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Caverta

By T. Tangach. Catawba College.

Fungal abscesses usually require excision as hyphae ag- pecially those in the early cerebritis stages 50 mg caverta, could be managed suc- gregate within the capsule making eradication difcult 100 mg caverta. Heineman and Braude caused by mould are generally limited to severely immunocompro- were the frst to suggest that brain abscess can be treated successful- mised patients caverta 100 mg. Tey require excision but are associated with a very ly without surgery caverta 100mg, reporting six patients with brain abscesses who high mortality 50mg caverta. Overall success rate was 74% caverta 50mg, with a mortality rate of 4% into the paranasal sinuses or middle ear caverta 50 mg. Because multiple abscesses tend to be smaller 100mg caverta, the role of larly relevant to immunocompromised patients who may harbour surgery is primarily diagnostic rather than curative . If there is one 868 Chapter 67 large abscess causing signifcant mass efect then this may be con- Summary sidered for operation and in some patients with multiple abscesses , Te majority of seizure disorders occurring afer brain abscess are aspiration of pus can be a life-saving measure [170]. Steroid treatment should be continued until rare in industrialized nations [182] and prevalence is highest in Lat- the neurological condition stabilizes and then tapered. It may be endemic in sub-Saharan Despite the reported success with non-operative management as Africa, although few studies have been carried out [183]. No strict proto- [184], Honduras [185], Brazil [186], Cuba [187], Colombia [188] cols can be devised; each case must be treated individually on its and Peru [189], and a resurgence of cases of epileptic seizures as- own merits, taking account of the factors described above. It is be- ever, the general aim in the acute situation is elimination of active ing diagnosed more frequently in developed countries as a result of suppuration. Consideration of long-term efect on seizures is less tourism to countries where the disease is endemic [191]. Tus, despite the best eforts, even successfully treated brain ab- Neurocysticercosis is a helminthiasis caused by the encysted scesses can result in long-term neurological morbidity [174,175] larval stage, Cysticercus cellulosae, of the pork tapeworm Taenia and this is most frequently related to seizures, cognitive dysfunc- solium. In the frst stage, a human (the defnitive host) ingests un- tion and focal neurological defcit, with up to 50% of patients suf- dercooked pork containing viable cysticerci from within which the fering permanent neurological defcit [176]. Te single most im- scolex hatches in the gut and attaches to the intestinal mucosa. Over portant factor infuencing mortality is the neurological condition 3 months, the tapeworm matures to a length of 2–7 m and gravid of the patient at the time of diagnosis [148]. When humans become intermediate hosts by acci- Te reported incidence of epilepsy following brain abscess is be- dental ingestion of eggs (faecal–oral spread), the lifecycle is com- tween 30% and 80%. Postmortem studies of expatriates from endemic zones have operatively went on to develop late epilepsy. Te mean onset time improved our knowledge of natural human infection and it is now of seizures for patients in this group was 3. In fact 50% of patients in the older group solitary parenchymal lesion is the most common form and seizures had their frst seizure during the frst year afer diagnosis compared are the most common symptom, presenting in 70–90% of patients. Analysis of seizure frequency Lesions may be multiple and can cause signifcant mass efect, hy- showed that the maximum frequency occurred during the fourth drocephalus, basal arachnoiditis and cerebral infarction. Tis pattern of spontaneous resolu- gested that the risk of developing late seizures is related to the loca- tion has important implications for the correct diagnosis and treat- tion of the abscess. Tere is some evidence that there is a Diagnosis reduction in seizures among patients treated with aspiration as op- Torough history and neurological examination may yield clues, posed to excision [148,178]. Resective surgery of vascular and infective lesions for epilepsy 869 Seizures are the commonest symptom and may occur when a cyst Table 67. Other common presentations include symptoms of raised intracranial Absolute pressure. Calcifcations on plain X-rays of thigh Ten to twenty per cent of patients will have intraventricular cysts. Minor Tese may cause hydrocephalus and can be accompanied by nausea Subcutaneous nodules and vomiting, headache, ataxia and confusion. Focal neurological Clinical manifestations suggestive of cysticercosis defcits are uncommon. Cysts within the basal cisterns can present Disappearance of brain lesions with anticysticercal therapy with signs of meningeal irritation, hydrocephalus, vasculitis and stroke. Cysticercal encephalitis with mul- Household contact with Taenia solium infection tiple parenchymal infammatory cysts and difuse cerebral oedema has been described in young girls and such patients are at risk of se- Data from [203]. It is visualized like a western blot, so Cerebral tuberculoma is the main diferential diagnosis and cri- that non-specifc bands can be ignored thereby ruling out crossre- teria for diferentiation are described by Rajshekar et al. Tuberculomas are, by contrast, A satisfactory international diagnostic protocol has yet to be usually irregular, solid, greater than 20 mm in size and present with agreed upon [202], although this has been addressed by a panel led a progressive defcit. Criteria are self-limiting condition whereas a tuberculoma is an active infection divided into categories based on the weight attached to each fea- that requires prolonged therapy with potentially toxic drugs. Te use of albendazole and praziquantel is not A study of 10 patients treated with praziquantel and albendazole recommended with single enhancing lesions because the cysticerci showed complete disappearance of 80% of fourth ventricular cysts. Of the other two cysts, one decreased signifcantly in size and the Good seizure control is usually achievable with a single lesion. Seven of these patients presented with epilepsy and sin- obstructive hydrocephalus, meningitis, encephalitis or spinal cord gle or multiple small enhancing parenchymal lesions and one with compression. Parenchymal cysts or calcifcations, or chronic men- hydrocephalus caused by a midbrain lesion. Tis conservative approach is since 1990 describe successful treatment of subarachnoid cysts with corroborated by other authors. Although surgery may still be indicated for sub- ment of 33 patients with large subarachnoid cysticercal cysts, for arachnoid cysts refractory to albendazole, anticysticercal therapy whom the usual recommendation would be surgical treatment. Some lesions, however, still of the patients in this series improved with albendazole and dexa- require surgical resection as frst-line treatment: cysts adjacent to methasone at 59-month follow-up. In most patients, improvement blood vessels and cranial nerves can cause an intense infammatory was rapid afer the initiation of treatment [216]. Unnecessary and complex cysts within the Sylvian fssure may occlude the mid- surgery or therapy with potentially toxic drugs should be avoided. Skull base cysts should be treated surgical- ly if there is symptomatic brainstem compression. Te incidence of intracranial tuber- ciated with hydrocephalus and this should be treated before any culoma is decreasing, particularly in Western countries and this decision is made regarding the cyst [212]. Tuberculoma should be distinguished Stool examination for proglottids Examine for subcutaneous nodules, fundoscopy from tuberculous meningitis although the two may coexist. Serological tests and intervals histopathology established tuberculosis as the cause. Diagnosis is further complicated by the fact that many patients Lesion persists with tuberculoma have no preceding history of tuberculosis infec- tion. In 1959, Obrador [220] showed that cerebral tuberculoma Management accounted for 20–40% of all intracranial masses. In 1972, the inci- Historically, tuberculomas were managed surgically, however the dence was put at 0. In 1987, a development of antituberculous chemotherapy has reversed this study in Saudi Arabia showed that tuberculoma constitutes approx- [233]. Delay in defnitive treatment can be devastating: these were caused by cerebral tuberculoma [2]. Because of their rarity, tuberculomas are if the diagnosis is likely, a trial of antituberculous therapy should not always considered in the diferential diagnosis of intracranial be begun without biopsy confrmation [214]. Furthermore, the exact pathophysiology is still not clear, early open brain biopsy as soon as intracranial tuberculoma is sus- partly because of the impossibility of reproducing tuberculoma in pected, especially in rapidly progressing cases. Cerebral tuberculomas with coexistent ex- timetres in diameter and walled of by fbrous tissue. Diagnosis should be reviewed if the anticipat- and haemagglutination are acceptably sensitive and specifc; ed improvement in clinical condition and radiological appearance however, all are limited by crossreactivity with T. Furthermore, corticosteroids should be not sufcient on their own to establish the diagnosis [239]. Hydatid bral abscess and cystic tumours such as metastasis, haemangioblas- (meaning ‘drop of water’) describes the fuid-flled cysts created by toma and glioma. Te adult abscesses and many neoplasms may produce perilesional oedema worm resides in the intestine and has a lifespan of approximately and also demonstrate signifcant contrast enhancement and a case 6 months. Sheep typically become intermediate hosts by ingesting report of solid cerebral Echinococcus mimicking primary brain tu- parasite ova in dog faeces. Arachnoid cysts are probably the intermediate hosts by ingesting parasite in dog faeces. On ingestion most difcult lesions to diferentiate from hydatid cysts; arachnoid of the ova, the larvae hatch and penetrate the intestinal mucosa. Two diferent histological types of cerebral hydatid cyst have been Management described: embryonal (primary) and scolical (metastatic or second- Establishing the diagnosis preoperatively is crucial, as this guides ary) [193]. Resective surgery remains the primary treat- escape fltration by the liver and lungs and become implanted in the ment of the disease. Due to their embryonal origin, primary cysts sion of large tumours containing cysts, that is aspiration and defa- are usually fertile because they contain many scolices. Primary cysts tion of the cyst before resection of the tumour itself, is absolutely are almost always solitary, reports of multiple primary cerebral hy- contraindicated as this risks turning a potentially curable condi- datid cysts being very rare [235]. In contrast, secondary metastatic tion into a chronic ongoing disease characterized by repetitive cyst cerebral hydatid cysts originate from infertile scolices of ruptured recurrence. If the primary cyst ruptures, the enclosed protoscolices fertile cysts and are therefore usually infertile. Cerebral cysts have spill into the surrounding parenchyma and each protoscolex is able a variable rate of growth of 1–5 cm/year but may expand relative- to transform into a secondary cyst. Most hydatid cysts are locat- ly quickly due to the immunological quiescence of the brain and a ed at the grey–white matter junction as a result of haematogenous scant fbroblastic response. Cystic expansion may lead to compres- spread, typically in the distribution of the middle cerebral arteries. In a series of 120 patients, However, deep brain or intraventricular lesions are virtually im- 6% of the cysts measured between 6 and 10 cm in diameter and six possible to resect without them rupturing. Rather than using sharp dissection, this method relies on gravity to deliver the cyst Diagnosis from the surrounding brain. Te patient is positioned on the op- Cerebral hydatid cysts can occur at any age, but are most common erating table such that the cyst is in a dependent position. In a series of 155 cases, 117 were children, with a mean bone and dural fap are refected and a cortical incision is made age of 7. Saline irrigation is used common mode of presentation in children is raised intracranial to dissect a tissue plane between the cyst and surrounding paren- pressure. If the lesion is deep to the cortical surface and complete signs of raised intracranial pressure occurring later. Te presenting resection is not feasible, careful cyst aspiration is recommended, symptoms and signs in reducing order of frequency in a group of with hypertonic saline or silver nitrate solution used to destroy 120 patients with cerebral hydatid disease were: headache (80%), protoscolices [243]. Its success in a limited number of zures (36%), reduced visual acuity (35%), ataxia (20%), somnolence these patients suggests that it may be preferred to surgery in certain (20%) and speech disturbance (15%) [237]. Albendazole can achieve cyst concentrations of Laboratory tests are not particularly helpful in establishing the up to 40% of serum concentrations, causing disruption of the cyst diagnosis. It could be used adjunctively to Resective surgery of vascular and infective lesions for epilepsy 873 shrink large superfcial cortical cysts, as this would facilitate remov- 18. Apolipoprotein E epsilon 2 is associated al and reduce risk of rupture during resective surgery. It is also useful in the treatment of secondary cysts that sure and size to risk of haemorrhage from arteriovenous malformations. Acta Neurochir Cyst rupture during attempted resection signifcantly afects 1970; 22: 125–128. Cerebral arteriovenous rupture may lead to severe anaphylaxis with circulatory shock and malformations. J Neurosurg 1970; 32: 503– cyst rupture occurred during surgery died within 36 days of sur- 511. Unruptured brain arteriovenous malformations should be treat- ed conservatively: Yes. Te natural history of symptomatic arteri- gation and administration of antihelminthic drugs. Invasive treatment of unruptured brain arteriovenous malformations is experimental therapy. Profle of intractable epilepsy in a tertiary 141 patients with brain arteriovenous malformations and seizures: factors as- referral centre. Neuropathology of cerebral arteriovenous malforma- logical and surgical correlation. J Neurosurg 2005; and results of surgery, and the role of intravascular techniques. Arteriovenous malformations: an analysis of 545 cases of to decrease the risk of haemorrhage in inoperable arteriovenous malformations. Long-term follow-up of seizures associated with cerebral arterio- intracranial arteriovenous malformations: long-term results. Te natural history of cavernous Bragg-Peak radiation for intracranial arteriovenous malformations. Vascular malformations and epilepsy: clinical considera- complication outcomes afer arteriovenous malformation radiosurgery. Chronic focal epileptiform discharge induced ed for arteriovenous malformations using gamma knife radiosurgery. Intractable epilepsy following radiosur- ic acid and somatostatin in epileptic cortex associated with low-grade gliomas. Neurosurgery 1997; 40: 425– neurons adjacent to cavernous malformations and tumors. Cavernous angiomas of the brain: Account of 14 personal for large arteriovenous malformations: indications and outcomes in otherwise un- cases and review of the literature. Cavernous angioma: a review stereotactic radiosurgery for cavernous malformations. Gamma knife surgery for cavernous heman- abscess afer penetrating craniocerebral injuries in Vietnam.

The tongue is lined by stratified squamous (protective) epithelium as caverta 50 mg, like the skin 50mg caverta, it is subject to ‘wear and tear’ caverta 100mg. The parathyroid glands are pinkish/brown glands usually found on the posterior aspect of the thyroid gland caverta 100 mg. In 90% of individuals 100mg caverta, there are four 50 mg caverta, two on each side 100 mg caverta, but this varies from two to six caverta 50mg. The superior parathyroid glands are fourth branchial pouch (endodermal) derivatives , whereas the inferior parathyroids arise from the third branchial pouch (also endodermal derivatives) . Therefore, the inferior parathyroid glands may get dragged down with the thymus into the mediastinum making the position of the inferior parathyroid glands highly variable. A consequence of this is that the inferior thyroid artery should always be preserved during a total thyroidectomy to prevent ischaemia of the parathyroid glands, which would render the patient hypocalcaemic, necessitating lifelong calcium supplementation. The parathyroid glands secrete parathyroid hormone from chief (or principal) cells. Calcitonin, on the other hand, is secreted by the parafollicular cells (also known as C-cells or clear cells) of the thyroid gland. The parathyroids can produce too much (hyperparathyroidism) or too little parathyroid hormone (hypoparathyroidism). Primary hyperparathyroidism usually results from a parathyroid adenoma (around 90% cases); a benign tumour of usually one (but sometimes more than one) parathyroid gland that leads to the overproduction of parathyroid hormone and hypercalcaemia. Exposure of the thymus through a midline sternotomy may rarely be necessary given the liability of the inferior parathyroid glands to end up in unusual positions. Less commonly, primary hyperparathyroidism results from multiple adenomas (4% cases of primary hyperparathyroidism), bilateral hyperplasia of the parathyroid glands (5% cases) or rarely a parathyroid carcinoma (1% cases). In the case of bilateral hyperplasia, always think about multiple endocrine neoplasia. Secondary hyperparathyroidism is usually seen in the setting of chronic renal failure or other causes of vitamin D deficiency (e. Tertiary hyperparathyroidism is commonly seen in the setting of renal failure and renal transplant patients and results when the parathyroid glands become autonomously functioning. Serum Parathyroid corrected Serum hormone calcium phosphate Primary ↑ ↑ ↑ hyperparathyroidism Secondary ↑ ↑ or normal ↑ hyperparathyroidism Tertiary ↑ ↑ ↑ hyperparathyroidism What imaging modalities can be helpful in localising parathyroid adenomas pre- operatively? Optic nerve Dural sheath Ophthalmic artery Sympathetics What runs through the superior orbital fissure? Medulla Meninges Vertebral arteries with its sympathetic plexus Spinal roots of accessory nerve Anterior spinal artery (formed from both vertebral arteries) Posterior spinal arteries Apical ligament of dens Tectorial membrane What runs through the foramen ovale? Mandibular division trigeminal (Vc) Lesser petrosal nerve Accessory meningeal artery Where is the internal auditory meatus located? Petrous temporal bone in the posterior cranial fossa What structures run through the internal auditory meatus? The extra-ocular muscles are innervated by the third (oculomotor), fourth (trochlear) and sixth (abducent) cranial nerves. The trochlear nerve and abducent nerve supply only one muscle, that is, the superior oblique muscle and the lateral rectus muscle, respectively. All the remaining muscles are supplied by the oculomotor nerve – that is, the superior rectus, inferior rectus, inferior oblique and medial rectus are all supplied by the oculomotor, or third, cranial nerve. Injury to any of these cranial nerves (third, fourth or sixth) may result in ophthalmoplegia and diplopia. The levator palpebrae superioris elevates the eyelid and has a dual innervation from both the oculomotor nerve and sympathetic fibres. The latter innervate a small smooth muscle portion of the levator muscle known as Muller’s muscle. The clinical significance of this dual innervation is that a third cranial nerve (oculomotor) palsy, or sympathetic interruption (Horner’s syndrome), may result in ptosis. To distinguish the two, it is essential to lift up the eyelid and inspect the pupil to see if it is enlarged (mydriasis in an oculomotor nerve palsy) or constricted (miosis in a Horner’s syndrome). In an oculomotor palsy, the eye points downwards and outwards from the unopposed action of superior oblique and lateral rectus, supplied by the fourth and sixth cranial nerves. Horner’s syndrome is associated with hemifacial anhidrosis, flushing symptoms and enophthalmos, in addition to ptosis and miosis. Posterior triangle of the neck What are the borders of the posterior triangle of the neck? Posterior border of sternocleidomastoid Anterior border of trapezius Middle one-third of clavicle Roof of skin, platysma, investing layer of deep cervical fascia and external jugular vein Floor of pre-vertebral fascia covering muscles, subclavian artery, trunks of brachial plexus and cervical plexus What are the contents of the posterior triangle? Nerves – Spinal root accessory and branches of cervical plexus Arteries – Superficial (transverse) cervical, suprascapular and occipital Veins – Transverse cervical, suprascapular and external jugular Muscle – Omohyoid with sling Lymph nodes – Level 5 What is the course of the spinal accessory nerve? It has been given the name spinal accessory since it originates from the upper end of the spinal cord (spinal roots, C1–C5). It passes through the foramen magnum and ‘hitches a ride’ with the cranial accessory nerve originating from the nucleus ambiguus. Its function is to supply only two muscles in the neck – the sternocleidomastoid and trapezius muscles. It traverses the posterior triangle of the neck from one-third of the way down the posterior border of the sternocleidomastoid muscle to one-third of the way up the anterior border of trapezius where it terminates (the ‘rule of thirds’). It is vulnerable to iatrogenic injury in procedures that necessitate dissection within the posterior triangle of the neck, such as excision biopsy of a lymph node. In a radical en-bloc lymph node dissection of the neck for malignant disease, the spinal accessory nerve may have to be deliberately sacrificed in order to obtain satisfactory clearance. What are the consequences of injury to the spinal accessory nerve in the posterior triangle of the neck? Damage to the spinal accessory nerve in the posterior triangle of the neck leads to a predictive weakness of the trapezius muscle. This results in an inability to shrug the shoulder on the side in which the spinal accessory nerve is affected and may result in winging of the scapula. The sternocleidomastoid muscle is typically spared as the branch to sternocleidomastoid is given off prior to the spinal accessory nerve entering the posterior triangle of the neck. The trapezius muscle also plays a role in hyperabduction of the arm and so activities such as combing one’s hair would become more difficult. In the long term, the trapezius palsy (with dropping of the shoulder) may result in a chronic, disabling neuralgia. This may occur as a result of pain from neurological denervation, adhesive capsulitis of the shoulder joint, traction radiculitis of the brachial plexus, or more commonly from fatigue. Major salivary glands: Parotid (predominantly serous exocrine secretion) Submandibular (mixed mucinous and serous) Sublingual (mainly mucinous exocrine secretion) Minor salivary glands: Scattered throughout the oral mucosa and submucosa (labial, buccal, palatoglossal, palatal and lingual) What important structures lie within the parotid gland? The retromandibular vein is the commonest culprit in a haematoma following parotidectomy. The facial nerve is the most superficial structure within the parotid gland and hence is extremely vulnerable to injury during parotid surgery. If the retromandibular vein comes into view, the facial nerve has already been severed! A facial nerve monitor should be used throughout and it is important to identify and protect the various branches of the facial nerve, which may be remembered by the mnemonic ‘Ten Zulus Baited My Cat’ (from top to bottom): Ten = Temporal branch Zulus = Zygomatic branch Baited = Buccal branch My = Marginal mandibular branch Cat = Cervical branch The branches of the facial nerve are also likely to be injured by a malignant tumour of the parotid which is usually highly invasive and quickly involves the facial nerve, causing a facial paralysis. The duct opens on the mucous membrane of the cheek opposite to the second upper molar tooth. The secreto-motor supply to the parotid (for secretion of saliva) is by way of parasympathetic fibres of the glossopharyngeal nerve (lesser petrosal nerve), synapsing in the otic ganglion and relaying onwards to the parotid gland through the auriculotemporal nerve. A direct consequence of the innervation of the parotid gland is a phenomenon known as Frey’s syndrome which may occur, not infrequently, following parotid surgery, or penetrating trauma to the parotid gland. It is caused by misdirected reinnervation of the auriculotemporal nerve fibres to the sweat glands in the facial skin following its injury. Marginal mandibular division of the facial nerve Hypoglossal nerve Lingual nerve How can injury to the marginal mandibular nerve be avoided in a submandibular gland excision? Raising flaps deep to the investing layer of deep cervical fascia so that the nerve is safe by being pulled laterally in a superficial plane. Sectioning the facial vein low in the exposure and reflecting it superiorly thereby drawing the marginal mandibular nerve superiorly away from the gland. Minimising bleeding around the nerve and avoiding diathermy in close proximity to the nerve. Use of the nerve stimulator – Facilitates identification of the marginal mandibular nerve through stimulation or contraction of the depressors to the ipsilateral lower lip. The area of facial skin bounded by the upper lip, nose, medial part of cheek and the eye is a potentially dangerous area to have an infection (the so called ‘danger area of the face’). An infection in this area may result in thrombosis of the facial vein, with spread of organisms through the inferior ophthalmic vein to the cavernous sinus. By the superficial middle cerebral vein, such thrombosis may spread to the cerebral hemisphere, which may be fatal unless adequately treated with antibiotics. Posteriorly: At the lower border of the pons, two vertebral arteries combine to form the basilar artery. At the upper border of the pons, the basilar artery terminates as right and left posterior cerebral arteries. Anteriorly: Each internal carotid artery gives off an anterior and middle cerebral artery. The circle is completed anteriorly by the single, anterior communicating artery which connects the two anterior cerebral arteries. The circle is completed posteriorly by the two posterior communicating arteries that connect the posterior cerebral arteries with the internal carotid arteries. See Chapter 43, ‘Cranial neurosurgery’, Bailey & Love’s Short Practice of Surgery 27th edition. Subarachnoid haemorrhage – Most commonly due to ruptured berry aneurysms (see above). Extradural haematoma – Most commonly due to head injury, resulting in a skull fracture (usually around the pterion of the skull) with rupture of the middle meningeal artery. Subdural haematoma – Can be acute or chronic, usually resulting from brain atrophy with stretching and rupture of bridging veins across the surface of the brain. Common risk factors include ageing, dementia, bleeding diastheses, anti-coagulants and chronic alcoholism. Intra-parenchymal bleed – This is a bleed within the brain substance, usually resulting from hypertension. Investing layer of deep cervical fascia Pre-tracheal fascia Pre-vertebral fascia Carotid sheath What layers does one encounter when a tracheostomy is performed? Skin Subcutaneous fat Superficial fascia with platysma Investing layer of deep cervical fascia Strap muscles – Sternohyoid muscle is encountered first, followed by sternothyroid Pre-tracheal fascia Thyroid isthmus Trachea Figure 1. Superior thyroid Superficial temporal Maxillary Lingual Facial Ascending pharyngeal Posterior auricular Occipital The internal carotid has no branches in the neck and therefore can be easily distinguished from the external carotid artery at surgery (Figure 1. Cricoid cartilage Larynx becomes trachea Pharynx becomes oesophagus Vertebral artery enters foramen transversarium of C6 vertebra Inferior thyroid artery and middle thyroid veins cross to thyroid gland Middle cervical sympathetic ganglion Carotid tubercle of Chassaignac Omohyoid (superior belly) crosses carotid sheath Spinal cord and vertebral column What type of joint are the inter-vertebral joints? Between each vertebral body lies an inter-vertebral disc which is made up of an annulus fibrosus of fibrocartilage, with an internal nucleus pulposus consisting of a semi-liquid gelatinous substance derived from the embryonic notochord. With age, the fibrocartilaginous annulus deteriorates and may weaken, often in the lower lumbar region, giving rise to a slipped, or prolapsed, disc. The relationship of the nerve roots to inter-vertebral discs is of great importance. At the level of the L4/5 disc, the fourth lumbar nerve roots within their dural sheath have already emerged from the inter-vertebral foramen and so are not lying low enough to come into contact with the disc. The roots that lie behind the posterolateral part of this disc are those of the fifth lumbar nerve and these are the ones likely to be irritated by the prolapse. Thus, the general rule throughout the vertebral column is that when a disc herniates (usually posterolaterally, rather than in the midline), it may irritate the nerve roots numbered one below the disc. The exception to this rule is in cauda equina syndrome where the disc typically prolapses centrally rather than posterolaterally. The base of the breast is fairly constant; from the sternal edge to the midaxillary line and from the second to sixth ribs. Two-thirds of its base overlies pectoralis major and one-third overlaps onto serratus anterior. Contraction of the underlying pectoralis major muscle (by putting one’s hands on their hips and pushing in) exacerbates any asymmetry between the breasts (e. Blood supply to the breast is mainly derived from the lateral thoracic artery (a branch of the second part of the axillary artery). However, the internal thoracic, thoracoacromial and posterior inter-costal arteries also send branches to the breast. The lymphatic drainage of the breast is of considerable anatomical and surgical importance because of the frequent development of breast cancer and the subsequent dissemination of malignant cells along the lymphatics to the neighbouring lymph nodes. Around 75% of the lymphatic drainage of the breast passes to 20–30, or so, axillary lymph nodes. Thoracic lymph nodes are difficult, or impossible to treat, but lymph nodes of the axilla can be removed surgically. The superficial lymphatics of the breast have connections with those of the opposite breast, anterior abdominal wall and supraclavicular lymph nodes. These tend to convey lymph from the breast when the other channels are obstructed by malignant disease, or following their destruction after radiotherapy or surgery. Pulmonary artery Main bronchus Pulmonary vein Bronchial arteries and veins Lymph nodes and lymphatic channels Autonomics What is a bronchopulmonary segment? There are typically 10 anatomically definable bronchopulmonary segments within each lung, each contains a segmental (tertiary) bronchus, segmental artery, segmental vein, lymphatics and autonomic nerves and are separated from their adjacent segments by connective tissue. Each is pyramidal in shape with its apex towards the lung root and its base towards the surface of the lung and is anatomically and functionally separate from the rest. The surgical importance of this is that diseased segments, since they are structural units, can be selectively removed surgically (segmentectomy).

This overview exfoliation of melanin-flled keratinocytes 50 mg caverta, ultimately is intended to provide the physician with the informa- fading dyschromias caverta 50 mg. In addition caverta 100 mg, lactic acid suppresses tion necessary for selecting the best topical therapies 80 J 100 mg caverta. Linder for their patients working to prevent and reverse the and proteoglycan: a quantitative comparison of the activities visible signs of aging caverta 100mg. Biochem J 277 cosmeceutical strategies to support more invasive pro- (Pt 1):277–279 cedures for patients with advanced dermal 15 50mg caverta. Kerkelä E caverta 50mg, Saarialho-Kere U (2003) M atrix metalloprotei- on transepidermal water loss 100mg caverta, stratum corneum hydration , nases in tumor progression: focus on basal and squamous skin surface pH , and casual sebum content. Int J Dermatol 41(1):21–27 hairless mouse skin: possible effect on decreasing skin 21. 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Baxter R (2008) Anti-aging properties of resveratrol: review lates, the anthranilates, and physical agents. Br J Dermatol 145(4):597–601 (2005) Chemoprevention of skin cancer by grape constituent 42. Chatelain E, Gabard B (2001) Photostabilization of butyl oxidative stress in mouse skin. Int J Oncol 21(6): methoxydibenzoylmethane (avobenzone) and ethylhexyl 1213–1222 methoxycinnamate by bis-ethylhexyloxyphenol methoxy- 65. J Invest Dermatol 129(7):1805–1815 Relative assessment of oxidative stress protection capacity 71. Farris P (2007) Idebenone, green tea, and Coffeeberry® compared to commonly known antioxidants. Biochim logues investigated by pulse radiolysis: redox reaction Biophys Acta 1556(2–3):187–196 involving ergothioneine and vitamin C. Saija A, Tomaino A, Lo Cascio R, Trombetta D, Proteggente A, tions on ex vivo human skin. J Cosmet Dermatol 5(2): De Pasquale A, Uccella N, Bonina F (1999) Ferulic and caf- 150–156 feic acids as potential protective agents against photooxida- 94. Biomed Pap M ed Fac Univ Palacky Olomouc Czech M ed Rev 6(6):601–607 Repub 147(2):137–145 96. Can J Physiol Pharmacol 71(9):725–731 Evaluation of the antioxidant actions of ferulic acid and cat- 97. Free Radic Res Commun 19(4):241–253 (2007) Protective effect evaluation of free radical scaven- 81. Int J Cosmet Sci and kinetin provide ineffective photoprotection to skin when 17:91–103 compared to a topical antioxidant combination of vitamins 98. Exp Vitamin A antagonizes decreased cell growth and elevated Dermatol 15(9):678–684 collagen-degrading matrix metalloproteinases and stimu- 83. F’guyer S, Afaq F, M ukhtar H (2003) Photochemoprevention lates collagen accumulation in naturally aged human skin. Photodermatol Photo- J Invest Dermatol 114:480–486 immunol Photomed 19(2):56–72 100. Carcinogenesis 20(11): Gamma-tocotrienol inhibits nuclear factor-kB signaling 2117–2124 pathway through inhibition of receptor-interacting protein 85. J Am Podiatr M ed Assoc 79(8):395–397 lagen promotes extracellular matrix production. Barrantes E, Guinea M (2003) Inhibition of collagenase Lorimier S, Antonicelli F, Soria C, Crepin M , Hornebeck W , and metalloproteinases by aloins and aloe gel. Life Sci Bellon G (2005) Elastin-derived peptides enhance angio- 72(7):843–850 genesis by promoting endothelial cell migration and tubu- 105. Ghersetich I, Lotti T, Campanile G, Grappone C, Dini G Am Coll Nutr 23(2):157–162 (1994) Hyaluronic acid in cutaneous intrinsic aging. J Pharmacol Exp Ther 308(2):767–773 Enhanced elastin and fbrillin gene expression in chroni- 110. J Invest Dermatol 103(2):182–186 chin-3-gallate on expression of matrix metalloproteinase-1 127. W ang X (1999) A theory for the mechanism of action of the and tissue inhibitor of metalloproteinase-1 in fbroblasts irra- a-hydroxy acids applied to the skin. J Invest Dermatol 116(6):853–859 topical glycolic acid: comparison with all-trans retinoic 112. Lippincott W illiams & characteristic of retinoic acid but without measurable W ilkins, Philadelphia, pp 203–256 retinoic acid levels or irritation. J Cosmet mal thickness and glycosaminoglycan content of sun-dam- Dermatol 18:3–5 aged skin. Narosa M ontiel A (2002) A synthetic hexapeptide (argireline) with Publishing House, New Delhi, pp 523–524 antiwrinkle activity. In: Schueller R, Romanowski P (1997) Human genital melanocytes as androgen target (eds) Conditioning agents for hair and skin, vol 21, cells. M arshall C (2002) The use of honey in wound care: a Clin 25(3):353–362 review article. J Drugs cation of honey in the management of radiation mucosi- Dermatol 6(1):32–39 tis. Fluhr J, Holleran W M , Berardesca E (2002) Clinical effects York, pp 205–218 of emollients on skin. Ando S, Suemoto Y, M ishima Y, Suemoto Y, M ishima Cosmetic science and technology series: skin moisturiza- Y (1993) Tyrosinase gene transcription and its control by mela- tion. Eaglstein W H (2001) M oist wound healing with occlu- 150s–155s sive dressings: a clinical focus. M aeda K, Fukuda M (1996) Arbutin: mechanism of its allergenic activity of lanolin. Kawai M (1998) Novel melanogenic enzymes inhibitor for J Cosmet Dermatol 3(2):88–93 controlling hyperpigmentation. Takema Y, Yorimoto Y, Kawai M , Imokawa G (1994) Age- France related changes in the elastic properties and thickness of 174. Br J Dermatol 131(5):641–648 M antas N, Kousta F, M istidou M , Kanelleas A, Stavrianeas 154. Dermatol Clin 15(4): study of a preparation containing undecylenoyl phenylala- 555–559 nine 2% in the treatment of solar lentigines. Elsevier Saunders, Philadelphia ance of facial hyperpigmentation by topical N-undecyl-10- 157. There are several advantages for using nerve blocks in aesthetic medicine (Table 9. They As less invasive, ambulatory aesthetic procedures have allow large areas to be anesthetized without infltrating become more popular over the last decade, so too has the entire treatment area. As well as obvious benefts to assessment of the volume and architecture of the tis- the patient by avoiding unnecessary general anesthesia sues is required during the procedure. Injecting smaller or sedation, nerve blocks are quick, reliable, and safe, volumes of anesthetic around main nerve branches, and may obviate the need for extensive infltrative compared to local infltrative anesthesia using larger anesthesia. The learning curve for basic nerve block volumes, may reduce the chance of lignocaine toxicity, techniques is short. These include blocks of The frst step in performing accurate nerve block the sensory nerves of the face, wrist block, and ankle technique is to study the anatomy of the sensory nerves, block. Although the techniques are straightforward, a the foramina from which they arise, and their relation- thorough knowledge of the anatomy of the nerves and ship to surrounding and underlying structures (Fig. It is important also to keep in mind that anatomic divisions of the trigeminal nerve: ophthalmic, maxil- variations exist, such as the presence of multiple lary, and mandibular nerves (Fig. In the face, the thesia in the face is achieved by blocking these nerves ophthalmic nerve supplies the forehead, upper eyelid, and their branches and allows most injectable, mini- and dorsum of the nose via the supraorbital, supratro- mally invasive, and laser resurfacing procedures to be chlear, infratrochlear, and external nasal nerves. The performed easily and without pain or discomfort for maxillary nerve supplies the lower eyelid, cheek, upper lip, ala of the nose, and part of the temple through the infraorbital, zygomaticofacial, and zygomaticotempo- P. The sensory fbers of the mandibular nerve Venus M edical, supply the skin over the mandible, lower cheek, part of Heritage House, Dundrum Offce Park, Dublin 14, Ireland the temple and ear, and the lower lip through the buc- e-mail: [email protected] venusmed. The trigeminal nerve (Cranial nerve V) has three main branches: ophthalmic division b (V1), maxillary division (V2), and mandibular division (V3) nerve, derived from the primary rami of the second and third cervical nerves, innervates the angle of the man- dible. Nerve blocks of the median, ulnar, and radial nerves anesthetize the skin of the hand and allow injectable procedures to be performed on the sensitive palmar surface without pain. Nerve blocks can also be used in conjunction with infltrative local anesthesia where procedures are more vigorous or extensive such as suture facelift techniques or autologous fat grafting. An infraor- foramina and location of sensory nerves where they are blocked: bital nerve block allows painless injection of fller below (1) Supraorbital notch. To anesthetize the malar and anterior cheek area, a foramen of deep branch of supraorbital nerve. In the authors view, lip enhancement with pterygoid plate (marked X) 9 Local Regional Anesthesia 89 Table 9. Augmentation of facial features using autologous Injection sites distant to treatment areas avoid tissue fat employs similar anesthesia with multiple regional distortion nerve blocks. The injection of botulinum toxin into the Anesthesia of the entire face is achieved using multiple facial palms of the hands for palmar hyperhidrosis is a painful blocks procedure unless a wrist block is performed. For plantar Avoid general anesthesia and sedation where invasive hyperhidrosis, an ankle block allows injections of botuli- treatments are performed Quick onset of local anesthesia (5–10 min) num toxin into the sole of the foot without the need for Safe and reliable with correct technique additional anesthesia. They include Nose contouring Infraorbital, dorsal nasal lignocaine, prilocaine, mepivacaine, and bupivacaine, Augmentation of tear trough Infraorbital, zygomaticofacial and act by blocking sodium channels in the nerve cell Laser skin resurfacing (full Supraorbital, supratro- membrane (Table 9. This depolarization prevents the face) chlear, infratrochlear, development of an action potential and blocks nerve infraorbital, zygomaticofa- impulses. Although equal success can be achieved cial, zygomaticotemporal, mandibular, mental with most of these agents [2], the author uses ligno- Chin enhancement M ental plus mylohyoid caine, with or without epinephrine, almost exclusively. The addition of epinephrine results in Botulinum toxin for plantar Posterior tibial, sural, local vasoconstriction that reduces the systemic absorp- hyperhidrosis saphenous tion of the anesthetic, improves the quality of the block, and prolongs the duration of anesthesia. A suffcient hyaluronic acid injections into the vermilion border and epinephrine concentration to achieve these effects is body of the lip should not be performed without nerve 5 mg/mL, or a concentration in solution of 1:200,000 blocks. Although guidelines exist for the maximum recom- insuffcient pain relief, whereas infltrative local anesthe- mended dosages of local anesthetic agents, both with sia can distort the tissues and interfere with the assess- and without epinephrine, the evidence to support the ment of a satisfactory aesthetic outcome. Calculating maximum dosages mental nerve blocks allow painless injections into the of local anesthesia should take into account the location lips within seconds. Complementary injections into the of the nerve block, age of the patient, medications, and frenulum of the upper and lower lips are sometimes any concurrent illness. The rate of absorption and peak required to ensure complete anesthesia of the central plasma concentration of local anesthetic depends on the portion of the lips. Occasionally, fllers are used to defne location of the block and especially on the vascularity of or shape the tip of the nose. A reduction in 10–20% should be made nerve makes these otherwise painful injections com- for the maximum dosage in elderly patients or those pletely tolerable. Local anes- volumizing procedures such as those using poly-L-lactic thetic with epinephrine should never be used for blocks acid are best performed following multiple nerve blocks, where there are end-arteries, such as the nose, fngers, or including infraorbital, mental, zygomaticofacial, zygo- penis, where intense vasoconstriction could compro- maticotemporal, buccal, and auriculotemporal nerve mise perfusion and lead to ischemia or necrosis. For laser skin resurfacing, these blocks, as nerve blocks described in this chapter, the following well as blocks to the supraorbital, supratrochlear, and materials are required (Fig. Lignocaine 1–2% with 1:200,000 epinephrine The infraorbital nerve is the largest cutaneous branch of 6. It emerges onto the face at the infraor- necessary) bital foramen, along a vertical line between the pupil and 7. The foramen 9 Local Regional Anesthesia 91 opens downward and medially, so the most accurate a nerve block approach is from below and medially, either intraorally or percutaneously [6]. For the intraoral approach, a 27- or 30-gauge needle is passed through the vestibule between the canine and frst premolar, aim- ing the needle toward the infraorbital foramen. The index fnger of the non-injecting hand rests on the infe- rior orbital rim to prevent inadvertent passage of the needle beyond the rim. The anesthetized area includes the lower eyelid, side of the nose, medial cheek, and upper lip. Alternatively, the nerve can be approached through the skin by injecting between the ala of the nose and the upper part of the nasolabial fold, directing the needle toward the infraorbital foramen. It passes under the nasal bone about 6 to b 9 mm from the midline and passes under the nasalis muscle toward the tip of the nose [7]. The dorsal nasal nerve supplies sensory innervation to the tip of the nose via its 1–3 branches. The block is made at the level of the periosteum at the junction of the nasal and cartilagi- nous parts of the nose on either side of the midline. It usually exists as several fascicles that are visible or palpable through stretched oral mucosa. The needle enters the vestibule between the canine and frst premolar (red dot) and aims toward the infraorbital foramen 92 P. Reaching the nerve percutaneously is also second premolar tooth 9 Local Regional Anesthesia 93 possible but is not frequently performed and may be a more painful [9]. To anesthetize the central part of the chin, this block is augmented by injecting a further 2–3 mL preperitoneally over the mental protuberance using a 27-gauge 1. The superfcial branch passes through the corrugator and frontalis muscles to innervate most of the forehead over the eyebrows and the anterior scalp.

100mg caverta

The interphalangeal joints of the toes are ginglymoid hinge joints which have extensive flexion and more limited extension due to the limitation of the metatarsal and collateral ligaments (Figs caverta 50mg. A caverta 50 mg,B: The metatarsophalangeal joints of the toes are also susceptible to overuse and misuse injuries with resultant inflammation and arthritis 50 mg caverta. The interphalangeal joints of the toes are ginglymoid hinge joints which have extensive flexion and more limited extension due to the limitation of the plantar and collateral ligaments 100 mg caverta. The primary function of the metatarsophalangeal and interphalangeal joints of the toes is to aid in the gripping function of the foot 50mg caverta. The articular cartilage of the metatarsophalangeal and interphalangeal joints of the toes are susceptible to damage caverta 100 mg, which left untreated caverta 100mg, will result in arthritis with its associated pain and functional disability 100mg caverta. Osteoarthritis is seen in the metatarsophalangeal and interphalangeal joints of the toes which results in pain and functional disability , with rheumatoid arthritis , posttraumatic arthritis, and crystal arthropathy also causing arthritis of the metatarsophalangeal and interphalangeal joints of the toes. Gout selectively afflicts the metatarsophalangeal joint of the first toe and is called podagra (Figs. Less common causes of arthritis-induced pain of the metatarsophalangeal and interphalangeal joints of the toes include other collagen vascular diseases, infection, psoriatic arthritis, villonodular synovitis, and Lyme disease (Figs. Acute infectious arthritis of the metatarsophalangeal joints of the toes is best treated with early diagnosis, with culture and sensitivity of the synovial fluid, and prompt initiation of antibiotic therapy. The collagen vascular diseases generally manifest as a polyarthropathy rather than a monoarthropathy limited to the metatarsophalangeal and interphalangeal joints of the toes, although pain of the metatarsophalangeal and interphalangeal joints of the toes, secondary to the collagen vascular diseases, responds exceedingly well to ultrasound-guided intra-articular injection. Gout frequently afflicts the first metatarsophalangeal joint and is called podagra. Plain radiograph demonstrating tophaceous gout of the first interphalangeal and tarsometatarsal joint. Plain radiograph demonstrating psoriatic arthritis of the metatarsophalangeal and first interphalangeal joint. Posteroanterior radiograph of the toes shows septic arthritis of the metatarsophalangeal joint. At the third joint there is loss of the normal articular cortical bone of both the metatarsal head and base of the proximal phalanx (arrowhead). Activity, including walking and weight bearing makes the pain worse, with rest and heat providing some relief. Sleep disturbance is common with awakening when patients roll over onto the affected foot. Some patients complain of a grating, catching, or popping sensation with a range of motion of the joints, and crepitus may be appreciated on physical examination. Functional disability often accompanies the pain associated with the many pathologic conditions that affect the metatarsophalangeal joints of the toes. Patients will often notice increasing difficulty in performing their activities of daily living and tasks that require standing, walking, or weight bearing. If the pathologic process responsible for pain of metatarsophalangeal and interphalangeal joints of the toes is not adequately treated, the patient’s functional disability may worsen and muscle wasting and ultimately frozen metatarsophalangeal and interphalangeal joints of the toes may occur. Plain radiographs are indicated in all patients who present with pain of the metatarsophalangeal and interphalangeal joints of the toes (Fig. Based on the patient’s clinical presentation, additional testing may be indicated including complete blood cell count, sedimentation rate, and antinuclear antibody testing. A: Anteroposterior radiograph showing an expanded lucent lesion in the fourth metatarsal shaft, sharply defined but no sclerotic rim. A: Aggressive lesion in the distal metaphysis of the second metatarsal exhibiting cortical destruction laterally and sclerotic soft tissue extension projecting medially. Longitudinal ultrasound image along the plantar aspect of the foot at the level of the first metatarsal head demonstrates an encapsulated, mildly heterogeneous collection superficial to flexor hallucis longus tendon consistent with an adventitial bursa. With the patient in the above position, the dorsal surface of the metatarsophalangeal joint of the affected toe is identified by palpation. A high-frequency small linear ultrasound transducer is placed in a longitudinal position over the metatarsophalangeal joint of the affected toe and an ultrasound survey scan is taken (Figs. The hypoechic metatarsophalangeal joint space is identified between the head of the metatarsal and the base of the proximal phalanges. When the joint space is identified, the joint is evaluated for the presence of arthritis, synovitis, effusion, crystal deposition, and abnormal masses including ganglion cysts (Figs. Ultrasound and color Doppler are used to identify synovitis and areas of neovascularity in healing tendons and joints (Figs. After the metatarsophalangeal joints and surrounding structures are evaluated the transducer is slowly moved distally to evaluate each interphalangeal joint of the toes (Figs. Correct longitudinal position for ultrasound transducer for ultrasound evaluation of the metatarsophalangeal and interphalangeal joints of the toes. Longitudinal ultrasound image of the great toe demonstrating a large osteophyte with associated intra-articular joint mice of the right first metatarsophalangeal joint. B: There is marked regional hyperemia when power Doppler is applied, consistent with inflammation. Longitudinal ultrasound image demonstrating erosion of the articular cartilage consistent with gouty arthritis and associated synovitis of the right first metatarsophalangeal joint. Longitudinal ultrasound image demonstrating synovitis in a patient with active rheumatoid arthritis presenting with an inflamed metatarsophalangeal joint. A: Longitudinal ultrasound image demonstrating tenosynovitis of flexor hallucis longus with an effusion in the tendon sheath. B: On plantar flexion of the big toe the fluid in the sheath moves proximally and displaces the tibial nerve. A: Dorsal aspect of joint showing a small- to moderate-sized effusion/synovial proliferation (arrowheads). There are several discrete echogenic foci within the joint consistent with crystal aggregates (arrows). There is a wide, deep erosion (arrows) with overhanging edges consistent with a gouty or crystal arthropathy. Longitudinal ultrasound scan shows enlarged hypoechoic bursa (B) superficial to flexor hallucis longus tendon (T) and first metatarsal head (M). Transverse ultrasound image demonstrating tendinitis with significant effusion involving the flexor tendons of the toes. Longitudinal color Doppler image demonstrating synovitis of the right first metatarsophalangeal joint. Longitudinal color Doppler image of the first metarsophalangeal joint demonstrating synovitis in a patient with active rheumatoid arthritis. Longitudinal color Doppler image demonstrating acute inflammation of the distal interphalangeal joint. Foreign body synovitis and infection should always be considered in the differential diagnosis of persistent plantar pain, especially in children and patients with altered sensation, such as diabetics (Figs. Ultrasound guidance can simplify aspiration and injection of the metatarsophalangeal and interphalangeal joints of the toes. A: Oblique radiograph of the right foot in a 2-year-old patient showing two perpendicular, faint, linear, dense structures in the region of the third metatarsal head (arrow). B: Sagittal ultrasound image at the plantar 1218 foot revealing a 5-mm linear structure consistent with a foreign body (black arrow) in the subcutaneous tissues over the third metatarsal head (white arrow). C: Sagittal ultrasound image showing 2-mm linear object (straight white arrow) embedded in a tendon (black arrow) overlying the third metatarsal head (curved white arrow). Ultrasound-guided needle localization to aid foreign body removal in pediatric patients. A small vertical incision (short arrow) for focal dissection was created directly inferior to the needle (long arrow) at the region of the needle tip. B: Sagittal image from high-frequency ultrasound-guided needle localization showing the needle (curved arrow) with its tip at the foreign object (straight arrow). Ultrasound-guided needle localization to aid foreign body removal in pediatric patients. Transverse ultrasound image demonstrating tenosynovitis of the extensor tendon of the great toe. Each joint is lined with synovium and the ample synovial space allows for intra-articular placement of needles for injection and aspiration. The metatarsophalangeal joints have a dense joint capsule and strong plantar and collateral ligaments, although fracture and subluxation may still occur (Figs. The metatarsophalangeal joints are also susceptible to overuse and misuse injuries with resultant inflammation and arthritis (Fig. Posteroanterior radiograph of the foot shows a comminuted fracture through the shaft of the proximal phalanx of the great toe, extending immediately distal to the proximal articular surface of the phalanx. Longitudinal ultrasound image of the great toe demonstrating a large osteophyte with associated intra-articular joint mice of the right first metatarsophalangeal joint. Ultimately, the first metatarsophalangeal joint may sublux, and the overlapping of the first and second toes worsens, resulting in a painful condition known as the hallux valgus deformity (Fig. The metatarsocuneiform joint may also play a role in the evolution of hallux valgus (Fig. Frequently an inflamed adventitious bursa may coexist with the bunion, further exacerbating the pain and cosmetic deformity (Fig. More common in women, bunion is usually the result of wearing shoes with a too-tight toe box, with the wearing of high-heeled shoes exacerbating the problem. The hallux valgus deformity with subluxation of the first metatarsophalangeal joint resulting in the overlapping of the first and second toes. Plain radiograph demonstrating the angle between the base of the first metatarsal joint and the articular surface of the medial cuneiform. Proximal reverse chevron metatarsal osteotomy and lateral release through 1 medial incision for hallux valgus correction. An inflamed adventitial bursa frequently accompanies the pain and functional disability associated with bunion. Some patients complain of a grating or popping sensation with use of the joint, and crepitus may be present on physical examination. In addition to the just-mentioned pain, patients who suffer with bunions develop the characteristic hallux valgus deformity, which consists of a prominent first metatarsal head and improper angulation of the joint, with overlapping first and second toes. Patients will often notice increasing difficulty in performing their activities of daily living and tasks that require standing, 1224 walking, or weight bearing. If the pathologic process responsible for pain of hallux valgus is not adequately treated, the patient’s functional disability may worsen and muscle wasting and ultimately a frozen first metatarsophalangeal joint may occur. Plain radiographs are indicated in all patients who present with pain of the hallux valgus (Fig. Based on the patient’s clinical presentation, additional testing may be indicated including complete blood cell count, sedimentation rate, and antinuclear antibody testing. With the patient in the above position, the dorsal surface of the metatarsophalangeal joint of the affected toe is identified by palpation. A high-frequency small linear ultrasound transducer is placed in a longitudinal position over the metatarsophalangeal joint of the affected toe and an ultrasound survey scan is taken (Figs. The hypoechoic joint space is identified between the head of the metatarsal and the base of the proximal phalanges. When the joint space is identified, the joint is assessed for degenerative changes, synovitis, effusion, crystal arthropathy as well as the angle between the articular surfaces of both joints (Fig. Correct longitudinal position for ultrasound transducer for ultrasound evaluation of the first metatarsophalangeal joint. Longitudinal ultrasound view of the metatarsophalangeal joint space of the great toe. Longitudinal ultrasound image demonstrating the plantar plate of the first metatarsophalangeal joint. Each joint is lined with synovium and the ample synovial space allows for intra-articular placement of needles for injection and aspiration. The metatarsophalangeal joints have a dense joint capsule and strong plantar and collateral ligaments, although fracture and subluxation may still occur (Figs. The metatarsophalangeal joints are also susceptible to overuse and misuse injuries with resultant inflammation and arthritis. Note the oblique fracture of the shaft of the proximal phalanx of the fifth toe (arrow), which occurred after striking a hard object. Note the characteristic transverse orientation of the fracture line of the base of the fifth metatarsal (arrow). Note the apophysis for the base of the fifth metatarsal separated by a longitudinally oriented lucent cleft (arrowhead). With skeletal maturation, this radiolucent cleft will eventually ossify and become united to the base of the fifth metatarsal. Ultimately, the fifth metatarsophalangeal joint may sublux, and a corn overlying the metatarsal head will develop along with an inflamed adventitious bursa may coexist with the bunionette, further exacerbating the pain and cosmetic deformity (Figs. Occurring more commonly in women, bunionette is most commonly the result of wearing shoes with a too-tight toe box, with the wearing of high-heeled shoes exacerbating the problem. B: Clinically, the patient generally presents with symptoms occurring laterally or plantar laterally, often with an adduction of the fifth toe. Significant corn and adventitial bursitis development can accompany the bunionette deformity. This patient also suffers from hallux valgus with a significantly inflamed adventitial bursa of the first metatarsophalangeal joint. Some patients complain of a grating or popping sensation with use of the joint and crepitus may be present on physical examination. In addition to the just-mentioned pain, patients who suffer with bunionette develop the characteristic bunionette deformity, which consists of a 1231 prominent fifth metatarsal head and improper angulation of the fifth metatarsal (Fig. Patients with a tailor’s bunion may present with a deformity that is due to a symptomatic lateral lesion (A) or a plantar keratotic lesion (B). Patients will often notice increasing difficulty in performing their activities of daily living and tasks that require standing, walking, or weight bearing. If the pathologic process responsible for pain of bunionette is not adequately treated, the patient’s functional disability may worsen and muscle wasting and ultimately a frozen fifth metatarsophalangeal joint may occur. Plain radiographs are indicated in all patients who present with pain of the bunionette (Figs. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing.

50 mg caverta

The suture lifts the dermis of the brow and suspends it via the anchored convergent barbs to the galea aponeurotica above the hairline to the lateral third of the brow caverta 50mg. About 10 mL of lidocaine with epinephrine (1:200 caverta 100mg,000) diluted with 10 mL of normal saline is drawn into a 20 mL syringe and infltrated subcutaneously along the path of the marked lines and in the lateral brow 50 mg caverta. Although anes- thesia of this area could be achieved with supraor- bital nerve blocks caverta 50 mg, the hydrotomy achieved with infltrative anesthesia allows easier passage of the needle in the subcutaneous tissues 50mg caverta. In the scalp 100mg caverta, at the proposed point of anchorage of the suture 100 mg caverta, infl- tration is made deep to the galea to the level of the periosteum caverta 100 mg. Two stab incisions are made in the scalp in line with the desired vector for lifting the lateral brow . Using a 16-gauge needle , a puncture is made through the skin at the tail of the brow and in the hair of the Fig. The frst needle, with suture should be pulled inferiorly when the patient is asked to force- attached, is passed from the tail of the brow, intrad- fully close the eyes, but should not rise when the patient is asked ermally, to exit at medial puncture. This avoids inadvertently denervating central portion of the suture will come to lie in the fbers of frontalis, which act to elevate the brow. One or more injections can be made in the orbicularis 2 weeks before a brow dermis of the brow. Placement below the dermis in lift to alleviate the depressor action of this muscle the subcutaneous tissue has a propensity to cut 406 P. Stab incisions dle then re-enters the medial puncture and passes using a #11 blade are made at the marked points. The subcutaneously along the marked path to exit from curved needle is passed from the upper medial inci- the incision in the scalp. The second needle passes sion to the lower medial incision, under the superf- from the tail of the brow, subcutaneously to exit the cial temporal fascia but above the deep temporal incision in the scalp. To fnd this plane, lift a tuft of hair above the the superfcial tissues above the lateral brow to avoid path of the needle and pass the needle deeply. The needles should be a thick layer of tissue covering the needle are cut from the sutures so that two barbed suture following passage, but it should not be so deep that ends exit from the scalp incisions. However, anchor- passed through the eye of the needle and the needle is age of the proximal cut ends of the suture under the withdrawn. Next, the needle is passed in the superf- galea further secures the lift and prevents slippage. A cial subcutaneous plane from the lower lateral inci- curved suture-passing needle is passed deep to the sion to the lower medial incision and the suture end is galea from one incision to the other and the suture threaded through the needle’s eye and brought to the ends are brought through the same incision and tied. Finally the needle is passed into the upper medial incision, taking a bite of periosteum and deep Suture lifting in the temporal area provides a subtle temporal fascia along the superior temporal fusion but important rejuvenation in the upper face by lifting line, and exits from the upper lateral incision. The the tail of the eyebrow, the lateral canthus, and the suture is brought from this incision to the upper upper cheek (Fig. In the periorbital area, ele- medial one so that both ends exit from the same inci- vation of soft tissues by 2–3 mm provides noticeable sion. The frst is along a line drawn perpen- the hairline, and elevate the tail of the brow and upper dicular to the tail of the eyebrow, just behind the tem- face. A second point is made just behind the inverted or tethered down, are released using the tip hairline 4–5 cm inferior to the frst point. The incisions heal quickly by second- points are made above the frst points in line with the ary intention. One of these points should be along is usual along the hairline but this contracts and the superior temporal crest line where the deep tem- disappears in 1–2 weeks. After skin preparation and sterile draping, local anes- thesia using lidocaine 1–2% with 1:200,000 adrena- 34. The inferior points mark the exit sites for 34 Suture Lifting Techniques 407 a c Fig. One of the superior incisions (b) is made along the the deep temporal fascia, and the needle receives the suture end superior temporal crest line (red dots). The suture is cut and buried by through the eye of the needle and the suture is brought back applying traction to the puncture site with the tip of an artery from point A to B. Some physicians pass the needle below the superfcial temporal fascia frst, and then redirect the needle to come superfcially into the subcutaneous plane at the level of the temporal hairline. However, it is easier to start the needle passage in the correct plane above the superfcial temporal fascia under direct vision at the temporal incision and continue into the malar fat pad in the same plane. As the needle is passed along its course, the nondominant hand gently grasps the tissues over the needle as it passes through the tem- ple and then malar fat pad. A blunt trocar, provided by the suture company, can be used to facilitate atraumatic passage of the needle through the tissues before emerg- ing from the skin. If the suture passes too superfcially it may catch the dermis and lead to irregularities. At this point, one The points should not be made below a line drawn from or more cones can be cut from the suture as outlined the lobule of the ear to the modiolus. Sutures passing above, making sure not to pull through any cones that below this line could disrupt with movement of the are to remain on the suture. If areas are infltrated with 2% lidocaine with 1:200,000 there are skin irregularities or dimples along the length epinephrine. A 3 cm incision is made in the temporal of the suture, these can usually be ironed out by gentle area and diathermy is used for hemostasis. The super- massaging of the overlying skin from proximal to dis- fcial temporal fascia is exposed, grasped with an artery tally as the proximal end of the suture is held frmly in forceps, and opened to expose the white shiny deep the other hand. The suture is not tied until all of The frst Silhouette suture is measured externally over the other Silhouette sutures have been placed. Usually the cheek to determine how many cones are needed to four sutures are placed in the midface to lift the malar run the length of the malar area. Once all of the sutures are in place, left on the suture, some of the proximal ones may be the half-circle needles are cut from the proximal ends visible under the thin skin of the temple area, or they and the suture ends are gently lifted. M inimal tension may catch on the superfcial temporal fascia when the is required to lift the soft tissues and improve the con- suture is retracted. Each suture is tied to its neighboring cones from the distal end of the suture after they exit at suture over the mesh and the incision is closed in two the inferior points. This suture lift rejuvenates by lifting the jowls used, most or all of them can be left on the suture. Although the lift alone softens the nasolabial plane above the superfcial temporal fascia toward the folds and oral commissures, combining the suture lift lower exit points. If the needle penetrates the superf- with fllers in these areas provides synergy and cial temporal fascia, the facial nerve is at risk of injury improves the results further (Fig. A number of cones (usually two) can be cut from the using a 4-0 nonabsorbable suture. The suture is then cut distal to the suture needle will pass is identifed by grasping the superf- one of the knots. Each pair of neighboring suture The Silhouette suture is placed over the face to measure how ends are gently retracted to lift the malar fat pad and tied to one many cones will span the malar fat pad and midface without another, suspending the tissues of the midface. This determines how many cones, closed in two layers 34 Suture Lifting Techniques 411 d e f g h i Fig. This is particularly effective when soft tis- sue augmentation with injectable fllers is performed in the midface at the same time (Fig. The hairline and one just below the zygomatic arch in suture end is passed through the eye of the needle front of the lobule of the ear. Between the upper two and the needle is withdrawn to the upper anterior points, the temporalis muscle can be felt when the incision. Lidocaine with epinephrine suture end from the lower incision to the upper is infltrated below the temporalis muscle above the lateral incision, except that the suture passage is ear and in the subcutaneous plane between all three slightly more anterior, creating a fgure-of-eight points. To avoid dimpling after the suture passes deeply from the upper lateral incision under has been placed, the tip of an artery forceps is the temporalis muscle and fascia and exits the ante- inserted into the incision below the zygomatic arch rior incision. In the correct position deep to the mus- and passed through the entirety of the dermis. A cle, any movement of the needle should rock the curved needle is passed subcutaneously from the patient’s head. The suture end is brought to the upper upper anterior incision toward the lower incision. At lateral incision where the two ends can be lifted gen- the level of the zygomatic arch, a deeper bite is taken tly and tied. It is important to stay jowl and jawline defnition and can even improve within 8 mm from the external acoustic meatus at the neck. Any dimpling or inversion of skin at the this level to void injury to the facial nerve. The nerve puncture sites is released using the tip of an artery always passes over the zygomatic arch at least 8 mm forceps. Some bunching of skin in front of the ear anterior to the external acoustic meatus, and usually and near the hairline is normal and smoothes out 2. M oving the needle in the correct plane should move the dle is passed in the subcutaneous plane from point F toward point patient’s whole head. At the lower border of the zygomatic arch a deeper bite is taken of the needle and the needle is withdrawn. Lifting the sutures lifts the patient’s jowls and even cially and exits from point E. The M arkings are made behind the ear and along the neck under the suture is cut just distal to the knot. Both sutures are retracted to lift the neck, and tied needle takes in the upper neck is shown. The needle should be with interrupted sutures made to exit perpendicular to the skin. Prendergast g Patients with excessive skin laxity usually require excisional surgery. The suture suspension technique using absorbable sutures is simple and quick (Fig. After infl- trative local anesthesia, two skin punctures are made: one behind the ear over the mastoid and one in the upper neck over the anterior border of the sterno- cleidomastoid muscle. The needle is passed through the upper point, deeply at frst to include the mastoid fascia or periosteum, and advanced in a sinusoidal path superfcially under the skin toward the lower h point. Before exiting from the lower incision, a deeper bite is taken to catch the posterior border of platysma. Another pass is made, taking a parallel course to the frst pass, and the end of the suture is passed from the lower to upper incision so that both ends of the suture exit behind the ear. The sutures are retracted enough to lift the platysma and improve the i contour of the neck, and tied. If there is dimpling of the skin at the lower puncture, an artery forceps tip is passed into the incision and gently lifted until the dimple is softened. The Silhouette suture lift begins with markings behind the ear and along the neck under M ild to moderate ptosis of the neck can be treated the mandible to a point just proximal to the midline. If there is signifcant ptosis in the midline, the Complementary nonsurgical procedures such as botu- path of the suture can continue past the midline to a linum toxins and infrared light tissue tightening are point just distal to it, so that the sutures act as a sling useful for platysmal bands and skin laxity, respec- in the submental region. The author uses suture suspension of the plat- midline, the needle frst exits from a point just proxi- ysma using absorbable sutures as well as subcutaneous mal to the midline. Before the needle exits completely lifting using coned sutures to improve neck ptosis. The cones have partially absorbed and the lowing placement of Silhouette coned sutures. The poly-l-lactic visible lumps have almost completely gone acid cones are too superfcial in the tissues. Patients are instructed to avoid the needle with the suture attached advances toward excessive animation for the frst week and to be gen- the midline. It is passed to a point just distal to the tle when handling the face for the frst 4–6 weeks. This allows fbrosis pulled until the most distal knot on the suture is just around the sutures and reduces the likelihood of visible. The suture is cut just distal to the knot and the cheese-wiring of the sutures through the tissues. For most cases, it is suffcient usually minimal, but are ameliorated using regular to exit the skin proximal to the midline without pass- cold packs and sleeping with the head elevated for ing underneath the chin. The proximal ends be provided, including a contact telephone number of the sutures are secured to the mastoid fascia using should the patient have concerns following the pro- the half-circle needles and tied to one another. Antibiotics, such as cephalexin, well tolerated using infltrative local anesthesia only. Simple analgesia is usually Sedation and general anesthesia are unnecessary and suffcient, although opioid-like analgesia such as increase the risks associated with the procedure. Tramadol is prescribed for the frst few days and M ild edema, ecchymosis, tenderness, and transient 424 P. Do not massage or rub vigorously the treatment area for at least 4 weeks; this could disrupt the sutures under the skin 2. W ear the head garment 24 h/day for 3 days and then in bed at night for a further 1 week 3. You may experience a tighter sensation over your face where skin has been retracted. Some of this tightness will lessen over 1–2 weeks as the skin relaxes into its new position 8. You may experience some swelling, bruising or tenderness over the frst week but this will subside and fade over time. If you notice increasing redness, swelling and tenderness a few days after the procedure that was not there before, call our clinic. Dimpling has occurred near the nasolabial fold on the right where the suture has tethered the dermis. Complications include infection, bleed- appropriate sutures using sterile technique and ing, palpability, visibility, skin irregularities, migra- excellent aftercare. If they do occur, they often tion, extrusion, prolonged pain, nerve injury, and resolve spontaneously or can easily be treated asymmetries (Figs.

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