A Clinimetric Overview of Scar Assessment Scales:

Suction-Based Optical Coherence Elastography for the Biomechanical Characterization of Pathological Skin Conditions: A Pilot Study

Accurate characterization of mechanical properties is crucial in the evaluation of therapeutic effects for problematic skin conditions. A pilot study was carried out using a novel optical coherence elastography (OCE) device, combining mechanical characterization through suction-based deformation and imaging through optical coherence tomography. Using AI-assisted image segmentation and a power-law model, we were able to describe the mechanical behavior, comparing with measurements from the most commonly used commercial instrument (Cutometer) and subjective analyses of stiffness using the Patient and Observer Scar Assessment Scale. Twenty subjects were included with either keloids or hypertrophic scars. Measurements were fast and produced no discomfort. Mechanical and structural (epidermal thickness and rugosity) descriptors in pathologic skin conditions differed significantly from those in control tissue. We showed for the first time, the clinical feasibility of this novel suction-based OCE device in evaluating mechanical and structural properties in pathological skin conditions such as scars.

Dual-wavelength dye laser combined with betamethasone injection for treatment of keloids: protocol of a randomised controlled trial

INTRODUCTION

Keloids, benign fibroproliferative tumours characterised by excessive fibroblast proliferation and over-deposition of extracellular matrix, pose a therapeutic challenge with high recurrence rates. Betamethasone (diprospan) injection (BI) is one of the most common non-invasive therapies for keloids. Pulsed dye laser (PDL) has the function of closing microvessels, which may become one of the auxiliary treatment methods of BI and may enhance its curative effect. Some studies suggest that the combination of a dual-wavelength dye laser (DWL) and BI may offer superior efficacy. This randomised controlled trial aims to evaluate whether the combined therapy of DWL+BI outperforms BI alone in treating keloids.

METHODS AND ANALYSIS

This single-centre, parallel positive control, randomised trial evaluates the efficacy and safety of DWL (585 nm PDL+1064 nm neodymium-doped yttrium aluminium garnet) combined with BI for keloid treatment. Enrolling 66 adult patients, participants are randomised into DWL+BI or BI groups in a 1:1 ratio. Over 12 weeks, each group undergoes four treatment sessions, ensuring blinding for outcome assessors. Data collection occurs at multiple time points (4, 12, 24 and 52 weeks), with primary outcomes assessing the Vancouver Scar Scale (VSS) improvement rate 24 weeks after the last intervention. Secondary outcomes include VSS improvement rates, changes in keloid volume, changes in relative perfusion index measured by laser speckle contrast imaging, Patient and Observer Scar Assessment Scale results and patient satisfaction. Safety assessments include vital signs, laboratory tests, pregnancy tests and self-reports of adverse reactions.

ETHICS AND DISSEMINATION

The results will be presented in peer-reviewed journals and at international conferences. This study is approved by the Ethics Committee of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Register (ChiCTR2400080148).

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.

Covering skin defects with a xenogeneic collagen matrix in comparison with a skin graft - A multicenter randomized controlled trial

The objective of this study was to analyze, in a randomized controlled multicenter trial, whether a xenogeneic collagen matrix (XCM) could be used to cover skin defects. Patients with the need for skin excisions were recruited and randomized to treatment with a skin graft after a period of granulation or to treatment with an XCM. The results were evaluated by two independent observers on the Patient and Observer Scar Assessment Scale. On this scale, scars are ranked from 1 to 10 in six different categories. Results range from 6 to 60, with lower scores representing scars closer to normal skin. The results 6 months after reconstruction were used as primary endpoint and compared in a non-inferiority approach. A total of 39 wounds in the head and neck region were analyzed. The mean results were 16.55 (standard deviation 6.8) for XCM and 16.83 (standard deviation 8.21) in the control group. The result of the XCM was not significantly inferior to the result of the skin graft (p = 0.91). Within the limitations of the study, it seems that the use of xenogeneic collagen matrices is a viable alternative to other approaches in small skin defects, and therefore should be taken into account whenever the reduction of patient morbidity to a minimum is the priority. TRIAL REGISTRATION: This trial was registered in the German Clinical Trials Register under registration identification number DRKS00010930 and can be found under the following URLs: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00010930. https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00010930.

From qualitative data to a measurement instrument: A clarification and elaboration of choices made in the development of the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS) 3.0

PURPOSE

To clarify and elaborate on the choices that were made in the development of the Patient Scale of the Patient and Observer Scar Assessment Scale 3.0 (POSAS 3.0), based upon the rich information obtained from patients during focus groups and pilot tests.

METHODS

The discussions described in this paper are a reflection of the focus group study and pilot tests that were conducted in order to develop the Patient Scale of the POSAS3.0. The focus groups took place in the Netherlands and Australia and included 45 participants. Pilot tests were performed with 15 participants in Australia, the Netherlands, and the United Kingdom.

RESULTS

We discussed the selection, wording and merging of 17 included items. Additionally, the reason for exclusion of 23 characteristics are given.

CONCLUSION

Based upon the unique and rich material of patient input obtained, two versions of the Patient Scale of the POSAS3.0 were developed: the Generic version, and the Linear scar version. The discussions and decisions taken during the development are informative for a good understanding of the POSAS 3.0 and are indispensable as a background for future translations and cross-cultural adaptations.

Short- and Long-term Outcomes of an Acellular Dermal Substitute versus Standard of Care in Burns and Reconstructions: A Phase I/II Intrapatient Randomized Controlled Trial

OBJECTIVE

Dermal substitutes promote dermal regeneration and improve scar quality, but knowledge gaps remain regarding their efficacy and indications for use. The authors investigated the safety and short- and long-term efficacy of an acellular dermal substitute in patients with full-thickness wounds.

METHODS

This intrapatient randomized controlled, open-label, phase I (safety) and phase II (efficacy) study compared treatment with Novomaix (Matricel GmbH), a dermal collagen/elastin-based scaffold, with split-thickness skin graft (STSG) only. The primary safety outcome was graft take at 5 to 7 days postsurgery. Postsurgical scar quality was assessed by measuring elasticity, color, and scores on the Patient and Observer Scar Assessment Scale at 3 months, 12 months, and 6 years.

RESULTS

Twenty-five patients were included, of which 24 received treatment allocation. Graft take and wound healing were statistically significantly lower/delayed in the dermal matrix group compared with STSG alone (P < .004). Serious adverse events were delayed epithelialization in four dermal matrix and three STSG study areas. At 12 months postsurgery, skin extension (P = .034) and elasticity (P = .036) were better for the dermal matrix group compared with the group receiving STSG alone. Other scar quality parameters at 12 months and 6 years did not differ between treatment arms.

CONCLUSIONS

The dermal substitute was a safe treatment modality for full-thickness wounds. Compared with STSG alone, time to wound healing was slightly increased. Nevertheless, scar quality at 12 months seemed somewhat improved in the wounds treated with the dermal substitute, indicative of enhanced scar maturation. In the long term, final scar quality was similar for both treatment modalities.

The Measure of a Scar: Patient Perceptions and Scar Optimization after Skin Cancer Reconstruction

In facial reconstruction after skin cancer resection, management and optimization of postoperative scar is a complex paradigm. Every scar is unique and presents a different challenge-whether due to anatomic, aesthetic, or patient-specific factors. This necessitates a comprehensive evaluation and an understanding of the tools at hand to improve its appearance. How a scar looks is meaningful to patients, and the facial plastic and reconstructive surgeon is tasked with its optimization. Clear documentation of a scar is critical to assess and determine optimal care. Scar scales such as the Vancouver Scar Scale, the Manchester Scar Scale, the Patient and Observer Assessment Scale, the Scar Cosmesis Assessment and Rating "SCAR" Scale, and FACE-Q, among others, are reviewed here in the context of evaluating postoperative or traumatic scar. Measurement tools objectively describe a scar and may also incorporate the patient's assessment of their own scar. In addition to physical exam, these scales quantify scars that are symptomatic or visually unpleasant and would be best served by adjuvant treatment. The current literature regarding the role of postoperative laser treatment is also reviewed. While lasers are an excellent tool to assist in blending of scar and decreasing pigmentation, studies have failed to evaluate laser in a consistent, standardized way that allows for quantifiable and predictable improvement. Regardless, patients may derive benefit from laser treatment given the finding of subjective improvement in their own perception of scar, even when there is not a significant change to the clinician's eye. This article also discusses recent eye fixation studies which demonstrate the importance of careful repair of large and central defects of the face, and that patients value the quality of the reconstruction.

The Importance of Psychometric and Physical Scales for the Evaluation of the Consequences of Scars-A Literature Review

BACKGROUND

Scars affect patients after trauma, burns, or surgical procedures and can generate both physical and psychosocial changes. The aesthetic damage represents the modification of a person's physical appearance, in its bodily integrity, causing numerous sufferings and determining social or economic consequences. The aim of this research is to evaluate the advantages and disadvantages offered by the available psychosocial and physical scar scales in assessing the physical, aesthetic, psychosocial, and juridical consequences of scars. This will aid to inform medical examiners about the most valued existing scales to allow them to select the most appropriate instrument to manage their patient.

METHODS

A broad search of relevant scientific studies on the psychosocial determinants of post-traumatic and surgical scars was conducted by using the following international database tools: PsycINFO, MedLine Social Science Index, Scopus, Web of Science, published from 1960 until 2022.

RESULTS

We analyzed 63 scientific studies to assess the advantages and limits of several psychometric and physical scar evaluation scales.

CONCLUSIONS

The researchers analyzed in this review highlight the advantages and limitation of existing instruments, evidencing the demand for future scar evaluation instruments and a scar-assessing algorithm that takes into account the physical, aesthetic, psychosocial, and legal consequences of scars.

Development of the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS) 3.0: a qualitative study

PURPOSE

The Patient and Observer Scar Assessment Scale (POSAS) is widely used for measurements of scar quality. This encompasses visual, tactile and sensory characteristics of the scar. The Patient Scale of previous POSAS versions was lacking input from patients. Therefore, the aim of this study was to develop the POSAS3.0, Patient Scale with involvement of adults patients with all scar types, complying with the highest clinimetric standards.

METHODS

From February 2018 to April 2019, a series of six focus group interviews were performed in the Netherlands and Australia to identify scar quality characteristics that adults with scars consider to be important. All focus groups were transcribed, anonymized and analysed using a thematic analysis. Relevant characteristics were formulated into items, resulting in a Dutch and English version of the Patient Scale. These drafts were pilot tested in Australia, the Netherlands and the United Kingdom, and refined accordingly.

RESULTS

A total of 21 relevant scar quality characteristics were identified during the focus groups. Two distinct versions of the POSAS3.0, Patient Scale were developed. The Generic version contains 16 items and can be used for all scar types, except linear scars. The Linear Scar version of the Patient Scale contains the same 16 items, with an extra item referring to the widening of scar margins. All included items are rated on a verbal rating scale with five response options.

CONCLUSION

Two versions of the POSAS3.0 Patient Scale were developed. Further field tests are being performed to establish the measurement properties and scoring algorithm of the scales.

A computational method for the investigation of burn scars topology based on 3D optical scan

Burn scar treatment is a difficult subject to address since the improper therapy can have a significant impact on people's quality of life. The evaluation of medical therapy over time should be based on objective measurement of the severity of burn scars and their progression. Unfortunately, most clinical assessments of scars are still reliant on physicians' subjective exams of patients. A profitable method to overcome the limitations of subjective assessment could be to leverage 3D scanning technologies. These could be used to retrieve the surface topology of burns. Accordingly, the goal of this study is to provide an objective approach for analysing the surface topology of burn scars using 3D scanning and roughness-based evaluation. In particular, two types of ISO-compliant profile and surface filters (Gaussian and Wavelet) derived from the analysis of roughness in the mechanical sector are implemented to discriminate form from roughness of scars. Once retrieved, the roughness surface is processed to derive a set of statistical parameters describing the scar surface topology. Three case studies were used to derive these parameters (a synthetic surface, an ostrich-skin surface and a set of scars). After the surface's roughness was determined, a comparison between healthy and unhealthy skin could be established. The devised methods prove their effectiveness in correctly retrieving the main surface characteristics of a burn scar. Therefore, by using the proposed method it will be possible to evaluate the effectiveness of medical therapy by comparing the healthy and scarred skin of a single subject.

Biosynthetic cellulose compared to porcine xenograft in the treatment of partial-thickness burns: A randomised clinical trial

AIM

The aim was to compare two dressing treatments for partial-thickness burns: biosynthetic cellulose dressing (BsC) (Epiprotect® S2Medical AB, Linköping, Sweden) and porcine xenograft (EZ Derm®, Mölnlycke Health Care, Gothenburg, Sweden).

METHODS

Twenty-four adults with partial-thickness burns were included in this randomized clinical trial conducted at The Burn Centers in Linköping and Uppsala, Sweden between June 2016 and November 2018. Time to healing was the primary outcome. Secondary outcomes were wound infection, pain, impact on everyday life, length of hospital stay, cost, and burn scar outcome (evaluated with POSAS).

RESULTS

We found no significant differences between the two dressing groups regarding time to healing, wound infection, pain, impact on everyday life, duration of hospital stay, cost, or burn scar outcome at the first follow up. Burn scar outcome at the 12-month follow up showed that the porcine xenograft group patients scored their scars higher on the POSAS items thickness (p = 0.048) and relief (p = 0.050). This difference was, however, not confirmed by the observer.

CONCLUSIONS

The results showed the dressings performed similarly when used in adults with burns evaluated as partial thickness.

Prediction model of laparoendoscopic single-site surgery in gynecology using machine learning algorithm

Introduction

Minimally invasive surgery has been widely used in gynecology. The laparoendoscopic single-site surgery (LESS) risk prediction model can provide evidence-based references for preoperative surgical procedure selection.

Aim

To determine whether the patients are suitable for LESS and to provide guidance for the clinical operation plan, we aimed to compare the clinical outcomes of LESS and conventional laparoscopic surgery (CLS) in gynecology. We constructed a LESS risk prediction model and predicted surgical conditions for the preoperative evaluation system.

Material and methods

A retrospective analysis was carried out among patients undergoing LESS (n = 1019) and CLS (n = 1055). Various clinical indicators were compared. Multiple machine model algorithms were evaluated. The optimal results were chosen as the model to form the risk prediction model.

Results

The LESS group showed advantages in the postoperative 12/24 h visual analog scale and Vancouver scar score compared with the CLS group (p < 0.05). The comparisons in other clinical indicators between the two groups showed that each group had advantages and the difference was statistically significant (p < 0.05), including operative time, estimated blood loss, and hospital stay. We evaluated the predictive value for various models using AUC values of 0.77, 0.77, 0.76, and 0.67 for XGBoost, random forest, GBDT, and logistic regression, respectively. The decision tree model was shown to be the optimal model.

Conclusions

LESS can reduce postoperative pain, shorten hospital stay and make scars acceptable. The risk prediction model based on a machine learning algorithm has manifested a high degree of accuracy and can satisfy the doctors’ demand for individualized preoperative evaluation and surgical safety in LESS.

A Cross-sectional Survey of Health Professionals Across Australia and New Zealand to Determine What Outcome Measures Are Important From a Clinical Perspective Post Hand Burn Injury

Outcome measures are used in healthcare to evaluate clinical practice, measure efficiencies and to determine the quality of health care provided. The Burns Trauma Rehabilitation: Allied Health Practice Guidelines advocates for the collection of outcome measures post burn injuries across different time points. These guidelines recommend multiple tools which can be utilized when measuring outcomes post burn injuries. The aim of this study was to gather information from specialist clinicians regarding their clinical practice and the outcome measurement tools used post hand burn injuries. This cross-sectional study used a survey design to collect data at one given point in time across a sample population. A total of 43 clinical specialists allied health professionals responded to the survey. Respondents indicated that their patients considered hand dexterity was the most important outcome. Three months post burn injury was the most common timepoint for measurement (n = 31, 72.1%) followed by six months (n = 27, 62.8%). Patient report of hand function (n = 42, 97.7%) and observation (n = 41, 95.3%) were the most frequently reported assessment methods. The Jamar Dynamometer (n = 40, 93%), goniometer (n = 39, 90.7%) and pinch gauge (n = 36, 83.7) were the most frequency cited assessment tools. The findings of this study suggest that clinical specialist allied health collect some outcome measures in their routine practice. Based on the respondent's perceptions of barriers when using outcome measures and lack of reliable/validated tools to measure hand burn outcomes, there is a need for further studies in this area.

Patient experience of scar assessment and the use of scar assessment tools during burns rehabilitation: a qualitative study

Background

Scar assessment plays a key role during burns aftercare, to monitor scar remodelling and patients’ psychosocial well-being. To aid assessment, subjective scar assessment scales are available that use health-care professionals’ and patients’ opinions to score scar characteristics. The subjective scales are more widely used in clinical practice over objective scar measures. To date, there is no research that considers patients’ views on scar assessment and the role of subjective and objective assessment tools. Therefore, the aim of this qualitative study was to explore patients’ perspectives on scar assessment and the utility of scar assessment tools during burns rehabilitation.

Methods

Semi-structured interviews were conducted with 10 adult burn patients who were being reviewed in clinic for scarring. Participants were recruited via their clinical care team and research nurses at the Queen Elizabeth Hospital, Birmingham, UK. Topics covered during interview included patient experience of scar assessment, the use of scar assessment tools and discussion surrounding important factors to be addressed when assessing scars. A thematic analysis using the Framework Method was conducted.

Results

Participants identified key subthemes that contribute towards the overarching theme of patient-centred scar assessment. These are: patient-led care; continuity in care; learning how to self-manage scarring; and psychological assessment. Links were demonstrated between these subthemes and the remaining themes that describe scar assessment strategies, indicating their potential patient-centred contributions. The subjective opinions of clinicians were found to be valued above the use of subjective or objective scar assessment tools. Scar assessment scales were perceived to be a beneficial method for self-reflection in relation to psychosocial functioning. However, minimal feedback and review of completed assessment scales led to uncertainty regarding their purpose. Patients perceived objective tools to be of primary use for health-care professionals, though the measures may aid patients’ understanding of scar properties.

Conclusions

Scar assessment tools should be used to support, rather than replace, health-care professionals’ subjective judgements of scarring. Adapting the way in which clinicians introduce and use scar assessment tools, according to patient needs, can support a patient-centred approach to scar assessment.

Reliability of the Patient and Observer Scar Assessment Scale in Evaluating Linear Scars after Thyroidectomy

OBJECTIVE

To compare the reliability of the Patient and Observer Scar Assessment Scale (POSAS) with the Vancouver Scar Scale (VSS) in evaluating thyroidectomy scars.

METHODS

At 6 months after the operation, 112 patients who underwent thyroid surgery via collar neck incision were evaluated by two blinded plastic surgeons and two senior residents using the VSS and the observer component of the POSAS. In addition, the observer-reported VAS score and patient-reported Likert score were evaluated. Internal consistency, interobserver reliability, and correlations between the patient- and observer-reported outcomes were examined.

RESULTS

The observer component of POSAS scores demonstrated higher internal consistency and interobserver reliability than the VSS. However, the correlations between the observer-reported VAS score and the patient-reported Likert score (0.450) and between the total sum of patient and observer component scores (0.551) were low to moderate.

CONCLUSIONS

The POSAS is more consistent over repeated measurements; accordingly, it may be considered a more objective and reliable scar assessment tool than the VSS. However, a clinician's perspective may not exactly match the patient's perception of the same scar.

Aesthetic Comparison of Abdominal Donor Site Scar Between Absorbable Dermal Staple and Subcutaneous Suture after Autologous Breast Reconstruction: A Prospective Randomized Controlled, Double-Blinded Study

BACKGROUND

Abdominal tissue transfer has become the most commonly used tool for breast reconstruction. However, a secondary operator is often responsible for donor closure, which leaves dissatisfaction to patients due to inconsistent donor scars. Now, an absorbable dermal stapler is popularized worldwide and currently used for wound closure in many surgical fields. In this study, we aim to evaluate the abdominal donor site scar in using an absorbable dermal staple compared to a conventional suture.

METHODS

This is a prospective, randomized controlled and double-blinded study. Between January 2018 and April 2019, a total of 30 patients who underwent breast reconstruction using abdominal flap were included. Donor sites were divided into equal halves, and the each dermal layer was sutured with either dermal staples or traditional suturing, respectively. At 1, 3 and 6 months after operation, the scar was evaluated by two blinded plastic surgeons by using the modified Manchester scar scale (MSS).

RESULTS

An averaged sum of modified MSS was lower for the side sutured with a dermal stapler at the first month (11.76 ± 2.12 vs. 12.28 ± 2.03, p = 0.097), third month (12.17 ± 1.86 vs. 12.62 ± 2.31, p = 0.301) and sixth month (11.28 ± 2.63 vs. 12.14 ± 2.76, p = 0.051). Also, the dermal stapler side scored significantly higher for patient satisfaction than did the suture side (4.03 ± 0.98 vs 3.66 ± 0.97, p < 0.05).

CONCLUSION

The objective outcome of the scar closed by an absorbable dermal stapler was not statistically superior to conventional suturing. (p > 0.05) In the subjective outcome, however, it showed a significantly higher patients' satisfaction (p < 0.05).

LEVEL OF EVIDENCE III

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 .

Gender differences in quality of life and psychological impact of facial burn scars in a tertiary care center

AIM

To compare the quality of life and psychological impact of cases of facial burn scar between male and female patients.

STUDY TYPE

An observational cross sectional study done in a tertiary care university level teaching hospital, on a hospital based sample over a period ranging from January 2018 to July 2019.

METHODOLOGY

The study was carried out on 32 patients of facial burn scar, who were screened for psychiatric diagnoses by MINI International Neuropsychiatric Interview; severity of depression and anxiety assessed by HDRS and HAM A; assessed for QoL and scar ratings of both patient and observer. QoL was assessed using the WHO QOL BREF questionnaire. The scar assessment was done with the help of POSAS by interviewing the patient and examination of the scar.

RESULTS

None of other socio-demographic variables patient showed any significant association with the number of psychiatric diagnoses of the patient or QoL domains; barring years of schooling, which had a significant positive correlation with the psychological domain score of QoL. Being male or female also did not show any significant differences with the anxiety or depression severity. No burn or scar related variable could reach significant association, except scar itching, stiffness scores of POSAS P and overall scar opinion score of POSAS O, with the number of psychiatric diagnoses of the patient. Extent of scar had significant negative associations with the physical and psychological domains of QoL. Significant negative correlations were found between scar variables like stiffness, pigmentation, relief, pliability, and overall opinion and QoL domain scores. The total observer score of POSAS and the overall opinion of observer had much stronger negative correlation than the patient score; the latter having a significant association with the depression severity as well.

CONCLUSION

No statistically significant gender difference in QoL and psychological impact of patients with facial burn scar were found. However educational level was found to positively influence the psychological well-being of the patients; whereas scar extent was found to negatively affect the physical and psychological domains of QoL.

Early physiotherapy experience with a biodegradable polyurethane dermal substitute: Therapy guidelines for use

OBJECTIVE

The purpose of this study was to investigate and develop range of motion (ROM) and mobilisation guidelines in adult patients where a newly developed synthetic dermal substitute was applied in our adult burn centre.

METHOD

A retrospective case note audit was conducted on the first 20 acute burn injured patients who had a synthetic dermal substitute applied. Data collected included days to commencement of ROM, days to clearance for mobilisation, and joint ROM achieved after dermal substitute application (prior to delamination) and after split skin grafting (SSG) for the elbow, knee and shoulder joints. Scar assessments were completed at 12 months after injury using two scar assessment scales.

RESULTS

Clearance to mobilise occurred at mean 10.4 and 4.9 days after dermal substitute and after skin graft application to lower limbs respectively. ROM commenced at a mean of 9.9 (upper limbs) and 12.7 (lower limbs) days after dermal substitute application. Following skin grafting, ROM commenced at a mean of 6.6 and 6.5 days for upper limbs and lower limbs respectively. Prior to dermal substitute delamination mean flexion at the knee (86.3°), elbow (114.0°) and shoulder (143.4°) was achieved. Mean ROM continued to improve after grafting with knee (133.2°), elbow (126.1°) and shoulder (151.0°) flexion approaching normal ROM in most cases. Mean extension of the elbow (-4.6°) was maintained close to normal levels after skin grafting. There were no recorded instances of knee extension contracture. Patient and Observer Scar Assessment Scale and Matching Assessment of Photographs of Scars scores indicated good cosmetic outcomes with relatively low levels of itch and minimal pain reported at 12 months after injury.

CONCLUSION

A steep learning curve was encountered in providing therapy treatment for patients managed with this relatively new synthetic dermal substitute. Trends indicated that as experience with this new dermal substitute grew, patients progressed toward active therapy earlier. A guideline for therapy treatment has been developed but will continue to be evaluated and adjusted when required.

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

BACKGROUND

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

OBJECTIVE

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

DATA SOURCES

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Hypertrophic Scar Improvement by Early Intervention With Ablative Fractional Carbon Dioxide Laser Treatment

BACKGROUND AND OBJECTIVES

Ablative fractional laser treatment has been used to improve the color and texture of hypertrophic scars with safe and effective results. However, no consensus on the optimal time to initiate fractional laser treatment is available. The effect on early-stage scars remains controversial. This study was designed to assess the efficacy and safety of ablative fractional carbon dioxide (CO₂ ) laser treatments for hypertrophic burn scars and to analyze the efficacy and safety in the early period within 3 months after injury.

STUDY DESIGN/MATERIALS AND METHODS

We performed a retrospective study of 221 hypertrophic scar patients. According to the time of the first laser treatment after injury, patients were divided into five subgroups, including less than 1 month, 1-3 months, 3-6 months, 6-12 months, and more than 12 months postinjury. One month after the last laser treatment, the scars were assessed by photography, the Vancouver Scar Scale (VSS), durometry, and spectrocolorimetry.

RESULTS

The patients included 118 males and 103 females. The average age was 33.6 years. Fire/flame was the primary injury source. Thirty-six percent of the patients underwent at least one fractional CO₂ laser treatment. All the included patients, including those treated within 1 month after injury, had significantly decreased VSS scores after laser treatment. We also noted that hardness and redness scores were decreased after treatment for both scars treated within 3 months and those treated more than 12 months after injury. Seepage (17.6%), bleeding (22.2%), and swelling (9.0%) were the main adverse events after laser treatment.

CONCLUSIONS

This study demonstrated the safety and efficacy of ablative fractional CO₂ laser treatment applied to early-stage burn scars. The optimal time for laser application for burn patients can be within 1 month after injury. Durometry and spectrocolorimetry were effective for assessing scars as objective modalities. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Reliability testing of the Matching Assessment using Photographs of Scars App

The Matching Assessment using Photographs with Scars assessment tool, published in 2005, enables accurate relocation and reassessment of scars. While used in Australia, uptake has been hampered by its paper manual format. With electronic records and increasing use of smart devices in health, here we report the development of the Matching Assessment using Photographs with Scars manual into a mobile application format: ClinMAPS^TM Pro. At the time of development, no other digital scar assessment applications were available. For clinical validation, the digitized Matching Assessment using Photographs with Scars module within ClinMAPS^TM Pro was used for intra- and inter-rater reliability testing. Convenience sampling was utilized to recruit burns patients representing 44 scars, based on predetermined power calculations. Three therapists, one experienced and two novice, acted as the assessors. Each therapist assessed preselected scars with the digitized Matching Assessment using Photographs with Scars. Re-assessment of the same scar sites occurred 3 to 7 days later. Inter-rater reliability testing scores of the new electronic assessment application showed fair to moderate agreement (combined Fleiss Kappa = 0.38-0.49, P < .0001). Intra-rater reliability scores between initial and repeat measures showed moderate to almost perfect agreement (Cohen's Kappa = 0.43-0.90, P < .0001). It was noted that for an experienced rater, intra-rater agreement demonstrated substantial to almost perfect agreement. Intraclass correlation coefficients calculated to allow for comparison between other published scar assessment tools demonstrated excellent reliability for all scar assessment parameters for both intra- (=0.76-0.91) and inter- (=0.76-0.98) reliability. Notably, reliability testing results confirm its intra- and inter-rater reliability. Our findings validate this novel concept for digitization of the previously paper-based scar assessment manual and prove that the Matching Assessment using Photographs with Scars within the ClinMAPS^TM Pro application is now readily available for clinicians and researchers internationally.

Ultrasound imaging of a scar on the knee: Sonopalpation for fascia and subcutaneous tissues

Persistent scar pain associated with healed surgical incisions after a trauma is a common and potentially debilitating type of fascial pain. At present, there is no universally effective treatment for persistent surgical or post-trauma scar pain. Herein we describe the successful objective diagnosis of debilitating scar pain by Ultrasound (US) imaging. The sonopalpation of the fasciae and subcutaneous tissues seems to be relevant to diagnose the real cause of the pain and why not to monitor the treatment.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Patient-reported Outcome Measures: The FACE-Q Skin Cancer Module: The Dutch Translation and Linguistic Validation

Background

Patient-reported outcome measures are becoming a standard component in the evaluation of surgical treatments. In 2010, the FACE-Q skin cancer module was developed: an English psychometric validated questionnaire that measures both patient quality of life and satisfaction with the surgical experience. The questionnaire consists of 11 subscales with a total of 96 questions. An officially translated version in Dutch is needed for accepted use in the Netherlands.

Methods

We translated the FACE-Q skin cancer module from English into Dutch in accordance with to the International Society for Pharmacoeconomics and Outcomes Research and World Health Organization guidelines. The translation occurs in three stages. First, a forward translation is performed by two independent professional translators, where discrepancies are solved by a third translator, a subject area expert. Secondly, a backward translation is performed and is compared with the original. Any discrepancies are solved by an expert panel. Version two is then pretested (cognitive debriefing) by 30 patients who have had a resection (Mohs surgery) of non-melanoma skin cancer in the face followed by reconstruction. The results of the pretesting exercise are evaluated and a final version of the translation was produced by the expert panel.

Results

In the first step, a conceptually equivalent Dutch translation of the FACE-Q was translated. In the second phase, the comparison between the forward and backward translation led to multiple retranslations. In step three, 48 annotations were evaluated by the expert panel, which led to 26 minor changes in items or instructions.

Conclusion

We created a conceptually and linguistically similar translation of the FACE-Q Skin Cancer Module through a thorough translation and linguistic validation process.

Systematic Review on the Content of Outcome Measurement Instruments on Scar Quality

Supplemental Digital Content is available in the text.

Measurements of scar quality are essential to evaluate the effectiveness of scar treatments and to monitor scars. A large number of scar scales and measurement devices have been developed, which makes instrument selection challenging. The aim of this study was to provide an overview of the content (ie, included items) of all outcome measurement instruments that measure scar quality in different types of scars (burn, surgical, keloid, and necrotizing fasciitis), and the frequency at which the instruments and included items are used.

3-D wound scanner: A novel, effective, reliable, and convenient tool for measuring scar area

This study aimed to investigate whether a three-dimensional (3-D) wound scanner could be used to measure the area of scars. Scar models were constructed using flesh-colored, brown-colored (simulating hyperpigmented scars), orange-colored (simulating scars with obvious vascularization), and white-colored (simulating hypopigmented scars) plastic. Each colored plastic was used to construct scar models with regular and irregular base surfaces (four each). Two human models were selected to simulate patients with scars, and the scar models were placed on the right cheek, right lower jaw-neck, right ulnar forearm, anterior tibial region of the right calf, and at the back of these human models for scar area measurement. Two experimenters separately measured the scar area vertically using the profile method, pixel method, and 3-D wound scanner. Each experimenter measured the scar area thrice. Regarding accuracy, we found significant differences between the data and standard value of various measurement methods (P<0.05); however, the ratio of the data and standard value using the 3-D wound scanner was 0.982, which was the closest to 1, and showed the lowest coefficient of variation. Regarding correlation, Spearman's coefficient using the 3-D wound scanner was 0.992, showing the strongest correlation. With respect to inter-experimenter reliability and stability of retesting, each Cronbach's coefficient of the 3-D wound scanner between the two experimenters was >0.90, showing high reliability; thus, fulfilling the requirements for clinical measurement. The 3-D wound scanner took an average time of 38.87±3.45s for measurement, which was significantly shorter compared that for other methods The 3-D wound scanner showed greater accuracy and correlation, and a shorter measurement time, compared with other measurement methods The inter-experimenter reliability and retesting stability of the 3-D wound scanner also fulfilled the requirements for clinical measurement.

Chinese expert consensus on clinical prevention and treatment of scar. BURNS & TRAUMA 2018;6:27. [PMID: 30263894 PMCID: PMC6154406 DOI: 10.1186/s41038-018-0129-9]

Following injury, Asian skin has a tendency toward hyperpigmentation and scar formation than Caucasians. A standardized algorithm tailored to Asian patients, especially Chinese patients, is in great demand. Twelve independent, self-selected academic and military physicians from the department of burn/trauma, plastic surgery and dermatology with extensive experience in treating scars were assembled on January 17, 2015, establishing the consensus panel. This consensus was then appraised, drafted, reviewed, and finalized during the following 3 years, aiming to standardize and improve scar prevention and treatment in China. Hopefully, it may also provide some advices and references for the management of scarring in Asian patients.

Early intervention in scar management and cutaneous burns with autologous platelet-rich plasma

Burn management options are controversial and a multiple-handled issue. However, platelet-rich plasma is gaining interest in several medical fields. Dermatologist worldwide are already publishing some reports about its benefits and personal experiences in their practices. A 40-year-old female with a second-degree burn by VASER-type liposculpture was treated with platelet-rich plasma and followed up for 10 months. After treatment, she showed rapid improvement with an adequate cicatrization results. Some studies suggest that the use of platelet-rich plasma which contains cytokines and growth factors that participate in cellular repair and cellular differentiation, thus improving healing time and re-epithelization. We present the case of a patient with a second-degree burn that rapidly improved with autologous platelet-rich plasma.

Coherency image analysis to quantify collagen architecture: implications in scar assessment

An important histological difference between normal, uninjured dermis and scar tissue such as that found in keloid scars is the pattern (morphological architecture) in which the collagen is deposited and arranged. In the uninjured dermis, collagen bundle architecture appears randomly organized (or in a basket weave formation), whereas in pathological conditions such as keloid scar tissue, collagen bundles are often found in whorls or in a hypotrophic scar collagen is more densely packed in a parallel configuration. In the case of skin, a scar disables the dermis, leaving it weaker, stiff and with a loss of optimal functionality. The absence of objective and quantifiable assessments of collagen orientation is a major bottleneck in monitoring progression of scar therapeutics. In this article, a novel quantitative approach for analyzing collagen orientation is reported. The methodology is demonstrated using collagen produced by cells in a model scar environment and examines collagen remodeling post-TGFβ stimulation in vitro. The method is shown to be reliable and effective in identifying significant coherency differences in the collagen deposited by human keloid scar cells. The technique is also compared for analysing collagen architecture in rat sections of normal, scarred skin and tendon tissue. Results demonstrate that the proposed computational method provides a fast and robust way of analyzing collagen orientation in a manner surpassing existing methods. This study establishes this methodology as a preliminary means of monitoring in vitro and in tissue treatment modalities which are expected to alter collagen morphology.

Influence on clinical parameters of depressomassage (part I): The effects of depressomassage on color and transepidermal water loss rate in burn scars: A pilot comparative controlled study

OBJECTIVE

Depressomassage is a non-invasive massage technique using a mechanical suction device that is used in the treatment of traumatic or burn scars. Since color and transepidermal water loss (TEWL) are respectively the most important physical and physiological characteristic of hypertrophic scar formation, we wanted to investigate the effects of depressomassage on the recovery of color and TEWL in burn scars compared to the traditional physiotherapy.

METHODS

In this pilot comparative controlled study a total 43 burn patients were included and allocated into 2 groups. All patients received standard physical therapy, and the test group received additional depressomassage during 6 months. Color was assessed using the POSAS questionnaire (for color, vascularity and pigmentation) and the Minolta Chromameter. TEWL was measured using DermaLab.

RESULTS

Patients of both groups were evaluated at baseline, after 1, 3 and 6 months and after 1year. The evidence for a difference in evolution of color and TEWL between both groups in our study was minimal.

CONCLUSIONS

In practice, precise indications to begin depressomassage have to be kept in mind. Perhaps other scar abnormalities such as decreased elasticity, increased thickness, excessive pain or itching could be sufficient reasons to begin depressomassage and should be assessed.

In vivo polarization-sensitive optical coherence tomography of human burn scars: birefringence quantification and correspondence with histologically determined collagen density

Obtaining adequate information on scar characteristics is important for monitoring their evolution and the effectiveness of clinical treatment. The aberrant type of collagen in scars may give rise to specific birefringent properties, which can be determined using polarization-sensitive optical coherence tomography (PS-OCT). The aim of this pilot study was to evaluate a method to quantify the birefringence of the scanned volume and correlate it with the collagen density as measured from histological slides. Five human burn scars were measured in vivo using a handheld probe and custom-made PS-OCT system. The local retardation caused by the tissue birefringence was extracted using the Jones formalism. To compare the samples, histograms of birefringence values of each volume were produced. After imaging, punch biopsies were harvested from the scar area of interest and sent in for histological evaluation using Herovici polychrome staining. Two-dimensional en face maps showed higher birefringence in scars compared to healthy skin. The Pearson's correlation coefficient for the collagen density as measured by histology versus the measured birefringence was calculated at r=0.80 (p=0.105). In conclusion, the custom-made PS-OCT system was capable of in vivo imaging and quantifying the birefringence of human burn scars, and a nonsignificant correlation between PS-OCT birefringence and histological collagen density was found.

Optimizing Postsurgical Scars: A Systematic Review on Best Practices in Preventative Scar Management

BACKGROUND

Scar management is critical for every plastic surgeon's practice and, ultimately, the patient's satisfaction with his or her aesthetic result. Despite the critical nature of this component of routine postoperative care, there has yet to be a comprehensive analysis of the available literature over the past decade to assess the best algorithmic approach to scar care. To this end, a systematic review of best practices in preventative scar management was conducted to elucidate the highest level of evidence available on this subject to date.

METHODS

A computerized MEDLINE search was performed for clinical studies addressing scar management. The resulting publications were screened randomized clinical trials that met the authors' specified inclusion/exclusion criteria.

RESULTS

This systematic review was performed in May of 2016. The initial search for the Medical Subject Headings term "cicatrix" and modifiers "therapy, radiotherapy, surgery, drug therapy, prevention, and control" yielded 13,101 initial articles. Applying the authors' inclusion/exclusion criteria resulted in 12 relevant articles. All included articles are randomized, controlled, clinical trials.

CONCLUSIONS

Optimal scar care requires taking into account factors such as incisional tension, anatomical location, and Fitzpatrick skin type. The authors present a streamlined algorithm for scar prophylaxis based on contemporary level I and II evidence to guide clinical practice.

Cross-cultural adaptation, reproducibility and validation of the Italian version of the Patient and Observer Scar Assessment Scale (POSAS)

The Patient and Observer Scar Assessment Scale (POSAS) is one of the most robust instruments to assess scar quality, but there is no Italian version, and no other competing instruments are available in Italian. The aim of this study was to translate and validate an Italian version of POSAS (POSAS-I). POSASv2.0 was culturally adapted in accordance with international standards. The psychometric assessment included acceptability/feasibility, internal consistency, reproducibility, construct validity and sensitivity to change. Cultural equivalence of POSAS-I with the English version was confirmed. The validation study included 102 subjects with surgical scars. Both subscales demonstrated acceptable internal consistency (Cronbach's α = 0·72-0·80). Reproducibility of the OSAS-I (ICCs = 0·93-0·94; SEM = 1·8 points; MDC₉₅ = 5·1 points) was superior to that of PSAS-I (ICC = 0·65; SEM = 5·7 points; MDC₉₅ = 15·7 points). OSAS-I showed moderate to good correlations with the Vancouver Scar Scale (VSS), Global Rating of Change Scale (GRCS) and PSAS-I. Sensitivity to change was large for PSAS-I (effect size = 1·08; standardised response mean = 0·96) and moderate to large for OSAS-I (ES = 0·69; SRM = 0·92). This study confirmed that POSAS-I can be used to assess patients with surgical scars in the Italian population. OSAS-I is useful for clinical and research purposes, while PSAS-I should be better used to capture patients' own opinions and symptoms in clinical settings.

Effectiveness of Autologous Fat Grafting in Adherent Scars: Results Obtained by a Comprehensive Scar Evaluation Protocol

BACKGROUND

Nowadays, patients normally survive severe traumas such as burn injuries and necrotizing fasciitis. Large skin defects can be closed but the scars remain. Scars may become adherent to underlying structures when the subcutical fat layer is damaged. Autologous fat grafting provides the possibility of reconstructing a functional sliding layer underneath the scar. Autologous fat grafting is becoming increasingly popular for scar treatment, although large studies using validated evaluation tools are lacking. The authors therefore objectified the effectiveness of single-treatment autologous fat grafting on scar pliability using validated scar measurement tools.

METHODS

Forty patients with adherent scars receiving single-treatment autologous fat grafting were measured preoperatively and at 3-month follow-up. The primary outcome parameter was scar pliability, measured using the Cutometer. Scar quality was also evaluated by the Patient and Observer Scar Assessment Scale and the DSM II ColorMeter. To prevent selection bias, measurements were performed following a standardized algorithm.

RESULTS

The Cutometer parameters elasticity and maximal extension improved 22.5 percent (p < 0.001) and 15.6 percent (p = 0.001), respectively. Total Patient and Observer Scar Assessment Scale scores improved from 3.6 to 2.9 on the observer scale, and from 5.1 to 3.8 on the patient scale (both p < 0.001). Color differences between the scar and normal skin remained unaltered.

CONCLUSIONS

For the first time, the effect of autologous fat grafting on functional scar parameters was ascertained using a comprehensive scar evaluation protocol. The improved scar pliability supports the authors' hypothesis that the function of the subcutis can be restored to a certain extent by single-treatment autologous fat grafting.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Outcomes Assessment After Hand Burns

Accurately assessing function and disability after hand burns is imperative to improving the management of patients. The biological, social, and psychological impact of these injuries should be considered. The International Classification of Functioning Disability (ICF) and Health Core Sets for Hand Conditions provides a guide to what should be measured and reported. Although many outcomes measures instruments are available to assess patients with hand or burn injuries, few are validated in the subpopulation of hand burns. Further efforts are required to investigate the ability of current assessment instruments to evaluate hand burn outcomes within the ICF framework.

Color Doppler Ultrasound Assessment of Activity in Keloids

BACKGROUND

The assessment of activity in keloids may be critical for defining their management. There is a lack of clinical scorings designed for the evaluation of keloids and biopsies may be contraindicated.

OBJECTIVE

To assess the sonographic activity of keloids in comparison with clinical scoring.

MATERIALS AND METHODS

A retrospective study of the clinical and color Doppler ultrasound (CDU) images of patients medically derived to CDU with the diagnosis of keloid was performed. Activity was evaluated clinically (modified Seattle Scar Scale) and CDU. Keloids were considered active when CDU detected vascularity within the lesion. Statistical analysis was performed (Wilcoxon-Mann-Whitney, Student t-test, and interobserver agreement).

RESULTS

Thirty-five patients with 42 keloids were evaluated. Color Doppler ultrasound provided the diameters, including depth, and vascularity. On CDU, 76% were active and 24% inactive. Clinically, Observer 1 found 55% and Observer 2 found 88% of active keloids. Interobserver agreement between clinical observers was moderate (k = 0.42). Subclinical fistulous tracts, involvement of the hypodermis, muscle, and calcifications were also found on CDU.

CONCLUSION

Color Doppler ultrasound can support the assessment of activity in keloids. Clinical evaluation alone can underestimate the activity in keloids. Relevant anatomical and subclinical features can be detected by CDU.

Increased burn healing time is associated with higher Vancouver Scar Scale score

Increased burn wound healing time has been shown to influence abnormal scarring. This study hypothesised that scar severity increases commensurate to the increase in time to healing (TTH) of the wound. Wound healing and scar data from burn patients treated by the Burn Service of Western Australia at Royal Perth Hospital were examined. The relationship between TTH and scar severity, as assessed by the modified Vancouver Scar Scale (mVSS), was modelled using regression analysis. Interaction terms evaluated the effect of surgery and total body surface area - burn (TBSA) on the main relationship. Maximum likelihood estimation was used to account for potential bias from missing independent variable data. The sample had a median age of 34 years, TTH of 24 days, TBSA of 3% and length of stay of five days, 70% were men and 71% had burn surgery. For each additional day of TTH, the mVSS score increased by 0.11 points (P ≤ 0.001) per day in the first 21 days and 0.02 points per day thereafter (P = 0.004). The relationship remained stable in spite of TBSA or surgical intervention. Investigation of the effect of missing data revealed the primary model underestimated the strength of the association. An increase in TTH within 21 days of injury is associated with an increase in mVSS or reduced scar quality. The results confirm that efforts should be directed toward healing burn wounds as early as possible.

Comparison of the Effectiveness of Ablative and Non-Ablative Fractional Laser Treatments for Early Stage Thyroidectomy Scars

Background

Open thyroidectomy is conventionally performed at the anterior side of neck, which is a body part with a comparatively great degree of open exposure; due to this, postoperative scarring may cause distress in patients. We aimed to compare the effects of ablative and nonablative fractional laser treatments on thyroidectomy scars. We examined medical records in a retrospective manner and analyzed scars based on their digital images by using the modified Manchester Scar Scale (mMSS).

Methods

Between February 2012 and May 2013, 55 patients with thyroidectomy scars were treated with ablative (34 patients) or nonablative (21 patients) fractional laser. Each patient underwent 4 laser treatment sessions in 3–4 week intervals, 1–2 months postoperatively. Scar improvement was assessed using patient images and the mMSS scale.

Results

The mean decrease in scar score was 3.91 and 3.47 in the ablative and nonablative groups, respectively; the reduction between 2 groups did not exhibit any significant difference (P=0.16). We used the scale once again to individually evaluate scar attributes. The nonablative group accounted for a considerably higher color score value (P=0.03); the ablative group accounted for a considerably higher contour score value (P<0.01). Patient satisfaction was high and no complications occurred.

Conclusions

Both types of fractional laser treatments can be used successfully for thyroidectomy scar treatment with minimal complications; however, results indicate that higher effectiveness may be obtained from the use of ablative and nonablative lasers for hypertrophic scars and early erythematous scars, respectively. Therefore, the appropriate laser for scar treatment should be selected according to its specific characteristics.

The Role of Topical Vitamin E in Scar Management: A Systematic Review

BACKGROUND

The practice of prescribing vitamin E after surgery for scar prevention and treatment is widespread and increasingly popular among both the public and clinicians. However, very little evidence exists for this "ritual."

OBJECTIVES

This review was undertaken to critically analyze the current literature about the effect of vitamin E on treating scars.

METHODS

The Cochrane, Medline, and PubMed databases were searched based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). The studies and levels of recommendation were graded according to the American Society of Plastic Surgeons (ASPS) criteria. Only prospective studies were included.

RESULTS

Only six studies met the inclusion criteria. Of these six included studies, three reported a significant improvement in the cosmetic appearance of scars when using vitamin E: one study used topical vitamin E in white children as monotherapy, and two studies used vitamin E in an adult population as combination therapy. The other three selected studies showed no significant improvement in scar appearance when using topical vitamin E as monotherapy. Two of the six included studies reported adverse events of vitamin E application: contact dermatitis and increased incidence of itching and rash.

CONCLUSIONS

We conclude that there is not yet sufficient evidence that monotherapy with topical vitamin E has a significant beneficial effect on scar appearance to justify its widespread use. Further prospective studies with vitamin E monotherapy and/or combination therapy are warranted to draw better conclusions regarding the value of vitamin E in the management of scar healing.

LEVEL OF EVIDENCE

2 Therapeutic.

Usability and effectiveness of Suprathel® in partial thickness burns in children

Purpose

Evaluation of usability and effectiveness of Suprathel^® in the treatment of partial thickness burns in children.

Methods

A prospective, observational study to evaluate adherence of Suprathel^® to the wound bed, reepithelialization time, grafting, wound colonization and infection, pain, dressing changes, length of hospital stay (LOS) and scar formation.

Results

Twenty-one children (median age 2.4 years, range 5 months–14 years) with a median total body surface area (TBSA) of 4 % (range 1–18) were included. Median LOS was 10 days (range 3–20). Median outer layer dressing changes was 3 (range 1–14). Suprathel^® was only adherent in wounds debrided with Versajet^®. Median reepithelialization time was 13 days (range 7–29). Three patients needed a split skin graft. There were 7 (33 %) patients with wound colonization before application of Suprathel^®. This increased to 12 (57 %) patients during treatment. One patient developed a wound infection. Median visual analog scale (VAS) scores for background and procedural pain in patients >7 years were 3.2 (range 2–5) and 3.5 (range 2–5), respectively. In younger patients, median background and procedural COMFORT-B scores were 13.8 (range 10–23) and 14.8 (range 13–23, p = 0.03), respectively. Patient and Observer Scar Assessment Scale (POSAS) scores were favorable after 3 and 6 months post burn.

Conclusions

Suprathel^® provides potential advantages regarding pain and scar formation, but extensive wound debridement is needed to achieve adequate adherence.

Clinimetric properties and clinical utility in rehabilitation of postsurgical scar rating scales: a systematic review

The aim of this study was to review and critically assess the most used and clinimetrically sound outcome measures currently available for postsurgical scar assessment in rehabilitation. We performed a systematic review of the Medline and Embase databases to June 2015. All published peer-reviewed studies referring to the development, validation, or clinical use of scales or questionnaires in patients with linear scars were screened. Of 922 articles initially identified in the literature search, 48 full-text articles were retrieved for assessment. Of these, 16 fulfilled the inclusion criteria for data collection. Data were collected pertaining to instrument item domains, validity, reliability, and Rasch analysis. The eight outcome measures identified were as follows: Vancouver Scar Scale, Dermatology Life Quality Index, Manchester Scar Scale, Patient and Observer Scar Assessment Scale, Bock Quality of Life (Bock QoL) questionnaire, Stony Brook Scar Evaluation Scale, Patient-Reported Impact of Scars Measure, and Patient Scar Assessment Questionnaire. Scales were examined for their clinimetric properties, and recommendations for their clinical or research use and selection were made. There is currently no absolute gold standard to be used in rehabilitation for the assessment of postsurgical scars, although the Patient and Observer Scar Assessment Scale and the Patient-Reported Impact of Scars Measure emerged as the most robust scales.

The application of platelet-rich plasma in the treatment of deep dermal burns: A randomized, double-blind, intra-patient controlled study

Platelet-rich plasma (PRP) is a fraction of blood with a platelet concentration above baseline. When platelets get activated, growth factors involved in wound healing are released. The application of PRP has shown good results in wound care, however, up to date no substantial research has been performed on the effect of PRP in burn treatment. This randomized double blind intra-patient controlled study investigates the effect of autologous PRP on wound healing in burns that require surgery with a meshed split skin graft (SSG). Fifty-two patients with various areas of deep dermal to full thickness burns, receiving surgery with a SSG were included after informed consent. Comparable study areas A and B (intra-patient) were appointed, randomized and either treated with a SSG and PRP or with a SSG alone. At day 5 to 7 postoperative, the epithelialization and graft take rate were assessed. Three, six, and twelve months postoperative, follow-up measurements were performed in the form of POSAS-questionnaires, DermoSpectroMeter, and Cutometer measurements. There was no statistically significant difference between the mean take rate nor the mean epithelialization rate at day 5-7 between the PRP-treated and control areas. However, PRP-treated wound areas showed more often better or equal epithelialization and take rates at day 5-7 than the standard treated areas. Minor effects were also seen in the reoperated and early operated subgroups. At 3, 6, and 12 months postoperative, POSAS scores from the patients and the observers, Dermaspectro-, and Cutometer measurements did not depict a significant difference between the PRP and standard treated areas. Concluding, the addition of PRP in the treatment of burn wounds did not result in improved graft take and epithelialization, nor could we demonstrate better scar quality. There was, however, a considerable variation in our clinical population.

Clinical effectiveness, quality of life and cost-effectiveness of Flaminal® versus Flamazine® in the treatment of partial thickness burns: study protocol for a randomized controlled trial

Background

Partial thickness burns are painful, difficult to manage and can have a negative effect on quality of life through scarring, permanent disfigurement and loss of function. The aim of burn treatment in partial thickness burns is to save lives, stimulate wound healing by creating an optimumly moist wound environment, to have debriding and analgesic effects, protect the wound from infection and be convenient for the patient and caregivers. However, there is no consensus on the optimal treatment of partial thickness wounds. Flaminal® and Flamazine® are two standard treatment options that provide the above mentioned properties in burn treatment. Nevertheless, no randomized controlled study has yet compared these two common treatment modalities in partial thickness burns. Thus, the aim of this study is to evaluate the clinical effectiveness, quality of life and cost-effectiveness of Flaminal® versus Flamazine® in the treatment of partial thickness burns.

Methods/Design

In this two-arm open multi-center randomized controlled trial, 90 patients will be randomized between Flaminal® and Flamazine® and followed for 12 months. The study population will consist of competent or temporarily non-competent (because of sedation and/or intubation) patients, 18 years of age or older, with acute partial thickness burns and a total body surface area (TBSA) of less than 30 %. The main study outcome is time to complete re-epithelialization (greater than 95 %). Secondary outcome measures include need for grafting, wound colonization/infection, number of dressing changes, pain and anxiety, scar formation, health-related quality of life (HRQoL), and costs.

Discussion

This study will contribute to the optimal treatment of patients with partial thickness burn wounds and will provide evidence on the (cost-)effectiveness and quality of life of Flaminal® versus Flamazine® in the treatment of partial thickness burns.

Trial registration

Netherlands Trial Register NTR4486, registered on 2 April 2014.