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Burn Scar ManagementBurn Scar Management
Michael Serghiou, OTR Michael Serghiou, OTR
Shriners Hospitals for ChildrenShriners Hospitals for [email protected]@shrinenet.org
Scar ManagementScar Management
Scar: The fibrous tissue replacing normal tissue destroyed by injury or disease.
Hypertrophic Scar: Overgrowth of dermal contents that remains with the boundaries of the wound.
Keloid: A scar that extends beyond the boundaries of the original wound.
Hypertrophic ScarHypertrophic Scar
HTS begins to appear 6 weeks to 3 months post burn.
Maximum height of scar is seen 3 to 9 moths post burn.
Average time for scar maturation is approx. 1 year; it can range from 6 months to 2 years.
Factors Contributing to Factors Contributing to HTS FormationHTS Formation
Prolonged healing time
Repeated harvesting of donor sites
Race Age
Location Depth Tension Gender
A rating scale for assessing scar maturation.
The scale rates 4 burn scar characteristics:
-Pigmentation -Vascularity -Pliability -Height
Vancouver Scar Vancouver Scar AssessmentAssessment
Pressure TherapyPressure Therapy
Effects of pressure through vascular support garments first reported by Dr. Silverstein in 1971
Effect of pressure through splinting first reported by Dr. Larson
Although mechanism of pressure effects on scars has not been identified, effects of pressure on hypertrophic scars are well documented
Pressure therapy i.e. garments
Inserts
Massage
Modalities
Treatment of Treatment of Hypertrophic ScarHypertrophic Scar
Accelerates scar maturation
Flattens the scar
Increases pliability
Decreases blood flow
Realigns collagen bundles
Decreases edema
Decreases the rate of collagen synthesis/lysis
Effects of Compression Effects of Compression TherapyTherapy
Should begin within 2 weeks of wound closure
Must be constant; 22-23 hours a day
Pressure is required until the scar is mature
Timing of Pressure Timing of Pressure ApplicationApplication
Pre-fabricated or custom made
Need to be worn 22 hrs. a day
Average garment pressure, 25-30 mmHg
10mm Hg minimum for hand scar remodeling
>40mm Hg destructive
Pressure GarmentsPressure Garments
Indications for PressureIndications for Pressure
If the wound heals in <10 days, no prophylactic pressure is required
If the wound takes 10 – 14 days to heal, prophylactic pressure is recommended for non-Caucasian patients
If the wound takes 14 – 21 days to heal, prophylactic pressure is recommended for patients of all ages and races.
If the wound takes more than 21 days to heal, prophylactic pressure is mandatory.
Methods of CompressionMethods of Compression
Elastic Bandages
Self-Adherent Elastic Wrap
Elastic Tubular Support Bandage
Ready-Made Garments
Commercial Products
Custom-Made Garments
ADVANTAGESADVANTAGES
Early pressure
Can be applied over burn dressings
Inexpensive
Recyclable
Provides adequate pressure
DISADVANTAGEDISADVANTAGESS
Easy to apply incorrectly
Needs to be reapplied every 4-6 hours due to slippage
Requires frequent inspection
Elastic BandagesElastic Bandages
ADVANTAGESADVANTAGESGood for only pressure
on hands and feet, esp. under 2
Controls edema
Provides vascular support
Minimizes early scar tissue formation
Can be applied over dressings
Can be applied to fragile tissue
Easily accommodates webspaces and inserts
DISADVANTAGEDISADVANTAGESS
Requires some skills and knowledge in application
Cannot usually be reused
Expensive
Fingers/toes may “stick” together
Self-Adherent Elastic Self-Adherent Elastic WrapWrap
ADVANTAGESADVANTAGES
Inexpensive
Can be an effective method of achieving pressure
May be more accepted by the patient
DISADVANTAGEDISADVANTAGESS
Pressure supplied may be adequate for optional scar control without inserts.
Commercially Available Commercially Available ProductsProducts
ADVANTAGESADVANTAGES
Used on healed burns that cannot tolerate shearing forces
Interim pressure device
Comfortable
Can be placed over dressing
Controls edema
DISADVANTAGESDISADVANTAGES
Limited to cylindrical body parts
Improper application or mess can cause skin breakdown or edema
Some patients are allergic to elastic
Same diameter throughout atapered extremity
Elastic Tubular Support Elastic Tubular Support BandageBandage
ADVANTAGESADVANTAGES
Less costly than custom garments
Available for immediate fit
Can be used as a means for definitive pressure or on an interim basis
DISADVANTAGESDISADVANTAGES
Budget and storage imitations
May require adjournments
Ready-Made Elastic Ready-Made Elastic Pressure GarmentsPressure Garments
ADVANTAGESADVANTAGES
Can be fit for every part of the body
Customized closures, materials, styles
Multiple Options
Variety of Colors
Multiple companies
DISADVANTAGESDISADVANTAGESExpensive
Not all insurances reimburse
Fit is dependent on accurate measurements
Difficult to don/doff
May cause skin breakdown
May retard/alter bone growth
Weight gain/loss should be stable
Custom-Made ElasticCustom-Made ElasticPressure GarmentsPressure Garments
Proper Fit of Custom Proper Fit of Custom GarmentsGarments
Extend garment 2 – 3” beyond scar Avoid stopping garment over muscle belly or joint Anchor garment so it does not slip Avoid zippers when possible If zippers are needed, avoid placing them over
scar and bony prominences Initial fitting should not be done by the patient at
home The garment should be tight enough that it is
difficult to pull away from the skin but does not compromise neurovascular status. Average 25 – 30 mm Hg.
Avoid wrinkles
Solutions for Wound Solutions for Wound Healing While Using Healing While Using
PressurePressure Foam donut so pressure spans the
wound site Soft fabric lining Wearing a soft interface under the
garment i.e., t-shirts, pantyhose Maintain good hygiene
Specific Complications of Specific Complications of Pressure TherapyPressure Therapy
Scar maceration Friction Tight fit over joints Hygiene
Materials used to accelerate the scar maturation process by applying added pressure on anatomical surfaces where appropriate pressure is difficult to achieve.
InsertsInserts
InsertsInserts Used under pressure garments where pressure is
not adequate to control or reduce scar hypertrophy
Indications: Area of concavity Active scar Scar bands
Contraindications Sensitive skin Blisters Open Wound Allergies to insert products Maceration of scar
A polymer based on the element silicone.
Used over joints, older scars, convex/concave surfaces for improving pliability of scar tissue.
Theoretically, does not require pressure to be of benefit in increasing pliability of scar tissue.
SiliconeSilicone
A closed cell gray liquid which is mixed with a catalyst to form a rubber textured insert.
Best used for facial inserts, web spaces, large flat body surfaces, breast cleavage and thick rigid scars.
Silastic ElastomerSilastic Elastomer
A white silicone elastomer putty base which is mixed with a catalyst to create a firm, rubbery closed cell insert.
Best worked in small to medium sized inserts.
Facial scars, ear canals, web spaces, “gutter” splint for volar finger contractures, palm, buttock crease, breast cleavage, thick rigid scars.
Otoform KOtoform KTM
An open cell tan colored liquid based silicone elastomer mixed with a catalyst to form a foam.
Best used for inserts in the palm, axilla, breast cleavage, buttock crease and over joints.
Prosthetic FoamProsthetic Foam
Cushioned strapping material
Good to use for fragile or sensitive webspaces
VelfoamVelfoamTM or Betapile or BetapileTM
A flesh colored closed cell foam
Best used on large flat body surfaces and for shoe inserts.
PlastizotePlastizoteTM
UVEX™ or W-clear™
An alternative form of pressure when adequate pressure cannot be achieved on the nasolabial folds, under the lip, and under and between breasts.
An alternative form of pressure when compliance with traditional pressure garments is a problem.
Hi Temperature PlasticHi Temperature Plastic
Massage is an effective modality for the maintenance of mobility, freeing restrictive scars, improving circulation and alleviating itching.
Should be performed a minimum of 2 times a day using a non-water based lotion or cream.
Scar MassageScar Massage
Types of Scar MassageTypes of Scar Massage
Gentle massage is performed to newly healed or recently grafted skin. Avoid massage over open areas.
Frictional/kneading massage is performed over healed and durable scar tissue, particularly areas of adherence and over bony prominences. Rotary, parallel and perpendicular motions are used.
Myofascial release techniques useful for scar adhesions.