Removal of Wires for Sternal Internal Fixation After Cardiac Surgery in Adolescents.

Objective: The objective of this study was to assess the safety and patient satisfaction of sternal wire removal surgery, rendering reference for clinical practice in the future. Methods: A total of 70 adolescent patients with completely healed sternum and no other diseases or able to receive surgery were randomly selected and subjected to sternal wire removal surgery. Besides, relevant data including patient age, gender, wire rupture, reason for wire removal, postoperative wire residuals, patient satisfaction, age at cardiac surgery, waiting time after cardiac surgery, and removal duration were recorded. Results: Raptured wire group exhibited higher proportions of males and chest pain cases and longer operative time than unruptured wire group. The demand for wire removal had no relation to gender, but patients receiving surgery due to chest pain were mainly aged 12-15 years old, those undergoing surgery due to employment and further education were mainly aged 9-12 years old, and those subjected to surgery sue to ruptures found in physical examinations were mainly aged 6-9 years old. According to statistics of wire rupture position, the rupture of the 4th wire accounted for the largest proportion, and rupture of multiple wires was found in some patients. No statistically significant differences were found in gender, age, age at cardiac surgery, and waiting time after cardiac surgery between patients with only one wire ruptured and those with multiple wires ruptured. Patients were grouped based on the absence and presence of chest pain, and it was found that chest pain group had a longer removal duration, but comparable age at cardiac surgery and waiting time after cardiac surgery, and the waiting time after cardiac surgery was a risk factor for chest pain. The waiting time after cardiac surgery was positively correlated with operative time, so we recommend that if there were symptoms of chest discomfort, it should be removed as soon as possible. However, due to the needs of the patients, no control group was set up, which is the limitation of this study. In the next step, we will conduct more long-term observation of the patients to confirm whether the chest pain can be relieved by itself without removing the wire. Conclusion: This study found that for adolescent patients with chest pain or other life troubles after cardiac surgery, removing the sternal internal fixation wire can quickly and effectively relieve the troubles, and is a safe and reliable treatment means. Therefore, if it is necessary to remove the wire, it should be removed as soon as possible to avoid wire breakage and increase the difficulty of surgery.

Low-level laser therapy versus trunk stabilization exercises on sternotomy healing after coronary artery bypass grafting: a randomized clinical trial.

The aim of this study was to investigate the effects of low-level laser therapy (LLLT) versus trunk stabilization exercises on sternotomy healing following coronary artery bypass grafting (CABG) surgery. Forty-five male patients who had acute sternal instability post-CABG surgery in the age range of 45-65 years were divided randomly into three equal groups (n = 15). The laser group received LLLT, while the exercise group received trunk stabilization exercises. The control group only received a routine cardiac rehabilitation programme, which was also provided to both the laser and the exercise groups. All groups were offered 12 sessions over 4 weeks. Sternal separation, median sternotomy photographic analysis, pain and activities of daily living (ADL) performance were evaluated pre- and post-treatment. Statistical significance was set at P < 0.05. There was a significant decrease among the laser group in upper-sternal separation, while the exercise and control groups showed a non-significant decrease. In terms of mid-sternal separation, laser and exercise groups showed a significant decrease while the control group showed a non-significant decrease. In terms of lower-sternal separation, the exercise group showed a significant decrease, while the laser and control groups showed a non-significant decrease. Post-treatment between-groups analysis showed a significant difference only among the laser and control groups with regard to upper-sternal separation, while analysis of the laser, exercise and control groups in the case of upper-sternal separation and the between-groups comparison in terms of mid- and lower-sternal separation revealed no significant differences. LLLT and trunk stabilization exercises were found to be the most effective methods for sternotomy healing post-CABG surgery, with LLLT offering superior performance in the case of the upper sternum while trunk stabilization exercises were more effective for the lower sternum.

Dalbavancin treatment in a deep sternal wound MRSA infection after coronary artery bypass surgery: a case report.

BACKGROUND: A deep sternal wound infection (DSWI) can become a severe complication after cardiac surgery, with in-hospital mortality rates reaching up to 35%. Staphylococci, particularly methicillin resistant Staphylococcus aureus (MRSA), play important roles in its etiology. CASE PRESENTATION: This case report presents a patient who underwent coronary artery bypass surgery, and suffered postoperatively from a DSWI caused by MRSA. The pathogen was susceptible to vancomycin and rifampicin in vitro; however, this therapy was clinically ineffective. Both clinical improvement and MRSA eradication were achieved after surgical debridement of the wound and the intravenous administration of dalbavancin. CONCLUSIONS: We decided to administer dalbavancin because of its convenient pharmacological profile. The patient's tolerance of the antimicrobial was good, the biochemical markers of inflammation returned to the normal ranges, and the microbiological results one week after the dalbavancin administration were negative. A good clinical outcome was achieved with both the surgery and antimicrobial administration. In this case, dalbavancin was more effective in the treatment of the sternal and surrounding tissue infections caused by MRSA, when compared to vancomycin.

Can Drainage Using a Negative-Pressure Wound Therapy Device Replace Traditional Sample Collection Methods?

BACKGROUND: In 2015 a new device for the collection of mediastinal fluid from patients with deep sternal wound infection (DSWI) in the presence of negative-pressure wound therapy (NPWT) became available. The present study was designed to evaluate whether changing sample collection devices increased micro-organism detection in patients undergoing NPWT. METHODS: During 2013-2014, 207 samples were collected and cultured from NPWT patients (n = 23) to demonstrate the presence of DSWI using reticulated polyurethane sponge culture, a swab, and blood culture. In 2015, a new collection device was introduced for specimen collection. A total of 357 samples (n = 17) were collected using the ESwab(™) (Copan, Murrieta, CA) for deep and superficial wound sample collection. In addition, blood culture devices were used for collecting mediastinal fluid aspirated directly from the wound and biologic fluid obtained from the NPWT device. Fisher exact test was performed to test the rate of independence rate of micro-organism identification using the NPWT sponge device and taking blood culture results as a reference for micro-organism identification. RESULTS: After the introduction of the new collection device in our hospital, an overall increase in the detection of micro-organisms (46.7%) was reported. During 2013-2014 our traditional microbiologic collection method did not detect a pathogen in 30.4% of patients. During 2015, the new sample collection approach, direct from the NPWT device, improved micro-organism detection by 10.4% and reduced DSWIs with undetected pathogens to 17.6% (p < 0.01). CONCLUSIONS: As a result of proficiency gained in the last year, the most representative specimen in wound infection was represented by mediastinal fluid collected directly from the wound and the NPWT device. Given the correlation between the blood culture of micro-organisms detected using the ESwab device from the wound, mediastinal drainage, and drainage from the NPWT device, we can assume that the NPWT device may replace the other biologic sampling devices.

Sternoclavicular osteoradionecrosis following treatment for head and neck cancer.

Osteoradionecrosis (ORN) is a well described complication of radiation therapy (RT) for head and neck cancer (HNC), with a past reported incidence as high as 10-18% [1,4] mostly involving the mandible. ORN rarely involves the sternoclavicular complex in HNC patients treated with RT. Here, we present a case of HNC treated with combined (cytotoxic) chemotherapy and radiation therapy (CCRT) complicated by ORN and osteomyelitis of the sternoclavicular complex involving large segments of both clavicles, the sternum, and the trachea.

Bone cement-enhanced sternal closure technique in cardiac surgery: effects on sternal union, pain and life quality.

BACKGROUND: Median sternotomy provides excellent access to all mediastinal structures in patients undergoing conventional cardiovascular surgery. Although this incision technique is associated with relatively lower complication rates, certain complications such as the sternal dehiscence may pose serious health consequences. In this regard, considerable effort has been paid to develop techniques aiming to improve sternal healing and to enhance postoperative recovery after conventional cardiac surgery. Among these, kryptonite bone cement, a biocompatible polymer with improved mechanical properties when combined with a standard wire cerclage, represents a promising novel approach that may help prevent sternal dehiscence. In this study, the effects of this particular type of bone cement on sternal healing, postoperative pain, and quality of life have been evaluated. METHODS: Kryptonite bone cement enhanced sternal closure was employed in a total of 100 patients undergoing conventional cardiac surgery between November 2009 and June 2012. Of these patients, 50 expressed their willingness to participate in this study. Each participant underwent a computerized tomography imaging for the radiological assessment of sternal healing. Pain and life quality of these patients have been evaluated by Wong-Baker faces pain scale and SF-36 health survey questionnaire, respectively. RESULTS: Mean duration of follow-up was 20.14 ± 7.36 months (range: 10-32). Mean age and body mass index were 71.32 ± 7.23 years (range: 55-85) and 28.34 ± 2.62 (21-34) kg/m2, respectively. Elderly patients (≥70), females and those with chronic obstructive pulmonary disease (COPD) comprised 64%, 26% and 40% of the study population, respectively. No patients had findings suggestive of dehiscence on CT images. No patients reported severe pain (i.e. all patients had a Wong-Baker faces pain scale score <4). Elderly (≥ 70 yr) subjects had better quality of life scores as compared to the remaining group of patients (< 70 yr) according to SF-36 Health Survey results. Vitality and emotional role scores were lower (63.5 ± 25.5, p = 0.018 and 41.7 ± 23.3, p = 0.001, respectively) in female patients. Patients with COPD had lower quality of life scores than those without COPD, particularly with respect to general health scores (73.3 ± 18.5; p = 0.012). CONCLUSIONS: Kryptonite bone cement, when combined with a standard wire cerclage, enhances mechanical strength, prevents sternal dehiscence, reduces postoperative pain and improves quality of life after conventional cardiac surgery. Long-term studies are warranted to better define the role of kryptonite bone cement in the prevention of sternal dehiscence.

Ozone therapy as an adjunct to vancomycin enhances bacterial elimination in methicillin resistant Staphylococcus aureus mediastinitis.

BACKGROUND: We aimed to investigate the influence of intraperitoneal ozone therapy on bacterial elimination and mediastinal inflammation in experimental Staphylococcus aureus mediastinitis. MATERIALS AND METHODS: Forty Wistar-Albino rats were randomized into five groups (eight per group) as follows: uncontaminated group, untreated contaminated group, ozone group, vancomycin group, and vancomycin + ozone group. Uncontaminated group underwent upper median sternotomy. The remaining four groups were inoculated with 0.5 mL 10(8) colony-forming units/mL methicillin-resistant Staphylococcus aureus in the mediastinal and sternal layers. Untreated contaminated group had no treatment. Rats in the vancomycin group received intramuscular vancomycin (40 mg/kg/d), and ozone was administered intraperitoneally (70 µg/mL, 1 mg/kg/d) in the ozone group for the treatment of mediastinitis. Vancomycin + ozone group rats were treated by the combination of both methods. At the end of 10 d, quantitative bacterial cultures and sternal tissue samples were obtained for determination of bacterial counts and histologic degree of inflammation. RESULTS: Both the vancomycin and the ozone treatments caused significant reduction of bacterial counts in quantitative bacterial cultures. Combination of vancomycin and ozone treatments resulted in further reduction of bacterial counts in mediastinum and sternum. Histologic examination of tissue samples revealed significant reduction in severity of mediastinitis related inflammation in vancomycin and vancomycin + ozone groups compared with untreated contaminated group. CONCLUSIONS: Ozone therapy as an adjunct to vancomycin leads to enhanced bacterial elimination in infected sternal and mediastinal tissues in experimental methicillin-resistant Staphylococcus aureus mediastinitis. The benefit of adjuvant ozone therapy is suggested to be related to its bactericidal effect.

Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study.

OBJECTIVE: The minimally invasive coronary artery bypass grafting (MICS CABG) operation performed via a small thoracotomy has not previously been examined in a direct comparison to sternotomy off-pump coronary artery bypass grafting (OPCAB). METHODS: We matched, according to age, gender, left ventricular function, and median number of distal anastomoses, 150 patients who underwent MICS CABG via small left thoracotomy, and 150 patients who received sternotomy OPCAB. All operations were performed by the same surgeon. RESULTS: There was no perioperative mortality (0/300). In the MICS CABG group, pump assistance was used in 28/150 (19%) patients, and conversion to sternotomy occurred in 10/150 (6.7%) patients. In the OPCAB group, conversion to on-pump occurred in 3/150 (2.0%) patients. There were four (2.7%) reoperations for bleeding and one (0.7%) for anastomotic revision in each group. The median hospital length of stay was 5 days for MICS CABG (average 5.4), and 6 days for OPCAB (average 7.2) (P=0.02). New-onset atrial fibrillation occurred in 35 (23%) MICS CABG patients and in 42 (28%) OPCAB patients (P=0.3). No wound infection occurred with MICS CABG versus six (4.0%) with OPCAB (P=0.03). A self-limiting left pleural effusion developed in 22 (15%) MICS CABG patients and in six (4.0%) OPCAB patients (P=0.002). The median time to return to full physical activity was 12 days in MICS CABG patients versus >5 weeks in OPCAB patients (P<0.001). CONCLUSIONS: MICS CABG is a valuable alternative for patients in need of multivessel CABG. The operation appears at least as safe as OPCAB, and associated with shorter hospital length of stay, less wound infections, and faster postoperative recovery than OPCAB.

Sternal metastasis of breast cancer: ex vivo hypothermia and reimplantation.

Breast cancer frequently metastasizes to the bone. When the sternum is involved, it usually presents as a solitary lesion. In such cases, resection is indicated, including with the intention to cure. This case report describes a technique for a complete exeresis of the sternum, ex vivo repair under hypothermia, and reimplantation. Cryosurgery is a well-known technique to resect bone metastases and was the procedure used in our patient. The follow-up after 2 years shows no evidence of tumor recurrence, with excellent results on aesthetic levels.

Kryptonite bone cement prevents pathologic sternal displacement.

BACKGROUND: Wire cerclage closure of sternotomy is the standard of care despite evidence of pathologic sternal displacement (> 2 mm) during physiologic distracting forces (coughing). Postoperative functional recovery, respiration, pain, sternal dehiscence, and infection are influenced by early bone stability. This translational research report provides proof-of-concept (part A) and first-in-man clinical data (part B) with use of a triglyceride-based porous adhesive to rapidly enhance the stability of conventional sternal closure. METHODS: In part A, fresh human cadaver blocks were subjected to midline sternotomy and either conventional wire closure or modified adhesive closure. After 24 hours at 37 degrees C, using a biomechanical test apparatus, a step-wise increase in lateral distracting force simulated physiologic stress. Sternal displacement was measured by microdisplacement sensors. In part B, a selected clinical case series was performed and sternal perfusion assessed by serial single photon emission computed tomography imaging. RESULTS: Wire closure resulted in measurable bony displacement with increasing load. Pathologic displacement (> or = 2 mm) was observed in all regional segments at loads 400 newton (N) or greater. In contrast, adhesive closure completely eliminated pathologic displacement at forces 600 N or less (p < 0.001). In patients, adhesive closure was not associated with adverse events such as adhesive migration, embolization, or infection. There was excellent qualitative correlation between cadaver and clinical computed tomographic images. Sternal perfusion was not compromised by adhesive closure. CONCLUSIONS: This first-in-man series provides proof-of-concept indicating that a novel biologic bone adhesive is capable of rapid sternal fixation and complete elimination of pathologic sternal displacement under physiologic loading conditions. A randomized clinical trial is warranted to further define the potential risks and benefits of this innovative technique.

Autologous platelet-rich plasma: effect on sternal healing in the sheep model.

Postcardiotomy sternal wound complications remain challenging. We looked at the effects of plasma rich in growth factors (PRGF) as an agent on sternal bone healing. In 24 female sheep, a median sternotomy was surgically created. In 12 of them (group control) the sternum was closed with three figure-of-eight wires. In 12 (group PRGF) three clots of autologous PRGF were applied over the sternum after its closure in the same manner as the control group. All sheep were killed at the nine-week follow-up. The sternum and the surrounding soft tissue was removed and fixed in formaldehyde. Transversal sections of the bone were obtained, decalcified and stained with hematoxylin and eosin. In the control group, we found extensive cartilaginous areas. In the PRGF group, the presence of trabecular bone tissue was common, with formation of hematopoietic medullary tissue. The process of new bone formation was accelerated in the PRGF group at the nine-week follow-up. In contrast, in the control group, the presence of cartilaginous tissue was the most common finding.

[Sternal metastasis from differentiated thyroid carcinoma: what management?]. / Que faut-il faire devant une métastase sternale d'un cancer différencié de la thyroïde?

OBJECTIVE: The aim of this study was to evaluate results of surgical management for sternal metastasis from differentiated thyroid carcinoma. METHODS: A retrospective study has been completed on patients treated in our department for sternal metastasis from differentiated thyroid carcinoma. RESULTS: Among the 235 patients who underwent thyroidectomy for thyroid cancer, seven (3%) had sternal metastasis during follow-up. These sternal metastasis were metachronous with an average delay of 10 years. Treatment corresponded to an excision of the upper half of the sternum including internal parts of the clavicle and the adjacent ribs (four cases), a reduction of the metastatic tumour mass (two cases) and one biopsy with no resection (one case). After sternal excision, reconstruction of the chest wall was obtained with the use of polyester prosthesis covered with pectoral muscle flap. Radioiodine was assigned to all patients as a complementary therapy. With an average follow-up of 58 months, no local or distant recurrence was observed in five patients (71%). Two patients had local and/or distant metastasis. CONCLUSION: Incidence of sternal metastasis is rare but does not preclude a large surgical resection. When possible, an aggressive management (surgical resection and radioiodine therapy) allows more than 70% relapse-free survival at 5 years.

Hyperbaric oxygen therapy with topical negative pressure: an alternative treatment for the refractory sternal wound infection.

Sternal osteomyelitis is a potentially lethal complication after cardiac surgery. It may be the cause of postoperative morbidity and mortality. We present a case of deep sternal wound infection after sternotomy. The patient received three treatments of surgical debridement, irrigation, topical negative pressure (TNP) dressing, and hyperbaric oxygen (HBO) therapy. Forty-five HBO therapy sessions were administered. After nine weeks, the sternal wound was healed and completely epithelialized. This conservative therapy can be an alternative and inexpensive method for the difficult sternal wound infection patient.

Topical application of autologous blood products during surgical closure following a coronary artery bypass graft.

OBJECTIVE: Surgical site wound complications are associated with increased cost, morbidity, and mortality following cardiothoracic surgery. Recent publications have advocated the application of autologous blood components as an adjunctive tool to surgical closure during various surgical procedures. The current study was intended to assess the safety and efficacy of the application of autologous platelet rich and platelet poor plasma to the sternal closure and saphenous vein harvest site during closure following a coronary artery bypass graft. PATIENTS AND METHODS: A retrospective analysis was performed on 1446 consecutive coronary artery bypass grafting procedures from two surgeons. A patient group receiving topical application of platelet rich and platelet poor plasma during closure of their chest and leg surgical incisions was compared to a patient population receiving standard treatment of care. Forty covariates were collected for each patient included in the study. Propensity scoring was used to adjust for baseline imbalance. Asymptotic logistic regression and exact statistical methods were used to determine the effect of the autologous blood application on infection and drainage of the sternal and leg wounds. RESULTS: One thousand, one hundred and twenty-eight patients had sufficient data to be included in the final analysis, with 571 of these patients receiving the treatment compared to 557 control patients. No treatment-related adverse events were noted and the application process did not significantly affect the operative time. CONCLUSION: This retrospective analysis of a consecutive series of patients receiving a coronary artery bypass grafting procedure concluded that application of platelet rich and platelet poor plasma significantly reduced occurrences of chest wound infection, chest drainage, and leg wound drainage. This novel therapy merits further investigation.

Infiltration of the sternotomy wound and the mediastinal tube sites with 0.25% levobupivacaine as adjunctive treatment for postoperative pain after cardiac surgery.

BACKGROUND AND OBJECTIVE: This study aimed to investigate the effect of 0.25% levobupivacaine infiltration of the sternotomy wound and the mediastinal tube sites on postoperative pain, morphine consumption and side-effects in patients undergoing cardiac surgery. METHODS: After obtaining Ethics Committee approval and informed consent,50 patients aged 18-65 yr, undergoing coronary artery bypass grafting, were included in this study. Anaesthesia was induced with 5 microg kg (-1) fentanyl, 0.3 mg kg (-1) etomidate, 1 mg kg (-1) lidocaine, 0.1 mg kg (-1) vecuronium and maintained with 1-2% sevoflurane, 50% oxygen in air and fentanyl. Patients were randomized into two groups before sternal wire placement: sternotomy and mediastinal tube sites were infiltrated with either 60 mL 0.25% levobupivacaine (infiltration group, n = 25) or 60 mL saline placebo (control group, n = 25). All patients received intravenous morphine patient-controlled analgesia (bolus dose: 2 mg, lock-out time: 15 min, 4 h limit: 20 mg) after extubation. Postoperative pain at rest and on coughing was assessed by a visual analogue scale (0-10). Pain scores,sedation scores (Ramsay scale), haemodynamic and respiratory parameters, arterial blood gases and morphine consumption were recorded. RESULTS: The times to extubation and visual analogue scale scores were similar between groups. Morphine consumption at 24 h was significantly lower in the infiltration group compared with the control group (29.5 +/- 5.1 vs. 42.8 +/- 4.7 mg, respectively, P < 0.05). The sedation scores were found to be significantly higher in the control group when compared with the infiltration group at 1, 2 and 4 h after extubation (P < 0.05), whereas sedation scores after 4 h were similar between groups. CONCLUSION: Infiltration of the median sternotomy incision and the mediastinal tube insertion sites with 0.25% levobupivacaine in addition to morphine patient-controlled analgesia was found to be effective in reducing postoperative morphine consumption when compared with morphine patient-controlled analgesia alone during the initial 24 h after cardiac surgery.

Use of continuous subcutaneous anesthetic infusion in cardiac surgical patients after median sternotomy.

UNLABELLED: The use of opioid analgesics to control pain after median sternotomy in cardiac surgical patients is worldwide accepted and established. However, opioids have a wide range of possible side effects, concerning prolonged extubation time, gastrointestinal tract dyskinesia and urinary tract disorders mostly retention. All these may lead to a prolonged ICU stay or overall hospitalization time increase. OBJECTIVE: To determine whether a continuous subcutaneous regional anesthetic infusion delivered directly to the sternotomy site would result in decreased levels of postoperative pain and opioid requirements in cardiac surgical patients undergoing median sternotomy. METHOD: The continuous subcutaneous infusion (OnQ Painbuster system) was applied in 37 patients. 3 patients were exempted due to prolonged ICU stay. 29 patients underwent CABG, 5 had AVR, 1 MVR and modified Maze, 1 patient had a 3-valve repair due to endocarditis and another one had reconstruction of the left ventricle. Requirements of opioid analgesics were recorded for 96 hours after operation. Pain was assessed using the visual analog scale and the total postoperative hospital length of stay was also measured. RESULTS: The postoperative pain was significantly diminished (0 - 3 at VAS). The mean postoperative length of stay was 5,8 days, rather improved compared to the average stay of 6,7 days. CONCLUSION: Continuous subcutaneous infusion of ropivacaine directly at the median sternotomy significantly diminishes postoperative pain and the need for opioid analgesic use. Moreover, it seems to reduce overall postoperative length of stay for all cardiac surgical patients.

Role of hyperbaric oxygen therapy in the treatment of postoperative organ/space sternal surgical site infections.

BACKGROUND: A prospective trial was designed to evaluate the effect of hyperbaric oxygen (HBO) therapy on organ/space sternal surgical site infections (SSIs) following cardiac surgery that requires sternotomy. METHODS: A total of 32 patients who developed postoperative organ/space sternal SSI were enrolled in this study from 1999 through 2005. All patients were offered HBO therapy. Group 1 included the patients who accepted and were able to undergo HBO therapy (n = 14); group 2 included patients who refused HBO therapy or had contraindications to it (n = 18). RESULTS: The two groups were well matched at baseline with comparable preoperative clinical characteristics and operative factors. Staphylococcus was the most common pathogen for both groups. The duration of infection was similar in groups 1 and 2 (31.8 7.6 vs. 29.3 5.7 days, respectively, p = 0.357). The infection relapse rate was significantly lower in group 1 (0% vs. 33.3%, p = 0.024). Moreover, the duration of intravenous antibiotic use (47.8 +/- 7.4 vs. 67.6 +/- 25.1 days, p = 0.036) and total hospital stay (52.6 +/- 9.1 vs. 73.6 +/- 24.5 days, p = 0.026) were both significantly shorter in group 1. CONCLUSION: Hyperbaric oxygen is a valuable addition to the armamentarium available to physicians for treating postoperative organ/space sternal SSI.

Effect of pulse width of a 595-nm flashlamp-pumped pulsed dye laser on the treatment response of keloidal and hypertrophic sternotomy scars.

BACKGROUND: Flashlamp-pumped pulsed dye lasers (PDLs) have successfully treated keloidal and hypertrophic scars. OBJECTIVE: The objective was to investigate the effect of pulse width of a PDL in treating keloidal and hypertrophic scars. METHODS: On each of 19 patients, keloidal or hypertrophic median sternotomy scars were divided into two segments. Both segments on all patients were randomly treated with a 595-nm PDL at a fluence of 7 J/cm(2) and pulse widths of 0.45 and 40 ms to both segments, every 4 weeks for a total of three treatments. Scar volume, height, erythema, and pliability were measured at Weeks 0, 4, 8, and 24. RESULTS: The volume of segments treated with 0.45- and 40-ms pulses decreased significantly after two treatments. Segments treated with a 0.45-ms pulse width showed significantly greater improvement than those treated with 40-ms pulses after three treatments. Elasticity of 0.45-ms segments was significantly higher than those of 40-ms segments, following two treatments. Pulse width had no significant effect in improvement of scar erythema. CONCLUSIONS: A pulse width of 0.45 ms of PDL was more effective in decreasing scar size and improving scar pliability than that of 40 ms. A 595-nm PDL was safe and effective in treatment of hypertrophic scars and keloids in dark-skinned individuals. This study was supported in part by an educational grant from the Dermatological Society of Thailand.