THE TREATMENT OF BURN SCARS: OUR EXPERIENCE

loannovich J., Panayotou R., Mantas N., Alexakis D.

Center of Plastic Surgery and Microsurgery, General State Hospital of Athens, Greece

SUMMARY. Scar evolution leads to three possible abnormalities: scar contractures, hypertrophic scars and keloids. As the quality of a scar is however unpredictable, preventive measures, including the use of fatty ointments and continuous pressure, should always be taken. Splints are also useful. The treatment of the three main abnormalities is described. No method is perfect and the aim in the treatment of burn scars must therefore be the prevention of abnormalities by early excision of the primary bum wound.

The scar is the end result of wound healing in the deep partial thickness and full thickness burns. According to its pathology, scar evolution leads to the formation of three different types of abnormality:

1. scar contractures
2. hypertrophic scars
3. keloids.

The evolution of the scar depends on various factors, of which some can be altered by therapeutic measures. Others can influence the quality of the scar in a negative way, such as the site of the scar, its healing process, the age, sex and race of the patient, etc. (Peacock and Winkle 1976).
Nevertheless, the quality of a scar is unpredictable, especially for the first 10-15 days after its appearance. For this reason preventive measures should be undertaken in time to avoid the manifestation of an abnormal scar (Tab. 1).
The experimental trials of Ohura (1989) have recently demonstrated that fatty ointments penetrate easily into the scars and the surrounding normal skin. It seems that the maintenance of a fatty milieu around the scar diminishes the period of aseptic inflammation and excludes irritation by the exfoliation of the new scar.
Many observations reveal that from the preventive point of view the combination of this treatment with continuous pressure has encouraging results, especially in extended burn scars.
Pressure does not allow the formation of interstitial oedema and restricts the development of new capillaries, when applied in a range of 15-40 min Hg (Harries and Pegg 1989).
For this purpose the well-known garments have been invented (Figs. 1, 2). They should be applied two weeks after grafting or when spontaneous healing has occurred. They should be worn for 9-12 months, all day long, until the scars become soft, flat and pale in colour.
Although compression was first described by

Dupuytren in 1832 there is still some controversy regarding its mode of action and even of its necessity. In our department we routinely use the combination of ointment and pressure garment treatment for at least 9-12 months for scars in all parts of the body, except the face, where the application of garments is not easily tolerated by our patients.

Preventive measures for scar formation, especially after skin grafting, include the use of splints, particularly in the neck, the upper extremities and hands. They lead, through immobilization, to a softening of the scar. Immobilization in an extreme extension position, as in burns of the neck, leads to diminished contracture (Fig. 3).

In burns, contracture usually appears when the scar line is vertical to the skin tension lines, as in scars over a joint. It should be emphasized that the primary treatment of the burn wound should actually aim to diminish scar contracture by grafting the patients as soon as possible. In some cases pediele flaps or even free flaps can be used primarily to cover the defect and prevent contracture.
The treatment of choice for scar contracture is scar revision, combined with another surgical procedure, according to the localization, extent and shape of the scar. For example, Z-plasty can redirect the scar and reduce skin tension (Fig. 4 a, b). If on the other hand the scar contracture leads to a restriction of the full range of motion, skin grafting or the use of a flap is indicated to cover the tissue defect.
Tissue expanders can be used today in different shapes and volumes as a secondary procedure to reconstruct defects (Fig. 5 a, b). We do not use tissue expansion for a primary closure of an open wound: In severe contractions skin grafts still give as good results as the myocutancous or fasciocutaneous axial flaps. It is up to the surgeon to decide which method to use.

Hypertrophic scars are more commonly seen in burn wounds. It is clinically very difficult to differentiate them from keloids arising from bum wounds, although they are different pathological entities.
Hypertrophic scars always develop when the primary excision is delayed more than 10 days post-bum. Due to aseptic inflammation, it is not advisable to operate before the first 8 months, unless the scar causes functional disorders. Meanwhile, in our department, we apply various conservative measures, depending on the scar extent.
Localized scars of small extent are treated with steroid injections. We have found that the use of an air-jet apparatus ("dermo-iet") is more efficient than the injection with an ordinary needle (Fig. 6). With such a needle it is more or less impossible to inject the medicament intralesionally, because of the fibres' density. The jet-apparatus has the property of having the appropriate pressure, and the moment of "firing", to insert the medicament intralesionally. It seems that the main advantage of the dermo-jet lies in the pressure, which causes a destruction of the irregularly woven fibres. It seems that steroids are also necessary, although it causes a destruction of the fibres. According to our policy we estimate the response to the treatment after the second session, when the hyperti-lophic scar becomes softer and itching disappears. The treatment continues in sessions till the scar becomes thinner and softer. The colour change is the last of the symptoms to be restored and is observed some months after the treatment is finished.

Fig. 4 Narrow axillary contracture (a), corrected by the use of multiple Z-plasty (b).

Fig. 5 Hypertrophic bum scar on the elbow area (a), and (b) the position of a rectangular tissue expander under the adjacent healthy skin for a latter reconstruction of the scar. (The tissue expander is partially inflated.)

The surgical treatment varies depending on the extent and the site of the hypertrophic scar. Small scars can be revised and removed, the defect being covered by local or distant flaps. In extensive scars tension should be released primarily, because the scar will not soften and more importantly constant irritation may lead to the formation of precancerous lesions. The defects resulting from the relief of tension are covered by split thickness skin grafts, which in some cases are meshed.
Small and multiple hypertrophic scars should be treated by dermabrasion (Schreuss 1949, 1965). We avoid applying this method during the late spring and summer time, since sun irradiation in our country can result in deeper coloured areas of the skin. In our experience the results are not very satisfactory when dermabrasion is applied to patients of darker skin, since it results in a whitish skin area.

Our experience in the treatment of keloids is limited, since in our population their incidence is very low. Irradiation (Chaoul's intensive irradiation) should not be considered the therapy of choice 'in benign lesions and in particular in keloids, because of its serious side effects. The combination of excision and post-operative irradiation seems to have good aesthetic results without being of any harm to the patient (Schumacher 1972).
The. application of continuous compression as well as of steroids is unfortunatelly not efficient for the treatment of keloids.
The use of the C02-laser to excise the keloid combined with local compression has been recently applied but the results are not encouraging (Apfelberg 1987).
The removal of the keloid and coverage of the defect with skin grafts or flaps, combined with continuous compression, seem to be the method which brings the most satisfactory results, and the fewest recurrences.
In conclusion, the treatment of scars cannot be generalized and should always be individualized for each patient. It should be stressed that our efforts to treat bums must always include the consideration of facing a future disfiguring or disabling scar.
It is evident that none of the above methods gives perfect results. For this reason the main aim in the treatment of burn scars is to limit their development by performing an early excision of the primary bum wound.

RÉSUMÉ. L'évolution des cicatrices porte à trois abnormalités possibles: les contractures cicatricielles, les cicatrices hypertrophiques, et les chéloïdes. Puisque la qualité de la cicatrice est toujours imprévisible, il faut en tout cas adopter des mesures de prévention, comme par exemple l'emploi d'onguents grais et la pression continuelle. Les échelles sont aussi utiles. Les auteurs décrivent le traitement des trois types principaux d'abnormalité. Il n'existe pas de méthode parfaite et le but du traitement des brûlures doit être pourtant la prévention des abnormalités à travers l'excision précoce de la zone primaire brûlée,

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