Alexander Uribe MD, FACS

• Associate Professor of Surgery, Jefferson Medical College, Philadelphia,
• Pennsylvania
• Attending Surgeon, Lankenau Hospital, Wynnewood, Pennsylvania

The division of the face into cosmetic zones is based on visible topographic boundaries and skin thickness hypertension 90 purchase diovan. Documentation of grading of skin changes blood pressure 3060 purchase diovan 160mg with mastercard, informed discussion arrhythmia band chattanooga cheapest diovan, and the treatment plan prehypertension systolic discount diovan line. The depth and effectiveness of resurfacing can be varied by changing the number of passes or the tissue irradiance heart attack vs angina buy diovan with a mastercard, or both blood pressure for men buy generic diovan 80 mg online. The laser tip is held perpendicular to the plane of the target skin to ensure uniform energy delivery and minimize skew. With focal laser handpieces, the laser must be held at the exact focal length to ensure correct and uniform irradiance. The handpiece is held motionless during the delivery to prevent overlapping and underlapping. The laser is then moved to a directly adjacent tissue area and the treatment repeated until the entire cosmetic zone has been treated. The forehead and glabella are a single cosmetic unit characterized by thick sebaceous skin. Resurfacing is generally heavier and more forgiving than in any other area of the face. Even with heavy resurfacing, forehead and glabellar rhytids often persist because of the unabated underlying frontalis and corrugator muscle activity. Scarring may develop if this extremely thin skin is treated like thicker facial skin. The medial third of the pretarsal and preseptal eyelid skin is prone to scarring and should be treated cautiously. The pretarsal skin should be left untreated in patients with significant lid laxity and risk of ectropion. The upper eyelid is treated like the lower eyelid with one pass or at most two low-density passes, placed superior to the upper eyelid crease. A specialized laser eyelid clamp bar (Khan-Baker Laser Eyelid Clamp, Storz Instrument Co. The lateral chin and cheek skin overlying the mandible is prone to scarring, heals slowly, and frequently provokes pruritus postoperatively. The nasolabial folds and marionette lines respond incompletely to even heavy laser resurfacing. These areas are generally treated with three passes and are not prone to scarring. Some upper lip rhytids are quite deep and impossible to remove completely without creating scarring. Treatment should extend barely across the vermilion border to avoid a demarcation line. With experience, more passes may be delivered to specific lip rhytids in patients at low risk for scarring. A nice benefit of resurfacing of the upper lip and chin area is a slight lip eversion and increased vermilion show. Concerns have been published regarding the tremendous propensity of the thin neck skin to scar. If active acne is present, resurfacing should be delayed to avoid further scarring due to reactivation of acne during the healing phase. Acne patients who have used Isotretinoin within the past 3 years or had facial X-ray irradiation may have impaired epithelialization or abnormal and unpredictable scarring. Elevated scars should be shaved until flush with the surrounding tissues, and then the scar and surrounding tissues are resurfaced in order to blend together after reepithelialization. Thin flat scars may be treated with a simple resurfacing in order to blend with surrounding areas. Widened scars may respond to laser excision followed by reapproximation of the wound edge. Trap-door deformities or tissue elevations often seen adjacent to scar edges may be flattened by resurfacing and shrinking the elevated areas. Some areas distended by chronic edema, including malar bags will respond well because the laser reverses the chronic collagen laxity. Depressed scars may be debulked using pinpoint pulsed laser vaporization techniques. In: Proceedings of the 27th Annual Symposium of the American Society of Ophthalmic and Plastic Reconstructive Surgery, Chicago. Such lesions are usually vaporized using a 3-mm-diameter single-spot pulsed laser technique. A color change from yellow-white to reddish brown indicates that the lesion has been completely vaporized, usually to the level of the orbicularis muscle. For unknown reasons (possibly related to the laxity of adjacent skin and extremely thin dermis) these deep laser wounds typically heal well without scarring. Titanium laser eye shield with unique antirotational posts and eyelash traction bar. Retreatments are generally lighter than the original treatment because part of the dermis has already been ablated. Although occlusive dressings are believed to accelerate wound healing and reduce immediate postoperative discomfort, the author advises against postoperative dressings because of the risk of infection and toxic shock. Patients are instructed not to pick at crusts because they may incite bleeding or scarring. Gauze sponges soaked in white vinegar and ice water, mixed as 1 tablespoon of white vinegar to 1 pint of chilled distilled water, are applied three times daily for a soothing antipruritic effect and for antibacterial activity. Topical antibiotics or other sensitizing topical agents should be avoided because 65% of patients develop contact dermatitis. Pretreatment oral antibiotics should provide adequate gram-positive coverage and prevent frank erysipelas or cellulitis. Acne or milia may present around the time of epithelialization or thereafter and are associated with topical white petrolatum application. Milia frequently follow laser resurfacing and appear clinically as a painless crop of small, white, dome-shaped elevations. These epidermal cysts probably result from occlusion of eccrine duct openings, which may explain why they are more common in patients who apply topical petrolatum-based products. Herpetic infections should be treated by increasing the Acyclovir, Valacyclovir, or Famciclovir dose to the levels used to treat herpes zoster, possibly including intravenous therapy. The lesions associated with laser resurfacing may appear atypical as a crop of small, raw, red lesions (more raw-looking than the surrounding resurfaced skin) clustered as a small grouping. There may not be a characteristic vesicular stage if the epidermis has not yet regenerated. These erosion-like lesions may progress to typical discrete white punctate lesions, and more lesions may appear if the outbreak is left unchecked. Candida may superficially colonize the moist skin surface, usually before reepithelialization. Some surgeons in humid locales routinely treat all patients prophylactically with a single oral dose of Fluconazole (Diflucan) 200 mg orally before resurfacing. However, the author has not found this necessary and avoids routine prophylaxis because of the significant drug interactions associated with Fluconazole, a fungal cytochrome P-450 inhibitor. Hyperpigmentation usually results from increased epidermal melanin as well as the accumulation of melanin in subepidermal macrophages. Itching is usually most intense along the mandibular border or pretrichial forehead. Patients may evidence telltale petechiae or excoriations and be unaware that they scratch and abrade this area while asleep. Treatment includes mild antiinflammatory steroids, ice packs or cool soaks, and an oral antihistamine such as oral Diphenhydramine (Benadryl) 50 mg taken before going to sleep. For the anxious or apprehensive patient in whom pruritus interferes with sleep, Doxepin hydrochloride (Sinequan capsules) 25 mg taken orally at bedtime should induce drowsiness, reduce anxiety, and diminish itching. Once reepithelialization is complete, the intense erythema may be disguised with a concealer consisting of a dense yellow or green base covered by a flesh tone. Concealer may be purchased from department store cosmetic counters or prepared for the patient during consultation with a makeup artist, skilled beautician, cosmetic consultant, or aesthetician. Although prolonged erythema beyond 3 months is occasionally noted in extremely fair individuals with clear skin, it eventually resolves in most instances. There are anecdotal reports of using the pulsed dye laser with a 1-mm spot size to treat persistent erythema. It is more common in patients who have received prior dermabrasion or deep chemical peeling. Application of a silicone gel or sheeting, alone or in combination, or Cordran tape, may also be helpful. When hypertrophic scarring is minimal to moderate and still vascular, it may respond to 585-nm pulsed dye laser treatment. True keloid formation may respond to intralesional steroids plus 585-nm pulsed dye laser irradiation. Gonzalez-Ulloa M, Castillo A, Stevens E, et al: Preliminary study of the total restoration of the facial skin. Ben-Bassat M, Ben-Bassat J, Kaplan I: An ultrastructural study of the cut edges of skin and mucous membrane specimens excised by carbon dioxide laser. Scarborough D, Bisaccia B, Schuen W, Swensen R: Anesthesia for the dermatological surgeon. American National Standards Institute: American National Standards for the safe use of lasers in health care facilities. While nasolacrimal duct obstruction should certainly be considered, it is essential to approach each patient with tearing with a comprehensive approach that considers each component along the path from tear production through tear drainage. This is essential, as normal tear production and drainage relies on a complex interplay of multiple ocular adnexal structures. Few data exist regarding the incidence and causes of acquired tearing or the percentage of patients with tearing who seek medical attention. Part of the difficulty in studying the epidemiology of the tearing patient resides in the difficulty in defining the problem. Patients who report tearing may mean different things: that they are wiping tears from their eyelids, that their eyes feel wet, and/or that their vision is blurred as if looking through water. Objectively, patients may have clear evidence of increased tear volume on the eye surface that may or may not visibly spill onto the cheek, and may be found to be holding a tissue in their hand as they enter the examination room. It is important to realize, however, that the tear volume may appear normal or low in the tearing patient. Such findings should not cause a symptom of tearing to be dismissed by the examiner. Finally, difficulty in studying tearing also lies in the fact that no standardized objectives or measurement tools exist to study tearing. Tearing occurs when relatively more tears are produced than can be drained through the normal outflow pathway. The result is an increased tear volume and, in some patients, epiphora, or spilling of the tears onto the cheek. Insufficient outflow in the setting of a normal tear production rate can also result in tearing. Abnormalities in this category may include lid malposition or atony, punctual stenosis or malposition, canalicular stenosis, and nasolacrimal duct obstruction. As with all chief complaints, details of the quality, quantity, aggravating and alleviating factors, and associated symptoms should be ascertained. Ascertaining whether the problem is unilateral or bilateral and under what conditions the tearing occurs or worsens may provide insight into the cause. Although there are exceptions, unilateral, constant tearing suggests insufficient lacrimal outflow, while intermittent bilateral tearing that is worse in cold or wind suggests tear film instability and/or aqueous deficiency with secondary reflex tearing. A history of tearing since childhood raises the possibility of untreated congenital nasolacrimal duct obstruction. A history of seasonal allergies is often present in this situation, but environmental exposures should also be considered. It should be noted that allergic rhinitis can also result in epiphora, presumably due to obstruction of the outflow pathway resulting from edema of the nasal mucosa. Patients with dacryolithiasis tend to be younger than those with primary acquired nasolacrimal duct stenosis and usually have intermittent rather than constant tearing. Pain within the eye itself can cause tearing, so trichiasis, corneal abrasions or foreign bodies, and intraocular inflammation must always be considered. While careful attention must be given to this possibility, investigation may not result in an identifiable cause. The patient should be asked about systemic diseases, particularly immunologic disorders including arthritis and thyroid disease, which may be associated with corneal problems that are manifested by tearing such as dry-eye syndrome, lagophthalmos, and superior limbic keratitis. Systemic inflammatory disorders such as sarcoid, Wegeners and certain neoplasms such as lymphoma can involve lacrimal drainage system and result in epiphora. In most cases the systemic lymphoproliferative disorder will be known about prior to developing epiphora due to infiltration of the lacrimal drainage pathways. A history of systemic malignancies should also be documented, as certain chemotherapeutic agents may impede lacrimal drainage outflow (see further ahead).

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Gnepp and colleagues have recently reported a rate of 21% for a series of 25 cases involving the paranasal sinuses arrhythmia svt purchase cheap diovan on-line, nasopharynx heart attack sam tsui chrissy costanza buy diovan 40mg otc, and orbit hypertension over 55 order diovan 80mg free shipping,61 which is much lower than the rates for lesions of the neck or other extraabdominal sites arrhythmia headaches cheap 40mg diovan with amex. Radiation and chemotherapy are reserved for tumors that cannot be excised completely blood pressure chart new discount diovan master card. Probably the most frequent setting is after radiation therapy for another orbital condition hypertension guideline update jnc 8 purchase diovan line, particularly in the setting of inherited retinoblastoma. The tumor may also arise in an adjacent sinus and become a secondary invader of the orbit. The spindle cells and the relative abundance of collagen help to distinguish this lesion from a rhabdomyosarcoma, which is sparsely endowed with collagen. Occasionally there may be a lobular pattern resembling that of a vascular leiomyoma. There is scanty cytoplasm, and the nuclei of the tumor cells are tapered, which helps to distinguish them from the blunter or rounded nuclear ends of smooth muscle proliferations. There is little nuclear pleomorphism unless the tumor has arisen as a result of prior radiotherapy. Fibrosarcomas are positive for vimentin and focally for smooth muscle actin, demonstrating its myofibroblastic differentiation. Results of electron microscopy fibrosarcoma56,59 are similar to that seen in fibromatosis, with a prominent rough-surfaced endoplasmic reticulum and myofilaments or intercellular junctions (see Table 242. In older series tumor size and depth were prognostic features and recurrence rates were high with incomplete resection. Wide local excision62a and even exenteration may be required during the first excision of a fibrosarcoma of the orbit, although exenteration is usually resorted to after the first recurrence, since the tumor is capable of hematogenous dissemination. Metasteses to the lungs and bone are possible, less often to regional lymph nodes. Postoperative adjunctive radiotherapy (in doses of 5000-6000 cGy with as much shielding of the globe as possible) and chemotherapy may be indicated. Although it has been speculated that prenatal orbital penetration might be a possible cause with associated inflammation, a partial clefting syndrome is also possible. In the series of four cases reported by Hertle and associates,66 there were histories of perinatal periorbital swelling along with ecchmyosis; it could not be adequately concluded whether these findings represented perinatal trauma or a prenatal inflammatory episode persisting until birth. The globe is frequently elevated vertically, and in contradistinction to thyroid ophthalmopathy, which is rarely if ever observed at birth, the thickening of the muscles from the fibrosis also extends to the tendons. Once thought to be a rare mesothelial or submesothelial neoplasm of the pleura and pericardium, it is now known to occur at almost every anatomical site71 with a prediliction occurring often in somatic soft tissue, and is thought to have a mesenchymal (possibly fibroblastic) origin. In fact, hemangiopericytoma is no longer considered a specific entity, but rather as a growth pattern which may be seen in many different types of neoplasms. With the reclassification of tumors with hemangiopericytelike features to solitary fibrous tumor, there has been substantial improvement in the recognition, subclassification and prognostic assessment of these lesions. Solitary fibrous tumors were once thought to be an extremely rare finding in the orbit. There are now over 50 cases reported in the literature,67 the largest series of which included six patients. The usual clinical presentation is one of slow onset of unilateral proptosis,72 and/or visual loss, although other complaints include eyelid swelling, blepharoptosis, and a palpable eyelid mass. The tumor has a predilection for the intraconal space; however, there are case reports of a solitary fibrous tumor arising in the caruncle,72a in the lacrimal gland72b and in the lacrimal sac. Although in the retroperitoneum these tumors may reach a large size (>100 mm), tumors in the orbit tend to be discovered earlier because of readily noticeable symptoms, and therefore tend to be much smaller. There may be pressure-induced remodeling of bone, but frank bony destruction is not a feature of solitary fibrous tumors. The differential diagnosis of solitary fibrous tumor of the orbit, based on the clinical signs and radiological features, includes schwannoma, cavernous hemangioma, fibrous histiocytoma, lymphoma, venous malformation, and metastatic disease. Because the signs and symptoms are so nonspecific, diagnosis can only be made by immunohistological examination. Microscopically, solitary fibrous tumors demonstrate a wide range of morphological features, from predominantly fibrous lesions containing large collagenized areas, to more cellular variants. The hypercellular areas are composed of round-to-spindle cells and may take on a fascicular, storiform or fibrosarcomatous pattern. The tumor cells contain uniform nuclei containing finely dispersed chromatin and inconspicuous nucleoli. Myxiod change, foci of chronic inflammation and interstitial mast cells are frequently seen. The more common fibrous variant tends to have many medium-sized vessels with thick hyalinized walls. Markers for epithelial and neural differentiation are negative,67 distinguishing these lesions from meningioma and schwannoma. Electron microscopy shows poorly differentiated fibroblast-like cells with vesicular nuclei, suggestive of fibroblast differentiation. Fat-forming solitary fibrous tumors (formerly known as lipomatous hemangiopericytomas) resemble the cellular variant, but are distinguished by a variable number of mature, nonatypical adipocytes. This variant is more prevalent in males, and behaves in an indolent manner in most cases. It has subsequently been described in a wide variety of extraorbital locations as well. The giant cells are typically of the multinucleated type, with the nuclei arranged in a floret pattern along the periphery of the cytoplasm. When it occurs in the periocular region, giant cell-rich variant of solitarty fibrous tumor has a distinct predilection for the eyelid, presenting either with eyelid swelling or palpable mass; orbital cases typically arise close to the eyelid and lacrimal gland,75 where it may cause proptosis or diplopia. This tumor is a relatively indolent lesion, although it may recur within the orbit after incomplete surgical excision. The differential diagnosis of the giant cell-rich variant of the solitary fibrous tumor includes the other variants, as well as 76 giant cell fibroblastoma, which, unlike the giant cell-rich solitary fibrous tumor, is typically a lesion of children. Finally, to date, giant cell fibroblastoma has not been reported within the confines of the orbit; the closest anatomic site is a paranasal sinus described in only one patient. Although the tumor usually behaves in a nonaggressive manner, recurrences and extension into local soft tissue do occur in 10-15%. Surgical en bloc removal with minimal tissue damage is the treatment of choice, and is usually curative. Incomplete excision,78c however, results in a higher recurrence rate and carries a potential for malignant transformation. Recurrent orbital lesions have been shown to have a higher mitotic index,78d and may show a progressive loss of heterozygosity78e leading to more aggressive phenotypes. They have the tendency to spread locally and to invade the surrounding tissues, including orbital bone, to enter the sphenoid sinus, cavernous sinus,78f the anterior cranial fossa. Solitary fibrous tumor metastases to orbit have also been seen, and may present as an irregularly enlarged or a well-defined mass associated with bony destruction. However, it is becoming clear that many tumors that were once diagnosed as fibrous histiocytomas would now be classified as solitary fibrous tumors based on immunohistochemical analysis. Additionally, our understanding of malignant fibrous histiocytoma has also undergone some important changes. Immunohistochemical analysis has led to the reclassification of many tumors originally thought to be malignant fibrous histiocytomas. Examples include: pleomorphic variants of liposarcoma, leiomyosarcoma, and rhabdomyosarcoma which can resemble malignant fibrous histiocytoma on light microscopy, but which are now easily distinguishable with ancillary studies. The pleomorphic malignant fibrous histiocytoma (or undifferentiated pleomorphic sarcoma), once thought to be the most common adult soft-tissue sarcoma, is now a diagnosis of exclusion, accounting for less than 5% of adult soft-tissue sarcomas. It is also uncertain how long it will take the peer review literature to reflect these changes in classification. Because of these difficulties, and in order to provide the most comprehensive text possible, what is known of orbital fibrous histiocytoma, both benign and malignant, will be presented as it is currently understood in the literature. Fibrous histiocytoma is known to occur deep in the orbit as well as in the eyelids,20,21 the tarsus,22 the lacrimal sac,23 and on the epibulbar surface,24 and is rarely metastatic to the orbit. Because the preponderant cell in most of these lesions is an elongated fibroblast-like cell, the tumor is included in this chapter, although others categorize it under histiocytic lesions. There are case reports of an orbital tumor in an infant78j,78k and a 3-year-old child. Clincially, patients often present with signs of orbital congestion, chemosis of the conjunctiva, lid retraction, motility disturbances, uncorrectable visual acuity deficits, and sometimes compressive optic neuropathy. Over the past 10 years, however, the growing use of immunohistochemical studies have clarified the cellular derivation of soft tissue tumors, and may ultimately prove this statement wrong. Fibrohistiocytic tumors contain cellular elements that resemble both fibroblasts and histiocytes, but studies suggest that the phenotype of the neoplastic cells most closely resembles that of fibroblasts. Thus, the term fibrohistiocytic should be viewed as descriptive in nature and not one that connotes histogenetic origin. Doppler ultrasonography reveals intermediate blood flow in a fibrous histiocytoma, in contrast to a higher velocity of flow in lesions that were formerly known as hemangiopericytoma and the total absence of flow in a cavernous hemangioma. On cut surface, they have a variably white and trabeculated appearance, depending on the amount of collagen deposition. Cystic myxoid and hemorrhagic areas may also be noted; usually hemorrhage denotes malignancy. In contrast to the cutaneous fibrous histiocytoma, deeper lesions demonstrate monomorphism, generally lacking foamy cells and giant cells. The frequently predominant elongated spindle-cell fibroblast cells are cytologically bland, with eosinophillic, ill-defined cytoplasm. The stroma may show hyalinization or myxoid change and there may be foci of necrosis. Malignant fibrous histiocytomas, or undifferentiated pleomorphic sarcomas as they are now classified, have marked cytological and nuclear pleomorphism and a high mitotic rate. Like the benign variant, a storiform pattern of growth is common and there may be areas of extensive necrosis and focal calcification. The spindle cells often appear fibroblastic, myofibroblastic or smooth-muscle like. In benign fibrous histiocytoma, immunohistochemical studies are generally unrewarding; the immunohistochemical stain for the intermediate filament vimentin is almost always positive, and the S100 protein staining will be negative. Electron microscopy reveals that most of the tumor cells display features of the fibroblast, namely, rough-surfaced endoplasmic reticulum, scattered mitochondria, and the absence of extracellular basement membrane production spaces. Despite its size, the lesion remains well circumscribed and partially surrounded by a pseudocapsule. The white appearance on the cut surface is the result of deposition of collagen by the fibroblasts in the tumor. Electron microscopy of tumors with a pleomorphic malignant fibrous histiocytoma pattern demonstrates ultrastuctural features of the specific lineage of cells, or may show relatively undifferentiated cells. The benign lesions were circumscribed, had small nucleoli within regular nuclei, and no mitotic figures. Such lesions are capable of recurrence if incompletely excised, which happened in 31% of the cases. However, the likelihood of malignant transformation on recurrence is small, and none of the patients in this category died. The tumors were more cellular, the nuclei were somewhat more hyperchromatic and crowded together, the nucleoli were more prominent, and mitotic activity, which generally was not pronounced, was in the vicinity of one mitotic figure per high-power microscopic field. The locally aggressive lesions underwent a 57% recurrence rate, and the malignant lesions exhibited a 64% recurrence rate, with six of 14 patients dying directly as a result of their malignancies. Widespread metastases can eventuate from 4 to 22 years after the first orbital recurrence. By contrast, the locally aggressive lesions had a 92% survival rate at 10 years, whereas patients with malignancy had only a 23% survival rate at 10 years. As already noted, malignant orbital fibrous histiocytomas can also arise after radiotherapy for retinoblastoma or an earlier orbital rhabdomyosarcoma. It is worth making a few comments about the highly distinctive appearance of fibrous histiocytoma that arises at the corneoscleral limbus. These benign lesions36 are usually acquired slowly in adulthood and have a yellow appearance. Both the cornea and contiguous sclera may be thickened, and the yellow appearance is more readily discernible in the corneal component, which is vascularized. Many clinicians are tempted to diagnose a dermoid or a dermolipoma, but these are always congenital lesions. Histopathologically, the benign lesions show a storiform pattern with a variable admixture of mono- and multinucleated lipidized histiocytes. Far more ominous are the epibulbar and corneoscleral malignant fibrous histiocytomas, which can be lethal. In these lesions, immunohistochemical methods for the identification of an antimacrophage factor and electron microscopic demonstration of lysosomes are helpful. Wide local excision coupled with cryotherapy to the epibulbar surface might be attempted at the time of first excision, but on recurrence, serious consideration should be given to radical surgery. A malignant epibulbar fibrous histiocytoma must be distinguished from a spindle-cell squamous carcinoma,39 a spindle-cell (sometimes desmoplastic) melanoma,40 and leiomyosarcoma. The immunohistochemical staining characteristics of these tumors are summarized in Table 242. For a well-circumscribed benign fibrous histiocytoma, local excision should be adequate therapy. Obviously, more generous margins must be taken if the lesion has features of a locally infiltrating and aggressive fibrous histiocytoma. For both the histologically benign and locally aggressive forms, if a considerable amount of tumor was left behind at the time of an initial diagnostic orbitotomy, plans should be made to return immediately to try to excise the entire lesion if possible, taking precautions to protect the extraocular muscles and the nerves in the orbit, including the optic nerve.

Even more careful patient selection is necessary in determining good candidates for this procedure hypertension age 60 discount diovan american express. Due to the higher placement of the surgical incision and lack of brow hairs to camouflage the incision blood pressure medication and lemon juice buy 40mg diovan mastercard, it is best suited for those with deep forehead creases heart attack survival rate order diovan 80 mg with visa. Depending on incision length and placement blood pressure 220 over 110 purchase diovan mastercard, greater lift can be conferred upon the heads of the brows as the incision is drawn through the midline blood pressure physiology order generic diovan on-line. The lateral extent of the incisions are limited by the lateral extent of the transverse forehead furrows blood pressure chart for age and weight order generic diovan. The lateral extent of the frontalis muscle may not extend all the way to the tail of the brow, and is associated with the involutional changes seen in temporal hooding. This will limit the degree to which the excision can proceed laterally and may limit the lift to the tail of the brow. Patients with minimal transverse furrows will likely be dissatisfied with the visible postoperative scar, even after it has matured. In an attempt to further camouflage the incision it may be placed at different heights and in different furrows on the right and left sides of the forehead, with the incision being interrupted but overlapping in the midline. This procedure provides good medial lift and will shorten the forehead, making it a good choice in those with a receding hairline. Depending on the incision design, the surgeon gains good access to the corrugator and procerus muscles in the midline. Unlike the direct browplasty, the entire fusiform excision is not performed initially. Vertical mattress sutures are placed to exaggerate the eversion and to result in a flat incision following wound contraction. Once the skin flap has been created inferiorly, this lip of the incision is elevated over the superior margin of the incision. This helps to determine the amount of forehead skin to be excised for the appropriate amount of lift in each region of the brow. Given the greater distance from brow hair to inferior lip of incision, one should slightly exaggerate and overelevate the brows to account for postoperative settling. As an adjunct to this procedure, in select cases permanent sutures may be passed deep in the wound through the superior orbicularis fibers and suspended above to the galea aponeurotica. The surgical wound is then closed in a fashion similar to that described for the direct browplasty. One exception is that the technique to exaggerate wound eversion is minimized for this incision. As the incision will be buried in a transverse furrow, a small amount of inversion may actually enhance the camouflage of the wound. While the number of suitable candidates for this procedure is less than others described, it can be a useful technique in the appropriately motivated patient. With appropriate sun protection, massage as described for browplasty, and most importantly time, it will fade to a more suitable appearance. Elevation of the central forehead in a cephalad direction reduces the transverse furrows. This surgical approach also offers excellent surgical access to the brow depressors, which may be excised or weakened during surgery. Patients with thinner hair may later complain of a visible part and incision when their hair is disrupted by the wind. Patients may also complain of postoperative scalp hypesthesia posterior to the incision line. Depending upon the amount of brow elevation desired there may be an unacceptable elevation or posterior shift of the hairline. This may create elongation of the forehead and must be considered when planning for this surgical procedure. The incision is marked beginning above the helix of the ear posterior to the temporal hairline and extending over the top of the head to a similar position on the contralateral side. The scalp has many perfusing vessels and care should be taken to maintain hemostasis as the incision proceeds from side to side. Raney clips can be applied to both margins of the scalp incision to provide temporary compression and minimize bleeding. Their use may obviate the need for excessive cautery which can be damaging to the hair follicles. Care should be taken to parallel the hair follicles during placement of this incision to further minimize hair loss. Over the central forehead a supraperiosteal or subgaleal dissection is then directed anterior toward the superior orbital rim. This is a relatively avascular plane and the dissection proceeds with minimal difficulty. The surgical plane is deep to the frontalis and will avoid injury to the frontal branch of the facial nerve. Blunt dissection in the glabellar area will help to identify the corrugator and procerus muscles which may be weakened or excised. The dissection is next carried laterally out over the temporalis muscle to provide greater elevation of the brow tail and lateral canthal area. The galea of the central pocket is contiguous with the temporal parietal fascia in the temporal area. It is within the temporal parietal fascia that the frontal division of the facial nerve courses and dissection must be beneath this layer. The surgeon must transition through the temporal line of fusion and identify the dense white, true fascia overlying the temporalis muscle. This layer, referred to as the superficial layer of the deep temporal fascia, provides a relatively avascular plane in which to release the overriding superficial temporal or temporal parietal fascia. To provide greater elevation of the brow, and mobility of the forehead flap, it is advisable to release the nondistensible periosteum. It is released with a combination of cutting and blunt dissection from one lateral canthus, along the superior orbital rims, to the contralateral canthus. The anterior flap of the incision is now advanced over the relatively immobile posterior flap. The amount of elevation desired is calculated and markings are made for excision of up to 2. The flap is then reinspected for bleeding and treated with bipolar cautery as necessary. Deep closure of the wound is performed with buried sutures through dermis and galea, with skin staples used for surface closure in hair-bearing scalp. The coronal forehead lift will meet with satisfaction in the appropriately counseled and motivated patient. The procedure is useful for improving the involutional changes of the brow and forehead that confer a tired or frustrated appearance to the patient. With the resting point of the brows now set at a more acceptable level the patient will experience less symptoms of forehead or eyelid fatigue. Care is taken to dissect around the supraorbital and supratrochlear neurovascular bundles. Once they are isolated the corrugator supercilli and procerus muscles are identified and weakened as necessary. The incision is somewhat camouflaged by placing it in the hairline at the junction of the hair-bearing and nonhair-bearing skin. By beveling the surgical incision, the deeper follicles may be induced to grow up through the wound, further camouflaging it. This procedure provides an advantage in patients with posterior displacement or recession of the hairline. By excising skin anterior to the incision, the forehead is shortened and the hairline advanced forward. Neither this procedure nor the coronal forehead lift should be considered in patients with male-pattern baldness, or the potential to develop it. Even with the most meticulous wound design and closure techniques, healing can remain somewhat unpredictable. High in the temporal area the dense white fascia over the temporalis muscle (superficial layer of the deep temporal fascia) is identified. Following this plane down to the lateral orbit and zygomatic arch will protect the frontal branch of the facial nerve which runs in the more superficial temporal parietal fascia (also know as the superficial temporal fascia). Assessment and Management of the Eyebrow that they may be limited to certain hair styles following this procedure to provide appropriate camouflage. The surgical dissection proceeds in the same planes as discussed for the coronal forehead lift. Due to the more anterior positioning of the wound, the ability to extend into the temporal region may be more limited. The surgical wound is closed with deep dermal sutures for eversion and to remove traction from the surface closure. As in the coronal forehead lift, the pretrichial forehead lift will result in hypesthesia posterior to the incision. The pretrichial forehead lift offers some advantages over the coronal approach, especially in the patient desiring a shorter forehead. The coronal brow incision can create a false part visible when the hair is wet or blown by the wind secondary to the surgical alopecia. Psychologically, it can also be difficult to gain patient acceptance for a procedure that involves an ear-to-ear incision, and the perception of "having their head cut open. The endoscopic midforehead elevation employs small, hidden incisions and minimal to no excision of skin. The procedure is based on endoscopic release of the forehead and temporal areas with elevation and temporary fixation to allow these structures to re-adhere to deeper structures in a more elevated and restful position. The relaxed tissue above the elevated forehead and temple region will contract with time, obviating the need for excision. Benefits of the endoscopic midforehead elevation technique include minimal small-incision sites that are hidden and can be adapted to various hair recession patterns to include malepattern baldness. Release of tissues in the lateral canthal region and over the temporalis muscle provide excellent reduction of temporal hooding, as well as reduction in the lateral laugh lines. With adequate release of periosteal attachments along the supraorbital rim, patients can achieve significant reduction in the transverse furrows of the forehead. Laterally, the procedure can be extended over the zygomatic arch and into the midface. Release of tissues in this area allows for elevation of the malar fat pad and a narrowing of the eyelid/ cheek junction. Under endoscopic magnification, the fibers of the corrugator and procerus muscles can be precisely weakened or excised. Depending upon the elevation and fixation techniques utilized, this procedure can result in a posterior shift in hairline, although significantly less than that experienced with a coronal brow lift. Given the distance from the incision site to the brow it is best to overcorrect to allow for postoperative relaxation of the skin. Despite the best closure techniques wound healing can be unpredictable and result in visible scaring. While many variations exist in techniques employed today, the goals of providing elevation to the brow and lateral canthal area, as well as rejuvenation and flattening of the forehead, remain constant. Centrally, a sagittal incision is placed in the midline, oriented in an anterior/posterior direction, set 0. A line is drawn from the nasal ala tangent to the lateral canthus on the ipsilateral side and into the temporal hair tuft. The hair is parted over each incision and various techniques are utilized to confine the hair and maximize exposure of the incision. All of the proposed incisions are injected with 1% Xylocaine with 1:100 000 epinephrine. This dilute tumescent solution produces excellent pain control, vasoconstriction, and minimizes blood loss. The central forehead pocket is dissected without the endoscope using tactile feedback from the external surface. Special endoscopic elevators are placed in either the sagittal or parasagittal incisions, and a subperiosteal dissection is carried down to ~2 cm above the orbital rim. A fullthickness incision is placed through dermis and then skin hooks are used to both retract and elevate the wound opening. This provides traction on the loose temporal parietal fascia and dissection is cautiously carried deeper until the dense white fascia covering the temporalis muscle is identified. With care taken to maintain the dissecting instrument on the fascia covering the temporalis muscle, the frontal nerve which runs in the more superficial temporoparietal fascia, is protected from injury. Generally five incisions placed behind the hairline are essential to complete the procedure. The endoscope is held in the nondominate hand while the dissector is used in the dominate hand to elevate the pocket. Using a beveled dissector, the dissection first proceeds medially toward the predissected central pocket over the forehead. By proceeding from lateral to medial in this pocket, the risk of entering the wrong plane is minimized. This allows the surgeon to release the line of temporal fusion down to the lateral canthal angle. The dissection is next carried inferiorly toward the zygomatic arch along the temporal fascia. Several centimeters above the arch of the zygoma, the fascia layer splits to provide an anterior and posterior cover to the intermediate fat pad. Entering this fat pad allows dissection down to the superior margin of the zygomatic arch.

Diseases

• Hip dysplasia Beukes type
• Kniest-like dysplasia lethal
• Choriocarcinoma
• Portuguese type amyloidosis
• Ladda Zonana Ramer syndrome
• Schlegelberger Grote syndrome
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• PIRA

There is a loss of the intracellular bridges that are seen between normal keratinocytes heart attack mortality rate order diovan once a day. Tumors can also be associated with mucin or amyloid deposition hypertension vs hypotension 40 mg diovan overnight delivery, fibroplasias arrhythmia definition order diovan with a visa, sclerosis blood pressure quit drinking order generic diovan pills, solar elastosis prehypertension heart attack generic 40mg diovan with amex, ulceration arrhythmia and stroke trusted diovan 40 mg, and inflammation. Superficial basal cell cancers are usually broader with the nests of basaloid cells extending into the papillary dermis. Fibroepithelioma of Pinkus appear as thin cords extending in a reticular pattern from the epidermis. Basal cell carcinoma may also show follicular, sebaceous, apocrine, eccrine, and squamous differentiation. Basaosquamous cell cancers share histological features of both types of cancer, but usually exhibit an aggressive growth pattern similar to squamous cell cancer. The more aggressive subtypes of basal cell carcinoma including infiltrative and morpheaform may demonstrate perineural invasion. Immunohistochemistry may help distinguish basal cell cancers from histologic mimickers such as trichoepitheliomas and Merkel cell cancers. In a follow-up study examining recurrence of periocular basal cell carcinomas, they found that infiltrative subtypes and those located in the medial canthal area were most likely to recur. These tumors had been treated with multiple excisions prior to orbital wall invasion. In addition to recurrences that can occur with incomplete excision of tumor that leads to greater morbidity, another important issue to consider with eyelid basal cell carcinoma is the need to maintain eyelid functional integrity while simultaneously achieving complete extirpation of tumor. Furthermore, the blinking action maintained by the eyelid helps to spread moisture evenly across the cornea to prevent excessive dryness. Lack of moisture can lead to complications including corneal ulcers and vision loss. Additionally other important anatomical entities including the lacrimal drainage system inhabit this area and need to be preserved, if possible, for normal function. Thus it is of utmost importance to maintain eyelid integrity while completely removing malignant neoplasms. Mohs micrographic surgery represents an optimal therapeutic option for eyelid basal cell carcinoma because it allows for tissue sparing and the most comprehensive margin examination to decrease the risk of recurrence. In an area such as the eyelid where every millimeter of spared tissue allows for a more optimal repair, Mohs surgery is a superior treatment option. In conjuction with an oculoplastic surgeon, the Mohs surgeon can often achieve complete removal of the basal cell carcinoma with minimal to no loss of functional eyelid integrity in their patients. Most complications were minor including contour deformity, rough skin graft, or corneal ulcers from sutures. Correctable ectropions occurred in eight patients, three of whom had preexisitng ectropions. Four patients with involvement and excision of parts of the lacrimal drainage system developed tearing which was unable to be satisfactorily corrected. Overall, the majority of patients did well with Mohs micrographic surgery, with maintenance of eyelid function and cosmesis. Mohs surgery not only allows for tissue sparing but also decreases the risk for recurrence because of complete examination of the histological margin. In the periocular area where recurrences can lead to greater morbidity complete excision is essential. Malhotra et al found a 2% recurrence rate at 5 years of periocular tumors treated in 397 patients. Additionally tissues which undergo squamous metaplasia including lung, salivary glands, and cervix can also develop squamous cell cancers. Cutaneous squamous cell carcinomas can be categorized into two types: tumors in sun-exposed areas which are generally chronic and indolent and rarely metastasize (<5%) and tumors arising on the lips, genitalia, and perianal areas which are more aggressive and have a greater risk of metastasis. Squamous cell carcinoma develops through an accumulation of mutations in a single keratinocyte. Keratinocytes undergoing malignant transformation undergo an orderly series of changes that pathologically correlate with mild, moderate, and severe dysplasia followed by squamous cell in situ, invasive carcinoma, regional lymph node metastases, and distant metastases. Risk factors for squamous cell carcinomas are similar to those associated with basal cell carcinoma. Ultraviolet radiation is a major risk factor; specifically, greater lifetime cumulative exposures increase the risk of developing squamous cell cancers. Ionizing radiation and arsenic exposure similarly are risk factors for squamous cell carcinoma. Additionally chronically inflamed skin lesions (discoid lupus erythematosus, lichen planus, porokeratosis, lichen sclerosus), chronic ulcers, burns, and scars also have the propensity to develop squamous cell carcinomas. Either missense mutations or deletions in p53 can result in malignant transformation. Invasive squamous cell carcinomas can clinically mimic actinic keratoses or in situ carcinomas. These tumors present as crateriform erythemous nodules with a central crust that grows rapidly. Any nonhealing lesion clinically suspicious for squamous cell carcinoma should be biopsied for further evaluation. These cells are enlarged with hyperchromatic nuclei, an increased number of nucleoli, and loss of polarity. Interesting they found that in 89% of patients, nodal disease was detected on physical examination and confirmed with imaging studies. This finding again points to the importance of clinically assessing lymph nodes in patients presenting with squamous cell carcinoma. Moore et al found that tumor recurrence, evidence of lymphatic or vascular invasion on histology, inflammation, poorly differentiated histology, invasion beyond the subcutaneous fat, perineural invasion, depth of invasion, and size of tumor all increased the risk of nodal metastasis. Specifically, lesions that were at least 4 cm in diameter and 8 mm in Breslow depth had greater risk of nodal metastasis. Cherpelis et al found that tumors greater than 2 cm in diameter, Clark level V poorly differentiated on, histology, at sites of previous radiation, with perineural invasion, single-cell infiltration, and small tumor nests as well as recurrent tumor were at greater risk for regional and distant site metastases. Faustina et al reported that periocular squamous cell carcinomas (upper eyelid, lower eyelid, lateral canthus medial canthus, and contiguous periocular skin) should be considered for sentinel lymph node biopsy, especially if they are greater than 2 cm in diameter or recurrent tumors. Although there is no consensus on treatment regimens for nodal involvmement by squamous cell carcinoma, complete nodal basin dissection with adjuvant radiation treatment is usually recommended. Invasive squamous cell cancer can be well differentiated, moderately differentiated, or poorly differentiated. Moderately differentiated squamous cell cancers have some evidence of keratinization, although evidence of well-formed pearls is not typically seen. In poorly, or undifferentiated squamous cell cancer, evidence of keratinization is absent, and keratin stains are often necessary to identify the tumor. The World Health Organization had classified squamous cell carcinomas into several histopathologic types as outlined in Table 248. Tumors near bone such as those in the medial or lateral canthus should especially increase suspicion for orbital involvement. Orbital signs of tumor invasion include globe displacement, especially proptosis or limited extraocular movements. Complete nodal basin dissection and adjuvant radiation therapy have been shown to improve locoregional control of squamous cell carcinomas with nodal metastases. Peripheral minimal perineural disease can often be cleared with complete extirpation of tumor by Mohs surgery and rarely requires further treatment. The most common initial site of metastasis is the regional draining lymph node basin. It is important to assess for lymph node status as these patients will require further intervention such as lymph node dissection and adjuvant radiation. Most commonly, squamous cell carcinomas of the head and neck present with lymph node disease in the parotid gland or the upper cervical nodes. It is essential to recognize perineural invasion as it is curable with radiation treatment. Forty-four percent of patients with evidence of perineural invasion on imaging had progression of disease. Only 12% of patients without evidence of gross perineural disease on imaging experienced progression. The risk of developing lentigo maligna increases with increased cumulative ultraviolet radiation exposure. In addition to developing almost exclusively in chronically sunexposed areas, lentigo maligna is also characterized by a prolonged radial growth phase. It is unclear exactly what percentage of lentigo maligna progresses to invasive lentigo maligna melanoma, but it is thought be < 5%. Clinical signs which may represent progression to invasive disease include increased size, color variegation, border irregularity, elevation, and/or new hypopigmented areas which may represent regression. It is important to consider the diagnosis of lentigo maligna of any large or enlarging brown patch (completely flat) located on head and neck areas. Therefore, multiple incisional punch biopsies are recommended to confirm diagnosis. This may explain high rates of recurrence with ablative treatments that only target superficial structures. Unlike superficial spreading melanoma, pagetoid spread of atypical melanoctyes is rarely seen. The diagnosis and margin control with Mohs surgery should be determined by an experienced dermatopathologist since there can be confusion with atypical melanocytic hyperplasia seen in sun-damaged skin. Conventional surgical excision of lentigo maligna with the standard 5 mm margin is not sufficient in 50% cases. Zitelli et al found that 9 mm margins would be necessary to achieve complete excisions of lentigo maligna in 97% of cases. However, many Mohs surgeons argue that the difficulty in confirming negative margins on frozen sections make traditional Mohs surgery unreliable for treating lentigo malignas. Problems with frozen sections include difficulty in differentiating melanocytes from keratinocytes, difficulty in differentiating sun-damaged melanocytes from the atypical melanocytes of melanoma, freeze artifact, and uneven staining. Barlow et al reported that the sensitivity of frozen sections in confirming negative margins in lentigo maligna was 59% and the specificity was 81%. In this procedure layers are taken like traditional Mohs surgery; however, the tissue is sent for rush paraffin-embedded sections that are then interpreted by the dermatopathologist. Special arrangements need to be made with the dermatopathologist to have the tissue processed horizontally in Mohs fashion. Once the margins are confirmed negative, the resultant surgical defect is repaired. Risk factors for developing sebaceous cell carcinoma include older age, female sex, history of radiation therapy, immunosuppression, Asian race, and prolonged use of thiazide diuretics. A diffuse pseudoinflammatory pattern characterized by unilateral eyelid thickening has also been recognized. When the sebaceous cell carcinoma originates from the glands of Zeis, it can present as an ulcerated nodule or a cutaneous horn. An irregular yellow mass in the medial canthus can represent a sebaceous cell carcinoma involving the caruncula. It is imperative to rule out sebaceous cell carcinoma in cases of unilateral blepharitis or conjunctivitis or in cases unresponsive to appropriate treatment. Other entities in the differential diagnosis of sebaceous cell carcinoma include chalazion, cicatricial pemphigoid, sarcoidosis, basal cell carcinoma, squamous cell carcinoma, melanoma, Merkel cell carcinoma, and lymphoma. Prompt diagnosis via biopsy is necessary for sebaceous cell carcinoma as regional lymph node metastases and distant site metastases, most commonly lung, liver, bone, and brain, can occur. Sebaceous cell carcinomas can classified into four histopathologic subtypes including lobular, comedocarcinoma, papillary, and mixed. The periorbital area is a common site for sebaceous cell carcinoma because of the abundance of sebaceous glands. The meibomian glands of the tarsus, the Zeis glands associated with cilia, the sebaceous glands present in the caruncle, and those in the eyebrow region are all at risk of developing sebaceous cell carcinoma. The upper eyelid is involved in 63% of cases, the lower lid in 27% of cases, and both in 5% of cases. The papillary type is seen in conjunctival tumors with papillary projections and areas of sebaceous differentiation. One consistent feature of sebaceous cell carcinoma is its ability to involve conjunctival epithelium. Furthermore all histologic subtypes of sebaceous cell carcinoma exhibit nuclear pleomorphism, high mitotic activity, and vacuolated cells with fine cytoplasm. Of these 44 patients, there were 20 patients for whom 5-year follow-up data was available. Five year follow-up data was available for three patients and revealed no evidence of recurrence. It s especially important is periocular locations as tissue conservation can allow for better function and cosmesis. Sebaceous cell carcinoma can rarely affect the orbital soft tissues (<1%) with more advanced cases exhibiting complete replacement of the orbital contents. The proximity of vital structures and the importance of obtaining clear surgical margins to prevent recurrence and potential regional spread has made Mohs micrographic surgery a suitable treatment option for periocular sebaceous cell carcinoma.

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