Scar Recurrence Research Articles

Superficial Radiation Therapy (SRT) for the Treatment of Recurrent Keloid Scars

Superficial Radiation Therapy (SRT) for the Treatment of Recurrent Keloid Scars

Reconstructing ‘dual-defect’ pressure sores in spinal patients

Background: Recurrent pressure sores and unstable scars over the bony prominences of the greater trochanter and ischium are a troublesome sequela of spinal injury. A reliable reconstruction is needed for patients with ‘dual-defect’ pressure sores in these locations. We modified the pedicled anterolateral thigh (ALT) flap to fit the reconstructive requirements of ‘dual-defect’ pressure sores.Methods: Eleven consecutive patients with concurrent pressure sores (> grade III) or unstable scar in one of the ‘dual-defect’ areas and an active pressure sore in the other were identified from the Victorian state tertiary referral centre for spinal injuries. We describe the technique and clinical experience of pedicled ALT flaps for reconstruction of ‘dual-defect’ pressure sores in this patient cohort. Preoperative status and minor and major postoperative complications were recorded. Results: Eleven consecutive pedicled myocutaneous ALT flaps were performed for reconstruction of ‘dual-defect’ pressure sores. Several key variations in the anatomical landmarks and the intra-operative flap raise technique that are integral to the use of the ALT flap for this application are described herein. The average dimensions of the cutaneous pressure sore defects were 6 x 4.9 cm (greater trochanter) and 8.2 x 6.7 cm (ischial). The average dimensions of the cutaneous paddle of the flaps raised were 27.3 x 8.4 cm. Two postoperative complications necessitated return to theatre but no incidences of flap loss were recorded. Conclusions: The modified pedicled myocutaneous ALT provides a robust reconstructive solution for resurfacing ‘dual-defect’ pressure sores in spinal patients. Further recommendations for future technical adaptations are made.

Cutaneous Metastases in Ovarian Cancer.

Skin metastases in ovarian cancer are uncommon, but their incidence may be increasing due to improved survival rates. Skin metastases can be divided into umbilical metastases, which are known as Sister Joseph nodules (SJNs) and are associated with peritoneal metastasis, and non-SJN skin metastases, which usually develop within surgical scars and in the vicinity of superficial lymphadenopathy. As most skin metastases develop after specific conditions, recognition of preceding metastatic diseases and prior treatments is necessary for early diagnosis of skin lesions. The prognosis of skin metastases in ovarian cancer varies widely since they are heterogeneous in the site of lesion and the time of appearance. Patients with SJNs at initial diagnosis and patients with surgical scar recurrences without concomitant metastases may have prolonged survival with a combination of surgery and chemotherapy. In patients who developed skin recurrences as a late manifestation, symptoms should be treated with external beam radiotherapy and immune response modifiers. Immune checkpoint blockade can enhance anti-tumor immunity and induce durable clinical responses in multiple tumor types, including advanced chemoresistant ovarian cancer. With the use of radiation therapy, which enhances the systemic anti-tumor immune response, immune checkpoint blockade may be a promising therapeutic strategy for distant metastasis, including skin metastasis.

Clinic-Based Surgical Treatment for Hidradenitis Suppurativa

We provide an evidence-based review of current procedures and provide a practical guide to surgically treating hidradenitis suppurativa in the office setting. Outpatient procedural management of hidradenitis suppurativa may include incision and drainage, intralesional triamcinolone, deroofing, excision, and lasers that achieve follicular destruction. Managing recurrent lesions, scarring, and sinus tracts often requires deroofing or excision. Recurrence rates are likely similar between deroofing and excision by sharp or laser techniques, and high patient satisfaction is consistently reported. Recently published treatment guidelines support the use of a variety of procedures that can be approached in the office setting. Optimizing treatment of hidradenitis suppurativa, a debilitating chronic condition, often requires a combination of procedural and medical interventions. The ability to offer a variety of surgical interventions based on patient preference in an office setting is an important asset for clinicians caring for hidradenitis suppurativa patients. In the future, research should focus on comparing the effectiveness and tolerability of these procedures in various settings.

Evaluation of hearing results in Behçet's disease

Objectives: Behçet's disease is an inflammatory rheumatic disease with recurrent scarring in the oral and genital area, as well as skin, eye, joint, vein, and nerve involvement. The aim of the study was to investigate the level of hearing in Behçet’s disease and whether there is a change in hearing levels as the level of the disease increases. Methods: In this study we examined 32 patients with Behçet’s disease and 50 healthy volunteers. All patients were evaluated with audiometry, tympanometry and acoustic reflex tests, as well as detailed ear, nose, and throat examinations. Results: Sensorineural hearing loss was observed in 9.3% of the patients with Behçet's disease, according to the audiological data, and all patients were bilateral. We also observed sensorineural hearing loss to be the fifth most common symptom in our study. Especially in high frequencies, there was positive correlation between hearing levels and disease exposure time (p < 0.05). Conclusions: We think that the audiological examinations should be included in the routine check-ups of Behçet's patients. In addition, a follow-up assessment of the hearing level of these patients with high frequency audiometry may be more meaningful.

Case series on abdominal wall implantation malignancy

Abdominal wall implantation malignancy or scar recurrence following laparotomy or laparoscopy is a rare and untoward occurrence. We present here a case series of five patients who developed scar malignancies, of which four patients underwent open abdominal surgery while the other had laparoscopic surgery.

Hidradenitis suppurativa and associated diseases

Hidradenitis suppurativa is a chronic, inflammatory, recurrent, debilitating skin disease characterized by recurrent abscesses, draining sinuses, and scarring, affecting principally areas of body friction. Although the disease pathogenesis is not fully understood, recent advances suggest that hidradenitis suppurativa should be viewed as a systemic inflammatory disease. Moreover, recent studies have defined hidradenitis suppurativa as a systemic disease linked to several comorbidities. Metabolic disorders including obesity and metabolic syndrome are the most common associated conditions observed in patients with hidradenitis suppurativa. Autoimmune diseases, like inflammatory bowel diseases, autoinflammatory diseases, spondyloarthritis, some genetic keratin disorders and also the risk of skin tumor seems to occur more frequently in these patients. This disease can also have severe effects on self-esteem and quality of life and can be associated with psychiatric diseases. The link between hidradenitis suppurativa and systemic associations may be attributed to common genetic or environmental factors or shared inflammatory pathways. Due to these reasons it is mandatory that clinical intervention for hidradenitis suppurativa must include consideration and attention to these comorbidities and complications. In this article we have reviewed current available literature on diseases that can occur together with hidradenitis suppurativa.

Scar Bolus Omission During Adjuvant Intensity Modulated Radiation Therapy (IMRT) Does Not Increase Risk of Incisional Recurrence for Oral Cavity Cancers

Locoregionally advanced oral cavity cancers have an increased risk of locoregional recurrence despite multimodality therapy. In an effort to decrease scar recurrences in the post-operative setting, bolus has historically been used to increase the dose to the neck scar in intermediate and high-risk contexts. Since transitioning to IMRT for most post-operative oral cavity cases, we have routinely omitted bolus placement on the neck scar. Here we examine rates of scar recurrences using this approach. This is an institutional review board approved retrospective study. Patients with intermediate or high risk squamous cell carcinoma of the oral cavity treated with post-operative IMRT were identified from an institutional database. Patients were treated using tomotherapy based IMRT. Demographics, clinical/pathologic parameters, dosimetric data, and cancer-related outcomes were recorded and analyzed. Statistical software was used to determine Kaplan Meier estimates for disease control and survival. Twenty-eight pts met inclusion criteria for this analysis and were treated from 2009 to 2017. Median age was 56 years old (range 35-75); 59% were male. All patients underwent complete resection of the primary tumor with selective neck dissection. Subsites included 11 floor of mouth (40%), 6 oral tongue (21%), 5 buccal mucosa (18%), 3 lower lip (11%), 2 hard palate (7%), and 1 retromolar trigone (4%). Seventy-one percent were pathologically node positive; 36% had extracapsular extension (ECE). Concurrent chemotherapy was used in 53% of patients. Twenty-four patients (86%) were treated using SIB technique. The post-operative neck was irradiated in all cases. Median dose to the highest risk volume was 6000 cGy (range 5800-6600 cGy). Median treatment package time was 95 days (range 76-137 days). Median follow up for surviving patients after treatment was 21 months (range 3-93 months). One patient experienced a local recurrence at 2 months. Four patients developed distant metastatic progression at a median of 3 months (range 1-16 months). No patients have experienced a regional nodal relapse and there have been no scar recurrences. 3-year actuarial estimates for DFS and OS are 74.7% and 87.4%. Scar recurrences after post-operative IMRT are rare. Bolus omission has not compromised disease control along the scar.

Application effects of CT angiography and three-dimensional reconstruction technique in repairing scar around the mouth and chin with expanded forehead axial flap

Objective: To explore application effects of CT angiography (CTA) and three-dimensional reconstruction technique in repairing scar around the mouth and chin with expanded forehead axial flap. Methods: From June 2013 to October 2017, 9 patients with hyperplastic scar around the mouth and chin after deep burns on face were admitted to our unit. The sizes of scars of patients ranged from 8 cm×7 cm to 13 cm×8 cm. One cylindrical skin soft-tissue dilator with nominal volume of 400 to 500 mL was implanted in forehead area of each patient. Five to six months after the dilator was implanted, scar around the mouth and chin was resected, and the dilator was removed. The secondary wound after scar resection was repaired by expanded forehead axial flap with bilateral superficial temporal vessel pedicles. Three of the nine patients received microstomia diorthosis at the same time. Before the operation, CTA and three-dimensional reconstruction were applied to obtain three-dimensional images of superficial temporal arteries and the branches in the donor site, which could identify the travel, adjacent location, and vascular anastomosis of the above-mentioned vessels to guide flap design. The sizes of flaps of patients ranged from 25 cm×9 cm to 30 cm×8 cm. Two to three weeks after the operation, flap pedicles were cut off, restored, and trimmed. The donor site was sutured directly. Ten to twelve days after the flap repair operation, the flap site received depilation treatment with semiconductor freezing point laser once a month for 4 to 6 times. Results: Flaps of all patients survived well, with no blood circulation disorder. The flaps of three patients were slightly bulky, while they were with natural appearance after flap thinning operation in 3 months post flap repair operation. During follow-up of 6 months to 2 years after the operation, color, texture, and thickness of the flaps were close to normal skin around scars. The appearance of perioral and mental region, and opening function of mouth improved significantly, with no recurrence of scar. Frontotemporal incision was hidden, hair on head grew normally, and reconstructed hairline was natural. Conclusions: Scar around the mouth and chin repaired with expanded forehead axial flap were with good appearance and function in operation area and good shape in donor site. CTA and three-dimensional reconstruction technique can provide clear three-dimensional images of superficial temporal arteries and the branches in expanded forehead axial flaps, which can provide reliable basis for preoperative designing of flap, reduce operative risk, and improve survival rate of flap, thus having clinical application value.

Surgical Scar Recurrence of Bone Metastases to the Femur: A Case Report

We report the case of a woman who presented with breast cancer metastases to the femur causing pathologic fracture of the femoral neck requiring surgery. She received adjuvant radiotherapy to the femur at that time that did not include the surgical scar tract. Almost four years after her surgery she presented with biopsy proven skin recurrence of breast cancer on the skin overlying her incision from her femoral surgery.Further imaging confirmed significant soft-tissue disease involving the underlying surgical scar tract. This case provides important information about the possibility of surgical scar recurrence after surgery for bone metastases which could indicate the need to include the area of the surgical scar tract and the entire prosthetic material in the post-operative radiotherapy volume.

Comparing Z-Plasty versus Z-Plasty and Skin Grafting for Surgical Tension-Free Treatment of Post-Burn Elbow Contractures: A Randomized Clinical Trial

Background: Elbow contracture is a common incidence. It has surgical treatments such as scar release and skin graft, Z or V-Y plasty, and lateral or medial arm flap. In this study, we compared Z-plasty versus Z-plasty and skin grafting in the surgical tensionfree treatment of post-burn elbow contractures. Methods: 30 patients with elbow joint extension restriction participated in this randomized clinical trial in two groups: experimental (Z-plasty with skin graft) and control (Z-plasty alone) groups. In both groups, Z-plasty was designed with a 60 angle. In the experimental group, the flaps were rotated without tension, and then the upper and lower parts of the flaps were grafted by a midsplit-thickness skin graft. The surgery area was examined regarding infections, wound healing time, necrosis, and scar. Significant differences were evaluated using unpaired student t-test. Results: Only seven participants in the control group had complications. The statistical analysis of all variables in both groups showed that Z-plasty with skin graft treatment had a significantly better result than the Z-plasty alone (P = 0.006). However, the two groups showed no significant differences in terms of infection, flap tip necrosis, surgery site infection, and feeling of pressure in joint extension or scar recurrence (P = 0.273). Conclusions: Tension-free flap must be used in patients with mild or moderate wide elbow scar contracture. Combining Z-plasty with skin graft is easy and has better results than Z-plasty alone. It is recommended using this technique in patients with intraoperative flap tension.

Correction of Cord Like Scars Using Running Opposing Y-V Plasty

Linear scars are a common problem in the plastic surgerypractice. Release is the first step in surgical treatment. Skingrafts, Z-plasty, local, regional or free flaps are used tolengthen the scar. In this article, we will use running y-v flapsfor scar lengthening. From January 2016 to April 2017, 20linear burn contractures of 15 patients were corrected usingmultiple Opposing Y-V plasty. Patients were followed-up fora period of 6 months at least. All scar contractures werecorrected successfully in all cases. One partial flap necrosiswas observed and managed successfully with dressing changes.During the follow up period, only one case showed recurrenceof contracture and required release and local advancementflap. linear scar contracture treatment modalities vary largely.Options for reconstruction include skin grafts, Z plasty andY-V flaps. Skin grafts carry the risks of recurrence of contractures.Z plasty should include flap undermining before flaptransposition which carries the risks of flap necrosis especiallyin burned skin. Multiple Y-V flaps carry the advantages oflow rate of scar recurrence and secondary contractures andhave the merits of being a safe technique with low incidenceof flap necrosis. Running Opposing Y-V-plasty is an optionfor correction of linear cord-like burn scar contractures. Ithas the advantages of being a safe and effective method withlaw morbidity.

Revision Hip Arthroscopy After Labral Reconstruction Using Iliotibial Band Autograft: Surgical Findings and Comparison of Outcomes With Labral Reconstructions Not Requiring Revision

To determine the causes of revision hip arthroscopy in patients who underwent labral reconstruction and to compare outcomes of these patients with patients who did not require a revision following reconstruction. Patients who underwent revision hip arthroscopy after previous labral reconstruction from 2006 to 2014 were included. Patients with less than 2-year follow-up, preoperative joint space of ≤2mm, or who underwent other reconstructive procedures at the time of labral reconstruction were excluded. Each patient was matched by year of surgery, age, gender, and the number of previous surgeries with 2 patients that underwent labral reconstruction but did not require a revision following the reconstruction. Preoperatively and at a minimum 2-year follow-up, outcome scores were collected including the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and HOS-Sports Scale, modified Harris Hip Score, Western Ontario and McMaster Universities Index (WOMAC), the 12-Item Short Form Health Survey (SF-12) Physical Component Summary, and the patient satisfaction outcome were collected. Differences between the preoperative and the postoperative outcomes score of each patient in the 2 groups was assessed using the paired t test. The Mann-Whitney U test was used to compare the 2 groups. From 347 patients who underwent iliotibial band autograft labrum reconstruction from 2006 to 2014, 28 hips (8%) in 26 patients (18 females and 8 males) had revision arthroscopy after labral reconstruction. The mean age was 32years (range: 16-64). The mean number of hip surgeries prior to the labral reconstruction was 1.9 ± 1.2. The average time from the last labral reconstruction procedure to revision labral reconstruction was 27months (range: 5-59). Procedures performed at revision included lysis of adhesions (100%), additional femoroacetabular impingement (FAI) correction (50%), ligamentum teres debridement (50%), psoas release (29%), labral augmentation or reconstruction (14%), and others. Following revision surgery after previous labral reconstruction, 4 patients (14%) underwent total hip arthroplasty and 2 (7%) patients required a subsequent revision arthroscopy (age 67 and 23) at 15months and 16months. The average follow-up time was 3.6 years ± 1year after revision following labral reconstruction and after labral reconstruction in the nonrevision group. No significant difference was detected in the outcome scores and postoperative satisfaction between the 2 groups. The HOS-ADL improved 16 points in the nonrevision group and 19 points in the revision group. Patients who underwent revision surgery after labral reconstruction were mostly female, with 2or more surgeries prior to reconstruction, and 14% required THA and 7% had recurrent scarring. In those who did not fail, outcomes significantly improved and were similar with patients who did not need revision. Adhesions and residual FAI were the most common findings during revision labral reconstruction. Level III, retrospective comparative study.

Earfold Implantable Clip System for Correction of Prominent Ears: Analysis of Safety in 403 Patients.

The Earfold system, a new treatment for the correction of prominent ears, consists of 3 components: the Earfold implant, the Earfold introducer, and the Prefold positioner. This is an interim report based on an ongoing analysis of safety in a series of patients treated for prominent ears with the Earfold implant between February 2013 and September 2014. Safety was assessed based on adverse event reports and the need for implant revision; follow-up is ongoing. Seven surgeons used 1,200 Earfold implants to treat 403 patients (ages, 7-70 years; 63% male); the time since the initial implant procedure now ranges from 30 to 48 months. To date, 145 patients (36%) have returned for a follow-up visit (mean, 7.7 months [range, 1-34 months]). Adverse events requiring intervention have affected 39 of 403 (9.7%) patients; these include implant revisions (n = 17 [4.2%], most often due to implant visibility), skin erosion over the implant (n = 15 [3.7%]), and infection (n = 7 [1.7%]). Bleeding, recurrence of prominence, hematoma, deformity, or adverse scarring did not occur. This interim analysis has shown that Earfold prominent ear correction system is associated with relatively few adverse events that require intervention; a small number of patients experienced infection, implant extrusion, or implant visibility that required revision. Most adverse events were related to either patient selection or technical errors at implantation. It is expected that with continued use of Earfold by surgeons experienced in otoplasty, the adverse event incidence will decrease.

Laparoscopic versus open treatment of gallbladder cancer: A systematic review and meta-analysis.

Background:The aim of this review was to evaluate the effect of laparoscopic surgery on the treatment of patients with gallbladder cancer (GBC).Methods:A comprehensive search of Medline and Cochrane Library was conducted to identify relevant articles. A meta-analysis was subsequently performed.Results:A total of 20 studies including 1217 patients met the inclusion criteria. The meta-analysis showed that the 5-year survival rate was significant higher in laparoscopic group than open group (48.4% vs. 38.5%; odds ratio [OR], 1.63; 95% confidence interval [CI], 1.22–2.19; P = 0.001). Although the scar recurrence rate was significant higher in laparoscopic group than open group (7.1% vs. 4.0%; OR, 2.10; 95% CI, 1.11–3.96; P = 0.02), the overall recurrence rates between two groups were not significant different (44.8% vs. 42.2%; OR, 0.86; 95% CI, 0.64–1.14; P = 0.29). In addition, compared with open extended cholecystectomy (EC), laparoscopic EC (LEC) was associated with less intraoperative blood loss, shorter post-operative hospital stays and insignificant less complication rate (10.0% vs. 18.3%; OR, 0.51; 95% CI, 0.15–1.73; P = 0.28).Conclusion:Laparoscopic simple cholecystectomy does not lead to a worse prognosis when applied on patients with GBC. LEC can be performed in specialised expert centres on elective patients.

Hair Transplantation into the Nape of the Neck

Background: Hair loss at the nape of the neck causes embarrassment and psychological stress in a number of patients due to a variety of causes including acne keloidalis nuchae and traction alopecia. Objectives: To report a case of hair transplantation into the nape of the neck as a treatment option for scarring resulting from acne keloidalis nuchae. Methods: 700 grafts where transplanted from the occipital donor area and transplanted by follicular unit extraction (FUE) into the nape area of a male patient with recurrent scarring folliculitis in that area. Results: Hair Restoration was successful with natural looking results. More tumescence than usual and skin traction was necessary to stabilize the skin during graft insertion due to soft skin in the nape area. Conclusions: Hair Restoration Surgery into the nape of the neck is an option for patients with hair loss in that area. FUE is the best method of hair transplantation allowing the selection of 1 and 2 hair FUE grafts in order to achieve a natural looking result in the nape area.

Diagnostic Accuracy of Optical Detection of Residual Colorectal Neoplasia After Endoscopic Mucosal Resection: Impact of Endoclip Closure at EMR Site

Introduction: Application of clips after EMR may reduce post EMR bleeding but also interfere with the recurrent adenoma detection at follow up due to nodular distortions of scar tissue. This could lead to an overtreatment of benign lesions. In a prospective trial, we aimed to evaluate the diagnostic accuracy of white light and narrow band imaging (NBI) with near-focus capability in recurrent adenoma detection with or without clip artifact. Methods: This prospective trial was started in January 2016 and is ongoing. Consecutive patients undergoing follow-up colonoscopy after a previous EMR of ≥20mm colorectal polyps were included. Endoscopists predicted the presence of neoplasia recurrence of EMR scars with or without clip artifact and their level of confidence (high or low) based on visual assessment of the previous EMR site subsequently with the four modalities 1) white light without and 2) with near-focus, and 3) NBI without and 4) with near-focus. Each EMR site was biopsied as a reference standard and histology assessed by a pathologist blinded to the endoscopist's visual assessment. Diagnostic accuracy was calculated for all diagnostic modalities for the real-time endoscopic assessment of the EMR scar tissue with or without clip artifacts. Results: A total of 172 patients (54% male, mean age: 65 years with 180 scar sites were included perprotocol, with a median follow up of 8 months (range: 3-71 months). At the original EMR, clips were used in 82/180 (45%) lesions. The rate of post-EMR scar clip artifact was 61% (50 of 82). Diagnostic accuracy for all EMR-scar sites with or without clip- artifact and confidence level in real time are shown at Table 1 and 2. The prevalence of residual neoplasia was 25% for all EMR scars. 27% of cases were over treated for benign disease when clips were used versus 8% of cases when clips were not used. Overall, clips reduced the proportion of high confidence diagnoses and appeared to lower the accuracy of EMR scar assessment in low confidence diagnoses but not for high confidence diagnoses.Table: Table. Diagnostic value of optical detection of residual neoplasia with or without clip artifactConclusion: These results suggest that clips used to close colonic EMR defects may impair the ability to accurately assess the EMR scar at follow up. Clips reduced the proportion of high confidence diagnoses as well as the accuracy of scar assessment in low confidence diagnoses, and furthermore, increased the proportion of over treated benign clip artifact. Alternative methods to potentially reduce post-EMR bleeding are needed.

Recurrent scarring papulovesicular lesions on sun-exposed skin in a 22-year-old man

KEY TEACHING POINTS.

A Rare Case of Recurrent Caesarean Scar Ectopic Pregnancy after Wedge Resection of Caesarean Scar Ectopic Pregnancy

A Rare Case of Recurrent Caesarean Scar Ectopic Pregnancy after Wedge Resection of Caesarean Scar Ectopic Pregnancy

Endoscopic ultra dream pulse laser surgery of laryngomalacia. Our experiences gained during the introduction of the method in Hungary

Congenital stridor and dyspnoe are caused by laryngomalacia in most cases. In this article we present a new, surgical method for treating severe laryngomalacia in patients under the age of 1, where ultrapulsated (UDP) laser beam is used for supraglottoplasty. Ultra dream pulse laser creates lesser thermical side damage in the tissue, therefore the risk of postoperative laryngeal oedema and scarring is lower. We present 10 cases and the endoscopic UDP-laser surgery of patients under the age of 1 with severe laryngomalacia. After the surgery the stridorous symptoms disappeared, and there was no evidence of postoperative laryngeal oedema, there was no need for reoperation or tracheotomy in any of the cases. UDP-laser surgery of laryngomalacia is proven to be a safe and effective surgial modality. During the follow up visits we experienced neither recurrence of stridor nor laryngeal scarring. Orv Hetil. 2017; 158(33): 1288-1292.