Holistic Approach to Burn Reconstruction and Scar Rehabilitation.

More than 11 million burn injuries occur each year across the world. Many people with burn injuries, regardless of injury size, develop hypertrophic scar, contracture, unstable scar, heterotopic ossification, and disability resulting from these sequelae. Advances in trauma systems, critical care, safe surgery, and multidisciplinary burn care have markedly improved the survival of people who have experienced extensive burn injuries. Burn scar reconstruction aims to improve or restore physical function, confidence, and body image. Like acute burn care, burn scar reconstruction requires thoughtful, coordinated approaches along the continuum of burn injury, recovery, and rehabilitation.

Keloids and Hypertrophic Scars.

Keloids are an exuberant response to skin wound healing in which abundant scar tissue grows beyond the boundaries of the inciting insult. Age, race, location, family history and personal history of keloids are relevant factors concerning the risk of developing keloids. Because keloids are prone to recurrence after surgical excision, post-operative management plays an important role in the treatment of keloids. There are many modalities that can be used to treat keloids or prevent their recurrence; a multimodal approach is often necessary in difficult cases.

Advantages of skin closure with subcuticular suture for liver resection on postoperative and cosmetic outcomes: a propensity matched analysis.

PURPOSE: The effects of subcuticular sutures on postoperative and cosmetic outcomes in patients who underwent liver resection have not been well studied. Here, we investigated the advantages of subcuticular suture compared to skin stapler regarding open liver resection. METHODS: We assessed 342 patients who underwent liver resection at Nara Medical University between 2008 and 2015. They were divided into two groups: subcuticular suture and staple groups. Baseline characteristics and perioperative outcomes were retrospectively compared using one-to-one propensity score matching analysis. RESULTS: In this period, 179 patients underwent skin closure with subcuticular sutures and 163 patients underwent skin closure with staples. After propensity matching, 85 pairs of cases were matched. The incidence of wound infection was similar in the two groups (3.5% in the subcuticular suture group and 9.4% in the staple group; p = 0.119). The length of hospital stay was significantly shorter in the subcuticular suture group than in the staple group (10 days vs 15 days; p < 0.001). In addition, the rate of patients who were discharged within 7 days after surgery was statistically higher in the subcuticular group (21.1% vs 3.5%, p = 0.001). Hypertrophic scar 6 months after surgery was significantly less frequent in the subcuticular group (9.4% vs 25.9%, p = 0.010). CONCLUSION: Subcuticular sutures might be advantageous for liver surgery reducing length of hospital stay and proportion of hypertrophic scar.

Hypopigmented burn hypertrophic scar contains melanocytes that can be signaled to re-pigment by synthetic alpha-melanocyte stimulating hormone in vitro.

There are limited treatments for dyschromia in burn hypertrophic scars (HTSs). Initial work in Duroc pig models showed that regions of scar that are light or dark have equal numbers of melanocytes. This study aims to confirm melanocyte presence in regions of hypo- and hyper-pigmentation in an animal model and patient samples. In a Duroc pig model, melanocyte presence was confirmed using en face staining. Patients with dyschromic HTSs had demographic, injury details, and melanin indices collected. Punch biopsies were taken of regions of hyper-, hypo-, or normally pigmented scar and skin. Biopsies were processed to obtain epidermal sheets (ESs). A subset of ESs were en face stained with melanocyte marker, S100ß. Melanocytes were isolated from a different subset. Melanocytes were treated with NDP α-MSH, a pigmentation stimulator. mRNA was isolated from cells, and was used to evaluate gene expression of melanin-synthetic genes. In patient and pig scars, regions of hyper-, hypo-, and normal pigmentation had significantly different melanin indices. S100ß en face staining showed that regions of hyper- and hypo-pigmentation contained the same number of melanocytes, but these cells had different dendricity/activity. Treatment of hypo-pigmented melanocytes with NDP α-MSH produced melanin by microscopy. Melanin-synthetic genes were upregulated in treated cells over controls. While traditionally it may be thought that hypopigmented regions of burn HTS display this phenotype because of the absence of pigment-producing cells, these data show that inactive melanocytes are present in these scar regions. By treating with a pigment stimulator, cells can be induced to re-pigment.

Ciliated and Mucinous Adenomatous Syringometaplasia: The Missing Link of the "Ciliated Eccrine Metaplasia" Theory in the Histogenesis of Cutaneous Eccrine Ciliated Cyst?

ABSTRACT: A variety of metaplastic changes has been reported in eccrine ducts and glands with squamous and mucinous syringometaplasia representing the most common histopathologic patterns. In the current case, a previously unreported variant of syringometaplasia was described in a female newborn with a 2-cm occipital cutaneous defect consistent with cutis aplasia. Over a more than 1-year period of local treatment, an enlarging plaque associated with local alopecia developed at the site of the original ulcerated area. A local excision demonstrated a superficial hypertrophic scar associated with a complete loss of hair follicles. In addition, there was a proliferation of eccrine glands and ducts lined by cuboidal epithelial cells arranged in a linear distribution beneath the scar area. Focal anastomosing of the proliferative ducts was identified. In few dilated ducts, the epithelial lining was composed of an inner layer of columnar cells with well-formed apical cilia and intracytoplasmic mucin and an outer layer of myoepithelial cells. The mucinous and ciliated cells were positive for epithelial membranous antigen and carcinoembryonic antigen, but negative for estrogen receptors, progesterone receptors, and thyroid transcription factor-1. Because this variant of eccrine metaplasia has not hitherto been reported in the literature, the term ciliated and mucinous adenomatous syringometaplasia was proposed for this unusual histologic finding. Mucinous and ciliated adenomatous syringometaplasia not only expands the spectrum of metaplastic changes in sweat gland units, but also might represent the missing link in the histogenesis of a subset of cutaneous ciliated cysts.

Hepatocyte Growth Factor Secreted from Human Adipose-Derived Stem Cells Inhibits Fibrosis in Hypertrophic Scar Fibroblasts.

AIMS: To study the effect of Adipose-derived stem cells (ADSCs) on fibrosis of hypertrophic scar-derived fibroblasts (HSFs) and its concrete mechanism. BACKGROUND: ADSCs have been reported to reduce collagen production and fibroblast proliferation in co-culture experiments. Conditioned medium from adipose-derived stem cells (ADSCs-CM) has successfully inhibited fibrosis by decreasing the expression of collagen type І (Col1) and α-smooth muscle actin (α-SMA) in rabbit ear scar models. Hepatocyte growth factor (HGF), the primary growth factor in ADSCs-CM, has been shown to reverse fibrosis in various fibrotic diseases. OBJECTIVE: To test the hypothesis that ADSCs inhibit fibrosis of HSFs through the secretion of HGF. METHODS: HSFs were treated with DMEM containing 0%, 10%, 50% and 100% concentration of ADSCs-CM. The effect of ADSCs-CM on the viability was determined by cell viability assay, and the collagen production in HSFs was examined by Sirius red staining. Expression and secretion of fibrosis and degradation proteins were detected separately. After measuring the concentration of HGF in ADSCs-CM, the same number of HSFs were treated with 50% ADSCs-CM or HGF. HGF activity in ADSCs-CM was neutralized with a goat anti-human HGF antibody. RESULTS: The results demonstrated that ADSCs-CM dose-dependently decreased cell viability, expression of fibrosis molecules, and tissue inhibitor of metalloproteinases-1 (TIMP-1), and significantly increased matrix metalloproteinase-1 (MMP-1) expression in HSFs. Collagen production and the ratio of collagen type І and type III (Col1/Col3) were also suppressed by ADSCs-CM in a dose-dependent manner. When HSFs were cultured with either 50% ADSCs-CM or HGF (1 ng/ml), a similar trend was observed in gene expression and protein secretion. Adding an HGF antibody to both groups returned protein expression and secretion to basal levels but did not significantly affect the fibrosis factors in the control group. CONCLUSION: Our findings revealed that adipose-derived stem cell-secreted HGF effectively inhibits fibrosis-related factors and regulates extracellular matrix (ECM) remodeling in hypertrophic scar fibroblasts.

Técnica Ronaldo Pontes de abdominoplastia em bloco / Ronaldo Pontes block abdominoplasty technique

Introdução: Abdominoplastia é um procedimento não apenas com características estéticas, mas também de reconstrução estrutural da parede abdominal. O objetivo do trabalho é mostrar a experiência dos autores em abdominoplastias, enfocando nos resultados estéticos da cicatriz e a evolução destes pacientes, aplicando as técnicas de ressecção em bloco do Professor Ronaldo Pontes (RP). Métodos: O estudo foi uma série retrospectiva de casos de 124 pacientes, entre março de 2014 a março de 2017, submetidos à abdominoplastia em bloco pela técnica RP. Resultados: Na nossa casuística, demonstrou-se uma mínima incidência de complicações encontradas com a técnica em Bloco RP, em comparação às encontradas na literatura, e, também, demonstrou um número pífio de casos de alterações na cicatrização. Conclusão: A técnica descrita e suas variantes atendem a necessidade de diversos tipos de casos e garantem cirurgias seguras e eficazes, com resultados muito satisfatórios, sendo uma técnica reprodutível.

Introduction: Abdominoplasty involves not only aesthetic characteristics but abdominal wall structural reconstruction. This study aimed to illustrate the authors' experience with abdominoplasty, focusing on the scar's aesthetic results and the evolution of application of the block resection technique of Professor Ronaldo Pontes (RP). Methods: The study included a series of retrospective cases of 124 patients treated between March 2014 and March 2017 who underwent RP block abdominoplasty. Results: In our studies, a minimal incidence of complications and a small number of healing alterations were noted with the RP block technique compared to those found in the literature. Conclusion: A técnica descrita e suas variantes atendem a necessidade de diversos tipos de casos e garantem cirurgias seguras e eficazes, com resultados muito satisfatórios, sendo uma técnica reprodutível.

An add-on therapy for neuropathic pain: Infiltration block with diclofenac sodium and lidocaine through the hypertrophic scar tissue.

In some situations, the cause of the supposed neuropathic pain might be related to abnormal tissue recovery such as scar formation due to wound retraction that might create mechanical compression on the nerve tissue. In this report we describe infiltration block with diclofenac sodium and lidocaine through the hypertrophic scar tissue to reduce mechanical stress in 3 patients. The infiltration technique might resolve the tension of the contracted scar tissue by tearing the adhesions and the eliminated mechanical compression would reduce the pressure on nerve tissue and hence neuropathic pain symptoms.

Comparative efficacy of intralesional triamcinolone acetonide injection during early and static stage of pathological scarring.

OBJECTIVE: This study aims to clarify whether the effect of intralesional triamcinolone acetonide injection during the early stage of scarring differs from the static stage, which still remains unclear. METHODS: A total of 108 patients with pathological scars were enrolled in this study and were divided into 2 groups according to the time of first treatment after injury: the early stage group(≤6 months after injury) and the static stage group(>6 months after injury). Patients of both groups were then treated with intralesional triamcinolone acetonide injection. The Vancouver scar scale was adopted for the evaluation of scars, and a durometer was utilized for the measurement of the hardness of the scar. The visual analog scale was adopted for the assessment of patients' subjective feelings (pruritus and pain). In the meantime, adverse drug reactions were also recorded. RESULTS: After intralesional injection of triamcinolone acetonide, most of the hypertrophic scars and keloids improved in color, thickness, softness, and vascular distribution. The hardness of scars improved significantly. The overall efficacy of the static stage group was superior to the early stage group. Most patients, after the injection of triamcinolone acetonide, had significant alleviation or even total loss of cicatricial pain and pruritus. CONCLUSIONS: This study demonstrates that the treatment efficacy was better when applied during the static stage of pathological scarring rather than the early stage, which might be due to macrophages and their released cytokines. This study provides new clinical evidence for optimizing drug therapy of pathological scars.

Management of epidermal cysts arising from scar tissues: A retrospective clinical study.

Few reports have described epidermal cysts (ECs) arising from scar tissues, and the standard course of treatment has not been established. We aimed to report the findings of a Korean patient series with ECs arising from scar tissues, to describe patient management in the context of previous publications, and to present a simple algorithm for managing ECs arising from scar tissues.We managed 6 patients with ECs arising from scar tissues, and retrospectively reviewed their demographic and clinical data.The scars were located on the anterior chest wall (n = 3), shoulder (n = 1), forehead (n = 1), and ear lobule (n = 1). Two patients with anterior chest wall scars, 1 with a shoulder scar, and 1 with an ear lobule scar had keloid scars, whereas the other patients had hypertrophic scars. The scar sizes ranged from 2 × 1 cm to 9 × 7 cm. The EC sizes ranged from 0.2 × 0.2 cm to 2 × 1.5 cm. Three patients underwent total scar revisions with complete EC excisions, 2 underwent partial scar tissue excisions with complete EC excisions, and 1 had laser therapy for the scar and EC. No complications occurred, and all patients' final outcomes were satisfactory during the mean follow-up period of 14.8 months.We successfully managed the patients with ECs arising from scar tissues. We recommend that surgeons and patients first decide whether the ECs and scar tissue should be completely removed. Moreover, consideration should be given to the options chosen for the management of ECs. Finally, postoperative scar care is necessary to prevent hypertrophic and keloid scar recurrences.

Risk factors for hypertrophic burn scar pain, pruritus, and paresthesia development.

Hypertrophic scar pain, pruritus, and paresthesia symptoms are major and particular concerns for burn patients. However, because no effective and satisfactory methods exist for their alleviation, the clinical treatment for these symptoms is generally considered unsatisfactory. Therefore, their risk factors should be identified and prevented during management. We reviewed the medical records of 129 postburn hypertrophy scar patients and divided them into two groups for each of three different symptoms based on the University of North Carolina "4P" Scar Scale: patients with scar pain requiring occasional or continuous pharmacological intervention (HSc pain, n = 75) vs. patients without such scar pain (No HSc pain, n = 54); patients with scar pruritus requiring occasional or continuous pharmacological intervention (HSc pruritus, n = 63) vs. patients without such scar pruritus (No HSc pruritus, n = 66); patients with scar paresthesia that influenced the patients' daily activities (HSc paresthesia, n = 31) vs. patients without such scar paresthesia (No HSc paresthesia, n = 98). Three multivariable logistic regression models were built, respectively, to identify the risk factors for hypertrophic burn scar pain, pruritus, and paresthesia development. Multivariable analysis showed that hypertrophic burn scar pain development requiring pharmacological intervention was associated with old age (odds ratio [OR] = 1.046; 95% confidence interval [CI], 1.011-1.082, p = 0.009), high body mass index (OR = 1.242; 95%CI, 1.068-1.445, p = 0.005), 2-5-mm-thick postburn hypertrophic scars (OR = 3.997; 95%CI, 1.523-10.487, p = 0.005), and 6-12-month postburn hypertrophic scars (OR = 4.686; 95%CI, 1.318-16.653, p = 0.017). Hypertrophic burn scar pruritus development requiring pharmacological intervention was associated with smoking (OR = 3.239; 95%CI, 1.380-7.603; p = 0.007), having undergone surgical operation (OR = 2.236; 95%CI, 1.001-4.998; p = 0.049), and firm scars (OR = 3.317; 95%CI, 1.237-8.894; p = 0.017). Finally, hypertrophic burn scar paresthesia development which affected the patients' daily activities was associated with age (OR = 1.038; 95%CI, 1.002-1.075; p = 0.040), fire burns (OR = 0.041; 95%CI, 0.005-0.366; p = 0.004, other burns vs. flame burns), and banding and contracture scars (OR = 4.705; 95%CI, 1.281-17.288, p = 0.020).

A Child With a Burn-Related Foot and Ankle Contracture Treated With Multiple Modalities.

PURPOSE: The presence of hypertrophic scars, which cross lower extremity joints, can often result in decreased range of motion, limitations in functional mobility, and gait deviations. This article reviews a case and describes a multimodal treatment approach. SUMMARY OF KEY POINTS: A 6-year-old girl developed aggressive hypertrophic scars following a burn injury. A multimodal treatment approach, including splinting, elastomers, and physical therapy, was developed. CONCLUSIONS: Rapid improvements were demonstrated in measured objective outcomes. RECOMMENDATIONS FOR CLINICAL PRACTICE: Early multimodal intervention, in addition to range of motion, stretching, massage, and compression garments, is recommended when treating hypertrophic scars. This case suggests that further study into a multimodal treatment approach may be beneficial to develop a standardized protocol for more efficient scar management.

In-the-bag decentration of an intraocular lens in a patient with a tendency to hypertrophic scarring.

We report a case of rapid anterior lens capsular contraction leading to decentration of a hydrophilic acrylic lens with stiff haptics (Rayner design). To our knowledge, this is the first report to investigate early capsular contraction with folding of the haptic over the optic in a patient with a tendency toward hypertrophic scar formation.

Effective symptomatic treatment for severe and intractable pruritus associated with severe burn-induced hypertrophic scars: A prospective, multicenter, controlled trial.

BACKGROUND: Burn-induced hypertrophic scars are disfiguring and can be associated with severe and intractable pruritus. No effective treatment modalities are currently available for symptomatic control of pruritus for most patients. We assessed the effect of the Antipruritic Hydrogel (CQ-01) in the symptomatic treatment of severe and intractable pruritus associated with burn-induced hypertrophic scars in a prospective, multicenter, controlled trial. METHODS: A pilot study was conducted in healthy adult volunteers to identify the most appropriate hydrogel formulation. A selected preparation called Chongqing No. 1 (CQ-01; a guar gum-based hydrogel impregnated with peppermint oil, menthol, and methyl salicylate by a nanoemulsion), showed an excellent symptomatic relief in an exploratory study in 2 patients with intractable pruritus. A statistically powered, prospective, multicenter, controlled study was then conducted in 74 patients to evaluate the efficacy and safety of a 24-h application of CQ-01 compared to a gel control and a negative control on three separate areas in each patient. Symptom assessment was based on our visual analog JW scale (ranging from 0 to 100) at baseline and various time points up to 7 days after application. Follow-up studies were conducted to determine the reproducibility of CQ-01 in repeated applications. RESULTS: Of the 74 enrolled subjects, the only observed adverse event was skin irritation reported in 6 patients (8%) and resolved shortly after gel removal. Compared to the baseline, the gauze negative control had a mean JW score reduction of 7; while the gel control and CQ-01 had a drop of 18 (p<0.001) and 36 (p<0.001), respectively. The CQ-01 clinical effect was significant for up to 3 days and waned slowly from 3 to 7 days. There was no statistical correlation between the treatment response and any of the demographic, patient or burn-related factors. Further studies showed a trend that repeated applications might be more effective, suggesting the absence of tachyphylaxis. CONCLUSIONS: This prospective, multicenter, controlled study showed that this novel hydrogel CQ-01 is safe and provides significant symptomatic relief for severe and intractable pruritus associated with hypertrophic scars, an unmet medical need for these patients. This effect is independent of the etiology of the burn trauma, extent of the scarring, and duration of the scar formation.

Dermolipectomia em âncora após cirurgia bariátrica: complicações e índice de satisfação dos pacientes / Anchor dermolipectomy after bariatric surgery: complications and patient satisfaction rate

INTRODUÇÃO: A obesidade é considerada pela Organização Mundial de Saúde (OMS) a principal pandemia do século. A obesidade mórbida tem como um de seus tratamentos mais efetivos a cirurgia bariátrica, e muitos pacientes necessitarão de cirurgia plástica reparadora após grandes emagrecimentos. Dentre as cirurgias em ex-obesos, a mais associada a complicações é a dermolipectomia. O propósito deste estudo foi mostrar a experiência do autor na dermolipectomia em âncora após grande emagrecimento, enfocando as complicações e a satisfação do paciente. MÉTODOS: Revisamos 40 prontuários de pacientes operados entre setembro de 2011 e abril de 2013, cinco deles não foram localizados e, por isso, excluídos do estudo. Foi solicitado que pontuassem de 1 a 4, sendo 1 (insatisfeito), 2 (pouco satisfeito), 3 (satisfeito), 4 (muito satisfeito). Consideramos as complicações trans e pós-operatórias, tempo cirúrgico, permanência hospitalar, tempo com dreno, idade e gênero. Foi realizada análise estatística dos dados, assim como estatística descritiva. RESULTADOS: Nosso estudo avaliou 35 pacientes, apenas um era homem (2,85%), a idade variou de 27 a 68 anos (média 41,25 anos), o peso pré-operatório variou de 58 a 108 kg (média de 73,6 kg), 94,28% dos pacientes sentiam-se satisfeitos (pontuação 3 e 4). A principal complicação foi o seroma 28,5%, seguida pela cicatriz hipertrófica (17,14%), nenhuma complicação maior foi verificada. O tempo médio do procedimento cirúrgico foi de 103 minutos (75-140 minutos). Alta ocorreu com 24h de internação hospitalar. CONCLUSÃO: A dermolipectomia em âncora é um método seguro e efetivo para o contorno corporal do ex-obeso.

INTRODUCTION: Obesity is designated by the World Health Organization (WHO) as the major pandemic of this century. Bariatric surgery is one of the most effective treatments of morbid obesity, since most patients are submitted to reconstructive plastic surgery after major weight loss. Among the surgeries carried out in the formerly obese, dermolipectomy is the procedure that is mostly associated with complications after surgery. The aim of this study was to report the experience of the author in performing anchor dermolipectomy after major weight loss, focusing on complications and patient satisfaction rate. METHODS: The medical records of 40 patients operated between September 2011 and April 2013 were reviewed in the study. Five patients were excluded from the study, since they could not be found. The patients were asked to score their satisfaction from 1 to 4, where 1 means dissatisfied, 2 poorly satisfied, 3 satisfied, and 4 very satisfied. Trans and post-operative complications, surgical time, hospital stay, drainage time, age, and gender were considered in the study. The data obtained were submitted to a statistical analysis and descriptive statistics. RESULTS: Among the 35 patients evaluated in our study, only one was male (2.85%). The age varied between 27 and 68 years (average age of 41.25 years). The preoperative weight varied from 58 to 108 kg (average of 73.6 kg); 94.28% of the patients declared themselves as satisfied (score 3 and 4). The main complication was the occurrence of seroma (28.5%), followed by hypertrophic scar (17.14%). No major complication was observed. The average surgical time was 103 minutes (75-140 minutes). The patient was discharged 24 hours after hospital admission. CONCLUSION: Anchor dermolipectomy is a safe and effective body contouring procedure to be carried out in the formerly obese.

Inhibition of mechanical stress-induced hypertrophic scar inflammation by emodin.

At least 50% of hypertrophic scarring (HS) is characterized by inflammation, for which there is currently no effective treatment available. Emodin is a major component of the widely used Chinese herb, rhubarb, which has been used to treat inflammation in several types of disease. However, few studies have investigated the efficacy of emodin in the treatment of HS. In the present study, a mouse model with mechanical stress­induced HS was used to investigate the effects of emodin (20, 40, 80, or 120 mg/ml) on HS, and to determine the potential underlying mechanisms. Treatment with emodin significantly attenuated HS inflammation, as determined by histopathological assessment of the scar elevation index, collagen structure and inflammation (P<0.05). Furthermore, treatment with emodin (40 mg/ml) markedly inhibited phosphoinositide 3­kinase (PI3K)/Akt activity (P<0.01) and this attenuation was associated with reduced expression levels of tumor necrosis factor­α, interleukin­6 and monocyte chemoattractant protein­1 (P<0.05) in the HS tissue. The results of the present study indicated that administration of emodin had therapeutic effects on the progression of HS and the underlying mechanism of this may be due to inhibition of the PI3K/Akt signaling pathway.