How to assess postsurgical scars: a review of outcome measures

iTRAQ-based proteomic profiling reveals different protein expression between normal skin and hypertrophic scar tissue

BACKGROUND

A hypertrophic scar is a unique fibrotic disease that only exists in humans. Despite advances in burn care and rehabilitation, as well as progress in the management during these decades, the hypertrophic scar remains hard to cure following surgical methods and drugs for treatment. In this study, we are looking forward to finding the multitude of possible traumatic mechanisms and the underlying molecular signal ways in the formation of the hypertrophic scar.

METHODS

We used isobaric tags for relative and absolute quantitation (iTRAQ) labeling technology, followed by high-throughput 2D LC-MS/MS, to determine relative quantitative differential proteins between the hypertrophic scar and normal skin tissue.

RESULTS

A total of 3166 proteins were identified with a high confidence (≥95 % confidence). And, a total of 89 proteins were identified as the differential proteins between the hypertrophic scar and normal skin, among which 41 proteins were up-regulated and 48 proteins were down-regulated in the hypertrophic scar. GO-Analysis indicated the up-regulated proteins were involved in extracellular matrix, whereas the down-regulated proteins were involved in dynamic junction and structural molecule activity.

CONCLUSIONS

In our study, we demonstrate 89 proteins present differently in the hypertrophic scar compared to normal skin by iTRAQ technology, which might indicate the pathologic process of hypertrophic scar formation and guide us to propose new strategies against the hypertrophic scar.

Does wound eversion improve cosmetic outcome?: Results of a randomized, split-scar, comparative trial

BACKGROUND

Wound edge eversion has been hypothesized to improve aesthetic outcomes after cutaneous wound closure. Data supporting this assertion are sparse.

OBJECTIVE

We sought to determine if wound eversion, achieved with interrupted subcuticular sutures, improves aesthetic outcome compared with planar closures.

METHODS

We undertook a prospective, randomized, split-scar intervention in patients who underwent cutaneous surgery. Half of the wound was randomized to an everted or planar repair; the other side received the opposite one. At 3- and 6-month follow-up, both the patient and 2 blinded observers evaluated the wound using the Patient Observer Self-Assessment Scale (POSAS).

RESULTS

The total observer POSAS score for the everted (13.59, 12.26) and planar (12.91, 12.98) sides did not differ significantly at 3 or 6 months, respectively. Similarly, there was not a significant difference in patient assessment between the everted (16.23, 12.84) and planar (15.07, 12.79) sides at 3 or 6 months, respectively. Finally, there was no significant difference between the 2 closure methods in terms of scar height or width at follow-up.

LIMITATIONS

This was a single-center trial, which used a validated but still subjective scar assessment instrument.

CONCLUSION

Wound eversion was not significantly associated with improved overall scar assessments by blinded observers or patient assessment.

Recombinant human growth hormone for treating burns and donor sites

BACKGROUND

Recombinant human growth hormone (rhGH) increases protein synthesis, therefore it is used in burns with a total body surface area (TBSA) greater than 40%, where there is frequently an increase in protein breakdown and a decrease in protein synthesis. This change in protein metabolism correlates with poor wound healing of the burn and donor sites.

OBJECTIVES

To determine the effects of rhGH on the healing rate of burn wounds and donor sites in people with burns.

SEARCH METHODS

For this first update we searched the Cochrane Wounds Group Specialised Register (searched 04 September 2014); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 8); Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library 2014, Issue 3); Ovid MEDLINE (1950 to September Week 4 2014); Ovid MEDLINE (In-Process & Other Non-Indexed Citations September 8, 2014); Ovid EMBASE (1980 to 2014 Week 35); and EBSCO CINAHL (1982 to 8 September 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing rhGH with any comparator intervention, e.g. oxandrolone or placebo, in adults or children with burns.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed trial quality and extracted data. The primary outcomes were the healing of the burn wound and donor sites and the occurrence of wound infections. The secondary outcomes were mortality rate, length of hospital stay, scar assessment, and adverse events: hyperglycaemia and septicaemia.

MAIN RESULTS

We included 13 RCTs (701 people). Six of the RCTs included only children aged 1 to 18 years and seven involved only adults (from 18 to 65 years of age). The mean TBSA of the included participants was greater than 49%. Twelve studies compared rhGH with placebo and one study compared rhGH with oxandrolone. Two trials found that compared with placebo, burn wounds in adults treated with rhGH healed more quickly (by 9.07 days; 95% confidence interval (CI) 4.39 to 13.76, I² = 0%). The donor site healing time was significantly shorter in rhGH-treated adults compared with placebo-treated participants (by 3.15 days; 95% CI 1.54 to 4.75, I² = 0%). Two studies in children with the outcome of donor site healing time could be pooled and the donor site healing time was shorter in the rhGH-treated children (by 1.70 days; 95% CI 0.87 to 2.53, I² = 0%). No studies reporting the outcome of wound infection were found. The incidence of hyperglycaemia was higher in adults during rhGH treatment compared with placebo (risk ratio (RR) 2.43; 95% CI 1.54 to 3.85), but not in children. Pooling the studies of adults and children yielded a significantly higher incidence of hyperglycaemia in the rhGH-treated participants (RR 2.65; 95% CI 1.68 to 4.16).

AUTHORS' CONCLUSIONS

There is some evidence that using rhGH in people with large burns (more than 40% of the total body surface area) could result in more rapid healing of the burn wound and donor sites in adults and children, and in reduced length of hospital stay, without increased mortality or scarring, but with an increased risk of hyperglycaemia. This evidence is based on studies with small sample sizes and risk of bias and requires confirmation in higher quality, adequately powered trials.

The efficacy of combined herbal extracts gel preparation in the prevention of postsurgical hypertrophic scar formation

Introduction

The objective of preventing surgical scar formation is to improve the quality of life for patients. Many medical products have been used in preventing hypertrophic scarring but an optimal treatment method has not been established yet. At the present, there are several studies demonstrating the potential of herbs in scar prevention. The purpose of this study was to evaluate the efficacy of combined herbal extracts gel (CHG) in the prevention of surgical scar formation.

Methods

All the patients who underwent bilaterally symmetric surgical procedures were selected using inclusion and exclusion criteria and were then treated with both the CHG (CHG group) and placebo gel. Each gel was applied on separate scars twice daily for 12 weeks. The scars were photographed and evaluated using Patient and Observer Scar Assessment Scale (PSAS and OSAS, respectively).

Results

The CHG-treated scars showed lower median PSAS scores than the placebo group in color, stiffness, thickness, irregularity, and overall scores, with statistically significant difference at 12 weeks. For OSAS, the scars in the CHG group showed lower median scores than the placebo group in pigmentation, thickness, and overall scores at 12 weeks. The median OSAS scores in vascularity, relief, and pliability differed from placebo group and were statistically significant at 8 weeks. No side effects were observed in either group.

Conclusion

The CHG might be effective in the prevention of surgical scarring.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-014-0055-0) contains supplementary material, which is available to authorized users.

Randomized controlled trial: comparison of two surgical techniques for closing the wound following ileostomy closure: purse string vs direct suture

AIM

Surgical site infection (SSI) is a common complication following ileostomy closure with a frequency of up to 40%. This prospective randomized controlled trial was initiated to compare two surgical techniques - direct suture (DS) and purse-string suture (PSS) - used to close the wound following ileostomy closure. The primary end-point was the SSI rate. Secondary end-points were cosmetic outcome [using two validated scales: the Patient and Observer Scar Assessment Scale (POSAS) and the Body Image Questionnaire (BIQ)] and the influence of other factors on the SSI rate.

METHOD

Of a total of 99 patients screened, 84 were included in this study. Forty-three patients were randomized into the PSS group and 41 were randomized into the DS group. Follow up was performed within 3 days after surgery, at discharge, and 30 days and 6 months after the operation.

RESULTS

In the PSS group there were no cases of SSI compared with 10 (24%) cases in the DS group (P = 0.0004). There were no statistically significant differences in cosmetic outcome between the two groups. No other statistically significant factors influencing the incidence of SSI could be identified.

CONCLUSION

The rate of SSI is significantly lower following PSS than following DS, and both techniques have a similar cosmetic outcome. PSS closure should be considered as standard of care for wound closure after ileostomy reversal.

A practical and objective approach to scar colour assessment

Scarring is a significant clinical problem following dermal injury. However, scars are not a single describable entity and huge phenotypic variability is evident. Quantitative, reproducible inter-observer scar assessment is essential to monitor wound healing and the effect of scar treatments. Scar colour, reflecting the biological processes occurring within a scar, is integral to any assessment. The objective of this study was to analyse scar colour using the non-invasive Eykona® Wound Measurement System (the System) as compared against the Manchester Scar Scale (MSS). Three dimensional images of 43 surgical scars were acquired post-operatively from 35 patients at 3-6 months and the colour difference between the scar and surrounding skin was calculated (giving ΔLab values). The colourimetric results were then compared against subjective MSS gradings. A significant difference in ΔLab values between MSS gradings of "slight mismatch" and "obvious mismatch" (p<0.025) and between "obvious mismatch" and "gross mismatch" (p<0.05) were noted. The System creates objective, reproducible data, without the need for any specialist expertise and compares favourably with the MSS. Greater scar numbers are required to further clinically validate this device--however, with this potential to calculate scar length, width, volume and other characteristics, it could provide a complete, objective, quantitative record of scarring throughout the wound-healing process.

Long-term evaluation of donor-site morbidity after radial forearm flap phalloplasty for transsexual men

INTRODUCTION

Phalloplasty using the radial forearm flap is currently the most frequently used technique to create the neophallus in transsexual men (formerly described as female-to-male transsexual persons). Although it is considered the gold standard, its main disadvantage is the eventual donor-site morbidity in a young, healthy patient population.

AIM

The study aims to examine the long-term effects of radial forearm flap phalloplasty in transsexual men and to evaluate aesthetic outcome, scar acceptance, bone health, and daily functioning.

MAIN OUTCOME MEASURES

Scars were evaluated with the patient and observer scar assessment scale, the Vancouver Scar Scale, and self-reported satisfaction. Bone health was assessed using dual X-ray absorptiometry and peripheral quantitative computed tomography, and daily functioning using a physical activity questionnaire (Baecke). These measurements were compared with 44 age-matched control women.

METHODS

This is a cross-sectional study of 44 transsexual, a median of 7 years after radial forearm flap phalloplasty, recruited from the Center for Sexology and Gender Problems at the Ghent University Hospital, Belgium.

RESULTS

We observed no functional limitations on daily life activities, a pain-free and rather aesthetic scar, and unaffected bone health a median of 7 years after radial foreram flap phalloplasty. Over 75% of transsexual men were either satisfied or neutral with the appearance of the scar.

CONCLUSIONS

Transsexual men, despite scarring the forearm, consider the radial forearm flap phalloplasty as worthwhile.

Linear scar reduction using silicone gel sheets in individuals with normal healing

OBJECTIVE

To examine the application of silicone gel sheets on linear scars due to surgical procedures.

METHOD

Ten individuals, with scars less than I year old, participated in the study. The Participant and Observer Scar Assessment Scale (POSAS) was used to evaluate scars on seven characteristics rated by visual analogue scales 0fAS). Participants applied silicone gel sheets to half of their scar for 6 months, and every 2 weeks POSAS data forms were completed. Linear mixed-effects analysis of variances (ANOVA)were used to determine if significant differences occurred between groups (treated and untreated scarsides) across the 6 months of data collection. To see if differences were found from the initial evaluation to final visit, Mann-Whitney U tests analysed between-group changes (treated and untreated scar sides), while Wilcoxon signed ranks tests compared within-group changes (evaluation of each scar side over time).

RESULTS

No significant differences in VAS ratings were observed when the two scar sides were compared, with the exception of overall opinion of the scar, as rated by an observer. For each group,significant changes from baseline to study end were observed for colour, stiffness and irregularities, as rated by the participant. Significant improvements for the treated versus untreated group were observed for pliability and pigmentation, as rated by the observer scale.

CONCLUSION

There was no evidence for improved healing when using silicone gel sheets. The results do not support using silicone gel sheets on linear scars for individuals with no history of abnormal scarring.

Local delivery of allogeneic bone marrow and adipose tissue-derived mesenchymal stromal cells for cutaneous wound healing in a porcine model

Wound healing remains a major challenge in modern medicine. Bone marrow- (BM) and adipose tissue- (AT) derived mesenchymal stromal/stem cells (MSCs) are of great interest for tissue reconstruction due to their unique immunological properties and regenerative potential. The purpose of this study was to characterize BM and AT-MSCs and evaluate their effect when administered in a porcine wound model. MSCs were derived from male Göttingen Minipigs and characterized according to established criteria. Allogeneic BM- or AT-MSCs were administered intradermally (1 x 10(6) cells) into partial-thickness wounds created on female animals, and covered with Vaseline® gauze or fibrin in a randomized pattern. Animals were euthanized at 7, 10, 14 and 21 days. Tissues were analyzed visually for healing and by microscopic examination for epidermal development and remodelling. Polymerase chain reaction (PCR) was used to detect the presence of male DNA in the specimens. All wounds were healed by 14 days. MSC-injected wounds were associated with improved appearance and faster re-epithelialization compared to saline controls. Evaluation of rete ridge depth and architecture showed that MSC treatment promoted a faster rate of epidermal maturation. Male DNA was detected in all samples at days 7 and 10, suggesting the presence of MSCs. We showed the safety, feasibility and potential efficacy of local injection of allogeneic BM- and AT-MSCs for treatment of wounds in a preclinical model. Our data in this large animal model support the potential use of BM- and AT-MSC for treatment of cutaneous wounds through modulation of healing and epithelialization.

Outcome after burns: an observational study on burn scar maturation and predictors for severe scarring

Long-term outcome of burn scars as well as the relation with clinically relevant parameters has not been studied quantitatively. Therefore, we conducted a detailed analysis on the clinical changes of burn scars in a longitudinal setup. In addition, we focused on the differences in scar quality in relation to the depth, etiology of the burn wound and age of the patient. Burn scars of 474 patients were subjected to a scar assessment protocol 3, 6, and 12 months postburn. Three different age groups were defined (≤5, 5-18, and ≥18 years). The observer part of the patient and observer scar assessment scale revealed a significant (p < 0.001) improvement in scar quality at 12 months compared with the 3- and 6-month data. Predictors for severe scarring are depth of the wound (p < 0.001) and total body surface area burned (p < 0.001). Etiology (p = 0.753) and age (p > 0.230) have no significant influence on scar quality when corrected for sex, total body surface area burned, time, and age or etiology, respectively.

Recombinant human growth hormone for treating burns and donor sites

BACKGROUND

Recombinant human growth hormone (rhGH) increases protein synthesis, therefore it is used in burns with a total body surface area (TBSA) greater than 40%, where there is frequently an increase in protein breakdown and a decrease in protein synthesis. This change in protein metabolism correlates with poor wound healing of the burn and donor sites.

OBJECTIVES

To determine the effects of rhGH on the healing rate of burn wounds and donor sites in people with burns.

SEARCH METHODS

We searched the Cochrane Wounds Group Specialised Register (searched 28 June 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6); Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (1950 to June Week 3 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations June 27, 2012); Ovid EMBASE (1980 to 2012 Week 25); and EBSCO CINAHL (1982 to 21 June 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing rhGH with any comparator intervention, e.g. oxandrolone or placebo, in adults or children with burns.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed trial quality and extracted data. The primary outcomes were the healing of the burn wound and donor sites and the occurrence of wound infections. The secondary outcomes were mortality rate, length of hospital stay, scar assessment, and adverse events: hyperglycaemia and septicaemia.

MAIN RESULTS

We included 13 RCTs (701 people). Six of the RCTs included only children aged 1 to 18 years and seven involved only adults (from 18 to 65 years of age). The mean TBSA of the included participants was greater than 49%. Twelve studies compared rhGH with placebo and one study compared rhGH with oxandrolone. Two trials found that compared with placebo, burn wounds in adults treated with rhGH healed more quickly (by 9.07 days; 95% confidence interval (CI) 4.39 to 13.76, I² = 0%). The donor site healing time was significantly shorter in rhGH-treated adults compared with placebo-treated participants (by 3.15 days; 95% CI 1.54 to 4.75, I² = 0%). Two studies in children with the outcome of donor site healing time could be pooled and the donor site healing time was shorter in the rhGH-treated children (by 1.70 days; 95% CI 0.87 to 2.53, I² = 0%). No studies reporting the outcome of wound infection were found. The incidence of hyperglycaemia was higher in adults during rhGH treatment compared with placebo (risk ratio (RR) 2.43; 95% CI 1.54 to 3.85), but not in children. Pooling the studies of adults and children yielded a significantly higher incidence of hyperglycaemia in the rhGH-treated participants (RR 2.65; 95% CI 1.68 to 4.16).

AUTHORS' CONCLUSIONS

There is some evidence that using rhGH in people with large burns (more than 40% of the total body surface area) could result in more rapid healing of the burn wound and donor sites in adults and children, and in reduced length of hospital stay, without increased mortality or scarring, but with an increased risk of hyperglycaemia. This evidence is based on studies with small sample sizes and risk of bias and requires confirmation in higher quality, adequately powered trials.

Use of botulinum toxin type A to improve treatment of facial wounds: a prospective randomised study

BACKGROUND

The tension vectors acting on the wound edges are transmitted to immature collagen fibres synthesised during the normal healing phase. This accounts for scar widening as well as hypertrophic and hyperpigmented scars. The aim of our study was to evaluate whether early injections of botulinum toxin type A (BTA), which induces temporary muscular paralysis, decreases tension vectors on wound edges and enhances scarring of facial wounds.

PATIENTS AND METHODS

Thirty patients with facial wounds were enrolled in this study and randomised into two groups with or without injection of BTA within 72 h postoperatively. BTA was injected into the facial muscles directly or indirectly involved in scar widening. Scars were assessed at a 1-year follow-up visit by patients using the Patient Scar Assessment Scale (PSAS) scale, by an independent evaluator using the Observer Scar Assessment Scale (OSAS) and the Vancouver Scar Scale (VSS), and by a board of six experienced medical specialists using the Visual Analogue Scale (VAS) with standardised photographs.

RESULTS

At the 1-year visit, 24 patients were reviewed and six patients were lost to follow-up. No statistically significant differences were found between the two groups for the PSAS, OSAS and VSS scores. However, the median VAS rated by the six evaluators was 8.25 for the botulinum toxin-treated group compared with 6.35 for the control group. This result was statistically different, demonstrating improved scarring with BTA.

CONCLUSIONS

Thanks to chemoimmobilisation, injections of BTA appear to improve cosmesis of facial wounds. Accordingly, they would be beneficial for use in young patients for wounds without tissue loss, lying perpendicular to the reduced tension lines of the skin of the face.

A review of the effects of moisturizers on the appearance of scars and striae

Scars are well known to have a stratum corneum (SC) that is malfunctional. Increases in transepidermal water loss and decreases in SC capacitance and conductance have been reported. Occlusion therapy is a well-known route to improving the signs and symptoms of scarring. Until recently that has been assumed to be totally pressure related. However, studies have demonstrated that the direct effects of hydration on keratinocytes and fibroblasts contribute to the reduction in hypertrophic scarring. Now it is well known that occlusion can regulate epidermal cytokine and growth factor production; changes in profibrotic and anti-fibrotic factors have been established. As a result, it is to be expected that moisturizers may improve the signs and symptoms of scars. As striae have been suggested to be anatomically similar to scars and as it is well established that paracrine signalling occurs in skin, it is expected that striae have similar SC issues. While one cannot exclude the effects of some of the ingredients used in the products, several studies are reported in this review that demonstrates that moisturization is a key component to reducing the clinical signs and symptoms of scars and striae. This is a good example of how knowledge of corneobiology leads to corneotherapies for these skin condition problems. The review is being written in memory of Professor Johann Wiechers who, before he died tragically in November 2011, performed two of the reported studies together with colleagues.

Hypertrophic scar

Hypertrophic scars are common complications of burn injury and other soft tissue injuries. Excessive extracellular matrix combined with inadequate remodeling of scar tissue results in an aesthetically and functionally unsatisfactory, painful, pruritic scar that can impair function. Treatment options are available to rehabilitation practitioners, but none are entirely satisfactory. An interdisciplinary clinical program is necessary for best outcomes. Challenges to be met by the rehabilitation community include research into the quantification of burn scar measurement, the effects of mechanical forces on wound healing and scar management, and the best combination of surgical, pharmacologic, and therapy interventions to maximize outcome from reconstructive procedures.