CO2 laser resurfacing for burn and traumatic scars of the hand and upper extremity

Background Scar formation is a normal part of the proliferative phase in wound healing where collagen is remodelled to better approximate normal skin. When collagen is not effectively redistributed, excessive scarring may occur. Recently, CO2 laser has emerged as an adjunct in improving scar quality via remodelling and redistribution of dermal collagen fibres. Due to the paucity of literature related to its use in the hands and upper extremities, we created a study to examine its effects on hypertrophic scars focused on the hands and upper extremities. Methods Patients treated with CO2 laser for hypertrophic scars of the hand and upper extremity were included. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) were used to assess the progression of scar quality. Unpaired t-tests were performed to determine statistical difference between pre- and post-treatment scores on each scale. Pearson correlation coefficients were used to understand the relationship between number of treatments and scar quality. Results Of the 90 patients enrolled, 54 patients completed serial scar assessment forms. All patient and observer-reported POSAS domains showed improvement ( P < 0.05) apart from Itching. All VSS domains showed improvement ( P < 0.05). There was moderate correlation between overall patient-reported opinion of scar quality and Discoloration, Stiffness and Thickness, and strong correlation between overall patient opinion and Irregularity (r = 0.715). All observer-reported domains were strongly correlated (r = 7.56–8.74) with overall observer opinion of scar quality. Conclusion The results of this study may further substantiate CO2 laser as a treatment modality for excessive scarring in a variety of surgical subspecialties. Lay Summary Complex trauma and burns that impact the skin sometimes result in abnormal healing of the skin called, “hypertrophic scarring”. In our study we assessed how using focused CO2 laser therapy impacts patients and health care provider assessment of wound progression. Our results were based upon patient reported and healthcare provider observations based upon two standardized forms the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). What we found is that after CO2 Laser Therapy, our 64 patients with 77 treated scars received on average almost 3 treatments and these treatments helped them with physical function and improved aesthetic appearance of their scars. The health care providers also found that the treatments improved functional and aesthetic end points. Overall, our study helps substantiate the body of evidence that using CO2 laser therapy improves aesthetics and function of hypertrophic scars in the upper extremity.

PATIENT AND OBSERVER SCAR ASSESSMENT FOLLOWING BASAL CELL CARCINOMA SURGERY: MULTICENTER QUASI EXPERIMENTAL STUDY

Objective: To assess patient and observer reported scar quality after Basal cell carcinoma surgery of face using the Patient and Observer Scar Assessment Scale (POSAS). Study Design: Quasi experimental study. Place and Duration of Study: Dermatology Department, Tertiary Care Hospitals at Multan and Karachi and Plastic Surgery Department, Tertiary Care Hospital Multan, from Apr to Sep 2020. Methodology: Patients with basal cell carcinoma that full filled inclusion and exclusion criteria were enrolled by consecutive sampling technique at Dermatology and Plastic Surgery Department after informed consent. Surgical excision was followed by reconstruction of defect either by direct closure or by rotation or advancement flap. Surgical scar was assessed independently at 8 weeks by POSAS. Data was analyzed with SPSS-23. Results: A total of 27 patients were enrolled in study. There were 11 (37.9%) males and 16 (59.25%) females between ages of 45-70 years. Basal cell carcinoma was located on cheek in 15 (55.5%), nose in 9 (33.3%), temple 2 (7.4%) and forehead 1 (3.7%) cases. Direct closure was performed in 6 (22.2%), rotation flaps in 10 (40.7%), and advancement flaps in 11 (40.7%) cases. Mean score of observer opinion about surgical scar between different surgical techniques was not statistically significant (p=0.191). How-ever, mean score of patient opinion of scar between different surgical techniques was statistically significant (p=0.032). Conclusion: POSAS is a valid tool for scar evaluation by patient and observer-reported scar qualities after Basal cell carcinoma surgery.

Tissue Stromal Vascular Fraction Improves Early Scar Healing: A Prospective Randomized Multicenter Clinical Trial

Background Wound healing and scar formation depends on a plethora of factors. Given the impact of abnormal scar formation, interventions aimed to improve scar formation would be most advantageous. Tissue stromal vascular fraction (tSVF) of adipose tissue is composed of a heterogenous mixture of cells embedded in extracellular matrix. It contains growth factors and cytokines involved in wound healing processes, eg, parenchymal proliferation, inflammation, angiogenesis, and matrix remodeling. Objectives In this study, we hypothesized that tSVF reduces post-surgical scar formation. Methods This prospective, double-blind, placebo-controlled, randomized trial was conducted between 2016 and 2020. Forty mammoplasty patients were enrolled and followed for 1 year. At the end of the mammoplasty procedure, all patients received tSVF in the lateral 5 cm of the horizontal scar of one breast and a placebo injection in the contralateral breast to serve as an intra-patient control. Primary outcome was scar quality using the patient and observer scar assessment scale (POSAS). Secondary outcomes were obtained with photograph evaluation and histological analysis of scar tissue samples. Results Thirty-four of 40 patients completed follow-up. Six months postoperatively, injection of tSVF had significantly improved postoperative scar appearance as assessed by POSAS questionnaire (observer and patient questionnaire). No difference was observed at 12 months postoperatively. No improvement was seen based on the evaluation of photographs and histological analysis of postoperative scars between both groups. Conclusions Injection of tSVF resulted in improved wound healing and reduced scar formation at 6 months postoperative, without any noticeable advantageous effects seen at 12 months.

Scar formation after lower eyelid incision for reconstruction of the inferior orbital wall related to the lower eyelid crease or ridge in Asians

Background: Transcutaneous lower eyelid approaches are associated with a risk of postoperative scarring depending on the distance between the incision line and the lower eyelid margin. The lower eyelid crease of Caucasians corresponds to a ridge-shaped fold in young Asians. However, this relationship has not been sufficiently evaluated in the latter. The authors, therefore, investigated the location of the scar and the lower eyelid crease or ridge to find the optimal location for the incision line.Methods: This study included 60 out of 139 patients who underwent inferior orbital wall reconstruction through a lower eyelid skin incision between July 2019 and June 2020. According to the location of the scar, the patients were classified into three groups: group A ( ≥ 2 mm above the lower eyelid crease or ridge), group B (within the lower eyelid crease or ridge to 2 mm above the lower eyelid crease or ridge), and group C (within the lower eyelid crease or ridge to 2 mm below the lower eyelid crease or ridge). At 6 or 12 months after surgery, the Patient and Observer Scar Assessment Scale (POSAS) score was obtained, the distance between the lower eyelid margin and the scar (DMS) and the distance between the margins of the peripheral pupil and the lower eyelid (DMPE) were measured, and the occurrence of ectropion was evaluated.Results: Group B had the lowest POSAS score (A: 22.7 ± 8.0, B: 20.9 ± 2.4, C: 32.5 ± 4.1, p < 0.001). Linear regression analysis showed that the DMS was positively correlated with the POSAS score (p < 0.001) and that the risk of DMPE widening increased as the DMS decreased (p = 0.029). None of the patients had ectropion.Conclusion: When using the transcutaneous approach for inferior orbital wall reconstruction, the optimal incision site is within the lower eyelid crease or ridge to 2 mm above the lower eyelid crease or ridge.

Effect of Using Silver Nylon Dressings on Postoperative Pain after Cesarean Delivery

Objective Silver dressings have been associated with a decrease in postoperative pain in selected populations, but it is unknown if the benefit can be observed after cesarean deliveries. We sought to evaluate the impact of silver nylon dressings in reducing postoperative pain after cesarean delivery. Study Design A secondary analysis of data from a blinded randomized clinical trial of women undergoing cesarean delivery scheduled and unscheduled at a single site was conducted. Women were recruited for participation from a single site and randomized to a silver nylon dressing or an identical-appearing gauze wound dressing. Wounds were evaluated in the outpatient clinic at 1 and 6 weeks after delivery and patient responded to the modified patient scar assessment scale. The primary outcome of this analysis was inpatient opioid and nonopioid analgesic dispensed. The secondary outcome was patient-reported pain at the 1- and 6-week postpartum visits. Data were analyzed using chi-square test, Student's t-test, Fisher's exact test, Wilcoxon–Mann–Whitney's test, and logistic regression where appropriate. A p-value of < 0.05 was considered significant. Results Among the 649 participants, women allocated to the silver nylon dressing group, when compared with the gauze group, were similar in the amount of dispensed opioid and nonopioid analgesic medications (morphine equivalent milligrams of opioids dispensed [82.5 vs. 90 mg, p = 0.74], intravenous nonsteroidal anti-inflammatory drugs (NSAIDs) [120 vs. 120 mg, p = 0.55], and oral NSAIDs [4,800 vs. 5,600 mg in the gauze group, p = 0.65]). After adjusting for confounding variables, postoperative wound infection (adjusted odds ratio [aOR]: 11.70; 95% confidence interval [CI]: 4.51–30.31) at 1-week postoperative and again at 6-week postoperative (aOR: 5.59; 95% CI: 1.03–30.31) but not gauze dressing was associated with patient-reported postoperative pain. Conclusion Among women undergoing cesarean delivery, silver nylon dressing was not associated with a reduction in postoperative pain. Key Points

Impact of Single-port Laparoscopic Approach on Postoperative Pain and Cosmesis for Acute Appendicitis: A Comparison with Multi-port Laparoscopic Approach

Background: Acute appendicitis is the most common surgical abdominal emergency. Single-port laparoscopic appendectomy (SPLA) has been suggested potential advantages including less postoperative pain and better cosmesis. The aim of this study was to compare the postoperative pain and cosmetic outcomes between SPLA and multi-port laparoscopic appendectomy (MPLA) for acute appendicitis.Materials and methods: The study included 47 patients who underwent SPLA and 51 patients who underwent MPLA for acute appendicitis between August 2014 and November 2017. The patient scar assessment questionnaire (PSAQ) was used to assess cosmetic outcomes. Results: MPLA involved a longer median operative time than MPLA (60 vs. 47.5 minutes, p=0.02). There were no apparent differences in the time before diet tolerance, length of hospital stay, inflammatory laboratory findings including C-reactive protein and white blood cell count, and postoperative complication rate. SPLA patients had a smaller total incision length (2.0 vs. 2.5 cm, p<0.001) and the total number of analgesics used on postoperative day 0 in the SPLA group was significantly lower than that of the MPLA group (1 vs. 1, p=0.011). The PSAQ scores showed that the SPLA group had a better overall outcome than the MPLA group with respect to total score (48 vs. 55; p = 0.026), appearance (15 vs. 18; p = 0.002) and consciousness (8 vs. 10; p = 0.005), but not in the satisfaction with appearance and symptoms subscales.Conclusion: SPLA is safe and feasible and provides better cosmetic outcomes and less analgesic requirements on the day of surgery compared to MPLA.

Umbilical trocar port site keloid management using a transposition flap after laparoscopic surgery

Background Keloids can occur anywhere in the human body. They are difficult to remove and can cause distress in patients. Although many options are available to treat keloids, no single method is considered the optimal treatment of choice. The authors encountered cases where an umbilical keloid developed at the trocar site after laparoscopic surgery and managed the keloid using a transposition flap.Methods A total of 10 umbilical keloid patients treated from 2013 to 2020 were included in this study. All patients developed a keloid due to the placement of a laparoscopic trocar incision port, and their major complaints varied from an asymptomatic nodule to pruritus or pain. All excisions were performed under local anesthesia, and transposition flaps were planned afterward. The surrounding tissue was rearranged so that the shape of the umbilicus was deformed to the minimum extent possible. The keloid scars were examined both preoperatively and 6 months postoperatively using the Patient and Observer Scar Assessment Scale (POSAS).Results All surgical wounds healed well without complications. The average time interval from laparoscopic surgery to keloid scar revision was 4.3 years. The mean postoperative follow-up period was 10.9 months, and no patient underwent reoperation. Four patients were treated with triamcinolone after surgery due to mild hypertrophy or pruritus. The POSAS observer scale showed significantly decreasing scores over time in all patients (P=0.002).Conclusions Cosmetically unfavorable keloids that form in the umbilicus following laparoscopic surgery can be improved with a simple procedure using excision and transposition flaps.

Impact of single-port laparoscopic approach on postoperative pain and cosmesis for acute appendicitis: a comparison with multi-port laparoscopic approach

Background: Acute appendicitis is the most common surgical abdominal emergency. Single-port laparoscopic appendectomy (SPLA) has been suggested potential advantages including less postoperative pain and better cosmesis. The aim of this study was to compare the postoperative pain and cosmetic outcomes between SPLA and multi-port laparoscopic appendectomy (MPLA) for acute appendicitis.Materials and methods: The study included 47 patients who underwent SPLA and 51 patients who underwent MPLA for acute appendicitis between August 2014 and November 2017. The patient scar assessment questionnaire (PSAQ) was used to assess cosmetic outcomes. Results: MPLA involved a longer median operative time than MPLA (60 vs. 47.5 minutes, p=0.02). There were no apparent differences in the time before diet tolerance, length of hospital stay, inflammatory laboratory findings including C-reactive protein and white blood cell count, and postoperative complication rate. SPLA patients had a smaller total incision length (2.0 vs. 2.5 cm, p<0.001) and the total number of analgesics used on postoperative day 0 in the SPLA group was significantly lower than that of the MPLA group (1 vs. 1, p=0.011). The PSAQ scores showed that the SPLA group had a better overall outcome than the MPLA group with respect to total score (48 vs. 55; p = 0.026), appearance (15 vs. 18; p = 0.002) and consciousness (8 vs. 10; p = 0.005), but not in the satisfaction with appearance and symptoms subscales.Conclusion: SPLA is safe and feasible and provides better cosmetic outcomes and less analgesic requirements on the day of surgery compared to MPLA.

Cardiac magnetic resonance strain and mechanical dispersion assessment in patients with chronic total coronary artery occlusion

Background Chronic total occlusions (CTO) are a frequent angiographic finding. Viability of CTO-subtended myocardium is dependent on the presence of an adequate collateral circulation. At rest, collateral supply may be sufficient to avert ischaemia and maintain normal systolic function. However, it remains unclear whether CTO-subtended myocardium may be considered truly normal, or whether subtle functional abnormalities may be present at rest. Purpose To determine whether, in the absence of infarction and hibernation, CTO-subtended myocardium remains functionally normal or whether abnormalities of strain and/or mechanical dispersion may be present at rest. Methods In a retrospective, single centre, observational study, we studied patients with ≥1 angiographically-diagnosed CTO referred for clinical stress perfusion cardiovascular magnetic resonance (CMR), and compared healthy volunteers (HVs) with a normal stress CMR scan. CMR imaging comprised functional and scar assessment with qualitative [visual] evaluation of infarction and segmental wall motion. Patients with infarction and/or wall motion score index (WMSI) ≥1 were excluded from further analysis. In remaining CTO subjects and HVs, segmental peak systolic longitudinal strain and circumferential strain were analysed (in 3 long-axis planes and 3 short-axis planes, respectively) and mechanical dispersion for both orientations was computed. Image analysis was performed using Medis (QStrain) software blinded to all clinical information. Results From a total of 389 patients with ≥1 angiographically-diagnosed CTO, 68 had normal WMSI and no infarction (63.0±11.7 years, 79.4% male, LVEF 62.6±4.5%). Fifty HVs (61.1±7.0 years, 74.0% males, LVEF 61.1±5.3%) were also studied. The majority of CTO patients had concomitant coronary artery disease in at least one non-CTO vessel (n=37, 54.4%). GLS was lower in CTO patients than HVs (−21.8%±1.5% versus −24.0±1.1%; p&lt;0.0001; Figure 1). By contrast, GCS was greater in CTO patients (−32.7±2.5% versus −28.8±2.1%; p&lt;0.0001). Mechanical dispersion was increased in CTO patients (Figure 2), both longitudinally (90.3±14.6 ms in CTO patients versus 68.6±11.1 ms in HVs; p&lt;0.0001) and circumferentially (66.7±9.1 ms versus 55.3±6.6 ms, respectively; p=0.02). Conclusion Subclinical changes in left ventricular dynamics are present at rest in CTO patients with fully viable myocardium and no evidence of resting regional wall abnormality. Further study is warranted to evaluate the potential association between mechanical dispersion and arrhythmic events in CTO. FUNDunding Acknowledgement Type of funding sources: Other. Main funding source(s): NIHR Clinician Scientist Award (CS-2018-18-ST2-007 to J.R.A.) and Research Professorship award (RP-2017-08-ST2-007 to G.P.M.). Figure 1. Strain analysis. CTO vs HV Figure 2. Mechanical dispersion. CTO vs HV