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Because the escape rate is usually quite slow buy cialis soft 20mg free shipping impotence zinc, these patients are almost always symptomatic with syncope or fatigue and shortness of breath safe cialis soft 20mg erectile dysfunction beat. Because syncope may be related to an associated ventricular tachycardia buy cialis soft 20mg on line erectile dysfunction pills cialis, we believe symptomatic patients should be studied buy generic cialis soft from india erectile dysfunction doctor in bangalore. Infra-His Conduction System The infra-His conduction system, which comprises the main bundle branches and fascicles, their ramifications, 18 and the Purkinje network, is the source of most of the clinically important heart block in adults. The His bundle is generally considered to trifurcate into the right bundle branch and the left bundle branch, which promptly fans 26 out into an anterior (superior) fascicle and a posterior (inferior) fascicle. However, because this fascicle probably contributes little to overall infra-His conduction, it is not discussed here. Although conduction disturbances can occur in each of the major fascicles, the integrity of overall A-V conduction can be maintained by a single functioning fascicle. Therefore, in this chapter the infra-His system is discussed as a single unit and the next chapter covers the implications of individual bundle branch and fascicular blocks. Each atrial complex is followed by a proximal His (H) bundle deflection with a fixed A-H interval, and each escape ventricular complex is preceded by a distal His bundle deflection with a normal H-V interval. Note that the prolonged H-V interval of 80 msec is obscured in the overall P-R interval, which is normal at 175 msec. As long as at least one fascicle conducts normally, the H-V interval, should not exceed 55 msec. It has been suggested, however, that the upper limit of normal may be 60 msec in the presence of complete left bundle branch block and an intact right bundle branch (Chapter 5). Most patients with infra-His delay have H-V intervals in the 60- to 100-msec range (Fig. Such marked infranodal delay is uncommon, and in our experience, it frequently progresses to high degrees of block. The H-V interval is 300 msec, and it is largely responsible for P-R prolongation in this patient. H-V prolongation in the more usual ranges (60 to 100 msec) can exist without any or minimal prolongation of the P-R interval (Fig. Similarly, a grossly prolonged H-V interval is unlikely in the presence of a P-R interval of 0. Nevertheless, the P-R interval is an extraordinary poor predictor of the H-V interval because the H-V interval is usually significantly smaller than the A-H interval, which is the major component of the P-R interval. In the presence of Type I block, a gradual prolongation of the H-V interval occurs until an A-H group is not followed by a ventricular depolarization (Figs. Although the H-V shows progressive prolongation, it is very rare for there to be a maximum increment of >100 msec, unlike the A-V node where this is common. Not uncommonly, careful analysis reveals that block below the His is a rate-related phenomenon (Fig. When it occurs spontaneously, it may be precipitated by a change in H-H of a few milliseconds (Figs. Pacing-induced block below the His is considered an indication for a permanent pacemaker (see Chapter 5). Intermittent infra-His conduction is frequent in the presence of alternating bundle branch block (Chapter 5). In any case, second-degree infra-His block is indicative of impending high-grade or complete infra-His block with the attendant problem that hemodynamic survival depends on an idioventricular escape rhythm. As with intra-His block, atropine and exercise failed to improve and may even have worsened conduction, while vagal maneuvers may actually improve conduction (Table 4-3). Third-degree infra-His block is the most common cause of spontaneous chronic complete heart block in adults over 30 years old; in our laboratory it accounts for approximately two-thirds of such patients. In third-degree infra- His block, dissociated A-H complexes have no relationship to the slow idioventricular escape rhythm (Fig. In addition, this slow rhythm may precipitate Torsades de Pointes, which causes syncope. Of note, is that retrograde conduction may be present in 20% to 40% of patients with intra- or infra-His block (Figs. There is gradual prolongation of the H-V interval and the third stimulus (S), and the resulting A-H complex is not followed by ventricular depolarization. The A-H and H-V intervals remain constant during conducted impulses at 85 msec and 95 msec, respectively. The third A-H complex, however, is suddenly and unexpectedly not followed by a ventricular depolarization. The complex following the blocked impulse shows no alteration in the conduction intervals. This disorder is rarely recognized and can be lethal because of unreliable escape rhythms. It may often be mistaken for a “benign” vagal episode, if the clinical situation suggests increased vagal tone; e. Resumption of conduction requires an appropriately timed escape beat, premature beat (sinus or ectopic) relative to Phase 4 depolarization causing the block. Value of Intracardiac Studies in the Evaluation of A-V Conduction Disturbances Several specific points are discussed in this section to emphasize the value of intracardiac studies in the diagnosis and management of A-V conduction disturbances. Although it has been suggested that His bundle extrasystoles reflect a diseased His bundle and may not differ greatly from His bundle block in their prognostic 12 significance, we believe that therapy should initially be directed at suppressing automaticity rather than at failing conduction. The atrium is paced at a cycle length of 700 msec with stable conduction intervals. Ventricular depolarization results from the fifth paced atrial complex and demonstrates no change in A-H or H-V intervals. Bottom: Ventricular pacing during complete antegrade A-V block demonstrates 1:1 V-A conduction. A retrograde His is seen following the ventricular electrogram during ventricular pacing because conduction proceeds up the left bundle branch. The “blocked” P wave in the surface leads has an atrial activation sequence identical to sinus rhythm. The intracardiac recordings demonstrate a junctional (His bundle) depolarization that fails to propagate antegradely but produces retrograde concealed conduction in the atrioventricular node, which is the cause of the blocked P wave. Increased automaticity in the His bundle rather than impaired conduction is responsible for this phenomenon. The observation of typical Type I block in the same patient, however, suggests that the site of block is the A-V node. Because high-grade block can occur anywhere in the A-V conduction system, an intracardiac study is essential for accurate localization when the site of block cannot be really determined. In the presence of third-degree block, the rate of the escape pacemaker also provides only limited information 18 about the site of block because of considerable overlap (Fig.

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These middle-aged should be undertaken since Mycobacteria cultures require patients are candidates for explantation and mastopexy buy cialis soft 20mg with amex does erectile dysfunction cause infertility, or several weeks and need to be carried out on tissue even simple implant removal cialis soft 20 mg lowest price erectile dysfunction treatment new drugs. Mastopexy is obviously the pro- 5 The Correction of Complications cedure of choice and discount cialis soft 20mg erectile dysfunction aafp, thanks to the increased breast vol- Due To Changes in Tissues ume order 20 mg cialis soft fast delivery erectile dysfunction treatment karachi, often provides satisfactory results without implant Surrounding the Implant replacement (Fig. It is interesting to notice that most of these women, although they have been satisfied for Tissue thinning represents a frequent reason for unsatis- many years with their breast augmentation, wish to have factory long-term results. In patients who had subglandular contours can be improved by lipostructure, but patients augmentation, the capsular tissue can be used during mas- showing this problem are often very thin and do not have topexy to strengthen the “new structure” of the breast suitable donor areas. Implant exchange is often advisable since this resistant tissue can be grabbed and moved by and cohesive gel prostheses are usually suggested. Lipostructure or filler injection (hyal- with larger base diameter and moderate projection should uronic acid) can be carried out in order to increase breast be used in these conditions in order to compensate for the volume in women undergoing implant removal. Scuderi N, Mazzocchi M, Fioramonti P, Bistoni G (2006) The effects of Zafirlukast on capsular contracture: preliminary report. Alfano C, Mazzocchi M, Scuderi N (2004) Mammary compliance: breast implant core study results at 6 years. Aesthetic Plast Surg Barcelona, May 2009 33:440 Inverted-T Scar Reduction Mammoplasty Michele Pascone and Andrea Armenio 1 Introduction quality of life is also demonstrated by the fact that women undergoing this operation are among the most satisfied. In It is a widespread belief that a woman’s physical and mental fact, after reduction mammoplasty patients often have a new well-being can be influenced by the dimension, shape, and vision of life and are more prone to practice activities that symmetry of her breasts. The dimension of a woman’s breast influences her life the treatment of gynecomastia. In 1848, breasts can have physical symptoms such as headache, cervi- Dieffenbach was probably the first to perform a reduction mam- cal pain, backache and shoulder pain, inadequate posture moplasty by removing the inferior two thirds and the posterior with shoulder incurvation, compression of the brachial segment of the breast, leaving a scar in the inframammary fold plexus with paresthesias of upper limbs, mastodynia, heavi- [1]. Thomas [2] and Guinaud [3] emphasized the use of the ness and fullness, skin maceration at the inframammary fold, inframammary fold as an access route for the removal of exces- intertrigo, and dermatosis (Table 1 ). These symptoms can considerably improve or completely The technical modifications proposed at the end of 1800 disappear after reduction mammoplasty. Several types of skin which allows the plastic surgeon to improve the patient’s and glandular excisions were proposed, and they all consisted Table 1 Summary scheme of the most frequent discomforts caused by breast hypertrophy Problems related to large breasts M. However, in this case an excessive distortion of the nipple-are- For this reason, in the operations described by other ola complex with tendency to retraction was determined. Even if some of these techniques have been paid on the skin overlying the residual mammary gland. In case it was necessary to remove a large amount of tissue, the reduction was either performed in a single step or, in particular cases, in two surgical steps. Being conventionally established as “normal” a 250– Subsequent modifications of the reduction mammoplasty 300 cc breast volume, breast hypertrophy is defined when the techniques involved the skin incisions and the design of the breast is bigger than 50 % of this volume. In 1956, Wise [7] described a pattern for the preoperative “Marked” hypertrophies are those in which 300–800 cc of drawing of the breast that gave reproducible results and min- imal complications, associated with satisfying breast shapes. The technique described by Skoog in 1963 instead is based on a lateral pedicle with an extremely reduced thick- ness compared to those described by the other surgeons. The advantage was the ease of movement of the pedicle without excessive breast distortions, but there was a high risk of areo- lar necrosis. McKissock [9, 10] described a vertical bipedicle flap, Weiner [11] described a superior-based flap, Orlando [12] and Guthrie a superomedial-based flap, and Courtiss F i g. With these technical expedients it became easier to beholder”) Inverted-T Scar Reduction Mammoplasty 195 Table 2 Approximate evaluation of the quantity of tissue to be 5 Classification of the Surgical removed according to body parameters Techniques Body type, height, weight, breast volume Longitype 152–172 cm 45–54 kg 150–250 cc The techniques of reduction mammoplasty can be classified Normotype 152–172 cm 54–63 kg 250–350 cc according to the type of nipple-carrying pedicle, the skin Brachytype 152–172 cm 63–72 kg 350–600 cc drawing and the subsequent residual scar, and the type of glandular resection to perform. In fact, breast dimension is not directly related to the quantity As we already mentioned, the choice of the nipple-carrying of the mammary gland. The glandular and connective components used are: are present in variable quantities. As a consequence, it is possible to classify breast hyper- • Superior trophies also according to the main component: • Superomedial • Superolateral • Glandular hypertrophy • Inferior • Adipose hypertrophy • Medial • Connective hypertrophy • Lateral • Vertical • Horizontal 4 Philosophy of Reduction Mammoplasty 7 Skin Drawing and Scar Shape The choice of the surgical technique to reduce breast volume depends on several factors. There is no technique that gives The choice of the nipple-carrying pedicle does not necessar- better results compared to the others, and it would be unreal- ily influence the skin drawing and the residual scars. For istic to think that it is possible to use a single technique for example, if we use a superior pedicle, we can choose a draw- the correction of all types of breast hypertrophies. On the ing with vertical residual scar (areola-mammary groove) or contrary, the best surgical technique should be chosen L or J scars or also inverted-T scar. The choice of the drawing is therefore determined Factors affecting the choice of the surgical technique are according to the skin and glandular resection to be per- numerous: the size and characteristics of the breast (main formed. In case of little reductions in young desires of the patient, and the preference of the surgeon. There are surgical techniques that convey shorter scars in • “Inverted-T” or “anchor” scar (Strombeck [8] 1960, spite of a less pleasant breast shape in the immediate postop- Pitanguy [15] 1960, McKissock [9, 10] 1972) (Fig. The breast tissue is highly vascularized by the internal mam- mary artery medially, the thoracoacromial and thoracodorsal arteries superiorly, branches of the lateral thoracic artery, and 9 Superior Pedicle Reduction several intercostal perforating vessels that pierce the pectora- Mammoplasty with Inverted-T Scar lis major muscle or that originate inferiorly to it. In this first part, only the techniques involving superior- However, it is advisable to preserve the most part of vascu- based flaps will be discussed. The skin of the upper pole of the allows to mold the breast in a reproducible manner, to breast is innervated by the supraclavicular branches of the remove the excessive skin component to a variable extent, cervical plexus. The contribu- • Breasts with a noncompletely volume-depleted upper tion of each nerve varies between the different corpses stud- pole ied, and in the same individual it varies between the left and right sides. Among these signs and symptoms, there are backache, pain in the cervical region and shoulders, lumbosacral pain, musculo- tensive cefalea, chronic mastitis, wrong posture with kypho- sis and/or lordosis and arthritis of the spinal cord, excessive tension of the bra straps over the shoulders with formation of furrows, paresthesias due to the compression of the brachial inframammary crease plexus, intertrigo of the inframammary fold, and difficulty in everyday life activities or sports as well as social discomfort and problems in wearing “normal” clothes. The authors sug- gest using this technique for breast reductions of less than F i g. In superior pedicle reduction mammoplasty with inverted- T scar, the preoperative drawing is of utmost importance and 9. Another contraindication is a previous reduction mam- moplasty with a non-superior pedicle. Another relative contraindication is represented by sternal notch and the midsternal line are marked (Fig. In around 19–22 cm along the midclavicular line or 20–23 cm case the nipple is more medial or lateral compared to the from the suprasternal notch along the midclavicular line. We draw a circumference open at the inferior pole with a The inframammary fold is marked with the arms down superior margin placed 1. In some cases of breast asymmetry, in fact, circle with a slightly flattened shape should have a 14–16 cm the fold could be higher in one of the breasts. The circumference will be open at the lower The neo-nipple will be placed at the level of the projection of pole as shown in Fig. The breast is rotated medially, and a the inframammary fold on the anterior surface of the breast, as 6–7 cm line is drawn from the inferior portion of the circumfer- shown in Fig. The nipple can be at a different height accord- ence along the line passing through the central point of the infra- ing to the patient’s characteristics (height, characteristics of the mammary fold as for reaching the breast meridian. The ideal position should be pillars of the breast will represent the portion of scar that F i g. Line A is the superior portion of the new nipple/areola com- to draw the lines of the lateral pillars. Such lines should be the ideal plex, Lines B-D and C-E represent the portion of scar from the inferior continuation of the breast meridian.

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This picture is often seen in states of obesity cheap cialis soft 20mg line prostate cancer erectile dysfunction statistics, encountered in this dissection unless the muscle fascia is or as one of the sequelae of significant weight loss proven 20 mg cialis soft erectile dysfunction beat filthy frank. Small vessels and cutaneous nerves patients order cialis soft pills in toronto cheap erectile dysfunction pills online uk, both fatty tissues and skin need to be resected buy generic cialis soft 20 mg line erectile dysfunction doctor singapore, i. Those with a history of The excess “pannus” is fully mobilized before initiating morbid obesity invariably have the most extensive upper excision (Fig. This class of patients vertical direction and the skin from the anterior and posterior also may have involvement of the forearm and elbow margins are stapled together (Figs. The tension regions requiring a longer incision for aesthetic removal of and aesthetic tightening are judged by looking and feeling redundant tissues. For further detail, the appreciated, the staple is removed and the vertical incision is reader is directed to a helpful algorithmic approach to these lengthened and the edges are stapled together again. A line is drawn between the inter- finally and then Medipore tape placed along the entire length vening segments and they are excised with scalpel and Bovie. The Staples are removed and the edges are stapled approximated closed incision, with drain in place, is shown (Fig. The same tailor tacking is employed once again with the proximal remaining pannus 7 Peri- and Postoperative Care and redundant skin is excised. Meticulous hemo- The postoperative inflammatory response, edema, and stasis is important but easily accomplished because of the ecchymosis seen in brachioplasty can be modulated to a cer- epinephrine-induced vasoconstriction. Pain control requirements tend to be minimal and proximal forearm adiposity juxtaposed to the elbow is then include mild narcotics initially and nonsteroidal anti- performed (Fig. Gentle compressive forces are rine into that area 10 min before initiating liposuction to provided to prevent fluid collection: an elasticized garment is avoid overdistention and maximize the ability to recognize worn for at least a month postoperatively and Medipore tap- the optimal contours in that area. The operative time has decreased by one Patients return to light work in 1 week but are advised to third or more by using this system. Just prior to final sutures are placed at proximal and distal wound margins, a #10 8 Avoidance of Complications Jackson-Pratt drain is placed by taking a long 3 mm liposuc- tion cannula and introducing it through an axillary stab inci- Brachioplasty represents a challenge for many surgeons and sion. The cannula is then advanced subcutaneously to the has historically had a high complication rate. Wound dehiscence to the tube (to help keep it temporarily fixed to the cannula) is or necrosis of the flap edges may occur, and post-massive pulled attached to the cannula through from the distal edge of weight loss patients may be slow to heal due to previously the incision through to the axilla (Fig. Dermabond is applied which is comparable to those rates in panniculectomy or belt 438 R. The authors found that skin-excision ultrasound-assisted lipoaspiration is avoided at the medial weight correlated with seroma rate and that each additional elbow due to the nearby course of the ulnar nerve. As in other body contouring proce- dures, the risk for seroma can be decreased with limitation 9 Results/Cases of undermining and placement of drains. If the tissues are not contoured symmetrically, contour irregularities includ- The following example is a 48-year-old female who under- ing depressions or folding of excess remaining tissues could went bilateral brachioplasty. Contour irregularities, if they do occur, are often due terior, and lateral views are shown (Figs. The reported scar revision rate after brachio- 13, 14, 15, 16, 17, and 18 and the postoperative results shown plasty is 10 % in some series [19], and this is an area of noto- in Fig. Nerve injury, major wound very aesthetic appearance to the upper arm with resolution of complications, and lymphedema are potential complications, the excessive posterior curvature of the arm. Hoy 10 Futures and Controversies Some authors advocate staging the definitive brachioplasty with an initial session of liposuction. The liposuction is performed 3–5 months prior to the brachioplasty to reduce the excess subcutane- ous fat: this is argued to maintain the skin’s elastic recoil proper- ties and reduces the extent of dissection [19]. Other approaches utilizing a short scar have been described to deal with less exten- sive deformities of the upper arm and employ selective liposuc- tion of key areas [20]. Increasingly, brachioplasty modifications are being proposed which are both tailored to the deformity and to patient expectations for scarring postoperatively [21]. Aly A, Pace D, Cram A (2006) Brachioplasty in the patient with massive weight loss. Plast some widening of the surgical scars Reconstr Surg 121:305–307 Brachioplasty 443 21. Atheneu, Bueonos Plication of the brachial fascia: an important step in dermolipec- Aires, p 336 tomy procedures of the arm. Clarkson P, Jeff J (1996) The contribution of plastic surgery in the treatment of obesity. Butterworth-Heinemann, Oxford, p 315 Hand Rejuvenation Cristina Spalvieri and Francesco Brunelli 1 Introduction more frequent. Techniques used for treatment of the aging face were first The hand is the organ responding to human desire, through experimented with and finally applied to the hand. Synergy which we experience and come into contact with the external between medical, surgical, and dermatologic techniques has world. Together with the face, it is the most exposed part of permitted the development of hand rejuvenation techniques. Because of its development and mobility, and the perfect sensibility of its teguments, the hand represents a highly sensitive organ of touch. Therefore, we can assert that man is At the beginning of the fifth week of gestation, the limb buds morphologically superior to animals thanks to both the hand become visible, presenting in a “paddle” shape. At the sixth week the bud apical ridge becomes flat and surgery starting with the treatment of malformations, further is separated from the more cylindrical proximal segment describing posttraumatic and oncologic reconstruction through a circular constriction. At the sixth corroborations this new discipline accurately described week, the cartilaginous framework may be recognized. The first ossification centers appear at the gery of the hand seems to run parallel to human evolution as edges of the long bones at the 12th week of development. Studies of anatomy, the center of primary ossification, the endochondral ossifica- orthopedics, neurosurgery, plastic surgery, and rehabilitation tion progresses toward the edges of the cartilaginous structure. A temporary cartilaginous tissue poets, painters, and sculptors have celebrated and portrayed named the epiphyseal plate, important for growth and bone the power and delicacy of the hand. In surgical fields aimed length, remains within both the diaphyseal and epiphyseal at perfection and of expertise, the demand for treatment of ossification centers. Melanocytes, responsible for the skin color, derive Dipartimento di Dermatologia e Chirurgia Plastica, from the neural crest and migrate into the skin. New cell Università di Roma “Sapienza” , Roma , Italy production ensues in the stratum germinativum. Sebaceous and Chirurgien orthopediste, Clinique Jouvenet, Institut de la Main, Paris , France sudoriferous glands derive from the epidermal layers [3 ]. Brunelli 3 Anatomy and Physiology of Aging The hand represents the ending extremity of the upper limb and ends with five free appendages named fingers. The skin, or tegumentary apparatus, consists of a dynamic variety of tissues and covers the body completely. It provides protection for the body and separates it from the external environment, finally connecting it with the inner tissues. The color of skin, changing with the race, depends essen- tially on three components: the yellow one of the corneous layer (keratin), the dark component of the epidermis (mela- nin), and the red constituent of the microcirculation (hemo- globin). Skin is composed of three anatomic-functional overlapping layers: the superficial one that named the epider- mis, the intermediate layer called the dermis, and the deeper layer named the hypodermis or subcutaneous tissue.

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While these three products are no longer marketed by their respective companies in the United States discount 20mg cialis soft mastercard erectile dysfunction of organic origin, some trocar-based kits are still available in the United States and worldwide purchase cialis soft 20mg with visa impotence ruining relationship. First cialis soft 20mg on-line erectile dysfunction pills amazon, a weighted speculum purchase genuine cialis soft best herbal erectile dysfunction pills, self-retaining retractor, or Deaver retractors are placed in the vagina. Allis clamps are positioned at the urethrovesical junction for traction and 1 cm distal to the vaginal apex. As opposed to an anterior colporrhaphy in which the vaginal epithelium and muscularis are split for plication, the mesh is placed underneath the muscularis to maintain a thickened vascularized epithelium in order to minimize mesh exposure or erosion. To enter this potential space, the surgeon injects a dilute vasopressin solution or 0. Irrigation may help during the dissection, as the defect is a glistening white line. A sagittal colpotomy incision is made between the Allis clamps long enough to admit two fingers comfortably. Next, countertraction along the entire incision line is achieved with either the serial Allis clamps or a self-retaining retractor. The vaginal epithelium and full-thickness muscularis are dissected away from the bladder defect. Sharp and blunt dissection of the bladder is then performed while keeping the muscularis and epithelium on the vaginal flaps. A number of different trocar types are available including helical-shaped trocars similar to those for transobturator slings and flexible straight trocars. Cutaneous incisions that are 4–7 mm in length are made over the appropriate locations for the obturator 1258 foramen and/or gluteus trocars. When placing multiple mesh arms through the transobturator space, the superior and inferior puncture sites should be at least 3 cm apart so the mesh can lay flat. Two fingers placed into the vagina can retract the colon, elevate the bladder, and minimize deviation of the trocar tip with direct palpation. If the surgeon conserves the uterus, then permanent sutures can be placed into the cervical stroma to stabilize the mesh. Cystoscopic and rectal examinations before, during, and after each portion of the surgery can be helpful. Once adequate hemostasis is obtained, the vaginal epithelium is closed with a continuous nonlocking stitch of delayed absorbable suture. Placing a lubricated vaginal pack may minimize bleeding and keep the mesh flat during healing. After desired tensioning, all ends of the mesh arms should be trimmed below the surface of the skin and the incisions closed. Concurrent procedures, such as a midurethral sling, should be done through a separate vaginal incision at this time. Nontrocar Mesh Kits The nontrocar or “single-incision” mesh kits have become increasingly popular and largely replaced trocar-based kits. The products avoid the potential complications associated with blind trocar passage through the transobturator space and ischiorectal fossa and allow mesh fixation via direct visualization. Additionally, most currently available nontrocar kits provide apical fixation to the sacrospinous ligaments bilaterally as well as anterior vaginal support. The technique for the nontrocar kits begins similarly to the technique for trocar-guided kit placement. For apical fixation, the surgeon palpates the location of interest then identifies the sacrospinous ligament at least 2 cm medial to the ischial spine. The mesh arms are slowly and individually adjusted to a loose tension, and then the mesh is sutured flat. Cystoscopy with visualization of ureteral flow is performed to ensure integrity of the bladder and ureters. Retropubic surgeries such as the Burch colposuspension are discussed in Chapter __. The preparation for vaginal paravaginal repair begins as for an anterior colporrhaphy. Marking sutures are placed on the anterior vaginal wall on each side of the urethrovesical junction, identified by the location of the Foley balloon after gentle traction is placed on the catheter (Figure 82. In patients who have had a hysterectomy, marking sutures are also placed at the vaginal apex. If a culdeplasty or apical suspension procedure is being performed, the stitches are placed but not tied until completion of the paravaginal repair and closure of the anterior vaginal wall. As for anterior colporrhaphy, vaginal flaps are developed by incising the vagina in the midline and dissecting the vaginal muscularis laterally. The dissection is performed bilaterally until a space is developed between the vaginal wall and retropubic space. Blunt dissection using the surgeon’s index finger is used to extend the space anteriorly along the ischiopubic rami, medially to the pubic symphysis, and laterally toward the ischial spine. If the defect is present and dissection is occurring in the appropriate plane, one should easily enter the retropubic space, visualizing retropubic, and paravaginal adipose tissue. After dissection is complete, midline plication of the bladder adventitia can be performed, either at this point or after placement and tying of the paravaginal sutures (Figure 82. Retraction of the bladder and urethra medially is best accomplished with the Breisky–Navratil retractor, and posterior retraction could be provided with a lighted right-angle retractor. If the white line is detached from the pelvic sidewall or clinically not felt to be durable, then the attachment should be to the fascia overlying the obturator internus muscle. The placement of subsequent sutures is aided by placing tension on the first suture. A series of three to six stitches are placed and held, working anteriorly along the white line from the ischial spine to the level of the urethrovesical junction (Figure 82. Starting with the most anterior stitch, the surgeon picks up the edge of the periurethral tissue (vaginal muscularis or pubocervical fascia) at the level of the urethrovesical junction and then tissue from the undersurface of the vaginal flap at the previously marked sites. Subsequent stitches move posteriorly until the last stitch closest to the ischial spine is attached to the vagina nearest the apex, again using the previously placed marking sutures for guidance. Stitches in the vaginal wall must be placed carefully to allow adequate tissue for subsequent midline vaginal closure. After all the stitches are placed on one side, the same procedure is carried out on the other side. The stitches are then tied in order from the urethra to the apex, alternating from one side to the other. The vaginal flaps are trimmed and closed with a running subcuticular or interlocking delayed absorbable suture. Cystoscopy Cystoscopy with visualization of ureteral flow is usually performed after cystocele repair, especially if slings or apical suspension procedures are also being performed. The purpose is to ensure that no sutures or mesh have been placed in the bladder and to verify patency of both ureters. Intraoperative release of the offending sutures almost always releases the obstruction without further sequelae. Few studies have addressed the long-term success of surgical treatments for anterior vaginal prolapse.

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