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De Decker I, De Graeve L, Hoeksema H, Monstrey S, Verbelen J, De Coninck P, Vanlerberghe E, Claes KEY. Enzymatic debridement: past, present, and future. Acta Chir Belg 2022; 122:279-295. [PMID: 35440290 DOI: 10.1080/00015458.2022.2068746] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Early surgical debridement of the deep second and third-degree burns is still the standard of care (SOC) to prepare the wound bed for skin grafting. However, this technique has some drawbacks that explain the growing interest in enzymatic debridement as an alternative. In this article, we provide a historic overview as well as the current state-of-the-art and future prospective of this type of non-surgical debridement. MATERIALS AND METHODS A narrative review of the available literature was conducted using a systematic search. RESULTS A total of 32 articles were included. The only enzyme mixture still used nowadays for burn eschar removal is bromelain-based. There is increasing evidence that this type of enzymatic debridement is a powerful tool to selectively remove the eschar in deep burns, thereby reducing the need for autologous skin grafting compared to surgical SOC. Moreover, off-label use of enzymatic debridement with NexoBrid® (facial, pediatric, and >15%TBSA burns) has proven to be effective and safe. CONCLUSION There is increasing evidence that bedside administered NexoBrid®, preferably under regional anesthesia, is a powerful tool for selective burn eschar removal. However, the clinical wound bed evaluation post-NexoBrid® procedure in relation to the optimal treatment decision-conservative treatment vs. surgery-is not yet completely elucidated. More high-quality prospective clinical trials are necessary to compare enzymatic debridement of objectively confirmed deep burns with the current standard treatment and assess the effectiveness of the eschar removal, the need for surgery, the healing time of such wounds, and the long-term scar quality.
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Affiliation(s)
| | - Liesl De Graeve
- Department of Plastic Surgery, Ghent University Hospital, Ghent, Belgium
| | - Henk Hoeksema
- Burn Center, Ghent University Hospital, Ghent, Belgium
- Department of Plastic Surgery, Ghent University Hospital, Ghent, Belgium
| | - Stan Monstrey
- Burn Center, Ghent University Hospital, Ghent, Belgium
- Department of Plastic Surgery, Ghent University Hospital, Ghent, Belgium
| | | | | | | | - Karel E. Y. Claes
- Burn Center, Ghent University Hospital, Ghent, Belgium
- Department of Plastic Surgery, Ghent University Hospital, Ghent, Belgium
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Patient- and Physician-Reported Outcome of Combined Fractional CO2 and Pulse Dye Laser Treatment for Hypertrophic Scars in Children. Ann Plast Surg 2021; 85:237-244. [PMID: 32349082 DOI: 10.1097/sap.0000000000002377] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hypertrophic scars are commonly seen in children and associated with pruritus, pain, functional impairment, and aesthetic disfigurement. Ablative fractional CO2 and pulse dye laser are emerging techniques to improve scar quality. Only limited data are available on children, nonburn scars, and patient-reported outcome. We aimed to investigate safety and outcome of repeated laser therapy for hypertrophic scars originating from burns and other conditions by means of patient- and physician-reported outcome measures. METHODS This was a retrospective before-after analysis of laser treatments in children with hypertrophic scars. Outcome was measured using Patient and Observer Scar Assessment Scale, Vancouver Scar Scale and Itch Man Scale. With respect to safety, laser- and anesthesia-related complications were analyzed. RESULTS Seventeen patients, aged 11.37 ± 4.82 years with 27 scars, underwent 102 distinct laser treatments, mainly combined CO2 and pulse dye laser (94%), with few CO2 only (6%). Vancouver Scar Scale total score before the first and after the first session decreased significantly from 7.65 ± 2.12 to 4.88 ± 1.73; Patient and Observer Scar Assessment Scale observer overall opinion also dropped from 5.88 ± 1.57 to 4.25 ± 1.70. Pruritus improved significantly. Patient age and timing of laser intervention did not have an impact on treatment response. Complications related to laser treatment were seen in 2% (wound infection, n = 2) and to anesthesia in 4% (insignificant n = 2, minor n = 1). CONCLUSIONS Combined laser therapy significantly improves quality, pain, and pruritus of hypertrophic scars in children. When provided by experienced laser and anesthesia teams, it is safe with a low rate of complications.
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Mahar PD, Spinks AB, Cleland H, Bekhor P, Waibel JS, Lo C, Goodman G. Improvement of Burn Scars Treated With Fractional Ablative CO2 Lasers—A Systematic Review and Meta-analysis Using the Vancouver Scar Scale. J Burn Care Res 2020; 42:200-206. [DOI: 10.1093/jbcr/iraa130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Fractional ablative CO2 laser is being used increasingly to treat burn scars; however, objective measures of outcome success vary widely. This systematic review and meta-analysis extracts and pools available data to assess the outcomes of patients with burn scars treated with fractional ablative CO2 laser. A search of MEDLINE, EMBASE, and the gray literature was performed. The review included studies that reported patients with a confirmed diagnosis of scarring as a result of a burn injury, who were treated with fractional ablative CO2 laser and whose progress was recorded using the Vancouver Scar Scale (VSS). Eight studies were included in the systematic review and meta-analysis. Treatment regimens varied amongst studies, as did patient outcomes. Pooled data revealed an average VSS improvement of 29% across 282 patients following fractional CO2 ablative laser treatment. Although the heterogeneity of treatment regimens across studies limits this systematic review’s ability to provide specific treatment recommendations, the overall trend towards improvement of burns scars treated with fractional CO2 laser based on the VSS encourages further exploration of this modality as a therapeutic tool.
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Affiliation(s)
- Patrick D Mahar
- Skin Health Institute and Royal Children’s Hospital, Melbourne, Victoria, Australia
| | | | - Heather Cleland
- Victorian Adult Burns Service, The Alfred Hospital and Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Philip Bekhor
- Department of Dermatology, Department of Dermatology, Royal Children’s Hospital and Laser Dermatology, Melbourne, Victoria, Australia
| | - Jill S Waibel
- Miami Dermatology and Laser Institute, Miami, Florida
| | - Cheng Lo
- Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Gregory Goodman
- Skin Health Institute and Dermatology Institute of Victoria, Melbourne, Australia
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Xi W, Xie Y, Zhang Z, Li K, Wang J, Li J, Feng S, Hultman CS, Liu Y, Zhang Y. 3D Mesh Releasing Method: A Retrospective Analysis of Fractional CO 2 Treatment on Contracture Scars. Lasers Surg Med 2020; 53:227-235. [PMID: 32432374 DOI: 10.1002/lsm.23262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 05/08/2020] [Accepted: 05/09/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES There has been reports on fractional CO2 laser successfully improving contracture scars that impair the function of a joint. It seems that certain contracture problems could be solved by laser instead of surgery. However, the clinical application could be difficult when the efficacy of the method remains unknown. The purpose of this study is to report the releasing capacity of the fractional CO2 laser on contracture scars based on a defined treatment method. STUDY DESIGN/MATERIALS AND METHODS We conducted a retrospective study in patients with limited function in joints caused by contracture scars. Fractional CO2 laser and our "3D mesh releasing" protocol were applied. The primary outcome was the improvement measured in range of motion (ROM) of the relevant joint before all intervention and 6 months after the last treatment. RESULT From November 2016 to January 2018, 11 joints of 10 cases were treated by the fractional CO2 laser. Patients went through 2.27 (standard deviation [SD] 1.42, 1-5) sessions. The average progress of ROM before and 6 months after all treatments was 19.13° (SD 10.25, P < 0.02). In six cases, we recorded that there was an 8.53° (SD 5.81, P < 0.02) of increase in ROM immediately after the laser session, and the average improvement reached up to 13.58° (SD 8.15, P < 0.02) after 2-3 months during the next follow-up. CONCLUSION The fractional CO2 laser could achieve functional improvement in contracture scars and it maintained its effect for at least 6 months. The "3D Mesh Releasing" protocol would help to standardize the treatment procedure. This modality has minimal-invasiveness and potentially could become a supplement to the current treatment choices for mild contracture scars. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.
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Affiliation(s)
- Wenjing Xi
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.,Department of Laser and Aesthetic Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yixin Xie
- Department of Burns Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zheng Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Ke Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Jingyan Wang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Jie Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Shaoqing Feng
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - C Scott Hultman
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Ying Liu
- Department of Laser and Aesthetic Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.,Department of Laser and Aesthetic Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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Onur Erol O, Agaoglu G, Jawad MA. Combined Non-Ablative Laser and Microfat Grafting for Burn Scar Treatment. Aesthet Surg J 2019; 39:NP55-NP67. [PMID: 30403775 DOI: 10.1093/asj/sjy291] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Burn scar treatment persists as an unsolved problem, involving thousands of affected patients disfigured for life. OBJECTIVES We sought to present our experience with the use of combined treatments for patients with burn scars. METHODS This was a case series report of the senior author's experience during 8 years utilizing the combined treatments of Fraxel Restore (fractional laser) and microfat graft injection for 288 patients with burn scars. RESULTS Laser treatment reduced scar intensity and attenuated skin irregularities and hyperpigmentation. All patients demonstrated marked improvement of skin texture and an increase in scar softness after 3 sessions of microfat grafting. However, the degree of improvement varied between patients and was related to the severity of the scar and the type of tissue. Overall, a 40% to 80% improvement was noted in our patients. All patients and their families expressed satisfaction with the results. CONCLUSIONS The combined treatment of Fraxel and microfat grafting is an effective technique for improving the appearance of a hypertrophic scar or keloid on burn patients. Fat tissue stem cells may have helped to repair the damaged skin. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- O Onur Erol
- ONEP Plastic Surgery Science Institute, Istanbul, Turkey
| | - Galip Agaoglu
- ONEP Plastic Surgery Science Institute, Istanbul, Turkey
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Abstract
A major burn is a severe injury with a global impact. Our system of medical evacuation has led to the survival of many severely injured service members. Burn rehabilitation is a complex and dynamic process and will not be linear. Recovery requires a comprehensive, interdisciplinary team-based approach, individually designed to maximize function, minimize disability, promote self-acceptance, and facilitate survivor and family reintegration into the community.
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Affiliation(s)
- Alan W Young
- Complementary and Integrative Medicine Service, Department of Pain Management, Brooke Army Medical Center, JBSA, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA; Rehabilitation Medicine, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
| | - William Scott Dewey
- Rehabilitation Services, Army Burn Center, U.S. Army Institute of Surgical Research, JBSA, 3698 Chambers Pass Suite B, Fort Sam Houston, TX 78234-7767, USA
| | - Booker T King
- Medical Corps US Army, Army Burn Center, U.S. Army Institute of Surgical Research, JBSA, 3698 Chambers Pass Suite B, Fort Sam Houston, TX 78234-7767, USA
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Enzymatic debridement of deeply burned faces: Healing and early scarring based on tissue preservation compared to traditional surgical debridement. Burns 2017; 43:1233-1243. [DOI: 10.1016/j.burns.2017.02.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 02/17/2017] [Accepted: 02/24/2017] [Indexed: 11/16/2022]
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Abstract
A recent advancement in the treatment of burn scars has been the use of the carbon dioxide (CO2) laser to perform fractional photothermolysis. In this analysis, we describe our results and patient-reported outcomes with the use of fractional CO2 laser for the treatment of burn-related scarring. We performed a retrospective study of all patients who underwent CO2 laser procedures for treatment of symptomatic burn scars and skin grafts at one accredited regional burn center. Burn injury and laser treatment demographics, as well as complications, are reported. A questionnaire was administered to all patients and included patient-reported outcome measures aimed at understanding the patient experience and their subjective response to treatment. A total of 387 CO2 laser procedures were performed on 131 patients for the treatment of symptomatic burn scars and skin grafts between October 1, 2011, and May 1, 2014 (average, 2.95 procedures/patient; range, 1-11). Average time between injury and first laser was 597.35 days (range, 60-13,475). Average time between laser treatments (when multiple) was 117.73 days (range, 22-514). There were no infections requiring treatment with oral antibiotics. Overall patient satisfaction with laser therapy was 96.7%. Patients reported reductions in neuropathic pain, tightness (contracture), and pruritus (54.0, 50.6, and 49.0%, respectively). Fractional photothermolysis utilizing the CO2 laser is a safe and effective modality for the treatment of symptomatic burn scars, donor sites, and skin grafts. Patient satisfaction with this procedure is high, and complications are low. Significant improvements in scar appearance, pliability, tightness, neuropathic pain, and pruritus were commonly reported.
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Bayram Y, Sahin C, Sever C, Karagoz H, Kulahci Y. Custom-made approach to a patient with post-burn breast deformity. Indian J Plast Surg 2014; 47:127-31. [PMID: 24987218 PMCID: PMC4075201 DOI: 10.4103/0970-0358.129646] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Second and third degree burns on breasts at preadolescent period may cause severe breast deformations. This deformation can be variable depending on severity and location of the burns, personal adolescent patterns, and treatment modality in acute burn period. A 21 year old female patient admitted to our department for her breast deformation due to burn contracture at the inferior pole of the right breast. On physical examination we defined that development of the volume of the right breast was equal to the left, and inferior pole of the right breast was flattened due to contracture, and nipple was projected to inferior. We found that inframammary crease of the right breast was 2 cm lower than that of left; andthe distance of nipple-inframamary crease was 4.7 cm while areola-inframmary crease was 2 cm. New nipple-areola complex level was identified according to left breast's level. Medial and lateral lines were planned to merge inferiorly at 2 cm above inframmary crease in a plan similar to vertical mammaplasty. Superior pedicle carrying nipple areola was desepitelised. Lower parenchymal V flap was transposed superiorly and attached to the pectoral muscle. Inferior parts of the lateral and medial glandular flaps were excised to form new inframammary crease. The desired laxity of skin at the lower pole was obtained by performing a new Z- plasty between lateral and medial skin flaps. Breast symmetry was confirmed by postoperative objective measurements between left and right breasts. Patient's satisfaction and aesthetic appearance levels were high. Breasts deformation patterns caused by burns, trauma and mass exsicion due to cancer could not be addressed with traditional defined techniques. Special deformations can be corrected by custom made plannings as we presented here.
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Affiliation(s)
- Yalcin Bayram
- Departments of Plastic Reconstructive and Aesthetic Surgery and Burn Unit, Gulhane Military Medical Academy, Ankara, Turkey
| | - Cihan Sahin
- Departments of Plastic Reconstructive and Aesthetic Surgery and Burn Unit, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Kadikoy, Istanbul, Turkey
| | - Celalettin Sever
- Departments of Plastic Reconstructive and Aesthetic Surgery and Burn Unit, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Kadikoy, Istanbul, Turkey
| | - Huseyin Karagoz
- Departments of Plastic Reconstructive and Aesthetic Surgery and Burn Unit, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Kadikoy, Istanbul, Turkey
| | - Yalcin Kulahci
- Department of Hand and Upper Extremity Surgery, Gulhane Military Medical Academy, Ankara, Turkey
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Ablative Fractional Photothermolysis for the Treatment of Hypertrophic Burn Scars in Adult and Pediatric Patients. J Burn Care Res 2014; 35:455-63. [DOI: 10.1097/bcr.0000000000000028] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Narinesingh S, Lewis S, Nayak BS. Use of 1540nm fractionated erbium:glass laser for split skin graft resurfacing: a case study. J Wound Care 2013; 22:510-3. [PMID: 24005785 DOI: 10.12968/jowc.2013.22.9.510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The field of laser skin resurfacing has evolved rapidly over the past two decades from ablative lasers, to nonablative systems using near-infrared, intense-pulsed light and radio-frequency systems, and most recently fractional laser resurfacing. Although fractional thermolysis is still in its infancy, its efficacy in in the treatment of skin disorders have been clearly demonstrated. Here we present a case report on the safety and efficacy of a 1540nm erbium:glass laser in the treatment of the waffle pattern of a meshed skin graft in a 38-year-old patient with type V skin in the Caribbean.
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Affiliation(s)
- S Narinesingh
- Registrar, Department of Surgery, North Central Regional Health Authority, EWMSC, Trinidad
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