Burn Scar ManagementBurn Scar Management

Michael Serghiou, OTR Michael Serghiou, OTR

Shriners Hospitals for ChildrenShriners Hospitals for Childrenmserghiou@shrinenet.orgmserghiou@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.

Red

Raised

Rigid

Pale

Planar

Pliable

Immature vs. MatureImmature vs. Mature

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

PressurePressureTherapyTherapy

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

InsertsInserts

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

ModalitiesModalities

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.