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The presence of an ulcerative plaque of greater than 60% occlusion is generally an indication for carotid endarterectomy discount viagra plus online. After 2 weeks buy viagra plus canada, abnormalities in regional blood flow and metabolic rate usually resolve order 400 mg viagra plus overnight delivery. Preoperative Management Preoperative evaluation: Stroke type buy discount viagra plus 400 mg on line, + neurologic deficits, residual impairments, cardiovascular status Coagulation management: Review plan with primary care and surgical teams to determine the risk versus benefit of the discontinuation or maintenance of such therapy perioperatively. Intraoperative Management Management of the patient after acute embolic stroke is directed toward the embolic source whether it is removal of the atrial myxoma, ventricular thrombi, or degenerative heart valves. Patients with acute strokes secondary to carotid occlusive disease present for carotid endarterectomy. They may be a manifestation of an underlying central nervous system disease, a systemic disorder, or idiopathic. Preoperative management: Preoperative evaluation of patients with a seizure disorder should focus on determining the cause and type of seizure activity and on the drugs with which the patient is being treated. Seizures in adults are most commonly caused by structural brain lesions (head trauma, tumor, or stroke) or metabolic abnormalities (uremia, hepatic failure, hypoglycemia, hypocalcemia, or drug toxicity or with- drawal). Seizures, particularly grand mal seizures, are serious complicating factors in surgical patients and should be treated aggressively to prevent musculoskeletal injury, hypoventilation, hypoxemia, and aspiration of gas- trointestinal contents. If a seizure occurs, maintaining an open airway and adequate oxygenation are the first priorities. Adverse side effects and signs of toxicity should be excluded clinically and by laboratory investigations. Antiseizure medications should ideally be continued throughout the perioperative period to maintain therapeutic levels, which should also be determined preoperatively. Ketamine and methohexital (in small doses) theoretically can precipitate seizure activity, and hypothetically, large doses of atracurium/cisatracurium or meperidine may be contraindicated because of the reported epileptogenic potential of their metabolites, laudanosine and normeperidine. Hepatic micro- somal enzyme induction should be expected from chronic antiseizure therapy. Clinical signs and symptoms: This neurodegenerative disease is characterized by bradykinesia, rigidity, postural instability, and resting (pill-rolling) tremor. Additional frequently occurring findings include facial masking, hypophonia, dysphagia, and gait disturbances. Early in the course of the disease, intellectual func- tion is usually preserved, but declines in intellectual function can occur and may be severe over the course of the disease. Thalamic inhibition, in turn, suppresses the motor system in the cortex, resulting in the dyskinesia, rigidity, postural instability, and tremor that are characteristic of the disease. Patients with moderate to severe disease are typically treated pharmacologically with dopaminergic agents, either levodopa (a precursor of dopamine) or a dopamine-receptor agonist. Levodopa is given with a decarboxylase inhibitor to retard the peripheral breakdown of the drug, thereby increasing its central delivery and decreasing the dose of levodopa that is required to control symptoms. Dopamine-receptor agonists include both ergot (bromocriptine, cabergoline, lisuride, and apomorphine) and nonergot derivatives (pramipexole and ropinirole). Abrupt withdrawal of levodopa can cause worsening of muscle rigidity and may interfere with ventilation. Phenothiazines, butyrophenones (droperidol), and metoclopramide can exacerbate symptoms as a consequence of their antidopaminergic activity and should be avoided. Anticholinergics (atropine) or antihistamines (diphenhydramine) may be used for acute exacer- bation of symptoms. Diphenhydramine is particularly valuable for premedication and intraoperative seda- tion in patients with tremor. Induction of anesthesia in patients receiving long-term levodopa therapy may result in either marked hypotension or hypertension. Cardiac irritability readily produces arrhythmias, so halothane, ketamine, and local anesthetic solutions containing epinephrine should be used cautiously. Adequacy of ventilation and airway reflexes should be carefully assessed before extubation of patients with moderate to severe disease. An awake craniotomy has been the norm for epilepsy surgery for some time, and, increasingly, it is being used for deep brain stimulation procedures as well. Characteristics: Slow decline in intellectual function (dementia); progressive memory impairment; decision- making impairments; emotional lability; extrapyramidal signs, including apraxia and aphasia Pathology: Neurofibrillary tangles that contain tau and neuritic protein plaques composed of the peptide β-amyloid Imaging: Marked cortical atrophy with ventricular enlargement Anesthetic Management Often complicated by disorientation and uncooperativeness Postoperative cognitive impairment is a frequent observation, persisting for 1 to 3 days after surgery. Consent must be obtained from the next of kin or a legal guardian if the patient is legally incompetent. Because the use of centrally acting drugs must be minimized, premedication is usually not given. Centrally acting anticholinergics, such as atropine and scopolamine, could theoretically contribute to post- operative confusion. Glycopyrrolate, which does not cross the blood–brain barrier, may be the preferred agent when an anticholinergic is required. Anesthetic agents are increasingly associated in laboratory studies with neuron injury and death. The implica- tions of general anesthesia delivery both in the elderly as well as small children is currently subject of much investigation and debate. It primarily affects patients between 20 and 40 years of age with a 2:1 female predominance. With time, remissions become less complete, and the disease is pro- gressive and incapacitating. Clinical manifestations frequently include sensory disturbances (paresthesias), visual problems (optic neuritis and diplopia), and motor weakness. Systemic effects of these therapies on coagulation, immunologic, and cardiac function should be reviewed preoperatively. Preoperative consent should discuss counseling of the patient to the effect that the stress of surgery and anesthesia might worsen the symptoms. In the setting of paresis or paralysis, succinylcholine should be avoided because of hyperkalemia. Regardless of the anesthetic technique used, increases in body temperatures should be avoided. Demyelinated fibers are extremely sensitive to increases in temperature; an increase of as little as 0. Presentation: Muscular weakness in the 40s to 50s, muscle atrophy, fasciculations, or spasticity; at first is asymmetric, progressing to generalized weakness within 2 to 3 years. Difficulty in weaning patients off mechanical ventilation postoperatively is not uncommon in patients with moderate to advanced disease. It is characterized by an immunologic reaction against the myelin sheath of peripheral nerves, particu- larly lower motor neurons. Presentation: Sudden onset of ascending motor paralysis, areflexia, and variable paresthesias; usually fol- lows a viral respiratory or gastrointestinal infections Anesthetic management is complicated by lability of the autonomic nervous system. Exaggerated hypo- tensive and hypertensive responses during anesthesia may be seen. As with other lower motor neuron disor- ders, succinylcholine should not be used because of the risk of hyperkalemia. The use of regional anesthesia in these patients remains controversial because it might worsen symptoms. When neuraxial techniques are chosen in patients with preoperative neurological deficits, dilute local anesthetic agents should be used to mitigate against the development of local anesthetic toxicity. Presentation: Impotence; bladder and gastrointestinal dysfunction; abnormal regulation of body fluids; decreased sweating, lacrimation, and salivation; and orthostatic hypotension Anesthetic management: Watch for severe hypotension, compromising cerebral and coronary blood flow. Extension upward into the medulla (syringobulbia) leads to cranial nerve deficits. Anesthetic management should focus on defining existing neurologic deficits as well as any pulmonary impairment caused by scoliosis. Succinylcholine should be avoided when muscle wasting is present because of the risk of hyperkalemia. Neuraxial techniques in the setting of elevated intracranial pressure are contraindicated. The majority of injuries are caused by fracture and dislocation of the vertebral column.

Each subject was asked to indicate which of three policies they favored with respect to smoking in public places discount 400mg viagra plus fast delivery. That is purchase viagra plus visa, the observed number of entities falling into each cell was determined after the sample was drawn buy 400mg viagra plus free shipping. As a result purchase viagra plus canada, the row and column totals are chance quantities not under the control of the investigator. We think of the sample drawn under these conditions as a single sample drawn from a single population. On occasion, however, either row or column totals may be under the control of the investigator; that is, the investigator may specify that independent samples be drawn from each of several populations. In this case, one set of marginal totals is said to be fixed, while the other set, corresponding to the criterion of classification applied to the samples, is random. The former procedure, as we have seen, leads to a chi-square test of independence. The two situations not only involve different sampling procedures; they lead to different questions and null hypotheses. The test of independence is concerned with the question: Are the two criteria of classification indepen- dent? The homogeneity test is concerned with the question: Are the samples drawn from populations that are homogeneous with respect to some criterion of classification? In the latter case the null hypothesis states that the samples are drawn from the same population. Despite these differences in concept and sampling procedure, the two tests are mathemati- cally identical, as we see when we consider the following example. Calculating Expected Frequencies Either the row categories or the col- umn categories may represent the different populations from which the samples are drawn. If, for example, three populations are sampled, they may be designated as populations 1, 2, and 3, in which case these labels may serve as either row or column headings. If the variable of interest has three categories, say, A, B, and C, these labels may serve as headings for rows or columns, whichever is not used for the populations. Before computing our test statistic we need expected frequencies for each of the cells in Table 12. By the same token, if the three populations are homogeneous, we interpret this probability as applying to each of the populations individually. Similar reasoning and calculations yield the expected frequencies for the other two rows. We see again that the shortcut procedure of multiplying appropriate marginal totals and dividing by the grand total yields the expected frequencies for the cells. Members of the German Migraine and Headache Society (A-8) studied the relationship between migraine headaches in 96 subjects diagnosed with narcolepsy and 96 healthy controls. We assume that we have a simple random sample from each of the two populations of interest. If H0 is true, X is distributed approxi- 2 mately as x with ð2 À 1Þð2 À 1Þ¼ð1Þð1Þ¼1 degree of freedom. Chi-Square Test Expected counts are printed below observed counts Rows: Narcolepsy Columns: Migraine No Yes All No 77 19 96 76. We conclude that the two populations may be homoge- neous with respect to migraine frequency. In summary, the chi-square test of homogeneity has the following characteristics: 1. Two or more populations are identified in advance, and an independent sample is drawn from each. Sample subjects or objects are placed in appropriate categories of the variable of interest. The calculation of expected cell frequencies is based on the rationale that if the populations are homogeneous as stated in the null hypothesis, the best estimate of the probability that a subject or object will fall into a particular category of the variable of interest can be obtained by pooling the sample data. The hypotheses and conclusions are stated in terms of homogeneity (with respect to the variable of interest) of populations. Test of Homogeneity and H0:p1 ¼ p2 The chi-square test of homogeneity for the two-sample case provides an alternative method for testing the null hypothesis that two population proportions are equal. Family History of Mood Disorders Early 18ðEÞ Later > 18ðLÞ Total Negative (A Bipolar disorder (B Unipolar (C Unipolar and bipolar (D) 53 60 113 Total 141 177 318 Source: Tasha D. Kennedy, “Early Age at Onset as a Risk Factor for Poor Outcome of Bipolar Disorder,” Journal of Psychiatric Research, 37 (2003), 297–303. Can we conclude on the basis of these data that subjects 18 or younger differ from subjects older than 18 with respect to family histories of mood disorders? The study used data from the Behavioral Risk Factor Surveillance System surveys of adults ages 18 years or older conducted in 1999 and 2000. The following table shows the number of observations of Hispanic and non-Hispanic women who had received a mammogram in the past 2 years cross-classified by marital status. Marital Status Hispanic Non-Hispanic Total Currently married 319 738 1057 Divorced or separated 130 329 459 Widowed 88 402 490 Never married or living as 41 95 136 an unmarried couple Total 578 1564 2142 Source: Steven S. Wilson, “Breast and Cervical Cancer Screening Practices Among Hispanic and Non-Hispanic Women Residing Near the United States–Mexico Border, 1999–2000,” Family and Community Health, 26, (2003), 130–139. We wish to know if we may conclude on the basis of these data that marital status and ethnicity (Hispanic and non-Hispanic) in border counties of the southern United States are not homogeneous. Do these data provide sufficient evidence for us to conclude that the two populations are not homogeneous with respect to competency rating 3 months after training? A respondent in each household was asked whether or not anyone in the household was bothered by air pollution. Of the remainder, 84 had worked at “moderate exposure” jobs, and 64 had experienced no known exposure because of their jobs. In an independent simple random sample of 250 industrial workers from the same area who had no history of cancer, 31 worked in “high exposure” jobs, 60 worked in “moderate exposure” jobs, and 159 worked in jobs involving no known exposure to suspected cancer- causing agents. Does it appear from these data that persons working in jobs that expose them to suspected cancer-causing agents have an increased risk of contracting cancer? The chi-square test is not an appropriate method of analysis if minimum expected frequency requirements are not met. If, for example, n is less than 20 or if n is between 20 and 40 and one of the expected frequencies is less than 5, the chi-square test should be avoided. A test that may be used when the size requirements of the chi-square test are not met was proposed in the mid-1930s almost simultaneously by Fisher (7,8), Irwin (9), and Yates (10). It is called exact because, if desired, it permits us to calculate the exact probability of obtaining the observed results or results that are more extreme. Data Arrangement When we use the Fisher exact test, we arrange the data in the form of a 2  2 contingency table like Table 12. We arrange the frequencies in such a way that A > B and choose the characteristic of interest so that a=A > b=B. Some theorists believe that Fisher’s exact test is appropriate only when both marginal totals of Table 12. Many experimenters, therefore, use the test when both marginal totals are not fixed. The data consist of A sample observations from population 1 and B sample observations from population 2. Test Statistic The test statistic is b, the number in sample 2 with the characteristic of interest. Appendix Table J gives these critical values of b for A between 3 and 20, inclusive. If the observed value of b is equal to or less than the integer in a given column, reject H0 at a level of significance equal to twice the significance level shown at the top of that column. If the observed value of b is less than or equal to the integer in a given column, reject H0 at the level of significance shown at the top of that column. Large-Sample Approximation For sufficiently large samples we can test the null hypothesis of the equality of two population proportions by using the normal approximation. Alternatively, when sample sizes are sufficiently large, we may test the null hypothesis by means of the chi-square test. Further Reading The Fisher exact test has been the subject of some controversy among statisticians. Some feel that the assumption of fixed marginal totals is unrealistic in most practical applications. The controversy then centers around whether the test is appropriate when both marginal totals are not fixed. For further discussion of this and other points, see the articles by Barnard (13–15), Fisher (16), and Pearson (17).

We now consider these characteristics for the sampling distribution of the sample mean buy 400mg viagra plus, x purchase 400mg viagra plus free shipping. Sampling Distribution of x: Functional Form Let us look at the distribution of x plotted as a histogram buy viagra plus no prescription, along with the distribution of the population purchase line viagra plus, both of which are shown in Figure 5. We note the radical difference in appearance between the histogram of the population and the histogram of the sampling distribution of x. Whereas the former is uniformly distributed, the latter gradually rises to a peak and then drops off with perfect symmetry. Sampling Distribution of x: Mean Now let us compute the mean, which we will call mx, of our sampling distribution. Thus, P xi 6 þ 7 þ 7 þ 8 þÁÁÁþ14 250 mx ¼ n ¼ ¼ ¼ 10 N 25 25 We note with interest that the mean of the sampling distribution of x has the same value as the mean of the original population. It is of interest to observe, however, that the variance of the sampling distribution is equal to the population variance divided by the size of the sample used to obtain the sampling distribution. That is, s2 8 2 sx ¼ ¼ ¼ 4 n 2 pffiffiffi2 pffiffiffi The square root of the variance of the sampling distribution, sx ¼ s= n is called the standard error of the mean or, simply, the standard error. These results are not coincidences but are examples of the characteristics of sampling distributions in general, when sampling is with replacement or when sampling is from an infinite population. To generalize, we distinguish between two situations: sampling from a normally distributed population and sampling from a nonnormally distributed population. Sampling Distribution of x: Sampling from Normally Distrib- uted Populations When sampling is from a normally distributed population, the distribution of the sample mean will possess the following properties: 1. The mean, mx, of the distribution of x will be equal to the mean of the population from which the samples were drawn. The variance, s2 of the distribution of x will be equal to the variance of the population x divided by the sample size. Sampling from Nonnormally Distributed Populations For the case where sampling is from a nonnormally distributed population, we refer to an important mathematical theorem known as the central limit theorem. The importance of this theorem in statistical inference may be summarized in the following statement. The Central Limit Theorem Given a population of any nonnormal functional form with a mean m and finite variance s2, the sampling distribution of x, computed from samples of size n from this population, will have mean m and variance s2=n and will be approximately normally distributed when the sample size is large. Note that the central limit theorem allows us to sample from nonnormally distributed populations with a guarantee of approximately the same results as would be obtained if the populations were normally distributed provided that we take a large sample. The importance of this will become evident later when we learn that a normally distributed sampling distribution is a powerful tool in statistical inference. In the case of the sample mean, we are assured of at least an approximately normally distributed sampling distribution under three conditions: (1) when sampling is from a normally distributed population; (2) when sampling is from a nonnormally distributed population and our sample is large; and (3) when sampling is from a population whose functional form is unknown to us as long as our sample size is large. The logical question that arises at this point is, How large does the sample have to be in order for the central limit theorem to apply? There is no one answer, since the size of the sample needed depends on the extent of nonnormality present in the population. One rule of thumb states that, in most practical situations, a sample of size 30 is satisfactory. In general, the approximation to normality of the sampling distribution of x becomes better and better as the sample size increases. Sampling Without Replacement The foregoing results have been given on the assumption that sampling is either with replacement or that the samples are drawn from infinite populations. In general, we do not sample with replacement, and in most practical situations it is necessary to sample from a finite population; hence, we need to become familiar with the behavior of the sampling distribution of the sample mean under these conditions. The sample means that result when sampling is without replacement are those above the principal diagonal, which are the same as those below the principal diagonal, if we ignore the order in which the observations were drawn. In general, when drawing samples of size n from a finite population of size N without replacement, and ignoring the order in which the sample values are drawn, the number of possible samples is given by the combination of N things taken n at a time. There is, x however, an interesting relationship that we discover by multiplying s2=n by ð N À n = N À 1. That is, s2 N À n 8 5 À 2 Á ¼ Á ¼ 3 n N À 1 2 4 This result tells us that if we multiply the variance of the sampling distribution that would be obtained if sampling were with replacement, by the factor N À n = N À 1 , we obtain the value of the variance of the sampling distribution that results when sampling is without replacement. When sampling is without replacement from a finite population, the sampling distribu- tion of x will have mean m and variance s2 N À n 2 sx ¼ Á n N À 1 If the sample size is large, the central limit theorem applies and the sampling distribution of x will be approximately normally distributed. The Finite Population Correction The factor N À n = N À 1 is called the finite population correction and can be ignored when the sample size is small in comparison with the population size. When the population is much larger than the sample, the difference between s2=n and s2=n N À n = N À 1 will be negligible. Imagine a population of size 10,000 and a sample from this population of size 25; the finite population correction would be equal to 10; 000 À 25 = 9999 :9976. Most practicing statisticians do not use the finite population correction unless the sample is more than 5 percent of the size of the population. The Sampling Distribution of x: A Summary Let us summarize the characteristics of the sampling distribution of x under two conditions. Sampling is from a normally distributed population with a known population variance: (a) mx ¼ m pffiffiffi (b) sx ¼ s= n (c) The sampling distribution of x is normal. Sampling is from a nonnormally distributed population with a known populationvariance: (a) mx ¼ m pffiffiffi (b) sx ¼ s= n; when n=N :05 rffiffiffiffiffiffiffiffiffiffiffiffi pffiffiffi N À n sx ¼ s= n ; otherwise N À 1 (c) The sampling distribution of x is approximately normal. Applications As we will see in succeeding chapters, knowledge and understanding of sampling distributions will be necessary for understanding the concepts of statistical inference. The simplest application of our knowledge of the sampling distribution of the sample mean is in computing the probability of obtaining a sample with a mean of some specified magnitude. What is the probability that a random sample of size 10 from this population will have a mean greater than 190? Solution: We know that the single sample under consideration is one of all possible samples of size 10 that can be drawn from the population, so that the mean that it yields is one of the x’s constituting the sampling distribution of x that, theoretically, could be derived from this population. When we say that the population is approximately normally distrib- uted, we assume that the sampling distribution of x will be, for all practical purposes, normally distributed. We also know that the mean and standard deviation of the sampling distribution are equal to 185. We assume that the pop- ulation is large relative to the sample so that the finite population correction can be ignored. We learn in Chapter 4 that whenever we have a random variable that is normally distributed, we may very easily transform it to the standard normal distribution. Our random variable now is x, the mean of its distribution is mx, pffiffiffi and its standard deviation is sx ¼ s= n. By appropriately modifying the formula given previously, we arrive at the following formula for transforming the normal distribution of x to the standard normal distribution: x À mx z ¼ pffiffiffi (5. This area is equal to the area to the right of 190 À 185:6 4:4 z ¼ ¼ ¼ 1:10 4:0161 4:0161 5. If a simple random sample of size 60 is drawn from this population, find the probability that the sample mean serum cholesterol level will be: (a) Between 170 and 195 (b) Below 175 (c) Greater than 190 5. They found in all adults 60 years or older a mean daily calcium intake of 721 mg with a standard deviation of 454. Construct the sampling distribution of x based on samples of size 2 selected without replacement. Imagine we take samples of size 5, 25, 50, 100, and 500 from the women in this age group. Specifically, an investigator may wish to know something about the difference between two population means. In one investigation, for example, a researcher may wish to know if it is reasonable to conclude that two population means are different. In another situation, the researcher may desire knowledge about the magnitude of the difference between two population means. A medical research team, for example, may want to know whether or not the mean serum cholesterol level is higher in a population of sedentary office workers than in a population of laborers. If the researchers are able to conclude that the population means are different, they may wish to know by how much they differ. A knowledge of the sampling distribution of the difference between two means is useful in investigations of this type. Sampling from Normally Distributed Populations The following example illustrates the construction of and the characteristics of the sampling distribution of the difference between sample means when sampling is from two normally distributed populations. Suppose, further, that we take a sample of 15 individuals from each population and compute for each sample the mean intelligence score with the following results: x1 ¼ 92 and x2 ¼ 105. If there is no difference between the two populations, with respect to their true mean intelligence scores, what is the probability of observing a difference this large or larger x1 À x2 between sample means? Solution: To answer this question we need to know the nature of the sampling distribution of the relevant statistic, the difference between two sample means, x1 À x2.

If your remains because torso skin laxity also occurs in the vertical hanging panniculus is symptomatic for recurring chronic direction order viagra plus with a mastercard, which is not fully treated cheap viagra plus 400 mg overnight delivery. Considerable judg- rash or infections or chronic disabling back ache buy viagra plus 400 mg on line, then our ment is used to achieve the optimum shape and skin turgor order viagra plus master card, office is likely to help you obtain some financial relief. At times, Financial Responsibilities it is desirable to perform additional procedures to improve The cost of surgery involves several charges for the services your appearance which may increase your costs. Hurwitz, Complications of Anesthesia: Both local and general anesthe- the hospital, anesthesia, laboratory tests, and possible sia involve risk, which will be discussed by your anesthe- outpatient hospital charges, depending on where the sur- siologist on the day of surgery. Depending on whether the cost of Plastic Surgery in Massive Weight Loss Patients 433 surgery is covered by an insurance plan, you will be 4. I acknowledge that no guarantee has been given by anyone responsible for necessary co-payments, deductibles, and as to the results that may be obtained. I consent to the photographing or televising of the complications develop from the surgery. Secondary sur- operation(s) or procedure(s) to be performed, including gery or hospital day-surgery charges involved with revi- appropriate portions of my body, for medical, scientific, sionary surgery would also be your responsibility. For purposes of advancing medical education, I consent to Informed consent documents are used to communicate informa- the admittance of observers to the operating room. I consent to the disposal of any tissue, medical devices, or condition along with disclosure of risks and alternative forms body parts which may be removed. I authorize the release of my Social Security number to define principles of risk disclosure that should generally appropriate agencies for legal reporting and medical meet the needs of most patients in most circumstances. It has been explained to me in a way that I understand: sidered all inclusive in defining other methods of care and a. There may be alternative procedures or methods of additional or different information which is based on all treatment. Informed consent documents are not intended I consent to the procedures and the above listed items to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are sub- ject to change as scientific knowledge and technology References advance and as practice patterns evolve. American Society of Plastic Surgeons Procedural statistics (2006) It is important that you read the above information care- Body contouring after massive weight loss, www. National Institutes of Health (1998) Clinical guidelines on the iden- tification, evaluation, and treatment of overweight and obesity in I have received, read, and given ample opportunity to adults: the evidence report. I recognize that during the course of the operation and (2008) Will all Americans become overweight or obese? Data obtained from American Society for Metabolic and Bariatric ered necessary or advisable. Ann Plast Surg 21(5):472–479 band placement: influence of time, weight loss, and comorbidities. Int J condition and quality of life in patients with morbid obesity before Adipose Tiss 1:5–11 and after surgical weight loss. Plast Reconstr Surg 82(2):299–304 weight loss and mortality in the severely obese. Pitanguy I (1971) Surgical reduction of the abdomen, thigh, and 1028–1033 buttocks. In: Peter Rubin abdominal laxity after massive weight loss: reverse abdominoplasty J, Alan M (eds) Aesthetic surgery after massive weight lost. Strauch B, Herman C, Rohde C, Baum T (2006) Mid-body contour- pp 37–48 ing in post-bariatric surgery patient. Lockwood T (1995) High-lateral-tension abdominoplasty with breast reshaping: the spiral flap. Hoy 1 Introduction 2 Anatomy and Consequences of the Aging Process One of the most common age- and obesity-associated body contour problems is upper arm skin laxity. This Glanz and Gonzalez-Ulloa described the development of the upper arm lipodystrophy tends to be especially pro- ptotic, aged upper arm with attenuated soft tissues and sag- nounced in female patients. The so-called “batwing” ging and descent of the nadir of the posterior arm curvature deformity is characterized by an unsightly development of [1]. But other authors have pointed out that most patients loose hanging skin of the posterior arm and is frequently would prefer the contour deformity associated with upper accompanied by excess adipose tissues as well. With the arm adiposity and skin excess over the long scar of a brachio- increase in frequency of bariatric procedures, body con- plasty [2]. However, those patients who are especially both- touring, including brachioplasty, has been also increasing. Indeed, most other body contouring problems are far more favorably camouflaged by warm weather clothing than the 3 Preoperative Planning upper arm “batwing” deformities. Even though brachioplasty (also referred to as upper In addition to a systematic approach to presurgical exami- arm dermatolipectomy) typically provides reliable long- nation of these patients, a series of photos and an exam in term correction of these problem areas, the resulting scars front of a large mirror are vital in evaluating and instruct- are some of the greatest disincentives for patients contem- ing prospective patients in what to expect from their bra- plating the procedure. Preoperative photographs should though hidden when the arms are positioned by the side, include the standard anterior-posterior, oblique, and lat- they can draw attention in poses with the arms abducted. A dynamic exam in front outcome by both minimizing scar hypertrophy and expe- of a large mirror should help educate the patient and sur- diting scar maturation. These images should be printed and readily available dur- ing the surgical procedure for easy reference, as the anat- R. Hoy tissue of the posterior arm, and the areas of planned resec- 5 Refining Approaches to Brachioplasty tion are tentatively marked. Typically, the incision place- ment will vary slightly as the flap is tailored on the The first aesthetic brachioplasty technique was published in operating table. Because Initial physical exam should concentrate on determina- patients had unacceptable cicatrical contractures, especially tion of asymmetries. An elliptical dermatolipectomy is in the axilla, subsequent authors sought to modify the proxi- always necessary and the distal apex in most cases can be mal extent of the scar. Previously described Z- or W-plasties limited to the distal upper arm, not crossing the elbow. The dorsal or following table illustrates various researchers’ technical con- inferior edge skin over the triceps muscle is typically much tributions and is modified from Pinto et al. Stretch marks which notoriously plague this inner Contemporary surgeons are increasingly adept at incor- arm region should be eliminated to the greatest extent pos- porating the brachioplasty as part of an upper-body rejuvena- sible. We begin marking by pulling in an inferior direction tion in the massive weight loss patient [12 – 14]. In fact, the on the lax soft tissues of the extended medial upper arm combination of brachioplasty with upper-back resection, and with the patient in the standing position. A lengthwise mark breast reconstruction, is now considered an upper-body lift is made while exerting this pull from just proximal to the [4, 15], which is analogous to the more common lower body elbow to the axilla. In a thorough analysis of their prospective registry of axillary skin is then pulled from the lateral edge of the pec- body contouring patients, Gusenoff and colleagues [14] toralis major in a posterior direction and brought as far found that patients who had experienced massive weight loss anteriorly as possible while allowing concealment within required longer, more extensive procedures and had more the axilla and then a right angle line continued in the midax- wound healing problems, but that the complications more illary line. Some patients present with complaints of xylocaine with epinephrine along the anterior longitudinal upper arm fullness, but may have good skin tone and rela- marking. Approximately 30 cc per arm is used to then inject tively little excess adiposity of the posterior upper arm. Incision is made under full These patients, especially younger patients with preserved epinephrine effect (Fig. Bovie dissection is used initially elasticity of the dermis, may respond better to upper arm until the muscular fascia is reached. This technique will not be supramuscularly, a plane which is surprisingly loose, and addressed in depth in this chapter, as it is not applicable as this maneuver easily separates the tissues to be eliminated a single technique for addressing more severe adiposity and from the underlying muscle fascia. This picture is often seen in states of obesity, encountered in this dissection unless the muscle fascia is or as one of the sequelae of significant weight loss. Small vessels and cutaneous nerves patients, both fatty tissues and skin need to be resected, 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.

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