How to assess postsurgical scars: a review of outcome measures

Analysis of trends and status of evaluation methods in thyroid scar

Background

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

Methods

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

Results

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

Conclusion

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

Knowledge and Practice of Scar Treatment Among Health Care Physicians in Saudi Arabia

Background The processes of wound healing and scar formation are complex phenomena that are determined by an intricate interplay of molecules and cells. A deviation from the anticipated trajectory of scarring can lead to the formation of hypertrophic scars and keloids. A wide range of therapeutic methodologies have been employed in the treatment of scars. This research paper seeks to enhance patient outcomes and the efficacy of scar repair as a whole by determining the knowledge of scar treatment and implementation in clinical practice in Saudi Arabia and thereby incorporating scientific findings into practical settings. Materials and methods This cross-sectional study, which included 237 participants, aimed to provide descriptive data on the knowledge and common practice of Saudi Arabian healthcare physicians with regard to scar prevention, treatment, and evaluation during the period from November 15, 2023, to December 11, 2023. Results In routine clinical practice, the most commonly employed subjective method for scar assessment is patient and observer scar assessment (162 (68.4%)) while the Modified Vancouver Scar Scale (91 (38.4%)) was commonly used for research purposes. However two-dimensional photography is the most frequently employed objective method in clinical practice (54 (22.8%)) and biomechanical properties (58 (24.5%)) for research purposes. Silicone scar therapy in the form of sheets or gel is the primary preventive measure in the prevention of keloids/hypertrophic scars across various patient populations. Corticosteroid injections and silicone are primary interventions within the initial 18-month period. Conclusion Although significant progress has been made in the field of scar management, standardization of procedures and increased adherence to evidence-based guidelines are still required.

Clinical evaluation of post-surgical scar hyperaesthesia: a longitudinal observational pilot study

Introduction

The mechanisms underlying persistent scar pain are not fully elucidated and evidence for the clinical evaluation of scar pain is limited. This pilot observational study investigated participation data and sought to identify objective clinical scar evaluation measures for future trials.

Methods

With ethical approval and consent, adults undergoing planned hand surgery were enrolled from one NHS hospital. At 1- and 4-months post-surgery scar thermal and mechanical pain thresholds were evaluated with quantitative sensory testing; peri-scar inflammation with infrared thermometry and pliability with durometry. Participation data were analysed with descriptive statistics; the association of clinical measures with patient reported scar pain was analysed.

Results

Twenty-one participants (22% eligible patients) enrolled before study closure due to the COVID-19 pandemic; 13 completed follow up. No adverse events or dropouts resulted from clinical scar evaluation. Seventy percent of participants reported undertaking topical, nonprescription scar treatment independently. Neuropathic Pain Symptom Inventory (NPSI) scores were dispersed across the score range, capturing variability in participant-reported scar symptoms. Scar morphology, pliability and inflammation were not associated with scar pain. Differences between scar and contralateral skin in thermal and mechanical pain sensitivity were identified.

Conclusion

People with acute hand scars participate in clinical research and independently initiate scar treatment. Clinical testing of acute post-surgical hand scars is well tolerated. The NPSI demonstrates utility for exploring scar pain symptoms and may support the elucidation of mechanisms of persistent scar pain. Clinical tests of thermal and mechanical and sensitivity are promising candidate clinical measures of scar pain for future trials.

Lay Summary

Background: it is unknown why some scars remain painful long-term. We do not know if scar flexibility, inflammation or sensitivity to temperature or pressure relate to scar pain. We investigated if patients would enrol in scar research, if scar testing was tolerated and if clinical tests are useful for future scar studies. Study conduct: with ethical approval and consent, adult hand surgery patients were enrolled from one NHS hospital. Scar pain, inflammation and response to thermal, sharp and pressure tests were assessed at 1- and 4-months after surgery. Statistically, we analysed study participation, tolerance for clinical scar tests and if the scar tests related to scar pain. Findings: 21 participants (22% eligible patients) enrolled before study closure due to the COVID-19 pandemic; 13 completed follow up. No participants were injured due to scar testing. 70% of participants reported treating their scar independently. Neuropathic Pain Symptom Inventory (NPSI) allows participants to give a broad range of answers about their scar symptoms. Scores for clinical tests of scar flexibility and inflammation did not relate to participant-reported scar pain. Scars were more sensitive to tests of pin prick and cold than unaffected skin. What we learned: people with new hand scars participate in research and independently initiate scar treatment. Clinical testing of post-surgical hand scars is well tolerated. The NPSI is useful for exploring scar pain symptoms and may help us to learn about persistent scar pain. Pinprick and cold clinical tests may be useful objective pain tests for future scar research.

Prospective Randomized Controlled Trial Comparing Absorbable and Nonabsorbable Sutures in A1 Pulley Release

BACKGROUND

Both absorbable and nonabsorbable sutures are used to correct palmar incisions or lacerations. Nonabsorbable sutures have been used without complications but require removal at a follow-up appointment. Alternatively, the use of absorbable sutures has increased in popularity as postoperative suture removal is not required but is associated with local immunological and inflammatory responses. In this study, we compared the scar quality and outcomes of nonabsorbable and absorbable sutures in A1 pulley release.

METHODS

Patients who underwent A1 pulley release were randomized to 1 of 2 suture materials. The Patient Scar Assessment Scale, Observer Scar Assessment Scale, Visual Analogue Scale, and Disabilities of the Arm, Shoulder, and Hand scores were collected at 2, 6, and 12 weeks postoperatively. Among the 41 patients included in the study, 23 were randomized to the nonabsorbable suture group, and 18 to the absorbable suture group.

RESULTS

There were no significant differences between the two suture groups in the aforementioned assessments. Complication rates were higher in the nonabsorbable suture group, but the difference was not statistically significant. Notably, 1 case in the absorbable suture group had uncontrolled postoperative bleeding and required reoperation.

CONCLUSION

We found no significant difference between the two materials in terms of the Patient or Observer Scar Assessment Scales, overall complication rates, symptom scores, or pain scores. Therefore, the choice using absorbable or nonabsorbable can be guided by other factors such as physician or patient preference, availability, and cost.

Quantitative evaluation of pediatric umbilical loop stomas: 2 decades of experience from a single institution

PURPOSE

Since pediatric stomas are often temporary, their creation, management, and closure should be simple, with minimal complications and excellent cosmetic results. We began employing umbilical stomas in 2000. This study aimed to characterize the ingenuity and utility of umbilical stomas and provide a quantitative evaluation of their cosmetic outcomes.

METHODS

We examined cases of stoma construction and closure surgery performed in our department from January 2000 to December 2022. The umbilical and non-umbilical stoma groups included 54 and 42 cases, respectively, and the findings for both groups were compared and analyzed.

RESULTS

The two groups showed no significant differences in the incidence of complications. The Manchester Scar Scale score for the umbilical stoma group (8.42 ± 1.85) was significantly better than that for the non-umbilical stoma group (16.31 ± 2.96; P < 0.01). Likewise, in Patient and Observer Scar Assessment Scale assessments, the umbilical stoma group showed significantly better scores in both the observer scale (9.48 ± 2.50 vs. 21.78 ± 7.26; P < 0.01) and the patient scale (10.5 ± 1.39 vs. 22.40 ± 7.35; P < 0.01).

CONCLUSIONS

Umbilical stomas are easy to manage and yield an inconspicuous closure incision with excellent cosmetic outcomes. Although patient selection is important, pediatric umbilical stomas are a valuable option that can be actively employed.

InCISE: Instrument for Comprehensive Incisional and Surgical Evaluation

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2166-2173, 2023.

Surgical treatment of septic arthritis of the hip in children: arthrotomy compared with repeated aspiration-lavage

PURPOSE

To review two cohorts of children treated by two different protocols (repeated needle aspiration-lavage vs. arthrotomy) for surgical treatment of septic arthritis of the hip (SAH).

METHODS

In order to compare between the two methods, the following parameters were checked: (a) Scar cosmesis was assessed by the Patient and Observer Scar Assessment Scale (POSAS). We considered satisfactory results (no scar discomfort) when POSAS was within 10% of the ideal score; (b) 24-h post-operative pain was evaluated by visual analog scale (VAS); (c) Complication rates of incomplete drainage (re-arthrotomy/therapy modification from aspiration-lavage to arthrotomy). The results were evaluated by the Student t-test or by the chi-square test.

RESULTS

Seventy-nine children (aged 2-14 years) admitted during 2009-2018 and available for at least two years of follow-up were enrolled. The POSAS score (range 12-120 points) at the latest follow-up was higher in the arthrotomy group compared with the aspiration-lavage group (18.10 ± 6.22 versus 12.27 ± 1.40, p < 0.001); 77.4% of patients treated by arthrotomy had no scar discomfort. The 24-h post-intervention VAS (range 1-10) was 5.06 ± 1.29 after arthrotomy and 4.03 ± 1.13 after aspiration-lavage, p < 0.04. Complications were three times more frequent in the aspiration-lavage group (8.8% in the arthrotomy group and 26.7% in the aspiration-lavage group, p = 0.045).

CONCLUSIONS

We conclude that the lower complication rate observed in the arthrotomy group outweighs by far scar cosmesis and post-operative pain advantages in the aspiration-lavage group. Arthrotomy as a drainage method is safer than aspiration-lavage.

Towards the Development of a Device for Assessing the Pliability of Burn Scars

Burn injuries requires post-accident medical treatment. However, the treatment of burns does not end with first aid because scarred skin must be managed for many years, and in some circumstances, for life. The methods used to evaluate the state of a burn scar based, for instance, on Patient and Observer Scar Assessment Scale or similar ones, often lacks in univocally assessing the scarred skin’s state of health. As a result, the primary aim of this research is to design and build a prototype that can support the doctor during scar assessment, and eventually therapy, by providing objective information on the state of the lesion, particularly the value of skin pliability. The developed tool is based on the depressomassage treatment probe named LPG, currently used to treat burn scars in a number of hospitals. It consists of a non-invasive massage technique using a mechanical device to suction and mobilize scar tissue and is used as a post-operative treatment to speed up the healing process to make the mark of the scar less visible. The prototype is specifically designed to be manufactured using Additive Manufacturing and was validated comparing its performances against the ones of a certified instrument (i.e., the Romer Absolute ARM with RS1 probe). Validation was carried out by designing and developing a tool to put the RS1 probe in the same measurement conditions of the new prototype probe. Tests performed to assess the performance of the devised prototype show that the probe developed in this work is able to provide measurements with a sufficient degree of accuracy (maximum error ±0.1 mm) to be adopted for a reliable estimation of the pliability value in a hospital environment.

Comparing running vs interrupted sutures for skin closure: A systematic review and meta-analysis

Continuous sutures and interrupted sutures have been widely applied to skin closure after non-obstetric surgery or traumatic wounds. Usually, continuous sutures were divided into transdermal or subcuticular sutures according to whether the stitches were placed through or below the epidermal layer. Interrupted sutures, on the other hand, involved penetration of the loose connective tissue beneath the skin layers, with stitches placed through the external skin layer. Complications including infection, dehiscence, and poor cosmetic appearance were not rare after suturing. Whether a suture method is a suitable option for rapid wound healing and long-term cosmetic appearance remains controversial. To examine the potential benefits and harms of continuous skin sutures vs interrupted skin sutures in non-obstetric surgery or traumatic wounds. Searching websites such as PubMed, the Cochrane Central Library, Web of Science and Embase, and ClinicalTrials.gov were systematically searched up to 5 January 2022 and were assessed and guided by Preferred Reporting Items for Systematic Reviews and Meta-analysis rules as well as guidelines. All relevant randomised controlled studies comparing continuous sutures with interrupted sutures of skin closure were analysed. The suture techniques and material used in each trial were recorded. The transdermal and subcuticular continuous sutures were separately compared with interrupted sutures in the subgroup analysis of dehiscence and cosmetic appearance because the visual appearance of these two continuous suturing techniques was significantly different. Ten studies including 1181 participants were analysed. Subcuticular continuous sutures had comparatively higher visual analogue scale (VAS) scores among patients and doctors than interrupted sutures (OR = 0.27, 95% Confidence Intervals [CI] = 0. 07-0.47, P < .01). Similarly, priority was found regarding transdermal continuous sutures and interrupted sutures (OR = 0.40, 95% CI = 0.21-0.60, P < .01). Five randomised controlled trials (RCTs) demonstrated relevant data about dehiscence events. The incidence of continuous suture was significantly lesser than that of interrupted suture (OR = 0.16, 95% CI = 0.07-0.37, P < .01). There was no significant difference between the infection events rates of two suture methods (OR = 0.69, 95% CI = 0.40-1.21, P = .62, I²  = 0%). This systematic review indicated the superiority of both transdermal and subcutaneous continuous sutures over interrupted sutures in skin closure in terms of wound healing and cosmetic appearance.

Exploring the Effects of Standardized Soft Tissue Mobilization on the Viscoelastic Properties, Pressure Pain Thresholds, and Tactile Pressure Thresholds of the Cesarean Section Scar

Background:

Objectives of soft tissue mobilization applied to cesarean section (C-section) scars are to decrease stiffness and to reduce pain. Research investigating these effects is lacking.

Materials and methods:

The authors conducted a descriptive, exploratory, proof-of-concept clinical study. Women aged 18 to 40 years who had undergone at least one C-section were recruited. A trained osteopath performed standardized mobilization of the C-section scar once a week for 2 weeks. Scar quality and pain characteristics, viscoelastic properties, pressure pain thresholds, and tactile pressure thresholds were measured before and after each session. Paired Student's t-tests and Friedman's test with Dunn–Bonferroni adjustment were performed to assess the immediate and short-term effects of mobilizations. Kendall's W and Cohen's d were calculated to determine effect sizes over the short term. Simple bootstrapped bias-corrected and accelerated 95% median confidence intervals were computed.

Results:

Thirty-two participants completed the study. The Patient and Observer Scar Assessment Scale questionnaire revealed differences with small and moderate effects for stiffness (p = 0.021, d = 0.43), relief (p < 0.001, d = 0.28), surface area (p = 0.040, d = 0.36), flexibility (p = 0.007, d = 0.52), and participant opinion (p = 0.001, d = 0.62). Mobilizations increased elasticity (p < 0.001, W = 0.11), decreased stiffness (p < 0.001, W = 0.30), and improved pressure pain thresholds (p < 0.001, W = 0.10) of the C-section, with small to moderate effects. The results also showed decreased tone and mechanical stress relaxation time, as well as increased tactile pressure thresholds at the different measurement times (p < 0.05), but trivial effect sizes (W < 0.10). Creep showed trivial effect and no significant difference (p = 0.09).

Conclusion:

This study showed that two sessions of mobilization of C-section scar might have a beneficial effect on some viscoelastic properties of the C-section as well as on pain. Some variables of interest useful for future empirical studies are highlighted.

ClinicalTrial. Gov NCT04320355.

Analysis of Study Designs and Primary Outcome Measures in Clinical Trials of Investigational Suture Materials

BACKGROUND

Clinical trials are a prerequisite for any investigational suture materials before a market approval application. The appropriate study designs and primary outcome measures are key to the validity and reliability of clinical trial results. This study aimed to characterize the study designs and primary outcome measures being applied in clinical trials of investigational suture materials.

METHODS

The systematic searches on PubMed, EMBASE, Web of Sciences, Scopus, and Cochrane databases were conducted to gather relevant studies published between January-2019 and May-2021. Data on general characteristics, suture intervention, study design, and primary outcome measures were extracted and analyzed.

RESULTS

Of 46 included studies, the majority of them were conducted with a randomized-controlled (93.5%), single-blind (50.0%), two-arm (84.8%), and parallel (76.1%) design with a 1:1 allocation ratio (95.7%). Through correlation network and heatmap analysis, the moderate-to-very strong correlations between some types of investigational suture materials and primary outcome measures were found including barbed vs non-barbed suture and suturing time, antibacterial-coated vs non-coated suture and wound infection, mono- vs multi-filament suture and wound healing index/markers, and different sizes of suture materials and scar assessment.

CONCLUSIONS

Our analysis provides guidance, with several key considerations, for designing a clinical trial evaluating investigational suture materials.

A Systematic Review And Meta-Analysis: Botulinum Toxin A Effect on Postoperative Facial Scar Prevention

BACKGROUND

Postoperative facial scarring can be a significant psychological burden for patients to carry after surgery, often resulting in prolonged mental health dysfunction. Currently, there is no established method to prevent facial scar formation; however, there are several methods to prevent facial scar hyperplasia and improve scar quality. Botulinum toxin A (BTA) has been widely used due to its properties of muscle paralysis and known success in plastic surgery and cosmetology. This meta-analysis aimed to evaluate the efficacy of BTA in preventing postoperative facial scar hyperplasia and improving scar quality.

METHODS

PubMed, MEDLINE, EMBASE, web of science, and Cochrane libraries were searched for randomized controlled trials (RCTs) (published before May 2021) wherein BTA was used for the treatment of facial scars. The efficacy and safety of BTA were evaluated by the following scales: the Vancouver Scar Scale (VSS), Visual Analog Scale (VAS), Observer Scar Assessment Scale (OSAS), Patient Scar Assessment Scale (PSAS), and Stony Brook Scar Evaluation Scale (SBSES); the BTA effect on scar width and complications was also assessed.

RESULTS

Ten RCTs involving 114 cases were included. Through quantitative analysis, the BTA injection group had a higher VAS score, lower VSS score, lower OSAS score, and smaller scar width. However, no significant difference was noted in the incidence of postoperative complications between the two groups.

CONCLUSIONS

This meta-analysis demonstrated that BTA can safely improve the appearance of postoperative facial scars by significantly inhibiting scar hyperplasia and improving scar quality.

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 .

Negative-pressure wound therapy after stoma reversal in colorectal surgery: a randomized controlled trial

Background

Stoma-reversal surgery is associated with high postoperative morbidity, including wound complications and surgical-site infections (SSIs). This study aims to assess whether the application of negative-pressure wound therapy (NPWT) can improve wound healing compared with conventional wound dressing.

Methods

This was a single-centre, superiority, open-label, parallel, individually randomized controlled trial. Patients undergoing stoma reversal were randomized (1 : 1) to receive NPWT or conventional wound dressing. The primary endpoint of the study was the rate of wound complications and SSIs after stoma closure. The secondary endpoints were postoperative wound pain, rate of wound healing after 30 days from stoma closure, and wound aesthetic satisfaction.

Results

Between June 2019 and January 2021, 50 patients were allocated to the NPWT group (all received NPWT, 49 were analysed); 50 patients were allocated to the conventional wound dressing group (48 received the treatment, 45 were analysed). No significant difference was found in wound-complication rate (10 per cent NPWT versus 16 per cent controls; odds ratio 0.61 (95 per cent c.i. 0.18 to 2.10), P = 0.542) and incisional SSI rate (8 per cent NPWT versus 7 per cent controls; odds ratio 1.24 (95 per cent c.i. 0.26 to 5.99), P = 1.000). The NPWT group showed less pain, higher aesthetic satisfaction (P < 0.0001), and a higher proportion of wound healing (92 versus 78 per cent; P = 0.081) compared with the control group.

Conclusion

NPWT does not reduce the incidence of SSI after stoma-reversal surgery compared with conventional wound dressing. However, NPWT improved the healing of uninfected wounds, reduced wound pain and led to better aesthetic outcomes.

Registration number: NCT037812016 (clinicaltrials.gov).

Cross-cultural adaptation into French and validation of the SCAR-Q questionnaire

PURPOSE

Most questionnaires designed to evaluate patient-reported outcomes regarding scarring are available in English. The objective was to generate a validated French version of the SCAR-Q questionnaire.

METHODS

The SCAR-Q questionnaire (including Appearance, Symptom and Psychological impact scales) was translated into French using a translation-back-translation process in accordance with international guidelines (ISPOR and WHO). For validation, two hundred patients consulting in our tertiary center completed the questionnaire. We tested scale reliability (Cronbach's α), floor/ceiling effects and item redundancy (inter-item correlations). Structural validity was tested using confirmatory factor analysis (CFA) with the robust weighted least squares (WLSMV) estimator and Delta parameterization. Model fit was examined using the root mean square error of approximation (RMSEA), the comparative fit index (CFI) and the Tucker-Lewis index (TLI). Correlations between scales and scale repeatability were tested (Spearman coefficient, Intra-class-coefficient).

RESULTS

Four steps were required to obtain a translation consistent with the original version. Two hundred patients completed the questionnaire for validation. Internal consistency analysis found Cronbach's alphas > 0.7 for all scales (0.90 < α < 0.97). No floor or ceiling effect was found for all items (max = 85%). A ceiling effect was observed for all scales. Appearance and psychosocial impact scale items showed redundancy, with many inter-item correlations above 0.7. The CFA of the original structure displayed a reasonable fit, with RMSEA = 0.065, CFI = 0.974 and TLI = 0.972. Scales were positively correlated (0.45 <  ρ < 0.65; p < 0.001). Test-retest intra-class correlation coefficients ranged from 0.94 to 0.99 for all scales.

CONCLUSION

A French version of the SCAR-Q questionnaire is validated, ready for use.

Validating Grading of Aesthetic Outcomes of Web Space Reconstruction for Finger Syndactyly: Crowdsourcing Public Perceptions Using Amazon Mechanical Turk

BACKGROUND

It has recently been attempted in the literature to analyze the aesthetic outcomes of syndactyly web space reconstruction utilizing dorsal pentagonal advancement flaps and dorsal rectangular flaps with skin grafting. The study utilized a categorical grading system for evaluating the aesthetic outcomes of reconstruction to be used in conjunction with a visual analog scale (VAS), which has yet to be validated in the assessment of aesthetic outcomes following web space reconstruction.

OBJECTIVES

To utilize crowdsourced public perceptions to validate the grading of aesthetic outcomes in web space reconstruction for finger syndactyly.

METHODS

A prospective study was conducted of random volunteers recruited through an internet crowdsourcing service to gain responses for a survey to analyze patient opinions toward the aesthetic outcomes of web space reconstruction. Outcomes were graded based on descriptions of the appearance, color, matte, and distortion of the reconstruction.

RESULTS

The excellent dorsal flap demonstrated a mean VAS score of 6.66 (95% confidence interval [CI] = 6.45-6.87), and the very good, good, and poor dorsal flaps had mean VAS scores of 5.94 (95% CI = 5.73-6.15), 4.98 (95% CI = 4.77-5.19), and 3.55 (95% CI = 3.31-3.79), respectively. The odds ratio for receiving an excellent rating was 4.21 (95% CI = 3.04-5.82) for excellent dorsal flap with P < 0.0001.

CONCLUSIONS

This study confirms and validates the assessment of aesthetic outcomes of web space reconstruction by the Yuan Grading Scale. This evidence may guide future practice such that recommendations can be made to align with the aesthetic preferences of the patient.

A Prospective, Single-Blinded, Bicentric Study, and Literature Review to Assess the Need of C2-Ganglion Preservation - SAVIOUR's Criteria

Objective

Joint manipulation for craniovertebral junction instability is often hindered by the C2-ganglion (C2G). Our study aims to compare the surgical outcome among patients with or without C2G preservation and discuss the technical nuances.

Methods

We did a prospective, bicentric study and included all the operated patients with craniovertebral junction anomaly. The outcome was assessed by the Pain Numeric Rating Scale, Patient Satisfactions Score, and Stony Brook Scar Evaluation Scale. The fusion was assessed using Lenke fusion grade.

Results

One hundred seventy-one patients (88 in group A and 83 in group B) were included. The most common symptom was spastic quadriparesis (n = 165, 96.5%) with median Nurick grade 3.3. Thirteen patients had suboccipital numbness and 12 patients had paraesthesia. Mean blood loss in group A was 490 ± 96.2 mL and group B was 525 ± 45.7 mL; median operative time was 217.9 and 162.2 minutes in the groups A and B, respectively (p < 0.05). At the follow-up (median, 46.8 months), Lenke fusion grade A was achieved in 92.4% and grade B in 7.6%. A trend suggesting better functional outcomes (numbness, parestheisa, scar outcome, and postoperative ulcer formation) in group A was seen with all 6 patients, who underwent O-C2 fixation, developed pressure sore.

Conclusion

Our results support ganglion preservation, especially in the subset of patients where occipital plating is required. Although the study fails to show any statistical significance, we suggest that one should always start with an ‘intent’ of preservation as the functional outcome is better.

Intra- and inter-evaluator reliability of the MyotonPRO for the assessment of the viscoelastic properties of caesarean section scar and unscarred skin

BACKGROUND

The clinical evaluation of viscoelastic properties of the Caesarean section (C-section) scar, such as stiffness and elasticity, is usually carried out using subjective scales and palpation techniques. There is currently no reliable and valid tool that objectively quantifies these properties. The MyotonPRO could fill this gap.

MATERIALS AND METHODS

Nineteen healthy women aged between 21 and 40 years with C-section scars participated in this reliability study. Two points, one on the scar and one on unscarred skin, were measured four times successively with the MyotonPRO by three independent evaluators on the same day. The intra-class correlation (ICC) coefficients were estimated using a two-factor ANOVA to determine the inter- and intra-rater reliability. The capacity of the MyotonPRO to discriminate the viscoelastic properties of the C-Section scar against unscarred skin was assessed using the Wilcoxon signed rank test.

RESULTS

The intra- and inter-rater reliability of the viscoelastic property measurements was good to excellent (ICC 0.99-1.00 and 0.87-0.98, respectively). There was no significant difference between C-section scar and unscarred skin in terms of elasticity (P = .737). Significant differences between C-section scars and unscarred skin tissue were observed for tone (P < .001), stiffness (P < .001), creep (P < .001), and mechanical stress relaxation time (P < .001).

CONCLUSION

The MyotonPRO is a reliable tool for an objective measurement of the viscoelastic properties of the C-section scar and unscarred skin. The MyotonPRO can discriminate the viscoelastic properties of the C-section scar against the unscarred skin, for tone, stiffness, creep and relaxation times, but not for elasticity.

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.

Surgical treatment of children and youth with congenital melanocytic nevi: self- and proxy-reported opinions

PURPOSE

The role of surgery in the management of congenital melanocytic nevi (CMN) is controversial. Data on surgical outcomes and predictors of satisfaction remain scarce.

METHODS

An online survey was employed following worldwide recruitment of youth aged 14-25 years (n = 44) and parents of children ≤ 18 years (n = 249) with CMN to query patterns of treatment and satisfaction with and opinions about the benefits of surgery.

RESULTS

In proxy-reports, 121 of 249 (49%) and in self-reports 30 of 44 (75%) participants underwent CMN excision. The most common reasons for surgery were psychosocial determinants, aesthetic improvement, and melanoma risk reduction. The overall satisfaction with surgical management was good, although no predictors for satisfaction could be identified. Higher current age of the child was found to predict decision regret in proxy-reports. Most participants indicated that having a scar is more socially acceptable than a CMN. Opinions differed on whether surgery should be deferred until the child is old enough to be involved in the decision-making process.

CONCLUSIONS

Whether and when to perform surgery in children with CMN is a multifaceted question. Awareness of common concerns as well as risks and benefits of surgery are essential to ensure critical reflection and balanced decision-making.

The Patient and Observer Scar Assessment Scale: Translation for portuguese language, cultural adaptation, and validation

Evaluating scars is fundamental to analyse the outcome of treatments that include surgical intervention. Scales facilitate this type of assessment, but most of these measuring instruments are in different languages. The Patient and Observer Scar Assessment Scale (POSAS) is one of the most robust instruments available in the literature for the evaluation of scars, although there is no validated version in Brazilian Portuguese. The aims of this study were to culturally translate and validate POSAS for the Portuguese language of Brazil and to test its reproducibility, face validity, content, and construct. Following the methodology proposed by Beaton DE, Bombardier C, Guillemin F, Ferraz, MB, Spine 2000, 25, 3186, the questionnaire was translated and adapted to the Brazilian culture. The reproducibility, face, content, and construct validity were then analysed. In all, the scale was applied to 35 patients with postoperative scars (patient version) and 35 hand surgery specialists (version for the observer). The internal consistency was tested by Cronbach's alpha, and construct validation was performed by correlating the translated instrument with the Brazilian Portuguese translation of the Vancouver Scar Scale (VSS). The cultural adaptation of POSAS Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/UNIFESP) was confirmed. Both subscales showed strong internal consistency (Cronbach's α = 0.77-0.93), demonstrating reliability. The reproducibility was excellent, and the adapted scale demonstrated significant intra- and inter-observer reproducibility (r > 0.9) (P < 0.05). The validity of the construct was significant and showed good sensitivity between POSAS EMP/UNIFESP and the VSS. This study confirmed that POSAS EPM/UNIFESP can be used to evaluate patients with surgical scars in the Brazilian population. It has proven to be useful for clinical and research purposes, lending itself to capturing medical opinions and those of the patients themselves.

Drainage tube hole suture improvement: Removal-free stitches

Surgical method improvements aim to optimize the patient experience. The problem of healing of the drainage tube hole has not received attention and is of concern because it can plague patient recovery. In this article we report on how we have improved the method of suturing the drainage tube hole and explore the safety and effectiveness of this method. Between December 2017 to August 2018, 102 patients underwent thoracoscopic lung resection (single port or single utility port) using different methods of suturing drainage tube holes. The intervention group received improved methods with subcuticular and intradermal suture and removal-free stitches, whilst the control group received a conventional mattress suture and fixed chest tube. A preset line was left to tie knots and close the hole after the removal of the chest tube. The stitches were removed 7-12 days after surgery. The baseline clinical features of the patients were subsequently analyzed. The objective and subjective conditions of scars were evaluated using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS) at one month after surgery. The intervention group (n = 71) and control group (n = 31) had balanced baseline clinical characteristics. There were no significant differences between the two groups in terms of three-day postoperative pain and postoperative hospital stay. In the intervention group, three patients (4.23%) had wound splitting that required re-suturing, which was better than five patients (16.13%) in the control group (P < 0.05). The incidence of pleural fluid outflow, wound infection, post-removal pneumothorax, chest tube prolapse and incisional hernia were not different between the two groups. We conclude that the objective and subjective evaluation results of scars were significantly different between the two groups (P < 0.05), and the experimental group was superior to the control group. A balanced result between aesthetic appearance and safety as regards video-assisted thoracic surgery can be achieved through the chest tube hole improved suture method. This method also improves the patient's recovery experience.

A dose-ranging, parallel group, split-face, single-blind phase II study of light emitting diode-red light (LED-RL) for skin scarring prevention: study protocol for a randomized controlled trial

BACKGROUND

Skin fibrosis is a significant global health problem that affects over 100 million people annually and has a profoundly negative impact on quality of life. Characterized by excessive fibroblast proliferation and collagen deposition, skin fibrosis underlies a wide spectrum of dermatologic conditions ranging from pathologic scars secondary to injury (e.g., burns, surgery, trauma) to immune-mediated diseases. Effective anti-scarring therapeutics remain an unmet need, underscoring the importance of developing novel approaches to treat and prevent skin fibrosis. Our in vitro data show that light emitting diode-red light (LED-RL) can modulate key cellular and molecular processes involved in skin fibrosis. In two phase I clinical trials (STARS 1 and STARS 2), we demonstrated the safety and tolerability of LED-RL at fluences of 160 J/cm² up to 480 J/cm² on normal human skin.

METHODS/DESIGN

CURES (Cutaneous Understanding of Red-light Efficacy on Scarring) is a dose-ranging, randomized, parallel group, split-face, single-blind, mock-controlled phase II study to evaluate the efficacy of LED-RL to limit post-surgical skin fibrosis in subjects undergoing elective mini-facelift surgery. Thirty subjects will be randomly allocated to three treatment groups to receive LED-RL phototherapy or temperature-matched mock irradiation (control) to either periauricular incision site at fluences of 160 J/cm², 320 J/cm², or 480 J/cm². Starting one week post-surgery (postoperative days 4-8), treatments will be administered three times weekly for three consecutive weeks, followed by efficacy assessments at 30 days, 3 months, and 6 months. The primary endpoint is the difference in scar pliability between LED-RL-treated and control sites as determined by skin elasticity and induration measurements. Secondary outcomes include clinical and photographic evaluations of scars, 3D skin imaging analysis, histological and molecular analyses, and adverse events.

DISCUSSION

LED-RL is a therapeutic modality of increasing importance in dermatology, and has the potential to limit skin fibrosis clinically by decreasing dermal fibroblast activity and collagen production. The administration of LED-RL phototherapy in the early postoperative period may optimize wound healing and prevent excessive scarring. The results from this study may change the current treatment paradigm for fibrotic skin diseases and help to pioneer LED-RL as a safe, non-invasive, cost-effective, portable, at-home therapy for scars.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03795116 . Registered on 20 December 2018.

Translation and cultural adaptation of an Arabic version of the patient scar assessment scale for thyroidectomy patients

Objectives:

To translate and validate an Arabic version of the patient scar assessment scale (PSAS). The cosmetic appearance of a thyroidectomy scar can critically influence a patient’s self-esteem. Moreover, scar evaluation tools are necessary for an evidence-based approach to scar management.

Methods:

This quantitative, observational, cross-sectional study was conducted by administering an Arabic-translated version of the PSAS. The translation process included a forward translation into Arabic by 3 fluently bilingual otolaryngologists, a back-translation into English, and a comparison with the original items. The questionnaires were distributed to patients who underwent thyroidectomies. We included patients who underwent surgery at least 2 months previously.

Results:

A total of 50 patients were included in this research. The internal consistency was 0.89, with a 95% confidence interval (CI) of 0.88-0.90. The score distributions showed high correlations for all items. The Arabic-translated PSAS showed good test-retest reliability, and the Pearson correlation coefficient between the test and retest administrations was 0.84 (p<0.001). With a possible range of 6-60 points, the standard error of the mean was 5.14, and the minimal detectable change was 14.2.

Conclusion:

This Arabic version of the PSAS was reliable for use in Arabic-speaking communities. It will allow for comparisons between the results of investigations conducted in different countries, which aids in the exchange of information within the international scientific community.

Prospective international multicenter observational study of Novosyn® Quick for skin closures in adults and children (SKINNOQ)

Background

This clinical trial evaluated the performance of a newly released fast-absorbable braided synthetic suture (Novosyn® Quick) in adults and paediatric patients undergoing elective skin closures.

Methods

This was a prospective international multicentre observational study. Two centres enrolled 100 patients, of which 50 were adults (visceral surgery, France) and 50 were paediatric patients (paediatric surgery, Germany). Surgeons used a 5-point Likert scale to assess handling characteristics of the suture. Patients and professionals used the Patient-Observer-Scar-Assessment-Scale (POSAS) to rate scar quality. Adverse events were monitored until 3 months postoperatively.

Results

Handling characteristics of Novosyn® Quick were in median rated very good by both general surgeons and paediatric surgeons. Patient components of POSAS (six questions; ten-level Likert scale; best possible score six) scored in median (range) 8.5 (6–28) in the paediatric group versus 12 (6–38) in the adult group, P = 0.01. Patients` overall opinions of POSAS were similar in both groups [mean (SD), 1.86 (0.99) in the paediatric group versus 2.08 (1.35) in the adult group, P = 0.3536]. Observer component of POSAS (six parameters; ten-level numeric rating scale, best possible score six) scored comparably in both groups [median (range), 8 (6–29) in the paediatric group versus 10 (6–28) in the adult group, P = 0.1403]. Observers overall opinion of POSAS favoured the paediatric patients group [mean (SD), 1.48 (0.61) versus 1.92 (1.06) in the adult group, P = 0.0131]. Adverse events in relation to wound healing were not observed in both patient groups.

Conclusions

Our findings indicate, that Novosyn® Quick is safe and reliable for skin closure in adults and paediatric patients and can be regarded as a viable alternative to Vicryl® Rapide.

Trial registration

This trial was registered prospectively with ClinicalTrials.gov under the registration number NCT02680886 on 5 February 2016.

The trial was approved by the Institutional Review Boards of both study locations (France: CCTIRS N° 16–103 and CNIL:MMS/CWR/AR163920; Germany: 398/15).

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0506-8) contains supplementary material, which is available to authorized users.

Objective and Patient-reported Assessments of Skin Grafts and Keystone Flaps-A Pilot Retrospective Cohort Study

Background:

The keystone perforator island flap provides a versatile form of reconstruction. Perceived benefits include better donor-recipient color match, less contour defect, and fewer complications. To date, there has been no high-quality evidence comparing keystone flaps to split-thickness skin grafts (SSG) from both a qualitative and quantitative point of view.

Methods:

The Objective and Patient Reported Assessments of Skin grafts versus Keystone flap cohort study compares keystone flaps with SSGs for the reconstruction of skin cancer defects. Patient-reported outcome measures were collected using the EuroQol 5 dimension scale and Patient and Observer Scar Assessment Scale (POSAS) questionnaires. Objective assessments of skin quality were assessed with the Courage and Khazaka system. Cost analysis was also performed.

Results:

Thirty-eight patients were studied: 20 keystone flaps and 18 SSGs. The keystone group had higher EuroQol 5 dimension scale scores (keystone median = 1.0; SSG median = 0.832; P = 0.641) indicating better general quality of life and lower POSAS scores indicating better disease/condition specific quality of life (keystone mean = 27.7; SSG mean = 35.7; P = 0.323). Observer POSAS scores were significantly lower in the keystone group compared with the SSG group (keystone mean = 10.889; SSG mean = 17.313; P < 0.001). Preservation of sensation was significantly better in keystone flaps (P = 0.006). There was an average £158/$207 (15%) saving when performing a keystone flap.

Conclusion:

This pilot study demonstrates a number of possible benefits of keystone flaps over SSGs. The results demonstrate the need for further research comparing these reconstructive options. We propose a prospective, controlled study using the methods developed in this pilot study.

Aesthetic Comparison of Two Different Types of Web-Space Reconstruction for Finger Syndactyly

BACKGROUND

Syndactyly reconstruction incorporates techniques of applying skin grafts or dorsal advancement flaps without the use of skin grafts. Comparative outcome studies of these two approaches are lacking. The authors' study compares the long-term aesthetic outcomes of these two flap techniques.

METHODS

Forty-five patients were included in the authors' study. The methods of reconstruction used were a dorsally based rectangular flap with skin graft from the groin and a dorsal pentagonal advancement flap without skin grafting. Eighteen independent raters completed a visual analogue scale and a unique classification scale to subjectively assess aesthetic outcomes. The authors used univariate analyses to determine which variables significantly influenced the outcome score. The authors then used multivariable regression models to compare the two flap types.

RESULTS

Dorsally based rectangular flaps with skin graft had statistically significantly better visual analogue scale scores and greater odds of receiving an "excellent" rating compared with dorsal pentagonal advancement flaps.

CONCLUSIONS

Despite the use of skin grafting, with its associated donor-site morbidity, dorsal rectangular flaps may offer better overall aesthetic outcomes for patients. Future comparative studies should incorporate functional and patient-reported outcomes to better assess the optimal reconstruction type.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Concealed cosmetic closure in total knee replacement surgery - A prospective audit assessing appearance and patient satisfaction

OBJECTIVE

With the trend towards accelerated rehabilitation, the method of skin closure has become increasingly important in orthopedic surgery. It is imperative to evaluate a technique that provides superior clinical and cosmetic results specifically for TKA, due to relatively thin skin anterior to the knee making poor wound healing an issue of concern. We conducted a prospective, single-arm audit evaluating the patient assessments of incision cosmesis for a novel technique in TKA wound closure called Concealed Cosmetic Closure (CCC).

METHODS

570 knees were included in the study whose wound was closed with concealed cosmetic subcuticular interrupted sutures (CCCIS) between January 2014 and May 2016. A validated, ordinal questionnaire, Stony Brooks Scar Evaluation Scale (SBSES) designed to elicit a score evaluating scar satisfaction was interviewed by the investigators to patients 6 months to 3 years postoperatively.

RESULTS

CCC is a simple and relatively rapid single-operator technique that takes about 7-10 min to close 11-17 cm knee incision. In our study, the mean score for Stony Brook Scar Evaluation Scale (SBSES) was 4.4 (SD of 0.73) (range 3-5). The scar was rated highly in terms of cosmesis, patient satisfaction and appearance of the wound.

CONCLUSION

CCC is an effective modality for skin closure in total knee arthroplasty providing superior cosmetic healing with minimal complications leading to improved long term patient satisfaction.

Improving Abdominal Plastic Scars with a Dietary Supplement-A Comparative Study

Introduction:

Massive weight loss following bariatric surgery has a major functional and aesthetic impact on patients. Many patients are nonetheless reluctant to undergo plastic surgery in connection with their former obesity because they fear potentially large scars, even though such scars are not visible (ie, they are covered by undergarments).

Purpose:

The aim of this study was to evaluate the quality of wound healing in patients receiving Celergen supplementation following abdominoplasty, compared with a control group. The hypothesis was that supplementation would speed up wound healing and improve scar quality.

Materials and Methods:

We conducted a prospective, monocentric, controlled study of patients undergoing abdominoplasty. A group of patients received Celergen, a food supplement, for 3 months and were monitored for 1 year after their surgery.

Results:

Of 33 patients who underwent abdominoplasty, 25 received Celergen supplements. There was no significant difference between the 2 groups. The mean time to wound healing was significantly better in the group receiving supplementation compared with the control group [respectively, 24.6 ± 9.31 days and 34 ± 13.48 days (P = 0.03)]. The Patient and Observer Scar Assessment Scale (POSAS) observer score was significantly better at 1 year in the group receiving supplementation compared with the control group [12.68 ± 6.6 and 17.38 ± 5.24 (P = 0.01), respectively]. There was no significant difference in the total POSAS score at 1 year (P = 0.166).

Conclusion:

Celergen supplementation significantly improved the time to healing and the POSAS observer score at 1 year for patients undergoing abdominoplasty.

Surgical approach for open reduction and internal fixation of clavicle fractures: a comparison of vertical and horizontal incisions

PURPOSE

This study was designed to compare the results of clavicle fracture open reduction internal fixation (ORIF) with standard horizontal incision versus vertical incision.

METHODS

ORIF surgery performed between October 2012 and August 2016 was included. The surgical approach was chosen according to surgeon preference as vertical or horizontal. Functional outcomes, fracture union, complications, scar appearance, skin irritation, and denervation around the scar were assessed at a minimum follow-up of three months.

RESULTS

Thirty-eight patients, age 39 ± 12 years, were operated upon, 22 through vertical incisions and 16 through horizontal incisions. There were no significant group differences in functional scores, fracture union, or complications. Two patients in the vertical incision group had a post-operative haematoma. The scar length was significantly shorter when a vertical incision was used (6.75 ± 1.25 cm vs 8.9 ± 2.3 cm, P = 0.001). The typical distribution of hypoesthetic skin area distal and lateral to the scar represented iatrogenic damage to the supraclavicular nerves and was found in 66% of patients. The mean hypoesthetic surface area was smaller in the vertical incision group (38 ± 29 cm² vs 48 ± 28 cm², P = non-significant).

CONCLUSION

Vertical incision results in shorter scars but may be associated with increased incidence of haematomas. Meticulous closure of the subcutaneous tissue is recommended.

Cosmetic outcomes of infraumbilical, supraumbilical, and transumbilical entry routes in laparoscopic surgery

OBJECTIVE

The aim of the present study was to determine which of the umbilical entry routes for intraperitoneal access has a better cosmetic result.

MATERIAL AND METHODS

This was a prospective study (Canadian Task Force classification II-1). In total, 105 patients who underwent laparoscopic surgery were included. A vertical or transverse umbilical incision is appropriately made for the trocar to be inserted, and an infraumbilical, supraumbilical, or transumbilical route was preferred for initial intraperitoneal access. Demographic data of patients, body mass indices, entry point of the trocars (infraumbilical-transumbilical-supraumbilical), type of incision (vertical-transverse), duration of the operation, and scar properties at postoperative week 12 were prospectively collected and analyzed. The Vancouver scar scale was used to evaluate the cosmetic results.

RESULTS

Cosmetic results did not differ statistically between the transumbilical-infraumbilical-supraumbilical groups. The variables, such as vascularity, height, and total score, of the Vancouver scar scale were significantly higher in patients who had transverse incisions. There was no statistically significant effect of using a Veress needle with the cosmetic results. There was no statistically significant correlation between age, gravida, body mass indices, skin thickness, time of entry, duration of the operation, and cosmetic results in terms of vascularity, height, and total score.

CONCLUSION

During laparoscopic surgery, each patient should be assessed individually for the satisfaction of the patient and, thereby, of the surgeon in terms of cosmetic outcomes. Vertical incision offers superior cosmetic effects than transverse incision. Further research is required to define long-term scar-related outcomes of the laparoscopic intraperitoneal access techniques.

Umbilical Quilting Suture Technique during Single-Port Laparoscopic Surgery

Background and Objectives

Single-port laparoscopic surgery (SPLS) is popular in the gynecological field, because it is less invasive and leaves a smaller scar. However, the postoperative shape of the umbilicus is often distorted due to the intensive procedures performed through the small opening. In this report, we describe a technique for forming a satisfactory umbilicus in SPLS.

Methods

From March 2016 through April 2017, 32 patients were treated with SPLS by a single gynecologic surgeon. Group A (14 cases) underwent conventional umbilicus closure, and group B (18 cases) underwent a quilting suture technique. The umbilical shapes of each group were assessed by a plastic surgeon as was the patients' satisfaction. Evaluations were performed immediately after surgery and every month for 6 months thereafter.

Results

The postoperative umbilical shape in group A showed features, such as loss of depression, disappearance of the central vertical line, and irregularly bulging tissue, whereas group B had a shape similar to that of the natural umbilicus and maintained its depression and vertical line. The average scores of the plastic surgeons' evaluations immediately after the operation were 10.4 for group A and 15.1 for group B. The final scores obtained 6 months after surgery were 15.2 and 17.8, respectively. The patients' satisfaction scores immediately after the operation were 4.9 for group A and 7.3 for group B. The scores increased gradually, to 8.1 and 9.2, respectively, at 6 months after surgery.

Conclusion

Performing quilting sutures during wound closure in SPLS is effective for making an ideal umbilicus and ensuring patients' satisfaction.

[The role of CO2-laser in scarring management]

AIM

To assess the role of CO2-laser in treatment of various scars and to determine the indications for its application.

PATIENTS AND METHODS

It has been carried out a prospective analysis of treatment of 218 patients with scars of different duration, locations and anatomic areas with the use of CO2-laser for the period 2011-2017. POSAS scale and sonography were used for analysis.

RESULTS

1. Laser therapy is not effective for scarring-related functional defects (contractures, ectropion, microstomia), when surgery is indicated. 2. The outcomes of treatment (both surgical and laser) depend on the time of existence of the scars rather their cause and anatomical region. 3. Laser therapy is not effective enough for formed scars existing over 12 months. 4. Laser therapy is effective for immature scars, especially indicated for cicatricial deformation when the aesthetics cannot be repaired with traditional surgery.

CONCLUSION

Application of CO2-laser in scars treatment with regard to its real efficiency determines the effectiveness of therapy.

Treatment of post-burn and post-traumatic atrophic scars with fractional CO2 laser: experience at a tertiary care centre

Scars are abnormal wound responses in predisposed individuals. They occur after any kind of wound and skin inflammation in predisposed individuals. Despite their benign nature, they can be aesthetically disabling. Although several approaches have been tried in their management, most of them have produced poor results. This study aims to assess the efficacy and safety of fractional CO₂ laser treatment in the management of post-burn and post-traumatic scars. One hundred consecutive patients (77 females and 23 males) affected by post-burn scars as well as post-traumatic atrophic scars were treated with monthly sessions of fractional CO₂ laser treatment. Patient's response to treatment was assessed clinically as well as improvement of scars by comparing the photographs taken before treatment with those taken 6 months after the last treatment session. Changes in skin texture, surface irregularity and pigmentation were assessed on a quartile grading scale and scored individually from 0 to 4. A mean of the three individual scores was calculated and the response was labelled as 'excellent' if the mean score achieved was > 3. A score of 2-3 was labelled as good response while a score below 1 was labelled as 'poor' response. A mean of six treatments per scar were required and all patients, followed up for 1 year after the last treatment, had optimum results and no recurrence. Response to treatment was excellent in 53.75%, good in 16.25% patients, and poor in 30% patients. Fractional CO₂ laser gives a very good result in the management of patients with post-burn scars as well as post-traumatic scars with minimal adverse effects.

Evaluation of donor site morbidity after medial triceps brachii free flap for lower limb reconstruction

INTRODUCTION

The medial head of the triceps brachii muscle (MTB)-free flap is an attractive solution to cover small-to-medium defects of the lower limb. This muscular head has no well-identified function, suggesting minimal impact of its removal on elbow mobility. The aim of this study was to evaluate the safety and reliability of the harvest procedure and the functional and cosmetic morbidity of this donor site.

MATERIALS AND METHODS

Twenty-four consecutive MTB-free flaps were performed for reconstructive surgery of the lower limb between 2011 and 2015. Patients and their records were retrospectively examined. Functional results were evaluated by assessing elbow extension strength using a dynamometer and with a QuickDASH questionnaire. Cosmetic results were assessed using the POSAS observer and patient scales.

RESULTS

Twenty-four patients were followed up postoperatively for an average of 33.9 [min 12-max 59] months. No major complication (in particular, no ulnar or radial nerve injury) occurred during harvest. No patient complained of elbow pain or reduction in strength. Elbow extension was complete in all patients and the mean strength was calculated at 89 [61.1-112.5] % of the opposite arm. The POSAS scale scored an average 8.6 [7-21] for the observer and 10 [7-26] for the patient. Cosmetic results using the POSAS scale were satisfactory in all patients.

CONCLUSIONS

Objective evaluation of patients who underwent an MTB-free flap for limb reconstruction shows no impact of the harvesting procedure on elbow extension. Patient satisfaction with the donor site was high. From this retrospective study, it appears that this surgery is safe, aesthetically acceptable, and has minimal impact on donor site elbow function.

Assessing cosmetic results after conventional thyroidectomy using the EASY-EYE_C: a double-blind randomized controlled trial

Purpose

The incidence of thyroid cancer is relatively high, especially in young women, and postoperative scarring after thyroidectomy is an important problem for both patients and clinicians. Currently, there is no available product that can be used for wound protection during thyroid surgery. We used the EASY-EYE_C, a new silicone-based wound protector.

Methods

We conducted a double-blind randomized controlled trial to assess the efficacy of the EASY-EYE_C with surgical scars. We studied 66 patients who underwent conventional total thyroidectomy or hemithyroidectomy performed by a single surgeon from August 2015 to June 2016. At 6-week follow-up, a single blinded physician observed the wounds to make clinical assessments using the Patient and Observer Scar Assessment Scale (POSAS), the Vancouver Scar Scale (VSS), and a modified Stony Brook Scar Evaluation Scale (SBSES).

Results

There were no significant differences by sex, age, type of surgery, body mass index, length of wound, incision site (from sternal notch), or thyroid weight, but the duration of operation was significantly shorter in the experimental group (E group). The e-group also had better POSAS scores than the control group (C group), with means of 43.2 (standard deviation [SD], ±15.9) versus 68.3 (SD, ±21.5), respectively (P < 0.05). The modified SBSES and VSS scores were similar to those from the POSAS.

Conclusion

In this study, all scores for evaluating outcomes were higher in the E group than in the C group. In addition, the operation time was significantly shorter in the E group. Therefore, the EASY-EYE_C may be useful for improving the cosmetic outcomes of conventional thyroid surgery.

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.

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.

Comparative Columellar Scar Analysis Between W Incisions and Inverted-V Incision in Open Technique Nasal Surgery

A visible scar on the columella is undesirable result for both patient and surgeon. So it is one of the major disadvantage of open nose surgery. Different columellar incision types have been used in open technique of nasal surgery. In this prospective study, we compare W incisions and inverted-V columellar incisions with a scar assessment scale. In this prospective randomized study, open nasal surgery (open rhinoplasty and open technique septoplasty) were performed on 93 patients between November 2009 and July 2012. The inverted-V incision was used on 31 patients (24 males, 7 females). The "W" incision was used on 62 patients (40 males, 22 females). The entire surgical procedure was performed by a single surgeon. The columellar incision was closed using 6-0 interrupted polypropylene sutures. All sutures were removed on the seventh postoperative day. Scars were assessed at 6 moths, with 3 items scar assessment scale, we observed satisfactory scar, pigmentation, and notching. We compared both groups and found that the scar pigmentation, notching and scar formation are similar to each other. As a result of this study we concluded that the inverted-V incision or "W" incision might be a similar choice in open nasal surgery.

Scar Assessment After Breast Augmentation Surgery with Axillary Incision versus Inframammary Fold Incision: Long-Term Follow-Up in Chinese Patients

BACKGROUND

The inframammary fold (IMF) incision is widely used in Western countries for breast augmentation surgery, whereas the axillary incision is the dominant approach used in China, because many Chinese surgeons believe that the Asian population has a higher risk of developing hypertrophic scars. However, comparative data of scar assessment through different incisions in Chinese patients are scarce. The aims of the study were as follows: (1) to evaluate the outcomes of scar assessment using the Vancouver scar scale (VSS), combined with patient satisfaction scoring, in the scar assessment after breast augmentation surgery; (2) to compare the long-term cosmetic effects of surgical scars between axillary and IMF incisions.

METHODS

Consecutive patients coming to our department for follow-up care at least 1 year after primary breast augmentation surgeries with axillary and IMF incisions between January 1, 2014 and December 31, 2014 were included in the research. Internal consistency, inter-rater reliability, and convergent validity were examined for the VSS and patient satisfaction scoring. The baseline characteristics and scar scores were tested using the Mann-Whitney U-test and Student's t test between the two groups.

RESULTS

Sixty-one patients underwent implantation surgeries through the axillary incisions, and 17 patients through the IMF incisions. There were no significant differences in age, follow-up time, body mass index, implant volume, or implant projection between groups. Reliability and validity of the VSS and patient satisfaction scoring were satisfactory. The scores of pigmentation were higher in the IMF group than those in the axilla group with statistical significance (P < 0.05). The scores of other subscales, overall VSS scores, and patient satisfaction were not statistically significant. The scars were significantly longer in the axilla group compared with the IMF group (P < 0.05).

CONCLUSIONS

The VSS combined with patient satisfaction scoring constitutes an effective tool to evaluate incision scars after augmentation mammaplasty. Scars in the axilla and IMF can achieve comparable cosmetic effects and patient satisfaction in Chinese women. Chinese patients with proper indications can receive breast augmentation surgery through the IMF incision, with fewer risks and less trauma, and get satisfactory scar appearance as through the axillary incision.

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 .

Purse-String Versus Linear Conventional Skin Wound Closure of an Ileostomy: A Randomized Clinical Trial

Purpose

Infection is one of the most frequent complications that can occur after ileostomy closure. The incidence of wound infection depends on the skin closure technique, but there is no agreement on the perfect closure method for an ileostomy wound. The aim of this study was to evaluate the incidence of infection, the patient's approval, and the patient's pain between purse-string closure (PSC) and the usual linear closure (LC) of a stoma wound.

Methods

This randomized clinical trial enrolled 66 patients who underwent a stoma closure from February 2015 to May 2015 in Sari Emam Khomeini Hospital. Patients were divided into 2 groups according to the stoma closing method: the PSC group (n = 34) and the LC group (n = 32). The incidences of infection for the 2 groups were compared, and the patients' satisfaction and pain with the stoma were determined by using a questionnaire.

Results

Infection occurred in 1 of 34 PSC patients (2.9%) and in 7 of 32 LC patients (21.8%), and this difference was statistically significant (P = 0.021). Patients in the PSC group were more satisfied with the resulting wound scar and its cosmetic appearance at one month and three months after surgery (P = 0.043).

Conclusion

After stoma closure, PSC was associated with a significantly lower incidence of wound infection and greater patient satisfaction compared to LC. However, the healing period for patients who underwent PSC was longer than it was for those who underwent LC.

Retroauricular full-thickness skin grafts in syndactyly repair: outcome and comparison with inguinal full-thickness skin grafts: retrospective (cross-sectional) study

OBJECTIVE

Most surgeons recommend the use of full-thickness skin grafts for syndactyly repair. Common donor sites include the groin and elbow, but only one publication has previously mentioned retroauricular skin. No publication has compared the results for full-thickness skin grafts between retroauricular and other donor sites. This study aims at comparing functional and aesthetic outcomes and parents' satisfaction with retroauricular vs inguinal full-thickness skin grafts.

METHODS

Eleven children with retroauricular and 15 with inguinal full-thickness skin grafts were included in this retrospective study. Examination included the Patient and Observer Scar Assessment Scale, parent satisfaction, and a colour match measurement.

RESULTS

Both pigmentation match and parents' overall impression of the donor site were significantly better for retroauricular than for inguinal full-thickness skin grafts.

CONCLUSION

Due to the excellent pigmentation match and the inconspicuousness of the donor site, this study recommends the use of retroauricular full-thickness skin grafts for syndactyly repair.

Short and long-term cosmesis of cervical thyroidectomy scars

Introduction Multiple surgical approaches to the thyroid gland have been described via cervical or extracervical routes. Improved cosmesis, patient satisfaction, reduced pain (procedure dependent) and early discharge have all been reported for minimally invasive approaches with similar safety profiles and long-term outcomes to conventional surgery. This review summarises the current evidence base for improved cosmesis with minimally invasive cervical approaches to the thyroid gland compared with conventional surgery. Methods A systematic review was undertaken. The MEDLINE(®), Embase™ and Cochrane databases were searched for relevant articles. Results A total of 57 papers thyroid papers were identified. Of those, 20 reported some form of cosmetic outcome assessment. There were 6 randomised controlled trials with 412 patients (evidence level 2B), 7 cohort studies with 3,073 patients (level 3B) and 7 non-comparative case series with 1,575 patients (level 4). There was significant heterogeneity between studies in terms of wound closure technique, timing of scar assessment and scar assessment scales (validated and non-validated). Most studies performed early scar assessments, some using non-validated scar assessment tools. Conclusions Assessment of cosmesis is complex and requires rigorous methodology. Evidence from healing/remodelling studies suggests scar maturation is a long-term process. This calls into question the value of early scar assessment. Current evidence does not support minimally invasive surgical approaches to the thyroid gland if improved long-term cosmesis is the goal.

Botulinum toxin for the prevention and healing of wound scars: A systematic review of the literature

BACKGROUND

Botulinum toxin injections have been investigated for the treatment or prevention of hypertrophic scars in several clinical studies. However, its clinical effectiveness has not yet been established.

OBJECTIVE

To examine all available evidence that support the use of botulinum toxin injections for the treatment or prevention of hypertrophic scars in current clinical practice.

METHODS

A systematic review searching the MEDLINE (1966 to 2014), Scopus (2004 to 2014), Popline (1974 to 2014), ClinicalTrials.gov (2008 to 2014) and Cochrane Central Register of Controlled Trials (CENTRAL) (1999 to 2014) databases together with reference lists from included studies was conducted.

RESULTS

Ten studies (255 patients) were included. Of these, 123 patients were injected with botulinum toxin type A, nine patients were offered botulinum toxin type B and the remaining 123 patients represented the control groups. Significantly improved cosmetic outcomes were observed among certain studies using the visual analogue scale (experimental group: median score 8.25 [range 6 to 10]) versus control group: median score 6.38 [range 2 to 9]; P<0.001) and the Stony Brook Scar Evaluation Scale (experimental group score: 6.7 versus control group score: 4.17; P<0.001) assessments. However, the methodological heterogeneity of the included studies, the lack of control group in the majority of them, the use of subjective scales of measurement and the frequent use of patient self-assessment precluded unbiased results.

CONCLUSIONS

Current evidence does not support the usage of botulinum toxin. Future randomized controlled trials are needed in the field to reach firm conclusions regarding its place in current clinical practice.

Efficacy and Safety of Fractional CO2 Laser Resurfacing in Non-hypertrophic Traumatic and Burn Scars

Background:

Fractional photothermolysis is one of the most effective treatment options used to resurface scars of different aetiologies.

Aim:

To assess the efficacy and safety of fractional CO₂ laser resurfacing treatment in the management of non-hypertrophic traumatic and burn scars.

Materials and Methods:

Twenty-five patients affected by non-hypertrophic traumatic and burn scars were treated with four sessions of fractional CO₂ laser resurfacing treatment at 6-weekly intervals. Patients were photographed at each visit and finally, 3 months after the end of treatment schedule. Response to treatment was assessed clinically as well as by comparing the initial photograph of the patient with the one taken at the last follow-up visit 3-months after the final treatment session. Changes in skin texture, surface irregularity and pigmentation were assessed on a quartile grading scale and scored individually from 0 to 4. A mean of the three individual scores was calculated and the response was labelled as ‘excellent’ if the mean score achieved was >2. A score of 1-2 was labeled as good response while a score below 1 was labeled as ‘poor’ response. The subjective satisfaction of each patient with the treatment offered was also assessed at the last follow-up visit.

Results:

The commonest site of scarring treated was the face followed by hands. Response to treatment was rated as excellent in 60% (15/25) patients while 24% (6/25) and 16% (4/25) patients were labeled as good and poor responders, respectively. Skin texture showed better response than other variables with average score of 2.44. Linear post-traumatic scars were seen to respond less than other morphological types. Majority of the patients (19 out of 25) were highly satisfied with the treatment offered. No long-term adverse effects were noted in any patient.

Conclusions:

Fractional photothermolysis with a fractional CO₂ laser gives excellent results in patients with post-burn scars with minimal adverse effects.

Limitations:

Lack of a control group and small sample size are limitations of this study.

Effect of Adhesive Strips and Dermal Sutures vs Dermal Sutures Only on Wound Closure: A Randomized Clinical Trial

IMPORTANCE

Although applying adhesive strips to a wound closure has been shown to have outcomes equivalent to those with cuticular suturing, it is unknown whether adhesive strips provide additional benefit compared with dermal suturing alone.

OBJECTIVE

To determine whether the addition of adhesive strips to a wound closed with buried interrupted subcuticular sutures improves outcomes following wound closure.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, randomized split-wound intervention was conducted between November 14, 2013, and May 16, 2014, in patients who underwent cutaneous surgical procedures at the University of California, Davis, outpatient dermatology clinic. Fifty-seven patients 18 years or older with postoperative defects of at least 3 cm, resulting from either Mohs micrographic surgical procedures or surgical excision, were screened for participation. Nine patients were excluded and 48 were enrolled.

INTERVENTIONS

Half of each wound was randomized to receive buried interrupted subcuticular sutures and overlying adhesive strips and the other half received buried interrupted subcuticular sutures only.

MAIN OUTCOMES AND MEASURES

At 3 months' follow-up, each patient and 2 blinded observers evaluated the wound using the Patient Observer Scar Assessment Scale.

RESULTS

The total mean (SD) Patient Observer Scar Assessment Scale score for observers for the side that received a combination of adhesive strips and buried interrupted subcuticular suturing (12.3 [4.8]) and the side that received sutures only (12.9 [6.3]) did not differ significantly at 3 months (P = .32). There was no significant difference in the total patient assessment scale score between the combination closure (14.0 [7.6]) and sutures only (14.7 [7.6]) sides at 3 months (P = .39). There was also no significant difference between the 2 closure methods in terms of mean (SD) scar width (both methods: 1.1 [0.8] mm, P = .89) at follow-up.

CONCLUSIONS AND RELEVANCE

Combination closure with adhesive strips and buried interrupted subcuticular suturing was not significantly associated with improved overall scar assessment compared with buried interrupted subcuticular suturing alone when evaluated by blinded observers or the patients themselves. Our results do not support the use of adhesive strips as a means to improve cosmetic outcomes or reduce scar width.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01979497.