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Mastectomy

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.

The decision to perform a mastectomy is based on various factors, including breast size, the number of lesions, biologic aggressiveness of a breast cancer, the availability of adjuvant radiation, and the willingness of the patient to accept higher rates of tumor recurrences after lumpectomy and/or radiation. Outcome studies comparing mastectomy to lumpectomy with radiation have suggested that routine radical mastectomy surgeries will not always prevent later distant secondary tumors arising from micro-metastases prior to discovery, diagnosis, and operation. In most circumstances, there is no difference in both overall survival and breast cancer recurrence rate. While there are both medical and non-medical indications for mastectomy, the clinical guidelines and patient expectations for before and after surgery remain the same.

Breast cancer
Despite the increased ability to offer breast conservation techniques to those with breast cancer, certain groups may be better served by traditional mastectomy procedures including:
 * women who have already undergone radiation therapy to the affected breast
 * women with 2 or more areas of cancer in the same breast that are too far apart to be removed through 1 surgical incision
 * women whose initial lumpectomy along with (one or more) re-excisions has not completely removed the cancer
 * women with certain serious connective tissue diseases such as scleroderma, which make them especially sensitive to the side effects of radiation therapy
 * pregnant women who would require radiation while still pregnant (risking harm to the child)
 * women with a tumor larger than 5 cm (2  inches) that doesn't shrink very much with neoadjuvant chemotherapy
 * women with cancer that is large relative to their breast size
 * women who have tested positive for a deleterious mutation on the BRCA1 or BRCA2 gene and opt for a preventive mastectomy since they are at high risk for the development of breast cancer.

Other uses
Mastectomy has non-cancer medical uses as well, including cosmetic or reconstructive surgery. Men with gynecomastia may be eligible for mastectomy, but minimally invasive surgical techniques also exist. Transgender men and non-binary people assigned female at birth may undergo a mastectomy as a gender-affirming surgery.

Side effects
Aside from the post-surgical pain and the obvious change in the shape of the chest and/or breast(s), possible side effects of a mastectomy include soreness, scar tissue as the site of the incision, short-term swelling, phantom breast pain (pain in the breast or tissue that has been removed), wound infection or bleeding, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound). If the lymph nodes are also removed, additional side effects such as lymphedema (swelling of the lymph nodes) may occur.

Upper limb problems such as shoulder and arm pain, weakness and restricted movement are a common side effect after breast cancer surgery. According to research in the UK, an exercise programme started 7–10 days after surgery can reduce upper limb problems.

Types
Currently, there are several surgical approaches to mastectomy, and the type that a person decides to undergo (or whether they will decide instead to have a lumpectomy) depends on factors such as the size, location, and behavior of the tumor (if one is present), whether or not the surgery is prophylactic, and whether the person intends to undergo reconstructive surgery.
 * Simple mastectomy (or "total mastectomy"): In this procedure, the entire breast tissue is removed, but axillary contents are undisturbed. Sometimes the "sentinel lymph node"—that is, the first axillary lymph node that the metastasizing cancer cells would be expected to drain into—is removed. People who undergo a simple mastectomy can usually leave the hospital after a brief stay. Frequently, a drainage tube is inserted during surgery in their chest and attached to a small suction device to remove subcutaneous fluid. These are usually removed several days after surgery as drainage decrease to less than 20-30 ml per day. People that are more likely to have the procedure of a simple or total mastectomy are those that have large areas of ductal carcinoma in situ or even those persons that are removing the breast because of the possibility of breast cancer occurring in the future (prophylactic mastectomies).  When this procedure is done on a cancerous breast, it is sometimes also done on the healthy breast to forestall the appearance of cancer there.  The choice of this "contralateral prophylactic" option has become more typical in recent years in California, most notable in people younger than 40, climbing from just 4 percent to 33 percent from 1998 to 2011.  However, the possible benefits appear to be marginal at best in the absence of genetic indicators, according to a large-scale study published in 2014.    For healthy people known to be at high risk for breast cancer, this surgery is sometimes done bilaterally (on both breasts) as a cancer-preventive measure. Women may also choose to have the a second healthy breast removed in a 'balancing' or 'symmetrizing' surgery so that they can have a flat chest. A systematic review found that women who had both breasts removed in this circumstance were, overall, satisfied with their decision. They had fewer complications than women who had breast reconstruction but had slightly more complications than women who had one breast removed.
 * Modified radical mastectomy: The entire breast tissue is removed along with the axillary contents (fatty tissue and lymph nodes). In contrast to a radical mastectomy, the pectoral muscles are spared.  This type of mastectomy is used to examine the lymph nodes because this helps to identify whether the cancer cells have spread beyond the breasts.
 * Radical mastectomy (or "Halsted mastectomy"): First performed in 1882, this procedure involves removing the entire breast, the axillary lymph nodes, and the pectoralis major and minor muscles behind the breast. This procedure is more disfiguring than a modified radical mastectomy and provides no survival benefit for most tumors. This operation is now reserved for tumors involving the pectoralis major muscle or recurrent breast cancer involving the chest wall. It is only recommended for breast cancer that has spread to the chest muscles. Radical mastectomies have been reserved for only those cases because they can be disfiguring and modified radical mastectomies have been proven to be just as effective.
 * Skin-sparing mastectomy: In this surgery, the breast tissue is removed through a conservative incision made around the areola (the dark part surrounding the nipple). The increased amount of skin preserved as compared to traditional mastectomy resections serves to facilitate breast reconstruction procedures. People with cancers that involve the skin, such as inflammatory cancer, are not candidates for skin-sparing mastectomy. The effectiveness and safety profile of skin-sparing mastectomy procedures have also not been well studied. In a skin sparing mastectomy, the skin flap may be perfused with fluids and indocyanine green angiography is sometimes suggested to help prevent the skin that has been saved from dying to improve reconstruction if there person wishes. There is no clear evidence on the effectiveness of this approach.
 * Nipple-sparing/subcutaneous mastectomy: Breast tissue is removed, but the nipple-areola complex is preserved. This procedure was historically done only prophylactically or with mastectomy for the benign disease over the fear of increased cancer development in retained areolar ductal tissue. Recent series suggest that it may be an oncologically sound procedure for tumors not in the subareolar position.
 * Extended Radical Mastectomy: Radical mastectomy with intrapleural en bloc resection of internal mammary lymph node by sternal splitting.
 * Prophylactic mastectomy: This procedure is used as a preventive measure against breast cancer. The surgery is aimed to remove all breast tissue that could potentially develop into breast cancer. The surgery is generally considered when a woman has BRCA1 or BRCA2 genetic mutations. The tissue from just beneath the skin to the chest wall and around the borders of the breast needs to be removed from both breasts during this procedure. Because breast cancer develops in the glandular tissue, the milk ducts and milk lobules must be removed also. Because the region is so large-ranging, from the collarbone to the lower rib margin and from the middle of the chest around the side and under the arm, it is very difficult to remove all of the tissue. This genetic mutation is a high-risk factor for the development of breast cancer, family history, or atypical lobular hyperplasia (when irregular cells line the milk lobes.) This type of procedure is said to reduce the risk of breast cancer by 100%. However, other circumstances may affect the outcome. Studies have shown that pre-menopausal women have had a higher survival rate after this procedure had been done.

Before surgery
Prior to undergoing the mastectomy, it is important to meet with the surgeon to discuss the relevant risks and benefits of receiving the surgery. Depending on the indication for mastectomy, there may be other options to address the clinical condition. One important consideration to discuss with the surgeon is whether breast reconstruction will occur and when this procedure will take place. One option is to have the reconstruction immediately after the mastectomy in the same surgery, whereas other patients opt for a subsequent surgery for reconstruction. This breast reconstruction surgery will be conducted by a plastic surgeon. In addition to the surgeon, a meeting with an anesthesiologist is pertinent in order to review the patient’s medical history and determine the plan of anesthesia.

Leading up to the day of the surgery, there are various considerations that patients can be cognizant of to facilitate their recovery following surgery. As with other surgeries that may lead to appreciable blood loss, it is advised not to take aspirin or aspirin-containing products for 10 days before the surgery. The reason for this is to prevent the anti-coagulative function of aspirin and other blood thinners that would make it difficult to achieve coagulation during the surgery. In addition, it is important for patients to tell the doctor about any medications, vitamins, or supplements that they are taking because some substances could interfere with the surgery. It is also pertinent for patients to not eat or drink 8 to 12 hours before surgery, however, there may be specific pre-operative instructions given by each patient’s care team.

Maintaining fitness and proper nutrition is also an important measure to consider prior to receiving a surgery because it has been shown that postoperative outcomes are improved in patients that exercise and maintain a healthy diet prior to surgery. In addition to nutrition and exercise, it is advised to reduce alcohol consumption and smoking. This concept of pre-rehabilitation is beneficial in mitigating post-operative complications and decreasing length of stay in the hospital. The rationale is that increasing a patient’s functional status prior to surgery will allow for a smoother and faster recovery in the postoperative setting.

Recent research has indicated that mammograms should not be done with any increased frequency than the normal procedure in women undergoing breast surgery, including breast augmentation, mastopexy, and breast reduction.

After surgery
Prior to leaving the hospital, people who have had a mastectomy will typically be given a prescription for pain medication to ameliorate any pain or discomfort at the surgery site. Recognizing signs of a surgical site infection including fever, redness, swelling, or pus is important. Any signs of infection should be reported to and assessed by a medical professional. In addition, signs of lymphedema due if lymph node removal is performed during mastectomy may be detected by the presence of heaviness, tightness, or fullness in the hand, arm, or axillary area region.

Regarding return to activity, it is advised not to engage in strenuous activity or lift objects above 5 pounds for up to six weeks after a mastectomy at the discretion of the physician. However, it is common for a member of the medical team to provide home exercises designed to maintain arm and shoulder movement and flexibility. Walking is also highly encouraged and allowed immediately after surgery. Most people who undergo a mastectomy can return to work and other regular physical activities in approximately 4 weeks after surgery.

People who have had a mastectomy will usually have a post-operative follow-up visit with their provider 1–2 weeks after surgery. The time at which a person can start to wear a bra or reconstructive breast varies and is often at the discretion of the physician.

Some people with breast cancer may require additional radiotherapy after their mastectomy procedure with the goal of reducing the risk of the cancer returning to the lymph nodes and the tissue remaining in the wall of the person's chest. The decision by the medical team for suggesting radiotherapy may differ between individual professionals. Most teams recommend radiotherapy after a masectomy for people who are at a higher risk of cancer recurrence including those with large breast tumours (5 cm and larger) and people with cancer that has spread to multiple axillary lymph nodes (4 or more). The necessity and usefulness of radiotherapy on people at slightly lower risk, for example, the cancer has spread to 1-3 axillary lymph nodes, is not as clear.

Trends
Between 2005 and 2013, the overall rate of mastectomy increased 36 percent, from 66 to 90 per 100,000 adult women. The rate of hospital-based bilateral mastectomies (inpatient and outpatient combined) more than tripled, from 9.1 to 29.7 per 100,000 adult women, whereas the rate of unilateral mastectomies remained relatively stable at around 60 per 100,000 women. From 2005 to 2013, the rate of bilateral outpatient mastectomies increased more than fivefold and the inpatient rate nearly tripled. The rate of unilateral mastectomies nearly doubled in the outpatient setting but decreased 28 percent in the inpatient setting. By 2013, nearly half of all mastectomies were performed outpatient. However, there are concerns that these rising rates of mastectomies are most greatly seen in women with node-negative and noninvasive lesions, which are subsets of patients that do not require mastectomy.

Frequency
Mastectomy rates vary tremendously worldwide, as was documented by the 2004 'Intergroup Exemestane Study', an analysis of surgical techniques used in an international trial of adjuvant treatment among 4,700 females with early breast cancer in 37 countries. The mastectomy rate was highest in central and eastern Europe at 77%. The USA had the second highest rate of mastectomy with 56%, western and northern Europe averaged 46%, southern Europe 42% and Australia and New Zealand 34%.

History
Breast surgery was first described 3000 years ago. In the earliest stages, breast tumors were treated with simple cauterization. Later, alternating incision and cauterization with complete removal of tumors was suggested by Leonides, one of the first breast oncologic surgeons recorded in history. Other surgeons recommended excision and cauterization only if the tumor could be removed completely; otherwise, avoiding surgery was recommended. Ambrose Pare (b. 1510), a well-known surgeon from Paris who was well-known for his experience treating soldiers who were injured, proposed a multi-tiered approach to breast surgery. While superficial cancers could be excised, more advanced cancers were managed through compression by lead plates to reduce blood supply to the tumor.

In the 1500s, William Fabry (b.1560), a German surgeon known as the father of German surgery, created a device that compressed and fixed the base of the breast during mastectomy, which subsequently allowed for faster excision of the breast. Another technique developed during this time to improve efficiency of breast dissection was using ligatures to achieve anterior traction. Despite the development of these techniques, there were few mastectomies actually performed at the time due to lack of qualified surgeons and the high morbidity, mortality and disfigurement associated with the surgery.

During the 1700s, large contributions in mapping lymph nodes for surgery were made by Pieter Camper (b. 1722) and Paolo Mascagni (b. 1752). Lymph node removal was advocated for in managing breast cancer. At this time, surgeries were still performed without proper aseptics and without anesthesia.

In the 19th century, Seishu Hanaoka, a Japanese surgeon, performed the first surgery in the world under general anesthesia. Many more advancements in anesthesia and aseptic technique were made during this century. William Roentgen discovered x-rays in 1895, which radically shifted breast cancer treatment from a solely surgical approach to the multi-pronged approach employed today, including imaging, hormonal therapy, radiation, chemotherapy and immunotherapy.

During the 20th century, progress was made towards skin-sparing mastectomies for treatment of breast cancer. Recent literature suggests that these procedures allow for improved aesthetic outcomes while also not increasing risk for local recurrence compared to conventional mastectomies.

For example, in 1937, the Tauton State Hospital in Massachusetts reported 1 mastectomy in its operating rooms that year, listed alongside other operations including colostomy (1), enterostomy (1), herniorrhaphy (4), laparotomy (1), and circumcision (2).

title: Mastectomy


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Plastic surgery

Plastic surgery is a surgical specialty involving the restoration, reconstruction, or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniofacial surgery, hand surgery, microsurgery, and the treatment of burns. While reconstructive surgery aims to reconstruct a part of the body or improve its functioning, cosmetic (or aesthetic) surgery aims to improve the appearance of it. A comprehensive definition of plastic surgery has never been established, because it has no distinct anatomical object and thus overlaps with practically all other surgical specialties. An essential feature of plastic surgery is that it involves the treatment of conditions that require or may require tissue relocation skills.

Etymology
The word plastic in plastic surgery is in reference to the concept of "reshaping" and comes from the Greek πλαστική (τέχνη), plastikē (tekhnē), "the art of modelling" of malleable flesh. This meaning in English is seen as early as 1598. In the surgical context, the word "plastic" first appeared in 1816 and was established in 1838 by Eduard Zeis, preceding the modern technical usage of the word as "engineering material made from petroleum" by 70 years.

History
Treatments for the plastic repair of a broken nose are first mentioned in the c. 1600 BC Egyptian medical text called the Edwin Smith papyrus. The early trauma surgery textbook was named after the American Egyptologist, Edwin Smith.

The Romans also performed plastic cosmetic surgery, using simple techniques, such as repairing damaged ears, from around the 1st century BC. For religious reasons, they did not dissect either human beings or animals, thus, their knowledge was based in its entirety on the texts of their Greek predecessors. Notwithstanding, Aulus Cornelius Celsus left some accurate anatomical descriptions, some of which—for instance, his studies on the genitalia and the skeleton—are of special interest to plastic surgery. Several ancient Sanskrit medical treatise mentions some types of plastic surgery in India such as the works of Sushruta and Charaka. These works were translated into the Arabic language during the Abbasid Caliphate in 750 AD. The Arabic translations made their way into Europe via intermediaries. In Italy, the Branca family of Sicily and Gaspare Tagliacozzi (Bologna) became familiar with the techniques of Sushruta.

A pioneer in all fields of surgery, the Arab physician, surgeon, and chemist Al-Zahrawi has been given the title of 'Father of Surgery', and some have described him as the first ever plastic surgeon, notably for his attention to and methods of incision, use of silk thread suture to achieve good cosmesis. He describes what is thought to be the first attempt at reduction mammaplasty for the management of gynaecomastia. He gives detailed descriptions of other basic surgical techniques such as cautery and wound management.

British physicians travelled to India to see rhinoplasties being performed by Indian methods. Reports on Indian rhinoplasty performed by a Kumhar (potter) vaidya were published in the Gentleman's Magazine by 1794. Joseph Constantine Carpue spent 20 years in India studying local plastic surgery methods. Carpue was able to perform the first major surgery in the Western world in the year 1815. Instruments described in the Sushruta Samhita were further modified in the Western world.

In 1465, Sabuncu's book, description, and classification of hypospadias were more informative and up to date. Localization of the urethral meatus was described in detail. Sabuncuoglu also detailed the description and classification of ambiguous genitalia. In mid-15th-century Europe, Heinrich von Pfolspeundt described a process "to make a new nose for one who lacks it entirely, and the dogs have devoured it" by removing skin from the back of the arm and suturing it in place. However, because of the dangers associated with surgery in any form, especially that involving the head or face, it was not until the 19th and 20th centuries that such surgery became common.

In 1814, Joseph Carpue successfully performed an operative procedure on a British military officer who had lost his nose to the toxic effects of mercury treatments. In 1818, German surgeon Carl Ferdinand von Graefe published his major work entitled Rhinoplastik. Von Graefe modified the Italian method using a free skin graft from the arm instead of the original delayed pedicle flap.

The first American plastic surgeon was John Peter Mettauer, who, in 1827, performed the first cleft palate operation with instruments that he designed himself.

Johann Friedrich Dieffenbach specialized in skin transplantation and early plastic surgery. His work in rhinoplastic and maxillofacial surgery established many modern techniques of reconstructive surgery. In 1845, Dieffenbach wrote a comprehensive text on rhinoplasty, titled Operative Chirurgie, and introduced the concept of reoperation to improve the cosmetic appearance of the reconstructed nose. Dieffenbach has been called the "father of plastic surgery".

Another case of plastic surgery for nose reconstruction from 1884 at Bellevue Hospital was described in Scientific American.

In 1891, American otorhinolaryngologist John Roe presented an example of his work: a young woman on whom he reduced a dorsal nasal hump for cosmetic indications. In 1892, Robert Weir experimented unsuccessfully with xenografts (duck sternum) in the reconstruction of sunken noses. In 1896, James Israel, a urological surgeon from Germany, and in 1889 George Monks of the United States each described the successful use of heterogeneous free-bone grafting to reconstruct saddle nose defects. In 1898, Jacques Joseph, the German orthopaedic-trained surgeon, published his first account of reduction rhinoplasty. In 1910, Alexander Ostroumov, the Russian pharmacist, and perfume and cosmetics manufacturer, founded a unique plastic surgery department in his Moscow Institute of Medical Cosmetics. In 1928, Jacques Joseph published Nasenplastik und Sonstige Gesichtsplastik.

Nascency of maxillofacial surgery
The development of weapons such as machine guns and explosive shells during World War I created trench warfare, which led to a rapid increase in the number of mutilations to the faces and the heads of soldiers because the trenches mainly offered protection to the body. The surgeons, who were not prepared for these injuries, were even less prepared for a large number of injuries and had to react quickly and intelligently to treat the greatest number. Facial injuries were hard to treat on the front line because of the sanitary conditions many infections could occur. Sometimes, some stitches were made on a jagged wound without thinking about the amount of flesh that had been lost, so scars after were hideous and disfigured soldiers. Some injured had important injuries and the stitches were not sufficient so some became blind, or were left with gaping holes instead of their nose. Harold Gillies, scared by the number of new facial injuries and the lack of good surgical techniques decided to dedicate an entire hospital to the reconstruction of facial injuries as fully as possible. He took into account the psychological dimension. Gillies introduced skin grafts to the treatments of soldiers, so they would be less horrified by looking at themselves in the mirror.

It is the multidisciplinary approach to the treatment of facial lesions, bringing together plastic surgeons, dental surgeons, technicians, and specialized nurses, which has made it possible to develop techniques leading to the reconstruction of injured faces. Harold Gillies identified the need to advance the specialty of maxillofacial surgery which would be directly dedicated to the management of war wounds at this time. He has developed a new technique using rotational and transposition flaps but also bone grafts from the ribs and tibia to reconstruct facial defects caused by the weapons during the war Gillies experimented with this technique so he knew that he had to start by moving back healthy tissue to its normal position and then he will be able to fill with tissue from another place on the body of the soldier. One of the most successful techniques in skin grafting had the aim of not completely severing the connection to the body. It was possible by releasing and lifting a flap of skin from the wound. The flap of skin, still connected to the donor site would then be swung over the site of the wound, this technique allows the maintenance of physical connection and ensures that blood is supplied to the skin and increases the chances of the skin graft being accepted by the body. At this time, we assisted also to improving in treating infections also meant that important injuries had become survivable mostly thanks to the new technique of Gillies. Some soldiers arrived at the hospital of Gillies without noses, chins, cheekbones, or even eyes. But for them, the most important trauma was psychological.

Development of modern techniques

The father of modern plastic surgery is generally considered to have been Sir Harold Gillies. A New Zealand otolaryngologist working in London, he developed many of the techniques of modern facial surgery in caring for soldiers with disfiguring facial injuries during the First World War.

During World War I, he worked as a medical minder with the Royal Army Medical Corps. After working with the renowned French oral and maxillofacial surgeon Hippolyte Morestin on skin grafts, he persuaded the army's chief surgeon, Arbuthnot-Lane, to establish a facial injury ward at the Cambridge Military Hospital, Aldershot, later upgraded to a new hospital for facial repairs at Sidcup in 1917. There Gillies and his colleagues developed many techniques of plastic surgery; more than 11,000 operations were performed on more than 5,000 men (mostly soldiers with facial injuries, usually from gunshot wounds). After the war, Gillies developed a private practice with Rainsford Mowlem, including many famous patients, and travelled extensively to promote his advanced techniques worldwide.

In 1930, Gillies' cousin, Archibald McIndoe, joined the practice and became committed to plastic surgery. When World War II broke out, plastic surgery provision was largely divided between the different services of the armed forces, and Gillies and his team were split up. Gillies himself was sent to Rooksdown House near Basingstoke, which became the principal army plastic surgery unit; Tommy Kilner (who had worked with Gillies during the First World War, and who now has a surgical instrument named after him, the kilner cheek retractor) went to Queen Mary's Hospital, Roehampton; and Mowlem went to St Albans. McIndoe, consultant to the RAF, moved to the recently rebuilt Queen Victoria Hospital in East Grinstead, Sussex, and founded a Centre for Plastic and Jaw Surgery. There, he treated very deep burns, and serious facial disfigurement, such as loss of eyelids, typical of those caused to aircrew by burning fuel.

McIndoe is often recognized for not only developing new techniques for treating badly burned faces and hands but also for recognising the importance of the rehabilitation of the casualties and particularly of social reintegration back into normal life. He disposed of the "convalescent uniforms" and let the patients use their service uniforms instead. With the help of two friends, Neville and Elaine Blond, he also convinced the locals to support the patients and invite them to their homes. McIndoe kept referring to them as "his boys" and the staff called him "The Boss" or "The Maestro".

His other important work included the development of the walking-stalk skin graft, and the discovery that immersion in saline promoted healing as well as improving survival rates for patients with extensive burns—this was a serendipitous discovery drawn from observation of differential healing rates in pilots who had come down on land and in the sea. His radical, experimental treatments led to the formation of the Guinea Pig Club at Queen Victoria Hospital, Sussex. Among the better-known members of his "club" were Richard Hillary, Bill Foxley and Jimmy Edwards.

Sub-specialties
Plastic surgery is a broad field, and may be subdivided further. In the United States, plastic surgeons are board certified by American Board of Plastic Surgery. Subdisciplines of plastic surgery may include:

Aesthetic surgery
Aesthetic surgery is a central component of plastic surgery and includes facial and body aesthetic surgery. Plastic surgeons use cosmetic surgical principles in all reconstructive surgical procedures as well as isolated operations to improve overall appearance.

Burn surgery
Burn surgery generally takes place in two phases. Acute burn surgery is the treatment immediately after a burn. Reconstructive burn surgery takes place after the burn wounds have healed.

Craniofacial surgery
Craniofacial surgery is divided into pediatric and adult craniofacial surgery. Pediatric craniofacial surgery mostly revolves around the treatment of congenital anomalies of the craniofacial skeleton and soft tissues, such as cleft lip and palate, microtia, craniosynostosis, and pediatric fractures. Adult craniofacial surgery deals mostly with reconstructive surgeries after trauma or cancer and revision surgeries along with orthognathic surgery and facial feminization surgery. Craniofacial surgery is an important part of all plastic surgery training programs. Further training and subspecialisation is obtained via a craniofacial fellowship. Craniofacial surgery is also practiced by maxillofacial surgeons.

Ethnic plastic surgery
Ethnic plastic surgery is plastic surgery performed to change ethnic attributes, often considered used as a way of "passing".

Hand surgery
Hand surgery is concerned with acute injuries and chronic diseases of the hand and wrist, correction of congenital malformations of the upper extremities, and peripheral nerve problems (such as brachial plexus injuries or carpal tunnel syndrome). Hand surgery is an important part of training in plastic surgery, as well as microsurgery, which is necessary to replant an amputated extremity. The hand surgery field is also practiced by orthopedic surgeons and general surgeons. Scar tissue formation after surgery can be problematic on the delicate hand, causing loss of dexterity and digit function if severe enough. There have been cases of surgery on women's hands in order to correct perceived flaws to create the perfect engagement ring photo.

Microsurgery
Microsurgery is generally concerned with the reconstruction of missing tissues by transferring a piece of tissue to the reconstruction site and reconnecting blood vessels. Popular subspecialty areas are breast reconstruction, head and neck reconstruction, hand surgery/replantation, and brachial plexus surgery.

Pediatric plastic surgery
Children often face medical issues very different from the experiences of an adult patient. Many birth defects or syndromes present at birth are best treated in childhood, and pediatric plastic surgeons specialize in treating these conditions in children. Conditions commonly treated by pediatric plastic surgeons include craniofacial anomalies, Syndactyly (webbing of the fingers and toes), Polydactyly (excess fingers and toes at birth), cleft lip and palate, and congenital hand deformities.

Prison plastic surgery
Plastic surgery performed on an incarcerated population in order to affect their recidivism rate, a practice instituted in the early 20th century that lasted until the mid-1990s. Separate from surgery performed for medical need.

Techniques and procedures
In plastic surgery, the transfer of skin tissue (skin grafting) is a very common procedure. Skin grafts can be derived from the recipient or donors:
 * Autografts are taken from the recipient. If absent or deficient of natural tissue, alternatives can be cultured sheets of epithelial cells in vitro or synthetic compounds, such as integra, which consists of silicone and bovine tendon collagen with glycosaminoglycans.
 * Allografts are taken from a donor of the same species. Kidney transplants are an example of allograft transfer. Joseph Murray, American Plastic Surgeon, is credited for completing the first successful kidney transplantation in 1954.
 * Xenografts are taken from a donor of a different species.

Usually, good results would be expected from plastic surgery that emphasize careful planning of incisions so that they fall within the line of natural skin folds or lines, appropriate choice of wound closure, use of best available suture materials, and early removal of exposed sutures so that the wound is held closed by buried sutures.

Reconstructive surgery
Reconstructive plastic surgery is performed to correct functional impairments caused by burns; traumatic injuries, such as facial bone fractures and breaks; congenital abnormalities, such as cleft palates or cleft lips; developmental abnormalities; infection and disease; and cancer or tumors. The goal of reconstructive plastic surgery is to restore both form and function.

The most common reconstructive procedures are tumor removal, laceration repair, maxillofacial surgery, scar revision, hand surgery and breast reduction plasty. According to the American Society of Plastic Surgeons, the number of reconstructive breast reductions for women decreased in 2018 by 4 percent from the year before. Breast reduction in men decreased in 2018 by 8 percent. In 2018, there were 57,535 performed.

Some other common reconstructive surgical procedures include breast reconstruction after a mastectomy for the treatment of cancer, cleft lip and palate surgery, contracture surgery for burn survivors, and creating a new outer ear when one is congenitally absent.

Plastic surgeons use microsurgery to transfer tissue for coverage of a defect when no local tissue is available. Free flaps of skin, muscle, bone, fat, or a combination may be removed from the body, moved to another site on the body, and reconnected to a blood supply by suturing arteries and veins as small as 1 to 2 millimeters in diameter.

Cosmetic surgery procedures
Cosmetic surgery is a voluntary or elective surgery that is performed on normal parts of the body with the only purpose of improving a person's appearance or removing signs of aging. Some cosmetic surgeries such as breast reduction are also functional and can help to relieve symptoms of discomfort such as back ache or neck ache. Cosmetic surgeries are also undertaken following breast cancer and mastectomy to recreate the natural breast shape which has been lost during the process of removing the cancer. In 2014, nearly 16 million cosmetic procedures were performed in the United States alone. The number of cosmetic procedures performed in the United States has almost doubled since the start of the century. 92% of cosmetic procedures were performed on women in 2014, up from 88% in 2001. 15.6 million cosmetic procedures were performed in 2020, with the five most common surgeries being Nose Reshaping, Eyelid surgery, Facelift, Liposuction, and breast augmentation. Breast augmentation continues to be one of the top 5 cosmetic surgical procedures and has been since 2006. Silicone implants were used in 84% and saline implants in 16% of all breast augmentations in 2020. The American Society for Aesthetic Plastic Surgery looks at the statistics for 34 different cosmetic procedures. Nineteen of the procedures are surgical, such as rhinoplasty or facelift. The nonsurgical procedures include Botox and laser hair removal. In 2010, their survey revealed that there were 9,336,814 total procedures in the United States. Of those, 1,622,290 procedures were surgical (p. 5). They also found that a large majority, 81%, of the procedures were done on Caucasian people (p. 12).

In 1949, 15,000 Americans underwent cosmetic surgery procedures and by 1969 this number rose to almost half a million people. The American Society of Plastic Surgeons (ASPS) estimates that more than 333,000 cosmetic procedures were performed on patients 18 years of age or younger in the US in 2005 compared to approx. 14,000 in 1996. In 2018, more than 226,994 patients between the ages of 13 and 19 underwent plastic surgery compared to just over 218,900 patients in the same age group in 2010. Concerns about young people undergoing plastic surgery include the financial burden of additional surgical procedures needed to correct problems after the initial cosmetic surgery, long-term health complications from plastic surgery, and unaddressed mental health issues that may have led to surgery. The increased use of cosmetic procedures crosses racial and ethnic lines in the U.S., with increases seen among African-Americans, Asian Americans and Hispanic Americans as well as Caucasian Americans. In Asia, cosmetic surgery has become more popular, and countries such as China and India have become Asia's biggest cosmetic surgery markets. South Korea is also rising in popularity due to their expertise in facial bone surgeries (see cosmetic surgery in South Korea).

Plastic surgery is increasing slowly, rising 115% from 2000 to 2015. "According to the annual plastic surgery procedural statistics, there were 15.9 million surgical and minimally-invasive cosmetic procedures performed in the United States in 2015, a 2 percent increase over 2014." A study from 2021 found that requests for cosmetic procedures had increased significantly since the beginning of the COVID-19 pandemic, possibly due to the increase in videoconferencing; cited estimates include a 10% increase in the United States and a 20% increase in France.

The most popular aesthetic/cosmetic procedures include:
 * Abdominoplasty ("tummy tuck"): reshaping and firming of the abdomen
 * Blepharoplasty ("eyelid surgery"): reshaping of upper/lower eyelids including Asian blepharoplasty
 * Phalloplasty ("penile surgery"): construction (or reconstruction) of a penis or, sometimes, artificial modification of the penis by surgery, often for cosmetic purposes
 * Mammoplasty:
 * Breast augmentations ("breast implant" or "boob job"): augmentation of the breasts by means of fat grafting, saline, or silicone gel prosthetics, which was initially performed for women with micromastia
 * Reduction mammoplasty ("breast reduction"): removal of skin and glandular tissue, which is done to reduce back and shoulder pain in women with gigantomastia and for men with gynecomastia
 * Mastopexy ("breast lift"): Lifting or reshaping of breasts to make them less saggy, often after weight loss (after a pregnancy, for example). It involves removal of breast skin as opposed to glandular tissue
 * Augmentation mastopexy ("breast lift with breast implants"): Lifting breasts to make them less saggy, repositioning the nipple to a higher location, and increasing breast size with saline or silicone gel implants. Recent studies of a newer technique for simultaneous augmentation mastopexy (SAM) indicate that it is a safe surgical procedure with minimal medical complications. The SAM technique involves invaginating and tacking the tissues first, in order to previsualize the result, before making any surgical incisions to the breast.
 * Buttock augmentation ("butt implant"): enhancement of the buttocks using silicone implants or fat grafting ("Brazilian butt lift") where fat is transferred from other areas of the body
 * Cryolipolysis: refers to a medical device used to destroy fat cells. Its principle relies on controlled cooling for non-invasive local reduction of fat deposits to reshape body contours.
 * Cryoneuromodulation: Treatment of superficial and subcutaneous tissue structures using gaseous nitrous oxide, including temporary wrinkle reduction, temporary pain reduction, treatment of dermatologic conditions, and focal cryo-treatment of tissue
 * Calf Augmentation: done by silicone implants or fat transfer to add bulk to calf muscles
 * Labiaplasty: surgical reduction and reshaping of the labia
 * Lip augmentation: alter the appearance of the lips by increasing their fullness through surgical enlargement with lip implants or nonsurgical enhancement with injectable fillers
 * Cheiloplasty: surgical reconstruction of the lip
 * Rhinoplasty ("nose job"): reshaping of the nose sometimes used to correct breathing impaired by structural defects.
 * Otoplasty ("ear surgery"/"ear pinning"): reshaping of the ear, most often done by pinning the protruding ear closer to the head.
 * Rhytidectomy ("face lift"): removal of wrinkles and signs of aging from the face
 * Neck lift: tightening of lax tissues in the neck. This procedure is often combined with a facelift for lower face rejuvenation.
 * Browplasty ("brow lift" or "forehead lift"): elevates eyebrows, smooths forehead skin
 * Midface lift ("cheek lift"): tightening of the cheeks
 * Genioplasty: augmentation of the chin with an individual's bones or with the use of an implant, usually silicone, by suture of the soft tissue
 * Mentoplasty: surgery to the chin. This can involve either enhancing or reducing the size of the chin. Enhancements are achieved with the use of facial implants. Reduction of the chin involved reducing the size of the chin bone.
 * Cheek augmentation ("cheek implant"): implants to the cheek
 * Orthognathic Surgery: altering the upper and lower jaw bones (through osteotomy) to correct jaw alignment issues and correct the teeth alignment
 * Fillers injections: collagen, fat, and other tissue filler injections, such as hyaluronic acid
 * Brachioplasty ("Arm lift"): reducing excess skin and fat between the underarm and the elbow
 * Laser Skin Rejuvenation or laser resurfacing: the lessening of depth of facial pores and exfoliation of dead or damaged skin cells
 * Liposuction ("suction lipectomy"): removal of fat deposits by traditional suction technique or ultrasonic energy to aid fat removal
 * Zygoma reduction plasty: reducing the facial width by performing osteotomy and resecting part of the zygomatic bone and arch
 * Jaw reduction: reduction of the mandible angle to smooth out an angular jaw and creating a slim jaw
 * Buccal Fat Extraction: extraction of the buccal pads
 * Body contouring: the removal of this excess skin and fat from numerous areas of the body, restoring the appearance of skin elasticity of the remaining skin. The surgery is prominent in those who have undergone significant weight loss resulting in excess sagging skin being present around areas of the body. The skin loses elasticity (a condition called elastosis ) once it has been stretched past capacity and is unable to recoil back to its standard position against the body and also with age.
 * Sclerotherapy: removing visible 'spider veins' (Telangiectasia), which appear on the surface of the skin.
 * Dermal fillers: Dermal fillers are injected below the skin to give a more fuller, youthful appearance of a feature or section of the face. One type of dermal filler is Hyaluronic acid. Hyaluronic acid is naturally found throughout the human body. It plays a vital role in moving nutrients to the cells of the skin from the blood. It is also commonly used in patients with Arthritis as it acts like a cushion to the bones which have depleted the articular cartilage casing. Development within this field has occurred over time with synthetic forms of hyaluronic acid is being created, playing roles in other forms of cosmetic surgery such as facial augmentation.
 * Micropigmentation: is the creation of permanent makeup using natural pigments to places such as the eyes to create the effect of eye shadow, lips creating lipstick and cheek bones to create a blush like look. The pigment is inserted beneath the skin using a machine which injects a small needle at a very fast rate carrying pigment into the skin, creating a lasting colouration of the desired area.

In 2015, the most popular surgeries were Botox, liposuction, eyelid surgery, breast implants, nose jobs, and facelifts. According to the 2020 Plastic Surgery Statistics Report, which is published by the American Society of Plastic Surgeons, the most surgical procedure performed in the U.S. was Rhinoplasty (Nose reshaping) accounting for 15.2% of all cosmetic surgical procedures that year, followed by Blepharoplasty (Eyelid surgery), which accounted for 14% of all procedures. The third most populous procedure was Rhytidectomy (Facelift) (10% of all procedures), then Liposuction (9.1% of all procedures).

Complications, risks, and reversals
All surgery has risks. Common complications of cosmetic surgery includes hematoma, nerve injury, infection, scarring, implant failure and end organ damage. Breast implants can have many complications, including rupture. In a study of his 4761 augmentation mammaplasty patients, Eisenberg reported that overfilling saline breast implants 10–13% significantly reduced the rupture-deflation rate to 1.83% at 8-years post-implantation. In 2011 FDA stated that one in five patients who received implants for breast augmentation will need them removed within 10 years of implantation.

Psychological disorders
Though media and advertising do play a large role in influencing many people's lives, such as by making people believe plastic surgery to be an acceptable course to change our identities to our liking, researchers believe that plastic surgery obsession is linked to psychological disorders like body dysmorphic disorder. There exists a correlation between those with BDD and the predilection toward cosmetic plastic surgery in order to correct a perceived defect in their appearance.

BDD is a disorder resulting in the individual becoming "preoccupied with what they regard as defects in their bodies or faces". Alternatively, where there is a slight physical anomaly, then the person's concern is markedly excessive. While 2% of people have body dysmorphic disorder in the United States, 15% of patients seeing a dermatologist and cosmetic surgeons have the disorder. Half of the patients with the disorder who have cosmetic surgery performed are not pleased with the aesthetic outcome. BDD can lead to suicide in some people with the condition. While many with BDD seek cosmetic surgery, the procedures do not treat BDD, and can ultimately worsen the problem. The psychological root of the problem is usually unidentified; therefore causing the treatment to be even more difficult. Some say that the fixation or obsession with correction of the area could be a sub-disorder such as anorexia or muscle dysmorphia. The increased use of body and facial reshaping applications such as Snapchat and Facetune have been identified as a potential triggers of BDD. Recently, a phenomenon referred to as 'Snapchat dysmorphia' has appeared to describe people who request surgery to resemble the edited version of themselves as they appear through Snapchat Filters. As a protest to the detrimental trend, Instagram banned all augmented reality (AR) filters that depict or promote cosmetic surgery.

In some cases, people whose physicians refuse to perform any further surgeries, have turned to "do it yourself" plastic surgery, injecting themselves and running extreme safety risks.

Minimally invasive cosmetic medicine
With the growing popularity of plastic surgery, has also come a widespread increase in minimally invasive alternatives involving intradermal and intramusclular injectables, including various neurotoxins such as Botox, Dysport, Xeomin, and Jeuveau, amongst others, alongside hyaluronic acid based dermal fillers.

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

title: Plastic surgery


text:
The IPCRESS File

The IPCRESS File is Len Deighton's first spy novel, published in 1962. The story involves Cold War brainwashing and includes scenes in Lebanon and on an atoll for a United States atomic weapon test, as well as information about Joe One, the Soviet Union's first atomic bomb. The story was made into a film in 1965 produced by Harry Saltzman, directed by Sidney J. Furie and starring Michael Caine; and a 2022 TV series, starring Joe Cole, Lucy Boynton and Tom Hollander.

Plot
The novel takes the form of the unnamed protagonist's personal report to the Minister of Defence, thus becoming the 'IPCRESS File' of the title. Events begin soon after the protagonist's transfer from military intelligence to WOOC(P), a small civilian intelligence agency reporting directly to the British Cabinet, where he works under the command of a man named Dalby. An intelligence broker code-named "Jay" is suspected to be behind a series of kidnappings of British VIPs with the intention of selling them to the Soviets, and the protagonist is assigned to meet Jay to secure the release of "Raven", a high-ranking scientist. While trying to meet Jay at a Soho strip club to negotiate Raven's release, the protagonist discovers Raven's unconscious body in a back room but is unsuccessful in trying to rescue him.

WOOC(P) learns that Raven is to be transferred to the Soviets in Beirut, and a rescue mission is organised. The protagonist is assigned as a lookout and kills the occupants of a car which suddenly arrives on the scene, believing them to be operatives working for Jay; they instead turn out to be members of the US Office of Naval Intelligence. The operation is otherwise a success and Raven is recovered, but investigation into Jay continues. A break appears when Housemartin, one of Jay's high-ranking operatives, is arrested in Shoreditch, but the protagonist and another operative arrive at the police station only to discover that Housemartin has been murdered in his cell. Information from the arrest enables WOOC(P) and the police to storm one of Jay's safe-houses, but it has been abandoned.

A military statistician, Carswell, and his assistant Murray, are assigned to WOOC(P) to attempt to find a statistical link between the disappearances of the scientists and to help with the administration of the department, the protagonist is assigned an assistant, Jean Tonnesen, a beautiful young woman towards whom he begins to develop romantic feelings.

Dalby reveals intelligence suggesting that Jay's operations will interfere with an American neutron bomb test in the Pacific. He, Jean and the protagonist are sent to the test site as British observers and while there the protagonist learns from an old friend in the CIA that the Americans suspect him of being a double-agent due to the deaths of the US operatives. Jean reveals that Dalby has been visiting an abandoned Japanese bunker on the island and while following Dalby to the scene the protagonist is present when the site is sabotaged, setting back the bomb test and killing a military police officer. The protagonist is arrested by the Americans and interrogated, before apparently being transferred to Hungary on suspicion of being a Soviet agent. There he is drugged and subjected to psychological and physical torture, and nearly cracks before eventually managing to escape—only to discover that he is in fact in London. The protagonist takes refuge with Charlie Cavendish, the father of a friend killed during the Second World War, and attempts to re-establish contact with WOOC(P) without being arrested. Charlie is killed by Jay's operatives, forcing the protagonist on the run; he approaches Dalby at his home, but discovers Dalby with Jay, Murray and another of Jay's operatives—confirming the protagonist's suspicions that Dalby is in fact the traitor.

The protagonist is discovered by Murray, who turns out to be an undercover operative from military intelligence also investigating Dalby. The protagonist escapes, but is captured and taken to meet Jay—he has, however, allowed military intelligence to follow them, and Jay and Dalby are arrested by Colonel Ross. The protagonist reveals to Jean that Jay and Dalby were using a process called "Induction of Psycho-neuroses by Conditioned REflex with StresS" (IPCRESS) to brainwash the VIPs into loyalty to the Soviet Union. The links that Carswell had discovered were in fact indicators of the personality traits that Jay had used to determine which VIPs would easily succumb to the process. Colonel Ross’ earlier attempt to sell information to the protagonist had been a test of his loyalty. The novel ends with the protagonist concluding his report to the Minister, revealing that Jay has turned and begun working for the British, while Dalby has ostensibly died in a car accident.

Background
In 1992 Deighton said that the inspiration to write the novel came from his real-life neighbour Anna Wolkoff, a White Russian émigrée who collaborated with a cipher clerk from the American embassy to spy for Germany in World War II. Deighton's mother cooked for Wolkoff's dinner parties and he said that he "vividly" remembered when MI5 officers came to arrest her: "The experience was a major factor in my decision to write a spy story at my first attempt at fiction." The plot involves mind control, the acronym IPCRESS of the title standing for "Induction of Psycho-neuroses by Conditioned Reflex under Stress". The brainwashing is similar to a shock technique called psychic driving pioneered by Donald Ewen Cameron in the 1950s, originally on unwitting mental hospital patients, which was used and funded by the Central Intelligence Agency's secret MKULTRA program in Canada.

Novel
Deighton's protagonist is unnamed, and this is maintained through all the sequels. Early in the novel we learn that he worked for Military Intelligence for three years before joining his present agency – WOOC(P) – as a civilian employee. WOOC(P) is described as "one of the smallest and most important of the Intelligence Units". It is never stated exactly what the initials stand for, although his previous boss refers to it as "Provisional".

We also learn in passing that he is from Burnley, Lancashire, and that he was born in 1922 or 1923.

WOOC(P) is a small department and the unnamed protagonist has a great deal of autonomy. He is resourceful and prepared for any eventuality, keeping an "escape package" containing money, a false passport and other documents circulating in the mail. Once a week he picks up the package from an accommodation address at a seedy London shop, and re-mails it to that address in a fresh envelope. He is also a gourmet who enjoys good food. Cooking features frequently in both the film and the novel; Deighton himself is an accomplished cook.

In common with several of his other early novels, the chapter headings have a "feature". In The IPCRESS File these take the form of each chapter being headed with a quote from a horoscope, which relates to the action in the chapter, though vaguely, as in most horoscopes.

The front cover, by Deighton's friend Raymond Hawkey, has been described as "the template for the covers of all subsequent airport novels".

Film
A film adaptation starring Michael Caine was released in 1965 and produced by the James Bond co-producer Harry Saltzman, assisted by several prominent members of the Bond production family. The film medium made it difficult to maintain the anonymity of Deighton's hero, who acquired the name Harry Palmer.

The character's name was chosen by Caine, who was having lunch with Harry Saltzman. They were trying to think of a name for the protagonist, and agreed that a boring name would best suit the protagonist's persona. Saltzman asked what would be the most boring name they could think of and Caine suggested the name Harry, then immediately apologised to Saltzman. However, Saltzman saw the funny side and pointed out that his real first name was actually Herschel, not Harry, so Saltzman was satisfied with it. The inspiration for the surname came from a boy called Palmer whom Caine knew at school. Caine described Palmer as: "the most boring boy I'd ever met".

The given name "Harry" actually occurs in a short sequence in the book where the unnamed protagonist is greeted by someone saying "Hello, Harry." This causes him to think, "Now my name isn't Harry, but in this business it's hard to remember whether it ever had been."

TV series
In December 2020, it was announced ITV would adapt The Ipcress File as a six-part TV serial.

title: The IPCRESS File


text:
Mescaline

Mescaline or mescalin (3,4,5-trimethoxyphenethylamine) is a naturally occurring psychedelic protoalkaloid of the substituted phenethylamine class, known for its hallucinogenic effects comparable to those of LSD and psilocybin.

Biological sources
It occurs naturally in several species of cacti. It is also reported to be found in small amounts in certain members of the bean family, Fabaceae, including Senegalia berlandieri (syn. Acacia berlandieri), although these reports have been challenged and have been unsupported in any additional analyses.

As can be observed from the table above, the concentration of mescaline in different specimens can vary largely within a single species. Moreover, the concentration of mescaline within a single specimen varies as well.

History and use
Peyote has been used for at least 5,700 years by Indigenous peoples of the Americas in Mexico. Europeans noted use of peyote in Native American religious ceremonies upon early contact, notably by the Huichols in Mexico. Other mescaline-containing cacti such as the San Pedro have a long history of use in South America, from Peru to Ecuador. While religious and ceremonial peyote use was widespread in the Aztec empire and northern Mexico at the time of the Spanish conquest, religious persecution confined it to areas near the Pacific coast and up to southwest Texas. However, by 1880, peyote use began to spread north of South-Central America with "a new kind of peyote ceremony" inaugurated by the Kiowa and Comanche people. These religious practices, incorporated legally in the United States in 1920 as the Native American Church, has since spread as far as Saskatchewan, Canada.

In traditional peyote preparations, the top of the cactus is cut off, leaving the large tap root along with a ring of green photosynthesizing area to grow new heads. These heads are then dried to make disc-shaped buttons. Buttons are chewed to produce the effects or soaked in water to drink. However, the taste of the cactus is bitter, so contemporary users will often grind it into a powder and pour it into capsules to avoid having to taste it. The usual human dosage is 200–400 milligrams of mescaline sulfate or 178–356 milligrams of mescaline hydrochloride. The average 76 mm peyote button contains about 25 mg mescaline. Some analyses of traditional preparations of San Pedro cactus have found doses ranging from 34 mg to 159 mg of total alkaloids, a relatively low and barely psychoactive amount. It appears that patients who receive traditional treatments with San Pedro ingest sub-psychoactive doses and do not experience psychedelic effects.

Mescaline was first isolated and identified in 1897 by the German chemist Arthur Heffter and first synthesized in 1919 by Ernst Späth.

In 1955, English politician Christopher Mayhew took part in an experiment for BBC's Panorama, in which he ingested 400 mg of mescaline under the supervision of psychiatrist Humphry Osmond. Though the recording was deemed too controversial and ultimately omitted from the show, Mayhew praised the experience, calling it "the most interesting thing I ever did".

Potential medical usage
Mescaline has a wide array of suggested medical usage, including treatment of alcoholism. However, its status as a Schedule I controlled substance in the Convention on Psychotropic Substances limits availability of the drug to researchers. Because of this, very few studies concerning mescaline's activity and potential therapeutic effects in humans have been conducted since the early 1970s.

Biosynthesis
Mescaline is biosynthesized from tyrosine which, in turn, is derived from phenylalanine by the enzyme phenylalanine hydroxylase. In Lophophora williamsii (Peyote), dopamine converts into mescaline in a biosynthetic pathway involving m-O-methylation and aromatic hydroxylation.

Tyrosine and phenylalanine serve as metabolic precursors towards the synthesis of mescaline. Tyrosine can either undergo a decarboxylation via tyrosine decarboxylase to generate tyramine and subsequently undergo an oxidation at carbon 3 by a monophenol hydroxylase or first be hydroxylated by tyrosine hydroxylase to form L-DOPA and decarboxylated by DOPA decarboxylase. These create dopamine, which then experiences methylation by a catechol-O-methyltransferase (COMT) by an S-adenosyl methionine (SAM)-dependent mechanism. The resulting intermediate is then oxidized again by a hydroxylase enzyme, likely monophenol hydroxylase again, at carbon 5, and methylated by COMT. The product, methylated at the two meta positions with respect to the alkyl substituent, experiences a final methylation at the 4 carbon by a guaiacol-O-methyltransferase, which also operates by a SAM-dependent mechanism. This final methylation step results in the production of mescaline.

Phenylalanine serves as a precursor by first being converted to L -tyrosine by L-amino acid hydroxylase. Once converted, it follows the same pathway as described above.
 * Mescaline biosynthetic pathways.svg

Laboratory synthesis
Mescaline was first synthesized in 1919 by Ernst Späth from 3,4,5-trimethoxy-benzoyl chloride. Subsequent to this, numerous approaches utilizing different starting materials have been developed. Notable examples include the following:
 * Hofmann rearrangement of 3,4,5-trimethoxy-phenyl-propionamide.
 * Cyanohydrin reaction between potassium cyanide and 3,4,5-trimethoxy-benz-aldehyde followed by acetylation and reduction.
 * Henry reaction of 3,4,5-trimethoxy-benz-aldehyde with nitromethane followed by nitro compound reduction of ω-nitro-trimethoxy-styrene.
 * Ozonolysis of elemicin followed by reductive amination.
 * Ester reduction of Eudesmic acid's methyl ester followed by halogenation, Kolbe nitrile synthesis, and nitrile reduction.
 * Amide reduction of 3,4,5-trimethoxy-phenyl-acetamide.
 * Reduction of 3,4,5-trimethoxy-(2-nitrovinyl)benzene with lithium aluminum hydride.
 * Treatment of tricarbonyl-(η6-1,2,3-trimethoxy-benzene) chromium complex with acetonitrile carbanion in THF and iodine, followed by reduction of the nitrile with lithium aluminum hydride.

Pharmacokinetics
Tolerance builds with repeated usage, lasting for a few days. Mescaline causes cross-tolerance with other serotonergic psychedelics such as LSD and psilocybin.

About half the initial dosage is excreted after six hours, but some studies suggest that it is not metabolized at all before excretion. Mescaline appears not to be subject to metabolism by CYP2D6 and between 20% and 50% of mescaline is excreted in the urine unchanged, with the rest being excreted as the deaminated-oxidised-carboxylic acid form of mescaline, a likely result of MAO degradation. The LD50 of mescaline has been measured in various animals: 212 mg/kg i.p. (mice), 132 mg/kg i.p. (rats), and 328 mg/kg i.p. (guinea pigs). For humans, the LD50 of mescaline has been reported to be approximately 880 mg/kg.

Behavioral and non-behavioral effects
Mescaline induces a psychedelic state comparable to those produced by LSD and psilocybin, but with unique characteristics. Subjective effects may include altered thinking processes, an altered sense of time and self-awareness, and closed- and open-eye visual phenomena.

Prominence of color is distinctive, appearing brilliant and intense. Recurring visual patterns observed during the mescaline experience include stripes, checkerboards, angular spikes, multicolor dots, and very simple fractals that turn very complex. The English writer Aldous Huxley described these self-transforming amorphous shapes as like animated stained glass illuminated from light coming through the eyelids in his autobiographical book The Doors of Perception (1954). Like LSD, mescaline induces distortions of form and kaleidoscopic experiences but they manifest more clearly with eyes closed and under low lighting conditions.

Heinrich Klüver coined the term "cobweb figure" in the 1920s to describe one of the four form constant geometric visual hallucinations experienced in the early stage of a mescaline trip: "Colored threads running together in a revolving center, the whole similar to a cobweb". The other three are the chessboard design, tunnel, and spiral. Klüver wrote that "many 'atypical' visions are upon close inspection nothing but variations of these form-constants." As with LSD, synesthesia can occur especially with the help of music. An unusual but unique characteristic of mescaline use is the "geometrization" of three-dimensional objects. The object can appear flattened and distorted, similar to the presentation of a Cubist painting.

Mescaline elicits a pattern of sympathetic arousal, with the peripheral nervous system being a major target for this substance.

According to a research project in the Netherlands, ceremonial San Pedro use seems to be characterized by relatively strong spiritual experiences, and low incidence of challenging experiences.

Mechanism of action
In plants, mescaline may be the end-product of a pathway utilizing catecholamines as a method of stress response, similar to how animals may release such compounds and others such as cortisol when stressed. The in vivo function of catecholamines in plants has not been investigated, but they may function as antioxidants, as developmental signals, and as integral cell wall components that resist degradation from pathogens. The deactivation of catecholamines via methylation produces alkaloids such as mescaline.

In humans, mescaline acts similarly to other psychedelic agents. It acts as an agonist, binding to and activating the serotonin 5-HT2A receptor with a high affinity. How activating the 5-HT2A receptor leads to psychedelia is still unknown, but it is likely that somehow it involves excitation of neurons in the prefrontal cortex. Mescaline is also known to have even greater binding affinity for the serotonin 5-HT2C receptor.

Difluoro-mescaline and trifluoro-mescaline are more potent than mescaline, as is its amphetamine homologue trimethoxy-amphetamine. Escaline and proscaline are also both more potent than mescaline, showing the importance of the 4-position substituent with regard to receptor binding.

United States
In the United States, mescaline was made illegal in 1970 by the Comprehensive Drug Abuse Prevention and Control Act, categorized as a Schedule I hallucinogen. The drug is prohibited internationally by the 1971 Convention on Psychotropic Substances. Mescaline is legal only for certain religious groups (such as the Native American Church by the American Indian Religious Freedom Act of 1978) and in scientific and medical research. In 1990, the Supreme Court ruled that the state of Oregon could ban the use of mescaline in Native American religious ceremonies. The Religious Freedom Restoration Act (RFRA) in 1993 allowed the use of peyote in religious ceremony, but in 1997, the Supreme Court ruled that the RFRA is unconstitutional when applied against states. Many states, including the state of Utah, have legalized peyote usage with "sincere religious intent", or within a religious organization, regardless of race. Synthetic mescaline, but not mescaline derived from cacti, was officially decriminalized in the state of Colorado by ballot measure Proposition 122 in November 2022.

While mescaline-containing cacti of the genus Echinopsis are technically controlled substances under the Controlled Substances Act, they are commonly sold publicly as ornamental plants.

United Kingdom
In the United Kingdom, mescaline in purified powder form is a Class A drug. However, dried cactus can be bought and sold legally.

Australia
Mescaline is considered a schedule 9 substance in Australia under the Poisons Standard (February 2020). A schedule 9 substance is classified as "Substances with a high potential for causing harm at low exposure and which require special precautions during manufacture, handling or use. These poisons should be available only to specialised or authorised users who have the skills necessary to handle them safely. Special regulations restricting their availability, possession, storage or use may apply."

Other countries
In Canada, France, The Netherlands and Germany, mescaline in raw form and dried mescaline-containing cacti are considered illegal drugs. However, anyone may grow and use peyote, or Lophophora williamsii, as well as Echinopsis pachanoi and Echinopsis peruviana without restriction, as it is specifically exempt from legislation. In Canada, mescaline is classified as a schedule III drug under the Controlled Drugs and Substances Act, whereas peyote is exempt.

In Russia mescaline, its derivatives and mescaline-containing plants are banned as narcotic drugs (Schedule I).

Notable users

 * Antonin Artaud wrote 1947's The Peyote Dance, where he describes his peyote experiences in Mexico a decade earlier.
 * Jerry Garcia took peyote prior to forming The Grateful Dead but later switched to LSD and DMT since they were easier on the stomach.
 * Allen Ginsberg took peyote. Part II of his poem "Howl" was inspired by a peyote vision that he had in San Francisco.
 * Ken Kesey took peyote prior to writing One Flew Over the Cuckoo's Nest.
 * Jean-Paul Sartre took mescaline shortly before the publication of his first book, L'Imaginaire; he had a bad trip during which he imagined that he was menaced by sea creatures. For many years following this, he persistently thought that he was being followed by lobsters, and became a patient of Jacques Lacan in hopes of being rid of them. Lobsters and crabs figure in his novel Nausea.
 * Havelock Ellis was the author of one of the first written reports to the public about an experience with mescaline (1898).
 * Stanisław Ignacy Witkiewicz, Polish writer, artist and philosopher, experimented with mescaline and described his experience in a 1932 book Nikotyna Alkohol Kokaina Peyotl Morfina Eter.
 * Aldous Huxley described his experience with mescaline in the essay "The Doors of Perception" (1954).
 * Jim Carroll in The Basketball Diaries described using peyote that a friend smuggled from Mexico.
 * Quanah Parker, appointed by the federal government as principal chief of the entire Comanche Nation, advocated the syncretic Native American Church alternative, and fought for the legal use of peyote in the movement's religious practices.
 * Hunter S. Thompson wrote an extremely detailed account of his first use of mescaline in "First Visit with Mescalito", and it appeared in his book Songs of the Doomed, as well as featuring heavily in his novel Fear and Loathing in Las Vegas.
 * Psychedelic research pioneer Alexander Shulgin said he was first inspired to explore psychedelic compounds by a mescaline experience. In 1974, Shulgin synthesized 2C-B, a psychedelic phenylethylamine derivative, structurally similar to mescaline, and one of Shulgin's self-rated most important phenethylamine compounds together with Mescaline, 2C-E, 2C-T-7, and 2C-T-2.
 * Bryan Wynter produced Mars Ascends after trying the substance for the first time.
 * George Carlin mentioned mescaline use during his youth while being interviewed in 2008.
 * Carlos Santana told about his mescaline use in a 1989 Rolling Stone interview.
 * Disney animator Ward Kimball described participating in a study of mescaline and peyote conducted by UCLA in the 1960s.
 * Michael Cera used real mescaline for the movie Crystal Fairy & the Magical Cactus, as expressed in an interview.
 * Philip K. Dick was inspired to write Flow My Tears, the Policeman Said after taking mescaline.
 * Arthur Kleps, a psychologist turned drug legalization advocate and writer whose Neo-American Church defended use of marijuana and hallucinogens such as LSD and peyote for spiritual enlightenment and exploration, bought, in 1960, by mail from Delta Chemical Company in New York 1 g of mescaline sulfate and took 500 mg. He experienced a psychedelic trip that caused profound changes in his life and outlook.

title: Mescaline


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Spy film

The spy film, also known as the spy thriller, is a genre of film that deals with the subject of fictional espionage, either in a realistic way (such as the adaptations of John le Carré) or as a basis for fantasy (such as many James Bond films). Many novels in the spy fiction genre have been adapted as films, including works by John Buchan, le Carré, Ian Fleming (Bond) and Len Deighton. It is a significant aspect of British cinema, with leading British directors such as Alfred Hitchcock and Carol Reed making notable contributions and many films set in the British Secret Service.

Spy films show the espionage activities of government agents and their risk of being discovered by their enemies. From the Nazi espionage thrillers of the 1940s to the James Bond films of the 1960s and to the high-tech blockbusters of today, the spy film has always been popular with audiences worldwide. Offering a combination of exciting escapism, technological thrills, and exotic locales, many spy films combine the action and science fiction genres, presenting clearly delineated heroes for audiences to root for and villains for them to hate. They may also involve elements of political thrillers. However, there are many that are comedic (mostly action comedy films if they fall under that genre).

James Bond is the most famous of film spies, but there were also more serious, probing works like le Carré's The Spy Who Came in from the Cold that also emerged from the Cold War. As the Cold War ended, the newest villain became terrorism and more often involved the Middle East.

History
The spy film genre began in the silent era, with the paranoia of invasion literature and the onset of the Great War. These fears produced the British 1914 The German Spy Peril, centered on a plot to blow up the Houses of Parliament, and 1913's O.H.M.S., standing for "Our Helpless Millions Saved" as well as On His Majesty's Service (and introducing for the first time a strong female character who helps the hero).

In 1928, Fritz Lang made the film Spies which contained many tropes that became popular in later spy dramas, including secret headquarters, an agent known by a number, and the beautiful foreign agent who comes to love the hero. Lang's Dr. Mabuse films from the period also contain elements of spy thrillers, though the central character is a criminal mastermind only interested in espionage for profit. Additionally, several of Lang's American films, such as Hangmen Also Die, deal with spies during World War II.

Alfred Hitchcock did much to popularize the spy film in the 1930s with his influential thrillers The Man Who Knew Too Much (1934), The 39 Steps (1935), Sabotage (1937) and The Lady Vanishes (1938). These often involved innocent civilians being caught up in international conspiracies or webs of saboteurs on the home front, as in Saboteur (1942). Some, however, dealt with professional spies, as in Hitchcock's Secret Agent (1936), based on W. Somerset Maugham's Ashenden stories, or the Mr. Moto series, based on the books of John P. Marquand.

In the 1940s and early 1950s, several films were made about the exploits of Allied agents in occupied Europe, which could be considered a subgenre. 13 Rue Madeleine and O.S.S. were fictional stories about American agents in German-occupied France. There were several films based on the stories of real-life British S.O.E. agents, including Odette and Carve Her Name With Pride. A more recent fictional example is Charlotte Gray, based on the novel by Sebastian Faulks.

Also during the period, there were many detective films (The Thin Man Goes Home and Charlie Chan in the Secret Service for example) in which the mystery involved who stole the secret blue-prints, or who kidnapped the famous scientist.

In the mid-1950s, Alfred Hitchcock returned to the spy genre with The Man Who Knew Too Much (1956 film), a remake of his 1934 film of the same name. He followed this up in 1959 with North by Northwest (1959), widely considered one of the most influential works within the spy genre.

The peak of popularity of spy films is often considered to be the 1960s when Cold War fears meshed with a desire by audiences to see exciting and suspenseful films. The espionage film developed in two directions at this time. On the one hand, the realistic spy novels of Len Deighton and John le Carré were adapted into relatively serious Cold War thrillers that dealt with some of the realities of the espionage world. Some of these films included The Spy Who Came in from the Cold (1965), The Deadly Affair (1966), Torn Curtain (1966), and the Harry Palmer series, based on the novels of Len Deighton.

In another direction, the James Bond novels by Ian Fleming were adapted into an increasingly fantastical series of tongue-in-cheek adventure films by producers Harry Saltzman and Albert R. Broccoli, with Sean Connery as the star. They featured secretive and flamboyant supervillains, an archetype that would later become a staple of the explosion of spy movies in the mid-to-late 1960s. The phenomenal success of the Bond series leads to a deluge of imitators, such as the eurospy genre and several from America. Notable examples include the two Derek Flint films starring James Coburn, The Quiller Memorandum (1966) with George Segal, and the Matt Helm series with Dean Martin. Television also got into the act with series like The Man from U.N.C.L.E and I Spy in the U.S., and Danger Man and The Avengers in Britain. Spies have remained popular on TV to the present day with series such as Callan, Alias and Spooks.

Spy films also enjoyed something of a revival in the late 1990s, although these were often action films with espionage elements or comedies like Austin Powers. Some critics identify a trend away from fantasy in favor of realism, as observed in Syriana, the Bourne film series and the James Bond films starring Daniel Craig since Casino Royale (2006).

Films
Some of the most popular films include:

Movie series (franchises)

 * Bulldog Drummond series (1922–1969) – 24 films
 * Mr. Moto series (1937–39, 1965) – 9 films
 * The Saint series (1938–1943) – 8 films
 * OSS 117 series (1956–2021) – 10 films
 * James Bond (1962–present) – 25 films
 * Harry Palmer (1965–1996) – 5 films
 * Matt Helm series (1966–1969) – 4 films
 * Lupin III (1974 – present) – 13 films and 28 TV specials
 * Carl Hamilton (1989–present) – 10 films
 * Jack Ryan (1990–2014) – 5 films
 * Mission: Impossible series (1996–2025) – 8 films
 * Austin Powers (1997–2002) – 3 films
 * Charlie's Angels (2000–2019) – 3 films
 * Spy Kids series (2001–2023) – 5 films
 * The Bourne series (2002–2016) – 5 films
 * XXX (2002–present) – 3 films
 * Infernal Affairs (2002-2003) – 3 films
 * Johnny English (2003–2018) – 3 films
 * Fast & Furious (2011–present) – 5 spy films
 * Kingsman (2014–2021) – 3 films

One-shots, sequels and remakes

 * Spione (1928)
 * The Mysterious Lady (1928)
 * Dishonored (1931)
 * Mata Hari (1931)
 * On Secret Service (1933)
 * The Lady of Lebanon (1934)
 * Madame Spy (1934)
 * The Man Who Knew Too Much (1934)
 * The Man Who Knew Too Much (1956)
 * The 39 Steps (1935)
 * Sabotage (1936)
 * The Lady Vanishes (1938)
 * The Spy in Black (1939)
 * Night Train to Munich (1940)
 * Virginia City (1940)
 * Saboteur (1942)
 * The Mask of Dimitrios (1944)
 * Ministry of Fear (1944)
 * I See a Dark Stranger (1946)
 * Notorious (1946)
 * 13 Rue Madeleine (1947)
 * The Third Man (1949)
 * Decision Before Dawn (1951)
 * My Favourite Spy (1951)
 * 5 Fingers (1952)
 * Pickup on South Street (1953)
 * Night People (1954)
 * The Man Who Never Was (1956)
 * Foreign Intrigue (1956)
 * Carve Her Name with Pride (1958)
 * The Silent Enemy (1958)
 * The Two-Headed Spy (1958)
 * The Quiet American (1958)
 * The Quiet American (2002)
 * North by Northwest (1959)
 * Our Man in Havana (1959)
 * The Pigeon That Took Rome (1962)
 * The Manchurian Candidate (1962)
 * The Manchurian Candidate (2004)
 * Charade (1963)
 * 36 Hours (1965)
 * The Spy Who Came in from the Cold (1965)
 * Arabesque (1966)
 * The Deadly Affair (1966)
 * The Defector (1966)
 * Derek Flint series
 * Our Man Flint (1966)
 * In Like Flint (1967)
 * Modesty Blaise (1966)
 * The Quiller Memorandum (1966)
 * Torn Curtain (1966)
 * The President's Analyst (1967)
 * Ice Station Zebra (1968)
 * Topaz (1969)
 * Darling Lili (1970)
 * The Kremlin Letter (1970)
 * The Tall Blond Man with One Black Shoe (1972)
 * The Odessa File (1974)
 * Three Days of the Condor (1975)
 * The Eagle Has Landed (1976)
 * Marathon Man (1976)
 * Telefon (1977)
 * Avalanche Express (1979)
 * Hopscotch (1980)
 * Eye of the Needle (1981)
 * Teheran 43 (1981)
 * Firefox (1982)
 * Top Secret! (1984)
 * The Falcon and the Snowman (1985)
 * Spies Like Us (1985)
 * Target (1985)
 * The Fourth Protocol (1987)
 * La Femme Nikita (1990)
 * The Russia House (1990)
 * Sneakers (1992)
 * Shining Through (1992)
 * Undercover Blues (1993)
 * True Lies (1994)
 * From Beijing with Love (1994)
 * The Long Kiss Goodnight (1996)
 * The Peacemaker (1997)
 * The Avengers (1998)
 * Ronin (1998)
 * Enemy of the State (1998)
 * Spy Game (2001)
 * The Tailor of Panama (2001)
 * Undercover Brother (2002)
 * Confessions of a Dangerous Mind (2002)
 *  I, Spy (2002)
 * The Recruit (2003)
 * Agent Cody Banks series
 * Agent Cody Banks (2003)
 * Agent Cody Banks 2: Destination London (2004)
 * Spartan (2004)
 * Walk on Water (2004)
 * Munich (2005)
 * Syriana (2005)
 * Black Book (2006)
 * The Good Shepherd (2006)
 * The Lives of Others (2006)
 * Breach (2007)
 * Charlie Wilson's War (2007)
 * Get Smart (2008)
 * Burn After Reading (2008)
 * Farewell (2009)
 * Knight and Day (2010)
 * Salt (2010)
 * Fair Game (2010)
 * The Debt (2010)
 * Red (2010)
 * Cars 2 (2011)
 * Page Eight (2011)
 * Tinker Tailor Soldier Spy (2011)
 * Haywire (2012)
 * Safe House (2012)
 * This Means War (2012)
 * Ek Tha Tiger (2012)
 * Argo (2012)
 * Vishwaroopam (2013)
 * A Most Wanted Man (2014)
 * Captain America: The Winter Soldier (2014)
 * Penguins of Madagascar (2014)
 * O21 (2014)
 * Spy (2015)
 * The Man from U.N.C.L.E. (2015)
 * Bridge of Spies (2015)
 * Iru Mugan (2016)
 * Atomic Blonde (2017)
 * Unlocked (2017)
 * Tiger Zinda Hai (2017)
 * Red Sparrow (2018)
 * Goodachari (2018)
 * Operation Finale (2018)
 * The Catcher Was a Spy (2018)
 * Red Joan (2018)
 * Goodachari (2018)
 * Raazi (2018)
 * Vishwaroopam 2 (2018)
 * War (2019)
 * Official Secrets (2019)
 * One Day: Justice Delivered (2019)
 * Kaappaan (2019)
 * Saaho (2019)
 * Romeo Akbar Walter (2019)
 * Satellite Shankar (2019)
 * The Courier (2020)
 * Tenet (2020)
 * London Confidential (2020)
 * Black Widow (2021)
 * Bell Bottom (2021)
 * Yaksha: Ruthless Operations (2022)
 * The Gray Man (2022)
 * Sardar (2022)
 * Zarrar (2022)
 * Pathaan (2023)
 * Operation Fortune: Ruse de Guerre (2023)
 * Heart of Stone (2023)
 * Argylle (2024)
 * The Ministry of Ungentlemanly Warfare (2024)

Television series
Some of the most popular television series include:

Classic era Modern era
 * Danger Man (1960–1968)
 * The Avengers (1961–1969)
 * The Man from U.N.C.L.E. (1964–1968)
 * I Spy (1965–1968)
 * The Wild Wild West (1965–1969)
 * Get Smart (1965–1970)
 * Mission: Impossible (1966–1973)
 * The Prisoner (1967–1968)
 * Callan (1967–1972)
 * Seventeen Moments of Spring (1973)
 * The Six Million Dollar Man (1973–1978)
 * The Bionic Woman (1976–1978)
 * The Sandbaggers (1978–1980)
 * Tinker Tailor Soldier Spy (1979)
 * Danger Mouse (1981)
 * Smiley's People (1982)
 * Reilly, Ace of Spies (1983)
 * The Equalizer (1985–1989)
 * MacGyver (1985–1992)
 * Æon Flux (1991–1995)
 * La Femme Nikita (1997–2001)
 * Nikita (2010–2013)
 * Alias (2001–2006)
 * 24 (2001–2014)
 * Kim Possible (2002–2007)
 * Foyle's War (2002–2015)
 * Spooks (2002–2011), aka MI-5
 * Burn Notice (2007–2013)
 * Chuck (2007–2012)
 * The Company (2007)
 * Archer (2009–present)
 * Human Target (2010–2011)
 * Rubicon (2010)
 * Strike Back (2010–2020)
 * Homeland (2011–2020)
 * Person of Interest (2011–2016)
 * The Americans (2013–2018)
 * The Blacklist (2013–present)
 * The Honourable Woman (2014)
 * Turn: Washington's Spies (2014–2017)
 * Madam Secretary (2014–2019)
 * The Bureau (2015–present)
 * Deutschland trilogy (2015-2020)
 * London Spy (2015)
 * Fauda (2015–present)
 * Counterpart (2017–2019)
 * Condor (2018–present)
 * Killing Eve (2018–present)
 * The Looming Tower (2018)
 * Jack Ryan (2018–2023)
 * The Family Man (2019–present)
 * The Spy (2019)
 * Alex Rider (2020–present)
 * Caliphate (2020)
 * Tehran (2020)
 * La unidad (2020–)
 * Andor (2022)

title: Spy film