By F. Irmak. Westmont College. 2019.

By rotating the kymograph drawn at a known speed order 50mg dramamine otc, Drake obtained a trace of voided urine volume against time order online dramamine. He calculated the maximum urine flow rate by a measurement of the steepest part of the volume–time curve buy dramamine master card. It is evident from his description that the apparatus was relatively crude and difficult to use cheap 50mg dramamine mastercard. Kaufman [7] commercially produced a modification of Drake’s flowmeter that was more refined but similarly made no direct recording of flow rate. The advent of electronics in medical instrumentation allowed the mass production of accurate and reliable recording devices. Von Garrelts [8] designed the first of the electronic urine flowmeters, which consisted of a tall urine-collecting cylinder with a pressure transducer in the base. The pressure transducer measured the pressure exerted by an increasing column of urine as the patient voided. Since a direct relationship existed between the volume voided and the pressure recorded, von Garrelts was able to produce a direct recording of urine flow rate by electronic differentiation with time. In 2016, it is 39 years since it was determined that uroflowmeters of acceptable accuracy were available [9]. The current accuracy of modern uroflowmeters is around ±2%–5%, despite the fact that a variety of different physical principles are currently used. Voiding time (second): This is the total duration of micturition, which includes interruptions. When voiding is completed without interruption, voiding time is equal to flow time. Time to maximum flow (second): This is the elapsed time from the onset of urine flow to maximum 835 urine flow. Easy to clean There have been many methods used for urine flow measurement, from measuring the time to void a given volume through audiometric and radioisotopic methods to even include high-speed cinematography. The most common method has been that of Drake [6] modified by von Garrelts and Strandell [11]—the measurement of urine weight. In addition, flowmeters have been produced that use the principles of air displacement, differential resistance to gas flow, electromagnetism, photoelectricity, electrical capacitance, and a rotating disc. Flowmeters employing the principles of weight transduction, a rotating disc, and a capacitance transducer are the best known and the most completely tested and validated of the flowmeters available. The rotating disc flowmeter depends on a servometer maintaining the rotation of the disc at a constant speed. Urine hits the disc, and the extra power required to maintain the speed is electronically converted into a measurement of flow rate. The transducer is in the form of a dipstick made of plastic and coated with metal, which dips into the vessel containing the voided urine. For clinical purposes, the measured and indicated flow rate should be accurate to within ±5% more than the clinically significant flow rate range [12]. The capacitance (dipstick) flowmeter is the least expensive to buy and has the advantage of no moving parts, which means mechanical breakdowns are eliminated. Automatic start and stop facilities in some modern flowmeters assist by minimizing patient and staff involvement during the uroflowmetry (Figure 53. It is essential in the clinical situation that every effort is made to make the patient feel comfortable and relaxed. If these requirements are ignored, psychological factors are introduced and a higher proportion of patients will fail to void in a representative way. Ideally, all free uroflowmetry studies should be performed in a completely private uroflowmetry room/toilet, lockable from the inside, and out of hearing range of other staff and patients. As crouching over a toilet seat causes a 21% reduction in the average urine flow rate [13], patients should be encouraged to sit to void. When video studies are combined with pressure–flow recordings in a radiology department, up to 30% of women may fail to void. Patients should be encouraged to attend for uroflowmetry with their bladder comfortably full. It is desirable that the measured urine flow rates should be for a voided volume within the patient’s normal range. This range can be determined if, in the week before the flow study, the patient completes a frequency–volume chart (urinary diary). On this chart, the patient enters the volumes of fluid consumed and the volumes of urine voided. Recent nomograms, however, provide normal reference ranges for urinary flow rates over a wide range of voided volumes. Abnormal or unusual flow curves and urinary flow rates, however, merit repeating the study. The clinical usefulness of flow rates had been attenuated by the lack of absolute values defining normal limits [14]. As urinary flow rates are known to have a strong dependence on voided volume [6,15], these normal limits need to be over a wide range of voided volumes, ideally in the form of nomograms. Studies on normal values for urinary flow rates in women include those of Peter and Drake [16], Scott and McIhlaney [17], Backman [18], Susset et al. Data and/or statistical analysis in these studies has not allowed effective nomogram construction. Study restrictions have included small patient numbers [19–23]; the use of outmoded or less well-evaluated equipment [15–16] and the incompleteness of data at lower voided volumes [15,18] due in part to the inaccuracy of some equipment at lower voided volumes [15]. Each woman voided once in a completely private environment over a calibrated rotating disc-type uroflowmeter; 46 voided on a second occasion. The maximum and average flow rates of the first voids were compared with the respective voided volumes. By using statistical transformations of both voided volumes and urine flow rates, relationships between the two variables were obtained. This allowed the construction of nomograms, which, for ease of interpretation, have been displayed in centile form (Figure 53. The results, after elimination of “abnormal” data, were much slower urine flow rates overall than those in the Liverpool nomograms and an age dependency of urine flow rates, not normally noted in asymptomatic women [15,22,24,26]. Most commonly, a minimum rate of 15 mL per second is quoted for the same parameter if at least 150 mL (or sometimes 200 mL) has been voided. The practice of artificially imposing minimum limits for the voided volume is difficult to justify [27] and very often impractical. Women with certain states of lower urinary tract dysfunction, those in whom the flow rate might be most important, may not be able to hold 200 mL. It has been demonstrated that 838 only 45% of voided volumes are more than 200 mL and 55% are more than 150 mL, making interpretation of fixed urine flow rates valid [28]. Because of the strong dependency of urine flow rates on a voided volume, a normal urine flow rate at 200 mL may not also be normal at 400 mL. A maximum flow rate of 15 mL/s might fall just within the fifth centile curve at 200 mL voided volume, though well below the same curve at 400 mL. The median voided volume of 171 and 175 mL in the aforementioned series [24,28] again highlights the need for normal reference ranges to include data at lower voided volumes. Both the maximum and average urine flow rates in the aforementioned study were found to have a strong and essentially equal dependence on voided volume. However, the centile lines onto which the maximum and average urine flow rates respectively fall for the same voided volume (centile rankings) are not interchangeable in an individual instance due to wide variations in urine flow patterns. The closer the urine flow pattern comes to the “ideal” flow time curve seen in Figure 53. No systematic deterioration of either flow rate at higher voided volumes was discernible from this population study. The same studies also found that there was no significant effect of parity on urine flow rates in normal women. Repeated Voiding There was a remarkable consistency in the centile rankings of the paired first and second voids in the study of Haylen et al. This consistency is further witnessed in the multiple voids from a single 25- year-old normal female volunteer (Figure 53. Clinically, in the majority of normal women, the centile rankings of successive voids will not differ widely.

Initially 50mg dramamine with amex, it was observed that detrusor contraction could be inhibited by pelvic floor muscle contraction that was induced by electrical stimulation [38–40] dramamine 50 mg amex. Then buy dramamine 50mg on-line, in the 1980s dramamine 50mg otc, 644 Burgio and colleagues demonstrated that voluntary pelvic floor muscle contraction can be used not only to occlude the urethra but also to inhibit detrusor contraction [8,20] (see Figure 42. Pelvic floor muscle control and exercise is taught in the same way as it is for stress incontinence. What differs is how women with urge incontinence are taught to use their muscles to manage urgency and prevent urine loss. Using Muscles to Prevent Urge Incontinence: Urge Suppression Strategies Most patients with urge incontinence feel compelled to rush to the toilet to void. This behavior can make incontinence more likely, because it increases intra-abdominal pressure on the bladder and increases the feeling of fullness, and when the patient reaches the vicinity of the toilet, she is exposed to visual cues that can trigger incontinence. Behavioral training teaches patients a new way to respond to the sensation of urge. Although it may seem counterintuitive at first, the urge suppression strategy encourages patients to pause, sit down if possible, relax the entire body, and contract pelvic floor muscles repeatedly to diminish urgency, inhibit the detrusor contraction, and prevent urine loss. After the urge sensation subsides, they are to proceed to the toilet at a normal pace [41]. Detrusor inhibition using pelvic floor muscle contraction can be taught and documented in the clinic. A handout for teaching patients about the urge suppression strategy appears in Figure 42. Patients are then encouraged to practice this urge suppression technique to manage urge and prevent incontinence episodes in their daily lives. The home program for urge incontinence follows the same daily exercise regimen as for stress incontinence. In addition, it is often helpful for women with urge incontinence to practice interrupting or slowing the urinary stream during voiding once per day. Not only does this provide practice in occluding the urethra and interrupting detrusor contraction, it does so in the context of the urge sensation, when patients with urge incontinence need it most. Some clinicians express concern that repeated interruption of the urinary stream may lead to incomplete bladder emptying in certain groups of patients. Therefore, caution is recommended when using this technique with patients who may be susceptible to voiding dysfunction. Behavioral training for urge incontinence has been tested in several clinical series utilizing pre–post designs. In randomized controlled trials using intention-to-treat models, mean reductions of incontinence range from 60% to 80% [20,21]. This urge suppression strategy can be combined with bladder training or delayed voiding as one of several coping techniques that can help patients postpone voiding. Bladder training is a behavioral intervention that was developed to break the cycle of urgency and frequency using consistent, incremental voiding schedules. Bladder drill was an intensive intervention, often conducted in an inpatient setting, in which 645 women were placed on a strict expanded voiding schedule for 7–10 days to establish a normal voiding interval [43,44]. Bladder training is a sequel to this procedure that increases the voiding interval more gradually, over a longer period of time, and is conducted in the outpatient setting [45–55]. This is believed to increase bladder capacity and decrease overactivity, resulting in improved bladder control. To follow this regimen, patients must resist the sensation of urgency and postpone urination. Several behavioral techniques have been used to help patients control the urge to urinate while they wait for their next scheduled void. The traditional approach has been to suggest various techniques for relaxation or distraction to another activity [52]. Patients are encouraged to distract themselves from the bladder by engaging in a task that requires mental but not physical effort, such as reading, calling a friend, or making a to-do list. Self-statements such as “I am in control of my bladder” and “I can wait” are also helpful. Bladder training programs have differed widely in terms of the instructional approach, intensity of clinical supervision, scheduling parameters, strategies for controlling urgency, frequency of schedule adjustments, criteria for increasing the voiding interval, length of treatment, and use of adjunctive treatments. At present, there is no evidence for determining which parameters are most effective. The classic study of outpatient bladder training is a randomized clinical trial that demonstrated a mean 57% reduction in frequency of incontinence in older women [52]. In this trial, bladder training reduced not only incontinence associated with detrusor overactivity but also incontinence associated with sphincter insufficiency, possibly because patients acquired a greater awareness of bladder function or that the exercise of postponing urination increased the use of pelvic floor muscles. A subsequent trial compared bladder training to oxybutynin; 73% of women in bladder training were reported to be “clinically cured” [53]. Identify with the patient the longest voiding interval that is comfortable for her. Patient Instructions: Empty your bladder… First thing in the morning Every time your voiding interval passes during the day Just before bed Teach coping strategies for occurrence of urge. Self-statements (affirmations) Distraction to another task Relaxation Urge suppression strategy (using pelvic floor muscle contraction) Gradually increase interval When patient is comfortable for at least 3 days By 30-minute intervals or clinical judgment based on patient confidence Delayed Voiding Another approach to helping patients to increase control and expand the interval between voids is delayed voiding. Unlike bladder training, delayed voiding does not involve putting patients on a predetermined voiding schedule. Instead, patients are taught urge suppression strategies and instructed to use them when they have an urge to void. When the urge subsides, instead of going to the bathroom immediately, they are encouraged to wait 5 minutes before voiding. Even a mild urge to void can prompt a trip to bathroom in a woman with urge incontinence, due to the fear of urine loss. However, most patients can be convinced to try a 5-minute delay, especially when they are in safe circumstances such as at home alone. Many are surprised to find that even with a brief delay, the urge subsides or disappears altogether. This enhances their sense of control and builds confidence to gradually increase the delay time to achieve a normal frequency. Increasing Voiding Frequency (Timed Voiding) It is quite common for health-care providers to advise patients with incontinence to simply increase their frequency of urination as a way to avoid a full bladder and its increased risk of incontinence. While increased frequency of urination can have an immediate benefit in terms of avoiding incontinent episodes, the long-term result is most likely counterproductive because the patient can lose the ability to accommodate larger volumes and tolerate bladder fullness. In addition, it feeds the cycle of urgency and frequency thought to perpetuate overactive bladder and exacerbate urge incontinence in the long run. Increasing the frequency of voiding is generally reserved for patients who void infrequently (<5 times per day). Often, these patients have never considered voiding more frequently because they do not have an urge to void. It may also be due to dementia or other cognitive impairments in patients who are unable to inhibit bladder contraction and unable to learn new skills for bladder control. A timed voiding schedule can prompt them to void before urgency with leakage occurs. It is possible for many patients to identify times in their day when they are at increased risk of incontinence, for example, 2 hours after morning coffee or during exercise, and they can plan strategic voids before those times. It provides information on the timing of symptoms and events that helps the clinician to understand the type, severity, and circumstances of urine loss and plan appropriate components of behavioral intervention. The diary is less recognized for its value in the treatment phase when it can be reviewed periodically to track the efficacy of various treatment components and guide the intervention. In research, it provides a validated measure of the frequency of voids and incontinence episodes and has also been used to measure the number and severity of urgency episodes. In addition to its value for the clinician, completing a daily diary can have direct benefit to the patient. Its self-monitoring effect enhances the patient’s awareness of voiding habits and patterns of incontinence. It encourages patients’ recognition of how their incontinence is related to their activities, for example, their physical activities or drinking patterns. In particular, understanding clearly the immediate precipitants of urine leakage optimizes the patient’s vigilance and readiness to implement the continence skills learned through behavioral treatment.

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In contrast purchase dramamine 50 mg amex, according to Nichols and Genadry [17] buy dramamine with paypal, a pulsion enterocele is secondary to increased abdominal pressure discount dramamine 50mg visa, whereas Zacharin states that a pulsion enterocele occurs as a late complication of pelvic surgery like hysterectomies and is associated with a large rectovaginal pouch [28] order dramamine 50 mg online. However, Zacharin is convinced that the depth of the pouch of Douglas has no bearing on enterocele development. He considers levator incompetence and relaxation of the fascial support to be the primary defects. Nichols and Genadry describe iatrogenic enteroceles as a sequela to operations that alter the vaginal axis like Burch colposuspension and congenital enteroceles, which are associated with an “unusually” deep pouch of Douglas (Figure 83. In theory, an enterocele can only develop when important anatomical factors change: the vagina becomes more vertical and the (deep) pouch of Douglas opens or the pubocervical and rectovaginal fascia are separated. Whether a discrete defect in the endopelvic connective tissue is also required remains a topic for discussion. Therefore, Zacharin’s observation of a common deep pouch of Douglas found only in Chinese females corroborates the ones mentioned earlier: their pelvic floor status including tone and support prevents an exposure of the rectovaginal pouch. Rectal Prolapse Colorectal surgeons view prolapse with a different attitude but have similar problems defining the pathophysiology of rectal prolapse, which might originate from the pouch of Douglas [30]. Altemeier described three types: type 1 is a false prolapse due to mucosal redundancy, type 2 is an intussusception without an association with the pouch of Douglas, and type 3 is a sliding hernia of the rectovaginal pouch [31]. Enteroptoses, or elongation of the rectosigmoid colon, are considered contributing factors [32]. Similar to vaginal enteroceles, type 3 rectal prolapse develops in the pouch of Douglas and basically is an enterocele bulging into the rectum, sometimes termed anterior rectal wall prolapse (Figures 83. Further Factors Old textbooks often quote other factors that might contribute to enterocele formation. Apart from established confounders for pelvic organ prolapse like aging, obesity, and constipation with excessive defecatory straining, connective tissue diseases, parity, and malnutrition especially in war times are also mentioned [33]. Obesity and constipation have been established as risk factors for pelvic organ prolapse [35–37]. A chylous ascites has been described to accentuate pelvic floor defects and cause an enterocele [38]. The classical example is the development of enteroceles after Burch colposuspension in up to 32% [39–41], which has not been described for suburethral tapes. It has also been recognized that enteroceles and rectal prolapse frequently coexist with other defects of pelvic floor support [42–44]. In a prevalence study of 639 women aged 45–85 years using the pelvic organ prolapse quantification of the International Continence Society, only 22% had no prolapse at all, 37% had stage 1, 29% had stage 2, 9% had stage 3, and 3% had complete eversion [45]. Unlike a cystocele or rectocele, an enterocele does not appear to cause any stereotypical and pathognomonic symptoms, and very often symptoms cannot be distinguished from those of any coexisting pelvic organ prolapse. Some women primarily complain of rectal symptoms like fullness and 1272 incomplete or difficult bowel emptying; however, in others, the prolapse symptoms are predominant [46]. Anorectal symptoms and degree of posterior prolapse do not seem to correlate [47,48]. Partial or complete obstruction of the urethra might result in voiding difficulties or retention [49,50]. Dyspareunia, “slackness at intercourse,” vaginal dryness, and coital incontinence are frequently reported by women with pelvic organ prolapse [51]. Mainly, a complication of previous pelvic floor surgery and hysterectomy, vaginal rupture, and evisceration has been reported in women with enteroceles [52]. Defects in the endopelvic connective tissue and their location with diminished vaginal rugae are a clue (Figure 83. Simultaneous bimanual examination of the tissues between the vagina and rectum under straining or in the standing position usually helps. An enterocele can be located in the anterior vaginal wall where it divides the pubocervical fascia in the posterior vaginal wall through the pouch of Douglas or it might separate the anterior and posterior endopelvic fascia at the vaginal vault (apical enterocele). Occasionally, peristalsis of the intestine bulging into the vagina establishes the diagnosis. If in doubt and a diagnosis is necessary, intraoperative evaluation during dissection will ascertain the presence or absence of an enterocele. However, perineal ultrasonography has gained popularity and has become the investigation of choice. Perineal ultrasound may depict an enterocele [53], especially when performed in an upright position. In a different patient, bulging into the rectum is also noted, explaining the patient’s evacuation problems (Figure 83. Although limited in the evaluation of structures located more proximally, it may provide information on endopelvic connective tissue defects and pelvic floor dynamics (Figures 83. But even with conventional 2D perineal ultrasound, an enterocele can be identified. Rectal ultrasound can also be helpful; sonographic diagnosis of an enterocele was confirmed intraoperatively in 27 of 29 cases in one study [56]. Viscerography or fluoroscopic imaging includes the opacification of the bladder, rectum, and vagina with contrast medium. Ideally, the investigation is performed dynamically during straining or coughing and comprises defecography. It will also provide further 1273 information on bowel emptying, rectal prolapse, or intussusception [47,57] although there are great variations of “normal” findings. It is therefore most valuable when the clinician performs the radiological investigations and interprets the findings in context with the symptoms. Defecation in this situation might be impossible for some patients, and for the diagnoses of enteroceles, it may be inferior to defecating fluoroscopy studies [59]. However, the pictures obtained are remarkable and usually provide an accurate diagnosis (Figure 83. Controlled studies assessing prevention of enteroceles are scarce but support modified McCall sutures with reattachment of the uterosacral ligaments to the vaginal vault during hysterectomy [61]. At the time of hysterectomy, Cruikshank and Kovac compared three available methods to prevent an enterocele in a randomized controlled trial [62]: obliteration of the pouch of Douglas by suturing the uterosacral ligaments in the midline, called the vaginal Moschcowitz-type operation; the McCall-type culdoplasty, where the uterosacral ligaments are plicated and attached to the vaginal vault and the sutures externalized; and the closing of the peritoneum with a purse-string suture. Up to 3 months 1274 postoperatively, all procedures were equally successful (100%). After 3 years, the McCall-type method was found to be superior for enterocele prevention with none of the 32 patients developing a symptomatic enterocele [62]. The prevention of an enterocele after a Burch colposuspension with or without additional pouch of Douglas obliteration by either approximation of the uterosacral ligaments or Moschcowitz-type horizontal purse-string sutures was reported recently [39]. Without Douglas obliteration, postoperative enterocele formation after 3–16 years (mean 9 years) occurred in 19%, whereas after the additional Moschcowitz procedure the incidence was 11% and after uterosacral ligament plication 2%. Whether extensive distal preparation of the bladder during abdominal hysterectomy with exposure of the pubocervical fascia might contribute to the development of anterior enteroceles is unclear. Also, the utilization of intrafascial hysterectomy might be of value but this has not been assessed systematically. During intrafascial hysterectomy, parts of the endopelvic fascia are maintained in their normal position and plicated over the vaginal vault to prevent separation and subsequent enterocele formation. As subjective and objective success and durability of our current surgical prolapse repairs remain limited and the women’s longevity is increasing, more patients might ask for conservative options. Conservative treatment of 1275 pelvic organ prolapse in general includes the use of pessaries [63] and pelvic floor muscle training [64]. Vaginal pessaries might prevent deterioration of the prolapse and alleviate symptoms of prolapse and are especially useful if there is a long waiting list for surgery [63]. There is an extensive range of mechanical devices available to reduce the prolapse, but literature on success and complications is inadequate especially if isolated enteroceles are considered. Pessaries are an option, and a trial of pessary fitting can easily be performed in clinics and can be managed by educated nurses or continence advisers. In a comparative study, pessaries alleviated pelvic floor symptoms similarly to prolapse surgery [63]. Dissatisfaction with pessary treatment was associated with the development of occult stress urinary incontinence [65]. The failure rates are high if there is insufficient pelvic floor support present and an additional solid repair is omitted.

The latter has as its upper limit the costal arch generic dramamine 50mg without a prescription, as lower limit a transverse line passing through the anterior superior iliac spine dramamine 50 mg without prescription, and as medial limit the lateral margin of the rectus abdominis muscle generic dramamine 50mg online. The venous blood flow is ensured by superficial epigastric veins generic dramamine 50mg line, tributaries of the femoral vein, the thoracic and axil- lary veins, and superficial venous branches of the last inter- costal veins, the lumbar veins, and the external pudendal vein. The large network of anastomoses between the superfi- cial and deep circulation, the knowledge of abdominal vas- Fig. Huger cular areas, and their appreciation during surgery allows one to perform large detachments in relative safety. The abdominoplasty determines an alteration in the lymphatic system, especially at the groin and subumbilical level, which can cause the onset of a postoperative seroma; however, tar- geted maneuvers of the technique can decrease the occur- rence of this complication [17, 18, 20 ]. For this reason it is essential for the • Zone 2: The blood supply derived from the branches of the success of the surgical procedure to search for any imperfec- superficial and deep circumflex iliac arteries and branches tions during the preoperative evaluation of the various units of the pudendal external artery. The superior limit is a of the abdominal region, in order to implement a modulated Aesthetic Abdominoplasty 329 represented by the umbilical scar, and for this reason the skin and subcutaneous tissue in this area are characterized by an almost entirely absent mobility on deep layers. In young and slim women, the umbilicus resembles an oval-shaped depression with a vertical major axis. It is located on the median xipho-pubic line at a variable distance, between 10 and 15 cm, from the top edge of the pubic region. This distance must be carefully measured and recorded, together with the marking of xipho-pubis line, preoperatively and intraoperatively, to perform a correct repositioning. It should be noted that, as the navel is the only point of reference of the entire abdominal region, any imperfection (congenital, acquired, iatrogenic) will lead, inevitably, to a significant alteration of the harmony not only of the aesthetic unit itself but also the entire abdominal region. From the aesthetic point of view, one can identify the ponent, which is quite mobile on the deep structures and following areas or units in the abdomen. This area is limited superiorly by the sternal xiphoid process Consequently, major aesthetic alterations of the entire and the costal arch, laterally by the lateral margin of the rec- abdominal region are concentrated in this area. The superior the deep planes, and is organized to form a single layer and limit is the costal arch, the medial limit is the lateral margin the presence, in normal-weight subjects, of a slight depres- of rectus abdominis muscles, and the lower limit an oblique sion on the skin surface relative to the surrounding planes, on line which, starting from the anterior-superior iliac spine, the median line corresponding with the linea alba. The fatty components are charac- terized by a discrete mobility on deep planes and are orga- 4. It is bilical region medially, while laterally it closely adheres to limited superiorly by the line passing through the lower edge the iliac crest. This area plays a key role, especially in of the last ribs, laterally by the lateral margin of the rectus women, in the definition of an “ideal” body profile. In abdominis muscles, and inferiorly by a transverse line women, in fact, the margin of the side draws a concavity passing through the anterior superior iliac spines. This line below the rib cage that suddenly changes in convexity at the represents the maximum circumference of the abdominal iliac crest, while medially it presents in the pararectal region region. Nisi 5 Selection and Evaluation of the Patient The main indication for abdominoplasty is represented by the correction of excess skin and fat of the abdominal region with or without skin and/or muscle wall laxity. In fact, there are many variables that, individually or synchronously, form the basis of changes in the aesthetic “ideal” of the abdominal region: • Age • Pregnancies • Changes in weight • Changes in posture • Past surgeries These changes can affect the skin-fat component, the Fig. In our clinical practice we prefer to distinguish various degrees of abdominal alteration in relation to the location and extension, with or without associated musculofascial laxity (Figs. In addition to a careful physical examination of the abdominal region, the clinician must perform a detailed clinical history of the patient and appropriate laboratory investigations (complete blood count, evaluation of liver and kidney function, lipids, coagulation, and electrolytes). Furthermore, it is important to submit the patient to X-ray control of the lung parenchyma to exclude the presence of pathology. In the case of significant diastasis of the abdomi- nal musculature and/or the presence of hernia or incisional hernia, it is very important to consider a preoperative study of lung function, which can be greatly affected by the increase in intra-abdominal pressure in the postoperative period plication result of a possible hernioplasty, or of a simple plication of the rectus abdominis muscles. Furthermore, blood values are to be taken into consideration in cases of patients with particularly low hemoglobin values and/or to be subjected to important dermoadipose removals, for which it is mandatory before surgery to organize a series of blood samples for use in the postoperative period if a blood transfusion is necessary. It is significant musculofascial laxity also very important to detect the anthropometric data of the • Grade V: The panniculus extends to the knee with patient, paying particular attention to body mass index which important musculofascial laxity can be, as reported in the literature, a reliable predictor of surgical risk [21]. In our clinical experience the importance Of course, as regards the abdominoplasty with only of assessments has been underlined by the use of a special aesthetic purposes, the indication for surgery is reserved for checklist that allows all health practitioners involved to ver- patients with distinct obesity of first and second degree. As with all surgical procedures, before planning an abdominoplasty it is necessary to make a careful analysis of 6 Photographic Acquisition the patient’s general condition, in addition to cessation of smoking at least for 2–3 weeks before surgery and stopping The iconographic acquisition also plays a fundamental role any pharmacological treatment (nonsteroidal anti- because with it, the surgical team can investigate and inflammatory drugs, oral contraceptives) from 10–14 days re-evaluate the clinical situation and the operative strategy, before surgery. In addition, it plays an important role in medico- fying and marking the landmarks useful for planning the legal terms. Particular attention should be paid to reporting any are acquired with a standardized method to obtain compara- scarring of the pelvic or abdominal area and the presence of ble iconography before and after surgery, and to promptly palpable swellings. In the orthostatic position, asymmetric place and precisely highlight the anatomical region of the distribution of abdominal adipose tissue and changes in surgical object, limiting to a minimum discrepancies and the level of the umbilical scar are also evaluated. Specifically for the abdominal patient in the supine position, the examiner palpates the region, the patient should be placed, completely naked and abdominal region with the abdomen relaxed (palpation barefoot, in the center and near the wall area chosen as static) or by running sequential contractions of the abdomi- background (preferably dark colored so as to highlight the nal muscles through coughing (dynamic palpation), which profile body and minimize any glare light), and the surgeon allows better evaluation of the “possible” presence of mus- must be positioned at a distance of 1. The patient’s positioning is fundamental to obtaining a com- prehensive and accurate acquisition of the abdominal region and, in particular: 7 Informed Consent • Frontal position: The patient is placed in front of the lens Proper administration of an informed consent to the patient with arms crossed behind the back (Fig. It must be precise, complete, and comprehen- should be folded behind the back and the patient laterally sive, and has to be administered to the patient within an ade- rotated by 90° from the front (Fig. It is necessary that it • Semi-lateral left and right position: In this position the contains the master data of the patient, the diagnosis, the arms should be folded behind the back and the patient type of surgery proposed with its description, the type of laterally rotated by 45° from the front (Fig. It is essential that the agreement has to be drawn up with common terms, supported by the equiva- lent strictly medical terminology in brackets, so as to be readily understandable by the patient. It must also not be merely delivered, but has to be read and discussed with the patient, well in advance of surgery, to settle any doubt or misunderstanding and to allow the patient to peacefully decide whether or not to undergo the surgery procedure. It must be signed by the patient or legal guardian, where required, and countersigned by the doctor who administers and (this is not strictly necessary but desirable) by at least one witness. In particular, the patient should stop taking oral contraceptives and drugs contain- ing acetylsalicylic acid, and smoking at least 2 weeks before the scheduled date of surgery. The night before sur- gery, the patient can safely eat dinner while in the morning of the day of the operation he or she must remain on an Fig. A upper limit empty stomach to avoid the possibility of “ab ingestis” of umbilical scar, B anterior superior iliac spine; C upper limit of pubic pneumonia as a result of anesthetic and/or intensive care region, D xipho-pubic line procedures. For the same reason, on the morning of surgery the patient must suspend drugs for oral intake and if sus- pension is not possible or contraindicated, the administra- quadrants, too difficult to tackle using a single transverse tion will continue intravenously. In most patients, then, and in case of an abdomi- the surgery the patient must be subjected to trichotomy of noplasty for purely aesthetic purposes, we opt for the sin- the pubic region and must begin to wear compressive gle transverse incision. In our clinical practice we prefer stockings of the lower limbs and the subcutaneous admin- to orient the choice of the skin incision according to istration, according to weight, of low molecular weight Grazer, which allows the removal of dermo-adipose excess heparin to minimize, together with the early mobilization with a residual low scar and therefore is easily of the patient in the postoperative period, the possibility of concealable. Furthermore, one must iden- before surgery or before the execution of the preoperative tify and mark the following landmarks: drawings, and must remove nail polish from hands and feet, any gold jewelry (rings, necklaces), piercings, and • Anterior-superior iliac spines to evaluate the lateral extent dental implants. This is gery, and is modulated and performed on the basis of clini- needed to highlight any asymmetries of the dermo- cal evaluation and the choice of type of incision, which adipose component, and is essential for the correct repo- can be exclusively transverse or transverse and vertical. The This last type of incision is to be reserved for patients with upper incision line can be identified, at the time of the pre-existing xipho-pubic scars from previous surgery or drawing, by running a series of pinch tests taking as a when the patient has experienced a massive weight loss as fixed point the lower incision line, and will then be re- a result of diet therapy or bariatric surgery, which presents evaluated, intraoperatively, at the time of removal of the significant dermo-adipose excess localized in lateral excess dermo-adipose portion (Figs. The surgical procedure starts with the execu- tion, following the preoperative drawing, of the skin incision with the use of a paunchy lancet (No. During the dissection, particular attention should be possible tension), the placement of the catheter, the disinfec- paid to the isolation and the coagulation or ligation of perfo- tion of the surgical area with iodine-povidone-based solu- rating arteries, which come through the fascia to the subcuta- tion, and the preparation of the operating field with sterile neous tissue and skin of the abdominal region; if cut too drapes (Fig. At the time of induction, we perform the close to the muscle fascia these vessels may retract, making antibiotic prophylaxis with intravenous infusion of it difficult to perform a correct hemostasis and requiring semi-synthetic penicillins or third-generation cephalosporins opening of the same muscular fascia for their retrieval and (in case of allergy we proceed with the administration of coagulation. In addition, particular attention should be paid Aesthetic Abdominoplasty 335 Fig. The abdominal flap is pinched at its median end by two Kocher clamps, replaced on the abdominal wall, pulled in a craniocaudal direction, and divided in half by a vertical incision starting at the lower portion of the future periumbilical incision (Fig. At this point, the surgeon proceeds with the detachment of the umbilical scar from the surrounding skin. In our clini- cal practice this is done by lifting the upper and lower umbil- ical apex with two Gillies hooks and performing a periumbilical incision in a shield shape; this allows the neo navel, once repositioned, to retrieve its natural shape with greater vertical axis; subsequently the navel is isolated from adipose tissue without, however, proceeding to excessive skeletonization (Figs. Once the dissection is performed, with particular atten- tion to hemostasis, the surgeon proceeds to the next surgical stage represented by the plication of the abdominal wall car- ried out by plication of the rectus and oblique muscles. We start by identifying and marking the medial margin of the rectus abdominis muscles; this emphasizes the muscular diastasis, if present, and identifies the edges of the muscle Fig. The rectus the incision that divides the flap vertically muscle plication is performed by placing separate stitches 336 C.

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