Advertisement

Updated Scar Management Practical Guidelines: Non-invasive and invasive measures

Open AccessPublished:May 13, 2014DOI:https://doi.org/10.1016/j.bjps.2014.04.011

      Summary

      Hypertrophic scars and keloids can be aesthetically displeasing and lead to severe psychosocial impairment. Many invasive and non-invasive options are available for the plastic (and any other) surgeon both to prevent and to treat abnormal scar formation. Recently, an updated set of practical evidence-based guidelines for the management of hypertrophic scars and keloids was developed by an international group of 24 experts from a wide range of specialities.
      An initial set of strategies to minimize the risk of scar formation is applicable to all types of scars and is indicated before, during and immediately after surgery. In addition to optimal surgical management, this includes measures to reduce skin tension, and to provide taping, hydration and ultraviolet (UV) protection of the early scar tissue. Silicone sheeting or gel is universally considered as the first-line prophylactic and treatment option for hypertrophic scars and keloids. The efficacy and safety of this gold-standard, non-invasive therapy has been demonstrated in many clinical studies. Other (more specialized) scar treatment options are available for high-risk patients and/or scars. Pressure garments may be indicated for more widespread scarring, especially after burns. At a later stage, more invasive or surgical procedures may be necessary for the correction of permanent unaesthetic scars and can be combined with adjuvant measures to achieve optimal outcomes.
      The choice of scar management measures for a particular patient should be based on the newly updated evidence-based recommendations taking individual patient and wound characteristics into consideration.

      Keywords

      Introduction

      Plastic surgeons play an important role in both the prevention and the treatment of unaesthetic scar formation following operations, trauma, burns or infections. Estimates indicate that each year around 100 million people in the developed world acquire scars following elective surgery and surgery for trauma.
      • Sund B.
      Of these, approximately 15% have excessive or unaesthetic scars.
      • Sund B.
      Scarring can also be a major source of dissatisfaction after a purely cosmetic surgical procedure such as aesthetic breast surgery.
      • Abu-Nab Z.
      • Grunfeld E.A.
      Satisfaction with outcome and attitudes towards scarring among women undergoing breast reconstructive surgery.
      Furthermore, a recent survey indicated that 91% of patients who underwent a routine surgical procedure would value any improvement in scarring.
      • Young V.L.
      • Hutchison J.
      Insights into patient and clinician concerns about scar appearance: semiquantitative structured surveys.
      Excessive scarring can have unpleasant physical, aesthetic, psychological and social consequences. Physical symptoms may include itching, stiffness, scar contractures, tenderness and pain.
      • Van Loey N.E.
      • Bremer M.
      • Faber A.W.
      • Middelkoop E.
      • Nieuwenhuis M.K.
      Itching following burns: epidemiology and predictors.
      • Bell L.
      • McAdams T.
      • Morgan R.
      • et al.
      Pruritus in burns: a descriptive study.
      The psychosocial effects of unaesthetic scarring include diminished self-esteem, stigmatization, disruption of daily activities, anxiety and depression.
      • Bell L.
      • McAdams T.
      • Morgan R.
      • et al.
      Pruritus in burns: a descriptive study.
      • Robert R.
      • Meyer W.
      • Bishop S.
      • Rosenberg L.
      • Murphy L.
      • Blakeney P.
      Disfiguring burn scars and adolescent self-esteem.
      • Bakker A.
      • Maertens K.J.
      • Van Son M.J.
      • Van Loey N.E.
      Psychological consequences of pediatric burns from a child and family perspective: a review of the empirical literature.
      There is a wide spectrum of cutaneous scarring ranging from mature linear scars to abnormal raised and widespread hypertrophic scars and major keloids. Hypertrophic scars stay within the boundaries of the original lesion and may spontaneously regress with time.
      • Juckett G.
      • Hartman-Adams H.
      Management of keloids and hypertrophic scars.
      • Alster T.S.
      • Tanzi E.L.
      Hypertrophic scars and keloids: etiology and management.
      Hypertrophic scars can be classified as linear or widespread with the former usually resulting from surgery or trauma, and the latter from burn injuries or extensive soft tissue trauma and/or infections. Keloids are excessive scars that grow beyond the boundaries of the original wound. They do not spontaneously regress and frequently recur after being excised.
      • Juckett G.
      • Hartman-Adams H.
      Management of keloids and hypertrophic scars.
      • Alster T.S.
      • Tanzi E.L.
      Hypertrophic scars and keloids: etiology and management.
      Keloids can be differentiated into minor or major with the latter being large, raised (>0.5 cm) scars that may be painful, pruritic and protruding. Histologically, there are additional differences between hypertrophic scars and keloids. For example, hypertrophic scars primarily contain well-organized type III collagen, whereas keloids contain disorganized type I and III collagen bundles.
      • Gauglitz G.G.
      • Korting H.C.
      • Pavicic T.
      • Ruzicka T.
      • Jeschke M.G.
      Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies.
      Although existing strategies for the management of hypertrophic scars and keloids are broadly similar, these histological differences suggest that, in the future, therapeutic approaches could be developed which are specifically tailored for these different types of scars.
      Currently, a wide variety of different scar management measures has been advocated both to prevent and to treat unaesthetic or excessive scar formation (Table 1). Recently, an international, multidisciplinary group of 24 experts developed a set of practical, evidence-based guidelines for the management of linear, hypertrophic and keloid scars which could be useful for surgeons, dermatologists, general practitioners and other physicians involved in the prevention and the treatment of scars.
      The panel developed these guidelines after reviewing new clinical and evidence-based data on scar management that have been reported since the publication of a previous set of guidelines by the International Advisory Panel on Scar Management in 2002.
      • Mustoe T.A.
      • Cooter R.D.
      • Gold M.H.
      • et al.
      International clinical recommendations on scar management.
      This review article is intended to provide surgeons and other physicians with an overview of the most relevant information from the updated guidelines. Whilst there are many published review articles on treatment approaches for hypertrophic scars and keloids, the current article is different in that it presents these new guidelines and discusses the most relevant aspects for surgeons. In particular, specific surgical techniques that are of benefit in both the prevention and treatment of scars are discussed.
      Table 1Overview of non-invasive and invasive treatments for scars.
      Non-invasive treatmentInvasive treatment
      • Well-accepted, evidence-based, and recommended treatments
      • Pressure/compression therapy
      • Intralesional corticosteroid injection
      • Silicone sheets and gels
      • Surgical scar correction
      • Investigational treatments and those with less supporting evidence
      • Oils, lotions and creams
      • Laser therapy
      • Massage therapy
      • Radiotherapy
      • Static and dynamic splints
      • Cryosurgery
      • Psychological counselling
      • Intralesional injection of other products
      • Antihistamine drugs
      The literature cited in this article includes the most relevant publications that were used to develop the recent evidence-based guidelines.
      In addition, PubMed was searched using terms including ‘scar prevention’, ‘scar treatment’, ‘hypertrophic scar’, ‘keloid’, ‘silicone’, ‘intralesional corticosteroid’, ‘pressure therapy’, ‘laser therapy’, ‘radiotherapy’ and ‘cryotherapy’ to identify additional studies and review articles on scar management that are of particular relevance to surgeons. Whilst this article is not a systematic literature review of treatment options for scar management, we do refer interested readers to our Scar Management Practical Guidelines book for more extensive lists of supporting references.

      Scar Management Practical Guidelines

      A summary of the updated guidelines on the practical management of linear scars, widespread hypertrophic scars and keloids is shown in Figure 1. The recommendations are discussed more in detail below with an emphasis both on universal preventive strategies applicable to every scar and on more invasive and specialized treatment of excessive scar formation.
      Figure thumbnail gr1
      Figure 1Practical guidelines for the management of linear (A), widespread hypertrophic (B) and keloid scars (C). Reproduced with the permission of Maca-Cloetens from ‘Scar Management Practical Guidelines’.

       Scar prevention

      Following surgery or trauma, the first priority should always be the prevention of abnormal scar formation. In the case of an operative procedure, scar prevention measures should be initiated during or even before surgery. In elective surgery, the position and the length of the incision line should be carefully considered and if possible should always be parallel to the relaxed skin tension lines. Excessive scar formation can also be prevented by a wide range of measures that reduce inflammation and provide rapid wound closure such as early debridement of dead tissue, reducing the risk of infection through rinsing and disinfection, and optimal dressings providing moist wound healing and/or early surgical wound coverage.
      • Bloemen M.C.
      • van der Veer W.M.
      • Ulrich M.M.
      • van Zuijlen P.P.
      • Niessen F.B.
      • Middelkoop E.
      Prevention and curative management of hypertrophic scar formation.
      During the operation, the surgeon should also ensure that excessive tension on the wound edges is avoided.
      The three major components of scar prevention immediately after wound closure are as follows: (1) tension relief, (2) hydration/taping/occlusion, and (3) pressure garments. Wounds which have greater tension on their edges, e.g., those perpendicular to Langer's lines, and those in the deltoid and sternal regions have a higher risk of developing excessive scarring,
      • Bayat A.
      • McGrouther D.A.
      • Ferguson M.W.
      Skin scarring.
      which can be reduced by the use of post-surgical taping for a 3-month period.
      • Reiffel R.S.
      Prevention of hypertrophic scars by long-term paper tape application.
      More recently, Gurtner et al. investigated the role of mechanical forces on scar formation and the effectiveness of a stress-shielding device in reducing mechanical stress and preventing excessive scar formation.
      • Gurtner G.C.
      • Dauskardt R.H.
      • Wong V.W.
      • et al.
      Improving cutaneous scar formation by controlling the mechanical environment: large animal and phase I studies.
      The device was made from silicone polymer sheets and pressure-sensitive adhesive and was applied to wounds immediately after skin closure. Studies in both animals and humans demonstrated that offloading mechanical forces with the stress-shielding device significantly reduced scar formation.
      • Gurtner G.C.
      • Dauskardt R.H.
      • Wong V.W.
      • et al.
      Improving cutaneous scar formation by controlling the mechanical environment: large animal and phase I studies.
      In addition, botulinum toxin A decreases tensile forces on post-surgical scars and results in significant improvements in the cosmetic appearances of scars compared with placebo injections.
      • Gassner H.G.
      • Sherris D.A.
      • Otley C.C.
      Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates.
      Moisturizing emollient and humectant creams and moisture-retentive dressings such as silicone sheets and fluid silicone gel have been shown to be beneficial for itching scars, and can also reduce the size and pain or discomfort associated with scars as well as improving their appearance. Studies have shown that, after wound healing, water still evaporates more rapidly through scar tissue and may take over a year to recover to pre-wound levels.
      • Suetake T.
      • Sasai S.
      • Zhen Y.X.
      • Ohi T.
      • Tagami H.
      Functional analyses of the stratum corneum in scars. Sequential studies after injury and comparison among keloids, hypertrophic scars, and atrophic scars.
      Silicone products may help to prevent excessive scar formation by restoring the water barrier through occlusion and hydration of the stratum corneum and need to be used as soon as the wound/suture is healed.
      • Mustoe T.A.
      Evolution of silicone therapy and mechanism of action in scar management.
      In patients with more widespread scars, such as after burns, pressure garments may also be used prophylactically in wounds that take >2–3 weeks to heal spontaneously with the device being applied as soon as the wound is closed and the patient can tolerate the pressure.
      • Engrav L.H.
      • Heimbach D.M.
      • Rivara F.P.
      • et al.
      12-Year within-wound study of the effectiveness of custom pressure garment therapy.
      Other strategies are currently under investigation for the prevention of scarring such as altering the levels of certain inflammatory cytokines such as transforming growth factor (TGF)-β3. This cytokine reduces connective tissue deposition and is mainly produced towards the end of the wound healing process.
      • Gauglitz G.G.
      • Korting H.C.
      • Pavicic T.
      • Ruzicka T.
      • Jeschke M.G.
      Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies.
      Initial clinical studies of avotermin, a human recombinant TGF-β3, have indicated that this treatment may reduce scar formation following full-thickness skin incisions.
      • Ferguson M.W.
      • Duncan J.
      • Bond J.
      • et al.
      Prophylactic administration of avotermin for improvement of skin scarring: three double-blind, placebo-controlled, phase I/II studies.
      Additional general preventive measures for all types of scars recommended in the latest guidelines (Figure 1(A–C)) include avoiding exposure to sunlight and the continued use of sunscreens with a high to maximum sun protection factor (>50) until the scar has matured.
      Randomized studies in animals and humans have shown that ultraviolet radiation increases scar pigmentation and worsens their clinical appearance.
      • Haedersdal M.
      • Bech-Thomsen N.
      • Poulsen T.
      • Wulf H.C.
      Ultraviolet exposure influences laser-induced wounds, scars, and hyperpigmentation: a murine study.
      • Due E.
      • Rossen K.
      • Sorensen L.T.
      • Kliem A.
      • Karlsmark T.
      • Haedersdal M.
      Effect of UV irradiation on cutaneous cicatrices: a randomized, controlled trial with clinical, skin reflectance, histological, immunohistochemical and biochemical evaluations.
      As a general rule, scars should always be re-evaluated 4–8 weeks after surgery to determine whether additional scar management interventions are required or whether preventive therapy can be terminated.

       Linear hypertrophic scars

      The guidelines recommend that the preventive therapy as described above is continued or intensified in patients who develop early hypertrophy in their linear scar at 6 weeks to 3 months after surgery or trauma.
      Pressure therapy may be initiated if this has not yet been applied.
      If there is further scar maturation 6 months after surgery or trauma, silicone therapy should be continued for as long as necessary. In patients with ongoing hypertrophy, more invasive measures are indicated such as the use of intralesional corticosteroids. This is the only invasive management option which currently has enough supporting evidence to be recommended in evidence-based guidelines.
      • Mustoe T.A.
      • Cooter R.D.
      • Gold M.H.
      • et al.
      International clinical recommendations on scar management.
      The most commonly used corticosteroid is triamcinolone acetonide 10–40 mg/mL which should be injected into the papillary dermis every 2–4 weeks until the scar is flattened.
      • Juckett G.
      • Hartman-Adams H.
      Management of keloids and hypertrophic scars.
      Between 50% and 100% of patients respond to this treatment with 9–50% experiencing recurrence.
      • Niessen F.B.
      • Spauwen P.H.
      • Schalkwijk J.
      • Kon M.
      On the nature of hypertrophic scars and keloids: a review.
      Excessive pain during injections can lead to non-compliance with the treatment. Other side effects include skin atrophy, hypopigmentation and telangiectasias.
      • Juckett G.
      • Hartman-Adams H.
      Management of keloids and hypertrophic scars.
      • Sproat J.E.
      • Dalcin A.
      • Weitauer N.
      • Roberts R.S.
      Hypertrophic sternal scars: silicone gel sheet versus Kenalog injection treatment.
      Although the likelihood of developing hypertrophic scars is often thought to be greater in children than in the elderly with much more time required for their scars to mature, there is hardly any evidence to support this in the literature.
      • van der Wal M.B.
      • Vloemans J.F.
      • Tuinebreijer W.E.
      • et al.
      Outcome after burns: an observational study on burn scar maturation and predictors for severe scarring.
      Despite the fact that there are very few studies on the technique of corticosteroid injections in children, most experts agree that this technique is not contraindicated in these young patients, but that dose adaption to the child's weight is advised to avoid systemic exposure.
      • Sclafani A.P.
      • Gordon L.
      • Chadha M.
      • Romo III, T.
      Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy: a randomized, prospective study and review of the literature.
      • Patel P.A.
      • Bailey J.K.
      • Yakuboff K.P.
      Treatment outcomes for keloid scar management in the pediatric burn population.
      The corticosteroid injection should always be limited to the scar itself and injection into the periscar tissues must be avoided as this may cause underlying fat atrophy irrespective of a patient's age.
      • Al-Attar A.
      • Mess S.
      • Thomassen J.M.
      • Kauffman C.L.
      • Davison S.P.
      Keloid pathogenesis and treatment.
      Additional injectable treatment options which may help to treat hypertrophic scars (and keloids) include bleomycin, 5-fluorouracil and verapamil, although the evidence to support these is currently more limited than for intralesional corticosteroids.
      • Aggarwal H.
      • Saxena A.
      • Lubana P.S.
      • Mathur R.K.
      • Jain D.K.
      Treatment of keloids and hypertrophic scars using bleomycin.
      • Fitzpatrick R.E.
      Treatment of inflamed hypertrophic scars using intralesional 5-FU.
      • Margaret Shanthi F.X.
      • Ernest K.
      • Dhanraj P.
      Comparison of intralesional verapamil with intralesional triamcinolone in the treatment of hypertrophic scars and keloids.
      Bleomycin is thought to work by decreasing collagen synthesis and, in a study of 50 patients, was shown to adequately flatten hypertrophic scars and keloids in 80% of patients.
      • Aggarwal H.
      • Saxena A.
      • Lubana P.S.
      • Mathur R.K.
      • Jain D.K.
      Treatment of keloids and hypertrophic scars using bleomycin.
      5-Fluorouracil inhibits fibroblast proliferation and has been shown to be an effective treatment for inflamed hypertrophic scars.
      • Fitzpatrick R.E.
      Treatment of inflamed hypertrophic scars using intralesional 5-FU.
      A combination of 5-fluorouracil and triamcinolone acetonide may be more effective at treating scars than the individual treatments.
      • Fitzpatrick R.E.
      Treatment of inflamed hypertrophic scars using intralesional 5-FU.
      • Davison S.P.
      • Dayan J.H.
      • Clemens M.W.
      • Sonni S.
      • Wang A.
      • Crane A.
      Efficacy of intralesional 5-fluorouracil and triamcinolone in the treatment of keloids.
      • Darougheh A.
      • Asilian A.
      • Shariati F.
      Intralesional triamcinolone alone or in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars.
      For example, this combination was associated with significantly greater reductions in scar size and erythema compared with triamcinolone acetonide alone in a 12-week double-blind study of 40 patients.
      • Darougheh A.
      • Asilian A.
      • Shariati F.
      Intralesional triamcinolone alone or in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars.
      Verapamil is a calcium channel antagonist which both decreases collagen synthesis and increases collagen breakdown. In a randomized, single-blind study of 54 patients with hypertrophic scars or keloids, scar vascularity, pliability, height and width were reduced with intralesional verapamil, although the rate of reduction in these parameters was slower than with intralesional triamcinolone.
      • Margaret Shanthi F.X.
      • Ernest K.
      • Dhanraj P.
      Comparison of intralesional verapamil with intralesional triamcinolone in the treatment of hypertrophic scars and keloids.
      A scar contracture is an abnormal shrinkage or shortening of a non-matured scar that can result in functional impairment and is often seen in combination with scar hypertrophy. Surgical correction of a scar contracture with a Z-plasty, a skin graft or a flap may be indicated at an early stage to release tension in the scar which eventually restores function and at the same time reduces scar hypertrophy.
      If the patient develops a permanent (>1 year) hypertrophic scar, surgical scar revision may be considered.
      • Mathes S.J.
      Plastic surgery.
      • Cooper J.S.
      • Lee B.T.
      Treatment of facial scarring: lasers, filler, and nonoperative techniques.
      Aesthetic correction of linear hypertrophic scars is usually done by simple resection and primary closure together with a type of tension-releasing technique such as undermining and approximation of the wound edges, subcutaneous sutures, adding a Z-plasty or the use of surgical taping and silicone gels after wound closure.
      • Mathes S.J.
      Plastic surgery.

       Widespread hypertrophic scars

      Early application of silicone and compression therapy is essential for patients who are at a risk of widespread hypertrophic scars following burns, mechanical trauma or necrotizing infections. Pressure and silicone therapy should be routinely applied in every wound that takes >2–3 weeks to heal or after skin grafting, and should be given as soon as the wound is closed and the patient can tolerate pressure.
      • Engrav L.H.
      • Heimbach D.M.
      • Rivara F.P.
      • et al.
      12-Year within-wound study of the effectiveness of custom pressure garment therapy.
      Pressure therapy has recently been considered as an ‘evidence-based’ modality for the treatment of scars.
      • Engrav L.H.
      • Heimbach D.M.
      • Rivara F.P.
      • et al.
      12-Year within-wound study of the effectiveness of custom pressure garment therapy.
      The mechanism of its action remains poorly understood despite its widespread use around the world. Part of the effect of pressure could involve reduction of oxygen tension in the wound through occlusion of small blood vessels resulting in a decrease of (myo)fibroblast proliferation and collagen synthesis.
      • Macintyre L.
      • Baird M.
      Pressure garments for use in the treatment of hypertrophic scars–a review of the problems associated with their use.
      Recent studies underline the critical role of cellular mechanoreceptors in the high success rate of compression therapy. Mechanoreceptors are involved in cellular apoptosis and are linked to the extracellular matrix. It is conceivable that increased pressure via the matrix regulates apoptosis of dermal fibroblasts and diminishes the hypertrophic process.
      • Reno F.
      • Sabbatini M.
      • Lombardi F.
      • et al.
      In vitro mechanical compression induces apoptosis and regulates cytokines release in hypertrophic scars.
      In addition, through the process of mechanotransduction, sensory nerve cells transduce mechanical pressure into intracellular biochemical and gene expression, thus synthesizing and releasing different cytokines that may play a role in the physiopathogenesis of proliferative scarring.
      • Yagmur C.
      • Akaishi S.
      • Ogawa R.
      • Guneren E.
      Mechanical receptor-related mechanisms in scar management: a review and hypothesis.
      Finally, besides these causative effects, pressure therapy can also provide symptomatic treatment benefits such as the alleviation of oedema, itchiness and pain which may contribute to the patient's well-being.
      • Ripper S.
      • Renneberg B.
      • Landmann C.
      • Weigel G.
      • Germann G.
      Adherence to pressure garment therapy in adult burn patients.
      The initial treatment of pressure and silicone therapy should be continued or intensified in patients with ongoing hypertrophy. Localized corticosteroid injections can also be indicated to treat the more excessive parts of hypertrophic scars and these can be supplemented with bleomycin, 5-fluorouracil and/or verapamil as appropriate.
      • Aggarwal H.
      • Saxena A.
      • Lubana P.S.
      • Mathur R.K.
      • Jain D.K.
      Treatment of keloids and hypertrophic scars using bleomycin.
      • Fitzpatrick R.E.
      Treatment of inflamed hypertrophic scars using intralesional 5-FU.
      • Davison S.P.
      • Dayan J.H.
      • Clemens M.W.
      • Sonni S.
      • Wang A.
      • Crane A.
      Efficacy of intralesional 5-fluorouracil and triamcinolone in the treatment of keloids.
      • D'Andrea F.
      • Brongo S.
      • Ferraro G.
      • Baroni A.
      Prevention and treatment of keloids with intralesional verapamil.
      These therapies should preferably be reserved for use in specialized centres in which there is a greater degree of expertise.
      Laser therapy is another invasive option which can be used to treat the surface texture of abnormal scars and may also be suitable for the treatment of residual redness, telangiectasias or hyperpigmentation.
      Vrijman et al., in a recent meta-analysis, demonstrated scientific evidence only for the pulsed dye laser (PDL) 585 and not for the intense pulsed light (IPL), the non-ablative fractional laser (NAFL) 1550 nm, the CO2 ablative fractional laser (AFL), the 532-nm laser and the 2940-nm erbium laser.
      • Vrijman C.
      • van Drooge A.M.
      • Limpens J.
      • et al.
      Laser and intense pulsed light therapy for the treatment of hypertrophic scars: a systematic review.
      Since the publication of this meta-analysis, a case series has been published confirming the efficacy of the PDL, especially in combination with occlusion/compression and intralesional corticosteroids.
      • Goppold A.
      • Kaune K.M.
      • Buhl T.
      • Schon M.P.
      • Zutt M.
      595 nm pulsed dye laser combined with intralesional corticosteroids in hypertrophic symptomatic scars following breast reduction surgery.
      In addition, there have also been several positive reports on the NAFL 1550 nm and the CO2 AFL.
      • Lin J.Y.
      • Warger W.C.
      • Izikson L.
      • Anderson R.R.
      • Tannous Z.
      A prospective, randomized controlled trial on the efficacy of fractional photothermolysis on scar remodeling.
      • Pham A.M.
      • Greene R.M.
      • Woolery-Lloyd H.
      • Kaufman J.
      • Grunebaum L.D.
      1550-nm nonablative laser resurfacing for facial surgical scars.
      • Ong M.W.
      • Bashir S.J.
      Fractional laser resurfacing for acne scars: a review.
      Various other lasers have also been used in the treatment of scars: Nd:YAG long pulse 1064 nm,
      • Akaishi S.
      • Koike S.
      • Dohi T.
      • Kobe K.
      • Hyakusoku H.
      • Ogawa R.
      Nd:YAG laser treatment of keloids and hypertrophic scars.
      Q-switch Nd:YAG,
      • Cho S.B.
      • Lee J.H.
      • Lee S.H.
      • Lee S.J.
      • Bang D.
      • Oh S.H.
      Efficacy and safety of 1064-nm Q-switched Nd:YAG laser with low fluence for keloids and hypertrophic scars.
      light-emitting diodes (LEDs) and photodynamic therapy (PDT).
      • Sakamoto F.H.
      • Izikson L.
      • Tannous Z.
      • Zurakowski D.
      • Anderson R.R.
      Surgical scar remodelling after photodynamic therapy using aminolaevulinic acid or its methylester: a retrospective, blinded study of patients with field cancerization.
      Finally, laser therapy has also been advocated for the prevention or minimization of both post-surgical and traumatic scars, and even in combination with botulinum toxin.
      • Capon A.
      • Iarmarcovai G.
      • Gonnelli D.
      • Degardin N.
      • Magalon G.
      • Mordon S.
      Scar prevention using laser-assisted skin healing (LASH) in plastic surgery.
      Although more clinical evidence on the use of lasers is needed, both for the choice of the device as well as for the settings/treatment schedules, the increasing number of articles being published on the successful management of hypertrophic scars with lasers is increasing the interest in this therapeutic modality.
      As mentioned previously, early surgery is always indicated in the case of contractures with functional impairment. Contracture release after burns in areas such as the neck and axilla are best performed with flaps rather than with skin grafts as flaps usually develop minimal secondary contraction and therefore produce excellent functional and aesthetic results.
      Long-standing or permanent widespread hypertrophic scars may be treated surgically, sometimes using the same techniques as for permanent linear hypertrophic scars. For larger scars, serial excision or skin stretching may be indicated which involves the advancement of adjacent skin by sufficient undermining after resection of the central part of the scar.
      • Verhaegen P.D.
      • van der Wal M.B.
      • Bloemen M.C.
      • et al.
      Sustainable effect of skin stretching for burn scar excision: long-term results of a multicenter randomized controlled trial.
      Subcutaneous sutures are needed to relieve the tension from the overlying skin given that this procedure involves stretching the skin. Surgical skin replacement (resurfacing) of unaesthetic widespread scars may be performed using autologous skin grafts.
      • Hierner R.
      • Degreef H.
      • Vranckx J.J.
      • Garmyn M.
      • Massage P.
      • van Brussel M.
      Skin grafting and wound healing-the “dermato-plastic team approach”.
      Dermal substitutes may also be used for skin resurfacing in patients with extensive skin trauma such as those with severe burns.
      • van der Veen V.C.
      • van der Wal M.B.
      • van Leeuwen M.C.
      • Ulrich M.M.
      • Middelkoop E.
      Biological background of dermal substitutes.
      Tissue expansion is also a very helpful technique for surgical scar correction, especially for reconstruction of the scalp. These surgical reconstruction procedures should ideally be performed in dedicated specialized centres.

       Keloids

      Keloids are also best treated in centres with specialized expertise. Patients with growing minor or major keloids should first be treated with silicones in combination with pressure therapy and intralesional injections of corticosteroids.
      Intralesional 5-fluorouracil, bleomycin and verapamil can also be considered, preferably in accordance with existing treatment protocols.
      • Juckett G.
      • Hartman-Adams H.
      Management of keloids and hypertrophic scars.
      • Aggarwal H.
      • Saxena A.
      • Lubana P.S.
      • Mathur R.K.
      • Jain D.K.
      Treatment of keloids and hypertrophic scars using bleomycin.
      • Fitzpatrick R.E.
      Treatment of inflamed hypertrophic scars using intralesional 5-FU.
      • D'Andrea F.
      • Brongo S.
      • Ferraro G.
      • Baroni A.
      Prevention and treatment of keloids with intralesional verapamil.
      • Naeini F.F.
      • Najafian J.
      • Ahmadpour K.
      Bleomycin tattooing as a promising therapeutic modality in large keloids and hypertrophic scars.
      If the keloid does not respond to 12 months of these treatments, then surgical excision should be considered always in combination with some form of adjuvant therapy as surgical excision alone has been associated with a high recurrence rate of 50–100% and may even result in enlargement of the keloid.
      • Juckett G.
      • Hartman-Adams H.
      Management of keloids and hypertrophic scars.
      Some experts recommend that the lateral parts of keloids should not be excised, but should be joined together and left in situ. However, others have objected to this proposal and consider that the cells from these lateral parts of the keloid are more active in terms of collagen production.
      • Syed F.
      • Ahmadi E.
      • Iqbal S.A.
      • Singh S.
      • McGrouther D.A.
      • Bayat A.
      Fibroblasts from the growing margin of keloid scars produce higher levels of collagen I and III compared with intralesional and extralesional sites: clinical implications for lesional site-directed therapy.
      The combination of scar resection and immediate post-operative radiotherapy was proposed many years ago, and both electron beam irradiation and brachytherapy with iridium 192 can be used after surgical removal of the keloid to reduce recurrence rates.
      • Rio E.
      • Bardet E.
      • Peuvrel P.
      • Pannier M.
      • Dreno B.
      Perioperative interstitial brachytherapy for recurrent keloid scars.
      Many objections have been raised concerning the potential side effects of post-operative radiotherapy, especially regarding the potential risk of inducing malignancy. However, on the basis of an extensive review of literature on this subject, Ogawa et al. concluded that the risk of malignancy attributable to keloid radiation therapy is minimal.
      • Ogawa R.
      • Yoshitatsu S.
      • Yoshida K.
      • Miyashita T.
      Is radiation therapy for keloids acceptable? The risk of radiation-induced carcinogenesis.
      An additional promising new invasive treatment modality for keloids is internal cryotherapy in which a metal rod is introduced into the keloid and the subsequent extreme cooling leads to tissue necrosis.
      • Har-Shai Y.
      • Amar M.
      • Sabo E.
      Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids.
      In a study of 10 patients, scar volume was significantly reduced by 54% after one intralesional treatment with no recurrence over an 18-month follow-up period.
      • Har-Shai Y.
      • Amar M.
      • Sabo E.
      Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids.
      Finally, imiquimod 5% is a topical immune response modifier which stimulates the production of interferon leading to increased collagen breakdown. Some studies have reported low recurrence rates of 0–29% following surgical excision of keloids and subsequent topical application of imiquimod 5% cream.
      • Berman B.
      • Kaufman J.
      Pilot study of the effect of postoperative imiquimod 5% cream on the recurrence rate of excised keloids.
      • Chuangsuwanich A.
      • Gunjittisomram S.
      The efficacy of 5% imiquimod cream in the prevention of recurrence of excised keloids.
      However, other studies have reported that imiquimod 5% cream is not effective at preventing keloid recurrence with recurrence rates of 89%.
      • Cacao F.M.
      • Tanaka V.
      • Messina M.C.
      Failure of imiquimod 5% cream to prevent recurrence of surgically excised trunk keloids.

      First-line non-invasive scar management: more evidence on the role of silicone therapy

      The latest guidelines for scar management advocate silicone therapy as a non-invasive first-line prophylactic and treatment option for both hypertrophic scars and keloids.
      Indeed, of the non-invasive options, silicone sheets and silicone gels are universally considered as the gold standard in scar management and the only non-invasive preventive and therapeutic measure for which there is enough supporting data to make evidence-based recommendations.
      • Mustoe T.A.
      • Cooter R.D.
      • Gold M.H.
      • et al.
      International clinical recommendations on scar management.
      Silicone therapy is an attractive alternative to more invasive treatment options as it is easy to use and is associated with only minimal side effects such as pruritus, contact dermatitis and dry skin.
      • Berman B.
      • Perez O.A.
      • Konda S.
      • et al.
      A review of the biologic effects, clinical efficacy, and safety of silicone elastomer sheeting for hypertrophic and keloid scar treatment and management.
      This therapy is believed to prevent and treat scars through occlusion and subsequent hydration of the scar tissue.
      • Mustoe T.A.
      Evolution of silicone therapy and mechanism of action in scar management.
      Silicone sheeting consists of a soft, semi-occlusive gel sheet made from medical-grade silicone that is reinforced with a silicone membrane backing to give the sheet increased durability and ease of handling. Some sheets use a combination of silicone and Teflon® (polytetrafluoroethylene) to create ultra-thin, flexible and durable sheeting. Patients may be reluctant to use the sheeting on exposed areas of the body, and compliance with treatment is a frequent concern.
      • Carney S.A.
      • Cason C.G.
      • Gowar J.P.
      • et al.
      Cica-Care gel sheeting in the management of hypertrophic scarring.
      Recently, fluid silicone gel formulations have been developed using the same basic long-chain silicone polymer that is used in silicone sheeting. This more recent formulation of silicone for scar treatment was specifically developed to overcome some of the problems encountered with silicone gel sheets such as the need for fixation and difficulties in using sheets on large areas or near joints as well as on exposed areas such as the face and hands. The fluid silicone gel is applied in a thin layer to the skin where it dries to form a transparent, flexible, gas-permeable, water-impermeable silicone sheet. Similar to silicone sheeting, silicone gels should not be applied to open wounds and can be used for as long as the patient derives benefit.
      The pivotal role of silicone sheeting for the prevention and treatment of hypertrophic scars and keloids resulting from many types of trauma, including burns and surgical excisions, has been established in many clinical studies with all but one showing positive effects.
      • Carney S.A.
      • Cason C.G.
      • Gowar J.P.
      • et al.
      Cica-Care gel sheeting in the management of hypertrophic scarring.
      • Gold M.H.
      • Foster T.D.
      • Adair M.A.
      • Burlison K.
      • Lewis T.
      Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets following a surgical procedure in an office setting.
      • Cruz-Korchin N.I.
      Effectiveness of silicone sheets in the prevention of hypertrophic breast scars.
      • Fulton Jr., J.E.
      Silicone gel sheeting for the prevention and management of evolving hypertrophic and keloid scars.
      • Katz B.E.
      Silicone gel sheeting in scar therapy.
      • Gold M.H.
      A controlled clinical trial of topical silicone gel sheeting in the treatment of hypertrophic scars and keloids.
      • Li-Tsang C.W.
      • Lau J.C.
      • Choi J.
      • Chan C.C.
      • Jianan L.
      A prospective randomized clinical trial to investigate the effect of silicone gel sheeting (Cica-Care) on post-traumatic hypertrophic scar among the Chinese population.
      • Majan J.I.
      Evaluation of a self-adherent soft silicone dressing for the treatment of hypertrophic postoperative scars.
      • Niessen F.B.
      • Spauwen P.H.
      • Robinson P.H.
      • Fidler V.
      • Kon M.
      The use of silicone occlusive sheeting (Sil-K) and silicone occlusive gel (epiderm) in the prevention of hypertrophic scar formation.
      A meta-analysis found that silicone sheeting reduces the incidence of hypertrophic scarring in high-risk individuals compared with no treatment (response rate: 0.46; 95% confidence interval 0.21–0.98).
      • O'Brien L.
      • Pandit A.
      Silicon gel sheeting for preventing and treating hypertrophic and keloid scars.
      Recent data have also shown that silicone sheeting can be used in combination with pressure therapy producing better improvements in post-traumatic hypertrophic scars than either therapy alone. The two treatments have complementary modes of action with the silicone therapy acting on the erythema and pliability of the scar, whereas the pressure therapy prevents scar thickening.
      • Li-Tsang C.W.
      • Zheng Y.P.
      • Lau J.C.
      A randomized clinical trial to study the effect of silicone gel dressing and pressure therapy on posttraumatic hypertrophic scars.
      Several clinical studies have indicated the beneficial effects of silicone gels in the prevention and treatment of scars.
      • Signorini M.
      • Clementoni M.T.
      Clinical evaluation of a new self-drying silicone gel in the treatment of scars: a preliminary report.
      • van der Wal M.B.
      • van Zuijlen P.P.
      • van de Ven P.
      • Middelkoop E.
      Topical silicone gel versus placebo in promoting the maturation of burn scars: a randomized controlled trial.
      • Murison M.
      • James W.
      Preliminary evaluation of the efficacy of dermatix silicone gel in the reduction of scar elevation and pigmentation.
      • Chan K.Y.
      • Lau C.L.
      • Adeeb S.M.
      • Somasundaram S.
      • Nasir-Zahari M.
      A randomized, placebo-controlled, double-blind, prospective clinical trial of silicone gel in prevention of hypertrophic scar development in median sternotomy wound.
      • Chernoff W.G.
      • Cramer H.
      • Su-Huang S.
      The efficacy of topical silicone gel elastomers in the treatment of hypertrophic scars, keloid scars, and post-laser exfoliation erythema.
      Several comparative studies with silicone sheets have shown that fluid silicone gels have at least equivalent efficacy although patients may find the gel formulations easier to use.
      • Chernoff W.G.
      • Cramer H.
      • Su-Huang S.
      The efficacy of topical silicone gel elastomers in the treatment of hypertrophic scars, keloid scars, and post-laser exfoliation erythema.
      • Karagoz H.
      • Yuksel F.
      • Ulkur E.
      • Evinc R.
      Comparison of efficacy of silicone gel, silicone gel sheeting, and topical onion extract including heparin and allantoin for the treatment of postburn hypertrophic scars.

      Conclusions

      Unaesthetic scarring is associated with physical and psychosocial consequences. Plastic surgeons play an essential role in minimizing scar formation after elective surgery and in correcting unaesthetic scars once matured. Choices regarding appropriate scar management measures should be guided by the clinical recommendations provided in this consensus article, but should also be tailored to individual patient and wound requirements. Preventive measures are a major priority and need to be applied before, during and immediately after wound closure. Treatment of hypertrophic scars, contractures and keloids is generally based on reducing mechanical tension in the scar, removal of the bulky scar tissue by reconstructive surgical techniques and/or injection of substances that promote collagen breakdown in situ. Silicone sheets and gels are recommended as the ‘gold standard’, non-invasive therapies for both the prevention and the treatment of hypertrophic scars and keloids with gels being preferred by patients. These products can be used in combination with other invasive and non-invasive treatment options to provide patients with optimal outcomes.

      Conflict of interest statement

      Stan Monstrey: None.
      Esther Middelkoop: The Association of Dutch Burn Centres received financial support from Meda Pharma BV for part of a clinical study comparing Dermatix topical silicone gel to a placebo cream. The Dermatix topical silicone gel was kindly provided by Meda Pharma BV.
      Jan Jeroen Vranckx: None.
      Franco Bassetto: None.
      Ulrich Ziegler: None.
      Sylvie Meaume: None.
      Luc Téot: None.

      Funding

      Editorial assistance in the preparation of this manuscript was provided by David Harrison, Medscript Communications, funded by Meda Pharma SA. The manuscript sponsors were given an opportunity to review an initial version of the manuscript.

      Acknowledgements

      The authors take full responsibility for the content of this publication. We thank the following authors of the Scar Management Practical Guidelines book for their invaluable contributions to the development of these guidelines: Nele Brusselaers (Burn Centre and Department of General Internal Medicine, Infectious Diseases and Psychosomatic Medicine, Ghent University Hospital, Ghent, Belgium), Maarten Doornaert and Henk Hoeksema (Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium), Anibal Justiniano (Institute of Health Sciences, Catholic University, Porto, Portugal), Benoît Lengelé (Anatomy Department, Catholic University of Louvain, Brussels, Belgium), Anne Le Pillouer-Prost (Clairval Hospital, Marseille, France), Ali Pirayesh (Amsterdam Plastic Surgery, Amsterdam, The Netherlands and Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium), Bertrand Richert (Dermatology Department, University Hospital Brugmann – Saint Pierre – Children's Hospital Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium), Fabrice Rogge (Plastic and Reconstructive Surgery, Bruges, Belgium), Diane Roseeuw (Dermatology Department, Free University of Brussels, Jette, Belgium), Claude Roques (CSRE Lamalou le Haut, Pediatric Rehabilitation Centre, Lamalou-Les-Bains, France), Xavier Santos Heredero (Plastic and Reconstructive Surgery Department, University Hospitals of Madrid Monteprincipe y Torrelodones, Madrid, Spain), Javid Vadoud (Clinique Parc Léopold, Brussels, Belgium), Eric Van den Kerckhove (Physical Medicine and Rehabilitation, University Hospital Gasthuisberg, KUL Leuven University Hospitals, Leuven, Belgium), Helga Van De Velde (Institute Helga Van De Velde, Ghent, Belgium), Nancy Van Loey (Association of Dutch Burns Centres, Beverwijk, Tthe Netherlands) and Antoine J van Trier (Department of Plastic, Reconstructive and Handsurgery, Red Cross Hospital, Beverwijk, The Netherlands).

      References

        • Sund B.
        ([Clinical Report])New developments in wound care. vol. 86. PJB Publications CBS, London2000: 1-255
        • Abu-Nab Z.
        • Grunfeld E.A.
        Satisfaction with outcome and attitudes towards scarring among women undergoing breast reconstructive surgery.
        Patient Educ Couns. 2007; 66: 243-249
        • Young V.L.
        • Hutchison J.
        Insights into patient and clinician concerns about scar appearance: semiquantitative structured surveys.
        Plast Reconstr Surg. 2009; 124: 256-265
        • Van Loey N.E.
        • Bremer M.
        • Faber A.W.
        • Middelkoop E.
        • Nieuwenhuis M.K.
        Itching following burns: epidemiology and predictors.
        Br J Dermatol. 2008; 158: 95-100
        • Bell L.
        • McAdams T.
        • Morgan R.
        • et al.
        Pruritus in burns: a descriptive study.
        J Burn Care Rehabil. 1988; 9: 305-308
        • Robert R.
        • Meyer W.
        • Bishop S.
        • Rosenberg L.
        • Murphy L.
        • Blakeney P.
        Disfiguring burn scars and adolescent self-esteem.
        Burns. 1999; 25: 581-585
        • Bakker A.
        • Maertens K.J.
        • Van Son M.J.
        • Van Loey N.E.
        Psychological consequences of pediatric burns from a child and family perspective: a review of the empirical literature.
        Clin Psychol Rev. 2013; 33: 361-371
        • Juckett G.
        • Hartman-Adams H.
        Management of keloids and hypertrophic scars.
        Am Fam Physician. 2009; 80: 253-260
        • Alster T.S.
        • Tanzi E.L.
        Hypertrophic scars and keloids: etiology and management.
        Am J Clin Dermatol. 2003; 4: 235-243
        • Gauglitz G.G.
        • Korting H.C.
        • Pavicic T.
        • Ruzicka T.
        • Jeschke M.G.
        Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies.
        Mol Med. 2011; 17: 113-125
      1. (Published by)Middelkoop E. Monstrey S. Teot L. Vranckx J.J. Scar Management Practical Guidelines. Maca-Cloetens, 2011: 1-109
        • Mustoe T.A.
        • Cooter R.D.
        • Gold M.H.
        • et al.
        International clinical recommendations on scar management.
        Plast Reconstr Surg. 2002; 110: 560-571
        • Bloemen M.C.
        • van der Veer W.M.
        • Ulrich M.M.
        • van Zuijlen P.P.
        • Niessen F.B.
        • Middelkoop E.
        Prevention and curative management of hypertrophic scar formation.
        Burns. 2009; 35: 463-475
        • Bayat A.
        • McGrouther D.A.
        • Ferguson M.W.
        Skin scarring.
        BMJ. 2003; 326: 88-92
        • Reiffel R.S.
        Prevention of hypertrophic scars by long-term paper tape application.
        Plast Reconstr Surg. 1995; 96: 1715-1718
        • Gurtner G.C.
        • Dauskardt R.H.
        • Wong V.W.
        • et al.
        Improving cutaneous scar formation by controlling the mechanical environment: large animal and phase I studies.
        Ann Surg. 2011; 254: 217-225
        • Gassner H.G.
        • Sherris D.A.
        • Otley C.C.
        Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates.
        Plast Reconstr Surg. 2000; 105: 1948-1953
        • Suetake T.
        • Sasai S.
        • Zhen Y.X.
        • Ohi T.
        • Tagami H.
        Functional analyses of the stratum corneum in scars. Sequential studies after injury and comparison among keloids, hypertrophic scars, and atrophic scars.
        Arch Dermatol. 1996; 132: 1453-1458
        • Mustoe T.A.
        Evolution of silicone therapy and mechanism of action in scar management.
        Aesthetic Plast Surg. 2008; 32: 82-92
        • Engrav L.H.
        • Heimbach D.M.
        • Rivara F.P.
        • et al.
        12-Year within-wound study of the effectiveness of custom pressure garment therapy.
        Burns. 2010; 36: 975-983
        • Ferguson M.W.
        • Duncan J.
        • Bond J.
        • et al.
        Prophylactic administration of avotermin for improvement of skin scarring: three double-blind, placebo-controlled, phase I/II studies.
        Lancet. 2009; 373: 1264-1274
        • Haedersdal M.
        • Bech-Thomsen N.
        • Poulsen T.
        • Wulf H.C.
        Ultraviolet exposure influences laser-induced wounds, scars, and hyperpigmentation: a murine study.
        Plast Reconstr Surg. 1998; 101: 1315-1322
        • Due E.
        • Rossen K.
        • Sorensen L.T.
        • Kliem A.
        • Karlsmark T.
        • Haedersdal M.
        Effect of UV irradiation on cutaneous cicatrices: a randomized, controlled trial with clinical, skin reflectance, histological, immunohistochemical and biochemical evaluations.
        Acta Derm Venereol. 2007; 87: 27-32
        • Niessen F.B.
        • Spauwen P.H.
        • Schalkwijk J.
        • Kon M.
        On the nature of hypertrophic scars and keloids: a review.
        Plast Reconstr Surg. 1999; 104: 1435-1458
        • Sproat J.E.
        • Dalcin A.
        • Weitauer N.
        • Roberts R.S.
        Hypertrophic sternal scars: silicone gel sheet versus Kenalog injection treatment.
        Plast Reconstr Surg. 1992; 90: 988-992
        • van der Wal M.B.
        • Vloemans J.F.
        • Tuinebreijer W.E.
        • et al.
        Outcome after burns: an observational study on burn scar maturation and predictors for severe scarring.
        Wound Repair Regen. 2012; 20: 676-687
        • Sclafani A.P.
        • Gordon L.
        • Chadha M.
        • Romo III, T.
        Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy: a randomized, prospective study and review of the literature.
        Dermatol Surg. 1996; 22: 569-574
        • Patel P.A.
        • Bailey J.K.
        • Yakuboff K.P.
        Treatment outcomes for keloid scar management in the pediatric burn population.
        Burns. 2012; 38: 767-771
        • Al-Attar A.
        • Mess S.
        • Thomassen J.M.
        • Kauffman C.L.
        • Davison S.P.
        Keloid pathogenesis and treatment.
        Plast Reconstr Surg. 2006; 117: 286-300
        • Aggarwal H.
        • Saxena A.
        • Lubana P.S.
        • Mathur R.K.
        • Jain D.K.
        Treatment of keloids and hypertrophic scars using bleomycin.
        J Cosmet Dermatol. 2008; 7: 43-49
        • Fitzpatrick R.E.
        Treatment of inflamed hypertrophic scars using intralesional 5-FU.
        Dermatol Surg. 1999; 25: 224-232
        • Margaret Shanthi F.X.
        • Ernest K.
        • Dhanraj P.
        Comparison of intralesional verapamil with intralesional triamcinolone in the treatment of hypertrophic scars and keloids.
        Indian J Dermatol Venereol Leprol. 2008; 74: 343-348
        • Davison S.P.
        • Dayan J.H.
        • Clemens M.W.
        • Sonni S.
        • Wang A.
        • Crane A.
        Efficacy of intralesional 5-fluorouracil and triamcinolone in the treatment of keloids.
        Aesthet Surg J. 2009; 29: 40-46
        • Darougheh A.
        • Asilian A.
        • Shariati F.
        Intralesional triamcinolone alone or in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars.
        Clin Exp Dermatol. 2009; 34: 219-223
        • Mathes S.J.
        Plastic surgery.
        (2–4)2nd ed. Elsevier Saunders, Philadelphia2006
        • Cooper J.S.
        • Lee B.T.
        Treatment of facial scarring: lasers, filler, and nonoperative techniques.
        Facial Plast Surg. 2009; 25: 311-315
        • Macintyre L.
        • Baird M.
        Pressure garments for use in the treatment of hypertrophic scars–a review of the problems associated with their use.
        Burns. 2006; 32: 10-15
        • Reno F.
        • Sabbatini M.
        • Lombardi F.
        • et al.
        In vitro mechanical compression induces apoptosis and regulates cytokines release in hypertrophic scars.
        Wound Repair Regen. 2003; 11: 331-336
        • Yagmur C.
        • Akaishi S.
        • Ogawa R.
        • Guneren E.
        Mechanical receptor-related mechanisms in scar management: a review and hypothesis.
        Plast Reconstr Surg. 2010; 126: 426-434
        • Ripper S.
        • Renneberg B.
        • Landmann C.
        • Weigel G.
        • Germann G.
        Adherence to pressure garment therapy in adult burn patients.
        Burns. 2009; 35: 657-664
        • D'Andrea F.
        • Brongo S.
        • Ferraro G.
        • Baroni A.
        Prevention and treatment of keloids with intralesional verapamil.
        Dermatology. 2002; 204: 60-62
        • Vrijman C.
        • van Drooge A.M.
        • Limpens J.
        • et al.
        Laser and intense pulsed light therapy for the treatment of hypertrophic scars: a systematic review.
        Br J Dermatol. 2011; 165: 934-942
        • Goppold A.
        • Kaune K.M.
        • Buhl T.
        • Schon M.P.
        • Zutt M.
        595 nm pulsed dye laser combined with intralesional corticosteroids in hypertrophic symptomatic scars following breast reduction surgery.
        Eur J Dermatol. 2011; 21: 262-263
        • Lin J.Y.
        • Warger W.C.
        • Izikson L.
        • Anderson R.R.
        • Tannous Z.
        A prospective, randomized controlled trial on the efficacy of fractional photothermolysis on scar remodeling.
        Lasers Surg Med. 2011; 43: 265-272
        • Pham A.M.
        • Greene R.M.
        • Woolery-Lloyd H.
        • Kaufman J.
        • Grunebaum L.D.
        1550-nm nonablative laser resurfacing for facial surgical scars.
        Arch Facial Plast Surg. 2011; 13: 203-210
        • Ong M.W.
        • Bashir S.J.
        Fractional laser resurfacing for acne scars: a review.
        Br J Dermatol. 2012; 166: 1160-1169
        • Akaishi S.
        • Koike S.
        • Dohi T.
        • Kobe K.
        • Hyakusoku H.
        • Ogawa R.
        Nd:YAG laser treatment of keloids and hypertrophic scars.
        Eplasty. 2012; 12: e1
        • Cho S.B.
        • Lee J.H.
        • Lee S.H.
        • Lee S.J.
        • Bang D.
        • Oh S.H.
        Efficacy and safety of 1064-nm Q-switched Nd:YAG laser with low fluence for keloids and hypertrophic scars.
        J Eur Acad Dermatol Venereol. 2010; 24: 1070-1074
        • Sakamoto F.H.
        • Izikson L.
        • Tannous Z.
        • Zurakowski D.
        • Anderson R.R.
        Surgical scar remodelling after photodynamic therapy using aminolaevulinic acid or its methylester: a retrospective, blinded study of patients with field cancerization.
        Br J Dermatol. 2012; 166: 413-416
        • Capon A.
        • Iarmarcovai G.
        • Gonnelli D.
        • Degardin N.
        • Magalon G.
        • Mordon S.
        Scar prevention using laser-assisted skin healing (LASH) in plastic surgery.
        Aesthetic Plast Surg. 2010; 34: 438-446
        • Verhaegen P.D.
        • van der Wal M.B.
        • Bloemen M.C.
        • et al.
        Sustainable effect of skin stretching for burn scar excision: long-term results of a multicenter randomized controlled trial.
        Burns. 2011; 37: 1222-1228
        • Hierner R.
        • Degreef H.
        • Vranckx J.J.
        • Garmyn M.
        • Massage P.
        • van Brussel M.
        Skin grafting and wound healing-the “dermato-plastic team approach”.
        Clin Dermatol. 2005; 23: 343-352
        • van der Veen V.C.
        • van der Wal M.B.
        • van Leeuwen M.C.
        • Ulrich M.M.
        • Middelkoop E.
        Biological background of dermal substitutes.
        Burns. 2010; 36: 305-321
        • Naeini F.F.
        • Najafian J.
        • Ahmadpour K.
        Bleomycin tattooing as a promising therapeutic modality in large keloids and hypertrophic scars.
        Dermatol Surg. 2006; 32: 1023-1029
        • Syed F.
        • Ahmadi E.
        • Iqbal S.A.
        • Singh S.
        • McGrouther D.A.
        • Bayat A.
        Fibroblasts from the growing margin of keloid scars produce higher levels of collagen I and III compared with intralesional and extralesional sites: clinical implications for lesional site-directed therapy.
        Br J Dermatol. 2011; 164: 83-96
        • Rio E.
        • Bardet E.
        • Peuvrel P.
        • Pannier M.
        • Dreno B.
        Perioperative interstitial brachytherapy for recurrent keloid scars.
        Plast Reconstr Surg. 2009; 124: 180e-181e
        • Ogawa R.
        • Yoshitatsu S.
        • Yoshida K.
        • Miyashita T.
        Is radiation therapy for keloids acceptable? The risk of radiation-induced carcinogenesis.
        Plast Reconstr Surg. 2009; 124: 1196-1201
        • Har-Shai Y.
        • Amar M.
        • Sabo E.
        Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids.
        Plast Reconstr Surg. 2003; 111: 1841-1852
        • Berman B.
        • Kaufman J.
        Pilot study of the effect of postoperative imiquimod 5% cream on the recurrence rate of excised keloids.
        J Am Acad Dermatol. 2002; 47: S209-S211
        • Chuangsuwanich A.
        • Gunjittisomram S.
        The efficacy of 5% imiquimod cream in the prevention of recurrence of excised keloids.
        J Med Assoc Thai. 2007; 90: 1363-1367
        • Cacao F.M.
        • Tanaka V.
        • Messina M.C.
        Failure of imiquimod 5% cream to prevent recurrence of surgically excised trunk keloids.
        Dermatol Surg. 2009; 35: 629-633
        • Berman B.
        • Perez O.A.
        • Konda S.
        • et al.
        A review of the biologic effects, clinical efficacy, and safety of silicone elastomer sheeting for hypertrophic and keloid scar treatment and management.
        Dermatol Surg. 2007; 33: 1291-1302
        • Carney S.A.
        • Cason C.G.
        • Gowar J.P.
        • et al.
        Cica-Care gel sheeting in the management of hypertrophic scarring.
        Burns. 1994; 20: 163-167
        • Gold M.H.
        • Foster T.D.
        • Adair M.A.
        • Burlison K.
        • Lewis T.
        Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets following a surgical procedure in an office setting.
        Dermatol Surg. 2001; 27: 641-644
        • Cruz-Korchin N.I.
        Effectiveness of silicone sheets in the prevention of hypertrophic breast scars.
        Ann Plast Surg. 1996; 37: 345-348
        • Fulton Jr., J.E.
        Silicone gel sheeting for the prevention and management of evolving hypertrophic and keloid scars.
        Dermatol Surg. 1995; 21: 947-951
        • Katz B.E.
        Silicone gel sheeting in scar therapy.
        Cutis. 1995; 56: 65-67
        • Gold M.H.
        A controlled clinical trial of topical silicone gel sheeting in the treatment of hypertrophic scars and keloids.
        J Am Acad Dermatol. 1994; 30: 506-507
        • Li-Tsang C.W.
        • Lau J.C.
        • Choi J.
        • Chan C.C.
        • Jianan L.
        A prospective randomized clinical trial to investigate the effect of silicone gel sheeting (Cica-Care) on post-traumatic hypertrophic scar among the Chinese population.
        Burns. 2006; 32: 678-683
        • Majan J.I.
        Evaluation of a self-adherent soft silicone dressing for the treatment of hypertrophic postoperative scars.
        J Wound Care. 2006; 15: 193-196
        • Niessen F.B.
        • Spauwen P.H.
        • Robinson P.H.
        • Fidler V.
        • Kon M.
        The use of silicone occlusive sheeting (Sil-K) and silicone occlusive gel (epiderm) in the prevention of hypertrophic scar formation.
        Plast Reconstr Surg. 1998; 102: 1962-1972
        • O'Brien L.
        • Pandit A.
        Silicon gel sheeting for preventing and treating hypertrophic and keloid scars.
        Cochrane Database Syst Rev. 2006; : CD003826
        • Li-Tsang C.W.
        • Zheng Y.P.
        • Lau J.C.
        A randomized clinical trial to study the effect of silicone gel dressing and pressure therapy on posttraumatic hypertrophic scars.
        J Burn Care Res. 2010; 31: 448-457
        • Signorini M.
        • Clementoni M.T.
        Clinical evaluation of a new self-drying silicone gel in the treatment of scars: a preliminary report.
        Aesthetic Plast Surg. 2007; 31: 183-187
        • van der Wal M.B.
        • van Zuijlen P.P.
        • van de Ven P.
        • Middelkoop E.
        Topical silicone gel versus placebo in promoting the maturation of burn scars: a randomized controlled trial.
        Plast Reconstr Surg. 2010; 126: 524-531
        • Murison M.
        • James W.
        Preliminary evaluation of the efficacy of dermatix silicone gel in the reduction of scar elevation and pigmentation.
        J Plast Reconstr Aesthet Surg. 2006; 59: 437-439
        • Chan K.Y.
        • Lau C.L.
        • Adeeb S.M.
        • Somasundaram S.
        • Nasir-Zahari M.
        A randomized, placebo-controlled, double-blind, prospective clinical trial of silicone gel in prevention of hypertrophic scar development in median sternotomy wound.
        Plast Reconstr Surg. 2005; 116: 1013-1020
        • Chernoff W.G.
        • Cramer H.
        • Su-Huang S.
        The efficacy of topical silicone gel elastomers in the treatment of hypertrophic scars, keloid scars, and post-laser exfoliation erythema.
        Aesthetic Plast Surg. 2007; 31: 495-500
        • Karagoz H.
        • Yuksel F.
        • Ulkur E.
        • Evinc R.
        Comparison of efficacy of silicone gel, silicone gel sheeting, and topical onion extract including heparin and allantoin for the treatment of postburn hypertrophic scars.
        Burns. 2009; 35: 1097-1103