and presence of the cervical stump. Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: A systematic review. Surgical management of pelvic organ prolapse in women: The updated summary version Cochrane review. Does local injection with lidocaine plus epinephrine prior to vaginal reconstructive surgery with synthetic mesh affect exposure rates? Management of complications arising from transvaginal mesh kit procedures: A tertiary referral center’s experience. Surgical management of mesh-related complications after prior pelvic floor reconstructive surgery with mesh. Early experience with mesh excision for adverse outcomes after transvaginal mesh placement using prolapse kits. Use of Surgisis mesh in the management of polypropylene mesh erosion into the vagina. Is early excision the right answer for early onset pain related to vaginal mesh placement? Bladder erosion after 2 years from cystocele repair with type I polypropylene mesh. Vaginal erosion, sinus formation, and ischiorectal abscess following transobturator tape: ObTape implantation. Using becaplermin gel with collagen products to potentiate healing in chronic leg wounds. Ischiorectal abscess and ischiorectal-vaginal fistula as delayed complications of posterior intravaginal slingplasty: A case report. Iliosacral bacterial arthritis and retroperitoneal abscess after tension-free vaginal mesh reconstruction. Polypropylene as a reinforcement in pelvic surgery is not inert: Comparative analysis of 100 explants. Transvaginal mesh technique for pelvic organ prolapse repair: Mesh exposure management and risk factors. Evaluation of a transvaginal mesh delivery system for the correction of pelvic organ prolapse: Subjective and objective findings at least 1 year after surgery. Transvaginal repair of anterior and posterior compartment prolapse with Atrium polypropylene mesh. Transvaginal repair of genital prolapse: Preliminary results of a new tension-free vaginal mesh (Prolift technique)—A case series multicentric study. Efficacy and safety of transvaginal mesh kits in the treatment of prolapse of the vaginal apex: A systematic review. Transvaginal excision of mesh erosion involving the bladder after mesh placement using a prolapse kit: A novel technique.

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The postoperative complications are the same as those related to any other prosthetic implantation apcalis sx 20mg lowest price. The implanted prosthesis may break because of 5 Complications wrong positioning or a subsequent dislocation buy apcalis sx 20mg with amex, or the break- age may follow a violent impact purchase 20 mg apcalis sx with visa, but it may even be related Depending on the technique and the materials used order 20 mg apcalis sx visa, all post- to the fragility of aged implants or other causes. These com- operative complications have been considered for each surgi- plications may require reoperation to remove or substitute cal technique discussed. The most common surgical technique adopted to treat this condition is resection, fol- Over the years the medicolegal discipline has reaffirmed the lowed by eversion, of the tunica vaginalis; an anterior trans- importance of giving complete information to patients before versal incision is performed over the affected hemiscrotum, they undergo medical or surgical treatment that may repre- thus to expose the testicle and its involucres. The external sent a risk as regards patient safety, complications, and tunica vaginalis (also called the parietal layer) is longitudi- adequate outcomes. Ann Surg 213(6):620–625, discussion about his health conditions, the characteristics of the pathol- 625–626 ogy he is affected by, and his perspectives and therapeutic 4. Urol Clin North Am 7:423 patient and the doctor requires a full explanation of patholo- 5. Kelâmi A (1987) Congenital penile deviation and its treatment with incorrect behavior and, furthermore, exposes the profes- the Nesbit-Kelâmi technique. Yachia D (1994) Our experience with penile deformations: patient about all the potential therapeutic options that could be incidence, operative techniques, and results. Alei G, Danti M (1990) The surgical treatment of penile curva- Considering the importance of the genitals and, in partic- ture: a modified Nesbit procedure. Int J Impot Res 2(Suppl 2): ular, of the penis on a psychological level, in most cases it 431–432 should seem opportune to support the informative phase of 14. Vardi Y, Gruenwald I (2009) The status of penile enhancement pro- the patient with a psychosexological counseling. Vardi Y, Har-Shai Y, Gil T, Gruenwald I (2009) A critical analysis tion of the candidate’s appropriateness to aesthetic surgical of penile enhancement procedures for patients with normal penile procedures should pay particular attention to which expecta- size: surgical techniques, success, and complications. Ann R Coll Surg Engl in plastic surgery: a snapshot of today with an eye on tomorrow. Lesavoy and Catherine Huang Begovic 1 Introduction 2 Embryology and Anatomy The first cosmetic vaginal surgery was reported in the litera- The external female genital organs include the mons pubis, the ture by Hodgkinson and Hait in 1984 [1]. Recently, there has labia majora and minora, the clitoris, and the vestibule of the been an increased interest in cosmetic surgical procedures of vagina. The mons pubis is the fatty tissue on top of the pubic the female genitalia [2 – 5]. Each labium The indications for labia reduction are generally orga- has an outer, pigmented surface and an inner smooth surface nized in the literature by three categories – women who covered with sebaceous follicles. The labia minora are also suffer from physical or functional complaints associated paired cutaneous folds medial to the two labia majora that with a genital abnormality, women without physical com- begin at the clitoris, extend posteriorly along the orifice of the plaints but want surgical intervention for cosmetic reasons, vagina, and end at the posterior edge of the labia majora. The anterior fold passes anterior to the clitoris specific complaints were vulvar pain and irritation riding a forming the clitoral hood and the posterior fold passes poste- bike, horseback riding, wearing tight underwear or clothes, rior to the clitoris forming the clitoral frenulum. Enlarged labia can signifi- an erectile structure situated between the two folds of the labia cantly impair a woman’s quality of life – causing constant minora and is homologous to the penis. Many women feel emo- 3 Surgical Techniques tional embarrassment with enlarged labia. In practice, there are wide variations in female genital anatomy and what is normal should be defined by the patient (Fig. Traditionally, labia minora reductions have been performed by trimming the labial edge and then oversewing the cut edge [5 , 14 – 16]. Patients differ in labia minora length, thickness, symmetry, and clitoral hooding minora, parts of the hood are removed on both sides of the labium with no tension on the suture line. To avoid a continu- vertical dimension of the labia minora but not the superfi- ous scar, another surgeon performed a running W-shaped cial excess. The inner wedge is designed as V extending resection from the frenulum to the posterior fourchette medially into the vagina while the outer wedge is curved instead of a straight curved line [9 ]. In nique using a central wedge or V excision of the most pro- 1998 Alter removed the entire wedge but in 2008 modified tuberant portion of the labia with re-approximation of the this technique to remove only the mucosa and outer skin anterior and posterior edges. This technique preserves the while attempting to keep most subcutaneous tissue – excis- normal edge and places the scar line on the inner and outer ing only what is necessary to produce a good cosmetic surface of the labia instead of along the edge. The anterior edge of the wedge starts at the middle ruptured hymen is removed, and the hymenal remnants are portion of the labia minora, and the posterior edge is defined re-approximated by a circular running suture [22]. When the by stretching the middle portion posteriorly until an ideal hymenal remnants are insufficient, a narrow strip of posterior shape is created. They felt that by keeping the excised vaginal wall is dissected for reconstruction. Choi and Kim preserve the entire outer They also describe a cerclage method where a 5-0 chromic edge of the labia minorum and simply de-epithelialize the catgut suture is introduced at the 6-o’clock position about central portion of the labia minorum [21]. They then re- 2–3 mm into the edge of the hymenal remnants and then run approximate the margins of the raw surface with a running clockwise into the submucosa to the 12-o’clock position. They feel this technique preserves the neu- The ends of the suture are tied for tightening. The excisions are tailored to remove more of the medial ellipse extending along the edge of the clitoral hood mucosal surface than the external squamous epithelium vertically thus excising excessive clitoral hood tissue but thereby making the scars more inconspicuous since they preserving enough to close the skin edges [18]. The tion of labia minora reduction, Pardo similarly describes excessive protuberant area is excised and the remaining trimming the clitoral hood to allow for a gentle transition edge is oversewn with a running suture. The edges of the inconspicuous since they are placed on the medial (inside) surfaces of labia minora to be excised are marked in a symmetric fashion on both the labia. The excisions are tailored to remove more of the mucosal surface edge is oversewn with a running suture than the external squamous epithelium thereby making the scars more 512 M. Huang Begovic Postoperatively patients are given antibiotics and told to apply a significant amount of lubricant to the surgical site for 2–3 weeks. Often times there is a web contraction at the posterior fornix causing pain and discomfort during intercourse and in severe cases result in severe ulceration of the posterior for- nix. The author has successfully released the web by per- forming a large Z-plasty (Fig. All of the patients whom the author has performed these procedures on have had significant relief of their symptoms. Lynch A, Marulaiah M, Samarakkody U (2008) Reduction Obstet Gynecol 109:1179–1180 labioplasty in adolescents. Plast Reconstr Surg Saunders Elsevier, Philadelphia, pp 1281–1294 122(6):1780–1789 6. Giraldo F, Gonzalez C, de Haro F (2004) Central wedge nymphec- plasty: how should healthcare providers respond? Saunders Elsevier, Philadelphia, pp 389–410 Should doctors reconstruct the vaginal introitus of adolescent girls 11. Pardo J, Sola V, Ricci P, Guilloff E (2006) Laser labioplasty of labia hymenoplasty. Int J Gynaecol Obstet 93(1):38–43 Ancillary Nonsurgical Treatments: Trunk and Abdomen David S. Chang 1 Introduction controlled trial, they provide some evidence in favor of non- invasive treatments to improve body contour. Body contouring procedures of the trunk and abdomen have In general, noninvasive treatments apply energy to the historically been among the top five surgical cosmetic proce- skin surface that causes collagen denaturation and neocolla- dures performed in the United States [1]. The types of energy that is delivered can be treatments for body contouring are the gold standard for broadly categorized into four groups: radiofrequency patients interested in surgically improving or correcting con- devices, optical devices, mechanical (suction, massage), and tour abnormalities [2]. The common pathway for skin tightening is via associated with the standard risks of any surgical procedure the production of heat. Cellulite is characterized by a skin surface irregularity million procedures in 2008 [1]. It is frequently compared to the appearance of cally evaluate new technology and procedures that claim to an orange peel or cottage cheese [6, 9]. The subjective nature of cosmetic pro- 90 % of postpubescent women and its exact etiology is cedures makes objective evaluation of results inherently dif- unknown. One blinded evaluation by your peers, or some other objective theory holds that cellulite is caused by herniation of fat from measure? Despite these questions, we must strive for the subcutaneous tissue into the dermis through dermal fas- evidence-based care that bases treatments on objective data cial bands only present in women [10]. The randomized controlled trial is the ology, its appearance is frequently disturbing to women and gold standard of evidence-based medicine, but this type of getting rid of it has created a billion dollar industry [6]. Most studies in plastic sur- Despite, or perhaps because of this, there is a general lack of gery are actually case-controlled studies or case series, which basic and clinical research into cellulite treatment [5 ]. Nevertheless, there are now numer- The search for the least invasive procedures that prom- ous of these studies showing variable efficacy of these non- ises the results of surgery without the risks and downtime invasive treatments to reduce torso circumference and has been the holy grail of cosmetic surgery. While these treat- ments may have a place in the cosmetic surgeons’ armamentarium, in general, minimally invasive treatments D. Twenty-six patients were treated on the 2 Treatment Modalities thighs and buttocks with 2 treatments 15 days apart. Sixty-eight percent of patients had a 20 % reduction in volume of subcutaneous fat. They do produces an alternating current that travels from the tip of not report on any objective evaluation of cellulite a probe to a grounding pad placed on the patient (mono- appearance. Energy does not reach the deep dermis or subcuta- mechanism for the effects on skin is the effects of thermal neous tissues. In wound healing response results in new collagen deposi- these small number of selected patients, there was a >50 % tion and remodeling [11]. In a study of ideal patient is in her 30s to mid-40s and has only early signs 50 patients treated weekly for 12 weeks, two-thirds were of aging with no actinic damage [14]. Skin complication is mild erythema and edema that resolves texture was measured using three-dimensional optical imag- within 24 h [15]. At 2 months, there was a 42–50 % improvement in skin lated to other parts of the body based on these studies, but texture. Lasers are the gold standard for ablative resurfacing of the In 1997, the then American Society of Plastic and skin, particularly in the face. Specifically, these devices target the have been more studies on Endermologie [23], but none has treatment of cellulite. Optical devices alone have been evalu- definitively shown it to be effective at either fat reduction or ated with variable success. The largest of these studies enrolled 85 utilizes light in the visible spectrum and is approved by the patients treated for 7 or 14 weeks [22]. It is widely variable results, but 90 % of patients reported a favor- thought to increase collagen thickness in the dermis [20]. Of the cream, Fink reported a 50 % improvement in cellulite appear- patients randomized to Endermologie, only 11 % showed ance. There was no control group, and 25 % of the patients improvement on clinical exam and less than one-third of dropped out of the study [19] making the results difficult to patients thought that there was improvement. In 11 patients, the results showed treated (arms, breasts, waist, hips, subgluteal region, thigh, slight improvement. Total body circumference was lower sound which showed a thinning of the dermis [9 ].

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