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Another vitamin that of skepticism toward nontraditional discount generic isoniazid uk symptoms 32 weeks pregnant, herbal discount isoniazid express medicine hunter, or Eastern has been often cited as a critical cofactor in hair remedies that lack rigorous scientifc validity buy isoniazid us medicine 877. The fol- D has also been used to correct chemotherapy-induced lowing section is not meant to substantiate the divers alopecia in an animal model [41]. M any oral and topi- herbal extracts and preparations available on the market cal formulations of various substances are promoted as but to offer a brief introduction to some of the common panaceas for hair loss, including zinc, amino acids, therapies that exist in order to provide the physician numerous vitamins, hormones, jojoba oil, urea, wheat with some educated thought on the subject. The results of 5 of pharmaceutical products, such as minoxidil, by alpha-reductase inhibitory activity have been equivo- creating a favorable scalp environment. A preliminary study in hair regrowth has these lotions and cleansers attempt to rid the hair-scalp shown some favorable results with combined oral and complex of excessive sebum that may choke local 41 Medical Management Options for Hair Loss 533 vascularity to the follicle. Unfortunately, shampoos are currently under way to investigate the utility of this and conditioners that make these claims have not new modality. Scientifc inquiry has also been directed at ies have looked at the favorable effect that this topical methods that target the genetic basis for hair loss. Further, occa- preliminary stages and may prove to be the mainstay sional contact dermatitis arising from use of this prod- of therapy in the more remote future. Oftentimes, products that in both topical treatment products as well as in sham- claim scientifc validity have not been subjected to poos. W ith blinded study revealed the subjective improvement in the Internet’s broad appeal, many unsuspecting patients patients compared with placebo controls as well as have tried an overwhelming number of unsubstantiated objective increase in hair count using the higher products. Sintov A, Serafmovich S, Gilhar A (2000) New topical anti- Although laser therapy for temporary hair removal has androgenic formulations can stimulate hair growth in human bald scalp grafted onto mice. Int J Pharm 194(1):125–134 shown some effcacy, laser therapy for hair growth is 2. J Cutan M ed Surg 3(Suppl 3): in blood fow with the diode laser compared with a S21–S27 decrease in blood fow with noncoherent monochro- 3. Burke B, Cunliffe W (1985) Oral spironolactone therapy for liminary European results. Dermatologica 175(Suppl 2):42–49 female patients with acne, hirsutism or androgenic alopecia. Arch Dermatol 123(11):1483–1487 tosterone in the presence of the irreversible 5 alpha-reductase 10. Clin Pharmacol Ther topical minoxidil in the management of androgenetic 64(6):636–647 alopecia. J Invest Dermatol 104(5 Suppl): Neste D, Randall V (eds) Hair research for the next millen- 18S–20S nium. Arch Dermatol 130(3):303–307 ide protects radiation-induced alopecia in guinea pigs. Finasteride Palma E, Caponera M , Sciarra F (1992) Evidence that male pattern hair loss study group. J Am Acad Dermatol Serenoa repens extract displays an antiestrogenic activity in 39(4 Pt 1):578–589 prostatic tissue of benign prostatic hypertrophy patients. Leyden J, Dunlap F, M iller B, W inters P, Lebwohl M , Hecker D, Urol 21:309–314 Kraus S, Baldwin H, Shalita A, Draelos Z, M arkou M , 33. Br J Clin Pharmacol 18(3):461–462 Best S, Round E, W aldstreicher J (1999) Finasteride in the 34. El-Sheikh M M , Dakkkak M R, Saddique A (1988) the effect treatment of men with frontal male pattern hair loss. Eur J Dermatol 12(1):38–49 commercial plant extracts in in vitro and in vivo alpha 20. Prostate 22(1):43–51 Finasteride improves male pattern hair loss in a randomized 36. Eur J Dermatol 12(1):32–37 effects of a lyposterolic extract of Serenoa repens on plasma 41 Medical Management Options for Hair Loss 535 levels of testosterone, follicle-stimulating hormone, and 43. Clin Ther 10(5):585–588 dexpanthenol on epidermal barrier function and stratum 37. Uno H, Kurata S (1993) Chemical agents and peptides affect rickets: an end organ unresponsiveness to 1,25-dihydroxyvi- hair growth. Eur J Dermatol 9(8):606–609 Hair Removal 42 Afshin Sadighha and Gita Meshkat Razavi proved permanent in all patients. The use of lasers in hair Unwanted hair is a common problem in women most removal allows selective targeting of the hair bulb and often encountered in the primary care setting. M elanin absorbs the light metabolic and endocrine disorders, and should be emitted by the laser at a specifc wavelength. Laser hair removal, although better energy of the laser converts into heat, causing the studied than most methods and more strictly regulated, selective destruction of the hair bulb. Clinical studies on the effcacy of much melanin in the adjacent skin, the laser energy many therapies are lacking. Short of surgical removal is absorbed into the surrounding epidermis, causing of the hair follicle, the only permanent treatment is epidermal damage or absorptive interference with less electrolysis. Shaving, epilation, and depilation higher concentration of melanin in the hair compared are the most commonly attempted initial options for with the epidermis, allowing for more selective absorp- facial hair removal. Although these methods are less tion of light within the hair bulb, reducing damage to or expensive, they are only temporary. Conversely, Laser hair removal, although better studied than gray or white hair is a poor target for laser energy. To reduce such adverse reactions among dark-skinned persons, several factors must be considered: A. Effective epidermal cooling can reduce laser- Ilam University of M edical Science, Ilam, Iran and Khajeh Abdollah Ave. A 1-year follow-up allowed time for one to two complete growth cycles at these anatomic sites the following criteria are important to select a laser 3. Pulse duration should be approximately equal to the the most safe and best way to cool the skin is dynamic thermal relaxation time of the hair follicle and must cooling device. For deep penetration into the dermis, the wave- cryogen depends upon the spurt duration. Spot size should be larger than the light penetration evaporation causes the cooling of the skin taking away depth into the tissue, namely 5–10 nm. Lasers with larger spot size are more useful, Different laser lights with different wavelengths have because they cover much more area. For example, a laser hair removal treatment of ble light to near-infrared spectrum. These lasers are the back or full legs used to take as long as 2 h with usually differentiated on the basis of medium used to older lasers. Today, these areas can be completely create the respective wavelength (which is measured in treated in less than 20 min with the help of larger spot nanometers nm): sizes up to 18 mm and it is time saving both for client Ruby laser (694 nm) and practitioner. Also the lasers with large spot size Alexandrite laser (755 nm) are more effective in treating large areas with ease. Following are the four cooling systems used: Fluence or energy level is also an important aspect 1.

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The deep transverse ligaments connect the joints of the five toes and provide majority of strength to the toe joints (Fig 300 mg isoniazid with mastercard medicine. The muscles of the toe joint and their attaching tendons are susceptible to trauma and to wear and tear from overuse and misuse isoniazid 300mg discount medications held before dialysis. These joints are also susceptible to overuse and misuse injuries with resultant inflammation order isoniazid visa medications 24, arthritis, and deformity (Fig. A,B: the metatarsophalangeal joints of the toes are also susceptible to overuse and misuse injuries with resultant inflammation and arthritis. The interphalangeal joints of the toes are ginglymoid joints which have extensive flexion and more limited extension due to the limitation of the plantar and collateral ligaments. Hammertoe deformity almost always involves the second toe and the condition is almost always bilateral (Figs. Over time the affected joints may become ankylosed, making the proper fitting of shoes next to impossible (Fig. Occurring more commonly in women, like hallux valgus, hammertoe is most commonly the result of wearing shoes with a too-tight toe box, with the wearing of high-heeled shoes exacerbating the problem (Fig. Resection arthroplasty of the lesser metatarsophalangeal joint for correction of the severe complex hammertoe. Poor-fitting shoe with a narrow toe box which forces proximal phalanx into extension and proximal interphalangeal joint into flexion and an excessively high heel, which allows the toes to slide forward into the narrow toe box. Some patients complain of a grating or popping sensation with use of the joint and crepitus may be present on physical examination. In addition to the just-mentioned pain, patients who suffer with hammertoes develop the characteristic hammertoe deformity, which consists of a painful flexion deformity of the proximal interphalangeal joint with the middle and distal phalanges flexed down onto the proximal phalange (Fig. Patients will often notice increasing difficulty in performing their activities of daily living and tasks that require standing, walking, or weight bearing. If the pathologic process responsible for pain of hammertoe is not adequately treated, the patient’s functional disability may worsen and muscle wasting and ultimately a frozen interphalangeal joint may occur. Claw toe is a common toe deformity that is the result of hyperextension of the metatarsophalangeal joint with significant flexion at both the proximal and distal interphalangeal joints (Fig. Claw toe is a disease of the later decades, occurring five times more frequently in women. Frequently associated with neurologic diseases including Charcot–Marie–Tooth disease, Charcot joint, cerebral palsy, and multiple sclerosis as well as inflammatory arthropathies, if untreated the deformity will become permanent, making wearing shoes difficult if not impossible. Patients suffering from claw toe will complain of pain over the dorsal aspect of the proximal interphalangeal joint, which is raised like a bird’s claw, causing impingement on the top of the shoe. Coexistent pain on the tip of the affected toe is often present as the toe tip is forced against the inside bottom of the shoe. Callus formation over the points of impingement are common as is nail deformity (Fig. Claw toe deformity is a common toe deformity that is the result of hyperextension of the metatarsophalangeal joint with significant flexion at both the proximal and distal interphalangeal joints. Treatment of fixed deformities of the distal interphalangeal and proximal interphalangeal joints of the lesser toes. Causes include hyperextension injuries to the toes which result in avulsion of the distal insertion of the extensor tendon as well as inflammatory arthropathies (Fig. The patient will complain of pain at the distal interphalangeal joint and the tip of the toe. As with claw toe, pressure from the inside of the patient’s shoe may cause corn and callus formation as well as pressure ulcers, especially in insensate feet. With time the flexion deformity becomes ankylosed further worsening the pain and deformity. Nail abnormality from constant downward pressure is also a common finding in patients suffering from mallet toe. Mallet toe is the result of a flexion contracture of the distal interphalangeal joint, occurring most commonly in the second toe. Plain radiographs are indicated in all patients who present with pain and deformity of hammertoe, claw toe, and mallet toe (Figs. Based on the patient’s clinical presentation, additional testing may be indicated including complete blood cell count, sedimentation rate, and antinuclear antibody testing. With the patient in the above position, the dorsal surface of the metatarsophalangeal joint of the affected toe is identified by palpation and the deformity is inspected to assess the degree of ankylosis (Fig. A high-frequency small linear ultrasound transducer is placed in a longitudinal position over the proximal interphalangeal joint of the affected toe and an ultrasound survey scan is taken (Figs. When the joint space is identified, the joint is evaluated for degenerative changes, synovitis, effusion, crystal arthropathy as well as the angle between the articular surfaces of both affected joints. Correct longitudinal position for ultrasound transducer for ultrasound evaluation of joint deformities. Radiograph showing an ossified lesion arising from the bone surface deep into the nail bed of the great toe. Given the constant pressure on the skin overlying the abnormally positioned joints, infection remains an ever present possibility. Ultrasound-guided injection of the toe deformity with local anesthetic and anti- inflammatory steroid will often provide dramatic symptomatic improvement, but surgery will usually be required to correct the cosmetic deformity. Longitudinal ultrasound view of the metatarsophalangeal joint space of the great toe. Dorsal aspect of the foot: Metatarsophalangeal joint digit 2 and extensor digitorum tendon longitudinal. The plantar digital nerves, which are derived from the posterior tibial nerve, provide sensory innervation to the major portion of the plantar surface (Fig. These nerves are subject to entrapment and resultant development of perineural fibrosis and degeneration resulting in the clinical syndrome known as Morton neuroma (Fig. The dorsal aspect of the foot is innervated by terminal branches of the deep and superficial peroneal nerves. Patients suffering from Morton neuroma present with the complaint of pain in the plantar surface with associated dysesthesias radiating into the adjacent toes. This pain syndrome is thought to be caused by perineural fibrosis of the interdigital nerves (Fig. There is often coexistent intermetatarsal bursitis as the pathogenesis of both pathologic conditions is similar (Fig. Although the nerves between the third and fourth toes most often are affected, the second and third toes and, rarely, the fourth and fifth toes can be affected. Axial T1-weighted (A) and postcontrast fat-suppressed T1-weighted (B) images demonstrating neuromas between the second and third and third and fourth metatarsal bases. C: Illustration of the location of Morton neuromas and intermetatarsal bursae with relation to the transverse metatarsal ligament. Morton neuroma change with an associated small effusion in the intermetatarsal bursa. Anechoic fluid (arrow) is seen within the bursa at the proximal dorsal aspect of typical Morton web space change (area between X’s). Patients commonly complain that it feels like they are walking with a stone caught in their shoe. Walking, standing, or wearing tight shoes makes the pain worse, with rest and heat providing some relief.

The fngers of the noninjecting hand feel for the nula must reach the inframammary crease along its length order 300 mg isoniazid fast delivery medicine 8 soundcloud. During the frst couple of weeks buy genuine isoniazid online symptoms underactive thyroid, the breasts feel hard buy isoniazid 300mg on-line medicine omeprazole, and there may the most common treatment-related adverse events be varying degrees of dysesthesia or hypoesthesia of include injection site pain, chest wall pain, swelling, the skin or nipples. These usually resolve within for 3 days, at which time the incisions have closed and a few days. Bleeding is unusual when epinephrine is used for vaso- Blunt cannula constriction, but can occur and should be controlled by frm external pressure over the breast for at least 10 min. Retrom am m ary space Palpable or visible lumps may occur if the product is injected outside the ligamentous boundaries of the breast or too superfcially (Fig. Lumps may also be due to encapsulation of the hyaluronic acid gel, which can present months after the procedure, leading to frmness, pain, or distortion of the tissues. In these cases, the gel and capsule can be disintegrated by closed capsulotomy – frm external pressure and massage – or by direct aspiration of the gel. Although lidocaine toxicity is possible, it should be avoided by administering less than 7 mg/kg of lidocaine with epinephrine. The infltration of anes- thetic diluted with physiologic saline in the retromam- mary space is not tumescent anesthesia, and should not Fibrous septum be considered as such for lidocaine dosage calculations. Visible lumps below the inframammary crease can be avoided by making the access incision above the breast Hyaluronic acid filler and not below the crease, and by staying just cephalad to the inframammary crease ligament during the infl- Fig. The tip of the cannula passes through the horizontal dure, such as in nipple position, may be amplifed by fbrous septum to lie at the inframammary crease ligament and the augmentation rather than improved. Filler is also injected proximal to the septum discussed with the patient beforehand. Although asym- as the cannula is withdrawn metries in breast size can be improved using M acrolane, achieving perfect symmetry is often limited by the tightness of the overlying skin, particularly tight infe- rior poles, and absence of a signifcant inframammary fold. Although the augmentation is not permanent, and provides only moderate augmenta- Fig. This is caused by placement or migra- tion of fller outside the ligamentous boundaries of the breast. The American Society for Aesthetic Plastic Surgery: cos- term host response to liquid silicone injected during soft metic surgery national databank statistics. Lahiri A, W aters R (2007) Experience with Bio-Alcamid, a to the breast: technique, results, and indications based on 880 new soft tissue endoprosthesis. In: Breast augmentation: principles and C, Gulisano M (2002) Bio-alcamid: a novelty for recon- practice. DeLorenzi C, W einberg M , Solish N, Swift A (2009) the 111(6):1883–1890 long-term effcacy and safety of a subcutaneously injected 22. DeLorenzi C, W einberg M , Solish N, Swift A (2006) Unacceptable results with an accepted soft tissue fller: poly- M ulticenter study of the effcacy and safety of subcutaneous acrylamide hydrogel. Aesthet Plast Surg 34(4):413–422 non-animal stabilized hyaluronic acid in aesthetic facial 24. Dermatol Surg 32(2):205–211 Fagrell D (2009) Body shaping and volume restoration: the 9. Aesthet Plast Surg 33(3):274–282 D (2005) Safety and effcacy of non-animal stabilized 25. Heden P, Olenius M , Tengvar M (2011) M acrolane for breast hyaluronic acid for improvement of mouth corners. Ann Chir Plast Esthét vessel supplying ligamentous suspension of the mammary 52(2):157–161 gland. Plast Reconstr Surg 120(7): 2034–2040 Cell-Assisted Lipotransfer 36 for Breast Augmentation Kotaro Yoshimura, Yuko Asano, and Noriyuki Aoi 36. However, obtained from liposuction aspirates can differentiate certain problems remain, including unpredictable out- into various cell lineages [7, 8] such as adipogenic, comes and a low rate of graft survival due to partial osteogenic, chondrogenic, myogenic, cardiomyogenic, necrosis. Thus, the adipose tissue–specifc pro- for breast augmentation by only a limited number of plas- genitor cells are now called “adipose-derived stem/ tic surgeons [1]. Adipose tissue is known to be rich in cause confusion during the evaluation of mammograms. Fur- Department of Plastic Surgery, thermore, the use of minimally manipulated fresh cells University of Tokyo School of M edicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan might lead to higher safety and effcacy in actual e-mail: yoshimura-pla@ h. Adipocytes endothelial cells, fbroblasts, and other cells constitute the remain- constitute more than 90% of tissue volume but only 15–25% of the der. Our research revealed estimated to be only about 15–25% of the total cell that aspirated fat contains only half the number of number (Fig. Both tissues eosin-stained microphotographs and scanning electron micro- were processed for isolation of stromal vascular fractions, which graphs; red scale bar = 200 mm, white scale bar = 40 mm). This cell fraction is called the “stromal vascular manipulations such as cell sorting or culture. For example, in centrifugation alone is likely to lead to better aspirated split or full-thickness skin grafting, the graft skin has fat engraftment. In adipose tissue, aspirated fat has a signifi- Enrichment of adipose progenitor cells can be supple- cantly lower progenitor:mature-cell ratio and this low mented with the stromal vascular fraction. There are ratio − progenitor-poor aspirated fat tissue is converted at least three experimental studies [6, 18, 19] demon- to progenitor-rich fat tissue. It was hypothesized that strating that supplementing adipose progenitor cells this progenitor-enriched fat tissue would not only sur- enhances the volume or weight of survived adipose vive better but would also preserve its volume with tissue. About a half of the collected liposuction aspirate (500–800 mL of aspirated fat) is used to harvest the 36. A 16- or 18-gauge needle However, surviving adipose grafts probably turn over (150-mm long) is used for lipoinjection and inserted during the frst 2–3 months after transplantation subcutaneously at one of the four points indicated in because they experience temporary ischemia fol- Fig. This turnover, the tally (parallel to the body) in order to avoid damag- replacement process of the adipose tissue, is con- ing the pleura and causing a pneumothorax. The grafts monly occurs during the frst 6 months following are placed into the fatty layers on, around, and under lipoinjection. A high-pressure injection can be performed with a disposable syringe with a threaded plunger. The injection nee- either one of two points on the areola margin or one of two dle is rigidly manipulated by an operator, while an assistant points at the inframammary fold in various directions and planes rotates the plunger according to the operator’s instruction to achieve a diffuse distribution. During the cell isolation period, the breast implants are nique helps to ensure a diffuse distribution of the graft removed through a periareolar incision made at the material; no injections are made into the mammary caudal third of the areola margin. Finally, the capsular ated at the deepest layer under the implant capsule and cavity is washed with saline and the periareolar incision completed with injection into the most superfcial sub- is closed. Again, in the deepest layer, it is impor- tant to insert and place the needle horizontally (parallel to the body) in order to avoid damaging the pleura. Lipoinjection the fatty and fuid portions of liposuction aspirates, between the capsule and the skin is done from the same respectively. The pellets are resuspended Evaluations and passed through a 100-mm mesh flter (M illipore, Billerica, M A). To eliminate any remaining collage- In order to evaluate outcomes, physical measurements nase, the cell pellets are washed at least three times (maximum and bottom breast circumferences, etc.

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Of the 22 who presented to the study mostly high effective 300mg isoniazid treatment mastitis, complex and/or recurrent fistulas who under- with impairment of continence 300mg isoniazid amex treatment juvenile arthritis, 15 (70 %) gained signifi- went fistulotomy [17] buy 300mg isoniazid with visa symptoms of high blood pressure. The overall recurrence rate was 7 % cantly improved continence, although no corresponding including 9 % of those patients referred by another colorectal improvement in anal manometry was seen. Mostly minor deterioration in control was them recurrent, with a recurrence rate of 6 % [33]. Of the 11 with impairment of con- effective way of healing high or recurrent fistulas; the risk of tinence before the study procedure, function improved in 9 (albeit mostly minor) incontinence is probably around one in (70 %) and remained static in the other two. This group of patients often have allowed oral intake on the second post-operative day and a chronicity and severity of symptoms as well as experience were discharged on day 4 with instructions to return to normal of failure which means they may be even more willing to diet on day 6. Experience of secondary anal sphincter repair after obstetric injury showed many wound failures and deteriorating results over time [34]. Fistulectomy In order to obtain the high cure rate of fistulotomy but obviate the risk of continence impairment associated with sphincter Some surgeons advocate fistulectomy as an alternative to fis- division, some surgeons have advocated immediate sphincter tulotomy. In 1985 Kronborg compared the two techniques in repair at the time of fistulotomy or fistulectomy. An early a randomised controlled trial and found that while complica- series of 120 almost exclusively low fistulas reported rapid tions and recurrence were similar, the fistulectomy patients wound closure following fistulotomy and immediate recon- took around a week longer to heal [35]. Lewis favoured core struction with three patients (4 %) suffering recurrence and all out fistulectomy and stated with some truth that since the patients satisfied with their functional outcome [28 ]. Higher tract is followed under direct vision and without probing, and recurrent fistulas have also been examined. In 1995 false passages are not created, secondary tracts are transected 9 Fistulotomy and Lay Open Technique 61 and more easily seen and the exact relation of the tract to the patients undergoing fistulotomy for intersphincteric tracts sphincter can be identified before division [36 ]. Toyonaga and colleagues undertook a prospective but not laid open 45 intersphincteric fistulas with a worsening of randomised observational study comparing fistulotomy with continence in 38 % of patients although the incontinence was core out fistulectomy in high transsphincteric fistulas in 2007 mostly minor and less than a third noted any alteration to their [37]. The Impairment occurred in 82, 24 and 44 % of patients with impairment was mostly to flatus or staining of undergar- high, middle and low tracts, respectively. Satisfaction was ments in both groups and occurred in 43 % after fistulotomy 87 % across the group in spite of this and perhaps due to the compared to 17 % after fistulectomy. All but two included and higher tracts were more likely to suffer inconti- fistulas were very low, being subcutaneous or intersphinc- nence [42 ]. Follow-up was only 12 weeks during which time there were no recurrences and no impairment of continence. The fistulectomy wounds took 2 weeks longer to heal but there Risk Factors for Incontinence was no difference in post-operative pain or return to social or sexual activity. Several studies have tried to identify risk factors for post- No clear advantage of fistulectomy over fistulotomy has operative incontinence after fistulotomy. Although the Toyonaga study suggested that preoperative incontinence was the only factor signifi- a better functional outcome, the non-randomised nature of cantly associated with post-operative impairment on multi- the study limits its impact. However, left after division, anorectal and perineal sensation, the con- Cavanaugh et al. However, tivariate analysis of 148 patients undergoing fistulotomy examples of consistency exist. For example, recent studies at for intersphincteric fistulas that low preoperative voluntary St Mark’s hospital examining patients undergoing fistulot- squeeze pressure and previous drainage surgery were asso- omy by a single surgeon have demonstrated a consistent ciated with a greater impairment of continence [10], level of impairment of continence (mostly minor, found in whereas Chang et al. In a recent study from the Oxford group location of internal opening and the presence of secondary Bokhari et al. Over all, it does seem that Impact of Incontinence and Recurrence a minor functional impairment may be less likely to dissat- on Quality of Life isfy the patient than recurrence. It is very difficult to assess the relative impacts on quality Impairment of continence does not necessarily equate to of life of recurrence and incontinence in an objective way poor quality of life. In the large series of fistulectomy and/or and different patients will have different expectations and fistulotomy patients published by Rosa et al. Those with had a permanent impairment of continence but the satisfac- recurrent fistulas and a pre-existing continence impairment tion rate in the study was 97 % [25]. However, in the study will likely have a different viewpoint to those with a short by Cavanaugh described above, quality of life indicators history of a primary fistula or those with a cultural emphasis were examined alongside the Faecal Incontinence Severity on personal hygiene during religious practices, for example. Index and a correlation was seen in which a greater degree Careful and detailed preoperative counselling helps the sur- of incontinence was associated with a deteriorating quality geon determine the patient’s approach to this dilemma and of life, especially with a very high incontinence score [7]. The fear of functional impairment is in so its influence on quality of life is not clear in this study, but our view over-exaggerated. Because of this fear, many sur- the significant improvement in quality of life after cure led geons perhaps undertake too many sphincter preserving the authors to conclude that cure should be sought despite the techniques, resulting in much recurrence and misery. Recurrence may be more likely to dissatisfy a patient than In 1996 Garcia-Aguilar et al. Careful patient selection and preopera- patients undergoing sphincter dividing surgery with a recur- tive counselling remain crucial when choosing fistulotomy. In fact, flatus incontinence nence disturbance, and one third would experience only alone was not significantly associated with dissatisfaction at inadvertent loss of flatus and occasional ‘skid marks’ on the all, although more frequent and more severe incontinence underwear. In referral centres and with much experience of episodes, and those which interfered with social activities, assessment that distance can be reduced to 1 cm and with were increasingly associated with dissatisfaction. But as Summary with all questionnaires/referendums, word choice signifi- cantly impacts on the result [2]. The degree of pain, success Fistulotomy works and has a recurrence rate of approxi- and impairment of continence, the latter described as ‘wors- mately 5 %. Patients mild mucus leakage/flatus incontinence, mostly related to were then asked to rank the scenarios and naturally patients internal sphincter division. The vague definition of impairment of continence the patient needs to understand the balance between cure falls exactly into the trap described above and allows the (mostly excellent) and potential functional deficit (usu- patient to assume atrocious bowel function when a minor ally minor). Marsupialization of fistulotomy wounds improves healing: a randomized controlled References trial. Surgical anatomy of the anal canal with spe- perianal fistulas and fistulotomy for low perianal fistulas: recurrent cial reference to anorectal fistulae. Factors affecting continence rence after surgical treatment for low and high perianal fistulas of after surgery for anal fistula. Factors affecting continence after fistulotomy by fistulectomy, primary closure and reconstitution. Change in anal continence after surgery for by total excision and primary sphincter reconstruction. Fistulotomy without external sphincter tion and primary repair of internal opening in the treatment of division for high anal fistulae. Fistulotomy with primary sphincter reconstruction in the manage- Fistulotomy in the tertiary setting can achieve high rates of fistula ment of complex fistula-in-ano: prospective study of clinical and cure with an acceptable risk of deterioration in continence. Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma.