By O. Iomar. Westfield State College. 2019.

Standardizing procedures where possible and taking stock of where and when adverse events and near misses may occur facilitate error prevention or mitigating their effect buy eldepryl 5mg free shipping. Establishing effective systems for reporting errors and adverse events further optimizes the ability to track them and opportunities to learn from them cheap 5mg eldepryl fast delivery. An organization’s culture of safety is the product of individual and group values cheap eldepryl online mastercard, skills, and behaviors that shape an organization’s commitment to and proficiency of their own safety programs [33]. A simple way to think about culture is “the way we do things around here and why we do them” [34]. Edgar Schein [35] advocated analyzing organizational culture at three levels to better understand shared basic assumptions and the processes by which they came to be. He asserted that the knowledge gained could then be used to facilitate organizational culture change as needed. The first level is comprised of observable behaviors that are evident in the workplace; the second level consists of the beliefs and values espoused by members within the organization; and the third level, perhaps the most important, consists of the basic underlying assumptions that may be taken for granted, are largely subconscious, and are not verbalized. According to Schein, these underlying assumptions may best inform why things unfold within an organization the way they do. For example, moving from a culture of shame and blame to one that is nonpunitive yet preserves accountability can provoke high anxiety for members in the organization and present challenging obstacles and consumption of valuable resources, especially the element of time. Establishing a safe and just culture is not an easy task and cannot be mandated [34]. Moving toward a culture of safety takes time, and incremental steps are needed to facilitate and solidify the change if it is to be longlasting. Transparency, professional responsibility, mutual accountability, and nonnegotiable mutual respect are among the key elements of a systems approach to error management [36–38]. Individual health-care providers are responsible for ethical practice, clinical competency, and mindfulness in the provision of safe patient care. Not all human errors result in adverse events, events that unexpectedly result in death, injury, extended hospital stay, or disability. Understanding how and why errors and adverse events occur provides a road map by which to obviate them. The study of human fallibility and the science behind why errors happen and how to mitigate and prevent their occurrence are encompassed by the field of human factors. Much has been written about human factors and their contribution to errors in the military and aviation and nuclear industry [39–41]. Human factors involve the interactions among humans and elements in their systems and the application of theory, principles, data, and methods designed to prevent error and optimize human and system performance. According to Catchpole [44], tremendous progress has been made over the past decade in the degree to which health-care providers have become aware of the role and value human factors can play in achieving better and safer human-centered health-care systems. The limitations of being human in combination with certain features of clinical practice within which health-care providers work often create challenges for delivering safe, high-quality care. Veltman [45] highlighted several clinical practice–related issues and inherent demands that weaken defenses to error and contribute to perinatal harm. These practice-related issues and demands, expanded from those of Veltman, are applicable to the field of surgery regardless of the specialty and locus of surgery-related activities, whether inpatient, outpatient, or office based (see Tables 10. They stress that the science of human factors does not promise instant solutions for improving healthcare. However, the partnership of human factors professionals with health-care professionals can generate relevant and long-term solutions designed to systematically address clinical practice–related issues and strengthen clinicians’ defenses to error, thereby facilitating patient safety and quality of healthcare. Process and procedures Adequacy of notes and management plan Consent and preparation Anesthetic procedures Operative events Blood loss Major and minor complications Error compensation and recovery Flow of information following patient Adequacy of notes and consent Specific intraoperative communication Handover Technical skills Ratings of good general surgical practice Ratings of operation-specific steps Identification of specific technical errors Team performance and leadership Leadership Team coordination Willingness to seek advice and help Responsiveness and flexibility Decision-making and situation awareness Patient limitations Operation limitations Surgeon’s limitations Team limitations Operative environment Availability and adequacy of equipment Availability of notes, records, etc. Noise and lighting Distractions Interruptions Phone calls, messages, events external to operating room Source: Modified from Vincent C et al. Of 444 surgical claims reviewed, 258 (58%) were confirmed as being due to surgical error. The majority (76%) were elective procedures involving the gastrointestinal tract (29%), spinal and nonspinal orthopedic procedures (24%), hysterectomies (7%), and the genitourinary tract (5%). The severity of the injury was deemed significant (temporary major, permanent minor, and permanent significant injury) in 55% and major (permanent major and permanent grave injury) in 10% and resulted in death in 23%. Most (54%) surgical injury–related cases were due to errors in operative technique, in which most (83%) involved more than one clinician. Surgical injury–related cases were analyzed for factors contributing to the occurrence of the error. These contributing factors included cognitive errors involving judgment (66%) or failure of memory or vigilance (63%), lack of technical competence or knowledge (41%), or communication breakdowns (24%) such as inadequate handoffs, unclear lines of responsibility, or conflict among personnel. Patient factors such as excess weight, difficult or unusual anatomy, and behavioral issues also contributed to the occurrence of surgical error. Other system factors contributing to surgical error included lack of supervision (18%), failed technology (15%), and excessive workload/inadequate staffing, fatigue, interruptions/distractions, and issues related to lighting or setup. Overall, 82% of cases involved system factors, human factors that are not cognitive related. Although data were limited to closed malpractice claims and overrepresented academic medical centers, their analysis characterized how human factors contribute to the occurrence of surgical error and can help to identify strategies by which to reduce patient harm. Hierarchical systems Poor teamwork and communication Yielding to patient pressures regarding clinical practice Overconfidence (hubris) Source: Modified from Veltman L, Obstet Gynecol, 10(5), 1146, 2007. The need for patient safety initiatives to be implemented in the outpatient setting was stressed by Bishop et al. National Practitioners Data Bank from 2005 through 2009, involving adverse events in the inpatient and outpatient setting. Of claims paid in 2009, they found that surgical adverse events were most common (34%), followed by diagnosis-related adverse events (21. Whereas in the outpatient setting, diagnosis-related adverse events were most common (45. Adjusting for population growth, they found a 45% increase in the frequency of such surgeries between 1988 and 1998. This analysis was limited to incontinence surgery requiring hospital admission, not accounting for those performed in the outpatient or office-based setting and their associated injuries or adverse events. Gilmour and Baskett [52] in 2005 found a low rate of urinary tract injury (3 per 1000 surgeries) at a benign gynecological surgery in Canada. They found a low rate of urinary tract injury (bladder or ureter), ranging from less than 1 per 1000 (subtotal hysterectomy with or without bilateral salpingo-oophorectomy) to 13 per 1000 surgeries (laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy). Of 634 procedures performed, they found perioperative complications occurred in 5. However, they found no differences in rates of intraoperative complications regardless of the surgical approach.

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With the aid of an end-to-end anastomosis sizer placed in the vagina and the rectum 5mg eldepryl mastercard, the rectovaginal space is identified and entered sharply generic eldepryl 5 mg with visa. This is an avascular space and if one is in the correct plane purchase eldepryl paypal, limited bleeding should occur. Following this, dissection of the bladder off the anterior vaginal wall is performed to the level of the bladder neck. Finally, the mesh is affixed to the anterior longitudinal ligament with two separate sutures of No. Of note, this procedure may also be combined with a vaginal approach to further correct a distal rectocele. One study revealed an improvement from 100% to 88% cure rate for constipation in 24 patients that were prospectively followed and evaluated pre- and postoperatively with standardized questionnaires, defecography, colon transit studies, anorectal manometry, and electrophysiology. This study also showed improvement in symptoms of vaginal bulge from 21% preoperatively to 4% postoperatively. In comparison, two studies showed a modest improvement (<50%) [56] or an increase [60] in the constipation rate (from 22% to 33% after a mean follow-up of 52 months). Reasons suggested for these observations include (1) unselective approach used in offering surgical treatment for persistent constipation [69], (2) retrospective analysis of the data [1], and (3) the possibility that patients with a pathologic transit study might have a less favorable outcome with respect to constipation [55,59]. In addition, the study by Kahn and Stanton showed an increase in rates of incomplete bowel emptying and fecal incontinence (4% preoperatively vs. All bowel function parameters showed improvement with overall patient satisfaction of 97% [61]. Additionally, a prospective study of 60 women who underwent posterior colporrhaphy with or without perineorrhaphy reported significant improvement of subjective bowel symptoms within 3–6 months postoperatively. Bowel evacuation scores improved by 42% and continence by 37% based on a validated questionnaire given pre- and postoperatively [62]. Both subjective and objective outcomes 1295 following repair of the posterior compartment vary due to the various surgical procedures that routinely accompany rectocele repair, making the ability to compare and contrast the current studies difficult. Preoperatively, there was no difference in dyspareunia in both groups, but postoperatively, the prevalence of dyspareunia was significantly lower in the group without posterior repair [63]. De novo dyspareunia rates after levatorplasty have been reported to range from 12. An additional study showed an increased rate of sexual dysfunction (18%–27%) after levatorplasty [60]. The postoperative introital calibers in patients with or without dyspareunia were not different. The reasons for the unexpectedly high rate of dyspareunia in that study are unclear. Site-Specific Rectocele Repair The surgical outcomes after a defect-specific rectocele repair are summarized in Table 84. Anatomic cure rates range from 56% to 100% after a mean follow-up period of 3–18 months. Improvements in constipation were seen in 43%–84% of patients [22,64,67] with de novo constipation rate of 3%–4%; however, Kenton et al. In addition, the lack of a standardized definition of constipation contributes to the difference in constipation rates seen in the literature after rectocele repair. Improvements in the symptoms of manual evacuation was noted in 36%–63% [22,64,67] with a de novo rate of 7% in one study [22]. Most studies report some improvement in dyspareunia after site-specific repair (35%–92%) [22,64–67] (Table 84. The only study where site-specific rectocele repair was not combined with other prolapse or incontinence surgery followed 42 women for a period of 18 months. Improvement in sexual function was reported in 35% and there were no patients who developed de novo dyspareunia [66]. This study showed higher anatomic recurrence rate in the site-specific repair group with similar rates of dyspareunia and bowel symptoms [68]. The results included both anatomic results and subjective condition-specific validated quality of life questionnaires. When compared to the site-specific graft-augmented group, both the traditional colporrhaphy and site- specific rectocele repair were improved (54%) and statistically significant. Also, recurrence of the prolapse to or beyond the level of the hymen developed in 20% of those who underwent a graft- augmented approach, compared to 7. There was no significant difference between the groups in regard to preoperative or postoperative dyspareunia, but improvement in sexual function was noted after rectocele repair, regardless of the technique used [69]. Graft-Augmented Approach The ideal mesh or graft material used to augment repairs of pelvic fascial defects remains elusive. It should be inexpensive and improve recurrence rates, should not be rejected, and should cause no detriment to sexual and bowel function. Anatomic cure rates range from 92% to 100% (12–30-month follow-up) with the transvaginal approach and 89% to 95% (12–29-month follow-up) with the transperineal approach. In the treatment group, a strip of mesh was incorporated into the imbricating endopelvic “fascia” during the midline plication. Thirteen recurrent rectoceles were noted at 1 year follow-up, with no differences observed between the two groups (10% vs. A total of 80 patients were allocated to each group with results reported at 12 months. Subjectively, there were no statistically significant differences between the groups for vaginal bulge symptoms or defecatory dysfunction. The authors concluded that augmentation with porcine submucosal graft was not superior to native tissue repair at 12 months [74]. The use of nonsynthetic grafts may have a lower erosion rate, although this has yet to be confirmed in randomized controlled trials. In a retrospective review by Dwyer and O’Reilly, polypropylene mesh was used as an overlay for repair of large or recurrent anterior and posterior compartment prolapse. Forty- seven women had mesh placed in the anterior compartment, 33 in the posterior compartment, and 17 had mesh placed in the both compartments.

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Bladder dysfunction was attributed to a significant reduction of detrusor contraction power (contractility) with concomitant abdominal straining due to impaired parasympathetic motor innervation [70] generic eldepryl 5 mg visa. Practical application and interpretation of free uroflowmetry results have to follow strict rules generic eldepryl 5 mg without a prescription. Uroflowmetry should always be combined with other clinical tests for the assessment of bladder function/dysfunction or screening of treatment eldepryl 5mg for sale. Good urodynamic practices: Uroflowmetry, filling cystometry, and pressure-flow studies. Recommendations for the urodynamic examination in the investigation of non-neurological female urinary incontinence. Drop spectro-meter: A non-obstructive, non-interfering instrument for analyzing hydrodynamic properties of human urination. Gammie A, Clarkson B, Constantinou C, Damaser M, Drinnan M, Geleijnse G, Griffiths D, Rosier P, Schäfer W, van Maastrigt R; International Continence Society Urodynamic Equipment Working Group. Hydrodynamics of micturition in healthy females: Pressure and flow at different micturition volumes. Uroflowmetry in healthy women: Development and validation of flow- volume and corrected flow-age nomograms. Defining achievable standards in urodynamics—A prospective study of initial resting pressure. Detrusor pressure uroflowmetry studies in women: Effect of a 7Fr transurethral catheter. The influence of a urethral catheter and age on recorded urinary flow rates in healthy women. Urinary flow rate recording: The impact of a single dose of a diuretic on clinic logistics and flow rate parameters. Effects of forced diuresis achieved by oral hydration and oral diuretic administration on uroflowmetric parameters and clinical waiting time of patients with lower urinary tract symptoms. Impact of intravenous furosemide on flow rate characteristics and clinic waiting times. An unusual complication following uroflowmetry: Water intoxication resulting in hyponatremia and seizure. An alternative way of presenting some features of the micturition of healthy males. Maximum and average urine flow rates in normal male and female populations— The Liverpool nomograms. Effect of different sized transurethral catheters on pressure-flow studies in women with 454 lower urinary tract symptoms. Visual assessment of uroflowmetry curves: Description and interpretation by urodynamists. Computerized artifact detection and correction of uroflow curves: Towards a more consistent quantitative assessment of maximum flow. Computerized assessment of maximum urinary flow: An efficient, consistent and valid approach. Urinary symptoms in women with gynecological disorders: The role of symptom evaluation and home uroflowmetry. Voiding dynamics in women: A comparison of pressure-flow studies between asymptomatic and incontinent women. Nonintubated uroflowmetry as a predictor of normal pressure flow study in women with stress urinary incontinence. Urodynamic obstruction in women with stress urinary incontinence—Do nonintubated uroflowmetry and symptoms aid diagnosis? A mathematical micturition model to restore simple flow recordings in healthy and symptomatic individuals and enhance uroflow interpretation. Preoperative urodynamic evaluation may predict voiding dysfunction in women undergoing pubovaginal sling. Normal preoperative urodynamic testing does not predict voiding dysfunction after Burch colposuspension versus pubovaginal sling. Clinical and urodynamic predictors of delayed voiding after fascia lata sub- urethral sling. Neurourological changes before and after radical hysterectomy in patients with cervical cancer. Filling cystometry: The method by which the relationship of pressure and volume in the bladder is measured during bladder filling. Pressure–flow studies of voiding: The method by which the relationship of pressure in the bladder and urine flow rate is measured during bladder emptying. Cystometry aims to evaluate detrusor and urethral function during the storage (filling) and voiding phases of micturition. It is essential that diagnoses made at the time of cystometry are related to the patient’s signs and symptoms and the physical findings at the time of examination. The aim is to reproduce the patient’s symptoms and to quantify the pathophysiological processes, thus providing an explanation of the patient’s problems and an understanding of their implications. Cystometry can also be used for research purposes or to provide objective measurements following particular treatments. The bladder is known to be an “unreliable witness”: urinary symptoms alone do not always allow the correct diagnosis to be made and inappropriate treatment may be given [2–6]. Urodynamics should not be performed without clear indications and a proposed urodynamics question(s) that will be answered by the investigation [7]. Cystometry should be preceded by the completion of a 3-day frequency/volume chart or bladder diary, e. Setting zero at atmospheric pressure: This can be done either prior to inserting the catheters into the patient or after insertion as long as the transducers are open only to the atmosphere. Zero pressure is set when an external transducer is open only to the environment (the other two sides of a 3-way tap are closed) or when the open end of a connected, fluid-filled tube is at the same vertical level as the transducer before insertion into the patient (Figure 32. Calibrating the transducers: They should be calibrated at 0 and +100 cmH O; the bladder (vesical)2 pressure (pves) and rectal or vaginal intra-abdominal pressure (pabd) lines should be in the positive range +5 to +50 cmH O (depending on body position, lying or standing, and body2 habitus); the detrusor pressure (pdet) should be between –5 and +5 cmH O [2 11].

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Organization of the sacral parasympathetic reflex pathways to the urinary bladder and large intestine purchase eldepryl with paypal. The dual sensory and ‘efferent’ function of the capsaicin-sensitive primary sensory neurons in the urinary bladder and urethra buy 5mg eldepryl fast delivery. Clinical studies of cerebral and urinary tract function in elderly people with urinary incontinence generic eldepryl 5mg with amex. Functional magnetic resonance imaging during urodynamic testing identifies brain structures initiating micturition. Naloxonazine and opioid-induced inhibition of reflex urinary bladder contractions. The effect of a low dose of intrathecal morphine on impaired micturition reflexes in human subjects with spinal cord lesions. Effects of tramadol on rat detrusor overactivity induced by experimental cerebral infarction. Tramadol inhibits rat detrusor overactivity caused by dopamine receptor stimulation. Effect of lumbar-epidural administration of tramadol on lower urinary tract function. Safety and efficacy of tramadol in the treatment of idiopathic detrusor overactivity: A double-blind, placebo-controlled, randomized study. The inhibitory effect of opioid peptides and morphine applied intrathecally and intracerebroventricularly on the micturition reflex in the cat. Central delta-opioid receptor interactions and the inhibition of reflex urinary bladder contractions in the rat. Enkephalinergic inhibition in parasympathetic ganglia of the urinary bladder of the cat. Age-associated changes in the monoaminergic innervation of rat lumbosacral spinal cord. Autoradiographic localization of 5hydroxytryptamine1A, 5-hydroxytryptamine1B and 5-hydroxytryptamine1C/2 binding sites in the rat spinal cord. Brain stem influences on the parasympathetic supply to the urinary bladder of the cat. Evidence for involvement of the subcoeruleus nucleus and nucleus raphe magnus in urine storage and penile erection in decerebrate rats. An unexpected association between urinary incontinence, depression and sexual dysfunction. Duloxetine compared with placebo for treating women with symptoms of overactive bladder. Effects of gamma-aminobutyrate B receptor modulation on normal micturition and oxyhemoglobin induced detrusor overactivity in female rats. A double-blind crossover trial of baclofen—A new treatment for the unstable bladder syndrome. Gabapentin: A novel drug as add-on therapy in cases of refractory overactive bladder in children. Micturition in conscious rats with and without bladder outlet obstruction— 371 Role of spinal alpha(1)-adrenoceptors. Spinal and peripheral mechanisms contributing to hyperactive voiding in spontaneously hypertensive rats. Tachykinins as modulators of the micturition reflex in the central and peripheral nervous system. Role of intrathecal tachykinins for micturition in unanaesthetized rats with and without bladder outlet obstruction. Elimination of rat spinal neurons expressing neurokinin 1 receptors reduces bladder overactivity and spinal c-fos expression induced by bladder irritation. Effects of neurokinin receptor antagonists on L-dopa induced bladder hyperactivity in normal conscious rats. Role of supraspinal tachykinins for micturition in conscious rats with and without bladder outlet obstruction. Role of supraspinal tachykinins for volume- and L-dopa-induced bladder activity in normal conscious rats. Efficacy and safety of a neurokinin-1 receptor antagonist in postmenopausal women with overactive bladder with urge urinary incontinence. A multicenter, double-blind, randomized, placebo controlled trial of a neurokinin-1 receptor antagonist for overactive bladder. Efficacy and safety of repeated dosing of netupitant, a neurokinin-1 receptor antagonist, in treating overactive bladder. Bladder dysfunction and parkinsonism: Current pathophysiological understanding and management strategies. On the localization and mediation of the centrally induced hyperactive urinary bladder response to L-dopa in the rat. Dopamine receptor subtypes that induce hyperactive urinary bladder response in anesthetized rats. Brusa L, Petta F, Pisani A, Miano R, Stanzione P, Moschella V, Galati S, Finazzi Agrò E. Central acute D2 stimulation worsens bladder function in patients with mild Parkinson’s disease. Brusa L, Petta F, Pisani A, Moschella V, Iani C, Stanzione P, Miano R, Finazzi-Agrò E. Acute vs chronic effects of l- dopa on bladder function in patients with mild Parkinson disease. Differential gene expression of cholinergic muscarinic receptor subtypes in male and female normal human urinary bladder. Muscarinic receptor subtypes modulating smooth muscle contractility in the urinary bladder. Muscarinic receptors of the urinary bladder: Detrusor, urothelial and prejunctional. Signal transduction underlying carbachol-induced contraction of human urinary bladder. Expression and functional role of Rho-kinase in rat urinary bladder smooth muscle. Functional role of M-2 and M-3 muscarinic receptors in the urinary bladder of rats in vitro and in vivo.

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One should be aware of the amount of ten- variation in the range of wound-healing complication rates sion placed on the dermatoglandular pedicle during nipple exists for multiple reasons discount eldepryl 5mg without a prescription. In vive because of ischemia buy 5 mg eldepryl, the surgeon should consider addition cheap eldepryl 5mg mastercard, there is wide variation of patient populations and converting to free composite nipple grafting intraopera- techniques used in mastopexy and breast reduction. Although grafted nipples have a higher incidence of wound-healing complications are related to excessive ten- projection loss and depigmentation, these sequelae are pref- sion on the closure and can be treated effectively with local erable to frank necrosis. Wound dehiscence or skin necrosis secondary to To avoid nipple–areolar loss, mastopexy and breast reduc- excess tension on the closure is significantly more problem- tion techniques that involve wide undermining of skin flaps atic after revision augmentation mastopexy because of the should not be used in revision cases where the integrity of risk of implant exposure. Blood sup- softened, local flaps composed of scar tissue can be used for ply must constantly be in the surgeon’s mind during all revi- nipple reconstruction, followed by areolar tattooing (Fig. Fat necrosis confounds an early or late result that is not satisfactory to the patient. Mammography interpretation is affected by fat by patient education, accurate diagnosis, careful preopera- necrosis, as it may appear as a solid mass associated with radi- tive planning, skillful technical execution of the primary opaque calcifications. This can usually be done remotely through a to correct an unfavorable result of breast augmentation, mas- pre-existing scar. We prefer to wait 9–12 months before mak- topexy, or reduction can be extremely challenging. Does the patient dislike the breast size, shape, asymmetry, nipple position, inframammary fold definition, 2. One must preoperative planning, with particular attention to how the beware of the patient who is unable to clearly articulate spe- previous surgery might have altered blood supply, is essen- cifically what is displeasing to her about her breasts. It should be routine practice Unsolicited pejorative comments about a previous sur- to study the previous surgeon’s operative report to determine geon may provide insight as to whether the patient is likely 298 J. Interestingly, the necrosis appeared at 14 days postoperatively, Healing by secondary intention at 1 year postoperatively. A similar observation has been result after nipple reconstruction with local flaps and areolar tattooing to be satisfied with revision surgery. It is important to assess Table 1 Reoperation rates: industry core study data for silicone-filled patient expectations and to determine whether these expecta- breast implants tions are realistic and whether they are likely to be met. The 6-year data Mentor Allergan surgeon should help the patient set realistic expectations by Primary augmentation 19. The timing of reoperation is an important clinical deci- sion that requires patience, judgment, and experience. The 4 Implant Malposition importance of delaying reoperation until scars have soft- ened , edema has subsided, skin color has returned to Implant malposition is not infrequently seen following breast normal, and tissues have achieved equilibrium cannot be augmentation. The surgeon should discuss the risks, judgment in planning, inappropriate implant selection, benefits, and possible outcomes of the planned procedure development of capsular contracture, inability of the patient’s with the patient and, if possible, with her significant other. Ideally, implant malposition can be detected at time of augmentation with silicone implants are listed in Table 1 the initial procedure and immediately corrected, although Reoperative Aesthetic Breast Surgery 299 b F i g. Malposition is often multifactorial, may be multidirec- Occasionally, reoperation may be averted by a simple tional, and is influenced by both intrinsic properties of the suture technique that can be performed in the office under implant (dimensions, volume, surface texture characteris- local anesthesia. The needle is then placed Immediate inferior displacement of the implant can result back through the second stab incision and passed subcutane- from pocket overdissection inferior to the inframammary ously toward the original stab incision. If this problem is recognized intraoperatively, the sub- through the original stab incision. Inferior capsulorrhaphy is the mainstay of Submuscular placement of an implant that is too large for reoperation for inferior implant malposition. The use of the dimensions of the breast in a patient with a tight infra- acellular dermal matrix has been described to reinforce cap- mammary fold may lead to a specific type of inferior sulorrhaphy in order to correct the various types of implant implant malposition known as a double-bubble deformity. One should remember that lowering the This deformity is characterized by the persistence of the position of the inferior pole of the implant causes not only original inframammary fold as a visible curvilinear inden- 300 J. To correct this defor- and quite often some perceptible remnant of the original mity, the implant can removed and replaced with a smaller fold persists and remains dissatisfying to the patient [21]. A sec- implant to the subglandular plane, with or without preop- ond method entails the complete obliteration of the erative deflation of the implants (Fig. View of inferior aspect of breast with the patient supine chest wall) c a b F i g. The capsulorrhaphy line should be placed at the desired location of the lateral breast border, as Lateral malposition should be additionally assessed by this is where the lateral aspect of the implant will lie. The needle is passed through the fixed and ment of the implants is accentuated in these positions. Lateral then through the mobile capsule at the superior extent of the malposition is usually due to technical error at the time of planned junction of the lateral breast border and chest wall. Once some knot tying in an area of limited accessibility through a the implant is placed, gentle finger dissection lateral to the limited incision. The capsulorrhaphy proceeds by advancing implant can smooth out the contour of the lateral breast bor- the needle in a superior to inferior direction through the der by releasing constricting bands of the overlying breast scored fixed and mobile capsule. Correction of lateral malposition generally requires rior limit of the capsulorrhaphy, which is easily accessible surgical intervention, with the goal of the procedure being to through an inframammary incision. If the knot cannot be obliterate the lateral recess of an excessively large lateral buried, the tails of the suture are left long to prevent rigid periprosthetic capsular space [21]. In fact, the constant contraction of the pectoralis over time When the implant pockets are positioned too close together, may well contribute to downward and outward displacement a condition known as synmastia (also known as symmastia) of the device. Synmastia is most commonly caused by overag- In summary, caution must always be exercised during lat- gressive division of the parasternal origins of the pectoralis eral pocket dissection at the time of primary or revision aug- major muscle, and can be quite challenging to correct. First, overdissection of the mastia has occurred with implants in a subglandular plane, lateral breast pocket can efface the contour of the lateral transition to the submuscular plane and leaving the paraster- breast border. Second, for subpectoral implants, muscular nal origins of the pectoralis major muscle intact may correct contractions of the pectoralis major tend to force the implant the problem. Third, sharp or electrocautery dissection lateral to the implant malposition using an accurately dissected neosub- lateral border of the pectoralis major muscle places the lat- pectoral pocket for implant placement (Fig. Various lateral capsulorrhaphy techniques have proved effective for medialization of the implant. This will demarcate the junction between the superior pole of the technique refers to development of a new pocket for the breast and the skin of the chest wall.