Topical modalities for treatment and prevention of postsurgical hypertrophic scars

Allium cepa: A Treasure of Bioactive Phytochemicals with Prospective Health Benefits

As Allium cepa is one of the most important condiment plants grown and consumed all over the world, various therapeutic and pharmacological effects of A. cepa were reviewed. Onion (Allium cepa) is a high dietary fiber-rich perennial herb that is placed under the family Amaryllidaceae. It contains high concentration of folic acid, vitamin B6, magnesium, calcium, potassium, and phosphorus as well as vitamins and minerals. It is widely used as an antimicrobial agent, but it showed anticancer, antidiabetic, antioxidant, antiplatelet, antihypertensive, and antidepressant effects and neuroprotective, anti-inflammatory, and antiparasitic effects and so on. It is said to have beneficial effects on the digestive, circulatory, and respiratory systems, as well as on the immune system. This review article was devoted to discussing many health benefits and traditional uses of onions in pharmacological perspectives, as well as the safety/toxicological profile. If more detailed research on this perennial herb is conducted, it will open the door to an infinite number of possibilities.

Tacrolimus action pathways in an ointment base for hypertrophic scar prevention in a rabbit ear model

BACKGROUND

Tacrolimus is used to prevent unaesthetic scars due to its action on fibroblast activity and collagen production modulation.

OBJECTIVES

To evaluate the action pathways, from the histopathological point of view and in cytokine control, of tacrolimus ointment in the prevention of hypertrophic scars.

METHODS

Twenty-two rabbits were submitted to the excision of two 1-cm fragments in each ear, including the perichondrium. The right ear received 0.1% and 0.03% tacrolimus in ointment base twice a day in the upper wound and in the lower wound respectively. The left ear, used as the control, was treated with petrolatum. After 30 days, collagen fibers were evaluated using special staining, and immunohistochemistry analyses for smooth muscle actin, TGF-β and VEGF were performed.

RESULTS

The wounds treated with 0.1% tacrolimus showed weak labeling and a lower percentage of labeling for smooth muscle actin, a higher proportion of mucin absence, weak staining, fine and organized fibers for Gomori's Trichrome, strong staining and organized fibers for Verhoeff when compared to controls. The wounds treated with 0.03% tacrolimus showed weak labeling for smooth muscle actin, a higher proportion of mucin absence, strong staining for Verhoeff when compared to the controls. There was absence of TGF-β and low VEGF expression.

STUDY LIMITATIONS

The analysis was performed by a single pathologist. Second-harmonic imaging microscopy was performed in 2 sample areas of the scar.

CONCLUSIONS

Both drug concentrations were effective in suppressing TGF-β and smooth muscle actin, reducing mucin, improving the quality of collagen fibers, and the density of elastic fibers, but only the higher concentration influenced elastic fiber organization.

A comparison of the efficacy of silicone gel containing onion extract and aloe vera to silicone gel sheets to prevent postoperative hypertrophic scars and keloids

Background

Hypertrophic scars and keloids are postsurgery problems. Some studies showed that onion extract and aloe vera might be beneficial for postoperative scars. However, few of the randomized clinical trials were investigated.

Aims

To compare the efficacy of silicone gel containing onion extract and aloe vera (SGOA) to silicone gel sheets (SGS) to prevent postoperative hypertrophic scars and keloids.

Methods

The prospective randomized assessor‐blind controlled trial was conducted with 40 patients who had undergone surgery. The patients were divided into two groups: one treated with SGOA, the other with SGS. The patients were evaluated after 1, 2, and 3 months. The objective assessment was to determine the incidences of scarring, erythema, and melanin values using Mexameter, and pliability through Cutometer. The subjective assessment consisted of the patient and observer scar assessment scale (POSAS) and patient satisfaction.

Results

After the 12‐week follow‐up, there was no statistically significant difference in the scarring incidence rate of both groups. There were no statistical differences in the POSAS score, erythema, and melanin value between both groups. Using objective assessment, pliability in the SGOA group was statistically significantly higher compared to the SGS group. Pain and itchiness significantly decreased in both groups. No adverse effects were reported in either group.

Conclusion

Silicone gel containing onion extract and aloe vera is effective as SGS for postoperative scar prevention.

Beneficial effects of an investigational wristband containing Synsepalum dulcificum (miracle fruit) seed oil on the performance of hand and finger motor skills in healthy subjects: A randomized controlled preliminary study

Miracle fruit (Synsepalum dulcificum) seed oil (MFSO) contains phytochemicals and nutrients reported to affect musculoskeletal performance. The purpose of this study was to assess the safety and efficacy of a compression wristband containing MFSO on its ability to measurably improve the hand and finger motor skills of participants. Healthy right-handed participants (n = 38) were randomized in this double-blind, placebo-controlled study of MFSO and vehicle wristbands. Subjects wore the wristband on their left hand 4-6 weeks and then only on their right hand 2-4 weeks; the contralateral untreated hand served as an additional control. Twelve hand/finger motor skills were measured using quantitative bio-instrumentation tests, and subject self-assessment questionnaires were conducted. With each hand, in 9/12 tests, the MFSO group showed a clinically meaningful average improvement compared with an average worsening in the vehicle group. Statistical superiority to the control treatment group was exhibited in 9/12 tests for each hand (p < .01). After discontinuing the MFSO wristband on the left hand, test values regressed toward baseline levels. Subjects favored the MFSO wristband over the control, rating it as effective in improving their motor skills. Use of the MFSO wristband may improve an individual's manual dexterity skills and ability to maintain this performance.

Effects of Topical Tamoxifen on Wound Healing of Burned Skin in Rats

Background

This study aimed to assess the effects of the topical application of tamoxifen on wound healing of burned skin in Wistar rats by evaluating 3 healing characteristics: fibrotic tissue thickness (FTT), scar surface area (SSA), and angiogenesis in the healed scar tissue.

Methods

Eighteen male Wistar rats were used in this study. A third-degree burn wound was made on the shaved animals’ back, measuring 2×2×2 cm. In the first group, a 2% tamoxifen ointment was applied to the wound twice daily for 8 weeks. The second group received a placebo ointment during the same period. The third group did not receive any treatment and served as the control group.

Results

The median (interquartile range=[Q1, Q3]) FTT was 1.35 (1.15, 1.62) mm, 1.00 (0.95, 1.02) mm, and 1.25 (0.8, 1.5) mm in the control, tamoxifen, and placebo groups, respectively (P=0.069). However, the FTT in the tamoxifen group was less than in the placebo and control groups. The median angiogenesis was 3.5 (3.00, 6.25), 8.00 (6.75, 9.25), and 7.00 (5.50, 8.25) vessels per high-power field for the control, tamoxifen, and placebo groups, respectively (P=0.067). However, the median angiogenesis was higher in the tamoxifen group than in the control group. No significant difference was observed in the mean SSA between the tamoxifen group and the control group (P=0.990).

Conclusions

Local application of tamoxifen increased angiogenesis and decreased the FTT, with no change in the SSA in burned skin areas. These effects are expected to expedite the wound healing process, reducing contracture and preventing hypertrophic scar and keloid formation.

Current Therapeutic Approach to Hypertrophic Scars

Abnormal scarring and its accompanying esthetic, functional, and psychological sequelae still pose significant challe nges. To date, there is no satisfactory prevention or treatment option for hypertrophic scars (HSs), which is mostly due to not completely comprehending the mechanisms underlying their formation. That is why the apprehension of regular and controlled physiological processes of scar formation is of utmost importance when facing hypertrophic scarring, its pathophysiology, prevention, and therapeutic approach. When treating HSs and choosing the best treatment and prevention modality, physicians can choose from a plethora of therapeutic options and many commercially available products, among which currently there is no efficient option that can successfully overcome impaired skin healing. This article reviews current therapeutic approach and emerging therapeutic strategies for the management of HSs, which should be individualized, based on an evaluation of the scar itself, patients’ expectations, and practical, evidence-based guidelines. Clinicians are encouraged to combine various prevention and treatment modalities where combination therapy that includes steroid injections, 5-fluorouracil, and pulsed-dye laser seems to be the most effective. On the other hand, the current therapeutic options are usually empirical and their results are unreliable and unpredictable. Therefore, there is an unmet need for an effective, targeted therapy and prevention, which would be based on an action or a modulation of a particular factor with clarified mechanism of action that has a beneficial effect on wound healing. As the extracellular matrix has a crucial role in cellular and extracellular events that lead to pathological scarring, targeting its components mostly by regulating bone morphogenetic proteins may throw up new therapeutic approach for reduction or prevention of HSs with functionally and cosmetically acceptable outcome.

Evidence-Based Scar Management: How to Improve Results with Technique and Technology

BACKGROUND

Scars represent the visible sequelae of trauma, injury, burn, or surgery. They may induce distress in the patient because of their aesthetically unpleasant appearance, especially if they are excessively raised, depressed, wide, or erythematous. They may also cause the patient symptoms of pain, tightness, and pruritus. Numerous products are marketed for scar prevention or improvement, but their efficacy is unclear.

METHODS

A literature review of high-level studies analyzing methods to prevent or improve hypertrophic scars, keloids, and striae distensae was performed. The evidence from these articles was analyzed to generate recommendations. Each intervention's effectiveness at preventing or reducing scars was rated as none, low, or high, depending on the strength of the evidence for that intervention.

RESULTS

For the prevention of hypertrophic scars, silicone, tension reduction, and wound edge eversion seem to have high efficacy, whereas onion extract, pulsed-dye laser, pressure garments, and scar massage have low efficacy. For the treatment of existing hypertrophic scars, silicone, pulsed-dye laser, CO2 laser, corticosteroids, 5-fluorouracil, bleomycin, and scar massage have high efficacy, whereas onion extract and fat grafting seem to have low efficacy. For keloid scars, effective adjuncts to excision include corticosteroids, mitomycin C, bleomycin, and radiation therapy. No intervention seems to have significant efficacy in the prevention or treatment of striae distensae.

CONCLUSION

Although scars can never be completely eliminated in an adult, this article presents the most commonly used, evidence-based methods to improve the quality and symptoms of hypertrophic scars, as well as keloid scars and striae distensae.

Assessing Risk and Avoiding Complications in Breast Reduction

Assessing risk and avoiding complications in breast reduction requires a meticulous history, systematic physical examination, management of expectations, and careful consideration and execution of operative technique. Attention should be paid to comorbidities. Shape, symmetry, contours, scar location, skin quality, nipple-areolar complex (NAC) shape, NAC position relative to inframammary fold, and NAC position relative to the volume of the breast should be evaluated. Because complications cannot always be anticipated, informed consent is a vital part of managing expectations. Intraoperative considerations include blood pressure control, limiting tension, delayed healing and tissue loss, and using applied anatomy to avoid malposition and asymmetry.

Guidelines for burn rehabilitation in China

Quality of life and functional recovery after burn injury is the final goal of burn care, especially as most of burn patients survive the injury due to advanced medical science. However, dysfunction, disfigurement, contractures, psychological problems and other discomforts due to burns and the consequent scars are common, and physical therapy and occupational therapy provide alternative treatments for these problems of burn patients. This guideline, organized by the Chinese Burn Association and Chinese Association of Burn Surgeons aims to emphasize the importance of team work in burn care and provide a brief introduction of the outlines of physical and occupational therapies during burn treatment, which is suitable for the current medical circumstances of China. It can be used as the start of the tools for burn rehabilitation.

One-stage cosmetic finger reconstruction using a second toe island flap containing terminal branches of the toe artery

INTRODUCTION

A finger reconstructed by toe transfer may have morphological defects. We report the results of second toe transfer for 1-stage finger reconstruction with an island flap based on terminal branches of the toe artery.

HYPOTHESIS

The technique can improve the morphological outcomes of reconstructed fingers.

MATERIALS AND METHOD

Between January 2008 and June 2011, toe-to-finger transfer was performed for 36 fingers in 31 patients. An island flap containing terminal branches of the toe artery was embedded in the neck of the second toe to eliminate the morphological defect caused by stenosis in that area.

RESULTS

All reconstructed fingers and all flaps survived. No donor site complications occurred. The mean follow-up was 8 months (range, 5 to 25 months). The morphology of the reconstructed finger was close to that of a normal finger, and a natural transition could be observed in the finger pulp, the finger neck, and the junction between the toe and the finger. Sensory recovery of the finger pulp ranged from S1 to S3+. The mean pinch strength of the reconstructed fingers was 48% to 60% of that of the contralateral side. The mean DASH scores were 52.9, 48.9, and 46.0 for patients that had the index, third, and fourth fingers reconstructed, respectively, and the lowest mean aesthetic score was 70.

DISCUSSION

The method provides good aesthetic and functional outcomes, and overcomes aesthetic difficulties associated with other methods of toe transfer for finger reconstruction.

Scar revision

Most surgical patients end up with a scar and most of these would want at least some improvement in the appearance of the scar. Using sound techniques for wound closure surgeons can, to a certain extent, prevent suboptimal scars. This article reviews the principles of prevention and treatment of suboptimal scars. Surgical techniques of scar revision, i.e., Z plasty, W plasty, and geometrical broken line closure are described. Post-operative care and other adjuvant therapies of scars are described. A short description of dermabrasion and lasers for management of scars is given. It is hoped that this review helps the surgeon to formulate a comprehensive plan for management of scars of these patients.