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Subcutaneous Fat Necrosis

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801. Paraneoplastic Diseases (Diagnosis)

and palmar surfaces of the fingers and palms (ie, mechanic's hands) Subcutaneous calcifications that may extrude chalky material through a sinus in the skin Photosensitivity The myopathy produces symmetrical weakness of the limb-girdle muscles and anterior neck flexors, with or without muscle tenderness. This weakness progresses over weeks to months, with variable involvement of the pharynx, upper esophagus, or respiratory muscles. In 1975, Bohan and Peter established laboratory criteria (...) for the diagnosis of DM. These include the following: Muscle biopsy findings consistent with DM (ie, evidence of necrosis in type I and type II fibers; magnetic resonance imaging [MRI] and magnetic resonance spectroscopy are now used prior to biopsy to decrease sampling error), regeneration, variation in fiber size, and perivascular inflammatory infiltrate Elevation of skeletal muscle enzyme levels, particularly creatine kinase levels Electromyographic changes consisting of the triad of short, small polyphasic


802. Nutritional Management in the Rehabilitation Setting (Diagnosis)

assessment." The history factor reviews weight change, dietary intake, gastrointestinal (GI) symptoms, functional capacity, and disease state in relation to nutritional requirements. The physical examination looks at loss of subcutaneous fat, muscle wasting, edema, and ascites. Screening Criteria The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) specifies that nutritional screening should be completed within 24 hours of admission of all hospital patients. This standard ensures (...) . [ , ] Standard formulas may overestimate their needs because of the increased fat mass in this population. Protein Needs The following factors need to be considered when estimating protein needs: Metabolic rate Body protein reserves Calorie intake Nutritional status Disease state Stress associated with critical illness Age Two ways to determine protein needs based on stress levels follow. Formulas Based on Stress Table 3. Blackburn's General Guide for Protein Needs Based on Stress level Status Estimated


803. Nonneoplastic Epithelial Disorders of the Vulva (Diagnosis)

, remain quiescent for months (even years), or worsen again after minimal trauma, surgery, or an inapparent triggering cause. Crohn disease Vulvar involvement in Crohn disease is uncommon. [ , ] Cutaneous changes may occur before the onset of bowel symptoms. The area of involvement may extend to the perineal and perianal area. Localized or generalized labial edema, with erosions and multiple painful ulcers of variable severity, may be observed. Ulcers may be solitary, deep, and necrotic, possibly (...) scattered among multiheaded comedones, but it may also involve the mons pubis, labia minora, and clitoris. In some cases, deep, painful subcutaneous nodules may ulcerate and ooze a purulent yellow discharge, leading to open sinuses and extensive scarring; in other cases, nodules may coalesce, thus forming conglobate plaques interconnected by sinus tracts. Over time, pseudoepitheliomatous hyperplasia may develop. Occasionally, vulval squamous cell carcinoma has been observed arising in chronic


804. Normal and Abnormal Puerperium (Diagnosis)

superficial injury to the skin and subcutaneous perineal tissue or vaginal epithelium only. Second degree lacerations extend into the musculature of the perineal body, including the deep and superficial transverse perineal muscles, the bulbocavernosus muscle, and the pubococcygeus muscle. Obstetric anal sphincter injuries (OASIS), which are third and fourth degree perineal lacerations are considered more severe forms of obstetric tears. Third degree lacerations extend beyond the muscles and involve


805. Obesity (Diagnosis)

absorptiometry (DXA) scanning is used primarily by researchers to accurately measure body composition, particularly fat mass and fat-free mass. It has the additional advantage of measuring regional fat distribution. However, DXA scans cannot be used to distinguish between subcutaneous and visceral abdominal fat deposits. The current standard techniques for measuring visceral fat volume are abdominal computed tomography (CT) scanning (at L4-L5) and magnetic resonance imaging (MRI) techniques. A simpler (...) in their development. (See Presentation.) Apart from total body fat mass, the following aspects of obesity have been associated with comorbidity: Fat distribution Waist circumference Age of obesity onset Intra-abdominal pressure Fat distribution Accumulating data suggest that regional fat distribution substantially affects the incidence of comorbidities associated with obesity. [ ] Android obesity, in which adiposity is predominantly abdominal (including visceral and, to a lesser extent, subcutaneous), is strongly


806. Orbital Fracture, Medial Wall (Diagnosis)

, including the canaliculi, the lacrimal sac, or the nasolacrimal duct, may be obstructed by compression from displaced bone fragments or severed by similar fragments. Another presentation of a medial wall fracture is enophthalmos, which results from the prolapse of tissue from the orbital cavity or enlargement of the cavity itself. In later stages, it may be caused by contracting necrotic muscles, orbital fat atrophy, or cicatricial contraction of the retrobulbar tissues. Previous Next: Indications (...) injury or whether it is part of an ethmoid-orbital fracture. Clinical findings suggestive of a medial wall fracture include periorbital edema and ecchymosis, (nasal) subconjunctival hemorrhage (all nonspecific), subcutaneous emphysema, epistaxis, CSF rhinorrhea, narrowing of the palpebral fissure with forced lateral duction, restriction of abduction, limitation of adduction, the acquired retraction syndrome or retraction of the globe on attempted abduction or adduction, horizontal diplopia


807. Oral Manifestations of Systemic Diseases (Diagnosis)

for hemostasis. In addition, adequate liver function is required for intestinal absorption of vitamin K, a fat-soluble vitamin critical to the formation of numerous clotting factors. The liver also is responsible for the metabolism of circulating estrogens and the secretion of bilirubin, a product of normal heme catabolism. The hepatic portal vasculature is also an important component of the circulatory system, which enables the immediate processing of nutrients absorbed in the small intestines. Numerous (...) ) deficiency, also known as scurvy Mucosal petechiae Hemorrhagic gingivitis Gingival bleeding Gingival hypertrophy Interdental infarcts Loosening or loss of teeth Schlosser et al, [ ] Leggott et al, [ ] Yasui et al [ ] Fat-soluble vitamins Vitamins A, D, E, and K are fat soluble and thus are readily stored in the body. [ ] While these reservoirs successfully prevent against deficiencies, the resultant risk of hypervitaminosis is increased. There are no oral manifestations vitamins E, D, or K toxicity


808. Nasal Reconstruction (Diagnosis)

skin graft and a subcutaneous transposition flap harvested from adjacent cheek fat. Using the graft to resurface the flap, the investigators stated, avoided the asymmetry and pincushioning that can occur in this area with local flaps. [ ] Burow Graft A Burow skin graft is a technique in which the most superior portion of the nasal wound is closed in a linear manner, and the dog-ear redundancy is donated to the nasal tip wound as a full-thickness skin graft (see the images below). Predictably (...) necrosis and nasal distortion can occur. Necrosis is particularly an unfortunate complication, because it introduces a larger surgical defect on the nose. Nonetheless, with proper experience, flap repairs of the nose offer significant advantages. Therefore, flaps constitute a large percentage of nasal reconstructive procedures performed by some surgeons. Although a full discussion of the various flaps relevant in nasal reconstruction is beyond the scope of this article, a few general comments


809. Mycosis Fungoides (Diagnosis)

by hemophagocytic syndrome, which may be associated with a rapidly progressive downhill course. Dissemination to extracutaneous sites is rare. Histologically, early lesions show focally atypical lobular lymphocytic infiltration of the subcutaneous fat that may also be confused with benign panniculitis. Later, infiltration of pleomorphic lymphoid cells into fat, with rimming of individual fat cells by the neoplastic cells, is accompanied by frequent mitoses, karyorrhexis, and fat necrosis. Cytophagic histiocytic (...) , and South America. Dermal and subcutaneous infiltration with invasion of the vascular walls and occlusion of the vessel lumen by lymphoid cells lead to tissue necrosis and ulceration. The malignant cells are usually CD2 and CD56 positive (NK phenotype), with cytoplasmic, but not surface, CD3 positivity. The cells contain cytotoxic proteins (T-cell intracellular antigen 1 [TIA-1], granzyme B, and perforin). (EBV) tests are commonly positive. Rarely, the cells may have a true cytotoxic T-cell phenotype


810. Systemic Lupus Erythematosus (Treatment)

and steroid use in patients with SLE when used in combination with standard therapy. [ ] In March, 2011, the US Food and Drug Administration (FDA) approved the use of belimumab in combination with standard therapies (including steroids, nonbiologic DMARDS [eg, hydroxychloroquine, azathioprine, methotrexate]) to treat active autoantibody-positive SLE. [ ] In July 2017, a subcutaneous (SC) formulation was approved that allows patients to self-administer a once-weekly dose. [ ] Patients of African-American (...) on a low-fat diet. Many patients with SLE have low levels of vitamin D because of less sun exposure; therefore, these patients should take vitamin D supplements. Exercise is important in SLE patients to avoid rapid muscle loss, bone demineralization, and fatigue. Smoking should also be avoided. Antimalarial therapy (hydroxychloroquine) has been shown to prevent disease flares and to decrease mortality. [ ] In contrast, high rates of sulfa allergy and anecdotal reports of disease flares have led

2014 eMedicine Emergency Medicine

811. Hand, Finger Nail and Tip Injuries

Grafts Reapplication of composite tip grafts, amputated parts containing bone fat or nail bed, can be considered for children younger than age 6 years. As composite tip grafts must initially survive by plasmatic imbibition until neovascularization, revascularization is not reliable for adults and tip grafts should not be reapplied for adults. The distal phalanx fracture is reduced and secured with internal fixation using a K-wire. The surrounding skin is approximated with absorbable chromic suture (...) . The proximal donor is closed as a longitudinal line to create a Y. This longitudinal limb is short and usually only needs two or three sutures. Distally, the flap can be repaired to the nail plate or nail bed. It is critical not to transect the arborizing vessels entering the flap in the subcutaneous plane and to avoid tension on the distal suture line to the nail plate. This flap can be mobilized to reconstruct distal transverse and dorsal oblique fingertip wounds smaller than 1 cm. [ ] Bilateral V-Y

2014 eMedicine Surgery

812. Granulomatous Diseases of the Head and Neck

demonstrates asymmetrical cervical lymphadenopathy, and contiguous, low-density, necrotic, ring-enhancing masses involving subcutaneous fat are typically minimal or absent in nontuberculous mycobacteria adenitis. A significant amount of inflammatory stranding in the subcutaneous fat is not usually seen as in bacterial abscesses. Diagnosis is by culture and sensitivity, which may take as long as 4 weeks and is reported in approximately 60% of patients. The purified protein derivative (PPD) test is either (...) of a triad of airway necrotizing granulomas, systemic vasculitis, and focal glomerulonephritis. If the disease does not involve the kidneys, it is called limited granulomatosis with polyangiitis. Although the cause of granulomatosis with polyangiitis is still not certain, it is believed to most likely have an autoimmune etiology. [ , , , , ] Symptoms Granulomatosis with polyangiitis most commonly occurs in whites during the third to fifth decades of life. Often, the patient initially presents

2014 eMedicine Surgery

813. Flaps, Random Skin Flaps

using a microsurgical technique. [ ] An example is the lateral thigh flap used in free-tissue transfer to the lower extremity for reconstruction. Previous Next: Vascularity of Skin Flaps The cutaneous vascular supply is composed of 3 main levels of vessels supplying the fascia, subcutaneous tissue, and skin. The subcutaneous vessels exit at the superficial fascia and divide the subcutaneous fat into a superficial and deep layer. It is formed by both musculocutaneous and septocutaneous arteries (...) . The cutaneous or subdermal vessels are the main blood supply to the skin. Located at the junction between the deep reticular dermis and subcutaneous fat, they are responsible for the dermal bleeding from the edge of the skin flap. The dermal or subepidermal vessels are located at the papillary ridge to the dermal-epidermal junction. They undergo changes in size from arteries to arterioles to capillaries. [ ] By definition, random skin flaps lack a specific named vessel. It is perfused from musculocutaneous

2014 eMedicine Surgery

814. Free Tissue Transfer, Lateral Thigh and Anterolateral Thigh

be hairy. Generally, a poor color match with the head and neck recipient site is common. If the patient is obese, a fasciocutaneous flap may not be possible. Lateral thigh flaps with large amounts of subcutaneous fat cannot be tubed adequately for laryngopharyngeal defects. The flap also cannot carry bone, but it can carry fascia. Anterolateral thigh flaps Contraindications to harvesting the anterolateral thigh flap include previous surgery or injury to the upper thigh compromising the pedicle. Morbid (...) because of the pale color of the flap. The flap harvests no muscle, and primary closure of the donor site is usually possible. are needed for donor site closure if the width is greater than 8-10 cm. The vessels are usually of good caliber and length. Disadvantages to the free lateral thigh flap include variability of the thigh vasculature and the unfamiliarity of most head and neck surgeons with the thigh area. The free fascial lateral thigh flap takes advantage of the abundant subcutaneous fatty

2014 eMedicine Surgery

815. Flaps, Muscle and Musculocutaneous Flaps

reconstructions (eg, gastrocnemius, soleus, vastus lateralis, latissimus dorsi) and sternal wounds (eg, pectoralis major). When taken with both its nerve and vascular pedicle, muscle flaps can be transferred as functional units for use in extremity and facial reanimation (eg, gracilis, rectus femoris). [ , , , , , , ] When muscle flaps are harvested as composite tissue flaps, they incorporate additional components, such as skin, subcutaneous tissue, fat, and, possibly, bone. Musculocutaneous flaps encompass (...) skin, subcutaneous tissues, and muscle, while myo-osteocutaneous flaps also contain bone. The musculocutaneous flap (skin, subcutaneous tissue, fat, and muscle) can be harvested as a regional pedicled flap that allows for greater rotation distances into a nearby defect than the local cutaneous flap, which requires elevation in close proximity to the defect. Because a skin paddle is provided, the musculocutaneous flap is generally preferred to the muscle flap alone because of its ability to provide

2014 eMedicine Surgery

816. Hypopharyngeal Cancer

, hyoid bone, thyroid gland, esophagus, or central compartment soft tissues, including prelaryngeal strap muscles and subcutaneous fat. T4b - The tumor invades the prevertebral fascia, encases the carotid artery, or involves mediastinal structures. The staging of the regional lymph nodes is as follows: NX: The regional lymph nodes cannot be assessed. N0: No regional lymph node metastasis is present. N1: Metastasis is found in a single ipsilateral node (≤ 3 cm at its greatest dimension). N2: Metastasis (...) response to chemoradiotherapy, the evaluation for progressive neck pain 4 months later revealed a bulky recurrence in the left neck. Note tumor (white arrows) surrounding the carotid artery (black arrow). Hemoptysis : Fetid breath is due to saprophytic bacterial overgrowth in fungating necrotic tumors. Physical Examination Assessment begins in the office with a thorough head and neck examination, including inspection, palpation, and indirect or fiberoptic examination. Flexible fiberoptic endoscopic

2014 eMedicine Surgery

817. Tissue Expansion

and compact bundles of collagen are formed and are oriented parallel to the expander surface. Collagen fibers are incapable of returning to their relaxed convoluted form once they have been stretched. Muscle tissue above or below the expander demonstrates atrophy but no alteration of function. This atrophy probably resolves following expander removal. Subcutaneous tissues display a relative paucity of adipose tissue. This loss of fat seems to be permanent. A dramatic increase in vascularity of the dermis (...) was not described until 1957, when Neumann related the use of a rubber balloon placed subcutaneously in the postauricular region. [ ] After gradual expansion over the course of 2 months, sufficient expanded skin was present to cover a cartilaginous reconstruction of a traumatic defect of the external ear. Unfortunately, the surgical community took little notice of this experience, even though Neumann's article appeared in a major surgical journal. The explosion in interest in tissue expansion did not occur

2014 eMedicine Surgery

818. Liposuction, Techniques: External Ultrasound-Assisted

48-minute sessions per week, reported that subcutaneous adipose tissue thickness was significantly reduced bilaterally in the gluteus and thigh areas, with fat mass in the trunk and lower limbs also decreasing. [ ] Next: History of the Procedure The use of liposuction was first described in 1976 by Georgio and Arpand Fischer. [ ] Tumescent liposuction is also called standard liposuction, liposuction, lipoplasty, liposculpture, liposculption, and suction-assisted lipoplasty. This type (...) regimen for ablating and remodeling subcutaneous deposits. [ ] Previous Next: Relevant Anatomy Adipose tissue is the tissue removed during liposuction procedures. The most common areas involved are the abdomen and thighs in women and the abdomen and flanks in men. Previous Next: Contraindications See the list below: Patients who are extremely obese or in poor health, especially those with cardiac problems, should not undergo external UAL. Only a limited amount of fat should be removed at each session

2014 eMedicine Surgery

819. Liposuction of the Face and Neck

of the Face and Neck Updated: Apr 13, 2016 Author: Manoj T Abraham, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA Share Email Print Feedback Close Sections Sections Liposuction of the Face and Neck Overview Background Cervicofacial liposuction involves the application of negative pressure through a hollow cannula in the subcutaneous plane to gently avulse fat cells and precisely sculpt undesirable fat deposits in the face and neck. In combination with other facial plastic and reconstructive procedures (...) with the . [ ] Fat could be removed through the submental and postauricular rhytidectomy incisions, or excess ptotic fat and skin could be excised directly from jowls and wattles. However, because it is technically challenging to remove subcutaneous fat deposits in an even manner with open techniques, these attempts often produced uneven skin contour. Historically, direct excision of skin and fat led to long visible scars that were predisposed to central depression and postoperative dog-ear formation. Given

2014 eMedicine Surgery

820. Liposuction, Large Volume: Safety and Indications

in the United States. Although liposuction is not a technically difficult procedure, it requires thoughtful planning and an artistic eye to achieve aesthetically pleasing postoperative results. The goal of the liposuction surgeon is to remove "target" fat, leaving the desired body contour and smooth transitions between suctioned and nonsuctioned areas. Careful selection of patients and proper surgical technique help avoid contour irregularity, and diligent perioperative care of the patient helps avoid (...) postoperative complications. Liposuction has evolved over the last several decades, with the introduction of and superwet techniques, , power-assisted liposuction, and, more recently, laser-assisted liposuction (see the images below). These advances have made the removal of larger volumes of fat with less blood loss easier and safer. However, large volume liposuction is a more complex and physiologically different procedure than traditional liposuction, in which small volumes of fat are removed. Cabot high

2014 eMedicine Surgery

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