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Subcutaneous Fat Necrosis

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861. Nerve Entrapment Syndromes of the Lower Extremity (Overview)

individuals, it pierces the deep fascia and emerges into the subcutaneous fat at approximately the level of the middle and lower third of the leg and at an average of about 10-15 cm above the tip of the lateral malleolus. [ ] At an average of 4-6 cm proximal to the ankle joint, the superficial peroneal nerve divides into a large (2.9 mm) medial dorsal cutaneous nerve and a smaller (2 mm), more laterally located intermediate dorsal cutaneous nerve. In 28% of patients, the superficial peroneal nerve (...) and lies between the vastus medialis laterally and the adductor magnus and adductor longus medially. The roof of the adductor canal is a dense bridge of connective tissue extending between these muscle groups. The saphenous nerve exits the canal by piercing the roof and becomes subcutaneous about 10 cm proximal to the medial epicondyle of the femur. The nerve may also pierce the sartorius. Once it becomes subcutaneous, the nerve branches to form the infrapatellar plexus, while the main branch continues

2014 eMedicine Surgery

862. Hemangioma (Overview)

. These are present from birth and do not involute spontaneously. [ , ] Hemangiomas occur most often in skin or subcutaneous tissue, and dermatologists, pediatricians, and primary care medical physicians typically treat these readily identifiable processes. One common example is the senile or , which is a benign, self-limited, small, red-purple skin papule seen in elderly patients. Another is the strawberry nevus, which is seen in approximately 0.5% of infants and spontaneously involutes in the vast majority (...) , such as the of and tumor-induced osteomalacia. Gorham disease is a process of massive osteolysis, which is believed to be within the spectrum of hemangiomatous disease. Hemangiomas occurring in the setting of multiple are part of the spectrum of . For patient education resources, see the , as well as . Next: Pathophysiology Hemangiomas are benign lesions with increased numbers of blood vessels. They can affect numerous tissue types (individually or in combination), including skin, subcutaneous tissue, viscera, muscle

2014 eMedicine Surgery

863. Plantar Fasciitis (Follow-up)

the superficial layers of the subcutaneous tissue, because corticosteroid injection into the superficial fat pad can cause fat necrosis and atrophy, which reduce the shock-absorbing capacity of the plantar heel Studies have reported success rates of 70% or better. [ , ] Corticosteroid injections have been shown to improve symptoms at 1 month but not at 6 months. It is recommended not to give more than 3 steroid injections within a year. A randomized, controlled study demonstrated that intralesional (...) corticosteroids. [ ] Potential risks of corticosteroid injection include plantar fascia rupture, which was found in almost 10% of patients after plantar fascia injection in one case series, [ ] and fat pad atrophy. [ , ] Long-term sequelae were found in approximately 50% of patients with plantar fascia rupture. [ ] Improper placement of a corticosteroid injection for plantar fasciitis can result in necrosis and atrophy of the plantar fat pad at the heel. This complication may result in significant pain

2014 eMedicine Surgery

864. Short-Bowel Syndrome (Follow-up)

mg/kg/day subcutaneously for 4 weeks, parenteral (0.16 g/kg/day) or enteral (30 g/day) glutamine supplementation, and a high-carbohydrate diet with 55-60% of calories coming from carbohydrates versus 20-25% from fat and 20% from protein. In 1997, Wilmore et al published their results on 87 patients treated with this regimen. [ ] After 4 weeks, 52% were completely off parenteral nutrition, and an additional 38% had significantly reduced parenteral nutrition requirements. The same investigators (...) of malnutrition and has been shown to benefit patient outcomes. TPN may be administered concurrently with enteral nutrition early in the clinical course of short-bowel syndrome because the ultimate goal in many of these patients is to enhance intestinal adaptation and render patients free of TPN as described by Wilmore et al in animal models. [ ] In many patients, intestinal adaptation, alone or in combination with modified and supplemented diets (eg, growth hormone, glutamine, high carbohydrate, low fat

2014 eMedicine Surgery

865. Spinal Instability and Spinal Fusion Surgery (Follow-up)

beforehand. Thigh-high compression stockings (TED hose) and sequential compression devices are applied preoperatively for prophylaxis of deep vein thrombosis (DVT) and are not removed until the patient is mobilized postoperatively. In patients who are at particular risk for DVT and pulmonary embolism (PE; eg, those mwho are paraplegic, quadriplegic, or bedbound prior to surgery), subcutaneous injections of low-molecular-weight heparin (LMWH) may begin before the operation, with the individual patient's (...) exposures, care is taken to spare any neural structures that might correspond to a variant crossing of the recurrent laryngeal nerve. The prevertebral fascia is opened and the esophagus and pharynx are retracted toward the contralateral side. A transverse cervical artery, often accompanied by a vein, is usually identified over the C7 vertebral body in the superior extension of the mediastinal fat pad. This artery and the fat pad can usually be swept inferiorly and preserved. If exposed, this artery

2014 eMedicine Surgery

866. Salivary Gland Tumors, Major, Benign (Follow-up)

or reconstructed to afford the best chance of maintaining tone in the muscle or muscles being innervated. Another potential complication is sacrifice of the greater auricular nerve causing loss of sensation to the ear lobule and surrounding skin. To avoid this, careful dissection through the subcutaneous plane is performed to permit identification and preservation of the nerve as the anatomy allows. The facial hollowing and loss of facial symmetry that may result from tumor and gland removal can sometimes (...) be addressed at the time of surgery by placing cadaveric human dermal matrix or even by rotating a portion of the nearby sternocleidomastoid muscle into the deficit. Other approaches using avascular fat graft (harvested from the patient’s abdominal wall) have also been described. Postoperative gustatory sweating (Frey syndrome) is rare but may occur with aberrant reinnervation of the parasympathetics after parotid surgery. Use of thick skin flaps, placement of human dermal matrix, or both may mitigate

2014 eMedicine Surgery

867. Distal Humerus Fractures (Follow-up)

and distally to the cubital tunnel to allow the nerve to lie within the subcutaneous tissues anteromedially to the cubital tunnel (transposition). [ , , ] Careful attention should be paid to the release of the medial intermuscular septum and distal dissection of the nerve within the flexor carpi ulnaris (FCU). A triceps-splitting approach is most commonly used for exposure of the distal humerus. This technique involves deep dissection down the middle of the arm over the olecranon, along with fascial (...) and lateral ligamentous attachments typically remain preserved, lending stability to the elbow after operative stabilization. Avascular necrosis (AVN) is extremely rare after distal humerus fractures. Isolated studies have reported an increased risk of AVN of the free-floating fragment after H-type intra-articular distal humerus fractures. The most common nerve injuries that are associated with ORIF of distal humerus fractures are ulnar nerve injuries. Ulnar neuropathy has been reported to occur in 7-15

2014 eMedicine Surgery

868. Diaphyseal Femur Fractures (Follow-up)

of the femoral neck is important to avoid the devastating complication of avascular necrosis (AVN). Some reports give the neck priority and recommend treating the neck separately with screws or a screw-plate device and the shaft with compression plating or retrograde nailing. If the neck fracture is discovered after an antegrade nail is placed, supplemental screws are placed anterior to the nail into the neck. If anatomic reduction cannot be achieved, the hardware should be removed and revised as previously (...) and is superficial with skin penetration (mortality, 0%) Type I occurs at greater than 12 m and penetrates only subcutaneous and deep fascia (mortality, 0-5%) Type II occurs at 5-12 m and penetrates beyond deep fascia (mortality, 15-20%) Type III occurs at less than 5 m and causes extensive tissue damage (mortality, 85-90%) Children Femoral-shaft fractures in children are associated with many of the same concerns as those in adults. [ , ] Again, the level of injury sustained by the patient is of great importance

2014 eMedicine Surgery

869. Decubitus Ulcers (Follow-up)

, ointments, creams, solutions, dressings, ultrasonography, ultraviolet heat lamps, sugar, and surgery. In choosing a treatment strategy, consideration should be given to the stage of the wound and the purpose of the treatment (eg, protection, moisture, or removal of necrotic tissue). An algorithm for assessment and treatment is available. [ , , ] General principles of wound assessment and treatment are as follows: Wound care may be broadly divided into nonoperative and operative methods For stage 1 and 2 (...) medical management of pressure ulcers relies on the following key principles: Reduction of pressure Adequate débridement of necrotic and devitalized tissue Control of infection Meticulous wound care If surgical reconstruction of a pressure injury is indicated, it cannot be emphasized too strongly that medical management must be optimized before reconstruction is attempted; otherwise, reconstruction is doomed to failure. That is, spasticity must be controlled, nutritional status must be optimized

2014 eMedicine Surgery

870. Foot Infections (Follow-up)

and aggressive treatment to preserve a limb or a life. Necrotizing fasciitis and gas gangrene are the two most common pedal surgical emergencies. Local tissue damage, progressive gangrene, and potential systemic toxemia and/or death can result from these infections. [ ] Necrotizing fasciitis Necrotizing fasciitis is characterized by widespread necrosis of fascia and deeper subcutaneous tissues, with initial sparing of skin and muscle. Eventually, skin involvement is noted, with cellulitis evolving (...) be unpredictable and are typically polymicrobial. Soft-tissue infections in the foot consist of any infectious process affecting the skin, subcutaneous tissue, adipose tissue, superficial or deep fascia, ligaments, tendons, tendon sheaths, joints, or joint capsules. Considering that there are more than 20 joints, 44 tendons, approximately 100 ligaments, four major compartments, and numerous fascial planes in the normal foot, one can readily appreciate the potential for complex problems. Many events can

2014 eMedicine Surgery

871. Blunt Chest Trauma (Follow-up)

or is associated with severe pain due to proximal brachial plexus injury. An above-elbow amputation may be the best approach for these patients. Chest-wall defects The management of large open chest-wall defects initially requires irrigation and debridement of devitalized tissue to prevent progression into a necrotizing wound infection. Once the infection is under control, subsequent treatment depends on the severity and level of defect. Reconstructive options range from skin grafting to well-vascularized (...) . Patients are in respiratory distress. They typically cannot phonate and frequently present with stridor. Other physical signs include an associated pneumothorax and massive subcutaneous emphysema. Blunt tracheal injuries are immediately life-threatening and require surgical repair. Bronchoscopy is required to make the definitive diagnosis. The first therapeutic maneuver is the establishment of an adequate airway. If airway compromise is present or probable, a definitive airway is established

2014 eMedicine Surgery

872. Bariatric Surgery (Follow-up)

and seromas, as well as fat necrosis, skin slough, infection, and deep vein thrombosis (DVT). In addition, the patient should be involved with a team that assesses nutritional and psychological issues as needed. [ ] Previous Next: Complications Early complications of Roux-en-Y gastric bypass are as follows: Anastomotic leak (1-3%) Pulmonary embolism, DVT (< 1%) Wound infection (more common with open approach) Gastrointestinal hemorrhage, bleeding (0.5-2%) Respiratory insufficiency, pneumonia Acute (...) and accessible through a port, which is attached by a catheter to the band. The port is placed subcutaneously in the anterior abdominal wall after the band is secured around the stomach. Adjustment of the band through the access port is an essential part of laparoscopic adjustable gastric banding therapy. Appropriate adjustments, performed as often as six times annually, are critical for successful outcomes. Patients must chew food thoroughly to allow food to pass through the band. Adjusting the inflation

2014 eMedicine Surgery

873. Wound Care (Diagnosis)

parathyroid hormone level. Skin biopsy reveals calcification of the arterial media and luminal stricture of small-to-medium blood vessels in the subcutaneous fat. Muscle biopsy shows patchy necrosis and atrophy. [ ] Necrobiosis lipoidica Necrobiosis lipoidica, a necrotizing skin lesion characterized by collagen degeneration and a granulomatous response, usually involves the anterior tibial areas, though it can also occur in the face, arms, and chest. Patients present with well-circumscribed, shiny (...) result is the inhibition of regeneration of skin cells from dividing basal cells. This may cause recalcitrant, painful skin ulcers. The surrounding skin is atrophic, with atrophy of hair follicles and a paucity subcutaneous fat. Ultraviolet radiation exposure, particularly ultraviolet B, causes sunburn initially and subsequently conveys a continuing risk of skin malignancy (eg, , , ). Excessive exposure to infrared radiation, which induces repeated or persistent skin hyperthermia of 43-47°C, may

2014 eMedicine Surgery

874. Thromboembolism (Follow-up)

administration of warfarin sodium is started after anticoagulation with SC or IV anticoagulants has been achieved is because warfarin can have an initial procoagulant effect, particularly in patients with protein C or protein S deficiencies, potentially causing fat necrosis. For patients whose treatment has included thrombolysis for acute, massive PE causing hemodynamic instability, heparin infusion should be started once the thrombin time (TT) or aPTT is less than twice the baseline value. Treatment (...) been reported following UFH treatment of more than 1 month's duration. Skin necrosis Coumarin derivatives can cause skin necrosis as a consequence of widespread subcutaneous microthrombosis. This can occur in individuals who are protein C–deficient, either genetically or owing to large loading doses of a coumarin derivative. Areas usually affected include the breasts, abdominal wall, and lower extremities. [ ] Recurrence Recurrence of thromboembolism had been documented following discontinuance

2014 eMedicine Surgery

875. Plantar Heel Pain (Overview)

cases. [ , , , , , , , , , ] For patient education resources, see and . Next: Pathophysiology The specialized soft tissue at the heel functions as a shock absorber. The subcutaneous structure consists of fibrous lamellae arranged in a complex whorl containing adipose tissues that attach with vertical fibers to the dermis and the plantar aponeurosis. [ ] The heel can absorb 110% of the body's weight during walking and 200% of the body's weight during running. The plantar fascia is a multilayered (...) specimens reveal collagen necrosis, angiofibroblastic hyperplasia, chondroid metaplasia, and calcification. The heel pain can also have a basis. The tibial nerve, with nerve roots from L4-5 and S2-4, courses in the medial aspect of the hindfoot, through the , under the flexor retinaculum, and over the medial surface of the calcaneus. The calcaneal branch, arising directly from the tibial nerve, carries sensation from the medial and plantar heel dermis. The tibial nerve divides into lateral and medial

2014 eMedicine Surgery

876. Unstable Pelvic Fractures (Follow-up)

. Additionally, a Morel-Lavalle lesion can be considered a contraindication to ORIF. This lesion is identified on the basis of a fluctuance under the skin of the involved area. Contusions and abrasions are often associated with the Morel-Lavalle lesion. It represents a large area of hematoma and fat necrosis under degloved skin. The lesion results from shearing of the subcutaneous tissue from the underlying fascia. Although the Morel-Lavalle lesion is a closed injury, it is associated with high rates (...) with pelvic trauma. The subcutaneous tissue is torn away from the underlying fascia, creating a cavity filled with hematoma and liquefied fat. The diagnosis is based on physical examination findings, including a soft fluctuant area that commonly occurs over the greater trochanter but may also occur in the flank and lumbodorsal region. Management is important because the presence of necrotic tissue and hematoma in the subcutaneous tissue increases the risk of infection. Open debridement is the preferred

2014 eMedicine Surgery

877. Abdominal Hernias (Overview)

rotation, adduction, or extension at the hip Sciatic hernia - Tender mass in the gluteal area that is increasing in size; sciatic neuropathy and symptoms of intestinal or ureteral obstruction can also occur Perineal hernias - Perineal mass with discomfort on sitting and occasionally obstructive symptoms with incarceration Umbilical hernia - Central, midabdominal bulge Epigastric hernia - Small lumps along the linea alba reflecting openings through which preperitoneal fat can protrude; may be adjacent (...) approaches to other hernia types may vary, as follows: Umbilical hernia - After exposure of the umbilical sac, a plane is created to encircle the sac at the level of the fascial ring, and the defect is closed transversely with interrupted sutures; if the defect is very large (>2 cm), mesh may be required Epigastric hernia - A small vertical incision directly over the defect is carried to the linea alba, and incarcerated preperitoneal fat is either excised or returned to the properitoneum; the defect

2014 eMedicine Surgery

878. Wound Care (Follow-up)

. These requirements can increase, however, for patients with sizeable wounds. Suspect malnutrition in patients with chronic illnesses, inadequate societal support, multisystemic trauma, or GI or neurologic problems that may impair oral intake. Protein deficiency occurs in approximately 25% of all hospitalized patients. Oftentimes, a thorough physical examination can reveal signs of malnutrition, such as temporal wasting, loss of subcutaneous fat, ankle/sacral edema, pronounced clavicles. Chronic malnutrition can (...) III Full-thickness skin loss into subcutaneous fatty tissues or fascia Distinct ulcer margin; deep crater (in general, 2.075 mm or deeper [the thickness of a nickel]) Debride; irrigate with saline; apply DuoDerm/Tegaderm 90 IV Full-thickness skin loss with extensive tissue involvement of underlying tissues Extensive necrosis; damage to underlying supporting structures, such as muscle, bone, tendon, or joint capsule Surgically debride; irrigate with saline (possibly under pressure); apply advanced

2014 eMedicine Surgery

879. Morton Neuroma (Follow-up)

obtain either total resolution of symptoms or improvement to a satisfactory level with footwear modifications and restrictions. [ ] Corticosteroid or local anesthetic injections may be helpful, especially when coupled with the aforementioned shoe modifications. A dorsal injection is administered with 40 mg of methylprednisolone or a similar corticosteroid and 1% plain lidocaine or 0.5% plain bupivacaine in the same syringe. To avoid steroid-induced skin necrosis, do not inject into the superficial (...) subcutaneous tissue. Injections should not be used indiscriminately, because the injection itself is associated with mild risk. High-quality evidence supports the use of corticosteroid injections for short-term (3-month) symptom relief. [ , ] Symptom relief may last longer in smaller neuromas (<5 mm). [ ] Alcohol sclerosing injections should be used with caution, in that they have not been shown to be reliably effective. [ , , ] Nonsteroidal anti-inflammatory drugs (NSAIDs) or antiseizure medications

2014 eMedicine Surgery

880. Intersection Syndrome (Follow-up)

occupations. The goals of therapy are strengthening, full ROM, and modification of equipment. The rehabilitation period may last 4-6 weeks. Previous Next: Complications Cortisone injections near the skin may cause depigmentation in patients who are dark skinned. These injections also may lead to subcutaneous fat atrophy or necrosis, infection, and tendon rupture, although, fortunately, these complications are rare. Theoretically, surgical release of the extensor retinaculum could lead to bowstringing

2014 eMedicine Surgery

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