Getting Powerful Shapely Glutes

Unlock Your Glutes

Unlock Your Glute glutes is a program designed to help the users in the reduction of belly fat. The users would only follow this program for four weeks- fifteen minutes two times a week and the program was slated to work for 4 weeks. Its main aim is to help in strengthening the users' glutes, which are the combination of muscles that strengthen the body and aid movements as well as in dealing with the weakness of the body and the frustration that comes with getting butts. The program was not created to be a quick fix. In fact, like different programs, it is tasking but not time-consuming. It affords the users to choose between carrying out their exercises in the house or at the gym. The exercises meant to be used have been explained in the book formats, the manual for the users to understand and choose the ones they are capable of doing before they proceed to follow the instructions given in the videos. In other words, the program comes in the format of a manual and videos that will help the users achieve their goal. More so, the videos are not merely videos for strengthening glutes, there are some others for strengthening your legs. Read more...

Unlock Your Glutes Summary

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Author: Brian Klepacki
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Highly Recommended

I started using this ebook straight away after buying it. This is a guide like no other; it is friendly, direct and full of proven practical tips to develop your skills.

I give this ebook my highest rating, 10/10 and personally recommend it.

Booty Type Training Program

The booty type training program aims at helping women acquire great butt shapes of their choice and step out of the house with full confidence in drawing all the men's' attention. The creator of this program goes by the name of Jessica Gouthro, but many of her clients have nicknamed her America's booty type coach. Through this program, Jessica has managed to help many women achieve their body shaping movements and also improve their backside. This program will help you learn a lot including the best workouts to perform and the best diet to observe to maintain permanent butt shape of choice. Jessica has put in place 60-day certificate of total money refund guarantee to any member who feels unhappy with this program which means that this program is risk-free and worth joining. Based on the many benefits associated with this booty type training program, I highly recommend it to every woman who wants to start the journey of having a sexy butt shape and experience how men always knock on her door. Read more...

Booty Type Training Program Summary

Contents: Ebooks
Author: Jessica Gouthro
Price: $17.00

Clinical manifestation

Often associated with history of sunbathing or walking barefoot on the beach tingling prickling, pruritus at site of exposure within 30 minutes of larvae penetration advancing, erythematous, often linear lesions, occurring on dorsa of feet, interdigital spaces of toes, anogenital region, buttocks, hands, and knees 2-3-mm-wide, ser-piginous, slightly elevated, erythematous tunnels, tracking 3-4 cm from penetration site vesicles with serous fluid occasional secondary impetiginization systemic signs peripheral eosinophilia and increased IgE levels

Dermatologic Physical Exam

Classic papular lesions have a predilection for flexural surfaces of joints and forearms. Other frequent sites are the dorsal hands, extensor shins, lateral neck, buttocks, sacrum, glans penis, and ankles (see Fig. 9). The face, scalp, palms, and soles are only rarely involved.

Considerations In Employing Simultaneous Open And Percutaneous Techniques

Stabilization of the SI joint using percutaneous screws is an exacting technique, as described above (10). In rotationally unstable injuries, SI screws may be used to achieve the final reduction, as well as stabilization. The patient is positioned supine on a radiolucent table. A liter bag of fluid swathed in gamgee can be placed posteriorly to allow the buttocks to hang a little, facilitating guidewire placement. A dry run with the image intensifier should be carried out, ensuring that anteroposterior (AP), inlet, and outlet views can be obtained. It is helpful to mark the floor of the operating room for the machine's position for the optimum views, as this speeds up intraoperative screening. After preparing the skin, the drapes should be applied and almost tucked under the patient's buttock to allow full access for the entry point.

Reconstructive Surgery

Small defects can be closed by primary suturing, especially where only the pliable scrotal skin is involved. Split thickness skin grafting is most often used and yields acceptable results, even in large defects (Hessel-feldt-Nielsen et al. 1986). Healthy skin from the legs, buttocks, and arms can be used, in a single or multiple settings. Skin defects on the penile shaft should be liberally grafted so as to prevent fibrotic scar formation with future erectile problems.

Gender Ethnicracial And Life Span Considerations

Because early cervical cancer is usually asymptomatic, establish a thorough history with particular attention to the presence of the risk factors and the woman's menstrual history. Establish a history of later symptoms of cervical cancer, including abnormal bleeding or spotting (between periods or after menopause) metrorrhagia (bleeding between normal menstrual periods) or menorrhagia (increased amount and duration of menstrual bleeding) dysparuenia and postcoital bleeding leukorrhea in increasing amounts and changing over time from watery to dark and foul and a history of chronic cervical infections. Determine if the patient has experienced weight gain or loss abdominal or pelvic pain, often unilateral, radiating to the buttocks and legs or other symptoms associated with neoplasms, such as fatigue.

Posterior Ring Injuries Sacroiliac Joint Injuries

The open approach to the posterior pelvic ring requires that the patient be placed in a prone position on bolsters (9). This can make monitoring difficult, but prone position is usually well tolerated by patients and may actually be beneficial for pulmonary function. After identifying the posterior superior iliac spine, a longitudinal incision is made either medially or laterally to this landmark depending on whether the injury involves the sacrum or the sacroiliac joint. For fractures involving the iliac wing, the proximal extent of the incision can be curved laterally along the iliac crest. Due to the bony prominence of the sacral spine, an incision directly over the sacral midline is fraught with wound complications, especially in those patients who must remain supine in the intensive care for prolonged periods. The most commonly used skin incision is made just lateral to the sacral midline, extending from the level of the posterior superior iliac spine distally for 8 to 10 cm. The...

Choosing Your Infusion

Cator will work with you to choose a set that will work best for you. There are some pump sets that have a cannula (plastic tubing) angled at 30 to 45 degrees, and some sets with a straight cannula (90 degrees). Most are made of Teflon, but there are some that are made of metal. The angled sets are more reliable than the straight sets in that they are less likely to get kinked, but the disadvantage of the angled sets is that the introducer needle is longer. Some sets need to be inserted manually, and others can be inserted with a spring-loaded insertion device. The insertion device makes it easier to place the sets in hard-to-reach places such as the buttocks. Inserting sets is clearly a little more painful than using a needle, but you are only doing it once every three days. For children, using a numbing lidocaine cream like EMLA or LMX 4 percent before insertion can make it easier.

Clinical Application Questions

A young mother seeks help for an uncooperative 5-year-old with a 7-day history of dermatitis of the right posterior thigh, right buttock, and right foot. Examination reveals patches of secondarily infected (impetiginized) dermatitis. Some areas are urticarial, while others are clearly vesicular. Excoriations are present, and the mother states that the eruption has gradually spread over several days. The vesicular eczematous areas and excoriations lead you to suspect toxicodendron exposure.

Structural Features of the Lower Extremity

The lower extremity, as defined by this volume, consists of the femur, tibia, fibula, and the bones of the ankle and foot (Fig. 1). These lower limb long bones are the strongest within the human body, building on our evolutionary heritage of bipedal locomotion. The lower extremity has evolved to accommodate large amounts of compres-sive stress, a condition that has been compounded by modern life, with its hard surfaces and the potential for concentrated forces from certain types of footwear (e.g., high heel shoes). The hip joint provides for a wide circular range of movement with limitation of movement largely defined by the interference of soft tissue. The thigh angles inward so that pressure on the femur must be redirected into the hip joint. This structure leaves the femoral neck relatively weak, although it is well supported by the large muscles of the buttocks and thigh.

Modificationgreater Trochanteric Osteotomy

If a Kocher-Lagenbach posterior approach is undertaken and exposure appears inadequate, there are several tricks for adding exposure. The proximal 1 -2 cm of the gluteus maximus sling may be tagged and detached, leaving a tendinous cuff to repair. This permits further posterior retraction of the gluteus maximus, may allow greater visualization and a wider field, particularly in patients who are somewhat obese. If further extension into the superior and lateral aspects of the ilium and the lateral aspect of the dome must be obtained, greater trochanteric osteotomy may be performed. Through retraction of the skin and tensor fascia anteriorly, the anterior and posterior aspects of the greater trochanter may be visualized. The deep aspect of the gluteus medius is then identified and dissected away from the gluteus minimus right at the level of the femoral head and neck. With a combination of direct visualization laterally and use of a clamp on the deep surface of the medius, the anterior...

Modified Extensile Lateral Approach

The hip is then flexed and a bolster is placed between the knees. The fascia lata is then opened longitudinally on the posterior margin of the femur in what would normally be the fascial incision of the Kocher-Lagenbach approach. Proximally the dissection divides between the fibers of the gluteus maximus. The most distal tendon insertion in the gluteus maximus may be partially released after being tagged to allow better mobilization of the posterior mass of the gluteus maximus. Trochanteric osteotomy is then performed. Abductor mass, specifically the gluteus medius, is elevated from the lateral capsule. Osteotomy may be performed with a Gigli saw, osteotome, or power cutting instrument. Osteotomy may be predrilled to plan for later fixation with two screws.

In Vivo Assays of Langerhans Cell Migration

Allergen-induced changes in human epidermal LC frequency and morphology. Sites identified on the hip or buttock were exposed to 50 mL of (A) 2 diphenylcyclopropenone in acetone, or an equivalent volume of (B) vehicle (acetone) alone. LC frequency and morphology were assessed following indirect immunofluo-rescence staining for CD1a expression of epidermal sheets prepared from skin biopsies taken 17 h later. Magnification x50. Fig. 1. Allergen-induced changes in human epidermal LC frequency and morphology. Sites identified on the hip or buttock were exposed to 50 mL of (A) 2 diphenylcyclopropenone in acetone, or an equivalent volume of (B) vehicle (acetone) alone. LC frequency and morphology were assessed following indirect immunofluo-rescence staining for CD1a expression of epidermal sheets prepared from skin biopsies taken 17 h later. Magnification x50.

Gracilis versus Gluteus

No randomized, controlled trials exist to compare the efficacy of the gluteus maximus muscle to the gracilis muscle in creating a neosphincter. Certain factors, such as anatomy and function, as well as the primary reason for fecal incontinence, dictate decision making. At our institution, the gluteus muscle is preferred in patients who require considerable muscle bulk, who need moderate resting tones with high squeeze pressures, who would benefit from a complete rectum wrap, and who have minimal rectovaginal scarring. Alternately, the gracilis muscle is chosen in patients who have a deficient perineal body, who have extensive scarring of the rectovaginal septum (requiring an anterior approach), who have some native sphincter function with moderate incontinence, and who have minimal needs for high squeeze pressures 7-22 .

Surgical Approach and Operative Technique

Following intubation and induction of general anesthesia, the patient is transferred to the prone, jack-knife position (Fig. 1b). Perirectal incisions are made laterally at the junction of the skin and anoderm, exposing the contralateral ischial tuberosity (usually the left), which is marked with a braided, permanent suture that is anchored in periosteum and later attached to the tendon of the transferred muscle Anterior and posterior rectal tunnels are developed with blunt and sharp dissection, avoiding rectal perforation. The lower third of the gluteus maximus muscle is then harvested through a sigmoid incision placed near the infragluteal crease. Effort is made to preserve the posterior cutaneous nerve of the thigh. The gluteus is detached from its insertion on the posterior gluteal tubercle of the femur, saving a strip of tendon and periosteum for later fixation to the ischial tuberosity (Fig. 1c)

Henoch Schonlein Purpura

Henoch-Schonlein purpura (HSP) is a disease that manifests symptoms of purple spots on the skin, joint pain, gastrointestinal symptoms, and glomerulone-phritis. HSP is a type of hypersensitivity vasculitis and inflammatory response within the blood vessel. It is caused by an abnormal response of the immune system. The exact cause for this disorder is unknown. The syndrome is usually seen in children, but people of any age maybe affected. It is more common in boys than in girls. Many people with HSP had an upper respiratory illness in the previous weeks. Purpuric lesions are usually over the buttocks, lower legs, and elbows. Besides purpuric lesions, nephritis, angioedema, joint pains, abdominal pain, nausea, vomiting, diarrhea, and he-matochezia can be seen. The scrotum can also be affected in 13 -35 of cases (Ioannides and Turnock 2001). While the testis and or scrotum can rarelybe involved, usually the scrotum is diffusely tender with erythema distributed all over the scrotum....

NOC Risk Detection

Assess infant up to 2 months of age for frank breech birth, cesarean birth, hip joint laxity or dislocation (Ortolani or Barlow test), degree of dysplasia or dislocation, shortened limb on the affected side (telescoping), broadened perineum, asymmetry of thigh and gluteal folds with increased number of folds and flattened buttocks.

Cauda Equina and Lumbosacral Plexus Disorders

The incidence and prevalence of cauda equina lesions are not known, but it is estimated that they constitute from 1 to 5 of spinal pathology 78 . Cauda equina compression is an acute emergency that may develop as a sudden major disk prolapse in a patient with a long history of sciatica or of previous lumbar or sacral laminectomy, sometimes postoper-atively following disk excision with hemorrhage at the operative site. The disk usually involved is L4-L5, but herniations at other levels can occur, inducing a similar syndrome. The clinical picture is characterized by weakness and sensory loss in the lower limbs, buttocks, and perineum, usually with marked impairment of bladder, bowel, erectile, and ejacula-tory function. Symptoms and signs vary depending on the nerve roots involved, the size and position of the disk herniated, and the dimension of the spinal canal. The patient complains usually a loss of sensation and burning pain in the perineum, with a characteristic saddle...

Dbride for Skin Ulcer or Cellulitis with CC

K pressure ulcer is an irregularly shaped, depressed area that resulted from necrosis of the epidermis and or dermis layers of the skin. Prolonged pressure causes inadequate circulation, ischemic ulceration, and tissue breakdown. Muscle tissue seems particularly susceptible to ischemia. Pressure ulcers may occur in any area of the body but occur mostly over bony prominences that can include the occiput, thoracic and lumbar vertebrae, scapula, coccyx, sacrum, greater trochanter, ischial tuberosity, lateral knee, medial and lateral malleolus, metatarsals, and calcaneus. Some 96 of pressure ulcers develop in the lower part of the body, with the hip and buttock region accounting for almost 70 of all pressure sores.

Vascular Complications in Pelvic and Acetabular Fractures

Iatrogenic injury to the superior gluteal vessels can occur during acetabular exposures utilizing a variety of posterior approaches because of the proximity of the vessels exiting superiorly from the greater sciatic notch. Injury can result in significant blood loss and gluteal muscle necrosis (2,3,49). Other than significant intraoperative bleeding, the clinical significance related to this iatrogenic injury and possible muscle necrosis is still in question (50).

Skin Preparation of Surgical Sites

Spores are usually not of concern, but the skin of buttocks and upper leg often has transient contamination with spores, especially that of Clostridium perfringens from feces, and operations with poor arterial supply (e.g., amputation of a leg for diabetic gangrene) carry special risk of endogenous gas gangrene. Bacterial spores are resistant to alcohol, chlorhexidine, and QACs, and only halogens, like povidone-iodine, have some activity, but require prolonged contact time 93 . This should be considered before high-risk operations. FDA categorized only iodine products with alcohol as category 1 agents (generally recognized as safe and effective) 77 .

Internal Anal Sphincter Weakness Minor Soiling

If patients report normal bowel habits with minor seepage, the best approach is to employ an anal cotton pledget to occlude the anal canal. This is held in place by the gluteal muscles and tissues and serves as a physical and absorbent barrier to anal seepage, somewhat analogous to a vaginal tampon. The use of a narrow panty liner serves as a contingency mechanism and prevents underwear staining. This is particularly useful for ambulatory persons and has the added advantage of being inexpensive and readily available. This device is often effective for patients with minor seepage due to anal cushion defects, i.e., after hemorrhoidectomy or fistula in ano.

Heterotopic Ossification

Heterotopic ossification (HO) is a common complication following acetabular surgery and can jeopardize the functional outcome of patients. Overall, rates of HO have been reported to vary from 45 to 100 , with the rate of severe HO between 14 and 50 when no prophylaxis is used (2,3,57,62,149,150-152). When nonoperative treatment is selected, HO is rare (50). A direct relationship between the severity of HO and loss of function has been demonstrated, thus making prophylaxis routine for most surgeons (151). Significant reported potential risk factors for HO development include head injury, type and severity of the fracture, time delay to surgery, trochanteric osteotomy, and associated injuries to the abdomen and chest (50,153-155). The most commonly reported and convincing risk factor for HO is the surgical approach, with the extended iliofemoral and the Kocher-Langenbeck approaches having the highest rate of HO and the ilioinguinal approach the lowest (50,63,152,154). The major...

Microdistribution None

Herpes genitalis in men is most common on the penile shaft. It is also seen on the foreskin and on the skin at the base of the penis. In women, lesions may occur on the vulva, within the vaginal vault, or on the cervix. Lesions are also common on the proximal thigh and buttock skin from primary inoculation. In homosexual and bisexual patients, perianal and anal lesions are seen.

Clinical Features Of

Cutaneous findings are present in the great majority of TSC patients and are the most easily identified sign of the disease. 1,2 Most lesions are of minor clinical significance, but facial angiofibromas can be a significant cosmetic issue. Hypomelanotic macules or white spots typically have a lance-ovate shape (Ash-leaf) and are most common over the trunk and buttocks. Three or more of these lesions are very unusual in the general population and thus are considered a major diagnostic criterion (Table 1). The lesions are present at birth and do not change, although they are more easily observed following suntanning. Facial angiofibromas are red to pink papules or nodules with a smooth surface that are found in a malar distribution and extending down to the chin. 1,2 They typically first appear between the ages of 2 and 6, and progress to a variable extent during puberty. Histological findings are dermal fibrosis and angiogenesis with occasional large glial appearing cells. Forehead...

Management of the polycystic ovary syndrome

Trans Vaginal Scan And Polycystic Ovarys

Hirsutism is characterized by terminal hair growth in a male pattern of distribution, including chin, upper lip, chest, upper and lower back, upper and lower abdomen, upper arm, thigh and buttocks. A standardized scoring system, such as the modified Ferriman and Gallwey score may be used to evaluate the degree of hirsutism before and during treatments (Fig. 39.4). Many women attend having already tried cosmetic techniques and so it may be difficult to obtain a baseline assessment.

Intrapartum management

Delivery Breech Primigravida

In most cases of breech presentation there is a tendency for mothers to have early bearing down sensation and hence cervical dilatation should be checked and the mother encouraged to bear down only when the breech has reached the perineal phase of the second stage. It is important not to intervene early and to have the mother in lithotomy only after the anterior buttock and anus of the baby come into view over the mother's perineum with no retraction in between contractions. An episiotomy may not be essential in multipara with a distensible perineum but may be an advantage in a primigravida. This is done with the regional block or with pudendal block and local infiltration of the perineum.

Neurophysiologic Investigations

A clinical neurological examination is performed with special attention to the status of the lower limbs and the perineal and buttock areas, particularly looking for signs of pyramidal and peripheral nervous system lesions 107 . Examination usually includes anal sphincter tone, strength in the S1-S2 innervated muscles (gastrocnemius, gluteal muscles), sensation extending from the soles of the feet to the perianal area, and presence of anal and bulbocavernous reflexes. Anal reflex is induced by pricking or scratching the perianal skin area, whereas bulbocav-ernosus reflex is evoked by a nonpainful clitoral or gland squeeze 108, 109 . Clinically elicited reflexes may be extinguished by mild or severe nerve lesions, whereas the same reflexes can be recorded neuro-physiologically, though with a prolonged latency and reduced amplitude, also in almost complete nerve lesions 110 .

Erythrokeratodermia variabilis

Transient, circumscribed, highly variable, figurate erythematous patches, sometimes surrounded by a hypomelanotic halo, involving any part of the skin lesions most prevalent during childhood and sometimes becoming less frequent as the patient ages burning sensation sometimes preceding or accompanying erythema variably changing, brownish, hyperkeratotic plaques with geographic borders, symmetrically distributed over the limbs, buttocks, and trunk flexures, face, and scalp usually spared

Risk For Impaired Skin Integrity

Defining Characteristics (Specify redness edema irritation of skin, perianal area, buttocks excoriation or maceration of skin enforced bed rest induration or fissure in skin scratching rash scales crusting disruption of skin surface destruction of skin layers with or without necrosis open wound with drainage pressure from cast, splint, brace, or other appliance device prolonged placement in one position.)

Physical Examination

Assessment must begin with a general examination to investigate possible underlying systemic illnesses that can cause incontinence. Therefore, it should include a neurologic assessment. Anorectal examination must be undertaken in the most comfortable position for the patient. Different options have been described, but the suitable one is the left lateral position, with flexed thighs and knees and with the buttocks slightly out of the limit of the table. This position usually allows a satisfactory inspection of the perineum. Before the examination starts, it is advisable to inspect the underclothes of the patient to check for soiling and the use of protective pads. Anorectal examination should include inspection, palpation, digital examination, and proctoscopy.

Digital Examination

When palpating the anal canal in its entire length and circumference, gaps can be observed indicating the presence of sphincter defects. However, the absence of these gaps does not exclude the presence of sphincter defects. Digital examination permits evaluation of the sphincter tone at rest and during squeeze. The positive predictive value of this examination to detect low pressure at rest or during contraction is high 2 . In any case, the perceived tone by digital examination must be considered only as a first approach because it is dependent on multiple factors, including the surgeon's experience, finger measurement of the observer, patient position and cooperation, and coexistence of other illness. As an example, neurologic diseases, even after spinal or cauda equina injuries, may present with an apparently normal sphincter tone, while radial traction at the anal margin or separating the buttocks may show an anal wink that normal individuals would not present 3 . Therefore, the...

Outcome Criteria

Change diaper frequently as needed (in infant), expose buttocks to air and apply skin protective ointment to buttocks and perianal area in infants and anal area in children if irritated and sore wash area with warm water after each diarrhea episode (commercial wipes may be used if skin not irritated).

History And Exam

This 38-yr-old man had 6 weeks of decreased contrast in vision OS, like a bad photocopy, with fading of colors and darkening. The other eye was fine. Two years earlier he had been hospitalized with numbness progressing from his feet to his buttocks over a few days, which resolved almost completely over several weeks. A year earlier he had

Glucagon Injection

A glucagon kit has a vial with 1 mg of powdered glucagon and a syringe containing diluting solution. To prepare the glucagon, inject all of the solution in the syringe into the vial of glucagon. Shake the vial to dissolve the glucagon and draw the solution back up into the syringe. Inject into the thigh, buttock, or arm. Glucagon injection works faster if it is injected into a muscle. For children who weigh less than forty-four pounds, inject half the contents of the glucagon syringe. Glucagon can cause nausea, and so the person being treated should be put on her side in case she vomits. The glucose level does not stay up for very long, and so once the person is awake, give her additional glucose by mouth. Using glucagon can allow the patient to be treated at home and avoid having to be admitted to the hospital, but paramedics should be called if the patient is having a seizure or is not responding within ten to fifteen minutes after the glucagon injection. If you know that the coma...

Operation

Once in the operating room, either general or regional anesthesia may be employed. A urinary catheter is placed. We prefer to place patients in the prone jack-knife position, although others favor the lithotomy position. Prone exposure is facilitated with a large, padded roll under the pelvis and with the buttocks taped apart. After standard skin preparation, a local anesthetic is injected to provide a regional nerve block and assist with hemostasis. Our preference is 0.25 bupivacaine with epinephrine. Anterior sphincter defects are best approached with an elliptical incision around the anterior portion of the anus over the perineal body. We prefer to use a needle-tip electrocautery for dissection and a circular, self-retaining retractor for exposure. For non-obstetric-related sphincter defects, the initial incision is made directly over the defect, with enough length to facilitate exposure of healthy muscle. Once the sphincter complex is freed from its surrounding structures, the...

Posterior Approach

The posterior, or Kocher-Langenbeck, approach is familiar to most orthopedic surgeons from arthroplasty experience, but this can often lead to a false sense of confidence in that the technique is different when attempting to reduce and stabilize a fracture. The general indications for this approach are posterior wall and posterior column fractures and T-type and both-column fractures, which require direct posterior exposure. Visualization from the greater sciatic notch to the ischial tuberosity including the lateral aspect of the posterior column and posterior wall is usually achieved, and while palpation of the superior lateral dome is possible, visualization past the 12 o'clock position necessitates some type of trochanteric osteotomy. Fundamental to current technique is an emphasis on minimizing subperiostial and external rotator dissection and gluteal muscle damage in an attempt to avoid heterotopic ossification.

Operative Technique

The patient is admitted on the day of surgery and prior to the operation is given an enema to empty the rectum. With induction of the anaesthetic, prophylactic antibiotics are given in the form of 1 g Cefoxitin and 500 mg metronidazole intravenously. The patient is placed in a prone jack-knife position, with the buttocks spread apart using adhesive tape. A curvilinear incision is made 6 cm posterior to the anus (Fig. 2), and dissection is directed to the intersphinc-teric plane, which is relatively bloodless. Fibres of the external sphincter are red in colour and contract with diathermy stimulation, while those of the internal sphincter are white and do not contract to diathermy current. Dissection is then deepened in the inter-sphincteric plane to the upper part of the external sphincter and puborectalis muscle, finally exposing the levator ani fascia and the mesorectal fat. This dissection is extended anteriorly to include half of the circumference of the anal canal. A deep 90...

Surgical Technique

The patient is positioned either prone or lateral, depending on surgeon preference, and prepped from the iliac crest down to the knee or below. The skin incision extends from the posterior inferior iliac spine down to the posterior one third proximal femur, the actual length dictated by the fracture and patient size. The gluteus maximus is divided in line with its fibers and the tensor fascia latae is split longitudinally. Bursal tissue overlying the greater trochanter is either split or resected, and careful palpation and blunt dissection are used to identify the gluteus medius and minimus insertions onto the greater trochanter, as well as the piriformis and short external rotator insertions onto the posterior proximal femur. In most cases, these posterior tendonous structures are intact, even in the face of posterior dislocation and associated capsular tearing. The gluteus minimus often has a deep reflection, which inserts on the superior lateral capsule, and failure to recognize...

Anatomy and Function

The gluteus maximus muscle arises from the outer surface of the os ileum, sacrum, coccyx, and sacro-tuberous ligament and inserts into the iliotibial tract and gluteal tuberosity of the femur. Motor innervation is derived from the inferior gluteal nerve, which is composed of nerve roots L5, S1, and S2 therefore, fecal incontinence secondary to spina bifida or myelomeningocele are absolute contraindications to gluteoplasty 23 . The superior and inferior gluteal arteries supply blood to the muscle at its proximal origin, making gluteoplasty contraindicated in those with Leriche syndrome 6 . Because the neurovascu-lar bundle is proximal, distal muscle transposition has little or no adverse effect 23 .

History

In 1902, Chetwood first described the use of the gluteus maximus muscle as an anal neosphincter. Transposing the gluteus muscles by crossing them underneath the ligamentous connection between the anus and the coccyx, Chetwood successfully treated a patient who developed fecal incontinence secondary to trauma 4 . Today, some argue that his reported results are a product of fibrosis as opposed to functionality 5 . In 1944, Bistrom also utilized the gluteus muscle in treating fecal incontinence. He created a hole in the detached origin of the muscle, through which he brought the rectal stump 24 . Over the next half century, attention turned from the gluteus maximus muscle as a potential neosphincter and focused on the gracilis muscle. In 1981, Bruining reintroduced the gluteus, describing a technique in which this muscle is detached from the femur and elevated to the level of the proximal neu-rovascular pedicle. Both muscles are then wrapped around the rectum, after splitting the distal...

Eruptive Xanthoma

Crops of red-yellow papules on buttocks and thighs EX presents as 1- to 4-mm reddish-yellow papules on the buttocks or extensor surfaces of the thighs and arms (Figure 31.1) (3). The lesions may be surrounded by an erythematous halo and usually occur in crops that may coalesce, forming plaques. Their presence is indicative of a triglyceride level that typically exceeds 2000 mg dL. Other clinical stigmata of EX include ocular, abdominal, and pulmonary findings. The most important ophthalmic complication is lipemia retinalis. On fun-doscopic examination, the retinal arteries and veins appear white and engorged. The risk of lipemia retinalis increases when serum triglyceride levels exceed 4000 mg dL. Abdominal pain is a common accompaniment to EX. The source of the pain may be due to acute pancreatitis or hepatosplenomegaly. Chest pain or dyspnea may also occur due to decreased pulmonary oxygen diffusing capacity that may be aggravated by abnormal hemoglobin oxygen affinity. The natural...

Initial Management

This requires a team effort involving general surgery, neurosurgery, urology, and orthopedic surgery, all directed at assessing the patient's injuries. The initial history should include the mechanism of injury, their current medications, any existing medical problems, and whether they were independent or limited ambulators prior to their injury. During the orthopedic physical examination, an effort should be made to touch all the bones, while avoiding the temptation to focus on obvious injuries. The spine should be inspected and palpated and the pelvis should be stressed looking for any instability. The examination should also include a thorough neurologic and vascular examination and an attempt should be made to look for any wounds, contusions, or hemorrhage along the flank, buttocks, or perineum (48). To complete the examination, the rectum and vagina should also be evaluated for any tears. In males, a high riding prostate or any other abnormality should be identified....

Emergency Surgery

Erectile Fracture

Experience now indicates that application of a pelvic binder (whether improvised or a commercially available orthosis) is easy and effective (10-12). It can be applied to a conscious patient in the following manner (Fig. 1). Having identified the need for a binder, a pillow should be folded in two to make a bolster and secured with sticky tape. A cotton sheet is then slid under the patient's buttocks to the level of the greater tro-chanters and tied with a single throw of a wreath knot at the front. Three cable ties should then be passed under this single throw. The bolster is placed behind the patient's knees, and two assistants then lean towards each other, pressing firmly on opposite trochanters. The single throw can then be pulled tight and secured with cable ties, and six-inch crepe bandages applied around the lower thighs (not the knees) and ankles, suitably padded (13). A radiograph must then be taken to confirm reduction, and when desired, inlet and outlet views also. Properly...

Blue Nevus

Malignant Melanoma Eyelid

CLINICAL PRESENTATION The common blue nevus appears as a solitary, smooth surfaced, well-circumscribed oval lesion that is flat to slightly elevated. It is usually less than 1 cm in diameter. Blue nevi vary in color from blue to blue-black and may have a grey or whitish center. They occur most often on the back of the hands, face, and on the buttocks. While they usually occur in the skin, blue nevi can also be seen in the sclera, conjunctiva, and orbit. When present from birth the nevus typically remains unchanged throughout life, but most develop later in life and can show very slow growth.

Enterovirus 71 HEVA

Enterovirus 71 is one of the two major HEV-A serotypes causing the relatively common hand-foot-and-mouth disease (HFMD) in children, the other being CVA16. In the western world, CVA16 has been dominating but in Southeast Asia, EV71 has caused severe outbreaks since the late 1990s with sometimes transmission of CVA16 coinciding. The usually self-limiting HFMD starts with fever followed by appearance of flat or raised red spots in the tongue, gums, and inside of the cheeks, as well as on palms, soles of feet, and occasionally buttocks. The spots may develop to blisters and in the mouth further turn to ulcers. The rash does not usually itch. Neurological complications, aseptic meningitis, encephalitis, and poliomyelitis-like polyneuritis are relatively common in EV71 but rare in CVA16 infections. In the large Southeast Asian epidemics during the last decade, meningo-encephalitis has occasionally been an alarmingly common complication with significant associated mortality especially in...

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