How to evaluate scar colour after burn injuries - A clinical comparison of the Mexameter® and the subjective scar assessment (POSAS/VSS)

INTRODUCTION

Scarring after burn injuries remains one of the major challenges in burn medicine and is the subject of current research. Accurate and high-quality assessment of scars is needed to enable exact outcome evaluation of different treatments. Our aim was to evaluate the most common subjective scar evaluation scores-the POSAS (Patient and Observer Scar Assessment Scale) and VSS (Vancouver Scar Scale)-in comparison with the objective device Mexameter® for colour evaluation.

METHODS

A prospective monocentre study was performed, which included 120 examined scar areas of 60 patients with third degree burns who had received skin grafts between 1975 and 2018 with a total burned surface area (TBSA) > 2%. Two different scar areas in comparison with one healthy skin area concerning 'colour', 'pigmentation', and 'vascularization' were evaluated by the Mexameter® MX 18, the OSAS, and the VSS by the same examiner, as well as the PSAS by the patient.

RESULTS

The mean TBSA of the 60 patients was 24.3%. In the OSAS, 61% of the scars were evaluated as 'hyper-', 19% as 'hypo-', and 19% as 'mix-pigmented'. Furthermore, 65% of the scars were estimated as highly vascularized. In the Mexameter®, the melanin index values of the scar areas compared to the healthy skin areas showed a small difference of 12 (p < 0.05). The mean difference of erythema between the scar and the healthy skin areas was 84 (p < 0.001). For the Mexameter®, moderate correlations were found when comparing 'erythema' with the OSAS category 'vascularization' (r = 0.33, p < 0.05) and 'melanin' with the OSAS parameter 'pigmentation' (r = 0.28, p < 0.05). When comparing the Mexameter® measurements to the OSAS questionnaire, 27% of the scars were wrongly evaluated as 'hyperpigmented' by the observer and 21% as 'hypervascularized', while showing low measurements in the device. Additionally, a novel Mexameter® ordinal scare scale was calculated.

CONCLUSION

In this study, we were able to show on a relatively large patient population that with the Mexameter®, the subjectivity of the scar colour assessment by examiner/patient can be overcome, but precise differentiation can still be ensured with subjective evaluation tools. We further introduced a novel Mexameter® Scar Scale. It is necessary to further investigate the vast range of objective devices and develop scar panels for with an incorporation of objective and subjective devices to further improve reliability with reduced bias in terms of scar assessment.

Accuracy of remote burn scar evaluation via live video-conferencing technology

OBJECTIVE

Telemedicine in outpatient burn care, particularly in burn scar management, may provide cost-effective care and comes highly rated by patients. However, an effective scar scale using both video and photographic elements has not been validated. The purpose of this study is to test the reliability of the Patient and Observer Scar Assessment Scale (POSAS) using live video-conferencing.

METHODS

A prospective study was conducted with individuals with healed burn scars in Kathmandu, Nepal. Three independent observers assessed 85 burn scars from 17 subjects, using the Observer portion to evaluate vascularity, pigmentation, thickness, relief, pliability, surface area, and overall opinion. The on-site observer was physically present with the subjects and used a live videoconferencing application to show the scars to two remote observers in the United States. Subjects used the Patient portion to evaluate the scar that they believed appeared the worst appearance and had the greatest impact on function.

RESULTS

The single-rater reliability of the Observer scale was acceptable (ICC>0.70) in overall opinion, thickness, pliability, and surface area. The average-rater reliability for three observers was acceptable (ICC>0.70) for all parameters except for vascularity. When comparing Patients' and Observers' overall opinion scores, patients consistently reported worse opinion.

CONCLUSIONS

Evaluation of burn scars using the Patient and Observer Scar Assessment Scale can be accurately performed via live videoconferencing and presents an opportunity to expand access to burn care to rural communities, particularly in low- and middle-income countries, where patients face significant access barriers to appropriate follow-up care.

Aesthetic outcome of intermediate closure versus intermediate closure followed by 2-octyl cyanoacrylate: A randomized evaluator-blinded split-wound comparative effectiveness trial

BACKGROUND

Dermatologic surgeons are increasingly using surgical adhesives in their practice. Studies comparing sutured wounds to those that utilize a combination of suturing and skin adhesive have not been previously conducted.

OBJECTIVE

To compare the cosmetic outcome and patient wound care satisfaction of an intermediate suture closure with an intermediate suture closure followed by the application of 2-octyl cyanoacrylate (2-OCA).

METHODS

Fifty patients were enrolled in a randomized, evaluator-blinded, split-scar study. Following intermediate sutured closure of a surgical defect, one side of the wound was randomized to receive an additional application of 2-OCA. After 3 months, the scar was assessed using the POSAS tool and patients reported wound care preferences.

RESULTS

As the primary outcome measure, the mean sum of observer POSAS was 12.80 for sutured closure alone versus 12.40 for sutured closures followed by 2-OCA (P = .49).

LIMITATIONS

Single-center study of a relatively homogenous population.

CONCLUSION

Although there were no significant differences in scar cosmesis, both patients and observers tended to prefer the side with an additional application of 2-OCA in most POSAS components, in overall opinion, and in patient wound care satisfaction. Dermatologic surgeons may add this to their practice without sacrificing scar outcomes or patient satisfaction.

From qualitative data to a measurement instrument: A clarification and elaboration of choices made in the development of the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS) 3.0

PURPOSE

To clarify and elaborate on the choices that were made in the development of the Patient Scale of the Patient and Observer Scar Assessment Scale 3.0 (POSAS 3.0), based upon the rich information obtained from patients during focus groups and pilot tests.

METHODS

The discussions described in this paper are a reflection of the focus group study and pilot tests that were conducted in order to develop the Patient Scale of the POSAS3.0. The focus groups took place in the Netherlands and Australia and included 45 participants. Pilot tests were performed with 15 participants in Australia, the Netherlands, and the United Kingdom.

RESULTS

We discussed the selection, wording and merging of 17 included items. Additionally, the reason for exclusion of 23 characteristics are given.

CONCLUSION

Based upon the unique and rich material of patient input obtained, two versions of the Patient Scale of the POSAS3.0 were developed: the Generic version, and the Linear scar version. The discussions and decisions taken during the development are informative for a good understanding of the POSAS 3.0 and are indispensable as a background for future translations and cross-cultural adaptations.

Prospective randomized controlled trial comparing the effect of Monocryl versus nylon sutures on patient- and observer-assessed outcomes following carpal tunnel surgery

Controversy remains regarding the optimal technique and suture type for wound closure after carpal tunnel surgery. Adult patients undergoing open carpal tunnel release were prospectively randomized to receive either interrupted, buried Monocryl sutures or traditional nylon horizontal mattress sutures for their wound closures. At the 2-week and 6-week postoperative visits, Patient and Observer Scar Assessment Scale questionnaires were completed. At 2 weeks, patients and observers had a significantly better opinion of incisions closed with Monocryl. By 6 weeks, neither patients nor observers found a difference between suture types in any category. Scars of wounds closed with Monocryl did not change appreciably in appearance between 2 and 6 weeks. However, patients and observers noted significant improvement in scar appearance in the nylon group over time. Monocryl suture represents an effective method for carpal tunnel closure that leads to improved patient- and observer-reported outcome scores in the early postoperative period compared with nylon.Level of evidence: II.

Randomized controlled trial comparing cosmetic results of midline incision versus off-midline incision for specimen extraction in laparoscopic colectomy

PURPOSE

A notable advantage of laparoscopic colorectal surgery is that only a small incision at the extraction site is necessary, which is considered to be cosmetically beneficial. Meanwhile, the optimal extraction site for the resected specimen in laparoscopic colectomy is controversial in terms of cosmetic benefit. This randomized controlled trial compares midline and off-midline extraction sites in laparoscopic colectomy in patients with colon cancer, with consideration of cosmetic benefits as the primary endpoint.

METHODS

Included were patients that underwent elective laparoscopic colectomy at WMUH between October 2014 and February 2017. Patients were randomly assigned to either midline incision group or off-midline incision group. Prospectively collected data included cosmetic results (patients and observer assessment scale) and complications including incidence of incisional hernia, SSI, and pain. This trial was registered with UMIN Clinical Trials (UMIN000028943).

RESULTS

Finally, 98 patients with colorectal cancer were analyzed. No significant differences were found between the two groups in patient and observer assessment scales of cosmetic results (midline 8 ± 1.1 vs off-midline 11 ± 5.9 p = 0.16, midline 13.5 ± 6.6 vs off-midline 15 ± 11 p = 0.58, respectively) or in postoperative pain. However, incisional hernia occurred in four cases in the midline group (8%), which was significantly higher than that in the off-midline group (no cases, 0%).

CONCLUSION

There was no significant difference in terms of cosmetic benefit, the primary endpoint, between the two groups. In this study, only the extraction site location was compared; future studies will examine differences depending on the incisional direction, including the incidence of incisional hernia.

The Efficacy of Intense Pulsed Light in the Treatment of Keloids and Hypertrophic Scars

Introduction: Different therapies have been applied to keloids and hypertrophic scars. Intense pulsed light (IPL) has recently been used but the evidence is limited. This study was to evaluate the effectiveness and safety of IPL as monotherapy for keloids and hypertrophic scars. Methods: This was a before-and-after interventional study on 16 patients with 50 scars who underwent IPL. Seven scars receive one IPL session, seven received two sessions, and 36 received three sessions. Outcomes were evaluated by the Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), scar ultrasound, colorimeter for pigmentation and erythema, and side effects. Results: After the treatment, most outcomes significantly improved except that the pigmentation of the scars did not change. Scar thickness significantly reduced by nearly 10% after the first IPL session, 15% after the second session, and>20% after the third session. All side effects were mild with crust (33.3-46%), blisters (8.3-40%), and hyperpigmentation around the scar (0-14%); the pain was moderate as assessed by the patients. Conclusion: IPL is a safe and effective treatment for keloids and hypertrophic scars. More studies are required to confirm our results.

Development of the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS) 3.0: a qualitative study

PURPOSE

The Patient and Observer Scar Assessment Scale (POSAS) is widely used for measurements of scar quality. This encompasses visual, tactile and sensory characteristics of the scar. The Patient Scale of previous POSAS versions was lacking input from patients. Therefore, the aim of this study was to develop the POSAS3.0, Patient Scale with involvement of adults patients with all scar types, complying with the highest clinimetric standards.

METHODS

From February 2018 to April 2019, a series of six focus group interviews were performed in the Netherlands and Australia to identify scar quality characteristics that adults with scars consider to be important. All focus groups were transcribed, anonymized and analysed using a thematic analysis. Relevant characteristics were formulated into items, resulting in a Dutch and English version of the Patient Scale. These drafts were pilot tested in Australia, the Netherlands and the United Kingdom, and refined accordingly.

RESULTS

A total of 21 relevant scar quality characteristics were identified during the focus groups. Two distinct versions of the POSAS3.0, Patient Scale were developed. The Generic version contains 16 items and can be used for all scar types, except linear scars. The Linear Scar version of the Patient Scale contains the same 16 items, with an extra item referring to the widening of scar margins. All included items are rated on a verbal rating scale with five response options.

CONCLUSION

Two versions of the POSAS3.0 Patient Scale were developed. Further field tests are being performed to establish the measurement properties and scoring algorithm of the scales.

Long-Term Outcome Analysis and Technical Refinements after Autologous Breast Reconstruction with PAP Flap: What We Have Learnt

Introduction

The profunda artery perforator (PAP) flap represents a valuable alternative to the deep inferior epigastric artery perforator flap which, nowadays, is considered the golden standard for autologous breast reconstruction. The goal of this study was to evaluate the long-term satisfaction, functional outcomes of the donor site following PAP flap-based breast reconstruction and to present our personal learning experience along with suggestions for technique refinements.

Methods

In this prospective single-center appraisal, 18 patients who underwent PAP flap-based breast reconstruction between January 2016 and November 2019 were enrolled. The Patient and Observer Scar Assessment Scale (POSAS) and the Breast-Q questionnaire were employed to evaluate the results 12 months postoperative. Data were analyzed with the Q-Score program. Complications were recorded in the medical database and classified with the Clavien-Dindo classification.

Results

In the questionable time frame, 164 female patients underwent free flap breast reconstruction. Of those, 18 patients that received PAP flaps (9 bilateral) were included in this study. We recorded one flap loss because of venous failure. Most complications concerned the donor site, including hematoma, seroma, and wound healing problems. Patients' satisfaction was high at 12 months post-surgery, despite critical evaluation of the donor site scar.

Conclusion

The PAP flap serves as an excellent option for breast reconstruction in patients who do not have abundant abdominal tissue. The overall clinical outcome was good and patients' evaluation showed high satisfaction after 12 months despite high complication rates. Modifications in planning and flap harvesting might improve the donor site outcome and the overall complication rate.

Translation and psychometric validation of the Finnish version of the Patient Scar Assessment Scale for use in patients with burn scars

BACKGROUND

The aim of this study was to create a Finnish scar assessment scale by translating and evaluating the psychometric properties of the Patient Scar Assessment Scale (PSAS), a part of the Patient and Observer Scar Assessment Scale (POSAS), with burn patients to enable its use in burn care.

METHODS

The translation process followed international guidelines with forward and backward translations and cognitive debriefing with patients. Psychometric validation was performed with adult patients with burns who had been treated at the Helsinki Burn Centre between 2006 and 2017 with skin grafting following the excision of deep second- or third-degree burns. To ensure reproducibility, the PSAS was sent to the study participants twice. The correlation between the PSAS and health-related quality of life (HRQL) was also tested.

RESULTS

In total, 192 patients, of whom 71 % were male, participated in this study. The mean (SD) age of the participants was 57 (17) years. The internal consistency of the PSAS was good, Cronbach's α 0.89 (95 % CI: 0.86-0.91). The reproducibility was also good concerning all items and the total score, ICC from 0.77 to 0.89. As expected, the total PSAS score correlated negatively with HRQL.

CONCLUSION

The PSAS was successfully translated and culturally adapted into Finnish and the newly translated version has good validity and reproducibility for assessing mature burn scars.

Evaluation of post-tracheostomy scars and their impact on persons' quality of life: A case-control study

Tracheostomy is one of the more commonly performed procedures in critically ill patients under mechanical ventilation. Postoperative scarring is one of the bothersome sequelae of tracheostomies. Scars distort physical appearance, especially when found on the head and neck, which could have a negative impact on quality of life. The aim of this study was to evaluate and assess the impact of post-tracheostomy scars on quality of life according to the tracheostomy method. A prospective, single-center, observational, case-control study was conducted. One hundred fifty-six persons with a post-tracheostomy surgical scar for more than four months were observed using the Patient and Observer Scar Assessment Scale and Dermatology Life Quality Index questionnaire. Persons were divided into two groups depending on the method of tracheostomy, and the duration of the cannulated period was considered in both groups. Statistical analyses were performed using SPSS ver. 16.0 (SPSS Inc., Chicago, IL, USA), and P values of <0.05 were considered significant. The patients who had a tracheostomic tube cannulation period of fewer than 15 days had better cosmetic results than those who had tracheostomic tubes for more than 15 days, regardless of the tracheostomy method: 6.64 ± 0.082 versus 16.15 ± 0.096 (P < 0.001) in the surgical tracheostomy group and 7.26 ± 0.211 versus 14.17 ± 0.379 (P < 0.05) in the percutaneous dilatational group. The Dermatology Life Quality Index scores had a mean value of 0.6 ± 0.01, which means that post-tracheostomy scarring in the present study had no effect on the person's quality of life. The aesthetic outcomes of post-tracheostomy scars after the open surgical tracheostomy technique did not significantly differ from those of the percutaneous dilatational technique in the present study. Persons with a long duration of tracheostomic tube ventilation showed worse aesthetic outcomes than those with short-term tracheostomic cannulation, which was not dependent on the tracheostomy technique. The Dermatology Life Quality Index showed that post-ttracheostomy scarring in the present study had no effect on the person's quality of life.

Early Laser for Burn Scars (ELABS): protocol for a multi-centre randomised, controlled trial of both the effectiveness and cost-effectiveness of the treatment of hypertrophic burn scars with Pulsed Dye Laser and standard care compared to standard care alone [version 1; peer review: 2 approved]

This paper outlines the protocol for a study that is being carried out at multiple centres across the UK in the next three years. It is a Research for Patient Benefit (RfPB) study funded by the National Institute for Healthcare Research (NIHR). The aim is to assess the effectiveness of treating hypertrophic burns scars with pulsed dye laser (PDL) at an early stage of scar formation. The objective is to improve Quality of Life for the patient by improving both the appearance and quality of burn scarring, as well as reducing its psychological impact. This is a parallel-arm randomised, controlled trial to compare PDL and standard care against standard care alone. The difference is measured between baseline and six-month follow-up. Recruits are within three months of healing from a burn injury; with wounds showing a defined potential for hypertrophic scarring. A total of 120 patients are recruited in a multi-centre study; with randomisation in a 1:1 allocation to each arm. The treatment arm receives 3 PDL treatments at six-week intervals in addition to standard care, whereas the control arm receives standard care alone. The primary outcome is the patient-rated part of the Patient and Observer Scar Scale (POSAS). Psychological and psycho-social impact is evaluated using the CARe burn scale (UWE, Bristol) and Quality Adjusted Life Years (QALY) is determined using the Short-Form Health Survey (SF-12). The study evaluates both the cost-effectiveness through an economic analysis and the patient-reported experience of the treatment by phone interviews.

Comparative study of surgical wound closure with nylon interrupted sutures and running subcuticular vicryl rapide suture after open release of the carpal tunnel

BACKGROUND

Surgical decompression of the carpal tunnel is considered the method of choice for its treatment with satisfactory results documented. Various methods and suturing materials have been used for closure of the surgical wound. In the present study, we compared interrupted mattress closure by means of nylon suture to running subcuticular closure with vicryl rapide suture. As far as we know, there is no similar study in the literature.

METHODS

A total of twenty patients were included in the study. Ten of them had their surgical wound closed with 3.0 nylon suture in an interrupted fashion and for the rest, a running subcuticular 3.0 vicryl rapide was used. All patients filled in a questionnaire about VAS perceived pain and a Quick DASH score sheet, preoperatively, at two and six weeks postoperatively. The cosmesis of the scar was assessed using the POSAS v2.0 system at two and six weeks after surgery and overall incidence of infections was noted as well.

RESULTS

There was no statistically important difference between the two groups of patients in regards to postoperative VAS pain levels at two and six weeks. Likewise, no statistically significant difference was evident as far as Quick DASH score, POSAS score and infections were concerned.

CONCLUSIONS

Our results suggest that the use of running subcuticular vicryl rapide suture is an attractive alternative to interrupted nylon sutures for closure after open carpal tunnel decompression, lacking any significant drawbacks.

LAY SUMMARY

Surgery for carpal tunnel decompression is considered the method of choice for its treatment with documented satisfactory results. Various methods and suturing materials have been used for closure of the surgical wound. In the present study, we compared the use of a non-absorbable suture, placed intermittently to an absorbable continuous intradermal suture. A total of twenty patients were included in the study. Half of them had their wound closed with the absorbable suture and the other half with the non-absorbable suture, as described above. All patients were evaluated as far as pain, scar characteristics, functional outcomes of the operated hand and incidence of infection, at two and six weeks after surgery. After analysis of the data, no significant differences were found between the two groups, suggesting that both of these techniques are equally safe and efficacious.

Experience performing partial fistulectomy through a single incision to treat pyriform sinus fistula in children

BACKGROUND AND OBJECTIVES

The surgical treatment of pyriform sinus fistula (PSF) is improving. The aim of this study was to investigate the effect of partial fistula excision in children with PSF assisted by using methylene blue.

METHODS

According to the method used to treat PSF infection, the patients were divided into a conservative treatment group, a single incision group (the children drained the abscess through the incision at the dermatoglyph of the cricothyroid joint), and a non single incision group (the children drained the abscess through the incision in the most obvious area of the abscess or ulceration). The data were retrieved from the electronic medical records (EMRs) and hospital information system （HIS）. The patient and observer scar assessment scale (POSAS) scores at 6 months after fistula resection were compared.

RESULTS

A total of 239 patients diagnosed with PSF underwent partial resection of the fistula through cervical approach with methylene blue. The success rate of the operation was 100%. The average operation time was 32 ± 13.2 min. The average hospital stay was 1 ± 0.2 days. There were 2 cases of transient hoarseness and 6 cases of wound infection. There were 17 patients in the conservative treatment group, 81 patients in the single incision group and 145 patients in the nonsingle incision group. The average POSAS scores of the three groups were 2.56 ± 0.6, 3.12 ± 0.84 and 4.56 ± 1.56, respectively, with significant differences among the three groups (P < 0.05).

CONCLUSIONS

Partial fistulectomy assisted by using methylene blue through a single incision in the neck for the treatment of PSF in children yields a high success rate, fewer postoperative complications and greater comfort than traditional surgery. This alternative surgery can be used to treat PSF in children.

Aesthetic outcome of simple cuticular suture distance from the wound edge on the closure of linear wounds on the head and neck: A randomized evaluator blinded split-wound comparative effect trial

BACKGROUND

Little data support the optimal distance of cuticular suture placement from the wound edge to achieve the most cosmetically appealing scar.

OBJECTIVE

To compare Patient and Observer Scar Assessment Scale (POSAS) scores for cutaneous sutures spaced 2 mm versus 5 mm from the wound edge in head and neck defects repaired via linear closure.

METHODS

Fifty patients were enrolled in this randomized, evaluator blinded, split-scar study. Surgical wounds were repaired with cuticular sutures 2 mm from the wound edge on one side and 5 mm on the other. POSAS scores and scar width were compared 3 months postoperatively.

RESULTS

The sum observer POSAS score for this study had a mean (SD) of 16.06 (6.49) on the 2-mm side and 15.82 (6.83) on the 5-mm side (P = .807). Similarly, no difference was seen between scar width with a mean (SD) of 0.100 cm (0.058 cm) on the 2-mm side and with mean (SD) 0.100 cm (0.076 cm) on the 5-mm side (P = .967).

LIMITATIONS

Linear repairs were studied on head and neck defects after extirpation of cutaneous malignancies, resulting in a homogeneous elderly white patient population.

CONCLUSION

Cuticular sutures placed 2 or 5 mm from the wound edge did not result in different cosmetic outcomes in linear closures on the head and neck.

Longitudinal monitoring and prediction of long-term outcome of scar stiffness on pediatric patients

Background

Hypertrophic scarring after burn injury is one of the greatest unmet challenges in patients with burn injuries. A better understanding of the characteristics of scar maturation and early prediction of the long-term outcome of scarring are prerequisites for improving targeted therapies and pivotal for patient counselling.

Methods

Repeated measurements of scar stiffness in 11 pediatric patients were performed over the course of 1 year using 2 suction devices, the Cutometer and the Nimble. In addition, the observer pliability score of the Patient and Observer Scar Assessment Scale was applied. This longitudinal study allowed quantification of the ability of each of the measured parameters to reflect scar maturation, as indicated by change in skin pliability/stiffness, over time (using linear regression); the ability to distinguish individual patients (intraclass correlation coefficient (ICC)); the correlation of the devices (Spearman correlation coefficient); and the ability to predict long-term scar maturation based on early scar assessment (using receiver operating characteristic).

Results

All the tools used showed significant longitudinal decrease of scar stiffness from 3 months until 12 months after the injury. The Nimble (ICC_patient ^Nimble = 0.99) and the Cutometer (ICC_patient ^Cuto = 0.97) demonstrated an excellent ability to distinguish between individual patients. The Nimble seemed to be able to predict the 12-month pliability of scars based on early (3-month) measurements (area under the curve (AUC)_12m ^POSAS = 0.67; AUC_12m ^C = 0.46; AUC_12m ^N = 0.79).

Conclusions

The results of this preliminary study suggest that all 3 tools provide suitable means to quantify alterations in scar stiffness over time. Initial evidence suggests the Nimble is most favorable for predicting changes in stiffness associated with long-term scar maturation. Further studies with a larger sample size are required to validate tissue suction as a clinical tool for analysis of changes of scar stiffness over time.

Comparing the running subcuticular technique versus the Donati technique in open carpal tunnel release: a randomized controlled trial

BACKGROUND

There are various skin suture techniques for wound closure following carpal tunnel release, and well-performed suturing will result in low post-operative scar tenderness. The aim of this study was to compare the Donati suture technique and running subcuticular technique in terms of surgical scar, post-operative pain and functional outcome in open carpal tunnel release.

METHODS

One-hundred forty-two patients were randomized using a computer-generated random number table into two groups receiving either running subcuticular suturing or Donati suturing after surgical intervention. We evaluated postoperative scarring using the Patient and Observer Scar Assessment Scale (POSAS), pain intensity using a verbal numerical rating scale, and functional outcomes using the Thai version of the Boston Carpal Tunnel Questionnaire after surgical decompression for carpal tunnel syndrome at 2, 6, and 12 weeks. Continuous data are reported as mean ± SD while normally distributed or as median (interquartile range) when the distribution was skewed.

RESULTS

Lower scores at 2 weeks were given by the patients receiving the running subcuticular suture technique than the Donati suture technique (15.3 ± 4.8 vs 17 ± 4.6, respectively, P < 0.05) while the observer scores were not significantly different (15.6 ± 5.8 vs 16.7 ± 5.2, respectively, P = 0.15). At both 6 and 12 weeks post-surgical decompression both patient and observer scores were not significantly different. There were no differences between the groups in terms of VNRS pain scores and functional Boston Carpal Tunnel Scores at all time points.

CONCLUSIONS

This randomized controlled trial found that although scarring assessments were slightly better in the earliest period following wound closure after surgical decompression in carpal tunnel syndrome using the running subcuticular suture, the final results at 3 months postoperative were not significantly different.

TRIAL REGISTRATION

The study was registered at https://www.thaiclinicaltrials.org/ (TCTR20191204002).

Surgical wounds in reduction mammoplasty: a comparison of Monocryl and Prolene sutures on scars

OBJECTIVE

The type of suture material affects the quality of scars. The aim of this study was to find the superior suture material for reduction mammoplasty between Prolene and Monocryl based on the comparison of scars.

METHOD

A prospective observational study was conducted at a university-based hospital in Mashhad, Iran between October 2015 and September 2017. Monocryl and Prolene suture materials, used for closing the outermost layer in mammoplasty, were compared. Patients' incision scars were assessed objectively according to the Patient and Observer Scar Assessment (POSAS) criteria. The relevant CONSORT guideline was used for reporting this study.

RESULTS

Seventy-eight women with a mean age of 36.8±9.5 years were entered into the study. The frequency of wound healing in both groups was 97.4% 1 month after surgery and by the third visit, 3 months after surgery, only one patient had a stretched scar. Moreover, wound inflammation in the first two visits was less frequent in the Prolene group that healed completely 3 months after surgery (after excluding the one patient with wide scar inflammation). The frequency of itching of the wound in the Monocryl group was 24.4%, 11.5% and 12.8% in the three follow-up visits, respectively, and the values for the Prolene group were 24.4%, 9.0% and 6.4%, respectively. No significant difference was seen between the two groups in terms of wound healing, inflammation and itching (p>0.05). Overall, 94.8% of patients were satisfied with the surgery.

CONCLUSIONS

Our study revealed that there was no significant difference between Monocryl and Prolene. Hence, either of the two suture materials can be used for wound closure in reduction mammoplasty.

Treatment of Keloids Using Plasma Skin Regeneration Combined with Radiation Therapy Under the Evaluation of Patient and Observer Scar Assessment Scale

Purpose

Keloids are caused by uncontrolled excessive proliferation of fibrous tissue. Multiple treatment strategies including steroid injection, surgical excision, laser therapy and radiation therapy have been reported. Few studies have evaluated the performance of plasma skin regeneration (PSR) in the treatment of keloid. This study aimed to evaluate the effectiveness of PSR combined with radiation therapy for keloids on different body parts.

Patients and Methods

A total of 71 patients with 98 keloids were enrolled in this study. Keloids <4 mm thick underwent single-dose PSR, while keloids ≥4 mm thick were administered compound betamethasone injection beforehand. Radiation therapy was administered after 24 hours and again 7 days later after PSR. The outcome was evaluated using the patient and observer scar assessment scale at 12 months post-treatment.

Results

Patient-reported average scores for all keloids significantly decreased from 35.05±9.94 to 21.84±7.04 (p < 0.05). Keloids on face and neck, chest, and back responded better than those on shoulders and limbs. The recurrence rate was observed to be 15.3% (15 out of 98). Adverse effects were mild.

Conclusion

PSR combined with radiation therapy is an effective and safe strategy to treat keloids. Location could be a factor that affects curative effects.

The impact of closed incisional negative pressure therapy on anterior lateral thigh flap donor site healing and scarring: A retrospective case-control study

BACKGROUND

The objective of this study was to investigate whether closed incisional negative pressure therapy (cINPT) is suitable to improve anterior lateral thigh (ALT) flap donor site healing and scarring.

METHODS

We identified 271 ALT free flaps of widths between 7 and 9 cm and primary donor site closure performed between January 2012 to December 2019. Patients were divided into cases of cINPT versus controls without cINPT as part of this retrospective case-control review. We compared the incidences of postoperative donor site complications (wound dehiscence, infection, seroma, hematoma) and the degree of scarring severity using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scales (POSAS).

RESULTS

A total of 106 ALT donor sites received cINPT (39%), whereas the remaining 165 donor sites received conventional dressings (61%). The distribution of gender, age, body mass index, comorbidities, and mean flap sizes were comparable between both groups. The occurrence of surgical wound dehiscence was significantly lower in the cINPT group (2.8%), when compared to controls (9.0%) (p = 0.04). Furthermore, the mean length of postoperative hospital stay was significantly shorter in the cINPT group (19 ± 8 days versus 21 ± 11 days; p = 0.03). CINPT was associated with a more favorable donor site scar quality when assessed by VSS (p = 0.03) and POSAS (p = 0.002).

CONCLUSION

The use of cINPT was associated with significantly less ALT donor site complications and superior scar quality accelerating patients' postoperative recovery.

A clinical comparison of pure knitted silk and a complex synthetic skin substitute for the treatment of partial thickness burns

Currently, many dressings are commercially available for the treatment of burn wounds. Some of these wound dressings remain on the wound, prevent painful dressing changes, and reduce tissue scarring. Nevertheless, still a wound dressing that is cost-effective, produces good wound healing properties, and has a high patient satisfaction is needed. Standard care of superficial burn wounds differs between burn centres. This study aimed to determine a dressing with easy appliance, accurate pain control, favourable outcome, and cost-effectiveness. Therefore, we compared the widely used but expensive Suprathel with the rather new but much cheaper Dressilk in the clinical setting. In a prospective clinical study, the healing of partial thickness burn wounds after simultaneous treatment with Suprathel and Dressilk was examined in 20 patients intra-individually. During wound healing, pain, infection, exudation, and bleeding were evaluated. A subjective scar evaluation was performed using the Patient and Observer Scar Scale. Both dressings were easy to apply, remained on the wound in place, and were gradually cut back as reepithelisation proceeded and showed similar times to wound closure. Dressing changes were not necessary, and neither infections nor bleeding was detected. Overall exudation and pain were highest in the beginning but declined during the wound-healing phase without significant differences. In the follow-up scar evaluation after 12 months, patients reported overall high satisfaction. Overall, the modern dressings Suprathel and Dressilk (solely made out of pure silk) led to safe wound healing without infection and rapidly reduced pain. There was no need for dressing changes, and they had similar clinical outcomes in scar evaluation. Therefore, both dressings seem to be ideal for the treatment of superficial burns. Because acquisition costs remain one of the main factors in the treatment of burns, Dressilk, which is ~20 times cheaper than Suprathel, remains a good option for the treatment of partial thickness burns.

Patient-reported scar quality of donor-sites following split-skin grafting in burn patients: Long-term results of a prospective cohort study

BACKGROUND

Skin grafting is the current gold standard for treatment of deeper burns. How patients appraise the donor-site scar is poorly investigated. The aim of this study was to evaluate long-term patient-reported quality of donor-site scars after split skin grafting and identify possible predictors.

METHODS

A prospective cohort study was conducted. Patients were included in a Dutch burn centre during one year. Patient-reported quality of donor-site scars and their worst burn scar was assessed at 12 months using the Patient and Observer Scar Assessment Scale (POSAS). Mixed model analyses were used to identify predictors of scar quality.

RESULTS

This study included 115 donor-site scars of 72 patients with a mean TBSA burned of 11.2%. The vast majority of the donor-site scars (84.4%) were rated as having at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and the overall opinion on 80.9% of the donor-site scars was that they deviated from normal skin 12 months after surgery. The overall opinion on the donor-site scar was 3.2 ± 2.1 vs. 5.1 ± 2.4 on the burn scar. A younger age, female gender, a darker skin type, and location on the lower leg were predictors of reduced donor-site scar quality. In addition, time to re-epithelization was associated with scar quality.

CONCLUSION

This study provided new insights in long-term scar quality of donor-sites. Donor-site scars differed from normal skin in a large part of the population 12 months after surgery. Results of this study can be used to inform patients on the long-term outcomes of their scars and to tailor preventive or therapeutic treatment options.

A Comparative Study on the Efficacy of Fractional CO2 Laser and Fractional CO2 Laser with Autologous Platelet-Rich Plasma in Scars

Context

Surgical correction of scars may not be an ideal solution in all cases and hence it is desirable to have a nonsurgical option available. Autologous platelet-rich plasma (PRP) and fractional carbon dioxide laser (FCL) offer an alternative treatment modality.

Aims

To compare the efficacy and safety of FCL and intradermal PRP with FCL in the management of postburn and posttraumatic scars.

Settings and Design

A prospective, randomized, observer-blinded, comparative study was conducted at a hospital skin centre from Oct 2016 to Sep 2018.

Subjects and Methods

A total of 67 patients with scars were randomly divided into two groups; Group I was treated with four sessions of monthly FCL and Group II was treated with four sessions of PRP and FCL. The patients were assessed using the Patient and Observer Scar Assessment Scale (POSAS) at baseline and 4 weeks after each session.

Statistical Analysis Used

For continuous variables, the summary statistics of mean ± standard deviation was used; for categorical data, number and percentage were used. Chi-square (χ2) test was used for association between two categorical variables. P value <0.05 was considered to be statistically significant.

Results

Thirty cases in each group completed the study. There was a significant improvement in the total score of POSAS (p < 0.001) in both groups, but the final difference between the two groups was not statistically significant (p = 0.793 and P = 0.278, respectively).

Conclusions

Fractional CO2 laser causes significant improvement in scar appearance. PRP in combination with FCL offers no additional advantage.

Exploring the relation between the EQ-5D-5L pain/discomfort and pain and itching in a sample of burn patients

BACKGROUND

The EQ-5D domain pain/discomfort (PD) uses one item to capture pain and other aspects of discomfort, like itching. This study explored how pain, itching and the EQ-5D-5L PD domain relate to each other in a sample of burn patients.

METHODS

Adult burn patients completed the EQ-5D-5L and the Patient and Observer Scar Assessment Scale (POSAS) 5-7 years after sustaining their injury. The POSAS includes a separate pain and an itching item. Spearman's correlation coefficient established the association between the EQ-5D-5L PD and the POSAS pain and itching item. With multivariable regression analysis the linear association between the POSAS pain and itching item and EQ-5D-5L PD domain was tested.

RESULTS

Data from 245 patients were included. Mean EQ-5D-5L index value was 0.87 and 39.2% reported at least slight problems on the EQ-5D-5L PD domain. Most patients gave corresponding answers on the EQ-5D-5L PD domain and on the POSAS pain (73%) and itching (70%) item. Spearman correlation coefficients of the EQ-5D-5L PD domain with the POSAS pain and itching were 0.468 (p < 0.001) and 0.473 (p < 0.001), respectively. Among respondents with pain and without itching and respondents with itching and without pain, Spearman correlation coefficients were 0.585 (p = 0.076) and 0.408 (p = 0.001), respectively. POSAS pain (unstandardized Beta = 0.14) and POSAS itching (unstandardized Beta = 0.08) were significantly associated with EQ-5D-5L PD domain (p < 0.001).

CONCLUSIONS

Our findings indicate that, in a sample of burn patients, pain and itching are captured by the broader EQ-5D-5L PD domain. The EQ-5D-5L PD domain can thus be used to assess pain and itching in relation to HRQL, but the POSAS pain and itching items are more sensitive. The EQ-5D-5L is, however, no replacement of the POSAS when the POSAS is used for its primary aim; assessment of scar quality.

TRIAL REGISTRATION

Netherlands Trial Register (NTR6407).

Burn scar outcome at six and 12 months after injury in children with partial thickness scalds: Effects of dressing treatment

INTRODUCTION

In line with other researchers in the field of burns' care, we think that research investigating the long-term outcome of scars is largely lacking. As scarring is of the utmost importance to the patient, clinicians who treat burns must aim to find treatments that lead to a good end result. The aim of this study was to study scar outcomes at six and 12 months after injury. It is an extension of a previous randomised controlled trial (RCT) in which two dressings (porcine xenograft and silver foam dressing) were examined with respect to their ability to help heal partial thickness scalds.

METHOD

Children aged six months - six years with acute partial thickness scalds, on the trunk, or extremities, or both, were included. In the previous study, the silver foam was found to have significantly shorter healing times than the xenograft. Children were assessed at six and 12 months after injury for this study, and photographs were taken of the burn site, and both the patient and observer scar assessment scale (POSAS) and the Vancouver scar scale (VSS) were completed and evaluated by blinded observers.

RESULTS

Of the 58 children from the original RCT, 39 returned to the clinic for evaluation of their scars at six months, and 34 at 12 months after injury. There were no differences in POSAS, VSS total scores, or incidence of hypertrophic scarring between the different dressings. Fifteen children were assessed as having hypertrophic scarring, all of whom had healing times that had extended beyond 14 days.

CONCLUSIONS

This study compared burn scarring after two different treatments for burns in children with partial-thickness scalds and the data suggested that neither dressing had a more favourable impact on scar outcome. The conclusion is, however, tempered by the non-return of all the patients to the follow up. However, as anticipated, regardless of the dressing used, longer healing times were associated with higher scar scores (more scarring) and hypertrophic scarring.

A Prospective Controlled Study on Long-Term Outcomes of Facial Lacerations in Children

Background: Although skin adhesives have been used for decades to treat skin lacerations, uncertainty remains about long-term results, and complications. Methods: In this prospective, controlled, single-blinded, observational cohort study, outcomes were assessed by five plastic surgeons with standardized photographs at 6-12 months using a modified Patient and Observer Scar Assessment Scale (POSAS) and Vancouver Scar Scale (VSS); additionally, the POSAS was performed by the patients/caregivers and the physician; pain, requirement of anesthesia, treatment time, costs, complications, and quality of live (QoL) were assessed. Results: A total of 367 patients were enrolled; 230 were included in the main analysis; 96 wounds were closed using tissue adhesives (group 1); 134 were sutured (group 2). Assessment by the independent observers revealed an improved mean modified overall POSAS score in group 1 in comparison with group 2 [2.1, 95% CI [1.97-2.25] vs. 2.5, 95% CI [2.39-2.63]; p < 0.001, d = 0.58] and mean VSS score [1.2, 95% CI [0.981-1.34] vs. 1.6, 95% CI [1.49-1.79], p < 0.001, d = 0.53]. At the early follow-up, dehiscence rate was 12.5% in group 1 and 3.7% in group 2 (p < 0.001); later on, one dehiscence remained per group. Mild impairment of QoL was found at the early follow-up in both groups, with no impairment remaining later on. Duration of treatment and treatment costs were lower in group 1. Conclusion: Both modalities of wound closure yield favorable esthetic results, and complications are rare. Adhesives are more cost-effective, and its application is less time-consuming; therefore, tissue adhesives offer considerable advantages when used appropriately. Trial Registration: Public trial registration was performed at www.ClinicalTrials.gov (Identifier: NCT03080467).

Patterns and predictors of burn scar outcome in the first 12 months after burn: The patient's perspective

OBJECTIVE

This study aimed to provide insight into the patterns and factors that predict burn scar outcomes at 3, 6 and 12 months after burn.

METHODS

The Patient and Observer Scar Assessment Scale (POSAS) was used to assess the scar formation of each patient. Structural equation modelling was used. The predictor variables used in this study were sex, three age categories, TBSA, depth of the wound and cause of the burn.

RESULTS

The POSAS patient total and individual item scores demonstrated a statistically significant decrease in the first 12 months after burn, except for the relief item. Male patients had a lower total and items scores (better scar quality) for pain and pruritus compared with female patients. Full thickness burns had a higher scores for pruritus, pliability, thickness and relief compared to the partial-thickness burns. Ages younger than 5 years, higher TBSA values and flame burns were predictors of various POSAS items at 3 and 6 months after burn.

CONCLUSION

The POSAS patient total and individual item scores demonstrated a statistically significant improvement in the scar quality in the first 12 months after burn, except for the relief. Sex, age, depth of the wound, the percentage of TBSA and flame burns were predictors of various POSAS patient items at 3, 6 and 12 months after burn.

Transabdominal ultrasound: Can it be used to detect and quantify adhesions/reported pain, following Caesarean section?

BACKGROUND

Caesarean section is common in the UK with post-procedural adhesions causing life-long clinical symptoms and impacting future pregnancies. This study's aim was to explore associations between these surgical adhesions, via transabdominal ultrasound findings, and perceived symptoms.

METHOD

Females demonstrating 1-3 transverse, lower-segment Caesareans were included. Visceral slide transabdominal ultrasound elicited positive adhesions (<1 cm movement) and negative adhesions (>1 cm movement). Scar tissue quality was assessed by the Patient and Observer Scar Assessment Scale (POSAS) and Numerical rating scales (NRS) described pain symptoms. The relationship between adhesions was explored using Fisher's exact test and multiple regression analysis.

RESULTS

Twenty-two subjects (mean-age 35) were recruited; twenty participants (91%) had undergone 1 Caesarean, one each of the remainder had undergone 2 and 3 Caesareans respectively. Increased Visceral slide (>1 cm) was seen as predictive of increased scar pain (R² = 0.76 (95% CI 0.12-0.28), P < 0.001).

CONCLUSION

Caesarean adhesion scans showed significant associations with pain symptomology. Comprehensive adhesion assessment needs to be developed to improve long term outcomes of adhesions. Transabdominal Ultrasound can be considered a useful, quick and non-deleterious alternative diagnostic tool to Laparoscopy, therefore preventing further adhesion formation.

Randomized Controlled Study Comparing Disposable Negative-Pressure Wound Therapy with Standard Care in Bilateral Breast Reduction Mammoplasty Evaluating Surgical Site Complications and Scar Quality

BACKGROUND

Negative pressure wound therapy (NPWT) for postsurgical incision treatment has demonstrated benefits. A prospective randomized study was developed including 32 patients who underwent bilateral breast reduction mammoplasty. Patients served as their own control and received NPWT to one breast and fixation strips to the other breast.

METHODS

The primary outcome was the number of wound healing complications within 21 days when comparing NPWT treatment with fixation strips. The secondary outcome was aesthetic appearance and quality of scarring using questionnaires [visual analogue scale (VAS) and Patient and Observer Scar Assessment Scale (POSAS)] scored at day 42-, 90-, 180- and 365-day follow-up using additional scar measurement modalities, such as viscoelasticity.

RESULTS

For the 32 included patients, the number of wound complications was significantly lower (p < 0.004) for the NPWT treated sites compared to fixation strips. POSAS and VAS scores at 42 and 90 days revealed a significantly better quality of scarring in the NPWT treatment breasts than in fixation strips. At 180-day follow-up, there was a significant improvement in total VAS scores, as well as a comparable improvement in POSAS scores. No consistent significant improvement in scar quality was demonstrated with the assays that were used.

CONCLUSIONS

Our study showed less complications and a significant improvement in quality of scarring in favor of the NPWT-treated sites. The results indicate NPWT to be an attractive option for these patients.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Aesthetic principles access thyroidectomy produces the best cosmetic outcomes as assessed using the patient and observer scar assessment scale

Background

Thyroid carcinoma (TC) is more likely to occur in young women. The aim of this study was to compare the aesthetic effect of different thyroidectomies.

Methods

One hundred twenty female patients who underwent thyroidectomy were evenly distributed into three groups: conventional access (CA), aesthetic principles access (APA) and minimally invasive access (MIA). The Patient and Observer Scar Assessment Scale (POSAS) was used as the assessment tool for the linear scar.

Results

The patients in the MIA group showed significantly less intraoperative blood loss, less drainage, a shorter scar length and a shorter duration of drainage than those in the CA group and the APA group. However, the operation time of 129.0 min in the MIA group was significantly longer than the 79.6 min in the CA group and the 77.0 min in the APA group. The best aesthetic score, as assessed by the Observer Scar Assessment Scale (OSAS), was obtained in the APA group. The Patient Scar Assessment Scale (PSAS) scores were significantly lower in the APA group and CA group than in the MIA group. Significantly lower objective scar ratings were found in the APA group than in the other two groups.

Conclusion

These results show that APA produced the best surgical outcomes in TC patients, indicating that conventional thyroidectomy can produce an ideal aesthetic result using the principles of aesthetic surgery. Thyroid surgery need not be performed through excessively short incisions for the sake of patient satisfaction with the scar’s appearance.

Trial registration

This clinical trial was retrospectively registered on ClinicalTrials.gov PRS on August 1st,2017 (NCT03239769).

Fractional CO2 laser treatment of caesarean section scars-A randomized controlled split-scar trial with long term follow-up assessment

BACKGROUND AND OBJECTIVES

Caesarean section (c-section) scars can be pose functional and cosmetic challenges and ablative fractional laser (AFXL) treatment may offer benefit to patients. We evaluated textural and color changes over time in AFXL-treated versus untreated control scars.

MATERIALS AND METHODS

A randomized, controlled, intra-individual split-scar trial with three sessions of AFXL-treatments for mature c-section scars. Settings of AFXL were adjusted to each individual scar. End-points were blinded on-site clinical evaluations at 1, 3, and 6 months follow-up (Patient and Observer Scar Assessment Scale [POSAS] and Vancouver Scar Scale [VSS]), blinded photo-evaluations, reflectance measurements, tissue histology, and patients satisfaction.

RESULTS

Eleven of 12 patients completed the study. At 1 month follow-up, AFXL-treated scars were significantly improved in pliability (POSAS P = 0.01 VSS P = 0.02) and smoother in surface relief (POSAS P = 0.03) compared to control scars. At 1-3 months, overall scar appearance was dominated by transient erythema and hyperpigmentation, confirmed by reflectance measurements (erythema% and pigmentation% peaked at 1 and 3 month follow-up, respectively). At 6 months follow-up, AFXL-treated scars improved on POSAS-total score though not significantly (P = 0.06). Correspondingly, blinded photo-evaluation found AFXL-treated scars significantly improved compared to controls (VAS P = 0.02). Histology indicated new dermal collagen and elastic fibers on AFXL-treated scars. At 6 months follow-up, a majority of patients (64%) favored subsequent AFXL-treatment of their untreated control scar tissue.

CONCLUSIONS

Scar remodeling is initiated 1 month after AFXL treatment, but overall scar improvement is concealed until laser-induced color changes resolve. At 6 months follow-up, the benefit of AFXL treatment on c-section scars emerges. Lasers Surg. Med. 49:189-197, 2017. © 2016 Wiley Periodicals, Inc.

Patient opinion of scarring is multidimensional: An investigation of the POSAS with confirmatory factor analysis

INTRODUCTION

Scarring is a significant consequence for patients following a burn. Understanding how patients perceive the physiological scar and define scar severity may provide valuable information regarding how the scar influences quality of life after burn. The Patient and Observer Scar Assessment Scale was the first scar assessment tool validated to include the patients' evaluation of the scars physical qualities, following a burn. Validation studies of this tool have previously been conducted for a discrete scar-site after burn. The aim of this study was to assess the structural validity of the POSAS to capture the patients' evaluation of the total area of burn scar(s).

METHOD

Statistical analysis was based on 508 completed POSAS forms from 358 patients. Exploratory factor analysis (EFA) was used initially to identify the number of factors within the tool, then confirmatory factor analysis (CFA) using structural equation modelling explored areas of misfit within each factor and whether the model provided a predicable structure to capture patient perception of scar severity.

RESULTS/DISCUSSION

The CFA analysis confirmed that a two dimensional model was superior to a unidimensional model when assessing the patient opinion of their total burn scar. The two dimensions were the physical scar (color, stiffness, thickness and irregularity) and the sensory scar (pain and itch). Further strain analysis of the two factor model identified additional domains. Independent factors influenced the perception of color forming a separate subdomain within the physical domain. Color is a visual characteristic, whereas the other three are predominantly tactile characteristics. A significant relationship between thickness and irregularity suggested they may form another subdomain, however further research is required to confirm this. Both pain and itch were recognized as independent, multidimensional latent variables, which require assessment tools with multidimensional structures.

CONCLUSIONS

When assessing the entire burn scar, three independent dimensions influence patient perception: (1) the physical scar, (2) pain and (3) itch. Within the physical domain, color formed a visual subdomain separate to a tactile subdomain. Further development of these domains within a high-order multi-dimensional structure is recommended.

Impact of facial burns: relationship between depressive symptoms, self-esteem and scar severity

OBJECTIVE

This study assessed the role of self-reported facial scar severity as a possible influencing factor on self-esteem and depressive symptoms in patients with facial burns.

METHOD

A prospective multicentre cohort study with a 6 months follow-up was conducted including 132 patients with facial burns. Patients completed the Patient and Observer Scar Assessment Scale, the Rosenberg Self-esteem Scale and the Hospital Anxiety and Depression Scale. Structural Equation Modeling was used to assess the relations between depressive symptoms, self-esteem and scar severity.

RESULTS

The model showed that patient-rated facial scar severity was not predictive for self-esteem and depressive symptoms six months post-burn. There was, however, a significant relationship between early depressive symptoms and both patient-rated facial scar severity and subsequent self-esteem. The variables in the model accounted for 37% of the variance in depressive symptoms six months post-burn and the model provided a moderately well-fitting representation of the data.

CONCLUSION

The study suggests that self-esteem and depressive symptoms were not affected by self-reported facial scar severity but that earlier depressive symptoms were indicative for a more severe self-reported facial scar rating. Therefore, routine psychological screening during hospitalisation is recommended in order to identify patients at risk and to optimise their treatment.

Patient reported facial scar assessment: directions for the professional

BACKGROUND

The face is central to our identity and provides our most expressive means of communication. Currently, the role of facial scarring in relation to self-esteem is unclear and the value of self-reported scar assessment is insufficiently understood. The aim of this study was twofold: (1) to assess the extent of agreement between patients' ratings and observers' ratings of facial scar characteristics; and (2) to examine if patients' and observers' scar characteristics ratings, or the differences, are associated with the patients' self-esteem.

METHODS

A prospective study was conducted including patients with facial burns. Patients completed the Patient and Observer Scar Assessment Scale (POSAS) and the Rosenberg Self-Esteem Scale 3 months post-burn.

RESULTS

Ninety-four subjects were included, 76 (81%) men and mean percentage TBSA burned was 12.4 (SD 10.4; range 1-50). Subject's and observer's assessment were significantly positively correlated and were identical in 53% of the cases. Subjects' assessments and discrepancy scores on the scar characteristic surface roughness were associated with self-esteem in multiple regression analysis.

CONCLUSIONS

The majority of the patients scored the quality of facial scars in a similar way as the professionals. Furthermore, facial scarring appeared only moderately associated with self-esteem. However, our study suggests that using both patients' and professionals' scar assessments provides more useful information regarding the patients' well-being relative to focussing on the separate assessments only. In particular a discrepancy between the patients' and professionals' view on surface roughness might be an early indication of psychological difficulties and a call for further clinical attention.