Lower Incision Research Articles

The Effect of Transverse Skin Incision Location on Wound Morbidity After Cesarean Delivery for Patients With Morbid Obesity [ID: 1377795

INTRODUCTION: The objective of this study was to assess whether placement of transverse skin incision below or above the panniculus for cesarean delivery in patients with morbid obesity is associated with postoperative wound complications. METHODS: We identified a cohort of all women with body mass index (BMI) higher than 40 who delivered by cesarean at our institution from 2016 to 2020, had complete postpartum records, singleton gestation, and transverse skin incision. Medical records were abstracted after IRB exemption. The primary outcome was composite wound morbidity (infection, disruption, or dehiscence). Secondary outcomes included operative time, neonatal outcome, and blood transfusion. Analysis was performed with χ2 and logistic regression including BMI percentile, diabetes, smoking, unscheduled surgery, and prior cesarean. RESULTS: Two hundred sixty-three patients had a low transverse incision and 65 had a high transverse incision. 14.6% of patients had wound morbidity. There were two reoperations and no fascial dehiscences or deep site infections. Patients with a high transverse incision had higher mean BMI (53.0 versus 45.9, P<.001) and were less likely to be in labor (relative risk 0.52, 0.28–0.96) but were otherwise similar to patients with a low incision. High transverse incision was associated with composite wound morbidity (adjusted odds ratio 5.12, 2.36–11.09) and increased operative time (61 versus 54 minutes, P=.02) but not other secondary outcomes. Results did not significantly differ when analysis was restricted to patients with BMI greater than 50. CONCLUSION: Wound morbidity was more frequent after high transverse skin incision for cesarean delivery. Prospective studies are needed to determine whether incision location or other factors caused this increase.

Accuracy of Cesarean Scar Indicators for Predicting Intra-abdominal Adhesions

Background: The cesarean section rate has increased in the last decade, a significant risk factor for intra-abdominal adhesion. This study investigated the diagnostic accuracy of cesarean scar indicators for intra-abdominal adhesions in pregnant women. Methods: This cross-sectional study was conducted on pregnant women with a previous cesarean section who were candidates for elective repeated cesarean section. We gathered demographic information, including age, number of prior cesarean sections, past medical and surgical history, the time since the last operation, and the inspection of the cesarean incision. The evidence of pelvic adhesion was calculated in the operating room by the Manchester scar scale, and intra-abdominal adhesions were graded using a modified Nair's classification. The data were analyzed by proper tests. Results: One hundred pregnant women were included in the study and divided into two groups with high and low incision indices. In the low incision index group, 82.1% had a history of one cesarean section, and 1.3% had three or more, and in the group with a high incision index, 54.5% had a history of one cesarean section, and 13.6% had three times or more (P < 0.05). Women with a high incision index had a higher adhesion rate than the other group (P < 0.001). The sensitivity and specificity of the scar index in the diagnosis of adhesions were 57.48% and 92.30%, respectively. Conclusions: It is challenging to accurately predict the severity of adhesions resulting from cesarean section, but it is urged to prevent an unnecessary cesarean section.

Cesarean scar niche: An evolving concern in clinical practice.

Increasing cesarean section rates have led to an increased awareness of associated complications such as the formation of cesarean scar niche, defined as an indentation at the site of the cesarean scar with a depth of at least 2 mm, diagnosed by ultrasound or magnetic resonance imaging. The precise prevalence of cesarean scar niche is unclear. The cause of a cesarean scar niche appears to be multifactorial and likely a combination of technical factors (low incision location), anatomical factors (uterine retroflexion), and patient factors, which might impair healing (body mass index, smoking, maternal age). Most patients with cesarean scar niche are asymptomatic; however, women can present with postmenstrual bleeding, pelvic pain, and subfertility. In pregnancy, cesarean scar niches have been associated with placenta accreta spectrum disorder and uterine rupture. Treatment should be reserved for symptomatic women. Hormonal treatment using either the combined oral contraceptive pill or a progesterone-containing intrauterine device may address irregular vaginal bleeding. Surgical management should be reserved for those in whom hormonal manipulation has failed or is contraindicated. The aim of this review was to summarize current literature pertaining to the cause, prevalence, diagnosis, and symptoms of cesarean scar niche and to make recommendations for managing this relatively new condition.

Fluvial bedrock gorges as markers for Late-Quaternary tectonic and climatic forcing in the Southwestern Alps

Fluvial incision is one of the major erosive processes acting at Earth's surface and is highly sensitive to tectonic, isostatic and climatic variations. The aim of this study is to distinguish between the short-term climatic fluctuations versus the long-term tectonic forcing contribution to Late-Quaternary fluvial incision, to better understand its timing and driving mechanism(s). To achieve this goal, we measured in situ-produced 36Cl concentrations along several river-polished gorge walls in Jurassic limestones of the Southwestern Alps. We then compared our dating results to previously-dated river gorges from nearby catchments. This allows us to highlight three trends of distinct incision dynamics, and to discuss their relationships with climate and tectonics. Trend 1 shows the direct impact of a paraglacial crisis in the rivers connected to glaciated areas. Trend 2 suggests an incision wave propagating along the non-glaciated tributaries following enhanced incision in the main streams. Trend 3 displays steady and low incision rates in gorges disconnected from any fluvial response to glacier retreat. Trend 3 also seems to highlight the potential of resistant lithologies to isolate portions of the river network from post-glacial incision propagation. Our analysis shows that gorges connected to upstream glaciers exhibit a significant response of fluvial incision to climatic fluctuations, evidenced by high-amplitudes incision rate variations hindering the long-term tectonic signal. In contrast, incision rates inferred from disconnected gorges are in agreement with previously-estimated long-term denudation and rock-uplift rates in the area. Based on the latter, we can conclude that Late-Quaternary river incision in the Southwestern Alps is readjusting to both short-term climatic forcing and long-term tectonic forcing.

Risk of Uterine Rupture and Dehiscence Among Women Attempting a Vaginal Birth After a Low Vertical Uterine Incision [A232

INTRODUCTION: The risk of uterine rupture after a prior low vertical (LVCS) is unknown. The objective of this study was to estimate the risk of uterine rupture in individuals attempting a trial of labor after cesarean delivery (TOLAC) with a prior LVCS. METHODS: This is a secondary analysis of the Maternal Fetal Medicine Units Network’s C-section Registry, a multicenter, prospective observational study. We included individuals with term singleton pregnancies undergoing TOLAC with a prior low transverse incision (LTCS) or LVCS and excluded those who received prostaglandins or had a history of myomectomy. Multivariate regression models were used to estimate the relative risk between uterine rupture with a prior LVCS compared to LTCS. After controlling for known confounders, our secondary outcome was uterine dehiscence. RESULTS: In this cohort, 14,773 individuals attempted TOLAC (14,665 prior LTCS; 108 prior LVCS). Uterine rupture occurred in 94 (0.7%) of women with prior LTCS and 1 (0.1%) woman with prior LVCS. Uterine dehiscence occurred in 101 (0.7%) of individuals with prior LTCS and 3 (2.9%) of individuals with prior LVCS. Compared to those with a prior LTCS, the risk of uterine rupture was not different (RR, 1.49; 95% CI, 0.21–10.58). However, the risk of uterine dehiscence was increased among those with prior LVCS (RR, 4.07; 95% CI, 1.31–12.63) compared to prior LTCS. CONCLUSION: Individuals with a prior LVCS have an increased risk of uterine dehiscence, but not uterine rupture, compared to prior LTCS. These results may inform counseling for those individuals considering TOLAC after prior LVCS.

V08-06 BILATERAL PYELOPLASTY WITH SINGLE PORT ROBOT - ONE INCISION, ONE POSITION

You have accessJournal of UrologyNOTES/LESS (V08)1 Sep 2021V08-06 BILATERAL PYELOPLASTY WITH SINGLE PORT ROBOT - ONE INCISION, ONE POSITION John Sheng, Chrystal Chang, Gregory Lovallo, Michael Stifelman, and Mutahar Ahmed John ShengJohn Sheng More articles by this author , Chrystal ChangChrystal Chang More articles by this author , Gregory LovalloGregory Lovallo More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , and Mutahar AhmedMutahar Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002041.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Da Vinci Single Port (SP) robotic system has made it feasible to perform robotic surgery through one incision. This technology advances minimally invasive surgery, allowing for multiple instruments through a single 25mm port. -In this video, we demonstrate the feasibility of performing bilateral retroperitoneal surgery through a single small Pfannenstiel incision. -We previously showed this surgery with an assistant port. Now we demonstrate the use of the remotely operated suction irrigation (ROSI) system in making this a true single port surgery. METHODS: A 26 year old female with bilateral symptomatic UPJ obstructions and multiple large left kidney stones presented for robotic assisted bilateral pyeloplasty and left pyelolithotomy. Whereas using a multiport approach may have necessitated more than 5 incisions to perform bilateral surgery, we demonstrate using one incision and re-docking the single port robot to perform bilateral pyeloplasty. We did not need to re-drape the patient in order to perform the second side. RESULTS: Our patient tolerated the procedure well with excellent cosmetic and functional outcomes. Foley catheter was removed 12 hours post op. Drain had minimal output and was removed 2 hours after foley removed. Patient was discharged within 18 hours of surgery without any narcotic use post operatively. Stents were removed 4 weeks later and the patient remains asymptomatic. A total of 24 single port pyeloplasties were performed by three surgeons at our institution over an 18 month period. Two, including the one described in this video, were bilateral. Average operative time was 128 minutes. Average estimated blood loss was 20cc. Average length of stay was 1.1 days. CONCLUSIONS: Using Single Port robot has the potential to: Have better cosmesis with only one incision. Have improved pain control. Be able to use lower incision on abdomen to perform kidney surgery by pointing instruments upward. Advance robotic surgery in an even more minimally invasive way. In this video, we are able to demonstrate bilateral retroperitoneal surgery without the use of an assistant port through a single small Pfannenstiel incision. Limitations: SP has a learning curve and is may not be able to translate multiport skills entirely to single port. Cannot use indocyanine green with single port system yet to be able to identify and preserve vascularity of ureter for reconstructive cases. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e602-e602 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Sheng More articles by this author Chrystal Chang More articles by this author Gregory Lovallo More articles by this author Michael Stifelman More articles by this author Mutahar Ahmed More articles by this author Expand All Advertisement Loading ...

Isthmocèle : définition, diagnostic, facteurs de risque, prévention, symptômes, complications, et traitements

ObjectivesTo review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche. MethodsReview of the literature, critical reflection, and pragmatic advice. ResultsThere is no consensus on the definition of caesarean scar niche. Some suggest an indentation≥2mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound±hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the “Caesarean scar syndrome”. The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness≥2.5mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases. ConclusionsA pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy.

Temperature Change from Diode Lasers in Oral Mucosa: An Ex Vivo Study.

Objective: The aim of this ex vivo study was to assess the mean temperature change deep in tissue during diode laser (980 vs. 810 nm) irradiation using continuous and pulsed laser and initiated versus noninitiated tips. Background data: Previous studies have determined thermal effects of diode lasers on tissue damage but have yet to compare the incision qualities of 980 versus 810 nm diode lasers. Further studies need to be done to determine the efficiency of diode lasers to create a safer protocol for clinicians. Methods: Ninety-six incisions of 20 mm length were made in three bovine tongues using diode lasers (980 and 810 nm). Both continuous and pulsed modes were tested with initiated (using blue articulating paper) and noninitiated glass fibers (n = 12 per group). Thermocouples attached to LabChart® software were used to measure mean temperature changes. Mean, standard deviations, and p values were conducted for each group to test the statistical significance (p < 0.05). Results: Quality of incisions were better using the initiated tips for both laser wavelengths. Pulsed mode with 810 nm diode laser produced the least mean temperature change in tissue. Overall, both pulsed and continuous mode showed similar thermal effects on tissue. Conclusions: Within the limitations of this study, noninitiated tips are responsible for diffuse irradiation in tissue and are associated with tissue temperature increase during surgery. Low incision quality was observed using noninitiated tips. The temperature changes seem to be dependent on the laser wavelength and are higher for 980 nm compared with 810 nm pulsed diode laser.

Effect of High Suspension and Low Incision Surgery Based on Traditional Ligation of Chinese Medicine in Treatment of Mixed Haemorrhoids: A Multi-centre, Randomized, Single-Blind, Non-inferiority Clinical Trial.

To observe the clinical effect of high suspension and low incision (HSLI) surgery on mixed haemorrhoids, compared with Milligan-Morgan haemorrhoidectomy. A multi-centre, randomized, single-blind, non-inferiority clinical trial was performed. Participants with mixed haemorrhoids from Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing Rectum Hospital, Air Force Medical Center of People's Liberation Army of China, and Puyang Hospital of Traditional Chinese Medicine were enrolled from September 2016 to March 2018. By using a blocked randomization scheme, participants were assigned to two groups. The experimental group was treated with HSLI, while the control group was treated with Milligan-Morgan haemorrhoidectomy. The primary outcome was the clinical effect evaluated at 12 weeks after operation. The secondary outcomes included the number of haemorrhoids treated during the operation, pain scores, use of analgesics, postoperative oedema, wound healing, incidence of anal stenosis, anorectal manometry after operation, as well as surgical duration, length of stay and total hospitalization expenses. A safety evaluation was also conducted. In total, 246 eligible participants were enrolled, with 123 cases in each group. There was no significant difference in the clinical effect between the two groups (100.00% vs. 99.19%, P>0.05). Compared with the control group, the number of external haemorrhoids treated during the operation and the pain scores after operation were significantly reduced in the experimental group (P<0.05 or P<0.01); the patient number with wound healing at 2 weeks after operation and the functional length of anal canal at 12 weeks after operation were significantly increased in the experimental group (P<0.05). There was no significant difference in the incidence of anal stenosis, the numbers of patients using analgesics and patients with postoperative oedema between the two groups after operation (P>0.05). The surgical duration and length of stay in the experimental group were significantly longer than those in the control group, and the total hospitalization expense was significantly higher than that in the control group (all P<0.05). No adverse events were reported in either group during the whole trial or follow-up period. HSLI had the advantages of preserving the skin of anal canal completely, alleviating postsurgical pain and promoting rapid recovery after operation. (Registration No. ChiCTR1900022883).

ISTHMOCELE: ETIOLOGY, CLINIC, DIAGNOSIS AND TREATMENT (Literature review)

Modern obstetrics is characterized with a loyal approach to surgical delivery, which has significantly affected the activity of maternity hospitals: the number of complications in childbirth from both the mother and fetus has decreased. The formed scar on the uterus is determined differently when examining the women in the postoperative period. Isthmocele is a hypogenic area in the myometrium within the site of postoperative scar in the form of a "niche", diverticulum or sac after cesarean section. It can lead to the development of diseases: abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, dyspareunia, infertility, adenomyosis, bladder dysfunction, as well as be the cause of ectopic pregnancy, uterine rupture, abnormalities in the placenta attachment of. Risk factors for isthmocele include low uterine incisions, a history of cervical removal, cervical dilatation of more than 5 cm, more than five hours of delivery, etc. For the first time the diagnosis of "isthmocele" is made at ultrasonic research, more often transvaginal one. The diagnosis is confirmed by hysteroscopy or constructive surgery. An important criterion for ismocele is the degree of deficiency, i.e. the ratio between the the biometry thickness on the scar and adjacent to the scar the myometrium area. Depending on the woman's reproductive plans, conservative or surgical treatment of isthmocele is recommended, using autologous stem cells to regenerate muscle tissue. Conservative treatment involves taking oral contraceptives. Surgical treatment includes the imposition of a two−row single−wing suture. The use of stem cells in the postoperative period allows a rise in the frequency of pregnancies in women with a scar on the uterus in the case of the isthmocele formation. Key words: isthmocele, cesarean section, myometrium, autocells.

Abdominal Wall Closure in Autologous Breast Reconstruction: Optimizing Aesthetics

Background: In contrast to cosmetic abdominoplasty, abdominal flap harvest can result a high degree of morbidity to the abdominal wall. Poor abdominal wall aesthetics that can result following free flap harvest including a high abdominal incision and post-operative hernia or bulge. We report our experience in optimizing cosmesis of the abdominal donor site with the use of a low incision, fascial plication and routine mesh reinforcement. Methods: A retrospective chart review of patients who underwent breast reconstruction with free abdominal tissue transfer from 2013-2017. Pedicled flaps and superior inferior epigastric artery flaps were excluded. Patient demographics, oncologic history, ablative and reconstructive surgery details focusing on abdominal closure techniques, and postoperative complications were evaluated. Results: 135 patients were identified who underwent 223 abdominal free flaps. 59 (26.5%) DIEP flaps were harvested, while 160 (71.7%) msTRAM and 4 (1.8%) fTRAM flaps were harvested (p<0.0001). 160 (71.7%) donor sites closures utilized polypropylene mesh, 9 (4.0%) were closed with biologic mesh and 3 (1.3%) closures used no mesh (p<0.0001). No hernias were observed (0%), while 6 abdominal bulges were identified (2.7%). There were no differences in the rates of abdominal bulge after donor site closure in the DIEP compared with msTRAM and fTRAM groups (3.4% vs 2.4%, p=0.7). No patients required mesh explantation during the study follow up period. Conclusion: To parallel cosmetic abdominoplasty, our authors advocate for a low incision, fascial plication and routine mesh reinforcement of the abdominal wall following free flap harvest.

Application of Color Doppler Ultrasound in the Clinical Diagnosis of Uterine Incision Infection

Objective: To observe the early changes of uterine incision defects after cesarean section by transvaginal color Doppler ultrasound, and to analyze the risk factors of their formation. Methods: A total of 181 women who underwent cesarean section from September 2016 to June 2018 and who underwent transvaginal ultrasound examination at 6 weeks, 3 months, and 6 months after birth were divided into two groups. (142 cases) and incision defect group (39 cases). The incision changes and the risk factors of incision defect in different periods of postpartum were analyzed. Results: Compared with the group with good incision healing, the length of the incision defect in the cesarean section at 6 months after delivery was shorter than that at 6 weeks after delivery (P &lt; 0.05). The results of non-conditional logistic regression showed that the number of cesarean sections increased and the number of operators was lower. Seniority, postoperative infection, posterior uterine position, and incision close to the cervix are risk factors for poor healing of uterine scars. Conclusion: As the postpartum time increases, the length of the cesarean section incision defect shortens; multiple cesarean sections, puerperal infections, posterior uterus, low incision position and inexperience of the operator are the risk factors for the formation of uterine incision defects and increase uterine scars. Risk of poor healing.

Using spatial patterns of fluvial incision to constrain continental-scale uplift in the Andes

Abstract Geomorphic archives, particularly longitudinal river profiles, are increasingly used as a proxy to reconstruct uplift rates in mountainous regions. Within the Atacama Desert, Northern Chile, slow, long-term erosion creates exceptional preservation of fluvial and alluvial surfaces. This enables river incision patterns to be used on a continental-scale (>250 km) along the western margin of the Andes (18°00'S to 20°15′S) and over a time frame from Miocene to Present day. The data show marked compartmentalisation of fluvial system behaviour with changes in incision rates from south to north creating 3 distinctly different regions. Within these different sectors, incision rates are broadly consistent between rivers suggesting a regional rather than a river specific control on rates. In Sector 1 (18°05′S to 19°20'S) the fluvial systems are exorheic with a terminal base level (the lowest base level to which the river system can erode) in the Pacific Ocean and span the Coastal Cordillera, Longitudinal Valley, Precordillera and western edge of the Western Cordillera. This constrains the total uplift over these regions to a minimum of 1200 m in 11 Myr with incision rates of ~200–120 m/Myr consistent with rapid but sustained uplift of the Andes in the Late Miocene. In Sector 2 (19°20'S to 19°50'S), to the immediate south, the rivers are shorter and terminate in the Longitudinal Valley, spanning only the Longitudinal Valley, Precordillera and the western edge of the Western Cordillera with lower incision rates of 100–50 m/Myr. Comparison of incision rates between Sector 1 and 2 can constrain the uplift of the Coastal Cordillera to 60 m/Myr which is in keeping with previous studies from the region. In southernmost Sector 3 (19°50'S to 20°10'S), the fluvial systems terminate in the Longitudinal Valley and span only the Longitudinal Valley and eastern part of the Precordillera with low incision rates of 50 to 25 m/Myr. Differences between Sectors 2 and 3 are attributable to drainage loss by tectonic beheading of catchments through uplift of the Cordillera de Domeyko fault system, placing a minimum constrain on uplift in this region of 50 to 25 m/Myr. This study demonstrates the applicability of large-scale fluvial archives to access not just the timing of uplift on a continental scale, but also the relative uplift of individual tectonic provinces.

Upper slope processes and seafloor ecosystems on the Sabrina continental slope, East Antarctica

This study applies detailed seafloor bathymetry data and seafloor images to understand upper slope features and how these influence the distribution of seafloor biota on the East Antarctic margin. The East Antarctic slope on the Sabrina margin has been shaped by diverse processes related to repeated glaciation. Differences in the morphology of gullies on the upper slope enable an understanding of the likely processes that have been active on this margin. Gully morphology varies according to changes in slope gradient, which may have driven variations in sedimentation. Areas of lower slope angles may have led to rapid sediment deposition during glacial expansion to the shelf edge, and subsequent sediment failure. Typically, gullies in these areas are U-shaped, initiate well below the shelf break, are relatively straight and long, and have low incision depths, consistent with formation due to mass wastage. Areas of higher slope angles likely experienced enhanced flow of erosive turbidity currents during glaciations associated with the release of sediment-laden basal meltwaters. Sediment-laden subglacial meltwater flows typically create gullies such as those we observe that initiate at, or near, the shelf break; are V-shaped in profile; and have high sinuosity, deep incision depths and a relatively short downslope extent. The short downslope extent reflects a reduced sediment load associated with increased seawater entrainment as the slope becomes more concave in profile. These differences in gully morphology have important habitat implications associated with differences in the composition and beta-diversity of the seafloor communities. This upper slope region also supports seafloor communities that are distinct from those on the adjacent shelf, highlighting the uniqueness of this environment for biodiversity. Conservation strategies therefore need to consider slope and shelf communities as distinct and equally important components of the Antarctic ecosystem.

Evolution of the Upper Yellow River as Revealed by Changes in Heavy-Mineral and Geochemical (REE) Signatures of Fluvial Terraces (Lanzhou, China)

Despite decades of study, the factors that controlled the formation and evolution of theupper reaches of the Yellow River, including uplift of the northeastern Tibetan Plateau, Pliocene-Pleistocene climate change, and autogenetic processes are still poorly constrained. The stratigraphicrecord of such paleogeographic evolution is recorded in the sequence of nine terraces formed duringprogressive incision of the Yellow River in the last 1.7 Ma. This article investigates in detail forsediment provenance in terraces of the Lanzhou area, based on heavy-mineral and geochemical(REE) signatures. Two main provenance changes are identified, pointing each to a majorpaleogeographic reorganization coupled with expansion of the upper Yellow River catchment andenhanced sediment fluxes. The first change took place between the deposition of terrace T9 (formedaround 1.7 Ma) and terrace T8 (formed around 1.5 Ma), when rapid fluvial incision point to tectoniccontrol and active uplift of northeastern Tibetan Plateau. The second change took place betweendeposition of terrace T4 (formed around 0.86 Ma) and terrace T3 (formed around 0.14 Ma), duringa period of low incision rates and notably enhanced sediment fluxes as a response to enhanced EastAsian Summer Monsoon and consequently increased precipitations, pointing instead chiefly toclimatic control.

Combined Transverse Incision and Pouch Incision for the Correction of Medial Epicanthus.

The epicanthal fold is a distinct characteristic of the upper eyelid in many Asians. To achieve satisfactory results, epicanthoplasty is usually performed with double eyelid plasty and blepharoptosis. Although many surgical procedures have been reported for the elimination of epicanthal folds, such as recurrence, copious designs, conspicuous scar, and unnatural palpebral contours are challenges to the surgeon and also make patients worried. From June 2010 to June 2015, epicanthoplasty was performed for 236 Chinese female patients using transverse incision combined with pouch incision. The transverse straight incision was performed in new inner canthus to the original eanthal corner point, after the original inner canthus corner point was reached, the oblique parallel incision was performed along the lower eyelid, so that full subcutaneous separation was obtained on the upper and lower incision, the malpositioned isomerous orbicular muscle and thickened tissue were released and excised, so that the epicanthus skin was naturally restored, and finally the incision was sutured without tension. The extent of postoperative scarring and improvement of the epicanthal fold were evaluated after surgery. The medial canthal distance was measured preoperatively and 12 months postoperatively. The average intercanthal distance decreased significantly from a mean of 41.68 ± 2.57 mm preoperatively to 37.14 ± 1.94 mm 12 months postoperatively (P < 0.05, paired t-test). And all patients were satisfied with the excellent aesthetic results in terms of an open medial canthus without definite recurrence, hypertrophic scarring, and other complications during the 12-month follow-up period. Epicanthoplasty with transverse incision and pouch incision is a simple and effective method for elimination epicanthal folds, resulting in a pleasant visualization, inconspicuous scar. However, its long-term effects require further study.

Effectiveness analysis of modified tarsal sinus approach for Sanders Ⅱ- Ⅲtype calcaneal fractures

To investigate the short-term effectiveness of modified tarsal sinus approach and traditional tarsal sinus approach in the treatment of Sanders Ⅱ-Ⅲ type calcaneal fractures. Between January 2015 and August 2017, 53 patients with Sanders Ⅱ-Ⅲ type calcaneal fractures were selected and divided into observation group (21 cases, using modified tarsal sinus approach for fracture reduction after exposure of the subtalar joint below the long and short fibular tendon) and control group (32 cases, using traditional tarsal sinus approach) by random number method. There was no significant difference between the two groups in terms of gender, age, side, cause of injury, fracture type, injury to operation time, and preoperative Böhler angle, Gissane angle, visual analogue scale (VAS) core ( P>0.05), which were comparable. The operation time, postoperative drainage volume, postoperative Böhler angle, Gissane angle, and postoperative angle improvement values of the two groups were recorded and compared. VAS score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and short-form 36 health survey scale (SF-36) score were used to evaluate the effectiveness. All the 53 patients successfully completed the operation without serious complications such as vascular and nerve injury and perioperative death. There was no significant difference in operation time and postoperative drainage volume between the two groups ( P>0.05). Patients in both groups were followed up 12-36 months (mean, 17 months). No infection, fracture displacement, failure of internal fixation, and malunion of fracture occurred after operation. None of the patients underwent secondary joint fusion. There was no significant difference in fracture healing time between the two groups ( t=0.30, P=0.77). The postoperative Böhler angle and Gissane angle at 2 days in the two groups were significantly improved when compared with those before operation ( P<0.05); however, there was no significant difference in Böhler angle, Gissane angle, and improvement value between the observation group and the control group at 2 days after operation ( P>0.05). VAS scores at 24 hours and 1 year after operation were significantly improved when compared with that before operation in both groups ( P<0.05). There was no significant difference in VAS scores between the two groups at 24 hours and 1 year after operation ( P>0.05). There was no significant difference in AOFAS scores between the two groups at 1 year after operation ( t=1.46, P=0.15). However, the SF-36 scale score at 1 year after operation was significantly higher than that of the control group ( t=2.08, P=0.04). At last follow-up, 2 patients in the observation group and 8 patients in the control group presented subtalar joint stiffness or pain, and there was no significant difference in the incidence between the two groups ( χ 2=1.98, P=0.16). The modified tarsal sinus approach for the treatment of Sanders Ⅱ-Ⅲ type calcaneal fractures has the advantages of minimal invasion, clear reduction under direct vision, reliable reduction and fixation, and low incision complications.

Effect of vacuum sealing drainage on the clinical effect of high perianal abscess and the expression of vascular endothelial growth factor and platelet-derived endothelial cell growth factor

Objective To observe the clinical effect of vacuum sealing drainage (VSD) in the treatment of high perianal abscess and its effect on the expression of vascular endothelial growth factor (VEGF) and PD-ECGF. Methods 40 cases of high perianal abscess were divided into 2 groups according to the random digital table method, with 20 cases in each group. In the study group, + VSD was closed to the internal and mouth closure of perianal abscess, and the control group was performed the traditional low position incision of the perianal abscess. Postoperative pain, , anal function, healing time, hospitalization time, treatment cost and recurrence rate were compared between the 2 groups. Serum levels of VEGF and PD-ECGF and their phosphorylation levels were detected at different time points. Results There were significant differences in pain and anal function score, wound healing and hospitalization time, treatment cost, recurrence rate between the study group and the control group (P 0.05). The postoperative 7 d study group (0.62±0.025) and the control group (0.45±0.038) all increased significantly, which was statistically significant compared with the postoperative 1 d (P 0.05). The postoperative 7 d study group (0.67±0.029) and the control group (0.49±0.016) all increased significantly, which was statistically significant compared with the postoperative 1 d (P<0.05). The difference was statistically significant between the two groups postoperative 7 d (P<0.05). Conclusion The application of VSD technology in patients with high anal abscess can make pain relief and heal and shorten hospitalization time, save cost and reduce relapse rate, and the anal function is effectively protected. By promoting the expression of VEGF and PD-ECGF, we can regulate wound angiogenesis and promote wound healing. Key words: Vacuum sealing drainage; High perianal abscess; Clinical efficacy; Vascular endothelial growth factor; Platelet-derived endothelial cell growth factor

Hysterotomy level at Cesarean section and occurrence of large scar defects: a randomized single-blind trial.

To study the association between the level of Cesarean hysterotomy and the presence of large uterine scar defects 6-9 months after delivery. This was a two-center, randomized, single-blind trial of a surgical procedure with masked assessment of the principal outcome under study. Women without a history of Cesarean section (CS) who underwent emergency CS at cervical dilatation ≥ 5 cm were randomized to high or low incision. Hysterotomy was performed 2 cm above and 2 cm below the plica vesicouterina in the high and low incision groups, respectively. Women were examined using saline contrast sonohysterography to assess the appearance of the hysterotomy scar 6-9 months after delivery. The main outcome was presence of a large scar defect, defined as the remaining myometrial thickness over the defect being ≤ 2.5 mm. Secondary outcomes were perinatal outcome, operative complications within 8 weeks after delivery and long-term outcome in a subsequent pregnancy. Of 122 patients enrolled in the trial, 114 were assessed by ultrasound examination, of whom 55 were randomized to high and 59 to low CS incision. Large scar defects were seen in four (7%) women in the high-incision group and in 24 (41%) in the low-incision group (P < 0.001; odds ratio, 8.7 (95% CI, 2.8-27.4)). There were no differences in operative complications and perinatal outcomes between the two groups. The median follow-up time was 4 years and 7 months, during which 56 (49%) women had a subsequent pregnancy. No significant differences were observed in the rate of complications in subsequent pregnancy and delivery between women who had low and those who had high incision at the index CS. Low Cesarean hysterotomy level in women in advanced labor is associated with higher incidence of large scar defects detected by transvaginal ultrasound examination 6-9 months after delivery. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Clinical effects of upper eyelid blepharoplasty using the dermis orbicularis muscle flap technique

Objective To develop a new technique of upper eyelid blepharoplasty for reducing surgical complications and improving cosmetic results. Methods In this study, 721 cases (9 males and 712 females, range in age 17-32 years) with single eyelid were performed with double eyelid blepharoplasty using this method (dermis orbicularis muscle flap technique, DOMF), 698 cases of which were simultaneously operated with epicanthoplastic surgery. In the operation, DOMF was harvested in the dermis edge in lower incision margin. The flap was sutured to levatoraponeuros at the superior border of the tarsus. Patients were followed up for three months to three years. Results It was concluded that unfavorable results included low fold in 12 cases, relapse in 3 cases, asymmetric crease in 4 cases, puffy eyelids in 5 cases, and sunken appearance in 4 cases. The physicians and patients were satified with the results. The eyelid appeared smooth without fold depression on downward gaze or eyes closed, and it was gentle and not overly puff as eyes opening. Conclusions The DOMF technique mimics the movement of congenital crease fold, which is easy to perform, creating a delicate, firm and smooth upper lid orientation. Key words: Blepharoplasty; Surgery, plastic; Dermis; Immobilization; Orbicularis muscle flap