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Zilinskas K, Mittal R, Hollowed K, Kahn SA. Prophylactic Antibiotics Are Unnecessary for Routine CO2 Laser Burn Scar Treatment. J Burn Care Res 2025; 46:178-182. [PMID: 39087666 DOI: 10.1093/jbcr/irae146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Indexed: 08/02/2024]
Abstract
CO2 ablative fractional laser (CO2 AFL) therapy is a safe and effective procedure when used in the treatment of hypertrophic scars for burn patients. It has a high patient satisfaction rate and a minimal side effect profile, typically consisting of postoperative pain, irritation, surgical site inflammation, and, in rare cases, infection. Although prophylactic antibiotics have historically been recommended, there is a paucity of literature on the topic and recent studies indicate that they may be unnecessary in routine cases. In this retrospective, single-center descriptive study, 230 cases in patients with hypertrophic burn scars treated with CO2 AFL therapy were compared. 28 cases were with the use of prophylactic antibiotics and 201 cases were without the use of prophylactic antibiotics. We found that there was no significant association between the use of antibiotics and the prevention of topical skin infection in cases treated with CO2 AFL therapy (P = 1). Therefore, we conclude that the omission of prophylactic antibiotics is not associated with an increased risk of infection and recommend that prophylactic antibiotics should not be indicated in the setting of routine CO2 AFL therapy for patients with hypertrophic burn scars.
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Affiliation(s)
- Kasparas Zilinskas
- Department of Burn Surgery, Medical University of South Carolina, Charleston, SC 29403, USA
| | - Rohit Mittal
- Department of Burn Surgery, Medical University of South Carolina, Charleston, SC 29403, USA
| | - Kathleen Hollowed
- Department of Burn Surgery, Medical University of South Carolina, Charleston, SC 29403, USA
| | - Steven A Kahn
- Department of Burn Surgery, Medical University of South Carolina, Charleston, SC 29403, USA
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Ma Y, Barnes SP, Chen YY, Moiemen N, Lord JM, Sardeli AV. Influence of scar age, laser type and laser treatment intervals on paediatric burn scars: a systematic review and meta-analysis. BURNS & TRAUMA 2024; 12:tkad046. [PMID: 38312741 PMCID: PMC10838059 DOI: 10.1093/burnst/tkad046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/24/2023] [Indexed: 02/06/2024]
Abstract
Background Laser therapy has emerged to play a valuable role in the treatment of paediatric burn scars; however, there is heterogeneity in the literature, particularly concerning optimal timing for initiation of laser therapy. This study aims to investigate the effect of factors such as scar age, type of laser and laser treatment interval on burn scar outcomes in children by meta-analysis of previous studies. Methods A literature search was conducted across seven databases in May 2022 to understand the effects of laser therapy on burn scar outcomes in paediatric patients by metanalysis of standardized mean difference (SMD) between pre- and post-laser intervention. Meta-analyses were performed using the Comprehensive Meta-Analysis software version 4.0. Fixed models were selected when there was no significant heterogeneity, and the random effects model was selected for analysis when significant heterogeneity was identified. For all analyses, a p-value < 0.05 was considered significant. Results Seven studies were included in the meta-analysis with a total of 467 patients. Laser therapy significantly improved Vancouver Scar Scale (VSS)/Total Patient and Observer Scar Assessment Scale (Total POSAS), vascularity, pliability, pigmentation and scar height of burn scars. Significant heterogeneity was found between the studies and thus subgroup analyses were performed. Early laser therapy (<12 months post-injury) significantly improved VSS/POSAS scores compared to latent therapy (>12 months post-injury) {SMD -1.97 [95% confidence interval (CI) = -3.08; -0.87], p < 0.001 vs -0.59 [95%CI = -1.10; -0.07], p = 0.03} as well as vascularity {SMD -3.95 [95%CI = -4.38; -3.53], p < 0.001 vs -0.48 [95%CI = -0.66; -0.30], p < 0.001}. Non-ablative laser was most effective, significantly reducing VSS/POSAS, vascularity, pliability and scar height outcomes compared to ablative, pulse dye laser and a combination of ablative and pulse dye laser. Shorter treatment intervals of <4 weeks significantly reduced VSS/POSAS and scar height outcomes compared to intervals of 4 to 6 weeks. Conclusions Efficacy of laser therapy in the paediatric population is influenced by scar age, type of laser and interval between laser therapy application. The result of this study particularly challenges the currently accepted initiation time for laser treatment. Significant heterogeneity was observed within the studies, which suggests the need to explore other confounding factors influencing burn scar outcomes after laser therapy.
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Affiliation(s)
- Yangmyung Ma
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Sabrina P Barnes
- Hull York Medical School, University Rd, Heslington, York YO10 5DD, United Kingdom
| | - Yung-Yi Chen
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Naiem Moiemen
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
- Department of Burns and Plastic Surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- Scar Free Foundation Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Janet M Lord
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
- Scar Free Foundation Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Amanda V Sardeli
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
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Won P, Cooper M, Justin Gillenwater T, Yenikomshian HA. Treatment of Hypertrophic Burn Scars With Laser Therapy: A Review of Adverse Events. Ann Plast Surg 2023; 91:715-719. [PMID: 37856225 PMCID: PMC10840736 DOI: 10.1097/sap.0000000000003712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
ABSTRACT Hypertrophic scarring, characterized by excessive scar tissue formation, is a debilitating outcome that significantly impairs physical and psychosocial recovery after burn injury. Hypertrophic scarring affects a substantial proportion of burn survivors, with reported prevalence as high as 70%. Fractional CO 2 laser (FCL) therapy, a therapy commonly used in acne scar treatment or skin rejuvenation, has become popular in treating hypertrophic scars. Little is known regarding FCL's adverse events for burn scar treatment. We hypothesize that FCL is a safe treatment modality with minimal adverse events in the management of hypertrophic burn scars. This is a retrospective chart review of adverse events after FCL at 2 centers within a single institution. Burn patients undergoing FCL between May 1, 2019, and June 1, 2021 were included. Demographics, injury etiology, laser treatment details, and adverse events were collected. A total of 170 patients, 77 (45.3%) males and 93 (54.7%) females, underwent 544 FCL therapies for burn scars. The average number of treatments per patient was 3 ± 2.23, with a range of 1 to 17 sessions. From the total 544 laser therapy sessions, 13 adverse events (2.4%) were reported. There were 5 reports (0.9%) of increased postprocedural pain and 1 report (0.2%) of increased paresthesia/numbness to laser site. Three instances (0.6%) of increased erythema and 4 reports (0.7%) of epidermal sloughing or blistering were reported. All but 5 patients (2.9%) reported improvements to scar symptoms. This study demonstrates minimal adverse events associated with FCL for hypertrophic burn scar treatment.
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Affiliation(s)
- Paul Won
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael Cooper
- LAC+USC Hospital, University of Southern California, Los Angeles, CA, USA
| | - T. Justin Gillenwater
- Division of Plastic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Haig A. Yenikomshian
- Division of Plastic Surgery, University of Southern California, Los Angeles, CA, USA
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Ma Y, Barnes SP, Chen YY, Moiemen NS, Lord JM, Sardeli AV. Influence of scar age, laser type and laser treatment intervals on adult burn scars: A systematic review and meta-analysis. PLoS One 2023; 18:e0292097. [PMID: 37756273 PMCID: PMC10529539 DOI: 10.1371/journal.pone.0292097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
AIM The study aims to identify whether factors such as time to initiation of laser therapy following scar formation, type of laser used, laser treatment interval and presence of complications influence burn scar outcomes in adults, by meta-analysis of previous studies. METHODS A literature search was conducted in May 2022 in seven databases to select studies on the effects of laser therapy in adult hypertrophic burn scars. The study protocol was registered with PROSPERO (CRD42022347836). RESULTS Eleven studies were included in the meta-analysis, with a total of 491 patients. Laser therapy significantly improved overall VSS/POSAS, vascularity, pliability, pigmentation and scar height of burn scars. Vascularity improvement was greater when laser therapy was performed >12 months (-1.50 [95%CI = -2.58;-0.42], p = 0.01) compared to <12 months after injury (-0.39 [95%CI = -0.68; -0.10], p = 0.01), the same was true for scar height ((-1.36 [95%CI = -2.07; -0.66], p<0.001) vs (-0.56 [95%CI = -0.70; -0.42], p<0.001)). Pulse dye laser (-4.35 [95%CI = -6.83; -1.86], p<0.001) gave a greater reduction in VSS/POSAS scores compared to non-ablative (-1.52 [95%CI = -2.24; -0.83], p<0.001) and ablative lasers (-0.95 [95%CI = -1.31; -0.59], p<0.001). CONCLUSION Efficacy of laser therapy is influenced by the time lapse after injury, the type of laser used and the interval between laser treatments. Significant heterogeneity was observed among studies, suggesting the need to explore other factors that may affect scar outcomes.
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Affiliation(s)
- Yangmyung Ma
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | | | - Yung-Yi Chen
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Naiem S. Moiemen
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Department of Burns and Plastic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Scar Free Foundation Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Janet M. Lord
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Scar Free Foundation Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Amanda V. Sardeli
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
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Dahm S, Lee G, Cleland H, Menezes H, Ng S. The use of carbon dioxide and intense pulsed light laser for the treatment of hypertrophic burn scars: A case series. Scars Burn Heal 2023; 9:20595131231202103. [PMID: 38022893 PMCID: PMC10655654 DOI: 10.1177/20595131231202103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Introduction Hypertrophic scarring is a common and debilitating consequence of burn scars. While there is limited evidence for current treatment options, laser therapy has been shown to be effective, low risk and minimally invasive. This study assesses the use of carbon dioxide lasers and intense pulsed light devices in the treatment of hypertrophic burn scars. Methods In this case series, patients were recruited from a hypertrophic burn scar waitlist and completed a Patient and Observer Scar Assessment Scale prior to and six weeks after laser therapy. The Nordlys (intense pulsed light) and CO2RE (carbon dioxide) systems from Candela Medical were used, with a range of settings used depending on the assessment of the burn scar. The differences between scores were calculated for the total Patient and Observer Scar Assessment Scale score, pain, itch, colour, stiffness, thickness, irregularity and the overall opinion of the scar. Statistical analysis was completed using a paired, two-tailed student T test. Results A total of 31 patients were recruited for this trial with a range of scar locations, surface areas and mechanism of burn injury. The calculated difference in mean showed a significant reduction for the overall Patient and Observer Scar Assessment Scale score (1.93, p < 0.0001), pain (1.39, p = 0.0002), itch (1.84, p = 0.0002), colour (1.97, p < 0.0001), stiffness (2.47, p < 0.0001), thickness (2.1, p < 0.0001), irregularity (1.89, p < 0.0001) and overall opinion (1.58, p = 0.0003). Conclusion Current management options for hypertrophic scarring have limited evidence. Laser therapy presents a minimally invasive procedure that can be completed under topical anaesthetic and has shown to be effective following a single treatment of combined carbon dioxide laser and intense pulsed light device therapy. Lay Summary Many people will suffer a burn injury throughout their life and up to almost 3 out of 4 people with burn injuries will suffer from hypertrophic scars (a thickened, red and itchy scar). These scars cause distress both due to their appearance and their reduction of function, particularly over a joint or muscle. Laser therapy, in which different wave lengths of light (pulsed light) or gas (carbon dioxide) target the scar, has been found to be effective and have minimal side effects in the management of hypertrophic scars. While individual lasers have been assessed and found to be effective and low risk, the combined use of multiple lasers on the same scar has not been extensively studied. We studied the effectiveness of both light and gas laser therapies on hypertrophic scars. Patients with hypertrophic scars completed a questionnaire that focused on their perspective of their scar (pain, itch, stiffness, thickness, irregularity, overall opinion) prior to the treatment. The patients then underwent laser therapy (with local anaesthetic gel) with either pulsed light and/or carbon dioxide (gas) laser. The type of laser used was decided by the clinician performing the therapy depending on scar location and thickness. Patients then re-completed the subjective survey six weeks following the laser therapy, and the results compared. We learnt that laser therapy (both light, gas and a combination of both) are effective (and low risk) in reducing the subjective burden of the scar for the patient.
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Affiliation(s)
- Sophia Dahm
- Victorian Adult Burns Service, Alfred Hospital, Melbourne, Australia
| | - Geoffrey Lee
- Victorian Adult Burns Service, Alfred Hospital, Melbourne, Australia
| | - Heather Cleland
- Victorian Adult Burns Service, Alfred Hospital, Melbourne, Australia
| | - Hana Menezes
- Victorian Adult Burns Service, Alfred Hospital, Melbourne, Australia
| | - Sally Ng
- Victorian Adult Burns Service, Alfred Hospital, Melbourne, Australia
- Department of Plastic and Reconstructive Surgery, Austin Health, Melbourne, Australia
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Inflammatory and infectious complications of laser therapy in treatment of hypertrophic burn scars: Correlations in literature review & case reports. Burns 2022; 48:1026-1034. [PMID: 34696952 DOI: 10.1016/j.burns.2021.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 09/21/2021] [Accepted: 09/24/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Hypertrophic burn scars contribute to morbidity through secondary symptoms of pain, pruritus, and scar contracture. Traditional treatment methods are now augmented by the use of monochromatic light therapies, which are generally accepted as safe and effective. However, little literature is available regarding the complications of laser treatments of hypertrophic burn scars and even less regarding inflammatory and infectious complications. METHODS A literature search using PubMed was performed to identify literature pertaining to infectious and inflammatory complications of cutaneous laser treatments. Additionally, we reviewed cases of inflammatory and infectious complications occurring at our institution after laser treatment of hypertrophic burn scars. RESULTS We identified 1 publication related to complications of laser therapy in the treatment of burn scars. In this series of 163 laser sessions, the reported incidence of adverse events was 25.1%, of which 6 cases 3.7% were related to inflammatory and infectious processes. In the 391 laser sessions performed at our institution (December, 2015 and July, 2016) 9 cases of inflammatory and infectious complications were noted yielding an incidence of 2.3%. Cases included 3 each of cellulitis, Systemic Inflammatory Response Syndrome (SIRS), and complicated SIRS. CONCLUSION We found the most common inflammatory complication was SIRS with MSSA positive wound cultures. Three cases underwent hospitalization along with fluids and vasopressors, despite negative blood cultures. In light of the high prevalence of MSSA in the natural skin flora and negative blood cultures, the inability to establish a true source of infection lead to declaring these cases "complicated SIRS" and not sepsis. Correlative factors that may have led to complications reported in our cases were: preoperative evidence of infection, no preoperative antibiotics administered, no postoperative antibiotic dressings, combined procedures, and large treatment areas. The true mechanism of inflammatory and infectious complication is yet to be determined, but we postulate that these factors place a greater challenge on an already burdened immune system. Determining whether this is a true causal mechanism, leading to an aggravated inflammatory response, benefits from further investigation. APPLICABILITY OF RESEARCH TO PRACTICE We urge institutions preforming such procedures to advise patients on preoperative wound preparation. We recommend that each individual with a preexisting history of infection and/or preoperative culture evidence of infection receive antibiotics, particularly when undergoing combined procedures or procedures involving higher surface areas. Although complications are rare, the benefits of these precautionary measures outweigh the risks when it comes to prevention and management.
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Tsai HH, Hsieh CH, Lin CH, Tsai YJ, Chi SY, Hsieh MH, Lin KC, Lin HP, Hsu SY. Facilitated delivery of topical steroids after fractional ablative carbon dioxide laser benefits postthyroidectomy hypertrophic scar. DERMATOL SIN 2022. [DOI: 10.4103/ds.ds_54_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Lv K, Liu H, Xu H, Wang C, Zhu S, Lou X, Luo P, Xiao S, Xia Z. Ablative fractional CO 2 laser surgery improving sleep quality, pain and pruritus in adult hypertrophic scar patients: a prospective cohort study. BURNS & TRAUMA 2021; 9:tkab023. [PMID: 34322556 PMCID: PMC8314205 DOI: 10.1093/burnst/tkab023] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/20/2020] [Indexed: 11/28/2022]
Abstract
Background Poor sleep quality is associated with a decrease in quality of life in patients with major burn scars, combined with pruritus and pain. Few interventions have been reported to improve the sleep quality of patients with scars. In the current prospective cohort study, we investigated the efficacy of CO2-ablative fractional laser (AFL) surgery vs conventional surgery in post-burn patients with hypertrophic scars with sleep quality as the primary study outcome. Methods In total 68 consecutive patients undergoing scar surgical treatment were recruited, including a CO2-AFL surgery cohort (n = 35) and a conventional surgery cohort (n = 33). A subgroup from the AFL cohort was selected. Sleep quality, pain and pruritus were evaluated. Multiple linear regression analyses were performed to reveal the effect of CO2-AFL surgery. Results The CO2-AFL surgery cohort had significantly lower Pittsburgh sleep quality index (PSQI) global scores than the conventional surgery cohort after the last surgical treatment. In the subgroup of patients receiving hardware sleep monitoring, CO2-AFL markedly increased deep sleep time, deep sleep efficiency and reduced initial sleep latency. Compared to the conventional surgery cohort, the CO2-AFL cohort presented significantly lower pain and pruritus scores. Correlation analysis showed pain and pruritus were significantly associated with PSQI scores, and there were also significant correlations between pain and pruritus scores. Multiple linear regression analysis showed that surgery method was negatively linearly correlated with visual analog scale (VAS) pain score, brief pain inventory (BPI) total, VAS pruritus score, 5-D itch scale total, four-item itch questionnaire (FIIQ) total and PSQI total. Conclusions CO2-AFL surgery significantly improved sleep quality and reduced pain and pruritus of hypertrophic scar patients. The alleviation of sleep disorder was associated with improvement of deep sleep quality including deep sleep time and deep sleep deficiency. Trial registration The Chinese Clinical Trial Registry (ChiCTR200035268) approved retrospectively registration on 5 Aug 2020.
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Affiliation(s)
- Kaiyang Lv
- Department of Plastic Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092; People's Republic of China.,Department of Burn Surgery, the First affiliated Hospital to Naval Medical University, Shanghai 200433, People's Republic of China
| | - Huazhen Liu
- Department of Burn Surgery, the First affiliated Hospital to Naval Medical University, Shanghai 200433, People's Republic of China
| | - Haiting Xu
- Department of Burn and Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, People's Republic of China.,Department of Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, People's Republic of China
| | - Caixia Wang
- Shanghai Institute of Laser Technology, Shanghai 200233, People's Republic of China
| | - Shihui Zhu
- Department of Burn Surgery, the First affiliated Hospital to Naval Medical University, Shanghai 200433, People's Republic of China
| | - Xiaozhen Lou
- Department of Burn Surgery, the First affiliated Hospital to Naval Medical University, Shanghai 200433, People's Republic of China
| | - Pengfei Luo
- Department of Burn Surgery, the First affiliated Hospital to Naval Medical University, Shanghai 200433, People's Republic of China
| | - Shichu Xiao
- Department of Burn Surgery, the First affiliated Hospital to Naval Medical University, Shanghai 200433, People's Republic of China
| | - Zhaofan Xia
- Department of Burn Surgery, the First affiliated Hospital to Naval Medical University, Shanghai 200433, People's Republic of China
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Patient- and Physician-Reported Outcome of Combined Fractional CO2 and Pulse Dye Laser Treatment for Hypertrophic Scars in Children. Ann Plast Surg 2021; 85:237-244. [PMID: 32349082 DOI: 10.1097/sap.0000000000002377] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hypertrophic scars are commonly seen in children and associated with pruritus, pain, functional impairment, and aesthetic disfigurement. Ablative fractional CO2 and pulse dye laser are emerging techniques to improve scar quality. Only limited data are available on children, nonburn scars, and patient-reported outcome. We aimed to investigate safety and outcome of repeated laser therapy for hypertrophic scars originating from burns and other conditions by means of patient- and physician-reported outcome measures. METHODS This was a retrospective before-after analysis of laser treatments in children with hypertrophic scars. Outcome was measured using Patient and Observer Scar Assessment Scale, Vancouver Scar Scale and Itch Man Scale. With respect to safety, laser- and anesthesia-related complications were analyzed. RESULTS Seventeen patients, aged 11.37 ± 4.82 years with 27 scars, underwent 102 distinct laser treatments, mainly combined CO2 and pulse dye laser (94%), with few CO2 only (6%). Vancouver Scar Scale total score before the first and after the first session decreased significantly from 7.65 ± 2.12 to 4.88 ± 1.73; Patient and Observer Scar Assessment Scale observer overall opinion also dropped from 5.88 ± 1.57 to 4.25 ± 1.70. Pruritus improved significantly. Patient age and timing of laser intervention did not have an impact on treatment response. Complications related to laser treatment were seen in 2% (wound infection, n = 2) and to anesthesia in 4% (insignificant n = 2, minor n = 1). CONCLUSIONS Combined laser therapy significantly improves quality, pain, and pruritus of hypertrophic scars in children. When provided by experienced laser and anesthesia teams, it is safe with a low rate of complications.
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Ou KL, Wen CC, Lan CY, Chen YA, Wang CH, Wang YW. The Optimal Application of Medium Potency Topical Corticosteroids in Preventing Laser-Induced Inflammatory Responses-An Animal Study. Life (Basel) 2021; 11:life11040350. [PMID: 33920511 PMCID: PMC8073345 DOI: 10.3390/life11040350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 01/07/2023] Open
Abstract
Background: During ablative fractional resurfacing (AFR) laser therapy, thermal damage to the skin is inevitable, resulting in inflammatory responses and small wounds. Corticosteroids are known for their anti-inflammatory effect. However, inappropriate application of corticosteroids carries the risk of delayed wound healing. Therefore, we aimed to find the optimal administration route, timing, and duration of medium potency corticosteroid treatment to prevent AFR laser-induced inflammatory responses and to minimize the risk of delayed wound healing. Methods: We determined the anti-inflammatory efficacy of corticosteroids by skin erythema and tissue biopsies on C57BL/6 mice. Wound healing was evaluated by crust area and epithelial gap. Finally, Masson’s trichrome stain and α-SMA immunohistochemistry stain were used to analyze scar contracture. Results: Our results demonstrated that one dose of medium-potency topical corticosteroid applied immediately after AFR laser treatment could prevent erythema effectively with minimal disruption to wound healing. Notably, when more than one dose was administered, wound healing was delayed and scar contracture was aggravated by the application of medium-potency topical corticosteroids in a dosage-dependent manner. Conclusion: Our findings suggested that single-dose medium-potency topical corticosteroids could potentially improve AFR laser-induced acute inflammatory responses in clinical applications.
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Affiliation(s)
- Kuang-Ling Ou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - Chia-Cheng Wen
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - Ching-Ya Lan
- Department and Graduate Institute of Biology and Anatomy, National Defense Medical Center, Taipei 114, Taiwan;
| | - Yu-An Chen
- Department of Health and Leisure Management, Yuanpei University of Medical Technology, Hsinchu 300, Taiwan;
| | - Chih-Hsin Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
- Correspondence: (C.-H.W.); (Y.-W.W.)
| | - Yi-Wen Wang
- Department and Graduate Institute of Biology and Anatomy, National Defense Medical Center, Taipei 114, Taiwan;
- Correspondence: (C.-H.W.); (Y.-W.W.)
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Matuszczak E, Weremijewicz A, Koper-Lenkiewicz OM, Kamińska J, Hermanowicz A, Dębek W, Komarowska M, Tylicka M. Effects of combined Pulsed Dye Laser and Fractional CO 2 Laser treatment of burn scars and correlation with plasma levels of collagen type I, MMP-2 and TIMP-1. Burns 2020; 47:1342-1351. [PMID: 33358398 DOI: 10.1016/j.burns.2020.12.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/13/2020] [Accepted: 12/07/2020] [Indexed: 12/13/2022]
Abstract
Hypertrophic burn scars remain a significant burden for patients and a challenge for clinicians. THE AIM Assessement of the efficacy of combined Pulsed Dye Laser and Ablative Fractional CO2 Laser therapy on hyperthophic scars and correlation with plasma levels of MMP-2, TIMP-1 and alpha-1 type I collagen. PATIENTS AND METHODS Twenty five pediatric subjects were enrolled into the study. Control group consisted of age-matched subjects admitted for surgical repair of inguinal hernia. For the assessment of the results of laser treatment we used the Vancouver scar scale (VSS), and Patient-Observer Scar Assessment Scale (POSAS). We also correlated clinical results with plasma levels of MMP-2, TIMP-1 and alpha-1 type I collagen. RESULTS All subjects reported the laser treatment resulted in improvement and were somewhat satisfied or very satisfied with their experience. No adverse events were reported. The levels of MMP-2, TIMP-1 and alpha-1 type I collagen in our patients with scars before laser threatment were higher in comparison to controls. We also found statistically significant decrease in the levels of MMP-2, TIMP-1 and alpha-1 type I collagen after laser treatment of burn scars CONCLUSIONS: Our study clearly shows that combined CO2-AFL treatment for burn scars improve texture, colour, function and alleviate pruritus. We believe that decrease in the levels of MMP-2, TIMP-1 and alpha-1 type I collagen after laser treatment of burn scars, reflects reduced dynamic of scar.
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Affiliation(s)
- Ewa Matuszczak
- Pediatric Surgery Department, Medical University of Bialystok, Poland; Biophysics Department, Medical University of Bialystok, Poland.
| | | | | | - Joanna Kamińska
- Department of Clinical Laboratory Diagnostics, Medical University of Białystok, Poland
| | - Adam Hermanowicz
- Pediatric Surgery Department, Medical University of Bialystok, Poland
| | - Wojciech Dębek
- Pediatric Surgery Department, Medical University of Bialystok, Poland
| | - Marta Komarowska
- Pediatric Surgery Department, Medical University of Bialystok, Poland
| | - Marzena Tylicka
- Biophysics Department, Medical University of Bialystok, Poland
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Karamanos E, Wang H, Shah AR. Clostridium difficile Infection in the Plastic Surgery Population: Lessons from the ACS NSQIP Database. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3281. [PMID: 33425595 PMCID: PMC7787286 DOI: 10.1097/gox.0000000000003281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/09/2020] [Indexed: 11/26/2022]
Abstract
Clostridium difficile-associated infections (CDI) have a significant impact on morbidity and mortality of hospitalized medical and surgical patients. There is a paucity of data regarding the incidence, impact, and modifiable risk factors in the plastic surgery population. METHODS The ACS NSQIP database was retrospectively queried for all cases performed by plastic surgeons during 2016. All plastic surgery cases, combined cases, demographics, and baseline clinical characteristics were extracted from the database. The study population was divided into 2 groups based on the development of CDI. Independent variables for development of CDI were identified. RESULTS During the study period, a total of 29,256 patients underwent a procedure by plastic surgery, with the most commonly performed procedures involving the breast (58%) and trunk (14%). Only 44 patients developed post-operative CDI (0.1%). Factors independently associated with development of CDI were wound classification at the end of the surgery, COPD, procedures involving the trunk, and surgery for reconstruction of pressure ulcers. Outpatient surgery was associated with decreased odds of developing CDI [AOR (95% CI):0.2 (0.1, 0.4), adj P < 0.001]. Staying overnight did not increase the odds of developing CDI; however, staying for >1 day in the hospital was associated with an increased risk of CDI development [AOR (95% CI): 1.03 (1.01, 1.13), adj P = 0.001]. Combined cases, ASA, body mass index, diabetes, and active smoking were not associated with CDI. CONCLUSIONS CDI are rare in the plastic surgery population and are most associated with trunk/decubitus ulcer reconstructions, inpatient hospital stay, and contaminated wounds. The patients that usually fit in these categories have acutely or chronically infected wounds, which are often treated with systemic antibiotics. For patient with decubitus ulcers and other trunk reconstruction, the guidelines for pre and post-operative systemic antibiotic usage is not well defined. For patients who have had trunk reconstruction, development of evidence-based antibiotic stewardship guidelines may help these patients by limiting antibiotic usage and thereby reducing the incidence of CDI.
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Affiliation(s)
- Efstathios Karamanos
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Tex
| | - Howard Wang
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Tex
| | - Amita R. Shah
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Tex
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Guo J, Zhu Z, Zhang D, Chen B, Zou B, Gao S, Zhu X. Analysis of the differential expression profile of miRNAs in myocardial tissues of rats with burn injury. Biosci Biotechnol Biochem 2020; 84:2521-2528. [PMID: 32867589 DOI: 10.1080/09168451.2020.1807901] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Fifteen percent third-degree burn rat model was used to identify miRNAs that are markers of burn injury-induced myocardial damage. Cardiac tissues were evaluated to determine miRNA profile sequencing. Pearson's correlation analysis was used between miRNAs and injury markers. ROC curve analysis was used to estimate miRNA's sensitivity and specificity for the diagnosis of myocardial damage caused by burn injury. The sequencing analysis revealed 23 differentially expressed miRNAs. Pearson's correlation analysis revealed that rno-miR-190b-3p and C5b9, rno-miR-341, rno-miR-344b-3p and TnI, rno-miR-344b-3p and CK-MB were significantly positively correlated, respectively. ROC curve analysis demonstrated that rno-miR-341, rno-miR-344b-3p, and rno-miR-190b-3p exhibited high sensitivity and specificity for the diagnosis of myocardial damage caused by burn injury. In conclusion, our results suggest that rno-miR-341, rno-miR-344b-3p, and rno-miR-190b-3p have the potential to be used as sensitive and specific biomarkers to diagnose myocardial damage caused by burn injury.
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Affiliation(s)
- Jingdong Guo
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University , Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University , Shenzhen, China
| | - Zhensen Zhu
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University , Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University , Shenzhen, China
| | - Dongmei Zhang
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University , Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University , Shenzhen, China
| | - Bo Chen
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University , Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University , Shenzhen, China
| | - Ben Zou
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University , Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University , Shenzhen, China
| | - Songying Gao
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University , Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University , Shenzhen, China
| | - Xiongxiang Zhu
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University , Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University , Shenzhen, China
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14
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Madni TD, Hoopman JE, Li X, Imran JB, Clark AT, Cunningham HB, Wolf SE, Kenkel JM, Phelan HA. Impact of a Laser Service Line for Burn Scar on a Dedicated Burn OR's Flow and Productivity. J Burn Care Res 2020; 39:811-814. [PMID: 29789856 DOI: 10.1093/jbcr/irx056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Our group began performing erbium-YAG 2940 wavelength fractional resurfacing of burn scar in our burn center's dedicated burn operating room (OR) in January 2016. The impact of these procedures on the performance of a mature, dedicated burn OR is unknown. All burn OR cases performed between January 1, 2015 and December 31, 2015 served as a pre-laser (PRE-LSR) historical control. A postintervention cohort of laser-only cases (LSR) performed between January 1, 2016 and August 17, 2016 was then identified. PRE-LSR and LSR cases were retrospectively reviewed for OR component times, and work relative value units (wRVU) billed. A total of 628 burn OR cases were done in 2015 (PRE-LSR), while 488 burn OR cases were done between January 1 and August 17, 2016. Of these 488, 59 cases were LSR (12.1%). Calculated on a monthly basis, significantly more cases were done per day in the LSR era (2.2 ± 0.4 cases/d) than PRE-LSR (1.6 ± 2.0 cases/d; P < .0001). The LSR group was significantly shorter than the PRE-LSR group for all OR component times (induction, prep, and procedure all P < .0001; transport out, P = .01; room turnover, P = .004). Aggregate OR component time was 79.2 ± 33.4 minutes for LSR and 157.5 ± 65.0 minutes for PRE-LSR (P < .0001). LSR yielded 6.9 ± 3.2 wRVU/h, while PRE-LSR generated 12.2 ± 8.9 wRVU/h (P < .0001). Despite significantly shorter OR component times and more cases being done per day, laser treatment of burn scar using a single 17108 Current Procedural Terminology code cuts wRVUs generated per hour in a mature burn OR roughly in half.
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Affiliation(s)
- Tarik D Madni
- UT Southwestern Department of Surgery, Dallas, Texas
| | | | - Xingchen Li
- UT Southwestern Department of Plastic Surgery, Dallas, Texas
| | | | - Audra T Clark
- UT Southwestern Department of Surgery, Dallas, Texas
| | | | - Steven E Wolf
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas
| | | | - Herb A Phelan
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas
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15
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New Developments for Fractional CO2 Resurfacing for Skin Rejuvenation and Scar Reduction. Facial Plast Surg Clin North Am 2020; 28:17-28. [DOI: 10.1016/j.fsc.2019.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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16
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Shirakami E, Yamakawa S, Hayashida K. Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence. BURNS & TRAUMA 2020; 8:tkz003. [PMID: 32341924 PMCID: PMC7175766 DOI: 10.1093/burnst/tkz003] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 08/28/2019] [Indexed: 12/31/2022]
Abstract
Once scar tissues mature, it is impossible for the surrounding tissue to regenerate normal dermal tissue. Therefore, it is essential to understand the fundamental mechanisms and establish effective strategies to inhibit aberrant scar formation. Hypertrophic scar formation is considered a result of the imbalance between extracellular matrix synthesis and degradation during wound healing. However, the underlying mechanisms of hypertrophic scar development are poorly understood. The purpose of this review was to outline the management in the early stage after wound healing to prevent hypertrophic scar formation, focusing on strategies excluding therapeutic agents of internal use. Treatment aimed at molecular targets, including cytokines, will be future options to prevent and treat hypertrophic scars. More basic studies and clinical trials, including combination therapy, are required to investigate the mechanisms and prevent hypertrophic scar formation.
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Affiliation(s)
- Eri Shirakami
- Division of Plastic and Reconstructive Surgery, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo, Shimane 693-8501, Japan
| | - Sho Yamakawa
- Division of Plastic and Reconstructive Surgery, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo, Shimane 693-8501, Japan
| | - Kenji Hayashida
- Division of Plastic and Reconstructive Surgery, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo, Shimane 693-8501, Japan
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17
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Madni TD, Nakonezny PA, Imran JB, Clark AT, Cunningham HB, Hoopman JE, Arnoldo BD, Wolf SE, Kenkel JM, Phelan HA. Patient satisfaction after fractional ablation of burn scar with 2940nm wavelength Erbium-Yag laser. Burns 2018; 44:1100-1105. [PMID: 29627130 DOI: 10.1016/j.burns.2018.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/11/2017] [Accepted: 02/05/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Fractional laser therapy is a new treatment with potential benefit in the treatment of burn scars. We sought to determine patient satisfaction after burn scar treatment with the Erbium-Yag laser. METHODS We performed a telephone survey of all patients who underwent fractional resurfacing of burn scars with the Erbium-Yag 2940 wavelength laser at Parkland Hospital from 01/01/2016 to 05/01/2017. Subjects were asked to rate their satisfaction with their scars' after treatment characteristics on a scale from 1 (completely unsatisfied) to 10 (completely satisfied). Subjects were also asked to assess their treatment response using the UNC 4P Scar Scale before and after treatment. RESULTS Sixty-four patients underwent 156 treatments. A survey response rate of 77% (49/64) was seen (age: 36.8+21 years; surface area treated=435+326cm2; 35% of burn scars were >2 years old; mean scar age of 1.02+0.4 years). Overall, 46/49 (94%) of patients reported some degree of scar improvement after treatment. Patient satisfaction scores were 8.3+2.3. Number of laser treatments included: 1 (31%), 2 (33%), 3 (18%), 4(10%), >5 (8%). Treatment depth, scar age, and number of laser procedures were not significant predictors of satisfaction or UNC 4P Scar scores. The paired t-test showed a significant reduction on each of the UNC 4P Scar scale items (pain, pruritus, pliability, paresthesia). One subject reported that she felt that the laser treatment made her scar worse (2%). CONCLUSION Burn patients treated with the Erbium-Yag laser are highly satisfied with changes in their burn scars.
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Affiliation(s)
- Tarik D Madni
- UT Southwestern Department of Surgery, Dallas, TX, United States.
| | - Paul A Nakonezny
- UT Southwestern Department of Clinical Sciences, Division of Biostatistics, Dallas, TX, United States.
| | - Jonathan B Imran
- UT Southwestern Department of Surgery, Dallas, TX, United States.
| | - Audra T Clark
- UT Southwestern Department of Surgery, Dallas, TX, United States.
| | | | - John E Hoopman
- UT Southwestern Medical Center, Dallas, TX, United States.
| | - Brett D Arnoldo
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas, TX, United States.
| | - Steven E Wolf
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas, TX, United States.
| | - Jeffrey M Kenkel
- UT Southwestern Department of Plastic Surgery, Dallas, TX, United States.
| | - Herb A Phelan
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas, TX, United States.
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18
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Ehrl D, Heidekrueger PI, Ninkovic M, Broer PN. Effect of primary admission to burn centers on the outcomes of severely burned patients. Burns 2018; 44:524-530. [PMID: 29463463 DOI: 10.1016/j.burns.2018.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/23/2017] [Accepted: 01/04/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Burns represent a special form of severe trauma. Due to long hospitalization, rehabilitation, and extensive scar treatment, severe burn injuries rank among the most expensive traumatic injuries regarding associated health care costs. The presented single-burn-center experiences evaluated the effects of primary versus secondary burn intensive care unit (BICU) admissions on outcomes in severely burned patients. METHODS Within 30 months, 186 patients were admitted to the BICU. The cases were divided into two groups depending on their admission type: "primary" vs. "secondary". All patients were analyzed retrospectively regarding the need for surgery, encountered complications, time of hospitalization and overall survival. RESULTS The incidence of primary BICU-admissions was 65.1%. Both patient groups were comparable regarding demographics, comorbidities, % TBSA burn, associated inhalation injuries, ABSI scores and intubation rates (p>0.05). Both groups received similar numbers of operations and had overall comparable mortality rates (p>0.05). However, duration until first burn excision, length of ventilation, as well as BICU- and overall hospital length of stay were significantly shorter in the "primary"- compared to the "secondary" group (p<0.05). CONCLUSION Several burn societies have published precise criteria of when a patient needs to be referred to a burn center. In the presented series, patients that were primarily treated at a BICU showed significantly better outcomes regarding several parameters. In order to further optimize treatment of burn patients it therefore appears that precise initial assessment and if appropriate respective primary transport to dedicated burn centers needs to be re-emphasized, especially among first- and emergency care providers.
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Affiliation(s)
- Denis Ehrl
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Germany; Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany.
| | - Paul I Heidekrueger
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany; Department of Plastic, Hand, and Reconstructive Surgery, University Medical Center, Regensburg, Germany
| | - Milomir Ninkovic
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
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19
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Issler-Fisher AC, Waibel JS, Donelan MB. Laser Modulation of Hypertrophic Scars. Clin Plast Surg 2017; 44:757-766. [DOI: 10.1016/j.cps.2017.05.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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20
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Willows BM, Ilyas M, Sharma A. Laser in the management of burn scars. Burns 2017; 43:1379-1389. [PMID: 28784339 DOI: 10.1016/j.burns.2017.07.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 05/10/2017] [Accepted: 07/05/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Burn scars are associated with significant morbidity ranging from contractures, pruritus, and disfigurement to psychosocial impairment. Traditional therapies include silicone gel, compression garments, corticosteroid injections, massage therapy, and surgical procedures, however, newer and advanced therapies for the treatment of burn scars have been developed. Lasers, specifically ablative fractional lasers, show potential for the treatment of burn scars. METHODS Both MeSH and keyword searches of the PubMed, Medline and Embase databases were performed and relevant articles were read in full for the compilation of this review. RESULTS Fifty-one relevant observational studies, clinical trials, and systematic reviews published in English from 2006 to 2016 were reviewed and summarized. CONCLUSION Laser therapy is effective for the treatment of burn scar appearance, including measures such as pigmentation, vascularity, pliability, and thickness. Ablative fractional laser therapy, in particular, shows significant potential for the release of contractures allowing for improved range of motion of affected joints. Patients may benefit from the use of lasers in the treatment of burn scars, and the safety profile of lasers allows the benefits of treatment to outweigh the risks. Laser therapy should be included in burn scar treatment protocols as an adjuvant therapy to traditional interventions.
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Affiliation(s)
- Brooke M Willows
- School of Medicine, University of Arizona, Phoenix, AZ, United States
| | - Muneeb Ilyas
- Department of Dermatology, Mayo Clinic Arizona, 13400 E. Shea Blvd. Scottsdale, AZ 85259, United States.
| | - Amit Sharma
- Department of Dermatology, Mayo Clinic Arizona, 13400 E. Shea Blvd. Scottsdale, AZ 85259, United States
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Abstract
Burn injury can result in hypertrophic scar formation that can lead to debilitating functional deficits and poor aesthetic outcomes. Although nonoperative modalities in the early phase of scar maturation are critical to minimize hypertrophic scar formation, surgical management is often indicated to restore hand function. The essential tenant of operative scar management is release of tension, which can often be achieved through local tissue rearrangement. Laser therapy has emerged as a central pillar of subsequent scar rehabilitation. These treatment tools provide an effective resource for the reconstructive surgeon to treat hypertrophic hand scars.
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Affiliation(s)
- Michael Sorkin
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109, USA
| | - David Cholok
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109, USA
| | - Benjamin Levi
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109, USA; Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109, USA.
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Abstract
Thermal injuries of the hand can have a great impact on function. Initial treatment should focus on the prevention of contracture through the use of tissue-sparing techniques and optimized occupational therapy. Surgical intervention should follow the standard reconstructive ladder and can involve several techniques from simple to complex including minimally invasive techniques, such as laser and steroid injection, contracture release and skin grafting, and local tissue rearrangement and regional flaps as well as distant pedicled and free flaps. Reconstructive surgery of the hand, when performed well, can lead to meaningful functional improvement in severe burns.
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Affiliation(s)
- Ryan P Cauley
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Lydia A Helliwell
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Matthias B Donelan
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Plastic and Reconstructive Surgery, Shriner's Hospital for Children, 51 Blossom Street, Boston, MA 02114, USA
| | - Kyle R Eberlin
- Plastic and Reconstructive Surgery, Shriner's Hospital for Children, 51 Blossom Street, Boston, MA 02114, USA; MGH Hand Surgery Fellowship, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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23
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Wong BM, Keilman J, Zuccaro J, Kelly C, Maynes JT, Fish JS. Anesthetic Practices for Laser Rehabilitation of Pediatric Hypertrophic Burn Scars. J Burn Care Res 2017; 38:e36-e41. [DOI: 10.1097/bcr.0000000000000427] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
A recent advancement in the treatment of burn scars has been the use of the carbon dioxide (CO2) laser to perform fractional photothermolysis. In this analysis, we describe our results and patient-reported outcomes with the use of fractional CO2 laser for the treatment of burn-related scarring. We performed a retrospective study of all patients who underwent CO2 laser procedures for treatment of symptomatic burn scars and skin grafts at one accredited regional burn center. Burn injury and laser treatment demographics, as well as complications, are reported. A questionnaire was administered to all patients and included patient-reported outcome measures aimed at understanding the patient experience and their subjective response to treatment. A total of 387 CO2 laser procedures were performed on 131 patients for the treatment of symptomatic burn scars and skin grafts between October 1, 2011, and May 1, 2014 (average, 2.95 procedures/patient; range, 1-11). Average time between injury and first laser was 597.35 days (range, 60-13,475). Average time between laser treatments (when multiple) was 117.73 days (range, 22-514). There were no infections requiring treatment with oral antibiotics. Overall patient satisfaction with laser therapy was 96.7%. Patients reported reductions in neuropathic pain, tightness (contracture), and pruritus (54.0, 50.6, and 49.0%, respectively). Fractional photothermolysis utilizing the CO2 laser is a safe and effective modality for the treatment of symptomatic burn scars, donor sites, and skin grafts. Patient satisfaction with this procedure is high, and complications are low. Significant improvements in scar appearance, pliability, tightness, neuropathic pain, and pruritus were commonly reported.
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25
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Busch KH, Bender R, Walezko N, Aziz H, Altintas MA, Aust MC. Combination of medical needling and non-cultured autologous skin cell transplantation (ReNovaCell) for repigmentation of hypopigmented burn scars. Burns 2016; 42:1556-1566. [PMID: 27156803 DOI: 10.1016/j.burns.2016.04.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 12/24/2022]
Abstract
Burn scars remain a serious physical and psychological problem for the affected people. Clinical studies as well as basic scientific research have shown that medical needling can significantly increase the quality of burn scars with comparatively low risk and stress for the patient with regards to skin elasticity, moisture, erythema and transepidermal water loss. However, medical needling has no influence on repigmentation of large hypopigmented scars. The goal of this study is to evaluate whether two established methods - needling (for improvement of scar quality) and non-cultured autologous skin cell suspension (for repigmentation) - can be successfully combined. Twenty subjects with mean age of 33 years (6-60 years) with scars from deep second and third degree burns have been treated. The average treated surface area was 94cm2 (15-250cm2) and was focused on prominent areas such as the face, neck, chest and arm. Percutaneous collagen induction or "medical needling" was performed using a roller covered with 3mm long needles. The roller is vertically, horizontally and diagonally rolled over the scar, inducing microtrauma. Then, non-cultured autologous skin cell suspension (NCASCS) was produced and applied using the ReNovaCell Autologous Cell Harvesting Device (Avita Medical), according to the manufacturer's instructions. The patients were followed 12 months postoperatively. Pigmentation changes were measured objectively, as well as with patient and observer ratings. Patient satisfaction/preference was also obtained. Taken together, the pigmentation ratings and objective measures indicate individual improvement in 17 of the study participants. The melanin increases seen 12 months after NCASCS treatment are statistically significant. Medical needling in combination with NCASCS shows promise for repigmentation of burn cars.
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Affiliation(s)
- K H Busch
- Department for Plastic and Reconstructive Surgery, Johanniter Hospital, Bonn, Germany
| | - R Bender
- Department for Plastic and Reconstructive Surgery, Johanniter Hospital, Bonn, Germany
| | - N Walezko
- Department for Plastic and Reconstructive Surgery, Johanniter Hospital, Bonn, Germany
| | - H Aziz
- Department for Plastic and Reconstructive Surgery, Johanniter Hospital, Bonn, Germany
| | - M A Altintas
- Department for Plastic and Reconstructive Surgery, Bergmannsheil und Kinderklinik Buer, Gelsenkirchen, Germany
| | - M C Aust
- Department for Plastic and Reconstructive Surgery, Johanniter Hospital, Bonn, Germany.
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Efficacy of intense pulsed light for the treatment of burn scar dyschromias: a pilot study to assess patient satisfaction, safety, and willingness to pay. Ann Plast Surg 2016; 74 Suppl 4:S204-8. [PMID: 25803326 DOI: 10.1097/sap.0000000000000447] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION No treatment algorithms exist to reliably treat burn scar dyschromias. Intense pulsed light (IPL) has been used successfully to treat hyperpigmentation disorders, but has not been studied extensively in the treatment of burn scars. The purpose of this investigation was to assess clinical efficacy and patient satisfaction with IPL for the treatment of burn scar dyschromia. METHODS Patients with burn scar dyschromias were treated using the Lume 1 platform (Lumenis) to target pigmented lesions, using fluences between 10 and 22 joules/cm and filters ranging from 560 to 650 nm. At the conclusion of the study, providers assessed changes in burn scar dyschromia, whereas patients were queried regarding satisfaction and perceived efficacy, using a 1 to 5 Likert scale. The patients, who were not charged for the IPL treatment, were queried regarding willingness to pay. RESULTS Twenty patients (mean age, 35.4 years; mean total body surface area, 27.6%; mean composite Fitzpatrick score, 3.9) underwent IPL treatment of burn scar dyschromias, an average of 3.2 years after injury. Mean fluence was 15.4 J/cm (range, 10-22 J/cm), and the most common filter used was 590 nm (range, 560-650 nm). Mean area treated was 90.7 cm, with a range of 4 to 448 cm. Complications included pain (4), hyperpigmentation (1), and blistering (2). Sixteen patients noted mild to moderate improvement, reporting a 4.5 for efficacy and a 4.4 for satisfaction. Regarding willingness to pay, patients would spend a mean of U.S. $7429 to completely remove their scars, but only a median of U.S. $350 to get the actual results that they received. Mean length of follow-up was 3.8 months, with a standard deviation of 2.2 months. CONCLUSIONS Patients perceived IPL as an efficacious modality in the treatment of burn scar dyschromia, with a high level of satisfaction, despite the potential for morbidity. However, we are reluctant to recommend IPL for routine treatment of burn scar dyschromias, given only minimal improvement observed, potential for complications, and a willingness to pay that is lower than the cost of providing care.
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Abstract
Patients and clinicians use skin color attributes such as color uniformity, color distribution, and texture to infer physiologic health status. Normalization of skin color, surface texture, and height are important treatment goals in the treatment of scars. Skin color, structure, and response to trauma, vary with ethnicity. The incidence of hypertrophic and keloid scar formation is influenced by these inherent skin attributes. Skin type influences the response to various modalities including laser therapy and surgical intervention, and skin differences must be considered in treatment planning to achieve optimal results.
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Affiliation(s)
- Marty O Visscher
- Skin Sciences Program, Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA.
| | - J Kevin Bailey
- Division of Trauma, Critical Care and Burn, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - David B Hom
- Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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Improving Comfort and Throughput for Patients Undergoing Fractionated Laser Ablation of Symptomatic Burn Scars. Ann Plast Surg 2015; 74:293-9. [DOI: 10.1097/sap.0000000000000367] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hypertrophic burn scar management: what does the evidence show? A systematic review of randomized controlled trials. Ann Plast Surg 2015; 72:S198-201. [PMID: 24835874 DOI: 10.1097/sap.0000000000000103] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Hypertrophic scars (HTS) are a source of morbidity for burn survivors and can present with a range of lifestyle-limiting problems. These include pruritus, pain, burning, stiffness, and contractures. Many solutions have been developed, but few have been studied in the form of a prospective, randomized control trial (RCT). Given the importance these RCTs carry in shaping the treatment of burn patients, we sought to systematically and critically review this portion of the burn literature. METHODS PubMed was used to perform 2 separate searches with limits that included Humans, English, and Randomized Controlled Trial. A keyword search using "hypertrophic," "Scar," "burn," and "treatment" was cross-referenced with a MeSH subject-heading search using "Cicatrix, Hypertrophic" AND "Burn." Studies were then reviewed and excluded if they did not address management of burn HTS in the non-acute setting. RESULTS Two literature searches resulted in a total of 32 articles. Twelve articles were excluded because they were not relevant to the topic (n = 10) or could not be obtained (n = 2). The remaining 20 articles contained 882 patients treated for hypertrophic scars. Breakdown based on topics included laser therapy (58 patients, 2 articles), silicone gel (204 patients, 7 articles), compression garment (236 patients, 4 articles), silicone + pressure (226 patients, 3 articles), topical emollients (58 patients, 2 articles), systemic therapy (62 patients, 1 article), intralesional therapy (18 patients, 1 article), and surgical treatment (20 patients, 1 article). While some articles had favorable conclusions (laser, emollients, surgical, and intralesional therapy) or unfavorable conclusions (systemic therapy), there were conflicting results on silicone and/or compression. CONCLUSIONS Despite hypertrophic scars being a common occurrence in burn survivors, both the number of studies and consensus for treatment are limited. Efforts to perform larger, adequately powered RCTs are needed, specifically in the areas of silicone, compression garments, and combination therapy.
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Ehanire T, Ren L, Bond J, Medina M, Li G, Bashirov L, Chen L, Kokosis G, Ibrahim M, Selim A, Blobe GC, Levinson H. Angiotensin II stimulates canonical TGF-β signaling pathway through angiotensin type 1 receptor to induce granulation tissue contraction. J Mol Med (Berl) 2014; 93:289-302. [PMID: 25345602 DOI: 10.1007/s00109-014-1211-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 09/23/2014] [Accepted: 10/15/2014] [Indexed: 01/30/2023]
Abstract
UNLABELLED Hypertrophic scar contraction (HSc) is caused by granulation tissue contraction propagated by myofibroblast and fibroblast migration and contractility. Identifying the stimulants that promote migration and contractility is key to mitigating HSc. Angiotensin II (AngII) promotes migration and contractility of heart, liver, and lung fibroblasts; thus, we investigated the mechanisms of AngII in HSc. Human scar and unwounded dermis were immunostained for AngII receptors angiotensin type 1 receptor (AT1 receptor) and angiotensin type 2 receptor (AT2 receptor) and analyzed for AT1 receptor expression using Western blot. In vitro assays of fibroblast contraction and migration under AngII stimulation were conducted with AT1 receptor, AT2 receptor, p38, Jun N-terminal kinase (JNK), MEK, and activin receptor-like kinase 5 (ALK5) antagonism. Excisional wounds were created on AT1 receptor KO and wild-type (WT) mice treated with AngII ± losartan and ALK5 and JNK inhibitors SB-431542 and SP-600125, respectively. Granulation tissue contraction was quantified, and wounds were analyzed by immunohistochemistry. AT1 receptor expression was increased in scar, but not unwounded tissue. AngII induced fibroblast contraction and migration through AT1 receptor. Cell migration was inhibited by ALK5 and JNK, but not p38 or MEK blockade. In vivo experiments determined that absence of AT1 receptor and chemical AT1 receptor antagonism diminished granulation tissue contraction while AngII stimulated wound contraction. AngII granulation tissue contraction was diminished by ALK5 inhibition, but not JNK. AngII promotes granulation tissue contraction through AT1 receptor and downstream canonical transforming growth factor (TGF)-β signaling pathway, ALK5. Further understanding the pathogenesis of HSc as an integrated signaling mechanism could improve our approach to establishing effective therapeutic interventions. KEY MESSAGE AT1 receptor expression is increased in scar tissue compared to unwounded tissue. AngII stimulates expression of proteins that confer cell migration and contraction. AngII stimulates fibroblast migration and contraction through AT1 receptor, ALK5, and JNK. AngII-stimulated in vivo granulation tissue contraction is AT1 receptor and ALK5 dependent.
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Affiliation(s)
- Tosan Ehanire
- Duke University School of Medicine, Duke University Medical Center (DUMC), Durham, NC, USA
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Taudorf EH, Danielsen PL, Paulsen IF, Togsverd-Bo K, Dierickx C, Paasch U, Haedersdal M. Non-ablative fractional laser provides long-term improvement of mature burn scars--a randomized controlled trial with histological assessment. Lasers Surg Med 2014; 47:141-7. [PMID: 25154734 DOI: 10.1002/lsm.22289] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Non-ablative fractional laser-treatment is evolving for burn scars. The objective of this study was to evaluate clinical and histological long-term outcome of 1,540 nm fractional Erbium: Glass laser, targeting superficial, and deep components of mature burn scars. MATERIALS & METHODS Side-by-side scar-areas were randomized to untreated control or three monthly non-ablative fractional laser-treatments using superficial and extra-deep handpieces. Patient follow-up were at 1, 3, and 6 months. Primary outcome was improvement in overall scar-appearance on a modified-Patient-and-Observer-Scar-Assessment-Scale (mPOSAS, 1 = "normal skin", 10 = "worst imaginable scar"). Secondary outcomes included histology, patient satisfaction (0-10), patient-assessed improvement, and safety. RESULTS Study was completed by 17 of 20 randomized patients with normotrophic (n = 11), hypertrophic (n = 5) or atrophic (n = 1) scars. Scar-appearance improved from laser-treatments (P < 0.001 vs. untreated) and histology at 6 months supported collagen-remodeling. Improvement appeared continuously during the post-operative period (mPOSAS baseline: 7 [5-8], 6 months: 4 [3-5] P = < 0.001). At 6 months, patients were satisfied with treatment (6 [3-9]) and 82% reported improved scar-texture. Treatments caused mild to moderate pain (4 [2-7]). Adverse effects decreased during follow-up and at final assessment, discrete erythema, hyperpigmentation or imprints from laser-grid were present in 11 patients. No patients experienced worsening of scar-appearance. CONCLUSIONS Combined superficial and deep non-ablative fractional laser-treatments induce long-term clinical and histological improvement of mature burn scars.
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Affiliation(s)
- Elisabeth H Taudorf
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Denmark
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Brewin M, Lister T. Prevention or treatment of hypertrophic burn scarring: A review of when and how to treat with the Pulsed Dye Laser. Burns 2014; 40:797-804. [DOI: 10.1016/j.burns.2013.12.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 11/25/2013] [Accepted: 12/17/2013] [Indexed: 11/29/2022]
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