醋酸曲安奈德配合585nm脉冲染料激光治疗增生性瘢痕疗效分析

目的：探讨醋酸曲安奈德联合585nm脉冲染料激光治疗增生性瘢痕的疗效。方法：收集并分析我科2004年1月～2008年12月使用醋酸曲安奈德加585nm脉冲染料激光治疗躯干、四肢及头面部58例增生性瘢痕患者的临床资料。结果：经过3个月的随访,58例增生性瘢痕患者临床治愈12例（占20．7％）,好转39例（占67．2％）,无效7例（占12．1％）,有效率为87．9％。结论：醋酸曲安奈德联合脉冲染料激光治疗是一项简单、有效的治疗方法,应用该方法可减轻患者痛苦和改善外观。     

Combination laser treatment for immediate post-surgical scars: a retrospective analysis of 33 immature scars

The application of laser treatments beginning on the day of stitch removal has been demonstrated to improve scar quality. However, there are few guidelines for the treatment of immature scars (ISs), which are defined as “scars whose features are not yet expressed.” The purpose of this study was to extract information about early combination laser treatment (CLT) beyond what is currently known by analyzing 33 pairs of pre-treatment and post-treatment photographs of ISs. Two hundred fifty medical records of patients with scars were reviewed, and 33 scars were included in the study. The included scars were treated with vascular lasers (585 or 532 nm) followed by 1550-nm fractional lasers from May 2014 to July 2015 (fewer than 52 days after stitch removal, Fitzpatrick’s skin types III–IV, mean age = 16.0 years). Blinded evaluators (one plastic surgeon and two dermatologists) evaluated the pre-treatment and post-treatment photographs. The pre-treatment photographs were scored on a spectrum from “0,” when no difference with the surrounding unaffected skin was observed, to “100,” when the worst scarring was present. The pre-treatment and post-treatment photographs were compared, and the results were graded on a spectrum from 0, when no difference between the pre-treatment and post-treatment photographs was observed, to 100, when no difference was observed between the post-treatment skin and the surrounding unaffected skin. Statistical analyses were performed with PASW 17.0, SPSS Korea, Seoul, Korea (p < 0.05). The improvement scores (ImS) and weighted scores (Wtd: i.e., weighted according to the pre-treatment scores) were used as dependent variables. The average improvement score was 87.98 (median = 90). Seventeen cases were scored as 100-point improvements. The facial and non-facial scars exhibited differences in the ImS and Wtd scores. The Wtd scores were negatively correlated with the temporal gap (in days) between stitch removal and the beginning of CLT. No significant difference in the Wtd scores was demonstrated between the two vascular laser groups. Patient age and Wtd score were negatively correlated, and a significant difference was observed in the Wtd scores between the age groups (≥15 and <15 years old). CLT for ISs results in excellent outcomes. Better results are achieved with earlier CLT initiation following stitch removal. Better outcomes can be expected for younger patients and for facial scars. We found that 532 and 585-nm lasers are equally effective for CLT of ISs.     

Laser in the treatment of hypertrophic burn scars

This prospective study looked at the outcome of laser (light amplification by stimulated emission of radiation) treatment for hypertrophic scarring. Dermatrade mark K laser (a set of combined lasers erbium:yttrium aluminium garnet/carbon dioxide, qualified as a class IV laser) was used. Between 21 June 2000 and 19 November 2002, at the Siemianowice Burn Center, Poland, 592 interventions, using laser, were performed on N= 327 patients (220 women and 107 men, aged between 3 and 80 years). The majority of cases [N= 223 (68.9%)] were patients with post-burn hypertrophic scars, and 104 cases (31.8%) had various types of hypertrophic scars. Evaluation took place using an adapted Vancouver Scar Scale and digital photographs as well as the patient's opinion. It was noted that after laser treatment, satisfactory results were achieved in 72% of cases. The scars had become less red (192/327 scored no redness at the end of the study versus 92/327 upon initial), less raised (272/327 scored a flat scar versus 72/327 upon initial) and demonstrated an improved viscoelasticity (192/327 scored a soft skin versus 62/327 upon initial). Laser treatment did not improve contractures in post-burn hypertrophic scars. Results were not confirmed using objective measurement tools, as these were not available to us.     

Silicone gel: a new treatment for burn scars and contractures

A new method of treatment for burn scar management is outlined using silicone gel sheets (Spenco Corporation MD-3071). The method has been applied to 42 patients with burns of varying degree and maturity. The results have been successful in all cases. The mode of action of the gel is unknown, but it does not rely on pressure. The method can easily be tailored to the individual needs of the scar and the patient. Individual initiative and a flexible approach to its use are advocated.     

Early intervention by Z-plasty combined with fractional CO2 laser therapy as a potential treatment for hypertrophic burn scars

The aim of this study is to determine whether Z-plasty combined with fractional CO₂ laser therapy can be a potential management option for hypertrophic burn scars in the proliferation stage. A total of 105 patients (46 male and 59 female patients) diagnosed with hypertrophic scars under tension but without any functional limitations were enrolled in this study. The Vancouver Scar Scale (VSS) score and scar height were analyzed and compared. The VSS scores for all scars were improved in all groups after treatment. The scar height was also significantly decreased in each group after treatment (P < 0.05). In the C group, the scar height decreased significantly to 2.62 ± 0.21 mm, which was the maximum extent at the ≦ 6 month time point compared to the decrease in the other groups. Compared to the > 12 month time point for the C group, there was a significant difference between the ≦ 6 month time point for the L group and the > 12 month time point for the Z group. The proportion of satisfied patients was highest at 89.47% at the ≦6 month time point in the C group and lowest at 65.52% at the > 12 month time point in the L group. Six representative cases are presented. Z-plasty can decrease the thickness of a hypertrophic burn scar, which not only reduces the scar tension but also makes it easy to treat the scar with a fractional CO₂ laser. Subsequent treatment with a fractional CO₂ laser can better improve the color and texture of the scar.     

Treatment of vasospasm with a 480-nm pulsed-dye laser

Laser energy at a wavelength of 480 nm was applied in 1-microseconds pulses of 3 to 10 mJ to two models of vasospasm. Rabbit common carotid arteries (CCA's) were constricted chronically by the application of human blood within a silicone sheath. Peak vasospasm developed 24 to 48 hours later, and persisted for up to 6 days. Endovascular laser treatment was delivered to 40 CCA's via a 200-microns diameter silica quartz fiber introduced through the femoral artery. The CCA caliber increased from 60% of the pre-vasospasm control diameter to a minimum post-laser diameter of 83% of control. No instances of laser-induced perforation or of arterial thrombosis were observed for up to 60 days after treatment. Prophylactic laser application to nine normal vessels was able to attenuate the development of vasospasm if blood was applied immediately thereafter (88% vs. 59% of control diameter, p less than 0.02), but not if blood was applied 7 days later. Studies in 16 normal CCA's established that there was a considerable margin between the laser energy required to induce dilatation and that which caused perforation, providing that the fiber remained relatively central within the artery. Morphological examination demonstrated focal loss of endothelial cells immediately after laser application, followed approximately 7 days later by the development of areas of intimal hyperplasia. Only minimal changes were observed in the medial or adventitial layers. In a second study, the basilar artery of seven dogs was constricted chronically by two intracisternal injections of autologous blood 3 days apart. Five dogs received endovascular laser treatment 7 or 10 days after the first injection, when basilar artery diameter was reduced to a mean of 61% and 77% of control, respectively. Immediately following treatment, basilar artery diameter increased to 104% and 102% of resting diameter, respectively. Both untreated and laser-treated arteries were smaller than the control diameter at 30 days (80% and 82%, respectively), but in each group the vasodilatory response to hypercapnia was preserved. These findings indicate that 1-microsecond laser pulses are well tolerated by systemic and cerebral arteries in two different animal models, and suggest that the 480-nm pulsed-dye laser may have an application for the treatment or prophylaxis of cerebral vasospasm.     

Evolving treatment in a decade of pediatric burn care

Backround

Over the last decade, an ambulatory burn care (ABC) and procedural sedation (PS) program was instituted at St Louis Children’s Hospital (SLCH). This study assessed the effect of these interventions on resource utilization.

Methods

The authors reviewed the hospital experience comparing 1993 with 2002 data regarding gender, age, burn depth, patient admissions, inpatient days, and ABC visits. Outcome measures included length of stay (LOS), incidence of infection, and hospital charges.

Results

Gender, age, and burn depth were similar; 192 patients were admitted in 1993. In 2002, there were 167 admissions and 118 patients treated solely on an ABC basis resulting in a total of 285 burn patients treated (+48%). Hospital days decreased from 2,041 (1993) to 963 (2002 [−53%]). LOS declined from 10.4 ± 8.3 days (1993) to 5.8 ± 14.2 days (2002 [−44%; P < .05]). PS was used sporadically in 1993, and increased to 71% in patients in 2002. There were no ABC visits in 1993 and 501 visits in 2002. The incidence of infection was 5.2% in 1993 versus 3.0% in 2002 (P < .05) Average charge per patient fell 45% from $13,286 (1993) to $7,372 (2002), adjusted to 1993 dollars using medical care price index.

Conclusions

Over a 10-year period, the program achieved a significant reduction in resource utilization while increasing the number of patients treated and maintaining a low incidence of infection. This was due in large part to a shift to ABC and the use of PS.     

Beneficial effects of extended growth hormone treatment after hospital discharge in pediatric burn patients

OBJECTIVE: To study the efficacy of growth hormone given to severely burned children from discharge to 12 months after burn and for 12 months after the drug was discontinued. SUMMARY BACKGROUND DATA: We have previously shown that low-dose recombinant human growth hormone (rhGH), given to children after a severe thermal injury, successfully improved lean muscle mass, bone mineral content, and growth. The aim of the present study was to investigate long-term functional improvements after treatment. METHODS: Forty-four pediatric patients with over 40% total body surface area burns were studied for 24 months after burn. Patients were randomized to receive either rhGH (0.05 mg/kg body weight) or placebo. Height, weight, body composition, serum hormones, resting energy expenditure, cardiac function, muscle strength, and number of reconstructive procedures performed were measured during rhGH treatment and for 12 months after treatment was discontinued. Statistical analysis used Tukey's multiple comparison test. Significance was accepted at P < 0.05. RESULTS: Height, weight, lean body mass, bone mineral content, cardiac function, and muscle strength significantly improved during rhGH treatment compared with placebo (P < 0.05). This treatment significantly increased GH, IGF-I, and IGFBP-3, whereas serum cortisol decreased (P < 0.05). The number of operative reconstructive procedures was significantly lower with rhGH (P < 0.05). Improvements in height, bone mineral content, and IGF-1 concentrations persisted after rhGH treatment (P < 0.05). No side effects with rhGH were observed. CONCLUSIONS: Administration of rhGH for 1 year after burn was safe and improved recovery. These salutary effects continued after rhGH treatment was discontinued.     

Topigel in the treatment of hypertrophic scars after burn injuries

The authors present the results of a medium-term study in which they investigated the therapeutic effect of the silicone elastomer TopiGel on developing hypertrophic scars in a group of patients after burn injuries classified as IIb or deeper. The hitherto published results are very encouraging. This medium-term study confirmed the hypothesis that TopiGel has a positive effect on the reduction, stabilization and normalization of hypertrophic scars. In 48 patients (96%) out of a total of 50, stabilization of the scar occurred as well as its functional and cosmetic normalization, although the subjective view of the patients or parents (in case of pediatric patients) differed in some instances. In two children (4%) only a significant reduction of the scar occurred and not normalization, due to incorrect application of the gel by the parents, lack of adherence to basic hygienic principles or the recommended procedure of gel application. In case of repeated complications, treatment was not pursued. In two patients (4%) treatment was discontinued for a short time due to an allergic skin reaction subsequently, treatment was resumed until complete stabilization of the scar was achieved. The study ruled out a positive therapeutic effect of the silicone sheet on the painfulness of a scar and old, mature hypertrophic scars.     

Pattern of burn injuries at a Kenyan provincial hospital

Burns are a significant cause of hospital admission in African countries. This study illustrates that the factors contributing to the burn injury, the susceptible populations, the hospital conditions and the causes of mortality are different from those experienced in the West. Suggestions to reduce the risks and improve first aid treatment of burns are discussed.     

烧伤后早期心肌损害与防治

Isehemia/hypoxia is one of the key clinical issues following severe burns, and isehemic/hypoxic damage of tissues and organs is still hard to be prevented or minimized by various fluid resuscitation regimens . To those who suffered severe bums, even though fluid replacement therapy is delivered promptly, isehemic/hypoxie damage of organs is still inevitable. Previously, blood flow in vital organs such as heart was eonsidered not to be reduced because of blood redistribution under the circumstance of stress. The postbum cardiac dysfunction has been mainly attributed to the reduced blood flow returned to the heart due to decreased blood volume caused by increased capillary permeability. Therefore, postbum cardiac dysfunction has been considered to be the result of burn shock. During the past two decades, we have performed serial studies on severe burns, and found that isehemie/hypoxie myocardial damage and functional impairment of myocardium due to activation of reninangio tensin system existing in the heart itself occur immediately after severe bums even before significant reduction in blood volume secondary to an increase of capillary permeability . Such prompt myocardial damage leads to cardiac deficiency, and it is also a precipitating factor for bum shock and isehemic/hypoxie injury of systemic tissues and organs. Therefore, we called it " shock heart" in our reports. The cellular and molecular mechanisms leading to myocardial damage were systematically investigated. Strategies for prevention of early postburn myocardial damage and dysfunction, and a new effective burn shock resuscitation regimen "volume replacement" plus "dynamic support" (cardiac support and myocardial protection) have been proposed based on our previous studies.     

Ultrapulsed fractional ablative carbon dioxide laser treatment of hypertrophic burn scars: evaluation of an in-patient controlled,standardized treatment approach

In this study, we aimed to quantify the effects of fractional ablative carbon dioxide laser therapy in the treatment of widespread hypertrophic burn scars. While many different pilot studies have described the potential of the technology and expert groups and current guidelines, alike, recommend its use, the level of evidence for the efficacy of fractional CO₂-laser treatment for burn scars is currently very low. Ten patients (three male, seven female) with hypertrophic burn scars were treated with a single course of fractional CO₂-laser therapy in an in-patient controlled setup, using a standardized treatment paradigm. Documentation was based on modern scar scales and questionnaires, like the Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), and Dermatology Life Quality Index (DLQI), as well as state of the art clinical measurements (PRIMOS, Cutometer). Over the course of 6 months after treatment, VSS and POSAS scores showed significant improvement in the rating of scar parameters, as did the quality of life rating according to the DLQI. In the treated scars, surface relief improved significantly, as S _max decreased by 1893 μm (?36.92%) (p = 0.0273) and S _z by 1615 μm (?36.37%) (p = 0.0488). Scar firmness in treated scars could be reduced by 30% after one treatment session, as R ₀ improved by 0.0797 mm (+30.38%) (p = 0.0212). Fractional ablative CO₂-laser treatment is a safe and efficacious option for the treatment of hypertrophic burn scars. While more treatment sessions are required for satisfying results, significant improvement is already apparent after a single course of treatment.     

二氧化碳点阵激光治疗烧伤瘢痕的研究进展

This paper reviews the new progress in the research of fractional carbon dioxide laser in treating hypertrophic scar after bum injury,which remains a challenging problem for burn care surgeons.There have been many traditional therapeutic approaches,such as compression remedy,operation,and so on.However,a satisfactory method is lacking to date.In recent years,the newly developed fractional carbon dioxide laser has been employed to treat different kinds of scars,and it has been proved to be effective in terms of an improvement of scar color,texture,and rigidity.It seems to be a promising method for scar treatment in future.     

增生性瘢痕的激光治疗进展

<正>瘢痕是机体组织受到创伤后异常修复的结果,在愈合过程中组织过度增生,就会形成增生性瘢痕(hypertrophic scar,HS)[1]。增生性瘢痕发生率高,常发生于手术、外伤、烧伤及炎症后,即使技术很熟练的手术和伤口护理也很难避免其发生。在瘢痕成熟和治疗的漫长时间里,数以百万的患者承受着持续的症状和功能障碍,对患者的心理、生理危害很大。既往的治疗方法有瘢痕内注射、压迫疗法、抗肿瘤药物治疗、细胞因子相关治疗、硅树脂凝胶覆盖、     

Study of patient-reported morbidity following V-beam pulsed-dye laser treatment of port wine stains

The V-beam pulsed-dye laser (PDL) (595 nm) has gained popularity in the treatment of port wine stains (PWS). It uses longer pulse durations than the standard flashlamp-pumped pulsed-dye laser (FPDL) (585 nm) and has an in-built cooling system to protect the epidermis. This should, theoretically, reduce the treatment-associated side effects, including discomfort. The aim of this questionnaire-based study was to confirm the clinical impression that V-beam PDL is well tolerated. The results were compared with a historical group of 62 PWS patients treated with FPDL. Fifty-one patients took part in the current study. Only 35.7% (vs. 81% in the historical comparison group) required topical anaesthetic prior to laser treatment. A shortening in the duration of bruising (8 vs. 10 days) and of symptoms such as burning and tightness (3 vs. 10 days) was recorded. Lifestyle change after treatment was recorded by fewer patients (39 vs. 57%). We conclude that V-beam PDL is better tolerated than FPDL when used at therapeutic levels in patients with PWS.     

Tissue expansion in surgical treatment of burn scars of the scalp

Deep burns of the scalp responsible of alopecia, used to be a real surgical challenge until apparition of tissue expansion in the 1980's. Tissue expanders are in this way employed in our unit of plastic surgery since more than 20 years, especially for head and neck reconstruction after burns. Thanks to operators and teams experience, incidence of postsurgical complications is still decreasing; in the same time, many improvements have been performed, regarding to surgical technique, choice of expanders (size, location...), or shape of flaps. All those technical details are discussed in order to optimize surgical results.     

Fractional ablative laser therapy for the treatment of severe burn scars: A pilot study of the underlying mechanisms

Ablative fractional resurfacing is clinically an efficient treatment for burn scar management. The aim of this pilot study was to investigate the poorly understood mechanisms underlying ablative fractional CO2 laser (AFL-CO2) therapy in relation to biomarkers S100 and 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1). S100 stains for Langerhans cells and neuronal cells, potentially representing the pruritus experienced. 11β-HSD1 catalyses the interconversion of cortisol and cortisone in cells, promoting tissue remodelling. Immunohistochemical analysis of S100 and 11β-HSD1 protein expression in the dermis and epidermis of the skin was performed on normal skin, before and after AFL-CO2 therapy. Data assessing outcome parameters was collected concurrently with the skin biopsies. 13 patients were treated with AFL-CO2 therapy. Langerhans cells decreased by 39% after 2nd treatment. Neuronal cells were overexpressed before treatment in the scar tissue by 91% but levels returned to that resembling normal skin. 11β-HSD1 expression in keratinocytes was significantly higher after laser treatment compared to before in scar tissue (p <0.01). No clear correlation was found in dermal fibroblast numbers throughout the treatment course. Whilst the role of the explored mechanisms and their association with clinical outcomes cannot conclusively be stated, this pilot study demonstrates promising trends that encourages investigation into this relationship.