Presentation scars

SCARS

Dr Alamzeb KhanPlastic Surgeon Northwest General Hospital & Research CentrePeshawar , PAKISTAN

Substitution of a

different cellular matrix

as a patch to re establish both physical and physiologic

continuity to the injured organ is called

scar formation

CLASSIFICATION OF SCARS

•Mature scar•Immature scar•Linear hypertrophic•Widespread hypertrophic•Minor keloid•Major keloid•Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg. 2002;110:560–571.

A light-colored, flat scar

A red, sometimes itchy or painful, and slightly elevated scar (remodeling). Many of these will mature normally over time

This usually occurs within weeks of surgery. These scars may increase in size rapidly for 3–6 months and then, after a static phase, begin to regress.

A widespread red, raised, sometimes itchy scar confined to the border of the burn injury

A focally raised, itchy scar extending over normal tissue. This may develop up to 1 year after injury and does not regress on its own.

A large (more than 10 cm2), raised (>0.5 cm) scar, possibly painful or pruritic and extending over normal tissue.

Keloids and Hypertrophic scars

The prolonged inflammationdelays the healing response and drives the formation of keloids and HSs

Exact cause is unknown

But

Huang C, Akaishi S, Hyakusoku H, et al. Are keloid and hypertrophic scar different forms of the same disorder? A fibroproliferative skin disorder hypothesis based on keloid findings. Int Wound J. 2012 Nov 22. [Epub ahead of print].

•Avoid injury or incision in keloid-prone persons•Avoid incision in keloid-prone areas• Incision along relax skin tension lines•Meticulous surgical techniques•Good wound care : rapid healing

Surgical

•Excision +postsurgical radiotherapy•Tension-reduction or shielding methods (z-plasty, w-plasty)•local flaps to cover the wound•Serial excision•Tissue expansion

Excision and post operative radiation

W-Plasty and Z-Plasty

W-Plasty

Z -PlastyZ-plasty

Release and skin grafting

Serial excision

Non surgical•silicon sheeting and gel•Pressure garments• injections (steroids, verapamil)•Topical application of steroids .•Snake oil

Silicone gel sheeting has demonstrated the ability to dramatically hasten hypertrophic scar maturation and decrease associated symptoms of pain, rigidity, and pruritus. Majan JI. Evaluation of a self-adherent soft silicone dressing for the treatment of hypertrophicpostoperative scars. J Wound Care. 2006;15:193–196.

Argument exists over silicone’s mechanism of action. One line of

evidence points to increased hydration from occlusion leading to a

decrease in inflammatory cytokines. Alternative

suggested mechanisms include a direct effect by silicone particles and an increase in static electrical fields.

Ahn, S. T., Monafo, W. W., and Mustoe, T. A. Topical silicone gel: A new treatment for hypertrophic scars and contractures. Surgery 106: 181, 1989.

In 2005 Van den Kerckhove et al found improved scar thickness when garment

pressure was above 15 mmHg.

Perhaps most discouraging was a 2009 meta-analysis of six RCTs, including thoseabove, which found only marginal improvements ofquestionable clinical significance in scar thickness.

Steroid has been shown to decrease collagen gene expression.Mixed with 2% plain Lidocaine in a 50 : 50 ratio, Triamcinolone 10 mg/mL is commonly used initially; if no response occurs, 40 mg/mL concentration is attempted. Injection are repeated monthly.

In multiple retrospectiveseries, complete flattening or greater than 80% volume reduction occurred in 73–85% of lesions treated with liquid nitrogenRusciani L, Rossi G, Bono R. Use of cryotherapy in the treatment of keloids. J Dermatol Surg Oncol. 1993;19: 529–534.

The application of snake oil in traditional African medicine, is a nutrition-based therapy that seems to have some efficacy. Louw L. Keloids in rural black South Africans. Part 3: a lipid model for the prevention and treatment of keloidformations. Prostaglandins Leukot Essent Fatty Acids 2000;63:255–262.

Acne scars

Acne affects up to 80% of the adolescent population.

The incidence of acne scarring is

about 95%.Goulden V, Stables GI, Cunliffe WJ. Prevalence of facial acne in adults. J Am Acad

Dermatol. 1999:41:577–580 1

History

•Most bothersome aspect of scarring

•How distressed is the patient

•Patient’s goals for treatment?

•Any prior procedure

•Any active acne?

•History of Post inflammatory hyperpigmentation

•History of keloids and hypertrophic scars?

Physical examination

•Good light •Give the patient a mirror to point out lesions•Active acne•Type of scar•Assess colour•Depth of the lesions•Stretch the skin and see if scars disappear•Palpate for fibrosis•Skin type

Treatment options for Post acne scars

•Resurfacing procedures•Lifting procedures•Excisional techniques•Other

Resurfacing with dermabrasion

Resurfacing with LASER

Thank you for listening