Currently known risk factors for hypertrophic skin scarring: A review

A comprehensive review of the application of 3D-bioprinting in chronic wound management

INTRODUCTION

Chronic wounds require more sophisticated care than standard wound care because they are becoming more severe as a result of diseases like diabetes. By resolving shortcomings in existing methods, 3D-bioprinting offers a viable path toward personalized, mechanically strong, and cell-stimulating wound dressings.

AREAS COVERED

This review highlights the drawbacks of traditional approaches while navigating the difficulties of managing chronic wounds. The conversation revolves around employing natural biomaterials for customized dressings, with a particular emphasis on 3D-bioprinting. A thorough understanding of the uses of 3D-printed dressings in a range of chronic wound scenarios is provided by insights into recent research and patents.

EXPERT OPINION

The expert view recognizes wounds as a historical human ailment and emphasizes the growing difficulties and expenses related to wound treatment. The expert acknowledges that 3D printing is revolutionary, but also points out that it is still in its infancy and has the potential to enhance mass production rather than replace it. The review highlights the benefits of 3D printing for wound dressings by providing instances of smart materials that improve treatment results by stimulating angiogenesis, reducing pain, and targeting particular enzymes. The expert advises taking action to convert the technology's prospective advantages into real benefits for patients, even in the face of resistance to change in the healthcare industry. It is believed that the increasing evidence from in-vivo studies is promising and represents a positive change in the treatment of chronic wounds toward sophisticated 3D-printed dressings.

Comparison of dual-plane micro-drop injection of botulinum toxin type A with two traditional methods for treating hypertrophic scars in the tension zone: A long-term clinical application study

BACKGROUND

Patients with hypertrophic scarring tend to experience recurrence after treatment, which often occurs in areas of the body with high skin tension.

AIMS

To evaluate better treatments aimed at reducing the risk of scar recurrence in areas of high skin tension.

METHODS

Patients were randomly divided into the following three treatment groups: botulinum toxin type A (BTA) via dual-plane micro-drop injections, triamcinolone acetonide (TAC) suspension, and CO2 via fractional CO2 laser. Interventions were implemented in all three groups once a month for three consecutive sessions. After the final treatment, scarring was evaluated at 1, 3, 6, 12, and 24 months using the Patient and Observer Scar Assessment Scale (POSAS).

RESULTS

The 3-month POSAS score for each scar indicator in the treatment groups was significantly lower than that in the preoperative groups (p < 0.001). The scar score in the TAC group decreased at 3 months and increased thereafter. For other groups, the scar score continually decreased at all time points according to the Patient Scar Assessment Scale. Based on the Observer Scar Assessment Scale, the scar score continuously decreased at all time points in the BTA group; in the TAC group, it decreased at 1 month and increased thereafter; and in the CO2 group, the scar score decreased at 3 months and subsequently stabilized.

CONCLUSIONS

All three treatment methods were effective. However, the BTA group experienced a reduced risk of scar recurrence and maintained long-term treatment effects.

Pressure-garment therapy for preventing hypertrophic scarring after burn injury

BACKGROUND

Burn damage to skin often results in scarring; however in some individuals the failure of normal wound-healing processes results in excessive scar tissue formation, termed 'hypertrophic scarring'. The most commonly used method for the prevention and treatment of hypertrophic scarring is pressure-garment therapy (PGT). PGT is considered standard care globally; however, there is continued uncertainty around its effectiveness.

OBJECTIVES

To evaluate the benefits and harms of pressure-garment therapy for the prevention of hypertrophic scarring after burn injury.

SEARCH METHODS

We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, two other databases, and two trials registers on 8 June 2023 with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing PGT (alone or in combination with other scar-management therapies) with scar management therapies not including PGT, or comparing different PGT pressures or different types of PGT.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials for inclusion using predetermined inclusion criteria, extracted data, and assessed risk of bias using the Cochrane RoB 1 tool. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 15 studies in this review (1179 participants), 14 of which (1057 participants) presented useable data. The sample size of included studies ranged from 17 to 159 participants. Most studies included both adults and children. Eight studies compared a pressure garment (with or without another scar management therapy) with scar management therapy alone, five studies compared the same pressure garment at a higher pressure versus a lower pressure, and two studies compared two different types of pressure garments. Studies used a variety of pressure garments (e.g. in-house manufactured or a commercial brand). Types of scar management therapies included were lanolin massage, topical silicone gel, silicone sheet/dressing, and heparin sodium ointment. Meta-analysis was not possible as there was significant clinical and methodological heterogeneity between studies. Main outcome measures were scar improvement assessed using the Vancouver Scar Scale (VSS) or the Patient and Observer Scar Assessment Scale (POSAS) (or both), pain, pruritus, quality of life, adverse events, and adherence to therapy. Studies additionally reported a further 14 outcomes, mostly individual scar parameters, some of which contributed to global scores on the VSS or POSAS. The amount of evidence for each individual outcome was limited. Most studies had a short follow-up, which may have affected results as the full effect of any therapy on scar healing may not be seen until around 18 months. PGT versus no treatment/lanolin We included five studies (378 participants). The evidence is very uncertain on whether PGT improves scars as assessed by the VSS compared with no treatment/lanolin. The evidence is also very uncertain for pain, pruritus, adverse events, and adherence. No study used the POSAS or assessed quality of life. One additional study (122 participants) did not report useable data. PGT versus silicone We included three studies (359 participants). The evidence is very uncertain on the effect of PGT compared with silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, adherence, and other scar parameters. It is possible that silicone may result in fewer adverse events or better adherence compared with PGT but this was also based on very low-certainty evidence. PGT plus silicone versus no treatment/lanolin We included two studies (200 participants). The evidence is very uncertain on whether PGT plus silicone improves scars as assessed by the VSS compared with no treatment/lanolin. The evidence is also very uncertain for pain, pruritus, and adverse events. No study used the POSAS or assessed quality of life or adherence. PGT plus silicone versus silicone We included three studies (359 participants). The evidence is very uncertain on the effect of PGT plus silicone compared with silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, and adherence. PGT plus scar management therapy including silicone versus scar management therapy including silicone We included one study (88 participants). The evidence is very uncertain on the effect of PGT plus scar management therapy including silicone versus scar management therapy including silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, and adherence. High-pressure versus low-pressure garments We included five studies (262 participants). The evidence is very uncertain on the effect of high pressure versus low pressure PGT on adverse events and adherence. No study used the VSS or the POSAS or assessed pain, pruritus, or quality of life. Different types of PGT (Caroskin Tricot + an adhesive silicone gel sheet versus Gecko Nanoplast (silicone gel bandage)) We included one study (60 participants). The evidence is very uncertain on the effect of Caroskin Tricot versus Gecko Nanoplast on the POSAS, pain, pruritus, and adverse events. The study did not use the VSS or assess quality of life or adherence. Different types of pressure garments (Jobst versus Tubigrip) We included one study (110 participants). The evidence is very uncertain on the adherence to either Jobst or Tubigrip. This study did not report any other outcomes.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend using either PGT or an alternative for preventing hypertrophic scarring after burn injury. PGT is already commonly used in practice and it is possible that continuing to do so may provide some benefit to some people. However, until more evidence becomes available, it may be appropriate to allow patient preference to guide therapy.

Non-coding RNAs in hypertrophic scars and keloids: Current research and clinical relevance: A review

Hypertrophic scars (HS) and keloids (KD) are lesions that develop as a result of excessive fibroblast proliferation and collagen deposition in response to dermal injury, leading to dysregulation of the inflammatory, proliferative, and remodeling phases during wound healing. HS and KD affect up to 90 % of the population and are associated with lower quality of life, physical health, and mental status in patients. Efficient targeted treatment represents a significant challenge, primarily due to our limited understanding of their underlying pathogenesis. Non-coding RNAs (ncRNAs), which constitute a significant portion of the human transcriptome with minimal or no protein-coding capacity, have been implicated in various cellular physiologies and pathologies and may serve as diagnostic indicators or therapeutic targets. NcRNAs have been found to be aberrantly expressed and regulated in HS and KD. This review provides a summary of the expression profiles and molecular mechanisms of three common ncRNAs, including microRNAs (miRNAs), long non-coding RNAs (lncRNAs), and circular RNAs (circRNAs), in HS and KD. It also discusses their potential as biomarkers for the diagnosis and treatment of these diseases and provides novel insights into epigenetic-based diagnosis and treatment strategies for HS and KD.

"Post Bariatric Male Chest Re-shaping Using L-shaped Excision Technique"

BACKGROUND

Male chest deformity after massive weight loss is complex and challenging to treat because of differing grades of excessive parenchyma/fat ptosis, nipple malposition, over-stretched skin, ill-defined infra-mammary fold, and prominent axillary rolls. Patients are eager to restore balanced upper body dominance. Two fundamental techniques are used for large breasts with moderate to poor skin elasticity; (1) the inferior pedicle Wise skin pattern and (2) double incision with free nipple graft technique.The author presents his experience in treating such severe breast deformities, besides correcting the prominent axillary rolls using an L-shaped mastectomy excision.

MATERIALS AND METHODS

Between March 2017 and December 2020, 55 consecutive patients were treated surgically for male chest re-contouring using the L-shaped mastectomy technique. Ages ranged from 20 to 57 years (median, 31 years). The average body mass index (BMI) was 29. The average follow-up period was 17 months (13-44 months).

RESULTS

Fifty-one patients (92.8%) reported greater levels of postoperative satisfaction with their results owing to lack of any major complication and minimal minor complications (two cases of minor ischemia that healed spontaneously, two small hematomas, two small seromas, and four hypertrophic scars).

CONCLUSION

The L-shaped excision is a useful procedure for severe grade gynecomastia with an atypical presentation in the form of complex chest deformity and prominent axillary roll after massive weight loss patients. The technique is associated with minor complications that are treated in an office setting. The technique preserves normal pigmentation and sensitivity of the nipple-alveolar complex.

LEVEL OF EVIDENCE IV

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

Scars

Wound healing occurs as a response to disruption of the epidermis and dermis. It is an intricate and well-orchestrated response with the goal to restore skin integrity and function. However, in hundreds of millions of patients, skin wound healing results in abnormal scarring, including keloid lesions or hypertrophic scarring. Although the underlying mechanisms of hypertrophic scars and keloid lesions are not well defined, evidence suggests that the changes in the extracellular matrix are perpetuated by ongoing inflammation in susceptible individuals, resulting in a fibrotic phenotype. The lesions then become established, with ongoing deposition of excess disordered collagen. Not only can abnormal scarring be debilitating and painful, it can also cause functional impairment and profound changes in appearance, thereby substantially affecting patients' lives. Despite the vast demand on patient health and the medical society, very little progress has been made in the care of patients with abnormal scarring. To improve the outcome of pathological scarring, standardized and innovative approaches are required.

Conformation Dependent Architectures of Assembled Antimicrobial Peptides with Enhanced Antimicrobial Ability

Antimicrobial peptides (AMPs) are a developing class of natural and synthetic oligopeptides with host defense mechanisms against a broad spectrum of microorganisms. With in-depth research on the structural conformations of AMPs, synthesis or modification of peptides has shown great potential in effectively obtaining new therapeutic agents with improved physicochemical and biological properties. Notably, AMPs with self-assembled properties have gradually become a hot research topic for various biomedical applications. Compared to monomeric peptides, these peptides can exist in diverse forms (e.g., nanoparticles, nanorods, and nanofibers) and possess several advantages, such as high stability, good biocompatibility, and potent biological functions, after forming aggregates under specific conditions. In particular, the stability and antibacterial property of these AMPs can be modulated by rationally regulating the peptide sequences to promote self-assembly, leading to the reconstruction of molecular structure and spatial orientation while introducing some peptide fragments into the scaffolds. In this work, four self-assembled AMPs are developed, and the relationship between their chemical structures and antibacterial activity is explored extensively through different experiments. Importantly, the evaluation of antibacterial performance in both in vitro and in vivo studies has provided a general guide for using self-assembled AMPs in subsequent treatments for combating bacterial infections.

Analysis of Risk Factors to Predict Occurrence and Prognosis of Postsurgical Hypertrophic Scar Development: A Review of 4238 Cases

PURPOSE

This study aimed to identify the risk factors associated with the occurrence and prognosis of hypertrophic scarring following thyroidectomy.

MATERIALS AND METHODS

A total of 4238 patients who underwent thyroidectomy were included in this study. A multivariable logistic regression model was developed to identify the risk factors for hypertrophic scar development and its prognosis.

RESULTS

Our analysis revealed that hypertrophic scar development was associated with younger age [odds ratio (OR)=0.949, p<0.0001], male sex (OR=0.562, p<0.0001), higher body mass index (OR=1.137, p<0.0001), prominent sternocleidomastoid muscles (OR=2.522, p<0.0001), scarring located within 1 cm of the sternal notch (OR=4.345, p<0.0001), and a history of keloid development (OR=2.789, p=0.0031). Additionally, scar location within 1 cm of the sternal notch (beta=4.326, p=0.0429) and a history of keloid development (beta=23.082, p<0.0001) were found to be associated with the prognosis of hypertrophic scarring.

CONCLUSION

The findings of this study provide valuable insights into the risk factors associated with hypertrophic scarring following thyroidectomy. Clinicians can use this information to predict the occurrence of hypertrophic scarring and its prognosis, and take preventative measures accordingly.

Extended Superolateral Cheek Lift With a Short Preauricular Scar: A Local Anesthesia-based Practicable Technique for the Correction of Moderate-degree Facial Aging Signs

An ideal technique applicable to middle-aged individuals with a moderate degree of facial aging signs has not yet been established. This study aimed to evaluate the utility of an extended superolateral cheek lift with a short preauricular scar technique for the correction of facial aging signs. A total of 200 female patients (mean age: 43 y, range 27-56 y) who underwent a local anesthesia-based extended superolateral cheek lift for the correction of facial aging signs confined to the malar and nasolabial area, lower eyelid, jawline, and neck were included. Data on the Global Aesthetic Improvement Scale, patient-reported outcomes, and complications were recorded at 1, 6, 12, and 24 months postoperatively. The Global Aesthetic Improvement Scale scores revealed exceptional improvement in 90% of patients along with no complications at month 24. None of the patients developed a depressed scar, skin necrosis, breaking of the superficial musculoaponeurotic system plication sutures, asymmetry, or facial nerve problems. At postoperative month 24, the appearance was reported to be very much improved by 90% of patients, and 94% of patients reported that they were very satisfied with the treatment and that they would recommend this treatment to friends and acquaintances. Our findings revealed the potential utility of an extended superolateral cheek lift with a short preauricular scar as a local anesthesia-based practicable technique for the correction of facial aging signs in middle-aged patients, offering a favorable postoperative outcome, lack of complications and high patient satisfaction in addition to invisible scars and a short-term postoperative recovery.

Development and validation of a risk assessment scale for pathological scarring

To develop a risk assessment scale for pathological scarring and validate its psychometric properties. This was a methodological study. Researchers developed the scale based on a literature review, qualitative study and Delphi expert consultation. Subsequently, 409 patients participated in the study to test the psychometric properties of the scale. We evaluated construct validity, content validity, internal consistency reliability, and interrater reliability. The researchers developed a scale consisting of three dimensions and 12 items. Factor analysis extracted a total of four common factors that accounted for 62.22% of the total variance. The results revealed that the item-content validity index (I-CVI) ranged from 0.67 to 1, while the scale-content validity index (S-CVI) was 0.82. Internal consistency reliability: Cronbach's α of the items ranged from 0.67 to 0.76, while Cronbach's α of the whole scale was 0.74. Interrater reliability: the Kappa number was 0.73. The final scale showed adequate construct validity, content validity, and reliability. It is appropriate for use in research and clinical practice settings to identify patients with a risk of pathological scarring. Further study is needed to confirm the scale's validity and reliability in other settings and populations.

Smart and versatile biomaterials for cutaneous wound healing

The global increase of cutaneous wounds imposes huge health and financial burdens on patients and society. Despite improved wound healing outcomes, conventional wound dressings are far from ideal, owing to the complex healing process. Smart wound dressings, which are sensitive to or interact with changes in wound condition or environment, have been proposed as appealing therapeutic platforms to effectively facilitate wound healing. In this review, the wound healing processes and features of existing biomaterials are firstly introduced, followed by summarizing the mechanisms of smart responsive materials. Afterwards, recent advances and designs in smart and versatile materials of extensive applications for cutaneous wound healing were submarined. Finally, clinical progresses, challenges and future perspectives of the smart wound dressing are discussed. Overall, by mapping the composition and intrinsic structure of smart responsive materials to their individual needs of cutaneous wounds, with particular attention to the responsive mechanisms, this review is promising to advance further progress in designing smart responsive materials for wounds and drive clinical translation.

Meshed dermal regeneration template for traumatic periocular tissue loss in the young population

The IntegraⓇ Dermal Regeneration Template (DRT) is a bioengineered dermal substitute that is becoming increasingly popular in the field of reconstruction. Its unique properties allow for immediate wound closure while providing a scaffold for tissue regeneration. Currently, it is commonly used to treat burns, ulcers, and complex wounds. In the setting of traumatic periocular tissue loss, only two prior reports have been published on its use for primary reconstruction. We present our institution's experience with a series of four young patients who received primary reconstruction with IntegraⓇ DRT as a full-thickness skin substitute for their large traumatic periorbital skin defects.

FTY720 in immuno-regenerative and wound healing technologies for muscle, epithelial and bone regeneration

In 2010, the FDA approved the administration of FTY720, S1P lipid mediator, as a therapy to treat relapsing forms of multiple sclerosis. FTY720 was found to sequester pro-inflammatory lymphocytes within the lymph node, preventing them from causing injury to the central nervous system due to inflammation. Studies harnessing the anti-inflammatory properties of FTY720 as a pro-regenerative strategy in wound healing of muscle, bone and mucosal injuries are currently being performed. This in-depth review discusses the current regenerative impact of FTY720 due to its anti-inflammatory effect stratified into an assessment of wound regeneration in the muscular, skeletal, and epithelial systems. The regenerative effect of FTY720 in vivo was characterized in three animal models, with differing delivery mechanisms emerging in the last 20 years. In these studies, local delivery of FTY720 was found to increase pro-regenerative immune cell phenotypes (neutrophils, macrophages, monocytes), vascularization, cell proliferation and collagen deposition. Delivery of FTY720 to a localized wound environment demonstrated increased bone, muscle, and mucosal regeneration through changes in gene and cytokine production primarily by controlling the local immune cell phenotypes. These changes in gene and cytokine production reduced the inflammatory component of wound healing and increased the migration of pro-regenerative cells (neutrophils and macrophages) to the wound site. The application of FTY720 delivery using a biomaterial has demonstrated the ability of local delivery of FTY720 to promote local wound healing leveraging an immunomodulatory mechanism.

Simultaneous bilateral femoral fracture in children

Introduction

Bilateral femoral fractures in children (BFFC) are an uncommon condition. Only a few cases were reported in the literature. The frequency and outcome in low-setting facilities are unknown. This study aims to describe our experience in managing BFFC.

Patients and Methods

A 10-year ongoing study spanning from 2010 to 2020 was held in a level-1 paediatric facility. We included all cases of BFFC on a bone-free disease with at least 10 months of follow-up time. Data were collected and analysed with statistical software.

Results

A total of eight patients with ten BFFC were collected. It involved mainly boys (n = 7/8) with median age of 8 years. Mechanism of injury were a road traffic accident (n = 4), a fall from height (n = 3), and been crushed by a falling wall (n = 1). Associated injuries were frequent (n = 6/8). Patients were managed nonoperatively with spica cast (n = 5) and by elastic intramedullary nails (n = 3). After 6.11 years of mean follow-up time, all fractures healed. The outcome was excellent and good in 7 cases. One patient sustained knees stiffness.

Conclusion

Non-operative management of BFFC showed satisfactory outcomes. Early surgical care must be developed in our low-income settings to reduce in-hospital stay and encourage early weight-bearing.

Electrospun Naringin-Loaded Fibers for Preventing Scar Formation during Wound Healing

Hypertrophic scars (HTSs) are aberrant structures that develop where skin is injured complexly and represent the result of a chronic inflammation as a healing response. To date, there is no satisfactory prevention option for HTSs, which is due to the complexity of multiple mechanisms behind the formation of these structures. The present work aimed to propose Biofiber (Biodegradable fiber), an advanced textured electrospun dressing, as a suitable solution for HTS formation in complex wounds. Biofiber has been designed as a 3-day long-term treatment to protect the healing environment and enhance wound care practices. Its textured matrix consists of homogeneous and well-interconnected Poly-L-lactide-co-poly-ε-caprolactone (PLA-PCL) electrospun fibers (size 3.825 ± 1.12 µm) loaded with Naringin (NG, 2.0% w/w), a natural antifibrotic agent. The structural units contribute to achieve an optimal fluid handling capacity demonstrated through a moderate hydrophobic wettability behavior (109.3 ± 2.3°), and a suitable balance between absorbency (389.8 ± 58.16%) and moisture vapor transmission rate (MVTR, 2645 ± 60.43 g/m2 day). The flexibility and conformability of Biofiber to the body surfaces is due to its innovative circular texture, that also allow it to obtain finer mechanical properties after 72 h in contact with Simulated Wound Fluid (SWF), with an elongation of 352.6 ± 36.10%, and a great tenacity (0.25 ± 0.03 Mpa). The ancillary action of NG results in a prolonged anti-fibrotic effect on Normal Human Dermal Fibroblasts (NHDF), through the controlled release of NG for 3 days. The prophylactic action was highlighted at day 3 with the down regulation of the major factors involved in the fibrotic process: Transforming Growth Factor β1 (TGF-β1), Collagen Type 1 alpha 1 chain (COL1A1), and α-smooth muscle actin (α-SMA). No significant anti-fibrotic effect has been demonstrated on Hypertrophic Human Fibroblasts derived from scars (HSF), proving the potential of Biofiber to minimize HTSs in the process of early wound healing as a prophylactic therapy.

A Review of Laser Therapies for the Treatment of Scarring and Vascular Anomalies

Significance: Laser use has become part of the gold standard of treatment as an effective adjuvant in multimodal therapy for pathologic scarring caused by burns, trauma, acne, and surgery, as well as vascular anomalies. Understanding indications and applications for laser therapy is essential for physicians to improve patient outcomes. Recent Advances: Since the 1980s, the medical use of lasers has continuously evolved with improvements in technology. Novel lasers and fractionated technologies are currently being studied in the hopes to improve treatment efficacy, while reducing complications. Recent advancements include acne treatment with novel picosecond lasers, new hypertrophic scar therapies with simultaneous laser and intense pulsed light use, and novel systems such as lasers with intralesional optical fiber delivery devices. In addition, optimizing the timing of laser therapy and its use in multimodal treatments continue to advance the field of photothermolysis. Critical Issues: Selecting the correct laser for a given indication is the fundamental decision when choosing a laser balancing effective treatment with minimal complications. This article covers the principles of laser therapy, the preferred lasers used for the treatment of scarring and vascular anomalies, and discusses the current evidence behind these laser choices. Future Directions: To optimize laser therapy, larger randomized control trials and split scar studies are needed. Continued advancement through better randomized controlled studies will help to improve patient outcomes on a broader scale.

Wound Pain as a Determinant of Function in Patients Hospitalised for Burns

Burn wounds most often occur on visible parts of the body. They therefore cause fear of disfigurement and rejection by those around them. In addition, they cause pain. The main aim of this study was to analyse factors affecting the functioning of patients hospitalised for burns. The study included 57 patients hospitalised for burns. Each person was surveyed twice: on day seven after admission and on the day of discharge from the hospital. The following research tools were used: a personal questionnaire to collect clinical data and the scales of the Katz Activities of Daily Living (ADL), the short-form McGill Pain Questionnaire (SF-MPQ), the Beck Depression Inventory (BDI) and the Satisfaction with Appearance Scale (SWAP). On the discharge day, compared to day 7, there was an improvement in the patient's level of functioning in all areas analysed. Pain intensity (p < 0.0001), depression (p < 0.0001) and dissatisfaction with appearance (p = 0.0239) decreased significantly. Improvements in daily functioning were also obtained (p < 0.0001). Multiple regression was performed to estimate the effect of selected variables on patients' level of functioning. Burn area (p = 0.0126), pain level (questionnaire part B: p = 0.0004 and questionnaire part C: p = 0.0208) and gender (p = 0.0413) had a significant impact on the level of daily functioning. Pain complaints are the most crucial predictor affecting the functional status and depression levels in burn wound patients. Increased levels of depression promote dissatisfaction with one's appearance.

Evaluating the Effect of Low Power Diode Laser 806 nm on the Healing of Unilateral Cleft Lip Scar: An Open-Label Comparative Study

OBJECTIVE

To investigate the effect of laser bio-modulation irradiation therapy on the scar after surgical correction of unilateral cleft lip.

DESIGN

a comparative, open-label study.

SETTING

we conducted the study in a university based tertiary hospital that recruited early wound healers of unilateral cleft lip correction.

PATIENTS

Eighty patients were divided into two groups: In study's group, patients undergo laser bio-modulation irradiation (n = 60); in the control group, patients were followed-up without intervention (n = 20).

INTERVENTION

In the study's group, patients underwent low-power diode Laser with wavelength of 806 nm and power of 100 mw.

MAIN OUTCOME

The change in the scar of cleft lip patients, which was assessed by clinical examination and ultrasound.

RESULTS

The median pigmentation score was significantly lower in the laser group (median = 1; IQR = 1-2) than the control group (median 2; IQR 1-3), with p-value of <0.001. Likewise, the median height score was significantly lower in the laser group (median = 1; IQR = 1-1) than the control group (median 1.5; IQR 1.5-2), with p-value of 0.001. The median pliability score was significantly lower in the laser group (median = 1; IQR = 1-1) than the control group (median 2.5; IQR 1-3), with p-value of <0.001. Finally, the median vascularity score was significantly lower in the laser group (median = 1; IQR = 1-1) than the control group (median 1.5; IQR 1-2), with p-value of <0.001.

CONCLUSION

laser bio-modulation irradiation therapy demonstrates a potential efficacy in managing the hypertrophic scars after surgical repair of unilateral cleft lip.

[Is it legitimate to propose surgery of the breast area before the end of puberty?]

Breast surgery is usually recommended for women who have completed puberty. Indeed, during adolescence the breast is constantly changing, the patient's weight is often unstable, the risk of inflammatory scars (hypertrophic or keloid) is higher and disturbances of areolar sensitivity can affect the patient's quality of sexual life. In addition, the risk of infection is not negligible, especially during an acne outbreak. In case of early implant placement, iterative changes should be planned. Finally, the result obtained is not always stable but above all the lack of psychological maturity and the legal need to obtain the agreement of both parents are obstacles to early surgery. However, the authors argue for the possibility of surgical correction of the breast around puberty, in particular because of the very clear positive psychological impact. Other arguments are also detailed: to ensure a breast reconstruction in successive stages started early, to limit the repercussions of hypertrophy, to correct thoracic or skin anomalies. These indications are illustrated by numerous clinical cases demonstrating the need for customized surgery on a case-by-case basis.

Elastic Silicone Occlusive Sheeting Versus Silicone Occlusive Sheeting in the Treatment of Scars: A Randomized Controlled Trial

Introduction

Hypertrophic scarring caused by conventional open thyroidectomy is prevalent among Asians and published trials have proved that silicone occlusive sheeting is a useful treatment for hypertrophic scarring. However, silicone occlusive sheeting does not effectively prevent scar widening. Here, we report elastic silicone occlusive sheeting as a new type of silicone application. In this study, we compared the effects of elastic silicone occlusive sheeting on scar width and appearance after conventional open thyroidectomy with those of silicone occlusive sheeting.

Methods

In this prospective, randomized, assessor-blinded study, a total of 74 patients who underwent conventional open thyroidectomy were recruited to undergo elastic silicone occlusive sheeting and silicone occlusive sheeting on the healed wound. Split scar study and scar quality were assessed on the basis of scar width, Vancouver scar scale, pain/itching visual analogue scale, and patients’ subjective degree of satisfaction with the scar, during the patients’ 6-month review.

Results

A total of 61 patients completed the study. Scar width, Vancouver scar scale score, and patients’ subjective degree of satisfaction indicated that elastic silicone occlusive sheeting was associated with narrower scars and significant improvement in scar appearance. The two methods did not differ significantly with regard to pain/itching visual analogue scale.

Conclusions

Our findings highlight elastic silicone occlusive sheeting as an effective treatment for scarring, resulting in narrower and better scars after conventional open thyroidectomy. The use of elastic silicone occlusive sheeting after conventional open thyroidectomy may minimize the formation of hypertrophic scars in the early postoperative period.

Trial Registration

ChiCTR2100049740.

Management of non-severe burn wounds in children and adolescents: optimising outcomes through all stages of the patient journey

Paediatric burn injuries are common, especially in children younger than 5 years, and can lead to poor physical and psychosocial outcomes in the long term. In this Review, we aim to summarise the key factors and interventions before hospital admission and following discharge that can improve the long-term outcomes of paediatric burns. Care can be optimised through first aid treatment, correct initial assessment of burn severity, and appropriate patient referral to a burns centre. Scar prevention or treatment and patient follow-up after discharge are also essential. As most burn injuries in children are comparatively small and readily survivable, this Review does not cover the perioperative management associated with severe burns that require fluid resuscitation, or inhalational injury. Burns disproportionately affect children from low socioeconomic backgrounds and those living in low-income and middle-income countries, with ample evidence to suggest that there remains scope for low-cost interventions to improve care for those patients with the greatest burden of burn injury. Current knowledge gaps and future research directions are discussed.

Skin Wound Tension Reduction Device Combined with Ablative Fractional Carbon Dioxide Laser to Reduce Scar Formation After Excision of Pediatric Facial Skin Lesions: A Prospective Cohort Study

Purpose

To investigate the efficacy of skin wound tension reduction device (SWTRD) combined with ablative fractional carbon dioxide laser (CO2-AFL) for the prevention of scar formation following the excision of facial cutaneous lesions in children.

Methods

Patients undergoing surgical excision of facial cutaneous lesions in our hospital between May 2019 and April 2021 were enrolled. After the excision of facial cutaneous lesions and based on the personal intents and conditions, patients were assigned to undergo SWTRD combined with CO2-AFL. Outcome evaluations were as follows: defect size, incision width, scar width, the Vancouver Scar Scale (VSS) and University of North Carolina 4P Scar Scale (UNC4P).

Results

A total of 25 pediatric patients (mean age, 9.88 years) were enrolled in the study. Following the treatment of SWTRD+CO2-AFL, scar widths were relatively narrow and the appearance of the incision scars was significantly improved. A significant reduction in the patient-reported UNC4P scores at 6 months (3, 1–4) was observed when compared with that at 2 months (0, 0–1) after surgery (p<0.001). A similar reduction in the VSS scar scale was also evident (6 months: 1, 0.75–2.5 vs 2 months: 6.5–8.5; p<0.001).

Conclusion

Combined SWTRD and CO2-AFL treatment effectively modulates the scar formation after the incision is healed and resulting in preventing scar widening, leading to the improvement of scar appearance, reduction in wound pain and pruritus and its overall prognosis.

Scar formation from the perspective of complexity science: a new look at the biological system as a whole

A burn wound is a complex systemic disease at multiple levels. Current knowledge of scar formation after burn injury has come from traditional biological and clinical studies. These are normally focused on just a small part of the entire process, which has limited our ability to sufficiently understand the underlying mechanisms and to predict systems behaviour. Scar formation after burn injury is a result of a complex biological system-wound healing. It is a part of a larger whole. In this self-organising system, many components form networks of interactions with each other. These networks of interactions are typically non-linear and change their states dynamically, responding to the environment and showing emergent long-term behaviour. How molecular and cellular data relate to clinical phenomena, especially regarding effective therapies of burn wounds to achieve minimal scarring, is difficult to unravel and comprehend. Complexity science can help bridge this gap by integrating small parts into a larger whole, such that relevant biological mechanisms and data are combined in a computational model to better understand the complexity of the entire biological system. A better understanding of the complex biological system of post-burn scar formation could bring research and treatment regimens to the next level. The aim of this review/position paper is to create more awareness of complexity in scar formation after burn injury by describing the basic principles of complexity science and its potential for burn care professionals.

Case study: Pilot testing of a local acupuncture intervention protocol for burn scars

BACKGROUND

Following burn injury and a prolonged duration of healing, scars may become hypertrophic, causing movement restriction, increased scar thickness, colour and pliability, and symptoms such as pain and itch. Acupuncture has emerged as a potentially beneficial treatment for neuroinflammation, which perpetuates the negative features of hypertrophic scars. The aim of this study was to pilot test an evidence-based methodology for applying and measuring the clinical effects of localised acupuncture for symptomatic scars, in a patient with a healed burn injury.

METHODS

A 71-year-old caucasian male presented with a hypertrophic scar that was painful and itchy after burn injury and subsequent skin grafting. He received acupuncture and massage treatment local to his scar as per the local (verum) group of the author's clinical trial under recruitment. Needles were inserted around the circumference of the skin grafted area and adjacent to areas of raised scar tissue within the grafted area and stimulated via bi-directional rotation. Outcome measures included a Numerical Rating Scale (NRS) for pain and itch, Patient and Observer Scar Assessment Scale (POSAS) self-assessment component and SF36 quality-of-life measure to capture any non-specific acupuncture effects.

CONCLUSION

Acupuncture applied locally around the scar was associated with short-term relief of symptoms and significantly reduced his subjective outcome measure scores relating to scar thickness, redness and pliability out to six months after injury. Some short-term increase in symptoms occurred on several occasions following treatment; however, treatment was well tolerated supporting the use of this protocol for a larger future clinical trial.

LAY SUMMARY

Following injury to the skin, scars can become raised, red and reduce movement. Other common symptoms may include pain and itch. Previous studies suggest acupuncture may help symptomatic scars, but more research is needed to confirm this with larger samples of patients.This case study tested the active treatment protocol for a clinical trial using acupuncture on symptomatic scars. A 71-year-old white man had a burn scar on his torso after a workplace accident. His treatment involved scar massage and local acupuncture. The acupuncture needles were inserted around the skin graft borders and thickened bands of scar tissue.Outcomes were measured using surveys recording symptoms, scar characteristics and quality of life. These were used to assess treatment effect and how well the protocol was tolerated. Over the course of treatment both pain and itch improvedThis case report showed that the treatment protocol was well tolerated, and that local acupuncture was associated with improved scar symptoms and physical characteristics up to six months after injury.

Microfluidic Cell Transport with Piezoelectric Micro Diaphragm Pumps

The automated transport of cells can enable far-reaching cell culture research. However, to date, such automated transport has been achieved with large pump systems that often come with long fluidic connections and a large power consumption. Improvement is possible with space- and energy-efficient piezoelectric micro diaphragm pumps, though a precondition for a successful use is to enable transport with little to no mechanical stress on the cell suspension. This study evaluates the impact of the microfluidic transport of cells with the piezoelectric micro diaphragm pump developed by our group. It includes the investigation of different actuation signals. Therewith, we aim to achieve optimal fluidic performance while maximizing the cell viability. The investigation of fluidic properties proves a similar performance with a hybrid actuation signal that is a rectangular waveform with sinusoidal flanks, compared to the fluidically optimal rectangular actuation. The comparison of the cell transport with three actuation signals, sinusoidal, rectangular, and hybrid actuation shows that the hybrid actuation causes less damage than the rectangular actuation. With a 5% reduction of the cell viability it causes similar strain to the transport with sinusoidal actuation. Piezoelectric micro diaphragm pumps with the fluidically efficient hybrid signal actuation are therefore an interesting option for integrable microfluidic workflows.

MicroRNA-18a-5p represses scar fibroblast proliferation and extracellular matrix deposition through regulating Smad2 expression

The aim of the present study was to investigate the expression and role of microRNA-18a-5p (miR-18a-5p) during the formation of hypertrophic scar (HS), and to further explore the molecular mechanisms involved. Downregulation of miR-18a-5p in HS tissues and human HS fibroblasts (hHSFs) was detected by reverse transcription-quantitative polymerase chain reaction. The binding sites between miR-18a-5p and the 3'-untranslated region of SMAD family member 2 (Smad2) were predicted by TargetScan and confirmed by dual-luciferase reporter assay. To investigate the role of miR-18a-5p in HS formation, the effects of miR-18a-5p downregulation or upregulation on hHSFs were subsequently determined. Cell proliferation was detected by an MTT assay, while cell apoptosis was measured by flow cytometry. In addition, the protein expression levels of Smad2, Collagen I (Col I) and Col III were examined by western blot assay. The findings indicated that miR-18a-5p downregulation in hHSFs significantly promoted the cell proliferation, decreased cell apoptosis and enhanced the expression levels of Smad2, Col I and Col III protein and mRNA, whereas miR-18a-5p upregulation in hHSFs exerted opposite effects. Notably, the effects of miR-18a-5p upregulation on hHSFs were eliminated by Smad2 upregulation. In conclusion, the data indicated that miR-18a-5p was downregulated during HS formation, and its upregulation repressed scar fibroblast proliferation and extracellular matrix deposition by targeting Smad2. Therefore, miR-18a-5p may serve as a novel therapeutic target for the treatment of HS.

A critical review on the potential role of adipose-derived stem cells for future treatment of hypertrophic scars

INTRODUCTION

Adipose-derived stem cells (ASCs) have recently gained researchers' interest as a solution to various diseases and conditions, including hypertrophic scar. This literature review aims to elucidate ASCs as a potential solution to alleviate hypertrophic scar in human subjects.

METHODS

Literature search was done in databases which includes PubMed, MEDLINE, and ProQuest using terms 'adipose derived stem cells', 'adipose cells', 'fat graft', 'fat grafting', 'autologous fat graft', 'fat injection', 'lipofilling', 'scar management', 'scar treatment', 'burn scar', and 'wound management'. The included articles which were published during year 2000-November 2020 must describe the use of ASCs or fat grafting or lipofilling as an attempt to alleviate hypertrophic scar.

REMARKS

Clinically, ASCs improve hypertrophic scars in terms of scar color, elasticity, texture, thickness, and size. Histologically, ASCs promotes healthy tissue regeneration, reduction in fibroblasts, and reorganisation of collagen, resembling those of normal skin. In terms of molecular aspects, ASCs alleviates hypertrophic scars through direct differentiation and paracrine mechanisms.

CONCLUSION

Adipose-derived stem cells, emerge to be a potential solution for alleviating hypertrophic scar, as demonstrated in various studies. However, there has been no studies conducted in human subjects to investigate the effect of ASCs on hypertrophic scar.

Quadrant Excision of Benign Lesions: A Prospective Outcome Study of Pediatric Patients

ABSTRACT

Serial excision is a commonly used technique for the excision of large lesions. The procedure in children is challenging due to different skin quality and unpredictable scar patterns compared to adults. Quadrant excision is a modification of serial excision. The authors report quadrant excisions in 3 pediatric cases with facial congenital melanocytic naevi in aesthetically challenging areas. Based on our results we recommend the use of this technique in similar cases.

Factors Influencing Hypertrophic Scarring after Thyroidectomy

OBJECTIVE

To identify the risk factors of hypertrophic scarring (HS) after thyroidectomy and construct a risk prediction model.

METHODS

From November 2018 to March 2019, the clinical data of patients undergoing thyroidectomy were collected for retrospective analysis. According to the occurrence of HS, the patients were divided into an HS group and a non-HS group. Univariate analysis and binary logistic regression analysis were conducted to explore the independent risk factors for HS. Receiver operating characteristic analysis was also carried out.

RESULTS

In this sample, 121 of 385 patients developed HS, an incidence of 31.4%. Univariate analysis showed significant differences in sex, age, postoperative infection, history of abnormal wound healing, history of pathologic scar, family history of pathologic scar, and scar prevention measures between the two groups (P < .05). Binary logistic regression analysis indicated that age 45 years or younger (odds ratio [OR], 1.815), history of abnormal wound healing (OR, 4.247), history of pathologic scarring (OR, 9.840), family history of pathologic scarring (OR, 5.708), and absence of preventive scar measures (OR, 5.566) were independent factors for HS after thyroidectomy. The area under the receiver operating characteristic curve was 0.837. When the optimal diagnostic cutoff value was 0.206, the sensitivity was 0.661, and the specificity was 0.932.

CONCLUSIONS

The development of HS after thyroidectomy is related to many factors, and the proposed risk prediction model based on the combined risk factors shows a good predictive value for postoperative HS. When researchers consider the prevention and treatment of scarring in patients at risk, the incidence of HS in different populations can provide theoretical support for clinical decision-making.

A Scoping Review of the Methodology Used in Studies of Genetic Influences on the Development of Keloid or Hypertrophic Scarring in Adults and Children After Acute Wounding

Significance: Keloid and hypertrophic scarring are common following acute wounds. However, the variability in scarring outcomes between individuals and in particular, the association between genetic factors and scarring, is not well understood. This scoping review aims to summarize the methodology used in studies of genetic influences on the development of keloid or hypertrophic scarring in adults and children after acute wounding. The objectives were to determine the study designs used, the characteristics of participants included, the tools used to assess scarring and the length of follow-up after wounding.

Recent Advances: The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline, Excerpta Medica Database (EMBASE), Web of Science, Biosciences Information Service (BIOSIS), Prospective Register of Systematic Reviews (PROSPERO), The Human Genetic Epidemiology (HuGE) Navigator (database of genetic association studies), and the genome-wide association study Catalog were searched from January 2008 to April 2020. Cohort studies and case–control studies that examined the association between one or more genetic variations and the development of keloid or hypertrophic scarring were eligible for inclusion. A narrative synthesis that grouped studies by wound type was conducted.

Critical Issues: Nine studies met the inclusion criteria (five in burns, four surgical wounds, and none in other types of acute wounds). Seven assessed hypertrophic scarring, one keloid scarring, and one both scar types. Seven studies used a prospective cohort design. All studies used subjective methods (clinician or patient observation) to assess scarring. There was considerable variation in how scar scales were operationalized.

Future Directions: This review identified a small body of evidence on genetic susceptibility to scarring after acute wounding. Further studies are needed, and in a wide range of populations, including patients with wounds caused by trauma.

Bioflavonoid Galangin Suppresses Hypertrophic Scar Formation by the TGF-β/Smad Signaling Pathway

Background

Hypertrophic scar (HS) is a benign fibroproliferative skin disease resulting from an aberrant wound healing process and can cause aesthetic and functional damage to patients. Currently, there is no ideal treatment to treat this disease. Galangin, a natural active bioflavonoid compound, is suggested to inhibit fibrosis and proliferation in certain cells.

Methods

In this study, we found Galangin could attenuate abnormal scar formation in an HS rabbit ear model. Additionally, the HE staining shows Galangin reduced scar elevation index (SEI) and Masson's trichrome staining changed collagen deposition.

Results

The expressions of type I collagen, type III collagen, and TGF-β1 were much lower under a proper dose of Galangin treatment, and Smad7 expression was also enhanced, which are examined by real-time PCR, immunohistochemistry, and western blot.

Conclusion

Our data indicated that Galangin can alleviate dermal scarring via the TGF-β/Smad signaling pathway probably by upregulating Smad 7 expression and, thus, suppressing the expression of type I and type III collagens and TGF-β1.

The efficacy and safety of fractional CO2 laser therapy in the treatment of burn scars: A meta-analysis

Although we have numerous publications about the effect of fractional CO₂ laser therapy for burn scars, quantitative data about its efficacy and safety are sparse. The purpose of this meta-analysis was to assess the efficacy and safety of fractional CO₂ laser therapy for the treatment of burn scars. Pertinent studies were identified by a search of PubMed, Embase and Web of Science up to 20 September 2020. Weighted mean difference (WMD) was conducted to combine the results, and a random-effect model was used to pool the results. Publication bias was estimated using Begg and Egger's regression asymmetry test. Twenty articles were included. Our pooled results suggested that fractional CO₂ laser therapy significantly improved the Vancouver Scar Scale (VSS) score (WMD = -3.24, 95%CI: -4.30, -2.18; P < 0.001). Moreover, the Patient and Observer Scar Assessment Scale (POSAS)-patient (WMD = -14.05, 95%CI: -22.44, -5.65; P = 0.001) and Observer (WMD = -6.31, 95%CI: -8.48, -4.15; P < 0.001) also showed significant improvements with the treatment of fractional CO₂ laser therapy. Fractional CO₂ laser significantly reduced scar thickness measured with ultrasonography (WMD = -0.54, 95%CI: -0.97, -0.10; P < 0.001). For other outcomes, including pigmentation, vascularity, pliability, and height of scar, vascularity and relief, laser therapy was associated with significant improvements. However, only the cutometer measure R2 (scar elasticity) (WMD = -0.06, 95%CI: -0.10, -0.01; P = 0.023) was significantly improved with the laser therapy, but cutometer measures R0 (scar firmness) (WMD = 0.03, 95%CI: -0.04, 0.09; P = 0.482) was not. Side effects and complications induced by fractional CO₂ laser were mild and tolerable. Fractional CO₂ laser therapy significantly improved both the signs and symptoms of burn scars. Considering potential limitations, more large-scale, well-designed RCTs are needed to verify our findings.

Human CD206+ Macrophages Show Antifibrotic Effects on Human Fibroblasts through an IL-6-Dependent Mechanism In Vitro

BACKGROUND

Pathologic scarring including keloid and hypertrophic scar causes aesthetic and physical problems, and there are clinical difficulties (e.g., posttreatment recurrence) in dealing with pathologic scarring. Understanding the mechanisms that underlie scar control in wound healing will help prevent and treat pathologic scarring. The authors focused on CD206+ macrophages in the wound-healing process, and hypothesized that CD206+ macrophages have antifibrotic effects on fibroblasts.

METHODS

The authors established a co-culture system for CD206+ macrophages and fibroblasts (cell ratio, 1:1). The authors examined the CD206+ macrophages' antifibrotic effects on fibroblasts after a 72-hour culture, focusing on fibrosis-related genes. To identify key factor(s) in the interaction between CD206+ macrophages and fibroblasts, the authors analyzed cytokines in a conditioned medium of the co-culture system.

RESULTS

Under co-culture with CD206+ macrophages, expression of the following in the fibroblasts was significantly down-regulated: type 1 (fold change, 0.38) and type 3 collagen (0.45), alpha smooth muscle actin (0.24), connective tissue growth factor (0.40), and transforming growth factor-beta (0.66); the expression of matrix metalloproteinase 1 was significantly up-regulated (1.92). Conditioned medium in the co-culture showed a high interleukin (IL)-6 concentration (419 ± 88 pg/ml). When IL-6 was added to fibroblasts, antifibrotic changes in gene expression (as observed under the co-culture) occurred in the fibroblasts.

CONCLUSIONS

The authors' in vitro results revealed that CD206+ macrophages have antifibrotic effects on fibroblasts by means of a paracrine mechanism involving IL-6. Understanding these effects, especially in vivo, will help elucidate the mechanism of scar control in wound healing and contribute to the development of new scar treatments.

Hypertrophic Scarring: Current Knowledge of Predisposing Factors, Cellular and Molecular Mechanisms

Hypertrophic scarring (HSc) is an age-old problem that still affects millions of people physically, psychologically, and economically. Despite advances in surgical techniques and wound care, prevention and treatment of HSc remains a challenge. Elucidation of factors involved in the development of this common fibroproliferative disorder is crucial for further progress in preventive and/or therapeutic measures. Our knowledge about pathophysiology of HSc at the cellular and molecular level has grown considerably in recent decades. In this article, current knowledge of predisposing factors and the cellular and molecular mechanisms of HSc has been reviewed.

Postoperative incision scars and cosmetic satisfaction of living liver donors

Cosmetic appearance is a major concern for living donors. However, little is known about the impact of a surgical scar on body image changes in living liver donors. The aim of this study was to identify potential factors that cause displeasing upper midline incision scar, and to evaluate the overall satisfaction regarding body image and scarring after living donor hepatectomy.Donors who underwent right lobe hepatectomy were recruited. Exclusion criteria included reoperation, refusal to participate, and lost follow-up. All donors were invited to complete the Vancouver Scar Scale (VSS) and the body image questionnaire. According to the VSS results of upper midline incision scar, donors were divided into 2 groups: good scarring group (VSS ≤4) and bad scarring group (VSS >4). we compared the clinical outcomes, including the demographics, preoperation, intraoperation, and postoperation variables. The study also analyzed the results of the body image questionnaire.The proportion of male donors was 48.9%. The bad scarring group consisted of 63% of the donors. On multivariate analysis, being a male donor was found to be an independent predictor of a cosmetically displeasing upper midline incision scar with statistical significance. The results of body image questionnaires, there were significant differences in cosmetic score and confidence score among the 2 groups.The upper midline incision and male donors have higher rates of scarring in comparison with the transverse incision and female donors. Donors who reported having a higher satisfaction with their scar appearance usually had more self-confidence. However, the body image won't be affected. Medical staff should encourage donors to take active participation in wound care and continuously observe the impact of surgical scars on psychological changes in living liver donors.

Scar Assessment After Breast Reconstruction: Risk Factors for Hypertrophy and Hyperpigmentation in Asian Patients

BACKGROUND

Breast scars after breast reconstruction can be hypertrophic and/or hyperpigmented, especially in Asian patients, whose skin is thicker and has increased melanin. Few studies have focused on breast scars after breast reconstruction, and the risk factors for an abnormal breast scar remain unknown.

METHODS

We examined 257 Asian patients who underwent an immediate 2-stage unilateral implant-based breast reconstruction. Vascularity, hypertrophy, and hyperpigmentation of the patients' breast scars were assessed at 1 year postoperatively. Risk factors for an abnormal scar were analyzed statistically. Analyzed patient factors included age, body mass index, incision site (frontal or lateral), breast size (the weight of the resected specimen), skin necrosis at the initial operation (expander placement), and adjuvant therapy.

RESULTS

At 1 year postoperatively, 161 patients (63%) showed normal vascularity, 77 patients (30%) showed mild vascularity, 18 patients (7%) showed moderate vascularity, and 1 patient (0.4%) showed severe vascularity. No patient factors were correlated with vascularity. Thirty-two patients (12%) showed hypertrophy, and the rate of hypertrophy was significantly higher in the patients with a lateral incision (n = 59) compared with those with a frontal incision (n = 198) (28.8% vs 7.6%, P < 0.01). Even in the frontal incision group, a lateral part of the frontal scar was likely to be hypertrophic. Forty-six patients (18%) showed hyperpigmentation, and the rate of hyperpigmentation was significantly higher in the patients with skin necrosis (n = 47) at the initial operation than those without skin necrosis (n = 210) (57.4% vs 9.0%, P < 0.01). Large breast was also a risk factor for hyperpigmentation due to its higher frequency of skin necrosis.

CONCLUSIONS

In Asian patients who undergo breast reconstruction, the use of a lateral incision is a risk factor for hypertrophy, and skin necrosis at the initial operation is a risk factor for hyperpigmentation at the breast scar.

Fractionated Ablative Carbon Dioxide Laser Therapy Decreases Ultrasound Thickness of Hypertrophic Burn Scar: A Prospective Process Improvement Initiative

INTRODUCTION

Carbon dioxide (CO2) laser treatment is routinely used to treat hypertrophic burn scars (HBS). Although prior research has documented subjective improvement in HBS after treatment, there is little data evaluating objective changes in scar characteristics after therapy. The aim of our process improvement project was to evaluate changes to scar thickness (ST) using high-frequency ultrasound in patients with HBS undergoing CO2 laser therapy.

METHODS

Ultrasound measurements of ST were obtained from patients with HBS before initial and at each subsequent treatment. ST, reduction in ST per treatment, and percentage reduction in ST from baseline were tabulated. Post hoc analyses examining the effect of initial ST and scar maturity on outcome were performed. First, patients were grouped by baseline ST into thicker (group 1, initial ST ≥ median value) and thinner (group 2, initial ST < median value) scar groups. Second, patients were divided into quartiles based on time from injury to treatment. Outcomes at each time point were compared with either Mann-Whitney U or Kruskal-Wallis tests, with Bonferonni corrections performed for post hoc subgroup analyses. Significance was set at P < 0.05.

RESULTS

Twenty-one consecutive patients with HBS treated with CO2 laser were included. All patients completed 1 or more treatment, 48% completed 2 or more treatments, and 28% completed 3 treatments. Median initial ST was 0.71 cm (0.44-0.98 cm), and median scar maturity was 7.5 months (4.9-9.8 months). Overall, ST decreased over the treatment course (P < 0.001), with post hoc analysis demonstrating that 2 treatments were required to achieve a significant ST reduction (P < 0.01). On subgroup analysis comparing initial ST, ST decreased significantly in group 1 (thicker scars) overall (P < 0.001) but not in group 2 (P = 0.109). ST reduction was greatest after 1 treatment in group 1 (P = 0.022) and group 2 (P = 0.061). Percent reduction was greater in group 1 relative to group 2 after 1 treatment (P = 0.016). On subgroup analysis of scar maturity, there were no significant differences in either baseline ST or ST at any subsequent visit.

CONCLUSIONS

Fractionated ablative CO2 laser treatment improved ST after 1 to 2 treatments. Patients with thicker scars demonstrated greater ST reduction than those with thinner scars. Ultrasound adequately assessed treatment response.

Petite miracles: insight into the nano-management of scarless wound healing

Scars affect millions of patients worldwide, yet their treatment efficacy and options clinically remain limited. In recent years, increased understanding of scar formation pathways leading to developments in nanotechnology have opened many opportunities for scar detection, prevention, and treatment due to the nanoscale features and therapeutic delivery capabilities of such technologies. Led by nanoparticles (NPs) and nanofibers, these novel strategies can aid in reducing scar contracture, improving wound-healing efficacy, and advancing progress towards scarless wound healing.

Prognostic tools for hypertrophic scar formation based on fundamental differences in systemic immunity

Unpredictable hypertrophic scarring (HS) occurs after approximately 35% of all surgical procedures and causes significant physical and psychological complaints. Parallel to the need to understanding the mechanisms underlying HS formation, a prognostic tool is needed. The objective was to determine whether (systemic) immunological differences exist between patients who develop HS and those who develop normotrophic scars (NS) and to assess whether those differences can be used to identify patients prone to developing HS. A prospective cohort study with NS and HS groups in which (a) cytokine release by peripheral blood mononuclear cells (PBMC) and (b) the irritation threshold (IT) after an irritant (sodium lauryl sulphate) patch test was evaluated. Univariate regression analysis of PBMC cytokine secretion showed that low MCP-1, IL-8, IL-18 and IL-23 levels have a strong correlation with HS (P < .010-0.004; AUC = 0.790-0.883). Notably, combinations of two or three cytokines (TNF-a, MCP-1 and IL-23; AUC: 0.942, Nagelkerke R2 : 0.727) showed an improved AUC indicating a better correlation with HS than single cytokine analysis. These combination models produce good prognostic results over a broad probability range (sensitivity: 93.8%, specificity 86.7%, accuracy 90,25% between probability 0.3 and 0.7). Furthermore, the HS group had a lower IT than the NS group and an accuracy of 68%. In conclusion, very fundamental immunological differences exist between individuals who develop HS and those who do not, whereas the cytokine assay forms the basis of a predictive prognostic test for HS formation, the less invasive, easily performed irritant skin patch test is more accessible for daily practice.

A prospective comparative study of radiotherapy effect upon scar quality

INTRODUCTION

The effect of radiation on uncomplicated postoperative scars is unclear. This study aimed to analyze irradiated and non-irradiated scars in patients with unilateral breast cancer, who underwent oncoplastic breast reduction surgery and radiation therapy (RT), to identify how postoperative scar changes with radiation.

METHODS

Twenty breast scars in 10 patients were analyzed after unilateral breast-conserving surgery, oncoplastic breast reduction, and RT. Scars were assessed using the Vancouver scar scale (VSS) by two independent blinded observers and three-dimensional scar analysis camera. Paired t-test between irradiated and non-irradiated scars in each patient and correlation of scar score differences with potential contributing factors were analyzed.

RESULTS

The VSS was significantly lower for the irradiated scar than that for the non-irradiated contralateral scar (1.40 vs. 4.05, p = 0.001), although time interval from the last radiation to scar assessment had a negative correlation with paired differences of VSS (Spearman's correlation coefficient: -0.637, p = 0.048). Compared with the non-irradiated scar, the irradiated scar showed a significantly high level of hemoglobin (1.04 vs. 1.26, p = 0.017) and melanin (0.55 vs. 0.63, p = 0.03).

CONCLUSIONS

Postoperative scars with radiation showed better results in objective and subjective assessments than scars without radiation. These findings suggest that radiation has a positive effect on general scar maturation.

Statin treatment and hypertrophic scarring after cardiac surgery

Wound healing process after surgical procedure plays a crucial role to prevent blood loss and infections. Hypertrophic scars might occur after surgery and are generally associated with an inflammatory burden. Cardiac surgery is intrinsically related to a strong systemic inflammatory state that might favor hypertrophic scarring. Besides lipid-lowering effects, statins are known for their pleiotropic and anti-inflammatory activity. The aim of this study was to investigate the impact of statins in the healing process after median sternotomy in patients undergoing cardiac surgery. All patients undergoing major cardiac surgery with median sternotomy and cardiopulmonary bypass, and subsequently evaluated in the outpatient clinic after discharge, were included in this study. A total of 930 Caucasian patients were retrospectively reviewed. At outpatient visit, 276 patients (29.7%) showed the formation of hypertrophic scars. Patients with hypertrophic scars tended to be younger (P = .001) and nonstatin users (P = .001). Logistic regression analysis confirmed the protective role of statins (odds ratio 0.39, 95% confidence interval 0.29-0.53, P = .001), after adjustment for age. A dose-dependent effect was confirmed, showing a more intensive protective effect for higher doses of statins. Statin use might be correlated with reduced hypertrophic scars after cardiac surgery through median sternotomy. A dose-dependent effect has been shown, and statin effect seems to be independent of age in a selected population undergoing surgery with an elevated inflammatory burden. Although further studies are warranted to elucidate the biologic mechanisms, the concept of using statins as anti-scarring agents is novel and should be investigated with tailored studies.

Primary Ciliary Signaling in the Skin-Contribution to Wound Healing and Scarring

Primary cilia (PC) are solitary, post-mitotic, microtubule-based, and membrane-covered protrusions that are found on almost every mammalian cell. PC are specialized cellular sensory organelles that transmit environmental information to the cell. Signaling through PC is involved in the regulation of a variety of cellular processes, including proliferation, differentiation, and migration. Conversely, defective, or abnormal PC signaling can contribute to the development of various pathological conditions. Our knowledge of the role of PC in organ development and function is largely based on ciliopathies, a family of genetic disorders with mutations affecting the structure and function of PC. In this review, we focus on the role of PC in their major signaling pathways active in skin cells, and their contribution to wound healing and scarring. To provide comprehensive insights into the current understanding of PC functions, we have collected data available in the literature, including evidence across cell types, tissues, and animal species. We conclude that PC are underappreciated subcellular organelles that significantly contribute to both physiological and pathological processes of the skin development and wound healing. Thus, PC assembly and disassembly and PC signaling may serve as attractive targets for antifibrotic and antiscarring therapies.

The UK National Artificial Eye Questionnaire study: predictors of artificial eye wearers' experience part 1-comfort and satisfaction

OBJECTIVES

To report associations with comfort and with appearance satisfaction in artificial eye wearers.

METHODS

Multicentre, observational, cross-sectional study, nationwide within the National Health Service England. The National Artificial Eye Questionnaire (NAEQ) was completed by 951 respondents. Multiple regressions assessed associations between the experiences of artificial eye wearers, routine management, changes over time, baseline and demographic parameters and their reported comfort, satisfaction with appearance and prosthesis motility.

RESULTS

Better comfort levels were associated with needing less lubrication (β = 0.24, p < 0.001), older age (β = 0.17, p = 0.014), less discharge (β = 0.16, p < 0.001), less frequent cleaning (β = 0.16, p = 0.043), and male gender (β = 0.06, p = 0.047). Greater satisfaction with the appearance of the artificial eye was associated with better perceived motility (β = 0.57, p < 0.001). Black ethnic origin predicted a lower satisfaction with the appearance (β = -0.17, p = 0.001). Greater satisfaction with the motility was associated with a better appearance rating (β = 0.51, p < 0.001), longer time of having an artificial eye (β = 0.13, p < 0.001), older age (β = 0.11, p = 0.042), and a shorter adjustment time (β = -0.07, p = 0.016). Of the testimonials concerning appearance aspects, the majority (21/45, 46.7%) were related to the effect on social interactions.

CONCLUSIONS

The results suggest that more attention should be given to the "dry anophthalmic socket syndrome" as a key cause of discomfort. Young patients are concerned particularly about the motility of the artificial eye. Over time satisfaction with the artificial eye movement is likely to improve.

Topical Scar Treatment Products for Wounds: A Systematic Review

BACKGROUND

There is an increasing number of over-the-counter topical products that are said to prevent pathologic scar formation and improve scar cosmesis. However, robust clinical data are lacking to substantiate these claims and to guide selection of topical products.

OBJECTIVE

To determine the effectiveness of topical scar management products, including silicone gel, Allium cepa onion extract, vitamin E, trolamine, and microporous tape.

METHODS AND MATERIALS

A PubMed search (2005-2019) was performed to identify studies of topical scar management products. Randomized controlled trials (RCTs), quasi-RCTs, meta-analyses, and controlled clinical trials were included for analysis.

RESULTS

A total of 34 trials were included in this study. Of the 16 trials investigating silicone gel sheets, numerous high-quality RCTs found that silicone gel sheets and silicone gels significantly improved scar outcomes. Only a limited number of studies supported the effectiveness of onion extract, vitamin E, trolamine, and microporous tape products.

CONCLUSION

Silicone gel products are an effective noninvasive treatment to prevent formation of pathologic scars and improve mature scars. Further high-quality studies are needed to elucidate the long-term effectiveness of these therapies.

Thermo-responsive chitosan hydrogel for healing of full-thickness wounds infected with XDR bacteria isolated from burn patients: In vitro and in vivo animal model

Treatment of non-healing skin wounds infected with extensively drug-resistant (XDR) bacteria remains as a big challenge. To date, different biomaterials have been applied for treatment of post-wound infections, nevertheless their efficacy for treatment of the wounds infected with XDR isolates has not been determined yet. In this study, the potential of the thermo-responsive chitosan (TCTS) hydrogel for protection of full-thickness wounds XDR bacteria isolated from burn patients was evaluated both in vitro and in vivo in a rat model. Antibacterial activity of the TCTS hydrogel against standard strain and clinical isolates of Acinetobacter baumannii, cytobiocompatibility for Hu02 fibroblast cells, degradation rate and swelling ratio were determined in vitro. MTT assay and disk diffusion test indicated no detectable cytotoxicity and antibacterial activity in vitro, respectively. In vivo study showed significant acceleration of wound healing, re-epithelialization, wound closure, and decreased colony count in the TCTS hydrogel group compared with control. This study suggests TCTS hydrogel as an excellent wound dressing for management of the wounds infected with XDR bacteria, and now promises to proceed with clinical investigations.