Scars caused by burns, scalds and other traumatic injuries often lead to severe physical and psychological pain and economic burden for patients. The earlier the trauma heals and the less scarring there is, the more timely the scar treatment is, the less sequelae there will be, if the correct treatment is taken early after the injury. Therefore, burn scar rehabilitation and scar repair is an important part of modern burn treatment, and timely and correct scar rehabilitation treatment can significantly improve the quality of burn healing and reduce the disability rate.
I. The formation of burn scars
The healing of burn wounds, scar formation and scar proliferation remodeling is a complex pathological process, and the repair of wounds is the process of scar formation, and the healing of wounds is scar healing. The deeper the trauma, the larger the scar formed, the longer the healing time, and the more serious the scar formation. Scar tissue is an adverse reaction of excessive trauma repair, which not only affects the appearance but also leads to various functional disorders in different degrees, which appears more prominent in self-healing deep II degree burn wounds.
Human skin is composed of epidermis, dermis and subcutaneous tissues, between which are distributed skin appendages such as sweat glands, hair follicles, hair and sebaceous glands, as well as blood vessels, nerves and lymph.
Injuries to the epidermis are mainly repaired by the proliferation of epidermal basal cells, usually with no or minor scars. Injury to the dermis and subcutaneous tissue results in scarring, which is associated with prolonged wound repair, inflammatory cell proliferation, fibrosis of granulation tissue, and excessive collagen deposition with collagen conformation disorders, which are the main causes of scar formation. Scar tissue lacks normal skin structure and usually has missing or damaged skin appendages such as hair follicles, sebaceous glands, and sweat glands, which also leads to uncomfortable symptoms such as dryness, itching, irritation, numbness, and pain. The common types of scars in clinical practice are: flat scars, hyperplastic scars, atrophic scars, contracture scars, depressed scars, scar scars, and scar cancer. Among them, there are two types of scars worth noting: keloid scars and hyperplastic scars. Hyperplastic scars bulge the skin surface but are confined to the range of the scar site; while keloid scars exceed its original onset range and invade the surrounding normal tissues, easily causing abnormal proliferation and even malignant changes.
Second, the characteristics and treatment of proliferative scars
The formation process of burn scars can be roughly divided into proliferative phase, stable phase and fading phase. The duration of proliferative phase varies from 3 months to 2 years, and most of them are around half a year to one year.
Hyperplastic scars are common in deep II degree self-healing wounds, thin to medium-thick skin implant wounds of III degree burn wounds, full skin and sutures around skin flaps. Also, most commonly, incisional scars after suturing of any incision also fall into this category. Hyperplastic scars appear as protruding surfaces, irregular in shape, uneven in height, flushed and congested, and solid and tough in texture. There is burning pain and itching sensation. Hyperplastic scars are characterized by early local swelling and hardening and congestion, with a superficial layer covered by a layer of atrophied epithelial cells, a middle layer of vascular proliferative scar expansion with inflammatory cell infiltration, and an underlying layer of fewer collagen fibers and a large amount of connective tissue proliferation. These scars are raised above the skin surface, with early localized thickening and hardening, and capillary congestion appearing red or dark red. The shape and size of hyperplastic scars vary depending on the circumstances of the injury: surgical incisions are often striped; scratching and injections can cause cords and small lumps; hyperplastic scars in the anterior chest are mostly transverse stripes, often with typical crabfoot-like branches, which some people call butterfly spots; for those occurring after burns or scalds, their size and thickness are closely related to the area and depth of the injury, and the deeper the injury, the thicker the hyperplastic scars The deeper the injury, the thicker the hyperplastic scar. Patients with hyperplastic scars show obvious family heritability. Hyperplastic scars have significant body sites, including the sternum, shoulder deltoid, jaw, and auricle. As the disease progresses, the hyperplastic scars gradually infiltrate the surrounding normal skin beyond the original extent of the injury. In the beginning, the fibers of the scar proliferate rapidly and in large numbers. After excessive fibers have proliferated, they often close the blood vessels inside the scar, causing it to become gradually ischemic.
Treatment of hyperplastic scars.
At present, local protection, medication, silicone, compression therapy, hormone closure and rehabilitation exercise are mostly used at home and abroad, and surgery is generally not recommended, and surgery will be considered after its proliferation and remodeling is completed. Other treatments such as grinding therapy, radiation therapy, fat injection method, chemical peeling method, perforated chisel excision method, laser skin rubbing method, etc. have different effects, and if used improperly, they will produce new scars, or uneven discoloration. Specific treatment methods are as follows.
(1) Local protection: pay attention to skin cleanliness and hygiene. When the burn wound is just healed, there are still a small amount of secretions and scabs, bacteria are easy to multiply quickly, plus the epidermis is thin and tender, the structure and function are not perfect, easy to occur infection, breaking. During this period, you can use neutral detergent to clean and keep dry and hygienic. Avoid excessive abrasion and excessive activity. Due to the imperfect structure and function of the scar epidermis, the epidermis is more susceptible to damage and some inappropriate treatments may aggravate the damage and stimulate scar proliferation. Local protection such as scar patches can be used.
(2) Topical medication: At present, the drugs such as silicone, moisturizing and anti-itch medicine, cumene cream, etc. When applying anti-scar medication, it is not advisable to massage excessively hard or for too long, which will cause the epidermis to separate from the fibrous plate layer to form blisters or blood blisters, and excessive activity of joint parts will likewise cause the epidermis to loosen and separate and blister.
(3) Intra-scar drug injection therapy: At present, the more applied ones are hormones and calcium antagonists, the former are Trimethoprim, Coninextron-A, and the latter are Verapamil, which have clear efficacy; there are other drugs such as collagenase, anti-tumor drugs, immunosuppressants, Benadryl, etc.
(4) Compression therapy: Its the most definite treatment method with the most definite efficacy, such as compression therapy with elastic sleeve should be applied promptly after the burn heals. As long as it is well executed, it will definitely have an effect, adhering to the principle of “early, tight and lasting”, with a pressure of 15-18 mmHg.
(5) Radiation therapy: For some stubborn and obvious hyperplastic keloids and keloid scars, radiation therapy can be chosen, but the indications and the scope and dose of irradiation should be strictly controlled to avoid adverse complications.
(6) Laser treatment: For some flat scars and punctiform scars, laser treatment is one of the ideal choices.
(7) Functional exercise: For some patients with severe dysfunction, functional rehabilitation training should be carried out at the same time as the above treatment, so that the joints are in a functional position, and patients should be urged to move actively, supplemented by passive activities, to help and encourage patients to pass the “pain barrier”, to carry out body therapy and massage, and to take bathing therapy, also known as hydrotherapy, and at the same time Occupational therapy and daily life training are also needed, and various devices and equipment can be used to help patients better. Try to take care of themselves and return to society.
3.Surgical treatment of burn scars
According to the characteristics and parts of the scars, the correct choice of surgery and timing, for the functional parts of the scar contracture, such as head, face, hand scars, eye scars, jaw and neck scars, should be operated as early as possible after the scars are stabilized, especially for children, should be treated earlier, and can be properly advanced plastic surgery. Otherwise, it can cause abnormal joint and bone development and vascular nerve shortening, resulting in disability.
(1) Direct excision and suturing: For small scars, direct excision and suturing can be used for treatment. However, it is not applicable to scars with pimples. Generally speaking, scars with a width of 100px or less in areas with loose skin and scars with a width of 25px or less in areas with tense skin can be excised and sutured directly.
(2) Split excision and suture: When the scars are wide and cannot be directly excised at one time, they can be excised in stages with an interval of 3 months to 6 months between surgeries.
(3) Scar excision and implantation: For scars that cannot be directly excised, scar excision and implantation can be used depending on the situation, and the skin is usually taken from a part of the body that is close to the scar site but not more hidden.
(4) Scar-cutting flap grafting: flap refers to a tissue block including skin and subcutaneous tissue with its own blood supply, and there are many types of flaps. Generally, the flap is commonly used as a random flap. The flap, especially the local flap, is similar in color, thickness and softness to the local tissue of the scar, and the repair result is ideal, so it is a better method, but it often requires multiple incisions and there is a risk of necrosis of the tissue block.
(5) Skin expansion followed by scar flap transfer: Skin expansion is a technique of implanting expanders in the deep surface of the skin and gradually expanding its surface skin area. The skin expander provides “extra” skin for repairing and replacing adjacent scar or other skin defects and deformities without skin donor area, and the repaired skin has the same color, texture, sensation and function as normal skin tissue. The skin expander is a balloon-like silicon capsule that can be injected with saline through an injection jug to expand the expansion capsule. The application of skin dilatation for skin scarring or other deformities generally requires two procedures and 1-3 months of dilation. In the first operation, the dilator is implanted under the normal skin adjacent to the area to be repaired. After the incision has healed, a certain amount of saline is injected into the dilator periodically, and the dilator gradually expands while the skin area on its surface is also expanded. If the expanded skin area reaches the required requirement for repair, a second surgery can be performed to remove the expander, excise the scar tissue, and then repair the skin defect in the form of a flap with the expanded excess skin. For patients with a large scar area and no normal skin around, additional skin tissue is obtained from a hidden area away from the defect using skin expansion techniques and repaired by skin grafting.
(6) Currently, microdermabrasion is popular: it has good therapeutic effect for superficial facial scars.