Psychosocial and quality of life impact of scars in the surgical, traumatic and burn populations: a scoping review protocol

Have the recent advancements in wound repair and scar management technology improved the quality of life in burn patients?

BACKGROUND

The negative physical and psychosocial impact of scars, in particular burn scars, has been well documented. Altered personal appearance together with impaired function related to pain, heat intolerance, and contracture formation may last a lifetime and eventually can lead to low self-esteem and poor social and psychological adjustments. Though most patients recover within the first years and many report generally good life satisfaction and moderate quality of life (QoL), some severely burned patients continue to report impaired QoL almost 10 years after injury. It is repeatedly mentioned in the literature that patients' QoL and health-related quality of life (HRQoL) can be improved by improving wound healing and burn scar quality. Determining whether advances in burn wound healing and scar management modalities are positively impacting the lives of surviving patients is the aim of this review.

METHODS

A systematic literature review was used to identify studies measuring QoL of patients surviving severe burn injuries following various interventions to improve burn wound healing and scar quality.

RESULTS

A limited number of studies was identified. Given the limited available data, a narrative review approach including qualitative studies and reviews in addition to identifying common themes, trends, and gaps in the existing literature was deemed more appropriate for a comprehensive analysis.

CONCLUSION

The assumption that progress made in recent decades to improve burn wound healing and scar quality would improve QoL remains largely hypothetical. Except for functional release of burn scar contractures, improved scar aesthetic quality does not necessarily translate into improved QoL of surviving patients. Well-designed comparative studies are largely lacking.

Application of Gelatin/Vanillin/Fe3+/AGP-AgNPs Hydrogels Promotes Wound Contraction, Enhances Dermal Growth Factor Expression, and Minimizes Skin Irritation

This study further investigates the potential of gelatin-based hydrogel cross-linked with vanillin and ferric ion (GVF), combined with andrographolide (AGP) and silver nanoparticles (AgNPs), as an anti-infection biomaterial for wound dressing, aimed at exploring the mechanisms that attenuate inflammation, enhance wound healing rates, and address allergic skin irritation. AGP-AgNPs were evaluated for cytotoxicity in human adult epidermal keratinocytes (HEKa) and the murine macrophage cell line (RAW 264.7), as well as for nitric oxide (NO) production in response to lipopolysaccharide-induced inflammation in RAW 264.7 macrophage cells. Skin-wound specimens from male Wistar rats were histologically analyzed for epidermal thickness and inflammatory changes. The mRNA expression profiling of dermal growth factors was assessed using RT-qPCR, and skin irritation tests were conducted in female New Zealand rabbits. These AGP-AgNPs exhibited significantly lower toxicity in HEKa and no toxicity in RAW 264.7. Interestingly, AGP-AgNPs at specific concentrations produced NO in RAW 264.7 control cells but were more effective in reducing inflammatory NO levels in RAW 264.7 cells pretreated with lipopolysaccharides, suggesting that AGP-AgNP composites are safe and effectively diminish inflammation. Furthermore, a marked increase in epidermal thickness and a reduction in histological inflammatory cells at wound sites were observed in rats treated with AGP-AgNPs/GVF hydrogels over 21 days. Upregulation of dermal genes promoting wound healing, including collagen types I and III, epidermal growth factor, transforming growth factor-beta, fibronectin, and vascular endothelial growth factor, but not fibroblast growth factor, was observed in a time-dependent manner. These results suggest that the anti-inflammatory properties of GVF/AGP-AgNP hydrogels could promote epithelialization, enhance cellular proliferation, support extracellular matrix synthesis, and facilitate angiogenesis. Additionally, rabbit skin in contact with GVF/AGP-AgNP hydrogels consistently displayed reduced levels of erythema and edema, with no swelling, and a standardized scoring system yielded low primary dermal irritation indices for this hydrogel. These findings suggest that the novel GVF/AGP-AgNP hydrogels possess anti-inflammatory-like activity and can modulate dermal growth factors for wound healing. This leads to reduced dermal irritation, making the formulation potentially suitable for safe topical applications in skin and wound care. However, comprehensive human studies and clinical trials should be required in the future.

Fractional CO2 Laser to Treat Surgical Scars: A System Review and Meta-Analysis on Optimal Timing

BACKGROUND

Surgical scars with textural changes can be disfiguring and uncomfortable for patients. Various laser therapies have shown promise in softening and flattening these scars. Therefore, the authors conducted a systematic review and meta-analysis on the efficacy of fractional CO2 laser in treating surgical scars.

OBJECTIVE

This study aims to present evidence from controlled trials investigating the efficacy of ablative carbon dioxide fractional laser in treating surgical scars.

MATERIALS AND METHODS

A literature search of Medline (via PubMed), Ovid, Web of Science, and Embase for relevant trials was conducted before March 2024. After assessing for inclusion, data extraction was performed using Population, Intervention, Comparison, Outcomes and Study criteria (PICOS). Quality, validity, and risk of bias were assessed using the RevMan5.3 risk of bias assessment tool.

RESULTS

A total of 14 controlled trials involving 492 participants or postsurgical scars were included in the system review and meta-analysis. Both in RCT and non-RCT settings, fractional CO2 laser therapy exhibited the same efficacious outcomes, with MD values of -0.63 (95% CI: -1.15 to -0.12; I2 = 70%; p = 0.02) and - 1.86 (95% CI: -2.65 to -1.07; I2 = 85%; p < 0.001), respectively. Moreover, furthermore analysis illustrated that initiating FRACTIONAL CO2 LASER treatment sessions at or within 1 month after surgery significantly reduced postoperative scars compared to control groups and groups on treatments initiated more than 3 months after surgery (MD: -1.66; 95% CI: -2.31 to -1.01; I2 = 89%; p < 0.001 and MD: -1.93; 95% CI: -2.24 to -1.62; I2 = 48%; p < 0.001). However, fractional CO2 laser treatment administered over 3 months after surgery did not significantly improve postoperative scars (MD: -0.17; 95% CI: -0.56 to 0.21; I2 = 37%; p = 0.37).

CONCLUSION

The systematic review and meta-analysis provide robust support for the efficacy of fractional CO2 laser in treating surgical scars, particularly when administered at or within 1 month after surgery. One treatment session within 1 month after surgery also can produce significant results, but most clinical trials support 2-3 treatment sessions or more.

A Review of Aesthetic Considerations for Treating the Transgender Patient

BACKGROUND

As gender diversity becomes increasingly embraced by society, and despite growing recognition of the unique needs of transgender patients, the literature remains devoid of guidelines for gender affirming facial feminization or masculinization techniques.

OBJECTIVE

The authors seek to identify and discuss target feminine and masculine facial features, as well as an armamentarium of surgical and nonsurgical strategies to effectively address and achieve them in the transgender population.

METHODS

A search of the National Library of Medicine database (PubMed) was undertaken to identify the existing literature on gender-affirming facial feminization and masculinization techniques.

RESULTS

The importance of assessing proportional relationships between the bitemporal, bizygomatic, and bigonial distances is discussed; ideal masculine faces possess a rectangular face shape, with ratios for these 3 areas tending toward 1:1:1. Conversely, the ideal female face is heart shaped with projection at the zygoma and a tapered jawline. Strategic positioning of the cheek apex serves as an anchor in sculpting a distinctly masculine or feminine face. Other considerations include the enhancement of skin quality and implications of hormonal therapy.

CONCLUSION

The aesthetic considerations provided in this study can serve as a valuable guidance for aesthetic physicians seeking to deliver optimal care for their transitioning patients.

Polynucleotide-based treatments for various facial scars including combat injuries

INTRODUCTION

This study examines the therapeutic efficacy of polynucleotide-based therapies, specifically REJURAN®, for managing scars and burns. Scars and burns present significant challenges in dermatology, often affecting patients' quality of life. Traditional treatments can be limited in effectiveness, prompting the exploration of innovative approaches like polynucleotide therapy, which utilizes salmon DNA to stimulate tissue repair, modulate inflammation, and enhance collagen production.

METHODS

A series of case studies was conducted, including diverse patient profiles with various types of scars and burns. The study evaluated the impact of REJURAN® on scar appearance, texture, and overall skin quality. Some cases also explored the combination of polynucleotide therapy with other treatments such as Platelet-Rich Plasma (PRP) and botulinum toxin.

RESULTS

Notable improvements were observed across cases, including reduced scar visibility and enhanced skin texture. The therapy proved effective in treating post-traumatic, post-operative, and burn-related scars, demonstrating its versatility and potential benefits. Combination therapies showed promising results, though further research is needed.

CONCLUSION

Polynucleotide-based therapy with REJURAN® shows promise in scar and burn management, offering a novel approach that leverages the body's regenerative processes. Further studies are recommended to confirm these findings and refine treatment protocols.

Gamified Interventions for Promoting the Psychosocial Well-Being of School-Aged Children: A Scoping Review

Gamified health interventions can offer child-centered and tailored health-promoting strategies. Evidence suggests that its various mechanics foster engagement that can be utilized to promote health and well-being and influence health behavior. At present, psychosocial challenges among school-aged children are becoming a global predicament. We conducted a scoping review to explore the range and nature of evidence on gamified interventions for promoting the psychosocial well-being of school-aged children from the general population. We followed the Arksey and O'Malley framework and extracted sources of evidence from five databases. Our review findings were summarized with basic numerical analysis and provided with narrative accounts based on a gamification taxonomy and the Template for Intervention Description and Replication (TIDieR). We identified 12 gamified interventions and included 23 records that reported their development and evaluation. Theories on emotions, behaviors, social skills, and mental health were commonly applied frameworks. Narrative was found as the most commonly used gamification mechanic (11/12, 91.7%), followed by avatar and tasks (10/12, 83.3%), feedback system and level progression (9/12, 75%), points (7/12, 58.3%), badges (5/12, 41.7%), progress bar (4/12, 33.3%), and virtual goods, reminders, and time pressure (2/12, 16.7%). The included sources of evidence reported significant improvements in some of the measured psychosocial outcomes; however, studies on this domain for this particular target group are still considerably limited. Further research is needed to determine how the applied theories and gamification mechanics brought about the change in psychosocial outcomes, bridging the gap in current evidence.

A Gaussian process approach for rapid evaluation of skin tension

Skin tension plays a pivotal role in clinical settings, it affects scarring, wound healing and skin necrosis. Despite its importance, there is no widely accepted method for assessing in vivo skin tension or its natural pre-stretch. This study aims to utilise modern machine learning (ML) methods to develop a model that uses non-invasive measurements of surface wave speed to predict clinically useful skin properties such as stress and natural pre-stretch. A large dataset consisting of simulated wave propagation experiments was created using a simplified two-dimensional finite element (FE) model. Using this dataset, a sensitivity analysis was performed, highlighting the effect of the material parameters and material model on the Rayleigh and supersonic shear wave speeds. Then, a Gaussian process regression model was trained to solve the ill-posed inverse problem of predicting stress and pre-stretch of skin using measurements of surface wave speed. This model had good predictive performance (R2 = 0.9570) and it was possible to interpolate simplified parametric equations to calculate the stress and pre-stretch. To demonstrate that wave speed measurements could be obtained cheaply and easily, a simple experiment was devised to obtain wave speed measurements from synthetic skin at different values of pre-stretch. These experimental wave speeds agree well with the FE simulations, and a model trained solely on the FE data provided accurate predictions of synthetic skin stiffness. Both the simulated and experimental results provide further evidence that elastic wave measurements coupled with ML models are a viable non-invasive method to determine in vivo skin tension. STATEMENT OF SIGNIFICANCE: To prevent unfavourable patient outcomes from reconstructive surgery, it is necessary to determine relevant subject-specific skin properties. For example, during a skin graft, it is necessary to estimate the pre-stretch of the skin to account for shrinkage upon excision. Existing methods are invasive or rely on the experience of the clinician. Our work aims to present an innovative framework to non-invasively determine in vivo material properties using the speed of a surface wave travelling through the skin. Our findings have implications for the planning of surgical procedures and provides further motivation for the use of elastic wave measurements to determine in vivo material properties.

The Attitudes of Patients Toward Orthopaedic Post-surgical Scars

Background Post-surgical scars (PSS) are an expected consequence of surgery. Several factors have previously been associated with PSS satisfaction including patient age and time elapsed post-operative. Little data are available regarding patient attitudes toward orthopaedic PSS. Knowledge of patient attitudes and the various associated factors may allow physicians to administer peri-operative care to mitigate the potential negative effects of PSS. Our study aims to investigate the attitudes of patients toward their PSS using quantitative scar assessment scales and to identify factors associated with PSS satisfaction. Methods We conducted a retrospective study with a follow-up. We included all patients with orthopaedic PSS on their upper or lower limbs between two and 18 weeks postoperative attending Cork University Hospital, Ireland, between February and August 2022. Patients completed an initial baseline questionnaire and then a follow-up questionnaire six months post-operative. The Patient and Observer Scar Assessment Scale (POSAS) evaluated PSS satisfaction. The European Quality of Life 5 Domain (EQ-5D), alongside several Likert scales, evaluated the patient's quality of life (QoL). Results In total, 91 patients were included. The mean POSAS score was 28.41 (95% CI, 25.85-30.97). Younger patient age (p=0.045) and decreased time passed post-operatively (p=0.002) were associated with poorer PSS satisfaction. Patients reporting their PSS appearing worse than expected were more likely to agree that their QoL had been adversely affected by it (p=0.001). Conclusion Most patients were satisfied with their orthopaedic PSS. This study identified several factors associated with poor PSS satisfaction. Our finding, which associated patient scar expectations and QoL, is novel and has not been previously examined. Accordingly, peri-operative interventions, including scar expectation management, may be implemented to mitigate scar-related QoL impact.

A systematic review of the comparison between needling (RF-needling, meso-needling, and micro-needling) and ablative fractional lasers (CO2, erbium YAG) in the treatment of atrophic and hypertrophic scars

The aim of this study is to compare needling (RF-needling, meso-needling, micro-needling) and ablative fractional lasers (CO2, erbium-YAG) in the treatment of atrophic and hypertrophic scars in a systematic review. The database was searched, and 10 articles were selected that were relevant in terms of content, topic, and purpose and met the inclusion criteria. Of all the articles reviewed in this study, there were 2 randomized split-face trials (20%), 1 controlled nonrandomized trial (10%), 1 controlled randomized phase III clinical trial (10%), 1 prospective trial (10%), 1 prospective nonrandomized open-label trial (10%), and 1 randomized comparative trial (10%), with the type of study not reported in 3 articles. We used Endnote X8 to review the articles and extract data. After review, the studies were analyzed and categorized. No statistically significant difference was found between the two methods, laser and micro-needling, in the treatment of atrophic and hypertrophic scars in 60% of the articles studied, and both showed significant improvement (70% or more improvement to complete response). Significant improvement was noted in 20% of the studies reviewed for the laser and micro-needling treatment methods. The results of this study show that needling and ablative fractional lasers are tolerable and safe procedures with no significant difference in the treatment of skin scars in sixty percent of the studies.

Analysis of images supplied by Skincam® can record the changes of some scar features that occur over time. Comparisons with the assessments of dermatologist and patients' perception

OBJECTIVE

The objective of the study was to assess in vivo the validity of a new imaging device in quantifying the scarring process over time and to compare its data with the expertise of dermatologist and patients' self-appraisals.

MATERIALS AND METHODS

A total of 37 Korean women, aged 20-50 year, with closed scars of different types, were enrolled after a dermatological evaluation. All subjects applied daily a hydrating cream on their scars for 2 months. Images of scars at different times (Day 0, Day 28, and Day 56) were taken and further analyzed, yielding various parameters such as color, luminance, size, volume, and depth of each scar. A dermatologist visually graded, at each time point, the clinical aspect of the scar, and patients were asked to answer to some questions dealing with their self-examination of their scar.

RESULTS

The changes in some scar features that occurred during the application period were quantified and statistically differed from the D₀ baseline value. Scars became of reduced size, lighter (Increased luminance), less red, less deep, and less voluminous. Some of these parameters (volume, lightness, smoothness, texture regularity) were statistically different at D₂₈ whereas some others (area, depth, redness) showed significant changes at D₅₆ . Dermatologist expertise and patients' assessments were in high agreement.

CONCLUSION

This methodological approach that uses a dedicated camera associated with image analysis, despite some inherent limits (size of the scar), appears as a valuable aid to surgeons in the management of scars, in the follow-up of a given procedure or treatment. Beyond scar management, this approach may be extended to other skin disorders such as acne.

Vacuum and Electromagnetic Fields Treatment to Regenerate a Diffuse Mature Facial Scar Caused by Sulfuric Acid Assault

Acid attacks are on the rise, and they cause extensive and deep burns, especially on the face. The treatments used to improve the aesthetic, functional and social impact of non-acid scars do not always prove useful for acid scars. This article reports the case of a woman with an extended, mature, acid facial scar, caused by sulfuric acid assault, treated with a recent new procedure that combines the application of vacuum and electromagnetic fields. Before and after the treatment, the aesthetic appearance, and motor function of the face and neck were evaluated, as well as the level of hydration, the amount of sebum, the elasticity, and the pH of the skin. The improvements highlighted after the treatment of the aesthetic and functional characteristics of the face and neck, and of the physical parameters of the skin seemed to indicate that this particular treatment induces tissue regeneration, even in the nerve component. However, it is evident that the rehabilitation pathways of facial wounds and scars must be personalized, and must include continuous psychological support for the patient.

Pediatric First-Degree Burn Management With Honey and 1% Silver Sulfadiazine (Ag-SD): Comparison and Contrast

Background The cardinal area of managing fire wounds is guided by adequately evaluating the burn-induced lesion's profundity and size. Superficial second-degree burns are often treated through daily reinstating with fresh sterile bandaging with appropriate topical antimicrobials to allow rapid spontaneous epithelialization. Around the world, a wide variety of substances are used to treat these wounds, from honey to synthetic biological dressings. Objective This study intended to determine honey's therapeutic potential compared with 1% silver sulfadiazine (Ag-SD) in arsenal-caused contusion medicament fulfillment. Methods A total of 70 cases were evaluated in this research work after fulfilling the required selection criteria during the study period of January 2014 to December 2014 and January 2017 to December 2017. Purposive selection criteria were adopted in the study to select research patients. The patients in Group-1 (n = 35) relied on honey as medication, while patients in Group-2 (n = 35) relied on 1% Ag-SD. Results In Group-1, exudation (68.4%) and sloughing (82.9%) were substantially reduced by Days 3 and 5 of therapeutic intervention, respectively. However, in Group-2, a reduction of exudation (17.1%) and sloughing (22.9%) occurred after Days 3 and 5 of treatment, respectively. Completion of the epithelialization process was observed among Group-1 and Group-2 cases. It was detected after Days 7 and 10 of treatment at 36.3% and 77% (Group-1) and 27% and 67% (Group-2), respectively. Around 3 ml of 1% honey was required per body surface area per dressing in Group-1. On the other hand, in Group-2, 2 gm Ag-SD was needed per body surface area per dressing. Conclusion Patients treated with honey found better clinical outcomes in managing superficial partial-thickness burns.

Low Baseline Expression of Fibrotic Genes in an Ex Vivo Human Skin Model is a Potential Indicator of Excessive Skin Scarring

One of the challenges plastic surgeons face is the unpredictability of postoperative scarring. The variability of wound healing and subsequent scar formation across patients makes it virtually impossible to predict if a patient's surgery will result in excessive fibrosis and scarring, possibly amounting to keloids or hypertrophic scars. There is a need to find predictive molecular indicators of patients or skin location with high risk of excessive scarring. We hypothesized that baseline expression levels of fibrotic genes in the skin can serve as a potential indicator of excessive scarring.

METHODS

An ex vivo model of skin fibrosis was used with abdominal and breast skin tissue from 45 patients undergoing breast reduction and/or abdominoplasty. Fibrosis was induced in skin explants in organ culture with transforming growth factor-β (TFGβ). Fibrotic gene response was assessed via quantitative real-time polymerase chain reaction and correlated with skin location, age, and baseline levels of fibrotic genes.

RESULTS

The increase in TFGβ-induced fibronectin1 (FN1) gene expression in skin explants was significantly higher than for Collagen 1A1, alpha smooth muscle actin, and connective tissue growth factor. Also, FN1 expression positively correlated with donor age. Moreover, lower expression of the fibrotic genes FN1, Collagen 1A1, and alpha smooth muscle actin correlated with a more pronounced fibrotic response, represented by higher induction levels of these genes.

CONCLUSIONS

Skin sites exhibit different baseline levels of profibrotic genes. Further, low baseline expression levels of fibrotic genes FN1, Collagen 1A1, and alpha smooth muscle actin, in donor skin may indicate a potential for excessive scarring of the skin.

Lasers and Intense Pulsed Light for the Treatment of Pathological Scars: A Network Meta-Analysis

BACKGROUND

Laser and intense pulsed light (IPL) therapies have shown promising effects on pathological scars, but the comparative effectiveness of laser and IPL therapies has not yet been studied.

OBJECTIVES

The aim of this study was to compare and rank the efficacy of laser and IPL therapies to determine the most effective treatment method for pathological scars.

METHODS

Relevant studies published up to February 2022 were identified by searching PubMed, Web of Science, Cochrane Library, CNKI, and Wanfang databases. We defined Vancouver Scar Scale score as the primary outcome. Both frequentist and Bayesian approaches were used to perform a network meta-analysis.

RESULTS

We included 25 trials with a total of 1688 participants. The rankings based on the surface under the cumulative ranking curve for the Vancouver Scar Scale score based on the Bayesian approach suggested IPL + CO2 (96.43%) > pulsed dye laser (PDL) + 1064-nm Nd:YAG (yttrium aluminum garnet) laser (86.21%) > PDL + CO2 (82.15%) > CO2 (58.97%) > 1064-nm Nd:YAG (57.03%) > PDL (52%) > 532-nm Nd:YAG (33.28%) > Er:YAG + IPL (28.38%) > Er:YAG (26.56%) > IPL (15.03%) > control (13.97%). The ranking results based on the frequentist approach were basically consistent with those based on the Bayesian approach.

CONCLUSIONS

The results of the network meta-analysis showed that the combination of IPL and CO2 laser has the highest probability of being the most effective intervention. However, our conclusions must be interpreted with caution due to the relatively few evaluation indicators included in our study. Future well-designed randomized controlled trials with large sample sizes are required to confirm our conclusions.

LEVEL OF EVIDENCE: 4

Intense pulsed light treatment for inflammatory skin diseases: a review

Although intense pulsed light (IPL) has been commonly used in the field of medical cosmetics in recent years, the exact outcomes of IPL in the treatment of inflammatory skin diseases remain unclear. To assess the clinical evidence for the use of IPL in the treatment of various inflammatory skin diseases and propose evidence-based recommendations, we searched for relevant publications in the PubMed and Web of Science databases and provided updated information. The inflammatory skin diseases treated with IPL consisted of acne vulgaris, rosacea, psoriasis, hidradenitis suppurativa (HS), atopic dermatitis (AD), Riehl's melanosis, lupus erythematosus, cutaneous sarcoidosis, pilonidal cysts, and pigmented actinic lichen planus (PALP). The efficacy of IPL treatment for these inflammatory skin diseases was described and evaluated. Forty-two studies were included to provide this assessment. The evidence suggests that IPL can effectively and safely improve acne vulgaris and rosacea (recommendation grade B). For other described inflammatory skin diseases, IPL can be used as a tentative or supplementary treatment (recommendation grade C and D). The main complications include transitory erythema, edema, and pain, with the possibility of hyperpigmentation, blisters, and a burning sensation in some individuals.

V-EMF treatment of facial scar: First results

AIM OF STUDY

This is a retrospective study aimed at evaluating the effectiveness of the use of electromagnetic fields and negative pressure treatment (V-EMF) for facial scars, from an aesthetic and functional point of view, and considering the variations in the levels of hydration.

MATERIAL AND METHODS

25 subjects with facial scarring were re-evaluated after being treated with the V-EMF method. The hydration levels of the scars before and after treatment were compared. The results were evaluated considering the satisfaction levels of the patients with the VAS, and of the medical specialists who performed the treatment, and of 3 independent dermatologists with the Likert scale.

RESULTS

Mean hydration levels of scars went from 41.8 to 53.3, with mean hydration levels of healthy reference points equal to 54.6. The minimum patient satisfaction level was 2 in the VAS. The minimum level of satisfaction of specialists and dermatologists was equal to IV on the Likert scale for all patients, except for 1 subject in which it was III for the specialist who had treated him. Anti-aging and re-pigmentation effects were also noted as secondary results.

CONCLUSIONS

From an aesthetic and functional point of view, and for the overall anti-aging effect of the treated area, V-EMF applied to facial scars has shown extremely promising results.

Creation of a nationwide breastfeeding policy for surgical residents: a scoping review protocol

INTRODUCTION

Breast feeding is recommended for the first year of a baby's life due to numerous benefits for both the child and mother. After returning from maternity leave, surgical trainees face extensive barriers to breast feeding and tend to terminate breast feeding earlier than guideline recommendations. The aim of this scoping review is to assess existing breastfeeding policies for surgical trainees at the national level including postgraduate medical education offices, provincial resident unions and individual surgical programmes.

METHODS AND ANALYSIS

A modified Arksey and O'Malley (2005) framework will be used. Specifically, (1) identifying the research question/s and (2) relevant studies from electronic databases and grey literature, (3) identifying and (4) selecting studies with independent verification, and (5) collating, summarising, and reporting data while having ongoing consultation between experts throughout the process. Experts will include a lactation consultant (AGB), a human resource leader (JI), a health information specialist (ES), two independent coders (NZ, LR) and a board-certified surgeon (JD). This work will take place as of December 2020 and be carried out to completion in 2021.

ETHICS AND DISSEMINATION

Ethics approval will not be sought for this scoping review. Research findings will be disseminated through publications, presentations and meetings with relevant stakeholders.

Safety and efficacy of treating post-burn pathological scars with extracorporeal shock wave therapy: A meta-analysis of randomised controlled trials

The clinical application of shockwave therapy has expanded to the treatment of pathological scars. The objective of this systematic review and meta-analysis is to quantitatively evaluate the efficacy and safety of extracorporeal shockwave therapy combined with comprehensive rehabilitation therapy on post-burn pathological scars compared to comprehensive rehabilitation therapy alone. The randomised controlled trials of extracorporeal shockwave therapy for post-burn pathological scars published in English and Chinese languages before October 2021 were included. The methodological quality and risk of bias of the selected articles were assessed with the Cochrane Collaboration's 'risk of bias' tool. RevMan software was applied for data analysis. This is the first systematic review and meta-analysis considering the effectiveness and safety of extracorporeal shockwave therapy on post-burn pathological scars. And nine randomised controlled trials involving 422 patients were included in this meta-analysis. The meta-analysis results showed that, compared with comprehensive rehabilitation therapy alone, extracorporeal shockwave therapy combined with comprehensive rehabilitation therapy was more effective in relieving pain (standardized mean difference [SMD] = -0.59, 95% confidence interval [CI]: [-0.87 to -0.31], p < 0.0001) and pruritus related to pathological scars (SMD = -0.94; 95% CI: [-1.25 to -0.63], p = 0.004), improving scars' appearance (SMD = -1.78, 95% CI: [-3.37 to -0.19], p = 0.03) and elasticity (SMD = 0.25, 95% CI: [0.29-0.21], p < 0.00001), decreasing scars thickness (SMD = -0.13, 95% CI: [-0.25 to -0.01], p = 0.04) and promoting the maturation status of scars (SMD = -2.86, 95% CI: [-3.96 to -1.76], p < 0.00001). There were no reported serious adverse events during and after extracorporeal shockwave therapy in the included studies. Available data preliminarily suggested that the combination of extracorporeal shockwave therapy and comprehensive rehabilitation therapy had better therapeutic effect on post-burn pathological scars than comprehensive rehabilitation therapy alone, without obvious side effects. However, further clinical well-controlled randomised controlled trials are needed. Systematic review registration ID: PROSPERO CRD42022297573.

Post-skin incision scar tissue assessment using patient and observer scar assessment scales: A randomised controlled trial

BACKGROUND

The scalpel was once the gold standard for surgical incisions. Electrosurgery has started to supplant scalpels but is not yet acceptable for skin incisions due to the risk of burns and deeper injury relative to the scalpels' neat incision with less tissue damage. The unnecessary burden of excessive scar formation makes comparing these two methods challenging. Therefore, this study aims to compare post-incision skin scarring created after monopolar electrosurgery and scalpel surgery, and evaluate the Patient and Observer Scar Assessment Scale (POSAS) suitability for assessing skin incision scars by comparing patients' and observers' scores.

METHODS

This self-controlled study involved patients undergoing elective and emergency skin surgery procedures. A singular wound site was created using two incision methods (monopolar electrosurgery and scalpel) simultaneously. Post-incision scar tissue formation was evaluated using the POSAS, a subjective scar assessment tool that involved patients self-reporting on pain, itching, color, thickness flexibility, and surface relief. Observer-rated vascularity, pigmentation, thickness, flexibility, and surface relief both using a 5-point Likert-type scale. We performed this assessment three months post-surgery, and the results were analyzed by a battery of statistical tests and linear mixed models.

RESULTS

Twenty patients were included in this study. Data analyzed using the paired t-test or Wilcoxon rank-sum test indicated no statistically significant differences between the scar tissue created by monopolar electrosurgery and scalpels according to both the patients and the observers. Correlation analyses between the patients' and observers' total POSAS scores indicated these followed a moderate linear relationship (r = 0.51; p < 0.001). Linear mixed models further supported the agreement of POSAS total scores between patients and observers. They also confirmed that electrosurgery was not inferior to the scalpel technique.

CONCLUSION

Scar tissue from skin incisions made by monopolar electrosurgery were indistinguishable from those created with a scalpel. The POSAS instrument is an acceptable means of assessing scar formation on the skin.

Efficacy and safety of pulsed dye laser for the treatment of surgical scars: a systematic review and meta-analysis

Various clinical trials have explored whether the pulsed dye laser (PDL) method is safe to treat scars, especially surgical scars. However, comprehensive evidence confirming the exact outcomes of PDL for treating surgical scars is lacking. The efficacy and safety of PDL in the treatment of surgical scars were determined through a review of several studies. The PubMed, Embase, Cochrane Library, and Web of Science databases were searched, and the main clinical outcomes were Vancouver Scar Scale (VSS) scores in terms of pigmentation, vascularity, pliability, and height. Review Manager 5.4 software was used for statistical analyses of the data; we chose a standardized mean difference (SMZ) to present the results with 95% confidence interval (CI). Overall, seven randomized controlled trials were used for this meta-analysis, all of these papers used 585 nm or 595 nm PDL with 7 mm or 10 mm spot size and a fluence of 3.5 to 10 J/cm² for treating surgical scars; besides, the pulse duration ranged from 450 μs to 10 ms. We found that PDL significantly resulted in decreased VSS scores (P = 0.02) in four aspects: pigmentation (P = 0.0002), vascularity (P < 0.00001), pliability (P = 0.0002), and height (P = 0.0002). Moreover, scar improvement was similar when using 585 nm and 595 nm PDL in terms of pigmentation (P = 0.76), vascularity (P = 0.34), pliability (P = 0.64), and height (P = 0.57). Furthermore, our review indicated that PDL has no obvious adverse effects for most people, except transitory erythema and purpura. The meta-analysis showed that both 585 nm and 595 nm PDL therapy can effectively reduce the VSS score, suggesting that PDL can be a safe and effective method for the treatment of surgical scars.

Efficacy of combined treatment with intense pulsed light and fractional erbium:YAG Laser in scar prevention: A randomized split wound trial

Various methods have been used for scar prevention; however, the optimal method remains unclear. We investigated the efficacy of combinational intense pulsed light (IPL)/fractional erbium-doped yttrium aluminum garnet (Er:YAG) laser treatment in early wound healing. This was a prospective, randomized, controlled split wound trial. Scars were divided into three sites: the combined IPL/fractional Er:YAG treatment, fractional Er:YAG laser treatment, and untreated control sites. Treatment was conducted in three sessions: at removal of stitches and after 4 and 8 weeks. Treatment efficacy was evaluated using the Patient Observer Scar Assessment Scale (POSAS) and Vancouver Scar Scale (VSS) scores. The erythema index (EI) and melanin index (MI) were measured. In the total POSAS score, the IPL/fractional Er:YAG site showed steady and significant improvement, in contrast to the other sites. At week 8, the combined treatment sites had better POSAS scores than the fractional Er:YAG laser alone sites (p = 0.001) and the control sites (p = 0.000). The effect of combinational treatment was maintained until the follow-up period by comparing the Er:YAG (p = 0.015) and control sites (p = 0.007). In terms of VSS scores, the IPL/fractional Er:YAG combined treatment sites had consistent improvement at week 8 (p = 0.005) and week 20 (p = 0.02) compared to that at week 4, while the other sites showed no such improvement. In conclusion, the combination of IPL and Er:YAG showed more favorable effects on scar prevention than Er:YAG or no treatment. IPL/Er:YAG therapy could be an effective and safe strategy in the early wound healing process for reducing scar formation.

Gazing Long into a Clinical and Social Abyss? Treating Hypertrophic Scarring and Keloids

This commentary discusses the unmet clinical and social needs associated with hypertrophic scars and keloids. The authors critically appraise these issues within the context of contemporary clinical standards of care and social mores catalyzed by the COVID-19 pandemic.

Daily Quality-of-life Impact of Scars: An Interview-based Foundational Study of Patient-reported Themes

Background:

Scars negatively impact mental health. Prior patient interview studies on cutaneous scars have elicited opinions pertaining to psychosocial effects, appearance, and symptoms. There remains a need for patient-reported opinions in broader contexts, including career and sexual well-being, to better understand patients’ experiences with their cutaneous scars.

Methods:

In this qualitative study, patients with cutaneous scars participated in semi-structured interviews. Transcripts were analyzed using a constant comparative approach using the data software QDAMiner, to generate a thematic framework encompassing patients’ experience with cutaneous scars.

Results:

In total, 37 patients aged 25–79 years (mean 45, SD 17.9) were interviewed. Patients presented with keloid (2/37, 5%), hypertrophic (5/37, 14%), atrophic (4/37, 11%), and linear surgical (18/37, 49%) scars. Opinions fell under 8 overarching themes. Patients spoke commonly about psychological and social well-being (references to the frequency of thinking about a scar and talking about scars with others were mentioned 56 times by 26 patients and 103 times by 29 patients, respectively, for example). Discussions of sexual well-being and career were elicited but rarer (references to feeling uncomfortable when naked and negative impacts on professional networking were mentioned 17 times by 7 patients and 5 times by 3 patients, respectively, for example).

Conclusions:

The relationship between determinants of patients’ opinions of their scars and their impact on quality-of-life is complex. These results expand upon the existing knowledge of the effects scars have on quality-of-life and can contribute to the development and validation of future scar outcome measures.