•Subjective scar measures have poor reliability unless repeated by more than one assessor.•Objective scar measures have been demonstrated to have good to excellent reliability.•Physical symptoms of ...scars such as pain and itch were found to be more important to patients compared to surface, area and colour although this finding was not sustained when corrected for multiple comparisons.
Research into the treatment of hypertrophic burn scar is hampered by the variability and subjectivity of existing outcome measures. This study aims to measure the inter- and intra-rater reliability of a panel of subjective and objective burn scar measurement tools.
Three independent assessors evaluated 55 scar and normal skin sites using subjective (modified Vancouver Scar Scale mVSS & Patient and Observer Scar Assessment Scale POSAS) and objective tools. The intra-class correlation coefficient was utilised to measure reliability (acceptable when >0.70). Patient satisfaction with the different tools and scar parameter importance were assessed via questionnaires.
The inter-rater reliabilities of the mVSS and POSAS were below the acceptable limit. For erythema and pigmentation, all of the Scanoskin and DSM II measures (except the b* value) had acceptable to excellent intra and inter-rater reliability. The Dermascan ultrasound (dermal thickness, intensity) had excellent intra- and inter-rater reliability (>0.90). The Cutometer R0 (firmness) had acceptable reliability but not R2 (gross elasticity). All objective measurement tools had good overall satisfaction scores. Patients rated scar related pain and itch as more important compared to appearance although this finding was not sustained when corrected for multiple comparisons.
The objective scar measures demonstrated acceptable to excellent intra- and inter-rater reliability and performed better than the subjective scar scales.
BACKGROUNDKeloid and hypertrophic scars represent an aberrant response to the wound healing process. These scars are characterized by dysregulated growth with excessive collagen formation, and can be ...cosmetically and functionally disruptive to patients.
OBJECTIVEObjectives are to describe the pathophysiology of keloid and hypertrophic scar, and to compare differences with the normal wound healing process. The classification of keloids and hypertrophic scars are then discussed. Finally, various treatment options including prevention, conventional therapies, surgical therapies, and adjuvant therapies are described in detail.
MATERIALS AND METHODSLiterature review was performed identifying relevant publications pertaining to the pathophysiology, classification, and treatment of keloid and hypertrophic scars.
RESULTSThough the pathophysiology of keloid and hypertrophic scars is not completely known, various cytokines have been implicated, including interleukin (IL)-6, IL-8, and IL-10, as well as various growth factors including transforming growth factor-beta and platelet-derived growth factor. Numerous treatments have been studied for keloid and hypertrophic scars,which include conventional therapies such as occlusive dressings, compression therapy, and steroids; surgical therapies such as excision and cryosurgery; and adjuvant and emerging therapies including radiation therapy, interferon, 5-fluorouracil, imiquimod, tacrolimus, sirolimus, bleomycin, doxorubicin, transforming growth factor-beta, epidermal growth factor, verapamil, retinoic acid, tamoxifen, botulinum toxin A, onion extract, silicone-based camouflage, hydrogel scaffold, and skin tension offloading device.
CONCLUSIONKeloid and hypertrophic scars remain a challenging condition, with potential cosmetic and functional consequences to patients. Several therapies exist which function through different mechanisms. Better understanding into the pathogenesis will allow for development of newer and more targeted therapies in the future.
BACKGROUNDIn 2002, an international advisory panel was convened to assess the scientific literature and develop evidence-based guidance for the prevention and treatment of pathologic scarring. ...Emerging clinical data, new treatment options, and technical advances warranted a renewed literature search and review of the initial advisory panel recommendations.
OBJECTIVETo update the management algorithm for pathologic scarring to reflect best practice standards at present.
MATERIALS AND METHODSManagement recommendations were derived from clinical evidence amassed during a comprehensive literature search and from the clinical experience and consensus opinion of advisory panel members.
RESULTSA combination approach using multiple modalities provides the maximum potential for successful treatment of hypertrophic scars and keloids. The advisory panel advocates a move toward more aggressive initial management of keloids, including earlier application of 5-fluorouracil. A growing body of clinical research supports a place in therapy for newer agents (e.g., bleomycin, onion extract, imiquimod, mitomycin C) and laser therapy (pulsed-dye, fractional) for scar management.
CONCLUSIONPrevention and treatment of pathologic scarring requires individualized care built upon the principles of evidence-based medicine and continues to evolve in step with technological and scientific advances.
To describe a surgical technique of laparoscopic resection of a cesarean scar pregnancy (CSP) with an immediate myometrial reconstruction. The advantage of such a technique is that it is a ...minimally-invasive procedure that can treat the ectopic pregnancy and the defected scar at the same time with good postoperative results.
Video article with the description of a surgical minimally-invasive technique.
Academic medical center.
A 34-year-old patient, Gravida 6 Para 4 Abortus 1, with a history of 4 previous cesarean sections presented to the emergency department with abdominal pain and vaginal bleeding. The patient was hemodynamically stable. An endovaginal ultrasound revealed a viable pregnancy of 8 weeks implanted in the cesarean scar, with a residual myometrium of <1 mm. Because of increasing abdominal pain, vaginal bleeding, and a desire to preserve future fertility, an emergent laparoscopy was performed.
Laparoscopy was performed using a CO2 AcuPulse laser device (Lumenis Inc. Salt Lake City, Utah). A continuous wave mode was used, with a power of 30 Watt and a round-shaped beam of 1.5 mm in diameter. The laser was connected to a 10-mm Hopkins endoscope 0° (Karl Storz, Tuttlingen, Germany). A complete adhesiolysis was performed, and the urinary bladder was detached from the anterior abdominal wall. The vesicouterine fold was opened to expose the isthmic part of the uterus where the ectopic pregnancy was implanted. The defected scar was resected en bloc with the pregnancy, using the laser. The limits of the resection depended on the residual myometrial thickness. We considered a myometrial thickness of >8 mm as healthy tissue. A metallic probe was introduced vaginally into the endocervix to differentiate the anterior part from the posterior part of the uterus. This probe facilitates the manipulation of the cervix and, thus, the laparoscopic intracorporeal suturing during the myometrial reconstruction. A 2-layered suturing was performed. The first layer of the suture consisted of 3 interrupted figure-of-8 sutures using a monofilament absorbable suture (Monocryl 0, ETHICON-Johnson and Johnson medical devices New Brunswick, New Jersey). A second superficial layer consisted of a continuous nonlocking suture using the same type of thread.
Laparoscopic excision of the CSP and immediate repair of the scar defect without any postoperative complications.
An emergent laparoscopy was performed, with excision of the CSP and immediate reconstruction of the residual myometrium. No complications occurred, the blood loss was estimated at 200 mL, and no blood transfusion was necessary. The patient was discharged 24 hours after the intervention. Six months after surgery, the remaining myometrial thickness was between 7 mm and 9.3 mm, and no residual cesarean scar defect (isthmocele) was visualized by ultrasound.
Cesarean scar pregnancy is a rare form of ectopic pregnancy. The incidence, however, is increasing as a consequence of the rising cesarean section rate. Different surgical and nonsurgical techniques have been described in the literature. Laparoscopic excision of a CSP is an effective and feasible technique with the advantage of an immediate myometrial reconstruction. The cesarean scar defect diminishes, and this potentially could improve the future fertility of the patient and decrease the probability of abnormal uterine bleeding and chronic pelvic pain.
Abordaje laparoscópico de embarazo en cicatriz de cesárea.
Describir una técnica quirúrgica de resección laparoscópica de un embarazo en cicatriz de cesárea (CSP) con reconstrucción miometrial inmediata. La ventaja de esta técnica es que es un procedimiento mínimamente invasivo que permite tratar el embarazo ectópico y el defecto de la cicatriz al mismo tiempo con buenos resultados postoperatorios.
Video articulo con la descripción de una técnica quirúrgica mínimamente invasiva.
Centro medico académico.
Paciente de 34 años, grávida 6 para 4 abortos 1, con una historia de 4 cesáreas previas se presenta en el servicio de urgencias con dolor abdominal y sangrado vaginal. La paciente estaba hemodinámicamente estable. Una ecografía transvaginal revela un embarazo viable de 8 semanas implantado en la cicatriz de cesárea, con un miometrio residual de <1mm. Debido al aumento del dolor abdominal, sangrado vaginal y deseo de preservar la fertilidad se realizó una laparoscopia de urgencia.
Laparoscopia realizada usando un dispositivo laser CO2 AcuPulse (Lumenis Inc. Salt Lake City, Utah). Se utilizó un modo de onda continua con una potencia de 30 Watt y un puerto redondo de 1.5mm de diámetro. El laser estaba conectado a un endoscopio 10-mm Hopkins 00 (Karl Storz, Tuttlingen, Germany). Se realizó una adhesiolisis completa, y la vejiga urinaria de separó de la pared abdominal anterior. La cicatriz defectuosa se eliminó en bloque con la gestación utilizando el láser. Los limites de la resección dependieron del espesor del miometrio residual. Consideramos el espesor miometrial de >8mm como tejido sano. Se introdujo una sonda metálica vaginalmente en el endocervix para diferenciar la parte anterior del útero de la posterior. Esta sonda facilita la manipulación del cérvix y, por tanto, la sutura laparoscópica intracorpórea durante la reconstrucción miometrial. Se realizó una sutura en dos capas. La primera capa de sutura consistió en 3 suturas ininterrumpidas con forma de 8 utilizando un monofilamento reabsorbible ((Monocryl 0, ETHICON-Johnson and Johnson medical devices New Brunswick, New Jersey). La segunda capa superficial consistió en una sutura continua sin cierre utilizando el mismo tipo de hilo.
Escisión laparoscópica de CSP y reparación inmediata de la cicatriz defectuosa sin complicación postoperatoria.
Se realizó una laparoscopia de urgencia con escisión del CSP y reconstrucción inmediata del miometrio residual. No ocurrieron complicaciones, la pérdida de sangre se estimó en 200ml, y no fue necesaria una transfusión de sangre. La paciente fue dada de alta 24h después de la intervención. Seis meses después de la cirugía, el espesor del miometrio residual era de entre 7mm y 9.3mm, y no se visualizó cicatriz residual (istmocele) mediante ecografía.
El embarazo en La cicatriz de cesárea es una forma rara de embarazo ectópico. La incidencia, sin embargo, esta aumentando debido a la tasa creciente de parto por cesárea. Diferentes técnicas quirúrgicas y no quirúrgicas han sido descritas en la literatura. La escisión laparoscópica de CSP es una técnica efectiva y reproducible con la ventaja de una reconstrucción miometrial inmediata. El defecto debido a la cicatriz de cesárea disminuye, y esto podría mejorar la fertilidad futura de la paciente y disminuir la probabilidad de sangrado uterino anormal y dolor pélvico crónico.
Deep dermal defects can result from burns, necrotizing fasciitis and severe soft tissue trauma. Physiological scar restriction during wound healing becomes increasingly relevant in proportion to the ...affected area. This massively restricts the general mobility of patients. External mechanical influences (activity or immobilization in everyday life) can lead to the formation of marked scar strands and adhesions. Overloading results in a renewed inflammatory reaction and thus in further restriction. Appropriate mechanical stimuli can have a positive influence on the scar tissue. "Use determines function," and even minimal external forces are sufficient to cause functional alignment (mechanotransduction). The first and second remarkable increases in connective tissue resistance (R1 and R2) seem to be relevant clinical indications of adequate dosage in the proliferation and remodulation phase, making it possible to counteract potential overdosage in deep dermal defects. The current state of research does not allow a direct transfer to the clinical treatment of large scars. However, the continuous clinical implementation of study results with regard to the mechanosensitivity of isolated fibroblasts, and the constant adaptation of manual techniques, has nevertheless created an evidence-base for manual scar therapy. The manual dosages are adapted to tissue physiology and to respective wound healing phases. Clinical observations show improved mobility of the affected regions and fewer relapses into the inflammatory phase due to mechanical overload.
In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of ...these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review.
All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available.
Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis.
Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.
Summary Improvements in acute burn care have enabled patients to survive massive burns that would have once been fatal. Now up to 70% of patients develop hypertrophic scars after burns. The ...functional and psychosocial sequelae remain a major rehabilitative challenge, decreasing quality of life and delaying reintegration into society. Approaches to optimise healing potential of burn wounds use targeted wound care and surgery to minimise the development of hypertrophic scarring. Such approaches often fail, and modulation of the established scar is continued although the optimal indication, timing, and combination of therapies have yet to be established. The need for novel treatments is paramount, and future efforts to improve outcomes and quality of life should include optimisation of wound healing to attenuate or prevent hypertrophic scarring, well-designed trials to confirm treatment efficacy, and further elucidation of molecular mechanisms to allow development of new preventive and therapeutic strategies.
The evidence base underpinning most traditional scar reduction approaches is limited, but some of the novel strategies are promising and accumulating. We review a number of commonly adopted ...strategies for scar reduction. The outlined novel agents are paradigmatic of the value of translational medical research and are likely to change the scenery in the much neglected but recently revived field of scar reduction therapeutics.
Background
In this study, we investigated the effect of matrix metalloproteinase-1 (MMP-1) on wound healing on skin in a model produced in rats.
Methods
Sixteen Sprague–Dawley male rats were included ...in the study. The four full-thickness skin wound was created on the dorsal area of each rat with 4.4 mm punch. The rats were randomly divided into two groups. MMP-1 and saline were administered intraperitoneally once daily for 7 days. The biopsies were taken from the separate wounds on the 4th, 7th, 14th and 21st days of the experiment. The lymphocytic response, vascular proliferation, fibroblast proliferation, epithelial hyperplasia, foreign body reaction, ulcer formation, acute inflammation, keloid scar formation and hypertrophic scar formation were compared in each group in histopathologically.
Results
In our study, epithelial hyperplasia on 14th day was significantly higher in the MMP-1 group compared to the control group (
p
< 0.05). The lymphocytic response on 4th and 21th days, the vascular proliferation on 4th day, the fibroblast proliferation on 4th and 7th days, the acute inflammation on 4th day and the hypertrophic scar formation on 7th, 14th, 21st days were significantly lower in the MMP-1 group compared to the control group (
p
< 0.05). No statistically significant difference was found in comparison with other parameters (
p
> 0.05).
Conclusions
MMP-1 improves the wound-healing process of skin with higher epithelial hyperplasia and reduces scar formation in the animal model. Therefore, MMP-1 can potentially be used as an effective anti-fibrogenic agent for preventing or treating the hypertrophic scar.
No Level Assigned
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
.
•Largest study to date on genetic variants associated with hypertrophic scarring.•No individual genetic variants achieved the cut-off threshold of significance.•Nervous system and cell adhesion gene ...pathways were associated with poor scar outcome.
After similar extent of injury there is considerable variability in scarring between individuals, in part due to genetic factors. This study aimed to identify genetic variants associated with scar height and pliability after burn injury. An exome-wide array association study and gene pathway analysis were performed on a prospective cohort of 665 patients treated for burn injury. Outcomes were scar height (SH) and scar pliability (SP) sub-scores of the modified Vancouver Scar Scale (mVSS). DNA was genotyped using the Infinium® HumanCoreExome-24 BeadChip. Associations between genetic variants (single nucleotide polymorphisms) and SH and SP were estimated using an additive genetic model adjusting for age, sex, number of surgical procedures and % total body surface area of burn in subjects of European ancestry. No individual genetic variants achieved the cut-off threshold of significance. Gene regions were analysed for spatially correlated single nucleotide polymorphisms and significant regions identified using comb-p software. This gene list was subject to gene pathway analysis to find which biological process terms were over-represented. Using this approach biological processes related to the nervous system and cell adhesion were the predominant gene pathways associated with both SH and SP. This study suggests genes associated with innervation may be important in scar fibrosis. Further studies using similar and larger datasets will be essential to validate these findings.
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