1. بسم الله الرحمن الرحيم وقل رب زدنى علما

2. SCAR SCAR AND AND KELIOD KELIOD

3. Dr. Imrana Aziz Assistant Professor Surgical Deptartment Dr. Imrana Aziz Assistant Professor Surgical Deptartment

4. Wound Healing I. Inflammatory Phase (Immediate to 2-5 days) I. Inflammatory Phase (Immediate to 2-5 days) A) Hemostasis Vasoconstriction Vasoconstriction Platelet aggregation Platelet aggregation B) Inflammation Vasodilation Vasodilation Phagocytosis Phagocytosis

5. II. Proliferative Phase ( 2 days to 3 weeks) II. Proliferative Phase ( 2 days to 3 weeks) A) Granulation Fibroblasts produce collagen Fibroblasts produce collagen Fills defect and produces new capillaries Fills defect and produces new capillaries B) Contraction C) Epithelialization

6. III. Remodeling Phase (3 weeks to 2 years) III. Remodeling Phase (3 weeks to 2 years) A) Increases tensile strength to wounds A) Increases tensile strength to wounds B) Organised, flatteed scar produce B) Organised, flatteed scar produce

7. ExudateScab Fine line RedRaisedItchyTendercontractionPaleFlatQuietcontractive 1-6 weeks Healing 2 wks- 2yrs Remodeling6mths-2yrsMaturation

12. Scars (Cicatrix) Scars (Cicatrix) A scar is a permanent patch of skin that grows over a wound. (after a cut, scrape, burn or sore, surgery cuts, infections, skin conditions like acne). A scar is a permanent patch of skin that grows over a wound. (after a cut, scrape, burn or sore, surgery cuts, infections, skin conditions like acne).woundacnewoundacne

13. Factor for ideal scar: Intrinsic: Intrinsic: Age: old person Age: old person Chronic disease Chronic disease Abnormal collagen syndrom: ehlers – danlos Abnormal collagen syndrom: ehlers – danlos Malnutrition Malnutrition Smoking Smoking Obesity Obesity

14. Extrinsic: Extrinsic: Achieve quiet primary healing Achieve quiet primary healing Clean incised edges,no tissue losS Clean incised edges,no tissue losS Avoid dehiscence or infection Avoid dehiscence or infection Minimise tension Minimise tension

15. Factor for ideal scar Align scar with wrinkle, injection or relaxed skin tension line Align scar with wrinkle, injection or relaxed skin tension line Site: eyelids, genitalia, palm vermilion Site: eyelids, genitalia, palm vermilion Fine lax skin Fine lax skin

16. Importance of line of langer`s: These are tension lines, due to the patterens of arrangement of collegen fiber in dermis. These are tension lines, due to the patterens of arrangement of collegen fiber in dermis. Skin creases, wrinkles of ageing parallel with tension lines. Skin creases, wrinkles of ageing parallel with tension lines. Incisions made along skin tension lines heal with minimum scarring. Incisions made along skin tension lines heal with minimum scarring.

17. Types of Scar Normal scar Normal scar Widened scar Widened scar Atrophic scar Atrophic scar Hypertrophic scar Hypertrophic scar Keliod scar Keliod scar

18. 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 scar: Widened scar: occurs in sites of higher. occurs in sites of higher. Atrophic scar: Atrophic scar: Acne vulgaris, varcella infection, immunization sites leave atrophic scar Acne vulgaris, varcella infection, immunization sites leave atrophic scar

20. Hypertrophic Scar Hypertrophic Scar These are overgrowth of fibrous scar tissue that remains within boundaries of original wound and tend to regress spontaneously These are overgrowth of fibrous scar tissue that remains within boundaries of original wound and tend to regress spontaneously

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

24. Aetiology Aetiology The cause is unknown The cause is unknown these scars seem to function autonomously resulating in an increase in the production of fibroblastic collagen and metaloproteinase and dec: in collagen degradation these scars seem to function autonomously resulating in an increase in the production of fibroblastic collagen and metaloproteinase and dec: in collagen degradation

25. Epidemiology Epidemiology common in people with darker skins, especially African-American races. common in people with darker skins, especially African-American races. The peak age is 10-30 years, The peak age is 10-30 years, keloids are less common at the extremes of age. keloids are less common at the extremes of age. There may be a family history of tendency to develop keloids There may be a family history of tendency to develop keloids

26. Presentation:Symptoms Cosmetic Cosmetic Tender Tender Painful Painful Itch Itch Burning sensation. Burning sensation. History of trauma :accidental, surgical or cosmetic, Burn scars or infected lesions, including acne, are more likely to form keloids. History of trauma :accidental, surgical or cosmetic, Burn scars or infected lesions, including acne, are more likely to form keloids.

27. Clinical features : Clinical features : Sites : the most common areas are sternum, shoulder, earlobe and cheek Sites : the most common areas are sternum, shoulder, earlobe and cheek Raised and irregular Raised 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 brown or pale with age. It is red in the early stages, but becomes brown or pale with age. No hair follicles or sweat glands within the scar. No hair follicles or sweat glands within the scar. Keloids over a joint can contract and restrict movement. Keloids over a joint can contract and restrict movement. Clinical course: The natural history is variable: Clinical course: The natural history is variable:

28. It is red in the early stages, but becomes brown or pale with age. It is red in the early stages, but becomes brown or pale with age. No hair follicles or sweat glands within the scar. No hair follicles or sweat glands within the scar. Keloids over a joint can contract and restrict movement. Keloids over a joint can contract and restrict movement. Clinical course: The natural history is variable: Clinical course: The natural history is variable:

29. Comparison of hypertophic and keliod feature Hypertrophic scar Keliod scar GeneticRaceSexAgeborders Not familial Not related F = M Children Remains whithin wound May be familial Black > white F > M 10-30 yrs Outgrows wound area

30. featureHYPERTROPHICKELIOD Natural history SiteEtiology Affect of prgnancy Subsides with time Flexor surface Related to tension Related to poor surgical technique. Not affacted Rarely subsides Sternum, shoulder, face Unknown Inc: risk in pregnancy and puberty

31. Hypertrophic Keliod Keliod Some immunological abnormalities Electron microscope shows thin organized collagen bundles. Not related to immunological abnormalities Electron microscope shows thick, disorganized collagen.

32. Management: Management: There is no universal treatment for abnormal scar. There is no universal treatment for abnormal scar. Medical treatment: Medical treatment: pressure dressing pressure dressing compressive dressing compressive dressing silicone gel pad. silicone gel pad.

33. cortisone injections cortisone injections Radiotherapy Radiotherapy Cryotherapy Cryotherapy Laser treatment Laser treatment

34. interpheron interpheron Cytotaxic drugs Cytotaxic drugs Other therapies Other therapies vit:E vit:E allantion allantion

35. Surgical treament Z plasty Z plasty Y-V advancement flap Y-V advancement flap Intensive Physiotherapy

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