Scar outcomes in dermatological surgery

Wound healing, scarring and management

Understanding wound healing is imperative for the dermatological physician to optimize surgical outcomes. Poor healing may result in negative functional, cosmetic and psychological sequelae. This review briefly outlines the physiology of wound healing, with a view to improving the management of wounds and scars, and minimizing the long-term scarring complications.

Review of infection and bleeding complications in excisional skin surgery

Skin excision is the primary treatment for skin cancer. Complication rates from skin cancer excision are generally low but rates of complications may vary according to procedural complexity, site and patient factors. It is important that patients are fully informed through the consent process considering individual circumstances, the Montgomery ruling and material risks. The clinician must use an evidence-based approach to the consent process and assessment of risk. We have searched the literature and reviewed the current evidence regarding complications, and their incidence where data were available, following excisional skin surgery. This article aims to enable clinicians to better inform patients during the consent process about associated bleeding and infection risk.

Therapeutic downregulation of neuronal PAS domain 2 (Npas2) promotes surgical skin wound healing

Attempts to minimize scarring remain among the most difficult challenges facing surgeons, despite the use of optimal wound closure techniques. Previously, we reported improved healing of dermal excisional wounds in circadian clock neuronal PAS domain 2 (Npas2)-null mice. In this study, we performed high-throughput drug screening to identify a compound that downregulates Npas2 activity. The hit compound (Dwn1) suppressed circadian Npas2 expression, increased murine dermal fibroblast cell migration, and decreased collagen synthesis in vitro. Based on the in vitro results, Dwn1 was topically applied to iatrogenic full-thickness dorsal cutaneous wounds in a murine model. The Dwn1-treated dermal wounds healed faster with favorable mechanical strength and developed less granulation tissue than the controls. The expression of type I collagen, Tgfβ1, and α-smooth muscle actin was significantly decreased in Dwn1-treated wounds, suggesting that hypertrophic scarring and myofibroblast differentiation are attenuated by Dwn1 treatment. NPAS2 may represent an important target for therapeutic approaches to optimal surgical wound management.

Dermatological surgery: an update on suture materials and techniques. Part 2

This is the second part of a two-part series summarizing the latest evidence related to suture materials and wound closure techniques in dermatological surgery. We critically appraised evidence focusing on the following consequences of suture choice: scar/cosmesis, pain, patient satisfaction, cost, infection and wound complications. We searched the databases MEDLINE, PubMed and Embase using the keywords 'skin surgery', 'dermatological surgery', 'sutures', 'braided sutures', 'monofilament sutures' and 'antibacterial sutures' to identify relevant English-language articles. This part of the review assesses the evidence for different types of buried sutures, including braided vs. monofilament sutures, longer-absorbing sutures and antibacterial sutures. The majority of trials were noted to be of poor quality, single-centre (thus lacking external validity) and underpowered, which presents challenges in comparing suture techniques in skin surgery. Future large-scale, multicentre, randomized trials are needed, with both surgeon and patient-assessed validated outcomes.

Comorbidities of scars in China: a national study based on hospitalized cases

Background

Scar comorbidities seriously affect the physical and mental health of patients, but few studies have reported the exact epidemiological characteristics of scar comorbidities in China. This study aimed to investigate the prevalence of scar comorbidities in China.

Methods

The data of 177,586 scar cases between 2013 and 2018 were obtained from the Hospital Quality Monitoring System based on the 10th edition of the International Classification of Diseases coding system. The total distribution of scar comorbidities and their relationship with age, aetiology and body regions were analysed.

Results

Six comorbidities (contracture, malformation, ocular complications, adhesion, infection and others) were the main focus. In general, male patients outnumbered females and urban areas outnumbered rural areas. The proportion of contractures was the highest at 59,028 (33.24%). Students, workers and farmers made up the majority of the occupation. Han Chinese accounted for the majority of the ethnic. The highest proportion of scar contracture occurred at 1-1.9 years of age (58.97%), after which a significant downward trend was observed. However, starting from 50 years of age, ocular complications increased gradually and significantly, eventually reaching a peak of 34.49% in those aged >80 years. Scar contracture was the most common comorbidity according to aetiology, and the highest proportion was observed in patients who were scalded (29.33%). Contractures were also the most frequent comorbidity in hands (10.30%), lower limbs (6.97%), feet (6.80%) and upper limbs (6.02%). The mean and median hospitalization durations were 12.85 and 8 days, respectively.

Conclusions

Contractures were the most common comorbidities, and different comorbidities tended to occur at different ages and with different causative factors.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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