Predictive validity of short term scar quality on final burn scar outcome using the Patient and Observer Scar Assessment Scale in patients with minor to moderate burn severity

Patient-reported scar quality in paediatric and adult burn patients: A long-term multicentre follow-up study

BACKGROUND

Burn scar maturation can take several years but is generally studied shortly after injury. Therefore, we investigated patient-reported scar quality up to 5-7 years post-burn.

METHODS

Patients with ≤ 20 % total body surface area burned completed the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS 2.0) on the same scar at 3, > 18 months (median 28 months) and 5-7 years (median 63 months) post-burn.

RESULTS

Fifty-eight patients (21 children; 37 adults) with a median total body surface area burned (TBSA) of 6.3 % participated. Average patient-reported scar quality (POSAS score) was generally worst at 3 months (median score: 4.2), best at 28 months (median score: 2.2) and intermediate at 63 months post-burn (median score: 3.4) (p < 0.001). Many patients (66 %) reported a median 1.8 point higher (worse) POSAS score at 63 months compared to 28 months post-burn, whereas 14 % reported an identical, and 21 % a lower (better) score. At any assessment, largest differences with normal skin were reported for scar colour. Univariate predictive factors of long-term patient-reported scar quality were scar quality at 3 months (p = 0.002) and 28 months post-burn (p < 0.001), full-thickness burn size (p = 0.033), length of hospital stay (p = 0.003), and number of surgeries (p < 0.001).

CONCLUSION

Two-thirds of patients with burns up to 20 % TBSA scored the quality of their scars worse at 63 months compared to 28 months post-burn. Whether this corresponds to increased dissatisfaction with scars in the long term should be further investigated. These new insights add to the body of knowledge on scar maturation and underscores the importance of discussing patients' expectations.

Long-Term Functional Outcomes after Hand Burns: A Monocentric Controlled Cohort Study

Background: Hand burns are involved in 80-90% of severe burn injuries. Even though hands correspond to a small total burn surface area (TBSA) of less than 5%, the loss of their functionality has a significant impact on the patient's life. Studies that provide long-term results regarding hand functionality after hand burns are scarce. Therefore, this study aimed to investigate functional long-term results in a patient-centric approach regarding burn depth, unilateral and bilateral hand involvement, and (non-)isolated hand burns as potential influencing factors in patients with hand burns. Methods: We conducted a controlled cohort study of patients with burned hands treated at our department between 2005 and 2022. Healthy age-, sex-, and handedness-matched participants were used as controls. Data on the demographics, burn-related injuries, and treatments were collected. For a patient-centric approach, we used the Disabilities of the Arm, Shoulder, and Hand Questionnaire (Quick-DASH) and the Michigan Hand Questionnaire (MHQ) as patient-reported outcome measures for functional long-term evaluation, and the Patient and Observer Scar Assessment Scale (patient scale) for assessing long-term scar quality. Results: We enrolled 61 patients with 88 affected hands and 63 matched control participants. Up to 77.1% of the participants were male, with a mean age of 50.7 (±15.5) years and a follow-up of 8.1 (±4.7) years. The mean TBSA was 13.9% (±15.8), with 72.4% of the hands presenting with deep partial-thickness and full-thickness burns and most of the patients had only one hand affected (55.7%). The hand burn patients perceived significantly worse long-term functional scores in every domain of the MHQ as well as in the "overall function" and "work" of the Quick-DASH. Superficial hand burns negatively affected the two-handed activities of daily living (p = 0.013) and aesthetic appearance (p = 0.005) when both hands were involved. Isolated hand burns were associated with more difficulties in work performance (p = 0.03), whereas patients with bilateral hand involvement perceived more pain (p = 0.025). Conclusions: The patients with hand burns can achieve satisfactory long-term functional outcomes over time, but they do not reach the same long-term hand functionality as the healthy matched control group. Our study revealed that factors such as burn depth, unilateral or bilateral hand involvement, and (non-)isolated hand burns indeed have an impact on certain aspects of perceived long-term hand functionality.

How to evaluate scar colour after burn injuries - A clinical comparison of the Mexameter® and the subjective scar assessment (POSAS/VSS)

INTRODUCTION

Scarring after burn injuries remains one of the major challenges in burn medicine and is the subject of current research. Accurate and high-quality assessment of scars is needed to enable exact outcome evaluation of different treatments. Our aim was to evaluate the most common subjective scar evaluation scores-the POSAS (Patient and Observer Scar Assessment Scale) and VSS (Vancouver Scar Scale)-in comparison with the objective device Mexameter® for colour evaluation.

METHODS

A prospective monocentre study was performed, which included 120 examined scar areas of 60 patients with third degree burns who had received skin grafts between 1975 and 2018 with a total burned surface area (TBSA) > 2%. Two different scar areas in comparison with one healthy skin area concerning 'colour', 'pigmentation', and 'vascularization' were evaluated by the Mexameter® MX 18, the OSAS, and the VSS by the same examiner, as well as the PSAS by the patient.

RESULTS

The mean TBSA of the 60 patients was 24.3%. In the OSAS, 61% of the scars were evaluated as 'hyper-', 19% as 'hypo-', and 19% as 'mix-pigmented'. Furthermore, 65% of the scars were estimated as highly vascularized. In the Mexameter®, the melanin index values of the scar areas compared to the healthy skin areas showed a small difference of 12 (p < 0.05). The mean difference of erythema between the scar and the healthy skin areas was 84 (p < 0.001). For the Mexameter®, moderate correlations were found when comparing 'erythema' with the OSAS category 'vascularization' (r = 0.33, p < 0.05) and 'melanin' with the OSAS parameter 'pigmentation' (r = 0.28, p < 0.05). When comparing the Mexameter® measurements to the OSAS questionnaire, 27% of the scars were wrongly evaluated as 'hyperpigmented' by the observer and 21% as 'hypervascularized', while showing low measurements in the device. Additionally, a novel Mexameter® ordinal scare scale was calculated.

CONCLUSION

In this study, we were able to show on a relatively large patient population that with the Mexameter®, the subjectivity of the scar colour assessment by examiner/patient can be overcome, but precise differentiation can still be ensured with subjective evaluation tools. We further introduced a novel Mexameter® Scar Scale. It is necessary to further investigate the vast range of objective devices and develop scar panels for with an incorporation of objective and subjective devices to further improve reliability with reduced bias in terms of scar assessment.

Hypertrophic Scar

Hypertrophic scars frequently develop post-burn, and are characterized by their pruritic, painful, raised, erythematous, dyschromic, and contractile qualities. This article aims to synthesize knowledge on the clinical and molecular development, evolution, management, and measurement of hypertrophic burn scar for both patient and clinician knowledge.

InCISE: Instrument for Comprehensive Incisional and Surgical Evaluation

OBJECTIVE

The evaluation of healing after head and neck surgery is currently qualitative and non-standardized, limiting the quality of surgical healing assessments in clinical and research settings. We sought to develop an objective, standardized wound assessment score, and hypothesize that a reliable instrument can be developed to evaluate head and neck surgical wounds.

METHODS

A prospective cohort study was conducted in a tertiary-care, academic head and neck surgery practice. Patients undergoing head and neck surgery were enrolled. A digital photograph protocol was developed for evaluating healing surgical wounds. A panel of experts developed and refined a wound healing score and established reliability, reproducibility, internal consistency, and validity of the score.

RESULTS

InCISE: Instrument for comprehensive incisional and surgical evaluation was created. The utility of our wound healing score was assessed using classical test theory. We performed the major steps of establishing reliability in head and neck surgeons: (1) internal consistency (Cronbach's α = 0.81), (2) inter-observer reliability (intra-class correlation = 0.76), and (3) intra-rater reliability (intra-class correlation = 0.87), and content validity (through focus groups). Our composite measure was found to have strong internal consistency, inter-rater reliability, and intra-rater reliability. Preliminary work suggests criterion validity via associations with physical health related quality of life (SF-12).

CONCLUSION

A wound healing score for head and neck surgery, InCISE, has been developed and is reliable, reproducible, and consistent. Although content validity is present and criterion validity is suggested, work continues to establish validity in this instrument to allow for expanded clinical and research use.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2166-2173, 2023.

Long-term scarring outcomes and safety of patients treated with NovoSorbⓇ Biodegradable Temporizing Matrix (BTM): An observational cohort study

Background/Aim

NovoSorb^Ⓡ Biodegradable Temporizing Matrix (BTM) is a relatively novel, biodegradable polyurethane-based dermal regeneration template. The aim of this study was to evaluate the long-term scarring outcomes and safety of BTM in patients who underwent dermal reconstruction involving ≥5% of the total body surface area.

Methods

This was a postmarket, multicenter, observational cohort study involving evaluation of long-term outcomes in patients treated with BTM. A total of 55 patients (35 from Royal Adelaide Hospital, South Australia, and 20 from Victoria Adult Burns Service, The Alfred, Victoria) who underwent dermal repair with BTM between 2011 and 2017 were screened for inclusion in this study. All patients had BTM implanted for ≥18 months.

Results

Fifteen eligible patients with a mean (SD) age of 49.1 (14.3) years completed study assessments. These patients had a total of 39 areas treated with BTM. Using the Patient and Observer Scar Assessment Scale, scar quality was reported to be good by both observers and patients, with a mean (SD) observer score across all lesions of 3.6 (1.2) and mean (SD) overall opinion of 3.8 (1.2) as well as a mean (SD) patient score of 3.5 (1.2) and overall opinion of 5.0 (2.2). No adverse events or adverse device effects were reported or identified.

Conclusion

The long-term scar quality is comparable to published studies. BTM is safe in the long term with no additional risks or adverse consequences being identified.

Protocol for a feasibility, acceptability and safety study of the PICO device (negative pressure wound therapy) in acute paediatric burns

INTRODUCTION

Negative pressure wound therapy (NPWT) in acute burn care may decrease the time to re-epithelialisation by more than 20%. Despite this, the perceived burden of use; including therapeutic, physical and financial, have limited the use of NPWT in acute burn care. This might be minimised by using the small, ultraportable, single-use NPWT device PICO as opposed to larger devices, which to date has never been studied in acute burn care. This research will; therefore, primarily assess the feasibility, acceptability and safety of PICO in paediatric burns. Secondary outcomes include time to re-epithelialisation, pain, itch, cost and scar formation.

METHODS AND ANALYSIS

This protocol details a clinical trial methodology and is pre-results. This single site, prospective, pilot randomised controlled trial will be conducted in an Australian quaternary paediatric burns centre. Participants must be aged ≤16 years, otherwise well and managed within 24 hours of sustaining a burn that fits beneath a PICO dressing. Thirty participants will be randomised to one of three groups: group A: Mepitel and ACTICOAT, group B: Mepitel, ACTICOAT and PICO and group C: Mepitel, ACTICOAT Flex and PICO. Patient outcomes will be recorded at each dressing change to assess efficacy and safety outcomes until 3 months postburn wound re-epithelialisation. Surveys, randomisation and data storage will be undertaken via online platforms and physical data storage collated at the Centre for Children's Health Research, Brisbane, Australia. Analysis will be done by using StataSE 17.0 statistical software.

ETHICS AND DISSEMINATION

Ethics has been obtained from Queensland Health and Griffith Human Research Ethics committees including a site-specific approval. These data will be disseminated via clinical meetings, conference presentations and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12622000009718.

Modified Colson flap with subcutaneous liposuction for one-stage donor site removal: A case series

OBJECTIVES

The aim of this study was to evaluate the functional and cosmetic results of an innovative procedure for modified Colson flap-graft consisting of immediate defatting of the flap by a liposuction cannula.

METHODS

A cross-sectional study was performed among patients with deep hand burns requiring a modified Colson flap between 2018 and 2021. Outcomes included functional and cosmetic assessment of the hand through a quality-of-life questionnaire, a sensitivity scale and a scar assessment scale.

RESULTS

During this period, 7 patients were operated on using our technique. One patient was lost to follow-up; 7 patients with a median age of 44 years were included, with a total of 10 burned hands. The burns were thermal in 5 out of 7 cases and the coverage concerned the whole hand in 50% of the cases. The flaps all received cannula defatting. The median time to flap weaning was 23 days (20 to 30 days). The median follow-up was 16 months. One case required remote flap weaning. The median POSAS (Patient and Observer Scar Assessment Scale) per patient was 4 and 2 per observer. The median BMRCSS (British Medical Research Council Sensory Scale) was 122. One case had recovered S2 sensitivity, the other cases had S3 or S4 sensitivity.

CONCLUSION

Immediate defatting is one of the factors in tegumental quality allowing rapid functional recovery of the hand. The cannula defatting technique does not appear to require additional defatting time. The use of the liposuction cannula allows a one-step, homogeneous, and easier defatting, with a lower risk of devascularization.

Burn injury characteristics, referral pattern, treatment (costs), and outcome in burn patients admitted to a hospital with or without a specialized Burn Centre (BURN-Pro)

PURPOSE

Data on the epidemiology, treatment, and outcome of burn patients treated at non-burn centre hospitals are not available. The primary aim was to compare the burn characteristics of patients admitted to a hospital with or without a specialized burn centre.

METHODS

This multicentre, prospective, cohort study enrolled patients with burns admitted to a hospital without a burn centre and patients with < 10% total body surface area (TBSA) burned admitted to the burn centre. Primary outcome measure was the burn-related injury characteristics. Secondary outcome measures were adherence to the Emergency Management of Severe Burns (EMSB) referral criteria, treatment (costs), quality of life, and scar quality.

RESULTS

During the 2-year study period, 48 patients were admitted to a non-burn centre and 148 patients to the burn centre. In the non-burn centre group, age [44 (P₂₅-P₇₅ 26-61) versus 30 (P₂₅-P₇₅ 8-52) years; P = 0.007] and Injury Severity Score [2 (P₂₅-P₇₅ 1-4) versus 1 (P₂₅-P₇₅ 1-1); P < 0.001] were higher. In the burn centre group, the TBSA burned was significantly higher [4% (P₂₅-P₇₅ 2-6) versus 2% (P₂₅-P₇₅ 1-4); P = 0.001], and more surgical procedures were performed (in 54 versus 7 patients; P = 0.004). At 12 months, > 85% of the non-burn centre group and > 75% of the burn centre group reported no problems in quality of life. Scar quality score was < 1.5 in both groups, with significantly poorer scores in the burn centre group (P ≤ 0.007).

CONCLUSION

Both groups differed in patient, burn, and treatment characteristics. At 12 months, quality of life and scar quality were good in both groups. Significantly poorer scar quality scores were found in the burn centre group. This might be related to their larger burns and more frequent surgery. The organization of burn care in the Netherlands seems to work adequately. Patients are treated locally when possible and are transferred when necessary.

Translation and psychometric validation of the Finnish version of the Patient Scar Assessment Scale for use in patients with burn scars

BACKGROUND

The aim of this study was to create a Finnish scar assessment scale by translating and evaluating the psychometric properties of the Patient Scar Assessment Scale (PSAS), a part of the Patient and Observer Scar Assessment Scale (POSAS), with burn patients to enable its use in burn care.

METHODS

The translation process followed international guidelines with forward and backward translations and cognitive debriefing with patients. Psychometric validation was performed with adult patients with burns who had been treated at the Helsinki Burn Centre between 2006 and 2017 with skin grafting following the excision of deep second- or third-degree burns. To ensure reproducibility, the PSAS was sent to the study participants twice. The correlation between the PSAS and health-related quality of life (HRQL) was also tested.

RESULTS

In total, 192 patients, of whom 71 % were male, participated in this study. The mean (SD) age of the participants was 57 (17) years. The internal consistency of the PSAS was good, Cronbach's α 0.89 (95 % CI: 0.86-0.91). The reproducibility was also good concerning all items and the total score, ICC from 0.77 to 0.89. As expected, the total PSAS score correlated negatively with HRQL.

CONCLUSION

The PSAS was successfully translated and culturally adapted into Finnish and the newly translated version has good validity and reproducibility for assessing mature burn scars.

Evaluation of Scar Quality after Treatment of Superficial Burns with Dressilk® and Suprathel®-In an Intraindividual Clinical Setting

Background: Various synthetic and biological wound dressings are available for the treatment of superficial burns, and standard care differs among hospitals. Nevertheless, the search for an ideal wound dressing offering a safe healing environment as well as optimal scar quality while being economically attractive is a continuing process. In recent years, Dressilk^®, which consists of pure silk, has become the standard of care for the treatment of superficial burns in our hospital. However, no long-term scar-evaluation studies have been performed to compare Dressilk^® with the often-used and more expensive Suprathel^® in the treatment of superficial burns. Methods: Subjective and objective scar evaluations were performed three, six, and twelve months after treatment in patients who received simultaneous treatment of 20 superficial burn wounds with both Suprathel^® and Dressilk^®. The evaluations were performed using the Vancouver Scar Scale, the Cutometer^®, Mexameter^®, Tewameter^®, and the O2C^®. Results: Both dressings showed mostly equivalent results in subjective scar evaluations. In the objective scar evaluations, the wounds treated with Dressilk^® showed a faster return to the qualities of non-injured skin. Wound areas treated with the two dressings showed no significant differences in elasticity and transepidermal water loss after 12 months. Only oxygen saturation was significantly lower in wound areas treated with Suprathel^® (p = 0.008). Subjectively, wound areas treated with Dressilk^® showed significantly higher pigmentation after six months, which was not apparent after 12 months. Conclusion: Both wound dressings led to esthetically satisfying scar recovery without significant differences from normal uninjured skin after 12 months. Therefore, Dressilk^® remains an economically and clinically interesting alternative to Suprathel^® for the treatment of superficial burns.

Management of non-severe burn wounds in children and adolescents: optimising outcomes through all stages of the patient journey

Paediatric burn injuries are common, especially in children younger than 5 years, and can lead to poor physical and psychosocial outcomes in the long term. In this Review, we aim to summarise the key factors and interventions before hospital admission and following discharge that can improve the long-term outcomes of paediatric burns. Care can be optimised through first aid treatment, correct initial assessment of burn severity, and appropriate patient referral to a burns centre. Scar prevention or treatment and patient follow-up after discharge are also essential. As most burn injuries in children are comparatively small and readily survivable, this Review does not cover the perioperative management associated with severe burns that require fluid resuscitation, or inhalational injury. Burns disproportionately affect children from low socioeconomic backgrounds and those living in low-income and middle-income countries, with ample evidence to suggest that there remains scope for low-cost interventions to improve care for those patients with the greatest burden of burn injury. Current knowledge gaps and future research directions are discussed.

Scar formation from the perspective of complexity science: a new look at the biological system as a whole

A burn wound is a complex systemic disease at multiple levels. Current knowledge of scar formation after burn injury has come from traditional biological and clinical studies. These are normally focused on just a small part of the entire process, which has limited our ability to sufficiently understand the underlying mechanisms and to predict systems behaviour. Scar formation after burn injury is a result of a complex biological system-wound healing. It is a part of a larger whole. In this self-organising system, many components form networks of interactions with each other. These networks of interactions are typically non-linear and change their states dynamically, responding to the environment and showing emergent long-term behaviour. How molecular and cellular data relate to clinical phenomena, especially regarding effective therapies of burn wounds to achieve minimal scarring, is difficult to unravel and comprehend. Complexity science can help bridge this gap by integrating small parts into a larger whole, such that relevant biological mechanisms and data are combined in a computational model to better understand the complexity of the entire biological system. A better understanding of the complex biological system of post-burn scar formation could bring research and treatment regimens to the next level. The aim of this review/position paper is to create more awareness of complexity in scar formation after burn injury by describing the basic principles of complexity science and its potential for burn care professionals.

Longitudinal monitoring and prediction of long-term outcome of scar stiffness on pediatric patients

Background

Hypertrophic scarring after burn injury is one of the greatest unmet challenges in patients with burn injuries. A better understanding of the characteristics of scar maturation and early prediction of the long-term outcome of scarring are prerequisites for improving targeted therapies and pivotal for patient counselling.

Methods

Repeated measurements of scar stiffness in 11 pediatric patients were performed over the course of 1 year using 2 suction devices, the Cutometer and the Nimble. In addition, the observer pliability score of the Patient and Observer Scar Assessment Scale was applied. This longitudinal study allowed quantification of the ability of each of the measured parameters to reflect scar maturation, as indicated by change in skin pliability/stiffness, over time (using linear regression); the ability to distinguish individual patients (intraclass correlation coefficient (ICC)); the correlation of the devices (Spearman correlation coefficient); and the ability to predict long-term scar maturation based on early scar assessment (using receiver operating characteristic).

Results

All the tools used showed significant longitudinal decrease of scar stiffness from 3 months until 12 months after the injury. The Nimble (ICC_patient ^Nimble = 0.99) and the Cutometer (ICC_patient ^Cuto = 0.97) demonstrated an excellent ability to distinguish between individual patients. The Nimble seemed to be able to predict the 12-month pliability of scars based on early (3-month) measurements (area under the curve (AUC)_12m ^POSAS = 0.67; AUC_12m ^C = 0.46; AUC_12m ^N = 0.79).

Conclusions

The results of this preliminary study suggest that all 3 tools provide suitable means to quantify alterations in scar stiffness over time. Initial evidence suggests the Nimble is most favorable for predicting changes in stiffness associated with long-term scar maturation. Further studies with a larger sample size are required to validate tissue suction as a clinical tool for analysis of changes of scar stiffness over time.

Effects of multiple modes of UltraPulse fractional CO2 laser treatment on extensive scarring: a retrospective study

The main therapeutic options for extensive scarring (e.g., > 20% of the total body surface area, or TBSA) after burns and trauma have focused on conservative treatments, such as compression, moisturization, and topical agent application. However, these treatments may not achieve optimal effects due to the large size and complexity of the scars. UltraPulse fractional CO₂ laser treatment is a novel approach that is currently a subject of intense interest; this treatment is most widely used to improve texture, pliability, and pigmentation in all types of scars. However, no studies on the independent use of UltraPulse fractional CO₂ laser treatment for extensive scars have been reported. This retrospective study evaluated a total of 21 patients, whose scars covered 20 to 65% TBSA. Scar thickness was measured by ultrasonography before treatment. Personalized treatment modalities and parameters were set according to the scar type and thickness. Scar formation and treatment effects were evaluated by photography, the Patient and Observer Scar Assessment Scale (POSAS), and patients’ judgment of effectiveness. Where the scars covered joints, joint function was assessed by measuring the maximum range of motion (ROM). With laser therapy, scars became flatter and lighter; furthermore, pruritus, pain, and discomfort decreased significantly. POSAS scores significantly decreased after laser therapy, including the item scores for pain and pruritus. There were no instances of joint contracture, ROM reduction, apparent functional impairment, serious adverse events, or comorbidities. This study demonstrates the safety and efficiency of UltraPulse fractional CO₂ laser treatment for extensive scarring.

Comparison of wound healing and patient comfort in partial-thickness burn wounds treated with SUPRATHEL and epictehydro wound dressings

Among the available dressings for partial‐thickness burn wound treatment, SUPRATHEL has shown good usability and effectiveness for wound healing and patient comfort and has been used in many burn centres in the last decade. Recently, bacterial nanocellulose (BNC) has become popular for the treatment of wounds, and many studies have demonstrated its efficacy. epicite^hydro, consisting of BNC and 95% water, is a promising product and has recently been introduced in numerous burn centres. To date, no studies including direct comparisons to existing products like SUPRATHEL have been conducted. Therefore, we aimed to compare epicite^hydro to SUPRATHEL in the treatment of partial‐thickness burns. Twenty patients with partial‐thickness burns affecting more than 0.5% of their total body surface area (TBSA) were enrolled in this prospective, unicentric, open, comparative, intra‐individual clinical study. After debridement, the wounds were divided into two areas: one was treated with SUPRATHEL and the other with epicite^hydro. Wound healing, infection, bleeding, exudation, dressing changes, and pain were documented. The quality of the scar tissue was assessed subjectively using the Patient and Observer Scar Scale. Wound healing in patients with a mean TBSA of 9.2% took 15 to 16 days for both treatments without dressing changes. All wounds showed minimal exudation, and patients reported decreased pain with the only significant difference between the two dressings on day 1. No infection or bleeding occurred in any of the wounds. Regarding scar evaluation, SUPRATHEL and epicite^hydro did not differ significantly. Both wound dressings were easy to use, were highly flexible, created a safe healing environment, had similar effects on pain reduction, and showed good cosmetic and functional results without necessary dressing changes. Therefore, epicite^hydro can be used as an alternative to SUPRATHEL for the treatment of partial‐thickness burn wounds.

Smart Scar Care-Industry 4.0 in Individualized Compression Garments: A Randomized Controlled Crossover Feasibility Study

Background:

We tested the workflow and comparability of compression garments (CG) automatically knitted from 3D-body-scan data (3DBSD) versus manually measured data for scar treatment. Industry 4.0 has found its way into surgery, enhancing the trend toward personalized medicine, which plays an increasingly important role in CG scar therapy. Therefore, we conducted a study to evaluate the workflow from 3DBSD to fast and precisely knitted CG and compared it with standard of care.

Methods:

A randomized controlled crossover feasibility study was conducted as part of the individual medical technology research project “Smart Scar Care.” Objective and patient-reported outcome measures were documented for 10 patients with hypertrophic burn scars at baseline and after wearing CG automatically knitted from 3DBSD versus CG from manually measured data for one month.

Results:

The “scan-to-knit” workflow and the study design were feasible in 10 of 10 patients. No adverse effects were found. 3DBSD showed a bias of half a centimeter compared with manually measured data and wider limits of agreement. With respect to fit, comfort, suitability, Vancouver Scar Scale, Patient and Observer Scar Assessment Scale, stiffness and microcirculation, this was a promising pilot study. Stiffness and blood flow were increased in scars compared with normal skin. The highest rank correlations were found between pain and itch, stiffness and Patient and Observer Scar Assessment Scale, Vancouver Scar Scale, and pain.

Conclusions:

These results indicate that automatically knitted CG using 3DBSD could become an alternative to the standard of care, especially with regard to economical and faster patient care. The produced scan data opens the door for objective scar science.

Scar Assessment Tools: How Do They Compare?

Healing after dermal injury is a complex but imperfect process that results in a wide range of visible scars. The degree of disfigurement is not the sole determinant of a scar's effect on patient well-being, with a number of other factors being critical to outcome. These include cosmetic appearance, symptoms such as itch and pain, functional loss, psychological or social problems, and quality of life. An accurate assessment of these domains can help clinicians measure outcomes, develop, and evaluate treatment strategies. A PubMed literature search was performed up to 31st March 2020. Ten objective scar measurements, four Clinician-Reported Outcome Measures (CROMs), six Patient-Reported Outcome Measures (PROMs), and one combined measure were evaluated for their reliability, clinical relevance, responsiveness to clinical change, and feasibility. Many quantitative tools were limited in their clinical relevance and feasibility, whereas few qualitative CROMs and PROMs have undergone rigorous assessment. This review examines currently available assessment tools, focusing primarily on subjective scar measurements (CROMs, PROMs), and offers a perspective on future directions in the field.

Scar quality in children with burns 5-7 years after injury: A cross-sectional multicentre study

Long-term scar formation is an important adverse consequence in children with burns, however, information regarding scar quality in the long-term is lacking. Therefore, we evaluated scar quality and its predictors in children with burns 5-7 years after injury. Parents of children with mild/intermediate burns (≤10% total body surface area burned), and of children with severe burns (>10% burned) completed the patient scale of the Patient and Observer Scar Assessment Scale (POSAS 2.0) for their children's-in their opinion-worst scar 5-7 years post-burn. Outcomes and predictive factors of scar quality were studied, and, for children with severe burns, POSAS parent scores were compared with observer scores. We included 103 children with mild/intermediate burns and 28 with severe burns (response rate: 51%). Most children (87%) had scars that differed from normal skin, with most differences reported for colour, and least for pain. Except for colour, children with severe burns had significantly higher scores (difference 0-2 points) on all scar characteristics (representing poorer scar quality) compared with children with mild/intermediate burns. Parent POSAS scores were on average 2.0-2.6 points higher compared to observer scores. Number of surgeries predicted both the mean POSAS and the mean overall opinion of a scar. In conclusion, 5-7 years post-burn, the scar of the majority of children differed from normal skin, especially on the characteristic colour. The uncovered insights are useful in counselling of children and their parents on expectations of the final outcome of their (children's) scar(s), and help in further targeting scar prevention strategies for the individual child.

Smartphone-based optical palpation: towards elastography of skin for telehealth applications

Smartphones are now integral to many telehealth services that provide remote patients with an improved diagnostic standard of care. The ongoing management of burn wounds and scars is one area in which telehealth has been adopted, using video and photography to assess the repair process over time. However, a current limitation is the inability to evaluate scar stiffness objectively and repeatedly: an essential measurement for classifying the degree of inflammation and fibrosis. Optical elastography detects mechanical contrast on a micrometer- to millimeter-scale, however, typically requires expensive optics and bulky imaging systems, making it prohibitive for wide-spread adoption in telehealth. More recently, a new variant of optical elastography, camera-based optical palpation, has demonstrated the capability to perform elastography at low cost using a standard digital camera. In this paper, we propose smartphone-based optical palpation, adapting camera-based optical palpation by utilizing a commercially available smartphone camera to provide sub-millimeter resolution imaging of mechanical contrast in scar tissue in a form factor that is amenable to telehealth. We first validate this technique on a silicone phantom containing a 5 × 5 × 1 mm³ embedded inclusion, demonstrating comparative image quality between mounted and handheld implementations. We then demonstrate preliminary in vivo smartphone-based optical palpation by imaging a region of healthy skin and two scars on a burns patient, showing clear mechanical contrast between regions of scar tissue and healthy tissue. This study represents the first implementation of elastography on a smartphone device, extending the potential application of elastography to telehealth.

Subjective Tools for Burn Scar Assessment: An Integrative Review

OBJECTIVE

To review the clinical and scientific literature on the subjective ways of assessing burn scars and describe their main characteristics.

DATA SOURCES

The Latin American, Caribbean Health Sciences Literature, Nursing Database, PubMed, CINAHL, and Scopus and Web of Science databases were used to search for studies published between 2014 and 2018 using descriptors in Portuguese, Spanish, and English.

STUDY SELECTION

After establishing the research question and the location and definition of the studies, as well as accounting for differences among databases and application of filters based on inclusion and exclusion criteria, 886 references remained.

DATA EXTRACTION

Investigators reviewed the titles and abstracts of the sample and selected 188 relevant studies for full review.

DATA SYNTHESIS

Twenty-six subjective forms of assessment were found; most research concerned the Patient and Observer Scar Assessment Scale and the Vancouver Scar Scale.

CONCLUSIONS

The Patient and Observer Scar Assessment Scale and the Vancouver Scar Scale are the most common scales for assessing burn scars and have similar evaluation points such as vascularization, pliability, pigmentation, and height, which are the main parameters that contribute to the general assessment and severity of a scar. There is a need to improve instructions for application of the scales to facilitate better understanding and improve agreement among evaluators.

Comparison Among Bone Marrow and Wheat Flour's Mixture and Standard Treatment on Healing Second-Degree Burn Wound in Rats

The treatment of extensive skin burns remains as a challenge for health care personnel. This study aimed to compare the combination of bone marrow and wheat flour with standard treatment on animal models. In this experimental study, 45 male rats were randomly assigned into three groups as follows: The first group was control (no treatment), the second group received bone marrow and wheat flour combination topically, and the third group received standard treatment (1% silver sulfadiazine). The treatment lasted for up to 21 days. On the 22nd day, the rats were killed. The number of blood vessels and hair follicles was measured in the burn wound bed. The area and depth of the wound were also measured. Data were analyzed using SPSS software version 16. The results showed that, complete closure of the wound was better in the bone marrow treated group compared with the group receiving the silver sulfadiazine and the control group. Furthermore, the wound healing was better in the silver sulfadiazine group compared with the control group. Microscopic examination revealed a significant increase in the number of hair follicles and blood vessels in the bone marrow and silver groups compared with the control group. The results showed that, the group treated with bone marrow, because of the presence of mesenchymal and stem cells can cause stimulating angiogenesis and producing vegetative tissue, hence it improved maturation, shrinkage, and contraction of the wound in comparison with the silver sulfadiazine and control groups.

How Does Octyl-2-Cyanoacrylate Tissue Adhesive Compare With Prolene Sutures in Cleft Lip Repair?

PURPOSE

Comparative evidence of the usefulness of octyl-2-cyanoacrylate tissue adhesive in cleft lip epidermal skin closure especially in Africans is still lacking. This study aimed to compare the outcome of wound healing after the use of Dermabond tissue adhesive and 5/0 Prolene sutures in cleft lip repair.

METHODS

This was a prospective randomized controlled clinical study. The sampled population was patients undergoing cleft lip repair at a tertiary health facility in Lagos, Nigeria. Study patients were randomly allocated to either group A (Dermabond) or group B (suture). The predictor variable was the type of material used in skin closure; the primary outcome variable was the esthetics of the resulting scar, and secondary outcome variables were wound healing complications. Assessment of the 3-month postoperative wound scar was performed using the cosmetic visual analog scale (CVAS) and the Hollander Wound Evaluation scale (HWES). Calculated sample size was 14 participants per group. Descriptive and comparative statistics were computed, and the P value was set at <0.05.

RESULTS

Analysis of result included 38 participants. Median age was 4 months and 52.6% were women. Two cases (5.3%) of wound healing complications were recorded (1 in each group). Blinded evaluation of the 3-month postoperative photographs yielded a mean CVAS score of 86.0 (±11.2) and HWES score of 5.0 (±0.9) for group A and a mean CVAS score of 76.5 (±14.5) and HWES score of 4.5 (±1.1) for group B. There was no statistically significant difference between these 2 groups based on the CVAS (P = .052) and HWES (P = .152).

CONCLUSIONS

The results of this study suggest Dermabond offers a comparable cosmetic outcome as 5/0 Prolene suture in epidermal closure of cleft lip. There was no statistically significant difference in wound complications and wound cosmetic scores between the 2 groups.

Scarring at Donor Sites after Split-Thickness Skin Graft: A Prospective, Longitudinal, Randomized Trial

OBJECTIVE

To investigate if previous findings on the association between dressing treatments and subjective opinion on final donor site scar outcome using the Patient and Observer Scar Assessment Scale (POSAS) can be confirmed objectively. The previous study showed that patients dressed with hydrofiber covered with film were more satisfied with their donor site scars than patients receiving porcine xenograft or polyurethane foam dressings.

METHODS

Scar outcome measurements were assessed by a blinded observer using POSAS and the Cutometer dual MPA 580 device to measure the viscoelasticity of skin.

RESULTS

A total of 17 participants were included in this study, five of whom were treated with hydrofiber, six with polyurethane foam, and another six with porcine xenograft. There were no significant differences among groups in any of the POSAS items or in the viscoelasticity measurements made with the Cutometer.

CONCLUSIONS

The investigators could not confirm previous associations between dressing treatment and long-term donor site scars. No associations between donor sites' healing times and final scarring were found. Hypopigmentation was reported in 15 of 17 donor sites evaluated.

The Natural Evolution of Facial Surgical Scars: A Retrospective Study of Physician-Assessed Scars Using the Patient and Observer Scar Assessment Scale Over Two Time Points

Background: The natural evolution of facial scars has not been well described. Identifying factors that correlate with optimal scar healing may help patients and physicians during the perioperative period. Methods: A retrospective study of 108 facial skin cancer patient scars was performed. The Patient and Observer Scar Assessment Scale (POSAS) was used to grade scars at two time points (1 week and 3 months postoperatively). Paired two-tailed t-tests identified differences in scar ratings between the time points. Analysis of variance (ANOVA) explored whether POSAS scores differed by anatomic site or reconstruction type. Receiver operating characteristic analysis was performed to identify if 1-week scar appearance correlated with scar appearance at 3 months. Results: Between 1 week and 3 months the total POSAS score improved by 36.3% and overall opinion of the scar improved by 38.6% (p < 0.001). Facial cosmetic units differed in their 1-week and 3-month scores and all anatomic sites demonstrated significant improvement between time points. Differential scoring occurred among reconstruction types. Scar appearance at 1 week was able to predict overall scar appearance at the 3-month visit (area under the curve = 0.7732). Conclusions: Early scar appearance predicts later scar appearance, and scars will improve by nearly 40% 3 months after surgery. These data can be used to assist with perioperative counseling and expectation management.

A systematic review to investigate outcome tools currently in use for those with hand burns, and mapping psychometric properties of outcome measures

BACKGROUND

Severe burn injuries to the hand impact multiple domains of function and participation. Measurement of outcomes after hand burn injuries is multifaceted and is influenced by several variables.

OBJECTIVE

The aim of this systematic review was to review outcome measures reported in studies used to measure outcomes after severe hand burn injuries; and to critically evaluate the reliability, validity and clinical utility of each hand assessment tool identified from the literature to determine suitability for use with the burn's population.

DATA SOURCES

A search of the published literature using electronic data bases MEDLINE, CINAHL, PEDro, OT seeker and PubMed was undertaken. Studies were included if they reported assessment tools and outcome measures used to determine hand function after severe burn injuries; were published in English and available in their full-length. Studies were excluded if they were related to a group under 18 years of age.

RESULTS

Thirty-four papers were included in this systematic review. A total of 25 outcome measures were confirmed for inclusion in this paper and each underwent further evaluation to identify their psychometric properties.

LIMITATIONS

A factor which could cause bias in this systematic review was the search was restricted to English language journals therefore excluding any primary papers in other languages. Mapping of the outcome measures to the ICF was conducted by the primary author which may give rise to bias however a member checking was conducted in order to remove this bias.

CONCLUSIONS

This review established that no one outcome measure meets all the psychometric properties of validity, reliability and responsiveness SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO: CRD42018085059.

A Novel, Reliable Protocol to Objectively Assess Scar Stiffness Using Shear Wave Elastography

The aim of this research was to investigate the use of shear wave elastography as a novel tool to quantify and visualize scar stiffness after a burn. Increased scar stiffness is indicative of pathologic scarring which is associated with persistent pain, chronic itch and restricted range of movement. Fifty-five participants with a total of 96 scars and 69 contralateral normal skin sites were evaluated. A unique protocol was developed to enable imaging of the raised and uneven burn scars. Intra-rater and inter-rater reliability was excellent (intra-class correlation coefficient >0.97), and test-retest reliability was good (intra-class correlation coefficient >0.85). Shear wave elastography was able to differentiate between normal skin, pathologic scars and non-pathologic scars, with preliminary cutoff values identified. Significant correlations were found between shear wave velocity and subjective clinical scar assessment (r = 0.66). Shear wave elastography was able to provide unique information associated with pathologic scarring and shows promise as a clinical assessment and research tool.

Objective quantification of burn scar stiffness using shear-wave elastography: Initial evidence of validity

Shear-wave elastography (SWE) is an ultrasound based technology that can provide reliable measurements (velocity) of scar stiffness. The aim of this research was to evaluate the concurrent validity of using both the measured velocity and the calculated difference in velocity between scars and matched controls, in addition to evaluating potential patient factors that may influence the interpretation of the measurements.

METHODS

A cross-sectional study of 32 participants, with 48 burn scars and 48 matched contralateral control sites were evaluated with SWE, the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS) tactile sub-scores.

RESULTS

Spearman's rho demonstrated high correlations (r > 0.7) between the measured scar velocity and both the POSAS and VSS pliability sub-scores, whereas moderate correlations (r > 0.6) were found with the calculated difference in velocity. Regression analysis indicated that the association of increased velocity in scars, varied by length of time after burn injury and gender. Body location and Fitzpatrick skin type also demonstrated significant associations with velocity, whereas age did not.

CONCLUSION

SWE shows potential as a novel tool to quantify burn scar stiffness, however patient factors need to be considered when interpreting results. Further research is recommended on a larger variety of scars to support the findings.

Burn scar outcome at six and 12 months after injury in children with partial thickness scalds: Effects of dressing treatment

INTRODUCTION

In line with other researchers in the field of burns' care, we think that research investigating the long-term outcome of scars is largely lacking. As scarring is of the utmost importance to the patient, clinicians who treat burns must aim to find treatments that lead to a good end result. The aim of this study was to study scar outcomes at six and 12 months after injury. It is an extension of a previous randomised controlled trial (RCT) in which two dressings (porcine xenograft and silver foam dressing) were examined with respect to their ability to help heal partial thickness scalds.

METHOD

Children aged six months - six years with acute partial thickness scalds, on the trunk, or extremities, or both, were included. In the previous study, the silver foam was found to have significantly shorter healing times than the xenograft. Children were assessed at six and 12 months after injury for this study, and photographs were taken of the burn site, and both the patient and observer scar assessment scale (POSAS) and the Vancouver scar scale (VSS) were completed and evaluated by blinded observers.

RESULTS

Of the 58 children from the original RCT, 39 returned to the clinic for evaluation of their scars at six months, and 34 at 12 months after injury. There were no differences in POSAS, VSS total scores, or incidence of hypertrophic scarring between the different dressings. Fifteen children were assessed as having hypertrophic scarring, all of whom had healing times that had extended beyond 14 days.

CONCLUSIONS

This study compared burn scarring after two different treatments for burns in children with partial-thickness scalds and the data suggested that neither dressing had a more favourable impact on scar outcome. The conclusion is, however, tempered by the non-return of all the patients to the follow up. However, as anticipated, regardless of the dressing used, longer healing times were associated with higher scar scores (more scarring) and hypertrophic scarring.

Patterns and predictors of burn scar outcome in the first 12 months after burn: The patient's perspective

OBJECTIVE

This study aimed to provide insight into the patterns and factors that predict burn scar outcomes at 3, 6 and 12 months after burn.

METHODS

The Patient and Observer Scar Assessment Scale (POSAS) was used to assess the scar formation of each patient. Structural equation modelling was used. The predictor variables used in this study were sex, three age categories, TBSA, depth of the wound and cause of the burn.

RESULTS

The POSAS patient total and individual item scores demonstrated a statistically significant decrease in the first 12 months after burn, except for the relief item. Male patients had a lower total and items scores (better scar quality) for pain and pruritus compared with female patients. Full thickness burns had a higher scores for pruritus, pliability, thickness and relief compared to the partial-thickness burns. Ages younger than 5 years, higher TBSA values and flame burns were predictors of various POSAS items at 3 and 6 months after burn.

CONCLUSION

The POSAS patient total and individual item scores demonstrated a statistically significant improvement in the scar quality in the first 12 months after burn, except for the relief. Sex, age, depth of the wound, the percentage of TBSA and flame burns were predictors of various POSAS patient items at 3, 6 and 12 months after burn.

Patient-reported scar quality of adults after burn injuries: A five-year multicenter follow-up study

Scar formation is an important adverse consequence of burns. How patients appraise their scar quality is often studied shortly after sustaining the injury, but information in the long‐term is scarce. Our aim was, therefore, to evaluate long‐term patient‐reported quality of burn scars. Adults with a burn center admission of ≥1 day between August 2011 and September 2012 were invited to complete a questionnaire on long‐term consequences of burns. We enriched this sample with patients with severe burns (>20% total body surface area [TBSA] burned or TBSA full thickness >5%) treated between January 2010 and March 2013. Self‐reported scar quality was assessed with the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS). Patients completed this scale for their—in their opinion—most severe scar ≥5 years after burns. This study included 251 patients with a mean %TBSA burned of 10%. The vast majority (91.4%) reported at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and 78.9% of the patients’ overall opinion was that their scar deviated from normal skin. Patients with severe burns had higher POSAS scores, representing worse scar quality, than patients with mild/intermediate burns, except for color, which was high in both groups. A longer hospital stay predicted reduced scar quality (both mean POSAS and mean overall opinion of the scar) in multivariate analyses. In addition, female gender was also associated with a poorer overall opinion of the scar. In conclusion, this study provides new insights in long‐term scar quality. Scars differed from normal skin in a large part of the burn population more than 5 years after burns, especially in those with severe burns. Female gender is associated with a poorer patients’ overall opinion of their scar, which may be an indication of gender differences in perception of scar quality after burns.

Towards a clinical and empirical definition of burn scarring: A template analysis using qualitative data

OBJECTIVE

This study aimed to describe the nature, scope or meaning of the concept 'burn scar', from the perspective of adults and children with burn scarring, caregivers of children with burn scarring and health professionals who were considered experts in the treatment of burn scarring. The impact of the identified characteristics on burn scar health-related quality of life (HRQOL) was also examined.

METHOD

Using a phenomenological qualitative approach, 43 transcripts from semi-structured interviews with people with burn scars (n=10 adults and n=11 children), their caregivers (n=9) and health professionals (n=13) were analyzed using template analysis.

RESULTS

Ten characteristics of burn scars were identified by health professionals: 'stretchability', 'hardness', 'raised', 'thickness', 'surface area', 'scar sensitivity', 'scar surface appearance', 'hydration', 'fragility', and 'color'. However, 'thickness', 'scar surface area' and 'hydration' were not described by children with burn scars and 'scar surface area' was not described by adults with burn scars or caregivers. All groups (adults, children, caregivers and health professional) perceived that the burn scar characteristics of 'stretchability' and 'scar sensitivity' impacted upon all indicators of burn scar HRQOL. The burn scar characteristics of 'fragility', 'scar surface appearance' and 'color' were largely perceived by all groups to impact upon the emotional and physical indicators of burn scar HRQOL alone.

CONCLUSIONS

This study identified there are differences in the burn scar characteristics considered important by health professionals and those characteristics that adult/child/caregivers perceived to impact on indicators of burn scar HRQOL. It is recommended that outcome measures of burn scarring include the burn scar characteristics of 'stretchability' and 'scar sensitivity' at a minimum. The inclusion of 'fragility', 'scar surface appearance' and 'color' should also be considered.