Our routine in pressure treatment of hypertrophic scars

Combined Non-Ablative Laser and Microfat Grafting for Burn Scar Treatment

BACKGROUND

Burn scar treatment persists as an unsolved problem, involving thousands of affected patients disfigured for life.

OBJECTIVES

We sought to present our experience with the use of combined treatments for patients with burn scars.

METHODS

This was a case series report of the senior author's experience during 8 years utilizing the combined treatments of Fraxel Restore (fractional laser) and microfat graft injection for 288 patients with burn scars.

RESULTS

Laser treatment reduced scar intensity and attenuated skin irregularities and hyperpigmentation. All patients demonstrated marked improvement of skin texture and an increase in scar softness after 3 sessions of microfat grafting. However, the degree of improvement varied between patients and was related to the severity of the scar and the type of tissue. Overall, a 40% to 80% improvement was noted in our patients. All patients and their families expressed satisfaction with the results.

CONCLUSIONS

The combined treatment of Fraxel and microfat grafting is an effective technique for improving the appearance of a hypertrophic scar or keloid on burn patients. Fat tissue stem cells may have helped to repair the damaged skin.

LEVEL OF EVIDENCE: 4

Rehabilitation following surgery for reconstruction of a foot defect

Background

This report illustrates the use of pressure for scar management to aid in foot re-shaping following a surgical intervention to repair an arterio-venous (AV) malformation.

Methods

This report describes the rehabilitation of a 13-year-old girl after surgical reconstruction of a defect in her left foot following the removal of an AV malformation. Early surgical attempts to repair the problem resulted in complications that required the amputation of toes 2, 3, and 4, and the use of a split thickness skin graft to cover the plantar surface of the medial longitudinal arch on the left foot. Following surgery, the patient had an antalgic gait pattern with decreased weight bearing on the left. The graft obliterated the left medial longitudinal arch and the patient would only weight bear on the heel. The patient had decreased metatarsal joint mobility on the affected side and no movement in the remaining toes. Left talocrural joint active range-of-motion (AROM) was within normal limits and gross ankle muscle force production was assessed to have a grade of 3/5.

Results

Treatment included reshaping the left foot using a pressure garment and orthotic, followed by interventions to address range-of-motion and muscle force production deficiencies. All treatment objectives were achieved and all patient goals were achieved.

Conclusions

Pressure was effective in re-shaping the foot to promote normal gait mechanics.

The use of pressure garments on hypertrophic scars

Hypertrophic scars are unsightly and can cause much distress to the sufferer. Pressure garments have been the preferred conservative management option for these scars for the last three decades. This paper reviews the history, underpinning theory and use of compression therapy in the management of hypertrophic scars particularly following burn injury. It is particularly aimed at clinicians who do not come into contact with this type of scarring frequently and are not familiar with its treatment. Other methods for managing hypertrophic scarring are also described briefly. Overall, there is a fair body of evidence to support the use of pressure garments, but it is not definitive research and further work is needed. However, the selection of any treatment must follow negotiation and agreement with the patient who will be required to continue treating their scars at home.

Influence of pressure supports on joint range of motion

Burn patients often complain of restricted mobility following application of elasticized nylon anti-burn-scar supports. This study was designed to analyse the influence of this type of pressure garment on joint range of motion (ROM). Data were compiled from 80 burn-affected joints of 17 burn patients placed in a support for the first time. Joint ROM was measured directly prior to, and again immediately following, the donning of the pressure support. ROM was measured using standard goniometric techniques. Range of motion increased in 26 joints (32.5 per cent), decreased in 26 joints (32.5 per cent) and showed no change in 28 joints (35 per cent) after application of the pressure garment. There were no correlations between ROM results and age, time postburn and per cent TBSA in this population. Patients were also asked if movement felt any different after the support was applied. Their varied comments, such as movement felt easier or more difficult, were consistent with the actual ROM data. It appears that there is no predictably detrimental change in joint ROM due to the application of pressure garments.

Acute excision or exposure treatment? Secondary reconstructions and functional results

To evaluate late-result of burn treatment 102 patients (52 treated with acute excision and grafting and 50 with exposure treatment and grafting on the 14th day) were examined 3 years after the burn injury. The series included patients with small, medium-sized and large burns, 56 of whom had used pressure bandages for about one year. During the first 3 years post-burn, 17 patients with contractures required release operations amounting to a total of 60 reconstructive procedures. At the follow-up 86 contractures, most of them of hands, could be demonstrated in 25 patients, but only 5 needed further reconstructions. No difference in late-result could be demonstrated between the two groups of patients treated by acute excision and by exposure.