Skar Yönetimi
Özet
Skar, deri bütünlüğünün bozulması veya cerrahi müdahale sonrası normal dokunun yerini fibröz dokunun almasıyla oluşan hipertrofik, atrofik ya da keloid tiplerindeki yara izleridir. Yara iyileşmesi; enflamasyon, proliferasyon ve remodeling (yeniden şekillenme) olmak üzere üç karmaşık fazdan oluşur. Genetik eğilim, yaş, anatomik bölge ve cerrahi teknik gibi birçok faktör skar gelişimini etkiler. Klinik olarak hipertrofik skarlar yara sınırında kalıp zamanla düzleşme eğilimi gösterirken; keloidler orijinal yara sınırlarının ötesine taşarak agresif büyür, ağrı ve kaşıntıya yol açar. Skar yönetiminde cerrahi teknikler (5A kuralları), atravmatik doku kullanımı, dikişlerin erken alınması ve doğru insizyon tasarımı en önemli değiştirilebilir faktörlerdir. Ameliyat sonrası erken dönemde nem dengesinin korunması, ilk haftalarda cilt bantlarıyla gerilimin azaltılması ve aylık kontroller hayati önem taşır. Tedavide intralezyonel steroid enjeksiyonları her iki skar tipinde de oldukça etkiliyken, basınç tedavisi daha çok hipertrofik skarlarda tercih edilir. Keloidlerde cerrahi eksizyon sonrası nüks oranı yüksek olup radyoterapi gibi ek tedaviler gerekebilir. Sonuç olarak, başarılı bir skar yönetimi ameliyat öncesi planlamadan başlayarak hastanın uzun dönemli aktif katılımını gerektiren multidisipliner bir süreçtir.
A scar is the replacement of normal skin with fibrous tissue following dermal disruption or surgery, manifesting as hypertrophic, atrophic, or keloid types. Wound healing progresses through three complex phases: inflammation, proliferation, and remodeling, influenced by genetic predisposition, age, anatomical location, and surgical technique. Clinically, hypertrophic scars remain within original wound boundaries and tend to flatten over time, whereas keloids extend beyond the borders, behave like benign tumors, and cause severe pain and itching. In scar management, the surgeon's technique (the 5As), atraumatic tissue handling, timely suture removal, and tension-reducing incision design along skin tension lines are key modifiable factors. Postoperative management involves controlling hydration, applying skin tapes to reduce tension, and performing monthly follow-ups during the peak remodeling phase. Regarding treatments, intralesional steroid injections are highly effective for both conditions, while pressure therapy is primary for hypertrophic scars due to low compliance and low efficacy in keloids. Keloids exhibit high recurrence rates up to 100% after simple excision, often requiring adjuvant radiation therapy despite potential risks. Ultimately, optimal scar management begins with careful preoperative planning and demands active, long-term patient participation throughout the remodeling process.
Referanslar
Tziotzios C, Profyris C, Sterling J: Cutaneous scarring: Pathophysiology, molecular mechanisms, and scar reduction therapeutics. Part II. Strategies to reduce scar formation after dermatologic procedures. J Am Acad Dermatol 2012;66:13-24.
Gangemi EN, Gregori D, Berhiella P, et al: Epidemiology and risk factors for pathologic scarring after burn wounds. Arch Facial Plast Surg 2008;10:93- 102.
Wolfram D, Tzankov A, Pülzl P, Pıza- Katzer H: Hypertrophic scars and keloids- A review of their pathophysiology, risk factors, and therapeutic management. Dermatol Surg 2009;35:171-81.
Slemp AE, Kirschner RE: Keloids and scars: a review of keloids and scars, their pathogenesis, risk factors, and management. Current Opinion in Pediatrics 2006;18:396-402.
Deliaert AE, Kerckhove E, Tuinder S, Noordzij SM, Dormaar TS, van der Hulst RR: Smoking and its effect on scar healing. Eur J Plast Surg 2012;35:421-4.
Kim JH, Sung JY, Kim YH, et al: Risk factors for hypertrophic surgical scar development after thyroidectomy. Wound Rep Reg 2012;20:304-10
Batra RS: Surgical techniques for scar revision. Skin Therapy Lett 2005;10:4- 7.
Witte M, Barbul A. General principles of woundhealing. SurgClin North Am 1997; 77(3):509-28
Vankoppen CJ, Hartmann RW. Advances in thetreatment of chronicwounds: a patent review. Expert Opin Ther Pat 2015;25(8):931-7.
Aksoy H, Özakpınar ÖB. Yara iyileşmesi ve oksidatif stres. Marmara Pharm J 2014; 18:153-8.
Paratz JD, Stockton K, Plaza A, et al. Intensive exercise after thermal injury improves physical, functional, and psychological outcomes. J Trauma Acute Care Surg 2012;73:186–194
Anthonissen M, Daly D, Janssens T, et al. . The effects of conservative treatments on burn scars: A systematic review. Burns 2016;42:508–518
Zhang YT, Li-Tsang CWP, Au RKC. A systematic review on the effect of mechanical stretch on hypertrophic scars after burn injuries. Hong Kong J Occup Ther 2017;29:1–9
Bae SH, Bae YC, Nam SB, Choi SJ. A skin fixation method for decreasing the influence of wound contraction on wound healing in a rat model. Arch Plast Surg. 2012;39:457–462.
Larson BJ, Longaker MT, Lorenz HP. Scarless fetal wound healing: a basic science review. Plast Reconstr Surg. 2010;126:1172–1180.
Wilhelmi BJ, Blackwell SJ, Phillips LG. Langer's lines: to use or not to use. Plast Reconstr Surg. 1999;104:208–214.
Alster TS, West TB. Treatment of scars: A review. Ann Plast Surg 1997;39:418–432
Verhaegen PD, van Zuijlen PP, Pennings NM, van Marle J, Niessen FB, van der Horst CM, Middelkoop E. Differences in collagen architecture between keloid, hypertrophic scar, normotrophic scar, and normal skin: an objective histopathological analysis. Wound Repair Regen. 2009;17:649–656.
Tang YW. Intra- and postoperative steroid injections for keloids and hypertrophic scars. Br J Plast Surg. 1992;45:371–373.
Rosen DJ, Patel MK, Freeman K, Weiss PR. A primary protocol for the management of ear keloids: results of excision combined with intraoperative and postoperative steroid injections. Plast Reconstr Surg. 2007;120:1395–1400.
Niessen FB, Spauwen PH, Schalkwijk J, Kon M. On the nature of hypertrophic scars and keloids: a review. Plast Reconstr Surg. 1999;104:1435–1458.
Bran GM, Goessler UR, Hormann K, Riedel F, Sadick H. Keloids: current concepts of pathogenesis (review) Int J Mol Med. 2009;24:283–293.
Son DG, Lee HG, Han KH, Kim JH. Radiation therapy following total keloidectomy; a preliminary report. J Korean Soc Plast Reconstr Surg. 2005;32:717–722.
