Treating Scars

Scar Solution Ebook By Sean Lowry

Scar Solution is a scientifically proven treatment that assists in fast scar removal naturally within months. It is effective in eliminating pitted acne scars, sunken scars and keloid scars. The author of this program is Sean Lowry, is a medical consultant and health researcher. Sean, some years ago suffered a skiing accident. This left ugly scars on her face which affected not only her skin but her whole life. This is a scientifically designed, clinically proven, dermatologist approved and tested program. In this program scars have been classified into specific categories based on their cause. Remedies have been given accordingly systematically eliminate each type of scar effectively. Based on the customer reviews of The Scar Solution, sufferers have been satisfied with the results of the miracle cure and most of them state that they will be recommending it to their family and friends. Tremendous results include breaking up the scar tissue so lessening their unsightly appearance on the skin; reversing hyperpigmentation and discoloration especially those caused by severe acne; and preventing the appearance of new scars, among others. Read more here...

The Scar Solution Natural Scar Removal Overview


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Pregnancies located below the internal os cervical and Caesarean scar ectopics

Caesarean Scar Pregnancy

Cervical pregnancy is defined as the implantation of the conceptus within the cervix, below the level of the internal os. Caesarean scar pregnancy is a novel entity, which refers to a pregnancy implanted into a deficient uterine scar following previous lower segment Caesarean section 48 . Prior to the introduction of high resolution transvaginal scanning, the distinction between cervical and Caesarean section scar pregnancies was not possible. In older literature 33 of 'cervical' pregnancies occurred in women with a history of previous Caesarean section, which indicates that scar pregnancies probably account for a significant number of ectopics below the level of the internal os 49 . The common characteristic of both cervical and Cae-sarean scar pregnancies is their implantation into myome-trial defects following previous intrauterine surgery (Fig. 14.8). In case of cervical pregnancy the implantation Fig. 14.8 A 7 weeks' Caesarean scar pregnancy with the gestational sac herniating...

Scar Versus Residual Disk

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

Obstetric complications

Obstetric concerns may also lead to advice to avoid pregnancy, that is, previous recurrent post-partum haemorrhage or multiple uterine scars with risk of placenta accreta. Women with prior histories of early onset or severe pre-eclampsia or preterm delivery may warrant prepregnancy counselling. Recurrence risks and treatment plans have been addressed in Chapters 13 and 18. Women may come for counselling following a previous traumatic delivery. Such visits are usually very valuable in helping women come to terms with adverse events in previous pregnancies, offering explanations for previous management plans and making clear plans for subsequent pregnancies. It is not uncommon for women to choose not to conceive following particularly traumatic deliveries, as they perceive that they will necessarily be exposed to the same stress with subsequent pregnancies. The extent to which such situations arise has not been sufficiently formally studied. One visit for counselling in such...

Discharge And Home Healthcare Guidelines

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

Clinical manifestation

Persistent, painful erosions on mucous membranes, often healing with scarring ocular involvement pain or the sensation of grittiness in the eye conjunctival inflammation and erosions keratinization of the conjunctiva and shortening of the fornices entropion with subsequent trichiasis skin tense vesicles or bullae, sometimes hemor-rhagic, sometimes healing with scarring or milia scalp involvement leads to alopecia

Gender Ethnicracial And Life Span Considerations

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

Conditions That May Simulate Psoriasis Vulgaris

Eruptive PV in its early stages can be indistinguishable from early PR. This diagnosis must always be considered in a patient with a positive family history for PV. In general, PV will progress unless treated, and as the lesions mature they develop the deeper color and loose silvery scale typical of that disease. Eruptive PV should always be considered with fixed PR. Usually PV lacks a herald plaque and the classic Christmas tree pattern. At this stage, the biopsy findings are generally inconclusive. A short period of observation will usually spare the victim the discomfort, scar, and expense of biopsy. As with SD, the presence of nail pitting favors a diagnosis of psoriasis. Discoid and subacute lupus erythematosus (LE) can occasionally resemble PV in onset, distribution, and lesional morphology. Lupus lesions usually have a deeper hue with telangectasias. Scarring, which is absent in psoriasis, tends to occur early in discoid LE. Arthralgias and systemic symptoms may be present,...

Vitamin C 101 Introduction

Pro-collagen-proline dehidrogenase (proline dehidrogenase) and procollagen lisine 5-dehidrogenase (lysine desidrogenase), involved in pro-collagen synthesis (22). Thus, vitamin C deficiency causes teeth losses, joint pains, bone and conective tissues disorders, and a deficient wound scar, all of which are characteristics of scurvy (22)

Dissecting cellulitis of scalp

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

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.

Regenerative Abilities In Vertebrates

Apart from wound healing (or wound repair), which is mostly closure of a wound by scar tissue, the degree of tissue renewal or regeneration in vertebrates varies in different tissues. In fact, what is different is the complexity involved in the mechanisms and magnitude of regeneration. The simplest form of regeneration is the axonal outgrowth seen in a severed nervous system. Regeneration by simple proliferation seen in organs, such as intestines, liver, or adrenal gland, is somewhat more complex. It involves proliferation of cells that compose the particular organ. Regeneration of other organs and tissues, on the other hand, can be channeled through proliferation and differentiation of stem cells. More complex types of regeneration involve dedifferentiation. In these cases (mostly seen in amphibia), a particular cell type at the damaged site dedifferentiates and then redifferentiates into the same type. Regeneration of CNS (brain, spinal cord), intestine and heart can be achieved by...

Primary Nursing Diagnosis

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

Clinical implication and current treatment modalities of diabetic inner BRB dysfunction Diabetic macular edema

After the reports of Early Treatment of Diabetic Retinopathy Study (ETDRS) focal grid laser photocoagulation was the standard treatment method in diabetic macular edema. Stabilization or some improvement of vision was acquired in patients with macular edema who received laser photocoagulation. Although it is still the most cost-effective treatment modality in diabetic macular edema, some patients suffer from the post-treatment paracentral scotomas (Striph et al., 1988) and enlarging atrophic laser scars (Schatz et al., 1991). Although rare, vision threatening complications like choroidal neovascularization and subretinal fibrosis were also reported (Cunningham & Shons, 1979). Because of the refractory macular edema and complications of laser treatment, several pharmacological treatment modalities had been introduced. Further delineation on the exact mechanism of action is still needed, but intravitreal steroid injection is a powerful treatment option in diabetic macular edema....

Origins of Multistage Theory

In the 1920s, several laboratories began to apply chemical carcinogens to experimental animals. Deelman (1927) summarized observations in which repeated applications of tar to skin led to a small number of tumors, after which tarring was stopped. A few days later, the skin was cut where no tumors had appeared. Most incisions developed tumors in the scars most such tumors were very malignant. Two distinct processes, tarring and wounding, combined to cause aggressive cancers.

Epidermolysis bullosa

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

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.

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...

Accuracy of Demonstrating Anorectal Sphincter Injury with Anal Ultrasound

EUS remains the gold standard in delineating the anatomy of the PR muscle and anal sphincter complex 18, 21,43-45 . EUS can visualize defects, scarring, thinning and thickening, difference in echogenicity, and other local alterations. The defects should be described, indicating their location (IAS, EAS, PR muscle), their size longitudinally (total, proximal, distal), and their circumference (degrees). Some semantic problems exist concerning the words defect, tear, scar, and fibrosis. Clear disruption of the IAS or EAS are described as defects. Tears are defined by interruption of the fib-rillar echo texture scaring is defined more by loss of normal architecture, with usually low reflectiveness 46 . Endosonography demonstrates sphincter defects with high accuracy 37, 47-52 . Sensitivity and specificity can reach almost 100 . The described defects are confirmed during surgery. There is a good reproducibility for sphincter defects and anal sphincter thickness 37, 53-56 . For the IAS, the...

Obstetric causes of collapse

Uterine inversion and uterine rupture can both contribute to maternal collapse as listed in Table 18.1 and their management is illustrated in Fig. 18.6 and 18.7. It is worth noting that 18 of the 42 cases of uterine rupture in the confidential inquiry into still births and deaths in infancy (CESDI) report had a laparotomy before a diagnosis was made 38 . Signs can be subtle and fetal heart abnormalities in the presence of a uterine scar should be taken extremely seriously and rarely, if ever, justify fetal blood sampling. Similarly, a multiparous patient with secondary arrest should arouse suspicion and syntocinon augmentation should only be decided after careful clinical assessment of the patient by a senior obstetrician.

Invited Commentary

These problems can be surgically improved by smoothing the scar ridge or reapproximating the muscle ends. However, internal anal sphincter disruption from stretching or hemorrhoid excisional surgery that includes some muscle fibers may not respond to conventional muscle reapproximation and necessitate consideration of one of the novel approaches to improve fecal leakage. Once again, the ability to detect defects in specific sphincter components and the size and configuration is mandatory.

Gastroesophageal Reflux Disease GERD

As healing occurs, the cells that replace the normal squamous cell epithelium may be more resistant to reflux but may also be a premalignant tissue that can lead to adenocarcinoma. Repeated exposure may also lead to fibrosis and scarring, which can cause esophageal stricture to occur. Stricture leads to difficulty in swallowing. Chronic reflux is often associated with hiatus hernia.

Azithromycin in Control of Trachoma

In trachoma hyperendemic areas, virtually all individuals are infected very early in life (prior to 2 years of age). Active disease is a disease of children. The infection rates drop dramatically after age 7-10 years. With resolution, the conjunctivae are scarred. Those that have had severe inflammation are more likely to develop scarring, which causes distortion of the eyelids. The cornea is then abraded by inturned eyelashes. This causes blindness. In the hyperendemic areas, the risk of blindness can be as high as 25 or more in those surviving to age 60 years.

Physiological Investigations

Skin excoriation infection Perianal perineal scars Patulous anus Perineal soiling Anal ectropion Hemorrhoidal prolapse Rectal prolapse Sphincter deficit Loss of perineal body Perineal descent Fistula Perianal perineal scars In patients with sphincter lesion, no electrical activity may be found in case of wide, complete replacement of normal muscular tissue with scar, or, more frequently, polyphasic potentials as signs of a reinnervation process. Polyphasic potentials do present multiple spikes of muscle activity, prolonged in duration, and an increased fiber density. In evaluating sphincter injury, EAUS has higher sensitivity and specificity compared with EMG in mapping the lesion however, only EMG can assess neuromuscular integrity. In this view, these two procedures are complementary to each other.

Clinical Application Questions

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

Gastroesophageal Reflux Disease Gerd Introduction

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

Dermatologic Physical Exam

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

Herpes ZosterDRG Category 272

Most patients recover completely, but approximately 12 experience complications that include postherpetic neuralgia (PHN), uveitis, motor deficits, infection, and systemic involvement such as meningoencephalitis, pneumonia, deafness, or widespread dissemination. In some patients, the scars are permanent.

Transforming Growth Factor beta TGFP

Scarring in the cornea and conjunctiva, fibrosis in the corneal endothelium, post-cataract surgery fibrosis of the lens capsule, excess scarring of tissue around the extraocular muscles in the strabismus surgery and proliferative vitreoretinopathy (Saika et al., 2009 Sumioka et al., 2011 Hills et al., 2011). Those properties of TGF- are confirmed in animal models (Yingchuan et al., 2010 Kowluru et al., 2010) as well as in patients with diabetic retinopathy (George et al., 2009 Abu El-Asrar et al., 2010). It is believed that TGF- plays a role in pathogenesis of diabetic retinopathy via hyperglycaemia and inflammation. Kowluru et al., 2010 have reported that both the duration of the initial exposure to high glucose, and normal glucose that follows high glucose, are critical in determining the outcome of the alterations in the inflammatory mediators such as IL-1 beta, NF-kB, VEGF, TNF-a including with TGF- in retinal.

Preoperative Evaluation

Visual inspection of the perianal region will often reveal seepage and skin breakdown. The presence of scar tissue from previous sphincter repairs or trauma should also be documented. Deformity or absence of the anterior perineal body is a common finding in severe obstetrical trauma and may require perineal reconstruction in addition to sphincteroplasty. Digital rectal exam will often demonstrate laxity in the sphincter at the injury site.

Practical management of prolonged pregnancy

The RCOG recommendations are an excellent guide to practice. Every effort should be made to ensure that dates are as accurate as possible. When the woman reaches 41 weeks she should meet with a consultant obstetrician. Women have a right to be informed of the small increase in risk associated with continuing the pregnancy after 41 weeks. Thornton and Lilford 82 showed that pregnant women are much more risk averse than are their caregivers. Following a vaginal examination, induction of labour should be offered on a date after 41 weeks that is acceptable to both the woman's wishes and the hospital resources. The vaginal examination could be accompanied by sweeping of the membranes, provided women are warned about the discomfort associated with this and are agreeable to proceed. Membrane sweeping reduces the need for 'formal' induction of labour 83 . The vaginal examination allows the obstetrician to inform the woman of the likely ease and success of induction of labour. For women who...

Genitourinary System Basic Care Plan Introduction

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

Epidermal Necrolysis Disease Spectrum

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

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).

Multiple Lumbar Spine Surgery Failed Back Syndromes

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

Herniated intervertebral disk

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

Selection Of Biopsy Site And Processing Technique

Generally, skin biopsies are very well tolerated and result in negligible scarring in individuals without a predilection to keloid formation. Discoloration at the biopsy site tends to be more prominent among darker pigmented individuals. The rate of infection even among neuropathic populations is small, approximately 1 500. Biopsy sites generally heal through a process of granulation without a need for cautery of suturing. Selection of the biopsy site depends on the clinician's intent. If the intent is to diagnose small fiber neuropathy, the availability of normative data is important. These data are available for several locations in the lower extremity by different processing techniques and to a lesser extent in the arm (7,8). Areas of trauma or where scar formation is present should be avoided as these can artificially lower epidermal nerve fiber densities. In general, a distal location where there are abnormalities on examination, particularly decreased sensibility to pin prick or...

Gracilis versus Gluteus

No randomized, controlled trials exist to compare the efficacy of the gluteus maximus muscle to the gracilis muscle in creating a neosphincter. Certain factors, such as anatomy and function, as well as the primary reason for fecal incontinence, dictate decision making. At our institution, the gluteus muscle is preferred in patients who require considerable muscle bulk, who need moderate resting tones with high squeeze pressures, who would benefit from a complete rectum wrap, and who have minimal rectovaginal scarring. Alternately, the gracilis muscle is chosen in patients who have a deficient perineal body, who have extensive scarring of the rectovaginal septum (requiring an anterior approach), who have some native sphincter function with moderate incontinence, and who have minimal needs for high squeeze pressures 7-22 .

Vesicoureteral Reflux Introduction

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

Surgical Approach and Operative Technique

After obtaining informed consent and providing discussion of the potential benefits and risks, patients receive a mechanical bowel preparation and are kept on clear liquids for several days prior to their procedure. Temporary diverting colostomy should be strongly considered in high-risk patients with recto-vaginal or perirectal fistulas, inflammatory bowel disease, or severe perirectal scarring with perineal deficiency. Topographic landmarks, including the sacrum, infragluteal crease, and borders of the gluteus, are marked in the preoperative holding area (Fig. 1a).

Microdistribution None

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

DescriptionSurgical Major Chest Procedures

NSCLC accounts for almost 87 of all lung cancers and includes three subtypes squamous cell carcinoma, adenocarcinoma, and large cell undifferentiated carcinoma. Squamous cell carcinoma, also associated with smoking, tends to be located centrally, near a bronchus, and accounts for approximately 25 to 30 of all lung cancers. Adenocarcinoma, accounting for 40 of all large cell carcinoma, is usually found in the outer region of the lung. One type of adenocarcinoma, bronchioloalveolar carcinoma, tends to produce a better prognosis than other types of lung cancer and is sometimes associated with areas of scarring. Large cell undifferentiated carcinoma starts in any part of the lung, grows quickly, and results in a poor prognosis owing to early metastasis approximately 10 to 15 of lung cancers are large cell undifferentiated carcinoma.

Diagnostic Assessment

The aim of clinical examination is to investigate perianal perineal scars, patulous anus, perineal soiling, anal ectropion, sphincter deficit, loss of perineal body, and perineal descent. During digital examination, resting and squeeze tones must be evaluated, whereas the puborectalis muscle needs to be assessed at rest, squeezing, and straining. Proctoscopy or, if necessary, colonoscopy is needed to ascertain absence of tumor recurrence or other bowel neoplasms. Physiology evaluation is of utmost importance. Anorectal manometry can offer information about alterations in resting and squeeze pressures, sphincter asymmetry by vector manometry, anomalies of rectoanal inhibitory reflex (sometimes absent, sometimes normal, sometimes not identifiable when resting pressure is very low), and rectal compliance. Assessment of rectal sensation (measuring threshold, urge, and maximum tolerated volumes) could be of help in interpreting pathophysiol-ogy in these patients. Endoanal ultrasound (or...

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.

Anal Instrumentation for Anastomosis General Introduction

Radiotherapy may further compromise continence after anterior resection 60 . A recent study evaluated patients from the Stockholm trials and compared patients who had preoperative radiotherapy with those who had not 61 . Whilst the indications for radiotherapy in these trials were a little outdated and regimens often included sphincter irradiation, this study had the advantage of a long follow-up (mean 14 years). It suggested that irradiated patients had significantly greater symptoms of faecal incontinence and soiling and more bowel movements per week. Although there was no preoperative data, patients in the irradiated group had significantly lower resting and squeeze pressures and more evidence of scarring on endoanal ultrasound. Similar detrimental effects of radiotherapy on continence and function amongst patients from the Swedish trial have also been reported 62 .

OCT interpretation qualitative analysis morphology and reflectivity

While performing qualitative analysis one should simultaneously perform morphological examination (changes in retinal profile - surface and posterior layers, and presence of abnormal structures) and reflectivity examination (hyper-reflectivity, hypo-reflectivity, and shadowing effects) (Brancato & Lumbroso, 2004). Pathological changes in retinal surface contour may represent disappearance of the normal foveal depression (in macular edema). Steepening of the foveal contour may be associated with epiretinal membranes, macular pseudoholes or lamellar holes. OCT can distinguish between lamellar holes, pseudoholes or various stages of full thickness macular holes. Pathological changes in posterior layers may be RPE detachments (form steep angles with the choriocapillaris) and neurosensory retinal detachments (form shallow angles with the RPE and protrude less). Retinal drusen produce wavy undulations of the pigment epithelium line. Abnormal intraretinal structures may be cotton wool...

Radial Nerve Injury at the Wrist

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

Exit Site Care Pre Implantation of PD Catheter

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

Background Information

Sam's mother reported that asthma has weakened his vocal cords, leading to scar tissue and nodules. According to the speech pathologist, he had a speech language evaluation for voice concerns at the hospital approximately a year before kindergarten, but no services were deemed needed. Sam was evaluated by the speech pathologist at BBE in the Spring of 2000. His language skills were screened with the Clinical Evaluation of Language Fundamentals-Third Edition Screening Test. Sam did not meet criteria to pass this

Prior Transurethral Resection of the Prostate

Prior transurethral resection of the prostate (TURP) can make the case more challenging. Clinical experience has proven that there is a wide variation in TURP technique and in the amount of tissue resected. In addition, the bladder neck is resected more aggressively by some surgeons than others. When the bladder neck has been extensively resected, the extent of scar formation can make it extremely challenging to define the border between bladder neck and prostate and to identify the ureteral orifices. Preoperative cystoscopic clarification of the shape of the prostate and the ureteral orifices is suggested. Furthermore, we recommend double-pigtail insertion during the preopera-tive cystoscopic evaluation. This provides a more secure bladder neck dissection in these patients. The double-pigtail stents can be extracted either after completion of the posterior part of the urethrovesical anastomosis or after the urethral catheter has been extracted (5th postoperative day).

Anovaginal and Rectovaginal Fistula Repair

If a rectovaginal fistula is present in addition to a sphincter defect, our earlier technique of overlapping sphincteroplasty is modified slightly into a transper-ineal repair. The same technique is applied with emphasis on separating the rectum and vagina and careful cephalad dissection through the fistulous communication and above the scarring. The vaginal defect is cored to remove any granulation tissue, and the defect is closed by imbrication. The rectal defect is excised if distal if quite large or cephalad, it is repaired with an endorectal advancement flap. The sphincters are repaired as described earlier, and the result is a multilayer repair that simultaneously repairs the fistulous defects, separates the anorectal and vaginal components, and repairs the muscle defect.

Gestational Carrier Surrogacy

Gestational surrogacy may be an option if you have normally functioning ovaries but do not have a uterus. You may lack a uterus because you were born that way or perhaps you've had a prior hysterectomy. This type of surrogacy may also be indicated when you possess untreatable scarring or other such abnormalities within your uterus. Another reason to choose gestational surrogacy could be if you have a medical condition where pregnancy would be dangerous to you (severe heart disease is one example).

Virus Transmission

Effective inoculation usually requires that leaves be abraded by means of either carborundum dust or by Celite (diatomaceous earth) suspended in the inoculum. Carborundum is a fine metal powder that creates microwounds in leaves when rubbed on the leaf surface, allowing virus to enter through the wounds. Leaves are usually dusted with carborundum before inoculation, then washed briefly to prevent carborundum remaining on the leaves from producing scars or more wounds as the plant grows. Celite is also a fine powder, but is usually suspended with liquid inoculum and applied during inoculation to create wounding. Although Celite is more gentle on plant tissue than carborundum, it too should be washed from leaves after inoculation. Inoculation occurs almost immediately upon rubbing a leaf with a virus suspension therefore, rinsing leaves with water soon after inoculation will not affect transmission. Although more difficult, some phloem-limited viruses can also be transmitted...

Subthreshold Micropulse Diode Laser Photocoagulation SMDLP

A study comparing the efficacy and side effects of conventional green laser photocoagulation and SMDLP treatment for diabetic CSME was conducted with prospective, randomized, double-masked manner. There were no statistically significant differences in best-corrected visual acuity (BCVA), contrast sensitivity and retinal thickness between the two laser modalities at 0, 4 and 12 months. It is found that laser scarring was much more apparent with conventional green laser than with the SMDLP (Figueira et al., 2009).

Results Of Fractures Operated More Than 21 Days After Injury

The data indicate acute treatment of acetabular fractures within 21 days of injury may achieve up to 80 good to excellent results. However, delayed reconstruction of acetabular fractures remains a controversial subject. There is, to date, little published data reported for reconstruction of acetabular fractures on a delayed basis. Letournel and Judet divided surgical repair into three time periods (i) injury to 21 days, (ii) 21 to 120 days, and (iii) beyond 120 days (9). Problems encountered after 21 days postinjury include changes in the soft tissue envelope, increased scar formation, resorption of fracture lines, and early callus, which ultimately hamper delayed reconstructive efforts.

Dermatologie Physical Exam

Scarring with a depression and peripheral epidermal tags are usually left after spontaneous regression (see Photo 43). Because keratoacanthomas are difficult to separate clinically and microscopically from squamous cell carcinoma, and since substantial scarring occurs after spontaneous involution, small- to moderate-sized lesions are usually removed by excisional surgery. Giant lesions, or those in locations where removal would be mutilating or require extensive reconstruction, should be referred to a dermatologic consultant for consideration of alternative treatment. Recurrences of keratoacanthoma can occur after any type of therapy, and after apparent spontaneous involution.

What should you tell the patient about keratoacanthoma

Answer Keratoacanthoma is classified as a benign lesion but shows many signs and microscopic features of malignancy. Although true keratoacanthomas do not metastasize, they can cause significant scarring and alteration when they occur on a cosmetically sensitive site. Treatment is recommended to minimize scarring and to distinguish keratoacanthoma from squamous cell carcinoma.

Malignant Liver Tumours 14621

Cholangiocarcinoma is the second most common primary liver tumour after HCC representing 10 of all primary hepatic malignancies. MRI demonstrates peripheral high signal on T2 weighted images with a central hypointense area due to scar tissue. Multi-phasic contrast enhanced studies showed progressive moderate enhancement in the peripheral part of the tumour. Although the morphological pattern of enhancement is similar to that seen in haemangio-mas the rate of enhancement is far slower.

Indicated Supporting Diagnostic Data

Undifferentiated, adenoid, and superficial BCC histologic patterns tend to be very responsive to treatment and are less likely to recur. Micronodular, spiky, and metatypical (basosquamous) patterns are more likely to recur and should be treated more aggressively. Morpheiform or sclerosing patterns, tumors that are recurrent after initial therapy, tumors arising in old scar tissue, or tumors that show neural invasion should all be treated aggressively.

Medical Kidney and Urinary Tract Infections Age 17 with CC

Acute pyelonephritis occurs 24 to 48 hours after contamination of the urethra or after instrumentation such as a catheterization. Complications include calculus formation, renal abscesses, septic shock, and chronic pyelonephritis. Chronic pyelonephritis is a persistent infection that causes progressive inflammation and scarring. It usually occurs after chronic obstruction or because of vesicoureteral reflux. This destruction of renal cells may alter the urine-concentrating capability of the kidney and can lead to chronic renal failure.

Tubal factor infertility

Tubal disease accounts for 15-20 of cases of primary infertility and approximately 40 of secondary infertility. It represents the aftermath of pelvic infection or surgery resulting in tissue damage, scarring and adhesion formation. This can affect tubal function and result in either partial or total tubal occlusion. As the distal portion of the tube is commonly affected, fluid can accumulate within the tubes causing a hydrosalpinx. Functional competence of the fallopian tubes implies not just patency but also the integrity of the mucosal lining or the endosalpinx. As any damage to the fallopian tubes tends to be irreversible correction can be difficult. Due to current limitations in investigating tubal function it is only possible to assess the macroscopic appearance and patency of the fallopian tubes.

Heterotopic Ossification

Even with prophylactic treatment, HO does occur and in some instances can become disabling for the patient by limiting hip motion. Surgical excision should only be considered if hip motion is limited and even then must be decided upon on a case-by-case basis. Verification that the ossification process has subsided is important since resection in the active phase can result in an even more significant recurrence. Monitoring blood alkaline phosphatase and bone scan activity for stabilization are two accepted methods for determing the appropriate timing of resection, should it be contemplated. If resection is planned, a preoperative CT is helpful for preoperative planning. Resection of the bone is usually done through the original approach used for fracture fixation. Care must be taken when resecting bone because the sciatic and superior gluteal nerves can be entrapped in the bone or surrounding scar tissue. If done carefully, excision of the HO can result in an improved range of motion...

Islet Cell Neoplasms Neuroendocrine Tumors

Benign microcystic adenoma of the pancreas in an asymptomatic woman as revealed on magnetic resonance. Axial T2-weighted image shows a well-circumscribe high intensity lesion (arrow) made up of innumerable small cysts. Multiple internal septa coalesce in a central scar (curved arrow). Fig. 6. Benign microcystic adenoma of the pancreas in an asymptomatic woman as revealed on magnetic resonance. Axial T2-weighted image shows a well-circumscribe high intensity lesion (arrow) made up of innumerable small cysts. Multiple internal septa coalesce in a central scar (curved arrow).

Clinical Examination And Screening Techniques To Identify The Patient At Risk Of Foot Ulceration

Biological skin substitutes, also known as living skin equivalents (LSE), are commercially available. The LSEs are produced through tissue-engineering technology. Available for epidermal, dermal, and composite (epidermal and dermal) wounds, LSEs offer distinct advantages compared with traditional skin grafting as their use is nonin-vasive, does not require anesthesia, can be performed in an outpatient setting, and avoids potential donor site complications, such as infection and scarring (97). Two LSEs were approved for use in diabetic foot ulcers, Dermagraft (Advanced Tissue Sciences Inc, La Jolla, CA) and Apligraf (Novartis Pharmaceutical Corp., Basel). Dermagraft consists of neonatal dermal fibroblasts cultured in vitro onto a bioabsorbable polyglactin mesh, producing a living, metabolically active tissue containing the normal dermal matrix proteins and cytokines. Dermagraft has been shown to incorporate quickly into the wound with good vascularization and with no adverse...

Renal Transplantation

The surgical management of an injured transplanted kidney is a complex procedure. A very short vascular pedicle and ureter, dense scarring, and a fibrous capsule may prevent any attempts at the direct repair of parenchymal, collecting system, and vascular pedicle injuries. Grade 1-3 injuries can be managed nonope-ratively with adequate hydration and observation. Grade 4-5 injuries may require exploration with de-bridement and drainage or simply a subcapsular ne-phrectomy if associated with life-threatening bleeding. Isolated vascular injuries have a poor prognosis. Renal arteriography may be helpful with embolization of the main artery to stop bleeding or with more selective embolization to salvage part of the kidney. When renal graft injury occurs, saving the patient's life is the first priority but the saving of the graft is also very important to maintain renal function.

Traumatic Brain And Spinal Cord Injury

There have been efforts to demonstrate the efficacy of creatine in experimental models of TBI and SCI (Hausmann et al., 2002 Rabchevsky et al., 2003 Scheff and Dhillon, 2004). Surgically-induced cortical contusions representing the sequelae of human closed-head injury were performed in mice. These resulted in severe behavioral deficits, cortical tissue loss, neuronal loss in the hippocampus, and blood brain barrier damage. Intraperitoneal injection of creatine, 3 mg kg day up to five days before injury, significantly reduced the TBI tissue damage. Neuroprotection was also observed in TBI rats fed creatine. Mitochondrial membrane potential was significantly greater in creatine-treated rats than untreated animals, with reduced levels of reactive oxygen species in treated rats. Induction of mitochondrial permeability transition was significantly inhibited in creatine-treated TBI animals. In a subsequent study, creatine administration significantly lowered free fatty acid and lactate...

Pathology and Histology

Cutaneous lesions due to VZV begin with infection of capillary endothelial cells, followed by direct spread to epidermal epithelial cells. The epidermis becomes edematous, with acantholysis and vesicle formation. Mononuclear cells infiltrate the small vessels of the dermis. Initially, vesicles contain clear fluid with cell-free virus, but later the vesicles become cloudy and contain neutrophils, macrophages, interferon and other cellular and humoral components of the inflammatory response pathways. Subsequently, the vesicles dry, leaving a crust that usually heals without scarring. Cells infected with VZV show eosinophilic intranuclear inclusions with multinucleate giant cell formation (Fig. 2A). These changes are

Pathology and Diagnosis

Histopathologic changes are a combination ofvirus-induced alterations (cell ballooning, condensed nuclear chroma-tin, and nuclear degeneration) and associated inflammatory responses. Virus-induced changes are generally within the parabasal and intermediate cells of the epithelium. Multi-nucleated giant cells are also formed and a clear (vesicular) fluid containing large quantities of virus, cell debris, and inflammatory cells appears between the epidermis and the dermal layer. An intense inflammatory response is seen in dermal structures, particularly in primary infection, and is accompanied by an influx of mononuclear cells, as host defenses are mounted. With healing, the vesicular fluid becomes pustular and, then, scabs. Scarring is uncommon. Similar histopathologic findings are seen in mucous membranes. Perivascular cuffing and areas of hemorrhagic necrosis are also seen in the area of infection, particularly in organs other than skin. In the brain oligodendrocytic

Pathology and Pathogenesis

In humans, pathologic changes in the liver include swelling and necrosis of hepatocytes in the midzone of the liver lobule, with sparing of cells in the portal area and surrounding the central veins. Viral antigen and RNA are demonstrable by immunocytochemistry and nucleic acid hybridization in cells undergoing these pathologic changes, and cytopathology is mediated by direct viral injury. Hepatocytes may undergo apop-tosis. Inflammatory changes are absent or minimal, and patients with hepatitis who recover do not develop residual scarring or cirrhosis. The kidneys show acute tubular necrosis, probably the result of reduced perfusion of blood rather than direct viral

Genital tract malformations

Imperforate Hymen

And bowel at the site where the natural vagina would have been, and this cavity is then lined by a split-thickness skin graft taken from the thigh and applied to the space on a plastic mould. The anatomical result can be very successful and remarkably good sexually. A review of 1311 reported cases gave a success rate of 92 6 . However, there are a number of difficulties and disadvantages of this technique, not least the post-operative period, which is painful and sometimes protracted. The graft does not always take well and granulation may form over part of the cavity giving rise to discharge. Pressure necrosis between the mould and the urethra, bladder or rectum may lead to fistula formation, but the most important disadvantage is the tendency for the vagina to contract unless a dilator is worn or the vagina is used for intercourse regularly. It is therefore ideal to perform this procedure when sexual intercourse is desired soon afterwards because the procedure will fail if the...

Evaluation of Eyelid Malpositions

Basal Cell Carcinoma Eyelid

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

Uterine hyperstimulation

Several cases of rupture of uterine scars following misoprostol induction have been reported. A recent retrospective study found significantly more cases of uterine rupture or dehiscence following cervical ripening with misoprostol than when oxytocin or prostaglandin E2 were used. Misoprostol should not be used in women with uterine scars.

Surgical Treatment Sphincter Repair

There are three methods of repairing the sphincter apposition, plication reefing, and overlapping sphincteroplasty 37 . Apposition has classically been associated with low success rates 91 . Scar tissue excision was later implicated in the failure of the apposition technique 37 . More recently, in a study of 40 patients with sphincter trauma over a 15-year period, an end-to-end apposition was performed with excellent results 95 . The technique involves minimizing dissection of the injured muscle to preserve vascularity and the preservation of scar tissue to help anchor the overlapped muscle. The authors advocate the apposition repair because of its simplicity and effectiveness. Plication or reefing can be performed anteriorly (vaginal mobilization, external sphincter division, levator ani plication followed by puborectal-is and external sphincter repair, or posterior plication of the external sphincter and levators) 96 . In 1975, Parks described the postanal repair for incontinence...

Cicatricial Pemphigoid

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

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.

Luetic Chorioretinitis


Congenital or acquired syphilis can present as pigmentary retinopathy that resembles, in some aspects, advanced retinitis pigmentosa 13 . However, the retinal pigmentary changes are more varied and patchy, and the pigment deposits are in clumps with large patches of black pigment associated with the chorioretinal scars (Fig. 3.30). Interstitial keratitis is often

Squamous Cell Carcinoma

Mild Basal Cell Carcinoma

INTRODUCTION Squamous cell carcinoma is a malignant tumor that most commonly affects elderly, fair-skinned individuals. It arises from keratinocytes of the epidermis. Unlike the more common basal cell carcinoma, squamous cell carcinoma tends to arise in precancerous areas of skin alteration or in areas of skin damaged by chronic sun exposure, ionizing radiation, carcinogens (e.g., arsenic), psoralen plus ultraviolet A (PUVA) therapy for psoriasis, and the human papilloma virus. Intrinsic factors that may contribute to its development include xeroderma pigmentosum, oculocutaneous albinism, and immunodeficiency. Chronic skin dermatoses, inflammation, ulceration, and contracted scars also are associated with the development of this tumor. In fact, scarring of the skin is the most common intrinsic factor leading to this tumor in black patients. Lymphatic spread and perineural invasion are possible.

Necrobiotic Xanthogranuloma

Plaques with prominent telangiectasia, as deeper violaceous plaques, or as flesh-colored nodules. The lesions are usually inflamed and become ulcerated and undergo some degree of scarring. The nodules can cause loss of function of the eyelid with secondary lagophthalmos and corneal exposure and subsequent ulceration. Associated ocular findings include episcleritis, scleritis, keratitis, uveitis, and proptosis.

Neurophysiologic Investigations

Examination of the EAS muscle holds the central position in Podnar's and Vodusek's algorithm for electrodiagnostic evaluation of the sacral nervous system 104 . With the patient in a comfortable lateral position with knees and hips flexed, after grounded electrically at the thigh, a standard concentric needle EMG electrode is inserted into the subcutaneous portion of the EAS muscle to a depth of 3-5 mm under the mucosa, 1 cm from the anal orifice 66, 104, 117, 118 . Both left and right halves of the subcutaneous EAS muscle must be examined separately, starting on the side with the clinical evidence of sphincter dysfunction (episiotomy scar tissue, patu-lous anus). If partial or complete atrophy of the subcutaneous EAS muscle is appreciated, a concentric needle electrode can be introduced 1- to 3-cm deeper through the skin to evaluate spontaneous activity, recruitment pattern, and functional contractile capacity of the deeper EAS and 4- to 5-cm deeper for examination of the PR muscle....

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.

Other Diseases That Mimic Traumatic Injury

Traumatic Injuries

Newborns with severe EB may present with peeling and blistering (bullae) of the skin at intrauterine pressure points, particularly the elbows, knees, and ankles (Fig. 1). The lesions look strikingly similar to partial thickness burns and are treated with protective dressings. In older children, trivial trauma, such as a fall, may lead to large areas of partial-thickness (and sometimes full-thickness) skin injury that may be confused with an intentional burn injury. Fortunately, many children with EB have both a family and a personal history of chronic cutaneous scarring from past injuries that allows for the appropriate diagnosis. Patients with EB who present with severe scarring will develop pseudosyndactyly of the digits. In longstanding cases (usually beyond childhood), squamous cell cancer can develop in the chronically damaged skin. Children with Ehler-Danlos syndrome are not, in general, born with abnormal-appearing skin and do not develop burn-like lesions from trivial trauma....

Epidermal Innervation In Clinical Trials

Fig. 5. (A) Method to measure collateral sprouting of human epidermal nerve fibers. Following removal of a standard 3 mm biopsy tissue plug (left frame), the site heals by a process of granulation (right frame). Nerve fibers within the dermis are not able to penetrate the collagen scar that forms in the healed biopsy site. The only mechanism for the re-epithe-lialized epidermis to become reinnervated is for fibers to sprout from the epidermis peripheral to the healed 3 mm incision line into denervated central zone. This collateral sprouting can be assessed by taking a larger concentric biopsy centered on the healed, original 3 mm biopsy site (dotted line, right panel). (B) Example of collateral sprouting. The yellow arrow indicated the location of the original 3 mm biopsy incision. Epidermal nerve fibers peripheral to the incision line grow into the central denervated epidermis by a process of collateral sprouting. These sprouts frequently grow along the epidermal side of the...

Structural uterine abnormalities

The prevalence and reproductive implications of uterine anomalies in the general population have not been clearly established. Hence, it is difficult to assess the contribution that congenital uterine anomalies make to RM. The prevalence of uterine anomalies among women with RM has been reported to range between 1.8 and 37.6 30 . This wide range reflects the differences in criteria and techniques used for diagnosis and the fact that available studies have included women with two, three or more miscarriages at both early and late stages of pregnancy. A recent retrospective review of reproductive performance in patients with untreated uterine anomalies has suggested that these women experience high rates of miscarriage and preterm delivery 31 . Open uterine surgery is associated with post-operative infertility and carries a significant risk of uterine scar rupture during pregnancy. These complications are less likely to occur after hysteroscopic surgery but no randomized trial assessing...

Folliculitis decalvans

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

Ocular Disease Caused by DNA Viruses

Adenovirus is probably the most common DNA virus to cause eye disease. Three common ocular syndromes have been identified. Simple follicular conjunctivitis occurs with infection by many adenovirus types and may be subclinical. Pharyngoconjunc-tival fever typically follows infection with adenovirus types 3, 4, and 7. As the name implies, patients have pharyngitis, conjunctivitis and fever, and may be misdiagnosed as having influenza. Epidemic keratoconjunctivitis, most often caused by adenovirus types 8, 19 and 37, is a highly contagious syndrome with significant morbidity. The conjunctivitis can be severe (Fig. 3) associated inflammatory conjunctival membranes can permanently scar the eyelids to the globe. Corneal involvement begins as a punctate epithelial keratitis and may proceed to a large central epithelial ulcer. Stromal keratitis presents about 2 weeks after the conjunctivitis as multifocal subepithelial corneal infiltrates, and causes both foreign body sensation and reduced...

Herpes and Varicella Zoster

Impetigo Eyelid

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

Ehlers Danlos syndrome

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

Apocrine Hidrocystoma

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

Hypothesis of Pathophysiology

Pelvic radiotherapy can play an important role in the pathogenesis of functional disturbances of continence 40-42 . In patients treated with pelvic radiotherapy for prostate, gynecological, bladder, anal, or rectal cancer, the incidence of FI is 3-53 43 . This is despite progress in irradiation procedure. The patient's age and presence of anal symptoms are described as risk factors. In their review article, Putta and Andreyev 43 assessed that rectal cancer seems to present the highest incontinence rate, probably due to the additive effects of surgery to those of radiotherapy. In this work, only 8-56 of incontinent patients were found affected in their quality of life. The authors interpreted this finding because patients do not feel or seem ill, will not report symptoms, as they believe they are inevitable consequences of radiotherapy treatment, of being old, or that there is nothing that can be done. With the aim of investigating bowel dysfunctions, Peeters et al. 44 sent a...

Role Of Mitochondria In Telodendria

Following the axon out to its termination we ultimately arrive at the synaptic 'bouton', 'knob' or 'end foot' (Figure 1.10). In some cases this termination is far more elaborate than a simple swelling and may form a complicated claw or other intricate structure. Within the termination the electron microscopist can usually detect mitochondria and synaptic vesicles other organelles are, however, scarce. We shall return to the structure of synapses later in this chapter and, in much more detail, in Chapters 15, 16 and 17. damaged regions and clear away necrotic material and in so doing they leave a glial scar. Astrocytes invade injured regions of the CNS (reactive gliosis) and are consequently responsible for the formation of glial scars (as mentioned above). There is evidence (as we shall see in Box 19.2) that astrocytes, at some stages in their life, are able to manufacture and secrete some

Molluscum Contagiosum

Verrucae Vulgaris Inclusion Bodies

Cheesy material that is easily expressed. Rarely a single lesion will grow as large as 3 cm in diameter (a so-called giant molluscum). Lesions may be single, but more typically are multiple (less than 50) because of the autoinoculable nature of the infection. Lesions may occur in the periocular region and, if found on the eyelid margin, may produce a follicular conjunctival reaction. Other ocular manifestations include epithelial keratitis, pannus formation, conjunctival scarring, and punctal occlusion. Primary conjunctival or limbal lesions may rarely occur. Patients who have acquired immunodeficiency syndrome often have an atypical presentation of molluscum contagiosum. Disseminated disease may be present and lesions are often more confluent. Such patients may have 30 to 40 lesions on each eyelid.

Pyelonephritis and Pyonephrosis

DMSA scan showing multiple photopenic areas consistent with renal scars (Courtesy H.G. Rushton) Although VCUG and renal US are necessary investigations that must be performed following the diagnosis and treatment of UTI in children, controversy persists regarding the utility of nuclear medicine renography to diagnose acute pyelonephritis. In general, most investigators believe that dimercaptosuccinic acid (DMSA) scanning could be safely omitted in children with mild to moderate infection however, patients with signs of upper urinary tract infection, including high fever (> 38.5 C), flank pain, or abnormalities detected on US, should undergo renography (Naber et al. 2001 Deshpande and Jones 2001) (Fig. 8.16). Not only will this act as a baseline, but also acute photopenic areas detected on DMSA can be subsequently reevalua-ted in order to determine if renal scarring has occurred.

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.

Acetabular Reconstruction Fixation Methods in Associated Fracture Patterns

We emphasize that the choice of approach is determined by the personality of the fracture, and T fractures can be very problematic. As Letournel stated himself, while the majority of fractures can be treated via a posterior approach, occasionally a supplemental anterior approach is needed. We concur in that a single approach is not the goal, and, if needed, a second approach should be done to ensure an accurate reduction. Whether one begins with an anterior or posterior approach, the ability to intraoperatively concede that a single approach may not be enough to do the job right is far more admirable than struggling with one approach. Likewise, it is preferable to have two surgical events and two surgical scars instead of one unacceptable treatment.

The Use of Diuretics in the Treatment of Ascites and Edema in Hepatic Cirrhosis

A great deal of clinical and experimental evidence is consistent with the classic underfill hypothesis which is outlined in Fig. 1. Hepatic pathology produces scarring, fibrosis, and nodular hypertrophy of the liver. These anatomic alterations restrict the flow of blood out of hepatic sinusoids producing post-sinusoidal venous blockade. Hydrostatic pressure within the sinusoids increases and the higher pressures are transmitted into the splanchnic veins and mesenteric capillary beds. These elevated hydrostatic pressures accelerate the filtration of fluid into the hepatic interstitium (spaces of Disse). The epithelium lining hepatic sinusoids is very permeable to albumin (it has a low albumin reflection coefficient), so that the fluid which accumulates in the hepatic inter-

Preoperative Assessment for Laparoscopic Simple Nephrectomy

When one is starting on the learning curve of laparoscopic simple nephrectomy, it is prudent to begin with kidneys that are affected by a minimal amount of inflammation, such as those with vascular disease causing renovascular hypertension, or those involved in symptomatic, chronic obstruction without infection. Smaller specimens like those resulting from reflux nephropathy are also ideal for the inexperienced laparoscopic surgeon. As the surgeon becomes more skilled in laparoscopy, large kidneys (hydronephrosis or ADPKD) that are more difficult to mobilize and dissect can be treated. The most difficult kidneys to treat laparoscopically, those affected by infections, previous surgery, or global scarring fibrosis, should be reserved for surgeons with a significant amount of laparoscopic experience. This is especially true in cases of xanthogranulomatous pyelonephritis (XGP) or renal tuberculosis.

Effects on Particular Organs or Organ Systems

Mechanisms that impair the release of triglycerides to the blood. Carbon tetrachloride and ethanol are among the substances that can cause this. Necrosis is caused by carbon tetrachloride, which forms free radicals in the liver, as well as by other halogenated hydrocarbons. Cirrhosis is the formation of scar tissue in the liver. It is also caused by carbon tetrachloride, although ethanol is most commonly associated with this condition. Although there is evidence to the contrary, the effect of ethanol may be related to nutritional deficiency associated with alcoholism. Cholestasis is an inflammation of the ducts carrying bile or a decrease in bile flow by other mechanisms. There are many types of liver cancer, and many chemicals are known to cause cancer in laboratory animals. The role of chemicals in human liver cancer is less clear, except for the notable case of vinyl chloride, which is known as a potent cause of angiosarcoma.

The umbilicus

The umbilicus is essentially a scar made from the remnants of the umbilical cord. It is situated in the linea alba and in a variable position depending on the obesity of the patient. However the base of the umbilicus is always the thinnest part of the anterior abdominal wall and is the commonest site of insertion of the primary port in laparoscopy. The urachus is the remains of the allantois from the fetus and runs from the apex of the bladder to the umbilicus.


Alphaherpesviruses typically cause localized lesions, particularly of mucosal surfaces of the respiratory and genital tracts or, less commonly, the skin. Progression is characterized by the sequential production ofvesicles, pustules, and shallow ulcers that become covered by a pseudomembrane and heal after 10-14 days, usually without scar formation (Figure 1).


Treatment of BCCs includes surgical excision, curettage and electrodesiccation, cryosurgery, Mohs' micrographic surgery, and ultrapulsed CO2 laser treatment. These methods, although effective, have economic, physical, and psychological implications, primarily because of the risk of scarring and recurrence. New, more inclusive selection criteria for surgery, combined with more effective neo adjuvant chemotherapy based on 5-fluoruracil and topically applied 5 imiquimod, are proving useful in reducing scarring. Radiotherapy is now avoided completely.

Brow Ptosis

TREATMENT Several procedures are available for the correction of brow ptosis. The choice depends upon a number of factors (i) the sex of the patient and, therefore, the desired brow contour (ii) the relative position of the brows (iii) the density of the brow cilia (iv) the presence of associated deformities such as crow's feet and prominent transverse glabellar folds and (v) the height of the scalp hair line or presence of male-pattern baldness. Each procedure has its advantages and disadvantages, and selecting the most appropriate operation must be individualized for each patient. The brow pexy is the simplest technique where the deep fascia of the frontalis muscle is fixed to periosteum to prevent the action of gravity from pulling the brows downward. More recently the trans-blepharoplasty Endotine (Coapt) has made this procedure more effective. In the direct brow lift an ellipse of skin is removed from above the brow, leaving a fine scar just above the brow hairs. However, this...

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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