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Subcutaneous Fat Necrosis

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881. Rhinoplasty, Tip Surgery

alteration on appearance and function. The anatomic layers of the nose are as follows: A covering envelope of superficial epidermis, dermis, and a subcutaneous layer of fat; nasalis muscle; and associated fascia: This external envelope is separated from the underlying support layer by a loose areolar layer. The areolar layer provides an easy, relatively avascular dissection plane through which the nasal cover can be safely elevated to expose the underlying osteocartilaginous support. A midlayer (...) soft tissue scarring or tissue necrosis must be avoided. Midlayer support The nose can be divided into an upper bony vault, a middle upper lateral cartilage vault, and a lower alar cartilage vault. The lower lateral vault (the tip and ala) contains the external valve, which consists of the nostril rim and inner nostril, made up of the caudal edge of the alar cartilage, the soft tissue ala, the membranous septum, and the nostril sill. The cartilage framework of the nasal tip is provided by the alar

2014 eMedicine Surgery

882. Skin Grafts, Full-Thickness

or destroyed in cases such as partial-thickness burns, abrasions, or split-thickness skin graft harvesting. These intradermal epithelial structures, such as sebaceous glands, sweat glands, and hair follicles, are lined with epithelial cells with the potential for division and differentiation. They are often found deep within the dermis, and in the face may even lie in the subcutaneous fat beneath the dermis. This accounts for the remarkable ability of the face to re-epithelialize even the deepest cutaneous (...) of the graft. This provides tension and a sense of graft thickness while the operating hand dissects the graft off of the underlying subcutaneous fat. Any residual adipose tissue must be trimmed from the underside of the graft because this fat is poorly vascularized and will prevent direct contact between the graft dermis and the wound bed. Trimming of residual fat is best accomplished with sharp curved scissors with the graft stretched over the nonoperating hand until only the white glistening dermis

2014 eMedicine Surgery

883. Skin Malignancies, Merkel Cell Carcinoma and Rare Appendageal Tumors

includes lesions that can emulate tumors. These benign lesions arise from either elastic tissue or dermal collagen. Often appearing to start from the fascia and extend into dermal and subcutaneous fat, these benign fibrotic nodules must be distinguished from fibrosarcomas. Palmar fibromatosis (Dupuytren contracture) Clinical presentation Palmar fibromatosis (PF) is a relatively common contracture of the palmar fascia, extending into the fingers, usually the fourth and fifth digits. [ ] Contracture (...) microscopic extensions beyond the visible lesion; therefore wide excision is recommended for treatment. Some have stated that Mohs surgery is preferred as a treatment. DFSP rarely metastasizes. DFSP should not be treated with radiation, as this can cause the neoplasm to exhibit more aggressive behavior. Pathogenesis Upon histologic examination, DFSP involves the dermis and often the subcutaneous fat. The lesion consists of plump spindle cells, which radiate from a fibrous center to form the characteristic

2014 eMedicine Surgery

884. Skin Flaps, Design

combinations of flaps and predict their success. Mastery of the use of local flaps requires the ability to predict long-term results and anticipate inevitable scarring and contracture. Next: Local Flaps: Anatomy and Physiology The microcirculatory system of the skin is composed of the deep vascular plexus at the junction of the subcutaneous fat and reticular dermis and the superficial plexus in the superficial dermal papillae in the papillary dermis. The superficial plexus of capillaries supplies the more (...) a detailed description is beyond the scope of this article, the delay phenomenon alters flap vasculature and results in a reorganization of the vessels along the long axis of the flap. Choke vessels become dilated, and the zone of necrosis is shifted toward the tip of the flap. Vascular endothelial growth factor seems to play a role in this phenomenon. A retrospective study by Inbal et al on free flap reconstructions employing vein grafts indicated that transposition arteriovenous loop grafts produce

2014 eMedicine Surgery

885. 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

886. Skin Grafts, Split-Thickness

in the subcutaneous fat beneath the dermis, which accounts for the remarkable ability of the face to reepithelialize even the deepest cutaneous wounds. Sebaceous glands (holocrine glands) secrete sebum that serves to lubricate the skin and make it more impervious to moisture. They are found over the entire surface of the body, except the palms and the soles and dorsum of the feet. They are largest and most concentrated in the face and scalp, where they are an anatomic focus for the development of acne. Sweat (...) placed intraorally or subcutaneously, the STSG should be harvested from the cutaneous portion of the free flap. [ ] A retrospective study by Rotatori et al indicated that in pediatric burn patients who undergo treatment with STSGs, the thigh, if used as a donor site, is particularly likely to develop hypertrophic scarring, while, among all possible sites, the scalp, arm, foot, and lower legs are less likely. [ ] Facial wounds, for the above-noted reasons, are often repaired with FTSGs. Preauricular

2014 eMedicine Surgery

887. Scar Revision

traumatized during closure may develop wound dehiscence or undergo skin-edge necrosis, thus leaving unsightly scars. Likewise, wounds that are unevenly or improperly repaired, become infected, or undergo foreign body reactions to sutures more frequently yield poor cosmetic results. Traumatic wounds traditionally yield poorer eventual scars. Common etiologies of widened or dehisced scars include wounds closed under tension, repairs not formed parallel to relaxed skin tension lines (RSTLs), or wounds (...) are at particular risk following revision procedures. Patients with a history of cigarette smoking and any nicotine intake are particularly are prone to flap necrosis and superficial epidermal slough, given the microvascular-constricting effects of nicotine. Carefully counsel patients who smoke that reconstructive procedures are severely compromised by ongoing cigarette smoking and that the failure rate is significantly higher if they continue to smoke. Cessation of smoking for 4 weeks prior to and after

2014 eMedicine Surgery

888. Hernias (Overview)

, 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 to the umbilicus (...) 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 is closed

2014 eMedicine Emergency Medicine

889. Gout and Pseudogout (Overview)

are as follows: Avoidance or restricted consumption of high-purine foods Avoidance of excess ingestion of alcoholic drinks, particularly beer Avoidance of sodas and other beverages or foods sweetened with high-fructose corn syrup Limited use of naturally sweet fruit juices, table sugar, and sweetened beverages and desserts, as well as table salt Maintenance of a high level of hydration with water (≥8 glasses of liquids daily) A low-cholesterol, low-fat diet, if such a diet is otherwise appropriate (...) chemotactic factors, and tumor necrosis factor (TNF)-α. [ , ] Neutrophil phagocytosis leads to another burst of inflammatory mediator production. Chatfield et al reported that the interaction of urate crystals with lysosomes results in the formation of web-like chromatin structures known as neutrophil extracellular traps (NETs) and subsequent cell death (NETosis), via a mechanism independent of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase. The urate crystal–induced NETs are enriched

2014 eMedicine Emergency Medicine

890. Fournier Gangrene (Overview)

and superficial fascia Because Fournier gangrene is predominately an infectious process of the superficial and deep fascial planes, understanding the anatomic relationship of the skin and subcutaneous structures of the perineum and abdominal wall is important. The skin cephalad to the inguinal ligament is backed by Camper fascia, which is a layer of fat-containing tissue of varying thickness and the superficial vessels to the skin that run through it. Scarpa fascia forms another distinct layer deep to Camper (...) , an obliterative endarteritis develops, and the ensuing cutaneous and subcutaneous vascular necrosis leads to localized ischemia and further bacterial proliferation. Rates of fascial destruction as high as 2-3 cm/h have been described. Infection of superficial perineal fascia (Colles fascia) may spread to the penis and scrotum via Buck and Dartos fascia, or to the anterior abdominal wall via Scarpa fascia, or vice versa. Colles fascia is attached to the perineal body and urogenital diaphragm posteriorly

2014 eMedicine Emergency Medicine

891. Burns, Thermal (Treatment)

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

892. Cellulitis (Treatment)

-shift polymorphonuclear neutrophils Previous Next: Surgical Examination and Drainage Urgent consultation with a surgeon should be sought in the setting of crepitus, circumferential cellulitis, necrotic-appearing skin (bronzing), evolving bullae, rapidly evolving cellulitis, pain disproportional to physical examination findings, severe pain on passive movement, or other clinical concern for necrotizing fasciitis. Wong et al have developed a scoring tool to assist in the diagnosis of necrotizing (...) fasciitis. [ ] Cellulitis associated with an abscess requires surgical drainage of the source of infection for adequate treatment. Serious concern for necrotizing fasciitis and/or the presence of necrotic skin should prompt examination of the fascial planes by immediate computed tomographic imaging or surgical direct observation, which, in most cases, can be performed at the bedside by an experienced surgeon. Circumferential cellulitis may result in compartment syndrome, which may require surgical

2014 eMedicine Emergency Medicine

893. Anemia, Sickle Cell (Treatment)

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 stress, which contributes (...) 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 iron, but it is administered

2014 eMedicine Emergency Medicine

894. Toxicity, Warfarin and Superwarfarins (Overview)

and in patients with preexisting protein C deficiency and is found, less commonly, in men and in patients with protein S deficiency. Patients initially become hypercoagulable because warfarin depresses levels of the anticoagulant proteins C and S more quickly than it does coagulant proteins II, VII, IX, and X. Extensive thrombosis of the venules and capillaries occurs within the subcutaneous fat. Women note an intense, painful burning in areas such as the thigh, buttocks, waist, and/or breast several days (...) ) who underwent dialysis, warfarin was found to be associated with a 44% higher risk of bleeding and did not reduce the risk of stroke. [ ] Skin necrosis Skin necrosis, usually observed between the third and eighth days of therapy, is a relatively uncommon, adverse reaction to warfarin. When skin necrosis occurs, it can be extremely severe and disfiguring and may require treatment through debridement or amputation of the affected tissue, limb, breast, or penis. It occurs more frequently in women

2014 eMedicine Emergency Medicine

895. Pediatrics, Respiratory Distress Syndrome (Overview)

permeability, influx of protein rich edema fluid into the alveolar sacs, dysfunction of surfactant production, and defective ion transport leading to impaired fluid clearance from alveolar cells. These changes are the hallmark of ARDS pathophysiology and are accompanied by dysregulated inflammation from dysfunctional leukocytes and influx of pro-inflammatory cytokines like interleukins and tumor-necrosis factor. The role of neutrophils in this mechanism is controversial. Animal models have favored both (...) , if they are associated with shock and thrombocytopenia. [ ] Other more common etiologies include bronchiolitis, aspiration pneumonia, aspiration of gastric contents, major trauma, pulmonary contusion, burns, inhalational injury, massive transfusions or transfusion-related acute lung injury (TRALI). [ , , , , , ] Transfusion of all type of blood products including packed red blood cells, fresh frozen plasma and platelets has been associated with development of ARDS. [ , ] Other causes include acute pancreatitis, fat

2014 eMedicine Emergency Medicine

896. Endometrium, Carcinoma

inexpensive, is noninvasive, and does not use ionizing radiation. Typical examinations include transabdominal sonography (TAS) and transvaginal sonography (TVS), which are supplemented by color Doppler imaging as needed. [ , , , , , , , , , , ] TAS is performed through subcutaneous fat and abdominal wall muscles and uses the full urinary bladder as an acoustic window. TAS transducers, needed in most patients to penetrate the abdominal wall and adequately visualize pelvic organs, have lower frequency (...) of the uterine contours; increased attenuation and prominent linear soft tissue stranding in the parametrial and periureteral fat; confluent soft tissue replacing the periureteral fat; and 3-dimensional parametrial soft tissue mass Stage IIIC: Metastases to pelvic and/or para-aortic lymph nodes. Stage IVA: Tumor invasion spreads into the urinary bladder or bowel mucosa. CT findings include the following: focal obliteration of the perivesical or perirectal fat; eccentric or asymmetric wall thickening, which

2014 eMedicine Radiology

897. Epiglottitis, Acute

thickening of the epiglottis, aryepiglottic folds, platysma muscle, and prevertebral fascia; obliteration of the pre-epiglottic fat planes; and reticulation of the subcutaneous fat. Emphysematous epiglottis is further characterized by soft-tissue lucencies representing gas within a swollen epiglottis. The finding of multiloculated fluid-density collections should raise the suspicion that an abscess exists. Edema and thickening of the supraglottic tissues with obliteration of the surrounding fat planes (...) safety, because patients must be supine for a lengthy period of time without direct surveillance. Few studies have reported MRI findings in acute epiglottitis. T1- and T2-weighted imaging shows thickening of the epiglottis, and there is marked enhancement of the epiglottis and often of the adjacent aryepiglottic folds following gadolinium administration. Areas of nonenhancement may represent necrosis or phlegmon. Cervical lymphadenopathy may also be seen. Previous Next: Ultrasonography Findings

2014 eMedicine Radiology

898. Cystic Fibrosis, Thoracic

-fluid level in the right upper lobe and subcutaneous emphysema. Extrapulmonary air, including pneumothorax, is a common complication in the presence of large air pockets (cysts). Pancreatic abnormalities In the advanced stages of CF, the exocrine tissues of the pancreas are often completely replaced by fat. On CT scans, the pancreas is composed purely of fat, which is isoattenuating relative to the adjacent retroperitoneal fat. (This finding is in contrast to the fatty replacement in aged and obese (...) successfully. Overall, false-positive and false-negative rates are relatively high. Stool fecal fat and pancreatic-enzyme secretion tests Stool fecal fat and pancreatic-enzyme secretion can be measured by collecting duodenal fluids after simulation with secretin and pancreatozymin. Decreased levels of pancreatic enzymes or elevated stool fat are expressed as the percentage of ingested fat in a 72-hour stool collection and can be indicative of CF, respectively. Molecular diagnostic tests The molecular

2014 eMedicine Radiology

899. Toxicity, Cocaine (Overview)

aspiration pneumonitis or after an intravenous injection of bacteria or toxic organic or inorganic materials Aneurysm or pseudoaneurysm: May be noted with mainlining (ie, directly injecting into a central artery or vein); this finding is an indication for further imaging studies In addition, radiography may be useful for evaluating cellulitis, an abscess, or a nonhealing wound in an intravenous drug user; it may reveal a foreign body or subcutaneous emphysema produced by gas-forming organisms (...) is fat soluble and freely crosses the blood-brain barrier. Cocaine appears to stimulate the CNS, with particular activity in the limbic system. There, it potentiates dopaminergic transmission in the ventral basal nuclei, producing the pleasurable behavioral effects that result in its widespread use. Cocaine enters the United States in the form of a hydrochloride salt, having undergone numerous steps in refinement from the original coca leaf. In its hydrochloride form, cocaine may be absorbed

2014 eMedicine Emergency Medicine

900. Systemic Lupus Erythematosus (Follow-up)

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

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