Most Effective Scars Treatment

The Scar Solution

The Scar Solution, an e-book authored by Sean Lowry, provides effective, yet natural and affordable, solutions to lessen the appearance of scars. Sean Lowry is not just your average author of an e-book. She can empathize with her readers because she also once suffered from the shame of scars on both the physical and psychological levels. 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. Scars are never the same for all. Different people may have scars on different parts of their body. The cause of scars too is never the same. Being fully aware of this fact the author of this program has provided complete support to users. Users have the option of contacting the author herself and seek her guidance on how to remove scars fast naturally. Read more...

The Scar Solution Natural Scar Removal Summary


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My The Scar Solution Natural Scar Removal Review

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All of the information that the author discovered has been compiled into a downloadable book so that purchasers of The Scar Solution Natural Scar Removal can begin putting the methods it teaches to use as soon as possible.

This ebook does what it says, and you can read all the claims at his official website. I highly recommend getting this book.

Scarring and Tympanosclerosis

Tympanosclerotic Plaques

A normal TM is often described as pearly in appearance. In fact, it is almost transparent. Scarring, which occurs in the middle fibrous layer, destroys this lucency. Scarring may result from repeated effusions or In some patients, there may be peripheral scarring with thin central areas of the drum. These thin areas lack the middle fibrous layer and usually represent healed perforations. Tympanosclerosis is a severe form of scarring a dense white plaque of hyaline substance (again, Fig. 5.3), perhaps even thickly calcified. These deposits are located in the middle layer of the drum and probably result from chronic, thick mucoid middle ear effusion ( glue ear ) that has finally dried up. It is important for the primary physician to recognize scarring and tympanosclerosis. They are sometimes mistaken for fluid, infection, perforation, or even cholesteatoma. Careful examination with the pneumatic otoscope, coupled with experience, will help.

Correlation With Pathology

The adult female breast is a large, modified sebaceous gland that consists mostly of fat, fibrous septa, and glandular structures. The weight range for a normal, mature female breast is 30 grams to over 500 grams, depending on the woman's body habitus. The breast typically comprises 15 to 25 lobes that are divided into multiple lobules, each containing 10-100 terminal milk-secreting alveoli. Numerous tiny milk-transporting ductules combine to form a single lactiferous duct that exits each lobule. About 15 to 25 such ducts converge at the nipple. The composition of the breast varies from individual to individual and with age and other factors. Pregnancy, lactation, menstruation, and menopause all introduce characteristic changes in breast physiology. For example, in postmenopausal involution of the breast, the lobular and alveolar structures regress and the vascularity of the intervening connective tissue is reduced. Eventually only small, occasional islands of functional breast...

Control and treatment

The prevalence of HEPC on carp farms varies from less than 1 10,000 to over 70 . It appears during low to moderate temperatures from late winter to early summer. Skin tumours are transient - they usually desquamate after some time and scar tissue may develop. Hines et al. (1974) noted the disappearance of these lesions as the water warmed up during the summer. Under experimental conditions (Sano et al., 1993a) regression occurred after shifting the water temperature from 7.5 C to 20-30 C but not after the raise from 7.5 to 15 C. Sano et al. (1991) noted HEPC recurrence in experimentally infected carp after 7.5 months. Reappearance has long been known from pond environment (Schaperclaus, 1941). Young carp develop these tumours more rapidly than older ones (Sano et al., 1991). Herpesvirus epidermal proliferation in carp does not generally cause mortality.

Antimitotic Application

Some surgeons advocate mitomycin C, an antimitotic agent, used as a topical application to discourage cell proliferation so as to reduce the amount of mucosal scar tissue that is the commonest cause of failure (Camara et al. 2000). You and Fang (2001) found that the topical application of mitomycin C was beneficial in patients undergoing an external DCR yet Zilelioglu et al. (1998) found it to be of no benefit. The only study of an antimetabolite in laser DCR was by Bakri et al. (2003) who found that the topical application of 5 FU failed to increase the patency rates in ELDCR.

Myocardial Regeneration

MCSs isolated from bone marrow also appeared to undergo differentiation into cardiomyocytes (27). Furthermore, cardiomyocytes derived from mesenchymal stem cells transplanted into ventricular scar tissue have shown to integrate with the myocardium and improve left-ventricular function (28,29). Several studies also supported the notion that adult bone marrow stem cells can migrate into the heart for myocardial regeneration. Administration of cytokines can expand and mobilize bone marrow stem cells into circulation. A 250-fold increase in circulating bone marrow stem cells was induced in mice after myocardial infarction with the combined use of SCF andG-CSF (24). This cytokine therapy resulted in a new brand of myocardium, consisting of myocytes and blood vessels, occupying 70 of the infarcted area, and improving cardiac hemodynamic functions. These experiments demonstrated the capacity of adult bone marrow stem cells to give rise to new myocytes, endothelial cells, and smooth muscle...

Body Architecture

When skin and the underlying tissue is wounded, the processes of repair come into operation. This includes the division of fibrob-lasts and other cells, the synthesis of collagen, and the renewal of a vascular supply. Wound repair, as well as blood clotting, is an essential mechanism for animal's ongoing survival. It is possible that the additional reserves of cell division that we see in fibroblasts, and some other types of cell, is an insurance against excessive tissue damage, which might otherwise be fatal. Although the repair of wounds is generally efficient, it has its limits. Major wounds leave abnormal scar tissue, often with inadequate blood and nerve supply. When major nerves are severed they cannot regenerate. Although broken bones will rejoin, the loss of part of a limb, such as a finger, cannot be replaced by regeneration. Some vertebrate species, such as amphibians, can regenerate lost parts quite effectively, but this ability was lost during mammalian evolution. and...

Sexual Reproductive Issues

Even in today's postsexual revolution society there is uneasiness in talking about sexual concerns. Whereas many patients feel comfortable in bringing up the subject of sex, others do not. In the interview process the nurse can simply ask if there are sexual concerns, questions, or dysfunction. This allows the patient to express such issues if they exist. It also further assesses the overall quality of life that the patient experiences in living with the complications of IBD. Alterations in body image (from steroids, surgical scars, fistulas, or ostomies), pain, and fatigue can alter sexual functioning. Optimizing medical therapy to gain remission and steroid-sparing are the primary goals with this issue. Surgical intervention may be necessary support groups, ostomy nurses, gynecologists, and urologists may be appropriate referrals. Often patients need an ear to talk openly to about this delicate topic in a nonthreatening environment.

Worksheet 63Prosecutors Investigative Questions

Actually, there are a few people I know who haven't been shocked or repulsed by my scars. That thought is overgeneralizing. My family seems to have gotten used to my scars. If they can, it's certainly possible that others could do the same especially if they cared about me. If someone really likes and cares about me, she ought to be able to look past my scars.

Porphyria Cutanea Tarda Diagnosis

The major clinical feature in porphyria cutanea tarda (PCT) is fragility of sun-exposed skin which causes the formation of blisters and erosions after minor trauma, particularly on the backs of the hands. Chronic skin damage may lead to scarring and thickening of the skin which resembles scle-roderma. Skin lesions are accompanied by liver abnormalities which vary from mild portal inflammation to cirrhosis. In patients with long standing untreated PCT there is an increased incidence of hepatocellular carcinoma. Neurological symptoms do not occur in PCT. Alcoholism and use of estrogens are precipitating factors of PCT.

Treatment of Acne General Considerations

Androgenization signs in female patients with acne tarda 20, 21 or patients with signs of acne inversa may necessitate an alternative treatment. The compliance of the patient is an additional important parameter for the therapeutic strategy to be considered and its success. Skin type (dark skin tends to postinflammatory hyperpigmentation) and, especially, the tendency for scar formation play a role in the selection of treatment 22 . Two to 7 of the patients with acne experience a severe course associated with considerable scarring. A severe course associated with the presence of potential generators of physical and psychotic scars may require a therapeutic regimen based on systemic drugs 3, 18 (table 1).

Voltage Mapping Guided Catheter Ablation

Intraoperative studies of patients with ischemic heart disease have shown that circumferential ablation of ventricular scar and or ablation connecting scar to an anatomic boundary is a successful therapy for ventricular tachycardia 51,52 . This substrate-based ablation approach eliminates scar-related exit sites and or isthmuses of the ventricular tachycardia re-entry circuit. In patients with ARVC D, fibrofatty replacement of the RV myocardium creates scars that are regarded as the arrhythmogenic disease substrate 2, 4, 5, 25 . The histopathologic arrangement of the surviving myocardium embedded in the replacing fibrofatty tissue may lead to non-homogeneous intraventricular conduction predisposing to reentrant mechanisms 42 . Hence, ventricular tachycardia in ARVC D is the result of a scar-related macro-reentry circuit, similarly to that observed in the postmyocardial infarction setting. This explains why RV voltage mapping-guided catheter ablation is successful in patients with ARVC...

Electroanatomic Voltage Mapping Beyond Traditional Imaging

The finding that significant loss of myocardium results in the recording of low-amplitude, fractionated, endocardial electrograms has been well established by intraoperative mapping 18 , conventional endocardial mapping 19 , and 3-D electroanatomic mapping technique 20-23 in patients after myocardial infarction who have ventricular scar. Similar findings have been reported in patients with ARVC D, in whom 3-D electroanatomic voltage mapping by CARTO may differentiate regions in the RV with scar from areas without scar 24, 25 . The hallmark pathologic lesion of ARVC D is a loss of the myocardium with replacement by fibro-fatty tissue of the RV free wall but sparing of the endocardium 2, 4, 5 . The myocardial atrophy accounts for variable degree of RV wall thinning, with areas so thin as to appear completely devoid of muscle at transillumination. 3-D electroanatomic voltage mapping has the ability to identify areas of myocardial atrophy and fibrofatty substitution by recording and...

Superior Gluteal Flap

Candidates include patients who fail qualification for implants due to prior chest-wall irradiation or implant anxiety or who have abdominal scars precluding TRAM reconstruction. Such scars may have resulted from laparotomies, enterotomies, previous abdominoplas-ties, liposuction, or TRAM harvests. This flap may represent the only autogenous option in thin patients who lack sufficient abdominal or lateral thigh tissue for unilateral or bilateral reconstruction. Like its counterpart, the inferior gluteal flap is indicated in rare patients who refuse prosthetic reconstruction and who are not candidates for either TRAM, lateral thigh, or latissimus flaps. Although the length of the donor inferior gluteal vessels enable anastomosis to the more forgiving thoracodorsal pedicle and the donor site scar is the least conspicuous of any autogenous option, harvest necessitates sacrifice of the gluteal motor nerve, occasional sacrifice of the posterior cutaneous nerve, and close dissection to the...

Magnetic Resonance Imaging Of The Breast

The sensitivity of contrast-enhanced MR imaging approaches 100 percent in the detection of invasive breast cancer when compared to mammography and physical examination.35,39,41 The specificity of breast MR imaging ranges from 37 to 97 percent.39,41,42 This wide range is attributed to the overlap in contrast enhancement of benign and malignant lesions. Higher specificity for breast MR imaging can be achieved using a dynamic contrast-enhanced technique with three-dimensional imaging. On dynamic contrast-enhanced studies, malignant lesions typically exhibit rapid enhancement, whereas benign lesions show slower or no enhancement. False-positive enhancing lesions include fibroadenomas, sclerosing adenosis, radial scars, mastitis, atypical hyperplasia, lobular neoplasia and normal breast tissue during various phases of the menstrual cycle.35-37 Magnetic resonance imaging is also capable of demonstrating mammographically and clinically occult in situ carcinoma.39-46 Highresolution...

Management options

In women with corrected scoliosis, the major problem for the anaesthetist is provision of regional analgesia and anaesthesia. The most common means of correction of kyphoscoliosis is with Harrington rods or with the newer adaptations, Luque and Cofrel-Duousset instrumentation. Each technique involves metal instrumentation and bone grafting. Although preservation of the L5 S1 interspace is a cardinal orthopaedic rule, instrumentation and grafting may extend down to L4 5 in up to 20 of cases. The level of skin scar is a poor guide to the level of fixation, and therefore operation notes and or X-ray film are extremely helpful during antenatal assessment. If there are no pre-pregnancy X-ray films available and there is doubt about the extent of instrumentation of the lumbar spine, relevant radiography may be performed during the third trimester of pregnancy. Successful insertion of both epidural and spinal needles is well described in women with Harrington rod fixation, but women should...

What causes an MS plaque

Damaged, but they are relatively preserved as compared with myelin. After the initial insult by these cells, scarring begins. This process varies greatly from one individual to another. Curiously, the macrophages contain hormones like brain-derived nerve growth factor that should stimulate repair. The macrophage also secretes another hormone that stimulates scarring (T-cell growth factor beta-1). The invading cells seeking to remove some unknown enemy virus or protein seem prepared to help in rebuilding the damaged tissue. Later in the development of the plaque, scarring occurs. It is this scarring that makes the plaque hard (sclerotic). In summary, the plaque is an area of intense inflammation with myelin damage where the nerve fibers are relatively preserved and show variable amounts of scarring.

Free Transverse Rectus Abdominis Myocutaneous Flap

And fat necrosis, and are inherent to the procedure's secondary blood supply and volume constraints.57'66'73-76'84-86 These complications may impose prolonged wound healing and considerable delay in the therapeutic sequence. Although the free TRAM procedure requires greater technical proficiency and a slightly longer operating time, the flap has unparalleled vascular reliability and versatility, and is the flap of choice in high-risk patients. These include obese patients, smokers, and those patients with prohibitive scars or who have had prior radiation treatment.73-76 The only absolute contraindications to free TRAM reconstruction include prohibitive scarring, violation of the inferior epigastric blood supply from previous abdominoplasty, suction lipectomy, extended Pfannenstiel's incision, or previous TRAM procedure. Pre-existing medical conditions may limit the patient's ability to tolerate 4 to 6 hours combined anesthesia time. This should be addressed preoperatively.

And Cold Instrument Surgery

Concomitant use of instruments such as the otodrill and microrongeur may be more effective in removing thick bone and less painful for the patient (Kong et al. 1994). In addition, using endoscopic instruments instead of laser vaporization to open the lacrimal sac may reduce scarring and improve patency rates (Szubin et al. 1999). An excessively tight stent may cut through the cana-liculus as well as the skin in between them. The raw surfaces may heal with a web, which buries the stent. This usually results in scarring and may disrupt the lacrimal drainage pump system. A migrated stent can be retrieved from the nose by cutting one of the tubes that forms the loop before the sleeve or knot. Premature loss of silicone stents may also occur from the knot becoming loose.

Conjunctivodacryocystorhinostomy with Jones Tube Intubation

In some instances, common punctum reconstruction cannot be accomplished because of extensive scarring involving the lacrimal sac or displaced lacrimal bone. Conjunctivodacryocysorhinostomy (CDCR) requires the placement of a Jones tube or similar bypass stent from the caruncle region directly through the lateral nasal mucosal wall following a large osteotomy. Prior to surgery, the patient requires counseling on the need for personal care of the tube and possible revision of the tube position.

Balloon Intracavitary Catheter Insertion

We insert the MammoSite either with the scar-entry technique (SET) or the lateral trocar tunneling technique. In the SET a 11 blade is used to reopen the lumpectomy scar approximately 0.75 cm under local anesthesia. The seroma is rarely more that 12 cm deep to the lumpectomy scar, making entry into the seroma easy. After the blade nick, a hemostat or Kelly clam is inserted under ultrasound guidance into the wound and gently opened, and this process repeated until a gush of seroma fluid emanates out of the hole. All the seroma is expressed with the hemostat in place. Immediately upon removal of the hemostat, it is replaced with the deflated MammoSite catheter, checking its position using the ultrasound. The balloon is inflated while the ultrasound image is observed. After the balloon is inflated, Steristrips are placed across the rest of the lumpectomy scar so that the wound does not propagate causing a dehiscence. Fig. 9.28 After the template is removed, the physician and physicist...

Preoperative abnormalities

Frictional or other trauma causes the formation of bullae in the dermis and mucous membranes.When healing takes place, scarring occurs.There appears to be a decreased number, or an absence, of anchoring fibrils in the dermis, together with an increase in collagenase activity in the blistered skin. 2. The scarring may result in flexion contractures of the limbs, fusion of digits, contraction of the mouth, and fixation of the tongue.

Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is recurrent inflammation of the apocrine sweat glands, particularly those of the axilla, genital, and perianal areas. It can result in obstruction and rupture of the duct and secondary infection. The lesions generally drain spontaneously, with formation of multiple sinus tracts and with hypertrophic scarring. Although not initially infected, the lesions frequently become secondarily infected. Often, patients with HS also are afflicted with acne, pilonidal cysts, and chronic scalp folliculitis thus, giving rise to the term follicular occlusion tetrad.

Problemsspecial considerations General problems of malignancy

These may be local (compression effects, local invasion, scarring, etc.), metastatic (e.g. liver involvement etc.) or general (malaise, anaemia, endocrine effects, weight loss and cachexia). There may also be problems relating to treatment, e.g. cytotoxic drugs, steroids, fibrotic effects of radiotherapy. There may be coagulation abnormalities or increased risk of deep-vein thrombosis necessitating anticoagulant therapy. Electrolyte disturbances may be a feature of the malignancy (e.g. hypercalcaemia) or its treatment.

Case Reports 21 Case

The onset of vitreous haemorrhages and two subsequent episodes of vitreitis and chorioretinitis in RE. He has been treated with systemic and subtenon's steroids. He tested positive for HLA B51 antigen, while a CT and NMR of the brain was negative. A fluorescein angiography disclosed a chorioretinal scar without signs of retinal vasculitis. A diagnosis of BD was made upon the systemic symptoms. No treatment was required at our first observation, neither for systemic nor for ocular symptoms. A relapse of anterior uveitis without retinal involvement was diagnosed 3 years later and treated with topical steroids and mydriatics. During the subsequent six years of follow-up no new ocular lesions occurred. Nevertheless the recurrence of transitory hemiparesis, oral ulcers, arthralgia and the onset of gastrointestinal symptoms (diarrhea, rectorrhagia) suggested the need for immunosuppressive therapy. Therefore cyclosporine A (3 mg kg day) was administered for the following six months, and,...

Access to Intrahepatic Ducts Provided by Partial Hepatectomy

In figure B it was chosen to do a cloacal anastomosis rather than a double-barreled anastomosis because the ducts were close and the intervening scar small. Although the center of the anastomosis may scar, the long lateral horns are mucosa to mucosa and effectively a double-barreled anastomosis results.

Materials And Methods

This case series study has been performed in 1999. Seventeen patients, who had at least one and half year of follow up at our clinic and presented macular edema were consecutively selected and included in the study. They were followed up for two more years with ophthalmic examinations and fluorescein angiographies (FA). Patients having initially optic atrophy, retinal vascular necrosis, and macular scars were not included.

Anthony P OliveMD and George D FerryMD

The child with Crohn's disease (CD) poses special challenges for all involved, including parents, extended family, school personnel, and medical caretakers. The unique psychosocial and physical changes encountered during childhood and adolescence make this period of time quite vulnerable to the many complications associated with this disease. The resulting physical and emotional scars can be permanent, with lasting repercussions into one's adult life. As such, the therapeutic goals in pediatric CD can be broken down into the following three basic principles (1) promote physical growth and development, (2) promote psychosocial growth, and (3) promote and improve quality of life. The strategies employed to achieve these goals are diverse and tailored to the individual, and include traditional medical and surgical approaches, nutritional therapies, psychological counseling, peer interaction opportunities, and aggressive involvement of the child's family and caretakers. Surgical...

STEP 4Common bile duct resection

Except in the very thin patient, it is very difficult to adequately excise the nodal tissue in the porta hepatis without resecting the common bile duct. This is particularly true if the patient has recently had a cholecystectomy, so that the scars from such surgery further complicate identification of nodal tissue and tumor. Resecting the common bile duct also allows the most certainty of resection of the cystic duct-common duct junction. Furthermore, resecting the common duct allows the safest dissection and inspection of the portal vein and hepatic arteries behind the tumor and in the hilar area.

Female Sexual Function

In those who have undergone vaginal surgery as part of their reconstruction, scarring is a common problem and can lead to stenosis and dyspareunia. The increasing recognition of the efficacy of vaginal dilatation alone has made this the initial treatment of choice 14 , as failure will not have a detrimental effect on vaginal perineal tissue. Nevertheless, there are cases where it is almost impossible to provide an adequate vagina without transferring healthy tissue such as bowel or skin. Hall et al. report that 8 out of 17 patients for whom enough information was available had vaginal scarring and impaired vaginal function. It was not known what effect this had on intercourse. It was felt that much of the problem lay in the unoestrogenised tissue that was operated upon in infancy. They recommended the deferment of vaginoplasty to the post-pubertal period if possible 9 . In those patients who have undergone repeated vaginal operations, the failure rate of subsequent operations is...

Implantation Techniques

There are three general placement methods the lateral techniques (either open or closed), and the scar entry technique or SET. The guidelines are summarized below. deflated MammoSite. The seroma is allowed to drain. The MammoSite is expanded using the 5-10 contrast agent saline mixture. No external suture is required to hold the balloon in place. The external portion of the MammoSite is then dressed. Alternatively, the device can also be implanted after lumpectomy surgery through the surgical scar. The procedure is referred to as the SET method. It is accomplished under local anesthesia by opening the surgical scar and carefully dissecting down to the lumpectomy cavity. Once the lumpectomy cavity is penetrated, the seroma fluid in the cavity is drained. The MammoSite is then inserted through this opening. The MammoSite is inflated with fluid to fill the cavity. Stitches on either side of MammoSite along the surgical scar are placed to prevent propagation of the wound opening.

[9 Sets of Transposon Generated Sequence Tagged Mutants for Structure Function Analysis and Engineering

Various genetic strategies are available to isolate libraries of mutants containing small in-frame sequence tags for proteins in bacteria (see reviews by Man oil and Traxler, 2000 Manoil, 2000 Gallagher et al., 2006). Thes e strategies exploit the ease of gen erating trans poso n inser tions in vitro or in vivo. Depending on the method used, one might isolate numerous different insertions into a gene of interest and then exploit those mutants to study topics as diverse as gene regulation, the role of the gene product for particular pathways, or protein structure and folding. Suitable transposon insertions are usually identified initially via the expression of a translational fusion protein such as -galactosidase or alkaline phosphatase (LacZ or PhoA). A subsequent processing step removes the majority of the transposon sequences but leaves behind a scar at the original site of the insertion, resulting in additional residues inserted into the polypeptide during translation. The size of...

Relapsing polychondritis

A rare, autoimmune, systemic inflammatory disease in which there is gradual destruction of the cartilage of the nose, ears,joints, larynx, and trachea. Inflammation, oedema, and scarring of the tracheal rings results in tracheal narrowing and dynamic airway obstruction.The condition usually presents between the ages of 40 and 60 years.Anaemia, early-onset, laryngotracheal stricture, saddle nose and systemic vasculitis are associated with a poor prognosis (Trentham & Le 1998).Anaesthesia may be required for surgical reconstruction of the nose or ear, or occasionally for treatment of upper airway obstruction, or lower airway collapse. In severe cases endobronchial stenting may be required (Faul et al 1999). Occasionally, patients with relapsing polychondritis become pregnant. In a series of 25 pregnancies in 11 patients, although about 30 of patients had a flare up of the disease that required treatment, none had significant involvement of the respiratory tract (Papo et al 1997).

Postoperative Care and Complications

Although conjunctivorhinostomy with flaps of the lateral nasal wall and or the conjunctiva with additional temporary stenting are commonly considered to be most effective in managing severe tear-duct dysfunction, they may be associated with secondary-intention healing and severe scarring. The most critical area for the development of a restenosis is the posterior wall of the new conduit next to the osseus perforation and the anterior ethmoid. Support of the lacrimal bypass by a cartilage-containing nasal septal flap provides autologous stenting of this area. Consequently, the risk for restenosis may be reduced.

To Prevent Complications and How to Treat Them

Closure of the newly created ostium may happen when bone has been left near the common canalicu-lus, serving as a scaffold for obliterative scarring. Intraoperative removal of the bone surrounding the common canaliculus, at the superior third of the lacrimal sac, prevents the bone to act as a scaffold for fibroblast ingrowth, and thus, obliterative scarring. Once the drainage is closed, leading to recurrent epiphora, it probably may need a revision surgery. Topical use of mitomycin C (MMC) is said to modulate the scarring process, preventing the occlusion 11 . Application of artificial tears (eyedrops) containing steroids and antibiotics help to maintain the patency. In our hands, the best prevention of obliterative scarring consists in creating a large ostium at the level of the common canaliculus.

Management of Failures of Laser DCR

The most common cause of failure is stenoses of the rhinostomy. In common with surgically created stomas in other parts of the body, the dacryocystorhinostomy also shrinks. The purpose of creating a large rhinostomy is to allow for the shrinkage but even so the nasal mucosa may grow over the bony opening and heal completely without any visible scarring. Other causes of obstruction of the internal nasal opening include granulations, adhesions, and synechia. Revision laser DCR surgery may be indicated and is easily performed with good success rates (Kong et al. 1994 Mirza et al. 2002). Some patients may ultimately require an external DCR.

Retinaldehyde and Retinylp Glucuronide

Finally, in patients with skin types III-VI retinoids can reduce the postinflammatory hyperpigmentation. They have in addition favorable effects on skin scarring. In summary, the following recommendations can be given for the use of topical retinoids (a) they should be first choice for most types of acne forms including acne comedonica and acne papulopustulosa grade I-II (b) combination of topical antimicrobials in inflammatory acne with topical retinoids is more efficacious (c) topical retinoids are essential for maintenance treatment (d) retinoids have a skin-repairing effect (scarring, hyper-pigmentation).

Endoscopic Therapy

After resuscitation is complete and pharmacologic therapy has been initiated, the focus shifts to endoscopic therapy. Before endoscopic therapy, gastric lavage may be required so that blood and clots can be removed from the stomach for improved visualization. The two endoscopic options for controlling variceal hemorrhage are (1) endoscopic sclerotherapy (ES) and (2) EVL. ES is successful in controlling acute variceal hemorrhage in 75 to 90 of cases and is also effective in reducing the incidence of rebleeding. During ES, a sclerosing agent (eg, alcohol or sodium tetradecyl) is injected into the distal portion of a varix, with the goal of inducing thrombosis and scarring. The procedure is carried out in the distal 5 cm of the esophagus, as this is where varices are most superficial and where they are the most likely to bleed. In those in whom ES is successful, it is repeated every 1 to 3 weeks with the goal of achieving circumferential obliteration of the varices. The complications of...

Problems during pregnancy

E.g. anaemia may become more pronounced mild cytotoxic-induced cardiomyopathy may become more severe. Finally, there may be direct effects of the malignancy or its treatment on the uterus and birth canal, e.g. cervical surgery and scarring, perineal scarring and abdominal adhesions.

Genital Anomalies Fertility and Sexual Problems

Patients with ARM have a high incidence of genital anomalies. Genital anomalies occur in 26 of boys 89 , the most common being undescended testes and hypospadias. The most common in girls are vaginal and uterine septation anomalies and vaginal agenesis 90 . Genital tract function has been reported to be impaired in almost half of patients because of vaginal scarring 90 . In sexually active females this often causes coital problems Matley et al. 91 found dyspareunia in four of nine adult females who had undergone repair of a vestibular anus. Vaginal scarring may interfere with deliveries, and today most females with significant ARM deliver by cesarean section 91,92 . Vaginal deliveries and pregnancies may also worsen fecal continence in patients with a history of vestibular fistula 91,93 . Late gynecological problems are especially common in patients with cloaca. A high percentage of postpubertal females with cloaca develop obstruction of some part of Mullerian structures, with...

Primary Low Grade BCell Lymphoma of the MALT Type and Immune Deviation

The occurrence of mucosa-associated lymphoid tissue (MALT) is not a ubiquitous finding in the nasolacrimal ducts (although it is a feature commonly found in symptomatically normal nasolacrimal ducts) 19 and is acquired in response to antigenic stimulation. Loss of tear-duct-associated lymphoid tissue (TALT) seems to be associated with the scarring of symptomatic dacryostenosis, suggesting that the presence per se of TALT does not lead to scarring 21 . Whether special types of bacteria, viruses, allergic reactions, or other factors, such as some type of immune deviation (see below), are responsible for the development of TALT in humans is not clear at present however, the occurrence of TALT may favor the rise of primary low-grade B-cell lymphoma of the MALT

Voltage Mapping Prognostic Implications

The main objective of management in patients with ARVC D is to prevent arrhythmic sudden death. However, there are no prospective and controlled studies assessing clinical markers which can predict the occurrence of life-threatening ventricular arrhythmias. It has been established that sudden death may be the first manifestation of the disease in previously asymptomatic young subjects and athletes 2,4,5 . Therefore, all identified or suspected patients are at risk of sudden death even in the absence of symptoms or ventricular arrhythmias. The most challenging clinical dilemma is not whether to treat patients who already experienced malignant ventricular arrhythmias (secondary prevention), but to consider prophylactic treatment in patients with no or only minor symptoms in whom the disease has been diagnosed during family screening or by chance (primary prevention) 8 . Furthermore, ARVC is a progressive disease and the patient's risk of sudden death may increase with time. The risk...

Anaesthetic management

Previous hospital records are helpful, since the position of the scar on the woman's back is not a reliable guide to the level of surgery. Most women will know whether they have had metal instrumentation of the spine or merely bony fusion. Those who have had instrumentation should be warned about possible

External vs Closed Approach

The endoscopic closed CDCRs have been also performed in past years because endoscopic visualization is critical in the placement of the Jones tube 22, 27, 28 . The advantages of endoscopic CDCR are the same as those cited for DCR, i.e., lack of cutaneous scar, shorter operation time, and blood loss 7, 28 . An endoscopic approach allows the surgeon excellent intranasal visualization to perform a middle turbinate resection and to assess the proper length and positioning of the tube. The technique for endonasal surgery is much more expensive than the equipment for a traditional external CDCR however, this fact has lost its importance because the equipment necessary for endoscopic CDCR is now readily available in most hospitals and ambulatory surgery centers 27 . That is why an endonasal approach is used more frequently than it was 20 years ago.

Skinsparing Mastectomy

Toth and Lappert first described skin-sparing mastectomy (SSM) in 1991.9 The technique is indicated for patients with early stage (I and II) breast cancer, patients managed with prophylactic mastectomy, and in attempts to facilitate a highly esthetic outcome through maximal skin preservation (Figure 11-1). Incisions are planned that will remove the breast, nipple-areolar complex, adjacent biopsy scars, and the skin over more superficial tumors. Kroll and colleagues in

Ray amputation in a neuropathic foot and its postoperative care

The wound was irrigated with 2 Milton for 4 days until a wound bed of pink, healthy granulations was present, after which it was cleansed with saline and dressed with a foam dressing. He was discharged after 3 weeks. The foot healed in 6 weeks with minimal scarring he received follow-up care in the diabetic foot clinic, and ulceration did not recur.

In vitro bench methods

Cell-labeled ischemic area. (Left) Dark-contrast labeled cells within scar in the anteroseptal wall (arrow). (Right) Single frame from a dynamic image series with additional positive contrast representing tissue perfusion show dark-contrast labeled cells locate throughout ischemic zones (arrows). Fig. 2. Cell-labeled ischemic area. (Left) Dark-contrast labeled cells within scar in the anteroseptal wall (arrow). (Right) Single frame from a dynamic image series with additional positive contrast representing tissue perfusion show dark-contrast labeled cells locate throughout ischemic zones (arrows).

The Patient with Unfamiliar or Rare Causes of Abdominal Pain

In contrast to the above disorders, our experience suggests it is far more fruitful to carefully examine the abdominal wall in patients with chronic pain. This is an aspect that is frequently overlooked by gastroenterologists. Pain arising primarily in the abdominal wall can result from a poorly defined group of conditions whose pathophysiology remains obscure. The diagnosis is suggested when the pain is superficial, localized to a small area that is usually significantly tender, associated with dysesthesia in the involved region, and a positive Carnett's sign (if a tender spot is identified, the patient is asked to raise his or her head, thus tensing the abdominal musculature greater tenderness on repeat palpation is considered positive). It is postulated that such tender spots are often due to entrapment neuropathy or a neuroma however, we speculate that they could also represent an extreme manifestation of referred pain (see above), particularly in the absence of a surgical scar or...

Voltage Mapping Clinical Implications

Electroanatomic RV low-voltage often appeared fractionated with a significantly prolonged duration and more extended beyond offset of the surface QRS than electrogram recorded from normal-voltage areas (Fig. 17.2). All these electrical abnormalities, either surface or intracardiac, reflect the distinctive pathoarrhythmogenic substrate of ARVC D, i.e., a fibrofatty scar, which accounts for a right intraven-tricular conduction defect and predisposes to life-threatening ventricular arrhythmias 42-43 .

Left Ventricular Involvement

A study from Canada by Lobo et al. 54 found that 45 of hearts of ARVC D showed left ventricular fibrous scars, although coronary atherosclerosis coexisted in some. In another North American series by Burke et al. 23 , microscopic subepicardial left ventricular involvement was present in 64 of fibro-fatty ARVC D. In a French series of sudden death due to ARVC D, Fornes and colleagues 55 reported a 40 incidence of left ventricular disease. However, in all series a severe diffuse biventricular involvement, mimicking dilated cardiomyopathy requiring heart transplantation, appears to be rare. Recently, d'Amati et al. 25 , in a series of transplanted hearts, found grossly biventricular involvement in 87 of cases with the so-called cardiomy-opathic pattern vs. 9 of those with the infiltrative (fatty) pattern.

Developmental Strengths and Needs of Adolescents

Deleterious models of male and female adult behavior that they have witnessed and, perhaps, incorporated and taken as their own. Further, teenagers who have witnessed domestic violence are more likely to be depressed, to behave in antisocial ways, and to be physically aggressive and anxious than are teens from nonviolent families. In addition to the psychological scars, teenagers may be recovering from physical abuse and injury, as they are more likely to intervene in parents' fights than are younger children.

Nippleareolar Reconstruction

Nipple-areolar reconstruction is a critical stage in breast reconstruction and may add remarkable realism to the new breast mound (Figure 11-12). Areolar tattooing facilitates symmetry in color, may camouflage minor discrepancies and scars, and lacks the morbidity associated with skin grafts. Nipple reconstruction is typically performed at a second stage, at the time of port removal, or breast mound revision.

Congenital varicella syndrome CVS A

Severe disease of the fetus resulting from maternal infection with Human her-pesvirus 3 during the first two trimesters of pregnancy. Clinical manifestations range from multisystem involvement resulting in death in the neonatal period to dermatomal skin scarring, limb hypoplasia, or both as the only defects. The disease is rare and the overall risk of zoster in infancy following maternal varicella infection in the second and third trimesters of pregnancy is about 2 .

David W LarsonMD and John H PembertonMD

Substantial morbidity, including scarring, continual seepage, and fecal incontinence, complicate perianal CD. Therapy is not standardized and debate continues on the role of operative intervention. The aim of this review is to discuss the perianal complications of inflammatory bowel disease (IBD) and provide appropriate surgical solutions.

Problems with the Outlet

Pouch outlet obstruction, usually due to anastomotic scarring and stricture, leads to incomplete evacuation. Not only will this increase stool frequency, but patients may complain of the need to strain, defecation may be painful, and there may be a recognition that the pouch has not been completely emptied. Incomplete evacuation often results in leakage of liquid stool around retained material in the pouch and the constant desire to defecate. The patient makes repeated and frustrating trips to the toilet. Typically, pouch outlet obstruction may cause a feeling of pelvic fullness or bloating, but systemic symptoms such as weight loss and malaise are absent. Many IPAA patients have mild degrees of anal stenosis, and the index finger should be inserted easily into the pouch through a rather snug anastomosis. Inability to pass the examining finger easily into the pouch, or marked tenderness on attempting to do so, are indicative of an anastomotic stricture.

Soft Tissue Infection

Diabetic bullae may also cause blisters in diabetic patients. They occur on the lower legs, the dorsum of the feet, hands, and forearms and less commonly, under the soles of the feet. Diabetic bullae more often affect men. They appear suddenly as tense and usually bilateral blisters, with diameters of 0.5 to several cm they contain clear fluid without any surrounding erythema and heal in a few weeks without scarring. Relapses are common.

Opened ampulla and common wall

Once a decision has been made to proceed with surgical relief of the obstructed bile duct, the choice of the appropriate operative procedure revolves around whether a resection is being done and the natural history of the problem causing the stricture. In this regard, the ultimate fate of the duodenum and lower bile duct figures prominently. By and large, resections of the bile duct are reconstructed with a Roux-en-Y cholehepatico-jejunostomy, or a hepaticojejunostomy if the anastomosis is up in the liver. Although it seems logical to bypass all benign strictures, a stricture situated high in the bile duct may be best handled by resection. The anastomosis is then performed in normal tissue above the scar. The reason is that a resection sometimes provides better exposure of the structures the surgeon wishes to preserve (portal vein and hepatic artery) while seeking more normal bile duct tissue. Conversely, benign strictures in the distal bile duct are often most expeditiously dealt...

Of Traumatic Canalicular Stenosis

Date by excising the scar and reanastomoses the normal lumen, followed by bicanalicular silicone intubation 50, 55 . A nasolacrimal probe is passed into the punctum and passed to the site of obstruction. The eyelid is incised at this location. The purpose is to identify the proximal and distal ends of the lacerated canaliculus. At this time bicanilicular intubation is completed, if possible.

Indications for Axillofemoral bypass

With experience and some technical modifications, reported results following AxFB procedures have improved over time.4 A major advance occurred with the development of externally supported polytetrafluoroethylene (ePTFE) and polyester grafts. These grafts are resistant to external compression from clothing, furniture and dependent positioning which otherwise might cause graft occlusion. Harris and associates reported 85 4-year actuarial primary patency following seventy-six AxFB procedures performed with externally supported ePTFE grafts.5 Most of these procedures were performed for indications other than aortic sepsis. These included extreme aortic calcification, dense abdominal and intestinal adhesions and scarring or obliteration of anatomic planes following previous procedures. Despite their improved results, however, Harris and associates continued to prefer anatomic, inline reconstruction whenever feasible, reserving AxFB for unusual and complicated situations.5

Poor Transilluminated Light Beam Spot

Creation of a rhinostomy laser ablation of mucosa, bone, and the medial wall of the lacrimal sac. Regularly clean the operative field to avoid charring and thermal injury which predisposes to excessive scarring and closure of the rhinostomy resulting in failure. A rhinostomy of at least 5 mm (preferably 10 mm) should be formed.

Immediate Reconstruction

Greater freedom in choosing clothing.6 Patients undergoing mastectomy and immediate reconstruction demonstrate a similar psychosocial outcome to that of breast conservation patients, having had lumpectomy with or without radia-tion.7 Body image may be adversely affected due to greater breast and donor site scarring compared to patients having undergone breast conservation. Overall, psychologic morbidity is similar, and clearly favorable compared to that of patients having had delayed reconstruction.8 The opportunity to attain optimal esthetic results is enhanced with immediate reconstruction. The newly raised mastectomy skin flaps tend to preserve the shape of the natural breast, providing a structural template that determines the shape of the underlying volume, whether an implant or flap reconstruction. Skin flap fibro-sis associated with delayed reconstruction represents inherent tissue loss and requires either greater tissue expansion or greater skin replacement at the time of...

Skin Anomalies Pathological Noninfective

Lichen sclerosis is an inflammatory condition of unknown aetiology that most commonly occurs in the anogenital skin of both men and women. The main symptoms are itchiness and soreness however, lichen sclerosis can occur without symptoms. Lichen sclerosis causes typical white plaques on the skin of the genitalia. Characteristic features in women are whitening and scarring atrophy, causing gradual destruction of normal vulval architecture, with burying of the clitoris and reabsorption of the labia minora. Eventual narrowing of the introitus is also known to occur. Lichen sclerosis may occur in skin already scarred or damaged (the Koebner phenomenon), so that trauma, injury, and sexual abuse have been suggested as possible triggers of symptoms in predisposed people. There is a small risk of developing squamous cell carcinoma on a background of lichen sclerosis, and biopsy of suspicious lesions is common.

Details of medical assessment

Each child is examined from head to toe rather than in systems. Height and weight are checked, as is head circumference in babies. Careful notes are made of all normal and abnormal findings, including any marks on clothing, e.g. tears, blood stains. All marks, contusions, abrasions, and lacerations must be measured. Drawings must be made. If an abnormality is found that has not been discussed previously in the history, then further questions are asked - most undisclosed events are recent minor childhood accidents or previous ones that have left scars. When the upper part of the body has been examined, the child is asked to put the clothes back on to that area before taking the clothes off the abdomen and legs. Finally, the genitalia and anal region are examined. This method minimises the embarrassment of the sensitive child.

Delgadito virus See Cao Delgadito virus

Dengue virus (DENV) A species in the genus Flavivirus. Causes an acute febrile illness in humans with symptoms ranging from clinically inapparent to severe fatal hemorrhagic disease. There is an incubation period of 5-8 days, and the symptoms last about 10 days with severe headaches, retro-ocular pain, and back and limb pains. Often there is a scar-letiniform or maculopapular rash. The most severe symptoms, hemorrhagic fever with shock, probably result from infection with one dengue virus serotype in persons immune to another (See dengue viruses 1-4). The natural hosts for the virus are Aedes mosquitoes, humans, and non-human primates. Aedes aegypti is the principal vector worldwide, but other important vectors are Aedes albopictus in Asia and the Americas, Aedes scutellaris in the Pacific, and Aedes africanus and Aedes luteocephalus in Africa. The virus is only transmitted by the bite of an infective mosquito vector. Following infection, humans and nonhuman primates usually develop a...

Reconstructive Surgery

The two main types of rectus abdominis myocutaneous flaps are the transverse rectus abdo-minis myocutaneous (TRAM) flap and the vertical rectus abdominis myocutaneous (VRAM) flap. The TRAM flap has a greater arc of rotation and a more symmetrical and easily concealed donor site than does the VRAM flap (Figure 10-5). The VRAM flap leaves a more noticeable donor scar but is technically easier to construct and has a more reliable blood supply (Figure 10-6). The

Impact of Genetic Results on Clinical Evaluation of Patients with ARVCD

Presence of an ARVC D genetic mutation in an affected proband. The proband usually has an overt form of the disease. In this subject, genetic result leads only to a confirmation of the disease diagnosis but it does not modify the clinical management that is related to the extent of the disease and degree of electrical instability. The degree of electrical instability is assessed on the basis of disease extent as well as presence of sustained ventricular tachycardia or previous ventricular fibrillation. If an ICD is indicated, we always prescribe antiarrhythmic drug therapy because we are aware that each ICD shock can create a new scar in a myocardium that already has a pathologic process.

Breast Ultrasonography

Ultrasound core-needle biopsy for histo-logic diagnosis requires more planning. When the lesion requiring a core-needle biopsy is identified, the skin is marked at the edge of the transducer for the proposed insertion site of the needle. The optimal insertion site and approach to the lesion is the shortest skin-to-lesion distance. For best cosmesis, care should be taken to avoid placing the scar of the insertion site near the inner portion of the breast. At this point, the breast is prepared with an appropriate antiseptic solution. The transducer is likewise prepared, or a sterile sleeve may be placed over the transducer. Sterile ultrasound gel is available in individual packets. The local anesthetic is then injected under direct ultrasound visualization. The skin is anesthetized as well as the track leading to the lesion. In addition, the local anesthetic is applied above, below, and to the opposite side of the lesion. The use of ultrasound visualization limits obscuring the lesion...

Should Everyone Be Tested

As recently as 1974, a leading medical text described CF as not only one of the most common disorders of childhood, but also one of the most enigmatic. Even its name reflects the mystery. The term cystic fibrosis was coined more than 60 years ago to describe the scarring found in the pancreas at autopsy, yet the far more devastating effects are on the lungs, in which the ravages of recurrent, serious pneumonia are evident at a glance. Most strange is the protean nature of the disease. Some children are severely ill from birth, others become ill only gradually over four or five years, and a few are quite well until young adulthood. Most patients have both lung disease and severe gastrointestinal problems, but some are burdened only with comparatively mild lung disease.

Gracilis Muscle Transplant

Pubis Malformation

The success of the operation of Holle et al. 19 depends on two points (1) There should be no scarring tient mucosal ectopy persisted, and three other children developed a keloid scarring of the distal thigh 25 . Twenty-eight out of 40 patients in whom the operation was performed at least 2 years previously developed good continence. The children ceased soiling and had regular stools or suffered a little staining under conditions of stress and diarrhea. Three children had a small degree of persistent soiling, but did

Tibial Below Knee Amputation

Tibial Amputation Technique Myoplastic

Breadths below knee joint level, at a time when many authors failed to be precise. On the other hand, later surgeons suggested a variety of tibial lengths. Consideration of French authors alone demonstrates that De La Charriere advised four fingers-breadths below the knee joint in 1692,37 Garangeot six in 1731,38 Sedillot both four and five fingers below the tibial tuberosity in 1839,39 Velpeau two or three fingers below the tuberosity in 1840,40 and Farabeuf five fingers below the joint or at least 10 cm of tibia in the late 19th century.41 In contrast, some believed amputation should be as low as possible to save life for, in the days before antiseptic surgery, mortality increased in proportion as the level of section approached the trunk. In the 17th century, Solingen argued for amputation just above the level of pathology provided a sound scar was obtained and was supported by Dionis at the beginning of the 18th century.42 In 1768, Ravaton who had extensive military experience...

Gangrene and Pre Renaissance Practice

Hand Gangrene

In the 2nd century a.d., Galen also counselled an expectant approach. Even in 1363, Guy de Chauliac confessed, after detailing instructions on how to amputate for gangrene either at joint level or through bone, that he himself never amputated but advised scarification of dead skin followed by the application of arsenic to the mortified area, ensuring healthy tissue was defended against arsenical attack with suitable dressings and, The distressing spectacle of acute traumatic amputations, domestic, battlefield or punitive in origin, must have encouraged the spontaneous application of coverings and, ultimately, medicated dressings to protect raw stumps, either undertaken by victims or their family. And in the case of transected fingers and toes, acceptable healing often followed, leading to recovery of adequate function, but for amputations above the hand and foot healing was more doubtful, and the best possible outcome often a thin painful scar fixed to bone, with poor residual...

Developments in the 21 Century


Branemark confirmed a secure bond between commercially pure titanium and living bone of the jaw,42 all attempts to attach prostheses had failed because of infection. Consequent to the success of titanium-anchored dental prostheses, a system to place implants in stump bone was tested. After initial titanium peg insertions, a period of 6 months healing was allowed before the stump scar was penetrated by a connecting implant to which a prosthesis was bolted.43 This system, termed osseointegration, proved satisfactory and although infections were encountered, most responded to antibiotics. More than 70 amputees have been treated in Sweden, 15 in Roehampton, London (Fig. 13.16) and 2 in Melbourne.

Late Stump Complications and Revision

Boy Amputees Stumps

Following surgery, amputation stumps may prove suitable for provision of satisfactory prostheses, or may not, because of a variety of established conditions. Earlier authors were especially concerned about continued suppuration, failure to heal, sugar-loaf formation with bone protrusion, painful scars and overlong below-knee stumps which prevented efficient use of a kneeling peg-leg. Poor or failed healing necessitated permanent bandaging to protect fragile tissues from further damage and also to absorb chronic discharge, a common picture demonstrated in Bosch's drawings of below-knee amputees (see Fig. 2.4). Bone protrusion was diminished by sawing off the excess, leaving a bony ulcer which might exfoliate spontaneously leaving, at best, an indurated and sensitive scar. Before anaesthesia, a few resolute patients insisted on or accepted reamputation, an operation particularly undertaken for the over-long stump the risks were great, mainly from infection, and not all survived (see...

Stump Preparation for a Prosthesis

Stump Crutch

Mobilisation with a temporary prosthesis or pylon. Understandably, before anaesthesia, antisepsis and asepsis, efforts were concentrated on preserving the amputee's life, threatened daily by serious hazards of haemorrhage and sepsis, perhaps for months after surgery, and on attempting to ensure a satisfactory scar despite prolonged healing. While it was recognised a sound stump underwent a process of reduction in girth over many months, methods of bandaging to assist this process are very much a 20th-century observation. However, Bigg, a medically qualified limb-fitter, wrote in 1885 that stumps enlarged immediately after operation and, when healed, gradually shrank over 10 to 15 months, or even 2 years, observing it was important to tell the patient of these changes for he had experience of amputees becoming disheartened and abandoning their loose prosthesis without seeking guidance. This consideration did not mean fitting should be delayed, provided alterations were made for...

Immediate Postoperative Care and Followup

Lacrimal System Endoscopy

The piece of Merocel is removed between days 5 and 7 after surgery. This period seems to be enough to produce a steady scarring of the mucosal flap onto the partially exposed bony wound. Instead of just pulling the Merocel, it seems better to rotate it, to prevent laceration of the mucosal flap. On the left side, rotation should be performed counterclockwise, on the right side clockwise. Fibrin clots and crusts, if any, are Sometimes, epiphora starts again during the follow-up. This may be secondary to collection of mucus in the remnant sac obstructing the drainage of the common canaliculus, which is known as lacrimal sump syndrome (Fig. 5.12). Soft external massage empties the sac. Once the scarring is completed, patients are visited 1 year later (Fig. 5.13).

Free Autogenous Muscle Transplant for Strengthening of the Levator Ani Palmaris Longus Transplant

Levator Plication

The problem with this operation is similar to that of transposition of denervated gracilis muscle described by Holle et al. 19 . Scarring of the pelvic floor prevents reinnervation, and fibrosis of the regenerating muscle graft remains a critical factor for the ingrowing nerve fibers. A further problem is the degree to which the graft is prestretched. On the one hand, it is necessary to prestretch the muscle sufficiently to obtain a better angulation of the anorectal angle and to achieve a compression of the rectum from both

Minimally Invasive Treatments for Leg Pain

If the effect of epidural steroid injections is local, i.e. a direct effect on the injured nerve root or on the ''leaky disc'', it is essential that the steroid reach the site of injury. Historically, epidural steroid injections have been performed ''blindly'', without any radiological guidance, however many factors may prohibit steroids from reaching the intended nerve root, such as scarring, adhesions, adipose tissue and septa, which may be present in the operated and non-operated backs. Thus theoretically drugs injected into a scarred epidural space will follow the path of least resistance, away from the painful site. Access of the epidural space with a flexible fibre-optic catheter via the sacral hiatus appears to be safe and efficient (Geurts et al., 2002). The procedure is done under local anaesthesia while continuously monitoring intra-epidural pressures, and patient's response. Normal nerve roots when touched cause paraesthesia, diseased ones pain, so patient report is...

Diagnostic Management

Cloacal Anomaly

Preoperative ultrasound may reveal tethered cord syndrome, sometimes associated with lipoma of the spinal canal or diastematomyelia. However, a tethered cord should be treated only when neurological problems start to arise. Many of the patients who have had detethering have experienced a retethering postoperatively due to postoperative scarring. Therefore, repeated neurological reviews by an experienced neurologist are necessary before untethering. On the other hand, it is true that once a deficit is established, it is unlikely to be improved after detethering the cord. The best time to operate on a tethered cord therefore remains an open question.

Conjunctival and Cartilage Containing Nasal Septal Flap

Palpebral Reconstruction Flap

After osseous perforation, incision of the conjunctiva, and creation of a connecting subcutaneous tunnel, an U-shaped incision is done to fashion a posterolateral based nasal mucosal flap of about 1x2-cm dimension (Fig. 11.3 a Arden 1990). The flap is rotated upward to reconstruct the superoposterior wall of the new conduit. For complete mucosal lining of the new conduit a medially based flap is elevated from the medial conjunctiva. It is rotated downward repairing the anteroinferior side of the wall (Fig. 11.3 a Arden 1990). Alternatively, the flap may be raised from the lower palpebral conjunctiva, 5 mm in the anteroposterior dimension and 15 mm in horizontal length (Huang 1992). Both flaps are sutured around a silicone tube of at least 2 mm in diameter facing the mucosal layer inward (Fig. 11.3b). For approximation of the mucosal edges 5-0 absorbable sutures are recommended. After correct positioning of the tube under endonasal endoscopic control, the skin is closed in layers....

Circular Operative Techniques

Amputation Stumps

Cheselden's double circular incision, suggested c. 1711, cutting muscles higher than skin this was better than a simple guillotine section but slow to heal and, as G shows, producing a puckered fragile scar. (From Cheselden W. Observations by Mr. Cheselden. In The Operations of Surgery of Mons. Le Dran (translation by Mr. Gataker). London Clarke, 1768.14) Fig. 7.4. Cheselden's double circular incision, suggested c. 1711, cutting muscles higher than skin this was better than a simple guillotine section but slow to heal and, as G shows, producing a puckered fragile scar. (From Cheselden W. Observations by Mr. Cheselden. In The Operations of Surgery of Mons. Le Dran (translation by Mr. Gataker). London Clarke, 1768.14) necessitated a second cutting, that is, bone section at a higher level. On anatomical grounds he considered the bandage or fillet usually tied between the tourniquet and the incision, to steady the soft tissues during incision, had the effect of preventing the...

Complications of Sacral Neuromodulation

The configuration of the electrode itself (incorrect fit to the nerve), surgical trauma, pressure caused by post-surgical edema, excessive scar formation and tension on the electrode cables are all potential contributors to neural damage 120 . The peripheral nerve may be affected adversely by chronic constriction and compression 103 . However, these risks are less important in the case of epineural electrodes than in intraneural ones 105 . In animal studies, excessive or prolonged stimulation may cause early axonal degeneration 114 . The risk of injury is also affected by the duration of continuous stimulation 5 . It is well known that needle insertion into the sacral foramen can result in damage to nerve root and vessels 107 . Because these structures are more likely to be found on the medial aspect of the foramen, injury can be minimized by using a more lateral foramen entry. Increasing the angle of needle entry in the vertical plan can increase the risk of injury to the vessels...

New Developments and Future Trends

Leukotrienes Inflammatory Mediators

Low-dose isotretinoin (0.1-0.3 mg ml day daily or intermittent use) can effectively control acne, also being cost-effective. Nevertheless, the daily dose is too low for the cumulative dose obtained to be definitively curative. Although studies have been centered on the use of low doses only in older patients with exceptionally oily skin or in patients with long duration acne 76-80 , there is a trend by practicing dermatologists to use low-dose isotre-tinoin in adolescent acne with a tendency to become inflammatory or in moderate acne as replacement of systemic antibiotics. The suggested rationale of such use is the effective control of inflammation with the final objective of preventing inflammation and the resulting scars. The approach taken is that of control and not of absolute resolution, since this resolution will occur in the majority of patients naturally. The simultaneous use of an effective topical therapy is mandatory. Since a large percentage of patients to be treated with...

Physiology The Unity ofCompanies 2003 Form and Function Third Edition

Organ systems are present, through the time of birth. Compare conceptus, embryo. fibrin (FY-brin) A sticky fibrous protein formed from fibrinogen in blood, tissue fluid, lymph, and semen forms the matrix of a blood clot. fibroblast A connective tissue cell that produces collagen fibers and ground substance the only type of cell in tendons and ligaments. fibrosis Replacement of damaged tissue with fibrous scar tissue rather than by the original tissue type scarring. Compare regeneration. fibrous connective tissue Any connective tissue with a preponderance of fiber, such as areolar, reticular, dense regular, and dense irregular connective tissues. filtrate A fluid formed by filtration, as at the renal

Finger and Hand Amputations and Disarticulations

Conservation of surviving fingers and part hands must have been an objective within historic times, but little is recorded before Woodall illustrated curved chisels, a mallet and a pair of cutters or nippers removing a finger through a phalanx in 1639 (see Fig. 9.2) and Scultetus illustrated similar instruments for removing a hand in 1653 (see Fig. 5.1). Such guillotine sections would have healed slowly and with sensitive terminal scars at best. In 1731, Garengeot criticised these methods of the Ancients, especially for fearing to amputate through the interphalangeal joints, and described two incisions over the lateral aspects of a finger joined by a circular incision to form flaps and cover bone ends including articular cartilage.75 Sharp also advised amputation through finger joints, for preference by circular incision beyond the joint.76 In 1814, C. Bell found a simple circular incision satisfactory for disarticulating fingers.77 Malgaigne considered section through a phalanx was...

Transient Bullous Dermolysis Of The Newborn

Junctional Epidermolysis Bullosa

Epidermolysis bullosa letalis (junctional epidermolysis bullosa, Herlitz's disease) in an infant with generalized involvement of the skin. Note the massive involvement of the lower extremities showing the denudation, scarring, and contractures. In this form of epidermolysis bullosa, the skin separates in the lamina lucida of the dermal-epidermal junction and blistering leads to mild atrophic changes. Junctional epidermolysis bullosa is the most severe form of epidermolysis bullosa. It is characterized by blistering and large erosions, mainly on the buttocks, trunk, and scalp without scarring unless complicated by secondary infection. Approximately 50 of these infants die within the first 2 years of life some survive into adulthood. Therefore, recently the term letalis has not been used.

Operations For Hernia Repair

Mcvay Hernia Repair

The use of polypropylene mesh in the repair of hernias has become increasingly popular over the years. Initially used for recurrent or large hernias, it has become popular for virtually all hernia repairs outside of the pediatric hernia repairs. The polypropylene mesh not only incites a significant scar formation, but also is knit as part of the scar making it more durable than the native tissues themselves. Further, when mesh is used in the repair, the tissues, which contain the hernia, do not have to be placed under tension to accomplish the repair.

Celery Stalk Appearance

Celery Stalk Lesions And Rubella

Cicatricial skin lesions of the neck and upper back in an otherwise normal infant following maternal varicella at 5 months gestation. These skin lesions are the most common finding after maternal varicella which presents in the 1st and early 2nd trimester. Maternal infection with varicella early in pregnancy is a cause of fetal malformations including reduction deformities of the limbs (hypoplastic limbs and or contractures) and scars along the length of the affected limbs. The infant may be small for gestational age and demonstrate features of central nervous system involvement (encephalomyelitis) and eye defects (microphthalmia, cataracts, and chorioretinitis).

Stephens Secondary Repair of Damaged or Hypoplastic Muscle Complex [2

Levator Ani

There have also been different degrees of leva-tor muscle scarring and destruction, particularly in its lowest portion, as a consequence of a pull-through of a very large rectum or muscle hypoplasia, or just an inappropriate preparation of the muscle complex. In some patients there is a gap between the upper part of the muscle complex being well developed at its posterior coccygeal attachment and hypoplastic close to the external sphincter fibers.

Venous Malformation Intestine

Angiomas Colon

B Point coagulation (APC) is used to coagulate newly forming vessels. Only a portion of the angiodysplasias should be coagulated to avoid risk of deep ulcerations or stenosis caused by scarring. b Point coagulation (APC) is used to coagulate newly forming vessels. Only a portion of the angiodysplasias should be coagulated to avoid risk of deep ulcerations or stenosis caused by scarring.

Reported and Illustrated Prostheses

The Socket Artificial Limb

We have already commented on the apparent escape of Hegesistratus from imprisonment in the 5th century B.C. (see Chapter 4), who in the process lost or removed his chained and perhaps gangrenous foot which he replaced with a wooden substitute of unknown construction.1 If limb substitutes were introduced for prehistoric amputees, it seems probable most efforts were concentrated on crippling lower limb loss, as unilateral upper limb amputations were generally accommodated by opposite upper limb function. Single-handed survival proved easier than single-footed survival, especially for hunter-gatherer and cave-dwelling communities whose lower limb mobility was essential in a harshly competitive environment. However,the Roman General Marcus Sergius,who lost his right hand during the Second Punic War (218-201 B.C.), had an iron hand constructed which, it is said, he wielded with great dexterity in battle.5 This device was an expensive rarity and even lower limb substitutes would have been...

Radical vaginal hysterectomy

Ureter Injury Uterine Artery

Post-operative mortality rate after abdominal radical surgery is almost negligible, the Suboth Mitra operation cannot be considered as the operation of choice. We used it, as does Massi today, as a solution for high-risk surgical patients, but imposing an operation which leaves three scars instead of one is not acceptable for low-risk patients. The technique of laparoscopy has changed everything. In 1986 we devised the laparoscopic lymphadenectomy in an attempt to avoid the 'three scars operation'. Subsequently the combination of laparoscopic lymphadenectomy with radical vaginal hysterectomy (RVH, or the 'coelio-Schauta' operation) became our elective method to treat early cervical cancer. RVH is an acceptable alternative to radical abdominal hysterectomy as long as it is combined with control of the regional lymph nodes. Before the era of laparoscopy such control could not be obtained other than by performing two lateral extraperitoneal abdominal incisions, leaving RVH suitable in...

Primitive Weapon and Cold Steel Injuries

Native Primitive Tribal Wars

Haemorrhage and the impossibility of closing the wound immediately, and at best resulting in paper-thin scars. Despite this, Mayor pursued the concept of instantaneous cutting, which he termed 'tachytomie,' putting forward an imaginary and entirely theoretical solution, in the form of giant secateurs whose precise mechanism he left to scientists and mechanics to resolve, a challenge never mastered.8 Guillotine section of limbs inevitably resulted in shortage of skin and soft tissues to cover bone ends, resulting in prolonged healing and painful stumps, and the practice disappeared in the early 18th century. However, in 1941 Harley reported the Masai of Lake Victoria, Kenya, were noteworthy for cutting off a damaged limb with a single stroke of a large sword, although neither the level of amputation nor the postamputation progress is recorded.9

ARVCD vs Idiopathic RVOT Ventricular Tachycardia Differential Diagnosis

These electrical markers reflect the distinctive pathologic substrate of ARVC D, i.e., a fibrofatty scar, which accounts for the right intraventricular conduction defect. However, in patients with early minor ARVC D, 12-lead ECG and SAECG may be unremarkable, thus limiting their diagnostic role. Conventional imaging modalities including echocardiography and contrast angiography demonstrate RV structural and functional abnormalities in overt forms of ARVC D. Two-dimensional echocardiography has significant limitations in the visualization and definition of morphofunctional abnormalities of the anterior wall and RVOT. It has been reported that some forms of localized ARVC D, particularly in the infundibulum, may exhibit normal RV volumes and preserved RV ejection fraction by RV angiography. A recent angiographic study of computer-based quantitative segmental contraction analysis of the RV free wall demonstrated that wall motion is nonuniform in...

Transverse Facial Cleft


Another example of congenital amputation of the left leg and the toes of the right foot by amniotic bands. In primary limb reduction defects, the skin at the amputation is smooth and there is underlying subcutaneous tissue. In secondary limb reduction deformities, the skin shows ulceration or scarring and has no underlying subcutaneous tissue. Radiography shows the stump of the bone is smooth in primary limb reduction defects and the stump of the bone is jagged in secondary defects. Figure 5.80. Another example of congenital amputation of the left leg and the toes of the right foot by amniotic bands. In primary limb reduction defects, the skin at the amputation is smooth and there is underlying subcutaneous tissue. In secondary limb reduction deformities, the skin shows ulceration or scarring and has no underlying subcutaneous tissue. Radiography shows the stump of the bone is smooth in primary limb reduction defects and the stump of the bone is jagged in secondary...

Diseases of the Myelin Sheath

Multiple sclerosis and Tay-Sachs disease are degenerative disorders of the myelin sheath. In multiple sclerosis (MS), the oligodendrocytes and myelin sheaths of the CNS deteriorate and are replaced by hardened scar tissue, especially between the ages of 20 and 40. Nerve conduction is disrupted with effects that depend on what part of the CNS is involved double vision, blindness, speech defects, neurosis, tremors, and numbness. Patients experience variable cycles of milder and worse symptoms until they eventually become bedridden. Most die from 7 to 32 years after the onset of the disease. The cause of MS remains uncertain most theories suggest that it results from an immune disorder triggered by a virus in genetically susceptible individuals. There is no cure.

Epidermolysis Bullosa

Epidermolysis bullosa is a heterogenous group of rare disorders causing severe bullous formation on the skin and mucosa membranes. Dystrophic epidermolysis bullosa is a hereditary form of this condition that also includes severe blister formation of the esophagus. These bullous lesions can occur in the proximal or distal esophagus and lead to scarring from minor trauma, including contact with food or acid reflux. Therefore, esophageal dilatation may worsen the preexisting damage already occurring in the esophagus. In this condition, mechanical dilatation is avoided since its shearing forces can lead to further strictures and perforation. If dilatation is necessary, hydrostatic balloons are preferred since only radial forces are applied. Patients may ultimately require esophageal resection in order to achieve sustained relief (McBride, 1989).

Disease Activity Index

A disease activity index (DAI) has to be calculated for each section of each eye, at each visit. The calculation is based upon the inflammatory state of the eye. The severity of the inflammatory indices is graded from 0 to 4. These indices are determined as follows Anterior uveitis (AU) cells, flare, keratic precipitate and hypopyon in the anterior chamber. Posterior uveitis (PU) cells, snow ball and snow banking in the posterior chamber. Retinal vasculitis (RV) periarteritis, periphlebitis, edema of disk and macula and retina, papillitis, and active peripheral lesions in retina. The visual acuity (VA) as an overall index of the eye function was determined by the Snellen chart. VA is influenced by the inflammatory state of the eye, and complications such as synechia, cataracts, vitreous organization, and retinal scars.

Exotic ungulate encephalopathy See prion diseases

Human herpesvirus 1 and 2 cause keratoconjunctivitis. Varicellavirus in chickenpox, about 4 of cases have some corneal or conjunctival involvement in shingles, vesicles may occur on the cornea and result in scarring. In congenital cytomegalovirus infection

Open Freehand Interstitial Catheter Insertion

Apbi Cross Catheter

The spacing between needles within a plane varies with the size of the implant. Smaller volumes require closer spacing and larger volumes can be cover with wider spacing. For example, when using a single-plane implant, the needle spacing typically is 1.0-1.2 cm. For double-plane implants, the spacing is 1.5 cm. In high-risk areas such as directly under the lumpectomy scar, smoother dose distributions under the skin can be obtained by adding extra catheters in between the original marks at a superficial depth. By adding these extra catheters, called the gauntlet under the skin, the dose under the skin can be feathered by varying the dwell times without overdosing the skin surface and running the late risk of telangiectasia.

Definition and Causes

Sigmoid Colon Stenosis

Benign stenoses can be caused either by inflammatory healing processes involving scarring (mainly associated with Crohn disease, but also ischemic colitis and NSAID nonsteroidal anti-inflammatory drug colitis) or they may occur as postoperative stricturing. Colitis. Stenosis is particularly common in fibrostenotic Crohn disease. Depending on the pattern of colon involvement, strictures can involve the terminal ileum, the Bauhin valve, or other colon segments. Strictures may appear with scarring and a smooth mucosa or they may also have variously deep ulcers if

Results of Clinical Trials with the Intrabeam System

In the pilot studies in the United Kingdom, the United States, Australia, Germany, and Italy testing the feasibility and safety of the technique, 301 patients (302 Cancers) underwent TARGIT as a boost dose (Vaidya et al. 2005a) and also received whole-breast EBRT. The median follow-up at the time of writing was 27 months, but the first patient was treated in July 1998 and the longest follow-up was 80 months). Amongst these patients, four have had local recurrence. These included one with diffuse recurrence at 10 months, one with a focus of DCIS in the scar at 32 months and two with a new primary outside the index quadrant at 40 and 77 months. It appears that given as a boost, TARGIT yields very low recurrence rates (actuarial rate 2.6 at 5 years).

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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