The impact of burn injuries on indigenous populations: A literature review.

INTRODUCTION: Ethnic minorities experience disparities in prevention and treatment of burn injury. Research focused on burn injuries in Indigenous populations is limited. This review summarizes literature on burn injuries in Indigenous populations to be considered to inform new research. METHODS: A search was conducted in CINAHL, Ovid MEDLINE, PSYCinfo and SocINDEX. for "burn OR scars OR scald OR deformity OR disfigurement" and "Aboriginal OR Indigenous OR First Nation OR American Indian OR Maori OR Native OR Torres Strait Islander OR Amerindian OR Inuit OR Metis OR Pacific Islander". Inclusion 1) peer reviewed studies of burns in Indigenous persons 2) in English. Exclusion 1) no data specific to Indigenous burns 2) not peer reviewed 3) not in full text 4) protocol publications. RESULTS: The search identified 1091 studies with 51 for review. Sixteen were excluded. The 35 included publications were published between 1987 and 2022. Findings indicated higher incidence of injury and poorer outcomes amongst Indigenous people. Indigenous people suffered more flame and inhalation burns, had longer lengths of stay, and more complications including hypertrophic scarring. Australian Indigenous patients struggle with a lack of culturally safe communication and support for aftercare. CONCLUSION: Racial disparities exist in burn injury incidence and outcome for Indigenous persons. Qualitative research in this area will help providers better understand the experiences of Indigenous burn patients to develop more culturally competent care. We are currently developing a study using qualitative hermeneutic methodology to learn about the experiences of Indigenous burn survivors' injuries, recovery, and social reintegration.

Safety assessment of the prophylactic use of silicone gel sheets (Lady Care®) for the prevention of hypertrophic scars following caesarean section.

This study aimed to investigate the side effects of silicone gel sheet (Lady Care®) and evaluate its prophylactic efficacy in preventing abnormal scarring. Sixty women who underwent caesarean section were recruited from September 2016 to September 2017 in this prospective study. Lady Care® was applied from the 2nd to the 6th postoperative months. Side effects of Lady Care® were evaluated through medical examinations and questionnaires. A plastic surgeon diagnosed abnormal scarring. Pruritus was diagnosed in 25 (47.2%) patients; folliculitis, four (7.5%); dry skin, four (7.5%); contact dermatitis, three (5.7%); wound infection, two (3.8%); and epidermolysis, one (1.9%), albeit with mild severity. Following Lady Care® application, no abnormal scarring and mild hypertrophic scarring was observed in 32 (64.0%) and 18 (36.0%) patients respectively. Of seven patients with pre-existing hypertrophic scars, only two showed hypertrophic scarring after Lady Care® application. Our findings support the safety and prophylactic efficacy of Lady Care®.Impact StatementWhat is already known on this subject? The incidence of abnormal scarring, i.e. keloid or hypertrophic scar formation after caesarean section (CS) is reported to be ∼41%. Abnormal or excessive scar formation can lead to functional limitations, pruritus, pain and cosmetic issues. Studies have also shown a prophylactic effect of the application of silicone materials against the development of hypertrophic and keloid scars, though prohibitive cost and lack of adhesiveness of such gel sheets are known factors limiting their usage.What the results of this study add? The new silicone gel sheet 'Lady Care®' has strong adhesive properties and is consequently not easily peeled off. Furthermore, it is easy to use and economically efficient.What the implications are of these findings for clinical practice and/or further research? This is the first clinical trial on the application of Lady Care® silicone gel sheet for the prevention of CS scarring. Our findings support the safety and prophylactic efficacy of Lady Care®.

Pediatric burn contractures in low- and lower middle-income countries: A systematic review of causes and factors affecting outcome.

In low- and lower middle-income countries (LMICs), timely access to primary care following thermal injury is challenging. Children with deep burns often fail to receive specialized burn care until months or years post-injury, thus suffering impairments from hypertrophic scarring or joint and soft tissue contractures. We aimed to examine the correlation between limited access to care following burn injury and long-term disability in children in LMICs and to identify specific factors affecting the occurrence of late burn complications. A systematic literature search was conducted to retrieve articles on pediatric burns in LMICs using Medline, Embase, the Cochrane Library, LILACS, Global Health, African Index Medicus, and others. Articles were assessed by two reviewers and reported in accordance with PRISMA guidelines. Of 2896 articles initially identified, 103 underwent full-text review and 14 met inclusion criteria. A total of 991 children who developed long-term burn sequelae were included. Time from injury to consultation ranged from a few months to 17 years. Factors associated with late complications included total body surface area burned, burn depth, low socio-economic status, limited infrastructure, perceived inability to pay, lack of awareness of surgical treatment, low level of maternal education, and time elapsed between burn injury and reconstructive surgery.

Perioperative Care Considerations and Management of Complications Involving Surgical and Technology Procedures.

Technology impacts the lives of everyone nowadays and has had perhaps a greater impact on the lives of facial plastic surgeons and the patients they seek to help with both surgery and procedures. This article will discuss modern technology's impact on intervening in the aging process including technology used for facial and skin rejuvenation and reconstruction concentrating on the techniques and care to minimize complications as well as dealing with complication from the treatments.

Cultural adaptation and validation of Patient and Observer Scar Assessment Scale for Turkish use.

BACKGROUND: This study aimed to evaluate cross-cultural adaptation, validation, and reliability of Patient and Observer Scar Assessment Scale (POSAS) for its Turkish use. METHOD: This study included 50 burn patients with hypertrophic scars who were aged 18-65 years (mean, 37.5±1.4years) and were admitted to Wound and Burn Treatment Center from February 2014 to April 2014. With regard to the cultural adaptation of POSAS from English to Turkish, the scale was translated by two people who worked in different health fields. POSAS was administered to the patients with a 1-week interval to evaluate the validity and reliability of the scale. Internal consistency of the scale was tested using the Cronbach alphamethod. RESULTS: The Cronbach alpha value for the observer measurements was found to be 0.93 (excellent), and that for patient measurements was found to be 0.77 (good). Accordingly, the internal consistency of the scale was established. CONCLUSION: The Turkish version of POSAS is a valid, reliable and culturally appropriate survey for evaluating hypertrophic scars. We believe that the Turkish version of POSAS will be an important clinical/scientific tool in the field of burn physiotherapy in Turkey, which will lead to new researches in this field.

Hypertrophic Burn Scar Research: From Quantitative Assessment to Designing Clinical Sequential Multiple Assignment Randomized Trials.

This article explores the current options for the quantitative assessment of hypertrophic burn scars. It also introduces a novel type of randomized, controlled trial, which relies on heterogeneity of the subject population to improve the predictive value of personalized treatment strategies.

Evaluating accuracy and reliability of active stereophotogrammetry using MAVIS III Wound Camera for three-dimensional assessment of hypertrophic scars.

OBJECTIVE: Current strategies for estimating positive scar volume following burns is limited to employing subjective scar scales. This study assesses the accuracy and reliability of Measurement of Area and Volume Instrument System (MAVIS) III, a portable 3D active stereophotogrammetric imaging system, for non-invasive assessment of hypertrophic scar volume and elucidates factors that leads to inaccurate volume determination. METHODS: To determine accuracy, hypertrophic scars arising in various skin and wound types were modeled using moldable putty substance. Volumetric measurements calculated by the camera's software were compared to measurements determined by fluid displacement. To assess inter-rater reliability, 25 images of patients with hypertrophic scars on various anatomical regions (hand, arm, leg, and flank area) were assessed by three blind evaluators. RESULTS: Volumetric measurements obtained from MAVIS III ranged from adequate to excellent accuracy (Pearson's correlation coefficient of 0.54-0.90) compared to measurements determined by fluid displacement. The reliability of volume determination of human hypertrophic scars was rated excellent (overall Intraclass correlation coefficient of 0.95). CONCLUSIONS: This study finds that MAVIS III is accurate in its volumetric measurements and is reliable between users; making it a potential candidate for non-invasive assessment of hypertrophic scars. Further considerations for refining active stereo-photogrammetry and the user interface of the software are also highlighted to allow superior evaluation of scar volume.

Assessment of the Combined Efficacy of Needling and the Use of Silicone Gel in the Treatment of C-Section and Other Surgical Hypertrophic Scars and Keloids.

OBJECTIVE: To evaluate the individual effectiveness of needling therapy using the Dermapen (Dermapen, Salt Lake City, Utah) and topical therapy with silicone gel (Kelo-cote, Sinclair Pharma, London, England), and their combined effectiveness for the treatment of linear surgical scars, hypertrophic scars, and keloids. MATERIALS AND METHODS: Twenty patients were randomly selected and equally divided into 2 groups (A and B), with each group of 10 including 6 patients with keloids and 4 with hypertrophic scars. Treatment assignments were random. In group A, the entire scar was treated by skin needling, with silicone gel applied to half of the scar. Patients in group B were treated with silicone gel on the whole scar, with only half of the scar also treated with skin needling. During follow-up visits, clinical photographs, evaluation of the scars' thickness, skin ultrasound, and modified Vancouver Scar Scale were performed. RESULTS: Group A showed an average improvement of 68% (P < .01) on the half of the scar with the combination treatment (skin needling plus silicone gel) compared with a 52% improvement on the half of the scar that was treated with only skin needling. Group B showed an average improvement of 63% (P < .01) where the combination treatment was performed, compared with 47% improvement on the area treated with only the silicone gel. CONCLUSIONS: In conclusion, the combination of these 2 treatments is safe and effective for the treatment of hypertrophic scars and keloids. These modalities achieved favorable results with each patient adhering to the study paramenters.

A validation study of scar vascularity and pigmentation assessment using dermoscopy.

INTRODUCTION: Vascularity and pigmentation are two important indicators of the maturing status of hypertrophic scars. We used the dermoscope to measure vascularity and pigmentation of hypertrophic scars to examine its validity and reliability. MATERIALS AND METHOD: Eighteen subjects were assessed using the Vancouver Scar Scale (VSS), spectrocolorimeter and dermoscope. Correlations between the measurements by these tools and reliability parameters were examined. RESULTS: A strong correlation was found between the redness measured by spectrocolorimeter and the RGB redness values of dermoscope pictures (r=0.890). A correlation was found between the lightness measured by spectrocolorimeter and the lightness of dermoscope pictures (r=0.536), and between the lightness by spectrocolorimeter and the blanched dermoscope pictures (r=0.448). The calculated RGB values of redness of the dermoscope correlated with the VSS vascularity score (r=0.625); the transformed VSS pigmentation score correlated with the lightness of the blanched dermoscope pictures (r=0.783). The intra-class correlation coefficient (3, 1) of the dermoscope was 0.980 for the redness measurement and 0.965 for the lightness measurement, while the intra-class correlation coefficient (2, 2) was 0.930 for the dermoscope redness measurement and 0.871 for the dermoscope lightness. CONCLUSION: The dermoscope is a promising objective tool for vascularity and pigmentation assessments of hypertrophic scars with good validity and reliability.

A multimodal assessment of melanin and melanocyte activity in abnormally pigmented hypertrophic scar.

Using a validated swine model of human scar formation, hyperpigmented and hypopigmented scar samples were examined for their histological and optical properties to help elucidate the mechanisms and characteristics of dyspigmentation. Full-thickness wounds were created on the flanks of red Duroc pigs and allowed to heal. Biopsies from areas of hyperpigmentation, hypopigmentation, and uninjured tissue were fixed and embedded for histological examination using Azure B and primary antibodies to S100B, HMB45, and α-melanocyte-stimulating hormone (α-MSH). Spatial frequency domain imaging (SFDI) was then used to examine the optical properties of scars. Hyperpigmentation was first noticeable in healing wounds around weeks 2 to 3, gradually becoming darker. There was no significant difference in S100B staining for the presence of melanocytes between hyperpigmented and hypopigmented scar samples. Azure B staining of melanin was significantly greater in histological sections from hyperpigmented areas than in sections from both uninjured skin and hypopigmented scar (P < .0001). There was significantly greater staining for α-MSH in hyperpigmented samples compared with hypopigmented samples (P = .0121), and HMB45 staining was positive for melanocytes in hyperpigmented scar. SFDI at a wavelength of 632 nm resulted in an absorption coefficient map correlating with visibly hyperpigmented areas of scars. In a red Duroc model of hypertrophic scar formation, melanocyte number is similar in hyperpigmented and hypopigmented tissues. Hyperpigmented tissues, however, show a greater amount of melanin and α-MSH, along with immunohistochemical evidence of stimulated melanocytes. These observations encourage further investigation of melanocyte stimulation and the inflammatory environment within a wound that may influence melanocyte activity. Additionally, SFDI can be used to identify areas of melanin content in mature, pigmented scars, which may lead to its usefulness in wounds at earlier time points before markedly apparent pigmentation abnormalities.

Logistics of building a laser practice for the treatment of hypertrophic burn scars.

INTRODUCTION: Although lasers can improve burn scars, such treatment has not been adopted universally, due to operational challenges starting a practice and the perception that such a program is not financially viable. We report the logistics of building a laser practice for the treatment of hypertrophic burn scars. METHODS: We analyzed the clinical, operational, and financial components of our laser practice, focusing on treatment of hypertrophic burn scars, using pulsed dye laser, fractional CO2 laser, and intense pulsed light. Cases were performed in an operating room, with anesthesia, after preauthorization. We examined professional charges and collections, case time, variable and indirect expenses, and breakeven volumes. RESULTS: Our practice grew as follows: 2008, 1 case; 2009, 44 cases; 2010, 169 cases; and 2011, 415 cases. Overall collection rate was 32.1%. Expenses incurred by the provider, per 8-hour session, included laser rental/lease ($2375), personnel salaries ($1900), and physician overhead ($808), for a total cost of $5083. Mean charge was $1642 per case; mean collection was $527 per case. Median case time (procedure plus turnover) was 40 minutes. In this model, breakeven volume is 9.7 cases per day; breakeven time is 49.7 minutes. Provider profit margin for 10 cases per day, or 83% capacity utilization, is $187 per day (income - expenses = $5270 - $5083). CONCLUSIONS: Despite high costs associated with starting and operating a laser practice for the treatment of hypertrophic burn scars, a sustainable enterprise can be achieved when the provider has accrued enough volume to batch cases over an entire day. Critical to achieving breakeven is preauthorization, controlling overhead, and efficient throughput.

Incidence and management of adverse events after the use of laser therapies for the treatment of hypertrophic burn scars.

INTRODUCTION: Hypertrophic burn scars may generate significant morbidity, due to intense pruritus, persistent dysesthesias, and contracture. Although treatment with pulsed dye laser and fractional CO2 laser may improve symptoms, incidence of secondary wound complications is not well known. We examined the adverse event profile of laser therapies for the treatment of hypertrophic burn scars. METHODS: We performed a descriptive, retrospective, 6-month study of all patients who underwent laser therapies, at an accredited regional burn center, to improve the vascularity, texture, thickness, and stiffness of symptomatic burn scars. Data regarding skin type, mechanism, area treated, and laser parameters were collected. Main outcome measures included pigmentation changes, blistering, rash, infection. χ analysis and Student t test were used to evaluate associations between variables. RESULTS: A total of 95 patients underwent 163 treatment sessions (mean, 2.7 sessions/patient) with pulsed dye laser (71%), CO2 laser (22%), and other lasers (7%). Forty-one adverse events were recorded: hyperpigmentation (2%), hypopigmentation (12%), mild blistering (27%), pain (37%), rash (7%), fever (10%), and infection (2%). Patients with scald burns were more likely to develop blistering, rash, and fever after treatment (all P < 0.05). Higher Fitzpatrick skin type was associated with hypopigmentation and blistering, whereas CO2 laser was associated with increased postoperative pain (all P < 0.05) CONCLUSIONS: Despite the frequent occurrence of pain and mild blistering after laser treatment of hypertrophic burn scars, major adverse effects were exceedingly rare, with improvement noted in all patients. Patients with higher Fitzpatrick skin types must be handled with care, to avoid complications of blistering and hypopigmentation.

A modified Vancouver Scar Scale linked with TBSA (mVSS-TBSA): Inter-rater reliability of an innovative burn scar assessment method.

BACKGROUND: Current scar assessment methods do not capture variation in scar outcome across the burn scar surface area. A new method (mVSS-TBSA) using a modified Vancouver Scar Scale (mVSS) linked with %TBSA was devised and inter-rater reliability was assessed. METHOD: Three raters performed scar assessments on thirty patients with burn scars using the mVSS-TBSA. Scoring on pigmentation, vascularity, pliability and height was undertaken for the 'best' and 'worst' areas of each scar. Raters allocated the total body surface area of the scar (%TBSA) to three mVSS categories (<5, 5-10, >10). Intra-class correlation coefficient (ICC) and weighted kappa statistic (kw) were used to assess inter-rater reliability. The data were also analysed for clinically relevant misclassifications between pairs of raters. RESULTS: Total mVSS scores showed 'fair to good' agreement (ICC 0.65-0.73) in the 'best' area of the scar while there was 'excellent' agreement in the 'worst' scar area (ICC 0.85-0.88). The kw of the individual mVSS components ranged from 0.44 to 0.84 and 0.02 to 0.86 for 'best' and 'worst' scar areas, respectively. Determination of scar %TBSA had 'excellent' reliability (ICC 0.91-0.96). Allocation of scar %TBSA to severity category <5 mVSS demonstrated 'good to excellent' reliability (ICC 0.63-0.80) and 'fair to good' reliability (ICC 0.42-0.74) for 5-10 mVSS category. However, misclassifications were observed for the total mVSS score in the 'worst' scar area and the allocation of scar %TBSA in the <5 mVSS category. CONCLUSION: Inter-rater reliability of mVSS scores depends on the severity of the scar area being assessed. The mVSS-TBSA method of allocation of scar %TBSA to two broad mVSS categories, namely <5 and ≥5 mVSS, has 'good to excellent' reliability. The mVSS-TBSA has demonstrated utility for both clinical and research purposes; however, there is potential to misclassify scar outcome in some cases.

Harnessing the Transparent Face Orthosis for facial scar management: a comparison of methods.

The Transparent Face Orthosis (TFO) is widely used in the treatment of facial burns to minimize hypertrophic scarring and maintain the contours of the face against deforming scars. Compression of the TFO is achieved with forces provided by the harness system (straps and anchors) used to secure the TFO on the face. A variety of harness system designs are used clinically yet none have been described or compared in the literature. The purpose of this study was to compare seven common methods of TFO harnessing including cost, time, and ease of fabrication. Results showed that harness systems vary in cost from $0.22 to 96.45 and take 2-49 min to fabricate. The 4-point harness was the least expensive and the easiest harness to fabricate. The Beanie Cap harness was the most complex system to make, while the Open Mask Stabilizer was the most expensive. The systems resulted in varying distributions of compression when depicted with three-dimensional laser scanned images. This description and comparison of fabrication materials and methods for TFO harnessing can guide clinicians within the burn community worldwide who have varying skills and resources for facial scar management.

Surgical excision of extensive anal condylomata is a safe operation without risk of anal stenosis.

INTRODUCTION: Anal condylomata acuminata was a well-known disease in ancient times but in recent years there has been a rapidly increasing number of people who suffer from this disease. The main cause of this disease is infection of human papilloma virus (HPV) which occurs through sexual contact. Currently there are three different ways to treat anal condylomata. Small changes of anal condylomata can be treated with local therapeutic agents, but the best results of treatment of extensive changes are obtained by surgical techniques. MATERIAL/METHODS: The study group consisted of 30 patients with diagnosed extensive anal condylomata who underwent surgery in Mikolaj Pirogow High Specialized Hospital in Lodz. The survey was conducted from 2007 to 2011. Patients had been directed to the surgical ward by general surgeons and practitioners, proctologists and urologists. The diagnosis was made after proctological assessment in the knee-chest position. RESULTS: All patients underwent surgery and had complete macroscopic electroexcision of anal condylomata. In the research group there was no mortality. Postoperative complications occurred in 4 (13.3%) patients--postoperative bleeding. Strong pain was present in 14 (46.7%) patients but only in the postoperative period. During postoperative follow-up there was no observed infection in the anal region or recurrence of disease. In the operated group there were no observed cosmetic deformations of the anus and/or the anal canal, narrow anal canal or functional fecal incontinence symptoms. CONCLUSIONS: Surgical treatment of anal condylomata is an effective and safe method for the patient. In our research there were no serious postoperative complications or recurrence of the disease during the follow-up period.

Absorbable versus nonabsorbable sutures in the management of traumatic lacerations and surgical wounds: a meta-analysis.

OBJECTIVES: To complete a systematic review of randomized controlled trials (RCTs) that compare the cosmetic outcomes and complications of traumatic lacerations and surgical incisions closed with absorbable sutures versus nonabsorbable sutures. DESIGN/METHODS: We searched MEDLINE, EMBASE, and Cochrane Central to identify all RCTs comparing absorbable versus nonabsorbable sutures that assessed cosmetic outcomes or complications. Reference lists of all identified trials were also searched. Two independent reviewers screened abstracts for eligibility, extracted study data, and assessed trial quality. Disagreements were resolved by consensus or a third party. RESULTS: Three hundred thirty-eight citations were retrieved, of which 7 met inclusion criteria. Studies were heterogeneous with respect to specific interventions and outcome measures; sample sizes ranged from 44 to 166. There was no statistically significant difference between absorbable and nonabsorbable sutures in short- or long-term cosmetic score, scar hypertrophy, infection rate, wound dehiscence, and wound redness/swelling. CONCLUSIONS: Our meta-analysis suggests a lack of large, methodologically sound RCTs evaluating the effectiveness of absorbable versus nonabsorbable sutures. Although our analysis demonstrates that nonabsorbable sutures seem to be no better than absorbable sutures in the management of wound repair, a large methodologically sound RCT is needed to adequately answer this question.

The assessment of erythema and thickness on burn related scars during pressure garment therapy as a preventive measure for hypertrophic scarring.

The aim of this study was threefold: (1) Assess the pressure loss of two types of pressure garments that are used in the treatment of hypertrophic scars after burn injury, (2) investigate the influence of two different levels of compression on erythema and thickness of burn scars and (3) examine the association between erythema and thickness. The study was a prospective trial in which 76 burn scars in 60 patients were objectively assessed with the Minolta Chromameter CR-300 for erythema and with the Dermascan C for thickness of the scar over a period of 3 months. Each patient was randomly assigned to a "normal" or "lower" compression class treatment, with respectively mean values of 15 and 10 mmHg pressure after wearing the garment for 1 month. Measurements for both parameters were taken at 0, 1, 2 and 3 months of treatment. Pressure garments with "normal" compression did lose significantly more compression over 1 month (4.82 mmHg) than did the garments from the low compression class (2.57 mmHg). Scars that were treated with garments from a "normal" compression class did score significantly better for thickness compared to the "low" compression class. The difference in thickness was most evident at 1 month. Thereafter no further significant improvement between the two different treatments over time could be obtained. This difference was not found for erythema. Positive correlations could be found between erythema and thickness values at all of the three test points while changes in erythema and thickness only correlated significantly after the first month. The pattern of change of both parameters correlated at a high level of significance after 3 months of treatment. These data suggest that pressure garments that deliver a pressure of at least 15 mmHg pressure tend to accelerate scar maturation and that measurements of the pattern of change of the erythema can be used to predict changes in scar thickness and vice versa.

Objective assessment of burn scar vascularity, erythema, pliability, thickness, and planimetry.

BACKGROUND: There is currently a lack of objective methods to assess scars. OBJECTIVES: The objectives of this study were to (1) determine the pattern of scar formation up to 24 months after a burn, compare clinical and photographic scar assessment, and determine what percentage of scars became hypertrophic after a major trauma and (2) replace each clinical parameter of a clinical scar scale by objective measurements. METHODS: Scars from 62 patients were evaluated from the acute phase up to 24 months after the burn, using photographs and clinical assessment during visits. Photographic planimetry helped estimate the percentage of scars that became hypertrophic. Thereafter, 69 patients had scars evaluated using clinical assessment and several instruments to evaluate pigmentation, erythema, pliability, thickness, and perfusion. The sensitivity and specificity of each instrument were determined regarding their ability to correlate with the parameters of hypertrophic and nonhypertrophic scars. Analysis of variance and Tukey's test were used in statistical analysis, with p<.05 indicating significance. RESULTS: Increased scar hypertrophy occurred between 6 and 12 months after the burn, and less than 30% of scars were hypertrophic at 18 to 24 months. Objective assessment of pliability and erythema, but not pigmentation, correlated significantly with clinical evaluation of hypertrophy. Hypertrophic scars had significantly higher perfusion than nonhypertrophic scars. A new scar rating system is proposed, based on the sensitivity and specificity of each instrument, to correlate with hypertrophic and nonhypertrophic scars. CONCLUSIONS: Objective rating systems using reliable instruments can be used to replace subjective scar assessment. Larger multicenter prospective studies should test this new scale in scars due to other mechanisms of injury.