Update on scar management: guidelines for treating Asian patients

The importance of hydration in wound healing: reinvigorating the clinical perspective

Balancing skin hydration levels is important as any disruption in skin integrity will result in disturbance of the dermal water balance. The discovery that a moist environment actively supports the healing response when compared with a dry environment highlights the importance of water and good hydration levels for optimal healing. The benefits of 'wet' or 'hyper-hydrated' wound healing appear similar to those offered by moist over a dry environment. This suggests that the presence of free water may not be detrimental to healing, but any adverse effects of wound fluid on tissues is more likely related to the biological components contained within chronic wound exudate, for example elevated protease levels. Appropriate dressings applied to wounds must not only be able to absorb the exudate, but also retain this excess fluid together with its protease solutes, while concurrently preventing desiccation. This is particularly important in the case of chronic wounds where peri-wound skin barrier properties are compromised and there is increased permeation across the injured skin. This review discusses the importance of appropriate levels of hydration in skin, with a particular focus on the need for optimal hydration levels for effective healing. Declaration of interest: This paper was supported by Paul Hartmann Ltd. The authors have provided consultative services to Paul Hartmann Ltd.

Surgical management for large chest keloids with internal mammary artery perforator flap

Therapy for large symptomatic keloids is often plagued with complicated reconstruction manner and recurrence. This article reports a rare treatment combination for a chest keloid with internal mammary artery perforator flap reconstruction and radiation therapy. We excised the keloid and covered the defect with an internal mammary artery perforator flap. Immediate electron-beam irradiation therapy was applied on the second postoperative day. There was no sign of recurrence over the follow-up period of 18 months. The combination of internal mammary artery perforator flap and immediate radiation therapy is useful when faced with chest keloids of similar magnitude and intractability.

The effects of conservative treatments on burn scars: A systematic review

A variety of conservative treatments for burn scars are available, but there is no clear consensus on the evidence. The purpose of this study was to summarize the available literature on the effects of conservative treatments of burn scars in adults. RCTs and CCTs were sought in three databases, reference lists of retrieved articles and relevant reviews. The Scottish Intercollegiate Guidelines Network scoring system was used to assess the quality of the selected studies. Information on the study characteristics, results and interventions was extracted. Twenty-two articles were included into the review and categorized in six topics: 5 on massage therapy, 4 on pressure therapy, 6 on silicone gel application, 3 on combined therapy of pressure and silicone, 3 on hydration and 1 on ultrasound. Pressure and silicone therapy are evidence-based conservative treatments of hypertrophic scar formation after a burn producing clinically relevant improvement of scar thickness, redness and pliability. Massage therapy could have a positive result on scar pliability, pain and pruritus, but with less supporting evidence. The use of moisturizers and lotions could have an effect on itching, but the findings are contradictory. Of all other non-invasive treatments such as splinting, casting, physical activity, exercise and mobilizations no RCTs or CCTs were found.

Techniques to minimize skin incision scar for external dacryocystorhinostomy

Although there has been a narrowing in the gap in successful functional outcomes between external and endonasal DCR, external DCR is still being frequently performed when cost, availability of additional surgical instruments and visual systems, surgeon's experience and preference are concerned. Nonetheless, skin incisions at the lateral nasal sidewall of the lower eyelid inevitably leave cutaneous scars. The purpose of this review is to evaluate the outcomes of current modified surgical practices that prevent a conspicuous scar in external DCR.

Asian Breast Augmentation: A Systematic Review

BACKGROUND

Economic, cultural, and regulatory phenomena may explain recent popularization of implant-based augmentation in Asia; but the collective Eastern experience remains limited. Asian surgeons and their patients rely on evidence-based medicine that originates elsewhere and may not be entirely relevant. Distinct anatomic and cultural features of Asian women warrant a tailored approach to breast augmentation. We explore the Asian experience with a thorough exploration of the recent literature.

METHODS

A literature search was performed for articles written after 2000, of Asian women who underwent augmentation mammoplasty using MEDLINE, Embase, and Pubmed Databases. Technique and outcomes data were summarized.

RESULTS

Twelve articles reported outcomes of 2089 women. Korea contributed most series (English language, 7), followed by China (3), Taiwan (1), and Japan (1). Silicone implants were used in 82.1% of women studied, and almost exclusively after 2009. More round (68.9%) than anatomic implants (31.1%) were placed. Non-inframammary (axillary, areolar, and umbilical) incisions were used in 96.9% of cases. Nearly all implants were positioned below the muscle or fascia; subglandular placement accounted for 1.1% of cases. Implant/nipple malposition (1.3%), capsular contracture (1.9%), hematoma (0.6%), and infection (0.2%) rates were reported in most series. Undesirable scarring was the most frequent complication (7.3%), but was reported only in 4 of 12 series.

CONCLUSIONS

Studies of Asian women undergoing augmentation mammoplasty are limited, often with ill-defined outcomes and inadequate follow-up. As experience accumulates, an expanding literature relevant to Asian women will provide evidence-based guidelines that improve outcomes and patient satisfaction, and foster innovation.

The evolution of negative pressure wound therapy: negative pressure wound therapy with instillation

Complex wounds pose a considerable burden to patients and the health-care system. The development of negative pressure wound therapy (NPWT) has revolutionised the treatment of these wounds. NPWT helps create a favourable wound healing environment by removing infectious material, decreasing oedema and promoting perfusion and granulation tissue formation. Additionally, NPWT has been reported to help reduce time to wound closure and length of hospital stay. Modifications of this foundation of wound care have added intermittent instillation with a dwell time to NPWT (NPWTi-d). This new system offers more comprehensive wound care through automated wound irrigation, allowing more control over the wound environment and the opportunity to deliver topical wound solutions directly to the affected tissues. A comparison between the two therapies, NPWT and NPWTi-d, is described, and two real-world applications of NPWTi-d are presented.

Aesthetic assessment in periciliary "v-incision" versus conventional external dacryocystorhinostomy in Asians

PURPOSE

To determine the functional and aesthetic outcomes of periciliary "v-incision" external dacryocystorhinostomy (DCR) and to compare with conventional approach.

METHOD

Charts review of consecutive cases of "v-incision" (VDCR) or conventional DCR performed in a single institute, between January 2007 and March 2014. All procedures were performed or supervised by a single surgeon. Two periciliary incisions were made near the skin-mucosal junction at the upper and lower eyelid margins medial to the punctum joining at the medial canthal angle to form a "v" shape. Subcutaneous dissection was carried out inferomedially to reach the anterior lacrimal crest. DCR was then performed in the usual manner. Functional success was defined as no persistent or recurrent epiphora and patency on irrigation of the lacrimal drainage system at least 6 months post-surgery. A cross-sectional aesthetic survey was conducted by asking the patients to rate their scar appearance satisfaction on a visual analogue scale (VAS). External photographs were graded by two independent, masked physicians using VAS as well as the Stony Brook scar evaluation scale (SBSES).

RESULTS

Sixty-one patients with median age of 64 years met the inclusion criteria, with median follow-up duration of 28 months. Thirty-eight eyes underwent VDCR, and 23 had conventional DCR. The functional success rate for VDCR was 83.3, 95 % confidence intervals (95%CI) [lower 0.68, upper 0.92] and for conventional DCR was 73.9 %, 95%CI [lower 0.54, upper 0.87]; without statistically significant difference (p = 0.38). VDCR patients rated higher aesthetic outcome on VAS (mean scores 95.5 ± 16.8 vs 82.9 ± 25.1, p = 0.03). On the SBSES, both observers gave higher aesthetic scores to the VDCR group (observer #1 4.6 ± 1.1 and #2 4.7 ± 1.2, p < 0.01) than conventional DCR (observer #1 3.1 ± 2.8 and #2 2.8 ± 2.1, p < 0.01). More patients reported that they could wear spectacles within 1 week post-VDCR (44.7 vs 4.3 %, p < 0.01).

CONCLUSION

"V-incision" external DCR has a similar functional success rate to that of the conventional approach and has superior aesthetic outcomes as reported by surgeons and patients. However, a higher proportion of trainees under supervision performed conventional DCR, and it is uncertain whether the outcomes were also influenced by the level of surgeon's expertise.

Low versus High Fluence Parameters in the Treatment of Facial Laceration Scars with a 1,550 nm Fractional Erbium-Glass Laser

Purpose. Early postoperative fractional laser treatment has been used to reduce scarring in many institutions, but the most effective energy parameters have not yet been established. This study sought to determine effective parameters in the treatment of facial laceration scars. Methods. From September 2012 to September 2013, 57 patients were enrolled according to the study. To compare the low and high fluence parameters of 1,550 nm fractional erbium-glass laser treatment, we virtually divided the scar of each individual patient in half, and each half was treated with a high and low fluence setting, respectively. A total of four treatment sessions were performed at one-month intervals and clinical photographs were taken at every visit. Results. Results were assessed using the Vancouver Scar Scale (VSS) and global assessment of the two portions of each individual scar. Final evaluation revealed that the portions treated with high fluence parameter showed greater difference compared to pretreatment VSS scores and global assessment values, indicating favorable cosmetic results. Conclusion. We compared the effects of high fluence and low fluence 1,550 nm fractional erbium-glass laser treatment for facial scarring in the early postoperative period and revealed that the high fluence parameter was more effective for scar management.

Time Heals All Wounds: Obstacles in Glaucoma Surgery from an Asian Perspective

Glaucoma is the leading cause of irreversible blindness worldwide and is a particular burden on the Asian population. Glaucoma surgeries such as trabeculectomy and glaucoma drainage implants are routinely performed to lower intraocular pressure (IOP) to prevent disease progression. However, scarring of the filtering bleb limits their long-term success and Asian eyes are more at risk. Although this is so, many existing studies have been done on Caucasian patients, but few have focused solely on Asian patients. Intraoperative anti-metabolites such as Mitomycin-C (MMC) and 5-Fluorouracil (5-FU) are the current mainstay of adjunctive treatments to reduce scarring, and in this review, we evaluate the evolution, benefits and side effects of these agents. Recently, newer methods of wound modulation including anti-vascular endothelial growth factor (VEGF) agents and collagen implants are also being investigated as part of a multi-pronged approach to tackle this problem. Some opportunities exist to limit scarring post-operatively, but it is an ongoing battle.

Considerations in non-Caucasian facial rejuvenation

Aging of the face is inevitable and undeniable. This process includes a loss of skeletal support, soft tissue volume depletion, and a decrease in skin elasticity. The contribution of these 3 factors varies between individuals with noticeable hereditary influence. Characteristic ethnic features have been described in the literature, but as societies have changed, many of these ethnic variations have blended together. Facial cosmetic procedures must to be tailored to address these variations in anatomy, and consideration must be given to enhancing the facial skeleton, adequately lifting the soft tissues, and planning careful incisions to be closed under no tension.