Effects of silicone gel on burn scars

Aim

To study the efficacy of silicone gel applied to hypertrophic burn scars, in reducing scar interference with normal function and improving cosmesis.

Methods

A randomised, double-blind, placebo-controlled trial involving 38 people with hypertrophic burn scars. Each scar was divided into two segments; silicone gel sheet was applied randomly to one of the two and placebo to the other. Participants were seen again after 1 and 4 months. Their data and wound characteristics were collected using the Vancouver scar scale.

Results

The median age of participants was 22 years (1.5–60 years) and 16 were male; 4 did not attend follow-up and were excluded from the study. There were no significant differences in baseline characteristics. Although after 1 month all scar scale measures were lower in treated areas, only the vascularity scale was significantly different between the two areas. After 4 months, all scale measures were significantly lower in the silicone gel group than in the control group, except for the pain score.

Conclusion

Silicone gel is an effective treatment for hypertrophic burn scars.     

Treatment outcomes for keloid scar management in the pediatric burn population

Introduction

Keloids scars are challenging problems facing many reconstructive surgeons and have proven to be resistant to many treatments. This is evident by the broad range of treatments available and implemented with inconsistent results. We reviewed our experience to better define the disorder and to evaluate the impact of specific treatment options as related to our patient population.

Methods

After obtaining Institutional Review Board approval, we examined the medical records of pediatric patients who were evaluated at our pediatric burn center between 2000 to 2008. All study subjects were identified as having keloid scars confirmed by clinical evaluation (raised scar extending beyond the margins of the original wound 0005 and 0010). Treatments included excision and grafting [split thickness autograft (STAG) or full thickness autograft (FTAG)], excision and grafting with steroid injection, excision and primary closure, or excision and primary closure with steroid injection. Patients were included only if there was follow-up of 12 months or greater.

Results

One hundred and ten subjects with a diagnosis of a keloid scar were identified. Twenty-six were treated with excision and skin grafting and 8 were treated with a steroid and surgery regimen. Of the patients treated with surgery and steroids, the treatment varied from an intra-operative injection to post-operative injections at 6-week intervals. The number of injections was determined by the administering surgeon and varied from one to three. Clinical end points were determined by the administering surgeon and included: (1) no further improvement in scar maturation or (2) absence of improvement. Recurrence was defined as return of a raised scar consistent with a keloid scar. The recurrence rate was 87.5% for patients treated with surgery and steroids and 80.0% for surgery only. This difference was not statistically significant.

Conclusions

Our data demonstrate that steroids do not significantly decrease recurrence in pediatric burn related keloids as compared to previously published series involving non-burn related keloids 0015 and 0025. This further emphasizes that burn related keloids respond differently to conventional treatments that have proven successful in keloid scars from other mechanisms of injury. A consistent and effective treatment algorithm should be implemented in treating keloid scars from burn wounds.     

A modified Vancouver Scar Scale linked with TBSA (mVSS-TBSA): Inter-rater reliability of an innovative burn scar assessment method

Background

Current scar assessment methods do not capture variation in scar outcome across the burn scar surface area. A new method (mVSS-TBSA) using a modified Vancouver Scar Scale (mVSS) linked with %TBSA was devised and inter-rater reliability was assessed.

Method

Three raters performed scar assessments on thirty patients with burn scars using the mVSS-TBSA. Scoring on pigmentation, vascularity, pliability and height was undertaken for the ‘best’ and ‘worst’ areas of each scar. Raters allocated the total body surface area of the scar (%TBSA) to three mVSS categories (<5, 5–10, >10). Intra-class correlation coefficient (ICC) and weighted kappa statistic (k_w) were used to assess inter-rater reliability. The data were also analysed for clinically relevant misclassifications between pairs of raters.

Results

Total mVSS scores showed ‘fair to good’ agreement (ICC 0.65–0.73) in the ‘best’ area of the scar while there was ‘excellent’ agreement in the ‘worst’ scar area (ICC 0.85–0.88). The k_w of the individual mVSS components ranged from 0.44 to 0.84 and 0.02 to 0.86 for ‘best’ and ‘worst’ scar areas, respectively. Determination of scar %TBSA had ‘excellent’ reliability (ICC 0.91–0.96). Allocation of scar %TBSA to severity category <5 mVSS demonstrated ‘good to excellent’ reliability (ICC 0.63–0.80) and ‘fair to good’ reliability (ICC 0.42–0.74) for 5–10 mVSS category. However, misclassifications were observed for the total mVSS score in the ‘worst’ scar area and the allocation of scar %TBSA in the <5 mVSS category.

Conclusion

Inter-rater reliability of mVSS scores depends on the severity of the scar area being assessed. The mVSS-TBSA method of allocation of scar %TBSA to two broad mVSS categories, namely <5 and ≥5 mVSS, has ‘good to excellent’ reliability. The mVSS-TBSA has demonstrated utility for both clinical and research purposes; however, there is potential to misclassify scar outcome in some cases.     

Effect of different pressure magnitudes on hypertrophic scar in a Chinese population

Introduction

This study aimed to investigate the effect of different pressure magnitudes on treatment outcomes of hypertrophic scars, and determine pressure loss over time.

Methods

A randomized clinical trial was adopted. 53 hypertrophic scar samples from 17 Chinese participants were recruited and randomly assigned into a high pressure group (20–25 mmHg) and low pressure group (10–15 mmHg) for a five-month intervention program. The scars were assessed objectively before intervention and monthly after intervention for thickness, color (redness, yellowness and lightness) and scar pliability. Pressure magnitude at each assessment was also measured. Two-way repeated ANOVA was used to compare for differences between groups.

Results

The results showed that both levels of pressure produced reduction in scar thickness and redness, but the improvement in the high pressure group was statistically better than that of the counterpart (both p < 0.05). Monthly pressure measurement revealed that pressure loss in the high pressure group was more severe. However, no major changes in other color parameters and pliability were observed for both the groups.

Conclusion

High pressure was demonstrated to be more effective for scar management, but it was also more prone to higher pressure loss. Pressure therapy integrated with regular monitoring of the interface pressure is suggested to improve its therapeutic efficacy.     

Reconstruction of large hypertrophic scar on trunk and thigh by means of liposuction technique

Objective

Hypertrophic scars on trunk and thigh are less important in function and appearance than those on face, neck, hand, foot and joint. However, patients suffer itching, pain and disfiguration. Thus far, neither non-surgical nor surgical methods treat these scars perfectly. This study reports on the application of liposuction technique to reconstruct these scars and reviews the outcomes.

Method

Between March 2000 and March 2008, we treated 26 hypertrophic scars on trunk and thigh (20 patients) using liposuction. Tumescent liquids were infiltrated and liposuction was performed in the areas of trunk and thigh where the scars located. Following scar excision, defects were covered by sliding flap created by liposuction. Incisions were closed without tension.

Results

Twenty-six hypertrophic scars were reconstructed in one stage by flaps of similar texture and colour in areas around the scars without wound dehiscence, infection, skin necrosis, sensory deficit, haematoma and seroma. The contours of liposuction areas were natural and even.

Conclusion

Large hypertrophic scar at sites rich in subcutaneous fat such as trunk and thigh can be reconstructed in one stage by liposuction technique, which is easy, safe, effective and economic. Although indications of liposuction scar reconstruction are strict, it is indeed a better option for appropriate cases.     

Patient reported facial scar assessment: directions for the professional

Background

The face is central to our identity and provides our most expressive means of communication. Currently, the role of facial scarring in relation to self-esteem is unclear and the value of self-reported scar assessment is insufficiently understood. The aim of this study was twofold: (1) to assess the extent of agreement between patients’ ratings and observers’ ratings of facial scar characteristics; and (2) to examine if patients’ and observers’ scar characteristics ratings, or the differences, are associated with the patients’ self-esteem.

Methods

A prospective study was conducted including patients with facial burns. Patients completed the Patient and Observer Scar Assessment Scale (POSAS) and the Rosenberg Self-Esteem Scale 3 months post-burn.

Results

Ninety-four subjects were included, 76 (81%) men and mean percentage TBSA burned was 12.4 (SD 10.4; range 1–50). Subject's and observer's assessment were significantly positively correlated and were identical in 53% of the cases. Subjects’ assessments and discrepancy scores on the scar characteristic surface roughness were associated with self-esteem in multiple regression analysis.

Conclusions

The majority of the patients scored the quality of facial scars in a similar way as the professionals. Furthermore, facial scarring appeared only moderately associated with self-esteem. However, our study suggests that using both patients’ and professionals’ scar assessments provides more useful information regarding the patients’ well-being relative to focussing on the separate assessments only. In particular a discrepancy between the patients’ and professionals’ view on surface roughness might be an early indication of psychological difficulties and a call for further clinical attention.     

Patient and parental scar assessment after single incision versus standard 3-port laparoscopic appendectomy: Long-term follow-up from a prospective randomized trial

Background

Single site laparoscopy for appendectomy is a technique with several case series suggesting a cosmetic advantage, but without prospective comparative data. We conducted a prospective, randomized trial comparing single site laparoscopic appendectomy to the standard 3-port approach, including scar assessment at early and long-term follow-up.

Methods

Enrolled patients over 12 years old and parents of patients less than 12 years old were asked to complete the validated Patient Scar Assessment Questionnaire (PSAQ) at early follow-up around 6 weeks and by phone after 18 months. The PSAQ consists of 4 scored subscales: Appearance, Consciousness, Appearance Satisfaction, and Symptom Satisfaction. Each subscale has a set of questions with a 4-point categorical response (1 = most favorable, 4 = least favorable). The sum of the scores quantifies each subscale.

Results

Early questionnaires were obtained from 98 3-port and 100 single-site patients with the single-site approach producing superior overall scar assessment (P = 0.003). By telephone follow-up, questionnaires were completed by 49 3-port and 56 single-site patients at a median of 25 (18–32) months. In this longer-term follow-up, overall scar assessment was not significantly different between groups (P = 0.06).

Conclusion

Patients or parents express superior scar assessment with the single site approach at early follow-up, but this difference disappears in the long-term.     

Videocapillaroscopy in postburn scars: In vivo analysis of the microcirculation

Objective

The aim of the study was the evaluation in vivo of the differences between the microcirculatory characteristics of the postburn scar and the healthy skin.

Methods

Twelve patients with postburn scars were included in the study, evaluating fifteen scar areas and twelve healthy skin areas by means of contact optical probe videocapillaroscopy. The examined areas for each patient were the right and the left upper limb. Capillary density, length and diameter, together with capillary distribution pattern (punctiform, reticular, directional) and the presence of microhaemorrhages and neoangiogenesis were studied.

Results

The results were obtained by two different researchers using the capillaroscope's software. Capillary loop diameter and length, capillary distribution pattern and presence of neoangiogenesis were found to be significantly increased in postburn scars compared with controls. There were also significant differences between hypertrophic tissue in the active phase and the one in the remission phase for capillary diameter and presence of neoangiogenesis.

Conclusion

Videocapillaroscopy showed “in vivo” a change in local microcirculation architecture using a microscope. Patients with hypertrophic burn scars showed a variety of microcirculatory changes, often clustered in a characteristic pattern of abnormally oriented, dilated capillaries and neoangiogenetic phenomena. This methodology is highly likely to be of value in the assessment and prognostication of burn outcome.     

Chin projection creation in patients with facial and cervical burn scar contracture

Background

Loss of cervicomental angle is characteristic of severe facial and cervical burned patients due to scar contracture. This micrognathia-like deformity is also seen in patients following chin and neck reconstruction using skin expanded flaps. The aim of modern plastic surgery is to restore a harmonious and symmetrical facial appearance for burn survivors.

Methods

Six facial and cervical burned patients with micrognathia-like deformity after neck reconstructions were reported. Chin augmentation with Medpor implant through submental approach was performed in 4 patients and intraoral access in 2 cases to restore their favorable chin projections. Five of them received cervicomental contour reconstruction simultaneously.

Results

Patient follow-up ranged from 12 to 18 months. No implants became exposed nor infected. All patients had satisfactory results. We reviewed our experience with the use of the Medpor implant in burn chin reconstruction including preoperative and postoperative radiograph analysis.

Conclusions

With proper patient selection, pre-operative planning, and taking care of details during operation, augmentation genioplasty with Medpor implant offers a reliable, simple and satisfactory solution for improving micrognathia-like facial configurations in patients with scar contracture following severe burns.     

The use of neoprene as a scar management modality

Purpose

Scar formation is one of the most functionally and cosmetically debilitating results of thermal injuries. Burn team members continuously search for new, cost effective, ways to prevent and treat hypertrophic scar formation. This study is a retrospective review of one facility's use of neoprene based products as an adjunct to, or in place of, traditional scar management techniques.

Methods

Records of all patients treated with neoprene patches or neoprene splints from March 2008 through April 2011 were retrospectively reviewed. Vancouver Scar Scores (VSS) were collected, photographs were reviewed and any documented problems reported by the patients were noted.

Results

Mean VSS scores were significantly lower at follow-up (5.3, SD 2.8) than at initial appointment (11.7, SD 1.4) with an estimated mean difference of 6.3 (P = 0.0001). A 95% confidence interval for this mean difference is 3.9–8.7.

Conclusions

In the reviewed cases, the use of neoprene inserts or splints resulted in a statistically significant reduction in hypertrophic scars with no secondary complications.     

Malignancy in chronic burn scar: A 20 year experience in Mosul – Iraq

Background

Marjolin's ulcer, a term used to describe a malignancy arising in chronic ulcers of the skin, sinuses, scar tissue, and especially burns scars. The majority of burn scar carcinomas are seen after a lag period in burns that were not grafted following injury.

Objective

To describe the epidemiology and its clinical characteristics of patients with Marjolin's ulcer arising in a chronic burn scar.

Design and patients

A case series study was done at Al-Jumhoori Teaching Hospital Burn Center, identifying 27 patients with chronic burn scar that underwent malignant transformation into a carcinoma, from January 1992 to December 2011. Data related to patients were retrieved from their medical records. All lesions were secondary to burns from various causes. All patients were proven to have malignancy by biopsy.

Results

Of the 27 Marjolin's ulcer patients, 18 were males and 9 were female (male to female ratio 2:1), and the mean age was 42.7 years (range: 18–80 years). Upon histological examination, all were diagnosed as well-differentiated squamous cell carcinoma. The lower limb was most frequently affected (81.5%). Treatment of the neoplasm consisted of excision and grafting in 81.5%, radiotherapy in 11.1% and amputation in 7.4%. Local recurrence was noted in 22.2%, and lymph node metastasis in 11.1%.

Conclusion

Chronic ulcer that undergoes malignant change was a common finding in the present study. All suspected masses or ulcers within chronic burn scars should be promptly biopsied.     

A guide to choosing a burn scar rating scale for clinical or research use

Introduction

A lack of high quality burn scar rating scales underpins the urgent need to introduce a guide for clinicians and researchers to choose the most appropriate scale for their requirements.

Methods

An updated electronic search of Medline, CINAHL, and EMBASE databases from 2010 to 2011 of a previous published systematic review were used to identify English articles related to burn scar rating scales. The clinimetric properties, content, purpose, characteristics of the subjects tested and feasibility of each scale were critically reviewed.

Results

An additional seven papers were identified by the updated search, bringing the total number of papers reviewed to 36. The majority (88%) covered items pertaining to the physical properties of the skin rated by an observer. All of the scales had been tested for the purpose of discriminating between patient groups; however, only preliminary evidence exists for the ability of the scales to measure change in scar properties over time. The majority of testing of scales occurred using Caucasian subjects, males, upper limb sites and adults.

Conclusions

This paper provides a guide to selecting the most appropriate burn scar rating scale for research and clinical practice by reviewing the content, purpose, test sample characteristics and feasibility of each scale.     

A systematic review of the quality of burn scar rating scales for clinical and research use

Introduction

Scar rating scales have the potential to contribute to better evaluation of scar properties in both research and clinical settings. Despite a large number of scars assessment scales being available, there is limited information regarding the clinimetric properties of many of these scales. The purpose of the review was to inform clinical and research practice by determining the quality and appropriateness of existing scales. This review summarises the available evidence for the clinimetric properties of reliability, validity (including responsiveness), interpretability and feasibility of existing scales.

Methods

Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1990 onwards were used to identify English articles related to burn scar assessment scales. Scales were critically reviewed for clinimetric properties that were reported in, but not necessarily the focus of studies.

Results

A total of 29 studies provided data for 18 different scar rating scales. Most scar rating scales assessed vascularity, pliability, height and thickness. Some scales contained additional items such as itch. Only the Patient and Observer Scar Assessment Scale (POSAS) received a high quality rating but only in the area of reliability for total scores and the subscale vascularity. The Vancouver Scar Scale (VSS) received indeterminate ratings for construct validity, reliability and responsiveness. Where evidence was available, all other criteria for the POSAS, VSS and the remaining 17 scales received an indeterminate rating due to methodological issues, or a low quality rating. Poorly defined hypotheses limited the ability to give a high quality rating to data pertaining to construct validity, responsiveness and interpretability. No scale had empirical testing of content validity and no scale was of sufficient quality to consider criterion validity.

Conclusions

The POSAS, with high quality reliability but indeterminate validity, was considered to be superior in performance based on existing evidence. The VSS had the most thorough review of clnimetrics although available data received indeterminate quality ratings. On the basis of the evidence, the use of total scores has not been supported, nor has the measurement of pigmentation using a categorical scale.     

Effectiveness of topical zinc oxide application on hypertrophic scar development in rabbits

Background

The etiology, biology, prevention and effective treatment of hypertrophic scars have not exactly been defined. Topical zinc oxide application was shown to be effective in the treatment of proliferative scars. We studied the effectiveness of topical zinc oxide ointment in the prevention of hypertrophic scar development by using the rabbit ear hypertrophic scar model.

Methods

Circular full-thickness skin excisions were performed on both ears of 10 rabbits. The rabbits were divided into two groups and topical 40% zinc oxide ointment was applied daily to one ear and the ointment base was applied as placebo to the other ear. Scar samples were taken in the 3rd week in group 1 and in the 6th week in group 2. All of the specimens were divided into two halves: one half for histopathologic/histomorphometric examinations and the other half for biochemical studies.

Results

Application of topical zinc oxide ointment decreased clinical scar hypertrophy scores significantly (p = 0.017) at 6th week in comparison with placebo. Topical zinc oxide also reduced nodule formation histopathologically at 6th week in comparison with placebo but this was not significant statistically (p > 0.05).

Conclusion

The findings of this study may have clinical implications on the management of human hypertrophic scars.     

Free medial thigh perforator flap for reconstruction of the dynamic and static complex burn scar contracture

Introduction

Dynamic and static complex scar contractures after burn commonly cause tendon adhesion, deep adipose tissue stiffness and further limitation of major joints motion. Skin autografting or locoregional flaps are not adequate reconstructive options, because of the easy recurrence and limitation of donor sites. Therefore, free perforator flaps are playing increasing role in reconstruction of complex scar contractures.

Patients and methods

The free medial thigh perforator (MTP) flap is an addition to the reconstructive armamentarium and is particularly useful since the medial thigh is commonly spared in burn injury. Between December 2001 and October 2005, eight patients with severe post-burn scar contractures received free MTP flaps treatment in the Linkou Burn Center. The free MTP flap harvest was modified to enhance its reliability and versatility. Flap sizes ranged from 5 × 15 cm to 8 × 24 cm. The follow-up period was from 12 to 26 months. Flap harvest is rapid, averaging 37.8 min.

Results

The significantly improved range of motion of the contracture joints approximated to normal activity at 6–22-month follow-up (p < 0.05). No free major MTP flap complication was noted, except for mild marginal necrosis in one case.

Conclusion

The free MTP flap with new modified harvest is a good choice for dynamic an static complex scar contractures of major joints, due to short harvesting time and few variations of the pedicle. However, thick skin paddle was considered in secondary hand reconstruction.     

Objective scar assessment—A new method using standardized digital imaging and spectral modelling

Introduction

Quantitative assessment of scars is needed in clinical practice and in scientific studies. To date, there have been no entirely objective methods available for these purposes. We introduce a new method developed for scar assessment combining standardized digital imaging (SDI) and spectral modelling (SpM). With this method, the estimated concentration changes (ECCs) of haemoglobin and melanin in the scar can be determined quantitatively.

Patient and methods

: In the current study, 22 skin graft donor site (SGDS) wounds were treated with two alternative dressing materials, Suprathel^® and Mepilex Transfer^®, side by side on the same wound. The SGSD scars were assessed using SDI and SpM. The scars were given subjective ratings by three surgeons using the POSAS and the Vancouver Scar Scale (VSS). The correlations between the ECCs of melanin and haemoglobin and the corresponding subjective ratings were calculated as well as the Intraclass Correlation Coefficient (ICC) of the subjective ratings.

Results

There was a statistically significant correlation between the ECCs of melanin and haemoglobin and the subjective ratings. A single observer could reliably assess pigmentation with the POSAS scale (ICC = 0.75) but not vascularity (ICC = 0.51). The reliability ratings of the VSS were unacceptably low.

Conclusions

The ECC values of haemoglobin and melanin give accurate documentation of the scar status. The results also show that the subjective ratings in this study were unreliable especially when interfering pigmentation and increased vascularity were both present at the same time.     

Ankle dorsiflexion postburn scar contractures: anatomy and reconstructive techniques

Background

Postburn ankle scar contractures cause functional limitations of all lower extremities and create a serious cosmetic defect, not allowing patients to use normal foot wear, and, therefore, needing surgical reconstruction. The anatomic features of ankle dorsiflexion contractures and their treatment have been covered in the literature far less than other joint contractures, and their treatment is still a challenge for many surgeons. A common treatment method is incisional release of the contracture and defect resurfacing with skin graft. Rarely, distally based sural or free flaps and Ilizarov fixator are used.

Methods

Anatomy of postburn ankle scar contractures in 55 patients was studied and contractures were surgically treated using a specific approach and technique. Follow-up results were observed from 6 months to 16 years.

Results

According to the anatomic features, dorsiflexion scar contractures were divided into three types: edge, medial, and total. Edge contractures were caused by burns and scars located on the lateral or medial ankle surface and were characterized by the presence of the fold along the anterior edge ankle; the skin of the anterior ankle surface was not injured. Medial contractures were caused by scars located on the anterior ankle surface and were characterized by the presence of the fold along the medial ankle line. Total contractures were caused by scars tightly surrounding the ankle. In fold's sheets of edge and medial contractures there is a trapeze-shaped surface deficit in length (cause of contracture) and a surface surplus in width which allows contracture release with local trapezoid flaps. For total contractures, wide scar excision and skin grafting were indicated.

Conclusion

Three anatomic types of ankle dorsiflexion scar contractures were identified: edge, medial, and total. An anatomically justified technique for edge and medial contractures is trapeze-flap plasty; total contractures are effectively eliminated with scar excision and skin grafting.     

Objective evaluation of the effect of autologous platelet concentrate on post-operative scarring in deep burns

Introduction

The healing of grafted areas after surgical treatment of deep burns frequently generates mutilating scars, and rises the risk of subsequent scar hypertrophy. Scar assessment based on clinical evaluation is inherently subjective, which stimulates search for objective means of evaluation.

Objective

The aim of this study was to objectively evaluate the effect of using autologous platelet concentrate (APC) in combination with split thickness skin grafting (STSG) on scarring processes following surgery of deep burns as compared with application of STSG alone.

Method

Selected viscoelastic properties of 38 scars on 23 patients in total were examined using the Cutometer MPA 580 under controlled conditions for long-term outcomes 1, 3, 6 and 12 months after surgery following deep burns.

Results

The findings of this study suggest that the STSG + APC combination reduces the time of scar viscoelastic properties recovery as compared with application of STSG alone. This was statistically significant for viscoelastic parameters R₂ and Q₁.

Conclusion

APC has been advocated to enhance scarring after surgery of deep dermal and full thickness burns. We objectively demonstrated that the viscoelastic properties of scars treated with STSG + APC combination return more rapidly to the plateau state than areas treated with STSG only.     

Prevalence of scar contractures after burn: A systematic review

Objective

Burn scar contractures are the pathological outcome of excessive scarring and ongoing scar contraction. Impairment of joint range of motion is a threat to performing activities in daily living. To direct treatment strategies to prevent and/or correct such contractures, insight into the prevalence, course, and determinants is essential.