Alternative Ways to Remove Scars

Scar Solution Book By Sean Lowry

The Scar Solution book is a result of personal testing, scientific research, trial and error which the author Sean Lowry experienced in months. She is a formal scar sufferer and medical researcher. With this program, she helped thousands of scar sufferers remove their ugly scars naturally. The Scar Solution book is specially designed and guaranteed to be one of the most effective skincare methods of the current century that helps to remove scars and brings about smooth skin. This treatment works to eliminate the ugly and stubborn scars even if they have been existing on your skin for a long time without the requirement for thousands of dollars spending on costly remedies or expensive, special supplements that are considered as miracle treatment for scars. Each purchase of the system comes with four free bonus books worth over $220 dealing with the subjects of moles, wart and skin tags as well as acne treatment roadmap, weight loss in relation to metabolism, achieving smoother skin and more. Read more here...

The Scar Solution Natural Scar Removal Summary


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Patchy Nonscarring Alopecia

Frequent use of hair permanents, hair straighteners, and hair dyes can lead to patchy hair loss marked by broken off hairs. Tight ponytails and tight braiding (especially corn-row braiding) may lead to traction alopecia that is usually nonscarring but in some persons can cause scarring if prolonged. Inquiry about hair care is always necessary in evaluating patients with alopecia. scalp. Currently in the United States the most common fungal organism causing this condition ( Trichophyton tonsurans) does not cause fluorescence with a Wood's light. Usually tinea causes a nonscarring hair loss. A severely inflammatory tinea can result in scarring. A potassium hydroxide slide and fungal culture establish this diagnosis. A fungal culture is more likely than a KOH to be positive in tinea capitis. Therapy with an oral antifungal agent is indicated.

Figure 276 Hair loss alopecia due to alopecia cicatrisata scarring Neutrogena Skin Care Institute

Alopecia of the scalp is of considerable concern to both men and women. It is helpful in differentiating among the many causes of alopecia to examine the hair and scalp and observe whether the hair loss is diffuse or patchy and whether the scalp appears scarred. A careful history and physical examination of the hair and scalp is most important. Nonscarring hair loss is more common than scarring hair loss ( Table27 2). Table 27-2 Types of Nonscarring and Scarring Hair Loss


Dermabrasion was first described as a debridement tool for burns in 1963 (25). It is a modification of tangential excision which removes tissue in even smaller increments and in smaller areas than one can with a knife. Advocates claim good results from this technique with less bleeding than with traditional debridement knives with easier access to difficult areas (26). In limited studies, dermabrasion has been shown to facilitate shorter wound healing times and a reduction in scar formation than burns treated with traditional tangential excision (27). The disadvantages of using dermabrasion are that it is generally slower than tangential debridement with a knife, and there is a spray of debrided tissue and fluid from the device which has obvious potential dangers to theatre staff.

Infectious and Inflammatory Lesions

Tracheomalacia appears in many forms. Short segments related to postintubation lesions have been resected, whereas longer segments have sometimes been splinted with external polypropylene rings, or internally with stents or T tubes.222 Expiratory collapse associated with chronic obstructive pulmonary disease was treated by Herzog and by Nissen with posterior membranous wall splinting and quilting, pulling the ends of the splayed, softened cartilaginous rings into a more normal C shape.309-311 Thin bone slabs, fascia lata, and later Goretex were used as splint materials. Rainer and colleagues reported results with perforated plastic splints of several designs in 1968.312 Wright and colleagues found posterior splinting of intrathoracic trachea and both main bronchi with strips of Marlex to be effective.313 Importantly, Marlex becomes permanently incorporated by scar tissue, preventing recurrence. The principal clinical benefit is the improved ease in raising secretions.

Cell Proliferation and Matrix Repair

The provisional fibrin matrix is populated with platelets and macrophages, which release growth factors that initiate activation of fibroblasts. Fibroblasts migrate into the wound using the fibrin matrix as a scaffold and proliferate until they become the most common cell type within about three to five days. As fibroblasts enter and populate the wound, they utilize MMPs to digest the provisional fibrin matrix and deposit large glycosaminoglycans (GAGs). At the same time, they deposit collagens onto the fibronectin and GAG scaffold in a disorganized fashion. Collagen types I and III are the main interstitial, fiber-forming collagens in ECM and in normal human dermis. Type III collagen and fibronectin are deposited by the fibroblasts within the first week, and later, type III collagen is replaced by type I (5). About 80 of dermal collagen is type I, which provides tensile strength to the skin (6). The collagen is cross-linked by lysyl oxidase, which is also secreted by fibroblasts. The...

Schwann Cells Respond To Injury

Schwann cells have a pivotal role in response to PNS injury. The PNS regenerative powers are in part due to intrinsic properties of Schwann cells that encourage spontaneous regeneration and have been the focus of much investigation. PNS axonal regeneration occurs through the initiation of signalling cascades that activate Schwann cells to produce neurotrophic factors, cytokines, extracellular matrix and adhesion molecules, which aid in regrowth of the injured nerve. These abilities are in direct contrast to CNS neuroglia, particularly astrocytes, which produce a hostile environment for axonal regeneration in response to injury. In the CNS, damage results in extensive glial scarring, the production of inhibitory factors and the lack of axonal guidance, both physical and molecular. Due to these reparative qualities, Schwann cells are becoming candidates for use in cell transplantation to treat demyelinating diseases of the PNS and CNS and spinal cord injury. Schwann cells are considered...

Squamous Epithelial Tumors

The lower incidence of tracheal squamous cell carcinomas compared with those of the bronchus is attributed by some to laminar airflow in the trachea (because of large diameter) and effective mucociliary clearance (because of evenness and absence of bifurcation). These may prevent accumulation of carcinogens in the mucosa which can promote a malignant transformation sequence.11 Six patients have been reported with tracheal squamous cell carcinoma arisen from tracheostomy scars, probably the result of carcinogenesis in active repair, similar to scar carcinoma elsewhere.12 One case was reported in a plumber exposed to asbestos.13

General Considerations

This procedure has shown little value for evaluation of primary tracheal tumors, particularly adenoid cystic carcinoma. The finding of involved lymph nodes adjacent to the tumor on one or both sides of the trachea does not make a patient unsuitable for surgical resection. These paratracheal lymph nodes are the first regional lymph node stations involved by a tracheal tumor and do not seem to carry the same significance for adenoid cystic carcinoma of the trachea as they do for carcinoma of the lung. I consider these to be N1 nodes with respect to a tracheal tumor. If the primary tracheal tumor is large, and invasion of other medi-astinal structures is suspected, then mediastinoscopy may be performed immediately prior to a planned exploration for resection under the same anesthesia. Surgical planes will thus not be confused by inflammatory scarring, which results if resection is delayed following mediastinoscopy.

William J Lindblad phd

Repair of damaged dermal tissue is accomplished by dynamic cell-cell and cell-matrix interactions involving activation of resident cells as well as cells that migrate into the lesion. Immediately after injury there is a hemostatic response that activates platelets. Platelets release transforming growth factor-P (TGF-P) and platelet-derived growth factor (PDGF), which begin the recruitment of inflammatory cells and activate several resident dermal cell types. The most notable early inflammatory response is the infiltration of neutrophils. These are necessary to control infection and begin clearing the damaged tissue but are not critical to the healing process. Wound healing begins a few days later with the infiltration of monocyte macrophages at the site. These cells release a number of cyotokines, synthesize extracellular matrix (ECM), and serve as a source of stem cells. The ECM becomes vascularized by angiogenesis and forms granulation tissue. Neovascularization is accomplished...

Replacement Of Collagenous Structures

Cell type provides for the deposition of matrix proteins and proteoglycans that are required for the proper migration and or cellular phenotypic behavior. Ultimately, a greatly expanded mesenchymal cell population synthesizes the massive deposits of collagenous ECM termed a scar.

Proteinase Inhibitors Of Inflammatory Demyelination

Renewed interest in the role of MMPs in promoting the traffic of leukocytes into the CNS has raised the possibility that inhibitors of these enzymes could modify the inflammatory process in the CNS. The metalloproteinase cascade is highly regulated by cytokines, which may also induce TIMPs 11 . For example IL- 1 can promote local synthesis of proteinases, while IL-6 and TGF-B both induce TIMP production. Recent efforts to alleviate clinical signs of EAE have focused on synthetic inhibitors of MMPs. One hydroxamate inhibitor, GM6001, was found to suppress the development of EAE or reverse established clinical symptoms respectively, when administered prophylactically or therapeutically 87 A broad spectrum MMP inhibitor, BB-1101 was effective in reducing the severity of EAE in the Lewis rat88, and completely blocked the onset of EAE and reversed severe acute disease in the SJL J mouse89 . Chronic relapsing EAE was also significantly modulated, with clinical improvement accompanied by a...

Cutaneous and Mucosal Manifestations The Primary Lesion

The primary lesion of rickettsialpox represents the site of inoculation of rickettsiae from the bite of an infected L. sanguineus mite and is described for 83 to 100 of patients in several large series (10,13,22,24,99,127,128). In its early stages, this lesion is a firm, nonpruritic, erythematous papule that soon enlarges and develops a central vesicle containing clear or opaque fluid. The lesion is generally painless and is often described by patients as a pimple, boil, or insect bite. Eventually, the vesicle ruptures and a dark brown or black crust develops over the lesion, forming the characteristic eschar (Fig. 5A). The eschar often is surrounded by a larger zone of erythema. Primary lesions range in size from 0.5 to 2.5 cm and are located, in order of decreasing frequency, on the upper extremities, lower extremities, back and shoulders, neck, face, chest, and abdomen. Eschars have also been reported uncommonly in the nostril and on the scalp, axillae, vulva, penis, buttocks, and...

Chronic Radiation Effects

Chronic ulceration of the conjunctiva can be seen following treatment with 60 Gy. This leads to symble-pharon formation, resulting in shortening of the for-nices, trichiasis (turning of lashes onto the ocular surface) and eyelid malpositioning. Goblet cell loss occurs at relatively low doses, resulting in tear film instability and dry eye symptoms, while doses over 50 Gy may result in keratinization of the conjunctiva. These keratin plaques constantly irritate adjacent cornea, occasionally causing scarring and visual loss. Necrosis may occur after radioactive plaque therapy for retinoblastoma patients, where doses to the conjunctiva between 90-300 Gy are used 1-3,10 .

Medical and Nursing Management

Often aid chronic conjunctival irritation by providing the lubrication necessary to replace lost tear volume and dilute toxic chemotherapeutic metabolites excreted into the tear film. Vitamin A ophthalmic ointment (tretinoin 0.01 or 0.1 ) may reverse squamous metaplasia and loss of vascularization from scar formation 12 .Patients with infectious conjunctivitis should be instructed to wash their hands frequently and take great care in interactions with others to prevent the spread of communicable diseases. In addition, sunglasses for protection from the sun and wind may be helpful in reducing symptoms. Severe conjunctival reactions, such as symblepharon and forniceal shortening, may require ophthalmolog-ic manipulations such as symblepharon lysis on a repeated basis or, alternatively, mucous membrane grafting with forniceal reconstruction may be necessary. Ophthalmologic referral is therefore indicated.

Potential For Cellbased Therapies

Cells from umbilical cord matrix may also be a source of cells for treatment of neurodegenerative disease. Medicetty et al. (91) treated rats with a unilateral 6-hydroxydopamine (6-OHDA) lesion that caused parkinsonian-like symptoms. Four weeks after the 6-OHDA lesion, rats were injected with umbilical cord matrix cells or sham transplants. Four weeks after transplantation, there was a significant decrease in apomorphine-induced rotatory behavior in the parkinsonian rats that received umbilical cord matrix cell transplants as compared with parkinsonian rats that received a sham transplant. Normal rats, without 6-OHDA lesions, were transplanted with umbilical cord matrix cells but showed no changes in behavior. This work suggests that umbilical cord matrix cells can target areas of neurodegeneration and play a role in healing of neural tissue. Amniotic cells may have a similar potential (92). Labeled amniotic epithelial cells were injected into monkeys with spinal cord injuries. Some...

Preoperative Evaluation

Biopsies of soft tissue tumors of the extremity should be placed axially. When performing an incisional biopsy it is important to ensure that the biopsy scar can be included in the definitive resection without sacrificing cosmetic or functional results. Hemostasis is extremely important, as bleeding with hematoma formation has the potential to spread tumor cells. Excisional biopsies are indicated for small, superficial tumors (generally 3 cm).

Results of Endonasal Frontal Sinus Surgery

In a second study 28-30 , endoscopic and CT examinations were systematically carried out. After 1298 months follow-up of patients with type II drainage, 58 of 83 frontal sinuses were ventilated and normal. A ventilated frontal sinus with hyperplastic mucosa was seen in 12 of cases. Scar tissue occlusion with total opacification on the CT scan was evident in 14 of cases. In 16 of cases, total opacification was due to recurrent polyposis. Patients were free of symptoms or had only minor problems in 79 of cases. After a period of 12-89 months following type III drainage, 59 of 81 frontal sinuses were ventilated and normal. A ventilated frontal sinus with hyper-plastic mucosa was seen in 17 of cases. Scar tissue occlusion with total opacification on the CT scan was obvious in 7 of cases and, in 16 of cases there was total opacification due to recurrent polyposis. The patients were free of symptoms or had only minor problems in 95 of cases. Already this first series of reevaluation of...

Diagnosis and Evaluation

Involvement of the carina by bronchogenic carcinoma must be assessed with great care by conventional imaging, which includes CT scan of the chest and upper abdomen. Crisp carinal tomograms can be useful to demonstrate the gross extent of the lesion, both within and without the lumen of the trachea, and to make clear the relative portion of airway that seems to be uninvolved by tumor (Figure 8-15). Final bron-choscopic assessment is best made with the Storz Hopkins magnifying telescopes through a rigid broncho-scope. Biopsies of tracheal mucosa proximal to the visible tumor may help to establish the feasibility of resection. Mediastinoscopy is very important for assessment of lymph nodes beyond the information obtained from CT scan. Mediastinoscopy is preferably performed concurrently with a planned resection so that tissue planes and definition of the tumor will not become obscured by inflammation and scar. Should preoperative adjunctive therapy be given following mediastinoscopy...

Functional Assessment

If the TSH is elevated then you're hypothyroid, and it's likely that the elevated TSH itself has contributed to the growth of the goiter. Of course, the TSH is most often elevated because of Hashimoto's thyroiditis (in industrialized countries), discussed in Chapter 5, or iodine deficiency (in much of the underdeveloped world), discussed in Chapters 1 and 3. Adequate thyroid hormone replacement reduces TSH levels to normal and often reduces the size of the goiter. However, sometimes there is so much scar tissue in the thyroid that thyroid hormone treatment doesn't shrink the goiter very much.

Complications of Surgery

The list of complications from endoscopic sinus surgery is long and extensive 41 however, careful understanding of the anatomy and constant visualization will help prevent the majority of these complications 26 . Most minor complications can be dealt with by careful attention during the postoperative period. Understanding that nasal polypoid disease can distort anatomy and obscure anatomy will provide the first step to avoidance of major complications. Constant visualization of instrumentation throughout the surgery will aid in prevention of inadvertent injury to the lamina papyracea or skull base. Careful dissection of mucosa and boney structures will help prevent iatrogenic injury to the normal sinus mucosa and thus prevent unpredictable scarring and surgical failure. Immediate identification of intraoperative trauma to the skull base or lamina papyracea at the time of occurrence will help prevent further damage to vital structures such as the orbital contents or dura. Once an...

Detection and Screening

Routine ear, nose and throat evaluation, including inspection of the oral mucosa for ulcers, indirect and direct laryngoscopy and nasopharyngoscopy may be included in the screening process to ensure a thorough assessment of the mucosa. It is important to look for nasal scarring, as this may interfere with the normal movement of mucus and sinus drainage, leading to recurrent sinusitis. The soft tissue of the head and neck should be evaluated for muscle hy-poplasia, fibrosis and ulceration. Irradiated skin often has impaired vascularity and the resultant thin skin is highly susceptible to minor trauma. Both an otoscopic exam and inspection of the auricle are necessary to rule out the presence of otitis externa and chondronecrosis, respectively. Detailed inspection of the ear canal can detect cerumen im-paction and tympanic scarring, both of which can lead to conductive hearing loss. In addition, the patient should be evaluated for the possible presence of otitis media or tympanic...

The Malignant Thyroid Nodule

Please note that you must never permit a surgeon to perform only a nodulectomy (surgical removal of the thyroid nodule without removing the complete half of the gland with the nodule). This would be considered substandard surgical care. Treating thyroid cancer (see Chapter 9) requires that the entire thyroid gland be surgically removed before any additional treatment can be given. Additionally, many thyroid cancers are multifocal, meaning that many individual tumors are present at different places in the thyroid gland, but frequently the surgeon cannot see this solely based on the obviously visible, or gross, physical appearance of the thyroid gland. Also, it's always safest for a surgeon to operate on a virgin side of the neck so that scarring from previous surgery has not obscured key landmarks inside the neck that help the surgeon to avoid complications. By performing a total thyroid lobectomy (removal of a com

Reconstruction after an Unsuccessful Repair

Reconstruction following a prior attempt is daunting because of reduced length of normal trachea available, and surgical scar, which makes dissection difficult, endangers recurrent laryngeal nerves, limits tracheal mobility, and may affect tracheal blood supply. Reoperation should be delayed for 4 to 6 months after a prior reconstruction to allow subsidence of tissue inflammation and edema, and maturation of scar. We

Postoperative Fistula

Early in the development of tracheal reconstruction, postoperative hemorrhage from the brachiocephalic artery occurred too frequently.3,4 Since cuff stenosis often lies at the level of the artery, the vessel was frequently dissected free from scar and the tracheal anastomosis made immediately behind it. Local infection or erosion at this point of confluence could lead to bleeding. Suture material, a foreign body, probably contributes. One surgeon, who formerly used fine wire for an anterior tracheal anastomosis, attributed some fistulas to abrasion by this unyielding material. Anastomotic dehiscence after tracheal reconstruction, most often managed with subsequent intubation, may expose the artery in what is now an infected space. If tracheal dissection is kept scrupulously close to the trachea and the artery is left undissected with its local tissue investment intact, hemorrhage will almost never follow. When the artery must be dissected because of adherence to tracheal scar, prior...

Appearance Preoccupations

Individuals with BDD are preoccupied with the idea that some aspect of their appearance is unattractive, deformed, ugly, or not right, when the perceived flaw is actually minimal or nonexistent (Phillips et al. 1993). Some patients describe themselves as hideous, repulsive, or looking like the Elephant Man (Phillips 1996a). Preoccupations usually involve the face or head, most often the skin, hair, or nose (e.g., acne, scarring, pale or red skin, thinning hair, a large or crooked nose). However, any body part can be the focus of concern, and patients typically worry about three or four body areas over the course of their illness (Phillips et al. 1993). In some cases, individuals with BDD report disliking their overall appearance or say they are generally ugly, because

Diffuse Scleroderma Systemic Sclerosis

Histologic examination of the skin shows generalized atrophy and hyalinization with entrapment of the eccrine glands in the scar tissue. The atrophic skeletal muscles lack the inflammatory component seen in dermatomyositis. The sedimentation rate is elevated early in the course of the disease. Other abnormal findings are related to the organs involved.

Heart Failure After Myocardial Infarction Results From Progressive Ventricular Remodeling

Heart failure after MI occurs as a result of a process termed myocardial remodeling. This process is characterized by myocyte apoptosis, cardiomyocyte replacement by fibrous tissue deposition in the ventricular wall (Atkins et al., 1999 Beauchamp et al., 1999 Beltrami et al., 2001), progressive expansion of the initial infarct area, and dilation of the left ventricular lumen (Colucci, 1997 Choi et al., 1998). Another integral component of the remodeling process appears to be the development of neoangio-genesis within the myocardial infarct scar ( Effects of Enalapil, 1987 Elefanty et al., 1997), a process requiring activation of latent collagenase and other proteinases (Field, 1998). Under normal circumstances, the contribution of neoangiogenesis to the infarct bed capillary network is insufficient to keep pace with the tissue growth required for contractile compensation and is unable to support the greater demands of the hypertrophied, but viable, myocar

Pathophysiologic Changes Induced by Cytotoxic Therapy

Pulmonary disease after chemotherapy or radiation therapy may also have obstructive or restrictive components. Obstructive diseases result from airway narrowing. This may be due to bronchospasm,mucus or luminal narrowing as a result of edema and inflammation or scarring 88 . Airway narrowing due to disease can be detected as a decrease in expiratory airflow. Pulmonary function tests demonstrate a decrease in the ratio of the volume exhaled in 1 second (FEVj) to the total exhaled forced vital capacity (FVC). Radiotherapy. Relatively similar histopathologic changes and resultant physiologic abnormalities are found in the lung following radiotherapy and chemotherapy. Injuries resulting from radiation to the lung are most likely present in all patients, even after very small doses of radiation. Studies of the immunologi-cal regulation of inflammation after radiation in animals have revealed a complex interaction between local tissues, resident cells and circulating immune cells, mediated...

Other Disorders Of Neuronal Migration And Cortical Formation

Ulegyria is another distinct cortical anomaly. Ulegyria is best characterized as a fusion of layer 1 at the depths of sulci with relative sparing of the crests of the gyri. The fusion is frequently associated with gliosis in the cortex, neuronal loss, and obliteration of the cortical lamination. The scarring at the depth of a sulcus and sparing at the surface of the brain results in a mushroom appearance when the gyrus is viewed on cross section. These lesions have very well-defined borders and discrete islands of preserved neurons within the lesion. The histology and location, frequently in an arterial zone, have led to the contention that ulegyria arises late in gestation or in early neonatal life as a vascular injury to the immature cortex, possibly related to hypoperfusion. Ulegyria may be clinically silent or manifest as seizures, similar to those of polymicrogyria discussed earlier.

Disorders of elasticity

EDSs I and II are similar, with II being more mild. EDS I is characterized by soft velvety hyperextensible skin that is fragile, tears easily, and heals poorly, with thin cigarette-paper scars. There is easy bruiseability. Over time, elastosis perforans serpiginosa can become a significant management problem. Patients have marked ligament laxity. Individuals with Ehlers-Danlos syndrome type III have essentially normal skin, but marked hyperextensibility of large and small joints. Electromicroscopy of skin shows abnormal collagen bundles in these conditions. In some families, mutations in the a1 chain of type 5 collagen (COL5A1) have been identified. Ehlers-Danlos syndrome type IV, the arterial or Sack-Barabas type, is autosomal dominant, as are Ehlers-Danlos syndromes type I, II and III. The skin in type IV is thin and taut, rather than velvety and soft. This is a disorder of type III collagen (COL3A1) and affects the lining of vessels and viscera. Rupture of these is the major...

Bladder Ureter and Urethra

Radiation can induce inflammation and fibrosis and cause dysfunction due to a reduction in bladder capacity and contractility. Although it is not certain, the underlying etiology seems to be radiation-induced vascular ischemia of the muscular wall 9-11 . The risk of developing bladder dysfunction is related to both the radiation dose and the percentage of the bladder wall irradiated 9, 12 . In data compiled in adults, it is clear that a small volume of the bladder can tolerate fairly high does of radiation 9, 12 , (Radiation for prostate or bladder cancer in adults routinely results in irradiation of portions of the bladder with 60-70 Gy.) However, high doses may cause focal injury to part of the bladder wall, resulting in bleeding and stone formation 13-17 . It is believed that stone formation is associated with bac-teruria, which can occur after damage to the bladder. When the entire bladder is irradiated, doses of 50 Gy may result in severe contraction and secondary whole organ...

Full Thickness Burns Third Degree

Full-thickness burns appear dry, white, or charred and inelastic. They are painless and avascular, and thrombosed vessels may be visible. A dry eschar covers the burn and may cause constriction of underlying structures. Healing occurs only from the edges by epithelial migration with scarring and contracture.15

Models of Human Development

Although this example takes a stage-like view of human development, another tradition looks to the work of Vygotsky and his followers, seeing development more as a process of internalization from social situations that scaffold for the thinking of the participant (1978). In addition to its Pi-agetian emphasis, the work of Adey and Shayer draws upon social scaffolding. Scar-damalia and colleagues developed an initiative initially called CSILE (Computer Supported Intentional Learning Environments) and now Knowledge Forum, that engages students in the collaborative construction of knowledge through an online environment that permits building complex knowledge structures and labels for many important epistemic elements such as hypotheses and evidence (Scardamalia, et al., 1989). The social character of the enterprise and the forms of discourse it externalizes through the online environment create conditions for Vygotskian internalization of patterns of thinking. Studies of impact have...

Photosensitivity dermatoses

Pityriasis Rubra Pilaris Face Treatment

This deficiency leads to pellagra, but other vitamins of the B group are contributory. The skin lesions are a prominent part of pellagra and include redness of the exposed areas of hands, face, neck, and feet, which can go on to a fissured, scaling, infected dermatitis. Local trauma may spread the disease to other areas of the body. The disease is worse in the summer and heals with hyperpigmentation and mild scarring. Gastrointestinal and neurologic complications are serious. Dementia, dermatitis, and diarrhea are the three Ds of pellagra.

Microscopic Features Histological Patterns and Cytological Variants Ultrastructure and Special Techniques

Brown Atrophy The Liver

The commonest architectural pattern is the plate-like or, as seen in two-dimensional histological sections, trabecular. Tumour cells grow in cords that vary in thickness from two to three to many cells. These are separated by sinusoids lined by flat endothelial cells. Kupffer cells are absent or reduced in number. Collagen fibres are increased in Disse's space surrounding the sinusoids and a basement membrane forms, i.e. they become 'capillarized'. The pseudoglandular pattern may result from dilatation of bile canaliculi or from central breakdown of cells in otherwise solid trabecula the contents are bile or proteinaceous fluid. Compact, solid or scirrhous patterns are rare and develop from compression, scarring and chemo-radiotherapy. The term 'sclerosing hepatic carcinoma' has been applied to tumours associated with hypercalcaemia. The gross appearance of intrahepatic tumours is of a grey-white, tough, scirrhous type of growth which is often solitary but may be multinodular, or a...

Indications and Contraindications for Palatal Advancement Pharyngoplasty

Partial or complete cleft palate Large torus palatinus (requires removal first) Maxillary advancement surgery (relative) Impaired palatal blood flow such as with radiation therapy or severe palatal scarring Impaired swallow Velopharyngeal insufficiency Obligate mouth breather (may worsen oral ventilation)

Posterior Glottic Stenosis

Tracheostomy Thyroid Cartilage

A posterior glottic stenosis is a band of scar tissue between the two arytenoids involving the mucosa and extending into the arytenoid muscle, preventing the vocal cords from abducting normally. It is often difficult to diagnose a posterior glottic stenosis with a mirror or a fiber-optic endoscope. One can be suspicious when the cords move briskly but not widely, as if tethered on a short cord. Usually, on direct laryngoscopy, when the cords are parted with the anterior tip of the laryngoscope, the stenosis can be readily seen as a thickened linear band of tissue between the arytenoids (Figure 35-3A). Laser division of this band is occasionally helpful, but usually open surgery is necessary. If a tracheostomy is not already present, one must be done. A laryngofissure is then performed through a horizontal incision over the midportion of the thyroid cartilage. The dissection is carried down to the strap muscles, which are separated in the midline. The perichondrium is incised in the...

Wound Bed Preparation

The medical wound management community on the other hand has been concentrating its care of wounds around a variety of topical modalities for the treatment of chronic wounds. Debridement can also be accomplished with topical therapies (17). Options include mechanical, autolytic, enzymatic, and biologic treatments. Each of these has its advantages and its role, but all of them have significant limitations. Mechanical debridement, such as wet to dry dressings, is essentially the process of ripping unhealthy tissue off of a wound. It is painful, nonspecific, and results in potentially worse postoperative scarring. Autolytic debridement capitalizes on the body's inherent ability to digest and rid itself of necrotic tissue. This process can be promoted with hydrocolloid dressings. However, it remains fairly nonspecific and uncontrolled. The potential of invasive infection is a risk. Industry has widely promoted enzymatic treatment of wound surfaces using papain urea or collagenase-based...

Resection and Reconstruction Anterior Subglottic Stenosis

Anterior Laryngeal Reconstruction

The distal line of resection of the lesion is placed below the level of stenosis, just above the first unin-volved tracheal ring or a ring that has good cartilaginous structure, even if slightly involved by inflammation or scar. This ring is bevelled backward from a high point in the anterior midline to the lower margin of that ring posteriorly on either side (see Figures 25-2A-D). The membranous wall is cut straight across. Only one ring is bevelled in this way, even though the inverted U of the superior anterior laryngeal resection line may seem to be a much sharper angle than that below. This avoids creating a floppy flap of cartilage anteriorly, which might occur if two rings were so trimmed. As a consequence, the trachea may arch forward slightly in the subsequent anastomosis. This may provide a better lumen at the anastomotic level. Initial dissection is similar to that described in the anterior approach to the trachea (see Chapter 24, Tracheal Reconstruction Anterior Approach...

Bronchial Sleeve Resection

Anastomotic stenosis after lung transplantation, sleeve resections, and bronchoplastic procedures now provide a common indication for endobronchial stenting. Anastomotic complications occur in 4 to 15 of lung transplant anastomoses.25 Anastomotic stenoses occur due to technical complications, dehis-cence with subsequent granulation and cicatricial scarring, and ischemia. Ischemia can also occur distal to the anastomosis and can cause ischemic stricture of the bronchus intermedius after right lung transplantation. Other patients may develop secondary bronchomalacia due to ischemia, airway distortion, or steroids. Most of these patients are not candidates for direct surgical reconstruction or anastomotic revision and so provide a good indication for endobronchial stenting. Anastomotic stricture after tracheal resection or bronchial sleeve resection is uncommon, occurring in approximately 5 of primary airway resections.3,26 Many of these patients may be candidates for reoperative...

Enteroenterostomy Stapled

Staples Tia Bowel Anastomosis Technique

A, When an ileostomy is a planned or potential portion of a procedure, preoperative preparation should include siting of the ileostomy. The patient should be examined in both the standing and sitting positions. The ileostomy should be placed in the right lower abdomen at the lateral border of the rectus sheath. The site should be marked preoperatively, with care taken not to place it near skin creases, previous incisions or scars, or areas of cutaneous disease. Improper positioning of the ileostomy site will result in poor appliance fit, discomfort, and leakage of intestinal contents. When an ileostomy is planned, a midline incision is preferable. B, An appropriately sized circular skin incision is made. In obese patients, excision of the underlying subcutaneous tissues is often useful in creating the ileostomy tract. The dissection should continue to the level of the anterior rectus sheath. C, An incision is created in the anterior rectus sheath. D, The rectus...

Congenital and Pediatric Lesions

Cantrell and Guild classified congenital tracheal stenosis in 1964 and reported a case of resection of what later was termed a bridge bronchus, with side-to-side anastomosis.283 Tracheal resection and primary anastomosis in children were explored by Carcassonne and colleagues in 1973, Mansfield in 1980, Nakayama and colleagues in 1982, and Grillo and Zannini, and Alstrup and Sorensen, in 19 84.284-288 Couraud and colleagues demonstrated long-term growth of anastomotic scars in 1990, particularly after resection of stenosis and anastomosis.289 Monnier and colleagues showed that single-stage laryngotracheal resection and anastomosis was also applicable in small children.167 This procedure appeared likely to largely replace cartilage graft procedures developed earlier.290 However, the length of many congenital tracheal stenoses prohibited resectional treatment.

Laryngotracheal Resection and Reconstruction

Laryngotracheal Reconstruction

A one-stage approach to subglottic stenosis characterized by cricoid involvement developed slowly. The initial work was done by otolaryngologists, but full development of the techniques was accomplished by thoracic surgeons who faced the problem of subglottic stenosis as it presented in the spectrum of post intubation tracheal stenosis. Conley removed the entire cricoid in 1953 for a chondroma, preserving the mucoperichondrium, which was held in place by a foam rubber stent.67 Great care was taken to avoid injury to the recurrent laryngeal nerves. Shaw and colleagues resected damaged or stenotic cricoids in 2 patients with anastomosis to the thyroid cartilage.27 Existing vocal cord paralysis simplified the problem in these patients. Ogura and Roper apposed the second tracheal ring to thyroid cartilage after subtotal excision of traumatically scarred and stenotic cricoid in 2 patients.94 The recurrent nerves were paralyzed, ary-tenoidectomy was done, and a stent was used...

Repair of Subglottic Laryngotracheal Stenosis

Single stage methods of repair (see Chapter 25, Laryngotracheal Reconstruction ) involve resection of the anterior cricoid arch and stenotic scar anterior to the posterior cricoid plate, with preservation of the posterior plate and perichondrium to protect the recurrent nerves, tailoring the distal trachea to reconstruct the subglottic airway and to resurface the posterior cricoid plate. Developed initially for adults, these techniques have been applied successfully in children, with considerable success.83-89 Monnier and colleagues described 15 children so treated, with 14 successes.90 Three were of congenital origin and 12 resulted from intubation. Decannulation was achieved in a single procedure in 14 of the patients. Follow-up in 10 of the children from 5 to 14 years showed good laryngeal growth despite removal of the anterior cricoid.68 Couraud and colleagues noted a similar experience, also with laryngeal growth.67 More recent experience further supports this approach, which...

Structures and Spaces

Lamella The Cribriform Plate

Cea and ends in an axial plane along the lateral nasal wall towards the choanna. This three-planar pattern of attachment is of paramount importance for the stability of the middle turbinate. This is most obvious after endoscopic surgical procedures, since surgical fracture of any of these planar attachments increases the likelihood of turbinate lateralization and secondary ostiomeatal complex postsurgical scarring and obstruction. In addition, the basal lamella of the middle turbinate represents the anatomic, embryo-logic and functional boundary between the anterior and posterior ethmoid sinuses. Any sinus spaces anterior to the basal lamella of the middle turbinate will drain towards the ostiomeatal complex, while any sinus spaces posterior to this structure will drain towards the sphenoethmoid recess.

Closure of Persistent Tracheal Stoma

Tracheostomy Stoma

A sufficiently generous circular incision is made around the stoma to define the skin, which will be preserved and used for closure (Figure 22-4A). The circular incision is encompassed by a horizontal tapered ellipse and the cutaneous triangles on either side are excised. This will provide linear closure. The upper and lower skin flaps with platysma attached are elevated a few centimeters over the midline scar and trachea and over strap muscles laterally. The edge of the circle of skin is dissected up from its margins toward the center, taking care to leave an adequate breadth of circumferential attachment to the trachea (Figures 22-4B,C) where the parasitic blood supply of the flap originates. Excessive skin may be trimmed from the margin of the circular flap. The flap is inverted on itself using a subcuticular suture of absorbable material such as 4-0 Dexon (Figure 22-4D). The stoma is thus sealed with full thickness skin, with an epithelial surface presenting inside the lumen of...

Subglottic Stenosis

Halloween Pumpkin Stencils

Under adequate exposure, three to four radial incisions are made through the scar tissue without causing a circumferential defect, since this is likely to induce rescarring. Care is taken to use short pulses of energy exposure of less than 1 sec usually 0.2 to 0.5 sec to avoid transmission of heat, which could result in further scarring. Islands of mucosa are preserved to assist with reepithelialization. The treated area experiences a race between scar formation and reepithelialization. The incised scar is further stretched or dilated with the use of sequential sizes of ventilating bronchoscopes, used in a corkscrew fashion as atraumatically as possible, until reaching an 8.5 mm ventilating bronchoscope. The CO2 microspot delivery system is preferred, due to the precise cutting nature of the focused beam, rather than a waveguide delivery system, which is nonfocused and subsequently less precise. The CO2 laser is preferred to the YAG and other lasers, due to both its superior precision...

Anticipate a Long Difficult Case and the Need for Other Specialists

Figure 40-3 Schematic showing injection of saline into the scar between rectum-rectal stump and posterior vagina, which may be fused inseparably. A 1- to 2-mm-thick septum can be made into a 7- to 10-mm septum, allowing some cushion against inadvertent rectal or vaginal injury. Internal iliac vein The internal iliac vein is injured if tearing or shearing of branches from the main trunk occurs. Also, in the irradiated pelvis, vascular structures may be covered by such dense indurated and adherent scar tissue that exploratory incisions may lacerate the internal or external iliac veins.

Laryngeal Problems Following Intubation

Tracheal Stint

Nearly two-thirds of adult patients with erosive lesions healed by primary epithelization within a month. In a third of the patients, a granuloma formed during healing, located largely on the medial side of the arytenoid cartilages. In many cases, the granuloma regressed spontaneously in 1 to 10 months, with a median of 60 days. The symptoms of a granuloma are irritative cough, hoarseness, and transient sensations of suffocation. Granuloma also occurs on the anterior portion of the vocal cord. In his study, Lindholm found two children who formed fibrous scars with circumferential stenosis at the level of the cricoid and a third with a posterior commissural scar bridging the interarytenoid space. Localization of damage is likely related to the curve of the endotracheal tube. When a relatively straight or slightly arched endotracheal tube is reshaped by the patient's airway, considerable force is exerted posteriorly against the medial sides of the arytenoid cartilages and the posterior...

Abridged Dictionaryindex

Pustular Bacterid

A chronic inflammatory disorder in adults on the scalp, the forehead, the nose and the cheeks, and rarely the trunk, characterized by the presence of papulopustular lesions that heal within a few days, leaving a smallpox-like scar. Recurrent outbreaks can continue for months and years. Aplasia cutis congenita. Rare condition showing absence of skin at the time of birth. It presents with ulcerations, especially on the scalp that heal with scars.

Complications of penile prosthetic surgery and their management

Erectile Radiology

In the face of infection the surgeon has two options. The first is to remove the prosthesis and reinsert it at least three months or more later. If this option is chosen, the penis will be noticeably shorter and the reinsertion procedure more difficult because of the scar tissue that forms during that interval. The second option is to use a salvage procedure, which entails removing the prosthesis and all foreign materials, cleaning the wound with a series of antiseptic solutions and reinserting a new prosthesis at the same operation. Mulcahy 32 reported a success rate of 85 with the salvage procedure. There are several circumstances in which salvage should not be considered. These include prosthesis infections in patients with diabetic ketoacidosis, life-threatening sepsis, and frank tissue necrosis or urethral erosion of the cylinders in the fossa navicularis. If one excludes these conditions, a salvage approach is a reasonable procedure. According to a technique first described by...

Types Of Jejunostomy Sabiston Book

Types Jejunostomy

A, Strictureplasty is a useful adjunctive technique for treating segments of small bowel narrowing as a result of chronic inflammation. Stricturoplasty is most commonly employed in the treatment of patients with Crohn's disease. When chronic scarring has caused obstruction secondary to a short-segment stricture, a stricturoplasty analogous to a Heineke-Mikulicz pyloroplasty may be used. Sutures are placed, and a longitudinal incision is made through the full thickness of the bowel wall. B, Tension on traction sutures converts the longitudinal incision into a transverse opening. The stricturoplasty is closed in a single layer using interrupted nonabsorbable seromuscular sutures (see inset). C, If the stricture is longer than 1 to 2 cm in length, a stricturoplasty analogous to a Finney pyloroplasty may be used. Seromuscular sutures approximating the bowel wall in the area of the stricture are placed. An incision traversing the stricture (dashed line) is...

Kathyjo A Jackson phd and Margaret A Goodell phd

Cellular-based therapies may be a future strategy for treatment of cardiac injury. Full differentiation of the heart leaves an organ without a stem cell population to respond to injury. This can be addressed by providing cardiomyocyte precursors from embryonic or adult stem cells. The coronary vasculature derives from both vasculogenesis from the putative hemangioblast and angiogenesis by sprouting from newly formed vessels from the proepicardium, which is formed from villi-like protrusions of the fetal liver. Interruption of the vascular supply leads to infarction of myocardium and death of myocardiocytes. Normally there is little or no regeneration of this tissue, which heals by the process of inflammation and scarring. Although some myocardiocytes may proliferate after injury, these represent

Extended Submandibular Approaches To The Inferior Border Of The Mandible

Rapper Coloring Pages Printable

Should more exposure of the mandible become necessary, the surgeon has several choices. For increased ipsilateral exposure, the submandibular incision can be extended posteriorly toward the mastoid region, and anteriorly in an arcing manner toward the submental region (Fig. 9-12). Once the incision leaves the direction of the resting skin tension lines, however, the resultant scar will be more obvious. To eliminate some of the undesirable scarring that may accompany the change in direction of the incision toward the submental area, one can step the anterior portion of the incision (Fig. 913) (3). Surgical splitting of the lower lip is another maneuver occasionally used in combination with incisions in the submandibular area to increase exposure to one side of the mandible. It is possible to divide the lower lip in several ways. Each method uses the principle of breaking up the incision line to minimize scar contracture during healing (Figs. 9-14 and 9-15).

Stages of Recovery from Acute Myocardial Infarction

Replacement of Dead Muscle by Scar Tissue. In the lower part of Figure 21-8, the various stages of recovery after a large myocardial infarction are shown. Shortly after the occlusion, the muscle fibers in the center of the ischemic area die. Then, during the ensuing days, this area of dead fibers becomes bigger because many of the marginal fibers finally succumb to the prolonged ischemia. At the same time, because of enlargement of collateral arterial channels supplying the outer rim of the infarcted area, much of the nonfunctional muscle recovers. After a few days to three weeks, most of the nonfunctional muscle becomes functional again or dies one or the other. In the meantime, fibrous tissue begins developing among the dead fibers because ischemia can stimulate growth of fibroblasts and promote development of greater than normal quantities of fibrous tissue. Therefore, the dead muscle tissue is gradually replaced by fibrous tissue. Then, because it is a general property of fibrous...

Postoperative Management

Wht Ileocolosotomy

Figure 9-21 The Penrose drain is tightened by placing sutures into the drain snugly around the base of the muscle this cuts through the muscle in 2 to 3 weeks, leaving a narrow scar. (From Surgery in Crohn's disease. In Anagnostides, A. A., Hodgson, H.J.F., and Kirsner, J.B. eds.J Inflammatory Bowel Disease. London, Chapman and Hall, 1991. Copyright Mayo Foundation.)

And Antrostomy Nasoantral Window

Of the maxillary sinus respiratory epithelium. During the procedure all the lining mucosa of the maxillary sinus is removed and will be replaced by a rind of scar tissue covered by cuboidal nonciliated epithelium as the sinus heals. Because there is no longer any active transport of mucous within the sinus, drainage must be created inferiorly through the inferior meatus. Since the floor of the maxillary sinus is lower than the floor of the nose, gravity does not serve entirely to drain the sinus. After a Caldwell-Luc procedure, plain films (Caldwell views) of the maxillary sinus will forever be abnormal with some degree of opacification. In recent times, it has been felt that creating aeration of the maxillary sinus via the natural ostium will allow for healing of the damaged mucosa of chronic sinusitis and reestablishment of the natural drainage system. Theoretically, respiratory epithelium within the sinus will regenerate. There may still, however, be a role for this operation in...

Strategies Using Cell Therapy to Induce Cardiomyocyte Regeneration in Adults with Heart Disease

Congestive heart failure remains a major public health problem and is frequently the end result of cardiomyocyte apoptosis and fibrous replacement after myocardial infarction (MI), a process referred to as left ventricular remodeling. Cardiomyocytes undergo terminal differentiation soon after birth and are generally considered to withdraw irreversibly from the cell cycle. In response to ischemic insult, adult cardiomyocytes undergo cellular hypertrophy, nuclear ploidy, and a high degree of apoptosis. A small number of human cardiomyocytes retain the capacity to proliferate and regenerate in response to ischemic injury. However, whether these cells are derived from a resident pool of cardiomyocyte stem cells or from a renewable source of circulating bone marrow-derived stem cells that home to the damaged myocardium is at present not known. Replacement and regeneration of functional cardiac muscle after an ischemic insult to the heart could be achieved either by stimulating...

Miscellaneous disorders affecting the hair

This problem is usually seen in the beard area of African American men. Close shaving in people with kinky or curly hair may cause the newly emerging hair shaft to grow back into the skin surface or pierce the follicular wall causing inflammation and a foreign body reaction. Clinically, it presents as papulopustules, which may lead to hyperpigmentation and scarring. Hair plucking and electrolysis can induce this same problem.

Obstructive Lesions of the Trachea

Granulation Tissue Tracheostomy

Lage, or by turning a flap, some scarring is inevitable during healing. Long after healing is complete, inspection, both bronchoscopically and radiologically, will demonstrate dimpling or deformity, an anterior shelflike projection, or softness of the anterior wall at the site of prior tracheostomy. A surprising degree of asymptomatic narrowing may occur. Nearly 50 narrowing of the cross-sectional area of the trachea, or even more, is necessary before a sedentary person experiences dyspnea. Three stomal lesions, seen alone or in combination, may cause obstruction. These are 1) granuloma, 2) a posteriorly depressed flap of tracheal wall above the stoma, and 3) anterolateral stenosis. The most common lesion of significance at the stomal level is anterolateral stenosis. Following removal of the tracheostomy tube, the patient gradually develops obstructive symptoms. The patient is found bronchoscopically to have an A-shaped stricture with an apex anteriorly, which involves the...

Transoral Approaches To The Facial Skeleton

The midfacial and mandibular skeleton can be readily exposed through incisions placed inside the oral cavity. The approaches are rapid and safe and the exposure is excellent. The greatest advantage of such approaches is the hidden scar. This section includes descriptions of maxillary and mandibular vestibular approaches to the facial skeleton. The midfacial and mandibular skeleton can be readily exposed through incisions placed inside the oral cavity. The approaches are rapid and safe and the exposure is excellent. The greatest advantage of such approaches is the hidden scar. This section includes descriptions of maxillary and mandibular vestibular approaches to the facial skeleton.

Subacute Radiation Pneumonitis

Radiologic changes consistent with fibrosis are seen in most patients who have received lung irradiation, even if they do not develop acute pneumonitis (Fig. 11.2). Chest radiographs have linear streaking, radiating from the area of previous pneumonitis, and sometimes extending outside the irradiated region, with concomitant regional contraction, pleural thickening and tenting of the diaphragm. The hilum or mediastinum may be retracted with a densely contracted lung segment, resulting in compensatory hyperinflation of the adjacent or contralateral lung tissue. This is usually seen 12 months to two years after radiation. When chronic fibrosis occurs in the absence of an earlier clinically evident pneumonitic phase 99,113,127 , chest radiography generally reveals scarring that corresponds to the shape of the radiation portal. Eventually, dense fibrosis can devel

Effect Of Spirulina On Fatty Liver

A fatty liver that was caused by excessive alcohol intake may result in liver inflammation (alcoholic hepatitis) and scarring (alcoholic cirrhosis), causing alcoholic liver disease. The development of an enflamed fatty liver in the absence of pregnancy and alcoholism is referred to as nonalcoholic steatohepatitis (NASH). The term nonalcoholic fatty liver disease (NAFLD) refers to fatty liver, NASH, and cirrhosis. Although NASH may occur in all ages and both genders, it is commonly found in middle-aged (40-60 year-old) women, many of whom are obese, or may have type 2 diabetes mellitus (insulin resistance) or hyperlipidemia.90 People who are neither overweight nor have diabetes mellitus or hyperlipidemia have been recently reported as suffering from NASH.91

Type III Endonasal Median Drainage

Howarth Lynch Operation

The principal difference between the endonasal median frontal sinus drainage and the classic fron-toorbital external Jansen 13 , Lothrop 16 , Ritter 23 , Lynch 17 and Howarth 12 operation is that the bony borders around the frontal sinus drainage are preserved. This makes it more stable in the long term and reduces the likelihood of reclosure by scarring 2 , which may lead to recurrent frontal sinusitis or a mucocele, not to mention the avoidance of external scar.

Suprasternal Region Part Incision

Mediastinal Tracheostomy

In anterior approaches, either cervical or cervicomediastinal laryngeal release, if necessary, may be performed best through a short transverse incision over the hyoid bone (Figure 23-4). The long U-shaped flaps favored by many otolaryngologists add nothing to the exposure and leave an unsightly scar, compared with two transverse ladder incisions. In a short-necked, older individual, with the larynx fixed at the suprasternal notch even despite cervical extension, a single collar incision carried a little further laterally on both sides may be elevated to provide access to the hyoid region for laryngeal release. The possibility of a high incision over the hyoid bone must be recalled when the field is draped.

Squamous Cell Carcinoma

As in basal cell carcinomas, many factors contribute to provide the soil for growth of a squamous cell carcinoma. A simple listing of factors is sufficient hereditarily determined type of skin age of patient (elderly) trauma from chemicals (tars, oils), heat, wind, sunlight, x-radiation, PUVA therapy (psoralen plus long wave ultraviolet light), and severe burns skin diseases that form scars, such as discoid lupus erythematosus, lupus vulgaris, and chronic ulcers ingestion of inorganic arsenic and in the natural course of xeroderma pigmentosum. Immunosuppressed patients, such as organ-transplant patients and patients with the acquired immunodeficiency syndrome, have an increased incidence of basal cell and squamous cell carcinoma.

Expiratory Collapse with Chronic Obstructive Pulmonary Disease

I early abandoned using strips of fascia lata as a material for splints, since an additional incision was required. Pericardium was used only briefly, for it seemed to attenuate with time. Goretex failed because it could not become firmly incorporated into the tracheal wall by ingrowth of scar tissue. Obstruction recurred in some. Numerous splinting materials have been used by others, including perforated solid plastic strips, lyophilized bone, and absorbable synthetic mesh. I found Marlex (monofilament knitted polypropylene mesh Davol Inc., Cranston, RI) to be very satisfactory. It is easily sutured into place and holds sutures well. Tissue ingrowth into its interstices fully and permanently incorporates the splint into the tracheobronchial walls, thus maintaining the restored curvature of the cartilages and preventing fluid from accumulating between the membranous wall and prosthetic strip as occurred with Goretex. figure 32-1 Posterior splinting procedure for expiratory...

Operative considerations

Inflatable implants may be implanted either infrapubically or scrotally. There is no evidence that any one surgical approach is best 27 . The transverse scrotal approach allows excellent exposure of most of the length of the corpora cavernosa. With this approach, the crura of the corpora cavernosa may be easily exposed as far back as the ischial tuberosities. This posterior exposure may be important when there is severe scarring of this segment of the corpora. At the same time, the distal part of the corpora may be easily exposed by degloving the penis from the surgical incision 14 . A ring retractor with hooks placed at the skin edges significantly facilitates the exposure of the surgical field. This retractor should be available during these procedures. Placement of a urethral catheter may be of help in identifying the urethra. In addition, if the reservoir is placed in Retzius' space, the bladder should be emptied first to minimize the risk of...

Primary Resection and Reanastomosis Initial Experiences

Despite continued concerns about the feasible length of tracheal resection and lingering doubts about cartilaginous healing, a number of successful resections and reconstructions with primary anastomosis were described in the 1950s and early 1960s, most often for shorter, benign lesions such as stricture.66 Conley successfully resected the second and third rings for scar in 1953, with end-to-end anastomosis.67 Kay removed four rings of proximal trachea for leiomyoma, without event, in 1951.68 Sweet, in 1952, resected a cervical cylindroma with end-to-end anastomosis and questioned whether this might be possible intrathoracically.69 Macmanus and McCormick, in 1954, excised a three-ring segment for the same tumor, which lay about 2 cm above the carina, with end-to-end repair.70 An anastomotic leak was patched with fascia lata and a protective tracheostomy added. Forster and colleagues reported in 1957 and 1958 a series of three successful cervical and cervicomediastinal tracheal...

Differential Diagnosis of Epidermal and Trichilemmal Cysts

Epidermal Fungs

A patient with several cysts in the scalp can be treated in another simple way. A 3- to 4-mm incision can be made directly over and into the cyst. The cheesy, foul-smelling contents can be evacuated by pressure and the use of a small curette. The sac can then be popped out of the hole with very firm pressure, or the sac can be grasped with a small hemostat and pulled out of the opening. No suturing or only a single suture is necessary. The resulting scar will be imperceptible in a short time.

Evaluation of Cell Morphology

As previously mentioned, Papanicolaou was the first to report the presence of breast epithelial cells in NAF, and found malignant cells in 1 of 438 asymptomatic women (Papanicolaou et al., 1958). NAF was found to contain not only epithelial cells, but also foam cells, a term used to describe the foamy appearance of the cytoplasm. He speculated, It thus appears possible that under the term foam cell we are dealing with a variety of cell types that, although morphologically indistinguishable , may vary in origin. Almost 50 years later, after numerous studies using panels of epithelial and macrophage markers, the origin of foam cells remains an area of debate (King et al., 1984 Krishnamurthy et al., 2002 Mitchell et al., 2001). In the report, Papanicolaou also evaluated breast cyst fluid collected from 100 subjects and contrasted cytologic findings in NAF with those in breast cyst fluid. He noted a relative scarcity of foam cells in breast cyst fluid, which are generally the most...

Management of Tracheal Trauma

Early experiences with tracheal and bronchial laceration and rupture have been described. In 1959, Hood and Sloan listed their 18 experiences with tracheal injuries in a series of 91 tracheobronchial cases from the literature, and these were more commonly of linear lacerations.26 Shaw and colleagues, in 1961, added 9 cervical and 4 intrathoracic tracheal ruptures, recommending primary repair of acute injuries and resection of scar with accurate anastomosis for post-traumatic stenosis.27 Baumann reviewed the limited knowledge about tracheal trauma in 1960, recommending tracheal bronchoscopy in all serious thoracic trauma.262 Ogura and Powers approached traumatic stenosis of the subglottic larynx aggressively in 1964.95 Chodosh as well as Ashbaugh and Gordon and others described laryngotracheal avulsion injuries.263,264

Atrial Flutter and IART

If the typical flutter isthmus is involved in the reentry circuit, the area between the tricuspid valve (TV) and IVC is targeted for ablation (Figure 10.3). It is relatively narrow and in most patients good ablation catheter-tissue contact is achievable, although furrows and ridges may reduce tissue penetration with RF energy. Complete bidirectional conduction block across the flutter isthmus is the end point for ablation. IART may be re-entrant around a right atriotomy scar or, less usually, an ASD patch (Nakagawa et al, 2001). The majority of patients with postoperative atrial flutter and TOF have circuits involving the typical flutter isthmus (Chan et al., 2000). Other isthmuses responsible for atrial flutter in postoperative TOF relate to atriotomy scars, breaks in the crista terminalis or areas of fibrosis. Ablation in relation to these circuits is performed by joining fixed anatomical structures or areas of scar that In patients following the Mustard procedure, barriers to...

Technique of Dilation

Mustard Flutter Ablation

A stenosis, particularly when inflamed, may be divulsed by dilation. Bits of granulation tissue and torn fragments of scar that remain on the tracheal wall are removed patiently and conservatively with biopsy forceps before withdrawing the bronchoscope. I have never encountered excessive bleeding with these maneuvers. Minimal bleeding from biopsy can be easily tamponaded with the bronchoscope, and soon stops. If spontaneous ventilation has been used, it is usually unnecessary to intubate the patient following the procedure. If undue secretions Stenosis due to postintubation cuff injury responds well in the short term to dilation since the pathology consists principally of a circumferential cicatrix. In contrast, stomal stenosis is the result of contraction of an anterior defect, which pulls the tracheal walls together. The dilating bronchoscope is therefore easily passed through a stomal stenosis, but the walls of the trachea snap back together again as soon as the dilating instrument...

Circumferential Subglottic Stenosis

Laryngeal Cleft

In these more difficult cases, the stenosis is circumferential and overlies the posterior cricoid plate as well (Figure 25-3A). The mucosa is involved with inflammation and scar or it has been destroyed. Idiopathic stenoses are always circumferential, as are most postintubation stenoses from endotracheal tubes as well as those from certain miscellaneous causes such as Wegener's disease or trauma.9,14,15 Exposure, dissection, and initial tracheal division are performed exactly as described for anterolateral subglottic lesions. The anterior and lateral laryngeal division is also executed in an identical fashion. Most often, the tracheal specimen is initially resected by dividing posteriorly along the lower border of the posterior cricoid plate (see Figure 25-3A). Alternatively, the specimen remains attached posteriorly, and the final separation of the stenosis is commenced higher on the posterior cricoid plate, as described below. We are left at this point with the anterior cricoid arch...

The Challenge of Creating Cultures of Thinking

Culture has been mentioned briefly in previous sections, but one still might ask What is it about culture, and cultures of thinking in particular, that demands attention (see Greenfield, Chap. 27, for further discussions on the role of culture) Three important motives are worthy of attention First, the supporting structures of culture are needed to sustain gains and actualize intelligent behavior over time, as opposed to merely building short-term capacity (Brown & Campione, 1994 Scar-damalia et al., 1994 Tishman, Perkins, & Jay, 1993). It is through the culture of the classroom that strategies and practices take on meaning and become connected to the work of learning. Second, culture helps to shape what we attend to, care about, and focus our energies upon (Bruner, Olver, & Greenfield, 1966 Dasen, 1977 Super, 1980). Thus, culture is integrally linked to the dispositional side of thinking and to the cultivation of inclination and sensitivity. Third, researchers and program developers...

J hamstring muscle tears

Contracted Coccyx Relaxed Coccyx

In fact, fibrous scarring frequently occurs after a tear in this muscle group, which creates friction that is especially painful and incapacitating during sport activity. Furthermore, this inelastic scar tissue is liable to tear during Intense effort. To prevent the formation of fibrous scar tissue in the hamstrings, it is essential to reeducate the muscles as soon as possible. A week after a tear, you must perform gentle stretches for the back of the thighs. The goal is to stretch the injured muscles and especially to soften the scar so that It doesn't tear when you resume training. Comment A massage therapist can also treat fibrous scars by using massage or mechanical techniques aimed at softening the lesion.

Clinical Manifestations

The first noticeable late effect consists of very slowly progressing atrophy, starting in the first few months after radiotherapy. The skin also loses its elasticity. If the injury is severe, telangiectasia (a spidery pattern of small blood vessels easily visible beneath the surface) will occur. In the dermis, fibrosis develops, with contraction and scarring in the field treated. Epilation can persist and nails will become brittle. Glands will no longer function normally the involved skin will not sweat, nor produce sebaceous

Step 2 Marking the Incision and Vasoconstriction

The skin is marked before injection of a vasoconstrictor. The incision is 1,5 to 2 cm inferior to the mandible. Some surgeons prefer to parallel the inferior border of the mandible others place the incision in or parallel to a neck crease (Fig. 9-3). Incisions made parallel to the inferior border of the mandible may be unobtrusive in some patient however, extensions of this incision may be noticeable unless hidden in the submandibular shadow. A less conspicuous scar result when the incision is made in or parallel to a skin crease. It should be noted that skin creases below the mandible do not parallel the inferior border of the mandible but run obliquely, posterosuperiorly to anteroinferiorly. Thus, the further anterior the surgeon makes an incision in or parallel to a skin crease, the greater the distance to dissect to reach the inferior border of the mandible. Both incisions can be extended posteriorly to the mastoid region if necessary.

Rationale and technical considerations

Titan Piece Penile Implant

Theoretically this approach is the most direct way to improve intracorporal blood supply, but long-term results of this operation are not satisfactory, because the cavernous artery is so small that the microsurgical anastomosis between it and the IEA is prone to thrombosis. In addition, intensive intracorporal scarring often resulted from the operative procedure 1,2 . In the face of these difficulties, it became obvious that anastomoses of the IEA had to be performed to recipient vessels outside the corpora cavernosa.

Alternative Incisions

The coronal incision has been modified repeatedly by surgeons. The principal difference in these surgical techniques involves the position of the skin incision. A major modification has been placement of the incision behind the ear (Fig. 6-25) (5,6). The advantage of this positioning is further camouflage of the scar. Any inferior extension of the coronal incision can be hidden within the postauricular fold or along the hairline. Even with well-placed incisions, the scar that forms may produce a separation of the hair that can become visible when the hair is wet, such as during swimming. A modification of the incision has been the use of a zig-zag incision instead of a straight incision within the hairline (Fig. 6-26) (7). The zig-zag incision helps break up the scar and make it less noticeable, even when the hair is worn short. The major disadvantage of this incision is the increased time needed for closure. Figure 6-26 Zig-zag incision to make the scar less obvious. Figure 6-26...

Maxillary Vestibular Approach

The Maxillary vestibular approach is one of the most useful when performing any of a wide variety of procedures in the midface. It allows relatively safe access to the entire facial surface of the midfacial skeleton, from the zygomatic arch to the infraorbital rim to the frontal process of the maxilla. The greatest advantage of the approach is the hidden intraoral scar that result. The approach is also relatively rapid and simple, and complications are few. Damage to the branches of the facial nerve is nonexistent as long as one stays within the subperiosteal plane, and damage to the infraorbital nerve is unusual with proper technique.

Long Term Complications

Reinsertion of the vertebral lamina is supposed to protect against this late complication. However, such an effect has not been proven in adults and could only be demonstrated for children 234, 316, 352 . Even after reinsertion of the lamina, one important posterior anchor remains unrestored - the interspinous ligament. Furthermore, atrophy and abnormal innervation of neck and back muscles may cause muscular imbalances, which alone may be sufficient to induce spinal instability despite reinserted laminae. Furthermore, spinal deformities may above be present before surgery, as demonstrated earlier. Nevertheless, we recommend reinsertion of the laminae in all patients with miniplates after removal of the tumor, to restore the anatomy as far as possible. Avoiding fixation of the neck and back muscles to an epidural scar, one may consider a favorable effect to avoid neck and back pain related to muscular tension on the dura. Reinserted laminae also make a reoperation easier in the case of...

Periorbital Approaches

Pterygomasseteric Fascia

A standard series of incisions has been used extensively to approach the inferior and lateral orbital rims. Properly placed incisions offer excellent access with minimal morbidity and scarring. The most commonly used approaches are those made on the external surface of the lower eyelid, the conjunctival side of the lower eyelid, the skin of the lateral brow, and the skin of the lower eyelid. This section describes these four approaches. Other periorbital approaches exists and can be useful. Existing lacerations of 2 cm or larger can also be used to approach the orbit.

Mandibular Vestibular Approach

The mandibular vestibular approach if useful for a wide variety of procedures. It allows relatively safe access to the entire facial surface of the mandibular skeleton, from the condyle to the symphysis. An advantage of this approach is the ability of constantly access the dental occlusion during surgery. The greatest benefit to the patient is the hidden intraoral scar. The approach also relatively rapid and simple, although access is limited in some regions, such as the lower border of the mandible at the angle and parts of the ramus. Complications are few but include mental nerve damage and lip malposition, both of which are minimized with proper technique.

Place Incisions in the Line of Minimal Tension

Figure 1- 1 - lines of minimal tension (released skin tension lines ) are very conspicuous in the aged face. These lines of creases are good choices for incision placement because the scars resulting from the incision are imperceptible. Figure 1- 1 - lines of minimal tension (released skin tension lines ) are very conspicuous in the aged face. These lines of creases are good choices for incision placement because the scars resulting from the incision are imperceptible.

Step 2 Marking the Incision and Vascoconstriction

Temporal Fascia

The skin is marked before injection of a vasoconstrictor. The incision begins approximately 1,5 to 2 cm superior to the zygomatic arch just posterior to the anterior extent of the hairline (Fig. 11-2). The incision then curves posteriorly and inferiorly, blending into a preauricular incision in the natural crease anterior to the pinna (same position as in the preauricular approach to the temporomandibular joint, see Chap. 12). The incision continues under the lobe of the ear and approximately 3 mm onto the posterior surface of the auricle intead of in the mastoid-ear skin crease. This modification prevents a noticeable scar that occurs during contractive healing of the flap, pulling the scar into the neck. Instead, the incision is well hidden by the ear, it curves posteriorly toward the hairline and then runs along the hairline, or just inside it, for a few centimeters.

Step 1 Locating the Incision Line and Preparation

Hemicoronal Incision

The amount of skeletal exposure depends on the inferior extent of the incision, not on the anteroposterior position. In most females and nonbalding males, the incision may be curved anteriorly at the vertex, paralleling but remaining 4 to 5 cm within the hairline (Fig. 6-8). In children, the incision is preferably placed well behind the hairline to allow for migration of the scar with growth. If a hemicoronal incision is planned, the incision curves forward at the midline, ending just posterior to the hairline. Curving the hemicoronal incision anteriorly provides the relaxation necessary for retraction of the flap.

Conditions That Cause Bizarre QRS Complexes

Ventricular system, with replacement of this muscle by scar tissue, and (2) multiple small local blocks in the conduction of impulses at many points in the Purkinje system. As a result, cardiac impulse conduction becomes irregular, causing rapid shifts in voltages and axis deviations. This often causes double or even triple peaks in some of the electrocardiographic leads, such as those shown in Figure 12-14.

Lower Eyelid Approach

A pproaches through the external side of the lower eyelid offer superb exposure to the inferior - *-orbital rim, the floor of the orbit, the lateral orbit, and the inferior portion of the medial orbital rim and wall. These approaches are given many names in the literature, based primarily on the position of the skin incision in the lower eyelid (e.g., blepharoplasty, subciliary, lower lid, subtarsal, infraorbital). Because of the natural skin creases in the lower eyelid and the thinness of eyelid skin, scars become inconspicuous with time. The laxity of skin here also makes the eyelid virtually immune to keloid formation. The infraorbital incision, however, is almost noticeable to some degree.

Step 2 Identification of and Marking Incision Line

One should carefully evaluate the skin creases around the orbit. If the tissues are edematous, the skin surrounding the opposite orbit can be used to obtain an appreciation for the direction of creases. If one chooses to use a crease at the midlevel of the lower eyelid, he should note carefully the direction of the skin crease. Commonly, the crease tails off inferiorly as it extends laterally (Fig. 2-13). If access to the orbital floor and inferior orbital rim are all that is necessary, this lower lid incision is satisfactory and will result in an imperceptible scar. This incision, however, should not change direction from the original skin crease or a noticeable scar will result. The tendency is to curve the incision superiorly as it extends laterally. This should be avoided, with the incision placed in the middle of the lower lid unless a natural skin crease does the same.

Surgical Anatomy Lower Eyelid

Inferior Orbital Septum

Embedded within the tarsal plates are large sebaceous glands called the tarsal or Meibomian glands, whose ducts may be seen along the lid margin. A grayish line or a slight groove sometimes visible between the lashes and the openings of the tarsal glands represents the junction of the two fundamental portions of the eyelid, the skin and muscle on one hand and the tarsus (the plate of closely packed tarsal glands) and conjunctiva on the other. This indicates a plane along which the lid may be split into anterior and posterior portion with minimal scarring.

Step 11 Suspensory Suture for Lower Eyelid

Sutures With Minimal Scarring

One problem that may accompany any incision to gain access to the infraorbital rim and orbital floor is a vertical shortening of the lower lid after healing. This probably occurs as a result of scarring and shortening of the orbital septum. To reduce the incidence of this problem, superior support of the lower lid for several days (or until gross edema has resolved) after surgery is beneficial. The most direct method involves the use of a suture placed through the skin surface of the lower lid just inferior to the gray line that is taped to the forehead (Fig. 2-28). This lifts and supports the lower eyelids in a lengthened position, and helps dissipate lid edema. One may examine the globe and vision simply by removing the tape from the forehead and opening the eyelids. To maintain gentle upward support to the lower eyelid, it is important that the suture be taped to prevent if from slipping. To accomplish this, a three-tape technique has proven effective. The first layer of tape is...

Aetiology The Consensus Model

Since the historical record shows that venous thrombosis has defied human understanding through two centuries of thought and experimentation, we must eschew oversimplified aetiological models. Nevertheless, it is widely agreed that venous thrombi typically originate in the venous sinuses and valve pockets of the lower limb when blood movement is interrupted retarded because the 'muscle pump' of immobile patients' legs is contracting less frequently (McLachlin et al. 1960). Alternatively, some writers assert that an injured intima may itself impair circulation and cause interruption or retardation of flow. Hamby (2005), for instance, wrote 'Sometimes blood clots sic will form when blood flow merely slows down and becomes sluggish, or when the interior walls of blood vessels become damaged or roughened, though no wound has occurred. . Clots usually form when blood flow becomes sluggish, as when there is roughness or scar tissue along the interior walls of a blood vessel that slows down...

Approaches To The Facial Skeleton

Surgery of the facial skeleton, however, differs from general orthopedics surgery in several important ways. First, the primary factor in incision placement is not surgical convenience but facial esthetics. The face is plainly visible to everyone, and a conspicuous scar may create a cosmetic deformity that can be as troubling to the individual as the reason for which the surgery was performed. Cosmetic considerations are critical in light of the emphasis that Western society places on facial appearance. Thus, as we will see in this text, all of the incisions used on the face must be placed in inconspicuous areas, sometimes very distant from the underlying osseous skeleton on which the surgery is being performed. For instance, placement of incisions in the oral cavity allows superb exposure of much of the facial skeleton with a completely hidden scar. Other important factors are the age of the patient, existing unique anatomy, and patient expectations. The age of the patient is...

Removal of Hamartomas

Chest Wall Lipoma Removal

The intramedullary part of a spinal lipoma does not display a cleavage plane toward the spinal cord tissue. Therefore, attempts ofradical resection are not recommended. As the lipoma does not display proliferative potential, decompression is all that is required. This may involve a partial resection of the extramed-ullary component in some cases. Usually, we just perform a laminotomy with a duraplasty (Fig. 3.51). As lipomas may be associated with arachnoid scarring 73, 171, 281 we prefer to leave the arachnoid membrane intact if no debulking is required.

Management ofMalacic Segments

Tracheal Stenosis

A small number of patients, in whom complete resection of both lesions would have been impossible, were managed by resecting the stenosis and by external splinting the malacic segment with specially designed polypropylene rings.16 Splinting was limited to the use of one or two rings. These rings were developed originally for construction of cervical cutaneous tubes. Their use in tracheal splinting is described in more detail in Chapter 32, Surgery for Tracheomalacia, Tracheopathia Osteoplastica, Tracheal Compression, and Staged Reconstruction of the Trachea. Splinting a malacic segment of the trachea in this way may be hazardous. Care must be taken not to free up such a thin and altered segment circumferentially throughout its entire length or it is likely to necrose, as occurred in one patient. Tracheomalacia resulting from softening or loss only of cartilages differs from malacia due to what is essentially total loss of the tracheal wall and scar replacement. The latter necroses...

Postirradiation Stenosis

Tracheal Softening

Tracheal stenosis subsequent to irradiation is seen only occasionally. Our experience is therefore related anec-dotally. Following external irradiation of the larynx and upper trachea for thyroid cancer in a young child, the larynx failed to develop to proper size and, years later, subglottic and upper tracheal stenosis became evident. In a small number of adults, high-dose external irradiation for thyroid and laryngeal carcinomas resulted, decades later, in severe subglottic and upper tracheal stenoses. In 3 additional patients with mediastinal Hodgkin's disease, severe stenosis of the midtrachea appeared a decade or more after apparently successful management, primarily by irradiation in doses in the range of 4,500 cGy. None of these patients had recurrence of neoplasm. In 1 patient who was explored, massive fibrosis was found, encasing the area of tracheal stenosis, presumably residual scar from the destroyed lymphoma.

Respiratory Papillomatosis

Our experience with laryngeal papillomas has been chiefly in adult patients. These patients tend to have more sessile lesions, which are well suited for treatment with the CO2 laser using a laser painting technique (Figure 37-3 Color Plate 9 ). This technique relies on delicately ablating the papilloma 50 microns at a time, using the laser in a sweeping fashion, at longer exposure settings such as 0.5 to 1 sec at 2 to 3 W of power. Gentle suctioning and cleaning of the treated area, with a small cottonoid moistened in a 1 1,000 adrenaline solution, is performed to remove char and control bleeding after each laser sweep. As the papilloma base is approached, the laser is intermittently applied using 2 W at 0.5 sec, at 25x magnification in the operating microscope. We recommend using a micro-whistle-tip suction close to the laser site of impact to remove hot steam of vaporization, which can be injurious to the normal epithelium. Papillomas involving the anterior commissure should be...

Frontal Sinus Obliteration

Although obliteration has been touted as the gold standard and safest method to treat the injured frontal sinus, there are many disadvantages, including facial scarring, frontal bone embossment, frontal neuralgia due to surgical injury of the supraorbital and supratrochlear sensory nerves, and donor site morbidity. In addition, the loss of physiologic ventilation of the sinuses hampers the use of radiographic studies in the evaluation of sinus disease. Patients may also complain of chronic frontal headache, which presents a diagnostic dilemma owing to limitations in radiographic evaluation of the sinus. Patients undergoing osteoplastic flap with autogenous adipose tissue obliteration display partial replacement of the fat graft with soft tissue (granulation and fibrosis) in most cases, and there are no consistent MRI features to distinguish recurrent sinusitis or early mucopyocele formation from expected adipose graft remodeling 23 .

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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