Evidence-Based Scar Management: How to Improve Results with Technique and Technology

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Ibrahim Khansa and colleagues have recently published a very interesting systematic review based on the available published literature entitled “Evidence-Based Scar Management: How to Improve Results with Technique and Technology” (Plast Reconstr Surg. 2016;138:165S–178S).1 We would like to congratulate Khansa et al. for their article, which analyzes and compares the currently available methods to prevent or improve hypertrophic scars, keloids, and striae distensae.
Their review points out how the risk of development of hypertrophic or aesthetically unpleasant scars can be reduced with tension-free closure, wound edge eversion, the use of occlusive dressings such as silicone gel, and early pulsed dye laser treatment. A multimodal approach is indeed the standard of care in the treatment of keloids.
Considering the data listed in the article and the interesting conclusions, we would like to add our more recent experience in the use of autologous fat grafting as a valid option in the treatment of scars.2 In different clinical settings, we have observed how autologous fat grafting has been proven to be an effective and safe procedure for treating scars of different origins, demonstrating the capability of lipostructure to achieve architectural remodeling and loose connective regeneration. Treated areas regain characteristics similar to those of normal skin, becoming softer and more elastic.
The benefits of using fat grafting depend on its regenerative properties, which in turn derive from its high content of cytokines and mesenchymal stem cells that are responsible for neovessel formation. We process fat with centrifugation to concentrate a higher number of viable cells with regenerative potential in a smaller amount of inoculum, which makes this method ideal for the treatment of retracting scar tissue.
In our clinical experience, autologous fat grafting is associated with amelioration both from aesthetic and functional points of view, showing its effectiveness also in improving scar-associated movement impairment. Moving from our experience, we recently published a series of 36 children affected by pathologic dwarfism treated for postsurgical scars resulting from correction of short stature.
Clinical assessment of the study population was conducted using a modified Patient and Observer Scar Assessment Scale, to which a new item was added in the patient section to investigate scar-related movement impairment. This new parameter has been shown to be the feature most closely related to overall patient satisfaction and therefore to patient quality of life.3 Furthermore, lipostructure is the unique scar therapy able to control the process of scar-associated neuropathic pain.
In our studies on postmastectomy pain syndrome and on Arnold neuralgia, we demonstrated how fat grafting can reduce pain with a clinical reduction of visual analogue scale scores.4 We postulate that the described analgesic effect is related to nerve liberation and to an induction of molecular changes in the microenvironment of posttraumatic scar, which is hostile to regeneration of the nervous system because of intrinsic inhibitory factors expressed by the extracellular matrix.4
These conclusions are confirmed by our experience in patients affected by postmastectomy pain syndrome after they have undergone radiotherapy. In this clinical setting, we hypothesize that mesenchymal stem cells could also inhibit production of proinflammatory cytokines, which can induce peripheral and central sensitization with a failed nociception system, leading to pain augmentation.5
In conclusion, considering its safety, efficacy, and optimal tolerability, we are persuaded that autologous fat grafting is an innovative surgical option for scar tissue treatment. Its regenerative effects are evident not only as an improvement of the skin’s complexion, but also as a reduction of pain and as better join mobility.
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