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Subcutaneous Fat Necrosis

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861. Hernias (Treatment)

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 Emergency Medicine

862. Inflammatory Bowel Disease (Treatment)

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

863. Hidradenitis Suppurativa (Treatment)

recurrence. The block of tissue excised should be adequately wide and sufficiently deep. To ensure that the deep coils of the apocrine gland are removed, the subcutaneous tissue down to the deep fascia, or at least 5 mm of subcutaneous fat, should be excised. The extent of the sinus tracts is intraoperatively marked by injecting 3-5 mL of a methyl-violet solution. Complete surgical excision is achieved when all color-coded areas are fully removed. In cases where blue-stained areas occurred (...) was developed. Wide excisions reach into the healthy deep subcutaneous fat, but the STEEP procedure with its successive tangential transsections leaves the epithelialized bottoms of the sinus tracts and a large extent of the subcutaneous fat intact, leading to more superficial and smaller defects. STEEP is done with the patient under general anesthesia. For the performance of the multiple transversal sections, electrosurgery has some important advantages over the carbon dioxide laser, since transversal

2014 eMedicine Emergency Medicine

864. Plantar Fasciitis (Treatment)

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 Emergency Medicine

865. Myocardial Infarction (Treatment)

variability and narrow therapeutic window. Low molecular weight heparin (LMWH) Enoxaparin is given at a dose of 1 mg/kg subcutaneously (SC) every 12 hours. It should be continued for the duration of hospitalization or until PCI is performed. A dose reduction is required for patients with impaired kidney function. Enoxaparin results in a more predictable and efficient anticoagulation compared to unfractionated heparin, leading to reduction in recurrent MI events [ , ] ; however, there is possibly a higher (...) bleeding risk in patients undergoing PCI. [ ] These findings were demonstrated in the Efficacy and Safety of Subcutaneous Enoxaparin in Non–Q wave Coronary Events (ESSENCE) trial. [ , , ] Bivalirudin Bivalirudin is direct thrombin inhibitor that is given as 0.1 mg/kg loading dose, followed by 0.25 mg/kg per hour only in patients managed with an early invasive strategy. This regimen is continued until diagnostic angiography or PCI. [ ] In the Acute Catheterization and Urgent Intervention Triage Strategy

2014 eMedicine Emergency Medicine

866. Pediatrics, Sickle Cell Disease (Treatment)

initiation of opioids for the treatment of severe pain associated with a vasoocclusive crisis Use of analgesics and physical therapy for the treatment of avascular necrosis In July 2017, the US Food & Drug Administration (FDA) approved L-glutamine oral powder (Endari) for patients age 5 years and older to reduce severe complications of SCD. [ , ] L-glutamine increases the proportion of the reduced form of nicotinamide adenine dinucleotides in sickle cell erythrocytes; this probably reduces oxidative (...) , and deferiprone. Deferoxamine is an efficient iron chelator. It is administered as a prolonged infusion intravenously or subcutaneously for 5-7 days a week. Although effective, there are significant challenges associated with its use that can result in non-compliance. [ ] Deferiprone and deferasirox, oral iron chelators, are effective for iron overload treatment and have differences (eg, different pharmacokinetics and adverse effect profiles). Deferasirox has a capacity similar to deferoxamine in chelating

2014 eMedicine Emergency Medicine

867. 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

868. 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

869. Nerve Entrapment Syndromes of the Lower Extremity (Diagnosis)

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

870. Intestinal and Multivisceral Transplantation (Diagnosis)

as a consequence of necrotizing enterocolitis may be associated with a history of prolonged neonatal ventilation and bronchopulmonary dysplasia. These conditions are associated with repeated hospitalizations and a propensity for prematurity in infants, which may give rise to behavioral and developmental problems that should be identified and addressed as early as possible. However, controlled trials to support this are lacking. The authors strongly believe that early intervention facilitates posttransplant (...) . 16(4):327-32. . Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet . 1973 Apr. 136(4):602-6. . Flowers RH 3rd, Schwenzer KJ, Kopel RF, et al. Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter-related infection. A randomized, controlled trial. JAMA . 1989 Feb 10. 261(6):878-83. . Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med . 2000 Mar 7. 132(5

2014 eMedicine Surgery

871. Radiation Therapy, 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

872. Prerhytidectomy Facial Analysis

related to ptosis of skin and soft tissue due to the effects of gravity, but it is also due to changes in volume distribution of the subcutaneous fat. These changes begin as early as the 30s with initial sagging of skin and deepening of the nasolabial folds. Aging continues to progress throughout the ensuing decades with deepening of wrinkles and the appearance of jowling. As facial fat redistributes and descends in some areas of the face, resorption of adipose occurs in others. Resorption of fat (...) , coarse rhytides, and irregular skin textures. One should pay particular attention to skin thickness in an individual patient. Thin skin generally heals better with less scarring but may show contour irregularities more easily. Subcutaneous tissues The youthful face is characterized by volume, balance, and distribution of superficial and deep fat. Facial aging is associated with loss of soft tissue fullness in certain areas, and descent or hypertrophy in others. An overall loss of volume occurs

2014 eMedicine Surgery

873. Skin, Tissue Expansion

muscle atrophies under expansion but retains its activity. However, adipose tissue undergoes permanent atrophy of 30-50% with loss of fat cells. [ , ] Increased epidermal mitotic activity demonstrated by Austad and others and increased numbers of radiolabeled keratinocytes suggest that new skin elements form in the expanded flaps. When compared with intraoperative tissue expansion as described by Sasaki, tissue expansion over a period of several weeks attains nearly 4 times the surface area and 3 (...) flaps raised, place the implant under the normal tissue, which lies adjacent to the defect. The flaps are developed in a variety of planes depending on the location and indication and may be submuscular, subgaleal, or subcutaneous. In general, the diameter of the base of the expander should be the same as that of the defect, while the pocket that is dissected must be larger than the unit. Most surgeons use blunt dissection (eg, fingers, urethral sounds, Metzenbaum tips) to develop the pocket

2014 eMedicine Surgery

874. Skin, Benign Skin Lesions

that consists of fat and cellular debris Sessile - Attached directly to the skin by a broad base; not pedunculated Vesicle - Fluid-filled lesion ≤5 mm Histologic terms Note that some of the terms below can be used to describe both a morphologic and a histologic finding; such terms are denoted with an asterisk (*). Histologic terms, with their most common definitions, follow: Acantholysis - Dissolution of intercellular integrity with fragmentation of epidermis Acanthosis - Hyperplasia of epidermal layer (...) . Whether this is a specific entity or a common pathway in healing and recovery of several nonspecific inflammatory conditions of the skin is debatable. No treatment is required; however, acrochordons are removed to address bleeding, irritation, cosmesis, and discomfort. Occasionally, a lesion may twist on its stalk and become painful, erythematous, and necrotic. They may be electrodesiccated, shaved, or removed with cryoablation. Larger acrochordons may require surgical excision for the best cosmetic

2014 eMedicine Surgery

875. Skin Resurfacing: Chemical Peels

as 900 glands/cm 2 may be found. Epithelial appendages are located deep within the dermis. In the face, these appendages may also be located in the subcutaneous fat beneath the dermis. The deep location of these structures and their density in the face account for the remarkable ability of this area to re-epithelialize the deepest cutaneous wounds. Previous Next: Mechanism of Action in Chemical Peeling Chemical peeling is the process of applying chemicals to the skin to destroy the outer damaged (...) , skin aging basically is the process of atrophy. Loss of subcutaneous tissue is the most obvious and recognizable sign of aging; however, skin, skin appendages, and cutaneous blood supply also atrophy with age. Both the epidermis and dermis thin, and cutaneous strength and elasticity are lost. Dermoepidermal adherence afforded by rete pegs is lost, and blistering or superficial epidermal loss commonly occurs with aged skin. Overall thinning and loss of integrity and wall strength of the cutaneous

2014 eMedicine Surgery

876. Skin Tumors, Vascular Lesions, Face and Neck

% of lesions by age 7 years. Involution leaves an area of expanded skin or mucosa (depending upon the location of the lesion) and loss of underlying normal subcutaneous fat and replacement with fibrofatty tissue. In addition, bone erosion or remodeling may have occurred due to the presence of the lesion. Presentation and physical examination Infantile hemangiomas usually present within the first few weeks to months of birth. The symptoms and signs are dependent upon the location and depth of the lesion (...) . Superficial lesions that affect the skin manifest as raised, red lesions that are somewhat firm to the touch (see the first image below). Subcutaneous lesions tend to manifest as deeper masses with a blue hue and an unaffected overlying skin layer (see the second image below). These deeper lesions are more difficult to differentiate from vascular malformations and other masses and more often require radiographic imaging to aid in diagnosis. Hemangiomas may also contain both superficial and deep elements

2014 eMedicine Surgery

877. Skin Resurfacing, Laser: Erbium YAG

to the deposition of abnormal elastic fibers, the degeneration of collagen, and the twisting and dilation of microvasculature. These are compounded with the intrinsic changes and result in a rough surface texture with wrinkling, scaling, dyspigmentation, telangiectasias, and skin laxity. [ , , , ] The accumulation of free radical damage probably plays a major role in both intrinsic and extrinsic processes. Underlying anatomic structures sag as deep layers loosen and subcutaneous fat accumulates or atrophies (...) . Furrows develop in the skin that overlies facial muscles. Surgically lifting the skin and subcutaneous tissue, rearranging the distribution of facial fat deposits, and paralyzing facial muscles with botulinum toxin are effective methods of addressing the underlying structural changes associated with aging, but they do not directly address the degradation in the quality of skin. One method of improving the condition of the skin is by "resurfacing" it, by removing the outer layers to the level

2014 eMedicine Surgery

878. Nasal Reconstruction, Principles and Techniques

beginning and ending at the inner semicircle and extending to the outer semicircle at the point where it crosses its central axis. The width of the first lobe is approximately 2 mm less than the width of the defect, and the width of the second lobe is approximately 2 mm less than the width of the first. Incise the bilobed flap and elevate it in a plane between the subcutaneous fat and nasalis muscle. Deepening the recipient wound down to the nasal skeleton, which almost always accommodates the thickness (...) ) Nasolabial flap. The base of the pedicle of this flap lies on the lateral nasal wall and is transposed a maximum of 60° to avoid a "bridge" effect of the flap crossing the nasofacial angle. See the list below: Design the flap with the central axis 45° from the axis of the nasal dorsum. Base the shape of the flap on a template taken from the defect. Incise the flap without the injection of epinephrine and elevate it between the subcutaneous fat and muscle fascia in an inferior-to-superior direction

2014 eMedicine Surgery

879. Nasal Reconstruction, Paramedian Forehead Flap

months later in final touch-up operations. Only after soft tissues had healed could large bone-and-cartilage pieces be placed as cantilever grafts to lift the dorsum and tip. Unfortunately, once gravity and the contractual effects of the healing process had destroyed nasal contour, it rarely could be regained. Covering skin became constricted and stiff. Multiple late revisions were required to sculpt subcutaneous tissue into a semblance of nasal shape. The infolding of forehead flaps for lining (...) was fixed both by their natural configuration and by the scar that surrounded them as they sat in the flap on the forehead awaiting transfer to the nose. When the nose finally was assembled, often little could be done to shape the cartilage fragments so that they resembled the subcutaneous architecture of a normal nose. They were glued to the undersurface of the flap and fixed in whatever position they had assumed on the forehead. At first glance, residual intranasal mucous membrane seems inadequate

2014 eMedicine Surgery

880. Scalp Reconstruction

is divided into 5 subunits: the central, the left and right temporal, and the left and right brow subunits. The soft tissue within this region is commonly divided into 5 layers: skin, subcutaneous tissue, aponeurosis (galea), loose areolar tissue, and pericranium. These layers easily are remembered using the mnemonic "SCALP" (see the image below). An external layer of thick skin is fixed to the underlying subcutaneous layer of fat. This subcutaneous layer is richly vascularized and provides a fibrous (...) the underlying bone, although they may be strongly adherent along the cranial sutures. As the pericranium approaches the superficial temporal line laterally, it divides to form 2 layers, the temporalis muscle fascia (deep temporal fascia) and the pericranium of the temporal bone. These 2 layers together invest the body of the temporalis muscle. Inferior to the temporalis muscle, the temporalis fascia splits to invest the superficial temporal fat pad, and then it inserts into the zygomatic arch. Although

2014 eMedicine Surgery

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