Ho Mhs Bms Skenario Ii_mgg III

7/26/2019 Ho Mhs Bms Skenario Ii_mgg III

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Skenario KeduaMinggu Ketiga

Tim Kurikulum Pendidikan Preklinik

Program Pendidikan Dokter

Universitas Islam Malang

2 0 0 9

ODUL mhs

Nama Mahasiswa : ............NIM : ............

Kelompok/ Tutor : ........... / ..


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1. IDENTIFIKASI KATA SUIT1. Krisis Kepercayaan Diri2. Acne Vulgaris

3. Papule

4. Pustule

5. Nodule

6. Dermatologist7. Scar Tissue

8. Keloid

9. Operasi Plastik

10. Biomolekular = molekul yang dihasilkan oleh sel hidup (protein lemak dan

kar!ohidrat"

11. Biomedikal = !iologis dan medis yang terkait dengan penerapan ilmu alam

(!iologi !iokimia !io#isika dll" dalam ilmu kedokteran$

KELOID ,,,oh,,,

U!AIAN S"ENA!I#

Susi pelajar SMU mengalami krisis kepercayaan diri akibat menderita Acne

vulgarisberat yang ditandaipapule, pustuledan nodule. Susi akhirnya mendatangi

Dermatologistuntuk mendapatkan pengobatan karena kondisi penyakitnya makin

parah. Seminggu menjalani pengobatan kondisinya berangsur membaik tetapi bekas

lukaAcne vulgaristidak dapat pulih seperti sedia kala, tampak adanya Scar tissue

dan Keloid pada wajah Susi.Keinginan Susi agar segera terbebas dari noda di

wajahnya diutarakan pada Dokter dan tindakan Operasi Plastik menjadi alternati

pilihan. Susi menghadapi suatu dilema di satu sisi dia menginginkan wajahnya

kembali pulih tetapi di sisi lain harus siap menerima resiko munculnya Keloid baru

pada luka sayatan operasi.

!. !pa yang terjadi pada diri Susi bila dikaji secara "iomolekular #

B. "agaimana kajian "ioetika Kedokteran dan !gama pada kasus Susi #


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$. %ENENTUAN %!#&EM ISTa. %engapa Susi menderita Acne &ulgaris ' (aktor penye!a! Acne &ulgaris"b. Bagaimana mekanisme ter!entuknya Scar tissue dan Keloid di )a*ah Susi '

c. Adakah hu!ungan Acne &ulgaris dengan Scar tissue dan Keloid pada )a*ah Susi '

d. Bagaimana proses ter*adinya +ound ,ealing '

e. Bagaimana !entuk-!entuk adaptasi sel setelah ter*adi .n*uri 'f. Bagaimana upaya pencegahan ter!entuknya Scar tissue dan Keloid 'g. Bagaimana saran dokter terhadap tindakan operasi plastik !ila ditin*au dari sisi

Bioetika Kedokteran '

h. Bagaimana tindakan operasi plastik !ila ditin*au dari sisi nilai-nilai Agama '

'. &!AIN ST#!MIN(

Bacalah tentang /

0$ .n*ury persisten

1$ .n#lamasi kronis

2$ +ound healing

3$ Adaptasi sel

). %ENENTUAN EA!NIN( #&*E"TI+E

0$ %emahami proses ter*adinya +ound ,ealling

1$ %emahami mekanisme pem!entukan Scar tissue dan Keloid$

2$ %emahami !entuk-!entuk adaptasi sel

3$ %emahami peran adaptasi sel (sisi positi# dan negati#"

4$ %emahami upaya pengham!atan pem!entukan Scar Tissue atau Keloid$

5$ %emahami peran gangguan adaptasi sel terhadap patogenesa penyakit

6$ %ahasis)a dapat men*elaskan konsep Bioetika Kedokteran dan nilai-nilai Agama


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,. "#N"E%T MA%%IN(


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MA%IN( K#NSE% %EM&ENTUKAN S"A! TISSUE DAN KE#ID

I-lamasi !emoeli-0%rolierasiemostasis

A-aplasia$umlah Sel %

MetaplasiaSel "erubah

AtropiUkuran Sel %

ipertropiUkuran Sel &

iperplasi$umlah Sel &

ADA%TASI SE

(a0al

&erhasil

2#UND EAIN( 1st atau $-

TISSUE !E%AI!INFAMASI AKUT

Fisik'adiasi, (ritan"enda )ajam, Suhu

&erhasil

(a0al

KEMATIAN SE*ekrosis!poptosis

INFAMASI K!#NIS

SI(N 3 S4M%T#M)umorKalor'uborDolor+unctio esa

Sel-ipoia, !cidosisKematian PM*, Steril PusKerusakan Sel

+askularKerusakan Katup/tra0asasi 1airanOedema

imatikaKerusakan imatik% Drainage& 1airan

MEDIAT#! INFAMASI

P2, "radikinin,-istamin, (345, eeukotrien

AKTI+ASIMAK!#FA(E

KE!USAKAN SE

IN*U!4 SEM.# / Aler0e-Kimiawi

)oksin+ree 'adikal


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5. SEF DI!E"TED EA!NIN(

A"NE +U(A!IS

S"A! TISSUEKeloid'olling Scar)hickened Scar

I%E!T!#%II%E!%ASIA

Kolagen 66$aringan *ormal 77

S"A! TISSUE'olling Scar

I%E!T!#%II%E!%ASIA

2likosaminoglikan 66O0ergrowth*eokolagenase 77

Prolierasi +ibroblast 6Sintesa Kolagen ((( 66Kolagen ((( ( 77

AT!#%IANA%ASI

S"A! TISSUE-ole Scar8alley Scar

NEK!#SIS

AT!#%IANA%ASI

F!EE !ADIKA 6O-9, O:9, -:O:

S"A! TISSUE-ole Scar8alley Scar

I%#KSIA

A"ID#SISNEK!#SIS

SU%A4Oksigen %*utrisi %

!EM#DEIN(Degradasi Kolagen 77'emodeling Kolagen 7

(!ANUASI-ormon ; 2+ 66/n

EM#STASISKoagulasi +aktor 668asokontriksi 66

2#UND EAIN(


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Acne vulgaris(commonly called acne" is a common skincondition caused !y changes in

pilose!aceous units skin structures consisting o# a hair #ollicleand its associated

se!aceous gland &ia androgenstimulation$ .t is characteri7ed !y nonin#lammatory

#ollicularpapulesor comedonesand !y in#lammatory papulespustules and nodulesin its

more se&ere #orms$ Acne &ulgaris a##ects the areas o# skin )ith the densest population o#

se!aceous #ollicles8 these areas include the #ace the upper part o# the chest and the !ack$Se&ere acne is in#lammatory !ut acne can also mani#est in nonin#lammatory #orms$ 90:Acne

lesions are commonly re#erred to aspimples !lemishes spots 7its or simply acne$

Acne occurs most commonly during adolescence a##ecting more than ;uently continues into adulthood$ The cause o# acne in adolescence is generally an

increase in male se? hormones )hich people o# !oth genders accrue during pu!erty$91:or

most people acne diminishes o&er time and tends to disappear@or at the &ery least

decrease@a#ter one reaches ones early t)enties$ There is ho)e&er no )ay to predict ho)

long it )ill take to disappear entirely and some indi&iduals )ill carry this condition )ell

into their thirties #orties and !eyond$92:

The #aceand upper neck are the most commonly a##ected !ut the chest!ackandshouldersmay ha&e acne as )ell$ The upper armscan also ha&e acne !ut lesions #ound

there are o#ten keratosis pilaris not acne$ Typical acne lesions are comedones

in#lammatory papules pustules and nodules$ Some o# the large nodules )ere pre&iously

called cysts and the term nodulocystichas !een used to descri!e se&ere cases o#

in#lammatory acne$93:

Aside #rom scarring its main e##ects are psychological such as reduced sel#-esteem94:and

according to at least one study depressionor suicide$95:Acne usually appears during

adolescence )hen people already tend to !e most socially insecure$ Carly and aggressi&e

treatment is there#ore ad&ocated !y some to lessen the o&erall impact to indi&iduals $94:

1. Causes o acneAcne de&elops as a result o# !lockages in #ollicles$ ,yperkeratini7ationand #ormation o# a

plug o# keratinand se!um(a microcomedo" is the earliest change$ Cnlargement o#

se!aceous glands and an increase in se!um production occur )ith increased androgen

(D,CA-S" production at adrenarche$ The microcomedo may enlarge to #orm an open

comedone (!lackhead" or closed comedone ()hitehead"$ +hiteheads are the direct result o#

skinpores!ecoming clogged )ith se!um a naturally occurring oil and dead skin cells$ .n

these conditions the naturally occurring largely commensal!acteriaPropionibacterium

acnescan cause in#lammationleading to in#lammatory lesions (papulesin#ected pustules

or nodules" in the dermisaround the microcomedo or comedone )hich results in redness

and may result in scarringor hyperpigmentation$90:

Primar! causes

Acne is kno)n to !e partly hereditary$ Se&eral #actors are kno)n to !e linked to acne/

amilyEFenetic history$ The tendency to de&elop acne runs in #amilies$ or

e?ample school-age !oys )ith acne o#ten ha&e other mem!ers in their #amily )ith

acne as )ell$ A #amily history o# acne is associated )ith an earlier occurrence o#

acne and an increased num!er o# retentional acne lesions$ 900:
http://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Hair_folliclehttp://en.wikipedia.org/wiki/Sebaceous_glandhttp://en.wikipedia.org/wiki/Androgenhttp://en.wikipedia.org/wiki/Papuleshttp://en.wikipedia.org/wiki/Blackheadhttp://en.wikipedia.org/wiki/Pustuleshttp://en.wikipedia.org/wiki/Nodule_(dermatology)http://en.wikipedia.org/wiki/Inflammationhttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-0http://en.wikipedia.org/wiki/Pimplehttp://en.wikipedia.org/wiki/Adolescencehttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-1http://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-2http://en.wikipedia.org/wiki/Facehttp://en.wikipedia.org/wiki/Chesthttp://en.wikipedia.org/wiki/Human_backhttp://en.wikipedia.org/wiki/Shoulderhttp://en.wikipedia.org/wiki/Armhttp://en.wikipedia.org/wiki/Keratosis_pilarishttp://en.wikipedia.org/wiki/Cysthttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-Thiboutot_2003-3http://en.wikipedia.org/wiki/Self-esteemhttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-Goodman-4http://en.wikipedia.org/wiki/Clinical_depressionhttp://en.wikipedia.org/wiki/Clinical_depressionhttp://en.wikipedia.org/wiki/Suicidehttp://en.wikipedia.org/wiki/Suicidehttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-5http://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-5http://en.wikipedia.org/wiki/Adolescencehttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-Goodman-4http://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-Goodman-4http://en.wikipedia.org/wiki/Hair_folliclehttp://en.wikipedia.org/wiki/Hyperkeratinizationhttp://en.wikipedia.org/wiki/Keratinhttp://en.wikipedia.org/wiki/Sebaceous_gland#sebumhttp://en.wikipedia.org/wiki/Androgenhttp://en.wikipedia.org/wiki/Dehydroepiandrosteronehttp://en.wikipedia.org/wiki/Adrenarchehttp://en.wikipedia.org/wiki/Blackheadhttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Poreshttp://en.wikipedia.org/wiki/Sebumhttp://en.wikipedia.org/wiki/Commensalhttp://en.wikipedia.org/wiki/Propionibacterium_acneshttp://en.wikipedia.org/wiki/Propionibacterium_acneshttp://en.wikipedia.org/wiki/Inflammationhttp://en.wikipedia.org/wiki/Inflammationhttp://en.wikipedia.org/wiki/Papulehttp://en.wikipedia.org/wiki/Papulehttp://en.wikipedia.org/wiki/Dermishttp://en.wikipedia.org/wiki/Scarhttp://en.wikipedia.org/wiki/Hyperpigmentationhttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-Simpson_2004-9http://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-Simpson_2004-9http://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-10http://en.wikipedia.org/wiki/Hair_folliclehttp://en.wikipedia.org/wiki/Sebaceous_glandhttp://en.wikipedia.org/wiki/Androgenhttp://en.wikipedia.org/wiki/Papuleshttp://en.wikipedia.org/wiki/Blackheadhttp://en.wikipedia.org/wiki/Pustuleshttp://en.wikipedia.org/wiki/Nodule_(dermatology)http://en.wikipedia.org/wiki/Inflammationhttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-0http://en.wikipedia.org/wiki/Pimplehttp://en.wikipedia.org/wiki/Adolescencehttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-1http://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-2http://en.wikipedia.org/wiki/Facehttp://en.wikipedia.org/wiki/Chesthttp://en.wikipedia.org/wiki/Human_backhttp://en.wikipedia.org/wiki/Shoulderhttp://en.wikipedia.org/wiki/Armhttp://en.wikipedia.org/wiki/Keratosis_pilarishttp://en.wikipedia.org/wiki/Cysthttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-Thiboutot_2003-3http://en.wikipedia.org/wiki/Self-esteemhttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-Goodman-4http://en.wikipedia.org/wiki/Clinical_depressionhttp://en.wikipedia.org/wiki/Suicidehttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-5http://en.wikipedia.org/wiki/Adolescencehttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-Goodman-4http://en.wikipedia.org/wiki/Hair_folliclehttp://en.wikipedia.org/wiki/Hyperkeratinizationhttp://en.wikipedia.org/wiki/Keratinhttp://en.wikipedia.org/wiki/Sebaceous_gland#sebumhttp://en.wikipedia.org/wiki/Androgenhttp://en.wikipedia.org/wiki/Dehydroepiandrosteronehttp://en.wikipedia.org/wiki/Adrenarchehttp://en.wikipedia.org/wiki/Blackheadhttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Poreshttp://en.wikipedia.org/wiki/Sebumhttp://en.wikipedia.org/wiki/Commensalhttp://en.wikipedia.org/wiki/Propionibacterium_acneshttp://en.wikipedia.org/wiki/Propionibacterium_acneshttp://en.wikipedia.org/wiki/Inflammationhttp://en.wikipedia.org/wiki/Papulehttp://en.wikipedia.org/wiki/Dermishttp://en.wikipedia.org/wiki/Scarhttp://en.wikipedia.org/wiki/Hyperpigmentationhttp://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-Simpson_2004-9http://en.wikipedia.org/wiki/Acne_vulgaris#cite_note-10http://en.wikipedia.org/wiki/Skin


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,ormonal acti&ity such as menstrual cyclesandpu!erty$During pu!erty an

increase in male se? hormones called androgens cause the #ollicular glands to get

larger and make more se!um$901:

.n#lammation skin irritation or scratching o# any sort )ill acti&ate in#lammation$

Stress$ +hile the connection !et)een acne and stress has !een de!ated scienti#icresearch indicates that increased acne se&erity is signi#icantly associated )ith

increased stress le&els$902:The National .nstitutes o# ,ealth (GSA" list stress as a

#actor that can cause an acne #lare$903:A study o# adolescents in Singapore

o!ser&ed a statistically signi#icant positi&e correlation 9H: !et)een stress le&els

and se&erity o# acne$904:

,yperacti&e se!aceous glands secondary to the three hormone sources a!o&e$

Bacteria in thepores$Propionibacterium acnes (P. acnes)is the anaero!ic

!acterium that causes acne$ .n-&itro resistance o#P. acnesto commonly used

anti!iotics has !een increasing$905:

Gse o# ana!olic steroids$906:

C?posure to certain chemical compounds$ Ihloracneis particularly linked to to?ic

e?posure to dio?ins namelyIhlorinated dio?ins$9citation needed:

Ihronic use o# amphetaminesor other similar drugs$90;:

Se&eral hormonesha&e !een linked to acne/ the androgens testosterone

dihydrotestosterone(D,T" and dehydroepiandrosterone sul#ate(D,CAS" as )ell as

insulin-like gro)th #actor 0(.F-."$

De&elopment o# acne &ulgaris in later years is uncommon although this is the age group

#or Josacea)hich may ha&e similar appearances$ True acne &ulgaris in adult )omen may!e a #eature o# an underlying condition such as pregnancy and disorders such aspolycystic

o&ary syndromeor the rare Iushings syndrome$ %enopause-associated acne occurs as

production o# the natural anti-acne o&arian hormone estradiol#ails at menopause$ The lack

o# estradiol also causes thinning hair hot #lashes thin skin )rinkles &aginal dryness and

predisposes to osteopenia and osteoporosis as )ell as triggering acne (kno)n as acne

climacterica in this situation"$

Diet

Chocolate

The popular !elie# that chocolate intake in and o# itsel# is a cause o# acne is not supported

!y scienti#ic studies$90


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Milk

Jecently three epidemiologicalstudies #rom the same group o# scientists #ound an

association !et)een acne and consumption o# partially skimmedmilk instant !reak#ast

drink sher!et cottage cheese and cream cheese$911:912:913:The researchers hypothesi7e that

the association may !e caused !y hormones (such as se&eral se? hormones and !o&ine

insulin-like gro)th #actor 0(.F-0"" or e&en iodine914:present in co) milk$

Carbohydrates

The long-held !elie# that there is no link !et)een diets high in re#ined sugars and

processed #oods and acne has recently !een challenged$915:The pre&ious !elie# )as !ased

on earlier studies (some using chocolateand Ioca-Iola" that )ere methodologically

#la)ed$915:916:91;:The recent lo) glycemic-load hypothesis postulates that rapidly digested

car!ohydrate #oods (such as so#t drinks s)eets )hite !read" produce an o&erload in !lood

glucose (hyperglycemia" that stimulates the secretion o# insulin )hich in turn triggers the

release o# .F-0$915:.F-0 has direct e##ects on the pilose!aceous unit (and insulin at high

concentrations can also !ind to the .F-0 receptor" 91


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2. #$at is %car Tissue &

Adhesions (scar tissue" is a dead #i!rotic tissue that #orms mostly in muscles tendons

ligaments #ascia and *oints$

Scar Tissue occurs as a result o# in*ury surgery or repetiti&e motion$ +hen a muscletendon or ligament is torn (strained or sprained" or ner&e is damaged healing occurs in

three stages called the in#lammatory response/ acute in#lammation repair and remodeling$

In acute inlammation' redness' s(elling' $eat and )ain occur$ This phase lasts

appro?imately 61 hours$ A#ter the in#lammation recedes repair !egins$ The damaged

tissues heal )ith adhesions or scar tissue #ormation rather than the #ormation o# !rand ne)

tissue$

+hen a muscle tightens up-- through a repetiti&e motion such as typing or a#ter it has !een

in*ured-- s)elling occurs and it restricts the o?ygen supply to the muscles and connecti&e

tissues (hypo?ia*. T$e lack o o+!gen also causes scar tissue to orm.

That scar tissue can adhere to muscle #i!ers pre&enting them #rom sliding !ack and #orth

properly$ .t can adhere to connecti&e tissues limiting the #le?i!ility o# a muscle or *oint$

And it can adhere to ner&e cells leading to carpal tunnel syndrome chronic !ack pain and

other conditions$

Scar tissue can !ind up many layers o# muscle and connecti&e tissue causing &arying

degrees o# limited mo&ement and pain$

Jesearch has pro&en scar tissue to !e )eaker less elastic more prone to #uture re-in*ury

and as much as 0 times more pain sensiti&e than normal healthy tissue$ Ihronic pain is

the result pain that could remain #or years a#ter the initial in*ury$

To a&oid the #ormation o# adhesi&e scar tissue a#ter an in*ury surgery or e?cessi&e

muscles o&eruse healing must take place in t$e )resence o a ull range o movement$

Scar tissue #orms as skin heals a#ter an in*ury or surgery$The amount o# scar tissue may !e

determined ,!t$e si-e' de)t$' and location o t$e (ound t$e age o t$e )erson

$eredit! and skin c$aracteristics$

The color o# a scar may !e pale pink !ro)n or sil&ery$ Some people tend to get scars

more easily and scars are more likely to #orm a#ter )ounds on certain parts o# the !ody$

Fuaranteed e##ecti&e all natural Scar Jemo&al

"o( scarring occursA scar is a natural part o# the healing process$ Skin scars occur )hen the deep thick layer

o# skin (the dermis" is damaged$ The )orse the damage is the )orse the scar )ill !e$ %ost

skin scars are #lat pale and lea&e a trace o# the original in*urythat caused them$ The

redness that o#ten #ollo)s an in*ury to the skin is not a scar and is generally not permanent$

The time it takes #or it to go a)ay may ho)e&er range #rom a #e) days to in some serious

and rare cases a #e) years$ Various treatments can speed up the process in serious cases$

Scars #orm di##erently !ased on the location o# the in*ury on the !ody and the age o# the

person )ho )as in*ured$ To mend the damage the !ody has to lay do)n ne)collagen

#i!ers (a naturally occurringproteinthat is produced !y the !ody !y #i!ro!lasts"$ .n

)ounded tissue these #i!ers are o&er e?pressed )ith collagen !ut not so in non )ounded

tissue$ Sta!le #orms o# topical &itamin I ha&e !een sho)n to impro&e collagen
http://www.mamashealth.com/doc/surgeon.asphttp://www.mamashealth.com/doc/surgeon.asphttp://www.amoils.com/scars.htmlhttp://en.wikipedia.org/wiki/Dermishttp://en.wikipedia.org/wiki/Injuryhttp://en.wikipedia.org/wiki/Collagenhttp://en.wikipedia.org/wiki/Collagenhttp://en.wikipedia.org/wiki/Collagenhttp://en.wikipedia.org/wiki/Proteinhttp://www.mamashealth.com/doc/surgeon.asphttp://www.amoils.com/scars.htmlhttp://en.wikipedia.org/wiki/Dermishttp://en.wikipedia.org/wiki/Injuryhttp://en.wikipedia.org/wiki/Collagenhttp://en.wikipedia.org/wiki/Protein


11/31

#ormation91:$ Jecent research has also implicated the gene product osteopontinin scarring

andGni&ersity o# Bristolha&e de&eloped a gel that inhi!its the process 92:93:$

An in*ury does not !ecome a scar until the )ound has completely healed$ And !ecause the

)ounded !ody tissue o&er e?presses collagen on the #i!ers and cannot re-!uild the ne)

tissue )ill ha&e a di##erent te?ture and >uality than the surrounding normal tissue$ This

collagen producing process results in a #ortuna scar$

Trans#orming Fro)th actors (TF" play a critical role in scar de&elopment and current

research is in&estigating the manipulation o# these TFs #or drug de&elopment to pre&ent

scarring #rom the emergency adult )ound healing process$ As )ell a recent American

study implicated the protein Ji!osomal s5 kinase(JSK" in the #ormation o# scar tissue and

#ound that the introduction o# a chemical to counteract JSK could halt the #ormation o#

Iirrhosis$ This treatment also has the potential to reduce or e&en pre&ent altogether other

types o# scarring$94:

A,normal scars

T)o types o# scars are the result o# the !ody o&erproducing collagen )hich causes the scarto !e raised a!o&e the surrounding skin$ ,ypertrophicscars take the #orm o# a red raised

lump on the skin !ut do not gro) !eyond the !oundaries o# the original )ound and they

o#ten impro&e in appearance a#ter a #e) years$Keloidscars are a more serious #orm o#

scarring !ecause they can carry on gro)ing inde#initely into a large tumorous (although

!enign" gro)th$

Keloid scars can occur on anyone !ut they are most common in dark-skinned people$ 95:

Keloid scars can !e caused !y surgery an accident !yacneor sometimes #rom!ody

piercings$ .n some people keloid scars #orm spontaneously$

Although they can !e a cosmetic pro!lem keloid scars are only inert masses o# collagen

and there#ore completely harmless and non-contagious$ ,o)e&er they can !e itchy orpain#ul in some indi&iduals$ They tend to !e most common on the shouldersand chest$

Alternately a scar can take the #orm o# a sunken recess in the skin )hich has a pitted

appearance$ These are caused )hen underlying structures supporting the skin such as #at

or muscle are lost$ This type o# scarring is commonly associated )ith acne !ut can !e

caused !y chickenpo? surgery or an accident$

Scars can also take the #orm o# stretched skin$These are called striae and are caused )hen

the skin is stretched rapidly (#or instance duringpregnancy signi#icant )eight gain or

adolescent gro)th spurts" or )hen skin is put under tension during the healing process

(usually near*oints"$ This type o# scar usually impro&es in appearance a#ter a #e) years$

Scar keloid Jaringan+ith the skins constant a!ility to shed old cells and create ne) ones cuts )ounds and

incisions are repaired$ ,o)e&er it is this &ery process that also results in scars o# all shapes

and si7es$ +hile a &isi!le scar may !e the end to the healing process the results &ary )ith

the indi&iduals and methods used to help the !ody speed skin repair$

A scar is gro)th o# collagen !eneath the skin that is #ormed as the result o# )ound healing8

there#ore e&ery cut or in*ury to the skin heals to #orm a scar$ A scar usually takes 01 to 0;

months to #ully mature$ Not all scars are the result o# )ounds !urns surgeries and

accidents$

%kin diseases caused ,! ,acteria' ungus' or viruses can also result in scarring.or

e?ample acne oten leaves a variet! o scars' and stretch marks are a #orm o# scars

caused !y )eight loss or gro)th$ Carly in the process scars are red or dark and raised !ut
http://en.wikipedia.org/wiki/Scar#cite_note-1http://en.wikipedia.org/wiki/Osteopontinhttp://en.wikipedia.org/wiki/University_of_Bristolhttp://en.wikipedia.org/wiki/University_of_Bristolhttp://en.wikipedia.org/wiki/Scar#cite_note-2http://en.wikipedia.org/wiki/Scar#cite_note-3http://en.wikipedia.org/wiki/Scar#cite_note-3http://en.wikipedia.org/wiki/Ribosomal_s6_kinasehttp://en.wikipedia.org/wiki/Cirrhosishttp://en.wikipedia.org/wiki/Scar#cite_note-4http://en.wikipedia.org/wiki/Organ_hypertrophyhttp://en.wikipedia.org/wiki/Keloidhttp://en.wikipedia.org/wiki/Keloidhttp://en.wikipedia.org/wiki/Keloidhttp://en.wikipedia.org/wiki/Scar#cite_note-5http://en.wikipedia.org/wiki/Acne_vulgarishttp://en.wikipedia.org/wiki/Acne_vulgarishttp://en.wikipedia.org/wiki/Body_piercingshttp://en.wikipedia.org/wiki/Body_piercingshttp://en.wikipedia.org/wiki/Shoulderhttp://en.wikipedia.org/wiki/Chesthttp://en.wikipedia.org/wiki/Fathttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Chickenpoxhttp://en.wikipedia.org/wiki/Stretch_markshttp://en.wikipedia.org/wiki/Stretch_markshttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Growth_spurthttp://en.wikipedia.org/wiki/Jointshttp://en.wikipedia.org/wiki/Scar#cite_note-1http://en.wikipedia.org/wiki/Osteopontinhttp://en.wikipedia.org/wiki/University_of_Bristolhttp://en.wikipedia.org/wiki/Scar#cite_note-2http://en.wikipedia.org/wiki/Scar#cite_note-3http://en.wikipedia.org/wiki/Ribosomal_s6_kinasehttp://en.wikipedia.org/wiki/Cirrhosishttp://en.wikipedia.org/wiki/Scar#cite_note-4http://en.wikipedia.org/wiki/Organ_hypertrophyhttp://en.wikipedia.org/wiki/Keloidhttp://en.wikipedia.org/wiki/Scar#cite_note-5http://en.wikipedia.org/wiki/Acne_vulgarishttp://en.wikipedia.org/wiki/Body_piercingshttp://en.wikipedia.org/wiki/Body_piercingshttp://en.wikipedia.org/wiki/Shoulderhttp://en.wikipedia.org/wiki/Chesthttp://en.wikipedia.org/wiki/Fathttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Chickenpoxhttp://en.wikipedia.org/wiki/Stretch_markshttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Growth_spurthttp://en.wikipedia.org/wiki/Joints


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)ill !ecome paler and #latter o&er time$ .t can take up to 13 months #or a scar to de&elop

and mature to its sta!le #orm and appearance$

There are three di##erent types o# scars /// atro)$ic' $!)ertro)$ic' and keloids$ Atrophic

scars are depressed and cause a &alley or hole in the skin$ ,ypertrophic scars are ele&ated

and )ill su!side )ith time$

Keloids are actually non-malignant tumors #ormed !y scar tissue that e?ceeds the

!oundaries o# an original incision or in*ury$ Keloidal scars are ele&ated e?pansi&e and

continue to gro)$ .n addition to appearance location and orientation are also important

considerations in determining scar type$ .# a scar is thickened does not in&ade normal

tissue and lies across the rela?ed skin tension lines (creases in the skin" then it is a

hypertrophic scar$ .# it is ele&ated and in&ading normal tissue then it is a keloid scar$

Keloids ha&e the appearance o# a raised amorphous gro)th and are #re>uently associated

)ith pruritus and pain$$ %icroscopy o!ser&ation re&eals randoml! organi7ed collagen

#i!ers in a dense connecti&e tissue matri?$ .n normal scars the collagen !undles are

arranged )arallel to the skin sur#ace$

An hypertrophic scar is a )idened or unsightly scar that does not e?tend !eyond theoriginal !oundaries o# the )ound$ Gnlike keloids an $!)ertro)$icscar reaches a certain

si-e and su,seuentl! sta,ili-es or regresses.Similar to keloids hypertrophic scars are

associated )ith adverse (ound $ealing actors$

%cars and t$e %kin e)air Process

The remo&al or reduction o# scars lesions and stretch marks #rom the skin depends on a

process called skin remodeling$ The skin is designed to $eal (ounds>uickly to )revent

,lood loss and inection$ Scars are manu#actured #rom a rapidly #ormed collagen glue

that the !ody deposits into an in*ured area #or protection and strength$ .n ideal skin healing

)ounded skin is rapidly closed and then the healed area is slo)ly reconstructed to remo&e

the residual collagen scars and !lend the skin area into near!y skin$

Scar collagen is remo&ed and replaced )ith a mi?ture o# skin cells and in&isi!le collagen

#i!ers$ This remodeling may continue in a skin area #or ten years$

.n children the remodeling rate is high and scars are usually rapidly remo&ed #rom in*ured

skin areas$ But as )e reach adulthood this rate diminishes and small scars may remain #or

years$

One )ay to accelerate remodelingis to induce a small amount o controlled skin

damage)ith a needle' laser' acid' or ot$er means' and t$en let t$e ,od! re)air

)rocesses re,uild t$e skin area.

A second method is to use en-!mes and i,ro,last )rolieratorsto increase the !odysnatural re!uilding processes and o!tain e&en !etter #inal results$ i!ro!lasts are the cells in

the !asal mem!rane o# the skin and they are the precursors o# all the structural elements o#

healthy skin including those that pro&ide tensile strength and elasticity to skin$ Cn7ymes

dissol&e or digest damaged and dying cells$

Keloid

Akeloid(also kno)n as a keloidal scar 90:/03


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itchiness9citation needed:sharp pains9citation needed:and changes in te?ture$ .n se&ere cases it can

a##ect mo&ement o# skin$

Keloids should not !e con#used )ith hypertrophic scars )hich are raised scars that do not

gro) !eyond the !oundaries o# the original )ound$

Keloids e?pand in cla)-like gro)ths o&er normal skin$ They ha&e the capa!ility to hurt)ith a needle-like pain or to itch )ithout )arning although the degree o# sensation &aries

#rom patient to patient$

.# the keloid !ecomes in#ected it may ulcerate$ The only treatment is to remo&e the scar

completely$ ,o)e&er the pro!a!ility that the resulting surgery scar )ill also !ecome a

keloid is high usually greater than 4$

Keloids#orm )ithin scar tissue$Iollagen used in )ound repair tends to o&ergro) in this

area sometimes producing a lump many times larger than that o# the original scar$

Although they usually occur at the site o# an in*ury keloids can also arise spontaneously$

They can occur at the site o# apiercingand e&en #rom something as simple as a pimple or

scratch$ They can occur as a result o severeacneor c$icken)o+scarring in#ection at a)ound site repeated trauma to an area e?cessi&e skin tension during )ound closure or a

#oreign !ody in a )ound$ Keloids can sometimes !e sensiti&e to chlorine$

Biologically keloids are i,rotic tumorscharacteri7ed !y a collection o# at!)ical

i,ro,lasts)ith e?cessi&e deposition o# e?tracellular matri? components especially

collagen #i!ronectin elastin and proteoglycans$ Fenerally keloids contain relati&ely

acellular centers and thick a!undant collagen !undles that #orm nodules in the deep dermal

portion o# the lesion$ Keloids present a therapeutic challenge that must !e addressed as

these lesions can cause signi#icant pain pruritus (itching" and physical dis#igurement$

They may not impro&e in appearance o&er time and can limit mo!ility i# located o&er a

*oint$

Keloids a##ect !oth se?es e>ually although the incidence in young #emale patients has !een

reported to !e higher than in young males pro!a!ly re#lecting the greater #re>uency o#

earlo!e piercing among )omen$ There is a #i#teen times higher #re>uency o# occurrence in

highly pigmented people$ .t is speculated that people )ho possess any degree o# A#rican

descent regardless o# skin color may !e especially suscepti!le to keloid occurrences$

Scars are al)ays #ormed to reconnect skin that has !een damaged$ .nitially they may !e

red or dark and rose a#ter the )ound has healed !ut )ill !ecome paler and #latter naturally

o&er time resulting in a #lat pale scar$$ Details on scar reduction at/ !iological )ound

healing

or reasons that are yet to !e #ully understood some people #orm raised scars that are red

and thick and may !e itchy or pain#ul and others de&elop scars that e?tend !eyond the site

o# an in*ury called keloid scars$

Keloid scars are actually thick puckered itchy clusters o# scar tissue that gro) !eyond the

edges o# a )ound or incision and rarely regress$ They occur )hen the !ody continues to

produce tough #i!rous protein (kno)n as collagen" a#ter a )ound has healed$

Keloid scars can result #rom any type o# in*ury to the skin including scratches in*ections

insect !ites tattoos or surgery procedures$ Keloid scars can appear any)here on the !ody

!ut most commonly occur o&er the !reast!one on earlo!es and on shoulders$

"!)ertro)$ic scarssometimes are di##icult to distinguish #rom keloid scars histologically

and !iochemically !ut unlike keloids hypertropic scars remain con#ined to the in*ury siteand o#ten mature and #latten out o&er time$ Both types o# scars secrete larger amounts o#
http://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Hypertrophic_scarshttp://en.wikipedia.org/wiki/Ulcer_(dermatology)http://en.wikipedia.org/wiki/Scarhttp://en.wikipedia.org/wiki/Collagenhttp://en.wikipedia.org/wiki/Collagenhttp://en.wikipedia.org/wiki/Wound_repairhttp://en.wikipedia.org/wiki/Piercinghttp://en.wikipedia.org/wiki/Acne_vulgarishttp://en.wikipedia.org/wiki/Acne_vulgarishttp://en.wikipedia.org/wiki/Chickenpoxhttp://66.249.89.132/translate_c?hl=id&sl=en&u=http://www.bioskinrepair.com/regeneration/biologyofwoundhealing.html&prev=/search%3Fq%3Dkeloid%2B%2526%2Bscarr%2Btissue%26hl%3Did%26client%3Dfirefox-a%26channel%3Ds%26hs%3DuUS%26sa%3DG&rurl=translate.google.co.id&usg=ALkJrhh6x43Hekv-PyWCcOIgkSP7pXoQ8Qhttp://66.249.89.132/translate_c?hl=id&sl=en&u=http://www.bioskinrepair.com/regeneration/biologyofwoundhealing.html&prev=/search%3Fq%3Dkeloid%2B%2526%2Bscarr%2Btissue%26hl%3Did%26client%3Dfirefox-a%26channel%3Ds%26hs%3DuUS%26sa%3DG&rurl=translate.google.co.id&usg=ALkJrhh6x43Hekv-PyWCcOIgkSP7pXoQ8Qhttp://66.249.89.132/translate_c?hl=id&sl=en&u=http://www.bioskinrepair.com/regeneration/biologyofwoundhealing.html&prev=/search%3Fq%3Dkeloid%2B%2526%2Bscarr%2Btissue%26hl%3Did%26client%3Dfirefox-a%26channel%3Ds%26hs%3DuUS%26sa%3DG&rurl=translate.google.co.id&usg=ALkJrhh6x43Hekv-PyWCcOIgkSP7pXoQ8Qhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Hypertrophic_scarshttp://en.wikipedia.org/wiki/Ulcer_(dermatology)http://en.wikipedia.org/wiki/Scarhttp://en.wikipedia.org/wiki/Collagenhttp://en.wikipedia.org/wiki/Wound_repairhttp://en.wikipedia.org/wiki/Piercinghttp://en.wikipedia.org/wiki/Acne_vulgarishttp://en.wikipedia.org/wiki/Chickenpoxhttp://66.249.89.132/translate_c?hl=id&sl=en&u=http://www.bioskinrepair.com/regeneration/biologyofwoundhealing.html&prev=/search%3Fq%3Dkeloid%2B%2526%2Bscarr%2Btissue%26hl%3Did%26client%3Dfirefox-a%26channel%3Ds%26hs%3DuUS%26sa%3DG&rurl=translate.google.co.id&usg=ALkJrhh6x43Hekv-PyWCcOIgkSP7pXoQ8Qhttp://66.249.89.132/translate_c?hl=id&sl=en&u=http://www.bioskinrepair.com/regeneration/biologyofwoundhealing.html&prev=/search%3Fq%3Dkeloid%2B%2526%2Bscarr%2Btissue%26hl%3Did%26client%3Dfirefox-a%26channel%3Ds%26hs%3DuUS%26sa%3DG&rurl=translate.google.co.id&usg=ALkJrhh6x43Hekv-PyWCcOIgkSP7pXoQ8Q


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collagen than normal scars !ut typically the hypertrophic type e?hi!its declining collagen

synthesis a#ter a!out si? months$ ,o)e&er hypertrophic scars contain nearly t)ice as

much glycosaminoglycan as normal scars and this and enhanced synthetic and en7ymatic

acti&ity result in signi#icant alterations in the matri? )hich a##ects the mechanical

properties o# the scars including decreased e?tensi!ility that makes them #eel #irm$

As )ith hypertrophic scarring people )ho ha&e de&eloped one keloid scar are likely to !eprone to this condition in the #uture and should alert their doctor or surgeon i# they are

likely to need in*ections or to ha&e any #orm o# surgery$

Atrophic scars are characteri7ed !y a thinning and diminished elasticity o# the skin due to a

loss o# normal skin architecture$ An e?ample o# an atrophic scar is striae distensae also

kno)n as stretch marks$

#$en t$e skin is damaged it )roduces gro(t$ actors'

in$i,itors o tumors and )roteins.

ollo)ing cutaneous in*ury or )ounding gro)th #actors are produced to stimulate theregeneration o# tissue and to induce the creation o# antimicro!ial peptides$ The gro)th

#actor response ceases a#ter regeneration o# the tissue )hen the physical !arrier protecting

against micro!ial in#ections is re-esta!lished$

Skin )ounds healing is a &ital process in&ol&ing proli#eration o# cellular elements )ith

accompanying synthesis o# e?tracellular matri? that results in replacement o# an open skin

)ound )ith tissue$ +ith the completion o# the dynamic process o# )ound healing a scar

remains in place o# the )ound$ Although scar di##ers #rom normal unin*ured skin a normal

scar returns #unctionality to the skin$ ,o)e&er that scar restores tensile strength to only

appro?imately ; o# normal unin*ured skin and stands out in appearance #rom the normal

surrounding skin$

The process o# )ound healing ho)e&er can go a)ry$ The )ounds o# some people undergo

a!errant healing resulting in the #ormation o# a!normal scars kno)n as keloids or

hyperthropic scars$ A#ter a )ound has occurred to the skin !oth skin cells and connecti&e

tissue cells (#i!ro!lasts" !egin multiplying to repair the damage$ The #i!ro!lasts #orm a

#rame)ork upon )hich the skin cells can migrate into and #ill in the )ound$ .t is the

,alance!et)een the rate o# replication o# #i!ro!lasts &ersus skin cells that is important

here$ .# the i,ro,lasts re)licate too uickl! they can #orm a dense net(orkthat is not as

easily penetrated !y the skin cells and that results in a large scar$ .# the skin cells keep up

)ith the #i!ro!lasts then little scar tissue is #ormed and the skin has a more normal

appearance a#ter the )ound has healed$

Scar tissue is the #i!rous connecti&e tissue)hich #orms a scar8 it can !e #ound on anytissue on the !ody including skin and internal organs )here an in*ury cut surgery or

disease has taken place and then healed$ Thicker than the surrounding tissue scar tissue is

paler and denser !ecause it has a limited !lood supply8 although it takes the place o#

damaged or destroyed tissue it is limited in #unction including mo&ement circulation and

sensation$ Other than )ith minor cuts and scrapes scarring is a common result o# any

!odily damage$

Scar tissue in the skin is in#erior to healthy normal skin #or se&eral reasons/ s)eat glands

are damaged or destroyed hair does not gro) !ack and there is less resistance to

ultra&iolet radiation$ Skin scars are normally #lat and pale illustrating the history o# the

in*ury )hich caused them yet o#ten a !ody )ill produce too much #i!rous tissue resultingin an e?tra thick or raised scar$
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Hypertrophic scars#orm as red lumps on the skin !ut stay )ithin the con#ines o# the

original )ound$Keloidscarsmay co&er the original )ound !ut then continue to gro)

causing a type o# tumorous gro)th$ ,ypertrophic and keloid scarscan occur in anyone !ut

are more common in younger and dark skinned people$ .n rare cases keloid scars #orm

)ithout )arning or in*ury$

%cars(also called cicatrices" are areas o# #i!rous tissuethat replace normal skin(or othertissue" a#ter in*ury$ A scar results #rom the !iologic process o#)oundrepair in the skinand

other tissueso# the !ody$ Thus scarring is a natural part o# the healingprocess$ +ith the

e?ception o# &ery minor lesions e&ery )ound (e$g$ a#ter accidentdiseaseor surgery"

results in some degree o# scarring$9citation needed:

Scar tissue is not identical to the tissue that it replaces and is usually o# in#erior #unctional

>uality$ or e?ample scars in the skin are less resistant to ultra&iolet radiation and s)eat

glandsand hair #olliclesdo not gro) !ack )ithin scar tissue$ Amyocardial in#arction

commonly kno)n as a heart attack causes scar #ormationin the heartmuscle )hich leads

to loss o# muscular po)er and possi!ly heart #ailure$ ,o)e&er there are some tissues (e$g$

!one" that can heal )ithout any structural or #unctional deterioration$

4. Acne vulgaris 5 %cars Tissue or Keloid

Skin diseases caused !y !acteria #ungus or &iruses can also result in scarring$ or

e?ample acne oten leaves a variet! o scars' and stretch marks are a #orm o# scars

caused !y )eight loss or gro)th$ Carly in the process scars are red or dark and raised !ut

)ill !ecome paler and #latter o&er time$ .t can take up to 13 months #or a scar to de&elop

and mature to its sta!le #orm and appearance$ Acne o#ten lea&es small scars)here the skin

gets a &olcanic shape$

Physical acne scars are o#ten re#erred to as .cepick scars$ This is !ecause the scars tend to

cause an indentation in the skins sur#ace$ There are a range o# treatments a&aila!le$Although >uite rare the medical condition Atrophia %aculosa Varioli#ormis Iutisalso

results in acne like depressed scars on the #ace$

Ice pick scars/ Deep pits that are the most common and a classic sign o# acne

scarring$

Box car scars/ Angular scars that usually occur on the temple and cheeks and can

!e either super#icial or deep these are similar to chickenpo?scars$

Rolling scars/ Scars that gi&e the skin a )a&e-like appearance$

Hypertrophic scars/ Thickened or keloidscars$

6. #ound "ealing

+ound healing is a comple? and dynamic process o# restoring cellular structures and tissue

layers$ The human adult )ound healing process can !e di&ided into 2 distinct phases/ the

inlammator! )$ase' t$e )rolierative )$ase' and t$e remodeling )$ase$ +ithin these 2

!road phases is a comple? and coordinated series o# e&ents that includes c$emota+is'

)$agoc!tosis' neocollagenesis' collagen degradation' and collagen remodeling$ .n

addition angiogenesis epitheli7ation and the production o# ne) glycosaminoglycans

(FAFs" and proteoglycans are &ital to the )ound healing milieu$ The culmination o# these

!iological processes results in the replacement o# normal skin structures )ith #i!ro!lastic

mediated scar tissue$ or more in#ormation on )ound healing &isit %edscapes +ound

%anagement Jesource Ienter$
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This process can go a)ry and produce an e?u!erance o# #i!ro!lastic proli#eration )ith a

resultant hypertrophic scar )hich !y de#inition is con#ined to the )ound site$ urther

e?u!erance can result in keloid#ormation )here scar production e?tends !eyond the area

o# the original insult$ Ion&ersely insu##icient healing can result in atrophic scar #ormation$

Ilick hereto complete a I%C acti&ity on e&idence-!ased medicine in )ound care$

Types of Wound Healing

Although &arious categories o# )ound healing ha&e !een descri!ed the ultimate outcome

o# any healing process is repair o# a tissue de#ect$

Primary healing delayed primary healing and healing !y secondary intention are the 2

main categories o# )ound healing$ C&en though di##erent categories e?ist the interactions

o# cellular and e?tracellular constituents are similar$

A #ourth category is healing that transpires )ith )ounds that are only partial skin

thickness$0

Categories of Wound Healing

Categor! 1

Primary )ound healing or healing !y #irst intention occurs )ithin hours o# repairing a #ull-

thickness surgical incision$ This surgical insult results in the mortality o# a minimal num!er

o# cellular constituents$

Categor! 2

.# the )ound edges are not reappro?imated immediately delayed primary )ound healing

transpires$ This type o# healing may !e desired in the case o# contaminated )ounds$ By the

#ourth day phagocytosis o# contaminated tissues is )ell under)ay and the processes o#

epitheli7ation collagen deposition and maturation are occurring$ oreign materials are

)alled o## !y macrophages that may metamorphose into epithelioid cells )hich areencircled !y mononuclear leukocytes #orming granulomas$ Gsually the )ound is closed

surgically at this *uncture and i# the cleansing o# the )ound is incomplete chronic

in#lammation can ensue resulting in prominent scarring$

Categor! 4

A third type o# healing is kno)n as secondary healing or healing !y secondary intention$ .n

this type o# healing a #ull-thickness )ound is allo)ed to close and heal$ Secondary healing

results in an in#lammatory response that is more intense than )ith primary )ound healing$

.n addition a larger >uantity o# granulomatous tissue is #a!ricated !ecause o# the need #or

)ound closure$ Secondary healing results in pronounced contraction o# )ounds$

i!ro!lastic di##erentiation into myo#i!ro!lasts )hich resem!le contractile smooth muscleis !elie&ed to contri!ute to )ound contraction$ These myo#i!ro!lasts are ma?imally

present in the )ound #rom the 0th-10st days$

Categor! 6

Cpitheli7ation is the process !y )hich epithelial cells migrate and replicate &ia mitosis and

tra&erse the )ound$ This occurs as part o# the phases o# )ound healing )hich are

discussed in Se>uence o# C&ents in +ound ,ealing$ .n )ounds that are partial thickness

in&ol&ing only the epidermis and super#icial dermis epitheli7ation is the predominant

method !y )hich healing occurs$ +ound contracture is not a common component o# this

process i# only the epidermis or epidermis and super#icial dermis are in&ol&ed$
http://emedicine.medscape.com/article/876214-overviewhttp://emedicine.medscape.com/article/1298013-overviewhttp://emedicine.medscape.com/article/1298013-overviewhttp://www.medscape.com/viewarticle/570628http://emedicine.medscape.com/article/1298129-overview#SequenceofEventsinWoundHealinghttp://emedicine.medscape.com/article/876214-overviewhttp://emedicine.medscape.com/article/1298013-overviewhttp://www.medscape.com/viewarticle/570628http://emedicine.medscape.com/article/1298129-overview#SequenceofEventsinWoundHealing


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!er!ie" of Wound Healing

The amalgam o# coordinated e&ents that constitute the process o# )ound healing is >uite

comple?$ The steps in the procession o# )ound healing include in#lammation the

i,ro,lastic )$ase' scar maturation' and (ound contracture$12+ound contracture is a

process that occurs throughout the healing process commencing in the #i!ro!lastic stage$1

The in#lammatory phase occurs immediately #ollo)ing the in*ury and lasts appro?imately

5 days$ The #i!ro!lastic phase occurs at the termination o# the in#lammatory phase and can

last up to 3 )eeks$ Scar maturation !egins at the #ourth )eek and can last #or years $1

An analogous system depicts the 3 phases as $emostasis' inlammation' granulation' and

remodelingin a continuous sym!iotic process$3This is the phase system used in this te?t$

Se#uence of E!ents in Wound Healing

ollo)ing tissue in*ury &ia an incision the initial response is usually !leeding$ The cascade

o# &asoconstriction and coagulation commences )ith clotted !lood immediately

impregnating the )ound leading to hemostasis and )ith dehydration a sca! #orms$ An

in#lu? o# inlammator! cells#ollo)s )ith the release o# cellular su!stances andmediators$ Angiogenesisand re/e)it$eli-ationoccur and the deposition o# ne) cellular

and e?tracellular components ensues$

Initial )$ase / "emostasis

ollo)ing &asoconstriction platelets adhere to damaged endothelium and discharge

adenosine diphosphate (ADP" promoting throm!ocyte clumping )hich dams the )ound$

The in#lammatory phase is initiated !y the release o# numerous cytokines !y platelets$

Alpha granules li!erate platelet-deri&ed gro)th #actor (PDF" platelet #actor .V and

trans#orming gro)th #actor !eta (TF-!" )hile &asoacti&e amines such as histamine and

serotonin are released #rom dense !odies #ound in throm!ocytes$ PDF is chemotactic #or

#i!ro!lasts and along )ith TF-! is a potent modulator o# #i!ro!lastic mitosis leading toproli#ic collagen #i!ril construction in later phases$ i!rinogen is clea&ed into #i!rin and the

#rame)ork #or completion o# the coagulation process is #ormed$ i!rin pro&ides the

structural support #or cellular constituents o# in#lammation$ This process starts immediately

a#ter the insult and may continue #or a #e) days$

%econd )$ase / Inlammation

+ithin the #irst 5-; hours the ne?t phase o# the healing process is under)ay )ith

polymorphonuclear leukocytes (P%Ns" engorging the )ound$ TF-! #acilitates P%N

migration #rom surrounding !lood &essels )here they e?trude themsel&es #rom these

&essels$ These cells cleanse the )ound clearing it o# de!ris$ The P%Ns attain their

ma?imal num!ers in 13-3; hours and commence their departure !y hour 61$ Otherchemotactic agents are released including #i!ro!lastic gro)th #actor (F" trans#orming

gro)th #actors (TF-! and TF-a" PDF and plasma-acti&ated complements I2a and

I4a (anaphylactic to?ins"$ They are se>uestered !y macrophages or interred )ithin the

sca! or eschar$4

As the process continues monocytes also e?ude #rom the &essels$ These are termed

macrophages$ The macrophages continue the cleansing process and manu#acture &arious

gro)th #actors during days 2-3$ The macrophages orchestrate the multiplication o#

endothelial cells )ith the sprouting o# ne) !lood &essels the duplication o# smooth muscle

cells and the creation o# the milieu created !y the #i!ro!last$ %any #actors in#luencing the

)ound healing process are secreted !y macro)$ages$ These include T78s' c!tokines andinterleukin/1 3I/1*' tumor necrosis actor 3T:8*' and PD78.


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T$ird )$ase / 7ranulation

This phase consists o# di##erent su!phases$ These su!phases do not happen in discrete time

#rames !ut constitute an o&erall and ongoing process$ The su,)$ases are i,ro)lasia'

matri+ de)osition' angiogenesis and re/e)it$eliali-ation$3

.n days 4-6 i,ro,lastsha&e migrated into the )ound laying do)n ne) collageno# thesu!types . and ...$ Carly in normal )ound healing t!)e III collagen )redominates!ut is

later replaced !y type . collagen$

Tropocollagen is the precursor o# all collagen types and is trans#ormed )ithin the cells

rough endoplasmic reticulum )here proline and lysine are hydro?ylated$ Disul#ide !onds

are esta!lished allo)ing 2 tropocollagen strands to #orm a triple le#t-handed triple heli?

termed procollagen$ As the procollagen is secreted into the e?tracellular space peptidases

in the cell )all clea&e terminal peptide chains creating true collagen #i!rils$

The )ound is su##used )ith FAFs and #i!ronectin produced !y #i!ro!lasts$ These FAFs

include heparan sul#ate hyaluronic acid chondroitin sul#ate and keratan sul#ate$

Proteogl!cansare FAFs that are !onded co&alently to a protein core and contri!ute tomatri? deposition$

Angiogenesis is the product o# parent &essel o##shoots$ The #ormation o# ne) &asculature

re>uires e?tracellular matri? and !asement mem!rane degradation #ollo)ed !y migration

mitosis and maturation o# endothelial cells$ Basic 878and &ascular endothelial gro)th

#actor are !elie&ed to modulate angiogenesis$

e/e)it$eli-ationoccurs )ith the migration o# cells #rom the periphery o# the )ound and

adne?al structures$ This process commences )ith the spreading o# cells )ithin 13 hours$

Di&ision o# peripheral cells occurs in hours 3;-61 resulting in a thin epithelial cell layer

)hich !ridges the )ound$ Cpidermal gro)th #actors are !elie&ed to play a key role in this

aspect o# )ound healing$This succession o# su!phases can last up to 3 )eeks in the clean and uncontaminated

)ound$

8ourt$ )$ase / emodeling

Ater t$e t$ird (eek the )ound undergoes constant alterations kno)n as remodeling

)hich can last #or years a#ter the initial in*ury occurred$ Collagen is degradedand

deposited in an e>uili!rium-producing #ashion resulting in no change in the amount o#

collagen present in the )ound$ The collagen deposition in normal )ound healing reaches a

peak !y the third )eek a#ter the )ound is created$ Iontraction o# the )ound is an ongoing

process resulting in part #rom the proli#eration o# the speciali7ed #i!ro!lasts termed

myo#i!ro!lasts )hich resem!le contractile smooth muscle cells$ +ound contraction occursto a greater e?tent )ith secondary healing than )ith primary healing$ %a?imal tensile

strength o# the )ound is achie&ed !y the 01th )eek and the ultimate resultant scar has

only ; o# the tensile strength o# the original skin that it has replaced$


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20/31


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;. ADAPTA%I %


22/31

- Sel mem!engkak sitoplasma pucat organel mem!engkak$

- Organ mem!esar dan le!ih !erat

Akumulasi %elular/

- Penim!unan su!stansi intrasel normal$ %is / lemak dihati

- Penim!unan su!stansi intra sel a!normal oleh karena gangguan meta!olisme$

- Penim!unan pigmenEpartikel yang tidak dapat dihancurkan$

A)o)tosis/

- Proses #isiologikEpatologik

- %engenai satu sel

- Sel melisut

:ekrosis/

- Kematian sel

- e*as terlalu !erat dan lama sehingga tidak dapat diper!aiki$

- .nti sel mula-mula men*adi mengecil hiperkormatik (piknotik"$

- Kemudian kromatin mengalami lisis (kariolisis"

-akhirnya pecah (karioeksis"

>entuk/,entuk Ada)tasi %el

1. Ada)tasi dari %el

8isiologi

M Jespon dari proses normal

Patologi

M Peru!ahan sel menyesuaikan dng lingkungan guna !ertahan hidup sesuailingkungan yg !eru!ah

angka$/langka$ Pen!esuaian

M Jeceptor !inding signal transduction protein transcription translation

e?port$

2. >entuk Ada)tasi sel.

!$ Atroi 3Atro)$!*

Deinisi/ pengisutan ukuran sel aki!at kehilangan !ahan sel penurunan #ungsi sel

Atro#i Organ

M Atro#i sel (selnya hidup"

M Apoptosis (selnya mati"

%e,a,

M Berkurangnya !e!an ker*a

M ,ilangnya persara#an


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M Berkurangnya per!ekalan darah

M Nutrisi yg tidak memadai

M ,ilangnya rangsang hormonEendokrin

M Ketuaan

Mekanisme >iokimia

M Penurunan sintesis protein

M Peningkatan kata!olisme protein

M Keduanya

Peru,a$an "istologi

M Penurunan ukuran sel

M Peningkatan auto#agi &acuole

M Peningkatan !adan residu (lipo#uscin"

c$ "i)ertroi 3"!)ertro)$!*

Deinisi penam!ahan ukuran dari sel-sel penam!ahan ukuran dari organ$

Pem!esaran pada organ ini pada sel yg tidak mampu !ermitosis$

Oleh karena peningkatan #ungsiErangsang hormon

Peningkatan Sintesa Protein dari interaksi hormon dan .nti DNA

Peningkatan Organela sel

Iontoh /

8isiologi

o Otot Skeletal dengan latihan

Patologi

o %iokardium pada hipertensi

%e,a,

o Kenaikan tantangan #ungsional

Otot skeletal pada latihan

miokardium pada hipertensi

o Stimulasi Spesi#ik hormonal

Gterus pada kehamilan


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d$ "i)er)lasi 3"!)er)lasia*

Deinisi penam!ahan *umlah sel pada organ atau *aringanan

,iperplasia dan ,ipertro#i sering tim!ul !ersamaan

8isiologi

,ormonal (mammae selama kehamilan"

Kompensasi (partial hepatektomi"

Patologi

o Kele,i$an $ormonal B gro(t$ actor

Peningkatan a!solute atau relati&e dari estrogen yg mele!ihi progesterone--

endometrial hyperplasia

o Proses kontrol tetapi menyu!urkan Iancer stimulasi hormonal yang

!erle!ihan pada in#eksi &irus (papilloma &iruses"

e$ Meta)lasia

Deinisi peru!ahan yg re&ersi!el dimana !entuk sel de)asa men*adi sel de)asa

yang lain

Pemograman Fenetic kem!ali dari stem sel (epithelial dan %esenchymal"

Meta)lasia %kuamosa e)itel es)irasi

%erokok sigarete

De#isiensi &itamin

A Fastric %etaplasia


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1$ Adaptasi Terhadap Penurunan Be!an Ker*a Sel

Berdasarkan 1 !agan di atas maka dapat disimpulkan !ah)a sel !eradaptasi terhadap

cedera ada 2 cara yaitu /

0$ %enam!ah atau mengurangi ukuran sel (hipertro#i dan atro#i"$

1$ %enam!ah atau mengurangi *umlah sel (hiperplasia dan in&olusi"$

2$ %eru!ah ukuran sel (metaplasia"$

. educing o %car Tissue

egulates dermal i,ro,last )rolieration and e+cess collagen and thus helps to pre&ent

and reduce keloid scars and hyperthropic scarring$ Acts as a potent antio+idant and anti/

inlammator!$ egulates ,lood vessel ormation and o+!genation (it$in t$e skin so

t$at e(er nutrients get into t$e scar tissues$ ,alts keloid scar itching$ Smoothes old

surgery scars and also rough and dry skin$

Surgical procedures can !e used to impro&e or minimi7e the appearance o# scars restore

#unction and correct dis#igurement resulting #rom an in*ury lesion or pre&ious surgery$Surgical re&ision is usually delayed until the scar lightens in color$ .t takes se&eral months

or e&en a year a#ter a )ound has healed #or the scar to lighten in color$ Surgery to re&ise

scars can !e done )hile the patient is a)ake or sleeping$

%edications(topical corticosteroids anesthetic ointments and antihistamine creams" can

reduce the symptoms o# itching and tenderness$

No treatment #or keloids is considered to !e 0 e##ecti&e$ Some o# the treatments that

are currently a&aila!le are descri!ed !elo)$ These treatments ha&e &arying degrees o#

e##ecti&eness$ All the in&asi&e methods o# treatment like surgery carry a serious risk o# the

keloid recurring and !ecoming !igger than it pre&iously )as$

%ederma@ Iontains allium cepa$
http://www.mamashealth.com/medicine/http://en.wikipedia.org/wiki/Medermahttp://www.mamashealth.com/medicine/http://en.wikipedia.org/wiki/Mederma


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Iontractu!e? Fel E ,e?ilak Fel @ These gels contain allium cepae?tract heparin

and allantoin$ De&eloped #or the treatment o# post-thyroidectomy scars these gels

are no) indicated #or the treatment o# all post traumatic (!urns acne piercings" or

post surgery scars and keloids$ Treatment is simple !ut re>uires perse&erance$ The

earlier the initiation o# treatment the !etter the prognosis$

Natural treatments @ Some scar treatments contain mucin #rom the snail heli?

aspersa mller$ The secretion #rom the snail regulates the skin healing and scar

#ormation process$ Topical application o# treatments )ith this ingredient on keloid

scars regulates andEor decreases dermal #i!ro!last proli#eration and e?cess collagen

production and thus pre&ents and reduces keloid scars and hyperthropic scars$9citation

needed:

Surgery @ Surgeryre>uires great care during and a#ter the operation$ Keloids that

return a#ter !eing e?cised may !e larger than the original$ There is a 4 chance o#

recurrence a#ter surgical remo&al$ ,o)e&er keloids are less likely to return i#

surgical remo&al is com!ined )ith other treatments$ Surgical or laser e?cision may

!e #ollo)ed !y intralesional in*ections o# a corticosteroid$ Plastic closureo# theskin including techni>ues such as &-plastyor )-plastyto reduce skin tension are

kno)n to reduce recurrence o# keloids #ollo)ing e?cision$

Dressings@ %oistened )ound co&erings made o# silicone gel(such as Dermati?"

or silasticha&e !een sho)n in studies to reduce keloid prominence o&er time$ This

treatment is sa#e and painless although some patients may e?perience increased

itchiness #rom )earing the dressing #or an e?tended period o# time$

Steroid in*ections @ Steroidin*ections are !est used as the scar !egins to thicken or

i# the person is a kno)n keloid #ormer$ A series o# in*ections )ith triamcinolone

acetonideor another corticosteroidmay reduce keloid si7e and irritation$ ,o)e&er

in*ections are o#ten uncom#orta!le and in large andEor hard scars can !e di##icult to

per#orm re>uiring local anesthetic #or people o&er 05 and #ull anesthetic #or people

under$ The treatment area can !ecome &ery pain#ul as the anesthetic )ears o##$

Iompression @ Iompression !andagesapplied to the site o&er se&eral months

sometimes #or as long as si? to t)el&e months may lead to a reduction in the si7e

o# the keloid$ This is the !est treatment #or pre&enting ne) scars$

Iryosurgery @ Iryosurgeryis an e?cellent treatment #or keloids )hich are small

and occur on lightly pigmented skin$ .t is o#ten com!ined )ith monthly cortisone

in*ections$ The use o# cryotherapy is limited since it causes skin !lanching$ .t

#ree7es the skin and causes sludging o# the circulation !eneath e##ecti&ely creatingan area o# locali7ed #rost!ite$ There is a slough o# skin and keloid )ith re-

epitheli7ation$

Jadiation therapy@ Clectron !eam radiation can !e used at le&els )hich do not

penetrate the !ody deeply enough to a##ect internal organs$ Ortho&oltage radiation

is more penetrating and slightly more e##ecti&e$ Jadiation treatments reduce scar

#ormation i# they are used soon a#ter a surgery )hile the surgical )ound is healing$

This is one o# the most e##ecti&e procedures$91:

asertherapy @ This is an alternati&e to con&entional surgery #or keloid remo&al$

asers produce a super#icial peel !ut o#ten do not reduce the !ulk o# the keloid$ The

use o# dye-tuned lasershas not sho)n !etter results than that o# cold lasers$ Arelati&ely ne) approach is to com!ine laser therapy )ith steroid in*ections$
http://en.wikipedia.org/wiki/Onionhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/w/index.php?title=Plastic_closure&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=V-plasty&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=V-plasty&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=W-plasty&action=edit&redlink=1http://en.wikipedia.org/wiki/Excisionhttp://en.wikipedia.org/wiki/Dressing_(medical)http://en.wikipedia.org/w/index.php?title=Silicone_gel&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Dermatix&action=edit&redlink=1http://en.wikipedia.org/wiki/Silastichttp://en.wikipedia.org/wiki/Steroidhttp://en.wikipedia.org/wiki/Triamcinolone_acetonidehttp://en.wikipedia.org/wiki/Triamcinolone_acetonidehttp://en.wikipedia.org/wiki/Corticosteroidhttp://en.wikipedia.org/wiki/Compression_bandagehttp://en.wikipedia.org/wiki/Cryosurgeryhttp://en.wikipedia.org/wiki/Radiation_therapyhttp://en.wikipedia.org/wiki/Orthovoltage_X-rayshttp://en.wikipedia.org/wiki/Laserhttp://en.wikipedia.org/wiki/Dye_laserhttp://en.wikipedia.org/wiki/Onionhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/w/index.php?title=Plastic_closure&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=V-plasty&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=W-plasty&action=edit&redlink=1http://en.wikipedia.org/wiki/Excisionhttp://en.wikipedia.org/wiki/Dressing_(medical)http://en.wikipedia.org/w/index.php?title=Silicone_gel&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Dermatix&action=edit&redlink=1http://en.wikipedia.org/wiki/Silastichttp://en.wikipedia.org/wiki/Steroidhttp://en.wikipedia.org/wiki/Triamcinolone_acetonidehttp://en.wikipedia.org/wiki/Triamcinolone_acetonidehttp://en.wikipedia.org/wiki/Corticosteroidhttp://en.wikipedia.org/wiki/Compression_bandagehttp://en.wikipedia.org/wiki/Cryosurgeryhttp://en.wikipedia.org/wiki/Radiation_therapyhttp://en.wikipedia.org/wiki/Orthovoltage_X-rayshttp://en.wikipedia.org/wiki/Laserhttp://en.wikipedia.org/wiki/Dye_laser


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Ne)er treatments @ Drugs that are used to treat autoimmune diseasesor cancer

ha&e sho)n promise$ These includealpha-inter#eron 4-#luorouraciland!leomycin$

,o)e&er there is a need #or #urther study and e&aluation o# this treatment

techni>ue$

. Treatments or skin scarsScars can ne&er !e completely remo&ed$ %any doctors ad&ise their patients to use &itamin

C supplements or creams to speed the healing process and keep the scar tissue suppler$

Surgeries are a&aila!le toremo&e scars !ut any surgery )ill al)ays make a ne) scar/ the

#ormer scar may !e less o!&ious !ut it )ill not go a)ay completely$ %urger! is not

recommended or $!)ertro)$ic or keloid scarring' as t$ere is t$e risk o recurrence

and (orse scarring.

Iurrently no scar can !e completely remo&ed96:although healing in em!ryos and some

animals e&en a#ter e?tended in*uries can occur )ithout scarring$ 9;:There#ore all treatments

)ill lea&e a trace !ut a num!er o# approaches ha&e !een tried )ith silicon gel sheeting and

steroid in*ections ha&ing the most )idely accepted role in general scar treatment$9uence corticosteroidtherapy !y in*ection into the scars )as introduced in

the 0


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suggest a manipulation o# local ionic charges or a decrease in production o# Qpro-

in#lammatoryR su!stances like TF1$901:

Dimethicone silicone gel appears to !e is as e##ecti&e as silicone sheeting in impro&ing scar

appearance$902:

Derma,rasionDerma!rasionin&ol&es the remo&al o# the sur#ace o# the skin )ith specialist e>uipment

and usually in&ol&es a general anaesthetic$ .t is use#ul )ith raised scars !ut is less e##ecti&e

)hen the scar is sunken !elo) the surrounding skin$

Collagen in?ections

Iollagenin*ections can !e used to raise sunken scars to the le&el o# surrounding skin$ .ts

e##ects are ho)e&er temporary and it needs to !e regularly repeated$ There is also a risk in

some people o# an allergic reaction$

aser surger! 5 resuracing

The use o# laserson scars is a ne) #orm o# treatment$ Se&eral cosmetic lasers ha&e !eenDA appro&ed #or the treatment o# acne scars!y using laser resur#acingtechni>ues$

Vascular lasers ha&e !een pro&en to greatly reduce the redness o# most scars 5M0 )eeks

a#ter the initial treatment$ .t has !een theori7ed that remo&ing layers o# skin )ith a car!on

dio?ideor Cr!ium/AFlasermay help #latten scars$ Scarring caused !y acne (le#t" and

photo 0 day a#ter scar re&ision surgery$ Area around sutures is still s)ollen #rom surgery

%urger!

Surgical e?cision o# hypertrophic or keloid scars is o#ten associated to other methods such

as pressotherapy or silicone gel sheeting$ one e?cision o# keloid scars ho)e&er sho)s ahigh recurrence rate close to 34$ A clinical study is currently ongoing to assess the

!ene#its o# a treatment com!ining surgery and laser-assisted healing in hypertrophic or

keloid scars$

adiot$era)!

o)-dose super#icial radiotherapy is used to pre&ent re-occurrence o# se&ere keloid and

hypertrophic scarring$ .t is usually e##ecti&e !ut only used in e?treme cases due to the risk

o# long-term side e##ects$

:atural remedies

Jesearch sho)s the use o# &itamin C and onion e?tract as a treatment #or scars isine##ecti&e$ Vitamin C causes contact dermatitis in up to 22 o# users and in some cases it

may )orsen scar appearance$ 903:904:Vitamin I normali7es collagen production and

encourages the production o# an organi7ed healthy collagen #rame)ork 905:)hich impro&es

scar appearance$ Vitamin I and some o# its esters also #ade the dark pigment associated

)ith some scars$ 906:
http://en.wikipedia.org/wiki/Scar#cite_note-11http://en.wikipedia.org/wiki/Scar#cite_note-11http://en.wikipedia.org/wiki/Scar#cite_note-12http://en.wikipedia.org/wiki/Dermabrasionhttp://en.wikipedia.org/wiki/General_anaesthetichttp://en.wikipedia.org/wiki/Collagenhttp://en.wikipedia.org/wiki/Allergic_reactionhttp://en.wikipedia.org/wiki/Laserhttp://en.wikipedia.org/wiki/Acne_scar_treatmenthttp://en.wikipedia.org/wiki/Laser_resurfacinghttp://en.wikipedia.org/wiki/Carbon_dioxide_laserhttp://en.wikipedia.org/wiki/Carbon_dioxide_laserhttp://en.wikipedia.org/wiki/Er:YAG_laserhttp://en.wikipedia.org/wiki/Laserhttp://en.wikipedia.org/wiki/Radiotherapyhttp://en.wikipedia.org/wiki/Scar#cite_note-13http://en.wikipedia.org/wiki/Scar#cite_note-14http://en.wikipedia.org/wiki/Scar#cite_note-15http://en.wikipedia.org/wiki/Scar#cite_note-15http://en.wikipedia.org/wiki/Scar#cite_note-16http://en.wikipedia.org/wiki/Scar#cite_note-11http://en.wikipedia.org/wiki/Scar#cite_note-12http://en.wikipedia.org/wiki/Dermabrasionhttp://en.wikipedia.org/wiki/General_anaesthetichttp://en.wikipedia.org/wiki/Collagenhttp://en.wikipedia.org/wiki/Allergic_reactionhttp://en.wikipedia.org/wiki/Laserhttp://en.wikipedia.org/wiki/Acne_scar_treatmenthttp://en.wikipedia.org/wiki/Laser_resurfacinghttp://en.wikipedia.org/wiki/Carbon_dioxide_laserhttp://en.wikipedia.org/wiki/Carbon_dioxide_laserhttp://en.wikipedia.org/wiki/Er:YAG_laserhttp://en.wikipedia.org/wiki/Laserhttp://en.wikipedia.org/wiki/Radiotherapyhttp://en.wikipedia.org/wiki/Scar#cite_note-13http://en.wikipedia.org/wiki/Scar#cite_note-14http://en.wikipedia.org/wiki/Scar#cite_note-15http://en.wikipedia.org/wiki/Scar#cite_note-16


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7. REPORTING

0$ Tutor menggali kem!ali ke!erhasilan !ela*ar mahasis)a melalui pertanyaan yang

mengarah pada kemampuan mahasis)a men*elaskan O yang ada

1$ O nomor 0 s$d 5 minimal 5; dikuasai$ Terapi dan proses hukum minimal 4;

2$ ,arap melakukan pemeriksaan pencapaian kompetensi pada tutorial ... denganmenanyakan mahasis)a satu persatu$

7. DAFTA! %USTAKA

1. Sil!ernagl$S ang$$ 12 Teks !tlas Ber"arna Pato#isiologi Pener!it Buku KedokteranCFI akarta$

1$ Jo!!ins 0ndocrinol ?etab '&(0/)* 391:-6. P%.D 0062


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0;$ Ioopenha&er +$%$ and ohnson D$D$ /BaileyCs Textbook o# Histology$ 6th ed$ Baltimore The

+illiams +alkins Io$ 0

Ho Mhs Bms Skenario Ii_mgg III

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Transcript of Ho Mhs Bms Skenario Ii_mgg III