Treatment for Scars

The Scar Solution Book By Sean Lowry

The Scar Solution by Sean Lowry is a new natural treatment program that provides people with an advanced and natural scar treatment. Sean Lowry is a medical researcher and a former scar sufferer. The results are amazing: Fast results in terms of removing the appearance of large, raised and discolored scars on the skin. This is because each type of scar has different causes and requires different techniques of treatment. The Scar Solution classified the causes of scars into their specific causes in order to effectively get them to vanish. Actually, The Scar Solution can help people achieve clear skin without skin tags and stubborn scars. If you feel not totally satisfied for any reason with the results that this program brings about, you just need to tell the author and require a full refund within 8 weeks. By this way, you will be able to get every dime of the money you invested back almost right away. Read more here...

The Scar Solution Natural Scar Removal Summary


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GAGs and Proteoglycans in Hypertrophic Scars

There are abnormalities in the amounts and nature of the GAGs in hypertrophic scars, which has been recognized for more than 30 years. Chondroitin 4 sulfate, which is barely detectable in normal skin, can be readily demonstrated in hypertrophic scars (98), where it is especially elevated in the characteristic nodular structures (99). DS, in contrast, is absent from all but the more normal appearing parallel-fibered areas of the scars (100). Swann et al. (101) later extracted proteoglycans from human skin and normal and hypertrophic scars with the powerful denaturing agent guanidinium chloride (to disrupt the collagen), and separated and studied them using techniques that had earlier been successfully applied to the proteoglycans of cartilage. The major conclusions were that the hypertrophic scars contained more proteoglycan than did normal scars and that this included a higher proportion of low-density DS pro-teoglycan. Subsequent work identified in these extracts a small DS...

Decorin Is Deficient in Hypertrophic Scars

Garg et al. (103) isolated L-iduronate-containing small proteoglycans from skin and postburn scar tissues. Although the two small proteoglycans were not separated, evidence was presented for an increased ratio of biglycan to decorin in the scar tissues compared to normal skin. In our own work, the absolute amounts of decorin, biglycan, and versican in human skin and in postburn hypertrophic and mature scars were measured using quantitative inhibition ELISA methods (9). The amounts of decorin in the hypertrophic scars were found to be about 25 of those in normal skin or in mature scars, while biglycan and versican were each about sixfold higher. The longer DS chains previously noted were found to belong to both decorin and biglycan. In normally healing incisional wounds in humans and experimental animals, decorin appears within about a week, at the same time as new collagen fibrils (104,105). In contrast, in healing second- and third-degree burn wounds, many of which become...

Role of TGFb in Hypertrophic Scarring

Excessive amounts and or uncontrolled activity of TGF-p have been implicated as a causative factor in many forms of fibroproliferative disease (108), including post-burn hypertrophic scarring (109). Circulating levels of TGF-p are about twofold higher in recovering burn patients than in normal subjects and remain elevated for several months after injury (110). The profibrotic effects of TGF-p on cultured fibroblasts include the stimulation of the synthesis of collagen, fibronectin, and GAG (111,112) the downregulation of MMPs and the upregulation of tissue inhibitors of matrix metalloproteinases (TIMPs) (113). TGF-p also downregulates the synthesis of decorin and upregulates the synthesis of biglycan and versican by human skin fibroblasts (114,115).

Hyaluronan Wound Healing and Scarring A New Perspective

In 1991 a paper was published suggesting that a new perspective should be taken on HA and wound healing (163). The background to this paper was the serendipitous discovery that HA extracted from human scar tissue and highly purified still had an identifiable collagen component using cyanogen bromide digests (164). This led to further studies of other HA preparations which indicated that all HA preparations had some protein 'association' (Table 2). The sources of these preparations were all animals with the exception of the preparation from Genzyme which was produced by bacterial fermentation. The effect of these HA preparations was then assessed on models of cell proliferation and matrix organization. HA preparations were used with and without prior digestion with hyaluronidase. The conclusion of these studies was that even after hyaluronidase digestion the extracts with a high protein content had significant effects on cell proliferation. It is now possible to review these findings...

Follicular Diseases Causing Scarring Alopecia

Follicular destruction results in scarring alopecia that can be classified as primary or secondary. In primary scarring alopecias, the follicle is the target of inflammation. In secondary scarring alopecias, the follicle is an innocent bystander that, nevertheless, is destroyed. Examples of secondary scarring alopecias include morphea and tumors (alopecia neoplastica). In this chapter, we will consider only the primary scarring alopecias. In this group of diseases, the inflammation can be primarily lymphocytic or neutrophilic. Although all parts of the follicle can be involved, the disease is felt to destroy the bulge area of the follicle, where the arrector pili muscles insert. This area contains the follicular stem cells necessary for regeneration of the lower follicle during normal follicular cycling. When this part of the follicle is destroyed, the follicle is doomed. The sebaceous glands are also destroyed in primary scarring alopecias. The destruction of these structures and the...

Fetal Vm Tissue Transplants

Fetal VM tissue transplanted into the dopamine-depleted caudate of the striatum always had better success than adrenal medulla grafts (50,51). Despite being allografts (the host is not the donor but is the same species as the donor), fetal VM tissue appeared to induce less immunorejection and gliotic scarring than did adrenal grafts (52-54). The immune reaction was not substantially different than that seen in sham surgeries (44). Fetal VM tissue placed into the dopamine-depleted caudate increased striatal dopa-mine content, normalized the HVA dopamine ratio, increased the density of DAT sites, and decreased dopamine receptor sensitivity (25,54-58). Additionally, in MPTP-treated monkeys, it was found that VM transplants increased cellular metabolic activity, as indicated by higher levels of mitochondrial cytochrome oxidase (59). All these measures of dopamine and metabolic activity are altered initially by MPTP treatment and subsequent dopamine depletion of the striatum (see The MPTP...

Advantages Of Injectable Systems For Bone Tissue Engineering Applications

One of the main advantages of injectable systems as tissue engineering devices is their ability to allow for the use of minimally invasive surgical procedures for their implantation in the body. These procedures minimize the damaging effects of large muscle retraction, reduce the size of scars, and lessen postoperative pain, allowing patients to achieve rapid recovery in a cost-effective manner.11 Injectable materials can also be easily placed in complex-shaped or relatively inaccessible defects1617 and then be reacted to form a polymer with the exact required dimensions, necessitating little or no additional shaping or modification of the device.18 These systems may, at the same time, provide immediate mechanical support to the healing tissue. Furthermore, there is usually a good adhesion of the polymer to the surrounding tissue due to their intimate contact and due to mechanical interlocking that often results from surface roughness.18

Anal Fissures Tears and Lacerations

Clinically, an anal fissure refers to a longitudinal laceration in the perianal skin and or mucosa of the anal canal. Anal fissures may be acute (usually healing within 2-3 weeks) or chronic and single or multiple. Most fissures will heal by first intention and not leave a scar. However, after healing, the site of some Whether an injury heals by first or secondary intention, the latter resulting in scar formation, depends on several factors, including the width and depth of the breach in the epithelium. Manser (134) reported scarring in 14 of the people examined because of possible anal intercourse. The Royal College of Physicians working party stated that in children, The only specific indicator of abuse is a fresh laceration or healed scar extending beyond the anal margin onto the perianal skin in the absence of reasonable alternative explanation, e.g., major trauma (173). Disappointingly, this report does not clarify how they differentiate between lacerations and fissures.

Risk Of Fetalneonatal Infection

Skin scars Congenital varicella syndrome was first described in 1947 but seems to have been forgotten until 1974, when a newly recognized case was described in Canada (9). Following this case report and review of the literature, many other reports of infants with a similar constellation of birth and developmental defects after maternal varicella followed (7,10). Eventually, it became possible to specifically implicate VZV causally in these classic birth defects by the use of polymerase chain reaction (PCR). Unlike infants with the congenital rubella syndrome, babies with the congenital varicella syndrome do not asymptomatically shed virus at birth or afterward. If they develop zoster, and about 18 will do so, then it is possible to demonstrate VZV by culture or other specific means. Using PCR, moreover, it has been possible to demonstrate VZV DNA in affected tissues, such as the skin scars typical of the syndrome. Approximately 75 affected infants have now been reported (7). Only a...

Search Detection Description Diagnosis

There are three methods commonly used for search. Search can represent a quick review of the image looking for areas that are most conspicuous. Search can represent a systematic search attempting to review all areas of the image. Search can be based on the expectation of finding features that point toward a single suspected disease or several suspected diseases. For example, Figure 7.5 shows a mammogram in which there is an abnormality, a mass. The mass is of high contrast and is quite conspicuous. It stands out from the background. Figure 7.6 shows a mammogram in which there are microcalcifications. Although each of these calcifications is of high contrast, they are small features. They can be found by a systematic search that surveys the entire breast tissue image, for example, by scanning up and down over the entire image, often with the use of magnification. If one is looking at a mammogram, one knows that there are only a few features of cancer. These include a mass,...

Inhibition of TNFa in Bullous Pemphigoid

There are a few reports on the effect of TNF-a antagonists in clinical variants of BP, an autoimmune bullous skin disorder associated with IgG autoantibodies against components of the dermo-epidermal basement membrane zone, such as BP180 and BP230. In the clinical variant mucous membrane pemphigoid, a disorder which is characterized by chronic blistering of the mucous membranes with secondary scarring, the TNF-blocker etanercept has been applied with great success. A 72-year-old woman with long-standing mucous membrane pemphigoid and acute exacerbation of oral lesions had already been treated with prednisone (1 mg kg day) in combination with azathioprine (100 mg day) and mycophenolate mofetil (2x1 g day) over a year, leading to a moderate clinical response. Etanercept (25 mg s.c. x2 week) in combination with prednisone (initially 60 mg day) led after the third cycle to the disappearance of newly developed blisters. Even though the corticosteroids were gradually tapered, the patient...

Age Related Macular Degeneration

In AMD, central visual acuity is lost due to death of macula photoreceptors located in the central portion of the retina. This pattern of vision loss is different than that in glaucoma, where peripheral vision is progressively lost. AMD can be broadly divided into two categories nonexudative, or 'dry,' AMD and exudative, or 'wet,' AMD. Dry AMD is characterized by the loss of photoreceptor cells in the macula following the death of supporting retinal pigmented epithelium (RPE) cells. Vision decline is usually gradual. Wet AMD is characterized by neovascularization of the choroidal capillaries (choroidal neovascularization (CNV)), which supply oxygen and nutrients to and remove waste products from photoreceptors and RPE cells. Wet AMD can be further subcategorized by the appearance upon examination by angiography of newly formed capillaries (1) predominantly classic, in which most of the newly formed blood vessels are well formed (2) minimally classic, in which most of the capillaries...

Electrostatic Repulsion Between Gags May Facilitate Collagen Fiber Formation

In a hydrated connective tissue such as skin, DS chains probably do not bind directly to one another, rather they are far more likely to exert a strong mutual repulsion as a consequence of their high density of negative charges. This does not, of course, preclude a role for decorin in connective tissue organization based on its physical and chemical properties. In the decorin null mouse, collagen fibrils are irregular in outline and form anastomoses and random fusions (50). Thus, the decorin that is normally present appears to define and delimit the surfaces of the collagen fibrils. The parallel orientation and association of collagen fibrils into fibers and fiber-bundles is impaired in the periodontal ligament of decorin deficient mice (51) and in postburn hypertrophic scars (52) (Fig. 5). The latter are deficient in decorin compared to normal skin or mature scars (9). Skin collagen defects are also seen in variant forms of Ehlers-Danlos syndrome, where mutations in a...

Biglycan and Tissue Organization

Figure 5 Section of human postburn hypertrophic scar tissue, stained with Cuprolinic blue and uranyl acetate, showing thin collagen fibrils embedded in an abundant interfibrillar matrix. Clumps of densely stained amorphous materials are probably biglycan and or versi-can. Note the paucity of periodically attached decorin DS chains on the collagen fibrils (contrast with Fig. 4). The scale bar represents 100 nm. Figure 5 Section of human postburn hypertrophic scar tissue, stained with Cuprolinic blue and uranyl acetate, showing thin collagen fibrils embedded in an abundant interfibrillar matrix. Clumps of densely stained amorphous materials are probably biglycan and or versi-can. Note the paucity of periodically attached decorin DS chains on the collagen fibrils (contrast with Fig. 4). The scale bar represents 100 nm.

Transforming Growth Factorb and SLRPs

In some experimental systems, administration of decorin may downregulate the production of TGF-p (78,79), providing a possible explanation for an effect on its biological activity that is independent of either direct binding to decorin or of competition for cell surface receptors. Notwithstanding the uncertainty surrounding the mechanism(s), there have been some spectacular successes in the use of decorin in experimental animals to treat TGF-p-mediated fibrotic processes such as glomerular nephritis (80), gliotic scarring (81), bleomycin-induced lung fibrosis (82,83), and intra-articular fibrous adhesions (84). TGF-p released from certain tumors is believed to contribute to their evasion of T-cell-mediated

Distinct Phenotype of Fibroblasts in Healing Burn Wounds

The abnormal chemical composition of the hypertrophic scar extracellular matrix might be explained as resulting from the known effects of TGF-p on the metabolism of fibroblasts. However, when fibroblasts are cultured from postburn hyper-trophic scars, they are found to have a permanently altered phenotype compared to those from uninjured skin of the same patients, often making more collagen, and always less collagenase (116), less nitric oxide (117), and less decorin with a longer DS chain (114). Some form of cell selection must therefore be operating, and the simplest explanation is probably that the fibroblasts in healing burn wounds are derived largely from the deep dermis or superficial fascia where they survived the original injury. Support for this suggestion comes also from the observation that fibroblasts from reticular dermis synthesize less decorin than do those from papillary dermis (118).

Summary and Conclusions

Cores, have been proposed for these small proteoglycans, including control of cell proliferation in general and of angiogenesis in particular. Reduced amounts of decorin, and or its replacement by biglycan and versican, are associated with disorganized and mechanically dysfunctional connective tissue in hypertrophic scars and certain variant forms of Ehlers-Danlos syndrome. Better understanding of the structures and activities of the SLRPs may lead eventually to novel therapies for fibrotic and metastatic disease.

Pathologic Effects of a Normal Complement System

The clearest examples of complement-mediated pathology are immune complex-mediated diseases. Systemic vasculitis and immune complex glomerulonephri-tis result from the deposition of antigen-antibody complexes in the walls of vessels and kidney glomeruli (see Chapter 18). Complement activated by these deposited immune complexes initiates the acute inflammatory responses that destroy the vessel walls or glomeruli and lead to thrombosis, ischemic damage to tissues, and scarring. Studies with knockout mice lacking the complement proteins C3 or C4 or lacking Fcy receptors suggest that Fc receptor-mediated leukocyte activation may also cause inflammation and tissue injury as a result of IgG deposition, even in the absence of complement activation.

Hyaluronan Localization in Vocal Fold Pathologies

There has been keen interest in the measurement of HA levels in the lamina propria of vocal folds that have been scarred given the possibility of using exogenous HA to treat the resultant dysphonia. Vocal fold scarring causes devastating vocal dysphonia and there are suboptimal treatment options. HA is the most prominent glycosaminoglycan in the fetal ECM (14), which heals without scar. The role played by HA in influencing the scarless nature of fetal wound healing has been well documented (15,16). Whether or not the use of exogenous HA will decrease the incidence or decrease scar formation in the vocal folds remains to be documented, but offers a stimulating area of wound-healing research. To date, HA levels have only been measured in two animal models, the rabbit and canine (17-21). At time points representing chronic scar (2 and 6 months after scar induction), utilizing histological measures, HA levels were not significantly different between scar and control. HA levels immediately...

Biomechanical Properties of Hyaluronan

An attempt to alter the in vivo viscoelastic properties of mucosal tissue with dilute (0.05 ) and concentrated (0.5 ) HA, Gray and co-workers (unpublished data) found that HA injections could possibly affect tissue viscosity. However, it appears that while increasing tissue viscosity and stiffness were possible, decreasing tissue viscosity and stiffness through HA injections were difficult. The viscoelastic effect of the dilute HA was very short, less than 24 h, possibly because of rapid diffusion away from the sight of injection. Concentrated HA did lead to a greater viscoelastic effect. This research demonstrates that optimization of HA (purity, rheological properties, molecular weight, concentration, etc.) is required and that HA is unlikely the sole factor in regulating tissue viscoelasticity. The unlikelihood of HA being the sole factor in regulating vocal fold tissue viscoelasticity is further supported by the findings of unaltered HA levels in vocal fold scar measured...

In Vivo Alteration of Hyaluronan Production

Applications in voice that would benefit from such a treatment including vocal fold scar, paralysis, paresis, and atrophy. All of the work to date has been accomplished in vitro. Hirano et al. (35) have demonstrated that treatment of normal canine laryngeal fibroblasts with hepatocyte growth factor, a potent mitogen of hepatocyte and modulates hepatic stellate cell proliferation, collagen formation and the expression of transforming growth factor beta 1, stimulated HA production up to 48 h. In a supplementary study, Hirano et al. (36), found an increase in HA levels from normal canine laryngeal fibroblast cultures up to 7 days with hepatocyte growth factor, epidermal growth factor, basic fibroblast growth factor, and transforming growth factor betal. This line of voice research is intriguing, unique and offer therapeutic potential for various vocal fold pathologies. One of the most significant advantages of this line of research is the production of in vivo autologous HA that would...

Legal Ideas of Responsibility

The use of evidence of genetic propensities for purposes of exculpation or mitigation comes into play after the defendant is charged with an antisocial act. If it is alleged that certain genes predispose people to commit antisocial acts, the criminal justice system may want to take action against an individual before he or she commits a crime. In such a situation, the U.S. Supreme Court decision in Robinson v. California(1962) could be applied to limit what the legal system can do to individuals who have an antisocial gene, but who have not yet committed any antisocial acts. In that case, a California statute made it a misdemeanor punishable by imprisonment for any person to be addicted to the use of narcotics. When the defendant was arrested, he had scar tissue marks on his arm, which was taken as an indication that he had previously used drugs. He was not under the influence of narcotics, nor was he suffering withdrawal symptoms when he was arrested. There was no proof he had used...

Diseases Characterized By Dermal Fibrosis

Diseases Characterized by Dermal Fibrosis SCAR Scar Hypertrophic Scar This chapter is devoted to those diseases characterized by fibrosis. This process principally affects the dermis, though the epidermis is often affected to a lesser degree. Diseases that are characterized by dermal fibrosis histopathologically exhibit a firm, fibrous change to the skin clinically. Some lesions that exhibit dermal fibrosis are elevated above the surrounding skin, such as a hypertrophic scar. Others are depressed below the surrounding skin, such as morphea. Dermal atrophy is also observed as a depression in the contour of the skin, though the texture would not be fibrotic on palpation. Epidermal atrophy is observed histopathologically as epidermal thinning and loss of the rete ridges clinically, it is observed as a subjective thin feeling of the superficial skin on palpation and is often associated with a smooth, wrinkled surface. Induration is a clinical term used to describe the firm, thickened...

Future Directions

Mackool RJ, Gittes GK, Longaker MT. Scarless healing the fetal wound. Clin Plast Surg 1998 25 357-365. 15. Adzick N, Longaker MT. Scarless wound healing in the fetus the role of the extracellular matrix. Prog Clin Biol Res 1991 365 177-192. 16. Moriarty KP, Cromblehome TM, Kerry GE, O'Donnell C. Hyaluronic acid-dependent pericellular matrices in fetal fibroblasts implications for scar-free wound repair. Wound Repair Regen 1996 4 346-352. 17. Rousseau B, Hirano S, Scheidt T, Welham NV, Thibeault SL, Chan RW, Bless DM. Characterization of vocal fold scarring in a canine model. Laryngoscope 2003 113 620-627. 18. Rousseau B, Hirano S, Chan RW, Welham NV, Thibeault SL, Ford CN, Bless DM. Characterization of chronic vocal fold scarring in a rabbit model. J Voice 2004 18(1) 116-124. 19. Thibeault SL, Rousseau B, Welham NV, Hirano S, Bless DM. Hyaluronan levels in acute vocal fold scar. Laryngoscope in press. 20. Thibeault SL, Bless DM, Gray SD. Interstitial protein alterations in rabbit...

The Role of Hyaluronan

There is now evidence to suggest that post-natal wound healing can be modulated, resulting in a decrease in scarring. Hellstrom (20) reported enhanced wound healing in tympanic membrane perforations in a rat model following the topical application of tissue-extracted HA. Membranes treated with HA appeared otomicroscopically normal (translucent) 3 months later in contrast to untreated membranes, which showed extensive opacification. In a follow up study it was reported that this effect was independent of molecular size or rheological properties of the HA but related to the concentration of the preparation (21). But what is the mechanism for the proposed effect of HA in wound healing and scarring The possibilities are

Post Operative Adhesions

Another area of clinical concern are the surgical scars that result in post-operative adhesions. Clinical studies have indicated that HA and cross-linked derivatives can be effective in preventing adhesions after endoscopic sinus surgery (127, 128). Experimental studies have assessed the efficacy of a hyaluronate carboxymethylcellulose gel using a rabbit uterine horn model. The positive benefits of applying the gel were demonstrated (129). Further studies confirm the positive benefits of HA based applications in rat and rabbit models of surgical adhesions (130,131).

Advantages and limitations of needle biopsy

The needle biopsy circumvents many of the disadvantages of the open muscle biopsy, which include higher costs, the need for general anaesthetic, increased scarring and the inconvenience of repeated biopsies (Goldberger et al. 1978 Edwards et al. 1980, 1983). The fact that many of our patients and control subjects have participated in several studies involving muscle biopsies emphasises that this technique is easy to learn, repeatable and relatively atraumatic. It is a safe procedure that is almost free of complication. As repeated biopsies are generally well tolerated, biopsies can be taken before, during and after acute or chronic intervention, e.g. insulin stimulation, lipid infusion, exercise, treatment with drugs, training etc.

Clinical Features

Primary extranodal organ involvement is uncommon in HL, unless related to direct extension. For example, while primary pulmonary presentations are rare, direct extension into the lung parenchyma is frequently observed, usually in the presence of adjacent mediastinal or hilar nodes. The lung is probably one of the most common nonlymphoid organs to be involved by HL, and such involvement may be manifested by linear infiltrates, pleural effusions, or nodular infiltrates demonstrated on chest X-ray or computed tomography (CT) scan. A rare patient may present with cough, wheezing, and endobronchial extension from an area of hilar lymphadenopathy. However, determination of pulmonary involvement can be quite problematic, as HL patients are predisposed to infectious complications including bacterial, viral, and atypical pneumonias. In addition, a history of granulomatous disease or fungal infection may be responsible for pulmonary scarring or nodules. The clinical setting, response to...

Transmission of Infectious Agents

Exposure to Infected Body Fluids As you learned in Chapter 9, AIDS is caused by exposure to infected blood. Hepatitis is another disease caused by contact with infected blood. There are at least six different hepatitis viruses, but the most dangerous is the virus known as hepatitis C. Exposure to hepatitis C leads to chronic liver diseases such as cirrhosis (irreversible, potentially fatal scarring of the liver), liver cancer, and liver failure. Hepatitis C ranks second to alcoholism as a major cause of liver disease and is the leading reason for liver transplants in the United States.

Presumed Ocular Histoplasmosis

Presumed ocular histoplasmosis is not seen in patients with active histoplasmosis. The evidence for infection in the originally described cases was necessarily circumstantial - hence the expression presumed ocular histoplasmosis . The syndrome consists of a certain type of haemorrhagic macular lesion (choroidal neo-vascularisation) combined with discrete foci of peripheral choroiditis and peripapillary scars.

Wallerian Degeneration of Nerve Fibers in the CNS Is Accompanied by Increased Expression of Clusterin in Astrocytes and

In central pathways, Wallerian degeneration creates distinctly different non-neuronal responses, which involve clusterin in two apparently unrelated ways. Along degenerating CNS pathways and in their termination territories there is proliferation of microglia and hypertrophy of astrocytes.1 Microglia gradually become phagocytes which incorporate and remove nerve fiber debris. Subsequently, tightly packed astrocytic processes replace the lost nerve fibers and develop a glial scar . In the area where axon terminals degenerate, astro-cytes may even undergo limited proliferation.

Identifying Genes that Extend Life Span Using a High Throughput Screening System

We developed a high-throughput functional genomic screening system that allows identification of genes prolonging lifespan in the baker's yeast Saccharomyces cerevisiae. The method is based on isolating yeast mother cells with a higher than average number of cell divisions as indicated by the number of bud scars on their surface. Fluorescently labeled wheat germ agglutinin (WGA) was used for specific staining of chitin, a major component of bud scars. The critical new steps in our bud-scar-sorting system are the use of small microbeads, which allows successive rounds of purification and regrowth of the mother cells (M-cell), and utilization of flow cytometry to sort and isolate cells with a longer lifespan based on the number of bud scars specifically labeled with WGA. Key Words Aging budding yeast wheat germ agglutinin WGA bud scar life span. The replicative lifespan of yeast is defined as the number of cell divisions or daughter cells (D-cell) that mother cells (M-cell) produce in...

Etiology of Adhesion Formation

Surgically induced adhesions are a complication of invasive surgical procedures (48). Adhesions induced by either trauma, surgical or otherwise, and pathology (i.e., endometriosis) can lead to a variety of complications including infertility, bowel obstruction, pain, impaired joint mobility, and unintended complications during reoperation (49-53). The etiology of surgically induced adhesions is thought to be a result of incidental trauma caused by tissue manipulation (54), desiccation (54), tissue ischemia, and a foreign body reaction to particulates (55-57). This damage leads to a wound healing response that results in the production of a serous exudate that leads to fibrin clot production (58-60). If the fibrin clot is relatively short lived then it is resorbed with concomitant normal wound repair. If, however, the fibrin clot resides for a longer time period then cells of fibroblastic phenotype are recruited to the site. These cells begin to generate collagen leading to a scar-like...

Changes In Aging Yeast

S. cerevisiae undergoes asymmetric division for most of its life span, producing a mother cell and a smaller daughter cell with each division. The cell wall of the daughter cell is synthesized de novo, and a permanent chitinous bud scar is left on the mother cell's surface at the site of attachment of the bud. (Adapted from Ref. 101.) Figure 1 Biomarkers of yeast aging. S. cerevisiae undergoes asymmetric division for most of its life span, producing a mother cell and a smaller daughter cell with each division. The cell wall of the daughter cell is synthesized de novo, and a permanent chitinous bud scar is left on the mother cell's surface at the site of attachment of the bud. (Adapted from Ref. 101.)

Other Viscosurgical Uses

The most extensive use of viscosurgery is in cataract surgery and intraocular lens implantation however, it is used for many other surgical treatments of diseases of the eye. The usefulness of highly elastoviscous hyaluronan solutions was discovered to make and maintain space, protect and manipulate tissues, and prevent excessive scar formation and adhesions. This very same functionality of hyaluronan-based OVDs led to other applications. The usefulness of Healon was tested early in various glaucoma surgeries. It was shown that viscoelastics enable surgeons to make safer and more aggressive procedures. In recent developments of glaucoma surgery, viscoelastics played an important role in the creation of a fistula between the anterior chamber and the subconjuntival space to restore normal outflow paths for the aqueous. They have been used to deepen and maintain the anterior chamber in trabeculectomy and to facilitate the outflow of aqueous into the superchoroidal space (cyclodialysis)...

Hyaluronan for Antiadhesion Wound Healing and Matrix Engineering

Early studies demonstrated that elastoviscous hyaluronan solutions could influence granulation tissue formation, and scarring (8). These studies established a firm foundation for developing hyaluronan-based products for the control of postsurgi-cal adhesions, wound healing, and tissue engineering. The term matrix engineering was coined by one of the authors (E.A.B.) to describe the use of hyaluronan-based matrices to control, direct, or augment tissue regenerative processes (72,73). Ongoing efforts to bring this concept into clinical practice will be described in this section.

Ocular Surface Disorders

When a modification of the tear film structure occurs, with consequent tear film instability, ocular surface stress will develop, resulting in a clinical condition known as dry eye. The classification of this disorder was carried out in 1995 by the National Eye Institute, dividing dry eye into two different types aqueous layer disorders and tear evaporation disorders (32). This classification is very useful to focus on the main causative factors of the disorder, although the clinical presentation is often a mix of the two pathogenic pathways (i.e., a reduced aqueous production often results in an inadequate lipid layer spreading and in excessive tear film evaporation meibomian gland disease is commonly associated with reduced aqueous secretion by the lacrimal gland). Aqueous layer deficiency is the most common cause of dry eye and is dependent on decreased secretion of the lacrimal glands, although increased evaporation of tears may also be involved. Main causes of tear aqueous...

Recurrentpersistent Melanocytic Nevus

The recurrent (persistent) nevus is defined as the appearance of macular pigmentation within the confines of the clinical scar of a previously biopsied (usually by shave technique) melanocytic nevus, usually after the passage of about six weeks to six months (Fig. 5A). Histologically regenerative and often irregular single cell and nested intraepidermal melanocytic proliferation, sometimes mimicking melanoma, overlies the dermal scar (Table 9) (Fig. 5B). On occasion, the latter intraepidermal component may show cytological atypia of melanocytes (Fig. 5C) and may extend into the dermal cicatrix. Commonly, a residual dermal nevus (corresponding to the original nevus) involves or resides at the base of the scar. It is important to verify the nature of the lesion originally biopsied and exclude malignant melanoma.

Osteopathic Treatment and Its Physiologic Effect

Osteopathic manipulative treatment may be performed using various techniques depending on the age and state of well-being of the patient, the region of the body to be treated, the experience of the practitioner, and the particular issues being addressed at the time. The whole patient must be considered. The initial evaluation includes a general physical examination. If possible, the patient's structure will be evaluated in the standing and sitting position, and then lying comfortably on the back. The examination progresses from the feet to the pelvis, the sacrum, the spinal column, the breathing motion of the ribs and the diaphragm, and the head. Scars, in any location, may be of great importance. If they are surgical scars, attention is addressed to the scar tissue deep beneath the visible scars. Structural and functional abnormalities are correlated with events described in the history.

Hyaluronan Drug Admixtures for Wound Healing

HA plays an important role in tissue repair. It is known to influence a number of events critical to successful wound healing, including inflammation, cell migration, angiogenesis, re-epithelialization, and scar formation (117). Naturally occurring HA has a short residence time in tissues because of cell metabolism and hyaluron-idase activity. HA is hydrophilic and can absorb large quantities of water to maintain tissue hydration levels necessary for healing. It has been used in wound healing for the treatment of venous, mixed etiology leg ulcers, diabetic foot ulceration (118-121), postsurgical wounds (122,123), and burns (124-127).

Focal Nodular Hyperplasia and liver cell adenoma

FNH often presents as an asymptomatic mass in the liver, which can mimic a well-differentiated carcinoma. However, there is usually a very specific scar-like lesion in the center, which differentiates it on imaging from this and from liver cell adenoma and other benign lesions 59 . In children it has been associated with other disorders such a sickle cell disease, vascular malformations, and limb hyperplasia 60 . It has also been described in children who have undergone treatment for solid tumors 61 .

Mechanistic Macro Models of Arrhythmias

Atrial arrhythmias are initiated by excess cardiac sympathetic nerve activity, scars, and fibrotic areas in the atria, or excessive stretch on atrial fibers. Such pathology can cause PACs from ectopic foci, or re-entry circuits in left, or right, or both atria (the two atria are not identical in this respect). A single maintained re-entry circuit will cause a tachycardia whereas multiple re-entries gives rise to atrial fibrillation. The site of origin of some atrial arrhythmias may be where large blood vessels enter the atria. parasympathetic nerve, damaged nodes due to nodal fibrosis Excess sympathetic nervous activity, scars, and fibrosis or stretch in atrial tissue Excess sympathetic nervous activity, scars, and fibrosis or stretch in ventricular tissue

Regeneration Of Adult Tissues And Organs

Following limb amputation, the first step of repair is the formation of blood clots, which seal damaged blood vessels and prevent bleeding. The second noticeable step is the migration of epidermal cells, together with proliferation, from the remaining limb to the wound area. The newly generated epidermal cells form wound epidermis that covers the area of damage. A unique feature for the regenerative response of the salamander limb is the lack of scar formation. There are few fibroblasts and little fibrotic connective tissue in the layer of wound epidermis. Such a feature is critical to the reconstruction of the severed limb. The third step is the formation of the regeneration blastema underneath the wound epidermis. Several mesodermal cell types, including osteoblasts, chondrocytes, muscular cells, and fibroblasts, undergo dedifferentiation and regain the phenotypes of embryonic stem cells, capable of transforming to the cell types and producing extracellular matrix components...

Hypoxic Ischemic Parenchymal Necrosis

Periventricular leukomalacia, a typical white matter lesion in neonates, is situated in front of or around the anterior horns it may extend posteriorly along the ventricular walls. Grossly, the periventricular white matter is yellow, soft, and chalky (Fig. 14.3). Histologi-cally, the necrotic tissue is invaded by macrophages and, in time, is replaced by a glial scar or a small cavity. Diffuse white matter changes interfere with myelination by affecting the premyelinating oligodendrocytes.

Craniosacral Therapy in Epilepsy

Ed and one externally rotated these corrections can usually be made in one session. The parietal bones are always assessed, and some resistance also often is present in the mobility of those bones. Advanced cranial work also assesses the brain lobes. Normally, one feels a smooth alternating rhythm from side to side in corresponding lobes. Typically, the lobes cycle through this alternating movement 5 to 6 times per minute. The brain lobes often feel sluggish in patients with epilepsy. Often the temporal lobe is involved, meaning the mobility or motility of the lobes is palpably different. Sometimes the movements are out of synch or barely palpable, there may be a racheting quality, or the presence of scar tissue can be identified by very sensitive hands. The quality of this movement can greatly improve over the course of a session, or several sessions, and can hold for many days, or even weeks, depending on the individual.

Literary Analysis

In Possessing the Secret of Joy the black liberal feminist Alice Walker dramatizes how her main character, Tashi, in an act oftribal allegiance, gets facial scarring and circumcision because she recognized it as the only remaining definitive stamp of Olinka tradition. The tribe's leader, who is compared to Nelson Mandela and even Jesus Christ, has instructed the people not to neglect ancient customs. He has been imprisoned by the white regime. Walker explores the effects of FGM in a dazzling style that simultaneously seems to contrast and to transcend cultural differences. The various viewpoints are artfully integrated into dialogue and flashbacks, intermixed with myths, symbols, and psychology. Walker uses the narrative device of renaming Tashi relative to her changing cultural and psychological state of mind for example, when referring to her evolving American self she is Tashi-Evelyn. In this way, Walker conveys the essence of Tashi's journey. However, Tashi is not described...

Tissue Augmentation

Is considered an important improvement over the previously available collagenbased fillers because it does not require skin testing prior to treatment, does not require overcorrection during the injection, and, moreover, because cross-linked hyaluronan can provide a longer lasting correction (57-59). Hyaluronan gels produced for viscoaugmentation behave as inert space filling implants that do not lose volume after injection, and which induce no inflammatory response. Most importantly, they are very elastic, unlike collagen gels. This high elasticity provides reversible deformability, allowing injection through narrow gauge needles (27-30 g) and providing improved flexibility when placing the dermal filler within the superficial layers of the skin. The products are injected into dermal tissues to smooth contour defects (e.g., depressions, scars, wrinkles) by lifting the skin surface from its connective tissue base. This section will describe the use of cross-linked hyaluronan gels that...

Epidermolysis Bullosa Acquisita

Sting-Perry pemphigoid, mucous membrane pemphi-goid or linear IgA bullous dermatosis. Mechanobullous EBA presents as a non-inflammatory disease with an acral distribution and skin fragility over trauma prone surfaces. The blisters and erosions heal with scarring and milia formation (Fig. 8.2G-I). Especially the mechanobullous form of EBA often reveals itself refractory to high doses of systemic glucocorticoids combined with immunosuppressive adjuvants. Other treatment options include the use of colchicines, high dose immunoglobulins or immunoadsorption.

Viscoprotection and Wound Healing

The utilization of hyaluronan-based materials to treat skin wounds is based on principles similar to those described for the control of postsurgical adhesions. The glycosaminoglycan composition of skin undergoes an orderly series of changes during wound healing, and is particularly enriched in hyaluronan during the first several days after wounding (86-88). Early studies demonstrated that hyaluronan (Healon) at concentrations between 5 and 9 mg ml decreased subcutaneous scar formation after surgical incisions (89). Exogenously applied 1 hyaluronan solutions were found to facilitate the healing of partial thickness skin wounds in rats with alloxan-induced diabetes (90). Early studies have demonstrated that hyaluronan controls multiple activities of lymphomyeloid cells relevant to wound healing and that the effect depends on its molecular weight and concentration (74). Fetal wounds are known to exhibit scarless healing, a fact that has been attributed to the higher concentration of...

Diseases That Lead to an Increased Risk of Kidney Failure

Laura Melton came to Johns Hopkins at the age of 56. She told us that in order to lose weight, she had been taking laxatives every day for 30 years and still takes 2 to 3 pills daily. She had first exhibited urinary protein in an exam 11 years earlier. Three years before, she had 500 mg per day of urinary protein (normal urinary protein amounts to less than 150 mg per day) and a slightly elevated serum creatinine level (1.5 mg per dl normal levels in women are below 1.3 mg per dl). Urinary protein had increased to 2.56 g per day. A kidney biopsy (removal of plug of kidney tissue with a needle) 10 months earlier showed glomerulosclerosis, meaning scarring of the glomeruli. Laura had had high blood pressure for three years, which had been treated irregularly. High serum cholesterol and triglyceride levels had been noted for at least 14 years, but had been treated only irregularly. Because of intermittent potassium deficiency, she was taking a potassium chloride supplement daily, but...

Untreatable Causes of Failing Vision

Scarring of the retina following trauma is another cause of permanent and untreatable visual loss, but the most dramatic and irrevocable loss of vision occurs following traumatic section of the optic nerve. One must be careful here before dismissing the patient as untreat-able because on rare occasions a contusion injury to the eye or orbit can result in a haemorrhage into the sheath of the optic nerve. Some degree of visual recovery can sometimes occur in these patients and it has been claimed that recovery might be helped by surgically opening the nerve sheath. There is one odd exception to this dramatic form of blindness that can follow optic nerve insult visual loss due to optic neuritis. Patients with retrobulbar neuritis (optic neuritis) nearly always recover their vision again, whether or not they receive treatment. The explanation is that the visual loss is caused by pressure from oedema rather than to damage to the nerve fibres themselves. It is hardly necessary to say that...

Viscoaugmentation A Hyaluronan Gels

Tissue engineering with viscoelastic hyaluronan focused first on its use as a tissue filler or tissue augmentator (viscoaugmentation). Unlike collagen and non-biological tissue fillers, hyaluronan is an extremely elastic molecule and as such provides elasticity to the intercellular spaces into which it is injected. Hylan B gel was first used for viscoaugmentation of the vitreus after retinal detachment surgery, and later for correcting facial wrinkles and depressed scars for vocal cord augmentation in glottal insufficiency and augmentation of the connective tissue in sphincter muscles to treat urinary incontinence.

Herpes Zoster Ophthalmicus

Occurs with remarkably little scarring of the skin considering the appearance in the acute stage. However, the cornea can be rendered permanently anaesthetic and the affected area of skin produces annoying paresthesiae, amounting quite often to persistent rather severe neu-ralgia,which can dog the patient for many years. Other complications include extraocular muscle palsies or rarely, encephalitis. Iridocyclitis is fairly common and glaucoma can develop and lead to blindness if untreated. At present, there is no known effective treatment other than the use of local steroids and acyclovir for the uveitis, and acetazolamide or topical beta-blockers for the glaucoma. Administration of systemic acyclovir or famciclovir early in the disease is known to reduce the severity of the neuralgia, but these medications need to be administered as soon as possible after the onset of symptoms for best effect. The disease has to run its course and the patient, who is usually elderly, could require...

Agerelated Macular Degeneration

In the wet type of macular degeneration a fan of new vessels arises from the choroid -choroidal neovascularisation (CNV). The growth of these new vessels seems to be important because they invade the breaks in Bruch's membrane. Serous or haemorrhagic exudate tends to occur and this can be either under the RPE or subretinal (Figure 19.3). A sudden loss of central vision might be experienced as the result of such an episode. Subsequently, healing of the leaking vascular complex results in scar tissue formation, which further destroys the central vision permanently.

Types of Corneal Ulcer

After a few days, or sometimes weeks, the epithelial lesion heals and at this point, complete resolution can occur or an inflammatory reaction can appear in the stroma deep to the infected epithelium. The eye remains red and irritable to an incapacitating degree and further dendritic ulcers might subsequently appear. In worse cases, the cornea can become anaesthetic so that, although the eye might be more comfortable, the problems of a numb cornea are added to the original condition. Healing tends to occur with a vascular scar. whether or not to apply a pad to the eye depends on the state of the corneal epithelium and also on the patient's response. In the worst cases, it might be advisable to perform a tarsorrhaphy, that is to say, the lids are stitched together in such a way that they remain closed when the stitches are removed. An alternative is to induce drooping of the eyelid by an injection of botu-linum toxin into the levator muscle. Surprisingly, the keratitis seems to heal...

Allergic Conjunctivitis

Unfortunately, patients with asthma and eczema can experience recurrent itching and irritation of the conjunctiva. Although atopic conjunctivitis tends to improve over a period of many years, it might result in repeated discomfort and anxiety for the patient, especially as the cornea can become involved, showing a superficial punctate keratitis or, in the worst cases, ulcer formation and scarring.

Incidence and Causes of Blindness

In Africa and Asia, the causes of blindness are rather different many children become blind from corneal scarring associated with vitamin A deficiency and measles. Cataract is the most important cause in adults but in certain areas, for example southern Sudan, onchocerciasis and trachoma are still a serious problem.

Acquired immune deficiency syndrome dementia

Including swelling of the joints, rash or scarring lesions of the skin, and numbness, weakness, or burning sensations. The most definitive test for SLE is an assessment of antinuclear autoantibodies. Additional diagnostic tests measure the presence of antibodies directed against double-stranded DNA, or Smith antigen.

Timing Route Of Transmission And Clinical Manifestations Of Neonatal Herpes Simplex Virus

Intrauterine HSV disease occurs in approx 1 in 300,000 deliveries (1). Although rare, in utero disease is unlikely to be missed because of the degree of involvement of affected babies. Infants acquiring HSV in utero typically have a triad of clinical findings consisting of cutaneous manifestations (scarring, active lesions, hypo- and hyper-pigmentation, aplasia cutis, or an erythematous macular exanthem), ophthalmological findings (micro-opthalmia, retinal dysplasia, optic atrophy, or chorioretinitis), and neurological involvement (microcephaly, encephalomalacia, hydranencephaly, or intrac-ranial calcification) (2-5). A summary of 71 infants with intrauterine HSV infection and disease is presented in Table 1.

Substance Intoxication Delirium

The physical examination of an individual with suspected illicit drug-induced delirium may reveal sclero-sed veins, pop scars caused by subcutaneous injection of agents, pale and atrophic nasal mucosa resulting from intranasal use of cocaine, injected conjunctiva, and pupillary changes. Toxicological screens are helpful but may not be available on an emergency basis.

Diagnosing Infection By Serologic Means

Finally, serologic testing is also useful for screening children with evidence of potential congenital infection (e.g., children with mental retardation and chorioretinitis or chorioretinal scars) who test seronegative for traditional TORCH agents. In one study, lymphocytic choriomeningitis virus (LCMV) was responsible for visual loss in two of four children, secondary to chorioretinitis in a population of severely retarded children (57). The diagnosis was realized by detecting elevated levels of IgG to LCMV in these children, a finding also noted by a French study of two children with chorioretinal scars for whom LCMV was detected by ELISA and confirmed by Western immunoblotting (58).

Impaired Drainage of Tears

Lus and thence into the tear sac (Figure 5.1). The tear sac is connected directly to the naso-lacrimal duct, which opens into the inferior meatus of the nose below the inferior turbinate bone. The lacrimal puncta are easily visible to the naked eye and, in the elderly, the opening of the lower punctum can appear to project upwards like a miniature volcano. Inadequate drainage of tears can result from displacement of the punctum the lower lid in the elderly sometimes becomes turned inwards (entro-pion) because the whole tarsal plate rotates on a horizontal axis (Figure 5.2). This, in turn, is caused by slackening of the fascial attachments of the lower margin of the tarsal plate. At first, the eyelid turns in whenever the patient screws up the eyes but, eventually, the lid becomes permanently turned in so that the lashes are no longer visible externally and rub on the cornea. Such patients complain of watering, sore eyes and the matter can be corrected effectively by eyelid surgery....

Discomfort and complications of needle biopsy

In general, most subjects experience only minimal discomfort with a few seconds' sensation of pressure or pain during the procedure. The pain experienced during biopsy is greater if the fascia is caught in the needle or if a nerve is touched or damaged. The response of subjects to biopsy is, however, somewhat variable, as is their account of subsequent feelings of discomfort. Muscle function is usually little impaired, and patients need not restrict their activities after biopsy, although a sensation of muscle stiffness may persist for 48 h or more. Complications of the needle biopsy procedure are rare but include infection, haematoma and denervation (Goldberger et al. 1978 Edwards et al. 1980, 1983). In our experience with 1,200 biopsies, haematoma formation at the biopsy site occurred on three occasions, but they were all resorbed spontaneously. Until now we have experienced no case of infection at the biopsy site. All wounds healed with a minimal visible scar.

Inflammatory Phase Modulation

SCAR Maturation SCAR Maturation As the extracellular matrix forms, the peripheral keratinocytes are undergoing increased mitosis and proliferation prior to migrating across the new matrix. The HA-rich matrix supports and promotes the proliferating basal keratinocytes (95-99) and facilitates their migration again through a CD44-mediated mechanism (100). After re-epithelialization has occurred the new matrix undergoes remodeling. This remodeling process can be prolonged and the tissue is referred to as scar. In the HA-rich matrix seen in the fetal wounds, HA may reduce collagen deposition, enhance remodeling and contribute to reduced scarring (101,102).

Peroxisomal Disorders

Cerebral X-linked adrenoleukodystrophy is typified by white matter demyelination that often starts in the parieto-oc-cipital regions bilaterally and then extends across the corpus callosum (Fig. 2A,B). The disease then progresses anteriorly and laterally as a confluent lesion to involve white matter of the temporal, parietal, and frontal lobes with relative sparing of the subcortical arcuate fibers (Fig. 1 ref. 87). In the minority of cases, the disease may start frontally and then progresses posteriorly. Pathologically, the affected areas can be divided into zones (88). Zone A is a central zone of scarring consisting of gliosis as well as scattered astrocytes. It is notable for absence of oligodendroglia, axons, myelin, and inflammatory cells. The adjacent peripheral zone B shows numerous perivascular

Role of Collagenase in Wound Healing

It is reasonable to assume, based on the research partly reviewed here, that collage-nase-1 has a key role in the wound healing process. Expression of collagenase in dermal cells, consistently found in repairing skin wounds seems more logical than the finding of collagenase in epithelial cells. Tissue repair involves the turnover of dermal fibrillar collagen, a process requiring the proteolytic activity of collagenases. Increased collagenolysis is needed throughout the remodeling phase leading to the formation of a mature scar, a process requiring months. During this period, there are marked changes in collagen composition, and the amount of type III collagen. Although transiently present in elevated levels in the early wound matrix, type III collagen expression decreases, and shifts towards the formation of type I collagen and the subsequent maturation of collagen into thicker and more compact fibers. Collagenases are obvious participants in this process and collagenase-1 seems to be...

Hyaluronan and Wound Healing Hypotheses

Whatever the case, a mechanism must be proposed where HA has a definite role in harnessing and manipulating the natural reparative capacity of tissue fibroblasts. This raises the question whether HA alone has the capacity to control events of such complexity as wound healing and scar maturation contain hydroxyproline. In the early stages of repair, when HA levels are high, cell migration plays a prominent role in restoring cellular continuity (22). Later, when HA concentrations fall and sulfated GAG concentrations are high, cell differentiation, collagen production, and tissue organization occur (23,24). The high molecular weight HA seems to inhibit the formation of capillaries (25) while angiogenesis is induced by degradation products of HA (26). Weigel et al. (27), have proposed a model for the role of HA in wound healing in which a HA-fibrin matrix forms which attracts inflammatory cells into the wound. This matrix is in turn modified by the cells entering the wound as they secrete...

And Techniques

Most closed heart surgery is performed through a lateral thoracotomy in the third or fourth intercostal space without rib resection. This includes isolated Blalock shunt and pulmonary artery banding operations. In this day of multiple mediastinal operations for staged repairs, it is not wise to add to mediastinal scarring with an initial simple palliative operation that can effectively be performed through a thoracotomy.


The understanding of cancer in adolescents is perpetually unfinished the final answers not yet known, if they ever will be. The age-old questions of etiology are still the same today as they have been for millennia. The challenge remains to use today's technology to better understand the exact causes responsible for the development of cancer in the young, which has perplexed those who have come before us, and prevent the disease in those who are yet to come. Until methods for etiology-derived prevention of cancer becomes available, efforts need to be continued to use the latest available tools for early diagnosis and therapy, and to reduce the visible and invisible scars of the disease and its treatment 18, 80 .

Perioperative Pain

Some nerve endings are spared, and pain can still be generated (72). Other pain generators include nerve regeneration with associated paresthesia and neuroma formation and nerve entrapment by scar or contractures. The phenomenon of hyperalgesia associated with partial full-thickness thermal injury is characterized by a decrease in the pain threshold and the development of spontaneous pain. This is likely to be mediated by increased sensitization of the A-5 fiber afferents at the site of burn injury (73).

The Globe

The slit-lamp is sometimes called the biomicroscope. By means of such optical aids, the cornea must be carefully inspected for scars or foreign bodies. The presence of vascular congestion around the corneal margin might be of significance. Closer inspection of the iris might show that it is atrophic or fixed by adhesions. Turbidity or cells in the aqueous might be seen in the beam of the inspection light. The lens and anterior parts of the vitreous can be examined by the same means.

Vesicouretic reflux

Led to scarring - no obvious increase in the urinary markers has been shown 23 . It is thought that most of the scarring as a result of reflux occurs in the first 2 years of life and new scarring is unusual after 5 years of age. These statistics clearly identify the need for a marker to detect the early effects of reflux. Renal scarring occurs predominantly when the reflux has ascended well up into the nephrons and the ensuing inflammation affects both glomerular and tubular function. Thus, the diagnostic inaccuracies of previously studied markers are attributable to the fact that these tests predominantly reflect proximal tubular damage. The need exists for a marker to detect the effect of reflux on the collecting duct (or, less satisfactorily, the distal tubule). From a clinical standpoint, the ideal situation would be that the paediatrician is able to screen for the effects of reflux early in life. This will enable appropriate prophylactic action to be taken to reduce the...


This commonly seen outward turning of the lower eyelid in the elderly is eminently treatable and responds well to minor surgery. Senile ectropion can begin with slight separation of the lower eyelid from the globe, and the malposition of the punctum leads to overflow of tears and conjunctival infection. Irritation of the skin by the tears and rubbing of the eyes lead to skin contracture and further downward pulling of the eyelids. Like entropion, ectropion can be cicatricial and result from scarring of the skin of the eyelids. It can also follow a seventh cranial nerve palsy caused by complete inaction of the orbicularis muscle this is called paralytic ectropion.

Medical Evidence

On average, 40 of complainants of sexual assaults will have no general injuries (37-41). Of those who are injured, most will have only minor injuries, which will fade rapidly or heal without a trace (37,38). Nonetheless, the whole body must be thoroughly inspected for stains (e.g., dirt and blood), injuries (including signs of substance use), skin disease, and scars (including self-inflicted injuries). All injuries must be described using the recognized nomenclature described in Chapter 4 and recorded in terms of site (measured, if possible, from a fixed bony point), two-dimensional size, covering surface (e.g., scabbing, bleeding, or swelling), and color. The body surfaces should then be palpated and a note made of the site and approximate size of any tender areas. More credence will be given to a finding of


Although a doctor practicing in the UK might rarely see a case of trachoma, and even then only in immigrants, it is the commonest cause of blindness in the world and, furthermore, the disease affects about 15 of the world's population. It is spread by direct contact and perpetuated by poverty and unhygienic conditions. Trachoma is caused by C. trachomatis serotypes A, B and C and affects underprivileged populations living in conditions of poor hygiene. The disease begins with conjunctivitis, which, instead of resolving, becomes persistent, especially under the upper lid where scarring and distortion of the lid can result. The inflammatory reaction spreads to infiltrate the cornea from above and ultimately the cornea itself can become scarred and opaque (Figure 6.3). At one time, trachoma was common in the UK, especially after the Napoleonic wars at the end of the eighteenth century. It had been eliminated by improved hygienic conditions long before the introduction of antibiotics.

Corneal Foreign Body

Dence of this occurrence on windy, dry days. Small foreign bodies also become embedded as the result of using high-speed grinding tools without adequate protection of the eyes. The dentist's drill can also be a source of foreign bodies, but the most troublesome are those particles that have been heated by grinding or chiselling. It is important to have some understanding of the anatomy of the cornea if one is attempting to remove a corneal foreign body. One must realise, for example, that the surface epithelium can be stripped off from the underlying layer and can regrow and fill raw areas with extreme rapidity. Under suitable conditions the whole surface epithelium can reform in about 48 h. The layer underlying, or posterior, to the surface epithelium is known as Bowman's membrane and if this layer is damaged by the injury or cut into unnecessarily by overzealous use of surgical instruments, a permanent scar might be left in the cornea. When the epithelium alone is involved, there is...


There are one or two factors that should always be borne in mind when treating patients with corneal foreign bodies in most instances, healing takes place without any problem but, rarely, the vision can be permanently impaired by scarring. Also, on rare occasions, the site of corneal damage becomes infected and if Figure 6.10. Beware of the full-thickeness corneal scar,when in doubt do an X-ray. Q3 Figure 6.10. Beware of the full-thickeness corneal scar,when in doubt do an X-ray. Q3

Bullous Pemphigoid

Bullous pemphigoid is an acquired blistering disease of the elderly, usually over the age of 60. Multiple medications have been reported to induce bullous pemphigoid, however, only furosemide has been convincingly implicated. Tense bullae form on flexor arms and legs, abdomen, and groin that heal without scarring. In urticarial BP, there are erythe-matous edematous plaques without overt blisters that resemble urticaria and sometimes eczema (Fig. 3A).

Clinical Aspects

The term myofascial pain syndrome appears to engender some confusion. Simons (29) notes that the term (MPS) has been used specifically with regard to a pain syndrome that is induced by TrPs found in the belly of a muscle, specifically not scar, ligamentous, or periosteal TrPs. The term has also been used generally to indicate many conditions that induce muscle pain without reference to and even in the absence of TrPs, making MPS an ambiguous identifier. He suggests the use of the term myofascial pain syndrome due to TrPs to be more specific, and the term regional muscle pain syndrome to be used as the more general term. It is thought that this is certainly correct one of the major difficulties with the entire concept of MPS has been the lack of specifics relating to the diagnosis and the basic terminology of the disorder. It was the Wolfe group (30) who in 1990 developed specific criteria for the diagnosis of fibromyalgia (see Chapter 8). This has yet to be accomplished for MPS with...

Other Injuries

The other anal injuries that have been described in complainants of anal penetration are bruises (2-4 ), abrasions (4-5 ), erythema (2-8 ), and swelling edema (2-6 ) (90,134). Slaughter et al. (90) described a high number of rectal injuries, in addition to the lacerations described (ecchymosis, n 1 abrasions, n 2 redness, n 1 and swelling, n 6) that were detectable among eight sexual assaults complainants who described anal contact (90). Although bruises are indicative of blunt trauma, the other findings may have innocent explanations, for example, a superficial abrasion of the anal verge has been identified on a child who interrupted the medical to pass a motion (observation of D. Rogers). Although erythema and swelling edema are also nonspecific findings, if they have completely resolved at a follow-up examination, it may be possible to relate them to the allegation. All these minor injuries would be expected to heal within 2 weeks of the incident without any residual scarring.

Case Histories

During birth, Jane had a small hemorrhage into the part of the brain that controls the right side of her body. This left a scar that later became a small cyst. At age 14, she began to experience episodes of a warm feeling in her right hand. Several years later, while taking important school examinations, the warm feeling was followed by uncontrollable jerking and twitching of her right thumb and then her hand.


Such betrayal is among the deepest wounds that can be endured. Because the therapist-client relationship replicates many essential elements of the parent-child relationship, it has great potential for both harm and healing. We hope that our discussion of the origins and treatment of interpersonal trauma provides a clear conceptual system to aid those who have taken on the noble task of helping to heal the emotional scars of clients who were violated as children.

Repair of Shunts

The proximal left subclavian artery trunk is isolated at its origin from the left-sided innominate artery. The dissection is performed high in the mediastinum above the innominate vein. Dissection here is safer because one avoids scar tissue, which may develop at the site of the subclavian artery to pulmonary artery anastomosis. An alternative exposure of this shunt is by dissection of the left pulmonary artery, starting within the pericardial space, until the region of the shunt anastomosis is seen. Figure 9-53. The proximal left subclavian artery trunk is isolated at its origin from the left-sided innominate artery. The dissection is performed high in the mediastinum above the innominate vein. Dissection here is safer because one avoids scar tissue, which may develop at the site of the subclavian artery to pulmonary artery anastomosis. An alternative exposure of this shunt is by dissection of the left pulmonary artery, starting within the pericardial space, until the...

Alopecia Areata

Many diseases of hair follicles result in alopecia, which is simply defined as any type of hair loss. The alopecias are conventionally grouped into nonscarring and scarring categories. Nonscarring alopecias may be localized or diffuse. Since the follicles are not destroyed in the nonscarring alopecias, there is potential for regrowth or return to normal hair density in these conditions. Follicular diseases that result in follicular destruction and permanent hair loss are termed scarring alopecias. There is some confusion in this categorization scheme because some of the nonscarring alopecias can eventuate over many years into areas of permanent alopecia through follicular drop-out.

Treatment of CN

The most common ocular changes that lead to nystagmus are lens opacities, macular scars (e.g., toxoplasmosis), retinopathy of prematurity, optic nerve hypoplasia, and macular hypoplasia. Macular hypoplasia is recognized by an absence of the ring and central reflexes of the inner retinal surface, as seen during ophthalmoscopy. There is also absence of an identifiable foveola. Macular hypoplasia is associated most commonly with albinism, rod monochro-macy, and aniridia. In the X-linked hereditary incomplete form of congenital stationary night blindness, it is primar-


Vascular dementia is caused by varying combinations of vascular insults to the brain, including arterial territory infarcts, distal field (watershed borderzone) infarcts, small and medium-sized lesions mainly in functionally important brain areas, lacunar infarcts and scars, white matter lesions, incomplete ischemic injury, hippocampal lesions, and sclerosis (Jellinger 2005). Several subtypes of vascular dementia have been described, based on either the number and distribution of lesions or the size of vessels involved (large vs. small vessels). An emerging consensus suggests that the subcortical pattern of damage is sufficiently homogeneous in terms of clinical, radiographic, and pathophysiological features to constitute a meaningful subtype, particularly with respect to treatment trials. Generalized arteriosclerosis secondary to hypertension, cerebral atherosclerosis, and diabetes usually are cited as the most common causes of thrombotic infarction, and cardiac disease and carotid...

Wound Healing

Following injury, the skin has a tremendous capacity to heal. When the injury involves disruption of the dermis, post-natal wounds heal with a macrophage-effected (8,9) fibro-proliferative repair process which results in the laying down of a new collagen-rich dermal matrix over which epidermal continuity can be reestablished. This process of repair and the subsequent reorganization of the dermal matrix results in scar formation. A scar is produced as the result of a reorganization of mesenchymal tissue produced in response to the healing of a wound. A wound is the discontinuity in tissue integrity. Such a discontinuity may be physical, as in a surgical incision, or functional, as in a dermal burn. A complex pathophysiological response results in a cascade of cell-matrix interactions that comprise the biological concept of wound healing. Such healing, as occurs in the post-natal human occurs by two major processes regeneration and repair (Fig. 1). Regeneration is illustrated by the...

Perfect Skin

This, then is an introduction to a chapter which is going to explore the current views on the role of hyaluronic acid in wound healing and scarring (the intrinsic role) and then look at medical developments of hyaluronic acid that have been used or are proposed to either reduce or eliminate scar development in healing wounds or to reduce the degree of matrix disorganization, a key attribute of scar tissue, in the established scar (the extrinsic role).


Atherosclerosis refers to the underlying progression in arterial dysfunction and remodeling that restricts blood flow to vessels in the peripheral vasculature.1 Taken from the Greek, athero (gruel or paste) and sclerosis (hardness), atherosclerosis describes the buildup of lipid-laden fatty deposits within the vessel wall that is often called atheroma or atherosclerotic plaques. As illustrated in Figure 1, temporal morphological changes accompany the progression of disease. In its early stages, atherosclerosis causes significant changes to the vessel wall with the accumulation of cholesterol and scar tissue. The lesion is preceded by a fatty streak in the intima below the endothelium, composed of lipid-enriched macrophages and T cells. These fatty streaks are usually symptomatically silent, are frequently observed in teenagers and young adults, and may either disappear or progress to more advanced disease. As the lesion develops, it is enriched in cholesterol-laden foam cells, becomes...


In children, the disease is often mild, unless they are immunocompro-mised, so they are unlikely to experience complications. In adults (defined as 15 yr or older), the picture is rather different (32). Secondary bacterial infection is common but rarely serious. There is an increased likelihood of permanent scarring. Hemorrhagic chicken pox typically occurs on the second or third day of the rash. Usually, this is limited to bleeding into the skin, but life-threatening melena, epistaxis, or hematuria can occur.

Animal Studies

Histochemical studies show that HA is a normal constituent of middle ear tissues although the functional significance of the occurrence of HA in the middle ear is still a matter of debate. Most probably it is the physico-chemical property of the molecule acting as a stress-absorber that results in its presence in the normal ear. The application in the abnormal ear has been proposed and experimentally evaluated in chronic tympanic membrane perforations. Topically applied HA applied to experimental tympanic membrane perforations not only accelerated the healing process but also reduced scar tissue in the healed tympanic membrane. Further studies have been performed with pieces of sponge manufactured from HYAFF7, the 100 ethyl ester of HA. Pieces of HYAFF7 sponges were placed into middle ear cavities and compared to cavities similarly treated with Gelfoam a gelatin sponge. When followed sequentially over 6 months the HYAFF7 sponges slowly degraded leaving cavities that were clean and...


In congenital syphilis, other possible features occur such as deafness and corneal scarring from previous interstitial keratitis. The scattered pigmentation in the fundus might suggest an inherited retinal degeneration but a careful family history together with electrodiagnostic testing of the eyes usually enables one to distinguish the two conditions. It is also important to


Dextran appeared to have beneficial activities in the treatment of wounds. To reduce its solubility, an emulsion polymerization of dextran using epichlorohy-drin as the cross-linking agent was carried out, which produced insoluble beads that swell in water. Dextranomer (Pharmacia, Inc., Piscataway, NJ) is such a dressing with polysaccharide beads, 0.1-0.3 mm in diameter. It is highly hygroscopic and 1 g can absorb 4 ml of water and swell until it is saturated. It has been shown that bacteria and cellular debris present in the wound are taken up by capillary action and become trapped in the spaces between the beads. When the dressing is changed, this debris will be washed away (13). Dextran accelerates the polymerization of fibrin and also influences the structure of the fibrin clot with the diameter of the fibrin fibers being broader when dextran is present (14). Dextran derivatives that mimic the action of heparin have been shown to protect heparin-binding growth factors associated...


Stipulated that the effect could be explained by several biological effects of the crowded molecular network of high average molecular weight hyaluronan. First, the migration of cells of the lymphomyeloid system is inhibited by such hyaluronan solutions (81). Second, the diffusion of fibrinogen, present in the postinjury exudate, is inhibited by the barrier of the hyaluronan molecular network (80). Third, as reported by several authors (81-83), the fibrin clot formation is delayed or inhibited by hyaluronan. Thus, the objective of the use of hyaluronan pastes or gels between wounded connective tissue surfaces is to prevent the formation of fibrin coagulum that would form a solid intercellular matrix connecting the healing tissue surfaces and provide scaffolding for invasion of cells, leading to the formation of collagen fibers that would permanently connect the two surfaces and form adhesions and excessive scars. The experimental studies extended to more complicated adhesion models...

Topical Heparin

Using a 5- or 10-cc syringe and a 30-gauge needle. Applications will be repeated every 5 min for 25-30 min. Following this initial treatment, the application is repeated two to three times a day using diminishing doses and duration of application until healing occurs. An alternative approach to the topical application when there are blisters present is to aspirate the blister fluid and inject heparin solution into the blister cavity. In Saliba's review, he reports that the topical application of heparin to burn wounds leads to a rapid relief from pain, rapid healing, and decreased scarring. The clinical results have been reported in meetings and meeting proceedings but there is a paucity of evidence in peer-reviewed journals. There are many published reports looking at the beneficial effects of systemic hep-arin administration in a wide range of conditions including burns. In addition, there are a large number of laboratory-based studies looking at the interaction between heparin...


Pathology After a typical 14-day incubation, smallpox causes high fever, malaise, prostration, headache, backache, myalgias, cramping abdominal pain, delirium, and a characteristic centrifugal rash with the synchronous appearance and resolution of initial red macules, then vesicles, pustules, ulcers, crusts, and pitted scars, most prominent on the face and extremities. CFR 30 . Differential diagnosis Chickenpox has a characteristic centripetal rash with asynchronously developing and resolving red macules, vesicles, pustules, ulcers, crusts, scabs, and shallow scars, most marked on the neck and trunk. Diagnosis Viral culture, antigen detection by ELISA and PCR.


The implantation of hyaluronic acid jellies, sheets, and membranes is a type of matrix engineering. Hyaluronic acid influences the invasion and activities of cells participating in the acute and chronic inflammatory process. It is proposed that implantation of hyaluronic acid should be used to prevent fibrous tissue formation and consequent development of adhesion and scars. With these words, viscose-paration with hyaluronan was introduced into therapeutics (72). Highly elastovis-cous hyaluronan solutions (called jellies at the time) regulated the mitogen-induced stimulation of peripheral blood lymphocytes (74). In dogs and owl monkeys, hyaluronan jellies significantly improved the healing of intra-articular wounds. In rabbits, hyaluronan reduced adhesion formation around tendons after injuries. Granulation tissue formation and development of scar tissues and adhesion were prevented when hyaluronan was introduced into the wound after injury or around implanted foreign bodies (8)....

Matrix Engineering

New hyaluronan derivatives are being continually developed because of their potential commercial and medical value. Consequently, our understanding continues to expand with respect to the ways in which different chemical modifications of hyaluronan can affect its physical and biological properties (102). Thiol-modified derivatives of hyaluronan-containing chondroitin sulfate, heparin, peptides, and protein have recently been tested for scar-free healing and adhesion prevention. Copolymers of hyaluronan and other glycosaminoglycans have been produced using multiple derivatization methods, and recently reported data suggest profound effects on the healing of skin wounds, abdominal and tendon injuries, and defects of soft tissues and cartilage (103). Both the chemical composition and the physical structure of hyaluronan-based materials can influence the signaling activity and expression of cells embedded in them (104). Promising animal data has been reported (105), but remains to be...

Craniosacral Therapy

Other common reasons for the inhibition of proper functioning of the cran-iosacral system are scarring or adhesions, inflammation, and vascular accidents. Any abnormalities in the structure or function of the nervous system, the musculoskeletal system, endocrine, or respiratory system may alter functioning in the craniosacral system. Conversely, an imbalance in the craniosacral system can impair normal functioning in these physiologic systems.

External Genitalia

For penile penetration of the vagina to occur, the penis must first pass between the labia minora and through the hymenal opening. The apposition of the penis and the posterior fourchette in the majority of sexual positions means that this area may be stretched, rubbed, or receive blunt trauma as vaginal penetration is achieved. Lacerations, abrasions, or bruises at the posterior fourchette have all been described after consensual sexual activity, although in all these cases, the examinations were enhanced by the use of toluidine blue or a colposcope (90,128,129). Wilson (131) has also described macroscopi-cally visible hematomata of the labia with consensual sexual activity. These injuries usually heal completely without residual scarring (90). Healing of lacerations of the posterior fourchette is predominantly by first intention, with no residual scarring being detected at follow-up assessments (90). Nonetheless, scarring may occur occasionally in these areas, but it is important...

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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