Scar Excision Research Articles

A New Uniform Protocol of Combined Corticosteroid Injections and Ointment Application Reduces Recurrence Rates After Surgical Keloid/Hypertrophic Scar Excision

Published reports indicate that corticosteroid injections can prevent recurrence after keloid excision, but the side effects of repetitive intralesional steroid injections may preclude treatment maintenance. Additionally, few of these studies employed a standardized treatment protocol. To analyze the results of a new uniform treatment protocol combining corticosteroid injections and ointment application designed to reduce recurrence rates after excisional surgery in individuals with keloids or hypertrophic scars. As a standard procedure, the first corticosteroid injection took place after removal of the sutures and then once every 2 weeks after that until it had been done five times. In addition, all postsurgical wounds received self-administered steroid ointment application twice daily for 6 months after suture removal. Postoperative follow-up in this series ranged from 24 to 57 months (median 32 months, mean 32.5 months). Recurrence occurred in three of the 21 keloid cases (14.3%) and one of the six hypertrophic scar cases (16.7%). We evaluated a new standardized adjuvant corticosteroid therapy to prevent recurrence after surgical keloid or hypertrophic scar excision. Using this method, we achieved low recurrence rates.

Skin Stretching for Burn Scar Excision - A Critically Appraised Topic.

Adults with burn scars are a clinical challenge, and the long term sequelae of burns can have a significant impact on the patient. Scar excision is thought to be the best treatment at present, as it results in a smaller scar. Scar stretching has shown promise in a previous study, as it may allow the surgeon to excise more burn scar. The goal of this study was to determine if good evidence exists for the use of burn scar stretching, in routine clinical practice, through the format of a critically appraised topic.A question was formulated using the Patient Intervention Comparator Outcome (PICO) method:–Patient – Adult burn victims–Intervention – Scar excision + skin stretching–Comparator – Scar excision–Outcome – Total remaining scarThe PICO question was used to develop a search query: “stretch* burn scar” (where ‘*’ represents a wildcard function). A search was then conducted using PubMed, SCOPUS, the Cochrane Library, and Trip Database. One paper was selected for critical appraisal following identification, screening, and eligibility evaluation.The paper was critically appraised using accepted methodology outlined by Straus et al. and reporting quality was assessed using the CONSORT statement for non-pharmacological trials.Areas of methodological or reporting weakness were highlighted.Burn scar stretching, using the device or technique in question, requires much further research before widespread usage in burns patients.

Unilateral Cervical Burn Scar Deformity Elimination With Contralateral Cervicothoracic Flap—A New Approach

Unilateral postburn cervical deformity is a severe cosmetic and functional defect and a challenging reconstructive problem. Many flaps have been suggested; however, after surgery, operational scars, located along the anterior neck's middle line, and the flap's skin differ from cervical healthy skin. A small flap resembles a patch. A more effective and safer technique is neck resurfacing with cervicothoracic adipocutaneous flap which had been used by the author in 32 burned patients. The flap's peculiarities are as follows: axis blood circulation via superficial cervical artery perforator; exclusion of platysma (flap is thin and elastic); and undamaged donor site. The mobilized healthy neck's skin with thin fat layer and adipocutaneous layer of the chest wall are elevated as a whole large flap. After scar excision, the cervicothoracic flap is advanced on the wound with tension. As a result of flap tension, the skin of neck's back, thoracic wall, and axilla are displaced to the anterior neck surface covering the donor wound. On an average, 6 cm of the deformed neck anterior surface was restored. No flap loss but only local superficial scar necrosis along the flap's border occurred. The cervical contracture and scar deformity (25 patients) were eliminated in all cases by a single procedure. For complete neck skin restoration, seven patients underwent staged reconstruction using the same technique. Excellent functional and good cosmetic follow-up results were achieved. The proposed technique is easy to plan and perform and yields good results; therefore, the author believes that the contralateral cervicothoracic flap's use is an exclusive option for unilateral cervical contracture and deformity elimination in adults and pediatric patients.

A Case Report of Anterior Nasal Atresia Caused by an Acquired Disorder

Atresia of the anterior nares is a rare disease caused by a congenital or acquired disorder. Car accidents, burns, postoperative scar, iatrogenic damage, and so on reportedly induce acquired atresia of the anterior nares. This report describes a rare case of nasal alar deformity and anterior nasal atresia caused by scar tissue formation following zona facialis. An 80-year-old woman was infected with herpes zoster at the right trigeminal nerve second division and intravenous acyclovir was administered. After treatment, increasing deformity of the right ala was gradually noted. The right nostril had closed completely in 10 months. She was treated with surgical enlargement of the stenosis using a nasolabial skin flap. Stenosis has not recurred during the six months since the nasolabial skin flap reconstruction. Various techniques have been used for reconstruction related to anterior nasal atresia: scar excision, skin graft, Z-plasty, V-Y advancement flap, composite graft, nasolabial skin flap, and others. It is important to choose an appropriate operative method for prevention of postoperative recurrence.

Natural Expansion of Artificial Dermal Template by Successful Full-Term Pregnancy

Extensive postburn scars of the trunk may cause breathing difficulty and, in female patients of reproductive age, render future pregnancy a serious reconstructive goal. Scar excision and skin grafting with or without artificial dermal templates is the current preferred management. A patient who underwent staged extensive grafting of the abdominal wall by dermal regeneration template and completed a full-term successful pregnancy is presented here. Although tissue expanders have been used to expand artificial dermal templates, natural expansion by pregnancy has not been previously documented. A 30-year-old woman with extensive chest and abdominal wall, bilateral gluteal and breast scars after burns sustained at childhood presented with difficulty in deep breathing. Abdominal scar tissue was excised and the abdominal wall was reconstructed by dermal regeneration template and autologous thin split-thickness skin graft in two stages. Six months postoperatively, spirometric values were improved by 15%, while 1 year later the patient completed successfully a full-term pregnancy. Reconstruction of extensive abdominal postburn scars by dermal regeneration template improves breathing by increasing elasticity and compliance of the reconstructed area. In female patients, the template can be extensively and naturally expanded by the gradually growing uterus, allowing for full-term pregnancy.

Shine on: Review of Laser- and Light-Based Therapies for the Treatment of Burn Scars

Restoration of form and function after burn injury remains challenging, but emerging laser and pulsed light technologies now offer hope for patients with hypertrophic scars, which may be associated with persistent hyperemia, chronic folliculitis, intense pruritis, and neuropathic pain. In addition to impairing body image, these scars may limit functional recovery, compromise activities of daily living, and prevent return to work. Three different platforms are now poised to alter our reconstructive algorithm: (1) vascular-specific pulsed dye laser (PDL) to reduce hyperemia, (2) ablative fractional CO2 laser to improve texture and pliability of the burn scar, and (3) intense pulsed light (IPL) to correct burn scar dyschromia and alleviate chronic folliculitis. In this paper, we will provide an overview of our work in this area, which includes a systematic review, a retrospective analysis of our preliminary experience, and interim data from our on-going, prospective, before-after cohort trial. We will demonstrate that laser- and light-based therapies can be combined with each other safely to yield superior results, often at lower cost, by reducing the need for reconstructive surgery. Modulating the burn scar, through minimally invasive modalities, may replace conventional methods of burn scar excision and yield outcomes not previously possible or conceivable.

Current management practice of breast borderline lesions—need for further research and guidelines

BackgroundBreast borderline lesions are usually diagnosed on needle biopsies of imaging abnormalities. The natural history of these lesions is unclear, and the literature is divided on appropriate management. It was hypothesized that management varies among surgeons and may be associated with surgeon and practice characteristics. MethodsA survey of 477 members of the American Society of Breast Surgeons was completed. Results were analyzed according to various surgeon and practice characteristics. ResultsMost respondents recommended routine excision for atypical ductal and lobular hyperplasia. Excision of radial scars and papillomas was much more variable, with only 50% recommending routine excision. Results differed by surgical dedication to breast surgery and fellowship training. Management of atypical ductal or lobular hyperplasia found at the margin varied significantly. The lack of a routine tumor board, low breast case volume, and low percentage of breast cases were associated with routine excision in these cases. ConclusionsBreast borderline lesions pose a clinical dilemma, with practice varying greatly among surgeons.

Cicatricial Canthal Webs

Cicatricial canthal webs present a complex reconstructive challenge for the eyelid surgeon. A combination of vertical skin deficiency, cutaneous and subcutaneous scar, and altered anatomy and blood supply can make surgical correction difficult and unpredictable. Patients typically are seen after blepharoplasty surgery or trauma with both cosmetic and functional (visual-field obstruction in lateral gaze) deficits. This is often a significant frustration to both the patient and the surgeon. A combination of a Y-to-V advancement flap, adjacent tissue rearrangement with Z-plasties centered on the arms of the Y (five-flap technique), and scar excision, when necessary, can be a useful procedure for revision of these webs. The charts of patients who underwent cicatricial canthal web revision in the solo private practice of the author over a 5-year period (2006-2010) were retrospectively reviewed. Each patient had a history of previous eyelid surgery or trauma that led to the development of the web. No patient had previous surgery to address the web. Each patient's presenting complaints were aesthetic, functional, or both, and each was previously told to avoid revision, as surgery to correct the web would make the condition worse. Patient's pre- and postrevision digital photographs, and patient and physician assessments, were reviewed to evaluate the results of surgery. Postoperative injections of subcutaneous steroid (Kenalog) and/or 5-fluorouracil (5-FU) were given as a treatment adjunct to modulate wound healing and prevent scarring when deemed appropriate. Eight patients were included in the study. Seven (88%) patients are women, and 1 (12%) patient is a man. The mean patient age is 46 years (range, 18-56 years), and the mean follow-up is 17 months (range, 9-30 months). Seven (88%) of the patients had lateral canthal webs after surgery, and 1 (12%) patient had a medial canthal web after a motor vehicle accident. Every patient voiced aesthetic concerns with the web, and 4 (57%) of the 7 patients with lateral canthal webs reported a visual deficit related to the defect. Six (75%) patients received 3 separate injections of Kenalog postoperatively, and 2 (25%) patients received the same number of injections composed primarily of 5-FU admixed with steroid. Each patient was satisfied with the aesthetic and functional result of surgery. Cicatricial canthal webs are an uncommonly reported finding that has received little attention in the literature. The condition has both aesthetic and functional implications, can be very bothersome and frustrating to patients, and can be intimidating to the treating surgeon. Although surgical revision carries risks of flap necrosis, scar, and worsened appearance, it can also significantly improve appearance and function. If the patient is realistic, understands the limitation of surgery, and will be happy with a moderate improvement, surgery should be strongly considered. The author found that revision of cicatricial canthal webs with the technique described in this article yields excellent results, given the limitations of the presenting problem.

The Incidence of Anterior Knee Pain and Crepitation After Total Knee Replacement: A Matched Pair Analysis between Rotating Platform and Fixed Bearing Posterior Stabilized Designs

Abstract Persistent pain, especially anterior knee pain, with or without crepitation, has been a persistent complaint after total knee arthroplasty in both rotating platform posterior stabilized (RP-PS) and fixed bearing posterior stabilized (FB-PS) designs. Because PFC Sigma RP-PS and FB-PS designs have identical femoral components, we hypothesized that the incidence of post-operative pain, anterior knee pain, asymptomatic crepitation, painful crepitation, and painful crepitation requiring scar excision is similar in both designs. Between March 2000 and May 2004, 81 near-consecutive RP-PS Total Knee Replacements (TKRs) were matched to 81 FB-PS knees based on gender, age, and body mass index. Radiographic analysis included alignment, fixation, and patellar tilt. Clinical assessments were performed at the time of follow-up using the Knee Society Scores. The incidence of anterior knee pain and crepitation was investigated using a detailed patient administered questionnaire. The incidence of post-operative pain, anterior knee pain, asymptomatic crepitation, and painful crepitation was similar in both groups (20.9 %, 19.7 %, 1.2 %, and 8.6 % in the RP-PS; and 20.9 %, 18.5 %, 0 %, and 6.1 % in the FB-PS, respectively). The severity of painful crepitation was also similar in both groups. None was excruciating. The incidence of painful crepitation requiring scar excision was slightly higher in the RP-PS group (6.1 % versus 2.4 %) but it was not statistically significant. In conclusion, there is a trend of increased incidence of painful crepitation requiring scar excision in the RP-PS TKR, although it was not statistically significant in this study.

Single-stage dorsal inlay for reconstruction of recurrent peno-glandular stenosis

To evaluate the validity of a single-stage dorsal inlay for recurrent peno-glandular stenosis following previous endourological or open urethroplastic surgery. Urethral glanular reconstruction included a deep dorsal incision followed by complete scar excision to create a deep groove presenting well-vascularized recipient bed ensuring appropriate graft healing. Between April 2002 and January 2008, a total of 34 patients (mean age 51.5 years, 14-85 years) were enrolled in the study. Congenital anomalies included hypospadia (n = 19, 53%) and epispadia (n = 2, 6%). Condition of strictures was either iatrogenic (n = 7), due to infection (n = 5), or traumatic (n = 1). Foreskin grafts were used in 13 cases, foreskin and buccal mucosa in one case, penile skin in 6 cases, and inguinal skin/thigh (harvested by electrodermatom) in 14 cases. The combination of meticulous scar excision with a deep incision of the glans was used to provide a well-vascularized grafting bed, thus ensuring excellent graft healing. The outcome analysis included urinary flow, urethral calibration >18 ch, voiding cystometry, and patient's satisfaction in a follow-up regime every 3 months. The average graft length was 4.7 cm (median 8, range 1.5-14). Mean follow-up was 70 months. In 31 patients (91%), no recurrent glanular stenosis was observed resulting in a post-operative flow of average 26.2 ml/s (11-53). Three post-operative wound infections occurred resulting in stricture recurrence, which was treated with internal urethrotomy, buccal mucosa, or penile skin inlay, respectively. Cosmetic results were satisfactory in all patients. Post-operative voiding parameters were significantly improved (P < 0.001). The single-stage dorsal inlay for reconstruction of peno-glandular stenosis represents a reliable method even if the urethral plate is severely scarred or has been excised during previous surgery. The good results imply that a well-vascularized graft and the technical approach seem to be more important than the substitute material.

Séquelles de brûlures des mains

Hand burns are common. Aesthetic and functional consequences are mixed together. Palmar and dorsal skin are very different. Palmar skin is thick and strong, dedicated to the prehension. Dorsal skin is very thin, creating a mobility plan dedicated to the flexion of the fingers. They are rarely isolated. Proximal nail retractions can occur after nail burns, with matricial exposition. We remove the scar and a full skin graft is done in order to give a normal proximal nail skin shape. They are fingers and wrist retractions. We often use collagen substitute to cover soft tissue defect after scar excision. Commissure retractions are treated by trident plasty. Electrical burns: we expose the case of a thumb amputation after necrosis by electrical burn, secondary treated by index policization. Children burns: the bridles appear during the growth, so we must follow this patient for a long time. Hand burns are frequent. Functional sequelae are often important: retractions, amputations. The orthopaedic treatment of these retractions is unspecific. We often use collagen substitute in our unit. The patient must be involved in his treatment, because it is very long and difficult.

Injection of human mesenchymal stem cells improves healing of vocal folds after scar excision—A xenograft analysis

Using a xenograft model the aim was to analyze if injection of human mesenchymal stem cells (hMSC) into the rabbit vocal fold (VF), after excision of an established scar, can improve the functional healing of the VF. Prospective design with an experimental xenograft model. The VFs of 12 New Zealand rabbits were injured by a bilateral localized resection. After 9 weeks the scar after the resection was excised and hMSC were injected into the VFs. After another 10 weeks 10 VFs were dissected and stained for histology. Lamina propria thickness and relative content of collagen type I were measured. Viscoelasticity of 14 VFs at phonatory frequencies was quantified by a simple-shear rheometer. The hMSC survival was determined using a human DNA specific reference probe, that is, FISH analysis. The viscoelastic measurements, that is, dynamic viscosity and elastic shear modulus for the hMSC-treated VFs, were found to be similar to those of normal controls and were significantly lower than those of untreated controls (P < .05). A significant reduction in lamina propria thickness was also shown for the hMSC treated VFs compared with the untreated VFs (P < .05). This histologic finding corresponded with the viscoelastic results. No hMSC survived 10 weeks after the injection. Human mesenchymal stem cells injected into the rabbit VF following the excision of a chronic scar, were found to enhance the functional healing of the VF with reduced lamina propria thickness and restored viscoelastic shear properties.

O11.4 Sustainable effect of skin stretching for burn scar excision: long-term results of a multicenter randomized controlled trial

O11.4 Sustainable effect of skin stretching for burn scar excision: long-term results of a multicenter randomized controlled trial

Sustainable effect of skin stretching for burn scar excision: Long-term results of a multicenter randomized controlled trial

Purpose Primary wound closure of large defects after burn scar excision may be facilitated by intraoperative stretching of the adjacent skin. In a randomized controlled trial (RCT), the effect of skin stretching for wound closure after scar excision (SS) was compared to scar excision without additional techniques (SE). Short-term results already showed that in the SS group larger scars could be excised in a one-step procedure. In this paper, the long-term scar outcome using reliable and valid measurement tools was evaluated. Basic procedures The percentage of total remaining scar area (i.e. remaining scar compared to preoperative scar), the percentage of linear scarring (i.e. surface area of linear scar compared to excised scar) and scar hypertrophy was measured at 3 and 12 months postoperatively. Main findings At 12 months postoperatively, the percentage of total remaining scar area was significantly lower in the SS group (26%) compared to the SE group (43%). The percentage of linear scarring (SS: 21%, SE: 25%) and the incidence of hypertrophy (SS: 29%, SE: 40%) were not significantly different between the treatment groups. Conclusions This RCT demonstrates the long-term beneficial and sustainable effect skin stretching for wound closure after scar excision without leading to wider linear scars or more scar hypertrophy.

Low Yield of Early Postoperative Imaging After Anastomotic Urethroplasty

To evaluate the necessity and clinical effect of posturethroplasty imaging. We reviewed our database of all urethroplasties performed by a single surgeon at our referral center during a 2-year period. The patients underwent voiding cystourethrography at a mean of 24 days postoperatively. The data analyzed included patient history and demographics, operative details, imaging results, and clinical outcomes. From 2007 to 2009, 210 patients underwent urethral reconstruction at our center. The patients undergoing meatoplasty or staged repairs were excluded, leaving 156 patients with postoperative imaging studies for analysis. Of 110 anterior urethroplasties, 59 (54%) consisted of excision and primary anastomosis, 28 (25%) an augmented anastomotic procedure, and 23 (21%) a pure ventral onlay with a flap or graft. All 46 posterior urethroplasties were performed with scar excision and primary anastomosis. Of the 156 patients, only 4 (3%) had extravasation on postoperative voiding cystourethrography (2 after posterior urethroplasty, 1 after augmented anastomosis, and 1 after ventral onlay)--all were successfully managed with catheter replacement and removal at a mean of 8 days afterward. None of the 59 men undergoing excision and primary anastomosis demonstrated extravasation. Extravasation on posturethroplasty voiding cystourethrography is rare after approximately 3 weeks of catheter drainage. Imaging can be omitted after uncomplicated excision and primary anastomosis urethroplasty.

Efficacy of Skin Stretching for Burn Scar Excision: A Multicenter Randomized Controlled Trial

Burn survivors are frequently faced with disfiguring scars. Various techniques exist to improve scar appearance, such as laser treatment and dermabrasion. Next to that, surgical reconstruction, such as scar excision is an option. This randomized controlled trial investigates whether a larger burn scar can be excised using a skin-stretching device for wound closure, thereby optimizing use of adjacent healthy skin. This technique may allow scar excision in a one-step procedure instead of two or more steps, which is necessary for serial excision and tissue expansion. Two arms were compared: scar excision and closure by skin stretch and scar excision without additional techniques. The primary outcome measure was scar surface area reduction. In addition, complications were registered. Fifteen patients were randomized for skin stretch and 15 patients were randomized for scar excision only. In the skin stretch group, 10 of 15 scars were completely excised compared with three of 15 in the scar excision-only group (p = 0.025). In the skin stretch group, a significantly larger reduction in scar area was achieved: 95 ± 11 percent of the scar was excised versus 78 ± 17 percent in the scar excision-only group (p = 0.003). One patient in the skin stretch group and three patients in the scar excision-only group experienced partial wound dehiscence (p = 0.598). In burn scar reconstructions, a significantly larger reduction in scar area can be achieved using a skin-stretching device compared with scar excision with no additional techniques, without an increased risk of complications. It was shown that skin stretching is of added value for scars that cannot be excised in a one-step procedure.

Cyberspace Chat: Part II: Bleaching necrosis from hair highlighting: prevention, treatment of the chemical burns and resulting scarring alopecia (grafts vs. scar excision and/or expanders and flap advancement)

Cyberspace Chat: Part II: Bleaching necrosis from hair highlighting: prevention, treatment of the chemical burns and resulting scarring alopecia (grafts vs. scar excision and/or expanders and flap advancement)

Late-onset persistent Descemet's membrane detachment following uncomplicated clear corneal incision cataract surgery

We report the case of a 76-year-old man who developed a late-onset Descemet's membrane detachment (DMD) 5 months after uncomplicated cataract surgery. Despite two air tamponade procedures that initially appeared successful, the DMD continued to return. After careful examination it was found that a surgical entry wound may have been scarred open (fish-mouthing), which continually promoted Descemet's membrane to detach. Excision of the abnormal scar led to an almost complete resolution of the DMD. To our knowledge, this is the first report of a pathological (fish-mouthing) entry wound causing a persistent, late DMD. We discuss the reasons why the management of late DMDs requires careful consideration.

Facial Acne Scarring

Facial Acne Scarring

Aplasia Cutis Congenita

Aplasia cutis congenita (ACC) is a rare congenital disorder characterized by absence of skin and adjacent tissue that usually affects the scalp, but any part of the body may be affected. Although ACC is more often superficial and small, it can be large and involve the underlying structures such as skull and dura, thus increasing the risk of hemorrhage, infection, and mortality. Controversy exists regarding nonsurgical versus surgical intervention for this condition. This study reviews indications and modalities for treatment of this rare congenital anomaly. Management of this anomaly depends on size, location, and structures at risk. Small lesions with intact underlying structures and lesions affecting extremities are treated in a conservative fashion with dressings and ointments followed by delayed scar excision. Aplasia cutis congenita scar excision often requires complex tissue rearrangement, tissue expansion, or skin grafting. Larger ACC lesions or lesions with exposure of vital structures require early surgical intervention. Initially, exposed vital structures and bony ridges can be protected using conservative measures. Delayed definitive repair can then be performed using scalp flaps, split- and full-thickness skin grafts, cultured epithelial autografts, delayed split rib cranioplasty, tissue expansion, and composite cranioplasty. Aplasia cutis congenita should be individually evaluated based on size, depth, location, and tissues involved. Using conservative and surgical modalities, one can achieve complete closure of the defect, thus avoiding risks of infection, hemorrhage, and further trauma.