Pressure-garment therapy for preventing hypertrophic scarring after burn injury

BACKGROUND

Burn damage to skin often results in scarring; however in some individuals the failure of normal wound-healing processes results in excessive scar tissue formation, termed 'hypertrophic scarring'. The most commonly used method for the prevention and treatment of hypertrophic scarring is pressure-garment therapy (PGT). PGT is considered standard care globally; however, there is continued uncertainty around its effectiveness.

OBJECTIVES

To evaluate the benefits and harms of pressure-garment therapy for the prevention of hypertrophic scarring after burn injury.

SEARCH METHODS

We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, two other databases, and two trials registers on 8 June 2023 with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing PGT (alone or in combination with other scar-management therapies) with scar management therapies not including PGT, or comparing different PGT pressures or different types of PGT.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials for inclusion using predetermined inclusion criteria, extracted data, and assessed risk of bias using the Cochrane RoB 1 tool. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 15 studies in this review (1179 participants), 14 of which (1057 participants) presented useable data. The sample size of included studies ranged from 17 to 159 participants. Most studies included both adults and children. Eight studies compared a pressure garment (with or without another scar management therapy) with scar management therapy alone, five studies compared the same pressure garment at a higher pressure versus a lower pressure, and two studies compared two different types of pressure garments. Studies used a variety of pressure garments (e.g. in-house manufactured or a commercial brand). Types of scar management therapies included were lanolin massage, topical silicone gel, silicone sheet/dressing, and heparin sodium ointment. Meta-analysis was not possible as there was significant clinical and methodological heterogeneity between studies. Main outcome measures were scar improvement assessed using the Vancouver Scar Scale (VSS) or the Patient and Observer Scar Assessment Scale (POSAS) (or both), pain, pruritus, quality of life, adverse events, and adherence to therapy. Studies additionally reported a further 14 outcomes, mostly individual scar parameters, some of which contributed to global scores on the VSS or POSAS. The amount of evidence for each individual outcome was limited. Most studies had a short follow-up, which may have affected results as the full effect of any therapy on scar healing may not be seen until around 18 months. PGT versus no treatment/lanolin We included five studies (378 participants). The evidence is very uncertain on whether PGT improves scars as assessed by the VSS compared with no treatment/lanolin. The evidence is also very uncertain for pain, pruritus, adverse events, and adherence. No study used the POSAS or assessed quality of life. One additional study (122 participants) did not report useable data. PGT versus silicone We included three studies (359 participants). The evidence is very uncertain on the effect of PGT compared with silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, adherence, and other scar parameters. It is possible that silicone may result in fewer adverse events or better adherence compared with PGT but this was also based on very low-certainty evidence. PGT plus silicone versus no treatment/lanolin We included two studies (200 participants). The evidence is very uncertain on whether PGT plus silicone improves scars as assessed by the VSS compared with no treatment/lanolin. The evidence is also very uncertain for pain, pruritus, and adverse events. No study used the POSAS or assessed quality of life or adherence. PGT plus silicone versus silicone We included three studies (359 participants). The evidence is very uncertain on the effect of PGT plus silicone compared with silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, and adherence. PGT plus scar management therapy including silicone versus scar management therapy including silicone We included one study (88 participants). The evidence is very uncertain on the effect of PGT plus scar management therapy including silicone versus scar management therapy including silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, and adherence. High-pressure versus low-pressure garments We included five studies (262 participants). The evidence is very uncertain on the effect of high pressure versus low pressure PGT on adverse events and adherence. No study used the VSS or the POSAS or assessed pain, pruritus, or quality of life. Different types of PGT (Caroskin Tricot + an adhesive silicone gel sheet versus Gecko Nanoplast (silicone gel bandage)) We included one study (60 participants). The evidence is very uncertain on the effect of Caroskin Tricot versus Gecko Nanoplast on the POSAS, pain, pruritus, and adverse events. The study did not use the VSS or assess quality of life or adherence. Different types of pressure garments (Jobst versus Tubigrip) We included one study (110 participants). The evidence is very uncertain on the adherence to either Jobst or Tubigrip. This study did not report any other outcomes.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend using either PGT or an alternative for preventing hypertrophic scarring after burn injury. PGT is already commonly used in practice and it is possible that continuing to do so may provide some benefit to some people. However, until more evidence becomes available, it may be appropriate to allow patient preference to guide therapy.

Micro-plasma radiofrequency and silicone gel dressings for treating early post-traumatic facial scars: A retrospective study

BACKGROUND

Although different options are available for treating post-traumatic facial scars, they remain a therapeutic challenge.

AIM

To evaluate the safety and effectiveness of combined therapy using micro-plasma radiofrequency (MPRF) technology and silicone gel (SG) dressings for treating post-traumatic facial scars.

METHODS

This retrospective study was conducted at a single center. Patients with facial injuries in the outpatient and emergency units of the Department of Plastic Surgery at our hospital underwent debridement and cosmetic sutures performed by the same surgeon from October 2020 to October 2021. In the first arm, patients with facial injuries were treated with MPRF technology and SG, and in the second arm, they were treated with SG dressings alone. We observed the safety and effectiveness of these treatments in both arms.

RESULTS

A total of 32 patients with facial injuries were treated with MPRF technology and SG dressings (combined treatment group), and 28 patients were treated with SG dressings alone (SG group). After 6 months of treatment, the Vancouver Scar Scale scores of the combined treatment and SG groups were 1.38 ± 0.71 and 4.39 ± 0.50, respectively, and the difference was statistically significant (P < 0.01). After 6 months of treatment, the effectiveness rate in the combined treatment group was 93.8%, which was significantly higher than that in the SG group (67.9%), and the difference between the two groups was statistically significant (P < 0.05). No obvious adverse reactions occurred in the two arms.

CONCLUSION

Treating early post-traumatic facial scars with combined MPRF technology and SG is significantly better than treating them with SG alone; moreover, the combined therapy is safe and effective.

Stem Cell-Enriched Hybrid Breast Reconstruction Reduces Risk for Capsular Contracture in a Hybrid Breast Model

BACKGROUND

Hybrid breast reconstruction (HBR) combines silicone implants with fat grafting to improve implant coverage, treating local tissue deficiencies and leading to a more natural breast appearance. Recent data also indicated less capsular contracture after HBR. The authors developed a novel technique and animal model of cell-assisted (CA) HBR to illuminate its effects on capsular contracture.

METHODS

Animals received silicone implants in a dorsal submuscular pocket. Although animals of the HBR group received fat grafting around the implant without stem cell enrichment, rats of the CA-HBR1 and the CA-HBR2 groups received stem cell-enriched fat grafting with 2 × 10 6 and 4 × 10 6 adipose-derived stem cells immediately after implant insertion. On day 60, animals underwent sonography and elastography imaging and were euthanized, and outcome analysis was performed by means of histology, immunohistochemistry, chemical collagen quantification, and gene expression analysis.

RESULTS

With this novel technique, long-term survival of adipose-derived stem cells within the implant pocket was demonstrated after 60 days after implant insertion. CA-HBR led to significantly reduced thickness and collagen density of capsular contractures. In addition, CA-HBR resulted in reduced fibrotic responses with less occurrence of collagen type I and transforming growth factor-β in capsule tissue. Moreover, the addition of stem cells suppressed fibrotic and inflammatory responses on a genetic level with significant underexpression of collagen type I and transforming growth factor-β1.

CONCLUSIONS

With this new technique and animal model, the authors observed a preventive effect on capsular contracture substantiating the basis of clinical outcomes of HBR. The authors propose that the addition of stem cells to HBR might booster its beneficial results.

CLINICAL RELEVANCE STATEMENT

Stem cell-enriched fat grafting around silicone implants may reduce the risk for capsular contracture after silicone breast implantation. While fat grafting alone already shows beneficial effects, the addition of stem cells to the fat graft can potentiate this effect.

A systematic review of the management of postoperative scars with silicone gel-based products in randomized controlled trials

Although postoperative scarring may be considered a cosmetic concern, it can greatly impact a patient's quality of life. This extends beyond psychosocial burden influenced by hypertrophic scars and keloids, as patients also experience discomfort and pain. This systematic review evaluates the efficacy of silicone gel (SG)-based products in preventing postoperative abnormal scar formation. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a PubMed search was performed to find randomized, controlled trials investigating the effect of SG-based products on postoperative wound healing. The search yielded 359 publications, but only 30 studies published between 1991-2022 were found to fit the inclusion criteria. Outcomes were extracted from the literature and subsequent quality and risk of bias assessments were performed. Most studies indicated improvement of at least one quality of the scar with the use of SG-based products. The greatest potential variable increasing bias was an inadequate control group. Studies also suffered from small sample sizes, use of unvalidated scar assessment scales, lack of double-blinding, and short follow-up periods. Overall, SG-based products demonstrated potential in preventing abnormal scar formation during postoperative healing, but further studies are required to validate the results of current literature.

Comparison of LeniScar Silicone Stick (AnsCare) With Traditional Silicone Gel (Dermatix Ultra) in Wound Scar Prevention and Removal

BACKGROUND

As we all know, the numbers of aesthetic surgery are increasing around the world. After the surgery, the scar would be a problematic issue for both the surgeons and the patients. Silicone has proven to be effective for keloids, hypertrophic scars, and prevention of scar formation in many literatures for a long time. In terms of scar prevention, silicone has been used in the form of silicone sheets in early times, which is later improved to be the form of silicone gel with the advantage of easier usage. Although silicone gel has improved greatly in the aspect of appearance and convenience of the silicone sheets, there are still some disadvantages of the gel form. Therefore, the LeniScar silicone stick (AnsCare) is invented.

OBJECTIVE

This article aimed to compare the results of scar treatment and prevention of the AnsCare LeniScar Silicone Stick versus the traditional silicone gel (Dermatix Ultra).

METHODS

This study was a prospective, nonblinded, randomized clinical study. There were a total of 68 patients from September 2018 to January 2020. Patients were divided into 2 groups with AnsCare (n = 43) and Dermatix (n = 25), who both were required to schedule regular outpatient clinic follow-up, and photographs were taken before use, 1, 2, and 3 months later after the usage for the record. The physician assessed the scar condition by the Vancouver Scar Scale (VSS). The scores of the VSS were further analyzed and compared.

RESULTS

The overall P value of total score of VSS was 0.635, which indicates that there is no significant difference in using AnsCare LeniScar Silicone Stick versus Dermatix Ultra silicone gel in terms of scar prevention and treatment. Individual items of VSS such as pliability, height, vascularity, and pigmentation all show no significant statistical difference in the 2 treatment products, with P = 0.980, 0.778, 0.528, and 0.366, respectively.

CONCLUSION

Traditional Dermatix Ultra silicone gel has been effective in the treatment of scar formation. AnsCare LeniScar Silicone Stick is statistically not different from the Dermatix Ultra silicone gel when comparing the treatment results of scar prevention. Furthermore, the AnsCare LeniScar Silicone Stick has the advantages of being time-saving with no need to wait for it to dry and application of precise amount to precise location, preventing waste or overuse.

Silicone gel sheeting for treating keloid scars

BACKGROUND

Keloid scarring is one of the most common types of pathological scarring. Keloid scars that fail to heal can affect a person's physical and psychological function by causing pain, pruritus, contractures, and cosmetic disfigurement. Silicone gel sheeting (SGS) is made from medical-grade silicone reinforced with a silicone membrane backing and is one of the most commonly used treatments for keloid scars. However, there is no up-to-date systematic review assessing the effectiveness of SGS for keloid scars. A clear and rigorous review of current evidence is required to guide clinicians, healthcare managers and people with keloid scarring.

OBJECTIVES

To assess the effectiveness of silicone gel sheeting for the treatment of keloid scars compared with standard care or other therapies.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was December 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that recruited people with any keloid scars and assessed the effectiveness of SGS.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment, data extraction and GRADE assessment of the certainty of evidence. We resolved initial disagreements by discussion, or by consulting a third review author when necessary.

MAIN RESULTS

Two studies met the inclusion criteria. Study sample sizes were 16 and 20 participants. The trials were clinically heterogeneous with differences in causes for scarring (e.g. surgery, infected wounds, and trauma), site (e.g. chest and back), and ages of scars. The duration of follow-up was three and four and a half months. The included studies reported three comparisons; SGS compared with no treatment, SGS compared with non-silicone gel sheeting (a dressing similar to SGS but which does not contain silicone), and SGS compared with intralesional injections of triamcinolone acetonide. One trial had a split-body design and one trial had an unclear design (resulting in a mix of paired and clustered data). The included studies reported limited outcome data for the primary review outcome of scar severity measured by health professionals and no data were reported for severity of scar measured by patients or adverse events. For secondary outcomes some data on pain were reported, but health-related quality of life and cost-effectiveness were not reported. Both trials had suboptimal outcome reporting, thus many domains in the risk of bias were assessed as unclear. All evidence was rated as being very low-certainty, mainly due to risk of bias, indirectness, and imprecision.  SGS compared with no treatment Two studies with 33 participants (76 scars) reported the severity of scar assessed by health professionals, and we are uncertain about the effect of SGS on scar severity compared with no treatment (very low-certainty evidence, downgraded once for risk of bias, once for inconsistency, once for indirectness, and once for imprecision). We are uncertain about the effect of SGS on pain compared with no treatment (21 participants with 40 scars; very low-certainty evidence, downgraded once for risk of bias, once for inconsistency, once for indirectness, and once for imprecision). No data were reported for other outcomes including scar severity assessed by patients, adverse events, adherence to treatment, health-related quality of life and cost-effectiveness. SGS compared with non-SGS One study with 16 participants (25 scars) was included in this comparison. We are uncertain about the effect of SGS on scar severity assessed by health professionals compared with non-SGS (very low-certainty evidence, downgraded once for risk of bias, once for indirectness, and once for imprecision). We are also uncertain about the effect of SGS on pain compared with non-SGS (very low-certainty evidence, downgraded once for risk of bias, once for indirectness, and once for imprecision). No data were reported for other outcomes including scar severity assessed by patients, adverse events, adherence to treatment, health-related quality of life and cost-effectiveness. SGS compared with intralesional injections of triamcinolone acetonide One study with 17 participants (51 scars) reported scar severity assessed by health professionals, and we are uncertain about the effect of SGS on scar severity compared with intralesional injections of triamcinolone acetonide (very low-certainty evidence, downgraded once for risk of bias, once for indirectness, and once for imprecision). This study also reported pain assessed by health professionals among 5 participants (15 scars) and we are uncertain about the effect of SGS on pain compared with intralesional injections of triamcinolone acetonide (very low-certainty evidence, downgraded once for risk of bias, once for indirectness, and twice for imprecision). No data were reported for other outcomes including scar severity assessed by patients, adverse events, adherence to treatment, health-related quality of life and cost-effectiveness.

AUTHORS' CONCLUSIONS

There is currently a lack of RCT evidence about the clinical effectiveness of SGS in the treatment of keloid scars. From the two studies identified, there is insufficient evidence to demonstrate whether the use of SGS compared with no treatment, non-SGS, or intralesional injections of triamcinolone acetonide makes any difference in the treatment of keloid scars. Evidence from the included studies is of very low certainty, mainly driven by the risk of bias, indirectness, and imprecision due to small sample size. Further well-designed studies that have good reporting methodologies and address important clinical, quality of life and economic outcomes are required to reduce uncertainty around decision-making in the use of SGS to treat keloid scars.

Silicone gel sheeting for treating hypertrophic scars

BACKGROUND

Each year, in high-income countries alone, approximately 100 million people develop scars. Excessive scarring can cause pruritus, pain, contractures, and cosmetic disfigurement, and can dramatically affect people's quality of life, both physically and psychologically. Hypertrophic scars are visible and elevated scars that do not spread into surrounding tissues and that often regress spontaneously. Silicone gel sheeting (SGS) is made from medical-grade silicone reinforced with a silicone membrane backing and is one of the most commonly used treatments for hypertrophic scars.

OBJECTIVES

To assess the effects of silicone gel sheeting for the treatment of hypertrophic scars in any care setting.

SEARCH METHODS

In April 2021 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled people with any hypertrophic scars and assessed the use of SGS.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, 'Risk of bias' assessment, data extraction and GRADE assessment of the certainty of evidence. We resolved initial disagreements by discussion, or by consulting a third review author when necessary.

MAIN RESULTS

Thirteen studies met the inclusion criteria. Study sample sizes ranged from 10 to 60 participants. The trials were clinically heterogeneous with differences in duration of follow-up, and scar site. We report 10 comparisons, SGS compared with no SGS treatment and SGS compared with the following treatments: pressure garments; silicone gel; topical onion extract; polyurethane; propylene glycol and hydroxyethyl cellulose sheeting; Kenalog injection; flashlamp-pumped pulsed-dye laser; intense pulsed light  and Gecko Nanoplast (a silicone gel bandage). Six trials had a split-site design and three trials had an unclear design (resulting in a mix of paired and clustered data). Included studies reported limited outcome data for the primary review outcomes of severity of scarring measured by health professionals and adverse events (limited data reported by some included studies, but further analyses of these data was not possible) and no data were reported for severity of scarring reported by patients. For secondary outcomes some pain data were reported, but health-related quality of life and cost effectiveness were not reported. Many trials had poorly-reported methodology, meaning the risk of bias was unclear. We rated all evidence as being either of low or very low certainty, often because of imprecision resulting from few participants, low event rates, or both, all in single studies. SGS compared with no SGS Seven studies with 177 participants compared SGS with no SGS for hypertrophic scars. Two studies with 31 participants (32 scars) reported severity of scarring assessed by health professionals, and it is uncertain whether there is a difference in severity of scarring between the two groups (mean difference (MD) -1.83, 95% confidence interval (CI) -3.77 to 0.12; very low-certainty evidence, downgraded once for risk of bias, and twice for serious imprecision). One study with 34 participants suggests SGS may result in a slight reduction in pain level compared with no SGS treatment (MD -1.26, 95% CI -2.26 to -0.26; low-certainty evidence, downgraded once for risk of bias and once for imprecision). SGS compared with pressure garments One study with 54 participants was included in this comparison. The study reported that SGS may reduce pain levels compared with pressure garments (MD -1.90, 95% CI -2.99 to -0.81;  low-certainty evidence, downgraded once for risk of bias and once for imprecision). SGS compared with silicone gel One study with 32 participants was included in this comparison. It is unclear if SGS impacts on severity of scarring assessed by health professionals compared with silicone gel (MD 0.40, 95% CI -0.88 to 1.68; very low-certainty evidence, downgraded once for risk of bias, twice for imprecision). SGS compared with topical onion extract One trial (32 participants) was included in this comparison. SGS may slightly reduce severity of scarring compared with topical onion extract (MD -1.30, 95% CI -2.58 to -0.02; low-certainty evidence, downgraded once for risk of bias, and once for imprecision). SGS compared with polyurethane One study with 60 participants was included in this comparison. It is unclear if SGS impacts on the severity of scarring assessed by health professionals compared with polyurethane (MD 0.50, 95% CI -2.96 to 3.96; very low-certainty evidence, downgraded once for risk of bias, and twice for imprecision). SGS compared with self-adhesive propylene glycol and hydroxyethyl cellulose sheeting One study with 38 participants was included in this comparison. It is uncertain if SGS reduces pain compared with self-adhesive propylene glycol and hydroxyethyl cellulose sheeting (MD -0.12, 95% CI -0.18 to -0.06). This is very low-certainty evidence, downgraded once for risk of bias, once for imprecision and once for indirectness. SGS compared with Gecko Nanoplast One study with 60 participants was included in this comparison. It is unclear if SGS impacts on pain compared with Gecko Nanoplast (MD 0.70, 95% CI  -0.28 to 1.68; very low-certainty evidence, downgraded once for risk of bias and twice for imprecision. There was a lack of reportable data from the other three comparisons of SGS with Kenalog injection, flashlamp-pumped pulsed-dye laser or intense pulsed light.

AUTHORS' CONCLUSIONS

There is currently limited rigorous RCT evidence available about the clinical effectiveness of SGS in the treatment of hypertrophic scars. None of the included studies provided evidence on severity of scarring validated by participants, health-related quality of life, or cost effectiveness. Reporting was poor, to the extent that we are not confident that most trials are free from risk of bias. The limitations in current RCT evidence suggest that further trials are required to reduce uncertainty around decision-making in the use of SGS to treat hypertrophic scars.

Effect of Soft Silicone Foam Dressings on Intraoperatively Acquired Pressure Injuries: A Randomized Study in Patients Undergoing Spinal Surgery

The use of prophylactic dressings to help prevent intraoperatively acquired pressure injuries (IAPIs) merits further study.

PURPOSE

To examine how the use of a soft silicone foam dressing affects the development of IAPIs in patients undergoing spinal surgery to obtain baseline data supporting evidence-based nursing care.

METHODS

Using a self-controlled study design, 64 patients requiring thoracic or lumbar surgery on a Wilson frame at a hospital in Seoul, South Korea, were recruited between February 12 and September 1, 2018; 50 patients were eligible. Basic demographic, health, and surgical data were obtained. Before surgery, the left or right side chest and iliac crest areas were randomly assigned to be covered with a soft silicone foam dressing. The areas were assessed at 2 time points: immediately after and 30 minutes after surgery. If an IAPI was present at 30 minutes after surgery, all sites were reevaluated after 7 days.

RESULTS

The majority of participants were male (26 participants, 52%). Average patient age was 62.54 (± 13.83) years, with a body mass index of 24.32 (± 4.23) kg/m2. Average length of surgery was 218.4 (± 137) minutes. Immediately after surgery, 26 IAPIs were observed and there was a significant difference between dressed and non-dressed chest areas for the number of IAPIs (4% vs. 28%; P = .002). After 30 minutes, the total number of IAPIs was 20 and the difference between IAPIs in the iliac crest area was significant between dressed and non-dressed areas (0% vs. 14%; P = .012). After 1 week, there were no chest or iliac crest IAPIs in the areas that had been covered by a dressing; however, 8 chest (61.5%) and 4 iliac crest (30.8%) area IAPIs remained when no dressing had been applied. The majority of IAPIs were stage 1 at all assessment times. After 1 week, 1 IAPI had evolved into a stage 3 injury.

CONCLUSIONS

The results of this study show that many stage 1 IAPIs do resolve over time and that use of soft silicone foam dressings during spinal surgery can significantly reduce IAPI rates. Additional longitudinal studies are needed to help guide postoperative skin assessment intervals and increase the understanding about the evolution of stage 1 IAPIs.

Efficacy of an Innovative Film-Forming Wound Dressing on Open Wounds

Standards in post-surgery wound care management require a rapid healing process in order to prevent and minimize abnormal scarring. For the healing process to start as early as possible, the ideal dressing should be applied directly on the open wound and perfectly adapt to it. The authors report a case study series regarding the efficacy of a flexible film-forming wound dressing in the form of a gel (Stratamed^®, Stratpharma AG, Switzerland) that is approved for the use on open wounds and injured skin. Evidence from the current study shows that, while remaining safe to use, the dressing was efficacious in promoting epithelialization and accelerated wound healing of areas in which skin integrity had been compromised, and at the same time prevented the formation of abnormal scars. Results were observed across a broad range of dermatologic surgical procedures. All treated conditions showed a beneficial outcome, as well as an overall favorable patient treatment perception.

[ASSESSMENT OF COMBINED PROPHYLAXIS OF PATHOLOGICAL POSTOPERATIVE FACE SKIN SCARS ACCORDING TO THE VANCOUVER SCALE]

The aim of the research was to study the effectiveness of combined prophylaxis of pathological postoperative face skin scars according to the Vancouver scale. The research involved 29 patients, aging 16-48 years old, who underwent maxillofacial surgery by extraoral accesses with wound primary intention healing. The patients were divided into three groups: the control group, which involved the patients, who after the surgery did not undergo any preventive measures to avoid pathological skin scars development, and two study groups. The patients of the first study group underwent the monotherapy comprising three sessions of extracorporeal shock wave therapy once every 4-5 days. The patients of the second study group underwent three sessions of extracorporeal shock wave therapy once every 4-5 days and local use of silicone gel Strataderm. The Vancouver scale was used to evaluate clinically the effectiveness of the suggested methods of pathological scars development prevention. It involved evaluation (in points) of their consistency, pigmentation, and vascularization. The scars were assessed on the 7th, 30th day after the surgery and in 6 months. Positive results were attained in the patients of both study groups; they were manifested by increased elasticity and compliance of scars, pigmentation becoming of just about surrounding skin natural color, normalization of blood supply to scars, and more rapid disappearance of suture marks. However, these positive signs were more significant in the patients of the second study group that allowed us concluding that combined use of extracorporeal shock wave therapy and local applying of silicone gel Strataderm was advisable.

Does the form of dressings matter?: A comparison of the efficacy in the management of postoperative scars between silicone sheets and silicone gel: a randomized controlled trial

BACKGROUND

Silicone sheet is commonly used for scar management but hard to apply to irregular surfaces or mobile areas, and difficult to conceal. On the contrary, silicone gel is easy to apply and nearly unnoticeable. Therefore, we conducted this study to compare their effectiveness.

METHODS

Patients undergoing horizontal cesarean section were included. Surgical wounds were divided into 2 halves. Patients randomly applied silicone sheets and silicone gel on either side of their wounds for 3 months. The wounds were assessed at 1, 3, 6, and 12 months after surgery. We used the Vancouver Scar Scale (VSS) for an objective evaluation and the visual analog scale (VAS) for a subjective evaluation.

RESULTS

There was no statistical significance between the silicone sheet and silicone gel groups with respect to VSS score. The silicone sheet group showed a statistically significant higher VAS score for itch at 1 month follow-up (1.18 ± 2.04 vs 0.35 ± 0.85, P = .01). However, the difference was less than 1 on a scale of 10, so it might not be clinically meaningful.

CONCLUSION

Silicone sheet group showed statistically significant worse VAS score in terms of itch. However, the difference was too small to be clinically meaningful.

Review of Silicone Gel Sheeting and Silicone Gel for the Prevention of Hypertrophic Scars and Keloids

BACKGROUND

Keloids and hypertrophic scars are fibroproliferative disorders of dermal tissue after skin injury. Many clinical control studies have reported evidence that silicone gel is effective in preventing and alleviating hypertrophic scarring. Whether silicone gel sheeting prevents hypertrophic scars or keloids requires clear evidence of its clinical effectiveness.

OBJECTIVE

This review investigated the effectiveness of silicone gel and silicone gel sheeting for the prevention of hypertrophic or keloid scarring in patients with newly healed wounds.

METHODS

The authors searched the MEDLINE, EMBASE, CINAHL, and CENTRAL databases (January 1, 1990 to September 24, 2014) for any randomized or quasi-randomized controlled trials or controlled clinical trials comparing silicone gel sheeting or silicone gel with a control group for prevention of hypertrophic scars or keloids. All collected trials were assessed for methodological quality, control group and treatment group, and number of participants developing hypertrophic scars and keloids. The authors calculated risk ratios (RR) from each trial for the development of abnormal scarring and combined these using random-effects model meta-analysis. Between-study heterogeneity was calculated by using the I2 statistic.

RESULTS

Ten trials in 9 studies were pooled (random effect; I² = 88%). There was a significant difference between the silicone gel sheeting group and the placebo group (RR 0.70; 95% confidence interval, 0.49-0.99; P = .04) in preventing the risk of hypertrophic scars.

CONCLUSION

There was statistical significance in the effectiveness of silicone gel and silicone gel sheeting on the prevention of keloids or hypertrophic scars, especially in skin lesion wounds. However, most of the trials evaluating silicone gel sheeting or silicone gel as a prevention of hypertrophic scars and keloids had poor quality with high or uncertain risk of biases either in study design or in conduct.

[CLINICAL ESTIMATION OF THE PROPHYLAXIS EFFICACY FOR POSTOPERATIVE PATHOLOGICAL CICATRICES OF FACIAL SKIN]

Efficacy of combined prophylaxis of postoperative pathological cicatrices of facial skin was studied. Application of extracorporeal shock—wave therapy and the silicone gel Strataderm have had impacted the clinical characteristics of the facial skin postoperative cicatrix positively: a shock—wave therapy promoted a sutural tracks involution, аnd the silicone gel Strataderm — normalization of the postoperative cicatrix pigmentation.

[Reaction to a black henna tattoo treated with mometasone furoate and silicone gel: case report]

Black henna tattoos have paraphenylenediamine (PPD), which contains a product of herbal origin, which due to its molecular characteristics is capable of inducing, in susceptible individuals, a type IV hypersensitivity reaction. It clinically manifests as a contact dermatitis that usually when it disappears, scarring and hypopigmentation are left in the injured area.

OBJECTIVE

To describe the case of a patient with hypersensitivity to henna tattoo and to present the most relevant phenomena associated with this condition.

CASE REPORT

The case of a 6 year-old patient with a black henna tattoo on his right leg, who was diagnosed with contact dermatitis probably attributed to PPD, is presented. Mometasone furoate and topical silicone gel treatment was started with good response.

CONCLUSION

Mometasone furoate and silicone gel are a good possible therapeutic option for treating contact dermatitis caused by PPD as the dermatosis was resolved without residual lesions.

Update on hypertrophic scar treatment

Scar formation is a consequence of the wound healing process that occurs when body tissues are damaged by a physical injury. Hypertrophic scars and keloids are pathological scars resulting from abnormal responses to trauma and can be itchy and painful, causing serious functional and cosmetic disability. The current review will focus on the definition of hypertrophic scars, distinguishing them from keloids and on the various methods for treating hypertrophic scarring that have been described in the literature, including treatments with clearly proven efficiency and therapies with doubtful benefits. Numerous methods have been described for the treatment of abnormal scars, but to date, the optimal treatment method has not been established. This review will explore the differences between different types of nonsurgical management of hypertrophic scars, focusing on the indications, uses, mechanisms of action, associations and efficacies of the following therapies: silicone, pressure garments, onion extract, intralesional corticoid injections and bleomycin.

Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) due to silicone implant incompatibility syndrome in three sisters

Three sisters who carried the BRCA-1 gene mutation had a preventive mastectomy and were reconstructed with silicone breast implants. After the reconstruction all three patients developed fatigue, arthralgia, myalgia and sleep disturbances within a period of four years. Because the complaints were thought to be related to the silicone breast implants, they were advised to have the implants replaced by non-silicone gel containing Monobloc Hydrogel breast implants. After this replacement operation, all complaints improved as evaluated 2.5 years later. Since the complaints developed during the presence of silicone implants and since the reversal was observed after replacement by hydrogel implants we postulate that our patients suffered from ASIA due to silicone implants, i.e. Silicone Implant Incompatibility Syndrome (SIIS). The generation of this syndrome in three sisters suggests that the susceptibility to the development of SIIS may be genetically determined.

Scleroderma renal crisis following silicone breast implant rupture: a case report and review of the literature

Systemic sclerosis (SSc) is a chronic multisystem autoimmune disorder characterised by progressive functional and structural abnormalities in blood vessels leading to microvascular dysfunction, excessive production and deposition of collagen leading to the fibrosis of skin and internal organs. The aetiology of the disease is unknown. However, exposure to various environmental factors, such as polyvinyl chloride and silica have been thought to play a role in the development of the disease. For this reason, silicone breast implants have been postulated as a cause for a range of autoimmune diseases including systemic sclerosis. This remains as yet unconfirmed. We report the case of a 52-year-old woman who presented with rapid development of skin thickening followed by scleroderma renal crisis (SRC) following rupture of silicone breast implants. This is the first published case of SRC in this setting. The literature on silicone and autoimmunity is reviewed.

A prospective placebo-controlled study on the efficacy of onion extract in silicone derivative gel for the prevention of hypertrophic scar and keloid in median sternotomy wound in pediatric patients

BACKGROUND

New topical treatments studied in adults have been published to be potentially effective in the treatment of hypertrophic scar and keloids. There is still no study in Thai children.

OBJECTIVE

To study the efficacy of 10% onion extract in silicone derivative gel for the prevention of hypertrophic scar and keloid in median sternotomy wound from open heart surgery in pediatric patients.

MATERIAL AND METHOD

Thirty-nine pediatric patients who had median sternotomy were recruited in this prospective randomized, double-blinded, placebo-controlled split-scar experimental study. The wound in each patient was divided into upper and lower parts, and the treatment with, either onion extract gel or placebo was randomly applied by block randomization onto each part of the wound twice daily after the seventh day postoperatively for six months. The incidence of scars, serial photographs of the wound, Vancouver Scar Scale (VSS), and adverse effect were assessed at each visit.

RESULTS

Thirty patients with the mean age of 4.3 years completed the 6-month study period. Six patients (20%) in onion extract gel group had no scar compared to one patient (3.3%) in placebo group (p = 0.04). Of the 27 patients with hypertrophic scar nine were from onion extract gel group and 18 from the placebo group (p = 0.02). Keloid was not statistically significant diferent in both groups (p = 0.29). VSS was not statistically significant different in all visits. One case had a pustule on the part of the onion extract in silicone derivative application at the sixth month.

CONCLUSION

Onion extract in silicone derivative gel can significantly decreased the incidence of hypertrophic scar from median sternotomy wound in pediatric patients. Keloid did not show statistically significant differences in both groups.

Silicone gel sheeting for preventing and treating hypertrophic and keloid scars

BACKGROUND

Keloid and hypertrophic scars are common and are caused by a proliferation of dermal tissue following skin injury. They cause functional and psychological problems for patients, and their management can be difficult. The use of silicone gel sheeting to prevent and treat hypertrophic scarring is still relatively new and started in 1981 with treatment of burn scars.

OBJECTIVES

To determine the effectiveness of silicone gel sheeting for:(1) prevention of hypertrophic or keloid scarring in people with newly healed wounds (e.g. post surgery);(2) treatment of established scarring in people with existing keloid or hypertrophic scars.

SEARCH METHODS

In May 2013 we searched the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL for this second update.

SELECTION CRITERIA

Any randomised or quasi-randomised controlled trials, or controlled clinical trials, comparing silicone gel sheeting for prevention or treatment of hypertrophic or keloid scars with any other non surgical treatment, no treatment or placebo.

DATA COLLECTION AND ANALYSIS

We assessed all relevant trials for methodological quality. Three review authors extracted data independently using a standardised form and cross-checked the results. We assessed all trials meeting the selection criteria for methodological quality.

MAIN RESULTS

We included 20 trials involving 873 people, ranging in age from 1.5 to 81 years. The trials compared adhesive silicone gel sheeting with no treatment; non silicone dressing; other silicone products; laser therapy; triamcinolone acetonide injection; topical onion extract and pressure therapy. In the prevention studies, when compared with a no treatment option, whilst silicone gel sheeting reduced the incidence of hypertrophic scarring in people prone to scarring (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.21 to 0.98) these studies were highly susceptible to bias. In treatment studies, silicone gel sheeting produced a statistically significant reduction in scar thickness (mean difference (MD) -2.00, 95% CI -2.14 to -1.85) and colour amelioration (RR 3.49, 95% CI 1.97 to 6.15) but again these studies were highly susceptible to bias.

AUTHORS' CONCLUSIONS

There is weak evidence of a benefit of silicone gel sheeting as a prevention for abnormal scarring in high-risk individuals but the poor quality of research means a great deal of uncertainty prevails. Trials evaluating silicone gel sheeting as a treatment for hypertrophic and keloid scarring showed improvements in scar thickness and scar colour but are of poor quality and highly susceptible to bias.

Role of silicone derivative plus onion extract gel in presternal hypertrophic scar protection: a prospective randomized, double blinded, controlled trial

Use of silicone derivative and onion extract had been reported in the prevention of hypertrophic scarring. Our experience showed the preventive use of silicone derivative plus onion extract gel on hypertrophic scars after median sternotomy. In a randomized, double blinded, placebo-controlled study, 60 patients after median sternotomy incisions were separated into two groups. All patients were treated either with silicone derivative plus onion extract gel (Cybele(®) scagel) or placebo gel twice daily for a total treatment period of 12 weeks. During each visit, pain and itching scores were graded by the patients and scar characteristics were observed by surgeons using the Vancouver scar scale. Pain and itch score values from patients' who applied silicone derivative plus onion extract gel was less than another group (P < 0·05). Pigmentation was significantly different between two groups (P < 0·05) and the reduction of scores on vascularity, pliability, height in treated group was not superior to the untreated group. No adverse events were reported by any of the patients. A silicone derivative plus onion extract gel is safe and effective for the preventing the hypertrophic scarring after median sternotomy.

Efficacy of topical cyanoacrylates compared to topical silicone gel in the treatment of hypertrophic scars

AIM

The effectiveness of cyanoacrylates compared to silicone gel in improving healing of hypertrophic scars was evaluated.

PATIENTS AND METHODS

Patients presenting hypertrophic scars 6 to 24 months old were enrolled. Asymmetrical scars were treated with cyanoacrylates, linear scars were divided in two parts, one treated with cyanoacrylates, the other with silicone gel. For 3 months, cyanoacrylates were applied every 3-5 days, silicone gel twice a day. Patients' and external observers' assessments were recorded over one year, and photographic records taken. Objective evaluations included width, length and elevation measurements. Statistical significance of parameter modifications was analysed with the Wilcoxon test.

RESULTS

A total of 150 patients were enrolled. Positive effects of both tested products were observed without major adverse effects, achieving final scars of better quality. Scar elevation was reduced significantly for both tested products, but apparently more for topical cyanoacrylates.

CONCLUSION

Cyanoacrylates have a positive effect on pathological scars at least comparable to that of silicone gel.

Case series: evaluation of a liquid silicone gel on scar appearance following excisional surgery--a pilot study

Efforts to improve the size and appearance of scars have included therapies as varied as laser treatments and onion extract gels. Silicone gel sheeting is well know to improve the appearance of hypertrophic scars, and may have a role in the management of routine surgical and traumatic scars. By varying the degree of cross linking, silicone elastomer can be a solid sheet or a liquid gel. In this pilot series, seven patients applied a liquid silicone gel twice a day to one half of a new surgical scar for three months. At the end of this time, the treated side was noticeably better in appearance in five of seven patients while two of seven had no difference. In no patient was the silicone treated side worse in appearance.

Silicone gel sheets relieve pain and pruritus with clinical improvement of keloid: possible target of mast cells

Silicone gel sheet treatment is widely used to treat hypertrophic scars and keloids since it is easily applied and prevents scar pain and itching. We used Cica-Care silicone gel sheets in the conservative treatment of six patients for 24 weeks and recorded pain, itching, redness, and scar elevation every 4 weeks. We also investigated the number of mast cells and Fas antigen expression in the lesional skin (one patient) before and after treatment. The pain and itching clearly decreased after 4 weeks of the silicone gel sheeting and disappeared after 12 weeks. Twelve weeks were required for a reduction in scar redness and elevation. After 24 weeks, a decrease in the number of mast cells and the enhanced expression of Fas antigen by lesional fibroblasts were observed. Thus, silicone gel sheeting is effective and safe, especially with more severe symptoms of pain and itching possibly induced by mediators derived from increased mast cells.

SUTURING OF A TEXTURED BREAST IMPLANT FILLED WITH COHESIVE SILICONE GEL TO PREVENT DISLOCATION

We present a case of unilateral anchoring of a style 410 breast implant filled with cohesive silicone gel (McGhan) with four 3/0 braided polyester (Mersilene) sutures. Reoperation after one week and magnetic resonance scanning after six months showed no leakage or bleeding of the prosthesis. Fixation is possible because of the development of cohesive silicone gel in breast implants. Follow up of this patient is necessary for evaluation of long term results.

Morphological analysis of the connective tissue reaction in linear hypertrophic scars treated with intralesional steroid or silicone-gel sheeting. A light and electron microscopic study

The linear hypertrophic scar has become the most common type of pathologic scarring. Silicone-gel sheeting is the first line therapy while intralesional steroid is the second. A light and electron microscopic analysis was carried out to reveal differences in tissue reaction following the two different treatments. Two groups of 12 patients each were treated for 4 months. For the first group, diluted Triamcinolone acetonide was injected until an inactive state was achieved. The other group of patients was treated with silicone-gel sheeting. The scars were examined every two weeks and their appearance documented. After reaching the expected therapeutic response, inactive scars were removed. The excised scars were evaluated through light microscopic histopathology and electron microscopy. The light and electron microscopic observations revealed marked differences following treatments. The activity of fibroblasts and the numbers of collagen fibers forming bundles decreased and the orientation of the collagen fibers was more variable in the treated scars. The amount of elastic fibers increased after both steroid and silicone-gel sheeting treatment. Vascularization was also slightly changed, with more capillaries and fewer pre-capillary arteries detected in the treated scars. Both treatments resulted in the same decrease in score but steroid treatment was more rapid in onset. We suggest that the two different treatments work through different mechanisms, although the final functional outcome is similar.

Nonsurgical management of hypertrophic scars: evidence-based therapies, standard practices, and emerging methods

Hypertrophic scars, resulting from alterations in the normal processes of cutaneous wound healing, are characterized by proliferation of dermal tissue with excessive deposition of fibroblast-derived extracellular matrix proteins, especially collagen, over long periods, and by persistent inflammation and fibrosis. Hypertrophic scars are among the most common and frustrating problems after injury. As current aesthetic surgical techniques become more standardized and results more predictable, a fine scar may be the demarcating line between acceptable and unacceptable aesthetic results. However, hypertrophic scars remain notoriously difficult to eradicate because of the high recurrence rates and the incidence of side effects associated with available treatment methods. This review explores the various treatment methods for hypertrophic scarring described in the literature including evidence-based therapies, standard practices, and emerging methods, attempting to distinguish those with clearly proven efficiency from anecdotal reports about therapies of doubtful benefits while trying to differentiate between prophylactic measures and actual treatment methods. Unfortunately, the distinction between hypertrophic scar treatments and keloid treatments is not obvious in most reports, making it difficult to assess the efficacy of hypertrophic scar treatment.

Hypertrophic scar model in the rabbit ear: a reproducible model for studying scar tissue behavior with new observations on silicone gel sheeting for scar reduction

Hypertrophic scarring poses a clinically relevant problem as it can be cosmetically disfiguring and functionally debilitating. A lack of animal models has hindered an understanding of the pathogenesis and development of new treatment strategies therefore has largely been empiric. Our group has developed a unique hypertrophic scar (HS) model in the rabbit ear. The model has been reproducible, quantifiable, and measurable over a time period of 1 month. We describe the development as well as the reliability and responsiveness of this model to different therapeutic agents, such as TGF-beta blockade, silicone occlusion, and application of collagen-synthesis inhibitors. Moreover, it has given insights into the mechanism of action of silicone sheeting occlusive treatment and ultimately suggests that the epidermis plays a critical role in the development of HS. Additionally, we will present new data supporting the importance of the epidermis and further clarify the mechanism of action of silicone sheeting. When a semi-occlusive polyurethane film was left in place for an additional time period, scar formation was reduced. HSs of this model covered with silicone sheets and five layers of Tegaderm showed a significant scar reduction by 80% compared with wounds with only one layer of Tegaderm. The HS model in the rabbit ear is a highly reliable, responsive, and practical model for studying scar tissue behavior. Furthermore, our data suggest that the degree and the duration of occlusion are most important for reducing scar tissue formation.

Levels of evidence for the treatment of keloid disease

INTRODUCTION

Keloid disease presents a significant burden for patients and a significant therapeutic challenge for clinicians. Multiple treatments have been proposed, but with the increasing drive towards effective use of resources, therapeutic options need to be evaluated in terms of the levels of evidence supporting their use.

AIM

To retrieve and review the primary clinical studies evaluating keloid disease therapy over the last 25 years and assign levels of evidence for the treatment modalities evaluated.

METHOD

A Medline search was conducted to identify all primary clinical studies evaluating the treatment of keloid disease, published in English since 1980 (excluding single case reports). Studies were assigned a level of evidence (LOE-1, highest quality to LOE-5, lowest) adapted from the Oxford Centre for Evidence-based Medicine.

RESULTS

13 (12%) of 112 studies retrieved were assigned LOE-2, 99 (88%) assigned LOE-4. There were no LOE-1 studies. Ten of the LOE-2 studies evaluated silicone-based therapy or laser therapy. Most studies evaluating steroids, cryosurgery, laser therapy and post-surgical adjuvant therapy provide level 4 evidence.

CONCLUSION

High quality research in evaluating keloid therapy is lacking. There is a definite need for well designed and properly reported randomised controlled trials, to provide clinicians with a sound body of evidence on which to inform decision making.

Topical treatments for hypertrophic scars

Hypertrophic scars represent an abnormal, exaggerated healing response after skin injury. In addition to cosmetic concern, scars may cause pain, pruritus, contractures, and other functional impairments. Therapeutic modalities include topical medications, intralesional corticosteroids, laser therapy, and cryosurgery. Topical therapies, in particular, have become increasingly popular because of their ease of use, comfort, noninvasiveness, and relatively low cost. This review will discuss the properties and effectiveness of these agents, including pressure therapy, silicone gel sheeting and ointment, polyurethane dressing, onion extract, imiquimod 5% cream, and vitamins A and E in the prevention and treatment of hypertrophic scars.

A prospective randomized clinical trial to investigate the effect of silicone gel sheeting (Cica-Care) on post-traumatic hypertrophic scar among the Chinese population

BACKGROUND

This study aimed to determine the efficacy of silicone gel (Cica-Care) on severe post-traumatic hypertophic scars among the Chinese population.

METHOD AND MATERIALS

A randomized clinical trial (RCT) was conducted on 45 Chinese patients with post-traumatic hypertrophic scars. Twenty-two subjects were placed in the experimental group with silicone gel sheeting (SGS) applied 24h per day for 6 months while all subjects were taught to massage the scar daily for 15 min serving as the control intervention. Scar assessments were conducted regularly to measure the changes in thickness, pigmentation, vascularity, pliability, itchiness and pain.

RESULTS

Two-way repeated ANOVA showed a significant difference between MT group and SGS group on scar thickness. The post hoc comparison analysis showed that the difference was significant at the post-2-month (p=0.008) and post-6-month (p<0.001) intervention. The SGS group also showed changes in pigmentation which resembled normal skin but no statistical significance was found. Pain, itchiness and pliability were also improved after intervention.

CONCLUSION

This study indicated that silicone gel sheeting (Cica-Care) was effective to reduce thickness, pain, itchiness and pliability of the severe hypertrophic scar among the Chinese population. The moisturization effect of the tough and hard scar might contribute to the reduction of the skin thickness after 6 month's intervention.

Influence of silicone on abnormal scarring

The problem of scarring represents a large area of an unmet medical need, since people with abnormal skin scarring may face physical and psychological consequences that may be associated with substantial emotional and financial costs. To date, treatment options are to leave the scar alone or use invasive or noninvasive management. Silicone is the key in noninvasive management, with the following overall results reported: great improvement of the scar appearance, easy to apply, painless, and almost free of side effects. When analyzing all presented results in this research sample, it becomes obvious that they are mainly based on subjective, not well-defined scar assessment by the individual without comparison to controls or rating against validated scores and therefore lacking real scientific or evidence-based criteria.

Silicon gel sheeting for preventing and treating hypertrophic and keloid scars

BACKGROUND

Keloid and hypertrophic scars are common and are caused by a proliferation of dermal tissue following skin injury. They cause functional and psychological problems for patients, and their management can be difficult. The use of silicon gel sheeting to prevent and treat hypertrophic scarring is still relatively new, and started in 1981 with treatment of burn scars.

OBJECTIVES

To determine the effectiveness of silicon gel sheeting for: (1) prevention of hypertrophic or keloid scarring in people with newly healed wounds (e.g. post surgery); (2) treatment of established scarring in people with existing keloid or hypertrophic scars.

SEARCH STRATEGY

Trials were identified from searches of the Cochrane Wounds Group Specialised Register (searched September 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005); MEDLINE (1989 to June 2002); EMBASE (1988 to May 2002); CINAHL (1982 to May 2002) and reference lists of articles and relevant reviews. The major supplier of silicon gel sheeting (Smith and Nephew) was approached for details of unpublished, ongoing and recently published trials.

SELECTION CRITERIA

Any randomised or quasi-randomised controlled trials, or controlled clinical trials comparing silicon gel sheeting for prevention or treatment of hypertrophic or keloid scars against no treatment, placebo, or any other treatment type except surgery.

DATA COLLECTION AND ANALYSIS

All relevant trials were assessed for methodological quality. Data were extracted independently by both reviewers using a standardized form, and the results cross-checked. All trials, meeting the selection criteria were assessed for methodological quality.

MAIN RESULTS

Thirteen trials, involving 559 people, ranging in age from 2 to 81 years, were included in the review. The trials compared adhesive silicon gel sheeting with control; non-silicon gel sheeting; silicon gel plates with added Vitamin E; laser therapy; triamcinolone acetonide injection, and non-adhesive silicon gel sheeting. In the prevention studies, when compared with a no treatment option; whilst silicon gel sheeting reduced the incidence of hypertrophic scarring in people prone to scarring, (RR 0.46, 95% CI 0.21 to 0.98) these studies were highly susceptible to bias. Silicon gel sheeting produced a statistically significant improvement in scar elasticity, (RR 8.60, 95% CI 2.55 to 29.02), but again these studies were highly susceptible to bias.

AUTHORS' CONCLUSIONS

Trials evaluating silicon gel sheeting as a treatment for hypertrophic and keloid scarring are of poor quality and highly susceptible to bias. There is weak evidence of a benefit of silicon gel sheeting as a prevention for abnormal scarring in high risk individuals but the poor quality of research means a great deal of uncertainty prevails.

A Randomized, Placebo-Controlled, Double-Blind, Prospective Clinical Trial of Silicone Gel in Prevention of Hypertrophic Scar Development in Median Sternotomy Wound

BACKGROUND

Hypertrophic scarring caused by sternotomy is prevalent among Asians. The effectiveness of silicone gel in scar prevention may influence the decision of surgeons and patients regarding its routine use during the postoperative period.

METHODS

The authors conducted a randomized, placebo-controlled, double-blind, prospective clinical trial. The susceptibility to scar development varied among patients; therefore, sternal wounds were divided into the upper half and the lower half. Two types of coded gel prepared by an independent pharmacist were used on either half. Thus, selection and assessment biases and confounders were eliminated.

RESULTS

One hundred wounds in 50 patients were randomized into two arms, 50 control and 50 silicone gels. The median age was 61 years and there were 34 men and 16 women. Ethnic distribution was 28 Malays, 18 Chinese, and four Indians. No side effect caused by the silicone gel was noted. Ninety-eight percent of patients had moderate to good compliance. The incidence of sternotomy scar was 94 percent. At the third month postoperatively, the silicone gel wounds were scored lower when compared with the control wounds. The differences were statistically significant in all parameters, including pigmentation (p = 0.02), vascularity (p = 0.001), pliability (p = 0.001), height (p = 0.001), pain (p = 0.001), and itchiness (p = 0.02).

CONCLUSIONS

The effect of silicone gel in prevention of hypertrophic scar development in sternotomy wounds is promising. There are no side effects and patients' compliance is satisfactory. This study may popularize the use of silicone gel in all types of surgery to minimize the formation of hypertrophic scars in the early postoperative period.

Effect of a silicone-containing dressing on exuberant granulation tissue formation and wound repair in horses

OBJECTIVE

To determine the effect of a silicone dressing on the rate and quality of repair of limb wounds and compare microvascular occlusion and apoptosis in wounds treated with the silicone dressing and those treated with a conventional dressing in horses.

ANIMALS

5 horses.

PROCEDURE

Horses received two 6.25-cm2 wounds on each metacarpus. Ten wounds were treated with a silicone dressing; the other 10 were treated with a control dressing. Quality of repair and wound size were evaluated at each bandage change. Time to healing and the number of excisions of exuberant granulation tissue were recorded. Biopsy specimens taken from healed wounds were evaluated semiquantitatively via histologic examination, p53 immunohistochemical analysis, terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) to quantify apoptosis, and electron microscopic examination to measure microvessel luminal diameters.

RESULTS

The silicone dressing surpassed the conventional dressing in preventing formation of exuberant granulation tissue and improving tissue quality. Microvessels were occluded significantly more often in wounds dressed with the silicone gel, which also diminished the expression of mutant p53, an indirect inhibitor of apoptosis, although greater apoptosis was not confirmed quantitatively by use of TUNEL.

CONCLUSIONS AND CLINICAL RELEVANCE

Because the silicone dressing inhibited the formation of exuberant granulation tissue, it may be integrated in a management strategy designed to improve the repair of limb wounds in horses.

Hypertrophic and keloidal scars: an approach to polytherapy

BACKGROUND

Cryotherapy and intralesional corticosteroids have been used separately or in combination as a treatment for hypertrophic and keloidal scars. The addition of silicone gel to the treatment schedule might be of interest.

METHODS

Twenty patients with hypertrophic and keloidal scars received two 15-s cycles (in total 30 s) of cryotherapy treatments at every session (once monthly for 12 months) with intralesional injections of trimcinolone acetonide 0.1% (10-40 mg/mL, once monthly for 3 months). Topical application of silicone gel was added three times daily (for 12 months). The control group included 10 patients who received treatment with silicone sheeting.

RESULTS

After 1 year there was improvement in all the parameters studied, especially in terms of symptoms, cosmetic appearance and associated signs (P < 0.0001) compared to baseline and compared to the control group.

CONCLUSION

Our study suggests that polytherapy may be an effective tool in the therapy of hypertrophic and keloidal scars.

[Silicone occlusive sheeting vs silicone cushion for the treatment of hypertrophic and keloid scars. A prospective-randomized study]

BACKGROUND

Silicone gel and silicone occlusive sheeting are widely used at present for the treatment of hypertrophic and keloid scars. In recent studies the possibility was raised that static electricity generated by friction activated silicone sheeting could be the reason for this effect, and that it can, with time, cause involution of hypertrophic and keloid scars. Objective of this study was to test this hypothesis and to observe weather a continuous and also an increased negatively charged static electric field will shorten the treatment period. A silicone cushion was developed with the purpose of increasing a negative static-electric charge to accelerate the regression process.

METHODS

From November 2001 to June 2002 we studied in a prospective randomized study, 72 patients with hypertrophic an keloid scars. The trial extended over a 8-month period. 37 patients underwent silicone occlusive sheeting, the remaining 35 patients underwent silicone cushion (Clinicel).

RESULTS

Treatment with the silicone cushions yielded 74,2% cessation of itching and burning followed by pallor and flattening of the scar, some markedly so, over a few weeks to 5 months period. Additional 25,7% had their scars resolved in up to 8 months of treatment. Four patients (11,4%) who add recalcitrant scars with little response to the use of the silicone cushion were given intralesional corticosteroid injections, in addiction to the use of the cushion, resulting in a fairly rayed resolution of these scars over a period of 2 months. Treatment with the silicone occlusive sheeting yielded 52,3% itching and burning cessation followed by pallor and flattening of the scar, some markedly so, over a few weeks to 5 months period. Additional 22,1% had their scars resolved in up to 8 months of treatment. In conclusion by comparing the results of this trial using silicone cushions for the treatment of hypertrophic and keloid scars with those obtained using silicone gel or occlusive sheeting, a much faster response was demonstrated.

[Pathological analysis of breast carcinoma after silicone gel injection]

OBJECTIVE

To explore the correlation between breast carcinoma and silicone gel injection for breast augmentation.

METHODS

Four cases of breast cancer after silicone gel injection were studied by means of clinical pathological analysis.

RESULTS

In the four women, breast lump of over 5 cm in diameter was found half year to 2 years after silicone injection. The tumor was misdiagnosed to inflammatory reaction of silicone gel injection. Definite diagnosis was made by histological examinations, which showed there was mucoid, light blue and well-distributed silicone gel among the nests of neoplasm cells. Lymph node metastasis of cancer cells was observed.

CONCLUSIONS

Silicone gel injection to the breast may be a reason for evoking or accelerating breast cancer. Breast cancer that occurred after breast augmentation with silicone gel injection could be misdiagnosed. Final diagnosis depends on biopsy. Silicone gel injection for breast augmentation should be abandoned.

Using silicone gel sheet for the treatment of facial telangiectasias with sclerotherapy

BACKGROUND

Telangiectasias are superficial cutaneous vessels that are visible to human eye and are present as a dilated venule, capillary, or arteriole. They are a common cause of concern, especially when located in face. Sclerotherapy is among the treatment alternatives, but facial telangiectasias are less responsive than those located on the leg.

OBJECTIVE

To show the effectiveness of silicone gel sheet in improving the results obtained by sclerotherapy in facial telangiectasias.

METHODS

Between 1998 and 2003, 32 patients were treated with sclerotherapy and silicone gel sheet (group 1). Twenty-six patients were treated with sclerotherapy and cotton ball (group 2), and 30 patients were treated only sclerotherapy (group 3). Patients were evaluated for 12 weeks for the degree of improvement and side effects. All complications, side effects, and number of sessions were also recorded at each follow-up visit. The number of sessions is limited to six. After the final follow-up visit, the photographs taken of each treatment site at baseline and at final visit were reviewed in a double-blinded manner based on a 0 to 4 scale by two physicians.

RESULTS

Fifty one of the 88 patients showed improvement totally. In the silicone sheet-sclerotherapy group, 22 of the 36 patients showed improvement. In the sclerotherapy-cotton ball group, 14 of the 26 patients showed improvement, and in the sclerotherapy-only group, 15 of the 30 patients showed improvement completely within the 12 weeks. The patients treated with sclerotherapy-silicone gel sheet (group 1) had more improvement than the other groups.

CONCLUSION

Combining silicone gel sheeting to sclerotherapy increases the success rate in treating facial telangiectasias, especially facial subunits, which have bone support.

[Analysis of curative result for keloid with integrated methods]

OBJECTIVE

To study the curative effects of keloid by operation combined with postoperative beta radiation and silicone gel sheeting.

METHODS

From 1996 to 2002, 598 patients with keloid (243 males, 355 females, aging 15-55 years with an average of 28.6 years) were treated by integrated therapy. Their disease courses were from 6 months to 6 years. The keloid area ranged from 1.0 cm x 1.5 cm-8.0 cm x 15 cm. First, keloid was removed by operation, and then the wounds were sutured directly (group suture) or covered with skin graft (group graft). In group suture, the operational sites were managed by beta ray radiotherapy 24-48 hours after operation. The total doses of radiation were 12-15 Gy, 5 times 1 week (group suture A) and 10 times 2 weeks (group suture B). Radiotherapy was not taken until stitches were taken out in group graft, and then the same methods were adopted as group suture B. After radiotherapy, silicone gel sheeting was used in 325 cases for 3-6 months.

RESULTS

All patients were followed up for 12-18 months. (1) The overall efficacy was 91.3% in group suture A (n = 196), and 95.8% in group suture B (n = 383), respectively. There was significant difference between the two groups (P < 0.01). (2) Radiotherapy was of no effect in 6 cases of group graft (n = 19). (3) Silicone gel sheeting had effectiveness in 185 cases. Silicone gel sheeting had no obvious effect on the overall efficacy, but it could improve the quality of texture and color of skin.

CONCLUSION

By use of integrated methods to treat keloid, if the wound can be sutured directly, skin grafting should not be adopted. The results in group suture B are better than those in group suture A; silicone gel sheeting should be used as possible.

The use of silicon gel for treating children's burn scars in Saudi Arabia: a case study

This case study is presented to illustrate the effectiveness of silicon gel as an important option in burn scar treatment and to provide treatment guidelines that address cultural, clinical and patient compliance issues in Saudi Arabia. The case study involves an 18-month-old child whose burn scar was treated for a period of 15 months with silicon gel. The Vancouver Burn Scar Scale assessment (Baryza and Baryza, 1995), used to track progress across the duration of treatment, reflected an improvement in the scar as the composite score changed from 9 to 2. Strategies for problem solving and addressing needs unique to the environment of Saudi Arabia were also developed over the treatment period. The findings of this case study indicate that silicon gel may be a superior treatment option under certain circumstances. Further research with a wider sample is indicated, given the high incidence of childhood burn injuries in Saudi Arabia.

Protocol for retrieval and analysis of breast implants

The Center for Implant Retrieval and Analysis has been established at Washington University's Division of Plastic and Reconstructive Surgery for the purpose of studying implantable devices retrieved after surgery or autopsy and assessing their condition after implantation. Since the early 1990s, significant experience has been gained in testing and analyzing silicone gel breast implants and, to a lesser extent, saline-filled devices. However, there has been no systematic method reported for collecting and evaluating these implants in a way that would permit different laboratories to compare their data. This article offers the plastic and reconstructive surgery community a standardized protocol for analyzing explanted silicone gel and saline-filled breast implants. The protocol gives surgeons a clearly defined approach for removing, handling, documenting, and shipping explanted breast implants. At the same time, biomaterials researchers can use the protocol to acquire implant data with reliable and reproducible methods. Because the study of saline implants has lagged behind the study of silicone gel implants, the article concludes with a demonstration of how this protocol can be applied to obtain mechanical properties data and use scanning electron microscopy to illuminate failure mechanisms of saline devices, including three explants removed after 20+ years in vivo.