Bladder perforation during needle passage is best avoided by emptying the bladder and providing finger guidance during needle passage through the retropubic space (which is not routinely done with percutaneous vaginal tape procedures for stress urinary incontinence) discount levitra professional 20mg without a prescription erectile dysfunction labs. If bladder perforation is appreciated purchase 20mg levitra professional impotence and depression, the needles should be withdrawn and then repassed more laterally. Care must be taken not to pass the needles too far laterally, which can risk injury to the external iliac vein. Following accidental bladder puncture with a small midurethral sling trocar, prolonged catheter drainage is not necessary. If the bladder is injured during the dissection between the vaginal epithelium and pubocervical fascia, it should be immediately repaired. Transvaginal repair should be attempted if possible, closing the bladder in two layers using self-absorbing suture. If exposure is suboptimal, it may be necessary to approach the bladder transabdominally, and it may even be necessary to approach the posterior bladder wall through an intentional anterior cystotomy. Following repair of the incidental and the intentional cystotomies, catheter drainage is recommended for 1–2 weeks. Cystography is the most definitive method to determine adequate healing prior to catheter removal. Bleeding may occur during the vaginal dissection, during perforation of the retropubic space, or during needle passage. Blood loss exceeding 500 cc or the need for blood transfusion has been reported to range from 1. Bleeding upon entry into the retropubic space can be difficult to manage, as it can be quite difficult to expose and ligate the perivesical venous plexus. An attempt at suture ligation is indicated, followed by packing with a laparotomy pad, or transvaginal insertion of a sponge-wrapped catheter with a 30 cc balloon into the retropubic space . If bleeding is adequately controlled, then the surgery should be completed by releasing the sling from its plastic sheaths and positioned under the midurethra in a tension-free manner. The vaginal epithelium should be closed in watertight fashion and the vagina packed with gauze. Ultimately, persistent heavy bleeding may require abdominal incision and an open retropubic exploration and suture ligation. Major bleeding during needle passage may signify external iliac or femoral vessel injury, which is usually caused by exaggerated flexion of the thigh and excessively lateral passage of the needle. Symptomatic retropubic hematoma and vaginal or labial hematoma occurs with a frequency of 1%–5% . Cystotomy can be avoided by infiltrating the anterior vaginal wall with 1:100,000 epinephrine solution, using sharp dissection superficial to the pubocervical fascia, and keeping the bladder empty. Bleeding during vaginal dissection should be managed with temporary packing or with suture ligation rather than electrocautery in order to minimize the risk of vesicovaginal fistula formation. An additional way to aid in distinguishing the bladder from an enterocele or high rectocele in the setting of high-grade multicompartment pelvic organ prolapse is the “cystoscopic light test” that illuminates the urinary bladder, differentiating a large cystocele from a high rectocele or enterocele  (see Figure 117. If cystotomy is suspected, the bladder should be filled with blue-colored fluid to visualize any extravasation or leakage. An injury that is less than 2 mm typically can be followed by Foley catheter drainage for 1 week and expectant management. Injuries that are greater than 2 mm but less than 1 cm either can be managed expectantly with a Foley catheter for 7 days or can be repaired. Bladder lacerations or defects greater than 1 cm should be surgically repaired in two layers —a mucosal and separate detrusor layer, performed in a watertight fashion using a self-absorbing suture. Repair should be attempted only after adequate tissue mobilization and debridement has been accomplished  in order to allow a watertight and tension-free repair. If more than one bladder wall injury is found, it is often easier to connect the lacerations into one large defect. It is vital to document the integrity of both ureters after cystotomy repair via direct or cystoscopic visualization of urinary efflux, as the risk of concomitant ureteral injury is as high as 10% in cases of bladder injury . Extension of the cystotomy anteriorly may be necessary in order to properly visualize the bladder trigone. Intravenous indigo carmine or methylene blue should be given in order to properly visualize ureteral efflux. If efflux is not 1755 demonstrated, or if high suspicion remains, retrograde ureteral stents should be passed over a floppy- tipped wire, ideally with fluoroscopic guidance. The patient should be transferred to a fluoroscopy- ready table prior to attempting passage of a guidewire, ureteral stent, or ureteroscope, thereby minimizing the risk of additional iatrogenic ureteral injury. A repair should only be performed after all surgery is complete, since other injuries may occur in the setting of abnormal anatomy. When the repair is completed, the closure should be tested to see if it is watertight by instilling colored fluid into the bladder catheter. Ureteral injury can happen in prolapse repair such as cystocele repair, enterocele repair, and vaginal vault suspensions. In prolapse repairs, ureteral injury should always be recognized and remedied intraoperatively. Rates of ureteral injury have been reported to range from 1% to 11% during vaginal vault suspensions, with highest rates during uterosacral ligament suspensions . Therefore, cystourethroscopy is absolutely indicated and visualization of urine efflux should be observed from both ureteral orifices. Difficulty visualizing efflux may be overcome by administration of intravenous indigo carmine and fluid challenge. If there is no efflux from the ureter, the surgeon should consider removing suspension sutures on that side as ureteral kinking is the most common cause of obstruction. Alternatively, the surgeon can attempt passage (and then removal) of a ureteral stent. Inability to pass a stent implies ureteral ligation and requires removal of the offending sutures, typically those sutures involving the cardinal ligament or posterior pubocervical fascia. Subsequent confirmation of urinary efflux should suffice, without the need for further evaluation or treatment. If a ureteral jet is not visualized, a surgeon with experience with urinary tract injury should be consulted intraoperatively. Retrograde pyelography and attempted retrograde placement of a ureteral stent are indicated. If there is doubt regarding the integrity of the ureter, an indwelling double-J ureteral stent should be left in place for 2 weeks. If the closure is tenuous, interposition of adjacent vascularized tissue such as a labial fat pad (omental flap in abdominal surgery) between the cystotomy repair and the vagina is recommended to reduce the risk of fistulization . The purpose of this flap often called a Martius flap is to introduce a new blood supply and separate the bladder and vaginal suture lines to obliterate dead space and protect from vesicovaginal fistula formation. The bladder can reepithelialize as early as 72 hours and regains its normal strength in approximately 21 days [39,40]. The bladder should be drained continuously for 2 weeks, with catheter removal following cystographic confirmation of complete healing.
Sampling is from a nonnormally distributed population with a known populationvariance: (a) mx ¼ m pﬃﬃﬃ (b) sx ¼ s= n; when n=N :05 rﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃ pﬃﬃﬃ N À n sx ¼ s= n ; otherwise N À 1 (c) The sampling distribution of x is approximately normal cheap levitra professional 20mg without prescription erectile dysfunction protocol scam. Applications As we will see in succeeding chapters order levitra professional with visa young erectile dysfunction treatment, knowledge and understanding of sampling distributions will be necessary for understanding the concepts of statistical inference. The simplest application of our knowledge of the sampling distribution of the sample mean is in computing the probability of obtaining a sample with a mean of some specified magnitude. What is the probability that a random sample of size 10 from this population will have a mean greater than 190? Solution: We know that the single sample under consideration is one of all possible samples of size 10 that can be drawn from the population, so that the mean that it yields is one of the x’s constituting the sampling distribution of x that, theoretically, could be derived from this population. When we say that the population is approximately normally distrib- uted, we assume that the sampling distribution of x will be, for all practical purposes, normally distributed. We also know that the mean and standard deviation of the sampling distribution are equal to 185. We assume that the pop- ulation is large relative to the sample so that the finite population correction can be ignored. We learn in Chapter 4 that whenever we have a random variable that is normally distributed, we may very easily transform it to the standard normal distribution. Our random variable now is x, the mean of its distribution is mx, pﬃﬃﬃ and its standard deviation is sx ¼ s= n. By appropriately modifying the formula given previously, we arrive at the following formula for transforming the normal distribution of x to the standard normal distribution: x À mx z ¼ pﬃﬃﬃ (5. This area is equal to the area to the right of 190 À 185:6 4:4 z ¼ ¼ ¼ 1:10 4:0161 4:0161 5. If a simple random sample of size 60 is drawn from this population, find the probability that the sample mean serum cholesterol level will be: (a) Between 170 and 195 (b) Below 175 (c) Greater than 190 5. They found in all adults 60 years or older a mean daily calcium intake of 721 mg with a standard deviation of 454. Construct the sampling distribution of x based on samples of size 2 selected without replacement. Imagine we take samples of size 5, 25, 50, 100, and 500 from the women in this age group. Specifically, an investigator may wish to know something about the difference between two population means. In one investigation, for example, a researcher may wish to know if it is reasonable to conclude that two population means are different. In another situation, the researcher may desire knowledge about the magnitude of the difference between two population means. A medical research team, for example, may want to know whether or not the mean serum cholesterol level is higher in a population of sedentary office workers than in a population of laborers. If the researchers are able to conclude that the population means are different, they may wish to know by how much they differ. A knowledge of the sampling distribution of the difference between two means is useful in investigations of this type. Sampling from Normally Distributed Populations The following example illustrates the construction of and the characteristics of the sampling distribution of the difference between sample means when sampling is from two normally distributed populations. Suppose, further, that we take a sample of 15 individuals from each population and compute for each sample the mean intelligence score with the following results: x1 ¼ 92 and x2 ¼ 105. If there is no difference between the two populations, with respect to their true mean intelligence scores, what is the probability of observing a difference this large or larger x1 À x2 between sample means? Solution: To answer this question we need to know the nature of the sampling distribution of the relevant statistic, the difference between two sample means, x1 À x2. Notice that we seek a probability associated with the difference between two sample means rather than a single mean. We would begin by selecting from population 1 all possible samples of size 15 and computing the mean for each sample. We know that there would be N1Cn1 such samples where N1 is the population size and n1 ¼ 15. Similarly, we would select all possible samples of size 15 from population 2 and compute the mean for each of these samples. We would then take all possible pairs of sample means, one from population 1 and one from population 2, and take the difference. Note that the 1’s and 2’s in the last line of this table are not exponents, but indicators of population 1 and 2, respectively. Sampling Distribution of x1 À x2: Characteristics It is the distribu- tion of the differences between sample means that we seek. If we plotted the sample differences against their frequency of occurrence, we would obtain a normal distribution with a mean equal to m1 À m2, the difference between the two population means, and a ÀÁÀÁ variance equal to s2=n þ s2=n. First, the means of two distributions can be subtracted from one another, or summed together, using standard arithmetic operations. Second, since the overall variance of the sampling distribution will be affected by both contributing distributions, the variances will always be summed even if we are interested in the difference of the means. For our present example we would have a normal distribution with a mean of 0 (if there is no difference between the two population means) and a variance of 2 2 ½ðÞ20 =15þ½ðÞ20 =15¼53:3333. The z value corresponding to À13, assuming that there is no difference between population means, is À13 À 0 À13 À13 z ¼ sﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃ ¼ pﬃﬃﬃﬃﬃﬃﬃﬃﬃ ¼ ¼À1:78 2 2 53:3 7:3 ðÞ20 ðÞ20 þ 15 15 By consulting Table D, we find that the area under the standard normal curve to the left of À1:78 is equal to. Sampling from Normal Populations The procedure we have just followed is valid even when the sample sizes, n1 and n2, are different and when the population variances, s2 and s2 have different values. The theoretical results on which this procedure 1 2 is based may be summarized as follows. Given two normally distributed populations with means m and m and variances s2 1 2 1 and s2, respectively, the sampling distribution of the difference, x À x , between the 2 1 2 means of independent samples of size n1 and n2 drawn from these populations is qÀÁﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃÀÁ normally distributed with mean m À m and variance s2=n þ s2=n. A solution to these problems is to take large samples, since when the sample sizes are large the central limit theorem applies and the distribution of the difference between two sample means is at leastÀÁapproximatelyÀÁnormally distributed with a mean equal to m À m and a variance of s2=n þ s2=n. To find probabilities 1 2 1 1 2 2 associated with specific values of the statistic, then, our procedure would be the same as that given when sampling is from normally distributed populations. If a nurse randomly visits 35 clients from the first and 40 from the second population, what is the probability that the average length of home visit will differ between the two groups by 20 or more minutes? Solution: No mention is made of the functional form of the two populations, so let us assume that this characteristic is unknown, or that the populations are not normally distributed. Since the sample sizes are large (greater than 30) in both cases, we draw on the results of the central limit theorem to answer the question posed. The corresponding value of z in the standard normal is ð x1 À x2 m1 À m2 20 À 15 5 z ¼ sﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃ ¼ pﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃ ¼ ¼ 1:23 2 2 16:4286 4:0532 s1 s2 þ n1 n2 In Table D we find that the area to the right of z ¼ 1:23 is 1 À :8907 ¼ :1093. We say, then, that the probability of the nurse’s random visits resulting in a difference between the two means as great as or greater than 20 minutes is. The curve of x1 À x2 and the corresponding standard normal curve are shown in Figure 5. Suppose we select a simple random sample of size 50 independently from each population. What is the probability that the difference between sample means xB À xA will be more than 8? If we take a random sample of 40 men and 35 women, what is the probability of obtaining a difference between sample means of 100 mg or more?
Unfortunately many examples of so-called entrainment (concealed or manifest) are not proven to be entrained discount levitra professional 20mg amex erectile dysfunction doctors in brooklyn. An example of entrainment of a macroreentrant atrial tachycardia is shown in Figure 8-146 purchase genuine levitra professional erectile dysfunction treatment medications. An analogous situation occurs when intra-atrial reentry occurs elsewhere in the atrium. Initiation and termination of intra-right atrial reentry can be accomplished by stimuli from the right (Fig. The mechanisms by which these tachycardias are terminated is unclear, but the right atrial location suggests some role of the muscarinic or adenosine receptors either directly (on K+ channels) or indirectly via adenyl cyclase. These arrhythmias must be distinguished from atrial tachycardias due to triggered activity which are typically able to be terminated by vagal maneuvers and adenosine. Atrioventricular conduction delay and/or block may or may not precede or be associated with tachycardia termination. No large studies have been conducted to systematically determine the effect of pharmacologic manipulation on intra-atrial reentrant arrhythmias. However, intravenous verapamil, digitalis, amiodarone, and beta blockers can terminate these arrhythmias. In my experience approximately one-third of tachycardias distant from the sinus node respond to these agents. There is some disagreement in the literature about responsiveness of intra-atrial reentry to pharmacologic and physiologic maneuvers. This may not represent its frequency in the general population, but may represent the fact that automatic atrial tachycardia is persistent and less easily treated than other atrial tachycardia mechanisms. As a consequence, it is more symptomatic so it is more often referred for electrophysiologic evaluation. Automatic atrial tachycardia tends to be either chronic and persistent or transient and related to specific events. In hospitalized patients, the most common form of automatic atrial tachycardia is transient. This is most often associated with myocardial infarction, exacerbation of chronic lung disease, especially with acute infection, alcohol ingestion, and a variety of metabolic derangements (e. Because most hospitalized patients with automatic atrial tachycardia are severely ill, the studies of automatic atrial tachycardia have only been performed in incessant and chronic cases. Incessant automatic atrial tachycardia is a not uncommon clinical problem in children and is being recognized more frequently in adults. However, the rates of automatic atrial tachycardias are influenced significantly by endogenous catecholamines and can go from 100 bpm at rest to greater than 250 bpm on exercise. Such tachycardias, when present for long periods of time, can lead to a reversible tachycardia-mediated cardiomyopathy. Because the rhythm is initiated by enhanced automaticity of a single focus, the first and subsequent P-wave and atrial activation sequences are identical. The atrial activation sequence during automatic atrial tachycardia depends on the site of the automatic focus but always differs from normal sinus rhythm. The most common sites of origin of automatic tachycardias are along the crista terminalis, the atrial appendages, the triangle of Koch, the pulmonary veins, and the coronary sinus. Most early sites exhibit multicomponent electrograms suggesting poor coupling in the region of enhanced impulse formation. Whether or not the uncoupling is necessary to allow automaticity to occur is unknown. Examples of an atrial tachycardia arising from the crista terminalis and the os of the coronary sinus are shown in Figures 8-150 and 8-151. The P-R and A-H intervals during automatic atrial tachycardia are directly related to the rate of the tachycardia; the faster the rate, the longer the intervals. However, in the majority of our patients (particularly with atrial tachycardias localized to the crista and the low atrial septum) adenosine produces transient slowing of the atrial tachycardia, but does not terminate it (Fig. Of all the pharmacologic agents only beta blockers have been useful in transient cases. Incessant atrial tachycardia responds poorly to antiarrhythmic agents and therapy is either a curative ablation (see Chapter 15) or rate control. Marked prolongation of the H-V interval, however, may alter the cycle at which bundle branch block first developed. The P-wave morphology differs from sinus, as does the atrial activation sequence (dotted lines, B). The initial and subsequent P waves have the same morphology and atrial activation sequence. The effects of stimulation during automatic atrial tachycardia are similar to those reported for other automatic tissues (e. One of the hallmarks of automaticity in normally polarized tissue is that pacing produces overdrive suppression. Abnormal automaticity in depolarized tissue may not exhibit overdrive suppression. There is a gradual shortening of the tachycardia cycle length followed by a pause in repetitive cycles consistent with exit Wenckebach from that focus. In my experience, this disorder is almost universally observed in young women, many of them in the medical field. These patients complain of palpitations in response to minimal exertion, excitement, and, in particular, stress. Although these patients manifest symptoms suggestive of autonomic dysfunction, the exact mechanism of the tachycardia and symptoms is poorly understood. Although there was no significant difference in autonomic tone from controls, based on heart rate variability, in the supine and upright position these patients exhibit decreased cardiovagal responses, beta-adrenergic hypersensitivity, and a high intrinsic heart rate. However at night they typically show a decreased heart rate, albeit higher than normals, suggesting some presence of vagal tone pharmacologic therapy is usually ineffective. Radiofrequency ablation of the sinus node has been effective in the short term, but has a high (70%) recurrence rate and limited effect on symptoms. Atrial Tachycardia Due to Triggered Activity Atrial tachycardia due to triggered activity is rare in the outpatient in the absence of digitalis intoxication. Most frequently, triggered atrial tachycardias occur during exercise, during acute illnesses associated with excess catecholamines, or in response to the use of adrenergic agents (e. These arrhythmias characteristically can be initiated and terminated by programmed stimulation. Rapid pacing is more effective than timed extrastimuli for both initiation and termination. While atrial pacing is the easiest method occasionally ventricular pacing with one-to-one retrograde conduction can initiate a triggered atrial tachycardia (Fig. The cellular calcium overload leads to development of a transient inward current that produces the delayed afterdepolarizations responsible for the tachycardia. Monophasic action potential recordings can be used to detect afterdepolarizations, but care must be taken to exclude artifact.
The ﬁrst scientiﬁc paper reporting tors buy discount levitra professional 20 mg on-line erectile dysfunction doctor memphis, however purchase levitra professional 20 mg visa erectile dysfunction drugs history, including skin priming and cleansing, skin the use of phenol peel to treat acne scars was published in type, anatomic location, volume and coat applications, as 1952. Later in 1972, Bake and Gordon further studied this well as exposure time to peeling agent and its pH, may inﬂu- agent, describing more in detail its beneﬁcial effects. All of these factors should be Another peeling agent, tricholoroacetic acid, became popu- considered before performing any peeling procedure, in lar during the 1980s. Ancient treatments from the Egyptian age used classiﬁed into [1, 7 ]: abrasive masks of alabaster particles as well as fermented grape skins bathed in sour milk [5 ]. Ve r y superﬁcial (Glycolic acid 30–50 %, Jessner solution used to rub their skin to enhance their beauty. S uperﬁcial (Glycolic acid, 50–70 % applied 3–10’; Catania , Italy Salicylic acid 25 % applied in 4–10 coats, Pyruvic acid G. Boxcar scars are oval/round The effect of very superﬁcial and superﬁcial peelings con- depressions with marked edges similar to chickenpox scars, sists of limited exfoliation, involving the upper part or the which can be either superﬁcial or deep. They do not classiﬁcation, acne scars can be divided into elevated, dys- require any particular post-treatment procedures afterwards trophic and depressed. The former are subdivided into hyper- and are associated with very low risk of side effects. Rarely, trophic, keloidal and papular, while the latter are subdivided mild to moderate erythema can be observed in limited areas. However, the reaction disappears spontaneously within a few Chronoaging refers to the physiological decline of skin days. Within the Medium-depth peelings involve epidermis and papillary skin, aging is associated with a loss of ﬁbrous tissue, slower dermis. They may cause protein denaturalization, clinically rate of cellular renewal and a reduced vascular and glandular appearing as skin bleaching (frosting), and stimulate histo- network. Barrier function that maintains cellular hydration logic modiﬁcations in connective tissue with new deposition also becomes impaired. These peels are mainly indi- mis) ﬂattens, particularly in the face, hands and feet. They also cause a quick and intense frost, characterized by ﬁne and coarse wrinkles, roughness, laxity, resulting in dermal regeneration with new deposition of col- pigmented spots and telangiectasia (dilated blood vessels). If not properly applied, this These cutaneous manifestations, particularly when extensive type of peeling may be responsible for severe complications, or severe, could be responsible for subsequent skin tumours which may require speciﬁc treatments. Cellular damage is caused by cumulative sun exposure of deep peelings is severe photoaging. Freckles are small ﬂat brown macules arising on the face and other sun-exposed areas, particularly during summer. The colour is due to local- The main indications of chemical peelings include acne and ized accumulation of melanin in keratinocytes. Actinic keratosis and lentigo asma”) or take oral contraceptive pills and live in sunny can also be successfully treated with peeling. The exact cause is unknown but hereditary, hormones Acne i s a chronic cutaneous disorder of the hair follicles and and sunlight exposure are important factors. Clinically, it is sebaceous glands, characterized by polymorphic lesions which possible to distinguish three main patterns: centre facial, appear in areas with a high concentration of sebaceous glands malar and mandibular [12 ]. It usually devel- Actinic keratosis i s a frequently encountered premalignant ops during adolescence, but it can affect any age group. Lesions can progress to chronic disease and are inﬂammatory follicular lesions (papules, pustules and nodules), usually multiple, characterized by small scaly bumps (measuring scars (atrophic, hypertrophic) and hyperpigmented lesions. Sometimes, they Table 1 Glogau classiﬁcation of photoaging appear as scaly atrophic and erythematous lesions. Mild pigmentary changes lesions) and inﬁltration around the base may indicate carci- 2. Minimal wrinkles and/or acne scarring Solar lentigo i s a benign pigmented lesion commonly 4. Patient age: 28–35 years observed in fair-skinned people on sun-exposed areas (neck, 5. Early actinic keratoses round or oval, irregularly shaped hyperpigmented macules, 3. Slight lines near the eyes and mouth; mild acne scarring varying in size from a few millimetres to 1 cm or more. Persistent wrinkles; moderate acne scarring Patient’s pre-treatment evaluation is very important. Patient age: 50–65 years satisfactory results of chemical peels depend not only on the 5. Actinic keratoses with or without skin malignancies aging and photoaging severity and any psychological dis- 3. Wrinkles throughout; severe acne scarring comfort or other skin disorders, must be considered in the 4. Patient’s lifestyle should always be evaluated in order to A s regards skin type and colour, they should be accurately treat patients able to avoid sun exposure and to use sun- examined in order to prevent post-treatment abnormal pigmen- screens, for a period varying from 15 days to 6 months if tation: thicker and sebaceous oily skins are more resistant to superﬁcial and medium-depth or deep peelings, respectively, peeling, and therefore require a deeper treatment than other are performed. Finally, subjects with signiﬁcant history or current evi- Anatomic localization is important as well, since those dence of any psychological discomfort or with immunocom- areas where adnexae are more represented, such as the face, promising diseases or allergies should not be treated. More sensitive areas, such as the periorbital skin, 6 Skin Priming require lighter treatments compared to forehead and glabella. Furthermore, concomitant disorders, such as atopic dermati- Skin priming is necessary to improve peels results. It allows tis, seborrheic dermatitis, psoriasis, contact dermatitis or an easier and uniform penetration of the peeling agent, rosacea must be carefully considered for their potential exac- reducing duration of the re-epithelisation and minimizing the erbation in the post peeling period. Skin aging, according to Glogau’s classiﬁcation (Table 1), It consists in the topical application of some compounds, should be evaluated as well. They cause a superﬁcial exfoliation, due to keratinocyte dis- In patients with a history of herpes simplex, a correct pro- cohesion, and allow a more uniform, faster and deeper pen- phylaxis with antiviral drugs from the prepeel period until etration of the exfoliating agents due to epidermal thinning. Silicone sheeting or pul- Peeling complications represent a question of matter which sating dye laser represent other therapeutic options, espe- needs to be carefully considered before performing a peeling and cially in case of evident thickening or scarring [1, 3 ]. Thus, Milia may occur after a period of 8–16 weeks from the deeper treatments show many potential complications [1, 14]. Among these, hyperpigmentation is the most com- A cneiform eruption may be observed in a small percent- mon one, but hypopigmentation is also observed, especially age of patients during reepithelization phase or immediately in case of deep peel. Although pigmentary changes can occur after, due to an exacerbation of pre-existing acne-prone skin after any depth of peeling and can involve all Fitzpatrick skin or overgreasing of the skin during the post-peeling period types, patients undergoing medium-depth peeling and with [14 ]. They could be of difﬁ- mentioned higher phototypes and oral contraceptives use [7 ]. Cardiotoxicity is an exclusive potentially severe compli- S carring represents a relevant complication possibly occur- cation occurring during phenol peeling. Atrophic scars, hyper- been demonstrated that phenol can be responsible for cardiac trophic scars or keloids may occur [7 ]. Patient’s pre-treatment toxicity, including tachycardia (arrhythmia), premature ven- evaluation is extremely important in order to investigate a his- tricular beats, bigeminy, atrial and ventricular tachycardia tory of poor healing or keloid formation. For care could be reserved in dark skinned patients that are at these reasons, this kind of peeling must be performed only higher risk for scarring.