Complete parameters in the preoperative assessment in plastic surgery.
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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Mycoparasitic relationships, where a predatory fungal species gains nutrients on the expense of a host fungus, are widespread within the fungal kingdom. By the modalities of this non-mutual relationship, biotrophic and necrotrophic mycoparasitic fungi with different gradations within this classification (contact, invasive or intracellular necrotrophic; haustorial or fusion biotrophic) can be distinguished [1]. Biotrophic mycoparasites co-exist and nourish on their living host in a balanced way and are specifically adapted to one or few host species. In contrast, necrotrophic fungi destructively invade and kill a broad range of hosts to gain nutrients from the remains of their prey [2]. Mycoparasitic fungi are prolific producers of a plethora of volatile and non-volatile secondary metabolites, favoring their ecological fitness and survival under certain environmental conditions. For example, the excretion of siderophores – affecting high affinity iron chelation – is strongly up-regulated under iron-limiting conditions [3] and several antimicrobial metabolites empower the successful perseverance within the ecological niche [4]. The mycoparasitic lifestyle obviously substantiates the overrepresentation of secondary metabolism-associated genes and the extensive excretion of a variety of secondary metabolites [2] enabling the fungus´ successful access to its prey as well as its thriving persistence in or assassination of the host. Furthermore, selected fungal secondary metabolites are known to exhibit beneficial effects on plants: They may promote vitality and growth of roots and shoots, enhance the resilience against abiotic stress factors and prime the plants immune system (induced systemic resistance; ISR) thereby enhancing its resistance and survival in case of prospective infections with pathogens [5]. In recent times, evidence accumulated that some secondary metabolites also act as communication molecules over species boundaries [6, 7].
A great diversity of mycoparasitic species exists in the fungal kingdom, especially within the order Hypocreales [8]. In this aspect Trichoderma (teleomorph Hypocrea), a worldwide abundant, diverse fungal genus, is one of the best-studied examples [2]. Trichoderma comprises necrotrophic mycoparasitic species like Trichoderma atroviride or Trichoderma virens, which are successfully applied in agriculture as biocontrol agents against plant pathogenic fungi of crop plants. Further they are reported to promote plant growth, vitality and systemic resistance via priming the plants’ immune system. The genomes of several Trichoderma species have been sequenced and analyzed revealing the ancestral mycoparasitic lifestyle of these fungi [9, 10]. The second largest lineage of mycorparasites within the Hypocreales is the genus Tolypocladium. Tolypocladium comprises, besides of some entomopathogenic species like Tolypocladium inflatum, mostly mycoparasitic species like the widespread on northern hemisphere Tolypocladium ophioglossoides which mycoparasitizes with a narrow host range on truffles of the genus Elaphomyces [11, 12]. In contrast to Trichoderma, the genus Tolypocladium exhibits an ancestral entomopathogenic lifestyle and developed to a mycoparasite by host jumping. The genomes of Tolypocladium species are rich in secondary metabolite gene clusters of which some, like the clusters for the production of peptaibiotics, seem to be exclusive to mycoparisitic lineages [12]. A further well-investigated mycoparasitic fungus is Escovopsis weberi. E. weberi is a contact necrotrophic mycoparasite on Leucoagaricus sp. in leaf-cutting ant agriculture [13]. As foraging for leaves causes considerable economic damages in neotropic agriculture by defoliation of a wide variety of crop plants, E. weberi would be a suitable biocontrol agent as it causes a breakdown of the fungal feeding structures, thereby starving out the ant colony leading to a collapse of the whole system [14]. Like other very specialized mycoparasites, the E. weberi genome exhibits a reduced size and content, but very unique secondary metabolite clusters for host attack, facilitating the excretion of fungicidal substances which can break down the host mycelia even without contact [15, 16]. Further examples of secondary metabolite analysis on mycoparasitic species include Stachybotrys elegans, a potential biocontrol agent against plant pathogenic Rhizoctonia solani [17] as well as Coniothyrium minitans and Microsphaeropsis ochracea co-culture antagonizing the plant pathogenic Sclerotinia sclerotiorum [18].
A characteristic trait of filamentous fungi is that their secondary metabolism-associated genes are mostly situated within subtelomeric regions of the chromosomes in large biosynthetic gene clusters present in the genomes in significantly greater numbers than secondary metabolites currently identified [19]. The unique and often uncommon biosynthetic pathways are mostly characterized by signature enzymes, often also transcription factors and transporters present in the respective gene clusters, which enable the secondary metabolite synthesis starting from simple precursors gained from primary metabolism like amino acids and acetyl-CoA [20]. Most common core enzymes are non-ribosomal peptide synthases (NRPSs), polyketide synthases (PKSs) and terpene-synthases or -cyclases [4]. In necrotrophic mycoparasitic species like T. atroviride and T. virens, genes for the biosynthesis of secondary metabolites are enriched compared to the only weakly mycoparasitic relative Trichoderma reesei. Within the two mentioned strong mycoparasites nearly half of all secondary metabolism-associated genes are positioned on non-syntenic regions in the genome and do not exhibit orthologs in the respective other species [21]. Depending on the species, environmental conditions, and even the strain, a plethora of different compounds is derived by the genus Trichoderma [2, 4], awakening hope on the detection of new substances. Since resistance development to the currently applied substances constitutes an increasing problem in agriculture and medicine, the need for environmentally sustainable biological control of pathogens and the discovery of novel antagonistic substances is essential. Secondary metabolites of mycoparasitic fungi could contribute to the solution.
Non-ribosomal peptides (NRPs) are synthesized by NRPSs, enzymes that characteristically consist of multiple domains synthesizing the peptide in one by one steps. Characteristic for NRPSs are the core domains for adenylation, thiolation and condensation. The generated NRPs are very diverse: they mostly comprise of proteinogenic and non-proteinogenic amino acids, can be linear or branched to cyclic with a varying length. After their synthesis outside of the ribosome, they frequently pass extensive secondary modifications. Many fungal NRPs have high economic and/or ecologic value like β-lactam antibiotics, the immunosuppressant cyclosporine A but also mycotoxins like gliotoxin.
The occurrence of NRPS genes is enriched within the genome of mycoparasitic T. atroviride for 60% and in T. virens for 180% to the wood-degrading T. reesei [21]. Further, the functional involvement of NRPS and PKS in the mycoparasitic interaction was supported by deletion experiments of the T. virens 4-phosphopanteteinyl transferase-encoding gene (ppt) – which is essential for NRPs and PKSs activation – resulting in mutant strains defective in mycoparasitism and induction of systemic resistance (ISR) in plants [22]. The main NRPSs derived metabolites in Trichoderma species are peptaibiotics, epipolythiodioxypiperazines and siderophores.
Peptaibiotics are mostly linear to rarely cyclic polypeptides, with a size of 0.5–2.1 kDa consisting of 4–21 residues. Characteristic for peptaibiotics is the inclusion of the non-proteinogenic amino acid α-aminobutyric acid (Aib). By module-skipping one NRPS is frequently capable of synthesizing a whole set of peptaibiotics [23, 24]. According to their sequence alignment and structure, peptaibiotics can be divided into several sub-clades: peptaibols, lipopeptaibols, lipoaminopeptides, cyclic peptaibiotics and two very special, small categories [25]. Because of their unusual synthesis and appearance, they are not included in regular protein databases, but in the “Comprehensive Peptaibiotics Database” [25].
Peptaibols are solely described for filamentous fungi exhibiting a mycoparasitic lifestyle, with a high abundance of over 80% of all known substances being derived from Trichoderma species [25]. Peptaibols are linear peptides, which besides of Aib include a characteristic acetylation of the N-terminus and a 1.2-amino-alcohol at the C-terminus. The first peptaibols, suzukacillin and alamethicin, have been described in the 1960s [26]. As demonstrated for alamethicin, the amphipathic character of peptaibols allows the voltage-dependent formation of helical structures acting as ion channels, thus spanning and permeabilizing the cell membrane and leading to cytoplasmic leakage and cellular breakdown [27].
Whereas all Trichoderma strains produce peptaibols, some substances are synthesized in a species- or even strain-specific manner [25]. For instance, in five different biocontrol agents containing species from the Trichoderma harzianum complex, peptaibols were the dominant secondary metabolites including three new and recurrent major groups present in all formulations [28]. Peptaibols play an important role in the mycoparasitic interactions as well as in induction of ISR in plants via up-regulation of the jasmonic acid and salicylic acid synthesis [29, 30]. In T. harzianum, peptaibols synergistically act together with hydrolytic, cell wall degrading enzymes on the cell wall destruction of the host fungus [31, 32]. Other mycoparasites such as T. ophioglossoides and E. weberi also comprise peptaibiotics-associated gene clusters, which are absent in plant- and entomopathogenic lineages of Hypocreales, suggesting the restriction of these genes to mycoparasitic species, further indicating their importance in the mycoparasitic interaction [11, 15]. The antifungal activity of the peptaibol trichokonin from Trichoderma pseudokongii caused extensive apoptosis by loss of the mitochondrial transmembrane potential resulting in apoptotic cell death in Fusarium oxysporum [33]. Similar evidences suggest a major involvement of peptaibiotics in mycoparasitism, substantiated by reports of antifungal action of peptaibols secreted by Clonostachys rosea against S. sclerotiorum [34], or Sepedonium tulasneanum against Botrytis cinerea and Phytophthora infestans [35].
Epipolythiodioxypiperazines (ETPs) are characterized by the presence of an inter- or intramolecular disulfide bridge and a diketopiperazine core. The toxicity of ETPs lies in the disulfide bridging which is facilitating the inactivation of proteins by conjugation and the elicitation of reactive oxygen species (ROS) [36]. The best known substance of this class is gliotoxin derived from T. virens Q-strains [37]. T. virens P-strains antagonize Pythium ultimum and do not produce gliotoxin but the terpenoid gliovirin, whereas Q-strains affect R. solani but not vice versa [38]. C. rosea also produces ETPs like verticillin A and gliocladines involved in the antagonism on nematodes [39] and glioperazine exhibiting antibacterial properties [40]. Whereas the role of gliotoxin (cluster comprising of 12 genes) as a virulence factor in human Aspergillus fumigatus infections and the self-protection via the gliT gene product of the biosynthetic gliotoxin cluster is well investigated, there is little and partially adverse information on the role of ETPs in biocontrol [36].
The weak mycoparasitic T. reesei exhibits an incomplete gliotoxin cluster whose genes were not expressed during confrontation with R. solani [4], whereas highly mycoparasitic T. atroviride does not contain a gliotoxin cluster [2]. The gliotoxin gene cluster of T. virens Q-strains consists of eight genes encoding the core enzyme gliP – an NRPS dioxypiperazine synthase – whose expression was induced during confrontation with R. solani [4]. Deletion of gliP resulted in gliotoxin production-deficient mutants, going hand in hand with a significantly reduced induction of ISR in cotton seedlings and antagonistic action against P. ultimum and S. sclerotiorum. Adversely, the mutants’ antifungal activity against R. solani remained unaltered [41]. The involvement of ETPs in mycoparasitic interactions stays unresolved and seems to depend on the combination of several – largely unknown – factors like synergistic interactions with other metabolites or enzymes [42], environmental conditions, the species, strain and even the host organism.
Siderophores of fungal origin are high affinity iron chelating, linear to cylic oligomeric secondary metabolites mostly characterized by a N5-acyl-N5-hydroxyornithine basic unit [3]. Several siderophores are derived by one NRPS and post-synthetic subsequent modification [43]. As bio-available iron is rare in natural habitats, but an essential trace element to most organisms, efficient chelation, uptake and storage mechanisms for iron play an important role in competition and perseverance, especially within dense microbial communities like in soil [44]. Siderophores are important metabolites in the response against oxidative stress in several fungi like Aspergillus nidulans, A. fumigatus, Cochliobolus heterostrophus, Gibberella zeae and T. virens; furthermore, they play a role in conidial germination and sexual development [4, 45, 46, 47].
Evidences accumulate that siderophores act in biocontrol as virulence factors against other microbes during iron competition. Further, they promote plant growth by the reduction of oxidative stress: in biocontrol of Fusarium wilt disease by Trichoderma asperellum strain T34, the tomato plants exhibited reduced numbers of infected roots and a decrease in iron-associated abiotic stress [48]. The over-representation of siderophores in Trichoderma hamatum strain GD12 was reported to beneficially influence the biocontrol of S. sclerotiorum and plant growth promotion in lettuce [49]. More direct evidence for an involvement of siderophores in mycoparasitic interactions exists in C. minitans: the expression of CmSIT1, a gene-mediating siderophore-iron transport, not only enhanced antifungal abilities but also reduced growth [50].
Polyketides (PKs) are derived from simple building blocks like acetyl-CoA or malonyl-CoA via consecutive PKS-mediated decarboxylative condensation and subsequent post-synthetic modification. Fungal PKSs are complex multi-modular enzymes, which obligatory include a characteristic ketoacyl-CoA-synthase (KS), an acyltransferase (AT) and an acyl-carrier (ACP) domain [20]. The structurally diverse PKs are the main class of secondary metabolites derived from fungi. The spectrum of substances ranges from spore pigments over antibiotics to toxins [2].
The T. virens and T. atroviride genomes are enriched for about 60% in PKS genes compared to T. reesei [21]. The C. rosea genome even exceeds this number with a total of 31 PKS genes [51], whereas the T. ophioglossoides genome comprises 15 PKSs [11]. The TMC-151 type PKs derived from C. rosea exhibits antibacterial properties [52], whereas T. ophioglossoides produces two antifungal and antibacterial substances: the polyketide ophiocordin and the NRPS-PKS hybrid enzyme-derived ophiosetin [11, 53, 54]. The deletion of pks4 – encoding an orthologue of the aurofusarin and bikerfusarin forming PKSs of Fusarium spp. – in T. reesei caused extensive changes in morphology as well as physiology and metabolism. In ∆pks4 mutants, the pigmentation of conidia and the generation of teleomorph structures were inhibited, and the stability of the conidial cell wall was reduced. Pks4 deletion decreased T. reesei’s antagonistic abilities in confrontation assays, lowered its antifungal effect mediated by water soluble and volatile metabolites and altered the expression pattern of other PKSs [55]. It seems that also within this metabolite class, the effects are more diverse and global, than hitherto expected.
Terpenoids are synthetized from the acetyl CoA-derived C-5-isopentenyl-diphosphate intermediates isopentenyl- and dimethylallyl-diphosphate. The C-5 units are subsequently processed via head-to-tail condensation by prenyl synthases and are post-synthetically modified by various enzymes resulting in different terpenoids originating from very few C-5 precursors [56]. Terpenoid biosynthetic clusters are characterized by the presence of a terpene cyclase gene [4]. Terpenoids are volatile to non-volatile substances constituting the highest abundant natural products on earth [37]. Terpenoids of fungal origin comprise phytohormones, mycotoxins as well as antibiotics and antitumor substances.
The C. rosea genome contains eight terpene synthase genes [51] and E. weberi comprises an expansion of six genes for terpene synthases in its genome, of which three lie within unique biosynthetic secondary metabolite clusters [15]. The majority of secondary metabolites of S. elegans secreted during mycoparasitizing R. solani are trichothezenes and atranones belong to the terpenoid class of secondary metabolites [17]. The T. virens genome comprises an enrichment of terpene cyclase genes compared to T. atroviride and T. reesei [57]. The production of several terpenoids was proven for Trichoderma species [58, 59], whereas their biosynthetic pathways mostly still remain obscure. The putative terpene cyclase vir4 is well-researched and only present in T. virens, but not in T. reesei or T. atroviride. Analysis of a mutant which exhibited defects in antibiotic production, a lack of viridin and viridiol synthesis and an under-expression of most of the genes of the vir4 cluster evidenced that the cluster is involved in viridin biosynthesis [60]. Generation of a vir4 deletion mutant and metabolic screening validated its involvement in terpene biosynthesis; the terpene cyclase gene vir4, however, turned out not to be involved in viridin or viridiol biosynthesis but in the synthesis of more than 20 volatile sesquiterpenes [61]. The involvement of terpenes in mycoparasitism relies unresolved, but there are hints: it is probable that genes underlying the mevalonate pathway also influence terpene synthesis. The hmgR gene codes for the glycoprotein 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase, which processes HMG-CoA to mevalonic acid. Accordingly hmgR-silenced mutants of T. harzianum exhibited decreased antifungal abilities [62]. Deletion of the trichodiene synthase genes tri4 and tri5 in Trichoderma arundinaceum resulted in a loss of harzianum A production, a reduced antagonism against host fungi and a decreased ISR in tomato plants [63, 64]. Expression of the T. arundinaceum tri4 and/or tri5 genes in T. harzianum mainly influenced plant wealth and defense by induced production of trichodiene and 12, 13-epoxytrichothec-9-ene (EPT) [65, 66], whereas tri5 overexpression in Trichoderma brevicompactum boosted the excretion of antifungal trichodermin [67, 68].
Ancestral and recent lifestyles fundamentally influence the existence as well as the expression of secondary metabolite genes and clusters up to the species or even strain level. The transcriptional responses of T. reesei, T. atroviride and T. virens – which all share an ancestral mycoparasitic lifestyle – to the confrontation with R. solani illustrates this fact very well. All three species exhibit few common metabolic responses but autonomous and specific strategies in defeating their opponent. Both potent mycoparasites, T. atroviride and T. virens, attack their hosts in the stage before physical contact, but with distinct strategies of antibiosis. T. virens offends mostly via the NRP biosynthetic pathway for gliotoxin synthesis, whereas T. atroviride combats mainly via the PKS biosynthetic pathway, as well as the excretion of 6-pentyl-α-pyrone (6-PP) – a volatile organic compound (VOC) with antifungal and plant growth-promoting properties [2]. Conversely, the transcriptional response of the only slightly mycoparasitic T. reesei is more defense-related and targeted on the excretion of cellulases, hemicellulases and ribosomal proteins before hyphal contact [69]. The long-term specialized lifestyle and co-evolution of E. weberi with its host in its relatively demarcated ecological niche facilitated the loss of a manifold of genes leading to a more or less obligatory mycoparasitism with limited growth and viability without the presence of the host. Hence, the E. weberi genome demonstrates a high degree of specialization, with a unique secretome containing an unusually high content of over 50% of proteins with unknown function. Further, the genome contains only 20% homologs with the closely related T. atroviride, T. virens and T. reesei and only 12% of the 1066 unique genes exhibit homology with proteins in the whole subdivision of Pezizomycotina [15].
Several environmental cues like temperature, light, carbon, nitrogen, pH and competing or synergistic organisms are known to influence the transcriptional regulation of secondary metabolism-associated gene clusters (Figure 1). Suboptimal environmental conditions thereby often facilitate and promote transcriptional activation or transcriptional reprogramming events [70]. In media containing chitin or B. cinerea cell walls, the predicted cutinase transcription factor 1 encoding gene of T. harzianum (Thctf1) was up-regulated. Thctf1 deletion mutants exhibited reduced antagonistic and antifungal ability, and the mutant strain did not synthesize two 6-PP derivatives, indicating a role of Thctf1 in secondary metabolism of T. harzianum [71]. Furthermore, the overexpression of the gene encoding multiprotein bridging factor 1 (Thmbf1) of T. harzianum – a transcriptional co-activator of Thctf1 – negatively regulated the antifungal abilities, as well as the expression of VOCs [72].
Overview on mycoparasitism-influencing factors and pathways in secondary metabolite biosynthesis of mycoparasitic fungi.
Like known for the production of mycotoxins in non-mycoparasitic species [73], secondary metabolite production in mycoparasitic fungi is governed by heterotrimeric G protein signaling and the associated cAMP-pathway, as well as mitogen-activated protein kinase (MAPK) cascades [74, 75]. T. atroviride mutants, lacking the MAPK-encoding gene tmk1 showed an enhanced production of peptaibols and of 6-PP [74]. First evidence for a positive regulation of the secondary metabolism by cAMP signaling came from T. virens ∆tac1 mutants bearing a deletion of the adenylate cyclase-encoding gene. The mutants were unable to offend Sclerotium rolfsii and R. solani, but showed a clear inhibition zone in direct confrontation with Pythium sp., pointing to a host-dependent expression of secondary metabolism-associated genes. Further, the mutant exhibited a diminished production of secondary metabolites like viridiol and a reduced expression of secondary metabolism-associated genes [75]. Prior to that, similar results were obtained for T. atroviride ∆tga1 mutants missing the subfamily I Gα protein-encoding gene. Deletion of tga1 led to a complete loss of overgrowth and mycoparasitism of different preys during direct confrontation and a decrease of 6-PP and sesquiterpene production as well as chitinase gene transcription. Despite the reduction in chitinase and 6-PP accumulation, the ∆tga1 mutant caused a strong growth inhibition of prey fungi in the interaction zone mediated by yet unidentified low molecular weight antifungal metabolites, thereby evidencing opposite roles of tga1 in regulating the biosynthesis of different antifungal substances in T. atroviride [76]. Similar to ∆tga1 mutants, transformants bearing a deletion of the subfamily III Gα protein-encoding gene tga3 were unable to overgrow and lyse prey fungi. However, absence of the adenylyl cyclase-stimulating Tga3 protein led to significantly reduced antifungal activity [77]. The global regulation of secondary metabolism and morphogenesis by the heterotrimeric VELVET protein complex, consisting of the S-adenosylmethionine-dependent methyltransferase LaeA and the velvet proteins VeA and VelB, was first described in A. nidulans [78]. Deletion of the laeA orthologue lae1 in T. atroviride led to a loss of mycoparasitic abilities in direct confrontation and a major reduction in the synthesis of 6-PP and water-soluble secondary metabolites. Further, the expression of eight mycoparasitism-related genes was decreased in the mutant. The deletion of vel1 – the veA orthologue – in T. virens caused defects in overgrowth and offense against the host in direct confrontation as well as in bioprotective plant interaction, accompanied by a decrease in the expression of several secondary metabolism-associated genes [79, 80].
In bacteria, it has been shown that at sub-inhibitory concentrations antibiotics serve as mediators of microbial communication and interaction with one of the outcomes being the production of cryptic metabolites [81]. Accordingly, the interaction with other fungi may shape the secondary metabolite profile of a specific fungus, making co-cultures a valuable tool for eliciting the activation of silent secondary metabolism-associated gene clusters.
Studies on the mutual effects of secondary metabolites produced during mycoparasitic interactions are rare however. Trichoderma-derived 6-PP was shown to suppress the synthesis of the Fusarium mycotoxins fusaric acid and deoxynivalenol (DON) [82, 83, 84, 85], suggesting that 6-PP acts as communication molecule that elicits biological responses in the interaction partners. On the other hand, fusaric acid and DON modulate 6-PP production as well as chitinase gene expression in T. atroviride and recent studies provided evidence that Fusarium mycotoxins induce defense mechanisms in mycoparasites such as T. atroviride and C. rosea which results in mycotoxin detoxification [59, 86]. C. rosea was shown to open the ring structure of zearalenone (ZEN), while Trichoderma spp. seem to convert ZEN into its reduced and sulfated forms and metabolize DON to deoxynivalenol-3-glucoside, a detoxification product of DON previously identified in plants [87, 88]. In the interaction of the mycoparasite T. arundinaceumwith B. cinerea, Botrytis-derived mycotoxins botrydial and botcinins attenuated trichothecene biosynthesis gene expression in Trichoderma while botrydial production was repressed by Trichoderma-derived harzianum A and aspinolide [89, 90, 91].
Co-culturing of mycoparasites with prey fungi simulates the conditions occurring during the mycoparasitic interaction in natural or agricultural systems and could hence encourage the production of secondary metabolites via communication and signaling molecules. Accordingly, pairwise interactions of Aspergillus niger, Fusarium verticilliodes and C. rosea led to metabolites that occurred in single cultures but were suppressed in dual cultures, and many new metabolites not present in single cultures were found in dual cultures [92]. Similar results were obtained in co-culturing experiments of T. harzianum and Talaromyces pinophilus with the accumulation of siderophores being induced in both interaction partners and the production of Talaromyces-derived 3-O-methylfunicone and herquline B being reduced. In addition, the novel substance harziaphilic acid was detected in the co-culture only [93].
Based on these studies, it is evident that secondary metabolites contribute to mycoparasitic interactions in various ways including inhibition of the activity or synthesis of mycoparasitism-relevant enzymes and other substances, by eliciting defense and detoxification responses or by triggering the production of cryptic metabolites. In most cases, however, information on the spatial distribution of the secreted substances is lacking and it is hence difficult to assign novel secondary metabolites specifically induced during the co-cultivation to its actual producer. Recently, mass spectrometry-based imaging (MSI) turned out as a valuable tool for in situ visualizing the dynamics and localization of small molecules released during microbial interactions [94]; however, reports on its application to mycoparasitic fungus-fungus interactions are still rare. By applying matrix-assisted laser desorption/ionization (MALDI)-based MSI for visualization and identification of secondary metabolites being exchanged during the mycoparasitic interaction of T. atroviride with R. solani [95], the diffusion of Trichoderma-derived peptaibols toward the prey and the accumulation of Rhizoctonia-derived substances at the borders of fungal interaction was tracked. Monitoring of the T. harzianum interaction with the fungal phytopathogen of cacao plants Moniliophthora roreri by MSI lead to the detection of T39 butenolide, harzianolide, sorbicillinol and an unknown substance specifically produced in the co-culture with a spatial localization in the interaction and overgrowth zones [96].
We acknowledge support by the Austrian Science Fund FWF (grant P28248) and the Vienna Science and Technology Fund WWTF (grants LS09-036 and LS13-086).
Patients who consult a plastic surgeon do so with the purpose of improving their body appearance to achieve the image of a beautiful body, increase their self-esteem, and to be more competitive in a globalized world where appearance is a determinant of success. Most are people looking for various alternatives during long time; they search on the Internet, with friends, with patients, in local or distant locations from their place of residence, inside or outside of their country. Some of them make face-to-face consultations with several plastic surgeons before deciding where to have surgery [1]. They seek perfection and full satisfaction to their demands, the best prices, and high expectations with each planned surgical procedure. Complications—small or catastrophic—have no place in the final results. Medical care for these people with special expectancies is a continuous defy, a constant challenge that keeps us at the top of our professional practice and able to achieve excellent results while keeping us competitive in a growing medical market [2, 3]. Fortunately, complications in this clinical environment are rare but often are catastrophic and, to a lesser extent, can be fatal. As in other areas of surgery-anesthesia, adherence to existing guidelines and recommendations is mandatory to avoid any possible unwanted effects.
In recent years, there has been an increase in litigation against the medical profession—justified or not—increasing the costs of health care [4, 5].
The aim of this chapter is to review several aspects related to complications that may occur in the perioperative period of people who undergo plastic surgery procedures under anesthesia.
In this clinical setting, there are certain general features of paramount importance that should always receive proper attention to avoid unexpected complications. Like any other types of surgical patients, people who desire plastic surgery should be meticulously evaluated regardless of the opinion of the plastic surgeon or the anesthesiologist involved. Standards and guidelines have been described with loose criteria or very strict principles according to the experiences of their authors. The main idea is to study these patients regarding factors that may be important to prevent unfortunate outcomes and staying away from unorthodox practices of our profession [6].
The preanesthetic-preoperative assessment is vital and of paramount importance in all patients who undergo plastic surgery. This clinical assessment is an easy, inexpensive, and essential way to decrease catastrophic incidents and complications. Unfortunately, these patients are often considered healthy by their doctors and are not adequately reviewed as determined by the respective certified standards.
During the preanesthetic evaluation, two major groups will be considered; the healthy people and the patients with systemic pathologies that modify their physical conditions (ASA). The evolution and marketing of plastic surgery have generated a third special group of patients—healthy or sick—who travel long distances in search of various aesthetic or reconstructive procedures. This group of patient-tourists has special characteristics that are challenging for the medical group, peculiarities that must be properly evaluated before the patients begin their trip to the surgical destination chosen by them or immediately after their arrival.
Preoperative assessment includes a complete medical history with physical examination. Laboratory and other exams are tailored to each patient depending on their past medical history and findings on previous exams. The current trend is to minimize this type of tests; however, when a perioperative complication occurs and the so-called routine tests (CBC, blood chemistry, blood clotting, blood group) were not carried out, the plaintiffs will have arguments against the medical-surgical team, which is why it is prudent to perform routine exams, leaving the electrocardiogram for hypertensive patients, patients with history of heart disease, diabetics, and healthy people over 50 years old. Table 1 lists the usual exams for all types of patients.
Parameters | ASA 1 | ASA 2–3 | Observations |
---|---|---|---|
Clinical history | Yes | Yes | The general and oriented clinical review made by the anesthesiologist anticipates problems such as difficult airway, spinal anomalies, mental alterations, family environment, and possibility of a lawsuit |
Physical examination | Yes | Yes | |
Specialist consultation | NE | Yes | It is prudent to know the opinion of the geriatrician, pulmonologist, cardiologist, endocrinologist, surgeon, family therapist in search of polypharmacy, drug interactions, etc. |
Electrocardiogram | Only >50 years old | Yes | Arrhythmias, ischemia, growth, or dilatation of heart cavities |
Chest X-ray | NE | Yes | Useful in smokers, suspected tuberculosis, neoplasms, emphysema, and kyphosis |
Echocardiogram | No | R | Compulsory study in patients with severe arterial hypertension, ischemic patients, and patients with dilated cardiomyopathy |
Spirometry | No | R | Its usefulness has not been demonstrated; however, it is recommended in chronic pneumopathy and smokers |
Blood test | Yes | Yes | Diagnosis of subclinical anemia |
Coagulation tests | Yes | Yes | TP, TPT, INR, and bleeding time are mandatory in anticoagulants, hepatocellular damage, severe sepsis, prolonged fasting, and extreme malnutrition |
Complete blood chemistry | Yes | Yes | Kidney, hepatocellular, metabolic and electrolyte evaluation |
Urinalysis | NE | Yes | Loss of blood and proteins, changes in urine density |
HIV, hepatitis, drugs, and pregnancy | R | R | They are requested based on the clinical history and experience data. HIV is prudent for the protection of medical and paramedical personnel |
Complete parameters in the preoperative assessment in plastic surgery.
NE = not essential; R = recommendable.
The patient, his/her relatives, or companions must be properly informed about the technical aspects and risks of surgery and anesthesia. This document is an indicator of communication between patients and their physicians and should be as complete as possible. While it is almost absurd to mention every risk inherent in each procedure, it is vital to mention the most frequent complications and talk about the possibility of catastrophic mishaps, always leaving open communication for any questions they might have. Although a well-informed consent does not exempt us from the responsibility of a serious failure, its absence has been a reason of demand in plastic surgery up to 43.8% [5].
Surgical units located outside hospitals for outpatient and short-stay procedures in plastic surgery started in the 1960s [7] and rapidly expanded. Currently, most plastic surgeons want to have their own surgical unit. In these surgical units, surgical and nonsurgical procedures are performed; from Botox injection, fillers, CO2 laser, minimally invasive surgeries such as hair transplantation to major surgeries such as abdominoplasty, breast reconstruction, body contouring procedures in post bariatric patients, and many more. Safety of each patient is the gold standard [8].
Although this type of surgery/anesthesia is valid from a point of view of functionality, resulting in lower costs and generating a higher income, it is prudent to mention that not these surgical units meet the normative requirements, transforming into surgical taverns [7], which could increase the possibility of considerable risks. Performing anesthesia outside a traditional hospital surgical room has gained popularity, and high-risk surgeries on ASA 2 and even some ASA 3 patients are frequently intervened in this area. Sometimes these scenarios are comparable to performing anesthesia outside the operating room [9, 10, 11], it is normative to have well-equipped anesthesia machines, standard monitoring (noninvasive blood pressure, electrocardiogram, oximetry, capnography, temperature), monitored recovery area, and well-trained nursing personnel, which ensures a morbidity-mortality rate comparable to that expected in a hospital operating room [10]. It is advisable to have equipment to avoid perioperative hypothermia as well as noninvasive ventilatory assistance equipment. Implementing WHO recommendations in relation to a surgical safety checklist allowed Rosenberg et al. [12] to reduce complications from 11.9 to 2.72% (p = 0.0006). These investigators optimized medical resource from 90.9 to 99.5% (p < 0.0001). Verbal confirmation on precautions on toxicity by local anesthetics increased from 0 to 91.3% (p < 0.0001), among other improvements. These authors also evaluated patient satisfaction, which increased from 57 to 90.8% (p < 0.0001). The current surgical room team must balance the safety and comfort of the patient and the medical group; light, sound, climate, air, temperature, humidity, ventilation, drafts, and noise are having a safer, efficient, and more professional environment [13].
The staff of ambulatory surgical units must receive continuing education to keep their certification up-to-date: surgeons, anesthesiologists, nurses, secretaries, and well-qualified administrators are required to ensure excellence. Simulation and educational programs enhance safety and make medical-surgical care systems more effective. Shapiro and his group [14] used a high-fidelity simulator mimicking various critical scenarios in a plastic surgery setting with a special regard to equipment training, communication, crisis, adherence to evidence-based protocols, and regulatory standards. They observed a high degree of acceptance and validity, arousing the participant’s interest in the importance of changing processes that improve patient safety and avoid errors. A prospective study on the safety of office-based surgery in Florida and Alabama, USA [15]—where reporting adverse events is mandatory—reviewed complicated events for 10 and 6 years, respectively, and found 46 deaths in Florida and 263 complicated procedures that required moving patients to nearby hospitals; 56.5% (26/46) were deaths and 49.8% (131/263) of the hospital transfers were related to cosmetic surgery. Of these, 67% of deaths and 74% of hospital transfers had been managed under general anesthesia. Liposuction, abdominoplasty with liposuction, and other cosmetic surgeries were related to 10 deaths and 34 hospital transfers. Only 38% of the units reporting adverse events were accredited, 93% of physicians were certified, and 98% had privileges in hospitals. Plastic surgeons reported the most events (45%). In 6 years, in Alabama, there were three deaths and 49 complications and hospital transfers; 42% (22/55) of the transfers and no deaths were associated with cosmetic surgery; 86% were done under general anesthesia. There were only two patients with complicated liposuction who were transferred to the hospital. Unlike units in Florida, 71% of units in Alabama were certified, with 100% certified surgeons. Plastic surgeons reported most events (42.3%). In both states, the complications of dermatologists were minimal or absent because their procedures are less invasive and with local or regional anesthesia. It is desirable that medical groups and health authorities establish a mandatory system that monitors deleterious events in this type of surgical environment to improve current guidelines based on the reality of each country or geographic region studied and can determine the permissible frequency of complicated events in plastic surgery [16].
There are several Government health agencies in charge of the certification of these surgical units that have the common goal of providing a similar and safe environment in this type of establishments. In Mexico, COFEPRIS and the Federal Sanitary System are responsible for verifying the functionality of this type of surgical units; from 2013 to February 2015, verified 1209 clinics provide cosmetic surgery services and found irregularities in 115, and 66 clinics were closed [17]. In the United States of America, the Joint Commission for Accreditation of Hospital Organizations (JCAHO), American Association for Accreditation of Ambulatory Surgery Facility (AAAASF), and American Osteopathic Association’s Healthcare Facilities Accreditation Program (HFAP) [18] are the organizations that regulate these aspects.
Perioperative safety is the primary goal in the comprehensive care of all patients; anesthesiologists, surgeons, nurses, paramedical staff, and health system administrators have developed guidelines aimed at improving safety in this surgical environment by strengthening preventive measures, assessment, pre-trans, and postoperative care to avoid complications. Some groups go beyond the usual recovery time, using pharmacological programs to reduce the incidence of chronic postoperative pain.
In the operating room, patient safety is a shared responsibility between professionals and staff who interact directly or indirectly with patients. As anesthesiologists, our responsibility ranges from patient assessment, anesthesia technique, and immediate recovery, although it can be extended beyond this moment when we use drugs with prolonged pharmacological effects, either as a delayed action or as chronic damage as is the case of arachnoiditis, chronic postoperative pain and perhaps CNS effects of general anesthesia for neonates could be included. Adequate monitoring (cardiorespiratory, temperature, neurological, metabolic, or neuromuscular blocking effects), the position of the patient in the operating table to avoid neurovascular compression injuries, the placement of antiembolic devices, maintenance of normothermia, facial and ocular protection, positioning the head, and avoiding burns and fires are just some of the aspects of which we are responsible during the trans and postoperative period [19, 20, 21]. Proper management of the airway is a challenge since there is always the possibility of anatomical anomalies in a patient, which makes it difficult and even impossible to secure an airway.
WHO began its safe surgery program, where checklists have proven their importance in reducing errors. No matter the surgical procedure—small or large—these recommendations list 10 essential objectives: (1) correct surgery site, (2) safe anesthesia, (3) airway management, (4) bleeding management, (5) avoid known allergies, (6) minimize risk of operative infections, (7) prevent the retention of foreign bodies, (8) correct identification of biopsies, (9) effective communication between the surgical team, and (10) systematic surveillance of surgical results. It is advisable to stick to this simple and very effective list. Its implementation is not easy, and it is necessary to understand the nature of the errors, the dynamics that exist between the systems and the people, as well as to create a culture that stimulates the patient’s safety [22, 23, 24]. In plastic surgery, it should be emphasized that it is important to identify the risks of deep vein thrombosis and pulmonary embolism (DVT/PE) and to establish that patients can benefit from prophylactic anticoagulation. Patients with hypertension should also be identified because of the implications not only in the cardiovascular and CNS systems but also in the perioperative bleeding. Another important factor is to understand the importance of reducing and treating hypothermia [25].
The time a patient remains anesthetized is directly related to the frequency of complications; hypothermia, deep venous thrombosis, pulmonary thromboembolism, changes in coagulation, bleeding, alterations in the immune system, and neurovascular compressions are some of the usual drawbacks in prolonged surgery-anesthesia [26]. In plastic surgery, there are procedures that require prolonged times such as patients with combined surgeries and postbariatric cases with large weight loss. Unfortunately, there is not enough information on these possible complications. Phillips et al. [27] retrospectively studied the relationship between the anesthetic time and the incidence of deleterious effects in 2595 plastic surgery procedures performed under general anesthesia and found that the majority were women with a mean age of 41 years. These authors divided their patients into two groups (less than 4 or more than 4 hours of anesthetic time): nausea and vomiting (2.8 vs. 5.7%, p = 0.0175) and urinary retention (0.7 vs. 7.6%, p < 0.0001), and 2.5% required reoperations due to surgical complications without statistical differences between the two groups. They had one patient with PE and one with DVT in the group of less than 4 hours of anesthesia. Five (0.19%) were admitted to a hospital for medical or surgical treatment (3 hematomas, 1 PE, and 1 DVT). There were no deaths in this series. Another study of 1200 patients with facial plastic surgery [28] performed under general anesthesia compared the patients with anesthetic time of less than 4 hours (14%) vs. longer anesthesia (86%). There were no catastrophic complications, and the morbidity in 100% of the patients was minimal: one respiratory failure, one patient CNS deficit, one drug allergic reaction, and one patient requiring hospital transfer. There were six cases of prolonged anesthetic recovery time. The incidence of morbidity was similar in both groups. These two studies demonstrated that the time of general anesthesia was not a major determinant in the immediate evolution of these patients operated in ambulatory surgery units.
This is a controversial context where plastic surgeons consider themselves qualified to perform some procedures with local anesthesia and superficial sedation without the presence of an anesthesiologist. Examples to these procedures are variable according to the routines and interests of each surgeon, such as, blepharoplasties, small volume liposuction, coronal and facial rhytidectomies, filler injections, and hair implants, to mention a few. The fact is that each surgical procedure should be properly monitored by the anesthesiologist in charge of patient safety (monitored anesthetic care), and let the surgeon concentrates on his procedures without distracting his attention in monitoring the patient, or administer sedative medications, analgesics, or anesthetics with a very narrow therapeutic window. Although complications are rare, there is no way to predict with certainty when a patient will have a sentinel event or a negative incident, for example, drug toxicity, overdose, drug interaction, hypertensive crisis, anxiety, airway obstruction, and broken heart syndrome, just to mention some of the many possibilities. These are complications that few surgeons are qualified to solve and are part of the anesthesiologist’s usual practice. In a series of catastrophic events in ASA 1 and 2 patients, we found a case of death during a ritidoplasty performed without the presence of the anesthesiologist [29]. The frequency of these events is not known, and it is advisable to avoid surgical procedures without the presence of an anesthesiologist, which is classified as negligence.
People who travel from one country to another to receive medical attention are called tourist-patients, and their characteristics have different aspects that can modify their risks: cultural traditions, language, common diseases in their region of origin, and physiological adjustments from their recent voyage, especially when being by plane longer than 6 hours. Their preanesthetic evaluation is done shortly after they arrive, and there could be special conditions that are not known by the treating doctors. This type of patient has proliferated in plastic surgery. In our practice, we consider them a management challenge, emphasizing an effective communication that facilitates preoperative assessment, professional care, and a safe return to their place of origin [30].
The choice of anesthesia method is the responsibility of the anesthesiologist, although patients and surgeons must be aware and consent with the anesthetic plan. In general terms, we can use any kind of anesthesia, although the anesthesiologist should be adapted to factors such as diverse as his/her own experience and knowledge, the characteristics of the surgical unit and the surgeon, the type and duration of surgery, and in particular the characteristics of each patient. It is noteworthy to mention that the best anesthesia is not the one that is best handled by the anesthesiologist, but the anesthesia procedure that engages better to each patient. In ambulatory patients, general anesthesia has a preponderant role due to its quick recovery [31], although its immediate side effects are more common when compared to regional anesthesia and have been linked to increased frequency of DVT/PE. When general anesthesia is given, protective ventilation should be used (a tidal volume of 6–8 mL/kg of ideal body weight, less than 30 cm H2O peak pressure, and PEEP 6–8 cm H2O), which prevents lung damage, specifically in prolonged surgery.
In our ambulatory and short-stay surgical unit, regional procedures are preferred, especially subarachnoid anesthesia with a lumbar approach for surgeries below T6 segment. We also use spinal anesthesia in some patients with combined surgical procedures up to T4. Single injection of spinal anesthetics and adjuvants is safe, rapid, easy to administer, inexpensive, with a certain degree of postoperative analgesia, and fewer immediate and late residual effects than general anesthesia [32, 33]. We do not use subarachnoid anesthesia with a thoracic approach. In breast, nose, and arm surgeries, we prefer general anesthesia. For facial surgery, we use conscious sedation mixed with local anesthesia [34], and we have just adopted Friedberg’s recommendation [35] with propofol or ketofol for facial surgery and sometimes as a sedative complement at the end of spinal anesthesia. The characteristics of propofol make it a safe drug when administered by an anesthesiologist and BIS (60–70) monitoring is recommended, although the Ramsey scale (3–4) can also be used [33, 35].
Monitored anesthesia care is a safe technique in ambulatory and short-stay units. It must be done by an anesthesiologist and goes from simple monitoring of the patient to the use of intravenous drugs and local anesthetics for longer procedures as rejuvenation facial surgery. The most used drugs are propofol, ketamine, midazolam, fentanyl, sufentanil, remifentanil, and dexmedetomidine always supplemented with nasal oxygen [34, 35, 36, 37, 38, 39].
Figure 1 shows a schema where the difference between alertness, conscious sedation, deep sedation, and general anesthesia are shown. The vertical line delimits the most relevant clinical data and the appropriate management [34]. Attachment to this scheme is a simple guide to avoid anesthesia complications, especially the airway and cardiovascular and central nervous systems.
Scheme showing the differences and limits of alertness, conscious sedation, deep sedation, and general anesthesia.
A patient may be complicated by anesthesia, surgery, or a combination of both, for example, infections, venous thrombosis, thromboembolism, bleeding (anemia or hematomas), inadequate scarring, neural damage, overhydration, postoperative emesis, or burns, just to name a few. It is usually impossible to attribute these complications to one single member of the team; therefore, all professionals should function as a teamwork and must share responsibilities as in those patients complicated with DVT/PE. In this chapter, we review the expected complications in anesthesia-plastic surgery and a group of rare incidents that could occur in this clinical setting of which we have observed some.
Complications of anesthesia can be classified into four different etiological categories: (1) health personnel errors; (2) adverse events to the anesthesia technique; (3) the physical condition of the patients; and (4) sentinel incidents or events. Anesthesia morbidity and mortality rates are approximately the same in countries with a similar life expectancy. The anesthesiologic community of a given country reduces their anesthesia morbidity and mortality data by an acceptable range for their societies using techniques according to their medical culture and historical traditions [40]. Although complications will always exist since erring is human [41], preventive measures are obligatory to reduce complications of anesthesia and to regulate our professional activity to reduce morbidity and mortality statistics [6]. Complications related to anesthesia are rare in plastic surgery, ranging from simple events to catastrophic outcomes, including death.
It is the most frequent complication in plastic surgery. Under normal conditions, human thermoregulation mechanisms maintain body temperature from 36.5 to 37.5°C. This homeostasis is achieved by thermoregulatory defense mechanisms such as vasoconstriction, vasodilation, sweating, or chills. Hypothermia is considered when body temperature drops below 36°C. It can occur in the perioperative period; preoperative phase is defined as 1 hour before induction (when patients are prepared for surgery), during the intraoperative phase (total anesthetic time) and postoperative phase (24 postoperative hours) [42, 43]. Unintentional intraoperative decrease in body temperature occurs in a large percentage of surgeries and is secondary to multiple factors. In anesthetized patients, body temperature usually drops 2°C but can drop up to 6°C due to changes done by general anesthesia at the center of thermoregulation, a thermal decrease depending on the dose of the anesthetic. Other important factors of hypothermia are the exposure of the patient to the cold environment of the operating rooms and the failure to actively warm patients. Hypothermia has negative effects such as increased infections, delayed healing, increased intra and postoperative bleeding, increased blood transfusion requirements, increased cardiac morbidity, prolonged duration of anesthetics, and coagulopathies [44, 45]. Therefore, it is necessary to use different methods to avoid it, to reduce its intensity, and to manage it with opportunity; mattresses with forced air or water heating, electrical devices, heating of the intravenous or irrigation solutions, room temperature, and thermal blankets, among others, have shown different degrees of efficacy [46, 47, 48, 49].
Some body contouring procedures such as liposuction of various regions, extended or circular abdominoplasty, and multiple surgeries expose body surface in a way that facilitate heat loss. If this is added to the fact that some surgeons are accustomed to utilizing antiseptic solutions in the skin area that will be operated minutes before positioning the patients in the operating table, it accelerates and increases the hypothermia and can be an incident that affects the patient outcome.
Perioperative hypothermia is a complication that must be anticipated, detected early, and treated in a timely manner.
Side effects to drugs used during anesthesia are sporadic. A background of allergies or hypersensitivity should be investigated at the time of the anesthetic evaluation and avoid its use. Among other drugs, there have been reports of allergies to local anesthetics, muscle relaxants, sugammadex, and propofol, with the most severe reactions to latex. Opioids, especially remifentanil, may induce hyperalgesia. There are undesirable reactions like malignant hyperthermia secondary to halogenated and succinylcholine. These patients must be managed with total intravenous anesthesia or regional anesthesia because local anesthetics are safer and have rarely been associated with this entity [50].
For a couple of decades, local anesthetic toxicity has been the subject of multiple publications. In plastic surgery, there is a controversy over the total doses accepted as safe. Since the original description by Klein [51, 52], various data on safe doses of lidocaine 0.1–0.05% plus epinephrine 1:1,000,000 in tumescent liposuction have been published. Segmental infiltration of reduced lidocaine concentration 0.02% has been used in broader liposuctions [53]. The latest research done in 14 human volunteers has shown that 28 mg/kg without liposuction and 45 mg/kg (dose range 9.2–52 mg/kg.) after liposuction are safe dosages. The authors reported serum lidocaine concentration below levels associated with mild lidocaine systemic toxicity. The probable risk of lidocaine toxicity without liposuction at a dose of 28 mg/kg and with liposuction at a dose of 45 mg/kg was ≤1 per 2000 [54]. Timely diagnosis and management of local anesthetic toxicity with intravenous lipids in severe cases are essential. Lipids in initial dose of 1.5 mL/kg, followed by infusion of 0.25–0.50 mL/kg for 30–60 min. This infusion can be increased if hypotension or asystole persists [55]. After the infusion of iv lipids is stopped, a recurrence of local anesthetics toxicity can happen, so these patients need to be observed for at least 24 hours more.
Rhinoplasty is a frequent, relatively simple outpatient procedure that can be catastrophically complicated. The trigeminal cardiac reflex is defined as sudden onset of parasympathetic dysrhythmia, bradycardia that can progress to sudden asystole in addition to hypotension, apnea, and gastric hypermotility. This reflex can be initiated with stimulation of the trigeminal nerve during infiltration of the local anesthetic in the nasal columella or during osteotomy [56, 57, 58, 59].
Postoperative emesis is a serious complication in plastic surgery as it may interfere with the results. It occurs after general or neuraxial anesthesia and has been associated with the use of opioids, being more frequent in young women, nonsmokers, and patients with a history of postanesthetic emesis. Prevention is necessary using preoperative medication such as dexamethasone and/or serotonergic antagonists. Metoclopramide has fallen into disuse because of its side effects.
It is associated in tumescent liposuction with large volumes and generous intravenous administration of hydro saline solutions that can induce arterial hypertension, pulmonary edema, and even death.
Although these events are not directly attributable to the anesthetic technique, this is one of the factors that may be involved. They are the most feared complications in surgery and are more frequent in liposuction and abdominoplasty [60]. The embolus can be hematic or fatty. The risk factors are young women, contraceptives, air travel of more than 6–8 hours, prolonged surgeries, and thrombophilic pathologies such as factor V Leiden [61, 62]. Preventive measures with elastic stockings and pneumatic compression, early mobilization, antiplatelet agents, heparins, and/or oral anticoagulants are mandatory in high risk patients since this complication is the leading cause of mortality in plastic surgery. In 1,141,418 outpatient surgery procedures, there were 23 fatal events, being the pulmonary embolism the cause in 13 patients. Abdominoplasty was the surgery most commonly associated with death from pulmonary embolism in an office-based surgery facility [63].
Most of these types of complications are sentinel incidents that make prevention, diagnosis, and management difficult. The following paragraphs describe some patients seen in our professional practice or referred by colleagues.
This entity occurs in ∼1:60,000 to 1:125,000 anesthetics procedures and is more frequent in cardiovascular and orthopedic surgery, although there are cases described in plastic surgery [64, 65]. It has been associated with prolonged prone position with the head positioned lower than the thorax, anemia, use of vasoconstrictors, or glycine [66, 67]. Transient or permanent postoperative blindness has also been described following facial injections of fillers as described later.
In our practice, we had a 38-year-old patient who underwent abdominoplasty, liposuction, and fat transfer in her buttocks under spinal-general anesthesia. She developed total blindness manifested in the immediate postanesthetic recovery. MRI showed occipital cortical edema (Figure 2), establishing the diagnosis of cortical blindness.
Blindness secondary to cerebral occipital cortical edema.
This rare effect has been reported in subarachnoid anesthesia attributing to sudden changes in endolymph. We had a young patient from Russia who lost her auditory acuity during 5 days after spinal anesthesia for liposuction-gluteal lipoinjection.
Takotsubo’s cardiomyopathy or broken heart syndrome is a stress-induced heart disease with sudden left ventricular failure without coronary damage [68]. A young woman developed this syndrome few minutes after nasal infiltration with lidocaine and epinephrine under anesthesia with sevoflurane. The surgery was canceled, and the patient was transferred to a nearby hospital where she was successfully managed.
It is a very rare entity with an estimated incidence of 0.1–0.2% but has the potential to cause adverse evolution in the psychological area inducing posttraumatic stress [69]. A 43-year-old patient who underwent transoperative awakening during general anesthesia with enflurane.
Anecdotal situation has been reported on few occasions. We had a case where the spouse tried to assassinate his wife at the end of conscious sedation for rhytidectomy. He injected her with vecuronium, but the timely resuscitation initiated by the recovery area nurse and the clinical suspicion followed to the administration of neostigmine reversed the respiratory failure. The patient was transferred to intensive care unit where the husband made two failed attempts to reinject muscle relaxants.
Some surgical complications are listed because of their importance and relation to anesthesia.
Infections are frequent in plastic surgery, from 4% up to 14%, including local infections, blood-borne infections, and distal infections such as pneumonia or infective endocarditis. Breast surgery—implants or reconstructions—body contouring procedures such as liposuction and abdominoplasty, or multiple procedures have been described with more risks of postoperative infections, especially if there are predisposing factors such as diabetes, HIV, cancer, or immunosuppressive treatment. Infections in plastic surgery can be minor due to microbial skin flora to severe cases affected with atypical or multiresistant opportunistic bacteria [70, 71]. The type of infection varies depending on the surgery and the patient. Choice of antibiotics must be meticulous based initially on the clinical suspicion, escalating the antimicrobial when the bacterium is isolated, and its sensitivity is known. The most isolated germs in implant-based reconstruction infections are Staphylococcus epidermidis, Staphylococcus aureus, Serratia marcescens, Pseudomonas aeruginosa, Enterococcus, Escherichia coli, Enterobacter, Group B streptococcus, Morganella morganii, Propionibacterium, and Corynebacterium. Initial cellulitis can be managed with oral fluoroquinolones. If this treatment fails, intravenous imipenem, gentamicin, and/or vancomycin must be prescribed [72, 73]. Severe infections with methicillin-resistant Staphylococcus aureus (MRSA) should be treated aggressively with vancomycin, teicoplanin, or tigecycline, in addition to draining infected sites. Cases with nontuberculous mycobacterial infections are fairly atypical, difficult to diagnose and treat [74, 75, 76, 77, 78, 79]. The antimicrobial treatment must be aggressive and prolonged, and when there are implants, these must be removed. Figure 3 shows a patient infected with Mycobacterium chelonae after liposuction.
M. chelonae after liposuction.
Necrotizing fasciitis is a rare, potentially fatal, complication in plastic surgery that occurs more in liposuction. It requires extensive, repetitive debridement, and appropriate antimicrobial scheme. The most common germ is Streptococcus pyogenes [80].
These are uncommon complications, although it does occur in patients undergoing prolonged procedures, especially in the postbariatric ones. A hematoma is present in up to 6% of patients after breast surgery. Facial surgery is rare but compromises long-term results. Most patients are reluctant to hemotransfusion. It is possible to correct moderate anemia without hemodynamic compromise with iron, folic acid, and erythropoietin. Figure 4 shows typical cases of bleeding that may complicate the definitive outcome of surgery.
Transoperative active bleeding and residual postsurgical hematomas.
Nerve ending injuries are common in liposuction and abdominoplasty and manifest as neuropathic pain. Preventive use of gabapentinoids is useful. Major nerve damage can be seen in facial and breast surgery. Inappropriate scarring is an unpredictable risk and sometimes produces neural entrapment with secondary chronic postoperative pain.
Liposuction is one of the procedures that are performed more frequently, and its complications are minimal such as seromas, deformities, and lymphoedema. Serious complications are rare, for example, hematoma (0.15%), pulmonary complications (0.1%), infection (0.1%), and PE (0.06%). When it is combined with other procedures, complication rates are higher. It has also been associated with catastrophic lesions such as pleuropulmonary, abdominal viscera, and vascular damage [81, 82].
Soft tissue volumetric augmentation with filler injections is the second most frequent nonsurgical procedure performed in plastic surgery, being the face and buttocks the areas more frequently injected. The increased use of a wide range of fillers has shown that they are not harmless, so it is crucial to briefly review possible complications. The transfer of autologous fat in the facial regions is the most used filling substance. There are a great variety of synthetic fillers that can be atoxic and nonimmunogenic or act as a foreign body and induce an immune reaction, granulomas, infections, fibrosis, and long-lasting or permanent body deformities [83, 84, 85]. Although very rare, transient or permanent blindness and cerebrovascular emboli are the most devastating complication of forehead and facial injection of synthetic fillers or autologous fat. It is believed that the injected filling can act as a retrograde embolus upon entering the ophthalmic artery or through the normal anastomosis between frontal branch of superficial temporal artery from external carotid artery and supraorbital artery from ophthalmic artery [86]. Cannata et al. [87] described a patient who was injected with polymethylmethacrylate microspheres in the legs, soon after developed infection at the site of injection, followed by postinfectious glomerulonephritis. Kidney biopsy revealed translucent, nonbirefringent microspherical bodies compatible with the injected filler. Figure 5 shows facial deformations secondary to injection of unknown filler, and Figure 6 is an MRI that shows fillers injected in the buttocks, which produce fibrosis and deformations of the region by erratic migration, which are very difficult or impossible to correct.
Severe facial deformities secondary to an unknown illegal filler.
Deformities in the buttocks secondary to unknown substances. Observe extreme fibrosis.
Undoubtedly, the meticulous selection of each patient is the key to success in plastic surgery. When a patient does not have a physical and mental state required to undergo plastic surgery, the procedure should be deferred or canceled regardless of the interests of the patient and/or the medical group. When the complexity and risk of the procedure exceed the capacity of the surgical unit and/or the medical group, it is appropriate to refer the patient to a surgical unit or hospital with adequate resources [9, 86, 87, 88, 89]. No anesthesia procedure should be considered as a minor method, and it is always necessary to work in a safe and effective surgical facility, following established guidelines, and in permanent communication with surgeons and nurses.
A study conducted in Havana Cuba [90] with 26 patients from that country found that personality traits can determine poor choice of people who apply for cosmetic surgery, some with psychosis and dysmorphophobia that induce expectations higher than the real ones.
We live in a society of litigation where the doctors are easy prey to the ambition of the lawyers and some patients, a society where the governments create groups that exaggerate the rights of the patients making them believe that the improper results of the medical procedures are by negligence. There is a social environment—especially in government hospitals—where physicians are forced to work with multiple deficiencies as a routine practice, where health workers do not have adequate equipment and supplies, with long hours of work and few or no rights at all. There are few and inadequate preventive or curative programs [91]. The syndrome of professional exhaustion (burnout syndrome) has not been considered as a professional disease. To err is human and in this inadequate situation, it becomes a potential threat.
Anesthesiology is a science, with a high risk of undesirable events secondary to the use of drugs and techniques with narrow safety margins that facilitate unexpected complications. On the other hand, plastic surgery is a specialty where the unrealistic high expectations of many patients mean that despite adequate results—surgeons and anesthesiologists can trigger demands—when these results are not what the patient expects, and even when there are no complications. A growing number of patients establish negligence or malpractice claims—justified or not—and our practice tends toward an environment with a high incidence of litigation that sometimes forces specialists to search for geographic areas with a lower incidence of lawsuits [92]. Frequently, decisions of the legal system do not depend on the opinions of medical experts, or medical experts are not properly trained to review the events of a lawsuit in all specialties of medicine and surgery. Patients, their families, and lawyers usually make demands that do not progress due to lack of elements that support malpractice. An attorney should not file a lawsuit without the opinion of a physician skilled in the subject [93].
Park et al.’s [94] study of negligence claims in plastic surgery found responsibility between 30 and 100% of the cases, although the courts recognized that the economic compensation should be adjusted according to the victim, especially when there are associated pathologies which limit and make fairer compensation. Paik et al. [5] reviewed 292 cases of verdicts and liquidation reports in cosmetic breast surgery; the most common lesion was breast disfigurement in 53.1%, and negligent misrepresentation was 98% more likely to be resolved in favor of the complainant, while fraud was 92% more amenable to the complainant. The most common causes of citation were negligence in 88.7% and lack of informed consent in 43.8%. About 58.3% of the cases were in favor of the defendant and 41.7% in favor of the plaintiff. The compensation percentage agreed was 33.4 and 8.3% settlement. Payments ranged from $ 245,000 to $ 300,000 USD. A study with 88 cases of demand found in the west legal database [95] examined facial surgery procedures and found that 62.5% were decided in favor of the surgeon, 9.1% made agreements out of court, and 28.4% went to court for damages due to medical malpractice. The average payment was $ 577,437 USD, and the jury average was $ 352,341 USD, with blepharoplasty and rhytidectomy being the most litigated. In 38.6% of these cases, there were faults in the informed consent. There were also quarrels and disfigurements, functional considerations, and postoperative pain. The authors emphasize the importance of communication between patients and physicians regarding expectations as well as document benefits, alternatives, and specific risks. These studies show that negligence favors the demands in this clinical environment and emphasize that adequate transparency and communication are the key in the doctor-patient relationship, as mentioned in a previous publication [6].
Lawyers have promoted the lawsuit as a part of their modus vivendi. “Have you suffered as a result of a cosmetic procedure that you believe is due to the negligence of the surgeon? If you believe that your surgeon acted negligently and outside of his/her duty to care for you as a patient, we can help you.” This type of information is found on the Internet, and it is associated to websites that guide patients on how to formulate their demands. In Colombia, doctors have expressed their concerns about the rigidity of their penal system [96], which temporarily suspended a plastic surgeon, in addition to imposing a prison for less than a year and compensation to the patient for 150,000,000 Colombian pesos (approximately 52,290 USD) in a complicated liposuction with necrotizing fasciitis. The authors discuss different legal, ethical, and surgical, among other topics, and at the end, they argue the possibility to stop practicing surgery due to legal imputations every time a complication occurs. Although this would be an extreme measure, there are many colleagues who have retired after an incident. Well-qualified and experienced anesthesiologists and surgeons are not exempt from perioperative complications.
Perioperative complications of patients undergoing plastic surgery are infrequent when the medical group adheres to established guidelines and recommendations. Although these complications cannot be avoided at 100%, it is mandatory to establish preventive programs, and when these events happen, the diagnosis and timely management are imperative. Preanesthetic assessment is mandatory including meticulous search for risk factors; less than 10% of physicians working in the surgical room have disruptive behavior, and up to 98% of clinicians have observing troublesome conduct. It has been mentioned that this inappropriate behavior can facilitate complications. As in hospitals, ambulatory surgery units and all personnel must be properly certified and maintained on a permanent basis [97, 98].
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She performed research in perioperative autotransfusion and obtained the degree of PhD in 1993 publishing Peri-operative autotransfusion by means of a blood cell separator.\nBlood transfusion had her special interest being the president of the Haemovigilance Chamber TRIP and performing several tasks in local and national blood bank and anticoagulant-blood transfusion guidelines committees. Currently, she is working as an associate professor and up till recently was the dean at the Albert Schweitzer Hospital Dordrecht. 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He is currently an associate professor at Department of Civil Engineering, Minia University, Egypt and the chairman of Department of Civil Engineering, High Institute of Engineering and Technology, Giza, Egypt. He is also a consultant engineer and head of structural group at Hamza Associates, Giza, Egypt. Dr. Moustafa was a senior research associate at Vanderbilt University and a JSPS fellow at Kyoto and Nagasaki Universities. He has more than 40 research papers published in international journals and conferences. He acts as an editorial board member and a reviewer for several regional and international journals. His research interest includes earthquake engineering, seismic design, nonlinear dynamics, random vibration, structural reliability, structural health monitoring and uncertainty modeling.",institutionString:null,institution:{name:"Minia University",country:{name:"Egypt"}}},{id:"84562",title:"Dr.",name:"Abbyssinia",middleName:null,surname:"Mushunje",slug:"abbyssinia-mushunje",fullName:"Abbyssinia Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Fort Hare",country:{name:"South Africa"}}},{id:"202206",title:"Associate Prof.",name:"Abd Elmoniem",middleName:"Ahmed",surname:"Elzain",slug:"abd-elmoniem-elzain",fullName:"Abd Elmoniem Elzain",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Kassala University",country:{name:"Sudan"}}},{id:"98127",title:"Dr.",name:"Abdallah",middleName:null,surname:"Handoura",slug:"abdallah-handoura",fullName:"Abdallah Handoura",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Supérieure des Télécommunications",country:{name:"Morocco"}}},{id:"91404",title:"Prof.",name:"Abdecharif",middleName:null,surname:"Boumaza",slug:"abdecharif-boumaza",fullName:"Abdecharif Boumaza",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Abbès Laghrour University of Khenchela",country:{name:"Algeria"}}},{id:"105795",title:"Prof.",name:"Abdel Ghani",middleName:null,surname:"Aissaoui",slug:"abdel-ghani-aissaoui",fullName:"Abdel Ghani Aissaoui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105795/images/system/105795.jpeg",biography:"Abdel Ghani AISSAOUI is a Full Professor of electrical engineering at University of Bechar (ALGERIA). He was born in 1969 in Naama, Algeria. He received his BS degree in 1993, the MS degree in 1997, the PhD degree in 2007 from the Electrical Engineering Institute of Djilali Liabes University of Sidi Bel Abbes (ALGERIA). He is an active member of IRECOM (Interaction Réseaux Electriques - COnvertisseurs Machines) Laboratory and IEEE senior member. He is an editor member for many international journals (IJET, RSE, MER, IJECE, etc.), he serves as a reviewer in international journals (IJAC, ECPS, COMPEL, etc.). He serves as member in technical committee (TPC) and reviewer in international conferences (CHUSER 2011, SHUSER 2012, PECON 2012, SAI 2013, SCSE2013, SDM2014, SEB2014, PEMC2014, PEAM2014, SEB (2014, 2015), ICRERA (2015, 2016, 2017, 2018,-2019), etc.). His current research interest includes power electronics, control of electrical machines, artificial intelligence and Renewable energies.",institutionString:"University of Béchar",institution:{name:"University of Béchar",country:{name:"Algeria"}}},{id:"99749",title:"Dr.",name:"Abdel Hafid",middleName:null,surname:"Essadki",slug:"abdel-hafid-essadki",fullName:"Abdel Hafid Essadki",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Nationale Supérieure de Technologie",country:{name:"Algeria"}}},{id:"101208",title:"Prof.",name:"Abdel Karim",middleName:"Mohamad",surname:"El Hemaly",slug:"abdel-karim-el-hemaly",fullName:"Abdel Karim El Hemaly",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/101208/images/733_n.jpg",biography:"OBGYN.net Editorial Advisor Urogynecology.\nAbdel Karim M. A. El-Hemaly, MRCOG, FRCS � Egypt.\n \nAbdel Karim M. A. El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n12-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n13-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n14- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis",institutionString:null,institution:{name:"Al Azhar University",country:{name:"Egypt"}}},{id:"113313",title:"Dr.",name:"Abdel-Aal",middleName:null,surname:"Mantawy",slug:"abdel-aal-mantawy",fullName:"Abdel-Aal Mantawy",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ain Shams University",country:{name:"Egypt"}}}],filtersByRegion:[{group:"region",caption:"North America",value:1,count:5681},{group:"region",caption:"Middle and South America",value:2,count:5161},{group:"region",caption:"Africa",value:3,count:1683},{group:"region",caption:"Asia",value:4,count:10200},{group:"region",caption:"Australia and Oceania",value:5,count:886},{group:"region",caption:"Europe",value:6,count:15610}],offset:12,limit:12,total:1683},chapterEmbeded:{data:{}},editorApplication:{success:null,errors:{}},ofsBooks:{filterParams:{topicId:"8"},books:[{type:"book",id:"10454",title:"Technology in Agriculture",subtitle:null,isOpenForSubmission:!0,hash:"dcfc52d92f694b0848977a3c11c13d00",slug:null,bookSignature:"Dr. Fiaz Ahmad and Prof. Muhammad Sultan",coverURL:"https://cdn.intechopen.com/books/images_new/10454.jpg",editedByType:null,editors:[{id:"338219",title:"Dr.",name:"Fiaz",surname:"Ahmad",slug:"fiaz-ahmad",fullName:"Fiaz Ahmad"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10502",title:"Aflatoxins",subtitle:null,isOpenForSubmission:!0,hash:"34fe61c309f2405130ede7a267cf8bd5",slug:null,bookSignature:"Dr. Lukman Bola Abdulra'uf",coverURL:"https://cdn.intechopen.com/books/images_new/10502.jpg",editedByType:null,editors:[{id:"149347",title:"Dr.",name:"Lukman",surname:"Abdulra'uf",slug:"lukman-abdulra'uf",fullName:"Lukman Abdulra'uf"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10504",title:"Crystallization",subtitle:null,isOpenForSubmission:!0,hash:"3478d05926950f475f4ad2825d340963",slug:null,bookSignature:"Dr. Youssef Ben Smida and Dr. Riadh Marzouki",coverURL:"https://cdn.intechopen.com/books/images_new/10504.jpg",editedByType:null,editors:[{id:"311698",title:"Dr.",name:"Youssef",surname:"Ben Smida",slug:"youssef-ben-smida",fullName:"Youssef Ben Smida"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10552",title:"Montmorillonite",subtitle:null,isOpenForSubmission:!0,hash:"c4a279761f0bb046af95ecd32ab09e51",slug:null,bookSignature:"Prof. Faheem Uddin",coverURL:"https://cdn.intechopen.com/books/images_new/10552.jpg",editedByType:null,editors:[{id:"228107",title:"Prof.",name:"Faheem",surname:"Uddin",slug:"faheem-uddin",fullName:"Faheem Uddin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10572",title:"Advancements in Chromophore and Bio-Chromophore Research",subtitle:null,isOpenForSubmission:!0,hash:"4aca0af0356d8d31fa8621859a68db8f",slug:null,bookSignature:"Dr. Rampal Pandey",coverURL:"https://cdn.intechopen.com/books/images_new/10572.jpg",editedByType:null,editors:[{id:"338234",title:"Dr.",name:"Rampal",surname:"Pandey",slug:"rampal-pandey",fullName:"Rampal Pandey"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10581",title:"Alkaline Chemistry and Applications",subtitle:null,isOpenForSubmission:!0,hash:"4ed90bdab4a7211c13cd432aa079cd20",slug:null,bookSignature:"Dr. Riadh Marzouki",coverURL:"https://cdn.intechopen.com/books/images_new/10581.jpg",editedByType:null,editors:[{id:"300527",title:"Dr.",name:"Riadh",surname:"Marzouki",slug:"riadh-marzouki",fullName:"Riadh Marzouki"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10582",title:"Chemical Vapor Deposition",subtitle:null,isOpenForSubmission:!0,hash:"f9177ff0e61198735fb86a81303259d0",slug:null,bookSignature:"Dr. Sadia Ameen, Dr. M. 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