Post-burn Scars Research Articles

Post-burn hypertrophic scars are characterized by high levels of IL-1β mRNA and protein and TNF-α type I receptors

Post-burn hypertrophic scars are characterized by increased collagen synthesis and hyperplasia, and may be associated with erythema, pain, dysesthesia, pruritus, and skin border elevation. Although the etiopathogenesis of hypertrophic scarring remains unclear, proinflammatory and profibrogenic cytokines are known to play an important role in general skin dysfunction. This study assessed mRNA expression, proteins, and type I receptors of tumor necrosis factor-alpha (TNF-α) and interleukin 1-beta (IL-1β) in normal skin, normotrophic and post-burn hypertrophic scars. Skin biopsies were obtained from 10 hypertrophic and 9 normotrophic scars, and 4 normal skin sites. Only post-burn scars covering more than 10% of the body were included. Ex vivo histopathological analysis evaluated scar maturity, in situ hybridization assessed mRNA expression, and cytokine protein and cytokine/cell colocalization were performed using single- and double-label immunohistochemistry, respectively. IL-1β is overexpressed in hypertrophic scars at the post-transcriptional level, associated primarily with keratinocytes and CD1a+ cells. Type I receptors for TNF-α are overexpressed in blood vessels of hypertrophic scars. The coordinated overexpression of IL-1β and TNF-α type I receptor may maintain the fibrogenic phenotypes of hypertrophic scars, even those in “remission”.

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.

The Role of Massage in Scar Management: A Literature Review

Many surgeons recommend postoperative scar massage to improve aesthetic outcome, although scar massage regimens vary greatly. To review the regimens and efficacy of scar massage. PubMed was searched using the following key words: "massage" in combination with "scar," or "linear," "hypertrophic," "keloid," "diasta*," "atrophic." Information on study type, scar type, number of patients, scar location, time to onset of massage therapy, treatment protocol, treatment duration, outcomes measured, and response to treatment was tabulated. Ten publications including 144 patients who received scar massage were examined in this review. Time to treatment onset ranged from after suture removal to longer than 2years. Treatment protocols ranged from 10minutes twice daily to 30minutes twice weekly. Treatment duration varied from one treatment to 6months. Overall, 65 patients (45.7%) experienced clinical improvement based on Patient Observer Scar Assessment Scale score, Vancouver Scar Scale score, range of motion, pruritus, pain, mood, depression, or anxiety. Of 30 surgical scars treated with massage, 27 (90%) had improved appearance or Patient Observer Scar Assessment Scale score. The evidence for the use of scar massage is weak, regimens used are varied, and outcomes measured are neither standardized nor reliably objective, although its efficacy appears to be greater in postsurgical scars than traumatic or postburn scars. Although scar massage is anecdotally effective, there is scarce scientific data in the literature to support it.

Heterotrophic Ossification on a Skin Graft in a Postburn Scar of the Chin

Some patients who have heterotrophic ossification (HO) in a postburn scar are occasionally seen in the clinic. The occurrence of HO following hip and abdominal surgery is common in males, whereas females are frequently affected following burns. The HO of skin grafts in burn scars of the superior body parts is uncommon, especially on the face. We report a recent case of a male patient in whom HO arose on skin grafts on his chin. The patient presented with a history of a painless chin mass for 48 years. Computed tomography scan suggested that the mass was located within subcutaneous tissue away from the lower jaw. The density of the mass was almost the same as the cortical bone of the lower jaw. The mass was completely resected under general anesthesia. It was a rectangular mass of 3× 0.5× 0.3 cm. Histological examination gave the diagnosis of HO, which was also confirmed by immunohistochemical stainings for vimentin. Recurrence was not found in this case by clinical and radiologic follow-up at 1 year after surgery.

Mechanical evaluation of the resistance and elastance of post-burn scars after topical treatment with tretinoin

OBJECTIVE:After burn injuries, scarred skin lacks elasticity, especially in hypertrophic scars. Topical treatment with tretinoin can improve the appearance and quality of the skin (i.e., texture, distensibility, color, and hydration). The objective of this prospective study was to examine the effects of treatment with 0.05% tretinoin for one year on the biomechanical behavior and histological changes undergone by facial skin with post-burn scarring. Setting: Tertiary, Institutional.METHOD:Fifteen female patients who had suffered partial thickness burns with more than two years of evolution were selected. Skin biopsies were obtained initially and after one year of treatment. The resistance and elastance of these skin biopsies were measured using a mechanical oscillation analysis system. The density of collagen fibers, elastic fibers, and versican were determined using immunohistochemical analysis.RESULTS:Tretinoin treatment significantly lowered skin resistance and elastance, which is a result that indicates higher distensibility of the skin. However, tretinoin treatment did not significantly affect the density of collagen fibers, elastic fibers, or versican.CONCLUSION:Topical tretinoin treatment alters the mechanical behavior of post-burn scarred skin by improving its distensibility and thus leads to improved quality of life for patients.

A prospective study on the role of gabapentin in post-burn pruritus

Gabapentin, used in the treatment of neuropathic pain, is suggested as an alternative treatment to antihistamines for post-burn itching. There is insufficient awareness about the etiopathogenesis and available treatment options for post-burn pruritus. To study the effect of gabapentin on post-burn itching, patients with post-burn pruritus not relieved with cetirizine tablet were offered gabapentin and assessed for response by the numerically graded self-report questionnaire ‘Itch Severity Scale’ for 6 months. Treatment success was determined by reduction in the itch scores, which were statistically analysed. Twenty-three patients with post-burns pruritic hypertrophic scars were studied. All patients had history of delayed burn healing (over 3 weeks). Twenty patients completed follow-up. All 20 reported a reduction in itching with gabapentin. Mean reduction in itch severity was 4.99 (statistically significant) within the first month of starting the therapy, with sustained effect seen for the duration of treatment. No serious side effects were reported. Eighty-seven per cent of patients showed good relief from itching within 1 month of starting treatment. Overall quality of life improved considerably. Gabapentin is suggested as a protocol for second-line option in post-burn pruritus. The ‘Itch Severity Scale’ is a reliable tool for pruritus measurement, including subjective parameters.

Reconstruction of Postburn Scar Contracture of the Thigh Using the Anterolateral Thigh V-Y Advancement Flap

Reconstruction of Postburn Scar Contracture of the Thigh Using the Anterolateral Thigh V-Y Advancement Flap

Normal skin and hypertrophic scar fibroblasts differentially regulate collagen and fibronectin expression as well as mitochondrial membrane potential in response to basic fibroblast growth factor

Basic fibroblast growth factor (bFGF) regulates skin wound healing; however, the underlying mechanism remains to be defined. In the present study, we determined the effects of bFGF on the regulation of cell growth as well as collagen and fibronectin expression in fibroblasts from normal human skin and from hypertrophic scars. We then explored the involvement of mitochondria in mediating bFGF-induced effects on the fibroblasts. We isolated and cultivated normal and hypertrophic scar fibroblasts from tissue biopsies of patients who underwent plastic surgery for repairing hypertrophic scars. The fibroblasts were then treated with different concentrations of bFGF (ranging from 0.1 to 1000 ng/mL). The growth of hypertrophic scar fibroblasts became slower with selective inhibition of type I collagen production after exposure to bFGF. However, type III collagen expression was affected in both normal and hypertrophic scar fibroblasts. Moreover, fibronectin expression in the normal fibroblasts was up-regulated after bFGF treatment. bFGF (1000 ng/mL) also induced mitochondrial depolarization in hypertrophic scar fibroblasts (P < 0.01). The cellular ATP level decreased in hypertrophic scar fibroblasts (P < 0.05), while it increased in the normal fibroblasts following treatment with bFGF (P < 0.01). These data suggest that bFGF has differential effects and mechanisms on fibroblasts of the normal skin and hypertrophic scars, indicating that bFGF may play a role in the early phase of skin wound healing and post-burn scar formation.

Resurfacing of Lower Face Scars With a Pre-expanded Flap From the Neck

Postburn scars of the lower face often cause serious deformities and dysfunction. Conventional methods including skin grafts and free flaps always lead to unsatisfactory outcomes. In this article, we describe a series of 8 patients with scars of the lower face treated with an expanded neck flap. Tissue expanders were implanted into the neck and inflated for 3 to 5 months. The expanded flap was then advanced cephalically to resurface the scars of the lower face. The mean follow-up period was 13 months. All 8 flaps survived well except 2 patients developed slight necrosis at the distal edge. The flaps were well matched to the surrounding skin with respect to color, texture, and thickness. The cervicomental angle appears normal. The range of mouth opening increased. In patients with lower face scars and a sufficient unharmed neck flap, use of a pre-expanded neck flap was suitable.

Comparison of efficacy of silicone gel, silicone gel sheeting, and topical onion extract including heparin and allantoin for the treatment of postburn hypertrophic scars

Comparison of efficacy of silicone gel, silicone gel sheeting, and topical onion extract including heparin and allantoin for the treatment of postburn hypertrophic scars

Traitement chirurgical des séquelles de brûlures profondes du sein : 25 ans d’expérience

Deep chest burns in prepubescent girl prevent the development of the mammary gland, because scar contracture becomes an inextensible envelope. In adults, scar contracture can deform the breast shape. The aim of this work is to define the interest of tissue expansion in breast reconstruction of prepubescent's and adult's post-burns scars.We conducted a 25-year retrospective study including patients treated surgically for deep thoracomammary burns. We studied following parameters: surgical techniques step by step, average time between each intervention, and morphologic and aesthetic results achieved.Twenty-eight patients have been operated between 1983 and 2008. Each patient has been operated on average 4.5 times (two to 12 times) during 6.3 years on average (1-19 years). Adult patients have showed a higher number of response (5.5 on average) than prepubescent girls (2.4 on average). Number of skin expansion has been 1.2 (0 to three) per patient. Sixty-two expanders have been placed (one to eight), 390cm(3) volume on average (180-1200). Delay of skin expansion has been about 7 months (4-10). Twenty-five breast implants have been raised on average 11 months (6-17) after debridement. Three changes of breast implant have occurred on average 5.3 years after insertion (3-8). Reconstruction of the areolonipple complex and controlateral symetrisation were conducted generally in the same time, 1 year after the last intervention. All patients will receive the possible additional volume (breast implant). Alternatives in breast volume reconstruction are lipomodelling and musculocutaneous expanded flaps. They are also discussed. Breast reconstruction in post-burns scars give clever cosmetic and morphologic despite of breast shape imperfections and apparent scars persistence satisfied cosmetic and morphologic results. These results, analyzed over a period of 25 years, show a qualitative change and decreased postoperative complications.Locoregional tissue expansion provide very clever results. In pre-pubescent grils, skin expanded flaps allow a near-normal mammary gland development. In adult women, they make the envelope that will receive the possible additional volume (breast implant). Alternatives in breast volume reconstruction are lipomodelling and musculo-cutaneous expanded flaps. They are also discussed. Breast reconstruction in post-burns scars give clever cosmetic and morphologic despite of breast shape imperfections and apparent scars persistence.

Endoscopic Approach for Tissue Expansion for Different Cosmetic Lesions in Pediatric Age

Background/Purpose: The use of tissue expanders in plastic and reconstruction surgery is now well established for large defects in adults & children. Tissue expansion is one of the reconstructive surgeon's alternatives in providing optimal tissue replacement when skin shortage is a major problem. Predesigned plan about the criteria of tissue expansion should be implied before embarking on removal of a lesion. Endoscopic placement of tissue expanders has the benefit of reducing operative time, major complication rate, time to full expansion and length of hospital stay compared to the open technique for tissue expander placement. Materials & Methods: The study was carried on 15 cases for which 22 expanders were inserted .All cases were in the pediatric age (6-15 years) .Nine cases had melanocytic pigmented naevi, four cases had post-burn scars, one had pigmented lymphangiomatous lesion & the last case had post grafting scarring .Eight patients needed single insertion of the expander followed by definitive reconstruction (2 months later), 4 cases needed multiple expanders on the same session & 3cases needed sequential expansion. The process of expander placement was done through a remote incision using endoscopic approach, after the required inflation (usually 2 months) reconstructive surgery was carried on for flap designing. Results: Twenty two expanders were inserted in 15 cases .operating time ranged from 50-70 min. (mean= 1 hour) in early cases .Later on the time was shortened to a mean of 40 ± 5 min. The mean duration for completion of expansion to the required dimensions needed for the flap was 2 months ( + 2 weeks ) . Complication rate was 18%. They occurred in 4 out of 22 expanders (hematoma ,wound dehiscence and seroma around 2 expanders). Conclusion: Tissue expansion in the pediatric population has its implication in different plastic problems. Endoscopic assisted expansion is a new trend in expander placement that has its role in decreasing complications related to insertion of expanders. Index Word: Tissue expansion- Endoscopic- Pediatric.

Videocapillaroscopy in postburn scars: In vivo analysis of the microcirculation

Objective The aim of the study was the evaluation in vivo of the differences between the microcirculatory characteristics of the postburn scar and the healthy skin. Methods Twelve patients with postburn scars were included in the study, evaluating fifteen scar areas and twelve healthy skin areas by means of contact optical probe videocapillaroscopy. The examined areas for each patient were the right and the left upper limb. Capillary density, length and diameter, together with capillary distribution pattern (punctiform, reticular, directional) and the presence of microhaemorrhages and neoangiogenesis were studied. Results The results were obtained by two different researchers using the capillaroscope's software. Capillary loop diameter and length, capillary distribution pattern and presence of neoangiogenesis were found to be significantly increased in postburn scars compared with controls. There were also significant differences between hypertrophic tissue in the active phase and the one in the remission phase for capillary diameter and presence of neoangiogenesis. Conclusion Videocapillaroscopy showed “in vivo” a change in local microcirculation architecture using a microscope. Patients with hypertrophic burn scars showed a variety of microcirculatory changes, often clustered in a characteristic pattern of abnormally oriented, dilated capillaries and neoangiogenetic phenomena. This methodology is highly likely to be of value in the assessment and prognostication of burn outcome.

Percutaneous collagen induction therapy: An alternative treatment for burn scars

Objective This study aims to evaluate percutaneous collagen induction (PCI) in post-burn scarring. Background Patients with scarring after burn frequently request help in improving the aesthetic appearance of their residual cicatricial deformity. Their scars are generally treated by tissue transfer, W- and Z-plasties, flaps, cortisone injections or ablative procedures that injure or destroy the epidermis and its basement membrane and subsequently lead to fibrosis of the papillary dermis. The ideal treatment would be to preserve the epidermis and promote normal collagen and elastin formation in the dermis. Patients A total of 16 consecutive patients (average age: 37 ± 15.5 years, average body mass index (BMI): 25.7) in Germany with post-burn scarring. Intervention PCI using the Medical Roll-CIT (Vivida, Cape Town, South Africa). This device was designed to multiply-puncture the skin to the level of the dermal scar to institute remodelling. Patients were prepared with topical vitamin A and C cosmetic creams for a minimum of 4 weeks preoperatively to maximise collagen stimulation. Outcome measures The outcome was measured rating (visual analogue scale (VAS) and Vancouver Scar Scale (VSS)), histological specimen 12 months after intervention. Results On average, patients rated their improvement as a mean of 80% better (±15.5) than before treatment. Histologic examination revealed considerable increase in collagen and elastin deposition 12 months postoperatively. The epidermis demonstrated 45% thickening of stratum spinosum and normal rete ridges as well as the normalisation of the collagen/elastin matrix in the reticular dermis at 1 year postoperatively. Conclusions This pilot study shows that PCI appears to be a safe method for treating post-burn scarring without destroying the epidermis. The procedure can be repeated safely and is also applicable in regions where laser treatments and deep peels are of limited use. However, it is necessary to initiate an efficacy trial to prove the data of this pilot study.

Post-burn scars and scar contractures

The mortality and morbidity from burns have diminished tremendously over the last six to seven decades. However, these do not truly reflect whether the victim could go back to society as a useful person or not and lead a normal life because of the inevitable post-burn scars, contractures and other deformities which collectively have aesthetic and functional considerations. This article gives an overview of the post-burn scars and scar contractures, especially their prevention, minimisation and principles of management.

Prosthodontist contribution in treating post-burn hypertrophic facial scars

The formation of hypertrophic scars is common following healing of the burn wound, particularly in children. The face is one of the areas of the body most frequently affected by burns. Scar formation as a result of burn wounds leads to contraction of the formed granulation tissue, which causes both aesthetic and functional impairment for the patient. Scarring has major psychological and physical repercussions. Scarring on the face and visible regions of the body can be very distressing for the patient. Prevention of scars involves early and continuous use of a compressive orthesis. However, their efficacy is often limited to the facial region because of the contours of this area of body. This paper describes a clinical case of post-burn hypertrophic scars treated with silicone gel sheeting applied with pressure under custom made auto-polymerizing resin stent.

Long‐Term Followup of Dermal Substitution with Acellular Dermal Implant in Burns and Postburn Scar Corrections

Full-thickness burn and other types of deep skin loss will result in scar formation. For at least partial replacement of the lost dermal layer, there are several options to use biotechnologically derived extracellular matrix components or tissue scaffolds of cadaver skin origin. In a survey, we have collected data on 18 pts who have previously received acellular dermal implant Alloderm. The age of these patients at the injury varied between 16 months and 84 years. The average area of the implants was 185 cm2. Among those, 15 implant sites of 14 patients were assessed at an average of 50 months after surgery. The scar function was assessed by using the modified Vancouver Scar Scale. We have found that the overall scar quality and function was significantly better over the implanted areas than over the surrounding skin. Also these areas received a better score for scar height and pliability. Our findings suggest that acellular dermal implants are especially useful tools in the treatment of full-thickness burns as well as postburn scar contractures.

Reconstruction of Cicatricial Microstomia and Lower Facial Deformity by Windowed, Bipedicled Deep Inferior Epigastric Perforator Flap

We performed simultaneous facial scar repair and oral aperture open with a windowed, bilateral, bipedicled deep inferior epigastric perforator flap (DIEP flap) in a 20-year-old male patient who had suffered from severe postburn scar of the face and neck in association with serious cicatricial microstomia. DIEP flap is a typical perforator flap that has less donor site morbidity because of a minimal sacrifice of muscles. Since bipedicled DIEP flap can provide the largest skin territory in the lower abdominal wall and ensure a sufficient blood supply to zone IV, it is very suitable for the repair of massive defects of the face and neck. From our challenging case, we learned that bilateral, bipedicled DIEP flap is an excellent option for the repair of large faciocervical defects. Bilateral, bipedicled DIEP flap, which can produce an excellent esthetic and functional outcome, has reliable blood perfusion, provides soft and pliable tissue, and causes the minimal donor-site morbidity.

Comparison of efficacy of silicone gel, silicone gel sheeting, and topical onion extract including heparin and allantoin for the treatment of postburn hypertrophic scars

We compared the efficacy of silicone gel (Scarfade ®), silicone gel sheet (Epi-Derm™), and topical onion extract including heparin and allantoin (Contractubex ®) for the treatment of hypertrophic scars. Forty-five postburn scars were included in the study. Patients with scars less than 6 months from injury were assigned at random to three groups each containing 15 scars, and their treatment was continued for 6 months. Scars were treated with Scarfade ®, Epiderm™ and Contractubex ®. Scar assessment was performed at the beginning of the treatment, and at the end of the sixth month when the treatment was completed by using the Vancouver scar scale. The difference between before and after treatment scores for each three groups was statistically significant. The difference between Scarfade ® group and Epi-Derm™ group was not significant; however, the differences of the other groups (Scarfade ®-Contractubex ®, Epiderm™-Contractubex ®) were significant. Silicone products, either in gel or sheet, are superior to Contractubex ® in the treatment of the hypertrophic scar. The therapist should select the most appropriate agent according to the patient's need and guidelines of these signs.

Neurophysiological and clinical study of pain in postburn hypertrophic scars

Neurophysiological and clinical study of pain in postburn hypertrophic scars