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Subcutaneous Fat Necrosis

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841. Inflammatory Bowel Disease (Follow-up)

and severity of disease; they may be administered intravenously (ie, methylprednisolone, hydrocortisone), orally (ie, prednisone, prednisolone, budesonide, dexamethasone), or topically (ie, enema, suppository, or foam preparations).Corticosteroids are limited by their adverse effects, particularly with prolonged use. The potential complications of corticosteroid use include fluid and electrolyte abnormalities, osteoporosis, avascular bone necrosis, peptic ulcers, cataracts, glaucoma, neurologic (...) and endocrine dysfunctions, infectious complications, and occasional psychiatric disorders (including psychosis). The consensus regarding treatment with these agents is that they should be tapered once remission has been induced. (see Surgical Intervention, below, for information on Tapering corticosteroids in the postoperative setting). Corticosteroids do not have a role in maintaining remission. Patients who are concerned about immunosuppressive therapies, including immunomodulators or anti–tumor necrosis

2014 eMedicine Emergency Medicine

842. Burns, Thermal (Diagnosis)

go completely through the eschar. The subcutaneous fat will appear to bubble up into the escharotomy wound. Bleeding is minimal and is easily controlled by pressure. Upon completion of the escharotomy, a dressing with antibiotics is placed on the wound, and the extremity is elevated to help maintain homeostasis. If the chest is involved and the eschar compromises ventilatory motion, perform an escharotomy involving the anterior chest. Incisions are made along the costal margin, along the anterior (...) be debrided (see the image below); the intact skin serves as a hermetic barrier, although the blister fluid can serve as an excellent medium for bacterial growth. Another argument for debridement is that removal of the blister roof allows topical agents to reach burn tissue. Blisters that are intact but are located in areas that have a high likelihood of rupture may be sharply debrided. The World Health Organization (WHO) recommends debridement of all bullae and excision of all adherent necrotic tissue

2014 eMedicine Emergency Medicine

843. Cellulitis (Diagnosis)

, the tissue is hemorrhagic and necrotic. Hematoxylin and eosin (H&E) stain, high power. This image shows deeper subcutaneous tissue involved in a case of cellulitis, with acute inflammatory cells and fat necrosis. Hematoxylin and eosin (H&E) stain, high power. This image shows cellulitis caused by herpes simplex virus, with the multinucleated organism in the center of the picture. of 14 Tables Table 1. Empiric Antibiotic Therapy for Cellulitis by Etiology and Anatomic Location Location Likely Organisms (...) E Herchline, MD; Chief Editor: Michael Stuart Bronze, MD Share Email Print Feedback Close Sections Sections Cellulitis Overview Practice Essentials The term cellulitis is commonly used to indicate a nonnecrotizing inflammation of the skin and subcutaneous tissues, usually from acute infection (see the image below). Cellulitis usually follows a breach in the skin, although a portal of entry may not be obvious; the breach may involve microscopic skin changes or invasive qualities of certain

2014 eMedicine Emergency Medicine

844. Burns, Chemical (Diagnosis)

as liquefaction necrosis. This involves denaturing of proteins as well as saponification of fats, which does not limit tissue penetration. Hydrofluoric acid is somewhat different from other acids in that it produces a liquefaction necrosis. The severity of the burn is related to a number of factors, including the pH of the agent, the concentration of the agent, the length of the contact time, the volume of the offending agent, and the physical form of the agent. The ingestion of solid pellets of alkaline (...) it gives up the proton; the strength of a base is determined by how avidly it binds the proton. The strength of acids and bases is defined by using the pH scale, which ranges from 1-14 and is logarithmic. A strong acid has a pH of 1, and a strong base has a pH of 14. A pH of 7 is neutral. Next: Pathophysiology Most acids produce a coagulation necrosis by denaturing proteins, forming a coagulum (eg, eschar) that limits the penetration of the acid. Bases typically produce a more severe injury known

2014 eMedicine Emergency Medicine

845. Thymus, Lesions

, tracheobronchial tree, and pleural space. (See the image below.) Thymic cystic teratoma. This thin-walled cystic mass contains a fat-fluid level. Seminoma On CT scans, seminomas are usually large and homogeneous, with soft tissue attenuation. Areas of low attenuation often are present secondary to necrosis and hemorrhage. Nonseminomatous tumor Nonseminomatous tumors include embryonal carcinoma, endodermal sinus tumor, choriocarcinoma, and mixed germ cell tumor. On CT scans, these lesions are often large (...) with lymphoma, associated lymphadenopathy is helpful in distinguishing normal thymus from abnormal thymus. On T1-weighted spin-echo images, thymic lipomas have areas of high signal intensity, because of their fat content; the signal intensity is similar to that of subcutaneous fat, with areas of intermediate signal intensity reflecting the presence of soft tissue. Although thymic lipomas can attain a large size, they invariably do not invade surrounding structures. However, they can cause mass effect

2014 eMedicine Radiology

846. Synovial Sarcoma

man who presented with a large midthigh mass on the right. On this T2-weighted image, the mass has become markedly heterogeneous, with high signal intensity depicting cystic regions of hemorrhage and necrosis. Note that portions of the mass are hyperintense relative to the subcutaneous fat. The location of the mass is somewhat atypical because it is centered at the level of the midshaft rather than near a joint. Axial T2-weighted magnetic resonance image of the hip in a patient with a mass (...) and the femur is preserved. Coronal T2-weighted magnetic resonance image of the thigh in a 45-year-old man who presented with a large midthigh mass on the right. On this T2-weighted image, the mass has become markedly heterogeneous, with high signal intensity depicting cystic regions of hemorrhage and necrosis. Note that portions of the mass are hyperintense relative to the subcutaneous fat. The location of the mass is somewhat atypical because it is centered at the level of the midshaft rather than near

2014 eMedicine Radiology

847. Breast Reconstruction, Refinements &amp

not want a contralateral reduction, or the flap may have some necrosis, requiring a partial resection. As mentioned earlier, a small implant can be placed behind the flap or a latissimus flap can be transferred to fill in the defect. Reduction of reconstructed breast When it is necessary to reduce the reconstructed breast, the surgeon has several options. Both direct excision of excess fat and liposuction can achieve the desired result. It may be premature to recommend ultrasonic liposuction (...) . This is an ideal time to resect areas of fat necrosis and to trim both abdominal and breast "dog ears." As previously mentioned, axillary fullness from a wide flap or from improper suture closure of the axilla is a common problem. In mild cases, liposuction and/or excision can correct this problem. In more severe cases, dissecting the flap off the chest wall and moving it medially may be necessary. Confirm symmetry of the IMF. This often is caused by violation of this boundary during the resection. If the IMF

2014 eMedicine Surgery

848. Breast Reconstruction, Perforator Flap

be delayed and considered later, when patients are more able to commit to discontinuance of their smoking. after any surgery are much more frequent in patients who smoke, and the incidence of fat necrosis within the reconstructed breast may also be higher. [ ] Morbid obesity has been shown to result in more frequent healing problems at the abdominal donor site. Otherwise, patients who are moderately obese fare as well as those who are not obese. Previous References Hartrampf CR, Scheflan M, Black PW (...) loss due to prior lumpectomy, radiation, or subcutaneous mastectomy, autogenous tissue reconstruction is one of the options available for restoring form. Congenital breast absence or underdevelopment ( ) may also be corrected with soft tissue perforator flap techniques. Perforator flap transfer is also an appropriate consideration in any setting in which autogenous tissue is preferred and an indication exists to avoid sacrifice of the muscle tissues traditionally associated with these techniques

2014 eMedicine Surgery

849. Breast Implants, Silicone: Safety and Efficacy

%; textured 9%) but suggests that texturing does not make any difference in reconstruction (smooth 13%; textured 12%). An undesirable adverse effect of texturing is an unpleasant rippling of the breast surface, especially — as can be the case in very small breasts — if little overlying tissue padding is present. This may be visible and unsightly or just palpable and annoying, depending on the thickness of normal breast tissue and subcutaneous fat available to mask the irregularities. For most women (...) , were under development or in experimental trial in the United States. Various hydrogels and a pure form of triglycerides were the 2 main formulations. The major advantage of the triglyceride formulation (Trilucent) was that it had a Z number (measure of radiolucency) similar to that of fat, thus resulting in little or no compromise of mammography. Another fill substance, polyvinyl pyrrolidone in saline, was briefly available, under the trade name Misty Gold. None of these products are currently

2014 eMedicine Surgery

850. Breast Reduction, Simplified Vertical

other in position long enough for them to heal together. It is important to take small bites and to suture fibrous tissue to fibrous tissue for this healing to occur. The author has yet to find a patient in whom this fibrous tissue cannot be found. Taking large bites of fat can result in fat necrosis and poor healing. Lassus does not suture the pillars, but his skin closure holds the pillars close to each other so that this healing process can take place. It is incorrect to try to push tissue (...) for the classic vertical techniques. Although the inferior pedicle can be used, it is reserved for revision in a patient who underwent a previous inferior pedicle procedure. [ ] Nipple necrosis The incidence of complete nipple necrosis is 0.5%. Partial nipple necrosis occurs in a similar percentage of patients. The author has been pleasantly surprised at how well the nipple and areola turn out without intervention. It is tempting to debride the necrotic tissue, but it is often best to leave it to separate

2014 eMedicine Surgery

851. Breast Reduction, Superior Pedicle

et al confirmed adequate vascularity of the superior pedicle with preoperative arteriograms on several patients. [ ] Author-noted advantages of the superiorly based pedicle technique include less skin undermining and simplified resections, which result in significant reductions in operative time. Importantly, these techniques foster preservation of dermoparenchymal relationships with maintained small vessel connectivity which, in turn, minimizes the risk of skin and fat necrosis. Shaping (...) with the superomedial pedicle in patients who smoke (compared to other techniques in patients who smoke). Limited undermining maintains vascular beds connecting parenchyma to skin with the pedicle axial on the very robust blood supply of internal thoracic artery perforators. More, the parenchyma targeted for resection falls in the "watershed" area between lateral and medial vascular zones, making fat necrosis far less common. Previous References Lassus C. Breast reduction: evolution of a technique--a single

2014 eMedicine Surgery

852. Breast Reduction, Moufarr&#232

l'oeil fashion. That technique remains in use in some surgical centers, but it has fortunately been replaced in most of them by reductions with transposition of the nipple, with consequent conservation of the nipple as a flap based on a vascular pedicle. The quality of a transposed nipple is clearly superior to that of a grafted one. A large pedicle was not required to keep the nipple alive; often, but not always, a thin strip of subcutaneous fat was sufficient. If the nipple survived the ischemia (...) is the Moufarrège total pedicle at 100%. Only a Biesenberger reduction based the nipple on a larger mass of the remaining breast; unfortunately, the Biesenberger method had too many problems inherent in the detachment of the breast from the pectoralis major, consequently causing interruption of the perforating vessels and a high rate of breast tissue necrosis. Thus, this type of reduction was abandoned. In 1976, Robbins, carrying on McKissock's work, based the nipple on a simple inferior pedicle, probably

2014 eMedicine Surgery

853. Body Contouring, Abdominoplasty

of the abdomen is usually quite loose, except at certain points of adherence, ie, the anterior superior iliac crests and the linea alba. The subcutaneous tissue is divided by 2 layers of fascia, the superficial fascia (Camper) and the deep fascia (Scarpa), which is continuous with the fascia lata of the thigh. [ ] With aging and pregnancy, fat tends to be distributed in the lower (infraumbilical) abdomen. Striae are common, especially after multiple pregnancies. Striae are reported to be the result (...) : Allen Gabriel, MD, FACS; Chief Editor: Jorge I de la Torre, MD, FACS Share Email Print Feedback Close Sections Sections Abdominoplasty Overview Background Abdominoplasty, one of the most commonly performed aesthetic procedures, has undergone a significant evolution over the past several decades. Kelly was one of the first surgeons to attempt to correct excess abdominal skin and fat. [ , ] Using a transverse incision, he was able to resect a 7450-g panniculus measuring 90 X 31 X 7 cm. Since that time

2014 eMedicine Surgery

854. Blepharoplasty, Lower Lid Arcus Marginalis Release

be required. Epiphora Epiphora is common in the first few postoperative days. Corneal irritation, which triggers hyperlacrimation, and ectropion, which removes the punctum from the surface of the globe, usually cause epiphora. Fat necrosis Fat necrosis manifests as small, painful, indurated nodules. Compresses and massage hasten their resolution. Injection of steroids into the lesions is effective but carries the risk of subcutaneous atrophy and hypopigmentation. Diplopia Diplopia is usually caused (...) == processing > Lower Lid Arcus Marginalis Release Blepharoplasty Updated: Nov 16, 2018 Author: Steven L Henry, MD; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC Share Email Print Feedback Close Sections Sections Lower Lid Arcus Marginalis Release Blepharoplasty Overview Overview Introduction An emerging concept in cosmetic surgery is that the characteristics of facial aging are a result of not only elastosis and sagging but also the atrophy of soft tissue and, particularly, fat. [ , ] The evolution

2014 eMedicine Surgery

855. Cancer of the Hypopharynx

, 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

856. Burns, Chemical

odor usually signals their presence. After phenol penetrates dermis, it produces necrosis of papillary dermis. This necrotic tissue may temporarily delay its absorption. When skin comes in contact with phenol, institute treatment immediately. Irrigate exposed area with large volumes of water delivered under low pressure. Dilute solutions of phenol are more rapidly absorbed through skin than concentrated ones, thus avoid gentle swabbing of surface of skin with sponges soaked in water. Because phenol (...) , and underlying dermal tissues are exposed to continuous necrotizing action. Both inorganic and organic acids denature the proteins of the skin, resulting in a coagulum, the color of which depends on the acid involved. Nitric acid burns result in a yellow eschar, whereas sulfuric acid eschar is black or brown. Burns caused by hydrochloric acid or phenol tend to range from white to grayish-brown. Following the initial exposure, cellular dehydration and further protein denaturation/coagulation occur

2014 eMedicine Surgery

857. Burns, Thermal

. Dermis Beneath the epidermis is the dermis, which is composed of a dense fibroelastic connective-tissue stroma containing collagen and elastic fibers and an extracellular matrix termed ground substance. This amorphous matrix is made up of an acid mucopolysaccharide protein combined with salts, water, and glycoproteins; it may contribute to salt and water balance, serve as a support for other components of the dermis and subcutaneous tissue, and participate in collagen synthesis. The dermal layer (...) , forehead, wrist, scalp, palm, and eyelid. Thickness varies with the individual's age. It is thinnest in the very old, where it is often atrophic, and in the very young, where it is not fully developed. Subcutaneous tissue The third layer of skin is subcutaneous tissue, which is composed primarily of areolar and fatty connective tissue. This layer shows great regional variations in thickness and adipose content. It contains skin appendages, glands, and hair follicles. Hair follicles extend in deep

2014 eMedicine Surgery

858. Skull, Fractures

to estimate the location of the edge of the dural tear on the scalp. Excellent outcomes in terms of bony coverage and dural plasty were achieved. The authors recommended a combination of MRI and CT scanning for surgical repair of growing skull fracture in children. [ ] Scalp injuries The scalp is made up of several tissue layers: hairy skin; subcutaneous fat and connective tissue; the galea, which is a thin fibrous layer to which the flat epicranial muscles are attached; a thin layer of connective tissue (...) parts of the skull, such as the orbital surfaces and the squamous portion of the temporal bone. Injury to the brain usually occurs in the path of the penetrating stab wound. Unlike missile injuries, stab wounds have no concentric zone of coagulative necrosis caused by dissipated energy, and unlike motor vehicle accidents, stab wounds cause no diffuse, shearing brain injury. Stab wounds may cause an intracranial hematoma or infarct. Cerebral damage caused by stabbing is largely restricted

2014 eMedicine Radiology

859. Pathology: Sarcomas of the Head and Neck

is predictive of clinical behavior and prognosis. Any mitotic activity is a sign of malignancy. Lesions associated with a poorer prognosis are those larger than 6.5 cm with more than 3 mitotic figures per 10 high-power fields, necrosis, and hemorrhage. Survival rates decrease dramatically when more than 4 mitotic figures per 10 high-power fields are present. Complete surgical excision is the treatment of choice for patients with hemangiopericytomas. Compared with other sarcomas of the head and neck (...) in fewer than 10% of cases and are usually associated with recurrent disease at the primary site. An overall 10-year survival rate of 70% has been reported for hemangiopericytomas; however, the 10-year survival rate in patients with lesions with aggressive histologic characteristics (eg, > 4 mitoses per 10 high-power fields, necrosis, hemorrhage, large size) decreases to 29%. Hemangiopericytomas are considered relatively resistant to radiation therapy; thus, radiotherapy is only an adjuvant therapy

2014 eMedicine Surgery

860. Facelift, Composite

potentially deepen this structure. Additionally, cheek fat cannot be repositioned adequately by traditional SMAS techniques because it remains tethered by the zygomaticus muscles, which have bony origins. The deep-plane and composite rhytidectomy techniques were designed to address this limitation of SMAS rhytidectomy. A deep subcutaneous plane is developed, separating the malar fat pad from its attachments to the zygomaticus muscles, which is joined with sub-SMAS dissection in the lower face. The result (...) Next: Etiology Aging is a natural phenomenon affecting both the deep and superficial structures of the face. Previous Next: Pathophysiology Aging affects both deep and superficial structures, including skin, subcutaneous fat, muscle, and bone. In the face, ptosis of deep anatomic structures contributes to the telltale signs of aging, such as midface ptosis, jowling, and deepened nasolabial folds. While SMAS rhytidectomy techniques address the neck and jawline with excellent results

2014 eMedicine Surgery

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