1) The latissimus dorsi myocutaneous flap is one of the largest soft tissue flaps that can be harvested. It receives its blood supply from the thoracodorsal artery and vein.
2) It has several advantages including a long vascular pedicle and arc of rotation, minimal donor site morbidity, and skin paddle color and texture match for head and neck reconstruction.
3) Disadvantages include the inability to perform simultaneous ablative and reconstructive surgery, risk of vascular pedicle compression, and increased risk of minor complications like seroma formation.
Advantages of Cervicofial flaps :
Operative time is short.
It causes minimum deviations in relations to important structures around cheek.
reduce surgical risk in high risk patients like old age, diabetic patients, un-controlled hypertension
It can provide excellent skin colour and texture match.
Advantages of Cervicofial flaps :
Operative time is short.
It causes minimum deviations in relations to important structures around cheek.
reduce surgical risk in high risk patients like old age, diabetic patients, un-controlled hypertension
It can provide excellent skin colour and texture match.
Flap coverage in upper extremities in trauma VishalPatil483
SEMINAR PRESENTED BY DR VISHAL PATIL ,IN THE DEPT OF TRAUMA SURGERY AND CRITICAL CARE, AIIMS RISHIKESH
INCLUDES-INTRODUCTION-CLASSIFICATIONS OF FLAP-COMPLICATIONS RELATED TO FLAP COVERAGE- FLAP USED IN HAND AND UPPER EXTREMITY SOFT TISSUE RECONSTRUCTION WITH PICTURES OF IT
Dedicated to my late professor safeer khalil whose guidance lives in our minds.professor late lady reading hospital peshawar and hayatabad medical complex peshawar
Dedicated to our late teacher professor dr umar khitab who taught us with full dedication .his legacy lives in the form of his students through out the world
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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.
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
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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3. Advantages
• Largest soft tissue flap that can be harvested in
the body.
• Versatility in soft tissue design.
• Donor site skin is hairless, with comparable color
match to that in the head and neck region.
• Donor scar is less noticeable.
• Longer arc of rotation.
• Breast or chest wall alteration is minimal.
4. Disadvantages
• Inability to perform ablative and reconstructive surgery
simultaneously (except in cases when recipient site is
located in posterior neck or scalp).
• Requires position change for flap harvesting.
• Long vascular pedicle coursing through the axilla and
neck may be more vulnerable to neck infection and
positional change.
• Risk of injury to brachial plexus
• Increased rate of minor complications (prolonged
wound drainage and seroma formation
5. Contraindications in PLDMF harvesting
• Patients who have had previous trauma or
axillary surgery (history of breast cancer) are
poor candidates for the PLDMF
• relatively contraindicated for patients in
whom significant upper-arm strength is
obligated for employment, sports (skiing), and
daily activities (paraplegic)
6. REGIONAL ANATOMY
• The latissimus dorsi is a fanlike
muscle with an origin located
in the spinous processes of the
lower 6 thoracic vertebrae,
lumbar vertebrae, sacral
vertebrae, and dorsal iliac
crest, via thora- columbar
fascia and the external oblique
muscle. The muscle fibers pass
laterally and are cephalized;
then, they insert between the
teres major and pectoralis
muscles at the humerus.
Together with the teres major,
it forms the posterior axillary
fold
7. REGIONAL ANATOMY
• The primary function of
the latissimus dorsi is
to adduct, extend, and
internally rotate the
arm (“posterior push”
motion)
8. REGIONAL ANATOMY
NEUROVASCULAR ANATOMY
• The latissimus dorsi muscle is a class V muscle
with a dominant pedicle (thoracodorsal artery
and vein) and secondary blood supply
(posterior inter- costal perforators).
10. SURGICAL DEVELOPMENT OF THE PEDICLED
LATISSIMUS DORSI MYOCUTANEOUS FLAP
• Patient Positioning
lateral decubitus position
11. Flap Design
• the identification of the
surgical landmarks.
Important surface land-
marks include the
following
• Anterior border of
the latissimus dorsi
• Scapular tip
• Mid axillary fold
• Posterior superior
iliac spine
12. Surface landmark indicated for flap design
An imaginary line was draw
from mid axillary fold to
pos- terior superior iliac
spine, this is reliable in
predicting the location of
anterior rim of latissimus
dorsi muscle. Skin paddle
shall not be designed too
far anteriorly beyond the
latissimus dorsi muscle,
anterior extension shall be
limited to a maximum of 2
cm. Skin paddle shall not be
designed above the scapula
tip
13. MARKING
• The anterior rim of the latissimus dorsi muscle
can be located by pinch palpation, and then
marked.
• pinch palpation can be difficult in obese subjects
• Alternatively, the anterior border of the muscle
can be predicted over an imaginary line from the
mid axillary groove to the posterior superior iliac
spine. It is approximately 8 cm below the
midpoint of the axilla, along this imaginary line,
where the vascular pedicle enters the
undersurface of the latissimus dorsi
14. SKIN PADDLE DESIGN
• A fusiform-shaped skin paddle is usually
designed along the imaginary line. Ideally, the
skin paddle should be located over the
proximal two-thirds of the latissimus dorsi
muscle (primary angiosome); however, the
exact location of this skin paddle is dictated by
the size of the defect and the arc of rotation.
15. Arc of rotation of the flap
• The PLDMF has a long vascular pedicle that can
reach as far as the skull vertex. Common
reconstructive defects include the oral cavity,
pharynx, facial skin, and scalp
The arc of rotation for the PLDMF is limited by
several factors:
• Proximal vessel dissection
• Tunneling methods: subcutaneous tunnel versus
interpectoral tunnel
• Location of skin paddle
16. SURGICAL PROCEDURE
The sequence of dissection can be easily broken
down into the following steps:
• Initial incision
• Vascular pedicle identification
• Skin paddle development
• Muscular incision
• Axillary dissection
• Mobilization
• Flap tunneling
17. Initial Incision
• Flap raising begins with an initial skin incision
down to the muscle fibers, following the
imaginary line and along the anterior border
of the skin paddle.
• The anterior border of the muscle rim can be
clearly exposed and separated from the
underlying fatty tissue in the lateral to medial
direction. This dissection plane is relatively
bloodless.
18. Pedicle Identification
• Along this anterior incision, a branch of thoraco-
dorsal artery running anteriorly and supplying the
serratus anterior muscle can be appreciated.
Dissection along this serratus branch proximally
can help to identify the thoracodorsal artery
(3–4 cm distal to the serratus branch). Alterna-
tively, the thoracodorsal artery also can be readily
located by palpating for its pulse underneath the
proximal muscle rim (2 cm medial to the anterior
rim of the latissimus dorsi)
19. Pedicle Identification
PLDMF was raised; the green
arrow indicates TDA
(thoracodorsal artery with
concomitant veins) running
parallel to flap longitudinal axis
before entering hilum. The blue
arrow indicates ante- rior serratus
distal branches before entering
the anterior serratus muscle.
Dissection of pedicle/TDA
proceeded proxi- mally into axilla
space, anterior serratus branches
(double asterisk) and scapular
angle branch (asterisk) were
ligated to increase the arc of
rotation of the PLDMF.
20. Skin Paddle Development
• Once the vascular hilum can be observed on
the undersurface of the muscle, an incision is
made circumferentially around the
posteromedial portion of the skin paddle. This
incision is made to the level of the fascia
overlying the muscle
• Before the muscle incision, anchorage sutures
are used to secure the skin paddle to the
muscle
21. Muscular Incision
• Working from the inferior to superior
direction, muscle fibers are transected along
the inferior pole and medial aspect of the flap.
It is prudent to constantly look after the
safety of the vascular pedicle running on the
undersurface of the flap. This part of the
dissection can be facilitated with the use of
ultrasonic scissors
22. Muscular Incision
• As the dissection proceeds proximally,
branches of thoracodorsal artery (transverse
branch to the latissimus dorsi muscle and to
the serratus and teres major muscles, angular
branch to the scapular tip) must be ligated to
fully mobilize the flap
23. Axillary Dissection
• Following the thoracodorsal artery to the
axilla, care should be taken to identify the
circumflex scapular and subscapular vessels
• This part of the dissection can be facilitated
with an assistant abducting and retracting the
arm.
• Care must be taken not to hyperabduct the
arm so as to avoid brachial plexus injury
24. Axillary Dissection
• During pedicle dissection, a thin cuff of tissue around
the pedicles should be preserved
• Fatty loose tissue around the pedicle provides a
cushion effect and helps to identify twisting of the
pedicle
• For most defects in the lower face and the neck,a
PLDMF can reach without sacrificing the circumflex
scapular vessel.
• The preservation of this vessel helps prevent twisting,
kinking, or torsion of these long pedicles during
delivery; however, if the defect is located midface or
superiorly, trans- action of the circumflex scapular
vessels is required to improve the arc of rotation
25. Axillary Dissection
• Careful inspection over the thoracodorsal
pedicle is a prerequisite, the thoracodorsal
nerve is transected if there is a potential of
nerve compression over the vascular pedicle.
However, the long thoracic nerve to the
serratus anterior muscle should be not be
intruded and must be preserved
26. Mobilization
• For the flap to be fully mobilized, the humeral
tendon of the latissimus dorsi muscle should
be skeletonized.
27. Tunneling
The last step of the procedure is to create a
tunnel for flap delivery
There are 2 methods for creating a tunnel: (1)
interpectoral tunnel and (2) subcutaneous
tunnel.
28. Interpectoral tunnel
• The tunnel is formed by blunt dissection (from lateral extending
medially) from the anterior axilla to the neck between the
pectoralis major and minor muscles.
• The latissimus dorsi myocutaneous flap will be entering the tunnel
and running medially to the thoracoacromial pedicle, reaching the
clavipectoral fascia underneath the pectoralis major muscle.
• A skin incision parallel and inferior to the clavicle is required. The
clavicle head portion of the pectoralis major muscle is transected to
create an exit pathway for the pedicled flap. This path should be
wide enough to accommodate the operator’s hand freely between
the axilla and neck. When tension is appreciated, several
maneuvers can be done:
• Separate the pectoralis minor from its insertion to the coronoid
process.
• Acromial branch of the thoracoacromial vessel can be ligated and
transected to avoid interference.
• Trimming of the proximal latissimus muscle.
29. Interpectoral tunnel
• Before flap delivery, meticulous hemostasis is
required to avoid a postoperative hematoma
that may, inadvertently, compromise the
vascular pedicle. After delivery, the
vasculature of the pedicle should be checked
to ensure that it is free of tension.
30. TUNNELING
• Blue indicates the area of
subpectoralis major muscle
undermining in preparing an
interpectoral tunnel; this
undermining procedure was
performed between the
enveloping fascia of pectoralis
muscles, which is almost a
bloodless field if the
thoracoacro-mial blood vessels
remain intact. Yellow indicates
area of subcutaneous
undermining in preparing a
subcutaneous tunnel.
•
31. Subcutaneous tunnel
• The dissection of the subcutaneous tunnel is
straightforward at the subcutaneous tissue
layer, especially if pectoralis flap has been
used. The PLDMF is rotated 180○ and passed
through the tunnel, reaching the defect region
32. Tunneling techniques comparison
SUBCUTANEOUS
ADVANTAGES
• Ease of dissection
• Limited compression
within the Tunnel
DISADVANTAGES
Shorter arc of rotation
INTERPECTORAL
ADVANTAGES
• Increase arc of rotation
DISADVANTAGES
• Difficult dissection
• Compression from the
pectoralis muscle
• Possible trauma to the
thoracoacromial artery
33. Post operative management
• The donor site defect can be closed primarily
with generous undermining in the
surrounding tissue. Usually, a skin paddle of
less than 8 cm in width can be closed without
the need for skin grafting.
• negative pressure drains placement
34. COMPLICATIONS
• Intraoperative
Complications
(1) unnecessary injury to
the serratus anterior or
long thoracic nerve
during dissection, or
(2) brachial plexus injury
from inadequate cushion
support during patient
positioning
• Postoperative
Complications
1) Donor site
• Seroma formation
• Functional deficits of the
shoulder and arm from
the loss of the latissimus
dorsi muscle are esti-
mated to average 7% in
most patients