Patient reported facial scar assessment: directions for the professional

A randomised investigation of film-forming silicone gel in superficial partial thickness face and neck burn patients: Indication of improved early scar pigmentation outcomes

INTRODUCTION

Burns to the face and neck are a source of considerable distress and a challenge to manage with dressings. Further, these often superficial injuries pose a risk of scarring and altered pigmentation. Silicone gels have emerged as a potential solution to the challenges of conservative management for face and neck burn injuries. The aims of this study were to explore the effect of topical silicone compared to routine treatment of conservatively managed burns to the face and neck.

METHODS

This single-blind, randomised, controlled trial compared topical silicone film-forming dressing to standard of care for superficial partial thickness burns to the face and neck. Time to healing was the primary outcome and secondary outcomes included: 1) scar assessments (modified Vancouver Scar Scale, Dermalab Combo and Patient and Observer Scar Assessment Scale) at six weeks and three months; and 2) pain intensity scale at wound review appointments.

RESULTS

Of the 55 participants in the face/neck study, 34 were male and 21 were female. Median age was 36 years (range from 25 to 47 years). The median time to healing for the silicone group was 9 days (CI 7.6 -10.4) and the control group was 7 days (CI 5.3- 8.7), p = 0.056. Analysis demonstrated significantly reduced pigmentation at six weeks in mVSS scores for the silicone group (Md = 0, IQR = 0) compared to the control group (Md = 0, IQR = 0 - 3), p = 0.043. We found no evidence of differences in reported pain between the groups (Silicone - Md = 1.15, IQR 0.3 - 4.5 vs control group - Md = 1.5, IQR 0.6 - 3.8, z = -0.63, p = 0.53). No other differences were observed, and no adverse events were associated with the topical silicone in the study whereas an infection and a reaction were experienced in the control group.

CONCLUSION

Film-forming silicone gel had comparable effects to standard of care emollient on wound healing of superficial partial thickness burns of the face and neck. Silicone treated wounds were associated with a significant improvement in scar pigmentation outcome at six weeks post-burn.

The effects of scar in psychological disorder: A bibliometric analysis from 2003 to 2022

Scars are fibrous tissues that replace normal tissue during the wound healing process. Scarring can lead to low self-esteem, social impairment, depression, anxiety, and other psychiatric and psychological distress, necessitating a comprehensive understanding of the latest perspectives, topical research, and directions in scarring-mental health. This is a biblioshiny and VOSviewer based bibliometric analysis study. All data were obtained from the Web of Science, and a total of 664 articles from 2003 to 2022 met the criteria. The last 7 years have been a period of rapid growth in the field, with 2022 having the highest number of articles. The United States is the core country with the highest production and citation rate. The most cited literature was written in 2003 by Van Loey NE et al. Van Loey NE is the most prolific and influential author in this field. The top five popular keywords include "quality of life", "depression", "management", "anxiety", and "prevalence". The paper concludes that the current focus of scholars in the field is on the treatment of scars and that multidisciplinary treatment of such patients is worth exploring. These findings provide relevant researchers with the current state of research and possible future directions in this field.

Modified Colson flap with subcutaneous liposuction for one-stage donor site removal: A case series

OBJECTIVES

The aim of this study was to evaluate the functional and cosmetic results of an innovative procedure for modified Colson flap-graft consisting of immediate defatting of the flap by a liposuction cannula.

METHODS

A cross-sectional study was performed among patients with deep hand burns requiring a modified Colson flap between 2018 and 2021. Outcomes included functional and cosmetic assessment of the hand through a quality-of-life questionnaire, a sensitivity scale and a scar assessment scale.

RESULTS

During this period, 7 patients were operated on using our technique. One patient was lost to follow-up; 7 patients with a median age of 44 years were included, with a total of 10 burned hands. The burns were thermal in 5 out of 7 cases and the coverage concerned the whole hand in 50% of the cases. The flaps all received cannula defatting. The median time to flap weaning was 23 days (20 to 30 days). The median follow-up was 16 months. One case required remote flap weaning. The median POSAS (Patient and Observer Scar Assessment Scale) per patient was 4 and 2 per observer. The median BMRCSS (British Medical Research Council Sensory Scale) was 122. One case had recovered S2 sensitivity, the other cases had S3 or S4 sensitivity.

CONCLUSION

Immediate defatting is one of the factors in tegumental quality allowing rapid functional recovery of the hand. The cannula defatting technique does not appear to require additional defatting time. The use of the liposuction cannula allows a one-step, homogeneous, and easier defatting, with a lower risk of devascularization.

Effectiveness of Autologous Fat Transfer in the Treatment of Scar-Related Conditions: A Systematic Review and Meta-analysis

BACKGROUND AND AIM

Autologous fat transfer (AFT) has been introduced as a potential treatment option for scar-tissue and its related symptoms. However, the scientific evidence for its effectiveness remains unclear. This meta-analysis aims to evaluate the available evidence regarding the effectiveness of autologous fat transfer for the treatment of scar-tissue and its related conditions.

METHODS

PubMed/Medline database was queried from its inception till the end of November 2021. All the relevant studies assessing the effect of autologous fat transfer in the treatment of scar-related conditions were pooled in using a random-effects model.

RESULTS

9 studies (n=179) were included in the meta-analysis. Pooled analysis demonstrates significant improvement in all subscales of the POSAS patient score with most prominent in color 2.4 points (95% CI 1.78-3.041), stiffness 2.9 points (95% CI 2.33-3.45), irregularity 2.2 points (95% CI 1.093-3.297) and thickness 1.8 points (95% CI 0.804-2.719), respectively. Pain and itch improved relatively lesser, 1.3 points (95% CI 0.958-1.674) and 0.6 points (95% CI 0.169-1.215), respectively. The POSAS observer scale showed a relatively lower improvement with the least in vascularity 0.5 points (95% CI 0.098-0.96), pigmentation 0.8 points (95% CI 0.391-1.276) and surface area 0.8 points (95% CI 0.34-1.25). Thickness improved by 1.4 points (95% CI 0.582-2.3), relief 1.0 points (95% CI 0.461-1.545) and pliability 1.5 points (95% CI 1.039-2.036).

CONCLUSION

Our findings demonstrate that autologous fat transfer (AFT) is a promising treatment for scar-related conditions as it provides beneficial results in the scar quality. Future research should focus on the long-term effects of AFT and high-level evidence studies such as, randomized controlled trials (RCTs) and cohort studies are required.

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 .

Longitudinal monitoring and prediction of long-term outcome of scar stiffness on pediatric patients

Background

Hypertrophic scarring after burn injury is one of the greatest unmet challenges in patients with burn injuries. A better understanding of the characteristics of scar maturation and early prediction of the long-term outcome of scarring are prerequisites for improving targeted therapies and pivotal for patient counselling.

Methods

Repeated measurements of scar stiffness in 11 pediatric patients were performed over the course of 1 year using 2 suction devices, the Cutometer and the Nimble. In addition, the observer pliability score of the Patient and Observer Scar Assessment Scale was applied. This longitudinal study allowed quantification of the ability of each of the measured parameters to reflect scar maturation, as indicated by change in skin pliability/stiffness, over time (using linear regression); the ability to distinguish individual patients (intraclass correlation coefficient (ICC)); the correlation of the devices (Spearman correlation coefficient); and the ability to predict long-term scar maturation based on early scar assessment (using receiver operating characteristic).

Results

All the tools used showed significant longitudinal decrease of scar stiffness from 3 months until 12 months after the injury. The Nimble (ICC_patient ^Nimble = 0.99) and the Cutometer (ICC_patient ^Cuto = 0.97) demonstrated an excellent ability to distinguish between individual patients. The Nimble seemed to be able to predict the 12-month pliability of scars based on early (3-month) measurements (area under the curve (AUC)_12m ^POSAS = 0.67; AUC_12m ^C = 0.46; AUC_12m ^N = 0.79).

Conclusions

The results of this preliminary study suggest that all 3 tools provide suitable means to quantify alterations in scar stiffness over time. Initial evidence suggests the Nimble is most favorable for predicting changes in stiffness associated with long-term scar maturation. Further studies with a larger sample size are required to validate tissue suction as a clinical tool for analysis of changes of scar stiffness over time.

Scar quality in children with burns 5-7 years after injury: A cross-sectional multicentre study

Long-term scar formation is an important adverse consequence in children with burns, however, information regarding scar quality in the long-term is lacking. Therefore, we evaluated scar quality and its predictors in children with burns 5-7 years after injury. Parents of children with mild/intermediate burns (≤10% total body surface area burned), and of children with severe burns (>10% burned) completed the patient scale of the Patient and Observer Scar Assessment Scale (POSAS 2.0) for their children's-in their opinion-worst scar 5-7 years post-burn. Outcomes and predictive factors of scar quality were studied, and, for children with severe burns, POSAS parent scores were compared with observer scores. We included 103 children with mild/intermediate burns and 28 with severe burns (response rate: 51%). Most children (87%) had scars that differed from normal skin, with most differences reported for colour, and least for pain. Except for colour, children with severe burns had significantly higher scores (difference 0-2 points) on all scar characteristics (representing poorer scar quality) compared with children with mild/intermediate burns. Parent POSAS scores were on average 2.0-2.6 points higher compared to observer scores. Number of surgeries predicted both the mean POSAS and the mean overall opinion of a scar. In conclusion, 5-7 years post-burn, the scar of the majority of children differed from normal skin, especially on the characteristic colour. The uncovered insights are useful in counselling of children and their parents on expectations of the final outcome of their (children's) scar(s), and help in further targeting scar prevention strategies for the individual child.

Subjective Tools for Burn Scar Assessment: An Integrative Review

OBJECTIVE

To review the clinical and scientific literature on the subjective ways of assessing burn scars and describe their main characteristics.

DATA SOURCES

The Latin American, Caribbean Health Sciences Literature, Nursing Database, PubMed, CINAHL, and Scopus and Web of Science databases were used to search for studies published between 2014 and 2018 using descriptors in Portuguese, Spanish, and English.

STUDY SELECTION

After establishing the research question and the location and definition of the studies, as well as accounting for differences among databases and application of filters based on inclusion and exclusion criteria, 886 references remained.

DATA EXTRACTION

Investigators reviewed the titles and abstracts of the sample and selected 188 relevant studies for full review.

DATA SYNTHESIS

Twenty-six subjective forms of assessment were found; most research concerned the Patient and Observer Scar Assessment Scale and the Vancouver Scar Scale.

CONCLUSIONS

The Patient and Observer Scar Assessment Scale and the Vancouver Scar Scale are the most common scales for assessing burn scars and have similar evaluation points such as vascularization, pliability, pigmentation, and height, which are the main parameters that contribute to the general assessment and severity of a scar. There is a need to improve instructions for application of the scales to facilitate better understanding and improve agreement among evaluators.

Establishment of a long-term hypertrophic scar model by injection of anhydrous alcohol: A rabbit model

The processes of hypertrophic scar formation are extremely complex, and current animal models have limitations in terms of the complete characterization of lesions. An ideal animal model is indispensable for exploring the complex progression of scar formation to elucidate its pathophysiology and to perform therapeutic testing. This study aimed to establish a long-term, consistent and easily testable animal model by injecting anhydrous alcohol into the dorsal trunk dermis of rabbits. The rabbits were injected with different amounts of anhydrous alcohol. Anhydrous alcohol was infiltrated into the subcutaneous and superficial fascia. The optimal amount of anhydrous alcohol was determined by measuring the area and thickness of the scar. The typical model was established by determining the optimum dosage, and then we analysed the histological characteristics and fibrosis-associated protein expression. The dermal scar was generated by treating with 2 ml/kg anhydrous alcohol and displayed histopathologic features that characterize human hypertrophic scarring, including a parallel collagen fibre orientation, dermal and epidermal thickening, broad collagen deposition and the loss of dermal adnexal structures. The expression of fibrotic pan-markers was also enhanced. Moreover, the scar features and duration were compared between the anhydrous alcohol model and the rabbit ear model. Our results show that injecting anhydrous alcohol in the rabbit model thickened the dermal tissue, stimulated dermal fibroproliferation and resulted in hypertrophic scars with protein and histologic features similar to those seen in humans. Taken together, the findings from this study show that our model could be a feasible and useful tool for further research on the pathogenesis of hypertrophic scars.

Gene Suppression of the Chloride Channel 2 Suppressed TGF-β1-Induced Proliferation, Collagen Synthesis, and Collagen Gel Contraction Mediated by Conjunctival Fibroblasts

BACKGROUND

Excessive scarring of filtering blebs is the main cause of surgical failure in glaucoma. Previous studies have highlighted the role of chloride channels (ClCs) in scar formation, whereas the role of ClCs in scarring of filtering blebs has not been studied.

OBJECTIVES

The objective of this study was to investigate the effects of the chloride channel 2 (ClC-2) on scar formation of filtering blebs after glaucoma filtering surgery.

METHODS

ClC-2 siRNA-transfected human conjunctival fibroblasts (HConFs) were cultured in type 1 collagen gels in the presence of transforming growth factor (TGF)-β1. Collagen gel contraction was evaluated based on the gel area. 3D-cultured HConFs were treated with the ClC blocker NPPB in the presence of TGF-β1, and cell proliferation collagen synthesis and contractility were measured. The expression levels of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) in HConFs were assessed by Western blotting and qPCR.

RESULTS

TGF-β1 induced cell proliferation, cell cycle progression, collagen synthesis, and collagen gel contraction in HConFs. TGF-β1 increased MMP-2 and MMP-9 levels but inhibited the expression of TIMPs. NPPB and ClC-2 siRNA transfection inhibited TGF-β2-induced cell proliferation, cell cycle progression, collagen synthesis, and collagen gel contraction, mediated by HConFs. TGF-β2-induced increases in MMP-2 and MMP-9 were also inhibited by NPPB and ClC-2 siRNA transfection, but TIMP expression was increased by NPPB and ClC-2 siRNA transfection.

CONCLUSIONS

These findings demonstrate that ClC-2 ClCs modulate TGF-β1-induced cell proliferation, collagen synthesis, and collagen gel contraction of HConFs by attenuating MMP-2 and MMP-9 production and by stimulating TIMP1 production. NPPB may therefore prove to be of clinical value for the inhibition of scar formation of filtering blebs.

Patient-reported scar quality of adults after burn injuries: A five-year multicenter follow-up study

Scar formation is an important adverse consequence of burns. How patients appraise their scar quality is often studied shortly after sustaining the injury, but information in the long‐term is scarce. Our aim was, therefore, to evaluate long‐term patient‐reported quality of burn scars. Adults with a burn center admission of ≥1 day between August 2011 and September 2012 were invited to complete a questionnaire on long‐term consequences of burns. We enriched this sample with patients with severe burns (>20% total body surface area [TBSA] burned or TBSA full thickness >5%) treated between January 2010 and March 2013. Self‐reported scar quality was assessed with the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS). Patients completed this scale for their—in their opinion—most severe scar ≥5 years after burns. This study included 251 patients with a mean %TBSA burned of 10%. The vast majority (91.4%) reported at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and 78.9% of the patients’ overall opinion was that their scar deviated from normal skin. Patients with severe burns had higher POSAS scores, representing worse scar quality, than patients with mild/intermediate burns, except for color, which was high in both groups. A longer hospital stay predicted reduced scar quality (both mean POSAS and mean overall opinion of the scar) in multivariate analyses. In addition, female gender was also associated with a poorer overall opinion of the scar. In conclusion, this study provides new insights in long‐term scar quality. Scars differed from normal skin in a large part of the burn population more than 5 years after burns, especially in those with severe burns. Female gender is associated with a poorer patients’ overall opinion of their scar, which may be an indication of gender differences in perception of scar quality after burns.

Combination of Melolabial Interpolation Flap and Nasal Sidewall and Cheek Advancement Flaps Allows for Repair of Complex Compound Defects

BACKGROUND

The paramedian forehead flap (PMFF) is the repair of choice for large nasal defects involving multiple cosmetic subunits. However, the PMFF may not be optimal for all patients. The combination of a melolabial interpolation flap (MLIF) and a nasal sidewall flap may serve as an alternative.

OBJECTIVE

To present the surgical technique and aesthetic outcomes of the alternative reconstruction for surgical defects of the lower nose.

MATERIALS AND METHODS

Fourteen patients with multisubunit nasal Mohs defects reconstructed alternatively were identified from 2 academic centers in this retrospective case series. Illustrations and photographs were used to demonstrate surgical technique and outcomes. Final aesthetic results were analyzed using the Patient and Observer Scar Assessment Scale.

RESULTS

The physician observer rated the scar outcome a mean score of 10.9 ± 3.3. Patients rated their results as a mean of 9.1 ± 4.7. The mean "Patient" Overall Opinion score was 2.3 ± 2.6 and the mean "Observer" Overall Opinion score was 1.9 ± 0.9. No patients reported problems with nasal airflow or obstruction, and cosmetic complications such as pincushioning or alar buckling were not observed.

CONCLUSION

The combined MLIF and nasal sidewall flap is an alternative repair for complex distal nasal defects.

MicroRNA-663 regulates the proliferation of fibroblasts in hypertrophic scars via transforming growth factor-β1

The present study determined the expression of microRNA (miR)-663 in hypertrophic scar (HS) tissues and investigate the regulatory mechanisms of miR-663 in HS. A total of 51 patients diagnosed with HS between December 2013 and February 2016 were included in the present study. HS tissues (experimental group) and HS-adjacent tissues (control group) were collected. Primary fibroblasts were obtained from HS tissue and transfected with small-interfering RNA against transforming growth factor (TGF)-β1 or miR-663 mimics. Reverse-transcription quantitative PCR was used to determine the levels of TGF-β1 mRNA and miR-663. Western blot analysis was performed to determine TGF-β1 protein expression. An MTT assay was employed to detect the proliferation of fibroblasts, and a dual luciferase reporter assay was performed to identify the binding of miR-663 with TGF-β1 mRNA. TGF-β1 was found to have a regulatory role in HS at the transcriptional level. The expression of TGF-β1 was upregulated in HS tissues, and knockdown of TGF-β1 in cultured fibroblasts led to inhibition of proliferation. The expression of miR-663 was downregulated in HS. miR-663 was revealed to regulate the expression of TGF-β1 by binding with the 3′-untranslated region of TGF-β1 mRNA. Elevated expression of miR-663 inhibited the proliferation of fibroblasts by regulating TGF-β1 expression. The present study demonstrated that upregulation of TGF-β1 in HS tissues is associated with the downregulation of miR-663 expression. miR-663 may regulate the proliferation of fibroblasts in HS and the expression of associated proteins.

MicroRNA-222 regulates the viability of fibroblasts in hypertrophic scars via matrix metalloproteinase 1

The present study aimed to determine the expression of microRNA (miR)-222 in hypertrophic scar (HS) tissues, and investigate the regulatory mechanism of miR-222 in HS. A total of 36 patients diagnosed with HS between August 2013 and May 2016 were included in the present study. HS tissues and HS-adjacent tissues were collected from patients. Primary fibroblasts were obtained from HS tissue. Reverse transcription-quantitative polymerase chain reaction was used to measure mRNA levels of matrix metalloproteinase 1 (MMP1) and miR-222. Western blotting was conducted to determine MMP1 expression and an MTT assay was performed to measure the viability of fibroblasts. A dual luciferase reporter assay was used to identify the binding of miR-222 to MMP1 mRNA. It was demonstrated that MMP1 serves a role in HS at the transcription level and that increased MMP1 expression inhibited the viability of fibroblasts. miR-222 serves a regulatory role in HS by targeting its target gene MMP1 and regulates the expression of MMP1 by binding to its 3′-untranslated region. The decreased expression of miR-222 suppresses the viability of fibroblasts by regulating MMP1 expression. The present study demonstrated that the downregulation of MMP1 in HS tissues is associated with the upregulation of miR-222 expression. miR-222 may therefore regulate the viability of fibroblasts in HS and the expression of related proteins via MMP1.

Study on the role of Hsa-miR-31-5p in hypertrophic scar formation and the mechanism

Hypertrophic scar (HS) formation is associated with the fibrosis of fibrocytes caused by excessive extracellular matrix (ECM) synthesis and deposition, the initial event of HS formation. Our high throughput screen of miRNA expression profiles identified hsa-miR31-5p, whose transcription level was most differentially in normal skin fibroblasts (NS) and HS among other miRNAs. The level of hsa-miR31-5p in HS was significantly higher than in NS. In-vitro functional experiments showed hsa-miR31-5p knockdown remarkably suppressed the proliferation of hypertrophic scar fibroblasts (HSFBs) under hypoxia, promoted cell invasion, and inhibited the expression of Collagen I and III and Fibronectin (FN), suggesting that hsa-miR31-5p knockdown effectively reduces HS formation caused by excessive ECM synthesis and deposition in HSFBs under hypoxia. Mechanism study showed that the regulation of HS formation by hsa-miR31-5p was mediated by its target gene, factor-inhibiting HIF-1 (FIH): under hypoxia, hsa-miR31-5p down-regulated FIH and thus increased the level of hypoxia inducible factor-1α (HIF-1α), which subsequently activated the HIF-1α fibrosis regulation pathway in HSFBs, and stimulated the proliferation and ECM synthesis in HSFBs, eventually resulting in fibrosis and scar formation. The data also show that knockdown of hsa-miR31-5p in HSFBs impaired the trend of increased proliferation, reduced invasion and excessive ECM synthesis and deposition caused by HIF-1a activation under hypoxia through upregulating FIH, indicating that knockdown of hsa-miR31-5p effectively inhibits the formation of HS. In conclusion, hsa-miR31 -5p plays an important role in HS formation by inhibiting FIH and regulating the HIF-1α pathway. Therefore, hsa-miR31 -5p may be a novel therapeutic target for HS.

A Multicenter Randomized Controlled Trial Evaluating a Cx43-Mimetic Peptide in Cutaneous Scarring

The transmembrane protein Cx43 has key roles in fibrogenic processes including inflammatory signaling and extracellular matrix composition. aCT1 is a Cx43 mimetic peptide that in preclinical studies accelerated wound closure, decreased inflammation and granulation tissue area, and normalized mechanical properties after cutaneous injury. We evaluated the efficacy and safety of aCT1 in the reduction of scar formation in human incisional wounds. In a prospective, multicenter, within-participant controlled trial, patients with bilateral incisional wounds (≥10 mm) after laparoscopic surgery were randomized to receive acute treatment (immediately after wounding and 24 hours later) with an aCT1 gel formulation plus conventional standard of care protocols, involving moisture-retentive occlusive dressing, or standard of care alone. The primary efficacy endpoint was average scarring score using visual analog scales evaluating incision appearance and healing progress over 9 months. There was no significant difference in scar appearance between aCT1- or control-treated incisions after 1 month. At month 9, aCT1-treated incisions showed a 47% improvement in scar scores over controls (Vancouver Scar Scale; P = 0.0045), a significantly higher Global Assessment Scale score (P = 0.0009), and improvements in scar pigmentation, thickness, surface roughness, and mechanical suppleness. Adverse events were similar in both groups. aCT1 has potential to improve scarring outcome after surgery.

Patient opinion of scarring is multidimensional: An investigation of the POSAS with confirmatory factor analysis

INTRODUCTION

Scarring is a significant consequence for patients following a burn. Understanding how patients perceive the physiological scar and define scar severity may provide valuable information regarding how the scar influences quality of life after burn. The Patient and Observer Scar Assessment Scale was the first scar assessment tool validated to include the patients' evaluation of the scars physical qualities, following a burn. Validation studies of this tool have previously been conducted for a discrete scar-site after burn. The aim of this study was to assess the structural validity of the POSAS to capture the patients' evaluation of the total area of burn scar(s).

METHOD

Statistical analysis was based on 508 completed POSAS forms from 358 patients. Exploratory factor analysis (EFA) was used initially to identify the number of factors within the tool, then confirmatory factor analysis (CFA) using structural equation modelling explored areas of misfit within each factor and whether the model provided a predicable structure to capture patient perception of scar severity.

RESULTS/DISCUSSION

The CFA analysis confirmed that a two dimensional model was superior to a unidimensional model when assessing the patient opinion of their total burn scar. The two dimensions were the physical scar (color, stiffness, thickness and irregularity) and the sensory scar (pain and itch). Further strain analysis of the two factor model identified additional domains. Independent factors influenced the perception of color forming a separate subdomain within the physical domain. Color is a visual characteristic, whereas the other three are predominantly tactile characteristics. A significant relationship between thickness and irregularity suggested they may form another subdomain, however further research is required to confirm this. Both pain and itch were recognized as independent, multidimensional latent variables, which require assessment tools with multidimensional structures.

CONCLUSIONS

When assessing the entire burn scar, three independent dimensions influence patient perception: (1) the physical scar, (2) pain and (3) itch. Within the physical domain, color formed a visual subdomain separate to a tactile subdomain. Further development of these domains within a high-order multi-dimensional structure is recommended.

Patient experiences and outcomes following facial skin cancer surgery: A qualitative study

Early melanoma and non-melanoma skin cancer of the facial area are primarily treated with surgery. Little is known about the outcomes of treatment for facial skin cancer patients. The objective of the study was to identify concerns about aesthetics, procedures and health from the patients' perspective after facial skin surgery. Semi-structured in-depth interviews were conducted with 15 participants. Line-by-line coding was used to establish categories and develop themes. We identified five major themes on the impact of skin cancer surgery: appearance-related concerns; psychological (e.g., fear of new cancers or recurrence); social (e.g. impact on social activities and interaction); physical (e.g. pain and swelling) concerns and satisfaction with the experience of care (e.g., satisfaction with surgeon). The priority of participants was the removal of the facial skin cancer, as this reduced their overall worry. The aesthetic outcome was secondary but important, as it had important implications on the participants' social and psychological functioning. The participants' experience with the care provided by the surgeon and staff also contributed to their satisfaction with their treatment. This conceptual framework provides the basis for the development of a new patient-reported outcome instrument.

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

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

The CLC-2 Chloride Channel Modulates ECM Synthesis, Differentiation, and Migration of Human Conjunctival Fibroblasts via the PI3K/Akt Signaling Pathway

Recent evidence suggests that chloride channels are critical for cell proliferation, migration, and differentiation. We examined the effects of transforming growth factor (TGF)-β1 on chloride channel expression and associations with human conjunctival fibroblast (HConF) biology. To investigate the potential role of chloride channel (CLC)-2 in migration, transition to myofibroblasts and extracellular matrix (ECM) synthesis of HconF, a small interfering RNA (siRNA) approach was applied. TGF-β1-induced migration and transition of fibroblasts to myofibroblasts characterized by α-smooth muscle actin (α-SMA) expression, supported by increased endogenous expression of CLC-2 protein and mRNA transcripts. ECM (collagen I and fibronectin) synthesis in HConF was enhanced by TGF-β1. CLC-2 siRNA treatment reduced TGF-β1-induced cell migration, transition of fibroblasts to myofibroblasts, and ECM synthesis of HConF. CLC-2 siRNA treatment in the presence of TGF-β1 inhibited phosphorylation of PI3K and Akt in HConF. These findings demonstrate that CLC-2 chloride channels are important for TGF-β1-induced migration, differentiation, and ECM synthesis via PI3K/Akt signaling in HConF.

Long-term scar quality in burns with three distinct healing potentials: A multicenter prospective cohort study

The laser Doppler imager is used in cases of indeterminate burn depth to accurately predict wound healing time at an early stage. The laser Doppler imager classifies burns into three estimated healing potentials as follows: high, <14 days; intermediate, 14-21 days; and low, >21 days. At this time, the relationship between these healing potentials and long-term scar quality is unknown. The objective of this study was to determine the long-term scar quality of burns with three distinct healing potentials. The secondary objectives were to compare treatment strategies in intermediate wounds, to study the effect of the timing of surgery on low healing potential wounds and to identify predictors of reduced scar quality. Hence, in a prospective cohort study, scar quality was determined in patients whose burns were assessed with laser Doppler imaging. Scar Quality was assessed with objective and subjective measurement tools, including overall scar quality (Patient and Observer Scar Assessment Scale) as a primary outcome and color and elasticity parameters. A total of 141 patients (>19 months postburn) with 216 scars were included. Wounds with high and intermediate healing potential did not significantly differ regarding scar quality. Wounds with a low healing potential had a significantly lower scar quality. Analysis of 76 surgically treated low healing potential wounds showed no significant differences in the primary outcome regarding the timing of surgery (≤14 days vs. >14). Predictors of reduced long-term scar quality were darker skin type and multiple surgeries. In conclusion, scar quality was strongly related to the healing potential category. Scar quality was very similar in high and intermediate healing potential wounds. No positive effects were found on scar quality or on healing time in surgically treated wounds with intermediate healing potential, advocating a conservative approach. Further studies should focus on the optimal timing of surgery in low healing potential wounds.

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.

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

Te n 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.

Effects of CCN3 on fibroblast proliferation, apoptosis and extracellular matrix production

CCN2 and CCN3 belong to the CCN family of proteins, which show a high level of structural similarity.Previous studies have shown that CCN2 mediates the ability of transforming growth factor (TGF)‑β to stimulate collagen synthesis, leading to keloid formation. CCN2 and CCN3 are opposing factors in regulating the promoter activity and secretion of this extracellular matrix (ECM) protein. Thus, we hypothesize that CCN3 possesses an anti‑scarring effect. However, the exact mechanism of CCN3 in this anti‑scarring effect remains unclear. The aim of this study was to investigate the mechanism of CCN3 in reducing scar formation. Palatal fibroblasts were obtained from the explants of the oral palatal mucosa of 8‑week‑old male Sprague‑Dawley rats. CCN3 overexpression vector was constructed and then transfected into cells. The inhibitory effects of CCN3 on cell growth were detected via the 3‑(4,5‑dimethylthiazol‑2‑yl)‑2,5‑diphenyltetrazolium bromide (MTT) assay. Apoptosis was measured using an Annexin V‑fluorescein isothiocyanate (FITC)/propidium iodide (PI) apoptosis detection kit and flow cytometry. The expression levels of collagen I, collagen III and α‑smooth muscle actin (α‑SMA) were determined by western blot analysis and RT‑PCR. Following treatment with TGF‑β1, we detected the expression of CCN3 and Smad1 in the fibroblasts. CCN3 significantly inhibited the growth and induction of apoptosis of fibroblasts. The expression of collagen I, collagen III and α‑SMA was lower in the CCN3‑transfected group as compared to the control and vector groups. TGF‑β1 stimulation efficiently suppressed the expression of CCN3 at the mRNA and protein levels, and CCN3 was required for TGF‑β1‑induced Smad1 phosphorylation. Results of this study demonstrated that CCN3 is involved in the proliferation and apoptosis of fibroblasts and the synthesis of ECM proteins. Therefore, CCN3 may play an important role in the development of scar tissue, and may represent a novel therapeutic target for reducing scar formation.