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An enterocele can only develop when other factors open and expose the deep pouch of Douglas buy 60 mg alli amex weight loss pills roseville ca. Normal pelvic floor support prevents opening and exposure of the pouch of Douglas purchase generic alli canada weight loss acupuncture. Vaginal Axis In a woman with normal pelvic organ support order alli without prescription weight loss 50, the pouch of Douglas is closed, irrespective of its depth, and lies nearly horizontally between the levator plate and the vagina [16–18]. It is known that operations that change the vaginal axis can lead to increased prolapse in the “unprotected” area. This is true for the higher incidence of cystoceles after sacrospinous fixations, where the position of the vagina is more posterior and also for the considerate rate of rectoceles and enteroceles after Burch colposuspensions or ventrofixations where the vagina is displaced anteriorly. A further process that changes the vaginal axis is excessive perineal descent (or descending perineum syndrome), which is often seen clinically in women with significant posterior vaginal wall prolapse (Figure 83. A deep pouch of Douglas is likely to accentuate the process of enterocele development once the vaginal axis is changed. Endopelvic “Fascia” The integrity of the anterior and posterior endopelvic fascia or connective tissue and its attachments is essential for normal pelvic organ support [8]. A defect in the endopelvic fascia or insufficiency is necessary for an enterocele to protrude. However, an intact endopelvic connective tissue might only prevent the enterocele from bulging into the vagina but not into the rectum causing an anterior rectal wall procidentia (Figure 83. It is not entirely apparent whether the endopelvic fascia is identical to the rectovaginal septum as the latter can be rather short [20], depending on the depth of the pouch of Douglas. Whole-thickness biopsies of the leading edge of radiologically proven enteroceles showed that in none of the 13 women examined the vaginal epithelium was in direct contact with the perineum and all had a well-defined vaginal wall muscularis [21]. These findings add to the ongoing controversy on whether the fascia exists or not. It has been suggested that it is a structure that is artificially created during surgical dissection. This debate is complicated by inconsistent histological studies, some of which do not substantiate the concept of a fascia between the rectum and vagina. However, it might simply be a question of definition: the fascia is a connective tissue usually with smooth muscle cells and it might also contain fatty or areolar tissue [22] (Figure 83. Whether the fascia is part of the vagina or rectum or whether it is a separate structure is of scientific but not clinical value. Fascia in the clinical sense means connective tissue that has tensile strength and is strong enough to hold sutures and support the underlying organs. These photos demonstrate a nearly normal position of the perineum at rest (a) but a “ballooning” of the perineum on straining (b). This patient had a large rectoenterocele that did not protrude outside the introitus. This stain is used to differentiate fibrous tissue (green) and smooth muscle (red). Note the amount of smooth muscle, organized connective tissue, and areolar tissue. Apart from bowel symptoms, which can be similar to complaints of patients with rectoceles or enteroceles, excessive perineal descent of more than 2 cm (measured in relation to the ischial tuberosities) is seen more frequently in women with posterior vaginal wall prolapse [24]. Solitary rectal ulcer, rectal prolapse, and intussusception are common concomitant findings [24,25]. The etiology is unclear, but reduced pelvic floor tone [26] with insufficient perineal and endopelvic fascial attachment and a deep pouch of Douglas and sigmoid colon elongation have been discussed. The term “ballooning” is also used to describe an enlargement of the genital hiatus during straining on perineal 3D ultrasound and is associated with pelvic organ prolapse [27]. Pulsion, Traction, Sliding, True, and Congenital: Concepts of Enterocele Development There are different concepts, and each one of them might be true in an individual patient. It is argued that a 1271 traction enterocele is accompanied by the loss of pelvic organ support [17] and a greater vault descent with normal anatomical connections between the pouch of Douglas and vagina [28,29]. In contrast, according to Nichols and Genadry [17], a pulsion enterocele is secondary to increased abdominal pressure, whereas Zacharin states that a pulsion enterocele occurs as a late complication of pelvic surgery like hysterectomies and is associated with a large rectovaginal pouch [28]. However, Zacharin is convinced that the depth of the pouch of Douglas has no bearing on enterocele development. He considers levator incompetence and relaxation of the fascial support to be the primary defects.


  • Confusion
  • Fatigue
  • Autofluorescence (a light technique)
  • Excessive alcohol use
  • Low blood pressure
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  • Foul or strong urine odor
  • Viral infection (most common)

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If horizontal lid shortening is required generic 60mg alli amex weight loss recipes, than a 1 cm vertical space between the inferior border of the the dermal orbicular pennant is left intact and a lateral can- tarsus and the incised capsulopalpebral fascia buy generic alli canada weight loss pills 2013 uk, a vertical thotomy is performed separating the upper and lower eyelids spacer graft is inserted (Fig 60 mg alli free shipping weight loss after pregnancy. Autogenous auricular carti- at the lateral commissure just as in a tarsal strip lateral canthal lage is preferred and does not have to be covered with con- procedure. Note that a complete lateral canthotomy and lyis of the inferior reti- nacular structures has been performed. The new lateral commissure will be formed by moving the new lower lid margin to the upper lid, thereby shortening the lower eyelid by 8 mm. The vertical mid-lamellar cicatrical retraction has been released and an auricular cartilage graft inserted. The remaining dermal orbicular pen- nant is used to augment the midfacial suspension (Fig. If the distance is greater than 1 cm (prominent horizontal lid laxity is made with the positive distraction and snap test of the lower eyelid (see Fig. Whenever there is a vertical cicatrical retaction of the mid lamella of the lower eyelid greater than 1 cm in vertical dimension, a spacer graft of autogenous material is required. If midfacial descent is diagnosed, the cheek and midface must be elevated with bony fixation to support the lateral canthus and lower eyelid position. The use of titanium screws, bone drill holes, and fascial suspension is required in these circumstances. To determine which type of lateral canthal procedure to utilize is directly related to the identification of seven cardinal physical diagnostic findings: (1) palpebral aperture, (2) vec- Fig. The cartilage is not cov- orbital bone distance, (5) canthal tilt, (6) mid lamellar verti- ered with conjunctiva cal lower eyelid retraction, and (7) midfacial descent. Plast Reconstr Surg vides a means of determining which type of lateral canthal 85:971–981 procedure and ancillary techniques will be required to man- 22. Plast Reconstr Surg 100:1262–1270; discussion 1271–1275 the preoperative physical findings, the more complex the 23. Patipa M (2004) Transblepharoplasty lower eyelid and midface lateral canthal tendon. A technique of value in the surgical treatment 113:1459–1468; discussion 1475–1477 of facial palsy. Clin Plast Surg 18:183–195 Plast Reconstr Surg 113:1469–1474; discussion 1475–1477 4. Fagien S (2011) Discussion: traditional lower blepharoplasty: is Surg 79:897–905 additional support necessary? Montandon D (1978) A modification of the dermal-flap canthal lift lar suspension: a simplified suture canthopexy. Ortiz-Monasterio F, Rodriguez A (1985) Lateral canthoplasty to cussion 2036–2041 change the eye slant. McKinney P (1977) Use of tarsal plate resection in blepharoplasty on atonic lower lids. Plast Reconstr Surg 59:649–652 Complications of Aesthetic Blepharoplasty and Revisional Surgeries Richard D. Zoumalan 1 Introduction • Dry eye • Eyelid hematoma Blepharoplasty has traditionally been one of the most com- • Infection mon aesthetic procedures performed and remains so today. Although relatively – Ptosis straightforward, complications ranging from mild skin blem- – Lagophthalmos ishes to vision-threatening emergencies can arise postopera- • Lower eyelid malposition tively. Many of these complications can be prevented with • Corneal exposure careful preoperative evaluation and proper surgical tech- • Strabismus nique. When complications do arise, their significance can Late (>6th week) be diminished by appropriate treatment and/or referral con- • Upper eyelid malposition sultation when necessary. It • Over- and under-resection of orbital fat is important to realize that some complications may arise in • Eyelid crease abnormalities during various postoperative timeframes. Early recognition • Malar festoons and appropriate treatment is essential, but the best therapeutic • Suture tracks option often differs based upon the timing from surgery.

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There have been many negative comments and editorials written suggesting that both the doctors and the patients should not be pursuing cosmetic vaginal surgery [44–46] order cheap alli on line weight loss 757. Many of those who imposingly opine are often ignorant of the patient and their disposition as well as their medical conditions and their associated symptoms [47] buy genuine alli line weight loss motivation quotes. Physical symptoms are usually associated with wearing certain types of clothing; engaging in activities such as walking alli 60mg without prescription weight loss 3 weeks, jogging, exercise, and bicycling; and finally intercourse. Yet, other patients are afflicted with emotional problems such as embarrassment, anxiety, and a loss of self-esteem. Cosmetic vaginal surgery does not always begin and end with labia minora reduction surgery, i. There are many different techniques that can be applied to enhance a woman’s genital cosmetic image. To understand the techniques, a basic understanding of the external genitalia is essential before undertaking surgical procedures. Anatomy The vulva is made up of the external genitalia including the mons pubis, clitoris, prepuce or clitoral hood, labia minora, labia majora, urethral meatus, hymen, and vestibule (Figure 116. The mons pubis is the adipose-laden area that lies superior to the pubic symphysis. This area is naturally covered with 1741 pubic hair and is a natural cushion during the impact of intercourse. The adipose area of the mons is contiguous with that of the hair-bearing labia majora. The labia majora are found bilaterally and converge both anteriorly above the clitoral prepuce and posteriorly at the perineum. The prepuce is actually the clitoral hood and acts like a protective covering over the clitoral gland. The labia minora are bilateral mucosal– cutaneous refolds located between the labia majora and vulvar vestibule. While there is a wide range of normal anatomic variants, in general, the labia minora are semicircular with a 3 cm long base and a free edge extending from the clitoris to the posterior commissure. The medial mucosal surface is derived from the primitive urogenital sinus and is shiny and pink. The free edge and the lateral cutaneous surface that are derived from the urethral folds are more deeply pigmented [48]. However, the deeper pigment tends to be a darker pink initially and then begins to darken with hormonal changes often but not always associated with pregnancy. Obviously, just like any other part of the human body, there are multiple normal variants of this anatomy. Just like a nose, all the structures can be anatomically similar but cosmetically dissimilar. The most common of all described cosmetic vaginal surgery is labia minora reduction or labiaplasty [48–51]. Labia Minora Reduction (Labiaplasty) Labia minora protruding past the distal edge of the labia majora can be of concern to women. As mentioned earlier, this condition can constitute a functional or cosmetic problem. Labial enlargement can be congenital as described by Caparo [52] and Radman [53] or can also be the result of androgenic hormones, manual stretching, and chronic irritation [52–55]. The primary reason for patients requesting this surgery was aesthetic dissatisfaction in 87% of cases, discomfort in clothing in 64%, discomfort when taking part in sports in 26%, and entry dyspareunia by invagination of the protuberant tissue in 43% [49]. We reported on a study of 131 patients undergoing labia minora reduction surgery and revealed the patients’ indications for having the surgery: 37% strictly cosmetic reasons, 32% strictly for physical symptoms, and 31% a combination of cosmetic reasons and physical symptoms [52]. Although there are still few papers on labial reduction surgery, there are a number of different techniques described in the literature. The two most commonly utilized techniques are known as excision or contouring technique and the wedge resection technique. The authors employ both techniques depending upon the patients’ requests and desires.

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Note the fattening of the body with extensive blunt force injury and fragmentation order alli australia weight loss websites. Note the clotted adherent epidural hemorrhage within the temporal region of the skull order alli with paypal weight loss pills garcinia cambogia dr oz. Note the membrane separa- In contrast alli 60mg without prescription weight loss pills 2, a chronic epidural hematoma generally leaves a tion with beading up away from the midline caused by fattened and less irregular cerebral cortex deformation. This hemorrhage occurred follow- ing a blunt impact to the face, causing hyperextension and rotation of the head with laceration of the right vertebral artery. These individuals lived from several hours to several days after the initial insult. Some areas of ecchymosis occurred in association with fresh needle marks from therapy. Hepatic cirrhosis is less commonly associated with laceration due to the increased fbrosis. A normal liver is the most common organ in the peritoneal cavity to lacerate in association with blunt force trauma. This indi- vidual sustained a comminuted skull fracture with mul- tiple central nervous system lacerations. There is also blister formation confned to this region associated with sepsis following infection associated with this trauma. Examples of these dent’s body consisted of slit-like perforations with multi- instruments include a knife, razor, box cutter, scalpel, ple, adjacent, parallel linear abrasions. Tis pattern injury sharp-edged piece of metal, broken glass bottle, broken is consistent with a serrated knife. Many of the images in glass window, scissor, ice pick, fork, propeller, screw driver, this chapter are designed to help with pattern recognition. Tis is in contrast to a blunt- force injury, where contact with the body is by a nonsharp Location and Direction of Injury object such as a baseball bat or the foor. Tis should be given with reference to a particular body A stab wound is typically made by a knife blade and position, usually standard anatomic planes. Each wound is defned as having a greater depth of penetration than should be documented by location on the body’s sur- surface dimension. An incised wound is a slicing-type face, and measured from vertical and horizontal planes injury where the surface dimension is greater than the of reference. Each injury anatomic planes are demonstrated with the body in an should have a documented location on the body, includ- upright position with the head tilted slightly upward, the ing a description of adjacent abrasions or contusions, legs together, the arms at the sides, and palms facing for- wound dimensions, depth of penetration, and direc- ward. Te head is superior and the feet inferior; medial tion of penetration into the body. Te posterior part of the body includes In cases where there are multiple injuries, it is acceptable the back, buttocks, and so on. It is good practice to take into or through the body should be given with reference overall photographs of the body before and afer clean- to three planes when possible: front–back, right–lef, and ing, as well as close-up photographs of each wound. Tis is important because it allows one to cor- Important aspects concerning interpretation of injury relate the injuries to possible assault descriptions and involve pattern recognition. One exam- ple where this would come in handy involved the arrest Wound Dimension of several suspects with diferent concealed weapons. Te police may approach you to render an opinion about Tis should be documented separately for each sharp- what type of weapon produced injuries so they can focus force injury, unless there are many that can be grouped their early investigation. Example: Tere are 319 320 Color Atlas of Forensic Medicine and Pathology twenty 1-inch to 2-inch by up to 1/4-inch, stab wounds Adjacent Abrasions and Contusions within a 5-inch to 7-inch region on the middle aspect of the right chest, which is centered 13 inches below Tese may indicate body contact from the knife handle, the top of the head and 4 inches to the right of the lower part of the knife blade, or the knife hilt. If the exists on the body and then again when in a relaxed knife blade penetrates a bone and there are hilt marks state. Te important aspect is to document the wound adjacent to the perforation site, one can extrapolate dimension in ranges that most closely refect the actual that the knife must have been stuck into the body with dimensions of the knife blade or instrument. A stab greater force than a blade that only penetrated half the wound can be put into a relaxed state by pressing the length of a blade.

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