Rating the burn scar

Eye Tracking to Determine Noticeability of Pediatric Facial Scar Characteristics to Adult Observers

OBJECTIVE

Determine objectively noticeable features of pediatric facial scars using eye-tracking software and explore how skin tone impacts scar perception.

STUDY DESIGN

Cross-sectional analysis.

SETTING

Tertiary care pediatric hospital.

METHODS

Ninety-seven naïve adult participants viewed 12 randomized photos using an eye-tracking device. Photos of 4 children with different Fitzpatrick (FP) tones were used to digitally create 3 images each: a scarless control, a hypertrophic scar, and a dyspigmented scar. Scar size and location were consistent. Gaze metrics were compared between skin tones and scar types.

RESULTS

Hypertrophic and dyspigmented scars had greater total fixation duration and fixation count than controls across all skin tones (P < .01). The dyspigmented scar of the FP2 child had greater total fixation duration (P = .01) and fixation count (P = .04) than the hypertrophic scar. The dyspigmented scar of the FP2 child had greater total fixation duration and fixation count than the dyspigmented scars of the FP6 and FP4 children (P < .01). The hypertrophic scar of the FP1 child had a longer total fixation duration than the hypertrophic scar of the FP6 child (P = .04). There were lower times to first fixation for both hypertrophic and dyspigmented scars in the FP1, FP4, and FP6 children (P < .04), and the dyspigmented scar in the FP2 child (P = .049).

CONCLUSION

Dyspigmented and hyperpigmented scars were viewed differently on children's faces with various skin tones. This highlights the importance of evaluating and accounting for both scar type and skin tone when counseling patients and families who experience facial scarring.

Comparing Innervated and Noninnervated Glabrous Skin Flaps for Volar Digital Defects: Insights from Patient-Reported Outcomes

BACKGROUND

Volar soft-tissue defects in digits necessitate reconstructions that restore appearance sensation and minimize complications. This study compared innervated toe pulp (TP) and noninnervated medialis pedis (MP) flaps for reconstructing such defects, focusing on objective and subjective outcomes.

METHODS

Between 1998 and 2017, 101 free glabrous skin flap reconstructions were performed at the authors' institution for volar digital soft-tissue injuries, comprising 75 TP flaps and 26 MP flaps. Follow-up assessments included the Michigan Hand Outcomes Questionnaire; Disabilities of the Arm, Shoulder and Hand Questionnaire; Foot and Ankle Disability Index; and sensory testing (static and moving two-point discrimination, Semmes-Weinstein monofilament test). Data analysis used the Mann-Whitney U test and Pearson correlation coefficients.

RESULTS

The study cohort included 29 participants (TP, n = 15; MP, n = 14) with an average follow-up of 106 months. Functional and sensory outcomes revealed no significant differences between TP flaps and MP flaps. Both flap types achieved satisfactory function and sensibility, with no statistically significant distinctions in patient-reported outcomes. Subjective complaints were similarly distributed across both groups, with a few reports of cold intolerance and discomfort at the donor site in the TP flap group.

CONCLUSIONS

TP and MP flaps provide adequate coverage and sensory outcomes for volar digital defects without significant differences between innervated and noninnervated flap transfers. The flap choice should be tailored to individual patient needs and defect characteristics, emphasizing the importance of patient-centered decision-making in reconstructive surgery. Further research is required to explore the long-term outcomes of these reconstruction methods, especially for larger defects.

Use of an electrospun bioveil is safe and does not decrease skin graft take on burn wounds: A randomised, controlled clinical trial

INTRODUCTION

Split-thickness skin autografts are the gold standard for surgical treatment of burns. In preclinical studies, the use of SKINHEALTEX PLGA, an electrospun poly(lactic-co-glycolide) acid (PLGA) bioveil, placed between autografts and their bed has shown potential to stimulate dermal regeneration, increase graft take and improve scar quality. These properties have not yet been evaluated in human clinical trials.

OBJECTIVE

The primary goal of this study was to evaluate tolerability and safety of SKINHEALTEX PLGA on human tissues, specifically, split-thickness skin autografts and wound beds of debrided burns.

MATERIALS AND METHODS

A double-blind randomised controlled clinical trial was conducted with adult patients with deep burns requiring surgical treatment, for 4 years (November 2018 to September 2022). Each patient acted as their own control, and they were followed for 12 months. In the control area a skin autograft was applied, while in the treatment area SKINHEALTEX PLGA was interposed between the autograft and the bed. The outcome variables were incidence of adverse events, the percentage of graft take (evaluated clinically), and Vancouver Scar Scale and Patient and Observer Scar Assesment Scale scores.

RESULTS

The bioveil was well tolerated in the 26 patients that were recruited. No adverse events related to SKINHEALTEX PLGA were observed. No statistically significant differences were observed in split-thickness skin autograft take and subsequent scar quality between the control group (split-thickness skin autografts alone) and the autograft and SKINHEALTEX PLGA group.

CONCLUSION

This is the first clinical trial investigating the application of an electrospun biomaterial in the treatment of burns using skin autografts. SKINHEALTEX PLGA is a biocompatible and safe product that can be applied as an interface between autografts and the debrided bed of a burn without reducing graft take. Further research is needed to assess the value of SKINHEALTEX PLGA for burn wounds and its potential as an administration route of molecules than enhance dermal regeneration in burn patients.

The efficacy of steroid tape for hypertrophic and keloid scars assessed using the SCAR-Q patient-reported outcome measure

BACKGROUND

Japanese people have a higher prevalence of hypertrophic and keloid scars than people of other ethnicities. Steroid tape is a simple, conservative treatment utilized broadly for scars in Japan but is largely overlooked elsewhere in the world. This study evaluated the efficacy of steroid tape for scars using a scar-specific patient-reported outcome measure, the Japanese SCAR-Q.

METHODS

A single-center, prospective cohort study of all patients treated with steroid tape for pathologic scars, including hypertrophic and keloid scars, was conducted. Primary outcome measures included SCAR-Q scores (both current and recalled baseline), and global rating of change scores.

RESULTS

One-hundred sixty-three patients were enrolled. The overall response rate was 95.7%. Steroid tape use was associated with significant improvements in SCAR-Q scores of 14.4 ± 16.5, 17.6 ± 17.7, and 15.1 ± 18.4 points for the Appearance, Symptom, and Psychosocial Impact scales, respectively. Global rating of change scores for scar appearance, associated symptoms, and psychosocial impact were also largely improved in >90% of patients. Steroid tape was easy to use and associated with few minor side effects. Post-treatment, Japanese patients continued to report hiding behaviors and a desire to change/remove their scar.

CONCLUSIONS

Steroid tape was associated with patient-reported scar improvement, and the treatment strategy should therefore be considered for conservative pathologic scar management. Nonetheless, Japanese patients still experienced significant psychosocial impacts from their scars after treatment. The personal impact of scars in this sample may be partially related to unique features of the Japanese culture.

Analysis of the Efficacy of Surgical Excision Combined with Electron Beam Therapy for Keloids

This study aimed to investigate the incidence and impact of patient characteristics and timing of postoperative electron beam therapy on the treatment efficacy of keloids. A total of 66 patients with keloids underwent surgical treatment and postoperative electron beam therapy. Follow-up was conducted for 43 patients, and treatment efficacy was analyzed for 39 patients. Statistical analysis was used to analyze incidence characteristics and effects of patient characteristics and timing of electron beam therapy on treatment efficacy. The study included 66 patients with 133 keloids. The timing of electron beam therapy significantly impacted treatment efficacy, with higher efficacy observed when performed 0-2 days after surgery compared to 3-5 days after surgery. Keloids are more common in women aged 20-40 years. The timing of electron beam therapy significantly impacted treatment efficacy, with higher efficacy observed when performed 0-2 days after surgery compared to 3-5 days after surgery.

Dermabond Prineo: a systematic review and meta-analysis

OBJECTIVE

Dermabond Prineo (Ethicon Inc., US) is a combination of a skin adhesive applied over a polyester mesh to reinforce and share tension equally over the surgical wound with the aim of reducing closure time and improving wound healing. The aims of this systematic review were to assess published data on Dermabond Prineo regarding infection rates, delayed wound healing, cosmetic appearance and application time compared to conventional wound closure techniques across multiple surgical procedures.

METHOD

A literature search was conducted according to PRISMA guidelines. The primary outcome was the incidence of wound infection after Dermabond Prineo compared to controls, namely traditional methods of wound closure such as staples, sutures and adhesives. Secondary outcome measures included allergic reactions and time taken for application.

RESULTS

A literature search using PubMed, SCOPUS and Science Direct identified 52 studies, of which 19 were eligible for qualitative synthesis and 12 for meta-analysis. The studies included reflected a broad range of applications of Dermabond Prineo for wound closure in abdominoplasty, mammoplasty and arthroplasty. Overall, all studies reporting on time taken for application found that Dermabond Prineo reduced time for wound closure. Meta-analysis identified a statistically significant reduction in wound infection rates (Dermabond Prineo 1.51%, control 2.13%; OR: 0.65 (0.46, 0.91); p=0.01) and a reduction in delayed wound healing (Dermabond Prineo 0.99%, control 1.79%; OR: 0.42 (0.18, 0.98); p=0.05). All three studies reporting on outcomes of scar cosmesis or long-term maturation attested to improved cosmetic results compared with sutures. The cost-effectiveness of Dermabond Prineo with a hypothetical model was discussed in two studies which concluded that it could achieve savings of $50-76 USD per patient, while a retrospective model found no statistically significant difference in total hospital costs or operating room time.

CONCLUSION

In this review, Dermabond Prineo showed lower wound infection rates and a reduction in delayed wound healing. Further studies are required to assess cost-effectiveness in a real-world setting.

Individualized surgical treatment using decellularized fish skin transplantation after enzymatic debridement: A two years retrospective analysis

Over the past few years, treatment of burn injuries has evolved beyond primary surgical therapy with the development of enzymatic debridement and new types of skin replacement materials by providing complex personalized therapy concepts aimed at preserving and replacing the dermal layer of the skin. The aim of our study was to develop an individualized treatment algorithm for mixed depth burn wound and evaluate the outcomes of individualized combined treatment of mixed depth burn wounds with enzymatic debridement and decellularized fish skin. A total of 18 patients with a mean age of 34.8 years and mean follow-up of 447.6 days were included. The mean total burn surface area was 12.3%. All patients received enzymatic debridement and an average area of 247.2 cm2 of decellularized fish skin. Days until complete epithelization were 49.4 ± 25.79 days. No patient developed scar contracture or keloid. The Patient and Observer Scar Assessment Scale (POSAS) observer scale showed an overall impression average of 2.2 ± 0.83. The POSAS patient scale showed an overall impression average 2 ± 0.7. The Vancouver Scar Scale showed an average score of 1.89 ± 1.45. In conclusion, combined treatment using enzymatic debridement and decellularized fish skin, polylactide membrane, or split skin grafts allows for a more individualized therapy for mixed depth burn wounds. Fish skin was found to provide a satisfying result in terms of the overall outcome of the developed scar tissue and could lead to a reduction in the area that requires autologous transplantation.

An Assessment of Current Clinician- and Patient-Reported Outcome Measures for Acne Scarring and Dyspigmentation: A Scoping Review

Acne-associated scarring and dyspigmentation (ie, erythema, hyperpigmentation) are common sequelae with significant psychosocial impact, but little is known about what measures are most often used to assess these outcomes. This scoping review evaluates the use of current patient-reported outcome measures (PROMs) and clinician-reported outcome measures (ClinROMs) for acne scars and dyspigmentation. For scars, 7 PROMs and 18 ClinROMs were used, with most being unvalidated. Similarly, for dyspigmentation, 4 PROMs and 8 ClinROMs were identified, but no validated PROMs were identified. These results highlight reliance on unvalidated measures in research and clinical trials and suggest the need for developing high-quality validated measures, particularly PROMs, to improve research quality and develop better treatments.

Scar Healing after Breast Reconstruction: A 5-year Follow-up in Asian Patients

Objectives

Hypervascularity, hypertrophy, and hyperpigmentation of breast scars often persist for several years after reconstruction. There are few reports on the long-term follow-up of postoperative scars after breast reconstruction. We previously reported that at 1 year after reconstruction, >30% of Asian patients showed abnormal scars. In this study, we followed these patients for as long as 5 years postoperatively.

Methods

We followed 101 Asian patients who underwent immediate two-stage implant-based breast reconstructions between 2013 and 2017 and still had abnormal scars involving hypervascularity, hypertrophy, or hyperpigmentation at 1 year postoperatively. We conducted annual follow-up for an additional 4 years, assessing the time until improvement and performing statistical analysis of factors related to the persistence and healing of abnormal scars.

Results

Hypervascularity improved in 12%, 37%, 68%, and 82% of patients at 2, 3, 4, and 5 years, respectively. Most cases improved between 3 and 4 years postoperatively. Among the patients with both hypervascularity and hypertrophy at 1 year, 36% had residual hypervascularity at 5 years compared with 9.8% of those with hypervascularity only at 1 year. Hypertrophy improved within 5 years in 56% of the cases. Hyperpigmentation improved within 5 years in only 21% of the cases. There was no significant association between abnormal scars and age or body mass index.

Conclusions

Even in Asian patients with persistent hypervascularity of breast scars, most cases improve within 5 years after reconstruction. However, hypervascularity tends to persist in cases that also show hypertrophy. Compared with hypervascularity and hypertrophy, hyperpigmentation showed worse 5-year improvement.

The Efficacy of Onion Extract on the Prevention or Treatment of Scars: A Systematic Review

Scars are common and debilitating outcomes of burn injury, with no current consensus regarding the gold standard in scar management. Noninvasive interventions such as silicone gels are popular adjuvant treatments due to ease of application. Onion extract (OE) has been proposed as a potential scar treatment modality due to its antimicrobial and anti-inflammatory properties. A systematic search of the literature was conducted using PubMed, Scopus, and Cochrane for articles published between January 2000 and December 2021. Inclusion criteria were studies (1) involved OE gel or OE treatment and (2) those assessing scar prevention or treatment outcomes. Patient and physician reported scar outcomes after treatment and adverse effects were recorded. A total of 21 articles were included in the final review. Five studies found statistically significant improvements in overall scores and individual Vancouver Scar Scale components in the OE treatment group compared to the silicone groups. Several studies found that combined treatment of OE with other topical treatment modalities such as triamcinolone or silicone gel produced significant improvements in scar symptoms. In this review, reported adverse effects were minimal, often consisting of self-resolving pruritus, irritation, and erythema. This review supports OE's potential utility in scar prevention and treatment. Most studies reported minimal adverse events with OE application and significant benefits in specific scar characteristics. Further research is needed to investigate scar outcomes after treatment with OE with larger sample sizes and a follow-up period greater than a year.

Development of a Simvastatin-Loaded Copolymer Acid-Sensitive Nanocarrier and Its Experimental Use in the Treatment of Keloids

OBJECTIVE

The lipid-lowering simvastatin (SIM) has been shown to be an effective inhibitor of keloid proliferation. However, due to its low water solubility and short half-life, simvastatin aggregates to the liver and does not reach the skin lesions after oral administration, which restricts its widespread clinical use. The development of nanomedicine provides the possibility for us to break through this bottleneck problem clinically. The objective of this study was to investigate the feasibility of using complex nanocontrolled delivery system (CNDS), simvastatin-loaded polyethylene glycol-poly lactic-co-glycolic acid (PEG-PLGA), in the treatment of keloids.

METHODS

In the in vitro study, the release of simvastatin in fibroblasts by CNDS@Simvastatin and its effect on inhibition of the proliferation of fibroblasts, Col Ι, and CTGF by the slow release of simvastatin were assessed. The efficacy of CNDS@Simvastatin in improving keloids and the biocompatibility and safety of CNDS@Simvastatin were examined in vivo by establishing a murine ear keloid model.

RESULTS

CNDS@Simvastatin showed sustained and uniform inhibition of the proliferation of fibroblasts, Col Ι, and CTGF via the gradual release of simvastatin over 72 h. It was efficient in the treatment of the murine ear keloid with no observable toxic side effects on various organs.

CONCLUSION

Simvastatin-loaded copolymer acid-sensitive nanocarriers, CNDS@Simvastatin nanospheres, were successfully developed in this study, and these were characterized by favorable physicochemical properties and biocompatibility.

Functional and Aesthetic Comparison between Grafts and Local Flaps in Non-Melanoma Skin Cancer Surgery of the Face: A Cohort Study

Background

Non-melanoma skin cancers represent more than 90 % of malignant skin tumors, with an incidence of 19.46 cases/100,000 people per year in Italy; however, their real incidence is underestimated. Although there are several therapeutic strategies, the only one that can guarantee a 95 % healing rate and the possibility of performing histological examination is surgical excision with subsequent reconstruction of the injured area with direct closure and with skin graft, local, regional, or free flaps in cases involving greater damage.

Material and Methods

Fifty-four patients underwent post-oncological head/face reconstructive surgery with skin graft or local flap between November 2021 and February 2023. The aesthetic outcomes (and the subsequent impact on the patients' lives) were assessed using the Vancouver Scar Scale, Manchester Scar Scale, and Visual Analog Scale with scars ranked by three independent surgeon observers.

Results

Patients who received reconstruction with local flaps demonstrated improved aesthetic and functional satisfaction, as well as improved aesthetic evaluation by independent surgeons.

Conclusions

The use of local flaps permits a more pleasing reconstruction (functionally and aesthetically) of post-oncological tissue defects of the face.

Development of the AIIMS Bhopal Pre-sternal Keloid Scale (ABPSKS): A Tool for Assessing Severity and Comparing Treatment Outcomes

Pre-sternal keloids are a distinct clinicopathological entity differing in many ways from keloids occurring elsewhere, as there are differences in pathogenesis, clinical presentation, and management. We have reviewed commonly used assessment scales like the Vancouver Scar Scale, the Patient and Observer Scar Assessment Scale, and the Detroit Keloid Scale and identified some shortcomings in applying them in assessing pre-sternal keloids. Therefore, we developed the AIIMS Bhopal pre-sternal keloid scale (ABPSKS), a pre-sternal keloid-specific tool to enable the assessment of the severity of the disease, the efficacy of treatment, and the comparison of outcomes of different treatment modalities. We have incorporated both the patient's and the observer's perspectives in our tool, and we have also incorporated certain measures that are distinct for pre-sternal keloids.

Nanocellulose significantly reduces number of anesthetics, hospital days, and in-patient dressing changes compared to PU-Foam Dressing: A prospective cohort study in children

BACKGROUND

Pediatric thermal injuries can have profound physical and psychological effects. Long-term care, including wound dressing selection, significantly impacts outcomes. This study compared treatment related variables and long-term results of bacterial nanocellulose (BNC) and polyurethane foam (PU-foam) dressings in pediatric burn care.

METHODS

A prospective cohort study comparing BNC (2018-2020) and PU-foam (2016-2018) in pediatric burn patients. Data included demographics, wound characteristics, infection rates, treatment duration, anesthesia procedures, dressing changes, scar assessments (POSAS, VSS), colorimeter measurements, and quality of life (CDLQI). Regression analyses were performed to correct for differences in burn depth.

RESULTS

After correction for burn depth, BNC showed a shorter hospital stay duration (p = 0.007), a lower number of procedures under general anesthesia (p<0.0001) and a reduced number of inpatient dressing changes (p = 0.006), compared to PU-foam, whereas wound infection rates did not differ between the treatment groups (p = 0.169). Scar outcomes (POSAS, VSS, colorimeter measurements) and quality of life (CDLQI) were comparable for both treatments.

DISCUSSION

BNC dressing benefits include significantly fewer anesthesia procedures, a reduced number of inpatient dressing changes and a shorter hospital stays, supporting the use of BNC dressing. Long-term scar outcomes with BNC are comparable to established dressings like PU-foam. Further randomized trials are necessary to confirm these findings.

The Potential of Chat-Based Artificial Intelligence Models in Differentiating Between Keloid and Hypertrophic Scars: A Pilot Study

BACKGROUND

Lasting scars such as keloids and hypertrophic scars adversely affect a patient's quality of life. However, these scars are frequently underdiagnosed because of the complexity of the current diagnostic criteria and classification systems. This study aimed to explore the application of Large Language Models (LLMs) such as ChatGPT in diagnosing scar conditions and to propose a more accessible and straightforward diagnostic approach.

METHODS

In this study, five artificial intelligence (AI) chatbots, including ChatGPT-4 (GPT-4), Bing Chat (Precise, Balanced, and Creative modes), and Bard, were evaluated for their ability to interpret clinical scar images using a standardized set of prompts. Thirty mock images of various scar types were analyzed, and each chatbot was queried five times to assess the diagnostic accuracy.

RESULTS

GPT-4 had a significantly higher accuracy rate in diagnosing scars than Bing Chat. The overall accuracy rates of GPT-4 and Bing Chat were 36.0% and 22.0%, respectively (P = 0.027), with GPT-4 showing better performance in terms of specificity for keloids (0.6 vs. 0.006) and hypertrophic scars (0.72 vs. 0.0) than Bing Chat.

CONCLUSIONS

Although currently available LLMs show potential for use in scar diagnostics, the current technology is still under development and is not yet sufficient for clinical application standards, highlighting the need for further advancements in AI for more accurate medical diagnostics.

LEVEL OF EVIDENCE IV

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

Full-thickness burn scar treatment using a combination of microneedling and platelet-rich plasma in animal model

Microneedling (MA) and platelet-rich plasma (PRP) therapies have shown potential for enhancing scar repair through collagen production and growth factor release, yet their effects on full-thickness burn scars remain underexplored. This study evaluated the impact of MA, PRP, and combined MA + PRP treatments on scar healing in a rat model of full-thickness burns. Fifty adult rats were divided into four groups: control, MA, PRP, and MA + PRP. Treatments were administered 21 days post-burn, and animals were evaluated at 14- and 21-days post-treatment. Macroscopic, histopathological, and morphometric analyses were performed to assess epithelialization, extracellular matrix (ECM) organization, and collagen deposition. The combination of MA + PRP demonstrated superior outcomes, showing enhanced ECM organization, significant collagen deposition, increased angiogenesis, and an improved inflammatory profile with mononuclear cell infiltration. Morphometric analysis confirmed a substantial increase in collagen content, particularly in the MA + PRP group, supporting improved tissue remodeling and scar maturation. These findings suggest that combined MA + PRP therapy may be a promising approach for promoting effective and accelerated burn scar healing. Further research is warranted to optimize protocols for clinical application.

Long-Term Assessment of Aesthetic Results in Omphalocele Repair with POSAS Scale

INTRODUCTION

Omphalocele (OM) is a congenital defect of the abdominal wall. The main goal of the surgical management is the survival of the neonate. However, the residual scar following the surgery can be extremely burdensome and negatively impact the quality of life (QoL) of these patients. The aim of this study is to assess the cosmetic results of the surgical treatment, the level of satisfaction of patients and surgeons, and the influence of the scar on the QoL of the patient.

MATERIALS AND METHODS

We conducted an observational retrospective cross-sectional study collecting all data regarding patients born with OM, operated at our Centre between 1998 and 2021. The cosmetic results of the surgical repair were evaluated using the validated Patient and Observer Scar Assessment Scale (POSAS). The assessment of the quality of life determined by the presence of the scar was conducted using PedQL 4.0. At last, the patients were visited by two paediatric surgeons and a medical student, which then scored the cosmetic result of the scar. Statistical analysis was conducted with Spearman linear correlation and Mann-Whitney test. A P-value below 0.05 was considered statistically significant.

RESULTS

In our study, we included a total of 19 patients, with a mean of 12 years of age at the time of the evaluation. The parameters with the major influence on the patient's general opinion of the scar were stiffness, thickness, and irregularity. We discovered significant differences in median values of all scores between the giant OM group and the nongiant OM group, in favour of the latter. Finally, we found a low grade of concordance between PedsQL filled by parents and patients.

CONCLUSION

The POSAS scale is a valid, feasible, and reliable tool for the assessment of the aesthetic outcome of surgical procedures. The original size of the defect is the most important factor acting on the result. However, it is crucial that any decision on plastic surgery to improve the looks of the scar must be postponed to the adult age of the patient.

LEVEL OF EVIDENCE IV

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

Fractional CO2 Laser for Burn Scars: A Comparison of Patient-Reported Outcomes Between Those With and Without Laser Treatment

Burn reconstruction outcomes are an area of growing investigation. Although there is evidence of measured physical improvements in scar characteristics after laser treatment, there is little information on patient-reported outcomes. The purpose of this study is to compare patient-reported outcomes between burn survivors with and without laser treatment. The study included participants in the Burn Model System National Database at a single center; participants that received outpatient laser treatment for burn scars were compared to a matched group of burn survivors that did not receive laser. The following outcomes were examined: Satisfaction With Life Scale, Mental and Physical Component Summary of the Veterans Rand Survey, and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity Scale. Regression analyses examined the associations between laser treatment and each outcome at 12 and 24 months. The study population included 287 adult burn survivors (65 laser group and 222 control group). The significant differences found between the 2 groups included: burn size (laser: 14.9, 13.5 SD, control: 8.9, 11.1 SD; P < .001), insurance type (P = .036), inhalation injury (laser: 17.2%, control: 2.7%; P < .001), and ventilator requirement (laser: 27.7%, control: 13.5%; P = .013). Laser treatment was not associated with any of the outcomes at both follow-up time points. Further research is needed to develop patient-reported outcome measures that are more sensitive to the clinical changes experienced by burn survivors receiving laser treatment.

Assessing Scar Outcomes Using Objective Scar Measurement Tools: An Adjunct to Validated Scar Evaluation Scales

BACKGROUND

The assessment of scar outcomes is important to both patient care and research focused on understanding the results of medical and surgical interventions. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) are validated and simple instruments to assess scars. However, these subjective scales have shortcomings. The VSS fails to capture patient perception and has indeterminate validity and reliability. The POSAS captures patient perception, but the observer scale has been shown to have moderate amounts of interrater variability. Studies highlighting the ability of objective scar assessment tools to produce reliable and reproducible results are needed. In this study, the authors aimed to validate the use of the FibroMeter, ElastiMeter, and SkinColorCatch as objective adjuncts in the assessment of hypertrophic scar and keloid outcomes.

METHODS

In this prospective single-center study, scars were assessed using the VSS, the POSAS, and the objective study tools (FibroMeter, ElastiMeter, and SkinColorCatch). Correlations between the different methods of scar assessment were measured.

RESULTS

The FibroMeter and SkinColorCatch showed significant correlations with the VSS total and the observer POSAS total. The ElastiMeter showed significant correlations with both the patient and observer POSAS totals. Unexpected correlations between ElastiMeter measurements and the vascularity or pigmentation of scars indicate that scoring of these categories may be influenced by how severe the scar looks to the observer subjectively, underscoring the need for reliable objective scar assessment tools.

CONCLUSION

The results highlight the ability of the FibroMeter, ElastiMeter, and SkinColorCatch to assess scars, and demonstrate their potential in serving as important adjuncts to previously validated scar assessment scales.

Botulinum Toxin to Improve Scar Quality in Cleft Lip Repair: A Systematic Review

OBJECTIVE

Cleft lip repair (CLR) can be complicated by hypertrophic scar or keloid. Botulinum toxin type A (BTA) may improve postoperative scarring by reducing muscle tension and cytokine activity at the scar site. This systematic review analyzes the available evidence regarding the effect of BTA on scar quality after CLR.

DESIGN

The search was conducted in 6 different databases in accordance with PRISMA guidelines (PubMed, Scielo, Embase, Scopus, Web of Science, and Cochrane) using "botulinum toxin" and "cleft lip" as keywords.

SETTING

Academic hospital.

PATIENTS

Exclusive to patients who underwent CLR and BTA injection.

OUTCOME MEASURES

Mean visual analog scores (VAS), mean Vancouver scar scale (VSS), scar width, and BTA or CLR-related complications.

RESULTS

Five studies for a total of 216 patients met inclusion criteria. Four studies reported on primary CLR during infancy while 1 study recruited older patients seeking revision. All patients had BTA (range: 1-2 units/kg) injected in the orbicularis oris muscle. One study documented BTA injections in additional perioral muscles. All 4 studies that measured scar width and had a saline control arm found a significant decrease in width with BTA injection. Improvement of VAS and VSS with BTA was reported in 3 of 5 studies and 2 of 5 studies, respectively. There were no reports of complications associated with BTA or CLR.

CONCLUSION

The existing studies support the use of BTA injection to improve scar quality following CLR with low concern for complication. Further investigations with a greater number of patients are necessary.

A Case Report of the First CEA Transplant in an HIV-Positive Burn Patient in South Africa Using a Novel Composite Culture Technique

Resource-limited burn centers are usually devoid of cultured epithelial autografts (CEA) owing largely to prohibitive costs. A modified CEA technique at our burn center incorporated cost-effective, routinely-used dressings with favorable outcomes. One unknown concern was the immunosuppressive effect that extensive burns and potentially human immunodeficiency virus (HIV) infection may have on graft take. This case study reports on the graft take outcomes of the first CEA transplanted in an HIV-positive patient with extensive burns in South Africa, using this technique. Graft take was determined after 21 days at 80% and a long-term follow-up of 8 years indicated good pigmentation return and skin pliability. Delayed diagnosis of pyoderma gangrenosum caused partial graft loss; however, successful regrafting occurred after pyoderma gangrenosum treatment and eradication. The case was considered clinically successful. HIV may not directly affect graft take, but may result in immunosuppressive conditions that delay graft take success.

Genetic influence on scar vascularity after burn injury in individuals of European ancestry: A prospective cohort study

After burn injury there is considerable variation in scar outcome, partially due to genetic factors. Scar vascularity is one characteristic that varies between individuals, and this study aimed to identify genetic variants contributing to different scar vascularity outcomes. An exome-wide array association study and gene pathway analysis was performed on a prospective cohort of 665 patients of European ancestry treated for burn injury, using their scar vascularity (SV) sub-score, part of the modified Vancouver Scar Scale (mVSS), as an outcome measure. DNA was genotyped using the Infinium HumanCoreExome-24 BeadChip, imputed to the Haplotype Reference Consortium panel. Associations between genetic variants (single nucleotide polymorphisms) and SV were estimated using an additive genetic model adjusting for sex, age, % total body surface area and number of surgical procedures, utilising linear and multinomial logistic regression. No individual genetic variants achieved the cut-off threshold for significance. Gene sets were also analysed using the Functional Mapping and Annotation (FUMA) platform, in which biological processes indirectly related to angiogenesis were significantly represented. This study suggests that SNPs in genes associated with angiogenesis may influence SV, but further studies with larger datasets are essential to validate these findings.

Utility of customized 3D compression mask with pressure sensors on facial burn scars: A single-blinded, randomized controlled trial

PURPOSE

A pressure of approximately 15-25 mmHg is used for effective compression therapy to prevent and treat hypertrophic scar formation in patients with burns. However, conventional facial compression garments present challenges owing to inadequate pressure distribution in curved areas such as the cheeks, around the mouth, and the slope of the nose. This study aimed to evaluate the utility of a custom-made 3D compression mask equipped with pressure sensors to treat facial burn scars.

METHODS

This single-blinded, prospective randomized controlled trial was conducted between May and October 2023, involving 48 burn scars in 12 inpatients with facial burns. We created the custom-made 3D compression mask equipped with pressure sensors, inner lined with biocompatible silicon, and a harness system using 3D printing technology, which can continuously monitor whether an appropriate pressure of 15-25 mmHg maintains. The biological scar properties, Vancouver Scar Scale (VSS), and Patient and Observer Scar Assessment Scale (POSAS) scores in patients with facial burns were assessed before applying the compression mask and garment and at 4 and 12 weeks after application.

RESULTS

Pre-application assessment of biological scar properties, VSS, and POSAS revealed no statistically significant differences between the 3D mask and control groups (p > 0.05 for all). Throughout the 12-week application, skin hydration and scar thickness significantly increased (p < 0.001) and reduced (p = 0.010), respectively, in the 3D mask group compared to the control group. Additionally, significant improvements in scar pliability (p = 0.004) and height (p = 0.009) of VSS, itching (p = 0.047), scar stiffness (p = 0.001), thickness (p = 0.011), and irregularity (p < 0.001) of POSAS-patient component, and scar thickness (p = 0.001), pliability (p = 0.012), and surface area (p = 0.027) of the POSAS-observer component were observed in 3D mask group throughout the 12-week application compared to the control group.

CONCLUSION

The customized 3D compression mask equipped with pressure sensors significantly improved scar thickness, skin hydration, and various assessment scale parameters throughout the 12-week application.

A comparative prospective study between the outcomes of one-stage Pelnac reconstruction and full thickness skin graft on donor site healing in the radial forearm and fibula flaps

OBJECTIVES

Dermal substitutes are classically used in a 2-stage procedure followed by skin graft for wound healing. This study aims to evaluate the possibility to use an alternative technique for radial forearm and fibula donor sites coverage using one-stage Pelnac reconstruction.

MATERIALS AND METHODS

21 patients who underwent radial forearm and fibula flaps harvest for reconstruction of head and neck defects after oncological surgery were enroled in the study. 13 patients were treated by one-stage Pelnac reconstruction of the donor site defect, 8 patients underwent full thickness skin graft. The Vancouver Scar Scale was used to evaluate the scar quality.

RESULTS

Most patients treated with one-stage Pelnac reconstruction showed good healing of the flap donor site, with minor complications, scar quality comparable to other treatment options and unimpaired function of the implicated limb. One patient had wound dehiscence at the radial forearm site, which was treated with secondary full thickness skin graft. In the group treated with FTSG we had three patients that developed complications, such as dehiscence of the graft and seroma. Overall, we reported comparable satisfaction with donor sites both for aesthetic and functional outcomes, in both groups of patients.

CONCLUSION

The use of Pelnac without a following skin graft provides a viable method for the reconstruction of radial forearm and fibula flaps donor site. A longer postoperative care is needed, but the long-term aesthetic and functional results are satisfactory in comparison with full thickness skin graft.

Combination of Cultured Epidermal Autograft and Meshed Skin Graft Enables Full-thickness Excision of Giant Congenital Nevus

Giant congenital melanocytic nevus (GCMN) is a skin condition characterized by an abnormally dark, noncancerous skin patch. Two main issues with GCMN are aesthetics and malignant transformation. Various methods of treatment are reported, but each method has its own disadvantages, such as risk of recurrence or restriction in the treatable area. We report three cases of GCMN treated with full-thickness excision and immediately covered with cultured epidermal autograft (CEA) combined with split-thickness skin graft (STSG). This is a single-center, single-arm, retrospective report of three cases. The nevus was excised at full skin thickness. Meshed STSG taken from scalp was grafted to the defect, and CEA was grafted over simultaneously. Two weeks later, CEA was applied again as a booster. The same procedures were performed until all nevi were excised. In all cases, nearly complete epithelialization was achieved at several weeks after operation. The reconstructed skin was elastic, and there was no persistent joint contracture. Vancouver Scar Scale score was 4-8. Mesh-like appearance was observed. A hypertrophic scar appeared in the area without meshed STSG. An intractable keloid was observed in one patient. No recurrence of the nevus was observed during the follow-up period. The donor site scar on the scalp was well hidden by the hair. Our method enables full-thickness resection and reconstruction of a wider area in a single operation while improving the take rate of CEA, with reasonable degree of scarring compared with conventional methods.

Addressing Burn Hypertrophic Scar Symptoms Earlier: Laser Scar Revision May Begin as Early as 3-6 Months After Injury

OBJECTIVES

Fractional ablative CO2 laser (FLSR) is used to treat hypertrophic scars (HTSs) resulting from burn injuries, which are characterized by factors, such as erythema, contracture, thickness, and symptoms of pain and itch. Traditionally, waiting a year after injury for scar maturation before starting laser treatment has been recommended; however, the potential benefits of earlier intervention have gained popularity. Still, the optimal timing for beginning laser intervention in patients with HTSs remains uncertain. This study aims to evaluate the ideal timing for the initiation of FLSR for HTSs using several qualitative and quantitative assessment measures. It was hypothesized that early intervention would lead to similar improvement trends as later intervention, however, would be more ideal due to the shortened time without symptom relief for patients.

METHODS

Patients who received three or more laser treatment sessions and completed both pre- and posttreatment evaluations were included in this analysis (n = 69). FLSR treatment was administered at 4-8-week intervals. Patients starting treatment before 6 months after injury were classified as the early-stage intervention group and those beginning treatment at 6-12 months after injury were classified as the late-stage intervention group. Demographic data, including the age of patients at the time of first treatment, age of scars at the time of first treatment, biological sex, ethnicity, Fitzpatrick skin type, and use of laser-assisted drug delivery, were collected by retrospective chart review. Patients were evaluated on six subjective scales and objectively for scar stiffness with durometry. For all scales, higher scores indicate worse scars. A two-way ANOVA, Student's t-test, and Mann-Whitney U-test were used to compare scores from the pre- to posttreatment evaluations.

RESULTS

There were no significant differences between the groups for any of the demographic or scar-specific variables; thus, differences in outcome can be attributed to the timing of intervention. Both groups demonstrated an improvement in scars with treatment over time (p < 0.05). Both early- and middle-stage initiation showed scar symptom improvement in five out of six scales. In the late-stage intervention, the Patient and Observer Scar Assessment Scale-Patient average score did not show improvement. In the early-stage intervention, the Vancouver Scar Scale total did not show improvement. Quantitative evaluation of scar stiffness by durometry did not show symptom improvement in either group. The Scar Comparison Scale demonstrated the greatest improvement across groups.

CONCLUSION

Laser treatment led to scar improvement in at least one scale at each stage of initiation. Both intervention timelines resulted in equivalent outcomes, and early intervention should be considered when initiating FLSR treatment in burn scars to alleviate symptoms earlier.

Long-Term Functional Outcomes Following Enzymatic Debridement of Deep Hand Burns Using Nexobrid®: A Retrospective Analysis

Background: For years, surgical debridement with autografting has been considered the standard of care in the treatment of severe burns of the hand. However, in recent years, enzymatic debridement has increasingly been reported as a good alternative, especially for burns of the hand, as it selectively preserves viable tissue. In this study, we aim to evaluate the long-term function of the hand after enzymatic debridement in deep dermal burns. Methods: A retrospective chart review was conducted as well as measurements of subjective and objective outcome measures through physical examination and Disabilities of the Arm, Shoulder, and Hand (DASH), Patient and Observer Scar Assessment Scale (POSAS), and Vancouver Scar Scale (VSS) scores. Results: A total of 32 enzymatically debrided hands of 24 patients were included with a mean age of 42.4 ± 16.8 years and a mean follow-up of 31 months. Postoperatively, 19 of these could be managed conservatively using skin substitutes such as "Suprathel", 13 had to undergo subsequent autografting. The mean DASH score for the entire study population was eight with a mean value of four in the conservatively managed group and fourteen in the autografted group. The mean Patient, Observer POSAS, and VSS values were nineteen, thirteen, and two. A total of 30 cases showed an effortless complete fist closure, and, also in 30 cases, patients attested to be satisfied with the esthetic appearance of the hand on being asked. Conclusions: The descriptive analysis of these results in our study population suggests that the enzymatic debridement of deep burns of the hand, especially combined with subsequent conservative management with skin substitutes, was associated with low long-term hand disability scores at a follow-up of two years.

Comparison of combination skin substitutes and skin grafts versus skin grafts only for treating wounds measured by Vancouver Scar Scale: A comprehensive meta-analysis

Background

Skin is the largest organ in the body and has multiple significant functions. A malformation or injury that compromises its integrity can lead to major issues or even mortality. Wound healing is a vital physiological process of the human skin which facilitates the repair of any damage and the preservation of homeostasis. Possible complications or infections that are fatal may ensue if the patient does not recover within the specified time. Therefore, it is essential to develop biomaterials which facilitate tissue regeneration and exhibit robust biological properties. We conducted a meta-analysis of randomized controlled trials to compare combinations of skin replacements and skin grafts to skin grafts alone for wound treatment, as measured by the Vancouver Scar Scale.

Methods

This meta-analysis utilized various databases, including as PubMed, ProQuest, Web of Science, Science Direct, Scopus, EBSCOhost, and ClinicalTrials.gov, to conduct a comprehensive search for randomized controlled trials that compared the effectiveness of combined skin substitutes and skin grafts to skin grafts alone in the treatment of wounds. The results primarily consisted of scar features assessed using the Vancouver Scar Scale.

Results

Meta-analysis was conducted on a sample of 216 participants from 7 randomized controlled trials. The trials were conducted from 2002 to 2015. The study demonstrated that the use of skin substitutes resulted in a statistically significant improvement in Vancouver Scar Scales ratings compared to skin grafts alone. The mean change was 1.38 (95% CI: 0.13-2.63; p = 0.03).

Conclusion

This meta-analysis indicates that the use of skin replacements provides substantial advantages and effectively aids in the closure of wounds. There is no inherent superiority among different skin substitutes. Instead, their suitability for specific patient wound circumstances is the determining factor. A comprehensive and advantageous skin substitute of significant magnitude is needed, rather than relying solely on grafts.

Keloid and Hypertrophic Scars Treatment

BACKGROUND

Hypertrophic scars are contained within the site of injury and may regress over time, while keloids spread beyond the borders of the initial injury and do not regress. On histologic examination, hypertrophic scars tend to have collagen in a wavy, regular pattern, whereas keloids have no distinct pattern of collagen.

OBJECTIVE

To retrospectively analyze improvement in keloid and hypertrophic scars characteristics following treatment with Ablative 10600 nm and a non-Ablative 1570 nm Hybrid Laser Device.

METHODS

Treatment parameters with the ProScan Hybrid Mode were 40 W/1.3-1.5 ms for the CO2 and 12 W/4 ms for the 1570 nm in a 1:1 ratio. Outcomes were assessed based on physician scar grading as measured by the Vancouver Scar Scale and patient-reported satisfaction. Excel was used for data analysis, and a p value < 0.05 was considered statistically significant. Adverse events and patient pain were also recorded.

RESULTS

A total of 31 hypertrophic scars and 30 keloid scars were treated. There was a significant reduction in Vancouver Scar Scale scores for both hypertrophic and keloid scars (62% ± 8% and 58% ± 7%; p = 2.6E-17 and p = 8.29E-26, respectively). In a scar-based comparison, a statistically significant difference was observed for all measures reflecting favorable outcomes for hypertrophic scars (VSS, p = 1.1E-05; satisfaction, p = 0.0112; pain, p = 0.00081). Only one adverse event was reported, a superficial burn treated with topical antibiotics.

CONCLUSIONS

The device was found to be safe and effective, with promising results for the treatment of hypertrophic and keloid scars.

LEVEL OF EVIDENCE II

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

Comparison of the wound healing and complications of zipper type closure adhesive tape and stapler for surgical wound suture: A randomized control, single-centre, open-label trial

Xkin closure is a newly developed medical suture device for lacerations and surgical wounds that can reduce scarring, pain and the risk of infection compared with conventional sutures or staplers. A randomized controlled study was performed to compare the wound healing effects and complications of Xkin closure with stapler closure. Fifty patients who underwent robot-assisted radical prostatectomy for prostate cancer were randomly assigned. Only the wound above the navel, which was extended to take out the prostate was targeted. The wound was examined at 2, 6 and 12 weeks after surgery, and the modified Vancouver Scar Scale (mVSS), scar height and side effects were assessed with a 3D skin analyser. Forty-six patients (23 Xkin, 23 Stapler) were analysed. The mVSS scores, vascularity and pliability were significantly lower in the Xkin group compared with the stapler group at the 12-week follow-up. No significant differences in the maximum peak and depth of the scars were detected between the two groups using 3D photographs at 12 weeks. Xkin is an effective wound closure method for improving scar outcomes. This method is expected to be widely used for surgical wounds and lacerations caused by trauma in daily life.

Preventive Effect of Hydrocolloid Dressings on Hypertrophic Scarring of Post-Cesarean Section Wounds: A Randomized Pilot Study

OBJECTIVE

To determine the prophylactic effect of hydrocolloid dressings on hypertrophic scarring in post-cesarean section wounds.

METHODS

Patients who underwent cesarean section (C/S) at the authors' hospital and provided informed consent to participate were randomly assigned to the intervention and control groups. The intervention group commenced applying hydrocolloid dressings to the wound on postoperative day 7 or 8 and continued with weekly dressing changes for 6 months. The control group refrained from any dressing application but was followed up. In each group, the condition of the wound was evaluated 6 and 12 months postoperatively using the Japan Scar Workshop Scar Scale 2015, the Patient and Observer Scar Assessment Scale version 2.0, the modified Vancouver Scar Scale, and patient-reported outcomes.

RESULTS

During this period, 135 patients underwent C/S at the authors' institution, and 47 (23 in the intervention group and 24 in the control group) were included in the analysis. In all assessment methods, the intervention group scored lower than the control group at 6 and 12 months after C/S. Twelve months after C/S, hypertrophic scarring (Japan Scar Workshop Scar Scale 2015 score of 6-15) was found in 14 of the 47 (29.8%) patients: 11 of 24 (45.8%) in the control group and 3 of 23 (13.0%) in the intervention group. The intervention's relative risk was 0.623 (95% CI, 0.417-0.930). The risk factor for hypertrophic scarring was midline vertical incision, with an odds ratio of 20.53 (95% CI, 4.18-100.92).

CONCLUSIONS

The study reveals that the application of hydrocolloid dressings to wounds reduces the risk of hypertrophic scarring after C/S.

Effect of a topical silicone gel and a polyurethane dressing on the evolution of scars

OBJECTIVE

To assess the effectiveness and safety of a topical silicone gel (BE + Gel reductor y reparador de cicatrices) and a polyurethane dressing (BE + Apósito reductor y reparador de cicatrices) on the evolution of scars of patients who were previously recruited in the emergency care unit while seeking wound care.

METHOD

A single center, stratified observational, open label study was performed in the emergency care unit of Donostia Universitary Hospital (recruitment) and in the Biodonostia Health Research Institute (intervention). Scars located in unexposed body areas with the dressing, and scars located in exposed areas with either the gel or the dressing. Investigators assessed interventions at day 1 and on weeks 4, 8 and 12. Vancouver Scar Scale (VSS) and a photographical assessment were used to determine the scars evolution, and the subjective perception of the scar was evaluated by means of a questionnaire administered to the patients.

RESULTS

Patients whose scars were treated with the silicone gel had an average initial VSS score of 5.4 ± 2.08. This value was reduced to 0.86 ± 1.17 after 90 days of treatment. Patients treated with the polyurethane dressing had an average initial VSS score of 5.8 ± 2.29. After 90 days of treatment, this average score was reduced to 0.33 ± 0.66. Positive evolution of scars was also supported by photographs and by a patient questionnaire.

CONCLUSIONS

Both treatments appear to be safe and effective, objectively, and subjectively, in the context of scar evolution.

A Prospective Study of Patients Presenting With Pre-sternal Keloids

INTRODUCTION

Keloid represents a pathological form of scarring. They are very common in the anterior chest area; nearly 50% of all keloids occur in this location. One of the reasons for this is that folliculitis and acne, known for triggering the development of keloids, are common on the anterior chest. The other reason is the tension load in this area due to the frequent movements of the upper limbs and the respiratory movements. These movements stretch the skin of the anterior chest horizontally. When this cyclical tension is imposed on the anterior chest wounds, there is an exacerbation and prolongation of the inflammation in the reticular dermis of the wound. These stresses induce the growth of keloids along the prevailing lines of skin tension.

MATERIALS AND METHODS

We performed a prospective study in which patients were recruited over a period of one year. Patients presenting with symptomatic pre-sternal keloids and requesting treatment but were unwilling to undergo surgical intervention were included in this study. Patients with a history of previous thoracic surgery were excluded. Baseline assessment and documentation of the lesion were performed. The study patients received three sessions of intralesional injections of a combination of triamcinolone acetonide and hyaluronidase at four weekly intervals. The final assessment was performed four weeks after the third session.

RESULTS

The study included 47 lesions in 47 patients with ages of the patients ranging from 16 to 70 years. Pre-sternal keloids were found to be more common among males than females, with a male-to-female ratio of 2.35:1. Patients presented with pre-sternal keloids that had been present for varying periods ranging from three to 81 months. All of our 47 patients completed the three sessions of the treatment. Following the treatment, there was an improvement in the patient's symptoms, as evidenced by the reduction in the mean pruritis scores and pain scores. There was an overall reduction in the size of the lesion. The decrease in the height of the lesions was more evident than the reduction in the craniocaudal or transverse dimensions of the lesions. There were improvements in Vancouver Scar Scale (VSS) vascularity scores and pliability scores following the treatment.

CONCLUSION

We conclude that pre-sternal keloids should be considered as a distinct clinico-pathological entity. There are differences with regard to pathogenesis, clinical presentation, and management when compared to keloids elsewhere. Treatment with intralesional injections of a combination of triamcinolone acetonide and hyaluronidase effectively relieves the symptoms and may be considered in patients not willing to undergo surgical intervention. Recurrences can occur and need further treatments.

Microneedling in the Treatment of Post-burn Hypertrophic Scars

INTRODUCTION

Post-burn hypertrophic scars are an important cause of physical discomfort, limitation of movements, psychological disorders, low self-esteem and reduced quality of life. Treatment for this condition is complex and involves several options. Microneedling, also known as minimally invasive percutaneous collagen induction, is an affordable minimally invasive option that can be combined with other treatments, including ablative ones.

OBJECTIVE

The goal of this study was to present our microneedling approach for the treatment of hypertrophic scars after burns.

METHOD

A prospective study of 15 patients with post-burn hypertrophic scars was conducted between October 2016 and June 2022. All patients were treated with microneedling and drug delivery of triamcinolone. Scars were evaluated using Vancouver Scar Scale (VSS), Burn Scar Assessment Scale (BSAS) and angle measurement for amplitude of movement evaluation of joints.

RESULTS

A significant improvement in the VSS score was obtained after microneedling (8.8 ± 0.44 to 4.1 ± 0.98; p = 0.012), especially in the acute group (less than 1 year after burns): 9.3 ± 0.49 to 3.5 ± 1.36; p = 0.041. There was a significant and progressive improvement of the scars throughout the treatment sessions in all criteria evaluated and in the ranges of joint movement (p = 0.012).

CONCLUSION

Our microneedling protocol promoted a significant improvement of post-burn scars, especially in acute hypertrophic scars, and in the amplitude of joint motion. Sequential treatments provided progressive improvement.

LEVEL OF EVIDENCE IV

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

Analysis of trends and status of evaluation methods in thyroid scar

Background

The incidence of thyroid cancer has increased over the decades, and patients prefer short thin scars after thyroidectomy due to their cosmetic visibility. Several scar assessment methods have been used to determine the most cosmetically optimal surgical method, but a widely accepted measurement tool is still lacking. This study investigates the usage status in the thyroid scar scale according to time, region, and study method.

Methods

The authors searched for articles on thyroid scars published between January 2000 and September 2022 in the PubMed database. The study included clinical studies that mentioned thyroid scar and scar scale, excluding articles that did not evaluate neck scars. Statistical analysis was performed using IBM SPSS Statistics 29.

Results

A total of 35 studies were included. Among them, 17 used the Vancouver Scar Scale (VSS), 17 used the Patient and Observer Scar Assessment Scale (POSAS), four used the Manchester Scar Scale (MSS), and four used the Stony Brook Scar Evaluation Scale (SBSES). VSS and POSAS were the most commonly used scar evaluation methods. VSS tended to be used frequently in Asia, while POSAS was used frequently in Europe and in randomized controlled trials.

Conclusion

VSS and POSAS are popular thyroid scar assessment methods, with regional variations. Standardization is needed for meaningful comparisons. Patient's subjective evaluations should be considered, given the cosmetic importance of thyroid scars.

Ultrasound measurement of traumatic scar and skin thickness: a scoping review of evidence across the translational pipeline of research-to-practice

OBJECTIVES

To identify the ultrasound methods used in the literature to measure traumatic scar thickness, and map gaps in the translation of these methods using evidence across the research-to-practice pipeline.

DESIGN

Scoping review.

DATA SOURCES

Electronic database searches of Ovid MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature and Web of Science. Grey literature searches were conducted in Google. Searches were conducted from inception (date last searched 27 May 2022).

DATA EXTRACTION

Records using brightness mode (B-mode) ultrasound to measure scar and skin thickness across the research-to-practice pipeline of evidence were included. Data were extracted from included records pertaining to: methods used; reliability and measurement error; clinical, health service, implementation and feasibility outcomes; factors influencing measurement methods; strengths and limitations; and use of measurement guidelines and/or frameworks.

RESULTS

Of the 9309 records identified, 118 were analysed (n=82 articles, n=36 abstracts) encompassing 5213 participants. Reporting of methods used was poor. B-mode, including high-frequency (ie, >20 MHz) ultrasound was the most common type of ultrasound used (n=72 records; 61% of records), and measurement of the combined epidermal and dermal thickness (n=28; 24%) was more commonly measured than the epidermis or dermis alone (n=7, 6%). Reliability of ultrasound measurement was poorly reported (n=14; 12%). The scar characteristics most commonly reported to be measured were epidermal oedema, dermal fibrosis and hair follicle density. Most records analysed (n=115; 97%) pertained to the early stages of the research-to-practice pipeline, as part of research initiatives.

CONCLUSIONS

The lack of evaluation of measurement initiatives in routine clinical practice was identified as an evidence gap. Diverse methods used in the literature identified the need for greater standardisation of ultrasound thickness measurements. Findings have been used to develop nine methodological considerations for practitioners to guide methods and reporting.

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.

Prediction of Intraperitoneal Adhesions in Repeated Cesarean Deliveries with Stria Gravidarum Scoring System: A Cross-sectional Study

BACKGROUND

The preoperative prediction of intraperitoneal adhesion (IPA) before repeated cesarean deliveries (CD), which are becoming more prevalent, is crucial for maternal health.

AIM

The aim of the study was to preoperatively predict IPA in repeated CD with the stria gravidarum (SG) scoring system.

METHODS

A total of 167 patients with at least one previous CD at or beyond 37 weeks of gestation were analyzed. Preoperative SG was calculated according to the Davey scoring system: 0-2 score were defined as mild SG (Group 1; n: 94, 56.2%), and 3-8 score were defined as severe SG (Group 2; n = 73, 43.8%). Preoperative previous cesarean incision features were evaluated according to the Vancouver scar scale. IPA was evaluated according to the Nair's and modified Nair's scoring systems.

RESULTS

Parity, younger age at first pregnancy, higher body mass index, number of previous CDs, rate of scar symptoms, Nair's and the modified Nair's scores were statistically significant in Group 2 (P = 0.01; P = 0.04; P = 0.007; P = 0.004; P < 0.001; P = 0.007; P = 0.02, respectively). Davey score ≥3 and Vancouver score ≥4.5 were determined as the cut-off value to predict IPA (P = 0.1 and 0.07, respectively). According to multivariate analysis, both Davey and Vancouver scores are independent factors in predicting IPA (P = 0.02 and 0.04, respectively).

CONCLUSION

Evaluating the SG score through the Davey score in women with a history of previous CD may assist in predicting IPA status before the planning of a subsequent surgery.

Accuracy of remote burn scar evaluation via live video-conferencing technology

OBJECTIVE

Telemedicine in outpatient burn care, particularly in burn scar management, may provide cost-effective care and comes highly rated by patients. However, an effective scar scale using both video and photographic elements has not been validated. The purpose of this study is to test the reliability of the Patient and Observer Scar Assessment Scale (POSAS) using live video-conferencing.

METHODS

A prospective study was conducted with individuals with healed burn scars in Kathmandu, Nepal. Three independent observers assessed 85 burn scars from 17 subjects, using the Observer portion to evaluate vascularity, pigmentation, thickness, relief, pliability, surface area, and overall opinion. The on-site observer was physically present with the subjects and used a live videoconferencing application to show the scars to two remote observers in the United States. Subjects used the Patient portion to evaluate the scar that they believed appeared the worst appearance and had the greatest impact on function.

RESULTS

The single-rater reliability of the Observer scale was acceptable (ICC>0.70) in overall opinion, thickness, pliability, and surface area. The average-rater reliability for three observers was acceptable (ICC>0.70) for all parameters except for vascularity. When comparing Patients' and Observers' overall opinion scores, patients consistently reported worse opinion.

CONCLUSIONS

Evaluation of burn scars using the Patient and Observer Scar Assessment Scale can be accurately performed via live videoconferencing and presents an opportunity to expand access to burn care to rural communities, particularly in low- and middle-income countries, where patients face significant access barriers to appropriate follow-up care.

Surgical approach to a rare case of Beckwith Wiedemann syndrome with left thigh hyperplasia

Thigh lift surgery is generally performed in patients with severe weight loss outcomes, particularly those undergoing bariatric surgery. However, there are other congenital malformation conditions that may require the same treatment, such as Beckwith Wideman syndrome.

Scar massage as an intervention for post-surgical scars: A practice survey of Australian hand therapists

Introduction

Scar massage is a commonly used treatment in hand therapy. The current empirical evidence that supports it is disparate and of variable quality, with no established effective dosage and method proposed. This study aimed to identify the current practice among Australian hand therapists using massage as an intervention for scarring following surgery to the hand and upper limb.

Methods

A purposely designed self-report online survey was emailed to current members of the Australian Hand Therapy Association (n = 958). Data collected included demographics, intervention techniques, conditions treated and protocols, scar assessment and knowledge and training about scar massage as a clinical intervention.

Results

A total of 116 completed questionnaires were received (a response rate of 12.1%). All respondents used scar massage as part of their clinical practice with 98% to improve soft tissue glide (n = 114), 92% for hypersensitivity (n = 107), and 84% to increase hand function (n = 97). Only 18% (n = 21) of respondents used standardised outcome measures, and most therapists had learned scar massage from a colleague (81%).

Conclusions

Commonalities in how respondents implemented scar massage were found. Participants reported relying primarily on clinical experience to inform their practice. Whilst scar massage was widely used, few respondents had received formal skills training or completed outcome measures regularly to formally evaluate its clinical efficacy or impact. Replication of this study with a larger international sample of participants is warranted to determine if these findings reflect general practice.

Comparison treatment of medium-sized volar fingertips defects with modified triangular neurovascular unilateral advancement flap versus digital artery dorsal perforator flap

PURPOSE

The reconstruction of medium-sized soft tissue defects of the fingertip remains a challenge for hand surgeons. The aim of this study was to compare the outcomes of modified triangular neurovascular unilateral advancement flap and digital artery dorsal perforator flap in the treatment of this injury.

METHODS

From May 2018 to May 2022, 70 patients with medium-sized volar soft tissue defects were enrolled. The patients were divided into two groups based on the flap type: modified triangular neurovascular unilateral advancement flap (Group A) and digital artery dorsal perforator flap (Group B). The debridement times, defect size, operation time, and flap survival rate were recorded. At follow-up, hand function, aesthetics, and complications were evaluated. Function was evaluated using the TAM score. The aesthetics of the reconstructed and donor sites were assessed using the vancouver scar scale (VSS). The static two-point discrimination of the finger pulp served as a measure of tactile agnosia.

RESULTS

A total of 10 patients were lost to follow-up for various reasons, resulting in 30 cases remaining in each group. The general information of the two groups showed no significant differences in age, sex, injury side, cause of injury, time from injury to surgery, and operation time (P > 0.05). Additionally, the debridement times and size of the defect were similar between the groups (P > 0.05). However, the operation time was significantly shorter in Group A compared to Group B (P = 0.001). With regard to complications, there was no significant difference between them. At one-month follow-up, TAM scores indicated that Group B performed significantly better than Group A. However, at the final follow-up period, there was no significant difference in TAM scores between the two groups. When considering the VSS, significant differences were observed between the two groups in both the reconstructed site and donor site.

CONCLUSION

Both flaps can effectively repair medium-sized fingertip defects. Furthermore, the modified triangular neurovascular unilateral advancement flap offers anatomical reconstruction possibilities, ensuring satisfactory sensation and cosmetic contour.

Re-recognition of the role of roughness in keloid assessment

BACKGROUND

Under visual observation, keloids are more rough than normal skin. This roughness may be used to assess the activity and severity of keloids but lacks the support of objective and accurate evidence. The purpose of this study was to verify the role of roughness in the development of keloids and to clarify the advantage of roughness in the comprehensive assessment of keloids.

METHODS

Patients with keloids who attended Peking Union Medical College Hospital were recruited. Keloids were classified into progressive, stable, and atrophic stages based on the change in size over the past year and blood perfusion. The keloids were evaluated using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). The roughnesses of the keloid and normal skin were measured using the Phaseshift Rapid In vivo Measurement Of the Skin (PRIMOS), and blood perfusion was measured using laser speckle contrast imaging (LSCI).

RESULTS

Thirty-three patients with a total of 81 keloids were included. The surface roughness values Sa, Sq, and Sz of the keloid region were 243.70 (143.85-328.05), 316.20 (179.85-475.20), and 1708.20 (1098.30-4087.20), respectively, which were 4.87, 4.80, and 3.08 times higher than those of normal skin. There were significant differences in roughness among the different keloid stages. A significantly strong correlation between roughness and other assessed indices was found.

CONCLUSIONS

Roughness as a morphological characteristic is of great value in the evaluation of keloids. It is recommended as an important examination for keloids.

Case report of the first Caucasian burn patient transplanted with Cutimed Sorbact®-based cultured epithelial autografts technique at Tygerberg Hospital, Cape Town, South Africa: An 8-year follow-up

Cultured epithelial autograft applications are limited by the associated cost and time constraints in resource-limited settings. A modified composite technique using the patients' own tissue and Cutimed Sorbact dressing was employed as a life-saving emergency measure. Since the non-Caucasian population was more commonly treated at the center, it was important to report the first Caucasian patient outcome, as the graft-take outcome for all populations was unknown. A 54-year-old male with extensive flame burns and a low chance of survival was admitted to the Tygerberg Burn Center. He received traditional skin grafts and cultured epithelial cells, after the 2 week-culture period using the current technique. Short- (⩽2 weeks) and long-term graft take (⩽8 years) was inspected. Good graft take and complete epithelialization was observed during short-term inspection with partially healed areas initially attributed to extensive burn depth and dressing removal. Long-term follow-up indicated a near normal tissue appearance and excellent pliability.

Working Towards Holistic Scar Assessment and Improved Shared Decision Making in Global Burn Care

Cutaneous burn scars impact various aspects of life. Scar treatment is mainly evaluated on scar characteristics. Consensus is needed on which other outcomes to capture, ensuring they are relevant to patients, clinicians, and researchers. The aim of this study was to identify, discuss and analyze outcomes related to cutaneous burn scarring, incorporating the voice of patients and views of healthcare professionals. For this, a Delphi process consisting of two survey rounds and a consensus meeting was initiated. Burn scar-related outcomes were identified from an existing comprehensive list of 100 outcomes by an international panel of patients, healthcare professionals and researchers. Fifty-nine outcomes were identified from the Delphi process as related to scarring (≥60% votes). Outcomes less impactful in relation to scar outcomes included psychosocial issues, sense of normality, understanding of treatment, costs and systemic issues. To represent a holistic assessment of outcomes related to cutaneous burn scarring, this Delphi process established a battery of outcomes currently included in scar quality assessment tools, and an expanded set of less frequently considered outcomes. Future work in this area must include the patient voice from developing countries. This is essential to identify globally applicable outcomes related to scarring.

Polish Translation and Linguistic Validation of the SCAR-Q

Introduction Patient-reported outcome measurements (PROMs) are gaining considerable popularity as tools to assess the effectiveness of the treatment in plastic surgery, being a complement to surgical outcomes. The SCAR-Q questionnaire has been recently developed for patients with surgical, traumatic, and burn scars. Aim The study aims to describe the process of translation and linguistic validation of the scar questionnaire (SCAR-Q) for use in Polish patients undergoing scar treatment. Material and methods An official Polish translation and language validation of the SCAR-Q were done in adherence to International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines. The process consisted of four steps: two independent forward translations, a back translation, a review of the back translation, and cognitive participant interviews. Results The field-tested version of the SCAR-Q consisted of 29 items across three scales measuring appearance concerns, symptoms, and the psychosocial impact of the scar. The forward translation was done by two independent translators and revealed specific difficulties in translation to the Polish language (4/29 items). The back translation showed no significant differences compared to the original English version. Cognitive debriefing interviews involved nine Polish patients with postraumatic scars, burn scars, and scars after skin tumor resection. Participants have not reported any major difficulties in understanding the content of the questionnaire. Conclusions The ISPOR provides a straightforward and thorough guideline for the PROMs translation process. The new SCAR-Q is an accessible and efficient PROM that can be implemented in Polish patients to assess the effectiveness of scar treatment.

68 Ga-FAPI-04 PET/CT in Assessment of Fibroblast Activation in Keloids : A Prospective Pilot Study

PURPOSE

Keloids are benign fibroproliferative disorders characterized by the massive proliferation of fibroblasts. Fibroblast activation plays a key role in the invasive growth of keloids. Therefore, a prospective pilot study was conducted to explore the value of 68 Ga-FAPI-04 PET/CT in the assessment of keloids activity.

PATIENTS AND METHODS

Twenty-five patients with keloid were enrolled to conduct 68 Ga-FAPI-04 PET/CT. All patients accepted surgery to remove part of the lesions within 1 week. SUV mean and SUV max were measured for semiquantitative analysis and compared with the Vancouver Scar Scale, Laser Speckle Contrast Imaging, pathology, and immunohistochemical stains.

RESULTS

A total of 123 lesions were detected in 25 patients, most of which were distributed in the anterior chest wall. The 68 Ga-FAPI-04 uptake was significantly different at different sites ( P < 0.0001). There was uptake heterogeneity within the keloid lesions, and a significant difference was found between the edge and center of some large lesions. The SUV max of 68 Ga-FAPI-04 showed significantly correlation with the Vancouver Scar Scale ( r = 0.565, P < 0.0001) moderately and the Laser Speckle Contrast Imaging parameters mildly. The SUV max of 68 Ga-FAPI-04 had a moderate correlation with FAPI expression ( r = 0.520, P = 0.022). Moreover, collagen, fibroblast activator protein, and Ki-67 expression were found higher at the edges of keloid tissue than in the center.

CONCLUSIONS

68 Ga-FAPI-04 PET/CT can reflect the distribution characteristics of activated fibroblasts in keloid tissue and may provide a novel method for keloid evaluation for further fibroblast-related therapies.

Microneedle Electroporation for Intralesional Administration of Corticosteroid Treatment of Keloid Scar

Abstract is missing (Short communication)

Micro-plasma radiofrequency and silicone gel dressings for treating early post-traumatic facial scars: A retrospective study

BACKGROUND

Although different options are available for treating post-traumatic facial scars, they remain a therapeutic challenge.

AIM

To evaluate the safety and effectiveness of combined therapy using micro-plasma radiofrequency (MPRF) technology and silicone gel (SG) dressings for treating post-traumatic facial scars.

METHODS

This retrospective study was conducted at a single center. Patients with facial injuries in the outpatient and emergency units of the Department of Plastic Surgery at our hospital underwent debridement and cosmetic sutures performed by the same surgeon from October 2020 to October 2021. In the first arm, patients with facial injuries were treated with MPRF technology and SG, and in the second arm, they were treated with SG dressings alone. We observed the safety and effectiveness of these treatments in both arms.

RESULTS

A total of 32 patients with facial injuries were treated with MPRF technology and SG dressings (combined treatment group), and 28 patients were treated with SG dressings alone (SG group). After 6 months of treatment, the Vancouver Scar Scale scores of the combined treatment and SG groups were 1.38 ± 0.71 and 4.39 ± 0.50, respectively, and the difference was statistically significant (P < 0.01). After 6 months of treatment, the effectiveness rate in the combined treatment group was 93.8%, which was significantly higher than that in the SG group (67.9%), and the difference between the two groups was statistically significant (P < 0.05). No obvious adverse reactions occurred in the two arms.

CONCLUSION

Treating early post-traumatic facial scars with combined MPRF technology and SG is significantly better than treating them with SG alone; moreover, the combined therapy is safe and effective.