Latest Treatment of Scars

Scar Solution By Sean Lowry

Scar Solution is a scientifically proven treatment that assists in fast scar removal naturally within months. It is effective in eliminating pitted acne scars, sunken scars and keloid scars. The author of this program is Sean Lowry, is a medical consultant and health researcher. Sean, some years ago suffered a skiing accident. This left ugly scars on her face which affected not only her skin but her whole life. This is Not a one-size-fits-all approach; Sean Lowrys system is based on a physiological approach that gives you 15 natural scar removal secrets that are simple to implement, affordable in price, and safe to apply. and 5 additional methods that will facilitate the healing and fading process of the scars. Based on the customer reviews of The Scar Solution, sufferers have been satisfied with the results of the miracle cure and most of them state that they will be recommending it to their family and friends. Tremendous results include breaking up the scar tissue so lessening their unsightly appearance on the skin; reversing hyperpigmentation and discoloration especially those caused by severe acne; and preventing the appearance of new scars, among others. Read more here...

The Scar Solution Natural Scar Removal Overview


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The writer has done a thorough research even about the obscure and minor details related to the subject area. And also facts weren’t just dumped, but presented in an interesting manner.

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Inflammationscarring Responses To Injury In The Foetalneonatal

The marked differences between scarring reactions in the skin of adult as compared with foetal neonatal animals have long been recognised. The documentation of similar ontogenetic differences in the scarring reactions of the brain have come to light relatively recently.2394 Thus, although the acute haemorrhagic phase appears similar to that of the adult with the invasion of haematogenous cells into the wound, the removal of necrotic tissue, and GFAP upregulation in astrocytes about the lesion no scar is formed over the subacute period in the rat cerebrum lesioned before 8 dpn. The growth of glial and neuronal elements across the wound ultimately obliterates all signs of the original lesion site. Normal mature scarring is acquired slowly over the period of 8 to 12 dpn. Scarring first develops subpially as fibroblasts and macrophages invade from the meninges and over the 8- to 12-dpn transitional period these cells penetrate more deeply to ultimately fill the wound, apparently...

Follicular Diseases Causing Scarring Alopecia

Follicular destruction results in scarring alopecia that can be classified as primary or secondary. In primary scarring alopecias, the follicle is the target of inflammation. In secondary scarring alopecias, the follicle is an innocent bystander that, nevertheless, is destroyed. Examples of secondary scarring alopecias include morphea and tumors (alopecia neoplastica). In this chapter, we will consider only the primary scarring alopecias. In this group of diseases, the inflammation can be primarily lymphocytic or neutrophilic. Although all parts of the follicle can be involved, the disease is felt to destroy the bulge area of the follicle, where the arrector pili muscles insert. This area contains the follicular stem cells necessary for regeneration of the lower follicle during normal follicular cycling. When this part of the follicle is destroyed, the follicle is doomed. The sebaceous glands are also destroyed in primary scarring alopecias. The destruction of these structures and the...

Glial Scar Formation In The

Glial Scar Mri Diffusion

Penetrating injuries of the CNS initiate a complex cellular wounding response comprising sequential and overlapping events. Acute haemorrhage and inflammation is associated with neuron degeneration this is followed by glial collagen scar formation, which is accompanied by an abortive regeneration response by axotomised but still viable neurons.1-3 The cellular events that culminate in glial scar formation are complex and are summarised in Figure 8.1. Whilst this figure illustrates the process of scar formation in the brain, the cellular events shown are representative of those that occur throughout the CNS. FIGURE 8.1 The spatial and temporal changes that occur after a penetrating injury to the cerebral cortex of the brain. During the acute phase (1 to 3 days postlesion (dpl)), a haemor-rhagic period results in an influx of haematogenous cells, including macrophages, which help to clear away necrotic tissue, whilst a reactive gliosis is initiated in the surrounding neuropil. In the...

Scar Versus Residual Disk

Magnetic resonance imaging (MRI) without intravenous contrast is at least as good as contrast computed tomography (CT) in distinguishing scar tissue from disk material, yielding an accuracy of 83 . The addition The criteria of importance in evaluating scar tissue versus disk material in the postoperative patient, based on Gd-DTPA-enhanced MRI, can be summarized as follows. - Scar tissue enhances immediately after injection, irrespective of the time since surgery (some scars continue to enhance for over 20 years) - Scar tissue can have a mass effect and may be contiguous with the disk space - Retraction of the thecal sac toward aberrant epidural soft tissue can be a helpful sign of scar tissue if it is present


Scarring is still the most dreadful complication of chemical peels. The contributing factors are 8 not well defined yet. Incidence of scarring with traditional Baker' formula is less than 1 22 , while with less aggressive phenol peels, the incidence is lower. The most common location of the scars is in the lower part of the face, probably due to more aggressive treatment in this area or due to the greater tissue movement, because of eating and speaking, during the healing process. Previous surgical lift elevates the neck skin to the higher position, imitating normal facial skin appearance. Thus, special precautions should be taken while peeling lower lateral portions of the face in post-surgical face-lift patients, even years later. We do not recommend combining deep chemical peels with any other surgical facial procedure, since skin undermining severely compromises the post-peel healing process and increases the risk of scarring. Isotretinoin therapy interferes with normal tissue...

Autoimmuneneuromuscular disorders

Including swelling of the joints, rash or scarring lesions of the skin, and numbness, weakness, or burning sensations. The most definitive test for SLE is an assessment of antinuclear autoantibodies. Additional diagnostic tests measure the presence of antibodies directed against double-stranded DNA, or Smith antigen.

Diagnosing Infection By Serologic Means

Finally, serologic testing is also useful for screening children with evidence of potential congenital infection (e.g., children with mental retardation and chorioretinitis or chorioretinal scars) who test seronegative for traditional TORCH agents. In one study, lymphocytic choriomeningitis virus (LCMV) was responsible for visual loss in two of four children, secondary to chorioretinitis in a population of severely retarded children (57). The diagnosis was realized by detecting elevated levels of IgG to LCMV in these children, a finding also noted by a French study of two children with chorioretinal scars for whom LCMV was detected by ELISA and confirmed by Western immunoblotting (58).

Evaluation and Diagnosis

Stereotactic computer-aided endoscopic sinus surgery should further improve safety, completeness of endoscopic resection, and operative time.48 Fried et al.49 introduced a new electromagnetic localizer in the InstaTrak System (Visualization Technologies, Inc., Wilmington, MA), which has become increasingly commonplace for difficult endoscopic sinus procedures. Endoscopic approaches generally avoid the complications of external operations, including external facial scars, nasal collapse, epiphora, dacry-ocystitis, transient blepharitis, lid edema, diplopia, nasocutaneous fistula, longer hospitalization, and more blood loss.7,44,47 The endoscopic sinus surgery approach has been shown to have recurrence rates comparable to those of external techniques (< 25 ). Long-term follow-up evaluation is needed to confirm this finding. Kamel44 reported no recurrences after endoscopic removal in 17 cases. His study was followed up for 43 months in the nasal cavity-exclusive group, but for only 28...

Consolidation Phase 8 to 20 Days Postinjury Figure

The duration of this phase is variable and is marked by a volume reduction in the core of the lesion, compaction of subbasal lamina astrocyte processes, and a down-regulation of GFAP about the wound. ED1+ microglia remain in the perilesion neuropil, but in the core of the wound most of the fibroblasts and macrophages disappear, although a few of each persist indefinitely.22 The greatly contracted core remains rich in fibronectin and collagen.30 During the subacute stage, astrocyte processes form an intensely GFAP+ multilayered palisade about the margins of the wound, but over the compaction period they either lose or contain less GFAP+ intermediate filaments. Processes become attenuated and thinned, bound to each other by multiple tight junctional complexes with minimal extracellular material between them. The laminin collagen IV+ basal lamina of the accessory glia limitans coating the opposed faces of the lesion may thus become separated by a thin sheet of acellular connective tissue...

Macrophage activation and deactivation

The life of a macrophage 'family' starts with the division of a pluripotent progenitor, and subsequent division of successive progeny associated with progressive transcription of genes that are required for the mature function of macrophages, and which distinguish the macrophage from other cell types. Individual cells receive further signals that direct them to adhere to endothelial cells, transmigrate, and adapt to whatever environment they encounter. If that environment is a site of inflammation, rather than a place of normal macrophage residence, the cell will be 'activated' to eliminate the challenge, be it dead cells or pathogens. Subsequently, the cell must be deactivated and either die or migrate out of the site to permit resolution and restoration of normal tissue architecture (or in some cases, a scar). This life story requires the macrophage to respond to hundreds, perhaps thousands of distinct signals produced by other cells, including other macrophages, as well as pathogen...

Responses Of Neurons To Injury

Recent data favours a lack of neurotrophic factors as a major cause of abortive CNS regeneration, since adult optic nerve fibres will regenerate across a transection site, invade the distal segment in large numbers,102 104 and traverse the optic chiasm into the optic tracts103 after the implantation of a Schwann cell graft into the vitreous body. The latter presumably provides a trophic stimulus to retinal ganglion cells which respond by regenerating their severed axons. Regrowth of the optic projection system is achieved without concomitant neutralisation of putative growth-inhibitory molecules in the optic nerve, thought to be concentrated in myelin membranes and on the plasmalemma of oligodendrocytes (see above), and which saturate the distal trajectory path throughout the nerve, chiasm, and tract for a protracted period after injury. Moreover, the scar does not constitute a barrier to regenerating axons, since growth cones both inhibit the de novo formation of a cicatrix and also...

Discharge And Home Healthcare Guidelines

PREVENTION OF BACTERIAL ENDOCARDITIS. Patients who have had surgery are susceptible to bacterial endocarditis, which will cause scarring or destruction of the heart valves. Bacterial endocarditis may result from dental work, surgeries, and invasive procedures, so people who have repaired or replaced heart valves should be given antibiotics before and after these treatments.

Evaluation of Eyelid Malpositions

Snapback Test

Rapidity of onset should be questioned in all patients. An acute-onset ptosis in an adult may be the result of a metabolic disturbance or compressive lesion. Hemorrhage into a preexisting, unsuspected eyelid or orbital mass can result in a sudden-onset ptosis especially in children, often associated with some degree of proptosis or motility disturbance. A history of recent trauma with new onset eyelid malposition should raise suspicion not only of scarring and or levator transection, but also for retained foreign body. Trauma without eyelid laceration is more likely to result in a contusive injury to the levator muscle or its nerve, with a high likelihood of spontaneous recovery. Orbital fractures can be associated with eyelid malpositions a ptosis that evolves over several days following eyelid trauma may indicate an enlarging hematoma or abscess. Gradual-onset of an eyelid malposition is more typical of involutional disease, but may occur with a paralytic or cicatricial process....

Diseases That Lead to an Increased Risk of Kidney Failure

Laura Melton came to Johns Hopkins at the age of 56. She told us that in order to lose weight, she had been taking laxatives every day for 30 years and still takes 2 to 3 pills daily. She had first exhibited urinary protein in an exam 11 years earlier. Three years before, she had 500 mg per day of urinary protein (normal urinary protein amounts to less than 150 mg per day) and a slightly elevated serum creatinine level (1.5 mg per dl normal levels in women are below 1.3 mg per dl). Urinary protein had increased to 2.56 g per day. A kidney biopsy (removal of plug of kidney tissue with a needle) 10 months earlier showed glomerulosclerosis, meaning scarring of the glomeruli. Laura had had high blood pressure for three years, which had been treated irregularly. High serum cholesterol and triglyceride levels had been noted for at least 14 years, but had been treated only irregularly. Because of intermittent potassium deficiency, she was taking a potassium chloride supplement daily, but...

Mandibular Reconstruction

As the advantages of vascularized bone became evident, a number of new donor sites for composite flaps were described. The fibula,38 iliac crest,39 and scapula40 donor sites have become the most popular sources of vascularized bone. Inherent differences in each donor site, with regard to bone stock, soft tissue quality, potential for sensory reinnervation, and pedicle geometry, dictate the best choice for reconstruction. The fibula, iliac, and scapula donor sites all provide bone stock sufficient for dental implants in most patients,41 which Urken et al.42 have demonstrated, is an essential factor for optimal oral rehabilitation. Successful reconstruction of the oral complex requires control of salivary continence, prevention of aspiration, functional mastication, and speech. Vascularized bone flaps permit primary reconstruction of the oromandibular complex, avoiding contractures and scarring which often complicate secondary reconstruction.42,43 Although the recipient bed is often...

Gender Ethnicracial And Life Span Considerations

Elicit a history of skin problems, the length of time skin disorders have existed, daily routine skin care, and current medications. Ask the patient about exposure to sunlight in particular, establish long-term patterns of exposure to sunlight, either at work or in recreational activities, and determine what form of sun protection the patient has customarily used. Record the patient's history of scars, vaccination sites, and burns. Establish a patient history of exposure to radiation or arsenic be sure to ask about the patient's occupational history to discover if he or she has been at risk of ingesting arsenic at an industrial site.

Swede Rutabaga Brassica napus subsp rapifera Brassicaceae

This is the root form of oilseed rape. The species is only known in cultivation, and is of European origin. It evolved as a hybrid between turnip (Brassica rapa subsp. rapa) and cabbage (B. oleracea var. capitata). Historical records indicate that it was grown in Finland in the 17th century and spread from Sweden to central Europe and had reached England by 1800. It is cultivated most in northern European countries and around the Baltic Sea and Russia. It was grown in the United States at the beginning of the 19th century. Swedes are grown as a food for humans, used mainly in stews or mashed as a vegetable, and have also been an important fodder crop for ruminants during winter. They can be distinguished from turnips in having ridged leaf base scars forming concentric rings at the top of the hypocotyl.

Timing Route Of Transmission And Clinical Manifestations Of Neonatal Herpes Simplex Virus

Intrauterine HSV disease occurs in approx 1 in 300,000 deliveries (1). Although rare, in utero disease is unlikely to be missed because of the degree of involvement of affected babies. Infants acquiring HSV in utero typically have a triad of clinical findings consisting of cutaneous manifestations (scarring, active lesions, hypo- and hyper-pigmentation, aplasia cutis, or an erythematous macular exanthem), ophthalmological findings (micro-opthalmia, retinal dysplasia, optic atrophy, or chorioretinitis), and neurological involvement (microcephaly, encephalomalacia, hydranencephaly, or intrac-ranial calcification) (2-5). A summary of 71 infants with intrauterine HSV infection and disease is presented in Table 1.

Discoid Lupus Erythematosus

Hypertrophic Verrucous Dle

The most common form of all chronic cutaneous variants is DLE, which can be localized or generalized, both with and without systemic manifestations of LE. Typical DLE lesions may be present at the onset of SLE in about 5 -10 of patients, and approximately 30 of patients may develop DLE lesions, usually of the generalized type, during the course of SLE (Cervera et al. 1993,Hymes and Jordon 1989,Tebbe et al. 1997). The localized form presents with sharply demarcated, erythematokeratotic, atrophic or scarring lesions, and it is often seen on the face and scalp, whereas the generalized form also involves the regions below the neck (Fabbri et al. 2003, McCau-liffe 2001, Patel and Werth 2002). DLE occurs mostly in the third to fourth decade of life however, in two recent studies, more than 40 children with DLE ranging in age from 2 to 16 years have been described in the literature (Cherif et al. 2003, Moises-Alfaro et al. 2003). Earlier reports indicated that DLE may be more prevalent in...

Patients Informed Consent

I understand that there is a small risk of developing permanent darkening or undesirable pigment loss at the treated site.There is a rare chance that a scar could develop. There is also a small risk that a bacterial infection could develop or there could be a flare of a pre-existing Herpes infection at the treated site,or the condition being treated could worsen after the peeling procedure. The benefits and side effects of the procedure have been explained to me in detail. All of my questions have been answered. CHEMICAL PEELING USING JESSNER'S SOLUTION. Jessner's peeling is often used to treat photodamage (sun-damaged skin), hyperpig-mentation (dark spots), texturally rough skin, acne, and scarring. It is a peeling agent which causes shedding of the outermost layer of the skin,the stratum corneum.

Epithelialization Contraction

The processes of epithelialization and contraction of the wound also occur during the proliferative phase. Epithelialization is the process where neighboring basal epithelial cells proliferate and begin to move into the wound from the edges to establish a barrier to fluid-loss and infection as they layer out across a wound surface. As the leading edges of these migrating cells contact one another, they undergo contact inhibition to arrest further migration and then proceed to reestablish a true multilayered epidermal layer. Epithelial buds also form from intact epithelial appendages in the middle of the wound, such as hair follicles and sweat glands. Well-approximated surgical wounds reepithelialize as rapidly as 24-48 hours and heal by the process called primary intention. Contraction on the other hand is the process where wound edges are mechanically approximated by contractile forces generated by special fibroblast called myofibroblasts, which have rudimentary actin-myosin...

When To Consider Revision Surgery

A group of patients who are more likely to require revision surgery are those who have had incomplete surgery with residual bony partitions and bulky persistent or recurrent disease. Poor healing in strategic areas with attendant scarring (e.g., frontal recess, posterior ethmoid sphenoid) or evidence of recirculation in an iatrogenic maxillary antrostomy that does not communicate with the natural ostium are other indications for revision surgery. Decisions with respect to revision surgery are again made significantly on objective grounds, having considered the radiographic and endoscopic appearance, as well as the subjective data.

Design in a Best Case Scenario

Still other design options that can be used to study cognitive vulnerability include cross-sectional, remitted disorder, and retrospective or follow-back designs (Alloy et al., 1999). First, cross-sectional (case control) studies compare a group with a disorder of interest to a normal control group (and, perhaps, groups with other disorders) on characteristics such as their respective scores on cognitive vulnerability measures. Such studies can be seen as preliminary tests or sources of hypotheses of potential vulnerability factors. Even so, they are wholly inadequate for establishing the temporal precedence or stability of a vulnerability independent of the symptoms of the disorder. That is, such designs are saddled with the alternative possibility that scores for the putative cognitive vulnerability are simply correlates, consequences, or scars of the disorder, rather than antecedent causes or risk factors of the disorder (Just et al., 2001 Lewinsohn, Steinmetz, Larson, &...

Safety Precautions For Using Vaccinia

Vaccinia virus is not to be confused either with variola virus, another member of the Orthopoxvirus genus that caused smallpox prior to its eradication, or with varicella virus, a herpes virus that causes chicken pox. Until 1972, vaccinia virus was routinely used in the United States as a live vaccine to prevent smallpox, and a residual scar, commonly on the upper arm, is evidence of that vaccination.

Bullous Lesions in Lupus Erythematosus

Lupus Tumidus

Bullous pemphigoid or may resemble the vesiculobullous lesions of dermatitis herpetiformis. If the bullous lesions rupture, they leave erosions, crusts, and pigmentary changes, and when they regress, scars, milium cysts, or calcinosis cutis can remain (Eckman and Mutasim 2002). In this form of bullous skin lesions, the activity of blistering may or may not coincide with the activity of the patient's systemic disease, and occasionally, mild and serious cases associated with organ-threatening disease have been reported (Gammon and Briggaman 1993, Sontheimer 1997). An important and interesting feature of these patients is also the dramatic response to treatment with dapsone even with very small doses (Hall et al. 1982, Yung and Oakley 2000). However, the drug could not be tapered and discontinued without rapid recurrence of the lesions. In a recent study, the efficacy of methotrexate in bullous SLE has also been reported in one patient (Malcangi et al. 2003). Histologically, the...

Acute Cutaneous Lupus Erythematosus

Transient Maculopapular Butterfly Rash

The localized form of ACLE usually begins with small, discrete erythematous macules and papules, occasionally associated with fine scales involving both the malar areas and the bridge of the nose while sparing the nasolabial folds (Fig. 6.1). This classic malar rash or butterfly rash can disappear without scarring and pigmentation or gradually becomes confluent and hyperkeratotic (Fig. 6.2), and facial swelling may be severe in some patients with this disease (Norden et al. 1993,Yell et al. 1996). Similar lesions have also been found to occur on the forehead, the V-area of the neck, the upper limbs, and the trunk. Furthermore, patients with ACLE may have diffuse thinning or a receding frontal hairline with broken hairs (lupus hair), telangiectasias and erythema of the proximal nail fold, and cuticular abnormalities (Patel and Werth 2002). Superficial ulcerations of the oral and or nasal mucosa are frequently accompanied with ACLE and may cause extreme discomfort in some patients. The...

Subacute Cutaneous Lupus Erythematosus

Subacute Cutaneous Lupus

Initially, SCLE lesions present with erythematous macules and papules that evolve into scaly papulosquamous or annular polycyclic plaques (Sontheimer et al. 1981). Approximately 50 of patients have predominantly papulosquamous or psoriasiform lesions (Fig. 6.4), and the other half have the annular polycyclic type (Fig. 6.5) a few patients may develop both forms of lesions (Sontheimer 1985a, Sontheimer et al. 1979). However, some groups have observed a predominance of the papulosquamous lesions, whereas others have noted an abundance of the annular polycyclic type (Callen and Klein 1988, Chlebus et al. 1998, Cohen and Crosby 1994, David-Bajar 1993, Fabbri et al. 1990, Herrero et al. 1988, Molad et al. 1987). One recent study found that 42 of the patients with SCLE studied exhibit the annular polycyclic form, 39 had the papulosquamous form, and 16 showed both manifestations (Parodi et al. 2000). Generally, lesions of this subtype heal without scarring but can leave long-lasting and...

Lupus Erythematosus Profundus

Lupus Profundus

LEP, historically referred to as Kaposi-Irgang disease or also known as lupus pan-niculitis, is a rare variant of CCLE in which pathologic changes occur primarily in the lower dermis and subcutaneous tissue. In 1883, subcutaneous nodules associated with LE were first described by Kaposi (Kaposi 1883), but the term lupus profundus was coined by Irgang (Irgang 1940) in 1940. Subsequently, different authors reported new cases and contributed to define the clinical and histopathologic characteristics of this disease (Arnold 1956, Sanchez et al. 1981, Tuffanelli 1971, Winkelmann 1970). Middle-aged women are predominantly affected however, in a recent study it has been shown that LEP in Asian patients is more frequent in a younger age group compared with the Caucasian population (Ng et al. 2002). The course of this subtype of CCLE is usually chronic and characterized by periods of remission and exacerbation. The major morbidity is usually disfigurement and disability related to pain, and...

Normal serum prolactin and FSH concentrations with history of uterine instrumentation preceding amenorrhea

Oral conjugated estrogens (0.625 to 2.5 mg daily for 35 days) with medroxyprogesterone added (10 mg daily for days 26 to 35) failure to bleed upon cessation of this therapy strongly suggests endometrial scarring. In this situation, a hysterosalpingogram or hysteroscopy can confirm the diagnosis of Asherman syndrome.

Primary Nursing Diagnosis

CL and CP are treated with a combination of surgery, speech therapy, and orthodontic work. Surgical repair of a CL is performed within the first month after birth. The repair improves the child's ability to suck. The optimal time to surgically correct a CP is controversial. Times range from 28 days of life to 18 months. Most surgeons prefer to perform the surgery at an early age, before faulty speech habits develop. The more extensive the surgery required, the later the surgery may occur. Surgical repair of CL (cheiloplasty) is usually uncomplicated with no long-term intervention, other than possible scar revision. Surgical repair of CP (palatoplasty) is more extensive and may require more than one surgery. If the infant has horseshoe defect, surgery may be impossible. A contoured speech bulb attached to the back of a denture appliance to occlude the nasopharynx may help the child speak.

Static Procedures For The Recovered Facial Palsy Patient

We have established a role for early temporalis muscle transposition in the treatment of this subgroup of patients, with excellent results.4 The surgical technique has been refined to deal effectively with both donor site defect problems and hypertrophic scarring at the oral commisure. Using this dynamic muscle transfer as an adjunct procedure permits efficient restoration of facial tone, symmetry, and purposeful facial movement in a patient population that previously waited up to 3 years after paralysis for any reanimation procedure. Not only is early function restored, but the natural regeneration of facial nerve fibers is not interfered with, so that ultimate restoration ofinnervation to the muscles of facial expression may still occur.

Indications and Contraindications

The deep-plane technique can be considered for most cases of primary rhytidectomy, except in the unusual situation, when simple skin redundancy is the only concern. It is particularly effective for advanced jowls and heavy nasolabial folds and for patients who smoke or have some other condition that predisposes them to compromised vascularity or infection. Patients with extremely thin skin in whom minor subcutaneous irregularities would be more evident are also better suited for the deep-plane rhytidectomy, as are those who are suceptible to hypertrophic scarring. Revision of a primary rhytidectomy that involved dissection in the sub-SMAS plane could conceivably increase the risk of facial nerve injury due to distortion of surgical landmarks by scar tissue. This will not be determined until more of these patients present for revision. Other contraindications are not specific to the deep plane technique and include patients with

Clinical Features

LyP is characterized by disseminated papules or nodules, which evolve and regress over a few weeks sometimes leaving behind scars. Often several papules are clustered (Fig. 1). The number of lesions in LyP can vary from few to hundreds (3). Although no definite predilection site has been identified, LyP lesions more often arise on the trunk, especially the buttocks, and extremities. In contrast to CD30+ LTCL, the face is less frequently involved in LyP. The individual LyP lesion starts as an erythematous, usually asymptomatic papule (initial stage). Within days or

Discoid Lupus Erythematosus Classic Appearance

Lesions evolve according to a characteristic time course. Fresh lesions first present as small, round, well-defined, slightly raised erythemas with dull surfaces that soon become rough to the touch and scaly. Scales are adherent and are often attached to the hair follicles (carpet tack phenomenon). Follicular orifices are first widened with keratotic plugs and may then disappear completely there is a gradual loss of hair in the lesions, leading to irreversible scarring alopecia. Lesions spread slowly and regress at the centers, which become smooth and sunken. Intermediate lesions become elevated and indurated at variable degrees and develop atrophy and loss of normal skin texture in their centers. At the periphery, rests of the active lesion remain as ring-like, arcuate, or polycyclic scaly erythemas that continue to spread. Old (burnt-out) lesions may be disfiguring they are large, with irregular borders, sharply demarcated, depigmented (porcelain white in dark skin), hairless, flat,...

Skin Excision And Closure

Next the temple tissues are elevated. No skin is removed, but a strong permanent suture to the underlying dermis and temporoparietal fascia of the inferior temporal flap is placed and advanced posteriorly and superiorly, securing it to the temporalis fascia. By avoiding any skin excision, the scar will be thin, with little chance of hair loss. Still, this strong deep suture provides effective elevation of the temple area without a stretched look.

Skin Resurfacing Laser or Peel

Since the mid 1990s, laser-assisted skin resurfacing has rapidly replaced chemical peels and physical dermabrasion as the most common means of skin exfoliation. Remarkably this has taken place with alarming rapidity and despite the lack of comparative trials. Evidence-based medicine has taught us the value of comparative trials. Without these we must ask ourselves the fundamental questions, how and why has this happened and is it justified Patients consulting with the cosmetic surgeon for improvement of the appearance of their face represent the broadest range of expression of any presenting problem in the specialty. They range from the preteen struggling with scarring from self-evacuation of acne pustules to the leathery alligatorlike skin of the working outdoorsman from the society matron who shuns photos of her profile to the 30-year-old manager who simply wants to improve and maintain her skin. An organized, logical approach to these problems will encourage problem-oriented...

Classification of Peel Depths

Therefore, the medium-depth chemical peel should only be obtained with the combination of 35 TCA and another agent such as Jessner's solution, solid CO2 or glycolic acid. The use of TCA in strengths greater than 35 ,should be discouraged with the exception of deliberate destruction of isolated lesions or where intentional controlled scarring is desired such as the treatment of ice-pick scars (Fig. 7.1).

Patients Willingness To Cooperate With The First Postoperation Week Regimen

Classically, patients who present to the emergency department with facial burns are treated with an open exposure, using an occlusive ointment. The patient must cleanse the area repeatedly to avoid bacterial infection and resultant scarring. The same regimen may be used after resurfacing, but inevitably the patient becomes sleep deprived and anxious as a result of this rigorous regimen. Because the resurfacing wound is rendered sterile by the heat of the laser, it is considered safe to use one of several types of occlusive membranes to cover the area, maintaining a sterile, moist environment for rapid reepithelialization. In most cases, this membrane is changed on day 3 or 4 postoperatively. Some patients insist on switching to the open exposure method at that point. There is no good evidence that there is any clinical difference in the results with either method.

Facial Versus Nonfacial Skin

Another critical consideration when performing a peel is realizing the difference of peeling facial versus non-facial skin. As a rule non-facial skin takes much longer to heal and is at much greater risk of scarring than when using a similar concentration on the face. This is due to the higher concentration of pilosebaceous units on the face compared with non-facial sites. These units play a critical role in reepithelialization. As a result if a peel is performed on non-facial skin such as the arms, upper chest and lower neck, one should proceed cautiously and not attempt concentrations greater than 25 TCA. Beyond the poor wound healing and higher risk of scarring, another major limitation of chemical peeling off of the face is lack of efficacy in comparison with facial peels. The remainder of this chapter is limited to peeling facial skin.

Comparison With Other Surface Modalities

Level III methods include CO2 resurfacing, phenol peels, and dermabrasion. Because of deeper penetration to or beyond the papillary-reticular junction, these manifest longer recovery and post-inflammatory erythema, as well as increased risk of scarring or pigmentary changes. They also produce the most significant improvement with regard to superficial rhytids, acne scars, and solar elastosis. I believe that CO2 resurfacing has effectively replaced the other two modalities in this level, but whether or not you agree, this algorithm may be useful in your consultation room. This simple approach permits every practitioner the ability to adapt it to his or her own preferences and needs.

Dissecting cellulitis of scalp

Chronic inflammatory disease characterized by painful suppurating lesions of the scalp, leading to scarring alopecia Perifollicular pustules tender nodules (some discharging pus or gelatinous material) intercommunicating sinuses between nodules patchy alopecia with scarring frequent recurrences over many years

Complications of Peptic Ulcer Disease

Obstruction can occur acutely as a result of edema and inflammation or chronically as a result of scarring. Obstruction is associated with ulcers of the pyloric channel or bulb of the duodenum. Acute obstruction can, in general, be treated conservatively with rehydration, correction of electrolyte abnormalities, and nasogastric tube decompression. Chronic obstruction occurs after repeated ulceration followed by healing. With untreated ulcer disease the lifetime risk of obstruction is approximately 10 . EGD is indicated to confirm the diagnosis and to exclude malignancy. Approximately 85 of cases of chronic obstruction are amenable to hydrostatic balloon dilatation. About 80 of these patients will experience immediate relief. About 40 will still be unobstructed at 3 months. Repeated dilation is sometimes necessary. Operative management consists of relief of the obstruction with additional definitive antiulcer surgery.

Advantages Disadvantages of TCA Peels

TCA peels confer several advantages for both the patient and physician. TCA is an inexpensive solution that can be easily prepared, is stable, and has a long shelf life. TCA, as opposed to peels such as Baker's phenol, does not have any systemic toxicity. In addition, as noted previously, it is a versatile agent that can be used for superficial, medium and deep chemical peeling. The frosting reaction can be a utilized as a reliable indicator for the depth of the chemical peel, making this a safe agent in the hands of the experienced dermatologist. However, TCA in concentrations > 40 has an unreliable penetration depth and can result in scarring.

Benign Hepatic Tumors

On CT, hemangiomas are sharply defined, hypodense masses compared to the adjacent hepatic parenchyma on unenhanced images. They have a distinctive enhancement pattern characterized by sequential contrast opacification beginning at the periphery as one or more nodular or globular areas of enhancement, and proceeding toward the center. The key factor is that all areas of lesion enhancement should appear with the same enhancement as blood pool elsewhere (Fig. 2). MRI is useful in differentiating heman-giomas from malignant hepatic neoplasms, based on very long T2 relaxation of the hemangioma compared with other hepatic masses. Other characteristic MRI features include a sharp margin and internal homogeneity. Similar to CT, key to diagnosis is typically early enhancing peripheral nodular enhancement on dynamic T1 images, with progressive fill-in on delayed images on dynamic gadolinium-enhanced MRI. However, in some cases, hemangiomas may be atypical. With both CT and MRI it is important...

Heterologous Cartilage Grafts Xenographs

Zyplast (Collagen Corporation, Palo Alto, CA) has been used as a temporary implant to camouflage contour abnormalities of the nasal dorsum during the convalescent period of rhinoplasty and to temporize before revision surgery. It also may be helpful to act as a spacer to prevent scar contracture of the nasal tissues before augmenting with a more permanent implant. The expense and transient longevity are negative points for its use. In addition, a skin test is necessary before injection to identify patients who might be sensitive to bovine collagen. Some surgeons recommend two skin tests separated by 30 days to identify additional patients who might demonstrate sensitivity.

Alloplastic Implants

Maas et al.17 pointed out that the clinical efficacy of implant material over the long term is dependent on the stability of the material to chemical degradation such as by hydrolysis and other oxidation-reduction reactions, as well as physiologic cellular activity directed against the material. The porosity of the implant materials plays an important role in host tissue ingrowth and subsequent stability. In addition, such factors as thin skin overlying the implant, scarring of the tissue bed, and the architecture facilitating stabilization of the implant play crucial roles in determining the longevity of the clinical result.17

Ehlers Danlos syndrome

Findings common to all subtypes skin hyperextensible, doughy, white, and soft, with underlying vessels sometimes visible small, spongy tumors (molluscoid pseudotumors) over scars and pressure points smaller palpable, and movable calcified nodules in subcutaneous tissue nodules in arms and over tibias skin fragility, with frequent bruises, lacerations, and poor wound healing hyperextensible joints, with frequent dislocations

Investigating the scene of death

With a plastic indicator strip or rectal thermometer) which could suggest death from a stimulant drug, tattoos which could suggest a drug culture, and fine parallel scars of the wrists or neck suggestive of a prior suicide attempt. A nearby plastic bag, particularly in the death of an elderly person with a chronic disease, suggests a death from the combination of asphyxia and drug overdose to terminate prolonged suffering (a method advocated by right-to-die organizations).

Differential Diagnosis

Clinical features Children and young adults Asian or Latin American origin Papular, vesicular, necrotic lesions, and scars Sun-exposed and covered areas Fever, malaise, failure to thrive, weight loss Lymphadenopathy, hepatosplenomegaly Histological features Epidermal necrosis Atypical lymphocytes Angiodestruction or panniculitis Immunophenotype

Association with Tumors

In rare cases of DLE, the development of skin tumors is reported. Basal cell carcinoma, keratoacanthoma, and squamous cell carcinoma may develop on atrophic scars as a long-term complication of DLE lesions (Dabski et al. 1986, Fanti et al. 1989, Halder and Bridgeman-Shah 1995, Stavropoulo et al. 1996). Cutaneous squamous cell carcinoma rarely shows distant metastasis, however, the tendency for LE-associated carcinoma to metastasize has been observed more frequently, with the rates varying from 0.5 to 2 (Millard and Barker 1978).

Glucocorticoid Therapy

Pharmacodynamic therapy with glucocorticoids (A). In unphysio-logically high concentrations, cortisol or other glucocorticoids suppress all phases (exudation, proliferation, scar formation) of the inflammatory reaction, i.e., the organism's defensive measures against foreign or noxious matter. This effect is mediated by multiple components, all of which involve alterations in gene transcription (p. 64). Glucocorti-coids inhibit the expression of genes encoding for proinflammatory proteins (phospholipase-A2, cyclooxygenase 2, IL-2-receptor). The expression of these genes is stimulated by the transcription factor NFkb. Binding to the glucocorticoid receptor complex prevents translocation af NFkb to the nucleus. Conversely, glucocorticoids augment the expression of some anti-inflammatory proteins, e.g., lipocortin, which in turn inhibits phospholipase A2. Consequently, release of arachidonic acid is diminished, as is the formation of inflammatory mediators of the prostaglandin and...

Epidermolysis bullosa

Bullae, erosions, and scarring of the hands Epidermolysis bullosa. Bullae, erosions, and scarring of the hands Pasini variant more extensive blistering, scarlike papules on the trunk (albopapu-loid lesions) involvement of the oral mucosa and teeth dystrophic or absent nails common Severe recessive variant (Hallopeau-Sie-mens) generalized blistering at birth subsequent extensive dystrophic scarring, most prominent on the acral surfaces, sometimes resulting in pseudosyndactyly (mitten-hand deformity) of the hands and feet flexion contractures of the extremities increasingly common with age dystrophy of nails and teeth involvement of internal mucosa sometimes resulting in esophageal strictures and webs, urethral and anal stenosis, phimosis, and corneal scarring intestinal malabsorption leading to a mixed anemia resulting from a lack of iron absorption and failure to thrive significant risk of developing aggressive squamous cell carcinomas in areas of chronic...

Clinical Application Questions

A 35-year-old woman seeks help regarding a progressive skin eruption that began on the ears and facial skin late in the previous summer. The lesions stabilized during the winter months but rapidly progressed with the return of warm, sunny weather. Physical examination reveals a scaling dermatitis with discrete and confluent plaques. Some plaques have a depressed center and scarring. Telangectasia, hypopigmentation, and hyperpig-mentation are evident. The rash is asymmetric on the face and ears but is symmetrically distributed over the V of the chest, dorsal arms, and forearms with sharp limitation at the collar and short-sleeve protection line.

General autopsy considerations

External examination in cases of oral drug abuse (i.e., pills or liquid medications) is generally not rewarding unless actual medication or medication residue is observed in the mouth or on the hands. However, as noted earlier, multiple parallel scars on the wrists or neck suggest prior suicide attempts and a subsequent suicidal drug overdose. Bite marks (contusions and lacerations) of the tongue and lower lip should be specifically sought because these frequently accompany terminal convulsions which may be the result of cocaine or tricyclic antidepressant toxicity. Stigmata of intravenous drug abuse are, naturally, the identification of fresh, recent, and old injection sites (Figure Sometimes these may not be evident if the user makes a conscious attempt to conceal such marks by using very small gauge needles, rotating injection sites, and by injecting in areas normally concealed even by warm weather clothing. This is especially likely to occur among those in the health...

Primary Versus Secondary Ossicular Reconstruction

Been failed ossicular reconstructions in the past, or previous operations have been followed with severe postoperative retraction, staging a reconstruction is prudent. Often, the decision to delay ossicular reconstruction is made on the basis of the severity of the disease encountered at the time of primary cholesteatoma removal. If the mucosa has been seriously damaged, is thick, edematous, and large amounts of middle ear mucosa need to be removed, postoperative scarring, fibrosis, and retraction are more likely. The timing of ossicular chain reconstruction is a judgment call that requires significant amounts of experience.

Apocrine Hidrocystoma

Sudoriferous Cyst Pathology

TREATMENT In general, no treatment is necessary. But when removal of the lesion is desired for diagnosis, cosmesis, or to diminish irritation or obstruction of vision, complete surgical excision is appropriate with meticulous removal of the intact cyst wall. In cases of multiple or recurrent lesions adherent to the epithelium, en-bloc excision via a blepharoplasty type incision may be a useful approach. Chemical ablation of the cystic epithelium with trichloroacetic acid has been reported to yield excellent results without scarring. Carbon dioxide laser vaporization has also shown good results.

Gastroesophageal Reflux Disease Gerd Introduction

Gastroesophageal reflux (chalasia, cardiochalasia) is the return of gastric contents into the esophagus and possibly the pharynx. It is caused by dysfunction of the cardiac sphincter at the esophagus-stomach juncture. Reasons for this incompetence include an increase of pressure on the lower esophageal sphincter following esophageal surgery or immature lower esophageal neuromuscular function. The result of the persistent reflux is inflammation, esophagitis, and bleeding causing possible anemia and damage to the structure of the esophagus as scarring occurs. It also may predispose to aspiration of stomach contents causing aspiration pneumonia and chronic pulmonary conditions. Most commonly affected are infants and young children. As the condition becomes more severe or does not respond to medical treatment and the child experiences failure to thrive, surgical fundoplication to create a valve mechanism or other procedures may be done to correct the condition.

Dermatologic Physical Exam

A loose white scale develops in some cases, and the lesions may simulate a papulosquamous disease. There is no follicular accentuation as in DLE, and the carpet-tack sign is negative. As the lesions evolve, they exhibit telangiectatic vessels and a dusky color not seen with pityriasis rosea or psoriasis. When the lesions regress they may leave mild epidermal atrophy, telangectasia, and hypopigmentation, but they do not scar. Annular lesions usually enlarge peripherally with a border that has erythema and loose white scale. The central areas show gray-white hypopigmentation. These lesions tend to coalesce to form polycyclic and gyrate patterns (see Chapter 2).

Real Examples of Results

The window of opportunity between the stage of neuro-praxia and the development of degeneration and scarring is fleeting and of uncertain length. The availability of a prognostic test to determine which patient will develop axon degeneration before it occurs would be ideal. As much as everyone would like to have such a test, unfortunately none exists. Surgical decompression performed when nerve excitability is normal will eliminate the risk of residual facial deformity. Decompression performed after loss of nerve excitability has occurred will minimize, but not always avoid, permanent poor results. The earlier surgery is done, the better the result, even in cases where the delay is months or years from the onset of complete palsy.

Age Related Macular Degeneration

In AMD, central visual acuity is lost due to death of macula photoreceptors located in the central portion of the retina. This pattern of vision loss is different than that in glaucoma, where peripheral vision is progressively lost. AMD can be broadly divided into two categories nonexudative, or 'dry,' AMD and exudative, or 'wet,' AMD. Dry AMD is characterized by the loss of photoreceptor cells in the macula following the death of supporting retinal pigmented epithelium (RPE) cells. Vision decline is usually gradual. Wet AMD is characterized by neovascularization of the choroidal capillaries (choroidal neovascularization (CNV)), which supply oxygen and nutrients to and remove waste products from photoreceptors and RPE cells. Wet AMD can be further subcategorized by the appearance upon examination by angiography of newly formed capillaries (1) predominantly classic, in which most of the newly formed blood vessels are well formed (2) minimally classic, in which most of the capillaries...

The Tympanic Membrane and Middle

Tympanic Membrane Scarring

Fig. 2.53 Scarring of the drum. a A gossamer-thin membrane can be seen to close this previously well-defined central perforation (arrow). At first sight with the auriscope, a central perforation would appear to be the diagnosis more careful examination with a pneumatic otoscope will show that this thin membrane moves and seals the defect, giving reassurance that the drum is intact. b Scarring of the drum with retraction onto the round window, promontory, and incus (arrows) is also evidence of past otitis media. It is sometimes difficult to be sure whether this type of drum is intact a thin layer of epithelium indrawn onto the middle-ear structures may seal the middle ear, and examination with the operating microscope may be necessary to be certain of an intact drum. Fig. 2.53 Scarring of the drum. a A gossamer-thin membrane can be seen to close this previously well-defined central perforation (arrow). At first sight with the auriscope, a central perforation would appear to be the...

Examination of the Heart in Cardiomyopathy

Histologic examination of the myocardium is critical to determining the cause of the cardiomyopathy. Thus, in addition to sections of tissue with obvious gross pathology, samples of the walls of all four cardiac chambers, the septum, and papillary muscles should be taken. In the past, the right ventricle has been relatively ignored, but because of the greater awareness of right ventricular infarction and right ventricular dysplasia cardiomyopathy, it should be a routine to examine the right ventricle carefully. For establishing the diagnosis of right ventricular cardiomyopathy, the most helpful single observation to make is one of fibrosis or scarring in the right ventricular wall with intermingling of fat these lesions are most often seen in the inflow region of the right ventricle on the posterior wall or in the anterior wall of the right ventricular outflow tract. These lesions can be commonly appreciated grossly if a careful examination of the heart is carried out.

History and Classification

Acne is a common disease affecting almost 100 of youngsters 1, 2 . Acne settles in the vast majority by 20-25 years of age but 1 of males and 5 of females exhibit acne lesions at 40 years of age 3 . Scarring occurs early in the course of acne and may affect, to some degree, 95 of patients from both sexes 4 . Differences in the cell-mediated immune response are involved in the personal tendency to develop post-acne scarring 5 . Acne scars are debilitating and socially disabling for the individual. Treatment of acne scars presents a challenge for a treating physician. Usually they cannot be effectively corrected by a single treatment modality because of their widely varied depth, width and structure. A few morphologic acne scar classifications have been proposed to assess the efficacy of different therapeutic options based on the scar types. Standard classification includes three basic types of scars icepick scars, rolling scars, and boxcar scars 6 . Icepick scars are narrow (< 2 mm),...

Serous and Mucinous Cystic Neoplasms of the Pancreas

Serous cystic neoplasms of the pancreas are observed in middle-aged and elderly women. This type of tumor rarely requires surgical treatment, whereas mucinous cystic tumors should be resected because of their malignant potential. Nevertheless, some surgeons prefer to resect the serous type as well. In general, the patient's age, overall condition, location of the lesion, and growth over time are factors that help in deciding if surgery is needed 34 . Often any cyst that increases in size, any symptomatic cyst, and cysts in older fit patients are selected for surgery. CT can accomplish preoperative differentiation of the two types in many cases. In serous cystic tumors, traditionally the diagnosis is made if the number of cysts within the tumor is more than six and the diameters of the cysts less than 2 cm 35, 36 . A newer nomenclature calls cysts < 1 cm definitely serous, > 1-2 cm equivocal and > 2 cm definitely mucinous. Grossly, these serous tumors appear either as solid...

Prepeeling Preparation

Treatment of acne scars must be individually tailored to address the specific findings. The patient has to understand that the scar revision process may require more that one surgical session. Punch excisions or elevations have to be performed 4-6 weeks before the peel, while subcision can be performed at the same session with the peel.

Peeling Technique

The full description of the deep chemical peel procedure is found in Chapter 8. Before the peeling, the subcision (subcutaneous incision) technique is used to free the fibrous bands from the base of the scars. For this purpose we use an 18-gauge 1.5-inch NoKor Admix needle (Becton Dickinson and Co). This needle has a triangular tip similar to No. 11 blade (Fig. 9.5). It allows smooth separation of fibrous cords. The needle is inserted through a skin surface, and its sharp edges are maneuvered under the defect to make subcutaneous cuts or incisions. The depression The Exoderm solution is applied evenly and gradually on the skin until full frosting is achieved (Fig. 9.6). At this stage we combine mechanical skin dermabrasion by using a Ti-polisher,which is sterile surgical equipment designed originally for cleaning cauthery tips during operations (Fig. 9.7). This simple disposable tool is available in any standard operating setting. Another option is to use sterilized gentle sandpaper....

Nasel Cyst Hearling Loss

Escision Simple Del Papiloma Nasal

A simple elliptical excision leads to unnecessary scarring, which is to be avoided on the face. Incisions are made in the relaxed skin tension lines of the face and a number of flaps devised, e.g., the rhomboid as demonstrated here to minimize scarring. Fig. 3.13 Scar revision. a When a scar on the face is prominent, simple excision and resuturing does not always give an improved result. b The breaking-up of the line when the scar is excised makes a scar considerably less evident. Facial scars may be improved markedly with techniques such as these but complete eradication is rarely possible. c One month after scar revision. d Nine months after scar revision. Fig. 3.13 Scar revision. a When a scar on the face is prominent, simple excision and resuturing does not always give an improved result. b The breaking-up of the line when the scar is excised makes a scar considerably less evident. Facial scars may be improved markedly with techniques such as these but complete eradication is...

Static Rehabilitation Procedures

A static sling procedure is generally indicated when the patient does not desire restoration of facial motion or is not medically fit to undergo a more extensive procedure under general anesthesia. Although static sling procedures do not restore facial motion, they do improve facial aesthetics for the patient by providing facial symmetry at rest and often will improve oral incompetence. Traditionally, a fascial graft, such as fascia lata from the thigh, is harvested and anchored from the zygomatic arch to the orbicularis oris, using the same techniques described for muscle transfer. In recent years, availability of highly biocompatible alloplastic implants has obviated the need for harvesting autologous fascia, which eliminates donor site scar and morbidity as well minimize operative time. The most commonly used alloplastic material for midfacial suspension is Gore-Tex,7 although Alloderm is also currently being used. The procedure is simple and easy to perform. A sheet of the...

Folliculitis decalvans

Final common pathway of various types of chronic folliculitis, producing progressive scarring Inflammatory process caused by obstruction or disruption of individual hair follicles and the associated pilosebaceous units, leading to scarring alopecia because of destruction of the follicular units role of staphylococcal follicular infection uncertain Occurs in women after age 30 and in men from adolescence onward bogginess or induration of affected areas of the scalp or other hair-bearing sites successive crops of pustules late finding of scarring alopecia

Herniated intervertebral disk

However, enhances on the delayed CT scan images (e.g., 40 minutes after injection of the contrast material). Disks are typically seen as areas of decreased attenuation with a peripheral rim of enhancement, whereas epidural scar enhances homogeneously Fibrosis (scar tissue) Six weeks to six months after lumbar spinal surgery, there is a gradual replacement of the immediate postoperative changes by posterior scar tissue. Fibrosis can be extradural (the most common type) and intradural (arachnoiditis). Patients with arachnoiditis have a history of multiple lumbar spine operations, with pain-free intervals ranging between one and six months. They usually complain of both back and leg pain in varying degrees, and the neurological evaluation is inconclusive. The diagnosis of scar tissue versus disk is extremely important. Surgery is not indicated for scar (epidural fibrosis), but may be beneficial if the disk can be diagnosed as a cause of the radiculopathy blunting of the caudal nerve root...

Disorders of the Esophagus

Difficulty swallowing is called dysphagia. It is a symptom of either an obstructive problem (such as cancer or scarring of the esophagus) or a muscular problem (such as megaesophagus, when the lower esophageal sphincter does not relax and allow food into the stomach). In cases of chronic heartburn and GERD, doctors usually prescribe medications to reduce the acid in the stomach and to hasten gastric emptying (moving food and acids out of the stomach and into the duodenum). In rare situations, surgery may be required to increase pressure on the lower esophagus. If the esophagus is badly scarred and narrowed, surgery also may be needed to widen the passageway. Heartburn and GERD are more than painful and inconvenient. If left untreated, they can cause bleeding or ulcers in the esophagus and also may lead to frequent infections. The esophagus may become permanently narrowed due to scarring from the exposure to stomach acid. People who have had heartburn for 5 or more years are at...

Risk Of Fetalneonatal Infection

Maternal Varicella

Skin scars Congenital varicella syndrome was first described in 1947 but seems to have been forgotten until 1974, when a newly recognized case was described in Canada (9). Following this case report and review of the literature, many other reports of infants with a similar constellation of birth and developmental defects after maternal varicella followed (7,10). Eventually, it became possible to specifically implicate VZV causally in these classic birth defects by the use of polymerase chain reaction (PCR). Unlike infants with the congenital rubella syndrome, babies with the congenital varicella syndrome do not asymptomatically shed virus at birth or afterward. If they develop zoster, and about 18 will do so, then it is possible to demonstrate VZV by culture or other specific means. Using PCR, moreover, it has been possible to demonstrate VZV DNA in affected tissues, such as the skin scars typical of the syndrome. Approximately 75 affected infants have now been reported (7). Only a...

Clinical manifestation

May begin with non-specific constitutional symptoms and signs prodromal pain or parathesias along one or more der-matomes, lasting i-i0 days, followed by patchy erythema in the dermatomal area of involvement and regional lymphadenopa-thy unilateral, grouped vesicles on ery-thematous base, with severe local pain vesicles initially clear, but eventually becoming pustular, rupturing, crusting, and involuting scarring ensues if deeper epidermal and dermal layers compromised by scratching, secondary infection, or other complications

Diseases Characterized By Dermal Fibrosis

Diseases Characterized by Dermal Fibrosis SCAR Scar Hypertrophic Scar This chapter is devoted to those diseases characterized by fibrosis. This process principally affects the dermis, though the epidermis is often affected to a lesser degree. Diseases that are characterized by dermal fibrosis histopathologically exhibit a firm, fibrous change to the skin clinically. Some lesions that exhibit dermal fibrosis are elevated above the surrounding skin, such as a hypertrophic scar. Others are depressed below the surrounding skin, such as morphea. Dermal atrophy is also observed as a depression in the contour of the skin, though the texture would not be fibrotic on palpation. Epidermal atrophy is observed histopathologically as epidermal thinning and loss of the rete ridges clinically, it is observed as a subjective thin feeling of the superficial skin on palpation and is often associated with a smooth, wrinkled surface. Induration is a clinical term used to describe the firm, thickened...

Disorders of the Bladder and Urethra

The urethra can become narrowed by scar tissue following catheter placement, surgery, injury, or repeated episodes of urethritis (see page 286). This condition, Urethral stricture can be treated in the doctor's office by widening the urethra from within with a thin, flexible instrument called a dilator. Sometimes the scar tissue must be removed surgically using a cystoscope, or a portion of the urethra must be removed surgically. Laser therapy also may be used to remove the scar tissue. Depending on where the stricture is located, a urethral stent (a tiny springlike device that holds the urethra open) can be inserted to keep the passageway open. However, if the stricture is too close to the sphincter muscle (which prevents leakage of urine from the bladder), a stent cannot be used. In some cases the affected segment of the urethra may be surgically reconstructed using tissue taken from another part of the body. Urethral stricture is a condition in which the urethra (the tube that...

Microdistribution None

Light applications of liquid nitrogen sufficient to produce a 0.5- to 1-mm rim of freeze at the perimeter of the base of the SK is usually sufficient for total removal. The advantage of this technique is the absence of scarring. Heavily pigmented persons must be warned about the possibility of posttreatment hyper- or hypopigmentation. This is especially important when working on the facial area. When patients express concern in this regard, we encourage treatment of one or two test lesions in an inconspicuous location before proceeding. During the sunny season, we strongly urge sun avoidance and the use of a sunscreen with makeup to prevent posttreatment darkening. Cryosurgery is the appropriate way to treat these lesions. On rare occasions one encounters an SK that simply will not respond to cryotherapy. When this occurs, the lesion must be biopsied to be certain it is not a more aggressive type of pigmented lesion. Once the lesion is found to be benign, therapy should consist of...

Identification of the Deceased

If identification cannot be made by fingerprints, dental records or X-ray, then positive identification can be made by DNA techniques. If none of the aforementioned methods of identification is possible, then only a tentative identification based on circumstances personal possessions or nonspecific characteristics such as tattoos, scars, or absence of organs, can be made.

Dangers in Current Techniques Supcroxol HeatLigh I Technique

The chances that the solution will spill onto the exposed skin of the face or hands is everpresent. If immediately rinsed, the result is usually just a white patch which gradually returns to normal color in a few hours. If not quickly rinsed off, however, the liquid can leave a nasty white burn that will itch initially, and then form a scar as the burnt tissue sloughs off.

Introduction to the Opportunistic Biplane Facelift

Tumescent anesthesia and fine cannula lipodissection, combined with electrocautery and laser dissection, all help minimize operative time (which averages 1 2 hours) and postoperative morbidity. Because the primary lift is in the deeper plane, we have essentially eliminated skin excision in the temple and occipital regions. Skin bunching in the mastoid area subsides after a few weeks, resulting in a completely hidden scar within the hair and a decreased incidence of skin injury behind the ear. We depend entirely on the deeper pull for the effectiveness of the lift. Skin excision in front of the ear is very conservative. This has produced much better healing and finer scars because of the total absence of pull on the skin.

Multiple Lumbar Spine Surgery Failed Back Syndromes

Patients with profound emotional disturbances and instability (e.g., alcoholism, drug abuse, depression) and those involved with compensation and litigation should undergo a thorough psychiatric evaluation. Even if they are found to have a genuine neurosurgical problem, the psychosocial problem should be dealt with first, as additional low back surgery would otherwise fail again. After exclusion of the psychosocial group of patients, a smaller group of patients with back and or leg pain due to mechanical instability or scar tissue remains only those patients with mechanical instability will benefit from additional surgery.

Aphthous Ulcers see p 172 ff

Traumatic Ulcer Tongue

This ulcer (periadenitis mucosa necrotica recurrens) looks similar to a simple aphthous ulcer and is the same histologically, but it behaves differently. It is less common, larger, persists for several weeks or months and may leave a scar. It occurs in more varied sites affecting the soft palate and even the pyriform fossa, where it presents with severe dysphagia. Carbenox-olone is used topically forthe lesions in the oral cavity. Fig. 4.18 Solitary aphthous ulcer. This ulcer (periadenitis mucosa necrotica recurrens) looks similar to a simple aphthous ulcer and is the same histologically, but it behaves differently. It is less common, larger, persists for several weeks or months and may leave a scar. It occurs in more varied sites affecting the soft palate and even the pyriform fossa, where it presents with severe dysphagia. Carbenox-olone is used topically forthe lesions in the oral cavity.

Epidermal Necrolysis Disease Spectrum

Early Photos Stevens Johnson Syndrome

CLINICAL PRESENTATION Erythema multiforme minor is characterized by round erythematous rapidly progressive mucocutaneous macules or papules. The borders are bright red with central petichiae, vesicles, or purpura. Conjunctivitis with blisters and ulcerations can be seen, and secondary infection is common. Lesions may coalesce and become generalized. Burning may be significant, but pruritis is generally absent. These lesions usually resolve over one to several weeks, but postinflammatory hyper- or hypopigmentation may occur. In EM major (Stevens-Johnson syndrome) prodromal symptoms occur in 50 of cases and include fever, malaise, sore throat, arthral-gia, vomiting, and diarrhea. Mucocutaneous involvement shows bullous lesions which become hemorrhagic and necrotic, leading to extensive denuded areas of skin and mucous membrane including the mouth and conjunctiva. Scarring results in lagophthalmos, trichiasis, symblepharon,

Battered Baby Syndrome

Battered Baby Syndrome

Severe head injuries are often associated with retinal hemorrhage. If the child survives, retinal scarring may result. Retinal hemorrhage can occur naturally from birth trauma, but in these instances, scarring does not occur.6 While retinal hemorrhage is more common in homicides, it can occur in severe accidental head injuries. Retinal hemorrhages are also seen in bleeding disorders, sepsis, vasculopathies, increased intracranial hemorrhage and, rarely, when there is abrupt and severe compression of the chest.7,8 Examples of the last entity are cardiopulmonary resuscitation and the effects of a shoulder harness in a car crash.8

Cicatricial Pemphigoid

Pemphigoid Eye

INTRODUCTION Cicatricial pemphigoid, also known as benign mucous membrane pemphigoid, essential conjunctival shrinkage, or ocular pemphigus is a progressive inflammatory disease of presumed autoimmune etiology. It variously involves mucous membranes of the mouth, conjunctiva, pharynx, nose, esophagus, vagina, urethra, and anus. Oral bullae and erosions occur in 90 of cases. Strictures of the esophagus, urethra, or anus sometimes occur late in the disease. Skin involvement is seen in less than 25 of cases and takes one of two forms a recurrent nonscarring vesiculobullous eruption, mainly involving the extremities and inguinal region, or in the form of localized erythematous plaques with associated vesicles and bullae on the face and scalp. The latter variant heals with small atrophic scars. Another variant of localized pemphigoid known as Brunsting-Perry type has skin lesions limited to the face and neck but with no mucosal involvement. Significant scarring of affected areas often...

Extent of Resection for Benign Tumors

Recurrent pleomorphic adenomas may present a more complex problem. The scarring and altered anatomy in such cases place the facial nerve at greater risk of surgical injury during the dissection. Under such circumstances, facial nerve monitoring during revision surgery may be helpful in reducing the risk of damage to the facial nerve. Frequently there are multiple foci of recurrence, and they may continue to manifest over several years. Provided that a recurrence is nonprogressive and asymptomatic, it may be prudent to observe such stable recurrent disease for sometime. During this period of observation, other recurrences may become manifest and, in such cases, multiple surgeries can thus be avoided.18 Another reason for observing small asymptomatic recurrent pleomorphic adenomas is the increased risk to the facial nerve during revision surgery. Radiotherapy may be considered in the treatment of recurrent pleomorphic adenoma when surgery is no longer a feasible option.

Peeling Preparation

Despite some general predictable outcomes, there is tremendous variability in the reactivity and responses to chemical peels. Even superficial chemical peeling can cause hyperpigmen-tation and scarring in susceptible individuals. Therefore, the author always performs the initial peel with the lowest concentration of the

Herpes and Varicella Zoster

Dermis Multinucleated Cells Neutrophils

CLINICAL PRESENTATION Following an incubation period of approximately two weeks and a prodrome of fever and malaise, the cutaneous lesions begin as a mild maculo-papular eruption. The papules evolve into clear vesicles that show an umbilicated center. Characteristic vesicles overlie a larger patch of erythema and develop in several successive crops. The vesicles become cloudy, rupture, and form crusts. Healing occurs over the ensuing few weeks with little or no scarring unless they become infected. In contrast to varicella, the lesions in herpes zoster are limited to a single dermatome however, hematologic dissemination of the virus can result in a few distant skin lesions as well. Pain in the region supplied by the involved nerve is not common but can precede the skin changes by several days. Preauricular adenopathy is often seen. The nasociliary branch of the ophthalmic nerve supplies sensation to the eye, with terminal branches going to the tip of the nose. Lesions on the tip of...

Radial Nerve Injury at the Wrist

Nonsurgical therapy involves the removal of precipitating or exacerbating causes, and this is often sufficient to achieve spontaneous recovery of radial nerve function within weeks. Neither steroid injections nor releasing the nerve from adherent scar tissue is usually indicated.

Genitourinary System Basic Care Plan Introduction

Urine descends through the ureters to the bladder, where it is stored until it is excreted via the urethra. Disease processes may cause inflammation, tissue damage, and scarring with resultant dysfunction of the organs or structures of the genitourinary system. Structural defects may be either congenital or acquired and can obstruct urine flow causing renal damage and possibly lead to kidney failure. The kidneys of infants and children are immature in regard to fluid and electrolyte balance because of their limited ability to concentrate urine. This creates increased risk for fluid and electrolyte fluctuations and the possibility of dehydration during illness. Renal function matures as the child grows.

Subarachnoid Hemorrhage

It is possible to have massive injury to the brain with minor focal sub-arachnoid hemorrhage, especially if death is rapid. This is seen most commonly in cases with massive mutilating injuries of the head, such as when an individual jumps several stories to the ground. There are massive, gaping, compound fractures of the skull, with partial or even complete avulsion of the brain. The brain may show spotty subarachnoid hemorrhage and no contusions. Absence of contusions in such cases is common. In one case, an individual had his head caved in with a baseball bat in front of a number of witnesses. The brain showed virtually no subarachnoid hemorrhage and no contusions, though there were extensive lacerations. Absence of hemorrhage following lacerations to the brain has been reported as much as 1 h after injury, and is presumably due to prolonged spasm of vessels.9 Subarachnoid hemorrhage may cause subsequent development of communicative hydrocephalus because of a lack of reabsorption of...

Exit Site Care Pre Implantation of PD Catheter

The exit-site should be identified and marked on the skin. This should be done in collaboration with the patient, the surgeon, the nephrologist, and the experienced PD nurse. The exit-site should be placed laterally either above or below the belt line, and it should not lie on a scar or in abdominal folds. It should be determined with the patient in an upright (seated or standing) position. Local trauma and hematoma during catheter placement should be avoided. The exit-site should be round and the tissue should fit snugly around the catheter. Sutures around the exit-site increase the risk of infection and should be avoided. The downward-directed exit-site is associated with significantly lower catheter related peritonitis 3 . Prophylactic antibiotics given at the time of catheter placement decreases the risk of infection 4, 5 . Vancomycin (1 g IV, single dose) at the time of catheter insertion is found to be superior to cephalosporin (1 g IV single dose) in preventing early...

Transfer across biological membranes

Introduces the drug directly into the venous bloodstream, thereby eliminating the process of absorption altogether. Substances that are locally irritating may be administered intravenously since the blood vessel walls are relatively insensitive. This route permits the rapid introduction of drug to the systemic circulation and allows high concentrations to be quickly achieved. Intravenous administration may result in unfavorable physiological responses because once introduced, the drug cannot be removed. This route of administration is dependent on maintaining patent veins and can result in extensive scar tissue formation due to chronic drug administration. Insoluble particulate matter deposited in the blood vessels is another medical problem associated with the intravenous route.

Medium and Deep Peels

Medium-depth peels also utilize glycolic acid 70 or Jessner's solution in combination with 35 TCA. Combination medium-depth peels are often used to treat moderate to severe photodamage. Fifteen Middle Eastern patients with atrophic or pitted acne scars were treated with a combination of Jessner's solution and 35 TCA peeling 11 . All patients were of light brown to dark brown complexion. Six percent had excellent improvement, 53 had moderate improvement and mild improvement was noted in 27 . Nine patients (73.4 ) developed transient post-inflammatory hyperpigmenta-tion which resolved after 3 months. Patients with light brown complexions did not develop hyperpigmentation. In the author's experience, aggressive peels of this nature have a substantially greater likelihood of inducing persistent hyperpigmentation and hypopigmentation in darker skin types. Clinicians should be acutely aware that deeper peels carry substantial risks of inducing scarring and hypopigmentation in...

Differential Diagnosis at Particular Sites Discoid Lupus Erythematosus of the Scalp

Scutula Favus

DLE of the scalp (Fig. 11.2A) typically arises as one or a few roundish erythematous plaques identical to DLE lesions elsewhere on the skin. When atrophy develops, they gradually transform into patches of scarring alopecia that may be surrounded by rims of scaly erythema. In the early phase, it must be distinguished from psoriasis and seborrheic dermatitis (see previously herein). In advanced stages, DLE may resemble all other instances of scarring alopecia. One important mark is that DLE of the scalp is often accompanied by analogous lesions of the face. Folliculitis decalvans, which in its active stages can hardly be confused with DLE because of its pustules and crusts, eventually leads to cicatricial alopecia, which is morphologically similar to that of lichen planopilaris (small areas of alopecia intermingled with tufts of normal hair, most often in the parietal and occipital areas). Similar hairless scars, although less extensive, may arise from furuncles and trichophytic...

Acanthosis Nigricans Groin

Acanthosis Nigricans Warts Groin

Telangiectases, thick port-wine stains, venous lesions high risk of scarring Telangiectases, thin port-wine stains, cherry angiomas, childhood hemangiomas, warts, scars, striae, poikilo-derma of Civatte, leg veins wrinkles and atrophic scars. Tx options Topical tretinoin, ammonium lactate, laser therapy, dermabrasion.

Vesicoureteral Reflux Introduction

The following effects of unrepaired reflux have been identified urine concentration ability is inversely proportional to the grade of reflux renal scarring lower-weight percentiles (in physical growth) hypertension proteinuria and those with bilateral scarring and an increased risk of developing end stage renal failure (as high as 30 ). In the majority of children, the problem will disappear spontaneously without surgical intervention if infection is controlled. Management of reflux includes antibacterial therapy for infection control.

Structure and Cells of the Cornea

The three cellular layers of the cornea differ markedly in mitotic and self-renewal abilities. In the corneal epithelium, mitotically active basal cells continuously renew the nonmitotic population of suprabasal cells, which subsequently flatten as they migrate to the surface, where they are lost by desquamation. The stromal keratocytes, on the other hand, show little cell division in the normal adult. They undergo rapid cell division after localization in the cornea in late embryogenesis, but after birth the keratocyte cell number stabilizes and little or no mitosis can be detected throughout the lifetime. In the case of inflammation or wounding, however, the stromal keratocytes become activated and mitotic. The phenotype of the activated keratocytes changes to resemble that of fibroblasts and myofibroblasts, and connective tissue matrix secreted by these cells during wound-healing becomes opaque scars. After healing the cells become quiescent, but human corneal scars are very slow...

TABLE 302 Glogau Classification

Mild pigmentary changes No keratoses Minimal wrinkles Patient age 20s or 30s Minimal or no makeup Minimal acne scarring Early to moderate photoaging Early senile lentigines visible Keratoses palpable but not visible Parallel smile lines beginning to appear Patient age late 30s or 40s Some foundation usually worn Mild acne scarring Acne scarring present makeup does not cover Makeup cannot be worn it cakes and cracks Severe acne scarring

Methodological Challenges Of Vulnerability Research In Bipolar Spectrum Disorders

Must temporally precede the initial onset of the disorder or, in the case of a vulnerability factor for the course of a disorder, precede episodes or symptom exacerbations of the disorder and it must exhibit some degree of stability independent of the symptoms of the disorder (but see Just, Abramson, & Alloy, 2001, for the argument that a vulnerability factor does not need to be immutable). Given these criteria, some research designs are more appropriate than others for testing vulnerability hypotheses (Alloy, Abramson, Raniere, et al., 1999). For example, cross-sectional studies that compare a group with the disorder of interest to a normal control group (and possibly, a group with a different disorder) on several characteristics can generate hypotheses about potential vulnerabilities, but are wholly inadequate for establishing temporal precedence or stability independent of symptoms of the disorder. Designs that compare individuals who have remitted from an episode of the...

Circumstances Surrounding Death

Gunshot Wounds Suicide

FIGURE 2.18 A postmortem X-ray revealed a bullet (arrow) next to the spine. The man had recently been shot because examination revealed no scar tissue around the bullet. See next photo. FIGURE 2.18 A postmortem X-ray revealed a bullet (arrow) next to the spine. The man had recently been shot because examination revealed no scar tissue around the bullet. See next photo. FIGURE 2.19 An X-ray of the pelvis revealed bullet fragments. These were surrounded by scar tissue, indicating the man had been shot before. See next photo. FIGURE 2.19 An X-ray of the pelvis revealed bullet fragments. These were surrounded by scar tissue, indicating the man had been shot before. See next photo.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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