How to assess postsurgical scars: A review of outcome measures

Purpose.?Complications of surgical incision include pathological scars with functional, cosmetic or psychological consequences. Postsurgical scar assessment is fundamental for a complete functional evaluation and as an outcome measure. Scar assessment scales are here reviewed and discussed from a clinical and psychometric point of view, with a clear definition of different scar parameters.

Method.?An extensive review of the English-language literature was conducted using the Medline database.

Results.?Four scales that satisfy psychometrical criteria were identified: Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), Manchester Scar Scale (MSS) and Stony Brook Scar Evaluation Scale (SBSES).

Conclusions.?To date, VSS is the most widely used rating scale for scars but POSAS appears the most comprehensive, taking into account the important aspect of patient's perspective. The MSS has been never used for research, while SBSES has only been very recently proposed.     

中西医一体化防治增生性瘢痕的研究现状

皮肤瘢痕是一个巨大的医学问题,每年约有1亿患者产生瘢痕。瘢痕的预防/治疗在很大程度上还没有得到满足的临床需求。瘢痕的形成通常是皮肤创伤的病理结果。而增生性瘢痕(hypertrophic scar,HTS)常发生在人深部损伤后。HTS通常被认为是组织收缩和过度的细胞外基质沉积的结果。肌成纤维细胞作为主要由成纤维细胞分化而来的效应细胞,在HTS的病理生理中起着至关重要的作用。多种生长因子、炎症因子参与了HTS发生的过程。目前,随着对HTS的深入探索和临床研究,各种创造性和有效的治疗方法正在萌芽。本文就HTS中西医形成机制研究进展进行综述,并针对其病理生理特点,对现有的中西医综合治疗方法进行综述。此外,我们进一步展望更适合的HTS中西医综合治疗的特色与方法。     

How to assess postsurgical scars: A review of outcome measures

Abstract

Purpose. Complications of surgical incision include pathological scars with functional, cosmetic or psychological consequences. Postsurgical scar assessment is fundamental for a complete functional evaluation and as an outcome measure. Scar assessment scales are here reviewed and discussed from a clinical and psychometric point of view, with a clear definition of different scar parameters.

Method. An extensive review of the English-language literature was conducted using the Medline database.

Results. Four scales that satisfy psychometrical criteria were identified: Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), Manchester Scar Scale (MSS) and Stony Brook Scar Evaluation Scale (SBSES). Conclusions. To date, VSS is the most widely used rating scale for scars but POSAS appears the most comprehensive, taking into account the important aspect of patient’s perspective. The MSS has been never used for research, while SBSES has only been very recently proposed.     

Effect of osteopathic treatment on a scar assessed by thermal infrared camera,pilot study

BackgroundScar formation is influenced by mechanical forces and may generate mechanical tension. Scars induce a temperature difference in the body objectified by thermal imaging camera. The osteopath’s task is to ensure the tissue good mobility in the body. The aim of this study was to measure the influence of osteopathic treatment on a scar by thermal camera.Method12 subjects were analyzed: 4 scars by wounds and 8 by operations. A thermal camera was used to measure the temperature variations of the scars and peri-scar area after cooled stimulation. Measurements were made before and after osteopathic treatment.Results/findingsA significant difference was found between the scar and the peri-scar area before osteopathic treatment (p = 0.044) and no significant difference after osteopathic treatment (p = 0.069). Results showed that osteopathic treatment on a scar induces a more homogeneous local warming temperature.ConclusionThe osteopathic treatment allows different warming between scar and peri-scar area; this suggests a modification of the connective tissue function after osteopathic treatment. Further studies are required to better understand the function of connective tissue and the mechanism of healing.     

A Novel,Reliable Protocol to Objectively Assess Scar Stiffness Using Shear Wave Elastography

The aim of this research was to investigate the use of shear wave elastography as a novel tool to quantify and visualize scar stiffness after a burn. Increased scar stiffness is indicative of pathologic scarring which is associated with persistent pain, chronic itch and restricted range of movement. Fifty-five participants with a total of 96 scars and 69 contralateral normal skin sites were evaluated. A unique protocol was developed to enable imaging of the raised and uneven burn scars. Intra-rater and inter-rater reliability was excellent (intra-class correlation coefficient >0.97), and test–retest reliability was good (intra-class correlation coefficient >0.85). Shear wave elastography was able to differentiate between normal skin, pathologic scars and non-pathologic scars, with preliminary cutoff values identified. Significant correlations were found between shear wave velocity and subjective clinical scar assessment (r = 0.66). Shear wave elastography was able to provide unique information associated with pathologic scarring and shows promise as a clinical assessment and research tool.     

Soft tissue mobilization techniques in treating chronic abdominal scar tissue: A quasi-experimental single subject design

IntroductionRoughly 17 million abdominal surgeries are performed annually in the U.S. Up to 17% of those may be readmitted for adhesion related problems. This study evaluated the effectiveness of soft tissue mobilization (STM) techniques at improving chronic pain, mobility restrictions and functional deficits following complex abdominal surgery.MethodsSubjects Two females aged 51 and 65.DesignSingle subject quasi-experimental A-B-A.InterventionFour 30-min treatment sessions of abdominal tissue mobilizations.Outcome measures Pain pressure threshold (PPT) and average scar mobility (ASM), Numeric Pain Rating Scale (NPRS), and the Oswestry Disability Index (ODI).ResultsSubject 1 ASM and PPT of the abdomen improved significantly and exceeded the established standard error of measurement (SEM). PPT of the scar decreased during the second baseline. This decrease exceeded the SEM for PPT but was not statistically significant. The changes in NPRS did not reach the minimal clinically important difference (MCID).Subject 2 abdominal PPT and ASM showed statistically significant improvements that exceeded their SEMs. Scar PPT showed improvement during the repeat baseline, however, this reached neither statistical significance nor the SEM.ConclusionsScar mobility and abdominal PPT improved both statistically and clinically in both subjects after only 4 sessions of STM. Scar pain measured by NPRS and PPT did not show significant improvement. This study demonstrated that STM can be an effective way to treat chronic abdominal scars by increasing scar mobility and reducing abdominal sensitivity to pressure. It is non-invasive, and is a less costly alternative to laparoscopic adhesiolysis.     

AtrialJSQnet: A New framework for joint segmentation and quantification of left atrium and scars incorporating spatial and shape information

Left atrial (LA) and atrial scar segmentation from late gadolinium enhanced magnetic resonance imaging (LGE MRI) is an important task in clinical practice. The automatic segmentation is however still challenging due to the poor image quality, the various LA shapes, the thin wall, and the surrounding enhanced regions. Previous methods normally solved the two tasks independently and ignored the intrinsic spatial relationship between LA and scars. In this work, we develop a new framework, namely AtrialJSQnet, where LA segmentation, scar projection onto the LA surface, and scar quantification are performed simultaneously in an end-to-end style. We propose a mechanism of shape attention (SA) via an implicit surface projection to utilize the inherent correlation between LA cavity and scars. In specific, the SA scheme is embedded into a multi-task architecture to perform joint LA segmentation and scar quantification. Besides, a spatial encoding (SE) loss is introduced to incorporate continuous spatial information of the target in order to reduce noisy patches in the predicted segmentation. We evaluated the proposed framework on 60 post-ablation LGE MRIs from the MICCAI2018 Atrial Segmentation Challenge. Moreover, we explored the domain generalization ability of the proposed AtrialJSQnet on 40 pre-ablation LGE MRIs from this challenge and 30 post-ablation multi-center LGE MRIs from another challenge (ISBI2012 Left Atrium Fibrosis and Scar Segmentation Challenge). Extensive experiments on public datasets demonstrated the effect of the proposed AtrialJSQnet, which achieved competitive performance over the state-of-the-art. The relatedness between LA segmentation and scar quantification was explicitly explored and has shown significant performance improvements for both tasks. The code has been released via https://zmiclab.github.io/projects.html.     

瘢痕移除后瘢痕皮回植原位皮肤再生治疗增生性瘢痕

背景:已有的研究表明原位皮肤再生法可使深Ⅱ度以内烧伤创面和供皮区刨面生理愈合无瘢痕,可促进Ⅲ度烧伤创面坏死组织液化排除、移植皮生长、减少减轻瘢痕,在瘢痕移除创面使用原位皮肤再生法以达到明显减轻瘢痕症状、减少瘢痕的效果,未见相关报道.目的:观察搬痕移除原位皮肤再生法治疗增生性瘢痕的效果.方法:选择烧伤或刨伤后出现多处增生性瘢痕的患者32例,男25例,女7例;年龄16～52岁;瘢痕病程1～11年.每例选择2处瘢痕相似的部位,进行自身对照.实验组采用瘢痕移除、瘢痕皮回植后应用美宝湿润烧伤膏药纱覆盖的原位皮肤再生法治疗:对照组采用瘢痕移除、瘢痕皮回植后应用传统凡士林覆盖治疗.观察比较疗效,应用温哥华瘢痕评估量表评估瘢痕增生情况.结果与结论:两组回植的瘢痕皮均成活.实验组创而愈合速度和质量优于对照组(P<0.05):瘢痕移除后6个月,实验组温哥华瘢痕评估量表评估均优于对照组(户<0.05,P<0.01),瘢痕所致的疼痛、瘙痒等症状消失,皮片平整且颜色较回植前明显改善,与周围皮肤接近.结果提示对自体皮源不足、瘢痕面积大的增生性瘢痕患者或不愿增加新的供皮区创面患者,应用瘢痕移除瘢痕皮回植原位皮肤再生的方法治疗是一种较理想的方法.     

Non-invasive evaluation of therapeutic response in keloid scar using diffuse reflectance spectroscopy

The pathogenesis and ideal treatment of keloid are still largely unknown, and it is essential to develop an objective assessment of keloid severity to evaluate the therapeutic response. We previously reported that our diffuse reflectance spectroscopy (DRS) system could assist clinicians in understanding the functional and structural condition of keloid scars. The purpose of this study was to understand clinical applicability of our DRS system on evaluating the scar severity and therapeutic response of keloid. We analyzed 228 spectral data from 71 subjects with keloid scars. The scars were classified into mild (0-3), moderate (4-7) and severe (8-11) according to the Vancouver scar scale. We found that as the severity of the scar increased, collagen concentration and water content increased, and the reduced scattering coefficient at 800 nm and oxygen saturation (SaO₂) decreased. Using the DRS system, we found that collagen bundles aligned in a specific direction in keloid scars, but not in normal scars. Water content and SaO₂ may be utilized as reliable parameters for evaluating the therapeutic response of keloid. In conclusion, the results obtained here suggest that the DRS has potential as an objective technique with which to evaluate keloid scar severity. In addition, it may be useful as a tool with which to track longitudinal response of scars in response to various therapeutic interventions.OCIS codes: (170.5280) Photon migration, (170.4580) Optical diagnostics for medicine, (170.6510) Spectroscopy, tissue diagnostics, (290.1990) Diffusion     

Quantification of Pediatric Burn Scar Stiffness Using Acoustic Radiation Force Impulse Ultrasound Elastography

The purpose of this study was to quantify the stiffness of hypertrophic scars using acoustic radiation force impulse ultrasound elastography. Sixteen pediatric patients with hypertrophic scars resulting from burn injuries participated in this study (mean age: 5.13, standard deviation: 3.20). Values for the elastic modulus (E) of scar and control sites were obtained. Scarred areas were found to be almost four times stiffer than control sites (scar E_mean = 39.29 kPa compared with control E_mean = 10.19 kPa) (p = 0.0004). Correlations between scar stiffness and clinician-reported subjective scar scale scores were not observed (r_s = 0.30, p = 0.27 and r_s = 0.25, p = 0.35 respectively). We found that acoustic radiation force impulse imaging can discriminate between hypertrophic scars and normal skin and should be considered a potentially valuable tool in the armamentarium of objective scar measures. Future research should focus on evaluating the technology's ability to detect scar change over time in order to determine responsiveness to treatment.     

The effect of silicone gel sheets on perfusion of hypertrophic burn scars

The mechanism of action of topical silicone gel sheets on hypertrophic scars is not well understood and their effect on the blood flow within hypertrophic scars has not been investigated. The purpose of this study was to examine whether application of silicone gel sheets produced any acute effects on blood flow in hypertrophic burn scars. Perfusion of hypertrophic scars and adjacent normal skin was measured using a laser Doppler with and without application of silicone gel sheets. Continuous measurements were made for 5 minutes before gel application, for 30 minutes during gel application and for 5 minutes following gel removal. Surface temperature of the scar was continuously monitored. An occupational therapist, blinded to the perfusion level, rated each scar using the Vancouver Scar Scale. Eighteen scars and adjacent control sites in sixteen adult burn patients (11 male, 5 female; mean age: 42 +/- 14 years) were evaluated. The mean scar age was 5.4 +/- 3.7 months. The mean Vancouver Scar Scale was 5.5 +/- 2.4. Hypertrophic scars demonstrated higher perfusion measurements at baseline compared to control areas (58.5 +/- 19.3 flux units vs 25.0 +/- 8.4 flux units; P < 0.001). Application of silicone sheeting gel did not significantly alter perfusion in either the hypertrophic scar or normal tissue from the baseline measurements. However, application of silicone gel sheeting did significantly increase the mean baseline surface temperature of the hypertrophic scar from 29 +/- 0.8 degrees C to 30.7 +/- 0.6 degrees C (P < 0.001). The mechanism of action of silicone gel sheeting probably does not involve an acute alteration in blood flow within the scar. However, surface temperature of the scar increased significantly following gel application, raising the possibility that temperature alteration is involved in the mechanism of action.     

A型肉毒毒素联合持续减张法及面部瘢痕切除术治疗面部小面积瘢痕患者的疗效评价

目的探讨A型肉毒毒素联合持续减张法及面部瘢痕切除术治疗面部小面积瘢痕患者的疗效。方法选取2019年1月~2020年6月我院面部小面积瘢痕患者126例,简单随机化法分为观察组(n=63)、对照组(n=63)。两组均行面部瘢痕切除术,术后对照组予以常规治疗,观察组予以A型肉毒毒素联合持续减张法。比较两组疗效、不良反应发生率、手术前后温哥华瘢痕量表(VSS)、术后1个月、3个月肉芽组织成熟分级及患者和观测者瘢痕评价量表(POSAS)。结果观察组优良率95.24%高于对照组76.19%(P<0.05);两组术后VSS评分逐渐降低,术后1个月、3个月观察组低于对照组(P<0.05);术后1个月、3个月观察组肉芽组织成熟分级优于对照组,OSAS、PSAS评分低于对照组(P<0.05);两组不良反应发生率对比,差异无统计学意义(P>0.05)。结论A型肉毒毒素联合持续减张法及面部瘢痕切除术治疗面部小面积瘢痕效果显著,可有效促进肉芽组织成熟,减轻患者瘢痕,提高美观满意度,且安全性高。     

兔耳瘢痕成熟过程中血管内皮细胞生长因子与缺氧诱导因子1α的表达

背景:尽管近20年来在组织、细胞和分子各个水平上展开了瘢痕的研究,但瘢痕形成的完整机制尚未阐明,探索瘢痕的形成的分子机制,寻求理想的瘢痕防治方法是医学研究和实践中一项紧迫而艰巨的任务。目的:观察兔耳瘢痕从形成到消退成熟过程中血管内皮细胞生长因子与缺氧诱导因子1α变化,探讨瘢痕形成的分子机制。方法:制作兔耳瘢痕从形成到消退成熟的动物模型,收集兔耳术后14,30,60和90d瘢痕和正常皮肤,应用苏木精-伊红染色方法观察兔耳术后各时间点瘢痕的组织形态学变化,免疫组织化学法方法检测术后各时间点血管内皮细胞生长因子、缺氧诱导因子1α在瘢痕组织中的表达。结果与结论:术后14d瘢痕组织中血管内皮细胞生长因子和缺氧诱导因子1α表达较其他时间点和正常组织均升高,而随着时间的延长,瘢痕的萎缩成熟,两者的表达水平逐渐降低,并在术后90d达到正常组织表达水平。结果表明缺氧诱导因子1α与血管内皮细胞生长因子在瘢痕组织内氧分压的变化过程中起到一定的调节作用。     

Smartphone-based optical palpation: towards elastography of skin for telehealth applications

Smartphones are now integral to many telehealth services that provide remote patients with an improved diagnostic standard of care. The ongoing management of burn wounds and scars is one area in which telehealth has been adopted, using video and photography to assess the repair process over time. However, a current limitation is the inability to evaluate scar stiffness objectively and repeatedly: an essential measurement for classifying the degree of inflammation and fibrosis. Optical elastography detects mechanical contrast on a micrometer- to millimeter-scale, however, typically requires expensive optics and bulky imaging systems, making it prohibitive for wide-spread adoption in telehealth. More recently, a new variant of optical elastography, camera-based optical palpation, has demonstrated the capability to perform elastography at low cost using a standard digital camera. In this paper, we propose smartphone-based optical palpation, adapting camera-based optical palpation by utilizing a commercially available smartphone camera to provide sub-millimeter resolution imaging of mechanical contrast in scar tissue in a form factor that is amenable to telehealth. We first validate this technique on a silicone phantom containing a 5 × 5 × 1 mm³ embedded inclusion, demonstrating comparative image quality between mounted and handheld implementations. We then demonstrate preliminary in vivo smartphone-based optical palpation by imaging a region of healthy skin and two scars on a burns patient, showing clear mechanical contrast between regions of scar tissue and healthy tissue. This study represents the first implementation of elastography on a smartphone device, extending the potential application of elastography to telehealth.     

兔耳瘢痕成熟过程中血管内皮细胞生长因子与缺氧诱导因子1α的表达

背景：尽管近20年来在组织、细胞和分子各个水平上展开了瘢痕的研究,但瘢痕形成的完整机制尚未阐明,探索瘢痕的形成的分子机制,寻求理想的瘢痕防治方法是医学研究和实践中一项紧迫而艰巨的任务。目的：观察兔耳瘢痕从形成到消退成熟过程中血管内皮细胞生长因子与缺氧诱导因子1α变化,探讨瘢痕形成的分子机制。方法：制作兔耳瘢痕从形成到消退成熟的动物模型,收集兔耳术后14,30,60和90d瘢痕和正常皮肤,应用苏木精-伊红染色方法观察兔耳术后各时间点瘢痕的组织形态学变化,免疫组织化学法方法检测术后各时间点血管内皮细胞生长因子、缺氧诱导因子1α在瘢痕组织中的表达。结果与结论：术后14d瘢痕组织中血管内皮细胞生长因子和缺氧诱导因子1α表达较其他时间点和正常组织均升高,而随着时间的延长,瘢痕的萎缩成熟,两者的表达水平逐渐降低,并在术后90d达到正常组织表达水平。结果表明缺氧诱导因子1α与血管内皮细胞生长因子在瘢痕组织内氧分压的变化过程中起到一定的调节作用。     

Rating the resolving hypertrophic scar: comparison of the Vancouver Scar Scale and scar volume

The increased focus of research interests and clinical documentation on outcomes demands that evaluation tools provide reliable and valid data. The Vancouver Scar Scale (VSS) was developed to provide a more objective measurement of burn scars; however, the validity (a test's ability to measure the phenomenon for which it was designed) of the VSS has not been tested. To examine the construct validity of the VSS, we compared it with scar volume, which has established face validity. Burn scars were evaluated monthly for a minimum of 7 months. Three scar volume measurements were performed on each scar. In addition, 3 independent examiners completed the VSS for the same scar. The data generated by these 2 measurements were used to establish the following: (1) the interrater agreement estimated by interclass correlation coefficient, (2) convergence validity, (3) the sensitivity of the assessments to discriminate changes in the scar over time, and (4) the prevalence of related parameters that are not currently being captured by the VSS. In an attempt to address some of the deficiencies of the VSS, we propose several modifications. We anticipate that these changes will increase the reliability and validity of the VSS through an increase in the awareness that training in the use of this scale is required, through improvement in the quality of the subscales, and through the documentation of additional pertinent information.     

瘢痕削除后刃厚皮片移植治疗烧伤后增生性瘢痕

目的：探讨烧伤后增生性瘢痕修复的手术方法。方法：1998-2004年，对14例30个部位烧伤后增生性瘢痕进行瘢痕削除后刃厚皮片移植。结果：所有病人术后外观改善，症状消除，效果满意。结论：瘢痕削除后刃厚皮片移植手术简单实用，在大面积深度烧伤后非功能部位增生性瘢痕的修复中尤为适用。     

Effects of biventricular pacing and scar size in a computational model of the failing heart with left bundle branch block

ObjectivesTo study the impact of biventricular pacing (BiV) and scar size on left ventricular (LV) regional and global function using a detailed finite element model of three-dimensional electromechanics in the failing canine heart.BackgroundCardiac resynchronization therapy (CRT) clinical trials have demonstrated that up to 30% of patients may be classified as non-responders. The presence of a scar appears to contribute to those that do not respond to CRT. A recent study in patients with myocardial scar showed that LV dyssynchrony was the sole independent predictor of reverse remodeling, and not scar location or size.MethodsTwo activation sequences were simulated: left bundle branch block (LBBB) and acute simultaneous BiV (with leads in the left and right ventricle) in hearts with chronic scars of various sizes. The dependence of regional function (mean fiber ejection strain, variance of fiber isovolumic strain and fraction of tissue stretched during ejection) and global function (left ventricular dP/dt_max, ejection fraction, stroke work) on scar size and pacing protocol was tested.ResultsGlobal function and regional function averaged over the whole LV during LBBB and BiV decreased as a function of scar size. In the non-scarred regions, however, regional function was largely independent of scar size for a fixed pacing site.ConclusionsThe model results suggest that uniformity of mechanical contraction in non-scarred regions in the failing heart during biventricular pacing is independent of scar size for a fixed pacing site.     

Quantitative spatial frequency fluorescence imaging in the sub-diffusive domain for image-guided glioma resection

Intraoperative 5- aminolevulinic acid induced-Protoporphyrin IX (PpIX) fluorescence guidance enables maximum safe resection of glioblastomas by providing surgeons with real-time tumor optical contrast. However, visual assessment of PpIX fluorescence is subjective and limited by the distorting effects of light attenuation and tissue autofluorescence. We have previously shown that non-invasive point measurements of absolute PpIX concentration identifies residual tumor that is otherwise non-detectable. Here, we extend this approach to wide-field quantitative fluorescence imaging by implementing spatial frequency domain imaging to recover tissue optical properties across the field-of-view in phantoms and ex vivo tissue.OCIS codes: (110.0110) Imaging systems, (110.0113) Imaging through turbid media, (170.6510) Spectroscopy, tissue diagnostics