Efficacy of Massage Techniques for Hypertrophic Burn Scars - A Systematic Review of Literature.

Despite advancements in burn care, evidence estimates that pathological scarring occurs in 32%-75% of cutaneous burns. Scar massage therapy is an under researched method of management for hypertrophic burn scars which has scope to be a low-cost treatment alternative. The aim of this systematic review was to determine the efficacy of scar massage techniques for common hypertrophic burn scar symptoms such as contraction, pruritus, pain and visibility. The keywords and corresponding MeSH terms were inputed into PubMed, EMBASE, Cochrane database of Systematic Reviews, University Library of Hull, York and Queen Mary, University of London. Following the implementation of predetermined inclusion and exclusion criteria, ten papers were included for data extraction. Quality assessment of all papers was performed using the Cochrane Risk of Bias tool and ROBINS-I tool. Data pertaining to the nature of the participant demographics, scar massage treatment, and study outcomes was extracted. Nine of the ten studies showed a significant improvement for scar massage treatment of hypertrophic burn scar symptoms despite using different massage techniques. Friction and oscillation massage was used in partnership to improve scar function, whereas effleurage and petrissage used in longer sessions was seen to improve scar visibility and pain. Scar pruritus was improved by each massage technique. Scar massage has been shown to be effective at improving scar outcomes. This paper suggests massage techniques should be tailored to the patients' symptoms. A large, randomized control trial is required to advance this area of research.

Massage, laser and shockwave therapy improve pain and scar pruritus after burns: a systematic review.

QUESTIONS: In adults with a burn injury, do non-invasive therapies improve pain and burn scar pruritus, elasticity and vascularisation? Are any effects maintained beyond the intervention period? DESIGN: Systematic review of randomised trials with meta-analyses. PARTICIPANTS: Adults with burn scars. INTERVENTION: The experimental intervention was a non-invasive (ie, non-surgical or non-pharmacological) therapy applied to the burn scar. OUTCOME MEASURES: Pain intensity, pruritus intensity, elasticity and vascularisation. RESULTS: Fifteen trials involving 780 participants were included. The results indicated a beneficial effect on pain intensity on a 0-to-10 scale after massage (MD -1.5, 95% CI -1.8 to -1.1), shockwave therapy (MD -0.8, 95% CI -1.2 to -0.4) and laser (MD -4.0, 95% CI -6.0 to -2.0). The results indicated a beneficial effect on pruritus intensity on a 0-to-10 scale after massage (MD -0.4, 95% CI -0.7 to -0.2), shockwave therapy (MD -1.3, 95% CI -2.3 to -0.3) and laser (MD -4.8, 95% CI -6.1 to -3.5). Massage, shockwave therapy and silicone produced negligible or unclear benefits on scar elasticity and vascularisation. The quality of evidence varied from low to moderate. CONCLUSION: Among all commonly used non-invasive therapies for the treatment of burn scars, low-to-moderate quality evidence indicated that massage, laser and shockwave therapy reduce pain and the intensity of scar pruritus. Low-to-moderate quality evidence suggested that massage, shockwave therapy and silicone have negligible or unclear effects for improving scar elasticity and vascularisation. REVIEW REGISTRATION: PROSPERO (CRD42021258336).

Effectiveness of various methods of manual scar therapy.

BACKGROUND: The skin is a protective barrier of the body against external factors, and its damage leads to a loss of integrity. Normal wound healing results in a correct, flat, bright, and flexible scar. Initial skin damage and patient specific factors in wound healing contribute that many of these scars may progress into widespread or pathologic hypertrophic and keloid scars. The changes in cosmetic appearance, continuing pain, and loss of movement due to contracture or adhesion and persistent pruritis can significantly affect an individual's quality of life and psychological recovery post injury. Many different treatment methods can reduce the trauma and surgical scars. Manual scar treatment includes various techniques of therapy. The most effectiveness is a combined therapy, which has a multidirectional impact. Clinical observations show an effectiveness of manual scar therapy. MATERIAL AND METHODS: The aim of this work was to evaluate effectiveness of the scar manual therapy combined with complementary methods on the postoperative scars. Treatment protocol included two therapies during 30 min per week for 8 weeks. Therapy included manual scar manipulation, massage, cupping, dry needling, and taping. RESULTS: Treatment had a significant positive effect to influence pain, pigmentation, pliability, pruritus, surface area, and scar stiffness. Improvement of skin parameters (scar elasticity, thickness, regularity, color) was also noticed. CONCLUSION: To investigate the most effective manual therapy strategy, further studies are needed, evaluating comparisons of different individual and combined scar therapy modalities.

The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Evolution of compressive mechanical properties of early hypertrophic scar during laser treatment.

Laser therapy has been widely used in the treatment of hypertrophic scars (HPS), but whether the mechanical properties of HPS tissue after laser treatment can be restored to those of normal skin remains unclear. In this paper, the relationship between the evolution of compressive mechanical properties and histological changes of HPS tissues following three successive combined pulsed dye laser (PDL) and fractional CO2 laser (CO2) treatments was investigated by compression tests and histological analysis. The early HPS model of rabbit ear was established by CO2 laser ablation. The loading-unloading tests and strain creep tests under the compression forces of 1 N, 2 N, and 3 N were carried out for normal skin, untreated HPS and HPS after different treatment times, respectively. The results showed that the compression ratio λ of all tissues revealed force dependence and rose with the increasing compression force, which was similar to the trend of most biological soft tissues. The histological changes of HPSs following laser treatment have a significant influence on the compressive mechanical response. Compared with the normal skin, the toughness and anti-deformation ability of HPS reduced due to the proliferation of collagen fibers and the destruction of elastic fibers, resulting in higher energy dissipation, compression ratio λ, and stable creep rate D, and lower elastic modulus. After three successive combined PDL/ CO2 laser treatments, the compressive mechanical properties and creep properties of HPS gradually approached that of the normal skin owing to the gradual restoration of the amount and distribution of collagen and elastic fibers in HPS. The results provide a new method for evaluating the clinical efficacy of laser therapy for treatment of HPS tissue.

The effectiveness of long Pulsed Nd:YAG Laser alone for treatment of keloids and hypertrophic scars versus its combination with bleomycin.

BACKGROUND AND OBJECTIVES: Pathological scars are benign hyper-proliferative growths of dermal collagen that causes severe psychological and physical problems. This study was performed to assess and compare safety and clinical efficiency of combined pulsed Nd-YAG laser and intralesional bleomycin versus pulsed Nd-YAG laser alone to treat the hypertrophic scars and keloids. PATIENTS AND METHODS: Randomly, 40 patients with hypertrophic scars or keloids were divided into two groups A and B. Group A were handled by pulsed Nd:YAG laser and intralesional bleomycin while group B were handled by pulsed Nd:YAG laser only. Response was assessed subjectively by clinical imaging and modified Vancouver Scar Scale (mVSS). While for objective evaluation, skin biopsies were taken from volunteer patients before and after treatment, and were examined by Hematoxylin and eosin staining (H&E) and Masson trichrome staining. RESULTS: Our study demonstrated almost complete improvement in 4 (20%) patients, partial improvement in 16 (80%) patients and 0 patient with no improvement in group A. Furthermore, in group B, we demonstrated almost complete improvement in 2 (10%) patients, partial in 14 (70%) patients and no improvement in 4 (20%) patients. Modified Vancouver Scar Scale reduced from 10.15 to 3.5 in group A and from 11.05 to 4.95 in group B. Elastica Masson-Goldner staining and Hematoxylin and eosin staining showed that treatment in both groups structurally changed tissue collagen. CONCLUSION: Long-pulsed Nd-YAG laser combined with intralesional bleomycin could be a promising way for treatment of keloids or hypertrophic scars.

Evidence-Based Nutritional Interventions in Wound Care.

BACKGROUND: The role of nutritional intervention in wound care has been a topic of controversy. Although the efficacy of macronutrient supplementation has been well described, there is a paucity of evidence and no official recommendation regarding the use of vitamins and minerals to optimize wound healing. This is the first review of vitamin and mineral wound intervention that systematically summarizes the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and distills the evidence by wound type. METHODS: In this comprehensive review, the authors outline the nutrients and delivery methods used in the identified studies, analyze reported treatment outcomes, summarize nutrient effectiveness, and propose evidence-based conclusions to improve wound healing outcomes and enhance the consistency of nutritional intervention in wound care. RESULTS: Thirty-six studies with a combined total of 2339 patients investigated the use of oral, topical, or intravenous vitamin and/or mineral supplementation for treatment of the following wound types: burn wounds (n = 3), pressure ulcers (n = 7), diabetic ulcers (n = 4), venous ulcers (n = 7), digital ulcers (n = 1), skin incisions (n = 9), hypertrophic scars (n = 4), and sinonasal wounds (n = 1). Improved outcomes were reported in patients with burn wounds receiving vitamins A, B1, B6, B12, D, and E and zinc, calcium, copper, magnesium, selenium, and zinc; patients with pressure ulcers receiving vitamin C and zinc; patients with diabetic ulcers receiving vitamin A, B9, D, and E; patients with venous ulcers receiving zinc; and patients with hypertrophic scars receiving vitamin E. CONCLUSIONS: Based on the high-level data provided in this review, the use of specific nutritional interventions may improve the outcome of certain wound types. Further investigation is warranted to draw definitive conclusions.

Hypertrophic Scar Outcomes in Fractional Laser Monotherapy Versus Fractional Laser-Assisted Topical Corticosteroid Delivery: A Randomized Clinical Trial.

Topical corticosteroid delivery following fractional laser treatment is an effective means of treating hypertrophic scars. However, the relative efficacy of adjuvant corticosteroid treatment vs fractional laser mono-therapy alone is unclear. The aim of this study was to compare the efficacy and safety of fractional laser-assisted topical corticosteroid delivery with fractional laser monotherapy in the treatment of hyper-trophic scars. In this randomized, comparative, split-scar trial of 19 subjects, a borderline significant reduction in scar thickness was observed at 3-month follow-up in the laser+steroid group compared with laser+petrolatum (p = 0.049). However, no significant long-term difference in scar flattening was observed between the 2 groups. Patient and Observer Scar Assessment Scale scores showed significant improvement in scar appearance from baseline without significant differences between treatment groups. In conclusion, fractional laser monotherapy is an effective treatment for hypertrophic scars, and the application of topical corticosteroid provides no long-term synergistic effect to fractional laser monotherapy.

Comparison between the portable pressure measuring device and PicoPress® for garment pressure measurement on hypertrophic burn scar during compression therapy.

PURPOSE: The current standard treatment for hypertrophic scars following burn injury is pressure garment therapy. The experimenters developed the novel portable pressure measuring device using silicon piezoresistive sensors. As PicoPress® is the most accurate (i.e., lowest variation and error) manometric sensor for pressure measurement, we sought to compare and examine the accuracy of the novel device regarding in vitro pressure measurements at the hypertrophic scar-pressure garment interface. METHODS: The novel device was designed to operate in non-corrosive media, such as air. The device can use up to six pressure sensing points and was developed to adjust the number of pressure sensors according to the size of the scar. Pressure measurements were acquired through a readout circuit consisting of an analog-to-digital converter, a microprocessor, and a Bluetooth transmission module for wireless data transmission to an external device. All signals were converted into mean pressure expressed in millimeters of mercury (mmHg). The mean pressure values measured by the sensors were compared to those obtained from PicoPress®. 55 garment pressures recordings were obtained from the sensors over this study conducted in 2018-February 2020. We then analyzed the test-retest reliability using the intraclass correlation coefficients (ICC). PicoPress® was also employed in the same pressure garments for obtaining similar measurements. A two way random effects model ICC with 95% confidence intervals was used to compare the mean pressure values obtained from the silicon piezoresistive sensors to the PicoPress® measurements. RESULTS: The test-retest reliability of the pressure sensors was close to the acceptable level for clinical use regarding stationary interface pressure measurement (ICC = 0.99, 95% CI 0.990-0.997). The mean pressure obtained from the silicon piezoresistive pressure sensors showed an accordance with the measurements from PicoPress® (ICC = 0.97, 95% CI 0.947-0.985). CONCLUSION: The novel device may present a viable alternative to PicoPress® for garment pressure measurements. In addition, the novel device improves adaptability to the hypertrophic scar shape and size. Complementary characteristics such as wireless transmission to an external device may allow burn patients to continuously wear the device for real-time measurements during pressure garment therapy, thus improving existing devices including PicoPress®.

Intense pulsed light versus cryotherapy in the treatment of hypertrophic scars: A clinical and histopathological study.

BACKGROUND: Different therapeutic modalities have been tried for hypertrophic scar treatment. To our knowledge, intense pulsed light (IPL) has not been previously evaluated in comparison with cryotherapy as a stand-alone treatment for hypertrophic scars. OBJECTIVE: We aimed to evaluate the efficacy of IPL as a monotherapy for hypertrophic scar treatment as compared with cryotherapy both clinically and histopathologically. METHODS: This study included 28 patients with hypertrophic scars. Patients were divided randomly and equally into two groups; group I patients received cryotherapy while group II patients received IPL. All patients received treatments for a total of six sessions or until resolution of the lesion whichever was nearer. The outcome was evaluated clinically and histopathologically. RESULTS: Scar height showed a significant decrease and scar color and pliability showed a significant improvement in group I. No significant changes were detected in group II except in scar pliability. Vancouver scar scale (VSS) mean decreased by -53.7% in group I versus -11.5% decrease in group II. Histopathologically, group I showed a significantly increased epidermal thickness and decreased dermal and collagen bundle thickness, while group II showed insignificant histopathological changes. Group I exhibited a statistically significant clinical and histopathological improvement compared to group II, yet with more complications. CONCLUSION: Cryotherapy is more effective than IPL in the treatment of hypertrophic scars both on clinical and histopathological level yet with more complications.

Application of Auriculotherapy for Post-Burn Scar Syndrome in Young Adults with Major Burns.

Background: A burn scar is a type of hypertrophic scar that can cause significant clinical symptoms, discomfort, and post-burn scar (PBS) syndrome in up to 77% of patients with burn injuries. Medication and rehabilitation are rarely effective at managing patient discomfort, and both laser and surgical interventions are postponed until the scar stabilizes and discomfort is tolerable. Objectives: The present study was conducted to investigate the effectiveness of auricular acupuncture among burn victims from the Formosa Color Dust Explosion in Taiwan. Methods: We enrolled 31 victims of the 2016 Formosa Color Dust Explosion who met the study inclusion criteria. The intervention involved placement of magnetic beads over the auricular Shenmen and Subcortex acupoints on one ear. Patients performed selfmassage five times per day, and both magnet beads were removed between the fifth and seventh days during the sessions. Several evaluation tools were used to assess clinical symptoms: the visual analogue scale for pain assessment, Burn Man Itch Scale for perceived patient itchiness, 5-D Pruritus Scale for sleep quality, and heart rate variability (HRV) for effects on the autonomic nervous system. Results: The clinical symptoms were significantly decreased following the intervention, but the effect did not endure. The normal-to-normal heart rate interval, heart rate analysis abnormalities, and very low frequency heart rate were significantly decreased among patients with abnormal HRV (SD < 40) following treatment. Conclusion: Stimulation of the auricular Shenmen and Subcortex acupoints may effectively reduce pain, itchiness, and sleep disturbances among patients with PBS syndrome.

Evaluation of the effect of hyperbaric oxygen therapy on hypertrophic scar formation in a rabbit ear model: An experimental study.

Hypertrophic scar is a disease with complicated treatment methods. Although there are numerous studies in the literature definitive therapy has not been reported yet. In this study, we aimed to evaluate the short and long-term effects of HBOT on hypertrophic scar formation in a rabbit ear model. A total of 20 male New Zealand rabbits weighing 2.1 to 2.4 kg were used in this study. The rabbits in group 2 were exposed to hyperbaric oxygen treatment for 7 days starting from the first day following biopsy punch, while no extra treatment was applied to the rabbits in group 1. Macroscopic scar thickness, histopathological parameters and HI were assessed in both of the 30th day and 60th day scars. Scar thickness was found significantly less in the scars of the rabbits exposed to HBOT (P < .05). And less dermal hypertrophy was also found in HI results of group 2.(P ≈ .022) There were differences between groups in terms of inflammation, vascularization and density of collagen fibrils. HBOT applied for 7 days from the first day of wound formation has both short and long-term effects on the triggering factors of hypertrophic scar, especially on inflammation.

Clinical observation for acupuncture treatment of a small area of hyperplastic scars in young and middle-aged women.

INTRODUCTION: Hypertrophic scars are a common disease in plastic surgery, which is the reaction of skin connective tissue to trauma beyond the normal range. Although scholars around the world have explored the tissue structure and formation mechanism of HS for decades, they are not satisfactory the result of. No effective treatment has been found. Therefore, the search for safe and effective treatments for HS has always been the focus of medical attention and research. Acupuncture therapy has a definite effect on HS and has unique advantages. METHODS/DESIGN: In this study, we will use our own front-to-back clinical research method. We plan to include 120 young and middle-aged female patients who meet the diagnostic criteria for HS. The untreated HS of the enrolled patients will be used as blank controls. The intervention group will be given acupuncture treatment. The assessment of scar area, color, hardness, thickness, itching and pain will be recorded for 30 days of treatment. DISCUSSION: This trial may provide evidence regarding the clinical effectiveness, safety, and cost-effectiveness of Acupuncture for patients with HS. TRIAL REGISTRATION: ClinicalTrials.gov, ChiCTR2000032624, Registered on 04 May 2020.

Mechanosensitive Aspects of Cell Biology in Manual Scar Therapy for Deep Dermal Defects.

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.

Modulating cationicity of chitosan hydrogel to prevent hypertrophic scar formation during wound healing.

It is of great clinical significance to design wound dressing materials with combined excellent wound healing properties and superior capability to suppress hypertrophic scar formation. This study aimed to examine if and how the cationicity of chitosan would affect the hypertrophic scar-related outcomes, through preparing carboxymethyl chitosan hydrogels with different genipin concentrations (2.5%, 5%, 10% and 15%, respectively). An optimum window of chitosan cationicity (5% in our case) demonstrated potential to mitigate hypertrophic scar in wound healing by suppressing the expression of a-smooth muscle actin (a-SMA) and promoting secretion of type I matrix metalloproteinases (MMP-1). In vivo, the CMCS-5% hydrogel again showed smaller, thinner and smoother wound appearance. Moreover, the CMCS-5% sample with additional incorporation of 2% (V/V) Aloe vera gel exhibited further improved performance in scar inhibition. Overall, such findings might have important implications in chitosan-based wound dressing design for high-quality wound repair and effective scar inhibition.

Comparison of Nd: YAG Laser and Combined Intense Pulsed Light and Radiofrequency in the Treatment of Hypertrophic Scars: A Prospective Clinico-Histopathological Study.

INTRODUCTION: Hypertrophic scars are fibroproliferative disorders, seen after burn, trauma, and/or surgery. We aimed to compare the clinical and histopathological results of 1064-nm Nd:YAG laser and combined intense pulsed light and radiofrequency in the treatment of hypertrophic scars. METHODS: Fifty patients with hypertrophic scars were included in this prospective, randomized study. Twenty-five patients were treated with Nd:YAG laser and 25 patients with combined intense pulsed light and radiofrequency (E-light). The scars were evaluated at baseline, during and at 3 months after the final treatment session using the Vancouver scar scale. Biopsy specimens from scars were obtained before, during, and 3 months after the final treatment session and were stained with hematoxylin and eosin stain, Masson's trichrome stain, and immunostaining procedures for collagen I, collagen III, and TGF-ß1. RESULTS: Significant improvements in the total Vancouver scar scale scores before and after the treatment in both groups (P < 0.001); however, a significant difference between both groups (P < 0.001), regarding the E-light, which showed better response than Nd:YAG laser. Hematoxylin and eosin and Masson's trichrome staining showed arrangement and thinning of collagen bundles and reduction in collagen density by in both groups, but the collagen bundles thinning and parallelism were more obvious in the E-light group. Significant decrease in the concentration of collagen I, collagen III, and TGF-ß1 in the E-light group as compared with the laser group (P = 0.005, P = 0.003 and P < 0.001, respectively). CONCLUSIONS: Both modalities were successful in the treatment of hypertrophic scars; however, a significant improvement in the clinical and histopathological findings was detected with the E-light method.

Effect of pressure therapy for treatment of hypertrophic scar.

BACKGROUND: Pressure therapy (PST) has been reported for the treatment of hypertrophic scar (HS) effectively. However, no study has assessed its effect and safety systematically. Therefore, this study will investigate its effect and safety for patients with HS. METHODS: A comprehensive literature search will be performed from the electronic databases and grey literatures. The electronic databases include MEDILINE, EMBASE, Cochrane Library, Web of Science, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure. All of them will be searched from inception to the present without language restrictions. Any randomized controlled trials on assessing the effect and safety of PST on HS will be considered for inclusion. In addition, we will also search grey literature to avoid missing any potential studies. RevMan V.5.3 software will be utilized for statistical analysis. RESULTS: This study will provide the most recent evidence of PST on HS by evaluating primary outcomes of scar pruritus and improvement of scar; and secondary outcomes of scar blood flow, elasticity, volume, pain and burning. In addition, we will also evaluate adverse events. CONCLUSION: This study will provide up-to-date evidence of PST in patients with HS.Systematic review registration: PROSPERO CRD42019136627.

Treatment of skin soft tissue embolism after hyaluronic acid injection for injection rhinoplasty in Asian patients.

INTRODUCTION: The purpose of this manuscript is to investigate the treatment of skin soft tissue embolization or vascular occlusion after the injection of hyaluronic acid (HA) for Injection Rhinoplasty (IR) in Asians with a special interest in the time occurrence of the occlusion. METHODS: A total of 35 cases were evaluated after receiving HA injections for IR who presented with a vascular occlusive event. They were divided into three stages based on the time to embolization. Immediate, ≤5 hours; early, ≤3 days; and late, >3 days. There were two cases of immediate, 28 deemed early, and five late. Methods to prevent tissue necrosis are reviewed in the manuscript based on these stages. RESULTS: Skin color gradually recovered to normal after 11 treatments in 11 patients with mild embolization. No ischemic aggravation or skin necrosis was observed in 19 patients with moderate embolization; red scarring was seen in two and hypertrophic scar with uneven skin color in one patient. The five patients in the severe category had longer healing, more red scars, and more hypertrophic scarring. CONCLUSION: The treatment of skin soft tissue embolization or vascular occlusion after HA IR in Asians can be effected by identifying the stage and degree of embolization and treating appropriately with the outlines presented in this manuscript.

Randomized controlled trial of the immediate and long-term effect of massage on adult postburn scar.

BACKGROUND: One objective of massage therapy applied to hypertrophic scar (HSc), is to improve the structural properties so skin possesses the strength and elasticity required for normal mobility. However, research supporting this effect is lacking. The objective of this study was to characterize the changes in scar elasticity, erythema, melanin, and thickness immediately after a massage therapy session and after a 12-week course of treatment compared to intra-individual matched control scars. METHODS: We conducted a prospective, randomized, single-blinded, pragmatic, controlled, clinical trial evaluating the impact of a 12-week course of massage therapy. Seventy burn survivors consented to participate and 60 completed the study. Two homogeneous, intra-individual scars were randomized to usual care control or massage therapy plus usual care. Massage, occupational or physical therapists provided massage treatment 3x/week for 12 weeks. Scar site characteristics were evaluated weekly immediately before and after massage treatment including elasticity (Cutometer), erythema and melanin (Mexameter), and thickness (high-frequency ultrasound). Analysis of covariance (ANCOVAs) were performed to test for immediate and long-term treatment effects. A mixed-model approach was used to account for the intra-individual scars. RESULTS: Scar evaluation immediately before and after massage therapy at each time point revealed changes for all scar characteristics, but the group differences were predominantly present during the early weeks of treatment. The within group long-term analysis revealed a significant increase in elasticity, and a reduction in thickness, during the 12-week treatment period for both the control scar (CS) and massage scar (MS). The increase in elasticity reached significance at week 8 for the MS and week 10 for the CS and the reduction in thickness at week 5 for the CS and week 7 for the MS. There was no significant within group long-term differences for either erythema or melanin. There were group differences in erythema at week 8 and 11 where the CS was less erythematous than the MS. CONCLUSIONS: The immediate impact of forces applied during massage therapy may lead patients and therapists to believe that there are long-term changes in elasticity, erythema, and pigmentation, however, once baseline measures, the control scar, and time were incorporated in the analysis there was no evidence of long-term benefit. Massage therapy applied with the objective of increasing scar elasticity or reducing erythema or thickness over the long-term should be reconsidered.