This document discusses blepharoplasty surgery to rejuvenate the upper and lower eyelids. It covers the goals of maintaining a youthful eyelid shape and position. The principles of the surgery include properly positioning the brows, restoring tone and position of the lateral canthal area and lower lids, and preserving skin, muscle and fat. It describes the anatomical changes that occur with aging around the eyes and indications for surgery. Pre-operative evaluation and different surgical techniques for the upper and lower lids are outlined, along with potential complications.
In this talk , we discuss the assessment and evaluation for patients presenting for cosmetic upper and lower lid blepharoplasty along with surgical technique.
In this talk , we discuss the assessment and evaluation for patients presenting for cosmetic upper and lower lid blepharoplasty along with surgical technique.
Micro vascular free flaps used in head and neck reconstruction /certified fi...Indian dental academy
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Micro vascular free flaps used in head and neck reconstruction /certified fi...Indian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
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Lecture 3 Facial cosmetic surgery
Maxillofacial Surgery
Dental Students Fifth Year second semester
Al Azhar University Gaza Palestine
Dr. Lama El Banna
https://twitter.com/lama_k_banna
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. Introduction
▪ Rejuvination of upper and lower eyelids
▪ AIM:
– Youthful upper and lower eyelids
– Maintaining original shape
▪ Blepheraplasty; focus on entire periorbital structures
3. Principals:
▪ Proper brow positioning, corrugator muscle removal & lif fold invagination when necessary
▪ Restoration of lateral canthal tone & position, intercanthal axis tilt
▪ Restoration of lower lid tone and position
▪ Preservation of maximal lid skin, muscle & orbital fat
▪ Midface lifting through reinforced canthopexy, enhanced by composite malar advancement
▪ Correction of suborbital groove with tear trough(or suborbital malar) implants, correcting malar bags
– Smooth transition between lower lid and cheek
▪ Control of orbital fat by septal restraint or quantity reduction
▪ Removal of only excessive tisse (skin, muscle, fat)
▪ Modification of skin to remove wrinkling, excision of small growths & blemishes
5. ▪ Palpebral fissure: 28-30mm (H)
,8-10 MM (V)
▪ Lateral commissure; 2mm
superior to medial commissure
(canthal tilt)
▪ Upper lid margin arch peaks at
centre of pupil
– Lateral migration: (weakened
medial levator horn)
▪ Lid crease
– Occidental: 8-10 mm in Females,
7mm in Males
– Asian: absent or 4-6mm from
lash margin
▪ Lid fold( excess skin & muscle)
6. ANATOMY
▪ UPPER LID
– Skin
– Muscle
– Structural support
– Fat compartments
– Gland
▪ LOWER LID
– Skin
– Muscle
– Fat compartments
– Supportive framework
Upper lid
Anterior lamella
• Skin with subcutaneous tissue
• Muscle(orbicularis occuli)
Posterior lamella
• Tarsoligamentous sling
• (upper lid
retractors,capsulopalpebral
fascia,,tarsal plate,lateral &
medial canthal tendons)
• conjuntiva
Lower lid
Anterior lamella
• Skin with subcutaneous tissue
• Muscle(orbicularis occuli)
Posterior lamella
• Tarsal plate and capsulopalpebral
fascia with inferior tarsus
• conjuntiva
7.
8.
9.
10.
11.
12.
13.
14.
15.
16. Anatomical changes of aging eye:
▪ Lateral migration of tarsal plate(weakening of medial horn
of levator apponeurosis
▪ Skin elasticity loss: periorbital rhytids
▪ Weak septum: periorbital fat bulging; puffy eyelids
▪ Herniation of nasal fat pad of upper eyelid
▪ Hollowing;superior sulcal hollowing or A-Frame deformity:
soft tissue volume loss
▪ Brow volume loss: brow flattening, brow ptosis; upper lid
hooding,lateral brow descent, narrowed brow lash distance
▪ Glabellar lines
▪ Eyelid bags, accentuation of lid cheek junction, tear trough
deformity
19. How to proceed:
▪ Preop evaluation:
▪ history and detailed clinical examination
▪ Attention to surrounding aging face
▪ Rule out RED flags; conditions with high
postoperative risk
▪ Photographs
▪ Patient’s concern and expectations
▪ Operative plan with or without adjunts
▪ Informed consent
20. Preop evaluation:
▪ Visual acuity by snellen’s chart
▪ Visual field
▪ Occular movements (6 positions of gaze)
▪ Globe position: (vector +-), (Hertel exophthalmometry)
▪ Shirmer’s test (DRY EYE) for tear production
▪ Poor bell’s phenomenon
▪ Rule out occular pathologies
▪ Any history of contact lens intolerance
25. ▪ LA,GA
▪ MAC (monitored anesthesia care; LA with sedation and analgesia)
▪ Retrobulbar hemtoma or eyelid hematoma
26.
27.
28.
29. ▪ To avoid risk of post op ptosis, a supratarsal
fixationof pretarsal skin muscle to levator
apponeurosis in midpupillary line, 6-0 vicryl
,mattress suture
30. ▪ Brow ptosis, excess brow fat pad corrected, lacrimal gland ptosis
corrected with fixation sutures
▪ ROOF addressed
▪ For Asian blepheraroplasty:
– low crease incision (4-6mm above lash line)
– Conservative resection of skin and fat
– To create a fold, multiple anchoring sutures through junction of upper tarsal
plate, levator insertion and dermis of upper lid skin
31. Lower lid blepharoplasty:
▪ Two approaches:
– Subciliary incision
– Tarsoconjuctival plus skin pinch approach
▪ Trans-septal
▪ retroseptal
▪ Through conjunctiva and capsulopalpebral fascia, through or behind
septum
▪ Minimal injury risks
32.
33.
34.
35.
36. Lower lid blepharoplasty:
▪ Two approaches:
– Subciliary incision
– Tarsoconjuctival plus skin pinch approach
▪ Subciliary Approach:
▪ Skin incision lateral to medial
▪ Stair-step incision through O.O muscle leaving 5mm pretarsal strip
▪ Skin muscle flap raised
▪ Dissection via septum to infraorbital rim
▪ Orbitomalar ligament released and tear trough deformity corrected.
▪ SOOF approached. Fat removed in conservative manner(all 3 compartments).
▪ Avoid injury to I.O.M (diplopia),avoid injury to arcuate expansion( further fat herniation)
▪ Arcus marginalis release, fat transposition, fat grafting
41. ▪ Two layered canthopexy:
▪ A: suture fixating tarsal
tail into the drilled hole
▪ B: 2nd layer orbicularis
suture
▪ C: lateral sutures fix
lateral orbicularis to
deep temporal fascia
▪ D:if midface is elected,
inferior drill hole can be
made to fixate midface
tissues
▪ E: bury the knot into the
drill hole
42.
43.
44. Postop care
▪ Eye drops; moisturizing
▪ Ophthalmic lubricating
▪ Intermittent forced lid closure
▪ Head; elevated posture
▪ Ice cold packs for 24 hrs
▪ Ophthalmic ointment at night
▪ Sutures removal (5-7 days)
45. Complications:
▪ Bleeding
▪ Over correction
▪ Retrobulbar hemorrhage
▪ Chemosis
▪ Globe perforation
▪ Vision loss (periorbital filler injection/intra arterial embolization)
▪ Injury to SOM/IOM: diplopia
▪ Corneal irritation
▪ Inflammatory/infectious complications
▪ Hypersensitivity reactions
▪ Deep orbital cellulitis with intracavernous extension
▪ Subcutaneous epidermoid cysts
▪ epiphora
▪ Suture abscess,granuolma,
Aging; changes in skin,muscle,fat,bone & ligamental structures,no single technique for all,common procedure but challenging, complications must be addressed
1.Brow ptosis and lid ptosis corrected at this time ideally
Superior arcade is 4 mm above lash line..
Lower arcade is 2 mm away from lash line…
Muscleorigin n insertion
pretarsal(superficial part;deep part as horner’s muscle) causes involuntary blinking,
preseptal (superficial & deep part;jones’ muscle) voluntary blinking+lacrimal drainage,
orbital: forceful eye closure;
supplied by frontal, zygomatic & buccal br of facial n.
Upper tarsal plate: 24mm(H), 8-10mm(V),anteriorly PTOO,LA, superiorly Muller’s m,conjunctiva posteriorly
Lower TP: 24mm(H), 4mm(V), PTOO anter,capsulopalpebral fascia inferiorly, conjunctiva post.tarsal plates attach to orbit with lat n medial canthal tendons and retinacular structures
Medial canthal tendon: ant reflection to nasolacrimal crest, post reflection to post. Lacrimal crest behind lacrimal sac.
Lateral canthal tendon: superficial(lat orbital rim periosteum) n deep( whitnall’s tubercle) parts, tarsal straps are separate structures attached tarsus to orbit
Superior transverse ligament of whitnall formed by facial thickening of Levator palpebrae superioris( medially to trochlea of SOM, laterally to lacrimal gland’s psedocapsule and lacrimal fossa
Inferior suspensory/transverse ligament, lockwood’s ligament ,attached medially to med retinaculum, lat. to lat.retinaculum,fuses with inf tarsal border through capsulopalpebral fascia.
Upper lid retractors: Levator muscle origin from lesser wing of sphenoid,apponeurosis inserts to ant surface of sup.tarsal late.apponerosis forms 5-7mm above tarsal plate..lateral horn(to lat orbital rim tubercle) separating lacrimal gland in two parts.medial horn inserts into deep part of medial canthal tendon.LPS supplied by occulomotor nerve
Muller musle smooth,from deep surface of levator to superior border of tarsal plate,sympathetic innervation.
Medial retinaculum: medial horn of LA, medial rectus check ligament, medial extensions of lockwood’s and whitnall’s ligaments, medial extension deep head of PTOO, orbital septum, medial canthal tendon
Lateral retinaculum: lateral horn of LA, lateral rectus check ligament, larteral canthal tendon, lateral extensions of lockwood’s n whitnall’s ligament, orbital septum ,deep part of PTOO, tarsal starp
Lower lid retractors: capsulopalpebral fascia;extension of inf rectus facscia, enclosing IOM, inseting into ant surface of tarsal plate, inf tarsal muscle(analogous to muller muscle) nserting into inf border of tarsal plate.
Orbital septum fuses with LA several mm above tarsal plate, but fuses few mm above tarsal plate in lower lid…
Nasal(pale white) and central/preapponeurotic(yellow) fat pads with interpad septum which is connected with trochlea of SOM, NASAL fat pad contains medial palpebral artery so careful, central is called preapponeurotic fat pad,responsible for lid fold fullness
Lower lid fat pads:3; nasal( similar to upper lid nasal fat, central and lateral(temporal)..nasal n central separated by IOM, central n lateral by interpad septum n arcuate expansion(lockwood’s lig extension)
Lacrimal gland;orbital and palpebral parts divided by lateral horn of levator connected by isthmus.
GLAND PTOSIS:dehiscence of SOMMERING’s ligament(fibrous interlobular septa connecting gland to lac fossa of orbit.
lateral to lacrimal gland, fat compartment” EISLER’S POCKET with EISLER’S fat, just above whitnall’s tubercle is landmark of this tubercle.
Mendelson described prezygomatic space bounded by Orbitomalar ligament/orbicularis retaining ligament and the zygomaticocutaneous lig
Orbitomalar lig n OO muscle origin from orbital rim define tear trough n lid-cheek junction
Malar fat pads(subcutaneous) below it
Supeior oblique: intortion, depression(adducted eye) and abduction
Inf oblique: extortion, elevation(adducted eye), abduction
Rule out diplopia,
Shirmer’s test: tetracaine eye drops, shirmer strip, after 5 min, less than 10 mm wetting : no skin excision,lateral canthopexy n lubricants n temp tarsorraphy
Lid fold asymmetry: lid ptosis, lid retraction, assyemtrical amount of soft tissue in upper lid,assymetrical brow position
Ptosis: congenital(poor excurtion n levator function), acquired(ptosis; levator function better,high lid crease) apponeurotic dehiscence, myogenic (MG), neurogenic (H.S),mechanical( tr or trauma)
2-3mm, 3-5mm, >5mm:mild moderate n severe ptosis
FES: large built males, upper lid eversion during forceful lid closure, post bleph chemosis,over-riding of lid and deparation from globe during closure,treat with tarsal resection n lat cathoplasty of upper lid
-ve tilt: canthal disinsertion,laxity or prominent eye or it is hereditary trait
-ve vector is relation of globe to the inf orbital rim n its overlying tissue in prominenet eye, globe projects anteriorly to it…poor globe support
+ve vector is normal vector where ant most aspect of glove is behind the infraorbital rim n its overlying soft tissues
Enophthalmos(deep set eyes): more internal placement of catho-pexy/plasty suture
Exosphthalmos(prominent eye) high lateral canthal anchoring suture
Prominent eye needs some infraorbital implants or lower lid spacers for suppoert
Point A,on lid crease at midpupillary line (8-10mm in F ,7mm in M), following lid crease point B just medial to carumcle(prevent webbing), laterally point C 5-6mm from lash margin,
Latera extension from point C in skin tension line( avoid extension to lateral orbital rim)
Point D at level of lateral canthus(preserving 10-15mm skin between lower border of brow and lash margin)
Crease drawn parallel to eyelid crease tapering medially
Lenticular skin excision in young,more trapezoid lateral in elderly
Skin excised
Muscle strip removed(very thin)
Septum opened
Fat exposed
If needed nasal fat pad removed with needle cautery
Avoid inj to medial palpebral artery
Avoid injuery to SOM and trochlea( diplopia and head tilting towards affected muscle side)
Excess fat removal: peaked arch deformity of lid crease and A-frame deformity/more hollow and aged appearance.
Interuupted nylon sutures lateral to lat.canthus, remaining continuous subcuticular stitches
Single point below the lateral canthus,medially extension 2-3 mm below lash line
Lateral extension of 6-10 in skin tension line,lateral extensions of upper n lower blepharoplasty incisons must be at least 10 mm away to avoid webbing
Chemosis: ophthalmic steroids, decongestants,oral steroids, tarsorrhaphy
Retrobulbar hematoma( immediate decompression,lateral canthotomy n cantholysis,surgical exploration,mannitol acetazolamide and oxygen)