Mariëlle E. H. Jaspers

Effectiveness of Autologous Fat Grafting in Adherent Scars: Results Obtained by a Comprehensive Scar Evaluation Protocol.

Background: Nowadays, patients normally survive severe traumas such as burn injuries and necrotizing fasciitis. Large skin defects can be closed but the scars remain. Scars may become adherent to underlying structures when the subcutical fat layer is damaged. Autologous fat grafting provides the possibility of reconstructing a functional sliding layer underneath the scar. Autologous fat grafting is becoming increasingly popular for scar treatment, although large studies using validated evaluation tools are lacking. The authors therefore objectified the effectiveness of single-treatment autologous fat grafting on scar pliability using validated scar measurement tools. Methods: Forty patients with adherent scars receiving single-treatment autologous fat grafting were measured preoperatively and at 3-month follow-up. The primary outcome parameter was scar pliability, measured using the Cutometer. Scar quality was also evaluated by the Patient and Observer Scar Assessment Scale and the DSM II ColorMeter. To prevent selection bias, measurements were performed following a standardized algorithm. Results: The Cutometer parameters elasticity and maximal extension improved 22.5 percent (p < 0.001) and 15.6 percent (p = 0.001), respectively. Total Patient and Observer Scar Assessment Scale scores improved from 3.6 to 2.9 on the observer scale, and from 5.1 to 3.8 on the patient scale (both p < 0.001). Color differences between the scar and normal skin remained unaltered. Conclusions: For the first time, the effect of autologous fat grafting on functional scar parameters was ascertained using a comprehensive scar evaluation protocol. The improved scar pliability supports the authors’ hypothesis that the function of the subcutis can be restored to a certain extent by single-treatment autologous fat grafting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Perforator-Based Interposition Flaps Perform Better Than Full-Thickness Grafts for the Release of Burn Scar Contractures: A Multicenter Randomized Controlled Trial.

Background: Burn scar contractures remain a significant problem for the severely burned patient. Reconstructive surgery is often indicated to improve function and quality of life. Skin grafts (preferably full-thickness grafts) are frequently used to cover the defect that remains after scar release. Local flaps are also used for this purpose and provide healthy skin subcutaneous tissue. The vascularization and versatility of local flaps can be further improved by enclosing a perforator at the base of the flap. Until now, no randomized controlled trial has been performed to determine which technique has the best effectiveness in burn scar contracture releasing procedures. Methods: A multicenter randomized controlled trial was performed to compare the effectiveness of perforator-based interposition flaps to full-thickness skin grafts for the treatment of burn scar contractures. The primary outcome parameter was change in the surface area of the flap or full-thickness skin graft. Secondary outcome parameters were width, elasticity, color, Patient and Observer Scar Assessment Scale score, and range of motion. Measurements were performed after 3 and 12 months. Results: The mean surface area between flaps (n = 16) and full-thickness skin grafts (n = 14) differed statistically significantly at 3 months (123 percent versus 87 percent; p < 0.001) and 12 months (142 percent versus 92 percent; p < 0.001). In terms of the secondary outcome parameters (specifically, the Patient and Observer Scar Assessment Scale observer score and color), interposition flaps showed superior results compared with full-thickness skin grafts. Conclusion: Perforator-based interposition flaps result in a more effective scar contracture release than full-thickness skin grafts and should therefore be preferred over full-thickness skin grafts when possible. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

In a clinimetric analysis, 3D stereophotogrammetry was found to be reliable and valid for measuring scar volume in clinical research

OBJECTIVES Volume is an important feature in the evaluation of hypertrophic scars and keloids. Three-dimensional (3D) stereophotogrammetry is a noninvasive technique for the measurement of scar volume. This study evaluated the reliability and validity of 3D stereophotogrammetry for measuring scar volume. STUDY DESIGN AND SETTING To evaluate reliability, 51 scars were photographed by two observers. Interobserver reliability was assessed by the intraclass correlation coefficient (ICC), and the measurement error was expressed as limits of agreement (LoA). To assess validity, 60 simulated (clay) scars were measured by 3D stereophotogrammetry and subsequently weighed (gold standard). The correlation of volumes obtained by both measures was calculated by a concordance correlation coefficient (CCC), and the measurement error was expressed as a 95% prediction interval. RESULTS The ICC was 0.99, corresponding to a high correlation of measurements between two observers, although the LoA were relatively wide. The correlation between 3D stereophotogrammetry and the gold standard was also high, with a CCC of 0.97. Again, the plot of the differences and LoA showed moderate agreement for the validity. CONCLUSION Three-dimensional stereophotogrammetry is suitable for the use in clinical research but not for the follow-up of the individual patient.

Sustainable effectiveness of single-treatment autologous fat grafting in adherent scars

Following severe injury, not just the skin but also the subcutis may be destroyed. Consequently, the developing scar can become adherent to underlying structures. Reconstruction of the subcutis can be achieved by autologous fat grafting. Our aim was to evaluate the long‐term scar outcome after single‐treatment autologous fat grafting using a comprehensive scar evaluation protocol. Scar assessment was performed preoperatively in 40 patients. A 12‐month follow‐up assessment was performed in 36 patients, using the Cutometer, the Patient and Observer Scar Assessment Scale, and DSM II ColorMeter. The Cutometer parameters elasticity and maximal extension improved with 28 and 22% (both p < 0.001), respectively. Nearly all scores of the scar assessment scale decreased significantly, which corresponds to improved scar quality. In addition, the mean melanin score was ameliorated over time. Thus, we demonstrated the sustainable effectiveness of single‐treatment autologous fat grafting in adherent scars, indicated by improved pliability, and overall scar quality.

In vivo polarization-sensitive optical coherence tomography of human burn scars : birefringence quantification and correspondence with histologically determined collagen density

Abstract. Obtaining adequate information on scar characteristics is important for monitoring their evolution and the effectiveness of clinical treatment. The aberrant type of collagen in scars may give rise to specific birefringent properties, which can be determined using polarization-sensitive optical coherence tomography (PS-OCT). The aim of this pilot study was to evaluate a method to quantify the birefringence of the scanned volume and correlate it with the collagen density as measured from histological slides. Five human burn scars were measured in vivo using a handheld probe and custom-made PS-OCT system. The local retardation caused by the tissue birefringence was extracted using the Jones formalism. To compare the samples, histograms of birefringence values of each volume were produced. After imaging, punch biopsies were harvested from the scar area of interest and sent in for histological evaluation using Herovici polychrome staining. Two-dimensional en face maps showed higher birefringence in scars compared to healthy skin. The Pearson’s correlation coefficient for the collagen density as measured by histology versus the measured birefringence was calculated at r=0.80 (p=0.105). In conclusion, the custom-made PS-OCT system was capable of in vivo imaging and quantifying the birefringence of human burn scars, and a nonsignificant correlation between PS-OCT birefringence and histological collagen density was found.

Insights into the use of thermography to assess burn wound healing potential: a reliable and valid technique when compared to laser Doppler imaging

Abstract. Adequate assessment of burn wounds is crucial in the management of burn patients. Thermography, as a noninvasive measurement tool, can be utilized to detect the remaining perfusion over large burn wound areas by measuring temperature, thereby reflecting the healing potential (HP) (i.e., number of days that burns require to heal). The objective of this study was to evaluate the clinimetric properties (i.e., reliability and validity) of thermography for measuring burn wound HP. To evaluate reliability, two independent observers performed a thermography measurement of 50 burns. The intraclass correlation coefficient (ICC), the standard error of measurement (SEM), and the limits of agreement (LoA) were calculated. To assess validity, temperature differences between burned and nonburned skin (ΔT) were compared to the HP found by laser Doppler imaging (serving as the reference standard). By applying a visual method, one ΔT cutoff point was identified to differentiate between burns requiring conservative versus surgical treatment. The ICC was 0.99, expressing an excellent correlation between two measurements. The SEM was calculated at 0.22°C, the LoA at −0.58°C and 0.64°C. The ΔT cutoff point was −0.07°C (sensitivity 80%; specificity 80%). These results show that thermography is a reliable and valid technique in the assessment of burn wound HP.

3D printing of patient-specific neck splints for the treatment of post-burn neck contractures

Dear Editor, Burn scar contracture is a common problem in healing burn wounds of the neck. It can cause both pain and dysfunction if not treated adequately [1]. The treatment of such wounds often involves a combination of surgery and splinting therapy [2]. A variety of splints, including the thermoplastic static neck splint [3], the Watusi collar [4], manually fabricated splints, and pre-fabricated splints such as the Philadelphia collar have been used for the management of scar contractures. However, each type of splint has its own advantages and disadvantages, and none of these splints seem to reduce the need for skin reconstruction nor delays the time until surgical reconstruction [5]. Medical applications for optical three-dimensional (3D) scanning and 3D printing are evolving rapidly [6], and both technologies could revolutionize the field of burn and wound care. More specifically, optical 3D scanners in combination with 3D printing technologies can be used to manufacture patient-specific devices such as splints for the treatment of post-burn neck contractures. The combination of these technologies could increase product customization, production speed, and cost-effectiveness of splint development. 3D printing is already being used for surgical planning, education, and implant customization [7]. Furthermore, facial masks have already been manufactured for burn patients using optical 3D scanning and 3D printing technologies [8, 9]. The aim of this study was to determine whether clinical use of these technologies for the production of patientspecific neck splints is feasible in a group of burn patients. A retrospective study was performed with six patients who had been treated for burns and burn-related neck contractures at the Red Cross Hospital Burn Center in Beverwijk, the Netherlands. Following admission, all patients with neck burns were scanned using an optical 3D scanner (Artec SpiderTM; Artec Group, Moscow, Russia). Following scanning, all patients received a 3D-printed neck splint consisting of silicone and medical-grade nylon (Fig. 1a–c) instead of a standard neck splint (which in our burn center is a manually fabricated neck splint). In order to determine patient satisfaction, a telephonic questionnaire was administered to all patients (Table 1). The study was approved by the regional Medical Ethics Committee of Noord-Holland, the Netherlands (M016-004). In light of the Declaration of Helsinki, all patients gave oral informed consent to start the intervention. Additional written informed consent was obtained from patients whose photographs were used for publication. One engineer with in-depth knowledge in medical 3D scanning performed all optical 3D scans, including postprocessing. Optical 3D scanning took 30 min, including setup (Fig. 1d). Computer-aided design was completed in approximately 4 h. 3D printing of the splints took approximately 4 days because not all the parts could not be printed in-house. Therefore, the total production time for one 3D-printed neck splint was 5 days. The thickness of the final silicone splints and overlying nylon honeycomb scaffolds were 5 and 3 mm respectively. The median follow-up after the initiation of the 3Dprinted splints was 7 months (interquartile range (IQR): * Correspondence: d.visscher@vumc.nl Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, VU University Medical Center, de Boelelaan 1117, 1081HV Amsterdam, the Netherlands 3D InnovationLab, VU University Medical Center, Amsterdam, the Netherlands Full list of author information is available at the end of the article

A systematic review on the quality of measurement techniques for the assessment of burn wound depth or healing potential

PURPOSE Reliable and valid assessment of burn wound depth or healing potential is essential to treatment decision-making, to provide a prognosis, and to compare studies evaluating different treatment modalities. The aim of this review was to critically appraise, compare and summarize the quality of relevant measurement properties of techniques that aim to assess burn wound depth or healing potential. METHODS A systematic literature search was performed using PubMed, EMBASE and Cochrane Library. Two reviewers independently evaluated the methodological quality of included articles using an adapted version of the Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. A synthesis of evidence was performed to rate the measurement properties for each technique and to draw an overall conclusion on quality of the techniques. RESULTS Thirty-six articles were included, evaluating various techniques, classified as (1) laser Doppler techniques; (2) thermography or thermal imaging; (3) other measurement techniques. Strong evidence was found for adequate construct validity of laser Doppler imaging (LDI). Moderate evidence was found for adequate construct validity of thermography, videomicroscopy, and spatial frequency domain imaging (SFDI). Only two studies reported on the measurement property reliability. Furthermore, considerable variation was observed among comparator instruments. CONCLUSIONS Considering the evidence available, it appears that LDI is currently the most favorable technique; thereby assessing burn wound healing potential. Additional research is needed into thermography, videomicroscopy, and SFDI to evaluate their full potential. Future studies should focus on reliability and measurement error, and provide a precise description of which construct is aimed to measure.

Autologous fat grafting; it almost seems too good to be true

With great interest we read the article by Gal et al. entitled: “Autologous fat grafting does not improve burn scar appearance: A prospective, randomized, double-blinded, placebocontrolled, pilot study” [1]. We would like to thank the authors for their contribution to the rapidly developing field of autologous fat grafting. Moreover, their efforts to conduct a randomized controlled trial (RCT) are appreciated, as there are many challenges and hurdles that must be overcome before such a study can be carried out. Gal et al. evaluated the effects of injection of autologous fat versus saline on mature burn scars in pediatric patients. Due to the fact that no benefit for fat grafting was observed after evaluating 8 patients, the decision was made to stop enrolling patients. Recently, we evaluated the effect of single-treatment autologous fat grafting in a large case-series (before-after design), showing remarkable improvement of scar quality at the short-term follow-up [2] and at 12 months postoperatively [manuscript in preparation]. Although our study was conducted in adult patients, we deem the scars included in both studies comparable after evaluating the photographs in the article. Therefore, we are surprised by their results, but at the same time we appreciate that the authors raise some important points, which require more debate and evidence to support or discourage autologous fat grafting in the future. However, we would like to make some comments concerning the design of their study. Remarkably, no preoperative baseline of the treated scars was assessed, nor an untreated control scar was evaluated. It is therefore in essence impossible and premature to draw conclusions from this study on any effect of both treatments. The most sensible explanation for the results of Gal et al. is: (1) both treatment methods cause a positive effect on burn scars, or (2) neither fat grafting nor normal saline injection causes a positive effect on burn scars. In addition, we feel that some remarks about the presented evaluation protocol need to be made, because this may explain why no differences between both treatments were found. The authors report on the use of the Vancouver Scar Scale (VSS). This instrument however, is not designed to indicate burn scar severity, but rather to show the presence or absence of a pathological condition, indicated by the categorical scale [3]. Moreover, the reliability of the VSS is moderate (Cohen’s Kappa of 0.5), requiring at least three observers to obtain substantial reliable data. Furthermore, it seems that their subjective patient questionnaire was not tested or validated, and items such as pain and itch were not included, whilst pain was an essential improved parameter in our study. Therefore, it would have been favorable if the authors used the Patient and Observer Scar Assessment Scale (POSAS), which is recognized as a highly reliable scar rating scale, and covers the patient’s perception of scarring [4]. In addition, scar assessment by objective tools such as the Cutometer and DSM II ColorMeter could have asserted more power to the study. Another important point of discussion is that very small scar areas of 5 5cm were analyzed and that both study areas were located adjacent to each other, making it rather difficult to even determine difference. Moreover, by selecting two adjacent areas, it has to be taken into account that fat or saline could have diffused from one area to another, hindering exact evaluation of each individual treatment. Altogether, the evaluation protocol used by the authors presumably had a negative impact on the ability and reliability to detect differences in scar outcome with only 8 patients. Besides the results of Gal et al., there are many studies that do support the use of autologous fat grafting in a wide range of indications. On the other hand, only few RCTs have been performed in this field, and therefore it is still unclear if the functional scar quality also improves when only adhesiolysis (and saline injection) is carried out. During adhesiolysis, the scar is released from the underlying structures, which may be beneficial for the scar’s pliability and the ultimate scar outcome. However, without fat grafting, scars will probably become adherent again and the potential remodeling effect by adipose derived stem cells within the fat graft will not be present [5]. Accordingly, substantial evidence obtained by larger RCTs using a comprehensive scar evaluation protocol is needed, to provide us with definite answers to the questions raised. Triggered by the contrast between the results of Gal et al. and our own positive results, the time has come that we are genuinely motivated to set up such a robust RCT. Only then we will find out if autologous fat grafting is too good to be true or if the use of this method can be further supported. b u r n s x x x ( 2 0 1 7 ) x x x – x x x JBUR 5193 No. of Pages 2

The FLIR ONE thermal imager for the assessment of burn wounds: Reliability and validity study

BACKGROUND Objective measurement tools may be of great value to provide early and reliable burn wound assessment. Thermal imaging is an easy, accessible and objective technique, which measures skin temperature as an indicator of tissue perfusion. These thermal images might be helpful in the assessment of burn wounds. However, before implementation of a novel measurement tool into clinical practice is considered, it is appropriate to test its clinimetric properties (i.e. reliability and validity). The objective of this study was to assess the reliability and validity of the recently introduced FLIR ONE thermal imager. MATERIAL AND METHODS Two observers obtained thermal images of burn wounds in adult patients at day 1-3, 4-7 and 8-10 after burn. Subsequently, temperature differences between the burn wound and healthy skin (ΔT) were calculated on an iPad mini containing the FLIR Tools app. To assess reliability, ΔT values of both observers were compared by calculating the intraclass correlation coefficient (ICC) and measurement error parameters. To assess validity, the ΔT values of the first observer were compared to the registered healing time of the burn wounds, which was specified into three categories: (I) ≤14 days, (II) 15-21 days and (III) >21 days. The ability of the FLIR ONE to discriminate between healing ≤21 days and >21 days was evaluated by means of a receiver operating characteristic curve and an optimal ΔT cut-off value. RESULTS Reliability: ICCs were 0.99 for each time point, indicating excellent reliability up to 10 days after burn. The standard error of measurement varied between 0.17-0.22°C. VALIDITY the area under the curve was calculated at 0.69 (95% CI 0.54-0.84). A cut-off value of -1.15°C shows a moderate discrimination between burn wound healing ≤21 days and >21 days (46% sensitivity; 82% specificity). CONCLUSION Our results show that the FLIR ONE thermal imager is highly reliable, but the moderate validity calls for additional research. However, the FLIR ONE is pre-eminently feasible, allowing easy and fast measurements in clinical burn practice.