Transcript Obtaining A Fine-Line Scar(good scar)

Dr.Osama Esmaeel Al-Mushhadany
Wound Healing
 Body attempt to restore tissue to its
structural and functional pre injury state.
 Wound healing either by regeneration or
repair
Wound Healing
All tissues repair except?
Liver and bone
Wound Healing Normally Proceeds in an
Organized Process
Four Phases of Wound
Healing
1-Hemostasis
2-Inflammation
3-Proliferation
4-Remodeling (maturation)
Classification of wound closure and
healing
By primary intention
2. By secondary intention
3. By tertiary intention
1.
Features of good scar
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Fine line scar
Absence of contour irregularities
No pigmentary irregularities
No contracture or distortion
Obtaining A Fine-Line Scar(good scar)
The final appearance of a scar is dependent on many factors:
(1) the age of the patient, type of skin and location on the
body.
(2) the tension on the closure.
(3) the direction of the wound.
(4) co-morbid conditions.
(5) the technique used for skin closure.
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Obtaining A Fine-Line Scar
 .Age.
 Who will have better scar a child or elderly patient?
Obtaining A Fine-Line Scar
 .Age.
 Loss of elasticity combined with changes in the subcutaneous tissue,
produce wrinkling, which makes scars in older individuals less obvious
and less prone to stretching.
 Child: raised red scar.
 Old age : flat white scar.
Obtaining A Fine-Line Scar
Type of skin:
Type of skin should also be taken into account. Skin that
is oily or pigmented, or both, produces more unsightly
scars..
Obtaining A Fine-Line Scar
 Certain anatomic areas produce unfavorable scars that
tend to become hypertrophic or widened. The
shoulder and sternal area are notable examples. On
the other hand, eyelid scars almost always heal with a
fine-line scar
Obtaining A Fine-Line Scar
Nutritional status can affect wound healing.
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Wounds gain strength less rapidly in the face of
protein depletion.
Vitamin A reverses the healing retardation caused by
steroids.
Vitamin C deficiency has long been known to cause
scurvy, characterized by a failure of collagen
synthesis.
Zinc is required for epitheliazation and fibroblast
proliferation.
Ferrous iron and copper are necessary for normal
collagen metabolism.
Obtaining A Fine-Line Scar
 Co-morbid conditions such as anemia,ureamia and
Diapedus can retard wound healing. .
Obtaining A Fine-Line Scar
 Atraumatic technique by:
 Minimizing damage to the skin edges with
atraumatic technique
 Debridement of necrotic or foreign material
 Good irrigation of traumatic or contaminated
wounds.
 Careful handling of tissue.
 No crushing or dryness.
 No strangulation or tension.
 Hemostasis.
 Sharp knife.
 No hot sponges.
Obtaining A Fine-Line Scar
Skin lines
The lines of tension in the skin were first noted byLanger(1861)
who described the normal tension lines of the skin, called
“Langer’s lines”. Or called “relaxed skin tension lines”
Excision of lesions is planned when possible so that the final
scar will be parallel to the relaxed skin tension lines. Maximal
contraction occurs when a scar crosses the lines of minimal
tension at a right angle. Wrinkle lines are generally the same
as the relaxed skin tension lines.
Method of homeostasis
 Electro-cautery.
 Ligature.
 Pressure and time.
 Clamping and twisting.
 Vasoconstrictor.
 Fibrin foam.
Methods of suturing
A. interrupted.
B. Vertical mattress.
C. Transvers mattress.
D. Subcuticular .
E. Continous.
Factors determine the severity of suture markers
1.Time of removal of stitches .
2.Diameter of the suture .
3. Relation to wound edges.
4. Region of the body.
5.Absence of infection.
6. Propensity for keloid.
When to remove the Stitches
from different body sites?
Sutures
Are the most common materials used to close a wound.
They are 2 types:
1. Absorbable:
a. Natural :
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b.
Catgut (plain , chromic) from submucosa of sheep intestine.
Collagen suture from flexors of beeves.
Synthetic:
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Polyglycolic A.(Dexon ).
Polyglactin 910 (Vicryl ).
PDS (polydiaoxonon suture).
Non-absorbable:
2.
1.
2.
Natural : silk, cotton. stainless steel.
Synthetic:
1.
2.
3.
Polyamide (nylon): degrade 20 % / year.
Polyester (Dacron, Ethibond)
Polypropylene ( Prolene).
Skin graft
 Definition: is a segment of epidermis and dermis that is
removed without its blood supply from donor site
transferred into a recipient site
 Types: according to:
 Origin:
 Autograft ,
allo-(homo), xeno(hetero)-, iso-graft
(identical twins)
 Thickness:
 Split-thickness graft(Thiersch
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graft):
thin ,intermediate, thick.
Full thickness graft (Wolfe graft).
Flaps
 “ part of tissue which retains its vascular attachment to
body, transplanted to reconstruct a defect.”
 The flap donor site closed by suture or SSG.
Skin tumors
Basal cell carcinoma (BCC)
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Most common, 75% of skin tumors.
Arise from basal layer of epidermis.
Affects white skin, Male: Female=3:2 .
Occurs on exposed parts: face, neck, scalp.
No metastasis.
Commonly Caucasian male older than 60 years
 Diagnosis: by biopsy (FNA, incisional biopsy ,
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excisional biopsy)
Treatment:
Surgery: excision with 2-5 mm. healthy margin, &
repair defect by skin graft or flap.
Radiotherapy: in large lesion, oldman, refusing
operation.
Cryotherapy: for primary lesion < 2 cm., but
hypopigmentation, scarring are disadvantages.
Squamous Cell Carcinoma
 (SCC) is second most common skin cancer.
 arises from the malignant transformation of
keratinocytes in the epidermis.
 arise either in normal skin or in preexisting lesion as
(actinic keratosis, leukoplakia, radiation keratosis,
scars( where called Marjolin ulcer).
 Clinically: present as irregular ulcer, everted edge,
indurated base,attached deeply, blood-stained
discharge,frequent lymph n. positive.
 Treatment: biopsy done.
 1- Excision
 Surgical excision with 10-mm margin
 If lymph n. positive: excise lesion with lymph n.
dissection.
 2-Radiation therapy is best used in older patients,
Alkhansah
ospital
Psc
Cleft lip and palate
 One of the most frequently encountered
congenital facial defects
Embryology: result of
breakdown in the normal lines
of fusion during the early stage
of fetal development
Etiology of the clefts
 The cause of the cleft lip and palate is
multifactorial involving both genetic and
environmental factors
 15% of the cleft cases are syndromatic with
more than 170 syndrome have it as a feature
 Smoking is now well known to increase the
incidence of clefting
 Multivitamine and folic acid in the 1st four
months of pregnancy is protective
Types of cleft lip and palate
Types of cleft palate
 Common questions asked by the family
 1-How to feed the baby
 2-Timing of surgery
 3-How many operation needed
Feedings
 It is important to keep the
cleft clean
 Breastfeeding is extremely
challenging.
 Repair :lip at 3 months or rule of 10 (10 pounds weight,
10 gm Hb, 10 weeks old).
 Palate : at 12-18 months, by Veau-Wardil, 4 flaps,
Langenbek.
 Aim of repair:
 lip: to improve appearance
 Palate: to achieve normal speech and prevent
regurgitation .
Millard op.
Veau-Wardil op.
Langenbek
 Effects on child :
 Inability to suck.
 Speech –nasal.
 Dentition deformity
 Nose deformity.
 Hearing defects.