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By Z. Einar. North Carolina School of the Arts.

These are injury to the nerve 100mg viagra soft, injury to the blood vessels and injury to the internal organs within the thorax or abdomen which is more dreadful and may be fatal viagra soft 100 mg. It is of immense importance to exclude any other injury which may be associated with the bone or joint injury viagra soft 50mg. In this context one must remember that thoracic and abdominal injuries 50mg viagra soft, which tend to be overlooked 50 mg viagra soft, are more dangerous viagra soft 50 mg. When a pathological fracture is suspected 100 mg viagra soft, an attempt should be made to know the cause of the pathological fracture viagra soft 100mg. In infants , multiple fractures may be seen in cases of osteogenesis imperfecta (brittle bones) , which is characterized by dwarfism, broad skull, blue sclera, scoliosis, ligament laxity, otosclerosis (although deafness may not appear until adult life) and various deformities. In adults generalized fibrocystic disease (hyperparathyroidism) and multiple myeloma are the causes of multiple fractures. In case of secondary carcinoma a thorough search should be made to get at the primary focus either in the breast or thyroid or bronchus or kidney or prostate etc. At least two views antero-posterior and lateral should be taken to determine which bone has been fractured, the line of fracture and the type of displacement. The antero-posterior view shows sidewise displacement — external or internal whereas the lateral view reveals anterior or posterior displacement. The three points are mainly noted while reading X-ray plate: (i) Situation — which bone is broken and which part of it? A careful assessment of the line of fracture is very important to know the mechanism of the injury and the treatment to be instituted, (iii) Displacement. There may not be any shift as the fragments may be impacted or overlap each other, (b) Tilt — may be again forwards, backwards and sideways, (c) Twist (rotation) which may be in any direction. Sometimes X-ray picture should be taken from different positions to locate the sites of fracture which are difficult to be revealed in classical antero-posterior and the lateral views. These are oblique view in scaphoid fracture, stereoscopic views in fracture of the skull and pelvis, special axial radiograph in fracture of the calcaneum. In old fractures, one should look for the following points — (i) Signs of union — callus formation which appears in X-ray as early as on the tenth day after fracture. Consolidation and bone remodelling take quite a long time and one should not wait for these signs as the signs of union. In fact union occurs long before these signs develop and clinical test is better evidence of union than the radiological evidence. If there is no local tenderness at the site of fracture and attempt at abnormal movement between the fracture fragments fails to produce any pain or movement, it Figs. Note that there is hardly any evidence of fracture fracture has been united (clinically) though in the lateral view, but the anteroposterior view reveals X-ray shows a small gap between the fracture dislocation with considerable displacement. Note that the lower fragment is shifted upwards, slightly laterally with a variety of and tilted posteriorly. The increased blood flow and increased osteoid tissue formation, which are the processes of tumour-cell invasion, can be demonstrated by locally increased concentration of the gamma- emitting radioisotope. The increased radioactivity is displayed either as a number of counts on a scaler or pictorially as a "hot­ spot" on a scintiscan. Infrequently, in case of very anaplastic carcinoma, indolent tumours such as thyroid cancer or some cases of myeloma, there may be little or no "hot-spot" seen. Scanning is performed 1 to 4 hours after the intravenous injection of 5 to 10 mCi 99 ’ of Tcm-phosphate complex. The distal piece ‘D’ remains through the urine within first 4 hours after unaffected. This is a complication of fracture of the scaphoid injection and pelvic lesions are liable to be which so commonly takes place through its waist. It should be remembered that the simple radiograph shows no abnormality until more than 50% of bone mineral has been destroyed and obvious metastasis may be present even in the absence of X-ray changes. Bony metastasis from cancer of prostate may be present despite normal acid and alkaline phosphatase levels. Bone scan sometimes demonstrates "silent" metastasis which has produced fracture, which was initially thought to be simple. Arthroscopy is extremely helpful to detect joint injuries and particularly the semilunar cartilage (meniscus) injuries of the knee. Of the above symptoms and signs local bony tenderness, local bony irregularity, crepitus and X-ray are the most important points to be remembered. Dislocation is diagnosed by (i) the deformity, (ii) abnormal swelling near a joint, (iii) rigidity of the joint in passive movements and X-ray. Diagnosis is made (i) by presence of tenderness on the ligament particularly at its bony attachment, (ii) passive stretching of the ligament will cause excruciating pain, (iii) there is no local bony tenderness or local bony irregularity and (iv) X-ray shows no bony injury. Sometimes severe traction on the nerve during injury or during overzealous manipulation may lead to axonotmesis. Immediate nerve injuries which are seen with different bone and joint injuries are — (i) the spinal cord or cauda equina injury in fracture-dislocation of the spine, (ii) the axillary nerve in shoulder dislocation or fracture neck of the humerus, (iii) the radial nerve in fracture shaft of the humerus, (iv) ulnar, median and/or radial nerve in supracondylar fracture of the humerus, (v) sciatic nerve in posterior dislocation of the hip and subtrochanteric fracture of the femur and (vi) the common peroneal nerve in fracture of the neck of the fibula. The most common example is the "tardy ulnar palsy" in supracondylar fracture of the humerus which has been malunited with Cubitus Valgus deformity and in fracture of the medial epicondyle of the humerus where the ulnar nerve is involved in callus and gradual injury to the nerve by bony irregularity if anterior transposition of the ulnar nerve has not been performed. Sometimes they are pressed upon by the displaced fragment and very rarely they are completely divided. If the impairment is due to displaced fragment, prompt reduction of the fracture or dislocation should be called for. Sometimes the impairment of circulation is due to incorrect application of plaster of Paris and these cases should be treated by immediate removal of the plaster and bandages till the pulsation of the artery comes back. If these procedures fail to bring about improvement in circulation, there is a place for immediate arteriography with a view to possible excision and grafting. Vascular injury may lead to gangrene in severe cases and late ischaemic contracture of muscles in less severe cases. The torn fibres may become adherent to the intact fibres, fractured site or capsule of the neighbouring joint. This may lead to stiffness of the joint and may require lengthy rehabilitation after the fracture has been consolidated. So every attempt should be made to keep the muscles active when the fracture is kept immobilized. Tendinitis is a very rare complication of a fracture and occasionally affect the tibialis posterior tendon following fracture of the medial malleolus. Such examples are injury to the urinary bladder and urethra in fracture of the pelvis, rectum in the fracture of the sacrum, lung, liver or spleen in fracture of the ribs and the brain in fracture of the skull. It may give rise to osteomyelitis with formation of sequestrum and sometimes absorption of bone overwhelms leading to disappearance of some part of the bone. The most dreadful complications of a compound fracture are the gas gangrene and tetanus. The causes are (i) inadequate immobilization; (ii) internal fixation which always delays union as the haematoma between the fracture ends which acts as a scaffold for union is disturbed and because the periosteum is stripped off and (iii) intact fellow bone — when one bone of the forearm or the leg remains unbroken, the fractured bone always takes longer time for union. To know whether the fracture concerned is a case of delayed union or non-union, X-ray is very much essential. In non-union there will be presence of sclerosis at the bone ends and a gap between them. Causes of non-union are (i) infection; (ii) interposition of soft tissue either periosteum or muscle between the bone ends; (iii) inadequate blood supply e. The commonest deformity is angulation, besides this there may be overlapping with shortening and mal-rotation. The causes of mal-union are (i) fracture was not reduced properly; (ii) after reduction redisplacement occurs within the plaster, for this a check X-ray after a week is advisable in certain fractures anticipating redisplacement, e. Fracture-separation of an epiphysis does not lead to growth disturbance as the fracture occurs through the metaphyseal plate keeping the epiphyseal cartilage intact. Sites of mal-union are those where the bone is cancellous so union occurs as a rule, but mal-union complicates due to imperfect position of the bone ends. It complicates fracture when the blood supply of one fragment was derived from the other fragment when the bone was intact. So after fracture the blood supply of one fragment becomes completely deficient and undergoes avascular necrosis. This avascular necrosis will lead to non-union and osteoarthritis of the involved joint. The avascular bone shows greater density due to the fact that it does not share in the general osteoporosis due to deficient blood supply. The common sites of fracture which are liable to undergo this complication are the fracture neck of the femur, fracture of the scaphoid, fracture of the neck of the talus where the body undergoes avascular necrosis and dislocation of the lunate bone when the whole bone becomes necrosed. Though muscles can survive 6 to 8 hours ischaemia in contradistinction to the nerve tissue which can survive only a short period of ischaemia, yet the muscles cannot regenerate whereas the nerves can regenerate. This condition is commonly seen in the forearm following supracondylar fracture of the humerus which leads to occlusion of the brachial artery either by thrombosis or spasm or by the displaced lower end of the upper fragment. Nerves are also affected by ischaemia suggested by pain, weakness and numbness of the finger, but the nerves regenerate. In the early stage diagnosis is made by impaired circulation of hand and fingers, absence of the radial pulse and inability of the patient to extend the fingers fully with complaint of pain in full passive extension. In the established stage there will be obvious flexion deformity of the wrist and the fingers. Actually this condition develops when the haematoma under the stripped periosteum is invaded by osteoblasts and becomes ossified. This condition is commoner in children and young adults in whom the periosteum is loosely attached to the bone. This condition is more commonly seen in elbow after supra-condylar fracture or fracture of the head of the radius. It is also seen in some cases of fracture neck of the femur after operative fixation. More commonly periarticular adhesions occur from effusion into the ligaments and the capsules. Stiffness following fracture occurs mostly in the knee joint, the elbow joint, the wrist joint and the finger joint. In the shoulder joint the synovial fold on the inferior aspect of the joint is redundant and becomes adherent causing limitation of abduction movement. The commonest example is the stiffness of the knee following fracture of the shaft of the femur due to adhesion of the quadriceps muscles. In these cases quadriceps-plasty does a lot to increase the movement of the knee joint, (ii) Myositis ossificans. After union the joint surface becomes irregular and thus results in osteoarthritis. Mal-union may be the cause of osteoarthritis particularly in weight bearing joints where the direction of stress transmission becomes abnormal. Avascular necrosis is another potential factor which may lead to osteoarthritis, (v) Unreduced dislocation. Pain and stiffness of the fingers, hyperaesthesia and moistness of the ankle is diagnostic of this condition. In this chapter only those particular points of clinical examination are mentioned which will be required for a particular joint. With fracture of the clavicle the patient often supports the flexed elbow of the injured side with the other hand. Similarly with anterior dislocation of the shoulder the patient supports the flexed elbow of Fig. Flattening in case of dislocation of the shoulder is due to inward displacement of the upper end of the humerus. Here, of of the right shoulder due to subcoracoid course prominence of the greater tuberosity can be felt. If there is any undue prominence at the acromial or the sternal end of the clavicle, the case is probably nothing but dislocation of acromioclavicular or sternoclavicular joint respectively. In subcoracoid dislocation of the shoulder an abnormal swelling can be seen in the deltopectoral groove, there will be undue prominence of the acromion process with flattening of the shoulder. There will be drooping of the shoulder with undue lengthening of the arm in fracture neck of the scapida. In contrast to this, flip considerable swelling of the shoulder just below the | acromion process occurs in fracture neck of the H i, -—I ■ humerus, without any loss of roundness of the X A W shoulder. The surgeon places his hands on the sternal ends of the clavicles of the both sides. Firstly, he palpates the sternoclavicular joints and then proceeds laterally on both sides to palpate the entire length of the two clavicles simultaneously. The two joints on two sides of the clavicle are also examined in this process to exclude any dislocation there. The sternal end of the clavicle is mostly anteriorly displaced in sternoclavicular dislocation, Fig. It is better felt by the be remembered that the conoid and trapezoid ligaments hand in the axilla. The surgeon first palpates the acromion processes of both sides with the fingers of his two hands. He now gradually slides his fingers downwards to palpate the greater tuberosity of the humerus on both sides. Disappearance of the greater tuberosity of the humerus and loss of resistance here indicate dislocation of the shoulder. He now gradually slides his fingers downwards along the line of the humerus on both sides. Local bony tenderness and bony irregularity at the surgical neck of the humerus suggest fracture neck of the humerus. Similarly if the surgeon goes down to palpate the shaft of the humerus, he may exclude the fracture at this site by absence of local bony tenderness and bony irregularity. It must be remembered that in an unbroken bone the medial epicondyle shows the direction of the head of the humerus, whereas the lateral epicondyle shows the direction of the greater tuberosity. If this relation is disturbed, one must suspect the possibility of fracture either at the neck of humerus or at the shaft.

Nevertheless viagra soft 100 mg, a trial of therapy is often necessary to rule out the nutritional neuropathies 100 mg viagra soft. Lumbar puncture 50 mg viagra soft, as already mentioned viagra soft 100mg, is useful in diagnosing Guillain–Barré syndrome 50mg viagra soft. These findings would suggest a diagnosis of cerebral vascular disease viagra soft 50mg, a space-occupying lesion of the brain 100mg viagra soft, migraine viagra soft 50 mg, or multiple sclerosis . Pain in the involved extremity , particularly radicular pain, should suggest a herniated cervical disk, spinal cord tumor, or cervical spondylosis. However, many other conditions, such as brachial plexus neuropathy, thoracic outlet syndrome, a cervical rib, Pancoast’s tumor, Raynaud’s disease, and sympathetic dystrophy, should also be considered. Finally, the various entrapment syndromes should be considered, such as carpal tunnel syndrome and ulnar nerve entrapment at the elbow. If the radial pulse diminishes in certain positions of the neck and shoulders, a thoracic outlet syndrome or cervical rib should be considered. A positive Tinel’s sign at the wrist would suggest a carpal tunnel syndrome and can be confirmed by a positive Phalen’s test. The ulnar nerve may also be entrapped in Guyon’s canal and the median nerve may be trapped at the elbow in a pronator syndrome. The presence of a positive cervical compression test or a positive Spurling’s test would suggest cervical spondylosis and herniated cervical disk. The presence of hyperactive reflexes in the upper or lower extremity would suggest a spinal cord tumor, multiple sclerosis, degenerative disease of the spinal cord, such as syringomyelia or amyotrophic lateral sclerosis, anterior spinal artery occlusion, and cervical spondylosis. The presence of normal or hypoactive reflexes in the involved extremity should prompt consideration of peripheral neuropathy, pernicious anemia, and brachial plexus neuropathy. If these are negative, the next logical step is to consult a neurologist or neurosurgeon. If tabes dorsalis is suspected, a blood or spinal fluid fluorescent Treponema pallidum antibody test may be done. A therapeutic trial of vitamin B6 or corticosteroids may diagnose carpal tunnel syndrome if a neurologist is not available. If the pathologic reflexes come and go, transient ischemic attacks, multiple sclerosis, migraine, epilepsy, and hypoglycemia should be considered in the differential diagnosis. Unilateral pathologic reflexes should signify either a brain tumor or vascular lesion. Bilateral pathologic reflexes should suggest an inflammatory or degenerative disease. However, multiple sclerosis may present with either unilateral or bilateral pathologic reflexes. Vascular lesions in the basilar circulation may also present with bilateral pathologic reflexes. The presence of facial palsy or other cranial nerve signs should make one look for a lesion in the brain or brain stem. The presence of headache or papilledema should prompt the investigation for a space-occupying lesion of the brain or brain stem. These findings would suggest a cerebral vascular accident such as cerebral hemorrhage or embolism. The findings of bilateral pathologic reflexes or unilateral pathologic reflexes with a normal sensory exam and no cranial nerve signs would suggest amyotrophic lateral sclerosis or primary lateral sclerosis. However, it is wise to get a neurology consultation before undertaking these expensive tests. If vascular disease is suspected, carotid scans to rule out carotid stenosis or plaque and a search for an embolic source using echocardiography and blood culture should be done. In fact, if a cerebral hemorrhage has been ruled out and there is no significant hypertension, a four-vessel cerebral angiographic study should probably be done. Serum protein electrophoresis and immunoelectrophoresis all may be necessary in the workup. The history of menorrhagia or metrorrhagia should suggest ectopic pregnancy, endometriosis, and threatened abortion, as well as retained secundinae. A positive pregnancy test is the key to a diagnosis of ectopic pregnancy when there is abdominal pain along with the abdominal mass. If there is a vaginal discharge, a smear and culture of the material should be made. If a distended bladder is suspected, catheterization for residual urine must be done. The gynecologist may do a laparoscopy, a culdocentesis, and, ultimately, an exploratory laparotomy. There is a history of heavy periods and on examination, she had an enlarged asymmetrical uterus. The pregnancy test is negative so, you suspect either uterine fibroids or endometriosis. The presence of a pelvic mass would suggest salpingo-oophoritis, ectopic pregnancy, endometriosis, uterine fibroid, or an ovarian tumor that is twisting on its pedicle. Be sure to do a rectovaginal examination as there may be a mass or fluid in the cul-de- sac. The history of metrorrhagia or menorrhagia would suggest ectopic pregnancy, threatened abortion, retained secundinae, uterine fibroids, and endometriosis. The presence of a positive pregnancy test would suggest an ectopic pregnancy or threatened abortion. If the pain is related to the menstrual cycle, mittelschmerz should be considered. The next step would logically be a pelvic or transvaginal ultrasound, but it is wise to consult a gynecologist before ordering expensive tests. The gynecologist may proceed with laparoscopy, culdocentesis, and, 486 ultimately, an exploratory laparotomy. If there is fever, a trial of antibiotics may be appropriate even if the workup is negative. The presence of a painful penile sore suggests chancroid, herpes simplex, herpes zoster, and balanitis. On the contrary, a painless penile sore should suggest chancre, lymphogranuloma venereum, epithelioma, granuloma inguinale, and papilloma. If there is inguinal adenopathy, lymphogranuloma venereum, epithelioma, and chancre should be suspected. A Tzanck test, serologic test, and viral isolation will help diagnose herpes zoster and herpes simplex. These findings suggest prostatitis, urethritis, cystitis, bladder calculus, bladder carcinoma, vaginitis, and abscesses of Cowper’s glands. These findings suggest hemorrhoids, perirectal abscess, anal fissure, anal ulcer, rectal carcinoma, and condylomata lata. Pelvic ultrasound will be helpful in diagnosing endometriosis, ectopic pregnancy, and pelvic appendicitis. The presence of a periorbital or facial rash should suggest contact dermatitis, angioneurotic edema, trichinosis, and herpes zoster. The presence of generalized edema suggests myxedema, cirrhosis, acute and chronic glomerulonephritis, congestive heart failure, and other disorders. The presence of fever suggests acute sinusitis, cavernous sinus thrombosis, orbital cellulitis, meningitis, and neurosyphilis. If there is fever, a nose and throat culture and blood culture should be done and antibiotics begun without delay. Trichinosis can be diagnosed by the skin test, serologic studies, or a muscle biopsy. In infants with pyloric obstruction, the vomiting is projectile, and the severe dehydration that follows, along with the right upper quadrant mass (a hypertrophied pylorus), helps to make the diagnosis. In adults with pyloric obstruction, the enlarged stomach with peristaltic waves going downward from left to right and a succussion splash are useful diagnostic signs. A flat plate of the abdomen (demonstrating the dilated stomach) and significant electrolyte alteration of metabolic alkalosis and potassium depletion will help confirm the diagnosis, but an exploratory laparotomy will remove all doubts. The peristalsis is transverse in small intestinal obstruction and vertical in large intestinal obstruction. Quinine, cocaine, atropine, and Apresoline are just a few of the drugs that may cause photophobia. Almost any condition of the eye may cause photophobia, including conjunctivitis, blepharitis, keratitis, iritis, corneal ulcers, and retinitis. Without fever or with only a low-grade fever, the presence of nuchal rigidity should suggest subarachnoid hemorrhage. If there is fever without nuchal rigidity, the workup can proceed as outlined on page 198. The fistula results from ruptured diverticulitis, ruptured appendix, or a neoplasm that forms a pelvic abscess that gradually eats its way into the bladder. Looking through her chart, you find laboratory results that show an increase in hemoglobin and hematocrit. Following the algorithm, you check for clinical signs of dehydration, and there are none. Her oxygen saturation is 96%, so pulmonary fibrosis or emphysema is an unlikely cause. You suspect polycythemia vera, but note that she is obese and has purple abdominal striae. If the plasma volume is decreased, think of dehydration, diuretic use, or other factors. Decreased oxygen saturation would suggest emphysema, pulmonary fibrosis, or cardiovascular disorder. An increase in the blood erythropoietin would suggest an erythropoietin-secreting tumor such as renal carcinoma or pheochromocytoma. A normal or decreased erythropoietin would point to polycythemia vera, heavy cigarette smoking, or methemoglobinemia. A hematology consult would be wise before undertaking any of the more expensive studies. The presence of these symptoms would suggest diabetes mellitus and hyperthyroidism. The presence of massive polyuria suggests diabetes insipidus or psychogenic polydipsia. The presence of mild polyuria should suggest chronic renal failure, renal tubular acidosis, hyperparathyroidism, and febrile illnesses. Also, a 24-hour urine collection for calcium may be done to help diagnose this condition. Microscopic examination of the urinary sediment will help diagnose renal disease, as will renal biopsies. The Hickey–Hare test and monitoring intake and output before and after vasopressin (Pitressin) will be useful in differentiating pituitary diabetes insipidus from nephrogenic diabetes insipidus. An endocrinologist should be consulted before ordering these expensive diagnostic tests. The presence of these symptoms would suggest diabetes mellitus or hyperthyroidism. This symptom would indicate that the patient has an insulinoma, Cushing’s disease, or idiopathic obesity. These symptoms would signal that the polyphagia is related to bulimia, hysteria, or other psychic disorder. If an insulinoma is suspected, plasma insulin or C-peptide levels may be done, or the patient may be hospitalized for a 72-hour fast with frequent blood sugar determinations. If hyperthyroidism, diabetes mellitus, insulinoma, and intestinal disorders have been ruled out, a referral to a psychiatrist would be indicated. Massive polyuria is usually because of pituitary or nephrogenic diabetes insipidus and psychogenic polydipsia. The presence of polyphagia and polydipsia suggests the possibility of diabetes mellitus and hyperthyroidism. The presence of a mild polyuria suggests chronic nephritis, renal tubular acidosis, hyperparathyroidism, Fanconi’s syndrome, and mild diabetes mellitus. The presence of glycosuria suggests diabetes mellitus, hyperthyroidism, and Fanconi’s syndrome. If renal disease is suspected, the urinary sediment should be examined microscopically and renal biopsy may be necessary. An endocrinologist and nephrologist should be consulted before undertaking expensive diagnostic tests. A soft popliteal swelling may be an abscess, varicose vein, Baker’s cyst, popliteal aneurysm, or swollen bursa. A firm popliteal swelling may be an osteosarcoma, periostitis, giant cell tumor, exostoses, lymphadenitis, lipoma, or fibroma. Masses that are connected to the bone are more likely exostoses, osteosarcomas, periostitis, or giant cell tumors. However, it is more cost-effective to seek an orthopedic consultation before ordering these tests or undertaking aspiration of the swelling. Children may take birth control pills early in life, and young boys may want to take anabolic steroids to increase their muscular mass. These findings would suggest a brain tumor, and a pinealoma is one that should be excluded. The presence of an adnexal mass would suggest a granulosa cell tumor or arrhenoblastoma.

In rare instances 100mg viagra soft, the trian- The posterior vagal trunk often is situated 2–3 cm lateral gular ligament must be incised viagra soft 100 mg, and the left lobe of the liver and posterior to the right wall of the esophagus 50mg viagra soft. Consequently viagra soft 50mg, its identification requires that when the sur- Using long DeBakey forceps and long Metzenbaum scis- geon’s right index finger encircles the lowermost esopha- sors 100 mg viagra soft, incise the peritoneum overlying the abdominal esopha- gus viagra soft 100mg, proceeding from the patient’s left to right 50 mg viagra soft, the fingernail gus (Figs viagra soft 50 mg. Use a peanut dissector go a considerable distance toward the patient’s right before to develop a groove between the esophagus and the adjacent the finger is flexed . The fingernail then rolls against the deep crux , exposing the anterior two-thirds of the esophagus aspect of the right branch of the crural muscle. At this point insert the right index finger gently maneuver is completed, the right trunk, a structure measur- behind the esophagus and encircle it. First, look for a major Left (Anterior) Vagal Trunks branch going toward the celiac ganglion. Second, insert a finger above the left gastric artery near the lesser curvature In our experience, whereas the posterior trunk often exists as of the stomach, and draw the left gastric vessel in a caudal a single structure in the abdomen, the anterior vagus divides direction. This applied traction to the posterior vagus, which into two or more trunks in more than 50 % of cases. The right trunk rarely divides main left trunk generally runs along the anterior wall of the in the abdomen above the level of the esophagogastric lower esophagus, and the other branches may be closely junction. Apply a long Mixter clamp to the nerve, place hemostatic The major nerve branches may be accentuated by caudal clips above and below the clamp, and remove a 2–3 cm seg- traction on the stomach, which makes the anterior nerves ment of nerve and submit it for histologic study. At the conclusion clips, remove segments from each of the anterior branches of this step the lower 5 cm of esophagus should be cleared of (Fig. One should see only longitudinal muscle forceps and sent to the pathology laboratory for analysis. For additional security when repairing a low agus, one or two sutures of 0 cotton or Tevdek should be esophageal tear, cover the suture line with gastric wall by placed to approximate the muscle bundles behind the esoph- performing a Nissen fundoplication. No attempt unpredictable and difficult to manage, a drainage proce- at fundoplication or any other antireflux procedure need be dure such as pyloroplasty or gastrojejunostomy is gener- undertaken unless the patient had symptoms or other evi- ally done with truncal vagotomy. If additional exposure is needed, do not hesitate to extend Proximal Gastric Vagotomy: Surgical 3 0 Legacy Technique Carol E. Chassin† Indications Prevention of Hematoma and Injury to Gastric Lesser Curve Peptic ulcer disease refractory to medical management See Chap. Preoperative Preparation Furthermore, rough dissection and hematomas in this area may damage the deserosalized muscle along the lesser curve Esophagogastroduodenoscopy to confirm the diagnosis to such an extent that necrosis may occur. Resuturing the peritoneum produces inversion of the desero- Pitfalls and Danger Points salized portion of the lesser curve and helps prevent perforation. Hematoma of gastrohepatic ligament Incomplete vagotomy Damage to innervation of pyloric antrum Preserving Innervation of the Antrum Injury to spleen Necrosis or perforation of lesser curvature of stomach The anterior and posterior nerves of Latarjet terminate in a configuration resembling the foot of a crow. This crow’s foot portion maintains innervation of the antrum and pylorus and Operative Strategy ensures adequate emptying of the stomach. Exposure Adequacy of Proximal Vagotomy The visibility of the area around the lower esophagus is greatly enhanced if the Thompson or the Upper Hand retrac- Hallenbeck et al. This required meticulous removal of all nerve branches reaching the lower 5–7 cm of the esopha- gus and the proximal stomach. Grassi noted that one reason the proximal vagotomy technique fails is that surgeons some- C. Chassin Postoperative Gastroesophageal Reflux between the left branch of the crux and the left margin of the esophagus. Pass the fingernail along the anterior wall of the Extensive dissection in the region of the esophagogastric aorta, and curve it anteriorly along the posterior aspect of junction may produce or exacerbate gastroesophageal reflux. As a result of this maneuver, undergo an antireflux procedure at completion of the proxi- the index finger almost invariably contains both vagal trunks mal gastric vagotomy. The siderably larger than the left and is almost always a single choice of procedure depends on the experience of the sur- trunk. The left (anterior) vagus can be identified generally at geon and the operative findings. Separate each vagal trunk gently from the esophageal wall, pulling the vagal trunk toward the right and the esophagus to the left. Documentation Basics Encircle each vagal trunk with a Silastic loop, brought out to the right of the esophagus. Findings Identification of Crow’s Foot Operative Technique Pass the left index and middle fingers through an avascu- Incision and Exposure lar area of the gastrohepatic omentum and enter the lesser sac. This enables the nerves and blood vessels along the With the patient supine, elevate the head of the operating lesser curvature of the stomach to be elevated and put on table 10–15°. The anterior nerve of Latarjet, which is the termi- point 5 cm below the umbilicus. Insert an Upper Hand or nation of the left vagus trunk as it innervates the anterior Thompson retractor to elevate the lower sternum about gastric wall, can be seen through the transparent perito- 8–10 cm. Insert a self-retaining retractor of the Balfour type neum adjacent to the lesser curvature of the stomach. It without excessive tension to separate the margins of the inci- intermingles with terminal branches of the left gastric sion. Depending on the patient’s body habitus, use a Weinberg artery, which also go to the lesser curvature. As the nerve or a Harrington retractor to elevate the left lobe of the liver of Latarjet reaches its termination, it divides into four or above the esophageal hiatus. On rare occasions this exposure five branches in a configuration that resembles a crow’s is not adequate, and the triangular ligament of the left lobe of foot. These terminal branches innervate the distal 6–7 cm the liver may have to be divided, with the left lobe retracted of the antrum and pylorus and should be preserved to the patient’s right. Identification of Right and Left Vagal Trunks Dissection of the Anterior Nerve of Latarjet Expose the peritoneum overlying the abdominal esophagus, After identifying the crow’s foot, insert a Mixter right- and transect it transversely using long Metzenbaum scissors angle clamp underneath the next cephalad branch of the and DeBakey forceps. Separate the clamp has broken through the peritoneum on both sides the anterior two-thirds of the circumference of the esophagus of these structures, divide them between Adson hemostats from the adjacent right and left crux of the diaphragm using and carefully ligate with 4-0 silk (Fig. Alternatively, scissors and peanut-sponge dissection under direct vision each branch may be double-ligated before being divided. Then encircle the esophagus with the right Repeat the same maneuver many times, ascending the index finger. To avoid leaving the poste- serve the innervation of the antrum, the hemostats must be rior vagus behind, pass the finger into the hiatus at the groove applied close to the gastric wall so as not to injure the main 30 Proximal Gastric Vagotomy: Surgical Legacy Technique 287 Fig. Take great care not to tear Preserve the hepatic branch of the vagus trunk also because any of these small blood vessels, as they tend to retract and it leaves the left vagus and goes to the patient’s right on its form hematomas in the gastrohepatic ligament obscuring way to the liver. Avoid trauma to the musculature of the gastric wall, as this area of the lesser curvature is not protected by Dissection of Posterior Nerve of Latarjet a layer of serosa. Continue dissection of the anterior layer of the gastrohe- Delineate the posterior leaflet of the gastrohepatic omentum patic ligament until the main trunk of the left vagus nerve is as it attaches to the posterior aspect of the lesser curvature of reached. Each branch of the left gastric artery and vein, tion, the left vagus nerve should be completely separated together with each terminal branch of the posterior nerve of from the wall of the esophagus for a distance of 6–7 cm Latarjet, should be individually isolated, double clamped, above the esophagogastric junction. Take care to make this divi- branching from the vagus nerve to this portion of the esoph- sion close to the gastric wall to preserve the main nerve of agus should be divided. Continue this dissection in a cephalad direction the left vagus to the stomach are interrupted, with the excep- until the previously identified right vagal trunk can be seen tion of those innervating the distal antrum and pylorus. If the surgeon’s left hand can be passed between the right of the completely bare lesser curvature. Now dissect the freed vagal trunks and the distal esophagus as well as away the posterior aspect of the esophagus from the poste- the gastric fundus, it helps ensure that the extent of the dis- rior vagus nerve for a distance of 7 cm above the esophago- section has been adequate. In addition, carefully inspect gastric junction so no branches from this trunk can reach the the longitudinal muscle fibers of the distal esophagus. Inadequate vagotomy results in recur- Repair of the Lesser Curvature rent ulceration. Unique to proximal gastric vagotomy is necrosis of Use interrupted 4-0 silk Lembert sutures to approximate the the lesser curvature. Close the abdominal results from trauma or hematoma of the gastric wall in an incision in the usual fashion, without drainage. Prevention requires accurate dis- section assisted by reperitonealization of the lesser curva- ture by suturing (Fig. At the end of this time the patient generally is able to be advanced to a normal diet. Usually the postoperative course is uneventful, and undesirable postoperative gastric sequelae, such as dumping, are distinctly uncommon. Indications for parietal cell vagotomy without drainage in gastrointestinal surgery. Proximal gastric vagotomy: effects of two operative techniques on clinical and gastric secretory results. Pyloroplasty (Heineke-Mikulicz 3 1 and Finney), Operation for Bleeding Duodenal Ulcer: Surgical Legacy Technique Carol E. Chassin† Indications Operative Strategy Pyloroplasty is now primarily used in patients undergoing Control of Bleeding emergency surgery for massive hemorrhage from duode- nal ulcer, when other methods of control (e. A vagotomy may be added if the This incision begins on the distal antrum, crosses the pylo- patient is noncompliant with medical therapy (see Chaps. If the ulcer is not seen, determine whether blood is coming from proximal or distal and extend the incision as needed. In case Preoperative Preparation of doubt, do not hesitate to insert a gloved finger into the stomach and palpate for the ulcer crater. Esophagogastroduodenoscopy (endoscopic control of hem- The most common situation is a posterior duodenal ulcer orrhage is frequently possible, obviating the need for eroding into the gastroduodenal artery. Occasionally, a gas- operation) tric ulcer erodes into the left or right gastric artery, the gas- Perioperative antibiotics troepiploic arcade, or (rarely) posteriorly into the splenic Resuscitation artery. Close communication with the Blood Bank Choice of Pyloroplasty Pitfalls and Danger Points Even if fibrosis and inflammation of the duodenum are pres- Suture line leak ent, as they may be with severe ulcer disease, in most cases a Inadequate lumen Heineke-Mikulicz pyloroplasty is feasible. When the duode- Failure to control hemorrhage num appears too inflexible to allow performance of this pro- cedure, or when the gastroduodenotomy has extended too long to allow easy transverse closure, the Finney pyloro- plasty or gastrojejunostomy should be elected. The latter two operations, although slightly more complicated than the Heineke-Mikulicz, ensure production of an adequate lumen for gastric drainage. The finger then If you do not see an ulcer crater, ascertain whether the slides toward the patient’s right. Overlying the fingertip is blood is coming from proximal or distal and extend the inci- not only a thin layer of peritoneum but also an avascular lat- sion as needed for adequate exposure. In a difficult situation, eral duodenal ligament that attaches the duodenum to the do not hesitate to insert your gloved finger into the incision underlying retroperitoneal structures. Incise the peritoneal layer with scissors or electrocautery As previously noted, the most common source of duo- and then stretch the lateral duodenal ligament with the fin- denal ulcer bleeding is posterior erosion into the gastro- gertip and divide it similarly. Transfix this artery with 2-0 silk sutures proximal and distal to the bleeding point. Place a third suture on the pancreatic side and deep to the Pyloroduodenal Incision for Heineke-Mikulicz bleeding point (Figs. This branch, generally the transverse pancreatic artery, may Make a 5 cm incision across the lower antrum, pyloric produce retrograde bleeding following apparently suc- sphincter, and proximal duodenum, with the incision cen- cessful proximal and distal ligation of the gastroduodenal tered on the pyloric muscle (Fig. Pluck the thrombus from the lumen of the ulcer- clamps to the cephalad and caudad cut ends of the pyloric ated artery to determine if hemorrhage control is sphincter, and draw them apart to open the incision. If the incision is relatively short, as shown versely, providing a patulous lumen for gastric drainage. A longer incision, or a fibrotic duodenum, may require closure by a Finney pyloroplasty. Both are described in the sections Emergency Procedure for Bleeding Ulcer that follow. Insert the first suture at the midpoint of the suture line Most techniques call for a through-and-through suture. Proceed with the closure from one corner to the gastric wall is much thicker than the duodenal wall, it is diffi- midpoint and then from the other corner to the midpoint, 31 Pyloroplasty (Heineke-Mikulicz and Finney), Operation for Bleeding Duodenal Ulcer: Surgical Legacy Technique 295 Fig. This prevents leakage from the one-layer suture line and adhe- sions between the suture line and the undersurface of the Finney Pyloroplasty liver, which may cause angulation and partial obstruction. Unlike the anterior midline gastroduodenotomy incision pre- Stapling viously described, for the Finney pyloroplasty the gastroduo- Instead of suturing the pyloroplasty incision as described denal incision is kept close to the greater curvature side of above, apply Allis clamps to the incision, approximating the the stomach and the pancreatic side of the proximal duode- tissues in eversion, mucosa to mucosa. Carefully inspect the staple line to be approximate the greater curvature of the stomach to the supe- sure satisfactory B formation has been carried out (Fig. After the incision has been made, the mucosal surface of both the gastric antrum and duodenum can easily be seen. Begin the mucosal suture at the inferior surface of the divided pyloric sphincter. Continue the suture in a caudal direction as a continuous locked stitch until the lowermost portion of the incision is reached. Approximate the anterior mucosal layer by means of a continuous Connell or Cushing suture (Fig. Close the anterior seromuscular layer by means of interrupted 4-0 silk Lembert sutures (Fig. Continue this suture Complications line for a distance of 5–6 cm from the pylorus (Fig. When the sutures have been tied, make an inverted Complications following this operation are rare, although U-shaped incision along a line 5–6 mm superficial to the delayed gastric emptying occurs occasionally, as does suture suture line (Fig. Chassin pylorus in nine patients who underwent a Heineke-Mikulicz pyloroplasty and three with a Finney pyloroplasty. There was marked improvement in three-fourths of the patients whose complaints were dumping and diarrhea. One can surgically reverse a pyloroplasty by reopening the transverse incision, identifying both cut ends of the pyloric sphincter, reapproximating the sphincter by inter- rupted sutures, and closing the incision in a longitudinal direction, thereby restoring normal anatomy. Impact of nonresective operations for compli- cated peptic ulcer disease in a high-risk population. Trends and outcomes of hospital- symptoms of dumping, diarrhea, or bilious vomiting of such izations for peptic ulcer disease in the United States, 1993 to 2006. Unfortunately, emptying problems (function obstruction) are common and there are no sure Gastrojejunostomy is performed for duodenal or gastric out- ways to prevent this complication. Operative Technique Pitfalls and Danger Points Incision Postoperative gastric bleeding Anastomotic obstruction Make a midline incision from the xiphoid to the umbilicus.

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Are combined same-day treatments the gen production and mechanical stretching in dermal extracellular future for photorejuvenation? Plast Reconstr Surg skin: 5 year results with intense pulsed light of the face viagra soft 50mg, neck 50mg viagra soft, and 2007; 120: 55–66S 100mg viagra soft. An objective assessment treatments alone and in combination with bilateral crow’s feet of botulinum toxin A efect on superfcial skin texture viagra soft 100 mg. Te efect of botulinum toxin OnabotulinumtoxinA treatment of mild glabellar lines in repose 100 mg viagra soft. Te use of nonablative radiofrequency venation: Botulinum toxin type A 50 mg viagra soft, hyaluronic acid dermal fllers viagra soft 50 mg, technology to tighten the lower face and neck viagra soft 100mg. Improvement of neck and cheek laxity with a bellar rhytides with a hyaluronic acid derivative compared with nonablative radiofrequency device: A lifing experience . Treatment of forehead/glabellar rhytide complex retrospective analysis of efcacy and safety in over 600 treatments . Remodeling of periorbital, of a low-energy multiple-pass technique leading to a clinical end temporal, glabellar, and crow’s feet areas with hyaluronic acid and point algorithm. Noninvasive skin tightening: Focus on new ultrasound ers, and combination therapies—consensus recommendations. Ultrasound tightening of facial and neck skin: A rater-blinded Multicenter, randomized, parallel-group study of the safety and prospective cohort study. Noninvasive lifing of arm, thigh, and knee fllers (24-mg/mL smooth, cohesive gel) alone and in combination skin with transcutaneous intense focused ultrasound. Te signifcance of this divine ratio is that, true to cosmetic use is now frmly entrenched and has classically been lim- Da Vinci’s belief, Phi proportions are found over the entire beau- ited to the sofening of undesirable dynamic facial lines, pathogno- tiful face2 (Figure 8. Te true mandate of the cosmetic physician, hard-wired into our “computer” brains and based on how closely however, when dealing with the feminine form, is to strive beyond we subconsciously recognize Phi proportions. Contrary to the across the world, regardless of their origin, most people seem to have common requests of patients to eliminate unsightly lines, afecting similar subjective ideas of what constitutes an attractive face. Creating the best variations of skin color and diverse features then provide for an end- rather than a diferent version of the patient requires a comprehensive less spectrum of Phi beauty that is unique for each individual. To approach to restore lost volume, smooth contours, and enhance facial paraphrase Hungerford, “beauty may actually reside in the Phi (eye) features naturally2 (see Chapter 7). Although truly the domain of autologous fat and pharmaceuti- Injection therapy restores youth by sofening aging lines, reestab- cally available “dermal” fllers, botulinum-based neuromodulators lishing fullness of features, and smoothing contours with gradual can also play a signifcant role in optimizing beauty by generating transitions. Individual ideal facial proportions can be dynamic expression, but the position of facial elements in the rest- obtained with the aid of a golden mean caliper—a tool for dynami- ing state through static muscle tension. Create Phi beauty, and youth accom- flling agents, the efect is quite ofen synergistic, optimizing both panies it—but pursuing youth does not necessarily create beauty the patient’s experience and outcome. An overly concave temple can detract from True facial beauty arouses the senses to an emotional level of pleasure facial attractiveness, and signify a stigma of advancing age. Perception excess convexity in a female temple can portend a masculine look of beauty is innate, as borne out by numerous studies confrming and distort the beautiful facial oval (or heart shape) preferred by most that newborn infants prefer attractive faces. Furthermore, in modern day ofering a more balanced and harmonious look to the upper face. Extensive research has further shown that regardless of our Deposition of botulinum toxin into the temporalis muscle within racial background, we seem to have similar subjective ideas about its fossa can reduce upper facial bulkiness and provide the initial what constitutes an attractive face. Leonardo Da Vinci, one of the world’s most superfcial temporalis muscle will lead to a hernia-type deformity of celebrated thinkers, insisted that there was a mathematical basis to its untreated deeper counterpart (similar to masseteric hypertrophy). Across the centuries, many other of the incobotulinum; 25 u of abobotulinum toxin) spaced 2 cm apart into world’s greatest intellectual minds, including Galileo, Michelangelo, the maximum convexity of the muscle usually sufce, followed by and Einstein were in awe of the fact that natural beauty appeared several minutes of pressure to minimize the risk of bruising from the dependent on this divine ratio. Furthermore, although maximal clench is dimin- bc), commonly regarded as one of the greatest of all classical Greek ished,17 no detrimental efect on chewing has been observed, as the sculptors. In simple algebraic terms, the golden section is the only masseter and pterygoid muscles remain the principle contributors to point dividing a line into two parts where the smaller segment in mastication. As such, the superior portion of the muscle is frmly adherent to the underlying bone and devoid of interposing fascia. Te periosteum and deep fascia of the forehead (galea aponeuro- (a) (b) tica) as they traverse the upper face under the frontalis muscle can- not continue under the temporalis muscle and as such lie over the muscle as the deep and superfcial temporal fascia respectively. This anatomical oddity, of a deep fascia lying on the surface of the mus- cle which bears its name, provides a resistant plane that is apprecia- bly felt when penetrating the region with a needle. Overlying this fascia in the posterior leaves of the superfcial temporal fascia are the superfcial temporal vessels (arteries and veins) and specifcally the frontal ramus of the superfcial temporal artery. Located in the depth of the muscle are the anterior and posterior deep temporal arteries (branches of the internal maxillary artery, second division), the middle temporal artery (connecting the deep and superfcial arterial system), and the prominent middle temporal vein approxi- mately 2 cm above the zygomatic arch. Deposition of botulinum toxin deep to the fascial layer is mandatory to access the bulky deep muscle as outlined above, and will require a 30-gauge needle of minimum ½ inch length. Prudent technique would require aspira- (c) tion before injection of toxin into the temporal muscle to mini- mize the possibility of intravascular washout limiting the clinical result. Post-injection pressure for several minutes, regardless of the appearance of blood through the puncture site, will diminish the possibility of delayed unsightly bruising. T e Beautiful Glabella and Botulinum Toxin Subtle diferences in glabellar appearance have a profound efect on beauty and youthfulness. Aging skin changes and actinic expo- sure lead to the appearance of lines, creases, and dyschromias com- pounded with tissue atrophy and volume loss. Bone remodeling leads to an increase in glabellar height and width, which can ofen be evi- denced by a paradoxical elevation of the medial brow in the elderly (Figure 8. This is to be distinguished from an elevated eyebrow resulting from increased frontalis activity as compensation for an upper eyelid partial levator dehiscence. Simply stated, com- cial gliding muscles, the frontalis (elevator) and the procerus (depres- plete loss of the tethering efect of medial corrugator pull, in combina- sor); and two deep brow depressor muscles, the paired corrugator tion with the unopposed oblique pull of the frontalis muscle, can lead and depressor supercilii. Trough their sof tissue attachments into to unnatural eyebrow splay post-treatment (Figure 8. Patients at the skin of the region, these antagonistic muscles both animate the risk for this medial canthal splay afer corrugator chemodenervation medial brow, and position it through resting tension depending on typically have mobile glabellar tissue that widens easily with digital the individual’s emotional state. Once these patients and depressors is somewhat stratifed as the frontalis blends superf- are identifed, the addition of a small amount of toxin into the upper cially with the deeper depressors. Varying the height and depth of toxin deposition according to the muscle action being targeted can alter the resting posi- tion of the medial brow. Phi harmony in the upper face dictates that the medial brows begin in a vertical line above the medial canthii at a 1. This technique is indicated when medial eyebrow position is too high and superior medial orbital hollowing is present to accom- modate the potentially redundant skin that may occur as a result of treatment. Te medial eyebrow Unlike other regions of the face where moderation is desirable to begins vertically above the medial canthus at a height equal to 0. It then extends laterally at an angle of 10–20 degrees to a maintain natural animation, it is ofen the goal of glabellar injec- peak located Phi (equal to the intercanthal distance) of the entire length of the tion therapy to obliterate depressor function that is responsible for eyebrow (1. Te corrugator supercilii runs from In summary, thorough observation and palpation of the glabellar a deep osseous origin to a lateral superfcial insertion into the dermis complex of muscles and overlying skin’s resistance to spread is neces- of the middle third of the eyebrow. Te dimensions of the corrugator sary in order to individualize the pattern of neurotoxin injections to supercilii muscle are more extensive than previously described and optimize beauty in the region. It arises from the frontal process of the maxilla approxi- within 1 mm from a line drawn vertically from the medial iris. Te triangular procerus is Needle injections of toxin in the region are best performed avoiding more superfcial and can be considered as a musculoaponeurotic these exact topographical landmarks to minimize bruising. Te frontalis is actually comprised of paired fat muscles originat- T e Beautiful Eyebrow and Botulinum Toxin ing from the occipitofrontal-musculoaponeurotic system of the scalp From its origin overlying the supraorbital ridge above the medial can- in an angulated direction from lateral to a more medial insertion into thus, the beautiful female eyebrow slopes upward and laterally at an the confuence of the glabellar complex and overlying dermis of the angle of 10–20 degrees. Te dermal insertion is beneath the eyebrow in its medial laterally at 0–10 degrees. Te frontalis glides easily over the frontal bone in its mimetic female brow is ideally located at the golden section of the brow length function due to the underlying galea, a thick fascia that is inter- (0. Individualizing the dose and location of upper muscle is limited to around 8 mm of vertical movement. Te authors contend that to raise a sagging forehead promontory has few signifcant vessels (periosteal branches brow is virtuous, but to contour it, divine. Although the more in-depth pre-injection assessment to determine those patients frontalis is considered to be a paired muscle with a midline aponeu- who may beneft from eyebrow positional changes. For instance, indi- rotic gap and lateral extent to the temporal fusion line, occasional viduals with a pre-existing high lateral arch to the eyebrow may obtain muscle fbers have been demonstrated both centrally as well as later- an accentuated and exaggerated arch if injections more efectively ally beyond the temporal crest margin. Te aesthetic injector should reduce the caudal displacement efects of the lateral sub-brow orbi- be wary of these variations in anatomy that are the culprit for post- cularis oculi muscle. This typically results in secondary lines above toxin residual central furrowing or lateral “Spocking” of the brow the lateral brow that disrupt the overall aesthetics. Te outlying tail of the eyebrow beyond cal palpebral aperture (“squintier” eyes in the elderly) (Figure 8. Like a skin-tightening procedures remain the workhorses of beautifcation cantilever, it must rely on the frontalis’ upward pull on the adjacent and rejuvenation in the middle face. In patients who demonstrate a sig- sofening of dynamic lines or unwanted tics and grimaces. Beautiful Eyes and Botulinum Toxin Adjusting the individual doses and “patterning” injections into the Te contribution of the eyes to overall facial attractiveness is over- frontalis according to the intended brow shape can allow this feature whelming. Originally a Western tenet of beauty, large prominent to approach Phi proportions (Figure 8. Contraction of the orbicularis oculi is therefore more sphincteric than vertical, drawing the eyebrow inferomedially toward the nose. This explains why chemodenervation of the lateral vertical fbers very ofen results in an upward and lateral excursion of the tail of the brow. Te orbicularis oculi muscle is much more expansive than appears on the surface, extending superiorly and inferiorly beyond the orbital rim in an “aviator glasses” shape, and occasionally laterally as far as the temporal hairline. This sometimes necessitates a second row of toxin injections more lateral from the lateral orbital rim to have the desired efect. Te nose lengthens and the tip droops, with retrac- tion of the columella, and alar base widening with superior excursion. Te periorbital complex typically shows signs of aging in the third decade of life with skin color and consistency changes. This early chronological senescence is not unexpected as the thin skin of the periorbital region is exposed to the stress of blinking an average of 1200 times per hour. Additionally, expansion of the inferolateral (middle age) and superomedial (advanced age) orbital rims, results in a volumetric increase of the bony orbit relative to its contents. Similar applications can be applied to those around the periorbita has been mostly for the improvement in the individuals with lower eyelid asymmetry with comparable dosing. While this has been quite efec- tive for improving facial appearances and delivering a more restful T e Beautiful Nose and Botulinum Toxin persona, other efects, now quite evident, with toxin use in this region Nasal enhancement is one of today’s most sought-after yet chal- include the changes to the position of the lateral (tail of the) eyebrow lenging cosmetic procedures. Understanding the local anatomy while injecting be found in its Phi proportions as well as the gentle transition botulinum toxin can deliver even greater aesthetic efects when the between its aesthetic units. Almost exclusively the domain of der- injector performs a more in-depth pre-injection assessment to deter- mal fillers, successful non-surgical nasal enhancement relies on mine eyelid fssure asymmetry. Of particular note is a pleasing nasal length position should not be underestimated. Tey frequently relay that it had ing for small bundles of each muscle to contract separately with been evident in photographs but that they were unaware of noninva- separate synergistic and counteracting functions. Te levator muscle and Muller’s muscle are both upper lid lus myrtiformis (depressor septi nasi muscle and musculus digas- elevators while the major lid depressors are certain regional com- tricus septi nasi labialis muscle) located at the base of the columella ponents of the orbicularis oculi muscle. Local chemical efects can can reduce unwanted tip depression creating a more open nasola- be seen with adrenergic agents such as naphazoline, antazoline, bial angle. When instilled onto the ocular surface, they have adrenergic secondary efects on Muller’s muscle and cause temporary contraction and upper eyelid elevation. Teir utility has become common in some forms of “small eyes” including botulinum toxin-induced lid ptosis. Similarly, upper eyelid elevation with the creation of “round eyes” can be achieved by reducing the efective force of the upper eyelid depressors (orbicularis oculi) through pre- cise chemodenervation. Surgical Anatomy Pearls: Tere has also been confusion as to where the most efective placement is and what that dose should be. Again, understanding the details of the periorbital anatomy will shed light on this. Te fbers of the orbicularis muscle at the lateral periorbita are more vertical hence contraction will cause the formation of “crow’s feet” and lateral brow depression. This results in a hyperkinesis Gummy Smile and Lip Asymmetries (similar to a Spock brow) of the alar portion of the transverse nasalis A gummy smile (greater than 2 mm of gingival show), in its mild form muscle (ofen referred to as the posterior dilator naris muscle) and may be considered cute in the young, but can ofen be distracting in lower lateral procerus, both of which elevate and rotate the drooping the adult. Te perioral complex consists of interdigitating lip elevators tip toward ideal Phi proprotions (Figure 8. Numerous anatomical variants of gummy smile authors’ experience that the major arterial branches appear to be have been described,33–38 however, the authors have found that for the located under creases in the overlying skin. This concept of surface purposes of injection therapy, three basic types exist, as defned by the topography being related to underlying structures has been well intended location of toxin injections: those that target the confuence of established. Other patients expose exces- to be somewhat stratifed in that superfcial fbers contribute more to sive gingiva by a rolling under of the upper lip vermilion with smil- pursing while deeper fbers more for lip position and support against ing, without a shortening of the ergotrid, resembling a roll-up blind. This explains the rationale behind deeper Chemodenervation in these instances should be directed symmet- injections when treating the “roll-up blind” form of gummy smile, rically at the deeper fbers of the orbicularis oris muscle under the with the caveat that the patient may experience some temporary white roll of the upper lip (Figure 8. Lip and smile A common request of patients seeking aesthetic facial improvement asymmetries secondary to uneven pull of mimetic muscles (e. While sofening unsightly marionette lines, relaxing these depres- measured masticatory function is dramatically decreased over several sor muscles leads to an elevation of the corner of the mouth through months44, patients do not report any difculty chewing hard food, the anatagonistic action of the levator anguli oris and zygomaticus change in facial expression, or speech disturbances; and any initial (major and minor) muscles. Of Beautifully proportioned lips exhibit horizontal vermilion show cautionary note is that instillation of toxin merely superfcially can from commissure to commissure equal to the distance from medial pupil to medial pupil (Phi of the intercanthal distance) (Figure 8. Te opposite should be avoided by excessive neuromodulation of the zygomaticus major in an attempt to eradicate upper cheek crow’s feet lines.

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It is only in case of this nerve that secondary suture may not be successful due to retraction of the cut ends viagra soft 50 mg. Though this viagra soft 100 mg, nerve supplies the Styloglossus viagra soft 100mg, Hyoglossus viagra soft 50mg, Geniohyoid and Genioglossus 50mg viagra soft, yet its main supply is to the intrinsic muscles of the tongue 100mg viagra soft. In this case 50 mg viagra soft, there will be anaesthesia of the whole upper limb except the upper part of the arm which is supplied by C3 100 mg viagra soft, 4 & 5 and by the intercostobrachial nerve . There will be also complete paralysis of the arm and scapular muscles , occasionally the long thoracic nerve supplying the serratus anterior or the nerve supplying the rhomboids may escape. It may affect new bom babies during difficult confinements or adult by a fall of weight on the shoulder. The muscles affected are biceps, brachialis, brachioradialis, supinator and deltoid. But if the 6th nerve is also affected, there will be an area of anaesthesia over the outerside of the arm and upper part of the outerside of the forearm. As the innervation of the hand is intact, functional improvement may be obtained conservatively by maintaining full range of passive movement of the limb to prevent contracture and the anaesthetic skin is protected to avoid pressure sores etc. Function of the limb can be best restored by arthrodesis of the shoulder and elbow joints. One may venture transplantation of muscles from the pectoral groups to the humerus. This type of lesion can occur when a falling person clutching at an object and hyper-abducting his arm or failing to obtain a foot-hold on a passing bus. The result is paralysis( of the intrinsic muscles of the hand (with claw-hand and features of combined median and ulnar nerves palsy) with anaesthesia of the inner one and half fingers. Very occasionally spasticity of the lower limb may be noticed associated with this condition, which is a result of damage to the pyramidal tract from haemorrhage following avulsion of the nerve roots. Recovery of function may occur when the lesion is due to stretching-(neurapraxia). But if the nerves have been ruptured, maldistribution of down-growing fibres will definitely lead to considerable reduction in functional efficiency. It is injured — (i) Due to fracture of the neck of the humerus; (ii) Dislocation of the head of the humerus; (iii) By a direct blow or (iv) Intramuscular injections. This nerve supplies the deltoid muscle and a portion of the skin on the lateral aspect of the arm which overlies the deltoid muscle. The patient also feels difficulty in raising the arm above right angle from a position in front of the body due to inability of rotation of scapula on the chest wall owing to paralysis of the serratus anterior muscle. Its main branch, the posterior interosseous nerve, which is concerned with supplying the extensor muscles of the wrist and fingers, may be injured at the elbow. Paresis of this nerve has occurred only after using 4 hours with this type of crutch without handgrips. Motor paralysis — (i) Triceps muscle — which causes inability to extend the forearm against resistance. However the patient can extend the interphalangeal joints with the unaffected interossei muscles (supplied by the ulnar nerve) and lumbricals (supplied by the median and ulnar nerves). So when the radial nerve is injured the patient will not be able to extend the metacarpophalangeal joint, but will be able to extend the interphalangeal joints. However paralysis of the brachioradialis can be tested by asking the patient to flex the elbow joint keeping the forearm in midprone position against resistance. This becomes difficult and the muscle will not stand out in case of brachioradialis paralysis. There will be also anaesthesia of the dorsum of the thumb and lateral three fingers upto the proximal interphalangeal joint owing to overlap by the ulnar nerve and median nerve. This is due to the fact that the branches supplying all the 3 heads of the triceps and the anconeus arise from the radial nerve before it reaches the radial groove. There is also anaesthesia on the back of the fingers upto the proximal interphalangeal joints except in the thumb where it reaches upto the nail, as both posterior cutaneous nerve of the arm and posterior cutaneous nerve of the forearm arise from the radial nerve before it reaches the radial groove. As the flexor carpi ulnaris remains active, the hand will be deviated towards the ulnar side particularly when the wrist is flexed. Flexion of the index finger will be fully affected though the flexion of other fingers may be carried out with the help of the medial part of the flexor digitorum profundus which is supplied by the ulnar nerve. Flexion of the terminal phalanx of the thumb becomes impossible due to paralysis of the flexor pollicis longus and the patient will fail to flex the terminal phalanx of the thumb against resistance while the proximal phalanx is being steadied by the clinician. Paralysis of the muscles of the thenar eminence is a characteristic feature of median nerve injury. The abductor pollicis brevis, opponens pollicis and flexor pollicis brevis, which constitute the thenar eminence are paralysed. Even the first dorsal interosseous and the two lateral lumbricals are also supplied by this nerve. While supply to the interosseous and lumbrical muscles are not very significant, yet paralysis of abductor pollicis brevis will be evident by the pen test, in which the patient is asked to touch a pen, which is kept at a slight higher level than the palm of the hand, with the tip of the thumb. Paralysis of opponens pollicis will be evident by the failure of the patient to touch the tips of the other fingers with the tip of the thumb. As the pronators of the forearm become paralysed, pronation of the forearm becomes feeble which will be particularly evident if the patient is asked to pronate his semiflexed forearm. Pronation of forearm becomes almost nil after midprone position, upto which brachioradialis can pronate the forearm. This anaesthesia will be extended over the tip of these fingers upto the middle of the middle phalanges on the posterior surface of these fingers and upto the nail bed of the thumb. These areas of sensory loss of course will be gradually reduced due to overlapping from adjacent nerves. It must be remembered that ulnar nerve passes superficial to the flexor retinaculum and hence is more often involved in cut injuries of the wrist. There will be slight deviation to the radial side of the hand when the wrist is flexed. Moreover the tendon of flexor carpi ulnaris just above its insertion into the pisiform bone will become impalpable when it is paralysed. There will be weakness of flexion of the little and ring fingers particularly at the distal interphalangeal joints. Paralysis of the muscles of the hypothenar eminence also occur due to injury to the ulnar nerve. This nerve supplies the abductor digiti minimi, flexor digiti minimi, opponens digiti minimi, both the heads of the adductor pollicis and sometimes a small twig to the flexor pollicis brevis. It also supplies all the interossei probably with the exception of first dorsal interosseous and to the third and fourth lumbrical muscles. The dorsal interossei are concerned with abduction of the fingers, while palmar interossei adduct the fingers. In case of ulnar paralysis a typical claw hand or Main en griffe will be noticed particularly in late cases. In this condition there is hyperextension of the metacarpophalangeal joints and flexion of the proximal and distal interphalangeal joints. In ulnar nerve paralysis though the first and second lumbricals are exempted yet this deformity can be obviously noticed in ring and little fingers. As the dorsal interossei are concerned with abduction of the fingers, if the patient is asked to abduct the fingers against resistance, he will be unable to do so in case of ulnar nerve palsy. A card is placed between the two fingers and asked to grip the card with the two fingers by adducting the fingers and the clinician tries to pull the card. The latter can assess the strength of the palmar interossei by the force of pull required for the purpose. If a patient with ulnar nerve injury is asked to hold a book between his hand and the thumb with the thumb straight he will fail to do so and he will try to hold the book by flexing the distal interphalangeal joint of the thumb with the help of flexor pollicis longus. As interossei alongwith lumbricals through extensor expansions are also concerned with extension of the proximal and distal interphalangeal joints, the strength of the interossei can be tested by asking the patient to straighten the finger against resistance while the clinician steadies the proximal phalanx of that finger. The lateral popliteal portion is affected nine times more commonly than the medial popliteal portion as the latter passes down on the inner and deep aspects of the sciatic nerve. The lower part of the lateral part of the leg is supplied by the superficial peroneal (musculocutaneous) nerve. The medial border of the foot is supplied by the saphenous nerve, whereas the lateral border of the foot is supplied by the sural nerve so these portions are exempted. Using these tests it is possible to distinguish between a nerve injury in which axons have not degenerated distal to the lesion (neuropraxia) and one in which Wallerian degeneration has occurred (axonotmesis or neurotmesis). Electromyography helps to read the electrical activity of a muscle during rest and activity. During weak contraction it records single action potential and in powerful contraction an interference pattern is observed due to more action potentials. Denervated muscle shows denervation potentials which appear within 1 to 2 weeks after injury. It also indicates whether any nerve injury is complete or incomplete and whether regeneration is taking place or not. Even the level of nerve injury can be determined by showing the changes of denervation of the muscles supplied by the nerve distal to the nerve injury. The duration and strength of the current used to excite a muscle is plotted in a graph as the strength duration curve. A normal muscle responds to stimuli varying in duration from 300 milliseconds to 1 millisecond without any increase in strength of the current. If the duration of current is decreased, the strength of current is to be increased to produce contraction. A totally denerved muscle needs either more strength of current or for a longer duration. Presently this investigation is mainly used to know the damaged of the cervical nerve roots after brachial plexus injury. Usually the pain starts following incomplete injury or division of the nerve, though occasionally such pain may not appear before 2 or 3 months. Accumulation of this substance causes vasodilatation and the part becomes red, sweats profusely and becomes increasingly painful. According to the site, cervico-thoracic or lumbar sympathectomy may be required, which are discussed below. These are mapped out by applying sweat-sensitive starch and iodine dusting on the axilla. When the hands are too much sweating, cervico-thoracic sympathectomy should be the treatment of choice. When the feet are sweating excessively with sodden and offensive feet, lumbar sympathectomy is justified. The arteries which have got smooth muscles in their walls, will be released of their spasms due to sympathectomy. These arteries are generally medium sized, small arteries, arterioles and arteriovenous communications. The limb will be warm, pain will be less and the ulcers may show signs of regression. The pathological conditions under this category, which are benefited by sympathectomy, are as follows : (a) Atherosclerosis. Some vascular surgeons suspect whether sympathectomy really increases the deep collateral circulation or simply increases vascularisation of the superficial tissue and skin. But one thing is certain, that if amputation is at all required, previous sympathectomy will definitely limit its extent. The symptomatic relief is rather temporary and almost always fails to yield permanent relief. By sympathectomy, one can only delay the progress of the disease, but cannot have a long term good effect. When sweating is sufficiently profuse to make one psychotic, this operation should always be called for. In the2 7 sympathetic trunk these fibres pass up to synapse about cells, situated mainly in the cervico- thoracic ganglia, from where post-ganglionic fibres pass to the brachial plexus, mainly the lower trunk. Most of the vaso-constrictor fibres supplying the arteries of the upper limb, emerge from the spinal cord in the ventral roots of 2nd and 3rd thoracic nerves. So these arteries can be denervated surgically by cutting the sympathetic trunk below the 3rd thoracic ganglion, severing the rami communicantes connected with the 2nd and 3rd thoracic ganglia and dividing the sympathetic trunk proximally just above the lower half of the cervico-thoracic ganglion (Tl part) distal to the attachment of the white ramus. Sympathetic fibres to the lower limb emerge from the spinal cord between T and L They9 r pass to the sympathetic trunk and then pass downwards, synapsing with the cells in lower lumbar and sacral ganglia from where post-ganglionic fibres arise and innervate the vessels of the lower limb. So removal of the lumbar sympathetic trunk just below the first ganglion proximally and below the 3rd ganglion distally will denervate the blood vessels of the lower limb. This denervation is essentially pre-ganglionic and particularly of those vessels below the knee level, as the cells lie in the lower lumbar and sacral sympathetic ganglia. This may be the main reason why sympathetic denervation of the vessels of the lower limb is more effective than that of the upper limb, which is a mixed pre- and post-ganglionic denervation. For axillary hyperhidrosis, the upper four or five thoracic ganglia should be removed (so axillary approach is more convenient). Cervico-thoracic sympathectomy can be performed by one of the three following approaches:— A. The head is rotated to the opposite side and the hand of the corresponding side is pulled downwards. An incision is made about 1/2 inch above the clavicle starting from the lateral border of the sternal head of the stemomastoid muscle to the medial border of the trapezius. After incising the skin, superficial fascia, platysma and investing layer of the deep cervical fascia, the clavicular head of the stemomastoid is divided and the inferior belly of omohyoid is retracted upwards to expose the scalenus anterior and the phrenic nerve. The phrenic nerve is safeguarded and the scalenus anterior is divided at its insertion to the first rib. The pleura is pushed downwards and laterally to expose the sympathetic trunk and the corresponding posterior ends of the ribs.

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