The Effect of Smoking on Sternal Scar Healing: A Prospective Cohort Study.

INTRODUCTION: Cardiothoracic surgery with a median sternotomy is an electing factor for the development of a hypertrophic scar. Hypertrophic scars, characterized by an increased vascularity, often result in aesthetic and functional problems. Smoking, due to its negative effects on vascularization, could therefore have an effect on scar healing. OBJECTIVE: A prospective cohort study was conducted to evaluate the effect of smoking on scar healing after cardiothoracic surgery with a median sternotomy incision. MATERIALS AND METHODS: One hundred patients who underwent cardiac surgery with a median sternotomy were divided into 3 groups: smokers, ex-smokers, and nonsmokers. Erythema values of the scar were measured with a colorimeter on 3 standardized parts of the scar. Scar evaluation was performed at 6 weeks, 3 months, 6 months, and 12 months after surgery. RESULTS: During 1 year, a total of 90 patients were followed after a median sternotomy; 10 patients were lost to follow-up. There were 23 smokers, 52 ex-smokers, and 15 nonsmokers with an overall mean age of 61.5 ± 8.83 years. No significant difference in redness as a parameter for hypertrophic scarring was observed between the 3 groups. Nevertheless, a trend in favor of the smokers was seen, as they developed less hyperemic scars. The caudal part of the scar showed a significantly higher incidence of hypertrophy compared with the middle and cranial part of the scar at all time points. CONCLUSIONS: It is presumed that a large sample size with younger patients is needed to confirm the results herein. Furthermore, more caudally located skin, especially the subxiphoidal part, is prone to hypertrophic scarring and should, for that reason, be avoided in the incision.

Satisfaction with Facial Appearance and Quality of Life after Treatment of Face Scars with a Transparent Facial Pressure Mask.

Treatment of facial hypertrophic scars and deformities has developed from the use of elastic fabric hoods to transparent facemasks. The clinical effects of these masks have been described. However, the psychological impact of wearing such a mask is not well documented. The aim of this study was to assess patients' satisfaction with their current facial appearance, to assess the end result of facemask therapy, and to assess the decision to have undergone facemask therapy by means of four different FACE-Q questionnaires. Out of the eligible 87 patients who completed the facemask therapy between January 2012 and November 2017, 42 filled out the questionnaires. These patients wore a custom-fabricated facemask because of facial hypertrophic scars and severe postsurgical facial irregularities. Patients who wore the mask 12 to 16 hours per day were significantly more satisfied with the end result compared with those who wore it 4 to 8 hours daily. Also, patients who wore the mask 8 to 12 and 12 to 16 hours each day were more satisfied to have undergone therapy compared with those who wore it 4 to 8 hours daily. Furthermore, patients who finished therapy 3 to 4 years and 4 to 5 years ago reported a significant higher satisfaction with facial appearance compared with those who completed therapy in a time period shorter than 1 year ago. Patients who finished therapy 3 to 4 years ago reported higher satisfaction with their facial appearance compared with those who finished therapy 2 to 3 years ago. Additionally, the Patient and Observer Scar Assessments Score (POSAS) showed a significant reduction between start and end of therapy. This study shows facemask therapy to result in long-lasting stable results. It also shows a longer daily wearing of the facemask to result in the highest satisfaction according to patients.

A new treatment of hypertrophic and keloid scars with combined triamcinolone and verapamil: a retrospective study.

BACKGROUND: Since the management of keloid and hypertrophic scars still remains a difficult clinical problem, there is need for adequate, effective therapy. In this study, we explored for the first time the efficacy and the potential synergetic effect of combined triamcinolone and verapamil for the treatment of hypertrophic and keloid scars. The objective was to assess the efficacy of combined intralesional triamcinolone and verapamil therapy for hypertrophic and keloid scars. METHODS: Fifty-eight patients with hypertrophic scars (n = 31) and keloid scars (n = 27) were included. A specific injection therapy scheme was applied. Five follow-up moments were chosen, with a maximum follow-up of nearly 2 years. The effects of combination therapy on scar pliability, thickness, relief, vascularization, surface area, pain, and pruritus were examined by means of the Patient and Observer Scar Assessment Scale (POSAS). RESULTS: Our results reveal a fast and abiding improvement of both keloid and hypertrophic scars after treatment with the combination therapy. All POSAS components showed a reduction in scar score, while scar relief, pain, itchiness, and surface area improved significantly (P < 0.05) in keloids. Significant improvement in hypertrophic scars was found in scar pigmentation, vascularization, pliability, thickness, pain, and surface area. Overall POSAS scores revealed statistically significant decreases between baseline and 3-4 months, 4-6 months, and >12 months after start of therapy in both keloids and hypertrophic scars. CONCLUSIONS: This study reveals that combined therapy of triamcinolone and verapamil results in overall significant scar improvement with a long-term stable result.Level of evidence: Level IV, therapeutic study.

Assessing blood flow, microvasculature, erythema and redness in hypertrophic scars: A cross sectional study showing different features that require precise definitions.

BACKGROUND: In hypertrophic scar assessment, laser Doppler imaging (LDI), colorimetry and subjective assessment (POSAS) can be used to evaluate blood flow, erythema and redness, respectively. In addition, the microvasculature (i.e. presence of microvessels) can be determined by immunohistochemistry. These measurement techniques are frequently used in clinical practice and/or in research to evaluate treatment response and monitor scar development. However, until now it has not been tested to what extent the outcomes of these techniques are associated, whilst the outcome terms are frequently used interchangeably or replaced by the umbrella term 'vascularization'. This is confusing, as every technique seems to measure a specific feature. Therefore, we evaluated the correlations of the four measurement techniques. METHODS: We included 32 consecutive patients, aged ≥18 years, who underwent elective resection of a hypertrophic scar. Pre-operatively, we performed LDI (measuring blood flow), colorimetry (measuring erythema) and the POSAS (subjective redness) within the predefined scar area of interest (∼1.5cm). Subsequently, the scar was excised and the area of interest was sent for immunohistochemistry, to determine the presence of microvessels. RESULTS: Only a statistically significant correlation was found between erythema values (colorimetry) and subjective redness assessment (POSAS) (r=0.403, p=0.030). We found no correlations between the outcomes of LDI, immunohistochemistry and colorimetry. CONCLUSIONS: Blood flow, the presence of microvessels and erythema appear to be different hypertrophic scar features because they show an absence of correlation. Therefore, in the field of scar assessment, these outcome terms cannot be used interchangeably. In addition, we conclude that the term 'vascularization' does not seem appropriate to serve as an umbrella term. The use of precise definitions in research as well as in clinical practice is recommended.

Three-dimensional imaging for volume measurement of hypertrophic and keloid scars, reliability of a previously validated simplified technique in clinical setting.

INTRODUCTION: Evidence behind many of the current treatments in hypertrophic and keloid scars remains limited. Current objective methods to assess efficacy and provide follow-up can be complex and are not easily applied in clinical setting. The aim of this study was to assess reliability of a recently validated simplified technique for volume measurement in clinical practice. METHODS: Volume measurement of 28 hypertrophic and keloid scars was conducted in 22 consecutive patients, using a three-dimensional stereophotogrammetry. Intra- and inter-rater reliability was assessed by the intraclass correlation coefficient (ICC) and the coefficient of variation (CV). The measurement error was expressed as limits of agreement (LoA). RESULTS: The simplified method for three-dimensional volume measurement showed good intra-rater reliability with an ICC of 0.997 and a CV of 7.3%, and a good inter-rater reliability with an ICC of 0.999 and a CV of 5.7%. The plot of the differences and LoA showed near-perfect agreement between observers. CONCLUSION: Objective evaluation of scar volume using the simplified three-dimensional measurement technique may complement subjective scoring and improve the ability to quantitatively compare the response to therapeutic methods.

One world one burn rehabilitation standard.

According to the World Health Organization (WHO) burns are a huge global health problem resulting in death and devastation to those who survive large burns as they are faced with significant functional limitations that prevent purposeful and productive living. Members of the International Society for Burn Injuries (ISBI) Rehabilitation Committee conducted a needs assessment survey in order to characterize how burn rehabilitation is implemented worldwide and how the international burn rehabilitation community can help improve burn rehabilitation in identified geographic locations which need assistance in rehabilitating burn survivors successfully. The results of this survey indicated that poor and in some cases resource limited environments (RLEs) around the world seem to lack the financial, educational and material resources to conduct burn rehabilitation successfully. It appears that there are vast discrepancies in the areas of education, training and capacity to conduct research to improve the care of burn survivors as evidenced by the variation in responses between the RLEs and developed countries around the globe. In some cases, the problem is not knowledge, skill and ability to practice burn rehabilitation, but rather having the resources to do so due to financial difficulties.

Efficacy of custom-made pressure clips for ear keloid treatment after surgical excision.

BACKGROUND: Mechanical pressure is increasingly applied as a means to prevent or treat keloid scars. AIM: The aim of this study is to analyze the long-term efficacy of our custom-molded pressure-adjustable earclips to prevent keloid recurrence after surgical excision. METHODS: Using our custom-molded earclip, 88 patients who had undergone ear surgery for keloid scars were treated for 12 h a day for 6-18 months. The mean follow-up was 6.5 years. The primary outcome was the recurrence of keloids with patient satisfaction being the secondary outcome as assessed by Patient and Observer Scale (POSAS). RESULTS: Keloid scars did not recur in 70.5% of treated patients. The Fitzpatrick scale, which classifies human skin by type, was significantly different between the recurrence and nonrecurrence group. Differences in other patient characteristics were not found between both groups. All parameters mentioned in the POSAS patient scale drastically improved after therapy. There were no severe side effects observed after the therapy. CONCLUSION: Our pressure-adjustable earclip model is an effective tool in the prevention of ear keloid recurrence and is associated with high patient satisfaction. Its benefits should prompt further studies on its value as an adjuvant therapy to surgery in keloid treatment. LEVEL OF EVIDENCE: Level III on the Evidence Rating Scale for Therapeutic Studies.

A simplified three-dimensional volume measurement technique in keloid scars: Validity and reliability.

INTRODUCTION: Effective treatment of keloid scars is important because patients are often confronted with major cosmetic, psychological, and social consequences. Three-dimensional (3D) imaging has been reported for the evaluation of keloid treatment. These techniques were complex to use in clinical practice. In this study, the validity and reliability of a simplified 3D volume measurement technique are defined. METHODS: Thirty-three scars were simulated using deformable modeling compound. The volume of the compound is calculated using the weight and density of the modeling compound, and it is compared with the 3D volume measurement. RESULTS: The mean simulated keloid volume was 2.884 cc. The correlation was very high (r = 0.999), but there was a significant mean difference of 0.252 cc (p < 0.001). This was corrected using a formula, actual volume = 1.072 × measured volume. This formula was validated using a new data set of 33 simulated scars. There was a nonsignificant mean difference of 0.010 cc (p = 0.731). CONCLUSION: This 3D measurement technique combined with the correcting formula is valid and reliable to be used in practice for the evaluation of keloid scar treatment.

Reliability of Repeated Measurements on Post-Burn Scars with Corneometer CM 825(®).

BACKGROUND/PURPOSE: The water content in burn scars, the parameter of stratum corneum water holding capacity, is an important feature in evaluation of biophysical properties of scars. Nevertheless, quantifiying this parameter is a challenge. In this study, the reliability of repeated water content measurements with Corneometer CM825(®) on (burn) scars was investigated. METHODS: Intra-observer reliability, inter-observer reliability and day-by-day variability were examined on 30 scars by means of intra-class correlation coefficient (ICC) and within-subject coefficient of variation (WSCV). Bland-Altman plots with '95% limits of agreement' were constructed. RESULTS: Results revealed excellent ICC values (ICCintra  = 0.985; ICCinter  = 0.984) with relatively low WSCV (WSCVintra  = 6.3%; WSCVinter  = 10.6%) for respectively intra- and inter-observer reliability. However, the Bland-Altman plot showed that more than 5% of differences were expected to exceed 4 a.u., the limit of what has been defined as a clinically acceptable difference. Results for day-by-day variability showed good ICC value (ICCday-by-day  = 0.849) and higher WSCV (WSCVday-by-day  = 20.5%). CONCLUSION: The Corneometer CM825(®) is an objective and sensitive instrument for water content measurements. On the basis of our results, we concluded that the instrument can be used in clinical trials, but only under very strict conditions with standardized test protocol, preferably in combination with the evaluation of other physiological parameters.

A comparative study of colour and perfusion between two different post surgical scars. Do the laser Doppler imager and the colorimeter measure the same features of a scar?

BACKGROUND/PURPOSE: The purpose of this study was to investigate the influence of different located post surgical scars on both perfusion and redness. The pattern of change and correlation between perfusion and redness of post surgical scars is also examined. METHODS: In this study, we measured redness and perfusion of the abdominal and breast scar of 24 women undergoing breast reconstruction with Deep Inferior Epigastric Perforator Free Flap surgery with the Minolta Chromameter CR-400/410 and the Moor Instruments laser Doppler imager 12IR, respectively, at different intervals post-operatively. RESULTS: The laser Doppler imager gives significantly higher values for the abdominal compared with the breast scar. There was no consistent correlation found between perfusion and redness at the different test moments for both locations. The scores of both parameters were significantly associated after 9 months follow-up for both locations. CONCLUSION: Scars closed with higher mechanical force show higher perfusion and prolonged activity; and more redness is associated with more perfusion for both post surgical scars. Nevertheless, there was no consistent correlation found between these parameters making the laser Doppler imager and the Colorimeter still non-replaceable instruments.

Smoking in relation to age in aesthetic facial surgery.

BACKGROUND: Smoking is a major cause of premature facial aging. Skin aging in general, often accompanied by wrinkling and furrowing, plays a significant role in the decision to undergo aesthetic surgery. Smoking may therefore be related to the demand for cosmetic surgery. This study aimed to compare smoking habits with respect to a standard cosmetic procedure (blepharoplasty) in the general population and to evaluate whether the age at surgery differs between smokers and nonsmokers. METHODS: A questionnaire was sent to 517 patients with valid reports describing dermatochalasis of the upper eyelid who subsequently underwent an upper-eyelid correction in 2004. Smoking habits, socioeconomic status, and medical history were evaluated. The patients were classified as smokers, ex-smokers with at least 1 year of smoking cessation, and never-smokers. RESULTS: Of the 353 questionnaires (68.3 %) returned, 345 were eligible for statistical analysis. The smoking habits did not differ between the blepharoplasty group and the general population. However, the smokers underwent surgery an average of 3.7 years earlier than the ex-smokers (p=0.0007) and 3.5 years earlier than the never-smokers (p=0.006). No significant difference was observed between the ex-smokers and the never-smokers. CONCLUSIONS: This is the first study to describe an association between smoking habits and an earlier need for upper-eyelid correction among ex- and never-smokers. The mechanism of skin restoration could result in a regenerative mechanism among ex-smokers, but further research is needed to support this hypothesis. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Smoking and its effect on scar healing.

Scar formation is influenced by several factors such as wound infection, tension, wound depth and anatomical localization. Hypertrophic scarring is often the result of an imbalance in the wound and scar healing process. The exact underlying pathophysiological mechanism remains unclear. Smoking has a higher risk of postoperative complications probably due to a diminished macrophage induction. Following our clinical impression that smokers without postoperative wound infections show esthetically better scars, we evaluated the scars after a reduction mammaplasty in smoking and nonsmoking patients in a prospective clinical trial. Between July 2006 and September 2007, 13 smokers and 30 non smokers with a reduction mammaplasty were included. They were recruited from Viecuri Medical Centre and Atrium Medical Centre in the Netherlands after written consent. Surgical data and data of the patients' condition were collected. Follow-up for erythema values of the scars was done with a colorimeter (The Minolta CR-300, Minolta Camera Co., Ltd., Osaka Japan) at 1, 3, 6 and 9 months postoperatively on four standardized postsurgical sites. ANOVA and Chi-square test were used for statistical analysis. In the smoking group, the scars were significantly less red compared to the nonsmoking group. No significant differences were found in BMI, resection weight and drain production between both groups. Although smoking is certainly not recommended as a preventive therapy to influence scar healing, this study confirms our assumption that smokers tend to have faster and less erythemateous scar healing to nonsmokers. Further research is needed to understand the mechanism of the effect of smoking on scars.

Predictors of mortality: a comparison between two burn wound treatment policies.

Retrospective review of outcomes and experiences of a single burn centre between two time periods during which a new wound care technique was employed after the first period. The time period was divided into two: 1977-1984 and 1984-1990. Due to the use of cerium nitrate-silver sulphadiazine, the introduction of serial excision and grafting became possible in the second time period. Multivariate risk-analysis was done by logistic regression analysis. The mortality rate decreased from 13.7% (1997-1983) to 4.7% (1984-1990). Results of multiple logistic regression analysis indicate that the change in periods was advantageous for patients with >50% TBSA, within the age group, 0 to 30 years. Obviously, the care which a patient receives has improved significantly. Many developments occurred simultaneously and it appears impossible to conclude that only the use of cerium nitrate-silver sulphadiazine was the reason for improved survival. Nevertheless, the use of cerium nitrate-silver sulphadiazine enables sequential excision and grafting and in consequence allows for many of these developments to occur.

Application of cerium nitrate-silver sulphadiazine allows for postponement of excision and grafting.

Early excision and grafting cannot always be performed due to patient's medical status, and the lack of adequate donor sites. The use of cerium nitrate-silver sulphadiazine cream, which causes the formation of a leather-like eschar with excellent resistance to infection, is an alternative method. In order to postpone operations by using cerium nitrate-silver sulphadiazine, we compared the differences in contamination of the grafted areas between early and delayed excision. Eighteen patients underwent excision and grafting within 5 days post burn and nineteen patients were surgically treated after 5 days. Twelve months later the grafted areas were evaluated. Contamination of the grafted area occurred in 17 patients. No differences in contamination occurred between the early and delayed excision group, 8 versus 9. Also no differences in type of organism cultured and follow-up results were found between the early and delayed excision group. Cerium nitrate-silver sulphadiazine allows surgical treatment to be delayed without an increase of contamination of the grafted area and does not adversely affect the long-term outcome.

Povidone-iodine ointment: no effect of split skin graft healing time.

In major burns, local treatment of the split skin graft after a burn injury is important to prevent serious infectious complications. Topical burn wound therapy may improve the bacteriological condition of the wound, which in turn may improve the successful take of a skin graft. Delay of wound healing is an undesired side effect of these topical anti-microbial agents. It is known that povidone-iodine has many clinical advantages. In view of this, the total healing time of the freshly grafted burn wound was studied. In this prospective study, comparable areas of the same patient were treated with povidone-iodine ointment or with simple vaseline gauze. There was no statistical difference in the total wound healing time between the treated and the control group.

Silicones in the rehabilitation of burns: a review and overview.

This article gives an overview of the use of silicones in the treatment and prevention of hypertrophic (burn related) scars. Of all non-invasive treatment modalities the use of continuous pressure and occlusive contact media, e.g. silicones, seem to be generally accepted as the only ones that are able to manage hypertrophic scarring without significant side-effects. A summary of the current opinions of the assumed working mechanisms of pressure as well as silicones is given. The use of silicones, either alone or in combination with pressure, is discussed. The recent development of custom made silicone devices has led to combinations of both modalities. Some of these, including the inflatable silicone insert systems (ISIS), are shown and discussed.

Reproducibility of repeated measurements on healthy skin with Minolta Chromameter CR-300.

BACKGROUND/AIMS: In this report the reproducibility of measurements with the Minolta Chromameter CR-300 on healthy skin was investigated. METHODS: Intra- and inter-rater reproducibility, reproducibility with two instruments and repeated measurements with a 1 week time lapse were examined on healthy skin of 30 volunteers by means of intra-class correlation coefficients (ICC) and standard error of measurements (SEM). RESULTS: Results showed excellent values for ICC in all the four conditions. CONCLUSIONS: On the basis of these results we concluded that the instrument provides reliable information and can be used in comparative clinical trials.