RESUMEN
The formation of a wide range of excessive scars following various skin injuries is a natural consequence of healing. Scars resulting from surgery or trauma affect approximately 100 million people per annum in the developed world and can have profound physical, aesthetic, psychological and social consequences. Thus, scar treatment is a priority for patient and physician alike. Laser treatment plays an important role in scar management with additional support from ancillary modalities. Subsequent to part 1: Burns scars, part 2 focuses on our strategies and literature review of treatment of keloid, hypertrophic, pigmented and acne scars where lasers are used in conjunction with other measures, and illustrated with case studies.
RESUMEN
INTRODUCTION: Significant controversy surrounds the effectiveness of negative pressure wound therapy although it has been in use for decades. Although many clinicians favor this modality in relation to its practicality, ease of use especially in complex wounds, it has faced the same challenges as other dressings in relation to evidence base of efficacy in relation to a number of outcome measures. In view of the current financial pressures on health care systems worldwide, this structured review systematically challenges the evidence for perioperative application of topical negative pressure (TNP) to split-thickness skin grafts (STSGs) through evidence-based critical appraisal, and extrapolate the mechanisms of action on the mechanisms through which TNP may aid wound healing. Weighted evidence-based recommendations regarding the impact of TNP on split skin graft quality and quantity of take as outcomes. METHODS: Phase 1: Structured literature search. Phase 2: Retrieved articles were critically appraised for rigor and methodological validity by 3 independent authors, then stratified according to a validated "levels of evidence" framework. Graded "current best evidence" recommendations could therefore be proposed. RESULTS: Of the 220 studies retrieved in the initial search, 38 studies satisfied our quality of evidence criteria. Current best evidence supports 2 complementary trends explaining the mechanisms whereby STSG benefits from TNP. Active stimulation of epithelial mitosis: TNP creates mechanical stretch which stimulates multiple signaling pathways up-regulating growth- and mitosis-associated epithelial transcription factors. Topical negative pressure also promotes microcirculatory flow (graft and wound edge), stimulates angiogenesis and basement membrane integrity (grade C). Prevention of complications: significant reduction of graft lift-off by edema, exudates, subgraft hematoma, and reduction of shear when compared to traditional dressings (grade B). Topical negative pressure promotes significant qualitative improvement in the final STSG result studies (level 1B). The role of TNP in prevention of infection is, however, equivocal and further research is required. No evidence of harm from TNP application was reported. CONCLUSIONS: Topical negative pressure increases quantity and quality of split skin graft take compared to traditional bolster dressings. The advantages are increased in irregularly contoured, technically difficult wounds and suboptimal recipient wound beds where it seems to be the best modality currently available. Large-scale randomized clinical controlled trials remain scanty in all areas of wound dressing research including negative pressure therapy.
