Scars Holistic Treatments

Scar Solution By Sean Lowry

This training system is developed by Sean Lowry a medical researcher and also a former scar sufferer. The Scar Solution book is actually an useful treatment available online that guides users on how to get clear skin without scars fast. Sean Lowry put her skills and knowledge as a medical researcher and scientist to good use, and in the process she came up with the scar solutions discussed in her aptly-titled The Scar Solution e-book. Sean Lowry adopted a different biotech approach to removing the appearance of scars avoiding harsh chemical solutions and toxic herbs. Instead of providing for a one-size-fits-all scar solution, she researched, tested and developed detailed treatments for the different types of scars! The results are amazing: Fast results in terms of removing the appearance of large, raised and discolored scars on the skin. This is because each type of scar has different causes and requires different techniques of treatment. Anyone can easily pick up a copy of this guide and start using it immediately. Written in simple English this guide clearly explains in detail about what is required to be done to treat the scars naturally. All that is required on part of users is to follow the instructions step by step for the time period specified. Read more...

The Scar Solution Natural Scar Removal Overview


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Scars And Contracture Scars

Scarring is a normal part of tissue repair except during fetal and early neonatal life. Whenever there is damage, fibro-blasts are attracted and they multiply and align themselves before extruding collagen fibrils which mature and undergo shortening. As a result of this, a longitudinal incision often shortens over a period of months unless it is subjected to excessive strain, when it stretches. The collagen is remodelled in order to adjust the alignment of the fibrils to strains exerted on them, but it never reaches the strength of the unwounded tissue.

Keloids and hypertrophic scars

Hypertrophic scars are characteristically elevated but remain within the limits of the initial injury and regress spontaneously. Keloids extend beyond the original wound and do not regress (Fig. 7-6).13 Even though they are most prevalent in patients between 10 and 30 years of age, keloids can occur at any age. Keloids are far more common in African-Americans than in other races. The underlying mechanism of hypertrophic scar and keloid formation is excessive collagen production with concomitant decreased collagen degradation. Although keloids have been shown to have an underlying genetic basis, various other contributing factors, such as andro-gens estrogens, immunologic alterations, and others have been implicated as well.

Previous abil surgeryNo midline scars

Of midline scars, the umbilical position is usually favored for establishing pneumoperitoneum and laparoscope placement. LUS examination of the liver requires access from the right subcostal region when using a (semi-)rigid probe, introduced laterally, between the midclavicular and anterior axillary lines. A second port is needed for full examination, preferably in the left subcostal or infra-umbilical areas. For LUS of the hepatoduodenal ligament, the transducer needs to be placed longitudinally and this requires access from the subxiphoid region. Usually two ports are sufficient although a third 5 mm trocar is useful for manipulation or retraction and for taking biopsies.

VT related to regions of scar

The majority of sustained monomorphic VTs are caused by re-entry involving a region of ventricular scar. The scar is most commonly caused by an old myocardial infarction, but arrhythmogenic right ventricular dysplasia, sarcoidosis, Chagas' disease, other non-ischaemic cardiomyopathies and surgical ventricular incisions for repair of tetralogy of Fallot, other congenital heart diseases, or ventricular volume reduction surgery (Batista procedure) can also cause scar related re-entry. Dense fibrotic scar creates areas of anatomic conduction block. Secondly, fibrosis between surviving myocyte bundles decreases cell to cell coupling, and distorts the path of propagation causing slow conduction, which promotes re-entry (fig 25.2).5 These re-entry circuits often contain a narrow isthmus of abnormal conduction. Depolarisation of the small mass of tissue in the isthmus is not detectable in the body surface ECG. The QRS complex is caused by propagation of the wavefront from the exit of the...

Keloid Scars

Keloid scars represent a hyperproliferative response of connective tissue to trauma (22). Known stimuli include burns, inflammatory acne, surgery, and ear piercing. The tendency to form keloids is inherited, although a precise mode of transmission has not been defined. There is a racial predisposition, and African-American people are more susceptible. The most frequent locations are the chin, earlobe, neck, shoulders, upper back, and sternum, probably in relation to skin tension and mobility. The posterior scalp may also be involved (acne keloidalis nuchae). By definition, keloids spread beyond the area of initial trauma. Lesions are firm, thick, hyperpig-mented papules, nodules, or plaques. They have a characteristic shiny surface and may be confluent. Histological examination shows dense fibrous tissue composed of thick collagen bundles and variable inflammatory infiltrates.

Effects of Alcohol on Liver Function

In alcoholic cirrhosis there is fibrocollagenous deposition, with scarring and disruption of surrounding hepatic architecture. There is ongoing necrosis with concurrent regeneration. Alcoholic cirrhosis is classically said to be micronodular, but often a mixed pattern is present. The underlying pathological mechanisms are complex and are the subject of debate. Induction of the MEOS and oxidation of ethanol by catalase result in free radical production. Glutathione (a free radical scavenger) is reduced in alcoholics, impairing the ability to dispose of free radicals. Mitochondrial damage occurs, limiting their capacity to oxidize fatty acids. Peroxisomal oxidation of fatty acids further increases free radical production. These changes eventually result in hepatocyte necrosis, and inflammation and fibrosis ensue. Acetaldehyde also contributes by promoting collagen synthesis and fibrosis.

Alcoholic Liver Disease

Alcoholic liver disease is among the top ten causes of mortality in the US with somewhat higher mortality rates in western European countries where wine is considered a dietary staple, and is a leading cause of death in Russia. Among the three stages of alcoholic liver disease, fatty liver is related to the acute effects of alcohol on hepatic lipid metabolism and is completely reversible. By contrast, alcoholic hepatitis usually occurs after a decade or more of chronic drinking, is associated with inflammation of the liver and necrosis of liver cells, and carries about a 40 mortality risk for each hospitalization. Alcoholic cirrhosis represents irreversible scarring of the liver with loss of liver cells, and may be associated with alcoholic hepatitis. The scarring process greatly alters the circulation of blood through the liver and is associated with increased blood pressure in the portal (visceral) circulation and shunting of blood flow away from the liver and through other organs...

Pancreatitis and Pancreatic Insufficiency

Pancreatitis occurs less frequently than liver disease in chronic alcoholics, and is characterized by severe attacks of abdominal pain due to pancreatic inflammation, while pancreatic insufficiency is due to the eventual destruction of pancreatic cells that secrete digestive enzymes and insulin. This destructive process is associated with progressive scarring of the pancreas together with distortion and partial blockage of the pancreatic ducts, which promote recurrent episodes of acute inflammatory pancreatitis. Since the pancreas is the site of production of proteases and lipases for protein and lipid digestion, destruction of more than 90 of the pancreas results in significant malabsorption of these major dietary constituents, as well as diabetes secondary to reduced insulin secretion. Consequently, patients with pancreatic insufficiency exhibit severe loss of body fat and muscle protein. Since the absorption of fat-soluble vitamins is dependent upon pancreatic lipase for...

Some types of cell that are important to brain function

The ependymal cells line the inner surfaces of the ventricles and, together with the neuroglial cells, appear to be involved in the exchange of material with the surrounding cerebrospinal fluid. The microglia can be considered as the macrophage cells of the brain whose function is to remove cell debris by a process of phagocytosis following neuronal damage. There is also evidence that the macroglia are involved in localized inflammatory processes within the brain and may play an important role in the cause of neurodegenerative diseases such as Alzheimer's disease (see Chapter 14). Damage to brain tissue is associated with the proliferation of neuroglia. This is termed gliosis and is associated with an increase in the number of macroglia and microglia. Scar tissue is frequently associated with gliosis.

Some Complications During Intensive Care

Diffuse alveolar damage (DAD) is a nonspecific pathological lung reaction occurring in different situations (e.g., pneumonia, aspiration, sepsis, shock, trauma, fat embolism, burns, near-drowning see Chapter 3, Subheading 3.4. Chapter 4, Subheading 5.2. and Table 1 Chapter 5, Subheading 4.4. and Chapter 8, Subheading 12.1. 46 ). In DAD, inflammatory cell mediators damage alveolar endothelial cells and pneumocytes, resulting in an exudative phase within the first week, characterized by heavy, red edematous lungs at autopsy (45). Microscopic examination reveals precipitation of fibrin membranes (hyaline membranes) in the alveoli, mononuclear cell inflammation in the interstitium, platelet and fibrin microthrombi, and, toward the end of the first week, proliferation of type II pneumocytes. This is followed by an organizing phase during which fibroblasts proliferate in the interstitium and alveolar spaces. There is either eventual resolution or progressive scarring, leading to honeycomb...

Specific Issues That Affect Evaluation And Treatment

The question frequently arises as to how long to leave a cricothyroidotomy tube in place in the larynx. A tube left in the narrow space between the cricoid and thyroid cartilages can erode both cartilages, and a bacterial chondritis may occur. The cartilages will be destroyed and eventually scar, leading to stenosis and loss of the function of the larynx. Because cricothyroidotomy has a higher incidence of airway stenosis, a cricothyroidotomy should be converted to a tracheostomy. 4 As a rule of thumb, if the airway will be needed for more than 2 to 3 days, the cricothyroidotomy should be changed to a tracheostomy. Otherwise, the cricothyroid tube may stay in place.

Differential Diagnosis

Most clinicians still rely on a set of criteria originally formulated by Kimonis et al. 1 Table 1 shows a current list of qualifying criteria. It is worth noting that a number of other related but apparently distinct disorders are recognized. Rombo syndrome 2 is a familial disorder with vermiculate atrophoderma, milia, hypotrichosis, trichoep-itheliomas, basal cell carcinomas, and peripheral vasodi-lation with cyanosis, whereas Bazex-Dupre-Christol syndrome 3 combines major characteristics of basal cell nevus syndrome (BCNS) with follicular atrophoderma, hypotrichosis, hypohydrosis, and minor skin defects. Occasionally, acquired BCCs develop after contact with arsenic and exposure to radiation, and even burns, scars, vaccinations, or tattoos are rare contributing factors.

Fingerprinting Methods

A relatively recent development in fingerprinting fungi has been the introduction of amplified fragment length polymorphism (AFLP) analysis see Vos and Kuipper (1997) Vos et al. (1995) . In this technique, total DNA is digested with restriction enzymes, and then short artificial oligonucleotides (linkers) are ligated to the restriction enzyme sites. Specific primers are then designed that show a particular degree of specificity to the linker sequences, and large fractions of the total DNA can then be amplified as fragments. The AFLP analysis generates many bands, and electrophoresis is usually undertaken in large polyacrylamide gels, it is however, possible to undertake more restricted studies that generate fewer bands and that can be analyzed in smaller electrophoresis systems e.g., Mueller et al. (1996) . At the conclusion of RAPD and AFLP analyses PCR bands of interest can be extracted, purified, and sequenced to produce sequence characterized amplified regions (SCARs). The...

Patterns of Disease and Patterns of Culture

Yet cultural meanings are also local and contested. This aspect of culture highlights its dynamic, changing quality and gives weight to forces of change and interaction. From this perspective, culture is constantly being transformed. People within groups may be aware of group norms, but those norms themselves change over time, and people choose to reject the norms or manipulate their behavior within them. For example, human beauty standards, and their health-related consequences, change dramatically over time. The corset allowed one set of health problems (muscle atrophy, liver damage) to emerge, whereas a century later breast augmentation caused others (pain, scar tissue, implant rupture). Food preferences, time pressure, and large-scale industrial meal production combine to create a new epidemic of obesity based on fast food and sedentism.

TABLE 351 Tissue Growth Factors and Their Effects

Wound contraction and scar remodeling occur over the next several months. Contraction significantly modifies the cosmetic appearance of treated wounds. An important principle of wound repair is to take this expected contraction into account and repair lacerations with everted edges. Remodeling is such a powerful process that, at the time of suture removal, it is impossible to predict the ultimate appearance of wounds.8 During wound healing, excess fibroblastic activity can create excess tissue, developing either a hypertrophic scar or a keloid. Hypertrophic scars are excess collagen confined to the original boundaries of the wound and are more common in areas of increased tissue tension. Keloids have excess scar tissue from the wound extending beyond the original borders. Keloids are most often seen in African Americans but can occur in any dark-pigmented skin area.

Physical Examination

Several factors should be noted and documented during wound examination (Xable 35 3). Areas with excellent vascular supply and a low incidence of infection include the scalp, face, neck, and trunk. Lacerations on the extremities are at increased risk for infection, and those on the feet and hands are at greatest risk. Lacerations on the hands can damage tendons, nerves, and joints important for normal function. Lacerations over joints may penetrate into the joint capsule and are at risk for hypertrophic scar formation. Any laceration over the metacarpophalangeal joint is suspicious for a clenched-fist injury. Lacerations in the perineum have a high likelihood for contamination.

General Considerations

Open injuries of the upper extremity require the clinician to perform a thorough examination for muscle tendon and nerve function, traversing the injured site. The neurological evaluation should include an assessment of two-point discrimination to diagnose not only major nerve injuries but also sensory nerve dysfunction. The choice of coverage to a wound may be affected by possible future surgeries, such as tendon transfers, repairs, or nerve grafts. For example, if it were known that a patient would require tendon transfers to restore flexor tendon function, a skin graft would not be adequate over the volar forearm due to the resulting scarring. A fasciocutaneous flap might be optimal to allow for adequate excursion of the transferred tendons.

Etiology Pathogenesis

Alport's syndrome results from the inability to form normal type IV collagen heterotrimers. When a5 (or a3 or a4) is mutated, there is an inability to form the normal heterotrimers of the GBM. The organs involved in Alport's syndrome reflect sites where these type IV collagen chains are normally expressed and are essential for function, namely the kidney, eye, and ear. In the kidney, heterotrimers of a3, a4, and a5 type IV collagen are expressed in the GBM, whereas a(1)22 (5)26 heterotrimers are expressed in Bowman's capsule and in some tubular basement membranes (5). At birth, a (1)22 heterotrimers are normally present in the immature glomerulus in the GBM, with gradual shift to the mature expression pattern. In the normal adult a (l)22 remains expressed in the mesangium and also in Bowman's capsule. The switch to normal adult a3, a4, a5 heterotrimers in the GBM cannot occur in Alport due to mutation in one of these chains. The mechanism(s) of progressive renal scarring in Alport's...

Renal Anatomy and Basic Concepts and Methods in Renal Pathology

Sclerosis refers to increased extracellular matrix and other material leading to obliteration of capillaries and solidification of all or part of the tufts. Sclerosis (glomerular scarring) may be associated with obliteration of the urinary space by collagen along with increased extracellular matrix in the capillary tufts. When the entire glomerulus is involved, this is known as complete sclerosis an older and less precise term is glomerular hyalin-ization. Segmental glomerulosclerosis implies a completely different pathologic process and often a disease. With segmental sclerosis, only portions of the capillary tufts are involved capillaries are obliterated by increased extracellular matrix and or large precipitates of plasma protein known as insudates. Crescents represent accumulation of cells and extracellular material in the urinary space. Crescents are the result of severe capillary wall damage with disruptions in continuity and spillage of fibrin from inside the damaged...

Pathology of outofhospital death

Postmortem arteriography and serial sectioning of the coronary arteries is not carried out routinely by hospital pathologists who frequently limit the procedure, as far as the heart is concerned, to cursory section of the coronary arteries. Histological examination is not routine, and in these circumstances neither non-occlusive thrombus nor plaque fissuring are often commented upon. In the UK heart attack study (UKHAS)4 1037 (83 ) of the 1247 out-of-hospital coronary deaths which we recognised in people up to 75 years of age came to necropsy. Occlusive thrombus was recognised by hospital pathologists in 23 of cases, recent myocardial infarction in 20 , and an old myocardial scar in 56 . Stenoses of one or more coronary arteries were present in all cases.

Circulatory Abnormalities

Changes in the delivery to the tissues of a normal amount of blood containing the proper amount of electrolytes, nutrients, and oxygen at the proper pressure can result in damage. Infarction is necrosis of tissue due to interruption of the blood supply, usually due to atherosclerosis. Myocardial (heart) and pulmonary (lung) infarcts are often immediately fatal, but they may heal, often with scarring and impaired function. There is considerable paleopathologic evidence of atherosclerosis and Egyptian tomb paintings give evidence of acute myocardial infarction, but experimental studies show that the necrosis of an acute infarct is indistinguishable from postmortem autolysis and thus probably undiagnosable.

Congenital Abnormalities

HYPERTROPHIC SCARS AND KELOIDS t healing process can also occur, as evidenced by the formation of hypertrophic scars appear to occur more frequently in areas that are under increased skin tension or constant motion earlobes appear to be an exception to this rule. The major difference between these two conditions is that while hypertrophic scars tend to remain within the original tissue injury site and will eventually regress over time, keloids grow beyond the boundaries of the injured site and do not regress. Keloids and hypertrophic scars also differ histopathologically. Keloids contain abundant mucin and large, thick bundles of collagen that lie haphazardly within the dermis. They are also quite vascular. The keloid extracellular matrix is composed primarily of glycoproteins and water. In contrast, hypertrophic scars contain well-organized fibrillar collagen, contain no mucin, are less vascular, and contain abundant myofibroblasts (38). It is unclear whether the pathogenesis of...

Reconstructive Surgery

Small defects can be closed by primary suturing, especially where only the pliable scrotal skin is involved. Split thickness skin grafting is most often used and yields acceptable results, even in large defects (Hessel-feldt-Nielsen et al. 1986). Healthy skin from the legs, buttocks, and arms can be used, in a single or multiple settings. Skin defects on the penile shaft should be liberally grafted so as to prevent fibrotic scar formation with future erectile problems. In extensive defects, especially where tendons are exposed, myocutaneous vascularized flaps should be used. Medial thigh flaps, e.g., the gracilis myocutaneo-us pedicle flap, give the best results, because of their close proximity to the perineum, good mobility, and hidden donor site scars (Banks et al. 1986 Paty and Smith 1992 Kayikcioglu 2003). Other flaps using the inferior epigastric arteries can also be considered.

Endometriosis and your fallopian tubes

Scarred Fallopian

Endometriosis can implant on the outside surface of the fallopian tubes and cause scarring. Just like burn scars can lead to contractures that distort limbs and other body parts, the endometriosis scarring can distort the fallopian tubes so they can't function properly. Endometrial implants can totally block the fallopian tube by forming scar tissue that destroys the fimbriae and sticks these tiny fingers together. As these delicate fingers become distorted and stuck, the end of the tube can close off, literally, keeping sperm and egg separated. When endometriosis develops on the surface of the ovary by retrograde menstruation or metaplasia, the inflammatory process begins and leads to adhesions (scar tissue). As a result, the ovary can become stuck to the tube, uterus, intestines, or pelvic wall. These adhesions (check out Figure 3-3) can cause pain and problems with the intestines and they can cause infertility. Another severe problem is endometrioma (cysts) inside the ovary. These...

Repair of Forehead Lacerations

The deep layers may be approximated in a similar fashion to the scalp. In this area, unrepaired muscle layers are more likely to produce noticeable scars, especially when the facial muscles of expression are involved. The superficial layers may be closed with 6-0 nonabsorbable interrupted suture (nylon, coated nylon, or polypropylene) or tissue adhesive. For deep wound under tension, a buried 5-0 intradermal, absorbable monofilament (e.g., Monocryl) or multifilament (e.g., Dexon or Vicryl) can be used. The epidermal layer can be closed with 6-0 nonabsorbable nylon in a simple, interrupted fashion with wound closure strips e.g., Steri-strips (3M Company) or Dermaseal (Personna Medical) over tincture of benzoin or with tissue adhesive.1 l6 These alternate methods of closure are especially attractive if the patient is at risk to develop keloids or hypertrophic scars (e.g., people with darkly pigmented skin). Care should be taken in the forehead to approximate the skin tension lines and...

Skin Surface Analysis

Microanatomy The Epidermis

Skin surface analysis is often tailored to the goals of restorative surgery or nonsur-gical treatments. Patients undergoing scar revisions require analyses to include the resting skin tension lines. In the patient undergoing nasal reconstructive surgery after Mohs' resection, an analysis of the topographical units of the face is important. If cutaneous resurfacing is planned, an analysis of skin type and reaction to solar damage are also needed. Koebner's phenomenon is also an important consideration. This phenomenon describes the tendency for some skin diseases such as psoriasis, lichen planus, discoid lupus erythematosus, and herpes simplex to localize to areas of recent surgery or scars.

Clinical Features

A change in the character of the patient's typical pain may herald a complication. Abrupt onset of severe or generalized pain may indicate perforation with spillage of gastric or duodenal contents and resulting peritonitis. Rapid onset of mid-back pain may be due to posterior penetration into the pancreas, with the development of pancreatitis. Nausea and vomiting may indicate gastric outlet obstruction from scarring or edema. Vomiting bright red blood or coffee-ground emesis, or passing tarry or melanotic stool or hematochezia indicates ulcer bleeding.

General features of CAH

The general features include symptoms of hepatitis, including nausea, anorexia, jaundice, hepato-splenomegaly, and biochemical evidence of liver parenchymal damage, in particular high levels of transminase enzymes in serum. The biopsy of the liver may show either of two histological lesions, named as chronic persistent hepatitis which is indolent and nondestructive, or chronic active hepatitis in which the main morphological feature is the disruption of the peripheral limiting plate of the liver lobule, with a periportal 'spillover' of the inflammatory exudate into the liver parenchyma 'piecemeal necrosis' (Figure 1). This lesion generates scarring and eventually macronodular cirrhosis (Figure 2). Hepatocellular carcinoma is a frequent late sequel in CAH due to chronic virus infection but is seldom seen in autoimmune hepatitis. There are features unique to each of the individual categories, as indicated below. Figure 2 Liver from a female aged 45 years with autoimmune hepatitis,...

Endometriosis and your pelvic cavity

Male Reproductive System

Endometriosis that implants on the peritoneum in the pelvic cavity (see Figure 3-5) can cause severe inflammation that leads to adhesions or scar tissue. These adhesions can then cause all these organs and tissues the uterus, ovaries, tubes, intestines, and bladder to stick to each other so they don't move in the usual manner. This restriction of movement and the inflammation due to endometriosis cause the pain or discomfort. In addition, these same adhesions can make the intestines, bladder, and reproductive organs malfunction. Endometrial implants in the pelvic cavity can result in scar tissue, which binds organs and tissue together. When the tissues and organs stick together, movement (such as occurs during sexual intercourse) results in pain. The eventual result may be a frozen pelvis, which is as bad as it sounds. S Scar tissue causes pain when structures stick together in unnatural ways. (Chapter 13 shows you how you can manage the physical pain associated with endometriosis in...

Just when everythings looking great nothing happens

The scarring and adhesions on and around the ovary can make it impossible for the egg to get out of its follicle, as if it's encased in concrete. Surgery to clear these adhesions and scar tissue may help in these cases. IVF, which removes the egg from the follicle with a needle, may also be successful.

In Situ Molecular Tools For Biocontrol Strains

As the biological strains of Trichoderma are difficult to distinguish from the indigenous strains of Trichoderma found in the field, Hermosa et al. (2001) developed a method to monitor these strains when applied to natural pathosystems. To this end they used random amplified polymorphic DNA (RAPD) markers to estimate genetic variation among sixteen strains of the species T. asperellum, T. atroviride, T. harzianum, T. inhamatum, and T. longibrachiatum. Analysis of the respective RAPD products generated were used to design specific primers. Diagnostic PCR performed using these primers specifically identified one of their strains (T. atroviride 11), and clearly distinguished this strain from other closely related Tricho-derma isolates, showing that SCAR (sequence-characterised amplified region) markers can be successfully used for identification purposes.

Adhesions tangle your fallopian tubes

A body's inflammatory response to endometrial implants can cause adhesions, or scar tissue, that really snarl up your fallopian tubes. Common sites for paratubal (around the tube) adhesions to form and, as a result, interfere with fertilization or egg embryo transport are

Criticisms Of Cognitive Vulnerability Research

Cognitive vulnerability research can be considered to play an important role in providing empirical support of the theoretical underpinnings of CBT, but it is important for cognitive vulnerability researchers to show the relevance of their research to cognitive assessment and treatment outcome evaluation in clinical practice. Demonstrating that CBT decreases patients' scores on cognitive vulnerabilities to depression, and that posttreatment on cognitive vulnerabilities are predictive of risk of relapse can go far in this direction. A past criticism of studies testing the cognitive vulnerability hypothesis is that the findings may be supportive of the alternative hypothesis that negative cognitive styles are a consequence or scar left by the past episodes of psychological problems rather than the hypothesis that negative cognitive styles provide vulnerability to depression. This criticism is now addressed by the CVD project and other prospective studies.

Introduction food safety and quality

Believe to stand for quality has become more closely aligned to the supermarkets' own definitions of quality, of which food safety is a part. Consequently, as greater numbers of consumers shop in supermarkets, suppliers are forced to adjust their own understanding of quality in line with that of supermarkets if they are to stay in business. At one time variation in the size and shape of a given fruit or vegetable, or the presence of a scar or blemish, did not denote poor quality. The apples placed in a bag by a greengrocer were all allowed to be a little different. Potatoes, carrots and parsnips came in different sizes and with residues of earth that indicated their origins as products of the land. In the modern consumer food marketplace the supermarkets have taken control of the education of consumers in matters of food. Now fruit and vegetables of the same kind have to appear all the same size, colour and shape, and with no obvious defects, if consumer expectations are to be met and...

Placenta Percreta Involving Urinary Bladder

The incidence of placenta accreta is estimated from one in 540 to one in 93,000 deliveries (Smith and Ferrara 1992). Placenta percreta is a variant of placenta accreta in which chorionic villi penetrate the entire thickness of the myometrium and may involve adjacent structures. Placenta percreta involving the bladder is extremely rare (less than 60 published cases) (Washecka and Behling 2002) and is encouraged by uterine scars and cesarean section.

Coronary revascularisation in heart failure patients

*For all patients with viable myocardium the three year mortality rate was 8 (80 had CABG). For patients with only fixed scar > 23 mortality rate was 50 (p 0.018). Only 40 had CABG with no difference in mortality with or without CABG. EF, ejection fraction. High risk coronary bypass is the most frequent conventional operation in heart failure patients. Incomplete myocardial infarction leaves viable but ischaemic myocardium within involved segments (flow metabolism mismatch). Hibernating myocardium is an unstable substrate for postinfarction dysrhythmic events and mortality, independent of age or LVEF (event rate 43 v 8 for scar).5 Hibernating myocardium will recover contractile performance with reduced risk of dysrhythmia after coronary revascularisation, but for global improvement in left ventricular function, sufficient reversibly ischaemic territory must be present. DiVerentiation between reversible ischaemia and infarction is made on clinical grounds (angina which responds to...

Clinical Description

Major diagnostic criteria for classic EDS are skin hyperextensibility, widened atrophic scarring, and joint hypermobility. Skin hyperextensibility should be tested at a neutral site, meaning a site not subjected to mechanical forces or scarring, such as the volar surface of the forearm. It is measured by pulling up the skin until resistance is felt. The skin is hyperelastic, which means that it extends easily and snaps back after release. Widened atrophic scarring is a manifestation of tissue fragility and occurs mainly over the knees, elbows, shins, forehead, and chin. It is characterized by splitting of the skin following relatively mild trauma, and formation of ''cigarette-paper scars,'' which are wide and thin scars, often with pigment deposition. Joint hypermobility is general, affecting both large and small joints. It is usually noted when a child starts to walk. It should be assessed using the Beighton scale, 3 the most widely accepted grading system for the objective...

Complications Of Penile Prostheses

Infection is the most devastating of complications associated with penile prostheses and nearly always results in removal of the prostheses, with long-term antibiotic coverage and wound drainage. Inability to clear the infection fully, as well as scar tissue formation, can limit the possibility of reimplantation of another device. Penile prostheses incite a foreign body reaction within the host. An inflammatory reaction occurs shortly after implantation and results in the formation of a scar-tissue capsule. Though this capsule helps hold the device in place, it also acts as a potentiator of infection. The surface of the prosthesis provides a site for bacterial adherence, as well as a local environment that is resistant to host defenses. The periprosthetic space created between the prostheses and the capsule acts as an ideal site for the growth of bacteria and the production of an extracellular matrix. This extracellular matrix, along with the relative avascular nature of the capsule,...

Compression Injury of the Cord

Chronic or acute narrowing of the spinal canal by more than 50 compromise of the free antero-pos-terior diameter entails the risk of compressing the cord (Scarff 1960). The acute compression caused by impact (Fig. 10.8a, b) results in an acute neurological deficit of the involved motor and or sensory axons in the cord. Chronic lesions of the cord may be caused by survival after impact-induced compression (Fig. 10.8c, d), as well as by congenital diseases of the vertebral column (achondroplasia), by neoplastic proliferation (Schwannoma, meningioma, carcinoma), by osteogenic degeneration (spondylosis, osteoporosis), by cartilaginous degeneration (protrusion of the intervertebral disc), by inflammatory diseases (spondylitis), or by iatrogenic events (myelograph- Fig. 10.8a-d. Mechanical spinal injury. a, b Acute compression injury associated with fracture of the spine, hemorrhages within the central parts of the spinal cord and softening of the compressed segment of the spinal cord c...

TABLE 791 Vomiting and Diarrhea The Gastroenteritis Mnemonic

PHYSICAL EXAMINATION Clinical clues may also assist in making the diagnosis. In addition to evaluating the ABCs, much of the physician's initial attention should be directed toward the assessment of hydration status. Severely volume-depleted patients require immediate intervention, lest circulatory collapse be imminent. The abdominal, genitourinary, and pelvic examinations are often revealing. Physicians should search carefully for tenderness, peritoneal signs, hernias, masses, and evidence of obstruction or torsion. The findings of a careful physical examination may point toward unsuspected causes of vomiting, such as bulimia (scars on the dorsum of hands), pneumonia (consolidative findings on lung examination), or Addison's disease (hyperpigmentation). The rectal examination is important. An anal fistula may be the only clue to Crohn's disease in an otherwise healthy teenager with vomiting, or may demonstrate fecal impaction.

Cancer Metastatic to the Skin

Intradermal or subcutaneous nodules of variable size that range from skin-colored to red or violaceous. Should the metastatic lesions be located on the umbilical area, they are known as Sister Mary Joseph's nodules (tumors from the GI and GU tract). Sometimes the lesions show a characteristic dermatomal or zosteriform distribution. Inflammatory metastases are red, indurated plaques resembling erysipelas. Cicatricial metastases resemble scars.

Cultural Construction of Gender

Men and women wear skirts made of skins, though nowadays most wear factory-made used clothes they receive as gifts from researchers or missionaries. Men usually wear short pants and no shirt, while women wear shukas (a small sheet) or kangas, a piece of cloth worn by women in East Africa. Women usually cover their breasts. Both sexes will often wear bead necklaces they make from organic materials, though they prefer glass beads they get in trade. They will also wear bead headbands. Both sexes have scars, small vertical or horizontal slits, on their cheeks which they get when they are around 2-3 years of age. These are done by the mother, uncle, or grandfather, as a way to mark them as Hadza. Both cut their hair very short. Females also sometimes cut off their eyelashes.

Harmful Effects of Female Circumcision or Female Genital Mutilation

The medical consequences of female genital mutilation are quite grave (El Dareer Koso-Thomas). In Africa an estimated ninety million females are affected (Hosken). Three levels of health problems are associated with the practice. Immediate problems include pain, shock, hemorrhage, acute urinary retention, urinary infection, septicemia, blood poisoning, fever, tetanus, and death. Occasionally, force is applied to position candidates for the operation, and as a result, fractures of the clavicle, humerus, or femur have occurred. Intermediate complications include pelvic infection, painful menstrual periods, painful and difficult sexual intercourse, formation of cysts and abscesses, excessive growth of scar tissue, and the development of prolapse and fistulae. A fistula is an abnormal passage a hole (opening) between the posterior urinary bladder wall and the vagina or a hole between the anterior rectal wall and the vagina. Late complications include accumulation of menstrual blood of...

Clinical Note continued

Diffuse interstitial pulmonary fibrosis is a thickening of the alveolar walls with collagen and scarring in the interstitium. As expected, fibrosis decreases the diffusing capacity (Dlco) experiments hypox-emia in patients with fibrosis at rest can be explained by Va Q heterogeneity. Uneven scarring of the lungs results in local changes in compliance and resistance (airway obstructions), leading to regional differences in time constants and ventilation (see Chapter 19). Local scarring may also affect resistance to pulmonary blood flow but not always in the same way it affects ventilation, leading to Va Q heterogeneity. Diffusion limitation for oxygen only becomes significant in patients with fibrosis during exercise.

Medical and Ethical Issues

Those who question the value of the procedure counter that the case for reductions in urinary tract infections, cancer rates, and sexually transmitted diseases is not convincing, or that many of the same benefits may be achieved through better personal hygiene (Poland Milos and Macris). While the procedure is generally safe, according to George Kaplan, there are risks of excessive bleeding, infection, removal of too much tissue, tissue damage and scarring, reactions to anesthetic agents, and retention of urine. It is also argued that the penile problems that may arise in uncircumcised males, such as phimosis or balanitis, can be prevented or effectively treated when they occur. Further, it is noted that pain-control measures are not consistently effective, carry their own risks, and are associated with some pain as well. Marilyn

Electroanatomic Mapping

Acquired, the reconstruction is updated in real time to progressively create a three dimensional chamber geometry colour encoded with activation time (fig 17.1). In addition to activation time maps, dynamic propagation maps displayed as movies of sequential activation on the computer workstation can be created. Additionally, the collected data can be displayed as voltage maps depicting the magnitude of the local peak voltage in a three dimensional model. These can be useful to define areas scarring and electrically diseased tissue. This system allows precise positioning of the catheter tip at a site of interest that was previously sampled, tagging of regions of interest, and marking positions of veins and valves.

Clinical experience

Although catheter ablation of atrial tachycardia guided by standard radiographic imaging has provided effective treatment in some populations, mapping complexity may lead to prolonged procedure and fluoroscopy time. Conventional ablation has been even more challenging in patients with congenital heart disease and previous surgery, as macro-reentrant arrhythmias arise utilising critical channels of slow conduction present within scars, or between scars and anatomic boundaries. Approaches for ablation have included identification of isolated diastolic potentials and entrainment mapping to identify critical circuit components, and creation of linear lesions between atriotomy scar and an anatomic barrier (for example, tricuspid annulus or inferior vena cava) to interrupt the re-entrant circuit. The presence of multiple re-entrant circuits, electrically silent scar zones, fractionated and small potentials, and arrhythmogenic substrate location distant from fluoroscopic landmarks has...

Aims of treatment and relevant outcomes

Treatment aims to remove or destroy the tumour completely and to minimise cosmetic and functional impairment. Success should therefore be measured by rates of recurrence or metastasis at fixed time points or survival analyses that document time to first recurrences in groups of patients. The morbidity of the procedure, as measured by short- and longer-term pain, infection, scarring, skin function and overall cosmesis should all be considered when choosing the appropriate treatment modality.28,29 In addition, the cost and tolerance to the specific treatment modalities should be considered.

Socialization of Boys and Girls

All girls and boys go through a ceremonial initiation when they are about age 6-8. Previous to this, they believe that the kachina dancers, masked dancers who impersonate the spirit beings called kachinas, are the real kachinas performing in the kivas and plazas. In this initiation into Hopi ceremonial life, they go through various rituals to impress on them the importance of their future religious duties. The most dramatic part of the initiation process for children comes when they all sit together in a kiva and the kachina dancers take off their masks, exposing themselves as the everyday men the children know. Some children already suspected this, finding it odd that a kachina had a scar or birthmark just like father's. To many, however, it is a great disillusionment, and some children become quite depressed for a time at what they feel is adult duplicity. After this initiation children begin to take a minor part in the village kachina ceremonies, and little boys can begin wearing...

Attainment of Adulthood

Ordeals of initiation allowed men to emulate the fortitude of women during childbirth, and to grow boys into adult males. Although men never attend birth, since they deem it polluting, male initiation is permeated by symbols of parturition and maternal nurture. This way, men effectively supplant the culturally lauded role of motherhood. Cicatrization purges neophytes' bodies of maternal blood, which inhibits the development of a masculine physique. But the resulting scars, which are visible emblems of manhood, are said by men to resemble the breasts and genitals of woman and female crocodile spirits. The rite forges exclusive masculine identity by aggressively exaggerating birth, maternal feeding, and moral mothering. At the same time, male initiation associates the female body with danger, pollution, castration, and somatic atrophy. Initiation thus constructs Iatmul manhood as an identity that opposes yet emulates motherhood.

Management Of Sudden Cardiac Death Risk

SCD risk may be generated by the presence of a primary disorder of cardiac electrical activity in the absence of any structural heart disease (considered here as SCD syndromes), or may be secondary to a cardiac disease process (most often myocardial in origin), which by its legacy of myocardial scarring and dysfunction creates the electrical substrate for sudden lethal arrhythmia, without premonitory symptoms. The evidence base shows that the most effective treatment for SCD prevention is to fit an implantable cardioverter-defibrillator (ICD),6-8 but the cost, morbidity, and mortality of this must be weighed against SCD risk in an otherwise (arrhythmia) asymptomatic population.

Epidemiology and Diagnosis

Physical examination is performed as a matter of routine. It should include a full cardiorespiratory assessment, neurological examination including cognitive state (specifically examining the low lumbar and sacral dermatomes and myotomes to rule out cauda equina syndrome), and examination of the abdomen, paying special attention to the kidneys and the presence or absence of a palpable urinary bladder. Examination of the external genitalia is important to ensure urethral catheterization is not going to be impossible and to identify phimosis or meatal stenosis, as well as to rule out associated infective complications such as epididymitis. If suprapubic catheterization is to be considered, then inspection of the lower abdomen to look for lower midline scars is essential (see Chap. 19, Surgical Techniques and Percutaneous Procedures).

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.

Distraction Osteogenesis

Distraction Osteogenesis Mandible

The method of distraction osteogenesis for maxillofacial application is extrapolated largely from the experiences with long bone distraction. First, division of the bone cortex (corticotomy) is required, preserving the medullary blood supply (e.g., inferior alveolar artery) and the periosteum. A latent period of up to 15 days (shorter for younger patients) is required for adequate callus formation and regeneration of central vessels and periosteal tissue. The external distraction device is connected to the underlying bones percutaneously via pins attached to a threaded bar for manual separation. Internalization of the distraction device to avoid cutaneous scarring has recently been studied (64). New bone formation occurs in -g Potential complications using distraction in the facial region include premature union, nonunion, elongated cutaneous scars, and patient intolerance of the device. Even very minor movement, other than the controlled daily distractions, can lead to fibrous...

Open Reduction with Internal Fixation

Three standard approaches are preferred anterolateral (15), direct lateral (16), and direct posterior (15). The choice of approach is predicated upon several factors, including the presence of scars from previous surgery, location of the nonunion, presence of radial nerve injury, and health status of the patient. The anterolateral and lateral approaches allow supine positioning, while the posterior approach requires the patient to be either in the lateral decubitus position or prone. The anterolateral and direct lateral approaches allow for extensile exposure of the humerus. Both permit isolation and examination of the radial nerve however, the direct lateral provides the most extensile exposure of the radial nerve proximally. The posterior approach avoids the radial nerve in the distal third of the humerus, but the nerve directly crosses the operative field in the middle third (17).

Postoperative Changes

Acute histological changes include ill-defined cell borders, epithelial exfoliation, vesicular nuclei, hemorrhagic glomeruli with capillary fibrin deposition, and intramural hemorrhage in large vessels 20 . Later changes are indicative of coagulation necrosis, which is eventually replaced by fibrotic scarring.

Postsurgery for Stress Incontinence

Occasionally, tapes and slings can cause problems related to fibrosis and scarring around the tape or sling. This can in turn cause BOO and ultimately AUR, but the management should initially be the same. In the long-term, the patient may need her sling or tape incised to relieve obstructed voiding.

Pathologic Findings Gross Findings

As high-grade reflux is such an important and representative form of chronic interstitial nephritis, it alone will be the focus of this discussion. When examined grossly, the kidney in patients with reflux and chronic interstitial nephritis (also called reflux nephropathy) has scarring primarily at the poles with dilated calyces and overlying thinned pale parenchyma. These areas have irregular, broad, deep scars with contraction. The other areas of kidney may not be affected, or may have a finely granular surface indicating ischemic effect. The walls of the affected calyces and pelvis are thickened. In contrast, with obstruction there are diffuse pelvicalyceal dilatation and uniform parenchymal thinning. Calculi may or may not be evident. The renal surface is smooth or finely granular with only shallow scars induced by ischemia.

Choosing how to approach a hysterectomy

In most cases where the surgery involves removing ovaries, the abdominal incision allows easier and less risky access for oophorectomy. Even when a cul-de-sac and other scarring aren't likely or present, adhesions are likely around the ovary in cases of endometriosis. In this situation, a vaginal removal of ovaries is more difficult and dangerous.

Chemotherapy with combination of drugs

The majority of the disseminated tubercle bacilli are engulfed by mononuclear phagocytes in the organs and replicate almost as rapidly as they do at the site of the initial focus of infection in the lung. At this stage, the specific cell-mediated immune response has not been developed, but within about a week of infection, clones of antigen-specific T lymphocytes are produced (15, 23). These lymphocytes release lymphokines, which stimulate macrophages and cause them to form a compact cluster or granuloma around the foci of infection (15, 23). Some of these macrophages fuse to produce multinucleated giant cells. The centre of the granuloma contains a mixture of necrotic tissue and dead macrophages, which is referred to as caseation (15, 23). The activated macrophages are able to markedly inhibit lf the multiplication of virulent tubercle bacilli (15, 23). The formation of the granuloma is usually sufficient to arrest the primary infection, and...

External Examination of a Submerged Body

Drowning Froth

Unzippered pants of an inebriated male who slipped into the water is seen uncommonly (1,9). Finding of material (e.g., weeds, sand) clutched in a victim's hands suggests struggling (6). Dirt under the fingernails could indicate the flailing of hands along a muddy bottom (Fig. 4). Wrist scars or recent self-inflicted sharp force injuries on a drowning victim point toward suicide (see Heading 3. and refs. 9 and 137). Facial or scalp blunt trauma means ruling out underlying cranial and cervical spine trauma however, cutaneous injuries are possible when the victim assumes a head-down position and scrapes the bottom (see Chapter 2, Subheading 3.3. Fig. 5 and refs. 11 and 29). The absence of external trauma in an unwitnessed submersion does not mean that drowning is the cause of death (13).

MTP Stiffness after Weil Osteotomy

Weil Osteotomy

Contraindications of Weil osteotomy are trophic troubles with cold foot, very thin foot or cheloid scar tendency, or very anxious and young patient (2). Fig. 17f.Weil osteotomy stiffness The best way to eliminate MTP stiffness is a large and harmonised shortening of the metatarsals with Weil osteotomy (and if necessary with M1 shortening by scarf, as in this picture).

Fine Wire External Fixation Operative Technique

Infected or contaminated distal humeral fractures represent a particularly difficult management problem. The use of fine-wire external fixation in a previously infected operative field has been shown to give acceptable results from an extremely difficult starting point. Ring (44) describes five cases treated in this way. Four were open fractures in adults treated initially with debridement and fixation, ranging from limited internal fixation with K wires and external fixation to full bicolumnar plating. Initial treatment had to be abandoned in each case because of the development of deep infection. One case was that of a 15-year-old male who had had nonunion of a lateral condylar fracture since the age of 2, which was complicated by an osteotomy with subsequent deep infection. The same operative strategy was used in each case. An olecranon osteotomy was performed via a midline posterior approach, including old scars wherever possible. After ulnar nerve transposition, a tongue and...

Reconstruction with Breast Implants

The most common form of breast reconstruction uses a saline-filled or sili-cone gel implant to rebuild the breast mound. This technique does not add new scars to the body, as the other techniques require. Implant reconstruction also requires less extensive surgery than other techniques, but more procedures are required to complete the reconstructive process.1,2

Hobo Spider Tegenaria agrestis

CLINICAL FEATURES, DIAGNOSIS, AND TREATMENT Local reaction to T. agrestis bite is similar to that of the brown recluse spider. The bite is initially painless, followed by induration and expanding erythma. Blisters eventually develop that rupture, leaving an encrusted, cratered wound. Healing occurs gradually over 45 days, often with a permanent scar. Severe headache is the most common systemic symptom, followed by nausea, vomiting, diarrhea, and lethargy. Aplastic anemia has been reported rarely as a severe complication.

Recruiting Circulating Stem Cell Reserves

The relative scarcity of progenitor cells residing in the adult myocardium has prompted a search for a renewable source of circulating somatic progenitor cells that might home to the heart in response to damage. The presence of such cell populations has gained credibility from observations of sex-mismatched cardiac human transplants in which a female heart is transplanted into a male host. In these patients, the presence of the Y-chromosome marks host-derived cells in the transplanted heart. Various numbers of Y-chromosome-positive myocytes and coronary vessels in the transplanted heart's male cells could be found. Cell fusion of host cells with donor cardiac cells, as has been proven for other regenerating tissues, was ruled out by the presence of a single X-chromosome. The presence of differentiated host cells in the transplanted tissues proves the existence of migratory precursor cells that are induced to differentiate by the cardiac milieu. Although this phenomenon could be a...

The Role of Tissue Expanders in Implant Reconstruction

A mastectomy normally removes a variable amount of breast skin with the nipple. The amount removed depends on tumor size and also on the location of the biopsy scar. The skin circulation and its healing ability are also compromised by mastectomy. Both of these factors prevent the immediate placement of a permanent implant at the time of mastectomy in virtually all patients. Tissue expansion is a process that replaces the missing skin in preparation for placement of a permanent implant later.

Breast Implant Controversies

Breast implants are thin-walled containers made of hard silicone plastic that are filled with saline (salt water) or silicone gel. They have been in use for 30 years and have an excellent safety record. The Institute of Medicine's recent review of breast implants and their safety found saline and silicone gel implants to be similar. Both types of implants were associated with local complications (rupture, scar formation called capsular contracture, and infection) but not with systemic complications as once feared. The decision to use saline implants versus silicone implants is often patient driven or determined by surgeon's preference.

Complications of Implant Reconstruction

The complications associated with breast implant reconstruction are listed in Table 14-1. Of these, scar tissue is perhaps the most problematic for the reconstruction patient as time goes on. The body normally forms a layer of scar tissue around any artificial material implanted beneath the skin. With breast implants, that scar tissue is called a capsule and the process of scarring and subsequent deformation of the breast shape is called capsular contracture. If the capsule which forms remains thin and pliable, it will be nonvisible and nonpalpable and of little concern to a patient. In some patients the capsule can become quite thick, resulting in a firm breast which can be distorted in shape. The variability in capsule formation is a reflection of each individual's biologic response to an implant as well as responses to infection around the implant and surgical bleeding around the time of surgery. Capsular contracture requires surgery to relieve symptoms. That surgery consists of...

Reconstruction with Body Tissue

The reconstruction is permanent, ages naturally, and rarely requires touch up procedures later in life. The main disadvantages are that there will be a scar left at the site where the tissue is taken from and that the operative procedure can be lengthy. The most common area used to donate tissue for breast reconstruction is the lower abdomen. This is called a TRAM flap. The term relates to the muscle supplying vascularity to the lower abdominal block of tissue that is transferred (Transverse Rectus Abdominis Myocutaneous flap).3-6 The back tissues (latissimus myocutaneous flap) can be used in some situations, but often an implant is needed in addition for adequate breast projection. The buttock, hips, and other areas of the body can also be used in special situations.

Reversal of Hartmanns procedure Figure

The operation involves reopening the old laparotomy scar, taking the colostomy back into the abdomen, and joining the proximal end to the distal end of the colon. The patient will then have two scars the laparotomy scar and the scar where the colostomy was in the left iliac fossa.

Traditional Surgical Approaches

Delayed Union Nonunion Decortication

There are many potential applications for the trochanteric slide. These include revision total hip replacement with or without leg length adjustment periprosthetic femoral fracture access to and treatment of femoral cortical deficiency removal of extraosseous bone cement osteotomy of the femur to correct varus, valgus, or rotational malalignment and trochanteric repositioning or rotational, length, or offset improvement. On the acetabular side, the slide approach facilitates bone grafting insertion of bilobed cups vertical relocation of the high hip center for developmental dysplasia, or girdlestone conversion and removal of heterotopic bone or excessive scarring.

Molecular Targets Used For The Detection Of Fungi

Regions the rRNA gene cluster are targeted. Other targets could also be used, including genes of the ergosterol biosynthesis (Morace et al. 1997), translation elongation factor genes (Vaitilingom et al. 1998), and the chitin synthase gene (Jordan 1994). For specific detection of a single genus or species, more variable regions of the genome, e.g., spacer regions of the rRNA gene cluster, or sequence characterized amplified region (SCAR) markers should be targeted. For the detection of mycotoxin producing fungi, sequences of the mycotoxin biosynthetic genes are the best targets. In the following, the targets used for molecular detection of fungi are dealt with, with special emphasis on mycotoxin producing fungi.

Gluteal Free Flap Reconstruction

Both the upper and lower buttock are another source of skin and fat tissue for breast reconstruction.9 These free flaps can be harvested with muscle based on the superior or inferior gluteal vessels (free superior gluteal flap or free inferior gluteal flap), or as perforator flaps leaving gluteus muscle intact (S-GAP or I-GAP flaps). There is a large scar created across the buttock with mild flattening of the buttock contour but this is imperceptible in normal clothing. The best candidates for a gluteal free flap reconstruction are healthy women who have a flat abdomen (no TRAM donor site) and a small or medium size breast with little natural sag.

UShaped Flaps and Jagged Lacerations

Trapdoor Deformity

A U-shaped skin flap is often caused by compressive forces on skin overlying bone. The flap usually has abraded skin and extends deep with attached subcutaneous tissues. The edges of the flap are usually irregular and fit together with adjacent wound edges, like a jigsaw puzzle. The survival of a rectangular-shaped flap is dependent on the blood supply from vessels that enter the flap at its base. Survival of a flap is more dependent on its length and not the width of the base wide and narrow-based flaps survive equally if they are of the same length. Other factors that favor survival include the following (1) the presence of direct cutaneous arteries or veins coursing the longitudinal axis of the flap (axial-pattern flap) (2) location of the flap in the head or neck, where the vascularity is excellent (3) younger patients and those without diabetes mellitus or arteriosclerosis (4) location above the knee and not in areas of scar or previous exposure to radiation, which, especially in...

Localized Skin and Soft Tissue Infection

Formed that progress to ulceration and scar formation. Mycobacterium ulcerans causes disease in children and young adults, producing necrotic lesions of skin and underlying tissue. 9 In our experience, five cases (four wound infections following a laparoscopic surgery and one injection abscess) of M. chelonae (three isolates) and M. fortuitum (one isolate) were isolated which were sensitive to imipenem, amikacin, and ciprofloxacin.

Idiopathic right ventricular outflow tract tachycardia

In contrast to scar related re-entry (see below) the automaticity that causes these tachycardias is often provoked by adrenergic stimulation and appears to be sensitive to increases in intracellular calcium. Treatment with calcium channel blockers (verapamil and diltiazem), which is contraindicated in most other types of VT, often suppresses the arrhythmia. P Adrenergic blockers are also often effective, particularly if the arrhythmias are provoked by exercise. Catheter ablation is a reasonable consideration when pharmacologic treatment is not effective or tolerated. It can be considered for patients with sustained VT, non-sustained bursts of VT, or frequent symptomatic ventricular premature beats. The focus is located by finding the earliest site of activation during tachycardia (activation sequence mapping) (fig 25.1), or by finding the site where pacing exactly reproduces the QRS

Management of intercostal catheters

After a thoracotomy, intercostal catheters are generally placed to lie at the apex and base of the chest with the intention of keeping the pleural space empty. If an intercostal catheter has to be inserted without an operation, then the area of choice is in the axilla where there are no muscles covering the chest wall and the scar is cosmetically acceptable. This can be done under local anaesthetic remembering that the most painful layers are the skin and pleura.

Arrhythmogenic right ventricular dysplasia

Arrhythmogenic right ventricular dysplasia is associated with fibrous and fatty scar tissue in the right and often the left ventricles. VT typically has a left bundle branch block-like configuration in V1, consistent with a right ventricular origin. When right ventricular involvement is extensive, the success of ablation is variable.11 Individual VTs can be ablated, but others may develop later possibly related to progression of the disease process. Ablation is reserved as a palliative treatment for frequent episodes. Although the right ventricle can be quite thinned, the risk of perforation during mapping does not seem to be substantially increased.

VT caused by nonischaemic cardiomyopathy

The mechanisms of sustained monomorphic VT in non-ischaemic cardiomyopathies (including idiopathic cardiomyopathy and valvar heart disease) are diverse. In a series of 26 patients with monomorphic VT the causes were scar related re-entry circuits in 62 of patients, an ectopic focus in 27 , and bundle branch re-entry in 19 .12 Ablation was successful for 60 of the scar related VTs and 86 of the VTs caused by focal automaticity. The difficulties in ablation of scar related VT are similar to those encountered in patients with prior myocardial infarction multiple tachycardias are not uncommon, but reduction in the number of episodes and termination of incessant tachycardia can often be achieved. Successful ablation of scar related VTs in patients with sarcoidosis, scleroderma, Chagas' disease,13 and late after repair of tetralogy of Fallot14 have also been reported, although experience is limited.

Postoperative Intestinal Lesions

A woman underwent cholecystectomy, choledochojejunostomy, and subtotal gastrectomy for organ damage due to a traffic accident at the age of 33 years. She began to have intermittent melena at age 40 years and was assigned a diagnosis of severe anemia. For investigation of the source of bleeding, she was admitted to our hospital and underwent double-balloon endoscopy at age 42. A long duodenal afferent loop was anastomosed to the jejunum by means of a Roux-en-Y anastomosis. Slightly longitudinal multiple ulcers were found in the afferent loop (Fig. 10.5.1a,b). Some of the ulcers were associated with oozing bleeding. These ulcers were found throughout the long afferent loop. Abnormal growth of intestinal bacterial flora in the blind loop was believed to be involved in the ulceration, and metronidazole (Flagyl) was given. Double-balloon endoscopy after 1 month of treatment showed an improvement in the ulcers with many scars (Fig. 10.5.1c,d). The primary cause of her anemia appeared to be...

Unstable monomorphic VT

Two approaches are being evaluated for ablation of scar related VT that is difficult to map with a roving catheter because of haemo-dynamic instability or instability of the re-entry circuit. One approach involves defining the area of scar from its low amplitude sinus rhythm electrograms (fig 25.2, top panels) then selecting portions of the scar likely to contain a part of the re-entry circuit based on the VT QRS morphology or pace mapping and then placing a series of anatomically guided ablation lesions through the abnormal region.15 16 Ellison and colleagues targeted the likely re-entry exit region in five patients with frequent unmappable VT. All three patients with prior myocardial infarction were free of recurrent VT during follow ups of 14-22 months. The procedure was not successful in the two with non-ischaemic cardiomyopathy.15 Marchlinski and colleagues applied a more extensive series of RF ablation lines through regions of scar in 16 patients with recurrent unmappable VT...

Current clinical application

Catheter ablation offers improved arrhythmia control in two thirds of patients who have a mappable scar related VT (table 25.1). It can be lifesaving for patients with incessant VT, and can decrease frequent episodes of VT causing therapies from an implanted defibrilla-tor. Before considering ablation possible aggravating factors should be addressed. Although myocardial ischaemia by itself does not generally cause recurrent monomorphic VT, it can be a trigger in patients with scar related re-entry circuits. Furthermore severe ischae-mia during induced VT increases the risk of mapping and ablation procedures. An assessment of the potential for ischaemia is generally warranted in patients with coronary artery disease who are being considered for catheter ablation. Patients with left ventricular dysfunction should also have an echocardiogram to assess the possible presence of left ventricular thrombus that could be dislodged and embol-ise during catheter manipulation in the left...

Left ventricular failure

The pathophysiology of late left ventricular dysfunction is greatly dependent on the preop-erative left ventricular load, and therefore the specific valve lesion corrected. When aortic valve replacement is undertaken for aortic stenosis, postoperative improvement in systolic and diastolic left ventricular function may occur over a period of years but is by no means inevitable. In aortic stenosis, severe left ventricular systolic dysfunction may be caused by afterload mismatch with an increase in left ventricular systolic pressure and wall stress leading to a reduction in stroke volume and ejection fraction. Under these circumstances, systolic function improves once left ventricular pressure is normalised. Alternatively, systolic dysfunction may be caused by reduced contractility as a result of hypertrophy and fibrosis or by the additional insult of scarring following myocardial infarction. When this is the case, postoperative improvement in left ventricular systolic function often...

Magnetic resonance scan

This agent is both filtered and resorbed by the kidney. It has high cortical fixation and is therefore the agent of choice for renal cortical imaging in cases of acute pyelonephritis and renal scarring. A non-functioning obstructed kidney can also have its tubular function assessed by a static renogram using technetium-labelled dimercaptosuccinic acid (DMSA).

Pulmonary artery stenoses

Pulmonary artery stenosis occurs most frequently in patients with tetralogy of Fallot. It may be present before surgery or may appear early or late after surgical repair (fig 28.1). It may be easily missed, particularly in adults and particularly when it is unilateral. Surgical repair of pulmonary artery stenosis may be technically difficult and narrowing may recur because of patch scarring and shrinkage, so when stenosis of a major branch occurs after surgery most centres would try transcatheter treatment before further surgery. Many pulmonary artery stenoses are elastic and recoil after simple balloon angioplasty,8 and some operators choose to proceed directly to stent implantation. Stenting may be technically difficult it carries risks of stent embolisation,

Integumentary Tissues

The integumentary tissues (skin, hair, nails) cover and protect the body. Two of the more classical and reproducible manifestations of aging can be seen in this system. The depigmentation of hair to gray or white is an almost universal aging effect given sufficient survival. Wrinkling of the skin, due to alteration in connective tissue composition, is another consequence of aging it should be assessed by the changes in skin texture only in the non-sun-exposed regions of the body. Beyond the cosmetic consequences of the aging integumentary tissues, wound healing is a health-relevant consideration. Healing of wounds is slower with increasing age, but the resulting scars have the same tensile strength. Reduced recruitment of vessels of the microvascular is a function of aging.

Iaortopulmonary collaterals

Obstruction to flow in the superior caval vein rarely occurs de novo. It is usually a consequence of scarring related to surgery, to the presence of venous catheters or pacemaker electrodes, or external compression by tumour. When obstruction occurs insidiously there may be no symptoms and no indication to intervene, but with rapid onset obstruction, when collateral veins have not had time to develop and enlarge, venous hypertension in the head and neck will prompt treatment (fig 29.1). Although these stenoses can be dilated using a balloon, stent implantation is usually required to prevent recoil.1 Self expanding as well as balloon expandable stents have been used with good effect. In the presence of complete obstruction reconstruction is sometimes possible by passing a long needle and then a guide wire through the obstruction, followed by ballooning and stent-ing. Because the vein is usually surrounded by scar tissue accidental perforation is unlikely to cause any more harm than...

Phase IIMiddle Phase Rehabilitation

Usually 7-10 days after surgery, the patient returns to the surgeon for reevaluation. A majority of the patients have progressed off of the crutches, the portal scars are healed, pain and swelling are diminishing, and mobility and muscle contraction are improving. At times, patients may still present with continued impairments such as pain, swelling, altered mobility and muscle length, poor static alignment, impaired muscle strength and endurance, diminished proprioception, and decreased cardiovascular endurance resulting in functional limitations. These key impairments may warrant referral to formal physical therapy for direct intervention. Physical therapy examination should include Pain, posture, range of motion, both arthrokinematic and osteokinematic, muscle length and flexibility, strength, proprioception, and gait.

Individual School Support

According to his teachers, Ted was failing in school. He did not keep up with basic hygiene (e.g., combing his hair, picking scars in class). But the behaviors of concern were being off-task and social isolation. and repetitive behaviors. Sleeping was described as head nodding or having his head on his desk. Repetitive behaviors involved playing with pencils or paper or picking at scars.

Squamous cell carcinoma

Squamous cell carcinoma of skin is more directly related to ultraviolet radiation than basal cell carcinoma. Other predisposing factors or conditions include radiation, chemical exposure (arsenic and organic hydrocarbons), burn scars and non-healing venous ulcers. Verrucous carcinoma is a low-grade or well-differentiated squamous cell carcinoma of skin or mucus membrane that presents as an exophytic ver-rucous, keratotic mass that grows slowly. It may involve the skin as well as the mucus membrane of the oral cavity (Fig. 20.12). Superficial biopsy typically shows hyperkeratoses and histological evidence of malignancy can only be diagnosed from the entire excised mass. Therefore, treatment by surgical excision should be undertaken based on clinical correlation. Squamous cell carcinoma should be treated by excision with at least 1 cm margins and clinically detected regional metastasis should be treated by radical or modified radical neck dissection.

Saprotrophs of Attached and Fallen Wood and Litter

The decay process often commences in the standing tree, in attached lower or stressed branches (Rayner and Boddy 1988). Fungi may gain access either through wounds, tissues following microbial or stress damage or via lenticels or leaf scars. Studies have indicated that pioneer species such as Stereum gausapatum, Phlebia rufa, Phellinus ferreus, Exidia glandulosa, and Vuilleminia comedens in oak or Daldinia concentrica, Hypoxylon rubiginosum, and Peniophora limitata in ash, can colonize living or recently dead wood. The host tree may instigate a response to this invasion, by accelerating localized premature heartwood tissue formation, which contributes to restriction of the invading front. The identification of massive decay columns comprising a single individual extending for several meters along branches known to have been dead for a single growing season only, indicated the involvement of latent invaders (see Endophytes) initially distributed within functional sapwood as dormant...

Melagenine pseudocatalase systemic antioxidant therapy

In general, autologous transplantation methods are indicated for stable and or focal lesions that are refractory to medical therapy.24 Koebner phenomenon should be absent, and tendency for scar or keloid formation should be ascertained. Stable disease is not uniformly defined across the studies.

Self Wounding and Self Mutilation

Death during hospitalization from acetaminophen toxicity. Radial line insertion. Multiple linear and irregular scars on forearm from previous self-wounding. Fig. 29. Death during hospitalization from acetaminophen toxicity. Radial line insertion. Multiple linear and irregular scars on forearm from previous self-wounding.

Salivary gland tumours

Benign and malignant salivary gland tumours can arise from the parotid gland, submandibular gland and rarely the sublingual gland. They typically present as a parotid or sub-mandibular mass. Approximately 10 of parotid and 50 of submandibular gland tumours are malignant. Both ultrasound and FNA are useful in delineating the nature of the salivary gland lesions. A CT scan may be required to evaluate a complex mass such as deep lobe tumours and invasive tumours. Common benign tumours are pleomorphic adenoma and Warthin's tumour (papillary cystadenoma lym-phomatosum). Pleomorphic adenoma is usually rubbery firm in consistency and may recur if not excised with an adequate margin. Warthin's tumour may be bilateral and tends to occur in the elderly. Malignant salivary gland tumours include mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma, adenocarcinoma, undifferentiated carcinoma, squamous cell cacinoma and lymphoma. Metastases to the parotid gland can originate...

TABLE 2373 Lesion Configuration Descriptors

Recognition of the primary lesion is vital in establishing the diagnosis. The primary lesion is the lesion which has not been altered by secondary issues, including healing, complicating infection, medication application, or scratching. Examples of primary skin lesions include macules, papules, nodules, tumors, cysts, plaques, wheals, vesicles, bullae, and pustules. Secondary lesions have had their appearance altered due to disease evolution or various external factors as noted above, and include crusts, scales, fissures, erosions, ulcerations, excoriations, atrophy, scarring, and lichenification. See T.aMe.237-4 for a listing with description of the various morphologic descriptors of dermatologic lesions refer to Ia.ble 23.7. . and T b. e 2.37 6 for a differential diagnosis of the various skin disorders relative to primary and secondary lesion morphologies that can use the Burn rule of 9's ( Chap 194, Thermal Burns) to estimate the degree of skin involvement.

Brown Recluse Spider Bites

CLINICAL FEATURES Because the bite itself is painless, patients cannot recall being bitten. Only a history of potential exposure can be elucidated. Rarely does a patient see the bite or capture the spider. About 6 to 8 h after the bite, pain associated with a red-to-violaceous discoloration develops. Two central puncture wounds are often visible on close inspection. Initially, the bite site may look like a bruise. It may even form a bulla. Over the next several hours to days, necrosis of the skin and subcutis will occur (Fig. 242-5). This reaction may remain localized or spread to 25 cm in diameter. The spread is in a gravitational direction. Healing is very slow and results in scarring. Secondary infection is common.

Self Inflicted Venipunctures

In less apparent locations (Fig. 41). Venipunctures owing to resuscitation need to excluded, a determination made more difficult if intravenous lines have been removed (Fig. 42). Track marks indicative of scarring from previous injections may be seen (Fig. 43). Fig. 43. Track marks (cutaneous scars on forearm) indicative of past intravenous drug abuse. Recent venipunctures (arrow). Fig. 43. Track marks (cutaneous scars on forearm) indicative of past intravenous drug abuse. Recent venipunctures (arrow).

Delayed Operative Procedures

Jury that provide supple soft tissue coverage. Soft tissue reconstruction should also consider the esthetic appearance of the upper extremity. If healthy granulation tissue or viable muscle is present following serial debridements, split thickness skin grafting from remote sites is optimal. For wounds needing thicker dermis with less contraction, a full-thickness graft is a preferred option. Meshing of a split-thickness graft allows efflux of the edema and blood and coverage of a wider area. The graft contracts as the wound heals, which leaves behind a smaller scar.

Immediate complications

This is usually a result of an unrecognized compartment syndrome where there is alternate necrosis of the muscles within a compressed myofascial compartment. Once the muscle tissue is necrotic, it is replaced by scar tissue. As the scar tissue matures it contracts, resulting in joint contractures and deformity across which the muscles act. This is most commonly seen in children after distal humeral fractures wherein the forearm muscles are commonly affected resulting in clawing of the hand, though it may also affect myofascial compartments in the leg, foot and very rarely in the thigh. Treatment in chronic cases is very difficult. It often requires prolonged physiotherapy with serial splintage to try and correct some of the residual deformity. However, in the established case, surgical release of the scarred muscles popularly known as the muscle slide procedures, with or without tenotomies, and joint contractures may be appropriate. To restore active function in the joints, tendon...

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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