الرحمالرحماللهاللهبسمبسمالرحيمالرحيمنن

علما زدنى رب علما وقل زدنى رب وقل

SCARSCAR

ANDAND

KELIODKELIOD

Dr. Imrana AzizDr. Imrana AzizAssistant ProfessorAssistant Professor

Surgical Deptartment Surgical Deptartment

Wound HealingWound Healing I. Inflammatory PhaseI. Inflammatory Phase (Immediate to 2-5 (Immediate to 2-5

days)days)

A) HemostasisA) Hemostasis Vasoconstriction Vasoconstriction Platelet aggregation Platelet aggregation

B) Inflammation B) Inflammation Vasodilation Vasodilation PhagocytosisPhagocytosis

II. Proliferative PhaseII. Proliferative Phase ( (2 days to 3 2 days to 3

weeks)weeks)

A) GranulationA) Granulation Fibroblasts produce collagen Fibroblasts produce collagen Fills defect and produces new capillaries Fills defect and produces new capillaries

B) ContractionB) Contraction

C) EpithelializationC) Epithelialization

III. Remodeling PhaseIII. Remodeling Phase (3 weeks to 2(3 weeks to 2 years) years)

A) Increases tensile strength to A) Increases tensile strength to wounds wounds

B) Organised, flatteed scar produceB) Organised, flatteed scar produce

ExudateExudate

ScabScab

Fine lineFine line

RedRed

RaisedRaised

ItchyItchy

TenderTender

contractioncontraction

PalePale

FlatFlat

QuietQuiet

contractivecontractive

1-6 weeks1-6 weeks

HealingHealing2 wks- 2yrs2 wks- 2yrs

RemodelinRemodelingg

6mths-2yrs6mths-2yrs

MaturationMaturation

Scars (Cicatrix)Scars (Cicatrix)

A scar is a permanent patch of skin A scar is a permanent patch of skin that grows over a that grows over a woundwound. (after a . (after a cut, scrape, burn or sore, surgery cut, scrape, burn or sore, surgery cuts, infections, skin conditions like cuts, infections, skin conditions like acneacne).).

Factor for ideal scarFactor for ideal scar::Intrinsic:Intrinsic:Age: old personAge: old personChronic diseaseChronic diseaseAbnormal collagen syndrom: ehlers –Abnormal collagen syndrom: ehlers –

danlosdanlosMalnutritionMalnutritionSmoking Smoking Obesity Obesity

Extrinsic:Extrinsic:

Achieve quiet primary healingAchieve quiet primary healing

Clean incised edges,no tissue losSClean incised edges,no tissue losS

Avoid dehiscence or infectionAvoid dehiscence or infection

Minimise tensionMinimise tension

Factor for ideal scarFactor for ideal scar

Align scar with wrinkle, injection or Align scar with wrinkle, injection or relaxed skin tension linerelaxed skin tension line

Site: eyelids, genitalia, palm Site: eyelids, genitalia, palm vermilion vermilion

Fine lax skinFine lax skin

Importance of line of langer`sImportance of line of langer`s::These are tension lines, due to the These are tension lines, due to the

patterens of arrangement of collegen patterens of arrangement of collegen fiber in dermis.fiber in dermis.

Skin creases, wrinkles of ageing Skin creases, wrinkles of ageing parallel with tension lines.parallel with tension lines.

Incisions made along skin tension Incisions made along skin tension lines heal with minimum scarring.lines heal with minimum scarring.

Types of ScarTypes of Scar Normal scarNormal scar Widened scarWidened scar Atrophic scarAtrophic scar Hypertrophic scarHypertrophic scar Keliod scarKeliod scar

Normal scar:Normal scar:Forms after 2-3 wks.Forms after 2-3 wks.Appear flatten to a linear white line.Appear flatten to a linear white line.

Widened scarWidened scar:: occurs in sites of higher.occurs in sites of higher.

Atrophic scarAtrophic scar::Acne vulgaris, varcella infection , Acne vulgaris, varcella infection ,

immunization sites leave atrophic immunization sites leave atrophic scarscar

Hypertrophic ScarHypertrophic Scar

These are overgrowth of fibrous scar These are overgrowth of fibrous scar tissue that remains within boundaries tissue that remains within boundaries of original wound and tend to regress of original wound and tend to regress spontaneouslyspontaneously

Keliod:Keliod:

scar in which there is overgrowth of scar in which there is overgrowth of dense fibrous tissue beyond the dense fibrous tissue beyond the wound limit. They do not regress wound limit. They do not regress spontanously.spontanously.

AetiologyAetiology The cause is unknownThe cause is unknownthese scars seem to function these scars seem to function

autonomously resulating in an autonomously resulating in an increase in the production of increase in the production of fibroblastic collagen and fibroblastic collagen and metaloproteinase and dec: in metaloproteinase and dec: in collagen degradation collagen degradation

EpidemiologyEpidemiology common in people with darker skins, common in people with darker skins,

especially African-American races.especially African-American races.

The peak age is 10-30 years, The peak age is 10-30 years, keloids are less common at the keloids are less common at the

extremes of age.extremes of age.

There may be a family history of There may be a family history of tendency to develop keloidstendency to develop keloids

Presentation:Presentation:

SymptomsSymptoms Cosmetic Cosmetic Tender Tender PainfulPainful Itch Itch Burning sensation. Burning sensation.

History of trauma :accidental, surgical or History of trauma :accidental, surgical or cosmetic, Burn scars or infected lesions, cosmetic, Burn scars or infected lesions, including acne, are more likely to form including acne, are more likely to form keloids. keloids.

Clinical featuresClinical features:: Sites : the most common areas are sternum, Sites : the most common areas are sternum,

shoulder, earlobe and cheekshoulder, earlobe and cheek Raised and irregularRaised and irregular Beyond the original line of trauma. Beyond the original line of trauma. rubbery texture. rubbery texture. It is red in the early stages, but becomes It is red in the early stages, but becomes

brown or pale with age. brown or pale with age. No hair follicles or sweat glands within the No hair follicles or sweat glands within the

scar. scar. Keloids over a joint can contract and restrict Keloids over a joint can contract and restrict

movement. movement. Clinical course: The natural history is Clinical course: The natural history is

variable: variable:

It is red in the early stages, but It is red in the early stages, but becomes brown or pale with age. becomes brown or pale with age.

No hair follicles or sweat glands No hair follicles or sweat glands within the scar. within the scar.

Keloids over a joint can contract and Keloids over a joint can contract and restrict movement. restrict movement.

Clinical course: The natural history is Clinical course: The natural history is variable: variable:

Comparison of hypertophic and Comparison of hypertophic and keliodkeliod

featurefeature Hypertrophic Hypertrophic scarscar

Keliod scarKeliod scar

GenetiGeneticc

RaceRace

SexSex

AgeAge

borderborderss

Not familialNot familial

Not relatedNot related

F = MF = M

ChildrenChildren

Remains Remains whithin wound whithin wound

May be familialMay be familial

Black > whiteBlack > white

F > MF > M

10-30 yrs10-30 yrs

Outgrows wound Outgrows wound areaarea

featurefeature HYPERTROPHICHYPERTROPHIC KELIODKELIOD

Natural Natural historyhistory

SiteSite

EtiologyEtiology

Affect of Affect of prgnancprgnancyy

Subsides with Subsides with timetime

Flexor surfaceFlexor surface

Related to Related to tensiontension

Related to poor Related to poor surgical surgical technique.technique.

Not affacted Not affacted

Rarely subsidesRarely subsides

Sternum, Sternum, shoulder, faceshoulder, face

UnknownUnknown

Inc: risk in Inc: risk in pregnancy and pregnancy and pubertypuberty

Hypertrophic Hypertrophic Keliod Keliod

Some immunological Some immunological abnormalitiesabnormalities

Electron microscope Electron microscope shows thin organized shows thin organized collagen bundles.collagen bundles.

Not related to Not related to immunological immunological abnormalitiesabnormalities

Electron microscope Electron microscope shows thick, shows thick, disorganized disorganized collagen.collagen.

Management:Management:There is no universal treatment for There is no universal treatment for

abnormal scar.abnormal scar.

Medical treatmentMedical treatment::pressure dressingpressure dressingcompressive dressingcompressive dressingsilicone gel pad. silicone gel pad.

cortisone injectionscortisone injections

RadiotherapyRadiotherapy

CryotherapyCryotherapy

Laser treatmentLaser treatment

interpheron interpheron

Cytotaxic drugsCytotaxic drugs

Other therapiesOther therapies vit:Evit:E allantionallantion

Surgical treamentSurgical treament Z plastyZ plasty

Y-V advancement flapY-V advancement flap

Intensive Physiotherapy Intensive Physiotherapy

Therapeutic scaring Therapeutic scaring

Many societies done the Many societies done the scarification as sign of beauty or scarification as sign of beauty or decoration. decoration.