Beruflich Dokumente
Kultur Dokumente
Carlos Derosas Residente de Ciruga Universidad de Santiago de Chile Complejo Hospitalario San Jos
Tutor: Dr. G. Mangelsdorff
CICATRIZ
Seal de una herida curada y cerrada que queda en los tejidos orgnicos.
RAE
Epidemiologia
Cerca de 100 millones de personas adquiere una cicatriz cada ao en el mundo desarrollado 38-70 % sufre cicatrizacin anormal
- Bayat A, McGrouther DA, Ferguson MW. Skin scarring. BMJ. 2003;326:8892. - Sund B, ed. New Developments in Wound Care. London: PJB Publications; 2000. - Gangemi EN, Gregori D, Berchialla P, et al. Epidemiology and risk factors for pathologic scarring after burn wounds. Arch Facial Plast Surg. 2008;10:93102. - Deitch EA, Wheelahan TM, Rose MP, Clothier J, Cotter J. Hypertrophic burn scars: Analysis of variables. J Trauma 1983; 23:895898. - Bombaro KM, Engrav LH, Carrougher GJ, et al. What is the prevalence of hypertrophic scarring following burns? Burns 2003;29:299302.
Bock O, Schmid-Ott G, Malewski P, Mrowietz U. Quality of life of patients with keloid and hypertrophic scarring. Arch Dermatol Res 2006;297:4338.
Van Loey NE, Van Son MJ. Psychopathology and psychological problems in patients with burn scars: epidemiology and management. Am J Clin Dermatol 2003;4:24572.
Fisiopatologa de la cicatrizacin
Clasificacin
Cicatriz Madura Inmadura Hipertrfica lineal Hipertrfica Ensanchada Queloide Menor Queloide Mayor
Mustoe, Thomas A., et al.; for the International Advisory Panel on Scar Management. International Clinical Recommendations on Scar Management Plastic & Reconstructive Surgery. 110(2):560-571, August 2002.
Mustoe, Thomas A., et al.; for the International Advisory Panel on Scar Management. International Clinical Recommendations on Scar Management Plastic & Reconstructive Surgery. 110(2):560-571, August 2002.
Patricio Andrades1, Susana Bentez1, Arturo Prado1,2 , Recomendaciones para el manejo de cicatrices hipertrficas y queloides. Rev. Chilena de Ciruga. Vol 58 - N 2, Abril 2006; pgs. 78-88
TIPOS DE CICATRICES
Inmadura
Madura
Inmadura Ensanchada
Madura Ensanchada
Atrfica Mltiple
Perry, Donna M.; McGrouther, Duncan A.; Bayat, Ardeshir. Current Tools for Noninvasive Objective Assessment of Skin Scars. Plastic & Reconstructive Surgery. 126(3):912-923, September 2010.
Hipertrfica inmadura
Hipertrfica madura
Perry, Donna M.; McGrouther, Duncan A.; Bayat, Ardeshir. Current Tools for Noninvasive Objective Assessment of Skin Scars. Plastic & Reconstructive Surgery. 126(3):912-923, September 2010.
Queloidea Inmadura
Queloidea Madura
Retrctil inmadura
Retrctil Madura
Perry, Donna M.; McGrouther, Duncan A.; Bayat, Ardeshir. Current Tools for Noninvasive Objective Assessment of Skin Scars. Plastic & Reconstructive Surgery. 126(3):912-923, September 2010.
Vascularidad
Pigmentacion
Plegabilidad
Altura
Caracteristicas Normal Rosada Roja Purpura Normal Hipopigmentacion Hiperpigmentacion Normal Flexible Blanda Firme Cuerdas Contractura Plana <2 mm 25 mm >5 mm Total score
Score 0 1 2 3 0 1 2 0 1 2 3 4 5 0 1 2 3 13
PROBLEMAS
ALTERNATIVAS DE MANEJO
Manejo Cicatrices
Corticoides intralesionales
Indicaciones:
Queloides Cicatrices Hipertrficas
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Corticoides intralesionales
Inhibe los mediadores inflamatorios Inhibe la proliferacin fibroblastica Inhibe la sntesis de colgeno Estimula la degradacin de colgeno Inhibicin del TGF-1 y TGF-2 Inhibicin del COL4A1 y COL7A1 en los Queratinocitos.
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Coticosteroides
Estudios muestran 50-100% de eficacia como monoterapia. 50% Recurrencia a 5 aos * 63% eventos adversos como
Hipopigmentacin Telagectasia Cicatrizacion tardia
*Muneuchi G, Suzuki S, Onodera M, Ito O, Hata Y, Igawa HH. Long-term outcome of intralesional injection of triamcinolone acetonide for the treatment of keloid scars in Asian patients. Scand J Plast Reconstr Surg Hand Surg. 2006;40:111 116.
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
5-Fluorouracilo
Principalmente usado para lesiones hipertrficas (y queloideas) 50% efectividad a los 12 meses Asociado tiene mejores resultados
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
5-Fluorouracilo
Inhibicin de la proliferacin fibroblastica Inhibicin de la sntesis de colgeno tipo I inducida por TGF-1
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Haurani, Mounir J.; Foreman, Kenneth; Yang, James J.; Siddiqui, Aamir, 5-Fluorouracil Treatment of Problematic Scars. Plastic & Reconstructive Surgery. 123(1):139-148, January 2009.
5-Fluorouracilo
21% de complicaciones (Ulceracin) Estudios con valor limitado Mayor efectividad con terapia asociada, principalmente con corticoides Necesita mas estudios controlados
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Bleomicina
Antibitico (Antitumoral, antiviral y antibacteriano) Indicacin Queloides y Cicatrices Hipertrficas Hemangiomas Aplicacin Intralesional multipunto
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Bleomicina
Inhibe la sntesis de Colgeno Inhibicin de la Lisil-oxidasa de TGF-1
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Bleomicina
Promisorios efectos (50-75%) 75% de hiperpigmentacin 10-30% atrofia Faltan estudios controlados.
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
LASER
Positiva eficacia en mltiples estudios La principal indicacin es reducir el eritema
Queloides Cicatrices hipertrficas Hiperpigmentadas Atrficas
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Pulsed dye laser in burn scars: Current concepts and future directions Brian M. Parrett, Matthias B. Donelan Review Article Burns, Volume 36, Issue 4, June 2010, Pages 443-449
Pulsed dye laser in burn scars: Current concepts and future directions Brian M. Parrett, Matthias B. Donelan Review Article Burns, Volume 36, Issue 4, June 2010, Pages 443-449
Pulsed dye laser in burn scars: Current concepts and future directions Brian M. Parrett, Matthias B. Donelan Review Article Burns, Volume 36, Issue 4, June 2010, Pages 443-449
LASER
Efectos Secundarios
Purpura post tratamiento Hiperpigmentacin (1/24)
Gel de Silicona
Indicado para la prevencin y tratamiento de cicatrices hipertrficas Alta efectividad desde el postoperatorio inmediato hasta 2 semanas Demostrado en estudios casos controles
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Gel de Silicona
Hidratacin Inhibicin del deposito de colgeno Down- Regulation del TGF-2
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Gel de Silicona
13 trials con 559 pacientes Evidencia dbil de los beneficios de esta tcnica en la prevencin de cicatrizacin anormal en individuos de alto riesgo
OBrien, L., and Pandit, A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst. Rev. 1: CD003826, 2006.
Terapia Compresiva
Principalmente para prevencin de cicatrizacin hipertrfica Muy usado para quemaduras Deben ser usados apenas se ha logrado la cicatrizacin 23 horas diarias hasta obtener una cicatriz madura 24 40 mmHg
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Terapia Compresiva
Reduce la tensin de oxgeno Inhibe la proliferacin de fibroblastos Inhibe la sntesis de Colgeno Aumenta la colagenolisis
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Terapia Compresiva
La evidencia actual no soporta la eficacia del tratamiento compresivo como monoterapia para la reduccin de cicatrices
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies
Radioterapia
Indicado como adyuvancia a la reseccin quirrgica de queloides Aplicacin hasta 24 horas post escisin
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Radioterapia
Inhibe la proliferacin de fibroblastos La formacin de brotes neovasculares
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Radioterapia
Por lo general post reseccin ( tres ciclos 15 Gy) Bajo Riesgo de carcinogenesis 16-47% recurrencia
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Crioterapia
Indicado en cicatrices hipertrficas y queloideas 51-76% de xito
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Crioterapia
Disminuye la sntesis de colgeno Destruccin mecnica del tejido cicatricial Disminuye la neovascularizacin
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Crioterapia
Complicaciones
Atrofia Hipo o hiperpigmentacin Dolor
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
CONTRACTUBEX GEL
10% de extracto de Cebolla acuoso, 50U de heparina por gramo, y 1% de Alantoina El extracto de Cebolla:
Propiedades inhibitorias de fibroblastos (fibroproliferacion y matriz extracelular) interacta con las molculas de colgeno induciendo la formacin de fibrillas mas delgadas
Heparina Ambos tienen propiedades en los procesos inflamatorios y la capacidad de sintetizar de los fibroblastos Efectos significativos en cicatrices nuevas e hipertrficas maduras. Efectividad superior a la de los corticoides en relacin al eritema, prurito, consistencia y tiempo de normalizacin de la cicatriz.
Ho WS, Ying SY, Chan PC, Chan HH. Use of onion extract, heparin, allantoin gel in prevention of scarring in Chinese patients having laser removal of tattoos: a prospective randomized controlled trial. Dermatol Surg 2006;32(7):8916.
BOTOX
Toxina Botulnica tipo A Usado en cicatrices defectuosas faciales Principio de la influencia de la musculatura sobre el proceso normal de cicatrizacin
Wilson, Adel M. Use of Botulinum Toxin Type A to Prevent Widening of Facial Scars Plastic & Reconstructive Surgery. 117(6):1758-1766, May 2006.
BOTOX
Induce quimiodenervacion de la neurona presinptica Previene la liberacin de acetilcolina Denervacin del musculo estriado por 2-6 meses
Wilson, Adel M. Use of Botulinum Toxin Type A to Prevent Widening of Facial Scars Plastic & Reconstructive Surgery. 117(6):1758-1766, May 2006.
BOTOX
Wilson, Adel M. Use of Botulinum Toxin Type A to Prevent Widening of Facial Scars Plastic & Reconstructive Surgery. 117(6):1758-1766, May 2006.
BOTOX
90% de satisfaccin No hay estudios en humanos que demuestren efectos no deseados
Wilson, Adel M. Use of Botulinum Toxin Type A to Prevent Widening of Facial Scars Plastic & Reconstructive Surgery. 117(6):1758-1766, May 2006.
Acido Hialuronico
Es un glicosaminoglicano (repeticin de unidades disacaridas no sulfatadas de acido glucuronico y N acetiglucosamina)
Restylane
Matarasso, Seth L.; Carruthers, Jean D.; Jewell, Mark L.; the Restylane Consensus Group Consensus Recommendations for Soft-Tissue Augmentation with Nonanimal Stabilized Hyaluronic Acid (Restylane) Plastic & Reconstructive Surgery. 117(3):3S-34S, March 2006.
Ac. Hialurnico
Aumento y relleno de cicatrices deprimidas o del acn. Inyectada paralela a la zona deprimida justo bajo la dermis Resultados satisfactorios en el panel de expertos
Matarasso, Seth L.; Carruthers, Jean D.; Jewell, Mark L.; the Restylane Consensus Group Consensus Recommendations for Soft-Tissue Augmentation with Nonanimal Stabilized Hyaluronic Acid (Restylane) Plastic & Reconstructive Surgery. 117(3):3S-34S, March 2006.
Ac. Hialuronico
Matarasso, Seth L.; Carruthers, Jean D.; Jewell, Mark L.; the Restylane Consensus Group Consensus Recommendations for Soft-Tissue Augmentation with Nonanimal Stabilized Hyaluronic Acid (Restylane) Plastic & Reconstructive Surgery. 117(3):3S-34S, March 2006.
Matarasso, Seth L.; Carruthers, Jean D.; Jewell, Mark L.; the Restylane Consensus Group Consensus Recommendations for Soft-Tissue Augmentation with Nonanimal Stabilized Hyaluronic Acid (Restylane) Plastic & Reconstructive Surgery. 117(3):3S-34S, March 2006.
Inyeccin Grasa
Autotransplante de tejido adiposo Indicacin en cicatrices deprimidas Cosecha desde zona periumbilical Inyeccin en varios planos
La Rusca, Ivan; Schonauer, Fabrizio; Molea, Guido. Core Fat Graft Transplantation for Depressed Scar Plastic & Reconstructive Surgery. 123(4):1394-1395, April 2009.
Inyeccin Grasa
La Rusca, Ivan; Schonauer, Fabrizio; Molea, Guido. Core Fat Graft Transplantation for Depressed Scar Plastic & Reconstructive Surgery. 123(4):1394-1395, April 2009.
Inyeccin Grasa
Seguimiento a 6 meses con buenos resultados estticos y baja tasa de reabsorcin Baja morbilidad y reacciones adversas
La Rusca, Ivan; Schonauer, Fabrizio; Molea, Guido. Core Fat Graft Transplantation for Depressed Scar Plastic & Reconstructive Surgery. 123(4):1394-1395, April 2009.
MICRODERMABRASION
Procedimiento mnimamente invasivo Componente abrasivo Cristales de oxido de aluminio + componente de aspiracin Descrito inicialmente para scar camouflaging por Monteleone en 1985. Indicado en Estras, hiperpigmentaciones, poros grandes, cicatrices del acn
Karimipour, Darius J.; Karimipour, Gholamreza; Orringer, Jeffrey S. Microdermabrasion: An Evidence-Based Review Plastic & Reconstructive Surgery. 125(1):372-377, January 2010.
MICRODERMABRASION
Karimipour, Darius J.; Karimipour, Gholamreza; Orringer, Jeffrey S. Microdermabrasion: An Evidence-Based Review Plastic & Reconstructive Surgery. 125(1):372-377, January 2010.
MICRODERMABRASION
Mnimo riesgo de eventos adversos Seguro en todos los tipos de pieles Bajo riesgo de cicatrices y alteraciones de la pigmentacin.
Karimipour, Darius J.; Karimipour, Gholamreza; Orringer, Jeffrey S. Microdermabrasion: An Evidence-Based Review Plastic & Reconstructive Surgery. 125(1):372-377, January 2010.
ULTRASONIDO
Sistema que entrega ondas acsticas Afecta las estructuras bajo estas
ULTRASONIDO
Incrementa la elasticidad de los tejidos cicatriciales Mejora la irrigacin Pocos estudios
Ultrasound: Underused? Kathy Henderson, PT, CS, RAA; Mandy Burnett, PTA; and Beth Reigart, MPH, OTR/L, C October 2004.
MASAJES
Indicado en prevencin y tratamiento de cicatrices hipertrficas y retractiles Mejoran significativamente la plegabilidad Activan cicarices Siempre debe usarse emolientes Pocos estudios que avalen su efectividad
Pessina MA, Ellis SM. Burn management. Rehabilitation. Nurs Clin North Am. Jun 1997;32(2):365-74.
ELEMENTOS EMERGENTES
Superfamilia TGF-
Anti agentes TGF-1 y TGF-2
Disminuyen la produccin de colgeno
Estimuladores de TGF-3
Disminuyen la proliferacin de fibroblastos
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
IECAS y ARA
Inhibicin de los mediadores inflamatorios Funcionan localmente sobre el sistema de angiotensina cutneos
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Minociclina
DESCONOCIDO Acta sobre metaloproteinasas Inhibicin de los mediadores inflamatorios Actividad antibacterial en heridas contaminadas
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Terapia Gnica
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Reish, Richard G.; Eriksson, Elof , Scars: A Review of Emerging and Currently Available Therapies Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
ALTERNATIVAS
TATUAJES DECORATIVOS
Decorative tattooing for scar camouflage: patient innovation G.A. Spyropoulou, F. Fatah Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 62, Issue 10, October 2009, Pages e353-e355
Dry Tatooing
CAMUFLAGE
FUNCTIONS OF FACIAL FOUNDATION Add facial color Blend facial color
COVERING ABILITY OF FACE POWDER INGREDIENTS* Titanium dioxide Kaolin Magnesium carbonate Magnesium stearate Zinc stearate Prepared chalk
Zinc oxide
Rice starch Precipitated chalk Talc Colored Facial Cosmetics Zoe Diana Draelos, MD From the Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem; and Dermatology Consulting Services, High Point, North Carolina *Listed in order of increasing opacity.
RESUMEN
Resumen
Existen distintas alternativas segn el tipo de cicatriz que se quiera manejar o prevenir El aspecto fundamental es conocer la fisiopatologa de los eventos para elegir la teraputica Se recomienda el tratamiento combinado Las necesidades del paciente son las que definirn la aplicacin o no de los distintos mtodos