Management of external ear keloids using form-pressure therapy

An automated design pipeline for transparent facial orthoses: A clinical study

STATEMENT OF PROBLEM

Transparent facial orthoses (TFOs) are commonly used for the treatment of craniomaxillofacial trauma and burns to prevent hypertrophic and keloid scarring. A TFO is typically customized to the patient's facial contours and relies on a precise fit to ensure good rehabilitative performance. A smart method of TFO design and manufacture is needed which does not require an experienced prosthetist, allowing for rapidly produced, well-fitting TFOs. Whether the rapid application reduces the final level of patient scarring is unclear.

PURPOSE

The purpose of this clinical study was to determine whether a scalable, automated design-through-manufacture pipeline for patient specific TFO fabrication would be successful.

MATERIAL AND METHODS

The automated pipeline received a 3-dimensional (3D) facial scan captured from a depth sensitive mobile phone camera. The scan was cleaned, aligned, and fit to a template mesh, with a known connectivity. The resultant fitted scan was passed into an automated design pipeline, outputting a 3D printable model of a custom TFO. The TFOs were fabricated with 3D printing and were both physically and digitally evaluated to test the fidelity of a digital fit testing system.

RESULTS

A total of 10 individuals were scanned with 5 different scanning technologies (STs). All scans were passed through an automated fitting pipeline and categorized into 2 groups. Each ST was digitally fitted to a ground truth scan. In this manner, a Euclidean distance map was built to the actual facial geometry for each scan. Heatmaps of 3D Euclidean distances were made for all participant faces.

CONCLUSIONS

The ability to automatically design and manufacture a custom fitted TFO using commercially available 3D scanning and 3D printing technology was successfully demonstrated. After considering equipment size and operational personnel requirements, vat polymerization (VP) technology was found to be the most promising route to TFO manufacture.

Triple Therapy Protocol for Primary and Secondary Auricular Keloids: A Prospective Outcome Evaluation

BACKGROUND

Ear keloid lesions present a significant challenge to the aesthetic surgeon. Keloids are known to recur and can cause severe cosmetic, functional, and psychological impairments. Several adjuvants to surgical removal have been promoted, with varying recurrence rates.

OBJECTIVE

To evaluate the effectiveness of triple therapy to treat secondary (and large primary) auricular keloids.

MATERIALS AND METHODS

Patients with secondary or large primary auricular keloids undergoing triple therapy were prospectively studied. Keloids were excised intramarginally under magnification and repeated triamcinolone acetonide 40 mg/mL injections were administered, followed by the application of a custom-made acrylate pressure device. Recurrent keloid formation and adverse events were monitored during a minimum of 6 months of follow-up.

RESULTS

Sixteen auricular keloid lesions (3 large primary and 13 secondary) were subjected to the proposed technique with a mean follow-up of 28 months. All cases that adhered to the protocol were free of keloid after triple therapy. Side effects were limited to 1 case of lobular atrophy and slight hypopigmentation. All patients were satisfied with the results.

CONCLUSION

The triple therapy protocol is highly effective in primary and secondary auricular keloid as long as patients remain compliant.

Mechanical pressure-induced dedifferentiation of myofibroblasts inhibits scarring via SMYD3/ITGBL1 signaling

Pressure therapy (PT) is an effective intervention for reducing scarring, but its underlying mechanism remains largely unclear. Here, we demonstrate that human scar-derived myofibroblasts dedifferentiate into normal fibroblasts in response to PT, and we identify how SMYD3/ITGBL1 contributes to the nuclear relay of mechanical signals. In clinical specimens, reductions in SMYD3 and ITGBL1 expression levels are strongly associated with the anti-scarring effects of PT. The integrin β1/ILK pathway is inhibited in scar-derived myofibroblasts upon PT, leading to decreased TCF-4 and subsequently to reductions in SMYD3 expression, which reduces the levels of H3K4 trimethylation (H3K4me3) and further suppresses ITGBL1 expression, resulting the dedifferentiation of myofibroblasts into fibroblasts. In animal models, blocking SMYD3 expression results in reductions of scarring, mimicking the positive effects of PT. Our results show that SMYD3 and ITGBL1 act as sensors and mediators of mechanical pressure to inhibit the progression of fibrogenesis and provide therapeutic targets for fibrotic diseases.

Nuclear medicine in the management of superficial skin abnormalities and institutional experience

Keloid, hypertrophic scars and basal cell carcinoma (BCC) falls under the category of non-melanoma skin cancer. Intralesional steroids, external beam radiation therapy, 5-Fluorouracil, cryotherapy, laser, etc are the available treatment options. However, recurrence has been reported with each type of treatment mode. In the present article, various treatment modes have been discussed and institutional experience of Rhenium-188 skin patches for the treatment of keloids and BCC has been discussed.

What Do We Know About Treating Recalcitrant Auricular Keloids? A Systematic Review and Meta-Analysis

Background:

Recalcitrant auricular keloids are keloids that have recurred after any previous treatment. They have been shown to have an increased likelihood of recurrence. There is no consensus on how best to treat recalcitrant auricular keloids. Here, we perform the first systematic review and meta-analysis investigating the evidence for treating recalcitrant auricular keloids.

Methods:

We searched MEDLINE, EMBASE, CINAHL, and EBM Reviews using specific keywords. Prespecified inclusion and exclusion criteria were used to assess article eligibility. Data were extracted for number of recalcitrant keloids, treatment modality, recurrence, and minimum follow-up time. Included articles were stratified by treatment and assigned a level of evidence (LOE) based on the Oxford Centre for Evidence-Based Medicine guidelines. A meta-analysis was performed to estimate recurrence rates with 95% confidence intervals for each treatment modality.

Results:

A total of 887 unique articles were identified and 13 included. Eleven were LOE III and 2 were LOE IV. Recurrence rates were found to be 9% (95% CI: 3%-25%) for excision with adjuvant brachytherapy, 14% (95% CI: 12%-17%) for excision with adjuvant compression therapy, 17% (95% CI: 3%-56%) for excision with adjuvant external beam radiation, and 18% (95% CI: 4%-53%) for excision with adjuvant steroid injections. No statistical significant difference was found.

Conclusions:

Data for treatment of auricular keloids are heterogeneous with few high-quality studies. Excision with adjuvant brachytherapy has the lowest recurrence rate in our analysis. Narrow confidence intervals reported here for brachytherapy and compression therapy may help surgeons more confidently recommend either of these treatment modalities to patients.

Keloids: a review of therapeutic management

Keloid scar formation arises from a disorganized fibroproliferative collagen response that extends beyond the original wound margins because of excessive production of extracellular matrix (ECM). Despite treatment options for keloid scars including medical and surgical therapies, such as intralesional steroid injection and surgical excision, the recurrence rate remains high. Herein we consolidate recently published narrative reviews, systematic reviews, and meta-analyses to provide an overview of updated treatment recommendations for keloidal scar formation. PubMed search engine was used to access the MEDLINE database to investigate updates regarding keloid incidence and treatment. More than 100 articles were reviewed. Keloid management remains a multimodal approach. There continues to be no gold standard of treatment that provides a consistently low recurrence rate; however, the increasing number of available treatments and synergistic combinations of these treatments (i.e., laser-based devices in combination with intralesional steroids, or 5-fluorouracil (5-FU) in combination with steroid therapy) is showing favorable results. Future studies could target the efficacy of novel treatment modalities (i.e., autologous fat grafting or stem cell-based therapies) for keloid management. This review article provides updated treatment guidelines for keloids and discusses insight into management to assist patient-focused, evidence-based clinical decision making.

Triamcinolone acetonide intralesional injection for the treatment of keloid scars: patient selection and perspectives

Keloids are pathological scars presenting as nodular lesions that extend beyond the area of injury. They do not spontaneously regress, often continuing to grow over time. The abnormal wound-healing process underlying keloid formation results from the lack of control mechanisms self-regulating cell proliferation and tissue repair. Keloids may lead to cosmetic disfigurement and functional impairment and affect the quality of life. Although several treatments were reported in the literature, no universally effective therapy was found to date. The most common approach is intralesional corticosteroid injection alone or in combination with other treatment modalities. Triamcinolone acetonide (TAC) is the most commonly used intralesional corticosteroid. The aim of this article was to review the use of TAC, alone or in combination, in the treatment of keloid scars. The response to corticosteroid injection alone is variable with 50-100% regression and a recurrence rate of 33% and 50% after 1 and 5 years, respectively. Compared to verapamil, TAC showed a faster and more effective response even though with a higher complication rate. TAC combined with verapamil was proved to be effective with statistically significant overall improvements of scars over time and long-term stable results. TAC and 5-fluorouracil (5-FU) intralesional injections were found to achieve comparable outcomes when administered alone, although 5-FU was more frequently associated with side effects. Conversely, the combination of 5-FU and TAC was more effective and showed fewer undesirable effects compared to TAC or 5-FU alone. Several kinds of laser treatments were reported to address keloids; however, laser therapy alone was burdened with a high recurrence rate. Better results were described by combining CO2, pulsed-dye or Nd: YAG lasers with TAC intralesional injections. Further options such as needle-less intraepidermal drug delivery are being explored, but more studies are needed to establish safety, feasibility and effectiveness of this approach.

Surgical excision and contoured custom made splint to treat helical keloid

Helical keloids are difficult to treat as surgical excision requires effective compression of the operative scar to prevent recurrence while retaining the contour and elasticity of the helix. The authors fabricated a conforming custom made post-operative splint from a commonly used dental material. Splints could be fabricated in both pre-operative and post-operative stage.

The effectiveness of pressure therapy (15-25 mmHg) for hypertrophic burn scars: A systematic review and meta-analysis

Although pressure therapy (PT) represents the standard care for prevention and treatment of hypertrophic scar (HS) from burns, its practice is largely based on empirical evidence and its effectiveness remains controversial. To clarify the effect of PT (15-25 mmHg) for HS, we performed the systematic review and meta-analysis. Several electronic databases were screened to identify related randomized controlled trials (RCTs). 12 RCTs involving 710 patients with 761 HS resulting from burn injuries were included. Compared with non/low-PT, cases treated with PT (15-25 mmHg) showed significant differences in Vancouver Scar Scale score (MD = -0.58, 95% CI = -0.78--0.37), thickness (SMD = -0.25, 95% CI = -0.40--0.11), brightness (MD = 2.00, 95% CI = 0.59-3.42), redness (MD = -0.79, 95% CI = -1.52--0.07), pigmentation (MD = -0.16, 95% CI = -0.32--0.00) and hardness (SMD = -0.65, 95% CI = -1.07--0.23). However, there was no difference in vascularity (MD = 0.03, 95% CI = -0.43-0.48). Our analysis indicated that patients with HS who were managed with PT (15-25 mmHg) showed significant improvements. Due to limitations, more large and well-designed studies are needed to confirm our findings and the side-effects of the PT may also need to be evaluated.

Custom made pressure appliance for presurgical sustained compression of auricular keloid

Keloid is dermal lesion characterized by nodular fibroblastic proliferation, which is considered an aberration of wound healing process. It is believed to be the confused scar that does not know when to stop growing. Pressure therapy using clips or splints is widely used for the treatment of keloids; however, it is often very difficult to control the amount and direction of pressure applied. Among the most common complications of this therapy is ulceration due to excessive pressure. A case of presurgical size reduction for a large ear keloid with a custom made pressure appliance is presented. This novel design of the appliance allows for better control over the amount and direction of the pressure applied on the scar tissue.

Clinical characteristics of facial keloids treated with surgical excision followed by intra- and postoperative intralesional steroid injections

BACKGROUND

The physiopathogenesis of keloid scars is not well understood. This report aims to present the authors' experiences with facial keloids, to evaluate their treatment outcomes via a prospective study, and to identify risk factors involved in facial keloid recurrence.

METHODS

Patients with facial keloids were treated with surgical excision followed by intra- and postoperative intralesional steroid injections at Kangbuk Samsung Hospital between July 2005 and June 2010. Of 15 keloids, 8 (53.3%) had previously been treated unsuccessfully at other hospitals. The follow-up period was 18 months, and therapeutic outcomes were evaluated based on recurrence or nonrecurrence.

RESULTS

The study evaluated 17 facial keloids in 15 patients. The overall recurrence-free rate was 76.5% after a follow-up period of 18 months. The authors hypothesized that the recurrence of keloids on the face is associated with both previous treatment and anatomic location.

CONCLUSIONS

The authors' protocol resulted in successful outcomes for the treatment of facial keloids. Patients with a history of previous treatment and keloids in the perioral region should be monitored closely for signs of recurrence and managed cautiously during treatment.

Outcomes of surgical excision with pressure therapy using magnets and identification of risk factors for recurrent keloids

BACKGROUND

In a previous study, the authors described an adjuvant pressure therapy using magnets for the management of ear keloids. The purpose of the present study was to build on this previous study by expanding the cohort of patients, evaluating treatment outcomes by means of a prospective study and identifying risk factors for recurrent ear keloids.

METHODS

The authors treated 1436 ear keloids in 883 patients with surgical excision followed by pressure therapy using magnets at Kangbuk Samsung Hospital over the 7.25-year period from December of 2002 to February of 2010. Six hundred eighteen of 883 patients (70 percent) had histories of treatment failure at other hospitals. The follow-up period was 18 months. Therapeutic outcomes were evaluated as recurrence or nonrecurrence. Comparisons between the two groups (recurrence versus nonrecurrence) were made using Mann-Whitney tests for continuous variables, the chi-square test and the Fisher's exact test for categorical variables, and multivariate logistic regression for investigating associations between possible risk factors and keloid recurrence.

RESULTS

The overall recurrence-free rate was 89.4 percent after a follow-up period of 18 months. Keloid recurrence was significantly associated with the presence of prior treatment history, keloid low growth rate, and high patient body mass index.

CONCLUSIONS

The authors' protocol results in excellent outcomes in cases of ear keloids. Patients with prior treatment history, low growth rates of keloids because of longer duration of disease, and high body mass index should be monitored closely for signs of recurrence and managed cautiously during ear keloid treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Therapeutic hotline: An alternative adjuvant treatment after ear keloid excision using a custom-made methyl methacrylate stent

The efficacy of most pressure devices developed for treatment of ear keloids is limited by the insufficient control of the applied pressure, sometimes causing pain and repeated bleeding with a subsequently increased risk of infections and cosmetic problems. The present study aims to describe the efficacy of the custom-made methyl methacrylate stent in patients that were surgically treated for ear keloids and afterward underwent pressure therapy. The recurrence rate of the ear keloids was evaluated after at least 12 months. Adjuvant treatment with the methyl methacrylate stent resulted in an 83% success rate in our experience with 23 patients that completed the intended therapeutic duration of 18 months. No cases of severe complications were seen during or after the treatment. Furthermore, all the items of the Patient and Observer Scar Assessment Scale resulted in a statistically significant improvement of the scar (p < 0.05). Postoperative pressure therapy with the custom-made methyl methacrylate stent seems efficacious, safe, and is usable for keloids of both the helix and the earlobe.