Formation of hypertrophic scars: evolution and susceptibility.

Formation of hypertrophic scars is a common complication of wound healing, and at present little is known about the incidence and risk factors. Our aim was to analyse the incidence, progression, and regression of postoperative hypertrophic scars over time and to identify risk factors of hypertrophic scars. Patients who had had bilateral reduction mammoplasty or median sternotomy incision were included in the study. All patients were examined at 3 and 12 months postoperatively. We recorded: height, weight, allergy status, smoking status, skin type, tanning, and shape of the scar 3 and 12 months postoperatively. Of the 204 patients who were included, 122 (60%) developed a hypertrophic scar within 12 months of operation. Of these patients, 117 (96%) developed a hypertrophic scar within 3 months of operation. Twelve months postoperatively, 66/204 patients (32%) had a hypertrophic scar. In 31 of the 66 of the patients with a hypertrophic scar 3 months postoperatively (47%), the hypertrophic scar(s) regressed after 3 and 12 months. Smoking and age were associated with formation of hypertrophic scars. In conclusion, 60% of patients developed hypertrophic scars postoperatively, typically during the first three months. Most hypertrophic scars that are present after three months are still hypertrophic after 12 months. Young, non-smoking patients are more susceptible to formation of hypertrophic scars.

Macrophages in skin injury and repair.

After recruitment to the wound bed, monocytes differentiate into macrophages. Macrophages play a central role in all stages of wound healing and orchestrate the wound healing process. Their functional phenotype is dependent on the wound microenvironment, which changes during healing, hereby altering macrophage phenotype. During the early and short inflammatory phase macrophages exert pro-inflammatory functions like antigen-presenting, phagocytosis and the production of inflammatory cytokines and growth factors that facilitate the wound healing process. As such, the phenotype of wound macrophages in this phase is probably the classically activated or the so-called M1 phenotype. During the proliferative phase, macrophages stimulate proliferation of connective, endothelial and epithelial tissue directly and indirectly. Especially fibroblasts, keratinocytes and endothelial cells are stimulated by macrophages during this phase to induce and complete ECM formation, reepithelialization and neovascularization. Subsequently, macrophages can change the composition of the ECM both during angiogenesis and in the remodelling phase by release of degrading enzymes and by synthesizing ECM molecules. This suggests an important role for alternatively activated macrophages in this phase of wound healing. Pathological functioning of macrophages in the wound healing process can result in derailed wound healing, like the formation of ulcers, chronic wounds, hypertrophic scars and keloids. However, the exact role of macrophages in these processes is still incompletely understood. For treating wound repair disorders more should be elucidated on the role of macrophages in these conditions, especially their functional phenotype, to find more therapeutic opportunities. This review summarizes macrophage function in skin injury repair, thereby providing more insight in macrophage function in wound healing and possible interventions in this process.

Therapeutic hotline: An alternative adjuvant treatment after ear keloid excision using a custom-made methyl methacrylate stent.

The efficacy of most pressure devices developed for treatment of ear keloids is limited by the insufficient control of the applied pressure, sometimes causing pain and repeated bleeding with a subsequently increased risk of infections and cosmetic problems. The present study aims to describe the efficacy of the custom-made methyl methacrylate stent in patients that were surgically treated for ear keloids and afterward underwent pressure therapy. The recurrence rate of the ear keloids was evaluated after at least 12 months. Adjuvant treatment with the methyl methacrylate stent resulted in an 83% success rate in our experience with 23 patients that completed the intended therapeutic duration of 18 months. No cases of severe complications were seen during or after the treatment. Furthermore, all the items of the Patient and Observer Scar Assessment Scale resulted in a statistically significant improvement of the scar (p < 0.05). Postoperative pressure therapy with the custom-made methyl methacrylate stent seems efficacious, safe, and is usable for keloids of both the helix and the earlobe.

Evaluation of a technical skills training program in surgical residents.

BACKGROUND: In recent years, the interest for training programs to teach technical skills has enormously grown. The aim of this study was to evaluate the influence of surgical training on the technical skills of surgical residents. METHODS: Forty residents participated in a training program consisting of 1 training day followed by 6 weeks of autonomous training. Participants were asked to rate their confidence with the open and laparoscopic knot-tying technique by a visual analog scale before and after the training day (post), and after the period of autonomous training (follow-up). Objective assessment was performed according to the Objective Structured Assessment of Technical Skills. RESULTS: Mean (+ or - standard deviation) baseline confidence of participants with the open technique was 68.2 + or - 14.5, increased post to 76.4 + or - 13.2 (P < 0.001), and was 77.8 + or - 9.6 at follow-up (not significant). Mean objective score was post increased from 19.2 + or - 3.5 to 21.4 + or - 3.4 (P = 0.001) but decreased to 20.2 + or - 4.1 at follow-up. For the laparoscopic technique, mean confidence increased from 20.6 + or - 14.4 to 47.2 + or - 19.0 post, and 62.7 + or - 14.0 at follow-up (P < 0.001 for both). Mean objective score was post increased from 22.1 + or - 8.2 to 34.9 + or - 6.4 (P = 0.001), which did not change at follow-up (33.3 + or - 7.5). CONCLUSIONS: In this study, confidence in the open knot-tying technique first increased after the initial training day and then stabilized, whereas the objective level initially improved, but returned to baseline level at follow-up. Regarding the laparoscopic technique, a significant increase of confidence after both the training and after 6 weeks of follow-up was observed. Improvement of the objective level after the training day was maintained at follow-up.

Accuracy and reproducibility of quantitation of left ventricular function by real-time three-dimensional echocardiography versus cardiac magnetic resonance.

The aim of this study was to investigate the accuracy and reproducibility of the quantification of left ventricular (LV) function by real-time 3-dimensional echocardiography (RT3DE) using current state-of-the-art hardware and software. Compared with cardiac magnetic resonance (CMR), previous generations of hardware and software for RT3DE significantly underestimated LV volumes partly because of inherent factors such as limited spatial and temporal resolution. Also, RT3DE volumes were compared with short-axis CMR data, whereas a combined short-axis and long-axis analysis is known to be superior. Twenty-four subjects (mean age 51 +/- 12 years, 17 men) in sinus rhythm and with good to excellent 2-dimensional image quality underwent RT3DE and CMR within 1 day. The acquisition of RT3DE data was done with current state-of-the-art hardware and software. Two blinded experts performed off-line LV volume analysis. Global LV volumes were determined from semiautomated border detection on the basis of endocardial speckle tracking with biplane projections using QLAB version 6.0. Volumes derived by magnetic resonance imaging were quantified from combined short-axis and long-axis series. The volume-rate on RT3DE was 33 +/- 8 Hz (range 19 to 42). Excellent correlations were found (R2 > or = 0.97) between CMR and RT3DE for global LV end-diastolic volume, LV end-systolic volume, the LV ejection fraction, and LV phase volumes (24 phases/cardiac cycle). Bland-Altman analyses showed mean differences of -7.1 ml, -4.2 ml, 0.2%, and -5.8 ml and 95% limits of agreement of +/-19.7 ml, +/-8.3 ml, +/-6.2%, and +/-15.4 ml for global LV end-diastolic volume, LV end-systolic volume, the LV ejection fraction, and LV phase volumes, respectively. Interobserver variability was 5.2% for global LV end-diastolic volume, 6.4% for LV end-systolic volume, and 7.6% for the LV ejection fraction. In conclusion, in patients with good acoustic windows, RT3DE using state-of-the-art technology provides accurate and reproducible measurements of global LV volumes, LV volume changes over time, and the LV ejection fraction.