The importance of biomechanics and the kinetic chains of human movement in the development and treatment of burn scars – A narrative review with illustrative cases

BackgroundBurn scars are a major clinical sequelae of severe burn wound healing. To effectively establish a successful treatment plan and achieve durable results, understanding the pathophysiology of scar development is of utmost importance.MethodsA narrative review of the principles of the kinematic chain of movement and the hypothesised effect on burn scar development based on properties of burn scars was performed. An examination of the literature supporting these concepts is presented in conjunction with illustrative cases, with a particular focus on the effect of combination treatments that include ablative fractional resurfacing with surgical contracture releases.DiscussionAblative fractional resurfacing combined with the surgical release of contractures are an effective treatment modality for burn scar reconstruction. This treatment approach seems particularly effective because it is one of the only approaches where the principles of functional kinematics can be addressed when tailoring a reconstructive approach to an individual burn patient. The presented cases illustrate the importance of recognising and including the principles of functional kinematic chains in any reconstructive treatment approach for burn scars. Further, epifascial contracture bands are cord like structures which can be found underneath the subcutaneous fat of scar contractures which follow the principles of functional kinematics. Contractures can be more efficiently released if these structures are divided as well.ConclusionAblative fractional resurfacing combined with local tissue re-arrangements is a promising approach to address the underlying forces leading to hypertrophic burn scarring. To achieve an optimal outcome, it is essential to recognise and address the origin of the pathology when treating burn scars. Ablative fractional laser resurfacing allows a different scar approach as it is not limited to one surgical site and thus enables for effective treatment at the cause of the pathology.     

Epitheliomas arising in scars: A clinical discussion and report

This report presents 3 cases of epithelioma arising in scars on the extremities. Two were cured by excision and 1 by amputation They had resisted radium therapy. A fourth case of epithelioma of the hand not in a scar resisted radium treatment. The arm was amputated and the patient died of metastases three years later.It is pointed out that the malignant ulcers arising in scar tissue extend and invade surrounding tissue more slowly than those not in scars.They are resistant to radiation.The treatment is early excision.     

Stabilization of fractures in the hand and wrist with traumatic soft tissue and bone loss

Open type III fractures of the hand or wrist with severe bone and soft tissue loss justify aggressive treatment to restore anatomy, assure healing, and maximize functional recovery. The techniques of modern wound excision used at initial surgery predictably result in a decompressed and surgically clean wound within a few days from injury in the vast majority of cases. This allows a safe application of delayed primary internal fixation and bone grafting for fracture restoration or joint arthrodesis as well as early wound closure or coverage. The immediate or early application of stable external devices, internal fixation, or combinations of the two along with early bone grafting restores the structural integrity of the skeleton, reduces pain, protects other repaired and reconstructed tissues, promotes the healing, and supports early and intensive functional rehabilitation of the hand and wrist. Early wound closure or coverage minimizes scar formation. Together, the early sequencing of effective wound debridement with skeletal stabilization and bone grafting and early wound closure or coverage provide the most favorable circumstances for healing and functional recovery of the seriously damaged hand and wrist.     

手部创面的分类与处理

目的 探讨手部创面的分类及处理原则。方法 ６００例手部创面患者据其创有的不同采取不同的治疗方法。结果 一次手术修复成功５４０例,二次手术换药愈合６０例。结论 手部创面可依其原因、深度、性质、范围四方面进行分类。尽早手术覆盖创面,选择适宜的覆物,避免形成挛缩线,减少瘢痕形成,兼顾骨关节、肌腱、神经及血供的重建需要,进一期重建或为二期重建创造条件,早期有效的功能锻炼并辅以理疗,均是处理手部创面的要点。     

节段设计原则在面部瘢痕外科治疗中的临床应用

目的 探讨节段设计原则在面部瘢痕治疗中的应用。方法 自2012年1月至2014年6月,对38例面部瘢痕患者,在修复面部瘢痕时,以面部张力线、组织器官活动分区,以及面部凹凸曲面为界,将瘢痕分解成多个节段瘢痕,对多节段瘢痕采用手术切除,常规美容外科技术分层减张缝合。于术后3~6个月手术切口愈合稳定后,将留存的节段间点状瘢痕行手术或点阵激光治疗。结果 术后随访1~3年,瘢痕质地、色泽较好,无明显瘢痕挛缩,无明显凹陷畸形。结论 针对面部线型瘢痕,根据面部皮肤张力线对其进行多节段分解,采用手术联合激光等综合手段,可以获得较好的美容效果。     

Wide spread scars, hypertrophic scars, and keloids

Patients with a wide scar may complain of having a "keloid," yet have a hypertrophic or a wide spread scar. The plastic surgeon should make the appropriate clinical diagnosis, because therapy varies depending on the condition present. A wide spread scar is best treated with excision and closure. A buried dermal flap may help to prevent recurrence, which is nevertheless likely to some degree. A hypertrophic scar can be distinguished from a keloid on clinical grounds. Although both may be red, nodular, and itchy, the keloid overgrows the original wound boundary and is much more likely to recur after surgical excision. Nonsurgical treatment of hypertrophic scars and keloids is similar, using repeated intralesional injections of Kenalog 40 mg per cc and sustained pressure on the lesion when possible. Surgical treatment differs for hypertrophic scars or keloids. Scar excision and closure, and selective Z-plasty, may be used in hypertrophic scars. In keloids, aggressive surgery is usually avoided, unless the lesion has a narrow pedicle. Surgery of keloids should be accompanied by intra- and postoperative Kenalog-40 injections, and on occasion by sustained pressure. Very large keloids may be resistant to medical management, and too aggressive for surgery owing to a high likelihood of recurrence. These difficult lesions serve as the impetus for continued biochemical and tissue culture research, seeking a biochemical means of control keloids.     

Treatment of post-burn perineal deformities in children]

The classification of scar injuries of the perineum, peculiarities of their clinical course and characteristics of functional disorders in 12 children are presented in this work. The treatment depended upon the character of pathology. In case of a "scar sail" the plasty with local tissues grafts was performed. The Filatov's graft was used for the plasty of the defect formed after the excision of the scars in an injury to the anus. The Filatov's graft was also used for the plastic reconstruction of the large pudendal lips in girls. In case of the rectum prolapse and extensive perineal scar changes the Filatov's graft and feeding pedicle graft, formed, in the vicinity, were used for the replacement of the large defect. The results of the treatment are described.     

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.     

Thermal injury model in the rabbit ear with quantifiable burn progression and hypertrophic scar

Hypertrophic scar is a major clinical outcome of deep‐partial thickness to full thickness thermal burn injury. Appropriate animal models are a limitation to burn research due to the lack of, or access to, animal models which address the endpoint of hypertrophic scar. Lower species, such as rodents, heal mainly by contracture, which limits the duration of study. Higher species, such as pigs, heal more similarly to humans, but are associated with high cost, long duration for scar development, challenges in quantifying scar hypertrophy, and poor manageability. Here, we present a quantifiable deep‐partial thickness burn model in the rabbit ear. Burns were created using a dry‐heated brass rod for 10 and 20 seconds at 90 °C. At the time of eschar excision on day 3, excisional wounds were made on the contralateral ear for comparison. Burn wound progression, in which the wound size expands over time is a major distinction between excisional and thermal injuries, was quantified at 1 hour and 3 days after the injuries using calibrated photographs and histology and the size of the wounds was found to be unchanged from the initial wound size at 1 hour, but 10% in the 20 seconds burn wounds at 3 days. A quantifiable hypertrophic scar, measured by histology as the scar elevation index, was present in both 20 seconds burn wounds and excisional wounds at day 35. ImageJ measurements revealed that the 20 seconds burn wound scars were 22% larger than the excisional wound scars and the 20 seconds burn scar area measurements from histology were 26% greater than in the excisional wound scar. The ability to measure both burn progression and scar hypertrophy over a 35‐day time frame suits this model to screening early intervention burn wound therapeutics or scar treatments in a burn‐specific scar model.     

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.     

Sustainable effect of skin stretching for burn scar excision: long-term results of a multicenter randomized controlled trial

Purpose

Primary wound closure of large defects after burn scar excision may be facilitated by intraoperative stretching of the adjacent skin. In a randomized controlled trial (RCT), the effect of skin stretching for wound closure after scar excision (SS) was compared to scar excision without additional techniques (SE). Short-term results already showed that in the SS group larger scars could be excised in a one-step procedure. In this paper, the long-term scar outcome using reliable and valid measurement tools was evaluated.

Basic procedures

The percentage of total remaining scar area (i.e. remaining scar compared to preoperative scar), the percentage of linear scarring (i.e. surface area of linear scar compared to excised scar) and scar hypertrophy was measured at 3 and 12 months postoperatively.

Main findings

At 12 months postoperatively, the percentage of total remaining scar area was significantly lower in the SS group (26%) compared to the SE group (43%). The percentage of linear scarring (SS: 21%, SE: 25%) and the incidence of hypertrophy (SS: 29%, SE: 40%) were not significantly different between the treatment groups.

Conclusions

This RCT demonstrates the long-term beneficial and sustainable effect skin stretching for wound closure after scar excision without leading to wider linear scars or more scar hypertrophy.     

Effect of skin graft thickness on scar development in a porcine burn model

Animal models provide a way to investigate scar therapies in a controlled environment. It is necessary to produce uniform, reproducible scars with high anatomic and biologic similarity to human scars to better evaluate the efficacy of treatment strategies and to develop new treatments. In this study, scar development and maturation were assessed in a porcine full-thickness burn model with immediate excision and split-thickness autograft coverage. Red Duroc pigs were treated with split-thickness autografts of varying thickness: 0.026 in. (“thin”) or 0.058 in. (“thick”). Additionally, the thin skin grafts were meshed and expanded at 1:1.5 or 1:4 to evaluate the role of skin expansion in scar formation. Overall, the burn-excise-autograft model resulted in thick, raised scars. Treatment with thick split-thickness skin grafts resulted in less contraction and reduced scarring as well as improved biomechanics. Thin skin autograft expansion at a 1:4 ratio tended to result in scars that contracted more with increased scar height compared to the 1:1.5 expansion ratio. All treatment groups showed Matrix Metalloproteinase 2 (MMP2) and Transforming Growth Factor β1 (TGF-β1) expression that increased over time and peaked 4 weeks after grafting. Burns treated with thick split-thickness grafts showed decreased expression of pro-inflammatory genes 1 week after grafting, including insulin-like growth factor 1 (IGF-1) and TGF-β1, compared to wounds treated with thin split-thickness grafts. Overall, the burn-excise-autograft model using split-thickness autograft meshed and expanded to 1:1.5 or 1:4, resulted in thick, raised scars similar in appearance and structure to human hypertrophic scars. This model can be used in future studies to study burn treatment outcomes and new therapies.     

Is surgery an effective and adequate treatment in advanced Marjolin's ulcer?

Malignancies in scars are generally known as Marjolin's ulcers. Between 1999 and 2004, 15 patients with Marjolin's ulcer were treated in our clinic. All lesions were secondary to burns of various causes. We perform a combined approach and aggressive surgery for treatment of Marjolin's ulcer; excision with safe margin, lymphatic dissection, postoperative radiotherapy, chemotherapy and amputation if needed. We think that the scar tissue acts as a barrier for the tumors, which will enlarge. We believe that, if we release this barrier like scar tissue, the virulent the spread of the tumor will be permitted. In this article, we consider whether or not surgical excision alone as recommended in the treatment of Marjolin's ulcers is adequate and effective. An aggressive combined approach is essential for treatment in early stages with high success rate. But there is no consensus for the treatment of advanced disease and results are generally unsuccessful.     

Predicting severity of pathological scarring due to burn injuries: a clinical decision making tool using Bayesian networks

It is important for clinicians to understand which are the clinical signs, the patient characteristics and the procedures that are related with the occurrence of hypertrophic burn scars in order to carry out a possible prognostic assessment. Providing clinicians with an easy‐to‐ use tool for predicting the risk of pathological scars. A total of 703 patients with 2440 anatomical burn sites who were admitted to the Department of Plastic and Reconstructive Surgery, Burn Center of the Traumatological Hospital in Torino between January 1994 and May 2006 were included in the analysis. A Bayesian network (BN) model was implemented. The probability of developing a hypertrophic scar was evaluated on a number of scenarios. The error rate of the BN model was assessed internally and it was equal to 24·83%. While classical statistical method as logistic models can infer only which variables are related to the final outcome, the BN approach displays a set of relationships between the final outcome (scar type) and the explanatory covariates (patient's age and gender, burn surface area, full‐thickness burn surface area, burn anatomical area and wound‐healing time; burn treatment options such as advanced dressings, type of surgical approach, number of surgical procedures, type of skin graft, excision and coverage timing). A web‐based interface to handle the BN model was developed on the website www.pubchild.org (burns header). Clinicians who registered at the website could submit their data in order to get from the BN model the predicted probability of observing a pathological scar type.     

采用人工真皮修复大面积烧伤早期手部创面的疗效观察

目的:观察早期应用人工真皮修复大面积烧伤患者手部创面的效果.方法:选取2009年1月-2010年9月就诊于北京市右安门医院的大面积烧伤患者38例,采用随机分组方法分为两组.人工真皮组19例在早期修复手部创面手术中用人工真皮覆盖创面,2周后用自体刃厚皮片覆盖.对照组19例创面早期切痂、行自体微粒+异体皮移植,后期肉芽组织...     

不增加辅助切口的带瘢痕皮肤扩张切疤术

目的：探讨如何消除常规皮肤扩张后行切疤术时必然增加的辅助切口瘢痕,以达到更佳美容效果。方法：以待切除的瘢痕为中心,扩张器置于瘢痕正下方,连带瘢痕周围的皮肤同时扩张。通过采用“Z”形折线切口、皮下紧密缝合切口、注意引流、延迟注水开始时间、严格控制每次注水量等方法,有效避免扩张过程中手术切口因张力过大而开裂。结果：面、颌颈、前臂等部位以带瘢痕皮肤扩张术切除瘢痕7例,不增加任何辅助切口,效果满意。结论：带瘢痕皮肤扩张术对适当面积的瘢痕切除具有更好的治疗效果。     

Splints and accessories following burn reconstruction.

Splints, exercise, traction, and compression garments are commonly accepted methods to minimize disabling scar formation. Although burn rehabilitation treatment has improved over the past 10 years, there is still no overnight cure for scars and contracture. The extent and depth of the burn injury, emotional strength and patience of the burn victim, and support systems available play an important role in scar treatment. Scar contracture is a frustrating complication for the recovering patient and burn team. Surgical reconstruction to correct functional impairment is often needed before wound maturation is complete. Splints are usually part of the postoperative treatment plan. When this is the case, patient understanding, compliance, motivation, and comfort are important to assure splint effectiveness. The treatments reviewed are specific for scar contracture limiting function of the upper body. Although they were presented as treatment of neck, mouth, axilla, and hand contractures, many of the principles and materials can be used after burn reconstruction of the lower extremities. Regardless of the area treated, assessment of patients is important to determine their specific needs in splint design.     

S‐I‐03 Differentiation of Mesenchymal Progenitor Cells Derived from Rat Bone Marrow

We showed mesenchymal progenitor cells(MPC) contain various cells, and the differentiational capacities and effects on wound healing were different each other. Bone marrow of the femur of adult F344 rat was suspended into culture medium and plated on a plastic dish.10–15 passaged cells were cloned in 100 types cells. For investigation of the differentiational capacity, the cells were treated by differentiational medium. The capacity of myogenesis was examined immunohistochemically with anti‐skeletal muscle myosin antibody. Osteochondrogenesis were investigated by alcian blue staining and adipogenesis by oil red O staining. The 53% of cells showed myogenesis, 78% osteochondrogenesis and 100% adipogenesis. The one type of cell showed amazing adipogenesis pattern, which we named “O” cell. Next we injected MPC and this “O” cell into the rats’ dorsal skin, and 1 cm full thickness incisional wounds were made immediately after. 2 weeks later, wounds were harvested and examined histologically. The wounds transplanted with high dose of MPC healed with very fine scar and collagen fibers were thick and aligned like normal dermis. But by transplanting the “O” cells, wounds healed with ordinary scar formation. By tansplantating mesenchymal progenitor cells, lesion healed with less scars. And there was a possibility that the MPC responded to the wound healing and regenerated dermal structure nearly normally. But the wounds healed not well by transplanting just “O” cell although it possesses the amazing differentiational capacity. The data demonstrate that plural types cells were necessary for wound healing.     

The link between hypertension and pathological scarring: Does hypertension cause or promote keloid and hypertrophic scar pathogenesis?

Pathological scars, namely, keloids and hypertrophic scars (HSs), are caused by excessive cutaneous wound healing that is characterized by histological extracellular matrix (ECM) accumulation, clinically relevant irritating symptoms, and frequent recurrence after surgical excision. To date, there are few effective and specific treatments. This partly reflects the poor understanding of the etiology of these scars and the lack of a suitable animal model. Systemic hypertension has been suggested to participate in pathological scarring. The evidence that supports this hypothesis is reviewed here. Thus, hypertension associates with changes that resemble the aberrant cutaneous wound‐healing phases that characterize pathological scar development. It also associates with profibrotic functional changes in the cells that constitute keloids and HSs (endothelial cells, pericytes/myofibroblasts, dermal fibroblasts, and mast cells) and profibrotic ECM remodeling. These hypertension‐associated changes are mediated to some extent by inflammation, hypoxia, and the angiotensin/renin‐angiotensin‐aldosterone system. Thus, hypertension may be an aggravating/risk factor for keloids and HSs. This will help to identify patients who are prone to heavy scars after surgery or postsurgical recurrence. Moreover, pharmacological agents for the prophylaxis and treatment of hypertension‐induced fibrosis in other organs may also be useful for keloids/HSs.