Fat transfer , also known as  fat graft ,  lipomodelling , or  fat injections , [ 1 ] [ 2 ]  is a surgical process in which a person's own fat is transferred from one area of the body to another area. The major aim of this procedure is to improve or augment the area that has irregularities and grooves. [ 3 ]  Carried out under either  general anesthesia  or  local anesthesia , [ 4 ]  the technique involves 3 main stages: fat harvesting (extracting adipose fat), fat processing (processing the extracted fat) and fat injection (reinjecting the purified fat into the area needing improvement). [ 5 ] [ 6 ]


Autologous fat transplantation is a widely used treatment modality because of its biocompatible properties and availability of fat for transplantation. [ 7 ]  The technique has become increasingly popular in recent years for soft tissue augmentation and volume replacement in both reconstructive and aesthetic plastic surgery.


Breast reconstruction is the surgical process of rebuilding the natural shape and look of a breast, using autologous tissue, prosthetic implants, or a combination of both. [ 8 ]  The procedure is most commonly performed in women - as part of their treatment - who have had  mastectomy  or surgery to treat  breast cancer . A doctor harvests fat from one or more areas of the patient's body where excess fat is available and grafts it to the breast for breast reconstruction surgery after a mastectomy or  lumpectomy . As the procedure uses the patient's own fat, the structural fat grafting for breast reconstruction surgery is a more natural process than implants and creates a smooth, more symmetrical, look. [ 9 ]


Fat transfer breast augmentation is a natural solution to restore shape and volume to the breasts, which may have been lost due to factors such as aging, pregnancy/breast feeding, or weight loss. [ 10 ]  Breast asymmetry can be corrected using the fat transfer procedure, and to give the breasts the same shape and size.  Breast augmentation  and correction of asymmetry using fat transfer is considered to be an overall safe procedure. [ medical citation needed ]  Any major weight gain or loss could have an impact of the procedure results because the fat transferred will behave like the fat in any other body part. The procedure is associated with certain risks such as  fat necrosis  or death of fat cells, a risk related to any type of fat grafting surgeries. Another risk is fat reabsorption, wherein the body may reabsorb the fat used (up to 50%) in the fat transfer augmentation procedure. [ 11 ]


Fat transfer in gluteal augmentation, also known as  buttock augmentation  with autologous fat grafting or gluteal lift (currently marketed as the "Brazilian butt lift"), represents one of the most rapidly evolving and increasingly popular operations in aesthetic surgery. [ 12 ]  This is a "dual-benefit" body contouring procedure, because fat is harvested from areas with surplus body fat to enhance contouring using  liposuction . [ 13 ] [ 14 ]  This fat is purified and prepared for transplantation into the gluteal region to increase buttock volume. The technique that can be performed under general and local anesthesia can also create an improvement in buttock shape, along with enhancing. [ 15 ]


The regenerative potential of lipofilling and the role of adipose-derived stem cells (ASCs) contribute to good results in facial fat transfer. In traditional techniques for facial rejuvenation, surgery was used involving the excision of muscle, skin, and/or fat. In contrast, modern techniques focus on using fat grafting [ 16 ]  to add volume to the "empty" facial compartments. Now, with more comprehensive understanding of facial aging constituents such as fat atrophy and ptosis of the facial compartments, fat grafting is considered a plausible facial rejuvenation technique, especially of the eyelids. [ 17 ]


Structural fat grafting can be an ideal option to treat the signs of aging or other appearance-related issues – such as prominent-looking veins and tendons, loss of fullness, thinning skin, arthritis and wasting of the hand. [ 18 ]  The procedure involves manually harvesting fat from one or more locations on the body via liposuction and placing it around the back of the patient's hand, and sculpting it into a smooth, uniform layer for an ideal appearance. [ 19 ]  To "fine tune" the results, additional fat transfer or injection of dermal filler products can be performed. [ 20 ]  Autologous fat transfer serves as a filler in the hand rejuvenation procedure. Besides, it also rejuvenates the soft tissue and skin on the posterior side of the hands. [ 16 ]


Autologous micro fat transplantation is often used to correct a low dorsum and a short nose. [ 21 ] [ 22 ]


Scars and burns caused due to various reasons such as injuries, chicken pox, acne, sun or radiation exposure, and more can be repaired with structural fat grafting. [ 23 ]  The procedure harvests fat from one or more areas of the body and places it anywhere on the body where tissue has been damaged. [ 24 ]  Structural fat grafting can improve the quality of aged and scarred skin, reduce pain and itchiness, heal radiation damage, treat chronic ulcers and reduce the appearance of scars on the face and body - including dimpling and deep depressions, resulting in thicker, softer, healthier skin. [ 25 ]


To ensure survivability, the fat graft should not be manipulated too much and it must be quickly reinjected. Possible complications are swelling, bruising,  hematoma  formation,  paresthesia  or donor-site pain,  hypertrophic scarring , infection, contour irregularities, and injury caused by the cannula to the underlying structures. [ 16 ] [ 3 ] [ 26 ]


Hair transplantation  is a  surgical  technique that removes  hair follicles  from one part of the body, called the 'donor site', to a bald or balding part of the body known as the 'recipient site'. The technique is primarily used to treat  male pattern baldness . In this minimally invasive procedure, grafts containing hair follicles that are genetically resistant to balding (like the back of the head) are transplanted to the bald scalp.


Hair transplantation can also be used to restore  eyelashes ,  eyebrows , beard hair, chest hair, pubic hair and to fill in scars caused by accidents or surgery such as face-lifts and previous hair transplants. Hair transplantation differs from  skin grafting  in that grafts contain almost all of the  epidermis  and  dermis  surrounding the hair follicle, and many tiny grafts are transplanted rather than a single strip of skin.


Since hair naturally grows in groupings of 1 to 4 hairs, current techniques harvest and  transplant  hair "follicular units" in their natural groupings. Thus modern hair transplantation can achieve a natural appearance by mimicking original hair orientation. This hair transplant procedure is called  follicular unit transplantation  (FUT). Donor hair can be harvested in two different ways: strip harvesting, and  follicular unit extraction  (FUE).


At an initial consultation, the surgeon analyzes the patient's scalp, discusses their preferences and expectations, and advises them on the best approach (e.g. single vs. multiple sessions) and what results might reasonably be expected.
 Laxometers  are used to measure the looseness (or more specifically,  laxity ) of the scalp. Pre-operative folliscopy will help to know the actual existing density of hair, so that postoperative results of newly transplanted hair grafts can be accurately assessed. Some patients may benefit with preoperative topical minoxidil application and vitamins. [ 1 ]


For several days prior to surgery the patient refrains from using any medicines which might result in intraoperative bleeding and resultant poor grafting. Alcohol and smoking can contribute to poor graft survival. Post operative  antibiotics  are commonly prescribed to prevent wound or graft  infections . [ 2 ]


Transplant operations are performed on an outpatient basis, with mild  sedation  (optional) and injected local  anesthesia . The scalp is shampooed and then treated with an antibacterial agent prior to the donor scalp being harvested. [ citation needed ]


There are several different techniques for harvesting hair follicles, each with their own advantages and disadvantages. Regardless of the harvesting technique, proper extraction of the hair follicle is paramount to ensure the viability of the transplanted hair and avoid transection, the cutting of the hair shaft from the hair follicle. Hair follicles grow at a slight angle to the skin's surface, so transplanted tissue must be removed at a corresponding angle. [ citation needed ]


There are two main ways in which donor grafts are extracted today: strip excision harvesting, and follicular unit extraction.


Strip harvesting (also known as  follicular unit transplantation  or FUT) is the most common technique for removing hair and follicles from a donor site. The surgeon harvests a strip of skin from the posterior scalp, in an area of good hair growth. A single-, double-, or triple-bladed scalpel is used to remove strips of hair-bearing tissue from the donor site. Each incision is planned so that intact hair follicles are removed. The excised strip is about 1–1.5 x 15–30 cm in size. While closing the resulting wound, assistants begin to dissect individual follicular unit grafts, which are small, naturally formed groupings of hair follicles, from the strip. Working with binocular  Stereo-microscopes , they carefully remove excess fibrous and fatty tissue while trying to avoid damage to the follicular cells that will be used for grafting. The latest method of closure is called 'Trichophytic closure' which results in much finer scars at the donor area.


The surgeon then uses very small micro blades or fine needles to puncture the sites for receiving the grafts, placing them in a predetermined density and pattern, and angling the wounds in a consistent fashion to promote a realistic hair pattern. The technicians generally do the final part of the procedure, inserting the individual grafts in place.


Strip harvesting will leave a thin linear scar in the donor area, which is typically covered by a patient's hair even at relatively short lengths. The recovery period is around 2 weeks and will require the stitches/staples to be removed by medical personnel or sub cuticular suturing can be done.


With Follicular Unit Extraction or FUE harvesting, individual follicular units containing 1 to 4 hairs are removed under local anesthesia; this micro removal typically uses tiny punches of between 0.6mm and 1.0mm in diameter. The surgeon then uses very small micro blades or fine needles to puncture the sites for receiving the grafts, placing them in a predetermined density and pattern, and angling the wounds in a consistent fashion to promote a realistic hair pattern. The technicians generally do the final part of the procedure, inserting the individual grafts in place.


FUE takes place in a single long session or multiple small sessions. The FUE procedure is more time-consuming than strip surgery. An FUE surgery time varies according to the surgeons experience, speed in harvesting and patient characteristics. The procedure can take anywhere from a couple hours to extract 200 grafts for a scar correction to a surgery over two consecutive days for a megasession of 2,500 to 3,000 grafts. [ 3 ]  With the FUE Hair Transplant procedure there are restrictions on patient candidacy. [ 4 ]  Clients are selected for FUE based on a fox test, [ 5 ]  though there is some debate about the usefulness of this in screening clients for FUE.


FUE can give very natural results. The advantage over strip harvesting is that FUE harvesting negates the need for large areas of scalp tissue to be harvested, so there is no linear incision on the back of the head and it doesn't leave a linear scar. Because individual follicles are removed, only small, punctate scars remain which are virtually not visible and any post-surgical pain and discomfort is minimized. As no suture removal is required, recovery from Micro Grafting FUE is less than 7 days. [ 6 ]


Disadvantages include increased surgical times and higher cost to the patient. [ 7 ]   It is challenging for new surgeons because the procedure is physically demanding and the learning curve to acquire the skills necessary is lengthy and tough. [ citation needed ]  Some surgeons note that FUE can lead to a lower ratio of successfully transplanted follicles as compared to strip harvesting.


Robotic hair restoration devices utilize cameras and robotic arms to assist the surgeon with the FUE procedure. In 2009, NeoGraft became the first robotic surgical device FDA approved for hair restoration. [ 8 ]  The ARTAS System was FDA approved in 2011 for use in harvesting follicular units from brown-haired and black-haired men. [ 9 ]


There are a number of applications for hair transplant surgery, including:


If donor hair numbers from the back of the head are insufficient, it is possible to perform body hair transplantation (BHT) on appropriate candidates who have available donor hair on the chest, back, shoulders, torso and/or legs. Body hair transplant surgery can only be performed by the FUE harvesting method and, so, requires the skills of an experienced FUE surgeon. However, there are several factors for a potential BHT candidate to consider prior to surgery. These include understanding the natural difference in textural characteristics between body hair and scalp hair, growth rates, and having realistic expectations about the results of BHT surgery.


The cost of hair transplantation depends on the individual hair loss and consequently on the number of necessary grafts. The average price per graft ranges between US$1.07 in  Turkey  up to US$7.00 in Canada. Some clinics also offer all-inclusive packages. [ 10 ] [ 11 ]
In the UK the cost can be between £4000–£8000 depending on location and area of implant. [ 12 ]


Hair thinning, known as "shock loss", is a common side effect that is usually temporary. [ 13 ]  Bald patches are also common, as fifty to a hundred hairs can be lost each day.


The use of both  scalp  flaps, in which a band of tissue with its original blood supply is  shifted  to the continue bald area, and free grafts dates back to the 19th century. In 1897, Menahem Hodara successfully implanted hair taken from the unaffected areas of the scalp on to the scars that were left bald by  favus . Modern transplant techniques began in Japan in the 1930s, [ 14 ]  where surgeons used small grafts, and even "follicular unit grafts" to replace damaged areas of  eyebrows  or lashes, but not to treat  baldness . Their efforts did not receive worldwide attention at the time, and the traumas of World War II kept their advances isolated for another two decades.


The modern era of hair transplantation in the western world was ushered in the late 1950s, when New York  dermatologist   Norman Orentreich  began to experiment with free donor  grafts  to balding areas in patients with male pattern baldness. Previously it had been thought that transplanted hair would thrive no more than the original hair at the "recipient" site. Orentreich demonstrated that such grafts were "donor dominant," as the new hairs grew and lasted just as they would have at their original home. [ 15 ]


Advancing the theory of donor dominance, Walter P. Unger, M.D. defined the parameters of the "Safe Donor Zone" from which the most permanent hair follicles could be extracted for hair transplantation. [ 16 ]  As transplanted hair will only grow in its new site for as long as it would have in its original one, these parameters continue to serve as the fundamental foundation for hair follicle harvesting, whether by strip method or FUE.


For the next twenty years, surgeons worked on transplanting smaller grafts, but results were only minimally successful, with 2–4 mm "plugs" leading to a doll's head-like appearance. In the 1980s, strip excisions began to replace the plug technique, and Carlos Uebel in Brazil popularized using large numbers of small grafts, while in the United States William Rassman began using thousands of "micrografts" in a single session. [ 5 ]


In the late 1980s, B.L. Limmer introduced the use of the stereo-microscope to dissect a single donor strip into small micrografts. [ 17 ]


The follicular unit hair transplant procedure has continued to evolve, becoming more refined and minimally invasive as the size of the graft incisions have become smaller. These smaller and less invasive incisions enable surgeons to place a larger number of follicular unit grafts into a given area. With the new "gold standard" of ultra refined follicular unit hair transplantation, over 50 grafts can be placed per square centimeter, when appropriate for the patient. [ 18 ]


Surgeons have also devoted more attention to the angle and orientation of the transplanted grafts. The adoption of the "lateral slit" technique in the early 2000s enabled hair transplant surgeons to orient 2 to 4 hair follicular unit grafts so that they splay out across the scalp's surface. This enabled the transplanted hair to lie better on the scalp and provide better coverage to the bald areas. [ original research? ]  One disadvantage however, is that lateral incisions also tend to disrupt the scalp's vascularity more than sagittals. Thus sagittal incisions transect less hairs and blood vessels assuming the cutting instruments are of the same size. [ citation needed ]


One of the advantages of sagittals is that they do a much better job of sliding in and around existing hairs to avoid follicle transection. [ original research? ]  This makes a strong case for physicians who do not require shaving of the recipient area. The lateral incisions bisect existing hairs perpendicular (horizontal) like a T while sagittal incisions run parallel (vertical) alongside and in between existing hairs. The use of perpendicular (lateral/coronal) slits versus parallel (sagittal) slits, however, has been heavily debated in patient-based hair transplant communities. Many elite hair transplant surgeons [ who? ]  typically adopt a combination of both methods based on what is best for the individual patient. [ original research? ]


Stem cells and dermal papilla cells have been discovered in hair follicles. [ 19 ]  Research on these follicular cells may lead to successes in treating baldness through hair multiplication (HM), also known as  hair cloning . [ 20 ] [ 21 ]


The  incisionless Fritsch otoplasty  is a minimally invasive procedure for pinning  protruding ears .


Michael H. Fritsch, MD, Professor, Indianapolis, Indiana, USA, named his method “Incisionless Otoplasty” and published it under this name in 1995, [ 1 ]  2004, [ 2 ]  2009 [ 3 ]  and 2013. [ 4 ]


The technique is used for protuberant "lop" ears to correct the problem in the least invasive way. From the back of the ear, permanent, non-absorbable sutures (called by Fritsch "retention sutures") are placed invisibly into the cartilage of the external ear pinna with a unique technique, whereby the stitch passes in and out of the same needle hole achieve the desired pathway for the suture to correct the protuberant ear. Kaye and others, made open micro-incisions to get the suture under the skin.  When the sutures are tightened, the ear moves towards the head. Patients were operated on using only the percutaneous incisionless technique. Fritsch pointed out that some ears needed not only re-creation of the antihelical fold of the pinna external ear, but also, a closer approximation of the conchal bowl to the mastoid process behind the ear; these retention sutures were also placed without incisions. Ears were satisfactorily corrected with this technique. This corresponds to the conventional Furnas Method, but without the large vertical access incision. [ 5 ]


Fritsch also sometimes combined with a technique of the traditional methods for correcting protruding earlobes, by opening the back of the earlobe and removing soft tissue from it. He found that his minimally invasive technique did not produce any satisfactory results in the case of pronounced conchal hyperplasia: "Mega ear".  This is how Fritsch described his method in 1995.


In his later publications, the antihelical cartilage "spring" is scratched or scored, sometimes quite deeply, with only a needle and without incisions. Narrow tunnels in the auricular cartilage created micro-scarring bands to augment the retention sutures and permanently correct the conchal bowl correction and pinna antihelix.  Later, Fritsch sometimes removed excessively thick soft-tissue or bone between the conchal bowl and the mastoid through 2mm incisions.  In this way, the Fritsch technique became a combination of several minimally invasive methods. Others have adopted this technique and modified it according to their own insights.


According to Fritsch:  Possibilities could include rare infection; bleeding;   hematoma ;  pain; discomfort; swelling; suture breakage; post-auricular suture bridging;  epithelial  inclusion with cyst formation.


According to Weerda: [ 6 ]  Cosmetically, the different procedures of all otoplasty surgery types can cause disfiguring cartilage edges along the anterior surface of the antihelix if the cartilage is scored too deeply or the perichondrium is injured; post-operative bleeding; hematoma; relapse (ears protruding again); hypersensitivity; pain with pressure and cold, pressure damage (necrosis) from too tightly fitting hard bandages; perichondritis (inflammation of the cartilage); stronger asymmetry of the ears (see also on  otoplasty ).


The  lip plate , also known as a  lip plug ,  lip disc , or  mouth plate , is a form of  body modification . Increasingly large discs (usually circular, and made from clay or wood) are inserted into a  pierced hole  in either the upper or lower  lip , or both, thereby  stretching  it. The term  labret  denotes all kinds of pierced-lip ornaments, including plates and plugs.


Archaeological evidence indicates that disk and plate labrets have been invented multiple times including in Africa (Sudan and Ethiopia; 5500–6000 BCE) [ 1 ]  Mesoamerica (1500 BCE), [ 1 ]  and coastal Ecuador (500 BCE). [ 1 ] [ 2 ]


In some African countries, a lower lip plate is usually combined with the dental extraction of two lower front teeth, sometimes all four.  Among the  Sara people  and  Lobi  of Chad, a plate is also inserted into the upper lip.  Other tribes, such as the  Makonde  of Tanzania and Mozambique, used to wear a plate in the upper lip only.


Many sources have suggested that the plate's size was a sign of social or economical importance in some tribes. [ citation needed ]  However, because of natural mechanical attributes of human skin, the plate's size may often depend on the stage of stretching of the lip and the wishes of the wearer.


Among the  Surma  and  Mursi  people of the lower Omo River valley in Ethiopia, [ 3 ]  about 6 to 12 months before marriage, a young woman has her lip pierced by her mother or one of her kinswomen, usually at around the age of 15 to 18. The initial piercing is done as an incision of the lower lip of 1 to 2 cm length, and a simple wooden peg is inserted. After the wound has healed, which usually takes between two and three weeks, the peg is replaced with a slightly bigger one. At a diameter of about 4 cm, the first lip plate made of clay is inserted. Every woman crafts her own plate and takes pride in including some ornamentation. The final diameter ranges from about 8 cm to over 20 cm. [ 4 ]


In 1990 Beckwith and Carter claimed that for Mursi and Surma women, the size of their lip plate indicates the number of cattle paid as the  bride price . [ 5 ]  Anthropologist Turton, who studied the Mursi for 30 years, denies this. [ 6 ]  LaTosky, meanwhile, argues that most Mursi women use lip plates, and the value of the ornamentation lies within a discourse of female strength and self-esteem. [ 7 ]


In contemporary culture, most girls of age 13 to 18 appear to decide whether or not to wear a lip plate. This adornment has caused the Mursi and Surma women to be treated as if they are a tourist attraction. [ 8 ]


The largest lip plate recorded was in Ethiopia, measuring 59.5 cm (23.4 in) in circumference and 19.5 cm (7.6 in) wide, in 2014. It belongs to Ataye Eligidagne. [ 9 ]


In South America among some Amazonian tribes, young males traditionally have their lips pierced and begin to wear plates when they enter the men's house and leave the world of women. [ 10 ] [ 11 ]  Lip plates there are associated with oration and singing. [ citation needed ]  The largest plates are worn by the greatest orators and war chiefs,  [ citation needed ]  such as  Chief Raoni  of the  Kayapo  tribe, a well known environmental campaigner. In South America, lip plates are nearly always made from light wood.


In the  Pacific Northwest  of North America, labrets have a long history of use, dating back at least five thousand years. At times they were used by both men and women, but in more recent times (e.g. 19th century) were associated with exclusive use by high ranking women. [ 12 ]
Among the  Haida ,  Tsimshian , and  Tlingit , they were once used by women to symbolize social maturity by indicating a girl's eligibility to be a wife.  [ citation needed ]  The installation of a girl's first plate was celebrated with a sumptuous feast. [ 13 ]


In western nations, some young people, including some members of the  Modern Primitive  movement, have adopted larger-gauge lip piercings, a few large enough for them to wear proper lip plates. Some examples are given on the  BME  website. [ 14 ] [ 15 ]


This practice can lead to infections, especially during the process of perforation.
It also complicates normal mouth functions such as salivating and eating. Gum irritation can also arise as consequence from plate rubbing, leading to related gum diseases and infections. Teeth gapping and erosion could happen as well.


For this reason, the  Ethiopian  government has put pressure on suppressing the practice. [ 16 ]


Tribes that are known for their traditional lip plates or labrets include:


In the late nineteenth and early twentieth centuries, African women wearing lip plates were brought to Europe and North America for exhibit in circuses and sideshows. Around 1930,  Ringling Brothers and Barnum & Bailey  promoted such women from the  French Congo  as members of the "Ubangi" tribe; the Ringling press agent admitted that he picked that name from a  map  for its exotic sound. [ 18 ]  The word was used in this way in the 1937  Marx Brothers  film  A Day at the Races . The word  Ubangi  was still given a definition as an African tribe in 2009 in some English-language dictionaries. [ 19 ]


Looksmaxxing  (sometimes spelled  looksmaxing ) is the process of maximizing one’s own  physical attractiveness . The term originated on male  incel   message boards  in the 2010s. [ 1 ] [ 2 ]  In the 2020s, the term left relatively obscure internet forums, and was popularised on  TikTok . [ 1 ]


Proponents of "looksmaxxing" encourage practices as "softmaxxing", including proper hygiene, skincare, hairstyles suited to one's face shape, exercise routines, wearing fashionable clothing, as well as " mewing ", a scientifically unsupported tongue posture practice purported to improve jaw structure. "Hardmaxxing" refers to more extreme and permanent methods, including undergoing cosmetic procedures such as  jaw surgery . [ 3 ]


While some looksmaxxing ideas have been deemed helpful for  self improvement , online forums have been criticized for contributing to  body dysmorphia . [ 1 ]  The spread of the concept on TikTok is said to exclude many of the "toxic" elements seen on forums. [ 3 ]


Softmaxxing, a variant of looksmaxxing, is a practice in which people perform several body care routines in an effort to improve ones physical appearance. Some of these practices are fairly common and standard, such as clearing up  facial acne , going to the gym, getting a new haircut, or  moisturizing . These practices are the most popular, and are considered "softmaxxing". Additional practices have been associated with looksmaxxing, with a popular example being the act of " mewing ", which involves performing various exercises with one's tongue with the goal of achieving a "square jawline". [ 4 ] [ 5 ]  These methods are the most popular ones shared around  TikTok , where men are typically the ones giving the advice. These methods were previously popularized with magazines such as  GQ ,  Esquire , and  Men's Health  sharing around skincare and hairstyle advice. Some that partake in "looksmaxxing" consider themselves to be making "facial gains". [ 5 ]


Some people who perform looksmaxxing have also performed more extreme methods. This has been coined as "hardmaxxing", and those who practice them refer to themselves as "hardmaxxers". Practices associated with hardmaxxing include getting implants or limb-lengthening surgeries, intentionally starving oneself ("starvemaxxing"), using moisturizers to attempt to appear more  white  ("whitemaxxing"), and withholding  sexual climax  in an effort to boost  testosterone  (" edging "). [ 4 ] [ 5 ]  An additional method, known as " bonesmashing  [ Wikidata ] ", refers to the act of hitting one's face against objects such as a hammer in order to create a "chiselled look". While this practice is considered an inside joke and few have actually done it, it has been warned as  misinformation . [ 6 ] [ 7 ] [ 8 ]


Some that partake in looksmaxxing also look for others to rate their appearance, with some engaging in anonymous message boards associated with  incel  sub-culture. This rating has been considered to be one's "sexual market value" (also known as SMV). [ 4 ] [ 6 ]  Those that determine this value usually check for a variety of different facial features. One of the most prominent features checked for is "hunter eyes", which refers to a positive  canthal tilt , resembling that of a predatorial animal. Additional features checked for include hollow cheeks and "pursed lips". [ 5 ] [ 6 ]  In order to achieve these features, some perform acts such as the aforementioned "mewing", rubbing against the orbital area, or even getting surgery. [ 6 ] [ 7 ] [ 3 ]


Those who receive a low rating are often harassed for their appearance afterwards, with some forms of harassment including suicide encouragement (known in some legal jurisdictions as "Incitement to Suicide"). [ 4 ]  Additional terms have been coined by these communities in an effort to "dominate others". These phrases include "mogging", which refers to asserting dominance over another person based on their appearance, and being "Y-pilled", which refers to one viewing themselves as more masculine than the other and is a spin on the phrase " redpilled ". [ 5 ] [ 7 ]


The practice originated on " manosphere " message boards such as Lookism.net and Incels.me in the 2010s. [ 9 ] [ 10 ]  In 2015, a forum site named Looksmaxxxer.com was registered to the  Internet Archive , [ citation needed ]  coining the term "looksmaxxing" and inspiring its usage on anonymous imageboard websites such as  4chan . Looksmaxxing became a TikTok trend in the 2020s, amongst mostly teenagers. [ 4 ] [ 5 ]


Looksmaxxing has been connected to incel sub-culture since its origins within it. [ 4 ] [ 5 ] [ 6 ]  Writing for  The Conversation , senior lecturer and researcher Jamilla Rosdahl of the  Australian College of Applied Psychology  considered the practice to convert young men into incels as a result of TikTok  algorithms . On the popularity of looksmaxxing amongst young people overall, she wrote that "where young people feel like they can’t control their environment, they may turn to trends such as looksmaxxing as something they can control," attributing several real world problems such as an unstable economy. [ 4 ]


Several acts associated with looksmaxxing have been criticized by doctors and dismissed as misinformation, including mewing and bonesmashing. [ 11 ] [ 12 ]


Neck rings , or  neck-rings , are any form of stiff  jewellery  worn as an ornament around the neck of an individual, as opposed to a loose  necklace . Many cultures and periods have made neck rings, with both males and females wearing them at various times.


Of the two most notable types, one is the  torc , an often heavy and valuable ornament normally open at the throat.  These were worn by various early cultures but are especially associated with the ancient  Celts  of the  European Iron Age , where they were evidently a key  indicator of wealth and status , mostly worn by men.


The other type is one or more spiral metal coils of many turns, often worn only by married women.


In a few African and Asian cultures, neck rings are worn usually to create the appearance that the neck has been stretched.


The custom of wearing neck rings is related to an  ideal of beauty : an elongated neck. Neck rings push the  clavicle  and ribs down. [ 1 ]  The neck stretching is mostly illusory: the weight of the rings twists the  collarbone  and eventually the upper ribs at an angle 45 degrees lower than what is natural, causing the illusion of an elongated neck. The  vertebrae  do not elongate, though the space between them may increase as the  intervertebral discs  absorb liquid.


The custom requires that the girls who wear the neck rings start before  puberty , in order to get the body used to them. These heavy coils can weigh as much as 11 pounds (5 kg).


Tourism  is often considered to encourage the use of neck rings  in Myanmar , as they are a popular attraction for tourists. [ 1 ]


Padaung  ( Kayan Lahwi ) women of the  Kayan people  begin to wear neck coils from as young as age two. The length of the coil is gradually increased to as much as twenty turns. The weight of the coils will eventually place sufficient pressure on the  clavicles  (collarbone) to cause them to deform and create an impression of a longer neck. [ 2 ] [ 3 ]


Small Kayan girls may wear brass collars from the age of two to five years old, as it is more comfortable to deform the collarbone and upper ribs slowly. The alternative, an accelerated process at around the age of twelve, when girls first begin to compete for the attention of boys, is painful.  Marco Polo  first described the practice to Western culture in c. 1300. Refugee practitioners in  Thailand  were first accessible to tourists in 1984.


The  South Ndebele peoples  of Africa also wear neck rings as part of their traditional dress and as a sign of wealth and status. Only married women are allowed to wear the rings, called  dzilla . Metal rings are also worn on different parts of the body, not just the neck. Traditionally these rings are given to a wife by her husband, and not removed until the husband's death; however, these rings are individual and do not function as a body modification. [ 4 ] [ 5 ]  The rings are usually made of copper or brass, usually stacked in multiples of three.


Modupe Ozolua  (b. October 10, 1973) is a Lebanese-Nigerian-American philanthropist and entrepreneur. She was the CEO of Body Enhancement Ltd and is the founding president of Empower 54 Project Initiatives (Empower 54) formerly known as Body Enhancement Annual Reconstructive Surgery (BEARS) Foundation.  [ 1 ] [ 2 ]


Princess Ozolua is the youngest of four children born to Prince Julius I. Ozolua, an educationist, and Princess Olua Mary S. Ozolua ( née  Otaru), an entrepreneur from Ososo, Akoko-Edo LGA,  Edo State .  [ 1 ]  Her name "Modupe" means "I give thanks" in  Yoruba .  [ 3 ]


She holds the traditional title "The Oyimizé of Ososo Kingdom" meaning "The One We Choose" from her mother's tribe.


Ozolua studied business management in  Southwestern College , graduated with honors, was inducted into the Alpha Pi Epsilon, chapter of  Phi Theta Kappa  and recognized as an outstanding student by the Southwestern Dean's Honorary List and the National Dean's List (1994 - 1995).  [ 4 ]  Princess Modupe Ozolua further studied at DeVry University where she obtained her Bachelor of Science in Technical Business Management and graduated with Magna Cum Laude honors.


Ozolua returned to Nigeria in 2001 and started Body Enhancement Ltd, [ 5 ]  a cosmetic surgery company and aesthetic laser treatments in Nigeria. [ 6 ]


In 2003, she founded Empower 54, formerly known as Body Enhancement Foundation, or Body Enhancement Annual Reconstructive Surgery (BEARS), [ 4 ]  an international humanitarian organization dedicated to providing humanitarian assistance such as medical missions, hunger eradication, education, female empowerment, and refugee programs to underprivileged Africans. Archbishop  Desmond Tutu  was a patron of Empower 54 since the creation of the organization in 2003. [ citation needed ]


All humanitarian aid rendered through Empower 54 is free to the beneficiaries. Empower 54's "Rise Above Terror" initiative has been active in rehabilitating women and children survivors of the  Boko Haram  terrorist group in Nigeria, through self-employment and education for the children at the IDP camps. Ozolua leads Empower 54 to enter communities attacked by Boko Haram in remote parts of North-East Nigeria and help survivors of insurgency attacks. [ citation needed ]


During one of the foundation's missions, she discovered the extremely malnourished children rescued from Boko Haram's captivity and facilitated the collaboration between Empower 54 and the Borno State Government in evacuating them to Maiduguri for urgent CMAM treatment. 1,500 children were evacuated from Bama, along with their families. [ 7 ]


Princess Ozolua writes articles focused on politics, charity and lifestyle which are published in Nigerian national newspapers and magazines.


Princess Ozolua married at 21 and divorced at the age of 23. She has a son. [ 8 ]


To improve the regulatory framework of CSOs in Nigeria, Princess Ozolua assumed the leadership position of Senior Special Assistant on NGOs and  People with Disabilities (PWD) in the Office of the Deputy President of the 9th Senate, National Assembly (Nigeria) from 2019 to 2023. In that role she was Chairperson, SOP on clearing charitable items into the Federal Republic of Nigeria (2020 - 2023). She initiated the project and oversaw implementation of the Standard Operating Procedure (SOP) Working Group's review, simplification, recommendations and harmonization of laws and policies relating to the clearing processes of charitable items into Nigeria. As Chair of the SOPWG, she was responsible for strategic inter-government negotiations and all stakeholders' support towards the creation of a new national SOP.
The SOPWG consisted of 130 members including National Assembly committee Chairs and Clerks; government ministries, agencies, security agencies, United Nations bodies, development partners, INGOs, CSOs, port service providers, diplomatic Corps and consultants.


CO-Chairperson, Technical Committee on the creation of an NGO National Database in Nigeria (2020 - Present). She initiated this project and oversaw the creation of the Nigerian government’s first-ever national database of NGOs operating in Nigeria with capacity for real-time interface with all regulating MDAs online platforms for ease of verification, national mapping, communication and dissemination of information and changes in laws and policies regarding CSO engagement in the country.


Ozolua successfully facilitated the partnership with the Federal Ministry of Finance, Budget and National Planning, negotiated inter-government and donors’ participation, and is also a strategic member of the Steering Committee members which consist of government ministries, government agencies, United Nations bodies, development partners, INGOs and CSOs. She also got development partners to sponsor the creation of the Nigeria Government's first national NGO database which now domiciled with the Federal Ministry of Finance, Budget and National Planning.


Government and CSO Multi-Stakeholders’ Forum
Initiated project and oversee the creation of Nigeria’s first government and Civil Society multi-stakeholders’ forum domiciled at the Federal Ministry of Finance, Budget and National Planning with focus of enabling seamless communication and review of policies regarding civil society legal frameworks in the country. Members of the forum consist of National Assembly legislators, government ministries, agencies, security agencies, United Nations bodies, development partners, INGOs and CSOs.


Improved collaboration between Nigeria National Assembly and CSOs
Ozolua successfully facilitated relationships between the 9th Assembly Senate and House of Representatives Committee Chairpersons and CSOs which enabled opportunities for alliances on amendment of laws regulating the CSO sector.


"Official website" .  Empower 54 .


Perineoplasty  (also  perineorrhaphy ) denotes the plastic surgery procedures used to correct clinical conditions (damage, defect, deformity) of the  vagina  and the  anus . [ 1 ] [ 2 ] [ 3 ]  Among the vagino-anal conditions resolved by perineoplasty are  vaginal looseness ,  vaginal itching , damaged  perineum ,  fecal incontinence ,  genital warts ,  dyspareunia ,  vaginal stenosis ,  vaginismus ,  vulvar vestibulitis , and decreased sexual sensation. [ 4 ]  Depending upon the vagino-anal condition to be treated, there are two variants of the perineoplasty procedure: the first, to tighten the  perineal muscles  and the vagina; the second, to loosen the perineal muscles.


A  perineoplasty  procedure repairs damage to the  perineum  and damage to the  vulva  that a woman might experience as a result of:


Clinically, the woman reports a feeling of physical looseness in her  vulvo-vaginal  area, which might be associated with decreased sexual satisfaction when compared to the degree of her sexual satisfaction before the incidence of the perineal damage. The indications can include detachment of the  anal sphincter  muscle, and the collapse of her rectum (rectocele). Perineoplasty is occasionally associated with posterior  colporrhaphy , and can be performed in conjunction with the procedure. [ 1 ] [ 5 ]


A perineoplasty procedure first involves a V-shaped incision to the posterior wall of the  vagina . Incisions atop the V-incision can be flat, curved, or angled upwards, which incision is applied is determined by the degree of  vaginal tightening  to be achieved. [ 1 ] [ 2 ]  Once the incision is made, any existing  scar tissue  and abnormal tissue fixations that resulted from previous injury or surgery or injury are removed. Depending upon the degree of damage occurred to the perineum, the corrections can include the:


Stitching of the muscles is carefully performed to avoid creating transverse ridges, and so produce a ridged interior surface in the vagina. [ 1 ]


A person who experiences painful sexual intercourse (dyspareunia), or who is afflicted with vaginismus (involuntary contraction of the puboccygeus muscles) can be treated with a variant perineoplasty procedure that loosens the over-tight vaginal introitus (entry). Some surgeons use a simple surface incision at the fourchette for such loosening, but generally is not the most effectively corrective surgical approach. [ 6 ]


To perform loosening perineoplasty, a triangle of skin is excised from below the vulvar vestibule with its base near the vestibule and its apex near the anus. This allows the removal of genital warts and the adjustment of musculature necessary to increase the size of the vagina. In this procedure, it is desirable to maintain the vaginal mucosa as much as possible. [ 6 ]  Recovery typically requires 4–6 weeks.


Perineoplasty is generally considered effective for treatment of dyspareunia, [ 6 ]  including that caused by  lichen sclerosus , [ 7 ]  and vaginismus. [ 6 ]  It is also considered an effective treatment for vulvar vestibulitis, although it is generally recommended following the failure of nonsurgical methods. [ 8 ] [ 9 ] [ 10 ]


Polypropylene breast implants , also known as  string breast implants , are a form of  breast implant  using  polypropylene  developed by Gerald W. Johnson.  Due to a number of  medical complications , the device has not been approved in the  European Union  or the  United States . [ 1 ]


Polypropylene implants absorb water very slowly, about <0.01% in 24 hours. [ 2 ]  The polypropylene, which is yarn-like, causes irritation to the implant pocket which causes the production of  serum  which fills the implant pocket on a continual basis. [ citation needed ]   This causes continuous expansion of the breast after surgery.   Growth can only be alleviated by removal of serum by syringe.  Problems can also arise if the breasts enlarge at different rates.  This can be corrected by removal of serum or introduction of sterile saline.  Continual breast growth will eventually result in "extreme, almost cartoonish breast sizes." [ 3 ]


String implants were only available for a very short time in the US before being removed from the market by the FDA around 2001. [ 4 ]


Polypropylene implants have created the largest recorded increases in breast size due to  surgical augmentation . They are rarely seen outside the  adult entertainment  industry.  Big-bust entertainers  Chelsea Charms , [ 5 ]   Maxi Mounds , [ 6 ]  Kayla Kleevage [ citation needed ] ,  Minka [ citation needed ] , Elizabeth Starr [ citation needed ] , and Teddi Barrett [ citation needed ]  are some recipients of polypropylene breast implants.


Scarless  Serdev Suture  suspension liftings  [1]  use percutaneous skeletal fixation of movable fascias without  incisions . In  Brazil  known as  fio elastico ., [ 1 ] [ 2 ]  are used to correct early  ptosis  and flabbiness in areas of face and body. The suture suspension techniques are described to lift, if necessary to form volume and to correct position of  soft tissue  without traditional incisions.


The techniques consist of passing closed  sutures , [ 3 ]  by needle perforations only, to lift movable fascias and fix them to non movable  skeletal structures   [2]  in several facial and body areas:


In face areas: [ 4 ]  total ambulatory SMAS Lift, temporal and supra-temporal suture SMAS lift,  scarless  brow suture lift, lateral cantus lifting, mid face suture lift, cheekbone lift and augmentation, lower smas-platysma face and  neck lift  using skin perforations only or by using hidden retro-lobular incisions, chin enhancement, form and position correction by suture, Serdev sutures for: nasal tip refinement; nasal tip rotation; nasal alar base narrowing, scarless Serdev suture method in prominent ears, chin  dimples  and smiling dimples by suture, permanent block of glabella muscles etc.


In body areas: scarless  breast lift  by suture and needle perforations only, scarless  buttock lift  by suture, abdominal flaccidity tightening by sutures, scarless inner thigh lift.


Tumescent liposuction  is a technique that provides local anesthesia to large volumes of subcutaneous fat and thus permits  liposuction .


While the suctioned fat cells are permanently gone, after a few months overall body fat generally returned to the same level as before treatment. [ 1 ]  This is despite maintaining the previous diet and exercise regimen. While the fat returned somewhat to the treated area, most of the increased fat occurred in the abdominal area. Visceral fat - the fat surrounding the internal organs - increased, and this condition has been linked to life-shortening diseases such as diabetes, stroke, and heart attack. Edit per the cited journal, the difference in visceral fat between control and intervention group was not significant  [ 1 ]


The tumescent technique for liposuction provides for local anesthesia via  lidocaine , eliminating the need for the administration of  sedatives  or  narcotics  during surgery. [ 2 ] [ 3 ]


A review published in 2011 stated tumescent liposuction was safe. [ 4 ]  During the first decade of the treatments use, deaths were reported with the treatment as the cause of death, dating back to 1999. [ 5 ]  By 2002, 23 deaths in five years had been reported in the European literature. [ 4 ]  Tierney  et al  (2011) said, "The most frequent complications were bacterial infections such as necrotizing fasciitis, gas gangrene, and different forms of sepsis. Further causes of lethal outcome were hemorrhages, perforation of abdominal viscera, and pulmonary embolism." [ 4 ]  Complications in this procedure are rare and typically minor. The most common include: skin irregularity, lumpiness, dimpling, loose skin, numbness, infections and scarring. However, these type of minor complications can easily be corrected in most cases. [ 6 ]


In many U.S. states, physicians are not required to have training to perform this cosmetic surgery procedure. [ 7 ]


Jeffrey Klein and Patrick Lillis, dermatologic surgeons, invented the tumescent technique. [ 8 ] [ 9 ]  The technique was developed in the 1980s, before it came to market in the 1990s. [ 8 ]  The technique was introduced to  Australia  in the early 1990s, with Daniel Lanzer named as one of the first to use the procedure in the country. [ 10 ]


Colorectal surgery  is a field in medicine dealing with disorders of the  rectum ,  anus , and  colon . [ 1 ]  The field is also known as  proctology , but this term is now used infrequently within medicine and is most often employed to identify practices relating to the anus and rectum in particular. [ clarification needed ]  The word  proctology  is derived from the  Greek  words  πρωκτός   proktos , meaning "anus" or "hindparts", and  -λογία   -logia , meaning "science" or "study".


Physicians specializing in this field of medicine are called colorectal surgeons or proctologists. In the United States, to become colorectal surgeons, surgical doctors have to complete a general surgery residency as well as a colorectal surgery fellowship, upon which they are eligible to be certified in their field of expertise by the  American Board of Colon and Rectal Surgery  or the  American Osteopathic Board of Proctology . In other countries,  certification  to practice proctology is given to surgeons at the end of a 2–3 year subspecialty  residency  by the country's board of surgery.


Colorectal surgical disorders include: [ 2 ]


Surgical forms of treatment for these conditions include:  colectomy , ileo/colostomy,  polypectomy ,  strictureplasty , hemorrhoidectomy (in severe cases of  hemorrhoids ), minimally invasive surgery, anoplasty, and more depending on the condition the patient has. Diagnostic procedures, such as a  colonoscopy , are very important in colorectal surgery, as they can tell the physician what type of diagnosis should be given and what procedure should be done to correct the condition. Other diagnostic procedures used by colorectal surgeons include:  proctoscopy ,  defecating proctography ,  sigmoidoscopy .   In recent times, the  laparoscopic  method of surgery has seen a surge of popularity, due to its lower risks, decreased recovery time, and smaller, more precise incisions achieved by using laparoscopic instruments. [ 3 ]


Mechanical bowel preparation (MBP) is a procedure lacking evidence in literature, [ 4 ]  wherein fecal matter is expelled from the bowel lumen prior to surgery, most commonly by using  sodium phosphate . [ 5 ]


Shafi Ahmed  is a chief surgeon, teacher,  futurist , innovator, professor and entrepreneur. [ 1 ]


Ahmed lives in London. He is married to Farzana Hussain, a  general practitioner , with whom he has two children. [ 2 ]


He was born on 26 January 1969 in  Sylhet District ,  East Pakistan  (now  Bangladesh ), and came to the United Kingdom as a child. [ 3 ]


Ahmed attended Chadwell Heath High School (now  Chadwell Heath Academy ) before attending the Redbridge technical college.


From 1988 to 1993, he studied medicine at  King's College Hospital  School of Medicine. As the elected President of the Medical and Dental Society, he helped introduce medical ethics into the curriculum.


During his surgical training in London, he undertook a period of research at The  Royal London Hospital  and the  Queen Mary University of London . In 2010, he obtained a PhD with a thesis entitled "The role of microarray profiling in predicting outcome in patients with colorectal cancer". [ 4 ]


Ahmed has been awarded four honorary PhDs (Honoris Causa) from Udabol University Bolivia, SIISDET Colombia, the University of Peru of Science and Informatics and EXIBED, Spain. [ citation needed ]


In 2017, he was appointed as an honorary professor at The  University of Bradford  and awarded an Honorary Doctorate of Medicine in 2019. [ 5 ]


In 2020 he was awarded the Spinoza Honorary professorship at the  University of Amsterdam . [ 6 ] [ non-primary source needed ]


Ahmed is a specialist advisor to the Abu Dhabi Ministry of Health to help deliver innovation and  digital health . [ 7 ]


Ahmed works in the Academic Centre of Surgery and has established  minimally invasive   colorectal surgery  at the  Royal London Hospital ,  Barts Health NHS Trust . [ 8 ]


His main clinical interest is  colorectal cancer , and he performs surgery for primary and recurrent disease as well as multi-visceral resections.


He has pioneered single incision  laparoscopic  colorectal surgery (virtual scarless surgery) and also works with liver surgeons to perform simultaneous laparoscopic liver and  bowel resections  for cancer. His other clinical interest is advanced stage 3/4  endometriosis , performing laparoscopic surgery with  gynaecologists . This has led to the development and recognition of a national centre for endometriosis. In addition, he has specialist experience in complex abdominal wall  hernias  and reconstruction. [ 3 ]


From 2010 to 2015, Ahmed was the lead clinician and multi-disciplinary team lead for colorectal cancer at Barts Health NHS Trust. He was also a CQC specialist advisor in general surgery. [ citation needed ]


Ahmed was the Associate Dean for Barts and the London undergraduate medical students at  The Royal London Hospital  from 2010 to 2019 and was the lead for surgery. He was programme director for core surgical trainees for North East London 2012–2013 and Tutor in Surgery for the Royal London Hospital 2011–2013. He teaches innovation and digital transformation for surgeons at  Harvard Medical School  and  Imperial College London . [ 9 ]


He is the civilian advisor for the  British Armed forces  for general surgery. [ citation needed ]


From 2013 to 2019, Ahmed was elected to the council of the  Royal College of Surgeons of England . [ 10 ]  He had numerous roles and led the International Surgical Training Programme. He was part of the Cancer 2020, 5 Year Forward View Taskforce 2015. [ 11 ]  He is a member of the court of examiners and is an international convenor of the MRCS for Bangladesh. [ 12 ]


In 2007, Ahmed was appointed as a Consultant General, Laparoscopic and Colorectal surgeon to  The Royal London Hospital  and  St Bartholomew's Hospital ,  Barts Health NHS Trust .


He was chosen to curate the  NHS  Twitter account from 27 February 2017 to 3 March 2017 and tweeted the world's first live operation via this account.


He was the clinical lead for surgery at the  NHS Nightingale  Hospital at Excel London during the COVID-19 pandemic in 2020.


Ahmed performed a live cancer operation at  The Royal London Hospital  on Channel 5 for the series  Operation Live  in 2018.


Ahmed is the module lead for an innovative new course at Barts and the London Medical School which aims to teach the third year medical students about future medicine and how to generate ideas to improve clinical care. [ 13 ] [ 1 ]  The students are taught by  digital health  innovators and those involved in Medtech from the UK and US.


Ahmed has been working on new technologies to enhance surgical education globally. His online videos have been watched hundreds of thousands of times, earning him the accolade of the most-watched surgeon in human history. [ 14 ]


He aims to teach surgery and surgical processes to thousands of students at a time using VR technology. [ 15 ]


Ahmed's company Virtual Medics developed the use of  wearable technology  in education and clinical practice. This has allowed the development of a web-placed platform to stream live and interactive teaching.


In May 2014, using  Google Glass , he performed and streamed a live operation to 14 thousand students across 132 countries and 1100 cities. [ 16 ]


Ahmed is the co-founder of Medical Realities, a group offering surgical training products, specialising in virtual reality, augmented reality and  serious games . [ 17 ]  Through Medical Realities, he aims to provide tutorials in a modular format to teaching hospitals around the world. This will be made accessible to students and surgical trainees.


On 14 April 2016, in collaboration with  Barts Health , Medical Realities and Mativision, he performed the world's first virtual reality operation recorded and streamed live in  360 degrees . [ 8 ] [ 17 ] [ 18 ] [ 19 ]  This was viewed by 55,000 people in 140 countries and 4000 cities and reached 4.6 million people on Twitter.


This event was covered worldwide on over 400 newspaper/online articles and  BBC Click , Sky News, ARD German, TRT News, South American NTN,  ABC News ,  Aljazeera , and Press TV. [ 20 ] [ 21 ] [ 22 ] [ 23 ]  His work has been featured on  Wired ,  The Guardian ,  The Telegraph , ABC News,  CNET ,  The Verge ,  Huffington Post , and Tech China. [ 24 ] [ 25 ] [ 26 ] [ 27 ] [ 16 ] [ 28 ] [ 29 ] [ 30 ]


On 9 December 2016, he performed the world's first live operation using Snapchat Spectacles where he trained 200 medical students and surgical trainees, which was covered by  Time  magazine, and  BBC . [ 31 ] [ 32 ] [ 33 ]  The operation has been viewed over 100,000 times. [ 34 ]


He is a non-executive director of Medic creations, GPDQ and Imera. [ 35 ]


He is the chair of the GIANT (Global Innovation and New Technologies) Health Event in London and also the chair of the Webit Health conference in Sofia, Bulgaria, which showcases startups, innovation, technology and entrepreneurship. [ 36 ] [ 37 ]


Ahmed is a three time  TEDx  speaker and four times Wired Health and international  keynote speaker , and a member of the faculty at Exponential Medicine,  Singularity University .


On 15 March 2017, Ahmed delivered the Cantor Technology Lecture at the  University of Bradford  and also delivered the public lecture to open the Digital Health Enterprise Zone. [ 47 ]


He is Vice-President of Proshanti, a local charity community project to set up a health programme in Bangladesh, He is an advisor to Beani Bazaar Cancer Hospital, Bangladesh. [ 48 ]  He also teaches and trains surgeons in Dhaka, Bangladesh where he is the Dean for education at Rahetid, a postgraduate surgical training centre. [ 49 ]


The  American Board of Colon and Rectal Surgery  ( ABCRS ) is a member of the  American Board of Medical Specialties  that issues certificates for practitioners of  Colorectal surgery .


The board was established in 1934 as the American Board of Proctology. [ 1 ]


This article about a United States health organization is a  stub . You can help Wikipedia by  expanding it .


The  American Osteopathic Board of Proctology  ( AOBPR ) is an organization that provides  board certification  to qualified  Doctors of Osteopathic Medicine  (D.O.) who specialize in the medical and surgical treatment of disorders of the  anus ,  colon , and  rectum  of the  gastrointestinal tract  ( proctologists ). The board is one of 18  medical specialty  certifying boards of the  American Osteopathic Association Bureau of Osteopathic Specialists  approved by the  American Osteopathic Association  (AOA), [ 3 ]  and was established in 1941. [ 1 ]  As of April 2011, there were 25 osteopathic proctologists certified by the AOBPR. [ 4 ]


To become board certified in proctology, candidates must have completed an AOA-approved  residency  in proctology and one year of practice as a licensed proctologist. [ 5 ]   Additionally, candidates must have successfully completed the required oral and written examinations. Since 2004, board certified osteopathic proctologists must renew their certification every ten years to avoid expiration of their board certified status. [ 6 ]  Physicians certified by the AOBPR are known as fellows of the American Osteopathic College of Proctology.


Anal dysplasia  is a pre-cancerous condition which occurs when the lining of the  anal canal  undergoes abnormal changes. It can be classified as  low grade squamous intraepithelial lesions  (LSIL) and high-grade squamous intraepithelial lesions (HSIL). [ 1 ]
Most cases are not associated with symptoms, but people may notice lumps in and around the  anus . [ 2 ]


Anal dysplasia is most commonly linked to  human papillomavirus  (HPV), a usually  sexually-transmitted infection . [ 3 ]  HPV is the most common  sexually transmitted infection  in the United States [ 4 ]  while  genital herpes  ( HSV ) was the most common sexually transmitted infection globally. [ 5 ]


Anal fistula  is a chronic  abnormal communication  between the  anal canal  and the perianal skin. [ 1 ]  An anal fistula can be described as a narrow tunnel with its internal opening in the anal canal and its external opening in the skin near the anus. [ 2 ]  Anal fistulae commonly occur in people with a history of  anal abscesses . They can form when anal abscesses do not heal properly. [ 3 ]


Anal fistulae originate from the  anal glands , which are located between the  internal  and  external anal sphincter  and drain into the  anal canal . [ 4 ]  If the outlet of these glands becomes blocked, an  abscess  can form which can eventually extend to the skin surface. The tract formed by this process is a fistula. [ 5 ]


Abscesses can recur if the fistula seals over, allowing the accumulation of  pus . It can then extend to the surface again – repeating the process. [ 5 ]


Anal fistulae  per se  do not generally harm, but can be very painful, and can be irritating because of the drainage of pus (it is also possible for formed stools to be passed through the fistula). Additionally, recurrent abscesses may lead to significant short term morbidity from pain and, importantly, create a starting point for systemic infection. [ 5 ]


Treatment, in the form of surgery, is considered essential to allow drainage and prevent infection. Repair of the fistula itself is considered an elective procedure which many patients opt for due to the discomfort and inconvenience associated with an actively draining fistula. [ 5 ] [ 3 ]


Anal fistulae can present with the following symptoms: [ 4 ]


Diagnosis is by examination, either in an  outpatient  setting or under  anaesthesia  (referred to as  EUA  or Examination Under Anaesthesia). The fistula may be explored by using a fistula probe (a narrow instrument). In this way, it may be possible to find both openings. The examination can be an  anoscopy . Diagnosis may be aided by performing a fistulogram, proctoscopy and/or sigmoidoscopy.
Possible findings:


Depending on their relationship with the  internal  and  external sphincter  muscles, fistulae are classified into five types:


Other conditions in which infected perianal "holes" or openings may include  pilonidal cyst .


There are several stages to treating an anal fistula:


Definitive treatment of a fistula aims to stop it recurring.  Treatment depends on where the fistula lies, and which parts of the  internal  and  external anal sphincters  it crosses. However, treatment is challenging as complete eradication of the anal sphincters may lead to continence impairment, but failure to excise the affected areas results in recurrence. Those already treated for recurring anal fistula are at higher risk to experience re-recurrence of the disease.  [1]


The VAAFT procedure is done in two phases, diagnostic and operative. Before the procedure, the patient is given a spinal or general anaesthetic and is placed in the lithotomy position (legs in stirrups with the perineum at the edge of the table).  In the diagnostic phase, the fistuloscope is inserted into the fistula to locate the internal opening in the anus and to identify any secondary tracts or abscess cavities. The anal canal is held open using a speculum and irrigation solution is used to give a clear view of the fistula tract. Light from the fistuloscope can be seen from inside the anal canal at the location of the internal opening of the fistula, which helps to locate the internal opening.  In the operative phase of the procedure, the fistula tract is cleaned and the internal opening of the fistula is sealed. To do this, the surgeon uses the unipolar electrode, under video guidance, to cauterise material in the fistula tract. Necrotic material is removed at the same time using the fistula brush and forceps, as well as by continuous irrigation. The surgeon then closes the internal opening from inside the anal canal using stitches and staples.


Some people will have an active  infection  when they present with a fistula, and this requires clearing up before definitive treatment can be decided.


Antibiotics  can be used as with other infections, but the best way of healing infection is to prevent the buildup of pus in the fistula, which leads to abscess formation.  This can be done with a  seton .


A literature review published in 2018 showed an incidence as high as 21 people per 100,000. "Anal fistulas are 2–6 times more prevalent in males than females, with the condition occurring most frequently in patients in their 30s and 40s." [ 20 ]


Anal stricture  or  anal stenosis  is a narrowing of the anal canal. [ 1 ]  It can be caused by a number of surgical procedures including:  hemorrhoid  removal and following  anorectal wart  treatment. [ 2 ]


Anismus  or  dyssynergic defecation  is the failure of normal relaxation of  pelvic floor  muscles during attempted  defecation . It can occur in both children and adults, and in both men and women (although it is more common in women). It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities with  parcopresis , or psychogenic fecal retention. [ citation needed ]


Symptoms include  tenesmus  (the sensation of incomplete emptying of the rectum after defecation has occurred) and  constipation . Retention of stool may result in fecal loading (retention of a mass of stool of any consistency) or  fecal impaction  (retention of a mass of hard stool). This mass may stretch the walls of the rectum and colon, causing  megarectum  and/or  megacolon , respectively. Liquid stool may leak around a fecal impaction, possibly causing degrees of liquid fecal incontinence. This is usually termed  encopresis  or soiling in children, and  fecal leakage , soiling or liquid  fecal incontinence  in adults.


Anismus is usually treated with dietary adjustments, such as  dietary fiber  supplementation. It can also be treated with a type of  biofeedback  therapy, during which a sensor probe is inserted into the person's  anal canal  in order to record the pressures exerted by the pelvic floor muscles. These pressures are visually fed back to the patient via a monitor who can regain the normal coordinated movement of the muscles after a few sessions.


Some researchers have suggested that anismus is an over-diagnosed condition, since the standard investigations or  digital rectal examination  and  anorectal manometry  were shown to cause paradoxical sphincter contraction in healthy controls, who did not have constipation or incontinence. [ 1 ]  Due to the invasive and perhaps uncomfortable nature of these investigations, the pelvic floor musculature is thought to behave differently compared to normal circumstances. These researchers went on to conclude that paradoxical pelvic floor contraction is a common finding in healthy people as well as in people with chronic constipation and fecal incontinence, and it represents a non-specific finding or laboratory artifact related to untoward conditions during examination, and that true anismus is actually rare.


Symptoms include:


To understand the cause of anismus, an understanding of normal colorectal anatomy and physiology, including the normal defecation mechanism, is helpful. The relevant anatomy includes: the  rectum , the  anal canal  and the muscles of the  pelvic floor , especially  puborectalis  and the  external anal sphincter . [ citation needed ]


The  rectum  is a section of bowel situated just above the anal canal and distal to the  sigmoid colon  of the  large intestine . It is believed to act as a reservoir to store stool until it fills past a certain volume, at which time the defecation reflexes are stimulated. [ 4 ]  In healthy individuals, defecation can be temporarily delayed until it is socially acceptable to  defecate . In continent individuals, the rectum can expand to a degree to accommodate this function. [ citation needed ]


The anal canal is the short straight section of bowel between the rectum and the  anus . It can be defined functionally as the distance between the anorectal ring and the end of the  internal anal sphincter . The internal anal sphincter forms the walls of the anal canal. The internal anal sphincter is not under voluntary control, and in normal persons it is contracted at all times except when there is a need to defecate. This means that the internal anal sphincter contributes more to the resting tone of the anal canal than the external anal sphincter. The internal sphincter is responsible for creating a watertight seal, and therefore provides continence of liquid stool elements. [ citation needed ]


The  puborectalis  muscle is one of the pelvic floor muscles. It is  skeletal muscle  and is therefore under voluntary control. The puborectalis originates on the posterior aspect of the  pubic bone , and runs backwards, looping around the bowel.


The point at which the rectum joins the anal canal is known as the anorectal ring, which is at the level that the puborectalis muscle loops around the bowel from in front. This arrangement means that when puborectalis is contracted, it pulls the junction of the rectum and the anal canal forwards, creating an angle in the bowel called the anorectal angle. This angle prevents the movement of stool stored in the rectum moving into the anal canal. It is thought to be responsible for gross continence of solid stool. Some believe the anorectal angle is one of the most important contributors to continence. [ 5 ]


Conversely, relaxation of the puborectalis reduces the pull on the junction of the rectum and the anal canal, causing the anorectal angle to straighten out. A  squatting posture  is also known to straighten the anorectal angle, meaning that less effort is required to defecate when in this position. [ 6 ]


Distension of the rectum normally causes the internal anal sphincter to relax (rectoanal inhibitory response, RAIR) and the external anal sphincter initially to contract (rectoanal excitatory reflex, RAER). The relaxation of the internal anal sphincter is an involuntary response. The external anal sphincter, by contrast, is made up of skeletal (or striated muscle) and is therefore under voluntary control. It can contract vigorously for a short time. Contraction of the external sphincter can defer defecation for a time by pushing stool from the anal canal back into the rectum. Once the voluntary signal to defecate is sent back from the brain, the abdominal muscles contract (straining) causing the intra-abdominal pressure to increase. The pelvic floor is lowered causing the anorectal angle to straighten out from ~90 o  to <15 o  and the external anal sphincter relaxes. The rectum now contracts and shortens in  peristaltic waves , thus forcing fecal material out of the rectum, through the anal canal and out of the anus. The internal and external anal sphincters along with the puborectalis muscle allow the feces to be passed by pulling the anus up over the exiting feces in shortening and contracting actions. [ citation needed ]


In patients with anismus, the puborectalis and the external anal sphincter muscles fail to relax, with resultant failure of the anorectal angle to straighten out and facilitate evacuation of feces from the rectum. These muscles may even contract when they should relax (paradoxical contraction), and this not only fails to straighten out the anorectal angle, but causes it to become more acute and offer greater obstruction to evacuation.


As these muscles are under voluntary control, the failure of muscular relaxation or paradoxical contraction that is characteristic of anismus can be thought of as either maladaptive behavior or a loss of voluntary control of these muscles. Others claim that puborectalis can become  hypertrophied  (enlarged) or  fibrosis  (replacement of muscle tissue with a more fibrous tissue), which reduces voluntary control over the muscle.


Anismus could be thought of as the patient "forgetting" how to push correctly, i.e. straining against a contracted pelvic floor, instead of increasing abdominal cavity pressures and lowering pelvic cavity pressures. It may be that this scenario develops due to stress. For example, one study reported that anismus was strongly associated with sexual abuse in women. [ 7 ]  One paper stated that events such as pregnancy, childbirth, gynaecological descent or neurogenic disturbances of the brain-bowel axis could lead to a "functional  obstructed defecation syndrome " (including anismus). [ 8 ]  Anismus may develop in persons with  extrapyramidal motor disturbance  due to  Parkinson's disease . [ 9 ]   This represents a type of  focal dystonia . [ 10 ]  Anismus may also occur with  anorectal malformation ,  rectocele , [ 11 ]   rectal prolapse [ 12 ]  and  rectal ulcer . [ 12 ]


In many cases however, the underlying pathophysiology in patients presenting with obstructed defecation cannot be determined. [ 13 ]


Some authors have commented that the "puborectalis paradox" and "spastic pelvic floor" concepts have no objective data to support their validity. They state that "new evidence showing that defecation is an integrated process of colonic and rectal emptying suggests that anismus may be much more complex than a simple disorder of the pelvic floor muscles." [ 13 ]


Persistent failure to fully evacuate stool may lead to retention of a mass of stool in the rectum (fecal loading), which can become hardened, forming a  fecal impaction  or even  fecaliths . [ citation needed ]


Liquid stool elements may leak around the retained fecal mass, which may lead to paradoxical diarrhoea and/or fecal leakage (usually known as  encopresis  in children and  fecal leakage  in adults). [ 14 ] [ 15 ] [ 16 ] [ 17 ]


When anismus occurs in the context of intractable  encopresis  (as it often does), resolution of anismus may be insufficient to resolve encopresis. [ 18 ]  For this reason, and because biofeedback training is invasive, expensive, and labor-intensive, biofeedback training is not recommended for treatment of encopresis with anismus.


The walls of the rectum may become stretched, known as  megarectum . [ 19 ]


In the  Rome IV classification , diagnostic criteria for "functional defecation disorders" are as follows: [ 20 ]


2 subcategories exist within the functional defecation disorders category:


For all of these Rome-IV diagnoses, diagnostic criteria must have been fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. [ 20 ]  The subcategories F3a and F3b are defined by age- and gender-appropriate normal values for the technique. [ 20 ]


Previous Rome criteria recommended that anorectal testing is not usually indicated in patients with symptoms until patients have failed conservative treatment (e.g., increased dietary fiber and liquids; elimination of medications with constipating side effects
whenever possible). [ citation needed ]


Several definitions have been offered:


Physical examination can rule out anismus (by identifying another cause) but is not sufficient to diagnose anismus.


The measurement of  pressures  within the rectum and anus with a  manometer  (pressure-sensing probe).


defecating proctogram , and  MRI defecography


Anismus can be subcategorized into 4 types based on the results of anorectal manometry testing: [ 22 ]


Anismus is classified as a functional defecation disorder. It is also a type of rectal outlet obstruction (a functional outlet obstruction). Where anismus causes constipation, it is an example of  functional constipation . Many authors describe an " obstructed defecation syndrome ", of which anismus is a cause. [ 24 ]


The  Rome II classification  functional defecation disorders were divided into 3 types, [ 25 ]  however the symptoms the patient experiences are identical. [ 26 ]


It can be seen from the above classification that many of the terms that have been used interchangeably with anismus are inappropriately specific and neglect the concept of impaired propulsion. Similarly, some of the definitions that have been offered are also too restrictive.


The rectal cooling test is suggested to differentiate between rectal inertia and impaired relaxation/paradoxical contraction  [ 27 ]


Other techniques include  manometry ,  balloon expulsion test ,  evacuation proctography  (see  defecating proctogram ), and MRI defecography. [ 28 ]   Diagnostic criteria are:  fulfillment of criteria for  functional constipation , manometric and/or EMG and/or radiological evidence (2 out of 3), evidence of adequate expulsion force, and evidence of incomplete evacuation. [ 28 ]   Recent dynamic imaging studies have shown that in persons diagnosed with anismus the  anorectal angle  during attempted  defecation  is abnormal, and this is due to abnormal (paradoxical) movement of the  puborectalis muscle . [ 29 ] [ 30 ] [ 31 ]


Initial steps to alleviate anismus include dietary adjustments and simple adjustments when attempting to defecate. Supplementation with a  bulking agent  such as  psyllium  will make stool more bulky, which decreases the effort required to evacuate. [ 23 ]  Similarly, exercise and adequate hydration may help to optimise  stool form . The anorectal angle has been shown to flatten out when in a  squatting position , and is thus recommended for patients with functional outlet obstruction like anismus. [ 5 ]  If the patient is unable to assume a squatting postures due to mobility issues, a low stool can be used to raise the feet when sitting, which effectively achieves a similar position. [ citation needed ]


Treatments for anismus include biofeedback retraining, botox injections, and surgical resection. Anismus sometimes occurs together with other conditions that limit (see  contraindication ) the choice of treatments.  Thus, thorough evaluation is recommended prior to treatment. [ 32 ]


Biofeedback  training for treatment of anismus is highly effective and considered the gold standard therapy by many. [ 18 ] [ 33 ] [ 34 ]
Others however, reported that biofeedback had a limited therapeutic effect. [ 35 ]


Injections of  botulin toxin type-A  into the  puborectalis muscle  are very effective in the short term, and somewhat effective in the long term. [ 36 ]  Injections may be helpful when used together with biofeedback training. [ 37 ] [ 38 ]


Historically, the standard treatment was  surgical resection  of the puborectalis muscle, which sometimes resulted in fecal incontinence. Recently, partial resection (partial division) has been reported to be effective in some cases. [ 35 ] [ 39 ]


Paradoxical anal contraction during attempted defecation in constipated patients was first described in a paper in 1985, when the term anismus was first used. [ 40 ]  The researchers drew analogies to a condition called  vaginismus , which involves paroxysmal (sudden and short lasting) contraction of  pubococcygeus  (another muscle of the pelvic floor).  These researchers felt that this condition was a spastic dysfunction of the anus, analogous to 'vaginismus'. However, the term anismus implies a psychogenic etiology, which is not true although psychological dysfunction has been described in these patients. Hence:


Latin  ani  - "of the anus"
Latin  spasmus  - "spasm"


(Derived by extrapolation with the term vaginismus, which in turn is from the Latin  vagina  - "sheath" +  spasmus  - "spasm")


Many terms have been used synonymously to refer to this condition, some inappropriately. The term "anismus" has been criticised as it implies a  psychogenic  cause. [ 41 ]  In the most widely accepted classification systems ( ICD-11  and  Rome-IV ), the term "dyssynergic defecation" is preferred. [ 21 ] [ 20 ]  As stated in the Rome II criteria, the term "dyssynergic defecation" is preferred to "pelvic floor dyssynergia" because many patients with dyssynergic defecation do not report sexual or urinary symptoms, [ 25 ]  meaning that only the defecation mechanism is affected.


Other synonyms include:


Anorectal anomalies  are congenital malformations of the  anus  and  rectum . [ 1 ]  One anal anomaly,  imperforate anus  has an estimated incidence of 1 in 5000 births. [ 2 ] [ 3 ]  It affects boys and girls with similar frequency. [ 4 ]


Examples of anorectal anomalies include: [ citation needed ]


This article about a  disease , disorder, or medical condition is a  stub . You can help Wikipedia by  expanding it .


Anorectal manometry  ( ARM ) is a  medical test  used to measure  pressures  in the  anus  and  rectum  and to assess their function. [ 1 ] [ 2 ]  The test is performed by inserting a  catheter , that contains a probe embedded with pressure sensors, through the anus and into the rectum. [ 3 ]  Patients may be asked to perform certain maneuvers, such as coughing or attempting to  defecate , to assess for pressure changes. [ 3 ]  Anorectal manometry is a safe [ 4 ]  and low risk [ 3 ]  procedure.


From 2014 to 2018, the international anorectal physiology working group (IAPWG) meet several times to develop consensus on  indications  for anorectal manometry. [ 5 ]  Their assessment concluded that anorectal manometry was indicated when used in assessment of  fecal incontinence ,  constipation , evacuation disorders (including  Hirschsprung's disease [ 6 ] ), functional anorectal pain and in the assessment of anorectal function  preoperatively  or after a traumatic  obstetric  injury. [ 5 ]  In addition to the indications outlined by the IAPWG, anorectal manometry has been used as a component of anorectal  biofeedback . [ 6 ]


Since its introduction in 2007,  high resolution  anorectal manometry (HR-ARM) has increasingly replaced conventional anorectal manometry as the standard. [ 7 ]  There has been increasing usage of high-definition (3D) anorectal manometry (HD-ARM) as well. [ 7 ]  Current advances in anorectal manometry include the development of  bedside  portable technology. [ 7 ]


After eliminating structural causes of  fecal incontinence  from the  differential diagnosis , anorectal manometry may be used to evaluate deficiencies in  sphincter  function or anorectal sensation. [ 4 ] [ 7 ]  An abnormal resting pressure or squeeze pressure may indicate problems with either the  internal anal sphincter  or the  external anal sphincter  respectively. [ 4 ]  Both increased and decreased anorectal sensation has also been detected in individuals with fecal incontinence. [ 6 ]  The use of HD-ARM can allow recognition of pressure asymmetry within the anorectum. [ 4 ]  Some patients with fecal incontinence benefit from muscle strength training which may make use of anorectal biofeedback. [ 6 ]


Anorectal manometry can be used in the diagnostic workup of individuals with  chronic constipation  without a known cause [ 8 ]  or with chronic constipation that has not improved on a trial of  laxatives  and/or  fiber . [ 9 ]  For example, on a  digital rectal exam , a physician may notice specific findings that point to  dyssynergic defecation , a cause of chronic constipation. [ 8 ]  In such instances, the physician may order an anorectal manometry study to verify their findings. [ 8 ]  Abnormal results, such as the presence of a  paradoxical  contraction of the anal sphincter muscles during  defecation  (i.e. the muscles are squeezing instead of relaxing), can also be used to guide treatment (e.g. anorectal  biofeedback ). [ 4 ] [ 8 ]  Other abnormal findings on manometry consistent with chronic constipation include an unsatisfactory generation of the propulsive  force  needed to defecate and a decreased movement of  pelvic floor  muscles. [ 4 ]


Anorectal manometry, especially HR-ARM and HD-ARM, has also been used to evaluate constipation due to structural causes such as a  rectocele , [ 2 ]  an  enterocele , or an intra-anal  intussusception . [ 4 ]


In infants and children, anorectal manometry may be used to assist in the diagnosis of  Hirschsprung's disease . [ 2 ]  The absence of the  rectoanal inhibitory reflex  (RAIR) is almost always  pathognomonic  for Hirschsprung's disease in this population. [ 6 ]  Anorectal manometry is not significantly less  sensitive and specific  when compared to the  gold standard  method of diagnosis, rectal suction  biopsy . [ 6 ]  In adults, the absence of the RAIR is less likely due to Hirschsprung's disease and may indicate the presence of  megarectum . [ 6 ] [ 7 ]


Functional anorectal pain includes disorders such as  levator ani syndrome ,  proctalgia fugax  and unspecified functional anorectal syndrome. [ 4 ]  Although diagnosis of these disorders is largely clinical, anorectal manometry may be used for further diagnostic assessment. [ 4 ]  For example, the degree of anal sphincter hypertension may be determined [ 7 ]  which may be useful information when treating functional anorectal pain with biofeedback therapy. [ 4 ]


The goal of anorectal  biofeedback  is to help patients improve  defecating  behaviors by providing patients with visual and verbal feedback. [ 10 ]  Visual feedback tools, such as anorectal manometry, are often used to aid patients in learning how to modify their behaviors. [ 10 ]  Patients may work on improving muscle strength, muscle relaxation or sensation during defecation. [ 8 ]


The effectiveness of anorectal biofeedback as a treatment remains an ongoing source of debate and research. A systemic review article [ 11 ]  concluded that although better than  placebo , there remained limited evidence demonstrating the effectiveness of anorectal biofeedback for chronic  idiopathic  constipation. [ 8 ]  In patients with  defecatory  disorders, including  dyssynergic defecation ,  pelvic floor  biofeedback therapy had been shown to be more effective than laxatives. [ 6 ] [ 9 ]  An American-European  Neurogastroenterology & Motility  task force (ANMS-ESNM) recommended the use of biofeedback in the short and long treatment of constipation with dyssynergic defecation and fecal incontinence. [ 10 ]  They did not recommend biofeedback treatment for constipation without dyssynergic defecation, nor in children with constipation. [ 10 ]


Types of anorectal manometry include:


HR-ARM and HD-ARM are newer methods that use multiple closely spaced sensors in the anus and rectum, compared to 3-6 widely spaced sensors used by non-HRM, to generate a more refined view. [ 3 ] [ 6 ]  An additional benefit to HR-ARM and HD-ARM is the increased ease in analyzing the results as pressure readings are displayed in both color and as a line plot. [ 3 ]  Accompanying the benefits shared by both high-resolution and high-definition methods, the HD-ARM method employs additional sensors placed circumferentially around the catheter allowing for closer interpretation of individual sensor pressure readings. [ 3 ]  In comparison to non-HRM, however, both of the newer methods utilize equipment that is more expensive and has a shorter  design life . [ 3 ]


The specifics of the equipment used for the procedure will ultimately depend on the type of manometry and the manufacturer of the device. Nonetheless, most share some common features: [ 3 ]


In 2019, the International Anorectal Physiology Working Group (IAPWG) released a standardized testing protocol for the use of anorectal manometry. [ 5 ]  One of the goals of this protocol was to standardize procedural techniques to better facilitate meaningful data sharing. [ 5 ]  This protocol is the most recent published guideline for anorectal manometry since the one published in 2002 [ 12 ]  which was not widely adopted. [ 7 ]


Fasting  is not a requirement for this procedure. [ 5 ]  Patients are  informed  as to how the procedure is performed, its benefits and risks. Risks include the possibility of developing discomfort, pain, minor bleeding, dizziness or a rare  perforation . [ 3 ] [ 13 ]  In the testing room, the patient is placed on their left side with their knees bent. [ 5 ]  A  digital rectal exam  is then performed prior to the procedure to evaluate initial anatomy and function, check for stool, and to assess patient's understanding of the verbal instructions employed during the procedure. [ 5 ]


Anorectal manometry is often performed alongside a rectal sensory test (RST) and a balloon expulsion test (BET). [ 5 ]  The RST is performed after the manometry while the BET may be performed immediately prior to the manometry or subsequent to the RST. [ 5 ]  The total time to conduct all three tests is 15 to 20 minutes. [ 5 ]


This test takes approximately 10 minutes. [ 5 ]  With the use of a lubricant, an anorectal manometry catheter is introduced into the anus. [ 5 ]  The catheter is advanced until the base of the balloon is above the  anal canal  by 3–5 cm (1.2–2.0 in) and the most  distal  sensor is below the  anal verge . [ 5 ]  In order, the following maneuvers are then performed:


During the rectal sensory test, air is placed into the catheter balloon and slowly inflated either continuously or step-wise. [ 5 ]  The patient is asked to verbalize when they first sense the balloon, when the urge to defecate is first present and when they can no longer tolerate the balloon. [ 5 ]


To perform the balloon expulsion test, a catheter with a balloon on its tip is introduced into the patient's anorectum. [ 5 ]  The balloon is then distended to 50ml with water. [ 5 ]  Patients are then instructed to transfer from lying on their side to sitting on a toilet. [ 5 ]  Next, patients are asked to push out the balloon as if they are defecating. [ 5 ]  The time it takes for the expulsion of the balloon is then recorded. [ 5 ]


The anal resting pressure is the recorded pressure within the anus during muscle relaxation. [ 6 ]  After insertion of the catheter, a short amount of time is allowed for the muscles to relax. Afterwards, pressures are recorded over 60 seconds. [ 5 ]  The  maximum  resting pressure is the highest pressure reached during this time period, while the  mean  resting pressure is the average pressure during this time period. In healthy individuals, women, especially older women, have an average lower anal resting pressures than men. [ 6 ]


The anal squeeze pressure is the recorded pressure within the anus during a voluntary contraction of the  external anal sphincter . [ 6 ]  Similar to resting pressures, squeeze pressures in healthy women are lower than healthy men. [ 6 ]  If using high-definition anorectal manometry, asymmetry in squeeze pressures can also be measured. [ 6 ]


During  defecation , the pressure in the anorectum should increase while the  external anal sphincter  should relax. If the pressure difference during defecation does not increase sufficiently, it may indicate poor propulsive force. [ 6 ] [ 14 ]  Additionally, inadequate relaxation of the sphincter during defecation is another abnormal finding. [ 6 ]  Another method to assess changes during defecation is to calculate an anorectal gradient (or defecation index) in one of two ways. [ 14 ]  The anorectal gradient is either calculated as a difference (rectal pressure - anal pressure) or as a  ratio  (rectal pressure / anal pressure). [ 14 ]  A positive difference or a ratio over 1 indicates normal findings. [ 14 ]  Abnormal findings on manometry does not definitively indicate illness as a significant number of healthy individuals have been found to have abnormal results. [ 6 ] [ 14 ]  Values recorded during a defecation trial are influenced by a number of factors including the degree of patient involvement in defecation efforts. [ 6 ]


In healthy individuals, in the process of defecating, the  internal anal sphincter  will  reflexively  relax. The lack of a  rectoanal inhibitory reflex  may indicate either the absence or the non-functionality of certain muscle or nerve structures involved in proper defecation. [ 3 ] [ 6 ]


Patients are assessed on their anorectal sensory perception via the inflation of a balloon. As the balloon is inflated, its volume is recorded at certain milestones: [ 5 ]  initial sensation of the equipment, start of the sensory urge to defecate and the point of maximum discomfort. [ 6 ] [ 3 ]  An increased level of sensation has been noted in disorders such as  fecal incontinence , while a decreased level of sensation has been seen in individuals with  dyssynergic defecation . [ 3 ]


As part of the 2020 IAPWG consensus manuscript, the group published the newly created London Classification for Disorders of Anorectal Function which aimed to standardize the interpretation of anorectal manometry findings. [ 5 ] [ 7 ]  The London Classification divided disorders into 4 parts:


Under each part, there are a list of diagnosis that are made based on manometry findings. For example, under part 2 (Disorders of anal tone and contractility), listed manometric diagnoses include: anal hypotension, anal hypertension, anal hypercontractility and combined anal hypertension and hypercontractility. [ 7 ]  Findings are also divided into: major findings, minor findings and inconclusive findings. [ 7 ]  Major findings are findings that are not present in healthy patient such as rectoanal areflexia, [ 7 ]  Minor findings are findings that are more commonly found in patients with anorectal disease compared to healthy patients, while inconclusive findings are findings that may be present in both groups. [ 7 ]


Centers rely on published data sets from healthy volunteers to evaluate test findings. [ 4 ]  However, the lack of standardization in equipment usage and procedural protocol, can in certain cases, impact the ability to determine what may be considered normal or abnormal values. [ 4 ]  This is further complicated by the limited amount of data on the impact of different epidemiological characteristics (such as age or gender) on said values. [ 4 ]  For an individual patient, findings on anorectal manometry, alone, does not dictate management. [ 7 ]  In addition to correlating manometry findings with clinical findings, as part of a diagnostic or evaluatory workup, the use of anorectal manometry may be complemented with other diagnostic tests such as  endoanal ultrasound ,  defecography  or gut transit studies. [ 7 ]  High resolution anorectal manometry also experiences pressure drift, variable linear changes in pressure readings over time, that could impact the clinical value of manometry findings in some specific situations. [ 6 ]


Anorectal varices  are  collateral  submucosal blood vessels  dilated  by backflow in the veins of the  rectum . [ 1 ]  Typically this occurs due to  portal hypertension  which shunts venous blood from the  portal system  through the  portosystemic anastomosis  present at this site into the  systemic venous system . [ 2 ] [ 3 ]  This can also occur in the  esophagus , causing  esophageal varices , and at the level of the  umbilicus , causing  caput medusae . [ 4 ]  Between 44% and 78% of patients with portal hypertension get anorectal varices. [ 3 ] [ 5 ]


Blood from the superior portion of the  rectum  normally drains into the  superior rectal vein  and via the  inferior mesenteric vein  to the  liver  as part of the  portal venous system . Blood from the middle and inferior portions of the  rectum  is drained via the  middle  and  inferior rectal veins . In  portal hypertension , venous resistance is increased within the  portal venous system ; when the pressure in the portal venous system increases above that of the  systemic , blood is shunted through the  portosystemic anastomoses . The shunting of blood and consequential increase of pressure through the collateral veins causes the  varicosities . [ citation needed ]


The terms  rectal varices  and  haemorrhoids  are often used interchangeably, but this is not correct. [ 6 ]  Haemorrhoids are due to prolapse of the  rectal venous plexus  and are no more common in patients with portal hypertension than in those without. [ 7 ]  Rectal varices, however, are found only in patients with portal hypertension and are common in conditions such as  cirrhosis . [ 8 ]


Unlike esophageal varices, rectal varices are less prone to bleeding, are less serious when a bleed does occur, and are easier to treat because of the more accessible location. [ 9 ]  However, in some cases, rectal varices can result in severe bleeding.  [ 10 ]


Typically, treatment consists of addressing the underlying portal hypertension. Some treatments include portosystemic shunting, ligation, and under-running suturing. [ 5 ]  Insertion of a  transjugular intrahepatic portosystemic shunt  (TIPS) has been shown to alleviate varices caused by portal hypertension. [ 1 ]  Successful treatment of portal hypertension that subsequently reduces anorectal varices provides a confirmation of the initial diagnosis, allowing for a distinction between varices and hemorrhoids, which would not have been alleviated by reduction of portal hypertension. [ citation needed ]


An  anoscopy  is a  medical examination  using a small, rigid, tubular instrument called an anoscope (also called a  rectal speculum ).  This is inserted a few inches into the  anus  in order to evaluate problems of the  anal canal . Anoscopy is used to diagnose  hemorrhoids ,  anal fissures  (tears in the lining of the anus), and some  cancers . [ 1 ] [ 2 ]


This test is usually done in a doctor's office. The patient is required to remove their underwear, and must either lie on their side on top of an examining table, with their knees bent up towards the chest, or bend forward over the table. The anoscope is 3 to 4 inches long and the width of an average-to-large bowel movement. The doctor will coat the anoscope with a lubricant and then gently push it into the anus and rectum. The doctor may ask the patient to "bear down" or push as if they were going to have a bowel movement, and then relax. This helps the doctor insert the anoscope more easily and identify any bulges along the lining of the rectum.


By shining a light into this tube, the doctor will have a clear view of the lining of the lower rectum and anus. The anoscope is pulled out slowly once the test is finished.


The patient will feel pressure during the examination, and the anoscope will make one feel as if they were about to have a bowel movement. This is normal, however, and many patients do not feel pain from anoscopy.