Background and Objectives: Scar rehabilitation is a complex process that incorporates medical, surgical, and physical therapeutic measures to best restore function and visual normalcy. Lasers have emerged as essential tools in the management of scars, with devices available to address scar size, dyschromia, and contour irregularities. As different lasers treat these different features, multi-laser, same session therapeutic approaches may offer a more comprehensive approach to scar revision. In this study, we aim to demonstrate the effect of a combinatorial, same session treatment with intense pulsed light (IPL) and fractional ablative CO 2 as compared to single laser treatment with fractional ablative CO 2 laser alone or control in the treatment of mature hypertrophic scars. Materials and Methods: This institutional review board-approved, randomized controlled trial, enrolled 23 healthy adults with large (>100 cm 2 ) hypertrophic scars who were randomized to one of three treatment arms: (i) IPL and CO 2 ablative fractional laser (AFL), (ii) CO 2 AFL alone, and (iii) control (no laser treatment). Subjects underwent a total of four treatment sessions at 6-8-week intervals with follow-up visits at 1, 3, and 6 months following the last treatment session. Primary endpoints included blinded scoring of before and after photographs via the Manchester Scar Scale (MSS). Secondary endpoints included the Patient-Observer Scar Assessment Scale (POSAS). Results: As compared to control and CO 2 AFL laser alone, the combination of CO 2 AFL and IPL demonstrated statistically significant improvement across a greater number of scar domains, as assessed by the MSS. 100% of subjects in both treatment groups showed a statistically significant decrease in the POSAS scale after the series of four treatment sessions. No adverse events were reported. Conclusion: Treatment with combined IPL and CO 2 AFL demonstrated higher average improvements across the majority of assessed scar domains, as compared to both control and CO 2 laser alone. The difference was not statistically significant in overall MSS score as expected due to the role of CO 2 as the main source of improvement. However, only the combination group had statistically significant improvement in both color and texture. These findings support the assertion that a multi-photo-thermolytic approach with combined IPL and CO 2 AFL can have a positive impact on the treatment of hypertrophic scars by using multiple wavelengths to maximize laser-skin interactions in targeting the different chromophores expressed in scar tissue. Lasers Surg. Med.
Background and Objectives: This study challenges the currently accepted treatment parameters of waiting 1 year following burn injury to treat the resultant scarring. It assesses the impact of treating burn and trauma wounds at less than 3 months of injury on scar formation, providing a new temporal paradigm to patients in the prevention and minimization of scar formation. Study Design/Materials and Methods: This randomized clinical trial included 19 patients with moderate-tosevere acute burn injuries less than 3 months from injury. The treatment areas underwent three fractional ablative CO 2 laser treatments at 8-week intervals. The primary outcomes were improvement in the Manchester Scar Scale (MSS) and photography. Secondary outcomes were optical coherence tomography (OCT), treatment time, immediate post-treatment response, and histology. Results: Upon blinded evaluation, 100% of treatment areas were correctly identified when compared with control. MSS scores before and after treatment were totaled with an averaged sum of 13.33 per scar at baseline to 8.39 after treatment, a 63% average improvement versus control (P < 0.001). Histology and OCT demonstrated a re-organization of the underlying skin structure. The average treatment time was 18 minutes. Immediate posttreatment responses were limited to mild-to-moderate erythema. Conclusions: Early intervention with ablative fractional laser on acute traumatic wounds resulted in significant decrease of scar formation compared with untreated areas on the same wounds, providing an impactful new time course to treat severe burn and trauma injuries. Lasers Surg. Med.
Background Coordination between breathing and swallowing helps prevent aspiration of foreign material into the respiratory tract. We examined the effects of anesthesia, and hypercapnia on swallowing-breathing coordination. Methods In a randomized controlled cross-over study, general anesthesia with propofol or sevoflurane was titrated using an up-down method to identify the threshold for suppression of the motor response to electrical stimulation of the forearm. Additional measurements included bispectral index, genioglossus electromyogram, ventilation (pneumotachometer), and hypopharyngeal pressure. During wakefulness and at each level of anesthetic, carbon dioxide was added to increase its end tidal pressure by 4 and 8 mmHg. A swallow was defined as increased genioglossus activity with deglutition apnea and an increase in hypopharyngeal pressure. Spontaneous swallows were categorized as physiological (during expiration or followed by expiration), or pathological (during inspiration or followed by an inspiration). Results A total of 224 swallows were analyzed. Anesthesia increased the proportion of pathological swallows (25.9% versus 4.9%), and decreased the number of swallows per hour (1.7 ± 3.3 versus 28.0 ± 22.3) compared to wakefulness. During anesthesia, hypercapnia decreased hypopharyngeal pressure during inspiration (-14.1±3.7 versus -8.7±2 mmHg), and increased minute ventilation the proportion of pathological swallows (19.1% versus 12.3%), and the number of swallows per hour (5.5 ±17.0. versus 1.3 ± 5.5). Conclusions Anesthesia impaired the coordination between swallowing and respiration. Mild hypercapnia increased the frequency of swallowing during anesthesia and the likelihood of pathological swallowing. During anesthesia, the risk for aspiration may be further increased when ventilatory drive is stimulated.
Background and Purpose Hypertrophic and keloid scars can have a dramatic impact on the quality of life for patients. Their complexity and multimodal nature also present significant challenges to physicians. Each scar presentation is unique due to influences such as the source of injury and specific healing properties of the patient. As such, each treatment must be equally individual. The goal of this study is to provide the tools to navigate complex hypertrophic and keloid scar treatment by outlining treatment algorithms that can be tailored to each specific presentation. Methods The authors combined a review of rising clinical research and consensus papers with lessons drawn from clinical practice to create comprehensive treatment recommendations. Results A wide variety of treatment options were incorporated into the algorithms which were drawn from world scar expert consensus including moisturization/compression, surgery, laser therapy, and laser‐assisted drug delivery. Scars of all ages were included and should be treated, though age should factor into treatment intensity. Particularly with hypertrophic and keloid scars, location and resulting tension is a primary consideration in treatment strategy. In keloid scars, radiation therapy can also play a role. Conclusion The authors propose that a combination treatment strategy customized to scar type, depth, texture, and dyschromia is necessary to produce optimal results. Early intervention is preferable though not essential to achieve scar mitigation. With careful and appropriate treatment algorithms, patients with debilitating scarring may recover significant function, cosmesis, and overall quality of life.
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