Reliability of the Patient and Observer Scar Assessment Scale in Evaluating Linear Scars after Thyroidectomy.

OBJECTIVE: To compare the reliability of the Patient and Observer Scar Assessment Scale (POSAS) with the Vancouver Scar Scale (VSS) in evaluating thyroidectomy scars. METHODS: At 6 months after the operation, 112 patients who underwent thyroid surgery via collar neck incision were evaluated by two blinded plastic surgeons and two senior residents using the VSS and the observer component of the POSAS. In addition, the observer-reported VAS score and patient-reported Likert score were evaluated. Internal consistency, interobserver reliability, and correlations between the patient- and observer-reported outcomes were examined. RESULTS: The observer component of POSAS scores demonstrated higher internal consistency and interobserver reliability than the VSS. However, the correlations between the observer-reported VAS score and the patient-reported Likert score (0.450) and between the total sum of patient and observer component scores (0.551) were low to moderate. CONCLUSIONS: The POSAS is more consistent over repeated measurements; accordingly, it may be considered a more objective and reliable scar assessment tool than the VSS. However, a clinician's perspective may not exactly match the patient's perception of the same scar.

Subjective Tools for Burn Scar Assessment: An Integrative Review.

OBJECTIVE: To review the clinical and scientific literature on the subjective ways of assessing burn scars and describe their main characteristics. DATA SOURCES: The Latin American, Caribbean Health Sciences Literature, Nursing Database, PubMed, CINAHL, and Scopus and Web of Science databases were used to search for studies published between 2014 and 2018 using descriptors in Portuguese, Spanish, and English. STUDY SELECTION: After establishing the research question and the location and definition of the studies, as well as accounting for differences among databases and application of filters based on inclusion and exclusion criteria, 886 references remained. DATA EXTRACTION: Investigators reviewed the titles and abstracts of the sample and selected 188 relevant studies for full review. DATA SYNTHESIS: Twenty-six subjective forms of assessment were found; most research concerned the Patient and Observer Scar Assessment Scale and the Vancouver Scar Scale. CONCLUSIONS: The Patient and Observer Scar Assessment Scale and the Vancouver Scar Scale are the most common scales for assessing burn scars and have similar evaluation points such as vascularization, pliability, pigmentation, and height, which are the main parameters that contribute to the general assessment and severity of a scar. There is a need to improve instructions for application of the scales to facilitate better understanding and improve agreement among evaluators.

Classification of Achilles tendon shortening induced by scar contracture and corresponding treatment strategies for pediatric patients - A single unit experience.

BACKGROUND: Achilles tendon shortening of pediatric patients caused by scar contracture poses a challenge for us. It always impairs walking function. In this article, we attempted to introduce a new classification of Achilles tendon shortening of pediatric patients and corresponding treatment strategies in our single center. METHODS: From 2001 to 2018, 65 patients (aging from 13 to 17-years-old, 34 females and 31 males, 21 cases with unilateral Achilles tendon shortening and 44 cases with bilateral Achilles tendon shortening) were recruited. The causes included trauma (n = 13), scald (n = 20) and burn (n = 32). The distance between the heel and the ground was from 3 to 18 cm. They were classified into three types: ≤5 cm, mild, n = 9; 5-10 cm, moderate, n = 30; ≥10 cm, serious, n = 26. They had a history from 7 months to 4 years (28 cases with less than 1.5 years and 37 cases with more than 1.5 years). Treatment methods: Scar-Achilles-Tendon (SAT) flaps and skin graft were used for moderate cases before special external fixation shoes were used for fixation for at least 6 months. External special shoes fixation was used for mild cases except 5cases still received SAT flap and skin graft. In serious cases, bone extraction was used for at least 6 months before receiving SAT flap and skin graft. RESULTS: The distance between the heel and the ground was 0 cm after treatment in 54 cases (mild, n = 9; moderate, n = 28; serious, n = 18). Recurrence was found in 11 cases (mild, n = 0; moderate, n = 5; serious, n = 6) after six months follow-up. There were 13 cases of tangential excision of eschar and 8 cases of escharectomy (P < 0.05) with flap necrosis affection. Among them, 9 cases with a medical history of less than 1.5 years had partial necrosis, 6 cases with a medical history of more than 1.5 years had partial flap necrosis(P < 0.05). Local necrosis was covered by skin graft again. Bone exposure was found in 5 serious cases. It was repaired by negative pressure therapy first and then skin graft was used. The walking ability (P < 0.05) and function (P < 0.05) of lower limbs were statistically improved after treatment. CONCLUSIONS: Different methods can be used according to the shortening degree of Achilles tendon of pediatric patients based on the new classification, which may be useful for future clinical work.

The Natural Evolution of Facial Surgical Scars: A Retrospective Study of Physician-Assessed Scars Using the Patient and Observer Scar Assessment Scale Over Two Time Points.

Background: The natural evolution of facial scars has not been well described. Identifying factors that correlate with optimal scar healing may help patients and physicians during the perioperative period. Methods: A retrospective study of 108 facial skin cancer patient scars was performed. The Patient and Observer Scar Assessment Scale (POSAS) was used to grade scars at two time points (1 week and 3 months postoperatively). Paired two-tailed t-tests identified differences in scar ratings between the time points. Analysis of variance (ANOVA) explored whether POSAS scores differed by anatomic site or reconstruction type. Receiver operating characteristic analysis was performed to identify if 1-week scar appearance correlated with scar appearance at 3 months. Results: Between 1 week and 3 months the total POSAS score improved by 36.3% and overall opinion of the scar improved by 38.6% (p < 0.001). Facial cosmetic units differed in their 1-week and 3-month scores and all anatomic sites demonstrated significant improvement between time points. Differential scoring occurred among reconstruction types. Scar appearance at 1 week was able to predict overall scar appearance at the 3-month visit (area under the curve = 0.7732). Conclusions: Early scar appearance predicts later scar appearance, and scars will improve by nearly 40% 3 months after surgery. These data can be used to assist with perioperative counseling and expectation management.

Clinimetric properties of a translated and culturally adapted Norwegian version of the Patient and Observer Scar Assessment Scale for use in clinical practice and research.

PURPOSE: To translate and culturally adapt the Patient and Observer Scar Assessment Scale, POSAS, to Norwegian and explore its test-retest, intra- and inter-tester reliability. METHODS: POSAS was translated into Norwegian following international guidelines in collaboration with an international translation bureau. Twenty-six adults and 24 children were recruited from a burns outpatient clinic. Three observer-categories: doctor, nurse and physiotherapist, assessed the patients' scars and scored the Observer scale for estimating inter-tester reliability. Photos of the scars were taken and used to score the Observer scale a second time for examining intra-tester reliability. The patients or parents/next of kin rated their scar on the Patient scale at the clinic and after two days at home for examining test-retest reliability. Intraclass correlation (ICC) and Kappa were used for statistical analysis. RESULTS: A Norwegian version of POSAS (POSAS-NV) was developed. Inter-tester ICC of the Observer parameters varied between 0.203 and 0.728, and for the total sum score, ICC=0.528 (0.280-0.708). Intra-tester ICC of the Observer scale ranged between 0.575 and 0.858. The Patient scale demonstrated high test-retest reliability. CONCLUSIONS: Intra-tester reliability of the Observer scale and test-retest reliability of the Patient scale of POSAS-NV were found satisfactory, but not inter-tester reliability of the Observer scale.

Objective quantification of burn scar stiffness using shear-wave elastography: Initial evidence of validity.

Shear-wave elastography (SWE) is an ultrasound based technology that can provide reliable measurements (velocity) of scar stiffness. The aim of this research was to evaluate the concurrent validity of using both the measured velocity and the calculated difference in velocity between scars and matched controls, in addition to evaluating potential patient factors that may influence the interpretation of the measurements. METHODS: A cross-sectional study of 32 participants, with 48 burn scars and 48 matched contralateral control sites were evaluated with SWE, the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS) tactile sub-scores. RESULTS: Spearman's rho demonstrated high correlations (r > 0.7) between the measured scar velocity and both the POSAS and VSS pliability sub-scores, whereas moderate correlations (r > 0.6) were found with the calculated difference in velocity. Regression analysis indicated that the association of increased velocity in scars, varied by length of time after burn injury and gender. Body location and Fitzpatrick skin type also demonstrated significant associations with velocity, whereas age did not. CONCLUSION: SWE shows potential as a novel tool to quantify burn scar stiffness, however patient factors need to be considered when interpreting results. Further research is recommended on a larger variety of scars to support the findings.

Reliability testing of the Matching Assessment using Photographs of Scars App.

The Matching Assessment using Photographs with Scars assessment tool, published in 2005, enables accurate relocation and reassessment of scars. While used in Australia, uptake has been hampered by its paper manual format. With electronic records and increasing use of smart devices in health, here we report the development of the Matching Assessment using Photographs with Scars manual into a mobile application format: ClinMAPSTM Pro. At the time of development, no other digital scar assessment applications were available. For clinical validation, the digitized Matching Assessment using Photographs with Scars module within ClinMAPSTM Pro was used for intra- and inter-rater reliability testing. Convenience sampling was utilized to recruit burns patients representing 44 scars, based on predetermined power calculations. Three therapists, one experienced and two novice, acted as the assessors. Each therapist assessed preselected scars with the digitized Matching Assessment using Photographs with Scars. Re-assessment of the same scar sites occurred 3 to 7 days later. Inter-rater reliability testing scores of the new electronic assessment application showed fair to moderate agreement (combined Fleiss Kappa = 0.38-0.49, P < .0001). Intra-rater reliability scores between initial and repeat measures showed moderate to almost perfect agreement (Cohen's Kappa = 0.43-0.90, P < .0001). It was noted that for an experienced rater, intra-rater agreement demonstrated substantial to almost perfect agreement. Intraclass correlation coefficients calculated to allow for comparison between other published scar assessment tools demonstrated excellent reliability for all scar assessment parameters for both intra- (=0.76-0.91) and inter- (=0.76-0.98) reliability. Notably, reliability testing results confirm its intra- and inter-rater reliability. Our findings validate this novel concept for digitization of the previously paper-based scar assessment manual and prove that the Matching Assessment using Photographs with Scars within the ClinMAPSTM Pro application is now readily available for clinicians and researchers internationally.

Evaluating Current Scar Assessment Methods.

Current scar surveys have included many questions to evaluate the physical characteristics of scars, with some expanding to include physical implications and patient opinions. This review provides an analysis of frequently used scar assessment methods to date and highlights potential areas for improvement. We build the case that a new assessment tool is necessary, specifically one that centers on psychosocial consequences of scars that influence patient decision making for treatment, allowing physicians to individualize treatment conversations with patients. We postulate that survey techniques used in consumer product marketing, such as choice-based conjoint analysis, may be effective in determining the factors strongly influencing patient decision making and spending in scar treatment; therefore, more research in this area is warranted. By incorporating these psychosocial and economic considerations driving scar treatment decisions, future scar assessment tools may accomplish much more than characterizing/documenting the clinical aspects of scars. Rather, these patient-centered, holistic tools may be implemented by plastic surgeons and other clinicians specifically to provide patients with personalized treatment options that maximize long-term patient satisfaction.

Cross-cultural adaptation and psychometric validation of the Patient Scar Assessment Questionnaire to the Spanish language in head and neck surgery.

External appearance is the main aesthetic outcome in patients who undergo surgical procedures. Scars located in exposed areas, such as the neck and face, are important for patients. There are at least eight instruments that are used to evaluate postoperative scars, but few fulfil standard methodological conditions. The Patient Scar Assessment Questionnaire (PSAQ) was designed and validated using psychometric methodology. However, this scale has not been translated or validated in the Spanish language. The aim of this study was to undergo a cross-cultural adaptation and psychometric validation of the PSAQ scale to the Spanish language in patients who underwent head and neck surgery. We followed The Professional Society for Health Economics and Outcomes Research (ISPOR) guidelines for the translation and validation of health-related scales. Forward and back translations were made by independent translators. We included adult patients who underwent thyroidectomy, parathyroidectomy, parotidectomy, and neck dissection. For the psychometric validation, we used a principal axis exploratory factor analysis with oblimin rotation. A reliability test involving Cronbachs alpha and the item-total correlation was performed and for the convergent/concurrent validity, we selected the Spanish version of the Vancouver Scar Scale. A total of 180 patients were recruited. Factor analysis showed a five-factor solution. Cronbachs alpha for the subscales was >0.7. The comparison between the PSAQ appearance subscale and the VSS demonstrated a high correlation (rho = - 0.89). In a sample of 62 patients, the test-retest evaluation showed high correlation (0.74-0.99). Our study supports the Spanish version of the PSAQ as a valid, reliable, and reproducible tool to assess the perception and impact of neck scars in Spanish-speaking patients who undergo head and neck surgery.

Laser Therapy of Traumatic and Surgical Scars and an Algorithm for Their Treatment.

BACKGROUND AND OBJECTIVES: This paper describes the laser techniques available for the treatment of surgical and trauma scars and develops recommendations for an algorithmic-based treatment approach based on extensive clinical experience and published data. STUDY DESIGN/MATERIALS AND METHODS: We reviewed the literature regarding laser treatment of surgical and traumatic scars and incorporated the clinical experience of the authors to develop an algorithm for the treatment of surgical and trauma scars. RESULTS: In order to develop treatment recommendations, scars were differentiated based on their clinical characteristics. Specific scar characteristics aid in determining the appropriate treatment strategy for different types of complex surgical and trauma scars. CONCLUSION: Laser therapy is first-line therapy for traumatic and surgical scars. The treatment approach should be guided by scar characteristics (e.g., anatomic location, type of injury, color, thickness, tension, scar age, and activity) and involves choosing the appropriate laser type and determining the benefit of combination therapy with surgical and nonsurgical treatment modalities to optimize treatment responses. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Atrial scar quantification via multi-scale CNN in the graph-cuts framework.

Late gadolinium enhancement magnetic resonance imaging (LGE MRI) appears to be a promising alternative for scar assessment in patients with atrial fibrillation (AF). Automating the quantification and analysis of atrial scars can be challenging due to the low image quality. In this work, we propose a fully automated method based on the graph-cuts framework, where the potentials of the graph are learned on a surface mesh of the left atrium (LA) using a multi-scale convolutional neural network (MS-CNN). For validation, we have included fifty-eight images with manual delineations. MS-CNN, which can efficiently incorporate both the local and global texture information of the images, has been shown to evidently improve the segmentation accuracy of the proposed graph-cuts based method. The segmentation could be further improved when the contribution between the t-link and n-link weights of the graph is balanced. The proposed method achieves a mean accuracy of 0.856 ± 0.033 and mean Dice score of 0.702 ± 0.071 for LA scar quantification. Compared to the conventional methods, which are based on the manual delineation of LA for initialization, our method is fully automatic and has demonstrated significantly better Dice score and accuracy (p < 0.01). The method is promising and can be potentially useful in diagnosis and prognosis of AF.

Adaptación transcultural del cuestionario POSAS (Patient and Observer Scar Assessment) para valoración de cicatrices / Transcultural adaptation of the POSAS questionnaire (Patient and Observer Scar Assessment) to assess scars

Resumen Introducción: La escala POSAS para evaluación de cicatrices está validada y muestra ventajas sobre otras escalas por integrar parámetros cualitativos y la opinión del paciente. Tiene un uso creciente en la práctica clínica, pero hace falta su adaptación transcultural para su aplicación local. Objetivo: Realizar una adaptación transcultural de la escala POSAS 2.0 original. Materiales y Método: Con técnica de traducción dinámica se efectuó traducción de POSAS en inglés, comparación de traducciones, traducción inversa y prueba piloto en observadores y pacientes. Resultados: Se obtuvo buena correlación de traducciones, los observadores y pacientes lograron comprender el instrumento adaptado en un estudio piloto. Conclusión: Obtuvimos una versión adaptada de la escala POSAS, aplicable a población local para valoración de diferentes tipos de cicatrices. Se puede someter la escala adaptada a procesos de validación.

Introduction: The POSAS scale for the evaluation of scars is validated and shows advantages over other scales by integrating qualitative parameters and the opinion of the patient. It has a growing use in clinical practice, but its transcultural adaptation is needed for its local application. Aim: To carry out a transcultural adaptation of the original POSAS 2.0 scale. Materials and Method: With dynamic translation technique, translation of POSAS in english, comparison of translations, inverse translation and pilot test in observers and patients. Results: Good correlation of translations was obtained, observers and patients were able to understand the instrument adapted in a pilot study. Conclusion: We obtained an adapted version of the POSAS scale, applicable to the local population for assessment of different types of scars. The adapted scale can be submitted to validation processes.

Vocal fold scars: a common classification proposal by the American Laryngological Association and European Laryngological Society.

PURPOSE: Vocal fold scar is one the most challenging benign laryngeal pathologies. The purpose of this paper is to propose a classification that will allow for a common description of this entity between laryngologists, prevent discrepancies in interpretation, allow for comparison of related studies, and offer a training tool for young laryngologists. METHODS/RESULTS: Based on the depth and laterality of scarring, we propose 4 types: type I, characterized by atrophy of lamina propria with/without affected epithelium; type II, where the epithelium, lamina propria, and muscle are affected; type III, where the scar is located on the anterior commissure; type IV, which includes extended scar formation in both anteroposterior and rostro-caudal axis with significant loss of vocal fold mass. CONCLUSION: We believe that our proposal is comprehensive and encompasses all existing iatrogenic and non-iatrogenic etiologies in a simple and concise manner. It also serves its purpose as a descriptive, comparative, and training tool.

Tracheostomy scar management by repositioning platysma muscle and applying an acellular dermal substitute.

BACKGROUND: A depressed tracheostomy scar can be esthetically unacceptable. We describe a new technique for managing tracheostomy scars using platysma muscle repositioning and the application of an acellular dermal substitute. METHODS: Seventeen patients with depressed tracheostomy scars were identified for scar management. The time between tracheostomy tube removal and scar management was 29 months. Before and after the surgery, the scar was rated using the Vancouver Scar Scale (VSS). RESULTS: After surgery, tracheal tug was eliminated in all patients and the appearance of the scar was much improved. The mean total VSS score improved from 8.265 to 2.324 (P < 0.0001). The follow-up period was 33.3 months. CONCLUSIONS: The management of tracheostomy scars by repositioning platysma muscle and applying an acellular dermal substitute is simple and efficient. The technique recovers the lost deep tissue volume, corrects tracheal skin tug, and enables tension-free skin closure to restore the normal contour of the neck.

A Review and Update of Treatment Options Using the Acne Scar Classification System.

BACKGROUND: An unfortunate consequence of acne vulgaris is residual scarring that can negatively affect a patient's quality of life. OBJECTIVE: Jacob and colleagues have previously described an acne scar classification system based on acne scar pathology that divided atrophic acne scars into icepick, rolling, and boxcar scars, and this review will evaluate new and developing treatment options for acne scarring. METHODS: A Medline search was performed on the various treatments for acne scars, and particular attention was placed on articles that used the acne scar classification system of icepick, rolling, and boxcar scars. RESULTS: Therapies for acne scarring included surgical modalities, such as subcision, and punch excision and elevation, injectable fillers, chemical peels, dermabrasion, microneedling, and energy-based devices. In the past decade, there has been a trend toward using cosmetic fillers and energy-based devices to improve acne scarring. CONCLUSION: There were few high-quality evidence-based studies evaluating the management of acne scarring. Many disparate acne severity scores were used in these studies, and the acne scar type was frequently undefined, making comparison between them difficult. Nonetheless, research into interventions for acne scarring has increased substantially in the past decade and has given patients more therapeutic strategies.

Postburn Neck Contracture: Principles of Reconstruction and a Treatment Algorithm.

BACKGROUND: Various techniques have been developed for postburn neck reconstruction, but a treatment algorithm is needed. METHODS: We retrospectively reviewed all patients treated for postburn neck contracture at our institution between February 2008 and December 2015. Necks were divided into one anterior subunit and two lateral subunits marked by the sternocleidomastoid muscle. Deformities were categorized into three types according to their size and location. Type I deformities involve less than one subunit, type II deformities involve at least one subunit but less than two subunits, and type III deformities affect two or more subunits. Type II deformities were further divided into type IIa deformities, which mainly involve the anterior region, and type IIb deformities, which mainly involve the lateral region. RESULTS: Local random pattern flaps were constructed for type I deformities. Pedicled flaps from the anterior chest and supraclavicular areas were preferred for type IIa deformities, and pedicled flaps from the back were preferred for type IIb deformities. Pedicled flaps from other areas were the second choice for type II deformities, followed by free and prefabricated flaps. For type III deformities, bipedicled flaps were usually required. At a follow-up of at least 12 months, all patients showed near-normal neck function, and aesthetic features were significantly improved. CONCLUSION: The proposed classification and treatment algorithm for postburn neck reconstruction may help achieve satisfactory outcomes.

Validation of 3D skin imaging for objective repeatable quantification of severity of atrophic acne scarring.

BACKGROUND: One major sequelae of acne is atrophic scarring, yet objective tools to assess scars are lacking. Neither depth nor volume of atrophic scars is readily evaluable clinically and standard 2D photography is significantly affected by lighting and shadows. The aim of our study was to define and evaluate parameters of 3D imaging that can be used to assess severity of atrophic acne scarring. METHODS: Single center study of 31 patients with acne scarring. A target area of 3 × 3 cm was defined on the face. The global severity of atrophic acne scarring in the target area was evaluated by 5 dermatologists and scars were counted and categorized by size (scars < 2 mm, 2-4 mm, and > 4 mm in diameter). Three dimensional images of the target area were acquired with the LifeViz Micro® system and analysis was performed using MountainsMaps® software. An algorithm was developed to quantify the scar volume loss: shape removal step, with an order 5 polynomial, and to calculate the Valley void volume 80% (Vvv 80%) defined in the ISO-25178 standard for 3D surface texture. RESULTS: Correlation coefficient of the Vvv parameter to mean global severity at the target area rating was 0.77. The volume of scars evaluated with the Vvv parameter was mainly impacted by scars > 2 mm. The evaluations demonstrated good repeatability (with an intra-class correlation coefficient ICC = 0.98). CONCLUSIONS: We demonstrate convergent validation to clinical assessment and repeatability of 3D skin imaging in atrophic acne scarring. Image analysis is straightforward and can be integrated into an automated workflow.

Acne Scars: How Do We Grade Them?

Acne vulgaris is a chronic inflammatory skin disease that can lead to permanent scarring. Although grading scales exist for acne scarring, there are many limitations, and there is still a need for a well validated gold standard scale for use in clinical practice or research trials. An objective measure of scar severity should be a component of global acne severity evaluations. This manuscript reviews currently available acne scar grading modalities: lesion counting; subjective self-assessment; Acne Scar Rating Scale (ASRS); evaluator-based qualitative and quantitative scarring grading systems; Echelle d'Evaluation Clinique des Cicatrices d'acne (ECCA); Global Scale for Acne Scar Severity (SCAR-S); and imaging. Despite the varying tools, most of the currently available scales do not account for scar color, depth, or change over time. A new, validated scale is needed that would allow for a more objective and accurate assessment of scar progression over time to assist with effective treatment and research.

[Therapy of scars with lasers]. / Laser und Narben.

Scar formation is the consequence of trauma to the skin that affects the deep parts of the dermis. Different scar types like immature, mature, atrophic, hypertrophic, or keloid scars can develop depending on factors like age, anatomic localization, cause of trauma, the course of the healing process, and individual predispositions. Keloids and hypertrophic scars are often associated with itching, pain, tautness of the skin, and functional impairments, thus, leading to significantly reduced quality of life in some patients. However, even seemingly physiologically healed scars can cause tremendous psychological strain as is the case with self-harm scars. Despite increased research efforts, the exact pathomechanisms of excessive scarring are still scarcely understood, and dependably effective treatment options are often lacking. However, through continually improving scientific progress, scar treatment paradigms for a variety of scar types, thus far often dominated by conventional treatment methods, are increasingly complemented by new laser technologies and wavelengths.