Scars Holistic Treatment

Scar Solution Ebook By Sean Lowry

The Scar Solution book by Sean Lowry is specially designed and guaranteed to be one of the most effective skincare methods of the current century that helps to remove scars and brings about smooth skin. This treatment works to eliminate the scars even if they have been existing on your skin for a long time without the requirement for thousands of dollars spending on costly remedies. This is Not a one-size-fits-all approach; Sean Lowrys system is based on a physiological approach that gives you 15 natural scar removal secrets that are simple to implement, affordable in price, and safe to apply. and 5 additional methods that will facilitate the healing and fading process of the scars. The Scar Solution contains only scientifically proven, natural scar treatment methods that are guaranteed to work. Everything is tested and proven to be 100% effective. Not only that, but many people start seeing results within the first 2 weeks. Read more here...

The Scar Solution Natural Scar Removal Overview


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Wound Management Repair of Small Defects and Scar Revision

Surgical procedures of up to 2.5 hours can be conducted under local anesthesia. More extensive operations and scar revisions call for general anesthesia. Care should be taken that the tape-secured endotracheal tube does not distort the face. The face should not be taped over during operations in the facial nerve area. We use a transparent film drape for this purpose (to allow facial nerve monitoring).

Positioning the smaller scars in RSTLs

Revision techniques involve excising the scar and dispersing the wound line into multiple segments. The W-plasty consists of segments 4-5-mm long arranged in a zigzag pattern (Fig. 2.8b). The new scars run in alternating directions and are barely perceptible after the wound has healed. In the broken-line technique the segments are placed in an irregular pattern (Fig. 2.8c). In both the W-plasty and broken-line techniques, the margins of the excision are fashioned so that they will fit together precisely like a lock and key. Generally this is done with a No. 11 blade that is held perpendicular to the skin surface when the cuts are made. The wound edges are then undermined with a No. 15 blade or pointed scissors (Webster 1969 Borges 1973 Haas 1991). Fine scars can also be managed by dermabrasion (see Chapter 16). The suture material of choice is 6-0 or 7-0 monofilament, and subcutaneous sutures should be placed whenever possible. Corners and triangles are secured with Gillies corner...

Management of scarring

Healing wounds in the acute phase should be held in apposition with sutures to minimise the blood clot and fibrin. After two weeks fibroblast activity increases and the wound enters the contraction phase which lasts about twelve weeks. It can be influenced by various factors including pressure, massage, steroids, anti-mitotic agents such as Mitomycin C, and vitamins such as Vitamin E and C. After twelve weeks the scar enters the phase of maturation and the fibroblasts become aligned. Activity can be monitored by the redness and thickness in the scar. If a wound is unsatisfactory it can be opened and re-sutured in the first two weeks. After that the fibroblast activity is intense and any scar revision is likely to be complicated by an excessive response. The scars should be left until they are judged to be mature which means they are no longer thick or red. This will certainly take three months, even after a clean primary surgical would, and after trauma it may take six to nine months...

Fetal Skin Heals Without Scarring

Fetal mammalian skin repairs without scarring after excisional wounding (Olutoye and Cohen, 1996). Re-epithelialization and fibroblast migration is more rapid in fetal wounds and there is less contraction. The granulation tissue lays down the normal architecture of ECM. Late in gestation, fetal skin changes its response to injury from regeneration to the adult response of fibrosis. In the rat and mouse, this transition takes place at 16-18 days of gestation, 3-5 days prior to birth. Comparison of fetal wound healing with adult wound healing is a valuable approach to elucidating the differ- ences between regeneration and fibrosis and how we might intervene to prevent scarring in adults.

Median Scars and Upper Lip Defects

Nasolabial Flap Take Down

In cases where the central portion of the upper lip is retracted upward due to scarring after a cleft repair, burn, or the irradiation of a hemangioma, the lip can be reconstructed using a method first described by Celsus (ca. 25 A.D.). A two-layer, crescent-shaped excision is made lateral to the alar groove on each side and extended along the nasal base. A portion of the scar can be excised (Fig. 6.8a). Both upper lip stumps are then rotated and carefully sutured together to bring down the retracted vermilion (Fig. 6.8b). The muscle stumps are carefully approximated with 4-0 or 5-0 absorbable suture material. After the vermilion scar has been divided and excised, a Z-plasty can be incorporated to add fullness to the upper lip and lower the vermilion (Fig. 6.9). With greater upward retraction of the upper lip, the incision along the nasal base and alar groove can be extended at an approximate right angle along the nasolabial fold. The flaps are then rotated toward the midline to...

Wound Management and Scar Revision

Eliptical Excision Suture

It is a general rule in facial plastic surgery to sacrifice as little skin as possible. Small wounds that extend obliquely into the tissue should be straightened whenever the surrounding tissue can be mobilized and the wound edges coapted without tension. A subcutaneous suture with a buried knot should always be placed to allow tension-free approximation of the wound margins (see Fig. 2.1). Because the subcutaneous tissue, epidermis, and dermis take different lengths of time to achieve adequate wound strength, early removal of the skin sutures from a wound without subcutaneous sutures would result in a broad, unsightly scar. < Fig. 2.8 Relaxed skin tension lines (RSTL) and scar revision, b Scar excision by W-plasty The W-plasty is an interdigitat-ing, zigzag-shaped excision with segment lengths of 34 mm. c Scar excision by the broken-line technique creates skin tags of varying shapes with an edge length of 3-5 mm. The edges interdigitate and should follow the RSTLs as closely as...

C Reduction of Scarring by Modulating the Inflammatory Response

A number of topical interventions that reduce the inflammatory response have been tried in an attempt to reduce scarring in adult skin wounds, particularly to reduce the presence of TGF-P1 and 2, or create a more fetal-like ECM. Hepatocyte growth factor (HGF) is an important growth factor in liver regeneration (Chapter 7). HGF has angiogenic, angioprotective, anti-inflammatory and antifibrotic activities (Matsumoto and Nakamura, 1996), but its expression has not been studied in healing skin wounds. However, injecting rat incisional skin wounds with a combination of rhFGF-2 protein (FiblastTM) and a plasmid expressing the HGF gene resulted in elevated fibroblast apoptosis in the granulation tissue and less extensive scarring than observed with either agent alone (Ono et al., 2004). The mechanism by which the antifibrotic effect was achieved is not clear, but the rhFGF-2 may have had an apoptotic effect and the HGF an anti-inflammatory effect at early stages of repair. Reduction of...

C Remodeling of Granulation Tissue into Scar

In the final phase of structural repair, the granulation tissue is remodeled into a relatively acellular fibrous scar tissue (figure 2.4). The scar differs from normal dermis in several ways (Miller and Gay, 1992 Davidson et al., 1992 Linares, 1996). Fibronectin and HA levels return to normal, but the level of decorin PG is lower than in normal skin, and the level of chondroitin-4-sulfate PG is much higher. The organization of the ECM is also different. The number of elastin fibers is reduced in scar tissue. Instead of the random basket-weave organization of normal dermis, type I collagen fibers in scar are broken down by MMPs and cross-linked by the enzyme lysyl oxidase into thick bundles oriented parallel to the surface of the wound. The MMPs appear to be produced by both the epidermis and fibroblasts of the granulation tissue. MMP synthesis by the fibroblasts appears to require an interaction with the epidermis, since synthesis is much reduced in vitro in the absence of epidermis...

Patient Safetyscar

For at least its first 12 years Leon Goldman's laboratory deemed the desirable end point of treating PWS by long-pulsed ruby laser treatment (136) as an improvement by producing collagen damage with superficial fibrosis to change the optical quality of tissue. In other words the end point was production of scar tissue but it was not ever called so except by Brauner (75) and Schliftman concerning argon laser, who also recognized the similarity of this opacification to the appearance of an opaque collagen skin test in transparent skin (Figs. 1.11-1.13). Such opacification was later cited as an adverse effect by Geronemus (177) but was mistakenly thought to be hypopigmentation. It was not a reflection of total and permanent destruction of melanocytes by the argon laser since these areas did tan in sunlight and even hyperpigmented without sun but represented a true scar. As a typical example, in a large review as late as 1986, Apfelberg and McBurney (60) cited a 14 incidence of scarring...


Dermabrasion is surgical scraping performed with a high-speed motorized handpiece (e.g., Aesculap) that delivers speeds of 15 000 to 25 000 rpm or higher. A large carborundum or diamond abrasive wheel is used. Indications Dermabrasion is done to remove scars above skin level due to burns or trauma, to lessen the visibility of traumatic tattooing, and to treat acne scars. Complications Persistent erythema, hyperpigmen-tation, or hypertrophic scarring. Postoperative care Cold compresses are used on the first postoperative day. Postoperative care also includes emolient skin ointments and protection from sun exposure.

Indications for the Technique

Candidates for this procedure are patients with recurrent carpal or cubital tunnel syndrome that failed at least two previous releases. Before surgery a history and physical examination must be performed. The principal complaint of the patient must be clearly defined. It must be noted if the patient had any relief of symptoms after the first operation to indicate scarring as the cause of recurrent symptoms. Physical examination should include measurement of two-point discrimination (TPD), range of motion, grip strength, Tinel's sign, and Phalen's sign. An electromyography (EMG) test is recommended to note worsening or improvement relative to a previous study. A detailed set of indications are c. patients with scarring of the median nerve or neuroma formation. A contraindication for the technique is chronic lower-extremity venous insufficiency.

Timing of Reconstruction

Delayed, staged reconstruction in the past was the primary method of treatment of severe injuries with multiple structural defects. In this treatment plan, vascularity is established, and the soft tissue injuries are treated with serial debridements, performed at 24-72 hour intervals. Appropriate wound coverage is performed when the wound is clean and all necrotic tissue has been debrided. This should be within the first ten days from injury. Bone, tendon and nerve reconstruction are delayed until soft-tissue equilibrium is achieved. This is when the tissues have healed and are free of infection, edema has resolved, scar tissue has matured, and the joints are supple and have achieved their maximum passive range of motion. Primary reconstruction of all structures is technically easier to perform acutely than later through a scarred tissue bed. It decreases the number of subsequent procedures, total hospitalization time and cost. Also, rehabilitation begins earlier. The development of...

Diagnostic Utility

Anti-factor XIIIa antibodies have a very limited number of conditions for which they are diagnostically useful. The tumor cells in dermatofibromas strongly express factor XIIIa in almost all cases (Fig. 10) (49,73). This is in contrast to dermatofibrosarcoma protuberans, whose cells are almost always negative with this marker. The cells in various other dermal conditions such as fibrous papules and pleomorphic fibromas have been shown to express factor XIIIa (Fig. 11), but while these observations provide interesting insights into pathogenesis and disease processes, they do not provide any additional diagnostic help (74). Spindle shaped cells in other fibrotic dermal processes including cells in scars and keloids do not express factor XIIIa (75).

Skin and Soft Tissue Reconstruction

Skin loss over a bony prominence, hardware or exposed tendons, as well as defects of the soft tissue envelope can be managed in a variety of ways. A simple approach is to leave the wound open and let it heal by secondary intention with granulation tissue. However, exposed tissues sensitive to desiccation, such as nerves and tendons, will become necrotic, scarring will be promoted and function will be compromised. Local muscle flaps are usually not suitable due to their participation in the injury, the limited amount of coverage that they provide and the resulting functional deficit. Two-stage distant pedicle flap procedures are avoided when possible, since immobilization of the reconstructed area will lead to stiffness.

B Models to Analyze the Molecular Differences That Distinguish Regeneration from Fibrosis

The first model compares wild-type tissues to genetic variations that confer a gain or loss of regenerative capacity. For example, there are several strains of mice that can regenerate ear and heart tissue (Heber-Katz et al., 2004), whereas the short-toe mutant of the axolotl causes deficiencies in limb regeneration (Humphrey, 1967). The second model is to compare the same tissues at developmental stages when they are capable of regeneration versus stages when they are not. For example, fetal skin in many mammalian species regenerates perfectly, but late in gestation the injury response switches to scar tissue formation characteristic of the adult (McCallion and Ferguson, 1996). The third model compares the same tissue between two species, one of which regenerates the tissue and the other does not. For example, the ability of cultured myotubes to re-enter the cell cycle in response to serum factors has been compared in the newt and mouse (Tanaka et al., 1999).

Tumour Regression Assessment After Pre Operative Therapy

Tumours treated prior to surgery may show marked macroscopic and histologic alterations compared to conventional colorectal tumours. The macroscopic characteristics of the lesions are quite different from the original ones sometimes lesions disappear and in most cases they leave a white area that resembles a scar. When there is no macroscopic evidence of the lesion or when there is a scar-like lesion, the entire area should be submitted for histologic evaluation. Cases following radiotherapy may have very few lymph nodes. In these cases, the pN can still be assessed and nonetheless appears to have a prognostic significance despite the small number of lymph nodes.

Cicatricial entropion

Cicatricial entropion causes misdirection of lashes when shortening of the posterior lamella follows contraction of scar tissue. The underlying pathology can vary and includes infection (trachoma chlamydia, chronic blepharoconjunctivitis and Herpes Zoster Ophthalmicus), toxic epithelial necrolysis (Stevens-Johnson syndrome), pemphigoid and trauma (chemical, thermal and mechanical). Histology is sometimes required to determine the nature of the condition.

The Effect Of Wound Type And Extent On Dermal Repair

Injury to the epidermis alone results in regeneration without scar, whereas wounds that penetrate the dermis result in repair by fibrosis (Yannas, 2001). The degree of dermal fibrosis depends on the type of tissue and the extent of the wound. The original tissue architecture is most closely restored in wounds made by shallow surgical incisions, where there is no loss of tissue and the wound edges either do not pull apart or are sutured together. These wounds heal primarily by simple fibro-blast proliferation with minimal scar formation because there is little wound space that needs to be filled in. Deep incisions in which the wound edges pull apart, as well as excisional wounds and burns that destroy substantial amounts of tissue, repair by the formation of extensive scar tissue. An interesting and important fact is that both regeneration and scarring occur simultaneously in excisional wounds. While the dermal connective tissue heals by fibrosis, the epidermis and the vasculature...

Clinical Findings and Diagnosis

Cutaneous leishmaniasis on the upper limbs can manifest clinically as nodules covered with crust, ulceration with a raised inflamed solid border, tissue necrosis, and lymphangitic forms (Figure 9.2). Advanced late forms present with scarring, skin atrophy, and pigmentary changes. A particular localised form caused by L. braziliensis is called 'chiclero ulcer' and affects the helix of one ear (Figure 9.3) but this species commonly manifests as a single violatious ulceration of the skin (Figure 9.4). Other regions of the body surface may be affected by pigmented and hyperkeratotic lesions in a clinical form named post-kala-azar dermal leishmaniasis. This clinical form presents after an episode of visceral leishmaniasis caused by L. donovani in cases originating from India and Africa.

Posterior lamella advance following lid split

Lid retraction in the upper lid can be managed by recessing the upper lid retractors or adding a posterior lamella graft. If the retraction is mild the posterior lamella of the eyelid can be advanced by totally freeing Muller's muscle and all the scar tissues under the conjunctiva. This can be done as part of an anterior lamella repositioning procedure with or without a grey line split, or more specifically as a procedure on its own. A grey line split is extended up onto the anterior surface of the tarsus and continued to totally free the posterior lamella from all tissue to the upper fornix. The lid lamellae are then held together with sutures that are passed from the fornix directly through to the skin. The terminal anterior surface of the advanced tarsus is left bare to granulate and the lid margin sutured directly to it (Figure 4.7).

Esophageal Strictures

Fluoroscopic dilatation has many advantages over bougienage because balloon dilatation is not limited by the diameter of the nose or pharynx, and the incidence of perforation with balloon dilatation is much lower than with bougie dilatation (FAsulAKis and ANDR0NiK0u 2003). Serial balloon dilatation is recommended because progressive stretching of scar tissue prevents tears and perforations. Scar tissue can limit success since fibrosis and altered blood supply reduce tissue elasticity (FAsulAKis and ANDR0NiK0u 2003). The balloon is inflated under fluoroscopy at the level of the stricture, applying uniform radial force that is less traumatic than the shearing force of bougienage. Fluoroscopy has the added advantage of allowing the radiologist to check that the stricture is dilated to a suitable diameter. After dilatation, the success of the procedure can be monitored immediately with the introduction of water soluble contrast medium to show an increase in esophageal caliber and to...

BDD and other body image pathologies

BDD presents as a preoccupation with an imagined defect in appearance or if a slight anomaly is present, the individual's concern is excessive (American Psychiatric Association, 1994). BDD is also referred to as dysmorphophobia and 'dermatological non-disease' (Cotterill, 1981) in the dermatological literature. In one study 8.8 of patients with mild acne had BDD (Uzun et al., 2003). The complaints in BDD commonly involve imagined or slight flaws of the face or head such as thinning hair, acne, wrinkles, scars, vascular markings, paleness or redness of the complexion, swelling, facial disproportion or asymmetry, or excessive facial hair. The most common areas of concern involve the skin and hair. Some associated features of BDD include repetitive behaviours such as excessive grooming behaviour. This may manifest as excessive hair combing, hair removal, hair picking or picking of the skin, or ritualised make-up application. The main purpose of the repetitive behaviour is to improve or...

Angiogenesis in Granulation Tissue

Angiogenesis, the regeneration of new blood vessels from existing vessels, is a crucial regenerative response in all injured tissues, whether the end result is scar tissue formation or restoration of normal tissue architecture. Thus, both regenerative and fibrotic environments both have common elements that promote blood vessel regeneration, insuring an adequate supply of oxygen and nutrients in each case. The initial fibrin matrix is normally hypoxic, thus, low-oxygen tension may be a signal for initiating angiogenesis in any kind of wound (Hunt and Hussain, 1992). The new capillaries of granulation tissue are sprouted from pre-existing vessels. Initially, the granulation tissue is hypervascu-larized, giving it a characteristic reddish appearance. As the granulation tissue is remodeled into scar tissue, the extra blood vessels are resorbed by apoptosis that may be induced by macrophages. Studies on the pupillary membrane, a vascular membrane covering the pupil of newborn rats, have...

Regeneration Screens

Regeneration screens have been carried out at both the cellular and whole-organismal levels to identify the small molecules and genes involved in the regenerative process. Inhibitory molecules associated with myelin and the glial scar limit axon regeneration in the adult CNS, but the underlying mechanism of such regeneration inhibition is not fully understood. A small molecule screen to search for compounds that can neutralize neurite outgrowth inhibitory activity associated with the CNS myelin identified several epidermal growth factor receptor kinase inhibitors. These compounds showed a remarkable ability to counteract the effects of myelin inhibition, and they promoted the significant axon regeneration of injured optic nerve fibers, which points to a promising therapeutic avenue for enhancing axon regeneration after CNS injury (Koprivica et al., 2005).

The Role of Wound Contraction in Dermal Repair

FIGURE 2.5 Diagram illustrating contraction of the skin in rodent (A) vs human (B) circular excisional wounds. Outer circle initial perimeter of the wound. Inner circle position to which the skin is drawn by contraction. Arrows indicate distance and direction moved by the skin. Stipple indicates area of granulation tissue. Human skin contracts much less, leaving a greater relative area to be filled in by granulation tissue and scar. FIGURE 2.5 Diagram illustrating contraction of the skin in rodent (A) vs human (B) circular excisional wounds. Outer circle initial perimeter of the wound. Inner circle position to which the skin is drawn by contraction. Arrows indicate distance and direction moved by the skin. Stipple indicates area of granulation tissue. Human skin contracts much less, leaving a greater relative area to be filled in by granulation tissue and scar. to decrease the area that needs to be covered by epidermis and filled in by scar tissue. Contraction is characterized by the...

Porphyria Cutanea Tarda

Other main clinical features include bullae and erosions on a background of normal skin with atrophic scars from healed previous lesions. Small milia may also be present. Patients may develop hypertrichosis and sclero-dermatous changes on the face. The diagnosis is made by history, clinical features and elevated urinary porphyrins and the treatment includes the discontinuation of exacerbating factors, phlebotomy or low-dose chloroquine, 125 mg twice a week.

Squamous Cell Carcinoma

Fair-skinned individuals with excessive sun exposure. Other aetiological agents may be relevant, such as arsenic ingestion, human papilloma virus infection, polycyclic aromatic hydrocarbons, industrial carcinogens (tar, pitch, crude paraffin oil), previous radiotherapy and chronic ulceration. Lesions arising in sun-exposed sites have a low risk of metastasis but this is increased in tumours arising on the lower lip, in scars or ulcers, anogenital mucosa or in immunocompromised patients. These carcinomas usually present as slowly evolving plaques or nodules, which may become eroded or ulcerate, usually on the head (Figure 9.31) and neck. They can also occur in the genital area and oral mucosa. Surgical excision is the treatment of choice but adjuvant radiotherapy or node dissection are required in metastatic lesions.

Seaborne Waterborne Conditions

Holiday-makers in tropical seawaters present to local doctors following contact with or traumatic skin injury from jelly fish, coral reefs, anemones, sea-urchins, and venomous fish. A variety of acute clinical pictures manifest as contact eczema, stings, burns, as well as penetrating injuries, whereas vasoactive phenomena represent the common pathogenic mechanism in direct skin poisoning. The returning traveller commonly has postinflammatory lesions characterised by hyperpigmentation and scarring. Chronic eczematous reactions and secondary bacterial infections require specific treatment.

Why does stigmatisation occur

Another approach to understanding stigmatisation is based on the 'beautiful is good' stereotype. There is considerable evidence for the suggestion that attractive people are viewed differently than unattractive people (Dion et al., 1972 Eagly et al., 1991). Attractive people tend to be seen more positively on a wide variety of dimensions, including intelligence, warmth and social competence, a view that develops in children while they are quite young. The notion that the converse also holds (i.e. that people with disfiguring conditions are perceived as 'bad') has not been tested directly, but media and literary portrayals that often equate evil with such skin conditions as scarring would suggest that a connection of this kind is often made.

How might stigmatisation be reduced

One approach is to reduce the visibility of a stigmatising mark. There is good evidence that cosmetic surgery (Sarwer et al., 1998) and cosmetic prostheses can help people feel better about themselves and their appearance. With respect to skin conditions, skin camouflage creams can be used to disguise skin blemishes such as scars and vitiligo. Kent (2002) found that clients who consulted the British Red Cross Skin Camouflage Service felt more confident in and exhibited less avoidance of social situations after their appointment than before. Although there was no measure of enacted or felt stigma in that study, qualitative comments indicated that clients were less preoccupied by how others would react to them. Laser treatment can also be helpful for those with port wine stains (Troilius et al., 1998), as is medical treatment for a variety of skin conditions including acne and eczema (Kurwa & Finlay, 1995 Kellett & Gawkrodger, 1999).

Revision Thyroidectomy

This operation is one of the most difficult of the thyroid operations. To one degree or another, the pristine surgical planes have been violated, which greatly increases the odds of damage to vital structures RLN, parathyroid glands, trachea, and esophagus. The first step is to get a clear understanding of the previous operation. If the contralateral lobe was resected for a nodule of indeterminate pathology and returned as cancer, returning to the operating room within the week is imperative so as to access the remaining lobe before the scarring sets in. If a different surgeon operated on the first side, then the details of the operation are needed, especially to ascertain if the RLN and parathyroids were already dissected on the remaining side. Even through scar, the important structures may once again be dissected free, but a wider exposure is needed and the surgeon must prepare for a longer, more tedious dissection. Also, active monitoring of the RLN with a specialized probe on the...

Endoscopic Harvesting

Following the introduction of endoscopic techniques in almost every field of surgery, the application of the techniques in reconstructive microsurgery represents the natural evolution of this trend. Less postoperative pain, smaller scars in the donor area better visualization of the operative field with the magnified video and better hemostasis are only a few of the advantages of this technique. These advantages have been seen in a recent series of patients in which latissimus dorsi harvesting was compared between the endoscopic technique and the traditional technique.53 Successful microvascular transplantation of gracilis muscle harvested with endoscopic guidance are also described in the literature.54,55

Partialthickness Tears

Andrews et al. (78) reported good success with debridement in a young and athletic group of patients. Snyder et al. (79) reported their results on arthroscopic cuff debridement with or without subacromial decompression. They had 85 satisfactory results, with similar results between those patients who had and did not have a decompression. Arroyo et al. (80) noted that young overhead athletes frequently develop subacromial scarring and bursitis owing to overuse and instability and that soft-tissue cleanout of the subacromial space may be helpful. Altchek and Carson (81) studied 50 throwing athletes with anterior shoulder pain, which was refractory to nonoperative treatment, and found that most had fraying of the articular surface of the cuff. Debridement of this area, combined with debridement of bursitis and coracoacromial ligament hypertrophy when noted, was associated with favorable results in 80 of cases.

Orbicularis muscle functioning normally

Tight skin, tight upper or lower lid retractors or tight conjunctiva prevent normal upper or lower lid movement and closure. Common causes are scarring and proptosis. Tight skin - is due to scarring (or occasionally skin loss). Diffuse scarring is treated with a skin graft linear scarring is treated with a z-plasty. Tight upper or lower lid retractors - may be due to overcorrected ptosis or scarring. The retractors are recessed with either excision of Muller's muscle (simple recession is usually ineffective), or recession of the retractors themselves (levator aponeurosis or lower lid retractors). This is done through the anterior (skin) or the posterior (conjunctiva) approach. A spacer (e.g. sclera) is optional in the upper lid but is essential in the lower lid. Alternately, in the upper lid adjustable sutures may be used.

Recipient Site Dissection Technique

In order to minimize surgical and ischemic time, it is recommended that recipient site preparation is done by a second surgical team simultaneously with the toe harvesting procedure. A pneumatic tourniquet is used to provide a bloodless field for dissection. Incisions, at the recipient site, are often dictated by scars from previous wounds. The thumb is usually prepared with fishmouth incisions, using either dorsal volar or lateral longitudinal incisions to raise the skin flaps. Exposures of the bone, dorsal veins, flexors, extensors, radial cutaneous nerve, digital nerves, and radial artery are done with minimal dissection to avoid devascularising the skin flaps. In the case of a second toe transfer which has triangular skin flaps in the dorsum and the volar aspect, a dorsal volar incision on the thumb stump is preferred to accommodate the transplant and also to provide side coverage with the recipient skin flaps.

Clinical Evaluation Of

Cystourethroscopy should be performed to examine for urethral stricture, bladder neck contracture, and other abnormalities of the bladder and urethra. Direct visualization of incomplete coaptation of the DUS is seen in some patients with sphincteric incontinence. Anatomic configuration of the vesicourethral anastomosis and scarring at the bladder neck should be assessed, as it may have implications for future therapeutic interventions.

Preoperative Planning

The soft tissue envelope is of paramount importance. Soft tissue defects can be reconstructed with transfer of composite FVFG with skin, fascia, muscle or combinations of these. However, not only the integrity, but equally importantly, the vas-cularity of the surrounding soft tissues should be assessed preoperatively. A history of high-energy trauma, infection, multiple previous procedures or irradiation suggests development of scar tissue, decreased vascularity of the soft tissue envelope, intraoperative difficulties and potential devastating complications for the unaware surgeon. The zone of soft tissue injury usually exceeds the dimensions of the skeletal defect. Scar tissue may extend well beyond the apparently injured area and involve the walls of blood vessels, compromising blood flow. In these circumstances, use of vein grafts may be warranted. Moreover, the possibility of previous arterial injury should be evaluated by clinical examination, Doppler assessment of flow and, if...

Technique of carbon dioxide laser resurfacing

The skin is thoroughly cleansed with saline and dried. The area of treatment is outlined and any deep wrinkles individually marked. The laser pattern and power are set, the laser tested and treatment commenced. The initial treatment centres on the individual wrinkles or scars outlined, with treatment to the shoulders or elevated areas adjacent to the deeper wrinkle or scar. The ablated debris is removed with saline soaked gauze swabs. Confluent laser passes are then made over the entire region or regions to be treated, taking care to avoid significant overlap of the laser pattern. The number of passes with the laser is dependent on the region of skin treated and the laser characteristics. Usually 1-2 passes are all that is required when treating periocular skin whilst 2-4 passes may be necessary in areas of thicker skin such as the forehead, cheeks or chin. All desiccated tissue must be carefully wiped away with saline swabs after each pass (Figure 8.6). Assessment of the depth of...

Recipient Site Preparation

The integrity and condition of the recipient site vessels and their adequacy of pulsation should be carefully assessed intraoperatively, especially in cases with a scarry soft tissue environment. Direct damage at the time of the initial injury or involvement of the vessel walls by scar tissue will result in compromised blood flow. As a consequence, thrombosis and occlusion of the anastomoses may be facilitated and even viability of the extremity could be endangered, if the remaining collateral circulation is inadequate. The surgeon should be prepared to use vein grafts in order to perform the anastomoses at healthy vascular walls. In defects related to previous infection and presence of scar we can establish an AV shunt through a looped vein graft at the time of the first operation, when debridement is carried out. This technique allows placement of the anastomotic sites on normal vessels.

Lungs and Respiratory System

The chronic lung disease (CLD) that sometimes follows RDS in preterm infants is also called bronchopulmonary dysplasia (BPD). BPD CLD is a chronic disorder that results from inflammation, injury, and scarring of the airways and the alveoli. It is associated with growth, health, and neurodevelopmental problems during childhood (see Chapter 11). Positive-pressure ventilation, high oxygen concentrations, infection, and other inflammatory triggers all contribute to lung injury but the primary cause of BPD CLD is lung immaturity. Especially for infants born at less than 28 to 30 weeks of gestation, the lung tissue is very fragile and the injured lung tissue

Regional Complications Donor Site

Transient weakness of the peroneal muscles and sensory abnormalities on the lateral aspect of the leg may be observed, as well as flexion contracture of the hallux, secondary to scarring of the FHL, which may require surgical release. Peroneal nerve injury, compartment syndrome and tibial fracture have been rarely reported.

Ophthalmic System and Vision

Environmental factors, including hypoxia, hyperoxia, variations in blood pressure, sepsis, and acidosis, may injure the endothelia (the cells that line) of the immature retinal blood vessels. The retina then enters a quiescent phase for days to weeks and forms a pathognomonic ridge-like structure of mesenchymal cells between the vascularized and the avascular regions of the retina by 33 to 34 weeks of postmenstrual age. In some infants, this ridge regresses, and the remaining retina is vascularized. In other infants, abnormal blood vessels proliferate from this ridge and progressive disease can cause exudation, hemorrhage, and fibrosis, with subsequent cicatrical scarring or retinal detachment (i.e., the retina is pulled off the back of the eye). The presence of plus disease, in which dilated and tortuous blood vessels occur in the posterior pole of the eye, is especially ominous for an adverse visual outcome.

Clinical Features

Dyspnoea, haemoptysis, lobar consolidation, pleural effusions, pneumothorax and hydropneumothorax. Some patients may expectorate the worm and if this occurs it is followed by resolution of the symptoms. Visceral gnathoso-miasis is associated with peripheral blood eosinophilia. Gastrointestinal involvement is rare, presenting as a right lower quadrant mass or acute abdominal pain mimicking appendicitis or intestinal obstruction. Diagnosis is often made by pathological examination of the material after resection. The genitourinary system is rarely involved. As in the case of other migratory worms, the eye may become involved and infection with gnathosomiasis is associated with uveitis, iritis, intra-ocular haemorrhage, retinal scarring, detachment and blindness. The immediate symptoms can be relieved by topical steroids but the definitive treatment is removal of the worm (Punyagupta et al., 1990).

What a Mortality Review Would Have Found

First, there was overwhelming evidence to show that Edward Vaughn was at a continuing high risk for suicide in the Lincoln County Jail, and that continuing high risk was known to various medical, mental health, and correctional personnel. This much was known (1) he had a history of mental illness, psychiatric hospitalization, and psychotropic medication (2) he was observed to be depressed, agitated, incoherent, quite tearful and crying, and displaying numerous self-inflicted injuries and scars (3) he self-reported both depression (feeling so bad) and suicidal ideation (can't live anymore), as well as requested to remain in the restraint chair when feeling the impulse to engage in suicidal behavior and (4) he

Diagnosis of Local Recurrence

Fluorodeoxyglucose positron emission tomography (FDG-PET scan) is a relatively new, very useful procedure that exploits the increased rate of glycoly-sis in tumour cells (Fig. 3). It can successfully distinguish scar tissue from tumour tissue, which can prevent an unnecessary second look surgery 42 . Schiepers et al. 45 compared CT and FDG-PET in the evaluation of 74 patients for recurrent colorectal

Therapies For Injured Peripheral Nerve

Crush injuries of peripheral nerves regenerate relatively well because the proximal and distal segments of the nerve remain aligned so that proximal axon stumps can regenerate into distal endoneurial tubes. Transections, or injuries that necessitate removing segments of nerve, are more difficult to repair. The cut ends of the nerves retract, and it is difficult to suture them back together. Fibroblasts invade the wound space, resulting in the formation of scar tissue that leads sprouting proximal axons to form neuromas. Continuous longitudinal sutures have been used successfully to bridge small gaps in the rat sciatic nerve (Scherman et al., 2004), but this does not suffice for larger gaps. Glial scar components

Therapies For Injured Spinal Cord

To achieve successful regeneration, neurons must survive and their axons must be able to enter the lesion, traverse it, exit the other side, and continue on to re-innervate targets. Several cell transplantation and pharmaceutical therapies have been developed to promote mammalian spinal cord regeneration, based on our knowledge of the events that occur after a spinal cord injury. Pharmaceutical (chemical induction) approaches include the use of neuroprotective agents, neutralization of myelin proteins, inhibition of gliosis, and degradation of glial scar ECM, and implanting biomaterial bridges to bypass glial scar and promote axon extension (Horner and Gage, 2000 Bjorklund and Lindvall, 2000 Talac et al., 2004). Glial cell transplants have been used to provide factors essential for axon extension, and NSCs and other cell types appear to have paracrine neuroprotective effects (Mansergh et al., 2004). Finally, rehabilitation programs have been designed that are aimed at rewiring spared...

Periurethral injectable agents

Teflon paste, silicone, fat and collagen have all been utilized as injectable agents to provide improved continence following prostatectomy. Osther and Rohl treated 25 patients with transperineal or transurethral injection of Teflon paste with 'good to moderate' results in 24 of patients with minimal morbidity.60 The retreatment rate, however, was 72 . The patients with the worst results had poor bladder compliance. Additionally, patients that failed the initial injection were usually no better on subsequent treatment. Deane et al. reported a 60 reapplication rate in their Teflon series, noting that patients requiring repeated injections did not improve, which they felt was probably due to local scarring from prior surgery.61 Despite some initally encouraging results, most of their patients failed within 3 months. Politano reviewed his greater than 20 year experience with Teflon paste for all types of post-prostatectomy incontinence.62 Of the over 700 patients treated, those with...

Strategies To Improve Ligament Healing

Researchers have tried to develop strategies to improve and speed up the healing process of injured ligaments. To this end, biological manipulation of scar-tissue formation has predominantly focused on the overexpression of growth factors, which have been revealed as an important influence to cutaneous wound healing. As described previously, this is because the healing process of the ligament is basically analogous to that of skin tissue.

Problems In Ligament Healing

Animal studies on ligament healing have revealed that the same sequence of events appears to occur in the ligament as observed in skin wound healing. The healing processes consist of inflammation (days to weeks), repair proliferation (weeks), and remodeling (months to years see Fig. 1). Through these biological processes, ligaments heal with scarring that is inferior to normal tissue biologically and biomechanically. In addition, owing to their relative hypocellularity and hypovascularity, ligaments generally have a lower healing potential than other soft tissues, e.g., skin. In fact, the tensile strength of injured skin recovers by 10 wk following injury (3), whereas gap-healing rabbit medial collateral ligament (MCL) of the knee reaches only about 30 of the normal ligament strength on a material basis (i.e., per square cross-section of material) at even 1-yr postinjury (4). Even a completely remodeled ligament at over 2 yr postinjury remains scar-like (5). Such ligament scar remains...

Dacryocystorhinostomy indications

Dacryocystorhinostomy Scar

A 12-15mm straight skin incision (8-10mm in children), starting just above the medial canthus and extending inferiorly, is made just medial and parallel to the angular vein (Figure 15.1). A straight incision in the thick paranasal skin tends to heal rapidly with an imperceptible scar, whereas more posterior incisions in the concavity of the thinner eyelid skin sometimes heal with a contracted, bridging scar (Figure 15.2). The incision should involve only skin and should not be carried straight down to the bone, as marked haemorrhage is common with the latter approach, due to disruption of the orbicularis muscle and the angular vessels. Figure 15.2 Bowed scar due to contracture in a posteriorly-placed dacryocystorhinostomy incision. Figure 15.2 Bowed scar due to contracture in a posteriorly-placed dacryocystorhinostomy incision. A large rhinostomy is fashioned using bone punches, trephine or a burr. When using punches, it is easiest to first enlarge the opening to at least 1cm in front...

Nelaton Flap Nasolabial Flap

The Nelaton flap has proved useful for reconstructing larger partial-thickness and full-thickness defects of the ala. The defect should be carefully measured and the flap designed slightly larger and longer. The flap is less satisfactory for bearded patients. The Nelaton flap is a superiorly based flap that is swung into the defect from the nasolabial fold. It can be infolded to reconstruct the alar rim. In men with heavy facial hair, the end of the flap should be thinned the hair bulbs will be resected. Generally there is no need to add cartilage for structural support. If the entire ala has been resected, the alar groove must be reconstructed in a second sitting. The donor defect in the nasolabial fold is easily closed by mobilizing the surrounding skin (Fig. 5.42b), which gives a barely perceptible scar. The alar rim can also be reconstructed with a nasolabial flap (Fig. 5.43).

Relaxed Skin Tension Lines Vascular Supply and Esthetic Units

The facial surgeon must be familiar with the location and distribution of the relaxed skin tension lines (RSTLs) in the face, the facial esthetic units (Fig. 2.20a-c), and the vascular supply of the face (Fig. 2.8e). Besides the RSTLs, attention should also be given to wrinkle lines in the aging face. Incisions or small excisions and sutures placed in the RSTLs will heal with fine, unobtrusive scars. Incisions and excisions made at right angles to these lines will often lead to broad, unsightly scars. Thus the plastic surgeon should always try to place the cuts used for incisions, excisions, and scar revisions (q.v.) in these lines to achieve good cosmetic results. The term esthetic units (see Fig. 2.20a-c) refers to circumscribed facial regions that should each be reconstructed as a separate unit whenever possible. The radical excision of tumors takes precedence over esthetic units, however. We shall return to this reconstructive concept in the sections that deal with specific facial...

Small Lateral Cheek Defects

Fig. 8.12a, b Small preauricular transposition flap (can be cut slightly smaller than the defect). Scar revision may be necessary as a secondary procedure. Fig. 8.12a, b Small preauricular transposition flap (can be cut slightly smaller than the defect). Scar revision may be necessary as a secondary procedure.

Harvesting a Bone Graft from the Iliac Crest

Tensor Fascia Lata Graft Harvest

Approach The somewhat thicker portions of the iliac crest (approximately 1.3-1.7 cm in diameter) are located in the anterior third between the anterior superior iliac spine (Fig. 15.1a, 3) and the iliac tubercle (Fig. 15.1a, Tub). The iliac spine is preserved anteriorly. An assistant presses down on the skin medial to the iliac crest so that the incision, and later the scar, will be lateral to the site where the bone graft is harvested. The incision should not be carried anteriorly past the iliac spine to avoid injury of the lateral femoral cutaneous nerve, as this would cause anesthesia or hypesthesia on the anterolateral thigh (Fig. 15.1b). The incision over the anterior iliac crest extends through the skin and subcutaneous tissue down to the periosteum. The length of the incision depends on the length of bone graft that will be removed. a Position of the patient. Pressing down on the abdominal wall draws the skin medially across the iliac crest, positioning the incision and scar...

Auricular Replantation by the Technique of Baudet 1972 and Arfai 1974 Weerda 1980

Facial 1974

A The film pattern traced from the opposite ear is reversed to determine the precise position of the reconstructed ear (see Fig. 10.13). Its position is also determined by the auricular remnants. b The old wound is opened, the scars are carefully excised, and the skin is undermined. The old wound edges are freshened, and the cartilage framework (Ge) is implanted (see Fig. 11.3). c The wound is closed. The ear-lobe remnant is placed at the anatomically correct site, and the skin is coapted to the framework by a suction drain (S) and several bolster sutures.

Earlobe Reconstruction in Two Stages

Fig. 10.20a) is folded behind the anterior one (1). c The wounds are closed. (The inferior skin is mobilized to place the scar behind the auricle.) a The defect is freshened, and a bilobed flap is cut to form the anterior side (1) and posterior side (2) of the proposed earlobe. The anterior flap (1) is slightly larger than the second flap. b Flap 1 is sutured into place, and flap 2 is folded under to cover the posterior side. c All defects are closed (a minor disadvantage is the visible scar below the earlobe). K cartilage support

Early and Late Complications After LAR

Stapled anastomosis besides its advantages is associated with the higher rate of anastomotic stenosis or stricture. The exact incidence of this complication is difficult to determine because the definition of stenosis is not well defined. Lett et al. and Fazio have defined a stricture as a narrowing that does not allow passage of a 15-mm sigmoidoscope. It is believed that, according to Kyzer and Gordon considered stenosis as any anastomosis that did not accept the 19-mm sigmoidoscope. The aetiology of anastomotic stenosis is not completely understood. When the colon is found to be ischaemic it may lead to further stricture above the anastomosis. It is proposed that stenosis may be caused by insufficient circulation in the marginal artery and this insufficiency may be aggravated also by irradiation. Experimental studies indicate that stapled anastomoses heal by second intention because the mucosa of the bowel segments is not in apposition but is separated by the muscular and serosal...

Direct brow lift browplasty

This procedure is particularly suitable for male patients with thick bushy eyebrows and receding hairlines (thereby masking brow scarring and avoiding coronal scarring), patients requiring a less extensive procedure and those with unilateral brow ptosis secondary to facial nerve palsy. The extent of tissue excision is marked with the patient sitting upright aiming to position the scar within the upper row of brow hairs. The lower skin incision is made with the scalpel blade bevelled such that the incision is parallel to the hair shafts. This obviates transverse sectioning of the hair follicles thus minimising brow hair loss. Skin and subcutaneous tissue, with underlying orbicularis muscle as necessary, are excised taking care to identify and therefore avoid damage to the supraorbital neurovascular bundle. If surgery is undertaken for seventh nerve palsy then tissue excision down to the periosteum with deep fixation of brow tissue to periosteum using interrupted 4 0 Prolene sutures is...

Median Forehead Flap with Soft Tissue Expansion

Fig. 5.53 Broad median forehead flap following preliminary soft-tissue expansion with a 200-mL expander. A small incision in the scalp gives access for inflating the envelope. The flap is dissected from the galea and periosteum in a subcutaneous plane, preserving the frontalis muscle (oblique forehead flap, see Fig 5.16). Better results without a rigid scar we can get with lateral expansion (see Fig. 4.5). Fig. 5.53 Broad median forehead flap following preliminary soft-tissue expansion with a 200-mL expander. A small incision in the scalp gives access for inflating the envelope. The flap is dissected from the galea and periosteum in a subcutaneous plane, preserving the frontalis muscle (oblique forehead flap, see Fig 5.16). Better results without a rigid scar we can get with lateral expansion (see Fig. 4.5).

Large Full Thickness Reconstruction of the Cheek and Commissure

Buccal Artery Myomucosal Flap

Ternal defects can be covered by two-layer advancement of the overlying and underlying soft tissues. A particularly effective technique is Esser's cheek rotation (Fig. 6.52a) combined with the advancement of buccal and mental soft tissues by making an incision inferomedial to the defect and into the chin and excising Burow's triangles. An attempt should be made to place the resulting scars in the RSTLs (Fig. 6.52b). Microvascular free flaps are also an option in selected cases.

Reinnervation of Granulation Tissue

Medical Images Vat Scars

FIGURE 2.4 Comparison of collagen organization in normal uninjured dermal architecture (a) vs collagen organization in dermal scar tissue (b). The collagen of the uninjured dermis has a reticular (basket-weave) organization, whereas the collagen in a repaired dermis is cross-linked into thick bundles parallel to the wound surface. Reproduced with permission from Linares, 1996, From wound to scar. Burns 22 339352. Copyright 1996, Elsevier. FIGURE 2.4 Comparison of collagen organization in normal uninjured dermal architecture (a) vs collagen organization in dermal scar tissue (b). The collagen of the uninjured dermis has a reticular (basket-weave) organization, whereas the collagen in a repaired dermis is cross-linked into thick bundles parallel to the wound surface. Reproduced with permission from Linares, 1996, From wound to scar. Burns 22 339352. Copyright 1996, Elsevier.

What types of stigmatisation do people encounter

Such perceptions and beliefs are not due to over-sensitivity. A number of experimental studies have demonstrated that people with disfiguring skin conditions encounter stigmatisation. For example, Kleck and Strenta (1980) compared reactions to a confederate of the experimenters when the confederate either had an unblemished face or had an artificial scar applied to a cheek. Clearly, other people reacted to the confederate quite differently under the two experimental conditions. They were more likely to judge the confederates behaviour negatively when a scar had been applied to the face. Stigmatisation can be more subtle than this. Rumsey et al. (1982) used make-up so it seemed that a person waiting at a traffic light had either a port wine stain to one side of the face, had an accident to the same side (as indicated by a bandage), or had an unblemished face. Other people waiting at

Frontotemporal Flap of Schmid and Meyer

What Total Composite Flap Facelift

Stage III After a total of 3-4 weeks the entire flap can be raised on its median pedicle, and the temporal flap is inset into the nasal defect (Fig. 5.17c). Stage IV About 3-4 weeks later the pedicle can be divided or opened up, inset to reconstruct the columella (Meyer 1988), or discarded. Additional stages Further steps may be needed to complete the insetting of the temporal flap in the nose, or scar revisions may be necessary to improve the outcome. This technique can also be used for alar reconstruction using a composite graft from the auricular concha (Fig. 5.18). Other flap options for partial nasal reconstruction are described on pages 47-51

Psychological Model of Adjustment to Cancer

According to Moorey and Greer's cognitive model of adjustment, the personal meaning of cancer, based on an idiosyncratic appraisal of the threat to survival and the threat to the self, is an important determinant of an individual's adaptation to their disease. Moorey and Greer's model helps to explain why any two individuals with the same disease may react very differently to a diagnosis of cancer. For someone who has relied heavily on their appearance for self-esteem, treatment associated with hair loss or scarring may be devastating. Someone else who

Potential of Nonregenerating Tissues

Regenerating Cells Muscle

Vated or participate in scar tissue formation after injury, indicating that mammals have considerable latent capacity for regeneration that is suppressed (Stocum, 2004b). TABLE 1.2 summarizes the nonregenerating tissues in which stem cells have been found so far. Both the spinal cord and the heart initiate regeneration that is then aborted by inhibitory factors in the injury environment leading to the formation of scar tissue (Chapters 5, 11). Thus, by changing a nonpermissive injury environment to a regeneration-permissive one, we may be able to initiate and or complete the regenerative process. Second, regenerative responses have been induced or enhanced in a number of tissues of experimental animals. Biodegradable, cell-free artificial regeneration templates have been used to induce dermal regeneration in excisional skin wounds and improve regeneration across gaps in peripheral nerves, though the results have been far from perfect (Yannas, 2001). A variety of neuroprotective...

Introduction The Challenge Of Acl Regeneration

The anterior cruciate ligament (ACL) is a primary stabilizer of the knee joint that is frequently injured, compromising knee stability and leading to degeneration of other joint structures. Because the ACL has a poor intrinsic healing capacity, surgical reconstruction is required to restore knee function in young active patients. Biological grafts are the gold standard for ACL reconstruction, resulting in formation of scar-like tissue, which remodels but remains structurally and biomechanically inferior to the normal ACL. The ultimate challenge of ACL reconstruction is ACL regeneration reestablishing the unique structure, function, and mechanical properties of the normal ACL. Despite significant recent advances (1), existing ACL reconstruction techniques do not result in ACL regeneration (2). In fact, regeneration of the musculoskeletal soft tissues, including ligament, tendon, meniscus, disc, and cartilage, remains an elusive goal. In contrast to bone and liver, which can regenerate...

Return Of The Scientific Methodthe Charge For The Future

In a similar vein, hyperbole (308-338) masked the true incidence of complications. Some cautious but perhaps courageous laser surgeons did report side effects and preached thoughtful reflection and methodology (222,319,349,355,462-469). This author raised the question of underreporting of scarring and the role of wound dressings in preventing hypertrophic scarring in 1984 (75). In a 1987 review Olbricht et al. (463) surveyed laser surgeons, 69 of whom had seen at least one case of hypertrophic scarring after argon laser and 64 after CO2 laser surgery, but no true incidence of scarring was tabulated. Lent and David (464) noted hyperpigmentation in 16 of laser-resurfaced patients postoperatively and Fitzpatrick et al. (319), 25 . Nanni and Alster (466) found a 37 incidence, more common in darker patients (up to 100 of Fitzpatrick type IV and V patients) (355,466), but this is reversible particularly with postoperative hydroquinones. Bernstein et al. (349) first made known the previously...

Tubed Pedicle Flap Bipedicle Flap

Bipedicle Flap Plastic Surgery

A A flap of appropriate size is outlined lateral to the tracheostoma and dissected to its margin. Skin triangles are excised above and below the defect and are discarded. The tracheostoma margin on the opposite side is freshened. b The flap is hinged over and sutured to the freshened epithelial border. The long laryngeal muscles are mobilized to cover the turnover flap (middle layer c A Z-plasty is performed to close the wound and place the scar in the RSTLs (dashed red line).

Postoperative Wound Care

As noted before, interpretation of adverse events when continuous wave lasers were employed for cutaneous laser surgery and epidermal necrosis ensued became obscured by the fact that scarring was underreported or redefined and postoperative care was not standardized, not mentioned in the literature or in lectures, and sometimes not given. Second-degree thermal wounds all scar and it is likely that the absence of postoperative dressings over the necrotic wound in early argon laser surgery was responsible for much of the incidence of hypertrophic scars. With proper postoperative dressings and antibacterial ointment the incidence of such scarring dropped to less than 1 (75,77) from a range of 3-16 or more (60,68,71,73,74,178,214,215) (Figs. 1.11 and 1.17). Brauner and Schliftman were early proponents of scrupulous postoperative wound care. Unfortunately, there was an accompanying and unexpected large incidence of contact dermatitis to bacitracin with large areas of coverage (216-218)....

It Takes A Nobel Prize Winner To Think Of It

Green Nobel Prize Goldman

Laser safety ANSI standards Personnel and patient safety plume Patient safety scar Minimal dose B. Cosman, scanners Chilling C. Chess Serendipity scars T. Alster It was only because of the ingenuity and persistence of this one man that lasers finally were made applicable to the treatment of human malformation and disease and degenerative changes (32). Since the ruby laser was the only one available, it was that which he turned on himself, laboratory animals, and other humans (33).* Goldman first exposed normal white and black skin and also white and black human skin covered with various black dyes to the ruby laser (34) and then attempted to treat cutaneous lesions such as seborrheic keratoses and superficial hemangiomas (33,35,36) and tattoos (37). Histologically, nonspecific thermal destruction of the cutaneous target occurred clinically, there was long-lasting oozing and crusting, usually resulting in scarring, which was fortunately only rarely hypertrophic. By

Therapies For Neurodegenerative Diseases

Multiple sclerosis (MS) is an autoimmune CNS disorder in which myelin is damaged and astrocytes proliferate to form scar, resulting in the blockade of electrical impulses along nerve axons, loss of sensation and coordination, and in severe cases, paralysis and blindness (Steinman, 1996). It affects 2.5 M people worldwide and is one of the most common neurological diseases of young adults (Zamvil and Steinman, 2003). Typically, the disease follows a relapsing and remitting pattern in which acute demyelinating episodes are followed by the generation of new oligodendrocytes and remyelination, but with increasing numbers of lesions that fail to remyelinate. FIGURE 6.11 Intravenous or intracerebroventricular injection of NSCs into EAE mice reduces glial scarring and modulates expression of neurotrophic mRNAs. a, b, reduction of area of reactive astrogliosis within demyelinating areas (arrowheads) as evidenced by Luxol fast blue staining, compared to (c) sham controls. Arrows indicate...

Primary Thyroidectomy

An incision is made in a skin crease about 2 cm cephalad to the clavicles. Once a surgeon gains more experience with this procedure, the transverse incision decreases in length from about 8 cm to about 4-5 cm. This generally results in an imperceptible scar, and negates the benefits of endoscopic assisted thyroidectomy, a much more complex and lengthy procedure. Superior and inferior flaps are raised in a subplatysmal plane. These really only need to be done in between the sternocleidomastoid muscles as more lateral dissection does not improve visualization. This is the basis for reducing the size of the incision to 4 cm in primary cases. The wound is copiously irrigated and meticulous hemostasis is achieved. Small suction drains can be placed with no deleterious effects to the RLN, but they are not always necessary. We now close our wounds with 4-0 Vicryl sutures to reapproximate the platysmal layer and then 4-0 Biosyn subcuticular sutures. This allows the patient to have no sutures...

Clinical Manifestations

Can Filariasis Infect Scrotum

The acute clinical course of filariasis may last for several days or up to 4-6 weeks with a fulminant episode. The diagnostic criteria for the identification of acute filarial attacks have been codified (World Health Organization, 1992) and require pain, tenderness and local warmth, with either lymphadenitis lymphangitis cellulitis (Shenoy et al., 1995) (for lungs and breasts) or epididymo-orchitis (for the scrotum). The presence of scars at typical locations, e.g. over the inguinal and epitrochlear lymph nodes, supports the diagnosis of filariasis (Figure 18a.1). In patients with filarial disease, acute attacks of ADL may involve the limb, breast or male external genitalia. Fig. 18a.1 Scar following rupture of subcutaneous abscess in Brugia malayi adenolymphangitis. Courtesy of Dr Stephen Hoffman Fig. 18a.1 Scar following rupture of subcutaneous abscess in Brugia malayi adenolymphangitis. Courtesy of Dr Stephen Hoffman It is now generally agreed that it is possible to distinguish the...

Surgical rehabilitation of the patient with dysthyroid eye disease

Although the use of a bicoronal flap for orbital decompression has been widely reported in the past, there is no advantage to the use of this large-incision approach. Likewise, the Lynch incision of the external ethmoidectomy approach often leaves an unsightly scar and gives only limited access - to the medial wall and medial part of the orbital floor.

Factors Influencing Nerve Regeneration

Different Suture Patterns Pictures

Technical details while enumerating the technical factors influencing regeneration. On the contrary, the loss of nervous tissue must be repaired by the use of grafts and since the studies carried out by Millesi the use of interfascicular nerve autografts represents the golden standard for this kind of lesion (Fig. 2.1E).2 Nerve grafts bridge the gap, guide regeneration and protect axons against the surrounding scar. Indeed, the introduction of nerve grafting greatly improved both the possibility and results of nerve surgery, even if, in the presence of a nerve gap over 10 cm, prognosis is poorer.11 Generally, we use the sural nerve as the donor nerve, or, in some cases, other pure sensory nerves such as the medial cutaneous nerve of the arm or forearm, or the posterior interosseous nerve at the wrist. However, this creates a damage in a sound area (skin scar, sensory loss in the donor area, risk of neuroma formation) moreover, at times these autografts are not long enough to repair...

Cell Dedifferentiation and Proliferation

Band Bungner

As their myelin is degraded, the Schwann cells dedifferentiate within the basement membrane to form cords of cells called the bands of Bungner (figure 5.5). They proliferate and migrate to form a continuous bridge across the lesion and down the length of the distal endoneurial tubes. Axotomized neurons, along with macrophages and platelets that have invaded the injury site, produce growth factors and cytokines that are mitogenic for Schwann cells (TABLE 5.1). Many of these molecules are the same ones responsible for the fibrosis of skin repair, such as FGF, PDGF, IL 1,2, and 6, TGF-P and IFN-y, as well as nerve-specific factors such as glial growth factor (GGF) (Fu and Gordon, 1997). When the gap in the nerve is too large to be bridged by dedifferentiating Schwann cells, fibroblasts enter the wound space and these same factors induce scar formation, preventing regeneration.

Complications of Encircling

Some of these events can be controlled with careful technique. Conjunctival scarring and chronic dry eye can be reduced by meticulous attention to Tenon's capsule and careful dual layer closure. (It is unfortunate that closure is at the end of a challenging and tiring operation and is often delegated without much supervision). Strabismus can be reduced by careful handling of orbital tissues and muscle retraction and by choosing small instead of large buckles 19-21 (Fig. 3.3). Meticulous restoring of the anatomy will limit scarring. Motility can be improved by postoperative ocular exercise. Erosion and string syndrome can be avoided by limiting constriction to 10 22 (Fig. 3.4). Overzealous constriction (high and dry) can be corrected later by cutting the band. More difficult post-surgical judgements are presented by insidious choroidal ischemia and reduced pulse amplitude 17,18 . Typically, the retina is attached and the vision is good yet there may be mild chronic irritation

Vein Wrapping for the Treatment of Recurrent Entrapment Neuropathies

Masear et al1 reported the technique of using venous wrapping of nerves to prevent scarring for severe and recurrent nerve compression. In their clinical study, both autograft and allograft of vein were used to wrap the median nerve after decompression. Their results showed marked improvement in pain. A remarkable absence of scarring around the vein graft was noticed during surgical exploration for secondary reconstruction in three patients. In 1991, Gould2 also described this technique for the treatment of the painful injured nerve in continuity. Koman et al3 evaluated the symptomatic and functional assessment of allograft umbilical vein wrapping for dystrophic median nerve dysfunction. Their encouraging results showed that wrapping the nerve with a vein graft following decompression can improve recovery of nerve function and be beneficial to patients with severe recurrent nerve compression. effect of vein wrapping on normal nerves using electrophysiologic and histologic evaluation....

Druginduced Immune Suppression

A 24-year-old nurse was engaged at short notice to start work for a nongovernmental organisation (NGO) in a malarial area of Ethiopia. Her parents' general practitioner, who was not aware of her personal medical history, gave pretravel advice. She was given adequate malaria prophylaxis, consisting of mefloquine and the usual vaccines for a healthy traveller. Two weeks after arrival at the site she experienced the first of several prolonged periods of febrile illness. Plasmodium falciparum was diagnosed once and treated, and a second time treated as such without laboratory investigation. Recovery every time, however, was of limited duration. After a short recovery she was treated for pneumonia, which was diagnosed on physical examination. After a stay of 4 months she still experienced physical unfitness and was unable to work. At this time she was fully examined by the visiting doctor of her NGO. He noted a large abdominal scar. On questioning she mentioned a laparotomy because of...

Cosmetic Implications

Patients should be advised about the scar, which will usually be a transverse cervicotomy performed in a skin crease, either with subcuticu-lar absorbable stitches or with metal clips 1 .In most patients the scar will leave a fine line similar to a crease in the neck, but in some cases broadening of the scar and keloid formation can occur. There may be some local reduction in sensation in the upper or lower skin flaps, which will gradually improve over the first 9 months postoperatively, and there may be redundant skin if there has been an extremely large goiter. Wound infection following thyroid surgery is very uncommon 2 . Tethering of the skin of the neck to the underlying laryngeal cartilage or trachea can occur, resulting in movement of the neck skin on swallowing or talking, but this is an uncommon complication and can be minimized by anatomical closure of the wound at the end of the operation.

Classification of Free Flaps

The donor site is usually both cosmetically and functionally acceptable. Endo-scopic dissection of the muscle may minimize even further the donor site scar. Skin grafted muscle flaps tend to be self-contouring, that is, the denervated muscle loses its initial bulk and often takes the contour of the area where it is transferred. Cosmetic results tend to be good. Skin grafted muscle does not change in size as the patient gains or loses weight, as occurs with The latissimus dorsi muscle5,11 is the single most useful muscle. Its large size allows coverage of almost any type of defect. Alternatively, the muscle can be split, the lateral portion of it can be transferred to cover small defects, leaving the medial portion and its innervation intact.21 The thoracodorsal branch of the subscapular vessel the largest branch of the axillary artery supplies the latissimus. The pedicle may be very long if the dissection includes the main subscapular vessels as far as the axillary artery. The donor...

An Overview of Female Infertility

When evaluating a patient for infertility, ideally the medical history and physical exam are obtained from the couple. One must obtain a complete obstetrical and gynecological history from the female. The menstrual history is an excellent indictor of ovulatory status. A complicated obstetrical history may suggest the need for maternal fetal medicine consultation prior to initiating therapy, especially if the planned infertility treatment predisposes to multiple births. The gynecologic history can give clues about risk factors for tubal scarring (Chlamydia infection, surgery for endometriosis) or cervical factor infertility (ablation for abnormal Pap smear). Infertility occurs when the fallopian tubes or fimbria are scarred or blocked and cannot transport the ovum or sperm, or serve as the site of fertilization. Previous history of salpingitis (tubal infection), pelvic inflammatory disease, endometriosis, or abdominal surgery can all lead to tubal scarring. Seventy-five percent of...

Complications of Colonic Resection

In patients with rectal cancer after AP resection it is difficult to differentiate fibrosis from recurrent tumor 27 . If baseline studies have been obtained, an increase in soft tissue in the rectal bed over time would favor recurrent tumor. Nodularity at the anastomotic site, enlarged nodes, and evidence of tumor elsewhere also favor malignancy. Early reports advocated magnetic resonance imaging as a more specific examination than CT in differentiating tumor from fibrosis. Initial reports showed higher signal intensity on T2-weighted images in tumor recurrence than in fibrosis with scar formation 33 . These findings proved to be unreliable, however, in part because tumor with desmoplastic reaction or inflammatory changes, such as those occurring after radiation therapy, may not demonstrate the typical T2 intensity. The use of contrast-enhanced dynamic MRI has been

Bacterial Mycetoma Aetiology and Pathogenesis

Figure 9.16 Bacterial mycetoma of the leg by Nocardia braz-iliensis. Deformity of the region with hiperpigmented skin, sinus tract formation, and scarring Figure 9.16 Bacterial mycetoma of the leg by Nocardia braz-iliensis. Deformity of the region with hiperpigmented skin, sinus tract formation, and scarring The clinical disease is characterised by a chronic course, with inflammation, formation of sinus tracts discharging 'grains', and progressive deformity of the affected foot. Healing of discharging sinus tracts over years determines scarring, with atrophic skin plaques and secondary pigmentary changes (Figure 9.16). Asymptomatic nodular or verrucous lesions can also be found, and in a few cases a variable range of symptoms is present. These include pain that often results from superimposed pyogenic infection, acute inflammation, and bone involvement. The chronic infection with deformity of the foot determines periosteal involvement and subsequently osteomyelitis. Variable but often...

Brief History Of Regenerative Biology And Medicine

In biology, the invention of the compound microscope in the early 1600s made it possible to view biological structure in greater detail than ever before and thus better understand the nature of biological phenomena. This technological leap forward led to the development of the science of microscopic anatomy in the 18th century. The comparative anatomist John Hunter (1728-1793) studied healing skin wounds and discovered granulation tissue and the transitional role it played in scar tissue formation (Brown, 1992). The dogma of organismic preformation, which held that the mechanism of ontogeny was growth of a tiny predelin-eated adult within the egg, was toppled by the studies of C.F. Wolff on chick embryos, which showed that the embryo developed in a continuum of epigenetic steps that built form out of amorphous substance.

Larger Contractures

A more severe contracture with fixation of the lower lip and destruction of the underlying skin can be managed much as in the upper lip (see Fig. 6.12) by excising the scar and then mobilizing the vermilion Fig. 6.30a, b Excision of a scar at the commissure. A Z-plasty is used to disperse the scars and place them in the RSTLs. Fig. 6.30a, b Excision of a scar at the commissure. A Z-plasty is used to disperse the scars and place them in the RSTLs.

Malignant orbital disease in children

Long-term side-effects of orbital radiotherapy include cataract, dry eye with secondary corneal scarring, loss of skin appendages (lashes and brow hair), atrophy of orbital fat and, if performed in infancy, retardation of orbital bone growth. There is also a risk of late radiation-induced orbital malignancy, such as fibrosarcoma and osteosarcoma, and there may be an increased propensity to certain other primary tumours in adulthood.

David J Reich Cosme Manzarbeitia Radi Zaki Jorge A Ortiz and Sergio Alvarez

Spontaneous bile leaks from the anastomosis or elsewhere are unusual late posttransplant because of the scarring process. However, patients may suffer a bile leak from the T-tube exit site, approximately 3 months posttransplant. Most centers that use T tubes to stent the biliary anastomosis bring the long limb of the tube out through the recipient bile duct. This is removed approximately 3 months posttransplant, following a normal cholangio-gram. T tubes used in the nontransplant setting are generally removed long before 3 months. However, transplant recipients do not form a mature tract until several months posttransplant because of heavy immunosuppression. Occasionally, 3 months is still not long enough to form a mature tract, and after T-tube removal, bile that leaks into the abdominal cavity causes peritonitis. Most leaks are self-limited and the only therapy required is hydration and antibiotics. Sometimes, severe peritonitis and even septic shock...

Incisional Hernia In Midline Pelvic

Scar Ossification A very unusual complication of abdominal surgery is heterotopic ossification of midline abdominal scars. This variant of myositis ossificans may actually contain both bony and cartilaginous elements and, much more rarely, bone marrow 103 . Most often supraumbilical longitudinal incisions are involved, with a strong male preponderance (10 1) 104 . The scar lies between the two rectus muscles, bordered anteriorly by the abdominal wall fascia and posteriorly by the anterior parietal peritoneum 104 . No distinct linkage with the type of surgical procedure or the suture material used has been established. The MR imaging characteristics were consistent with the underlying pathology 103 . A low intensity rim corresponded with fibrous tissue and or calcium at the scar periphery. The central signal varies with the fat from marrow elements. Figure 1.38. Ossified scar. Right posterior oblique abdominal film (A) and left anterior oblique film from a double-contrast enema (B) on...

Normal Healing Responses

In the past, there was debate regarding whether healing of tendon injury was predominantly an intrinsic or extrinsic phenomenon. The extrinsic mechanism depends on fibroblasts and inflammatory cells entering from the periphery of the injury to effect repair of the tendon. The intrinsic mechanism involves migration of fibroblasts and inflammatory cells from within the tendon and epitenon. It is now believed that tendon healing involves both intrinsic and extrinsic mechanisms, with the latter predominating in the early phases and the intrinsic predominating in a more delayed fashion. Some hypothesize that an imbalance favoring the extrinsic mechanism leads to increased collagen content at the repair site, as well as a suboptimal level of collagen organization and, hence, material properties of the reparative tissue. Consequently, predominance of the extrinsic mechanism may cause scar formation and adhesions between the tendon and surrounding tissues.

Fetal Wounds Have a Minimal Inflammatory Response

A major difference between fetal and adult wounds is that fetal wounds exhibit a minimal inflammatory response (McCallion and Ferguson, 1996 Yang et al., 2003 Ferguson and O'Kane, 2004), suggesting that as it matures during development, the immune system response to injury suppresses regeneration in favor of scar tissue formation. Platelets are few in number in the fetal wound. Only small numbers of platelets, neutrophils, and macrophages are present up to 18 hr after wounding (Cowin et al., 1998). All types of macrophages were eventually recruited to the fetal wound, but their numbers and persistence were much lower than in adult wounds. These observations suggest that the types and proportions of growth factors and cyto-kines associated with the inflammatory environment are different in fetal wounds compared to adult wounds. The negative influence of the inflammatory response on regeneration has been further established by experiments in which the molecular composition of the wound...

Resorbable Matrices And Tissue Engineering Of Ligaments Future Possibilities

Ture tissue, such as a maturing ligament scar following trauma (or else a remodeling autograft ) may help to confer creep resistance because of the resulting large surface area available for interaction with the surrounding ground substance. This is particularly important in the period shortly after ligament reconstruction, when the immature structure may elongate irreversibly under the cyclic loads imposed during function and rehabilitation, which would cause a return of joint laxity. Maturing ligament repair tissue has been shown to be more susceptible to creep than a normal ligament (59).

Cellular and ECM Differences Between Fetal and Adult Wound Healing

This normal pattern of collagen synthesis and architecture is associated with three other differences from adult wounds in ECM synthesis. First, fetal wound fibroblasts synthesize higher levels of HA and HA receptor (DePalma et al., 1989 Longaker et al., 1989 Alaish et al., 1993), giving them more opportunity to bind HA and thus for cell movement. HA has been shown to inhibit fetal fibroblast proliferation (Mast et al., 1993) and to decrease scar formation in wounds of adult tympanic membranes (Hellstrom and Laurent, 1987). Conversely, treatment of fetal rabbit skin wounds with hyaluronidase or HA degradation products alters the regenerative response toward fibrosis (Mast et al., 1991, 1995). Second, sulfated PG synthesis does not accompany collagen synthesis in fetal wounds (Whitby and Ferguson, 1992). Third, fetal skin has a higher ratio of type III to type I collagen (Epstein, 1974 Merkel et al., 1988).

Regulation of Cytoskeletal Organization in Chemotaxis

Scheme for the establishment of the new leading edge. At the leading edge, the polymerization of actin filaments is stimulated by profilin. The interaction between between WASP or SCAR and the Arp2 3 complex has been suggested to be important for nucleation of actin filaments. New nucleation site can also be created by severing existing actin filaments by severing proteins such as cofilin and severin. Rac Cdc42 proteins appear to regulate the activity of WASP. Actin crosslinking proteins stabilize the actin filaments into networks and they are regulated by intracellular pH and or Ca2+ concentration. Ponticulian and talin are thought to link actin filaments to the leading edge of the plasma membrane. Myosin I function as a link between actin filaments and membrane and as a motor protein that is required for the extension of pseudopodice. Fig. 3. Scheme for the establishment of the new leading edge. At the leading edge, the polymerization of actin filaments is stimulated by...

Top Hair Solution Medicine In World

A wide variety of topical agents have been tested for their efficacy in accelerating repair of acute wounds in normal skin. The growth factors TGF-P, FGF-2, EGF, GH, and IGF-1 can accelerate the repair of acute wounds in experimental animals. FGF-2 and GH have this effect in human patients. Other agents reported to accelerate the repair of skin wounds are extract of the Celosia argentea leaf, vanadate, oxandrolone, the opoid fentanyl, ketanserin, oleic fatty acids, pig enamel matrix, and the peptide HB-107. These agents increase the rate and extent of re-epithelialization, angiogenesis, and cellularity of granulation tissue. Removal of eschar from burn wounds by debriding agents such as papain urea improves repair. Still other topical agents act to reduce scarring by decreasing levels of TGF-P, thus mimicking a fetal wound environment more closely. Chitosan, the COX-2 inhibitor celicoxib, HGF, and anti-TGF-P antibodies all reduce TGF-P in wounds promote healing with less scarring, as...

Reconstruction of Large Commissural Defects

Reconstruction Oral Commisure

Fig. 6.52 Large full-thickness reconstruction of the cheek and commissure by Esser's cheek rotation combined with a tongue flap (Lexer 1909 Weerda 1985). a The defect is excised and the epithelium turned inward. An Esser cheek rotation flap is outlined. An incision is made below the lower lip, and the skin is mobilized. b All defects are closed, and the scars are dispersed with Z-plasties in the RSTLs. The Burow's triangles are closed. Residual defects in the oral portion of the cheek can be covered with a superiorly or posteriorly based flap of tongue mucosa. The pedicle is divided about 3 weeks later (see Fig. 6.43). Fig. 6.52 Large full-thickness reconstruction of the cheek and commissure by Esser's cheek rotation combined with a tongue flap (Lexer 1909 Weerda 1985). a The defect is excised and the epithelium turned inward. An Esser cheek rotation flap is outlined. An incision is made below the lower lip, and the skin is mobilized. b All defects are closed, and the scars are...

Prophylaxis in Fellow Eye of Primary Retinal Detachment What Not to Do and What to Do

The second very significant event that influenced the thinking regarding prophylactic treatment was the invention by Meyer-Schwickerath 2 of an effective method to deliver controlled photocoagulation energy to the retina to produce discrete retinal burns which later became converted into small scars.

Axons of Amphibian and Fish Optic Nerve

In contrast to the mammalian optic nerve, spinal cord or brain, where astrocytes help form a glial scar that impedes axon extension, the astrocytes of the optic tract promote axon extension in the adult newt and in Xenopus tadpoles (Reier and Webster, 1974 Turner and Singer, 1974 Stensaas and Feringa, 1977 Reier, 1979 Scott and Foote, 1981 Bohn et al., 1982). The astrocytes in the degenerated distal portion of the cut optic nerve hypertrophy and form a longitudinal band within the basement membrane synthesized by the pia mater (Turner and Singer, 1974 Bohn et al., 1982). These astrocytes are different from those of mammals in that they do not express GFAP, but do express nestin and cytokeratin intermediate filaments and desmo-somal proteins (Rungger-Brandle et al., 1989).

Medical Models of Abnormality

The medical model gained support when people realized that some bizarre behaviors were due to brain damage or other identifiable physical causes. For example, people with scars in certain areas of the brain may have seizures. Also, people who contract the sexually transmitted disease syphilis, which is caused by microorganisms, can develop aberrant behavior ten to

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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