[Medical Needling: effect on skin tension and elasticity of hypertrophic burn scars]. / Medical Needling ­ Effekt auf hypertrophe Verbrennungsnarben hinsichtlich der Hautspannung und -elastizität.

BACKGROUND: Burn scars are a serious psychological and physiological problem for affected individuals. Clinical studies and scientific research have shown that Medical Needling improves scar quality in terms of skin elasticity, moisture, transepidermal water loss and erythema. At the same time, patients are confronted with a comparatively low-risk therapy without any postoperative complications. OBJECTIVE: The goal of our study was to examine the influence of Medical Needling on mature hypertrophic scars with regard to skin elasticity and tension. A total of 20 patients with an average age of 34.6 years and second or third-degree burn scars were treated. Scars that were at least 2 years old and had healed by secondary intention met the criteria for inclusion in the study. METHODS: Medical Needling is performed using a roller covered with needles of 3 mm length. The needling device is rolled over the scar in three directions: vertically, horizontally and diagonally. The procedure of puncture leads to multiple micro wounds and intradermal bleeding, which induces the post needling regeneration cascade. The patients were followed up for 12 months postoperatively. The results were evaluated by means of objective and subjective measurement methods. RESULTS: Objective measurements show that Medical Needling improves pathological values of skin tension and elasticity. Depending on the scarring, a reduction in tension or an increased tightness of overstrained and lax skin was recorded. Rigid scars gained vital features and profited from a physiological degree of elasticity. CONCLUSION: Medical Needling proves to be a promising approach for the treatment of mature hypertrophic scars with pathological changes of skin elasticity and tension.

In vivo reflectance-mode confocal microscopy assessments: impact of overweight on human skin microcirculation and histomorphology.

Reflectance-mode confocal microscopy (RCM) enables in vivo assessment of the human skin. Impact of overweight on both human skin microcirculation and histomorphology has not been investigated in vivo. The purpose of this study is to evaluate both microcirculation and histomorphology in vivo in overweight. In 10 normotensive overweight nondiabetic individuals (OW-group, BMI 29.1 ± 2.7 kg/m(2)) and 10 age- and sex-matched healthy lean controls (CO-group, BMI 20.4 ± 1.9 kg/m(2)) the following parameters were evaluated using RCM: dermal blood cell flow (DBCF), density of dermal capillaries (DDC), epidermal thickness (ET), and epidermal cell size (ECS). DBCF was counted at 63.11 ± 4.14 cells/min in OW-group and at 51.06 ± 3.84 cells/min in CO-group (P < 0.05). DDC was reduced in OW-group (4.91 ± 0.39 capillaries/mm(2)) compared to the controls (6.02 ± 0.64 capillaries/mm(2), P < 0.05). Histometric evaluation of ET reveals thickening in OW-group compared to the CO-group (54.79 ± 4.25 µm versus 44.03 ± 3.11 µm, P < 0.05). ECS differed significantly (P < 0.05) in OW-group (821.3 ± 42.02 µm(2)) compared to the controls (772.6 ± 34.79 µm(2)). Inverse correlation of dermal capillary density and overweight point to reduced total tissue perfusion while positive related blood cell flow reveals vasodilatation. Increase of both ET and cell size indicates remodeling of cutaneous histomorphology, maybe as an early stage of adiposity-related skin condition.

Local burn versus local cold induced acute effects on in vivo microcirculation and histomorphology of the human skin.

BACKGROUND: The impact of burns and colds on human skin microcirculation and histomorphology has not been compared as yet. Reflectance confocal microscopy (RCM) enables in vivo insight in human skin on cellular and subcellular levels. We evaluated analogies and differences of thermal injuries on microcirculation and histomorphology in vivo using RCM. METHODS: Local superficial burn (6 female, 4 male; aged 28.4 ± 2.9 years, burn group) versus superficial cold (4 female, 6 male; aged 30.4 ± 5.2 years, cold group) was induced on the dorsum of the hand in an experimental immersion hand model. In vivo RCM was performed prior (control), immediately (t1) and 15 minutes (t2) following thermal injury to evaluate: Individual blood cell flow (IBCF), functional capillary density (FCD), epidermal thickness (ET), and granular cell size (GCS). RESULTS: In the burn group, IBCF was increased at t1 (78.02 ± 2.60/min) and remained elevated at t2 (84.16 ± 3.04/min). In the cold group, IBCF decreased at t1 (12.62 ± 2.12 min) and increased at t2 (74.24 ± 3.14/min, P < 0.05) compared to the controls (58.23 ± 3.21/min). FCD was 6.74 ± 0.52/mm(2) in controls and increased at both t1 (7.82 ± 0.72/mm(2)) and t2 (8.02 ± 0.81/mm(2)) in the burn group. In the cold group, FCD decreased at t1 (2.60 ± 0.42/mm(2)) and increased at t2 (7.92 ± 0.44/mm(2), P < 0.05). ET increased at both t1 (43.12 ± 4.08 µm, P > 0.05) and t2 (47.26 ± 4.72 µm, P < 0.05) in the burn group. In the cold group, ET decreased at t1 (39.92 ± 3.14 µm, P > 0.05) and increased at t2 (44.72 ± 4.06 µm, P < 0.05) compared to the controls (41.26 ± 3.82 µm). Control GCS was 726.9 ± 59.4 µm(2) and increased at both t1 (739.8 ± 69.8 µm(2), P > 0.05) and t2 (762.6 ± 71.4 µm(2), P < 0.05) in the burn group. In the cold group, GCS decreased at t1 (712.4 ± 53.8 µm(2), P > 0.05) and increased at t2 (742.6 ± 64.8 µm(2), P < 0.05). CONCLUSIONS: Superficial burn induces more cellular destruction and cold leads to huge fluctuation in tissue perfusion, however, with moderate impact on histomorphology. The effect on dermal capillaries suggests a selective neural control and cold injuries might down-regulate this system, much more than burns can activate it.

Percutaneous collagen induction therapy: an alternative treatment for burn scars.

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

Insight in microcirculation and histomorphology during burn shock treatment using in vivo confocal-laser-scanning microscopy.

PURPOSE: Microcirculatory disturbances are well known during shock; however, the accompanied histomorphological alterations are widely unknown. We used high resolution confocal-laser-scanning microscopy for the evaluation of microcirculation and histomorphology during Burn Shock treatment. METHODS: Confocal-laser-scanning microscopy was performed in 10 burn shock patients (4 women, 6 men; aged 40.6 +/- 11.4 years, burn extent >20% body surface area) initially and 24 hours after shock resuscitation. Ten matched hemodynamic stable burn intensive care unit patients served as controls. The following parameters were evaluated: quantitative blood cell flow, cell size of the granular layer, basal layer thickness, and epidermal thickness. RESULTS: Quantitative blood cell flow in controls was 62.45 +/- 3.39 cells per minute. Burn shock significantly reduced blood cell flow to 37.27 +/- 3.64 cells per minute; fluid resuscitation effectively restored baseline blood flow (65.18 +/- 3.76 cells per minute) after 24 hours. Granular cell size was 793.61 +/- 41.58 microm(2) in controls vs 644.27 +/- 42.96 microm(2) during burn shock. Post resuscitation granular cell size measured 932.74 +/- 38.83 microm(2). Basal layer thickness was 14.84 +/- 0.59 microm in controls, 13.26 +/- 0.54 microm in burn patients at admission and before resuscitation, and 17.50 +/- 0.46 microm after resuscitation. Epidermal thickness in control patients was 49.60 +/- 2.36 microm, 37.83 +/- 2.47 microm in burn patients at admission and 69.50 +/- 3.18 microm after resuscitation. CONCLUSIONS: Confocal-laser-scanning microscopy provides a noninvasive tool for simultaneous evaluation of microcirculation and tissue histomorphology. It may help to assess the adequacy of and response to resuscitation of burn patients early after trauma.

Morbidity and recurrence after completion lymph node dissection following sentinel lymph node biopsy in cutaneous malignant melanoma.

OBJECTIVE: To assess the nature and rates of complications and recurrences after completion lymph node dissection (CLND) following positive sentinel lymph node biopsy (SLNB) in melanoma patients. SUMMARY BACKGROUND DATA: In contrast to SLNB, CLND is associated with considerable morbidity. CLND delays nodal recurrence, thereby prolonging disease-free survival (DFS), but not overall melanoma-specific survival. Elaborate studies on morbidity and recurrence rates after CLND are scarce. Therefore, many controversies concerning extent and nature of CLND exist. METHODS: We conducted a retrospective study on 100 melanoma patients, on whom we performed CLND between October 1999 and December 2005. The median observation period was 38.8 months. RESULTS: We performed a total of 102 CLNDs, [46.1% axillary (47/102), 42.2% groin (43/102), 11.8% neck (12/102)]. Groin dissection (GD) and axillary dissection (AD) led to comparable morbidity (47.6% and 46.8%), but complications were more severe in GD, mandating additional surgery in 25.6% (11/43), versus 8.5% (4/47) in AD. Of the GD patients, 18.5% (8/43) were readmitted for complications compared with 10.4% (5/47) of AD patients. Only 8.3% (1/12) of ND patients suffered complications, mandating neither readmittance nor further surgery. During the median observation period, 65 (65%) of these patients showed DFS, and 35 (35%) exhibited recurrences after a median DFS of 12.5 months. Of the recurrences, 31.4% were nodal, 42.9% distant, and 25.7% local/in-transit. Of our AD patients, 28.3% suffered recurrences (13/46), as did 33.3% of the GD (14/42) and 66.7% of the ND patients (8/12). CONCLUSIONS: CLND is fraught with considerable morbidity. Local control of the dissected nodal basins was achieved with a modified radical approach in ADs (levels I + II only) and, to a lesser extent, GDs, but not in NDs. Clinical trials are necessary to establish guidelines on the extent of lymphatic dissection.

Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity.

BACKGROUND: Skin laxity, rhytides, and photoaging are generally treated by ablative procedures that injure or destroy the epidermis and its basement membrane, at least in the beginning, and subsequently lead to fibrosis of the papillary dermis. The ideal treatment would be to preserve the epidermis and promote normal collagen and elastin formation in the dermis. Percutaneous collagen induction takes us closer to this ideal. METHODS: The authors performed a retrospective analysis of 480 patients in South Africa and Germany with fine wrinkles, lax skin, scarring, and stretch marks treated with percutaneous collagen induction using the Medical Roll-CIT to produce tighter, smoother skin. Most patients had only one treatment, but some have had as many as four treatments. Patients were prepared with topical vitamin A and C cosmetic creams for a minimum of 4 weeks preoperatively. RESULTS: On average, patients in Germany rated their improvement between 60 and 80 percent better than before the treatment. Histologic examination was carried out in 20 patients and showed a considerable increase in collagen and elastin deposition at 6 months postoperatively. The epidermis demonstrated 40 percent thickening of stratum spinosum and normal rete ridges at 1 year postoperatively. CONCLUSIONS: Percutaneous collagen induction was started in 1997 and has proved to be a simple and fast method for safely treating wrinkles and scars. As opposed to ablative laser treatments, the epidermis remains intact and is not damaged. For this reason, the procedure can be repeated safely and is also suited to regions where laser treatments and deep peels cannot be performed.

Posttraumatic lipoma: fact or fiction?

BACKGROUND: Both trauma and lipomas are a common occurrence in surgical practice. Lipomas are usually benign adipose tumors with as-yet unexplained pathogenesis and etiology. A link between soft tissue trauma and the formation of lipomas has been described, with the latter being named posttraumatic lipomas. METHODS: Twenty-three cases of posttraumatic lipomas in 19 patients treated at our institution between August 2001 and January 2005 were reviewed with regard to medical history, magnetic resonance imaging findings, intraoperative findings, clinical chemistry, and histology. RESULTS: The mean age of the patients was 50.0 years (+/-15.5). The average time between soft tissue trauma and lipoma formation was 2.6 years (range, 0.5-6.0 years). Sixteen of the 19 patients reported extensive and slowly resolving hematoma formation after the traumatic event. Nine of 23 lipomas were found on the upper extremities, 3 on the lower extremities, 9 on the trunk, and 2 on the face. All tumors were located epifascially. Twenty-two lipomas were removed by simple excision and, in one case, aspiration lipectomy was performed. Pathology demonstrated capsulated and noncapsulated benign adipose tumors in 23 cases. The average body mass index, amounted to 30 kg/m(2) (+/-7.6 kg/m(2)). Seven patients without known bleeding disorders presented with an elevated partial thromboplastin time. CONCLUSIONS: The pathogenetic link between soft tissue trauma and the formation of posttraumatic lipomas is still controversially discussed. There are 2 potential explanations to correlate soft tissue trauma and adipose tissue tumor growth. The first is the formation of so-called posttraumatic pseudolipomas by prolapsing adipose tissue through fascia resulting from direct impact. A second possibility points toward lipoma formation as a result of preadipocyte differentiation and proliferation mediated by cytokine release following soft tissue trauma and hematoma formation.