Current scales for assessing human scarring: a review

Comparison of Laparoscopic Approaches for Dismembered Pyeloplasty in Children With Ureteropelvic Junction Obstruction: Critical Analysis of 11-Year Experiences in a Single Surgeon

OBJECTIVE

The choice of different laparoscopic approaches of laparoscopic pyeloplasty (LP) in children remains controversial. We present a comparison of different approaches of LP in children and a critical analysis of 11-year experiences in a single surgeon.

MATERIALS AND METHODS

There were 1750 patients (1889 sides) who underwent LP between 2003 and 2014 reviewed. The diagnosis and outcomes of ureteropelvic junction obstruction (UPJO) were reviewed based on clinical and imaging data. Retroperitoneal laparoscopic pyeloplasty (RPLP) were performed in 451 cases (RPLP group), conventional transperitoneal laparoscopic pyeloplasty (CTLP) were performed in 311 cases (CTLP group), transumbilical single-site laparoscopic pyeloplasty (TSLP) were performed in 322 cases (TSLP group), and transumbilical multiport laparoscopic pyeloplasty (TMLP) were performed in 805 cases (TMLP group). We assessed preoperative clinical data and outcomes, and analyzed the transition experience. Data are expressed as medians for continuous variables.

RESULTS

The start of oral feeding, hospital stay, and the operative time of RPLP group were 1.10 ± 0.10 days, 5.22 ± 1.32 days, and 138.2 ± 20.1 minutes, respectively. Compared with the other 3 groups, the start of oral feeding was the soonest, hospital stay was the shortest, and the operative time was the longest in the RPLP group (P < .01 or .05). The cosmetic result of the TMLP group was 7.07 ± 1.20 scores, and there are significant differences in cosmetic results between the TMLP group and the other 3 groups (P < .05).

CONCLUSION

Although the 4 laparoscopic approaches for LP in children with UPJO are safe and efficient procedures with equivalent success rates, we recommend RPLP or TMLP as a treatment option for children with UPJO.

Patient-Reported Outcome Instruments for Surgical and Traumatic Scars: A Systematic Review of their Development, Content, and Psychometric Validation

BACKGROUND

Patient-reported outcomes (PROs) are of growing importance in research and clinical care and may be used as primary outcomes or as compliments to traditional surgical outcomes. In assessing the impact of surgical and traumatic scars, PROs are often the most meaningful. To assess outcomes from the patient perspective, rigorously developed and validated PRO instruments are essential.

METHODS

The authors conducted a systematic literature review to identify PRO instruments developed and/or validated for patients with surgical and/or non-burn traumatic scars. Identified instruments were assessed for content, development process, and validation under recommended guidelines for PRO instrument development.

RESULTS

The systematic review identified 6534 articles. After review, we identified four PRO instruments meeting inclusion criteria: patient and observer scar assessment scale (POSAS), bock quality of life questionnaire for patients with keloid and hypertrophic scarring (Bock), patient scar assessment questionnaire (PSAQ), and patient-reported impact of scars measure (PRISM). Common concepts measured were symptoms and psychosocial well-being. Only PSAQ had a dedicated appearance domain. Qualitative data were used to inform content for the PSAQ and PRISM, and a modern psychometric approach (Rasch Measurement Theory) was used to develop PRISM and to test POSAS. Overall, PRISM demonstrated the most rigorous design and validation process, however, was limited by the lack of a dedicated appearance domain.

CONCLUSIONS

PRO instruments to evaluate outcomes in scars exist but vary in terms of concepts measured and psychometric soundness. This review discusses the strengths and weaknesses of existing instruments, highlighting the need for future scar-focused PRO instrument development.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

In-Depth Survey of Scarring and Distress in Patients Undergoing Bilateral Axillo-Breast Approach Robotic Thyroidectomy or Conventional Open Thyroidectomy

PURPOSE

Oncologic and surgical outcomes of bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT) are comparable with those of open thyroidectomy (OT). We compared degree of scarring and psychological/physical distress between OT and BABA RoT.

MATERIALS AND METHODS

Study included 129 cases of thyroidectomy (78 OT, 51 BABA RoT). Patients were evaluated by psychology consultant using 5-point scale questionnaire.

RESULTS

BABA RoT was associated with lower degree of scarring than OT (7.8 vs. 11.7, P<0.001). Psychological distress immediately after operation and during surveillance period was higher in OT than in BABA RoT (3.1 vs. 2.6, P=0.009 and 2.4 vs. 1.9, P<0.001). Physical distress (pain and exercise limitation) did not differ between groups (2.5 vs. 2.6, P=0.321 and 2.0 vs. 1.9, P=0.0175).

CONCLUSIONS

BABA RoT was associated with less scarring and psychological distress than OT. BABA RoT might be alternative for patients who are concerned about neck scar.

Cosmetic Appearance of Port-site Scars 1 Year After Laparoscopic Versus Robotic Sacrocolpopexy: A Supplementary Study of the ACCESS Clinical Trial

STUDY OBJECTIVE

To prospectively measure trocar site appearances 1 year after surgery in women participants in the Abdominal Colpopexy: Comparison of Endoscopic Surgical Strategies Trial, a 2-center randomized surgical trial (NCT01124916).

DESIGN

Supplementary analysis of a surgical trial that randomized women to robotic or laparoscopic sacrocolpopexy (Canadian Task Force classification I).

SETTING

Operative trial.

PATIENTS

Women undergoing clinically indicated sacrocolpopexy for symptomatic stage ≥II pelvic organ prolapse were randomized to laparoscopic abdominal sacrocolpopexy (LASC) or robotic abdominal sacrocolpopexy (RASC). Trocar skin incision closure was standardized by using Dermabond (Ethicon, Somerville, NJ).

MEASUREMENTS AND MAIN RESULTS

Photographs of all incision sites were taken at baseline (immediately), 6 weeks, 6 months, and 1 year after surgery. Study coordinators scored each incision with the validated Stony Brook Evaluation Scale (SBES), a 5-point wound evaluation scale. We calculated the average of all scars scores per case to determine the percent of optimal wound healing (0%-100%) for each case as well as the proportion of cases meeting 100% wound repair scoring. Wound repair scores across groups were tested with the Wilcoxon rank sum test. The overall proportion of cases in each group meeting "optimal" wound recovery (scores of 100%) was tested with the Fisher exact test. Seventy-eight women with a mean age of 59 years (range, 26-79 years) were randomized to LASC (n = 38) or RASC (n = 40). We did not detect significant differences in baseline characteristics or rates of dropout between the 2 study groups (5 in LASC and 7 in RASC, p = .60). Pain in the initial postoperative period was higher in the robotic arm although groups were similar at 2 weeks. Nearly all cases (75/78) contributed wound repair data (36 laparoscopic and 39 robotic). Laparoscopic surgeries require significantly fewer incisions (median = 4; range, 4-6) than robotic surgeries (median = 5; range, 4-6; p < .001). SBES scores at 6 weeks were not different for LASC and RASC (p = .426). By 6 months, the scores were better in the LASC group (84.8% ± 8.8% vs 78.5% ± 7.2%, p = .031), and this finding remained at 1 year (93.4% ± 7.2% vs 85.9% ± 8.8%, p = .001). The proportion of cases with optimal wound repair (score of 100%) was higher in the laparoscopic arm at 1 year after surgery (12/27 vs 4/33, p = .008).

INTERVENTIONS

Women were randomized to robotic assisted laparoscopy or laparoscopy.

CONCLUSION

Wound appearance using the SBES was better in the LASC group, suggesting that there may be alterations in the mechanism for wound initiation and/or healing based on the minimally invasive route used for sacrocolpopexy.

Practice guidelines for the application of nonsilicone or silicone gels and gel sheets after burn injury

The objective of this review was to systematically evaluate available clinical evidence for the application of nonsilicone or silicone gels and gel sheets on hypertrophic scars and keloids after a burn injury so that practice guidelines could be proposed. This review provides evidence based recommendations, specifically for the rehabilitation interventions required for the treatment of aberrant wound healing after burn injury with gels or gel sheets. These guidelines are designed to assist all healthcare providers who are responsible for initiating and supporting scar management interventions prescribed for burn survivors. Summary recommendations were made after the literature, retrieved by systematic review, was critically appraised and the level of evidence determined according to Oxford Centre for Evidence-based Medicine criteria.

Cutaneous Scar Prevention and Management: Overview of current therapies

Cutaneous scarring is common after trauma, surgery and infection and occurs when normal skin tissue is replaced by fibroblastic tissue during the healing process. The pathophysiology of scar formation is not yet fully understood, although the degree of tension across the wound edges and the speed of cell growth are believed to play central roles. Prevention of scars is essential and can be achieved by attention to surgical techniques and the use of measures to reduce cell growth. Grading and classifying scars is important to determine available treatment strategies. This article presents an overview of the current therapies available for the prevention and treatment of scars. It is intended to be a practical guide for surgeons and other health professionals involved with and interested in scar management.

Characterizing tissue stiffness at the tip of a rigid needle using an opto-mechanical force sensor

We present a novel device that allows the user to measure the Young Modulus of a material at the opening of a 5 mm diameter needle. The device relies on a miniaturized cantilever spring mounted at the end of the needle and interrogated via Fabry-Pérot optical fiber interferometry. The probe is repetitively brought in and out of contact with the sample at the end of the needle by means of a steel cable that is controlled via a piezoelectric actuator located at the proximal end. We demonstrate the ability of our device to detect and quantify layers of varying stiffness during needle insertion in a gelatin phantom and to successfully locate tissue boundaries in bovine liver tissue embedded in gelatin.

Short and long-term cosmesis of cervical thyroidectomy scars

Introduction Multiple surgical approaches to the thyroid gland have been described via cervical or extracervical routes. Improved cosmesis, patient satisfaction, reduced pain (procedure dependent) and early discharge have all been reported for minimally invasive approaches with similar safety profiles and long-term outcomes to conventional surgery. This review summarises the current evidence base for improved cosmesis with minimally invasive cervical approaches to the thyroid gland compared with conventional surgery. Methods A systematic review was undertaken. The MEDLINE(®), Embase™ and Cochrane databases were searched for relevant articles. Results A total of 57 papers thyroid papers were identified. Of those, 20 reported some form of cosmetic outcome assessment. There were 6 randomised controlled trials with 412 patients (evidence level 2B), 7 cohort studies with 3,073 patients (level 3B) and 7 non-comparative case series with 1,575 patients (level 4). There was significant heterogeneity between studies in terms of wound closure technique, timing of scar assessment and scar assessment scales (validated and non-validated). Most studies performed early scar assessments, some using non-validated scar assessment tools. Conclusions Assessment of cosmesis is complex and requires rigorous methodology. Evidence from healing/remodelling studies suggests scar maturation is a long-term process. This calls into question the value of early scar assessment. Current evidence does not support minimally invasive surgical approaches to the thyroid gland if improved long-term cosmesis is the goal.

Extracorporeal Shock Wave Therapy: An Emerging Treatment Modality for Retracting Scars of the Hands

Prolonged and abnormal scarring after trauma, burns and surgical procedures often results in a pathologic scar. We evaluated the efficacy of unfocused shock wave treatment, alone or in combination with manual therapy, on retracting scars on the hands. Scar appearance was assessed by means of the modified Vancouver Scar Scale; functional hand mobility was evaluated using a range-of-motion scale, whereas a visual analogue score was implemented for detecting any improvements in referred pain. Additionally, biopsy specimens were collected for clinico-pathologic correlation. For each active treatment group, statistically significant improvements in modified Vancouver Scar Scale were recorded as early as five treatment sessions and confirmed 2 wk after the last treatment session. Analogous results were observed when assessing pain and range of movement. Histopathological examination revealed significant increases in dermal fibroblasts in each active treatment group, as well as in neoangiogenetic response and type-I collagen concentration.

Two-Step Incision for Periarterial Sympathectomy of the Hand

Background

Surgical scars on the palmar surface of the hand may lead to functional and also aesthetic and psychological consequences. The objective of this study was to introduce a new incision technique for periarterial sympathectomy of the hand and to compare the results of the new two-step incision technique with those of a Koman incision by using an objective questionnaire.

Methods

A total of 40 patients (17 men and 23 women) with intractable Raynaud's disease or syndrome underwent surgery in our hospital, conducted by a single surgeon, between January 2008 and January 2013. Patients who had undergone extended sympathectomy or vessel graft were excluded. Clinical evaluation of postoperative scars was performed in both groups one year after surgery using the patient and observer scar assessment scale (POSAS) and the Wake Forest University rating scale.

Results

The total patient score was 8.59 (range, 6-15) in the two-step incision group and 9.62 (range, 7-18) in the Koman incision group. A significant difference was found between the groups in the total PS score (P-value=0.034) but not in the total observer score. Our analysis found no significant difference in preoperative and postoperative Wake Forest University rating scale scores between the two-step and Koman incision groups. The time required for recovery prior to returning to work after surgery was shorter in the two-step incision group, with a mean of 29.48 days in the two-step incision group and 34.15 days in the Koman incision group (P=0.03).

Conclusions

Compared to the Koman incision, the new two-step incision technique provides better aesthetic results, similar symptom improvement, and a reduction in the recovery time required before returning to work. Furthermore, this incision allows the surgeon to access a wide surgical field and a sufficient exposure of anatomical structures.

A comprehensive evidence-based review on the role of topicals and dressings in the management of skin scarring

Wound healing after dermal injury is an imperfect process, inevitably leading to scar formation as the skin re-establishes its integrity. The resulting scars have different characteristics to normal skin, ranging from fine-line asymptomatic scars to problematic scarring including hypertrophic and keloid scars. Scars appear as a different colour to the surrounding skin and can be flat, stretched, depressed or raised, manifesting a range of symptoms including inflammation, erythema, dryness and pruritus, which can result in significant psychosocial impact on patients and their quality of life. In this paper, a comprehensive literature review coupled with an analysis of levels of evidence (LOE) for each published treatment type was conducted. Topical treatments identified include imiquimod, mitomycin C and plant extracts such as onion extract, green tea, Aloe vera, vitamin E and D, applied to healing wounds, mature scar tissue or fibrotic scars following revision surgery, or in combination with other more established treatments such as steroid injections and silicone. In total, 39 articles were included, involving 1703 patients. There was limited clinical evidence to support their efficacy; the majority of articles (n = 23) were ranked as category 4 LOE, being of limited quality with individual flaws, including low patient numbers, poor randomisation, blinding, and short follow-up periods. As trials were performed in different settings, they were difficult to compare. In conclusion, there is an unmet clinical need for effective solutions to skin scarring, more robust long-term randomised trials and a consensus on a standardised treatment regime to address all aspects of scarring.

Comparative study for evaluating the cosmetic outcome of small-incision access retroperitoneoscopic technique (SMART) with standard retroperitoneoscopy using the Observer Scar Assessment Scale: are small incisions a big deal?

AIM

To compare the scars and cosmetic results of trocars of 3, 5, and 10 mm in cases by small-incision access retroperitoneoscopic technique pyeloplasty (SMARTp) and standard laparoscopy pyeloplasty (SLp).

METHODS

Between January 2012 and October 2013, 20 pyeloplasties were performed: 12 with SMARTp and 8 with SLp techniques. A 5-mm homemade balloon trocar was used to create the retroperitoneal space. In SMARTp, 3- and 5-mm trocars were used and in SLp, 5- and 10-mm trocars were used. All patients underwent a ureteral (Double-J) stent placement preoperatively. The study included a total of 72 trocar-site scars: 3 mm (24 scars), 5 mm (24 scars), and 10 mm (24 scars). Cosmetic outcome was assessed at the 3rd, 12th, and 24th month of surgeries by the Observer Scar Assessment Scale (OSAS).

RESULTS

Mean age was 34.7±10.5 (19-52) years, and mean follow up was 18.7±9.2 months. Fifteen patients (75%) underwent Y-V plasty, and 5 (25%) underwent Anderson-Hynes pyeloplasty. Mean operative time was 125.4±28.7 minutes. There was only minimal blood loss, no need for conversion to standard laparoscopic or open pyeloplasty, no intraoperative complications, and only two postoperative complications were recorded: retroperitoneal hemorrhage and wound infection and both were treated conservatively. There were significant differences between objective questions of "vascularization" in a 3-mm trocar and "thickness" in a 10-mm trocar. Twenty-four months after surgery, the cosmetic data assessed by OSAS showed statistically significant differenecs in favor of the 3-mm trocar sites versus the 10-mm trocar sites (OSAS: 13.8±3.9 vs 24.6±1.7; p=0.006) with no statistically significant difference between 3- and 5-mm port sites.

CONCLUSIONS

The SMARTp is proved to be an efficacious and tolerable procedure with better cosmetic results and can be used for the treatment of ureteropelvic junction obstruction (UPJO) in suitable patients. We believe that this technique is likely to become an established procedure.

How do patients score cosmesis after laparoscopic natural orifice specimen extraction colectomy?

AIM

Laparoscopic colorectal resection results in improved cosmetic outcome and better presumed body image. Laparoscopic NOSE colectomy omits an incision for specimen extraction and is supposed to further improve postoperative cosmesis. This study aimed to assess the cosmetic benefit.

METHOD

Forty-nine patients who underwent a NOSE colectomy for bowel endometriosis from September 2009 to September 2013 were matched for age, American Society of Anesthesiologists (ASA) grade and body mass index (BMI) with patients who underwent a conventional laparoscopic colectomy for the same indication. Patients were asked to complete a questionnaire consisting of a body scale and a cosmetic scale and the Patient Scar Assessment Questionnaire (PSAQ) including five subscales (appearance, symptoms, scar consciousness, satisfaction with appearance and satisfaction with symptoms).

RESULTS

Patient demographics were similar between both groups. Patients were assessed at a median postoperative follow-up of 41 months in the NOSE colectomy group and 35 months in the conventional resection group. The median body image questionnaire score was 15 for NOSE colectomy and 18 for conventional resection (P = 0.027). The respective median PSAQ scores were 56 and 71 (P = 0.002). There was a good relationship between the PSAQ score and the body image questionnaire (Spearman correlation coefficient 0.82).

CONCLUSION

Depending on the scoring system used, the cosmetic outcome may be better after NOSE colectomy than conventional laparoscopy in patients having surgery for endometriosis. The comprehensive body image questionnaire, being shorter and easier to use, could be a valid tool for assessing cosmesis after NOSE procedures.

Reliability of photographic analysis of wound epithelialization assessed in human skin graft donor sites and epidermolysis bullosa wounds

Background

In many clinical trials on cutaneous healing, wound closure is the primary endpoint and single most important outcome parameter, making precise assessment of this time point one of utmost importance. The assessment of wound closure can be performed either by subjective clinical inspection or with a variety of methodologies anticipated to provide more objective data. The aim of this study was to examine intra- and interrater variability of blinded photographic analysis of wound closure of human partial thickness wounds, as well as the reliability of remote photographic analysis of wounds with that of direct clinical assessment.

Methods

Two plastic surgeons, a dermatologist, and a maxillofacial surgeon constituted our rater panel. High-resolution images of patient wounds derived from two randomized controlled clinical trials (EU Clinical Trials Register numbers EudraCT 2009-017418-56 (registered 12 January 2010) and EudraCT 2010-019945-24 (registered 13 July 2010)) were individually assessed by the blinded, experienced study raters. The reliability of photographic image analysis was tested using intraclass and interclass correlation. The validity of photographic image analysis was correlated with clinical assessments of documented time to heal from the study centers’ files.

Results

The results demonstrated that the mean intraclass correlation coefficient of all four examiners was excellent (r = 0.79; 95 % confidence interval (CI), 0.61, 1.00)). The interrater correlation coefficient was good (r = 0.67; 95 % CI, 0.57, 1.00)) and therefore acceptable. The agreement between remote visual assessment and clinical assessment at the time of healing was good (r = 0.64; 95 % CI, 0.52, 0.76)) with an overall difference of about 1 day.

Conclusions

Remote photographic analysis of cutaneous wounds is a feasible instrument in clinical open-label studies to evaluate time to wound closure. We found that it was a reliable method of measuring wound closure that correlated satisfactorily with clinical judgment, bolstering the potential relevance in the current era of evolving application and dependency in the field of telemedicine.

Trial registration

EU Clinical Trials Register EudraCT numbers 2009-017418-56 (date of registration: 12 January 2010) and 2010-019945-24 (date of registration: 13 July 2010).

Population perception of surgical approach in minimally invasive surgery

INTRODUCTION

The aim of this study was to better understand the impact that public opinion might have on surgical approaches in urologic minimally invasive surgery (MIS).

METHODS

We collected surveys from 400 participants, including the general population (n = 220) and paramedical staff (n = 180). Participants were anonymous. The survey included 16 questions on the characteristics and preference for the surgical approach if a urologic MIS were performed on them.

RESULTS

The responders preferred the transumbilical approach (57.0%) to the subcostal approach (43.0%). In particular, the preference for a transumbilical approach was significantly higher in females (65.1% vs. 49.3%, p = 0.0014). Similarly, when participants were divided into two groups (<50 years and ≥50 years), the preference for the transumbilical approach was significantly higher in the younger group (60.8% vs. 48.0%, p = 0.0187). Logistic regression analysis revealed that preference for this approach was about 2 times more likely to rise in the females (p = 0.032).

CONCLUSIONS

Preference for the transumbilical approach was significantly higher young female respondents. This patient subset most values the cosmetic benefits of transumbilical approach in urologic MIS.

Reliability of Repeated Measurements on Post-Burn Scars with Corneometer CM 825(®)

BACKGROUND/PURPOSE

The water content in burn scars, the parameter of stratum corneum water holding capacity, is an important feature in evaluation of biophysical properties of scars. Nevertheless, quantifiying this parameter is a challenge. In this study, the reliability of repeated water content measurements with Corneometer CM825(®) on (burn) scars was investigated.

METHODS

Intra-observer reliability, inter-observer reliability and day-by-day variability were examined on 30 scars by means of intra-class correlation coefficient (ICC) and within-subject coefficient of variation (WSCV). Bland-Altman plots with '95% limits of agreement' were constructed.

RESULTS

Results revealed excellent ICC values (ICCintra  = 0.985; ICCinter  = 0.984) with relatively low WSCV (WSCVintra  = 6.3%; WSCVinter  = 10.6%) for respectively intra- and inter-observer reliability. However, the Bland-Altman plot showed that more than 5% of differences were expected to exceed 4 a.u., the limit of what has been defined as a clinically acceptable difference. Results for day-by-day variability showed good ICC value (ICCday-by-day  = 0.849) and higher WSCV (WSCVday-by-day  = 20.5%).

CONCLUSION

The Corneometer CM825(®) is an objective and sensitive instrument for water content measurements. On the basis of our results, we concluded that the instrument can be used in clinical trials, but only under very strict conditions with standardized test protocol, preferably in combination with the evaluation of other physiological parameters.

Single-incision and NOTES cholecystectomy, are there clinical or cosmetic advantages when compared to conventional laparoscopic cholecystectomy? A case-control study comparing single-incision, transvaginal, and conventional laparoscopic technique for cholecystectomy

BACKGROUND

The aim of the present study was to compare the clinical and cosmetic results of transvaginal hybrid cholecystectomy (TVC), single-port cholecystectomy (SPC), and conventional laparoscopic cholecystectomy (CLC). Recently, single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery have been developed as minimally invasive alternatives for CLC. Few comparative studies have been reported.

METHODS

Female patients with symptomatic gallstone disease who were treated in 2011 with SPC, TVC, or CLC were entered into a database. Patients were matched for age, body mass index, and previous abdominal surgery. After the operation all patients received a survey with questions about recovery, cosmesis, and body image.

RESULTS

A total of 90 patients, 30 in each group, were evaluated. Median operative time for CLC was significantly shorter (p < 0.001). There were no major complications. Length of hospital stay, postoperative pain, and postoperative complications were not significantly different. The results for cosmesis and body image after the transvaginal approach were significantly higher. None of the sexually active women observed postoperative dyspareunia.

CONCLUSIONS

Both SPC and TVC are feasible procedures when performed in selected patients. CLC is a faster procedure, but other clinical outcomes and complication rates were similar. SPC, and especially TVC, offer a better cosmetic result. Randomized trials are needed to specify the role of SPC and TVC in the treatment of patients with symptomatic gallstone disease.

Longitudinal burn scar quantification

Quantitative studies of the clinical recovery of burn scars are currently lacking. Previous reports validate the objective, precise, diagnostic capabilities of high-frequency ultrasound to measure thickness, the Cutometer(®) to measure pliability and the Mexameter(®) to measure erythema and pigmentation of scars. Thus, we prospectively quantified clinical characteristics of patient-matched, after burn hypertrophic scar (HSc), donor site scar (D) and normal skin (N) using these instruments. One investigator measured 3 sites (HSc, D, N) in 46 burn survivors at 3, 6, and 12 months after-burn. A mixed model regression analysis, adjusting p-values for multiplicity of testing, was used to compare means among sites and time points. Participants were 41.2±13.5 years old, 87% males, predominantly Caucasian, with an average of 19.5% body surface area burned. HSc thickness decreased significantly between 3 and 6, 6 and 12, and 3 and 12 months (all p<0.0001), but remained thicker than D and N skin (all p<0.0001). Pliability differed significantly between HSc, D and N sites at all time points (all p<0.0001), with HSc and D increasing between 3 and 12 months (p<0.05) but not reaching normal. HSc and D sites were significantly more erythematous than normal skin (p<0.05) at 3 and 6 months but D sites approached normal by 12 months. The only time points at which pigmentation significantly differed were the HSc and D sites at 6 months. Thickness, pliability, erythema and pigmentation of N skin remained similar over the 12 months. We found that post-burn HSc thickness, pliability and erythema differed significantly from D and N skin at 3, 6, and 12 months and does not return to normal by 12 months after-injury; however, significant improvements towards normal can be expected. Donor sites are redder than normal skin at 3 and 6 months but can be expected to return to normal by 12 months. Although the color of HSc and D sites change markedly with time these color changes are primarily due to changes in redness of the site, not melanin in this primarily Caucasian population.

Reconstruction after skin cancer excision through a dermal induction template: our experience

Dermal substitutes offer alternative approaches for wounds of all thicknesses where sufficient donation sites are not available for self-grafts. Several dermal substitutes are described in literature. This study included 20 patients treated with a dermal induction template after the removal of malignant skin cancers situated in various parts of the body. The participants were especially aged patients with multiple skin cancers, and complex clinical conditions, often affected by pathologies such as cardiopathy, diabetes mellitus, and hypercholesterolaemia, and receiving pharmacological multi-therapies, particularly antiplatelets and anticoagulants. In many of these patients, the general complex clinical picture provided significant contraindication for complex reconstructive surgery because of the high risk involved. All patients achieved complete healing about 8 weeks after the first surgery. By using a dermal induction template, it was possible to cover substantial loss of substances without the need of autologous tissue, with smoother and less apparent scar, minor occurrence of hypertrophic and retracted scars, better flexibility of healed skin and therefore a better result from an aesthetic point of view.

Reliability of scar assessments performed with an integrated skin testing device - the DermaLab Combo(®)

BACKGROUND

The DermaLab Combo(®) is a device with potential to make objective measurements of key scar components - pigmentation, vascularity, pliability and thickness. This study assessed the inter-rater and test-retest reliability of these measurements.

METHOD

Three raters performed scar assessments on thirty patients with burn scars using the DermaLab Combo(®). Measurements of pigmentation, vascularity, pliability and thickness were made and intra-class correlation coefficients (ICC) were derived for inter-rater and test-retest reliability.

RESULTS

Inter-rater reliability was found to be "excellent" in the 'best' and 'worst' areas of the index scar and normal skin for pigmentation (ICC: 0.94-0.98) and thickness (ICC: 0.86-0.96). Test-retest reliability was also "excellent" for pigmentation (ICC: 0.87-0.89) and thickness (ICC: 0.92-0.97) in all areas. Vascularity showed "good" to "excellent" inter-rater reliability (ICC: 0.66-0.84) in all areas however test-retest reliability was "low" (ICC: 0.29-0.42). Test-retest reliability was "excellent" for pliability (ICC: 0.76-0.91). Technical limitations were encountered making measurements in some scars for thickness, and in particular, pliability.

CONCLUSION

The DermaLab Combo(®) measured pigmentation, thickness and pliability with "excellent" reliability. If future studies provide protocols to improve test-retest reliability of vascularity measurements and obtain pliability measurements more successfully, the DermaLab Combo(®) will be valuable device for scar assessment.

Patient-reported satisfaction and cosmesis outcomes following laparoscopic adrenalectomy: Laparoendoscopic single-site adrenalectomy vs. conventional laparoscopic adrenalectomy

INTRODUCTION

We evaluate patient-reported satisfaction and cosmesis of laparoendoscopic single-site adrenalectomy (LESS-A) in comparison with that of conventional laparoscopic adrenalectomy (CLA).

METHODS

A total of 19 and 104 patients who respectively underwent LESS-A and CLA between May 1996 and June 2011 were included in the study. Questionnaires inquiring about scar pain (0: not painful, 10: very painful), satisfaction (0: not satisfied, 10: very satisfied) and cosmesis (0: very unsightly, 10: very beautiful) on the basis of a visual analogue scale were sent to patients postoperatively.

RESULTS

The respondents consisted of 11 and 54 patients who underwent LESS-A and CLA, respectively. There was no significant inter-group difference in age, sex, affected side or body mass index. No significant differences were observed in operative time or estimated blood loss. There were also no significant differences in pain (0.67 vs. 0.57, p = 0.393), satisfaction (8.92 vs. 8.46, p = 0.453), or cosmesis score (8.58 vs. 8.00, p = 0.487) between the LESS-A and CLA groups overall. In female patients, the satisfaction score was significantly higher in the LESS-A group than in the CLA group (10.0 vs. 8.72, p = 0.049). In young patients (<50 years old), the satisfaction score was also significantly higher in the LESS-A group than in the CLA group (9.17 vs. 6.38, p = 0.036).

CONCLUSIONS

Young patients and female patients who had received LESS-A adrenal surgery were more satisfied with the scar outcomes than were the young patients and female patients who had received CLA. We suggest that this patient subset most values the cosmetic benefits of LESS-A.

Comparison of scalp and abdomen as split-thickness skin graft donor sites for aural stenosis repair

To evaluate and compare the scalp and the abdomen as split-thickness skin graft donor sites for aural stenosis repair. A total of 34 patients with aural stenosis were included in the study. All the patients underwent meatoplasty using split-thickness skin grafts. Among them, the skin graft donor site was the scalp in 11 patients and the abdomen in the other 23 patients. The surgical team followed the patients in the outpatient department for at least 6 months after surgery. Evaluations concerned healing of the donor site, hair regeneration of the donor site, survival of split-thickness skin grafts, reoccurrence of aural stenosis and hair growth in the ear canal. The incidences of reoccurrence of aural stenosis in the two groups were compared. Subjective scar evaluation of the donor sites was performed using the Patient Scar Assessment Scale (PASA). The scale items were pain, itching, color, stiffness, thickness and irregularity. All the scalp and abdominal donor sites healed well with no sign of infection. Hair regrowth and reepithelialization was observed at all the scalp donor sites. Pink discoloration was observed at the scalp donor sites in six patients 2-3 months after surgery and disappeared 6-9 months after surgery. Scars were observed at the scalp donor sites in two patients 6 months after surgery. No alopecia was observed at the scalp donor sites. The scars and pink discoloration were hidden in the hair. Scars and/or discoloration were observed at all the abdominal donor sites 12 months after surgery. All the scalp and abdominal skin grafts survived with no sign of infection. Hair growth was observed in the ear canals in two patients in the scalp group. The incidences of reoccurrence of aural stenosis were 0 % (0/23) in the abdominal group and 9.1 % (1/11) in the scalp group, respectively (Chi square test, p > 0.05). The PASA values about color, stiffness, thickness and irregularity were higher in the abdominal group than in the scalp group (Mann-Whitney U test, p < 0.001). The PASA values about pain and itching were the same (Mann-Whitney U test, p > 0.05). The scalp meets most requirements of an ideal donor site of skin grafts for aural stenosis. The advantages of scalp as a donor site include easy accessibility in the operative field, simple postoperative care, low risk of infection, rapid wound healing, minimal interference with rehabilitation, and minimal scar formation.

Comparison of poliglecaprone-25 and polyglactin-910 in cutaneous surgery

BACKGROUND

Few clinical studies have compared deep absorbable sutures. Poliglecaprone-25 and polyglactin-910 are two of the most commonly used absorbable sutures in cutaneous surgery.

OBJECTIVES

To compare the rate of suture extrusion, degree of lumpiness, and appearance of scars from wounds closed with poliglecaprone-25 and polyglactin-910.

METHODS

Poliglecaprone-25 or polyglactin-910 was used for closure of the deep part of Mohs defects. The number of extruded sutures and the number of lumps were recorded at each follow-up visit. Photographs of 1-week and 3-month postoperative scars were rated on a visual analogue scale.

RESULTS

One hundred forty patients completed the study. There was a statistically significant difference in the percentage of extruded sutures between poliglecaprone-25 (3.1%) and polyglactin-910 (11.4%) (p < .01). There was not a statistically significant difference in the percentage of lumps (both 22%) or overall appearance of scars at 1 week or 3 months.

CONCLUSION

Poliglecaprone-25 resulted in significantly less extruded sutures than did polyglactin-910, although both resulted in the same degree of lumpiness and similar-appearing scars at 1 week and 3 months.

Hybrid transvaginal cholecystectomy, clinical results and patient-reported outcomes of 50 consecutive cases

OBJECTIVE

The aim of this study was to report the clinical and cosmetic results of transvaginal hybrid cholecystectomy (TVC).

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) has been developed as a minimal invasive alternative for conventional laparoscopic cholecystectomy. Although transvaginal NOTES procedures are becoming increasingly popular, data focussing on body image, cosmesis and sexual recovery are rare.

METHODS

Our clinic started to perform the TVC in the beginning of 2011. Female patients with symptomatic gallstone disease that were treated between January 2011 and April 2012 with TVC were entered in a prospective database. All patients received a survey postoperative with questions about recovery, cosmesis and body image.

RESULTS

Fifty consecutive patients were treated with a TVC. There were no major complications. Mean operative time was 61 min. In five patients (10 %), a conversion to another type of cholecystectomy was necessary. None of the sexually active women observed dyspareunia postoperative. The results for cosmesis and body image after the transvaginal approach were excellent.

CONCLUSIONS

TVC is a safe and feasible procedure when performed on selected patients. The transvaginal route seems to result in excellent cosmetic outcomes without gynaecologic complications after short-term follow up. Randomised trials are needed to specify the role of TVC in the treatment of patients with symptomatic gallstone disease and to detect differences in cosmetic outcomes.

Successful treatment of depressed, distensible acne scars using autologous fibroblasts: a multi-site, prospective, double blind, placebo-controlled clinical trial

Background A previous clinical trial evaluating autologous fibroblasts (human dermal) injections for the treatment of facial contour deformities found significantly greater improvements in wrinkle and acne scar appearance than with placebo treatment.

Objective To compare the efficacy and safety of autologous fibroblast treatment of moderate to severe, depressed, distensible facial acne scars with that of vehicle control.

Methods This was a randomized multicenter, double-blind, placebo-controlled trial in subjects with bilateral moderate to severe acne scarring; subjects served as their own controls. Skin biopsies were obtained from randomized subjects for fibroblast production. Subjects (n = 99) underwent three intradermal injection sessions with 2 mL of autologous fibroblast suspension (10–20 million cells/mL) on one cheek and vehicle control (cell culture medium) on the other at 14-day intervals. Efficacy was based on the blinded subject’s, evaluator’s, and independent photographic viewer’s (IPR) assessment of acne scarring 1 to 4 months after the last treatment.

Results Autologous fibroblast treatment was associated with significantly greater treatment success than vehicle control for the subject (43% vs 18%), evaluator (59% vs 42%), and IPR assessments. Autologous fibroblast injections were well tolerated, without permanent adverse effects.

Conclusions Autologous fibroblast injections safely and effectively improved the appearance of depressed distensible acne scars.

Quantification of the physical properties of keloid and hypertrophic scars using the Vesmeter novel sensing device

There is still no objective method or reliable device to measure and assess the physical properties of keloid and hypertrophic scars. Using the Vesmeter, we measured the physical properties of keloid and hypertrophic scars, and investigated how their physical properties changed during the process of clinical follow-up. We followed up 11 patients with keloid (n = 6) and hypertrophic (n = 5) scars for 4 months, and measured their physical properties three times over a 2-month period using the Vesmeter. Measurements included hardness, elasticity, penetration depth, relaxation time, viscosity and viscoelastic ratio. All physical properties were measured simultaneously while an indenter was pressed onto the lesion and digitalise the measured data by analysing the wave forms of the lesion's surface behaviour. Data collection was repeated three times for each measurement point, and the average of these three values was used. Overall hardness and viscosity decreased in nine patients, whereas penetration depth increased in nine. Relaxation time decreased in nine patients and elasticity increased in six. Vesmeter was considered to be an objective, convenient and comparatively reliable measuring device for the quantification of the physical properties of keloid and hypertrophic scars.

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.

Cosmetic and functional outcome after stoma site skin closure in children

PURPOSE

To evaluate the functional and cosmetic outcome of stoma closure in children after straight closure (SC) versus purse-string closure (PSC).

METHODS

The patients (n = 33, age 16-159 months), operated at a median age of 6 months (1-121 months) between 2007 and 2009 in our hospital, were studied to evaluate whether the proposed superiority of the PSC technique is applicable in children. The patients were operated with SC or PSC. The most common causes of the temporary stomas were necrotizing enterocolitis, Hirschsprung's disease and anal atresia. A validated scoring-system questionnaire (patient and observer scar assessment scale),POSAS was sent to the parents containing questions concerning pain, itchiness, colour, stiffness, thickness and irregularity of the scar completed by a visual analogue scale to evaluate an overall opinion.

RESULTS

25 families (SC; n = 12, PSC;n = 13) participated. The differences between the two groups are largest, although not statistically significant, for discoloration, stiffness, thickness and irregularity, with better scores in the PSC group. There was a better total POSAS score in the PSC group whilst the VAS shows very modest differences.

CONCLUSION

Our study indicates advantages of the PSC technique after stoma closure with better cosmetic and functional outcome. To be able to show statistically significant differences between PSC and SC a larger study would be useful.

A clinical evaluation of Biobrane(®) and Suprathel(®) in acute burns and reconstructive surgery

BACKGROUND

In the treatment of superficial partial-thickness burns, various skin substitutes and temporary dressings offer potential advantages over traditional treatments. Nonetheless, the search for an ideal temporary skin substitute or biosynthetic wound dressing is still a continuous quest. This research aimed to provide objective data on the long-term outcome of Biobrane(®) and Suprathel(®).

METHODS

Eight months after the initial burn treatment of Biobrane(®) and Suprathel(®), skin elasticity was measured objectively using a Cutometer(®) and the scarring process was quantified using the Vancouver Scar Scale (VSS).

RESULTS

The median healing time for patients treated with Biobrane(®) was up to 1.8 days shorter then the Suprathel(®) group. Regarding the Vancouver Scar Scale (VSS), neither the single parameter, nor the total score were significantly different in both groups. In comparison, the Biobrane(®) group demonstrated superior Cutometer(®) parameters in regards to maximal extension, elasticity, retraction and pliability. Despite higher levels of Biobrane(®) group, the differences in the viscoelastic analysis of both substitutes did not vary significantly.

CONCLUSION

Using both substitutes, we observed satisfying results in superficial partial-thickness burn treatment, without any significant differences. Since the treatment of burned patients is associated with high socioeconomic load, the cost factor should be one of the most important criteria in dermal substitute selection.