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      The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation.

      Plastic and Reconstructive Surgery
      Adolescent, Adult, Aged, Attitude to Health, Burns, complications, Cicatrix, classification, etiology, pathology, Humans, Linear Models, Middle Aged, Observer Variation, Patients, Questionnaires, Reproducibility of Results

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          Abstract

          At present, various scar assessment scales are available, but not one has been shown to be reliable, consistent, feasible, and valid at the same time. Furthermore, the existing scar assessment scales appear to attach little weight to the opinion of the patient. The newly developed Patient and Observer Scar Assessment Scale consists of two numeric scales: the Patient Scar Assessment Scale (patient scale) and the Observer Scar Assessment Scale (observer scale). The patient and observer scales have to be completed by the patient and the observer, respectively. The patient scale's consistency and the observer scale's consistency, reliability, and feasibility were tested. For the Vancouver Scar Scale, which is the most frequently used scar assessment scale at present, the same statistical measurements were examined and the results of the observer scale and the Vancouver scale were compared. The concurrent validity of the observer scale was tested with a correlation to the Vancouver scale. Furthermore, the authors examined which specific characteristics significantly influence the general opinion of the patient and the observers on the scar areas. Four independent observers have each used the observer scale and the Vancouver scale to assess 49 burn scar areas of 3 x 3 cm belonging to 20 different patients. Subsequently, the patients completed the patient scale for their scar areas. The (internal) consistency of both the patient and the observer scales was acceptable (Cronbach's alpha, 0.76 and 0.69, respectively), whereas the consistency of the Vancouver scale appeared not to be acceptable (alpha, 0.49). The reliability of the observer scale completed by a single observer was acceptable (r = 0.73). The reliability of the Vancouver scale completed by a single observer was lower (r = 0.69). The observer scale showed better agreement than the Vancouver scale because the coefficient of variation was lower (18 percent and 22 percent, respectively). The concurrent validity of the observer scale in relation to the Vancouver scale is high (r = 0.89, p < 0.001). Linear regression of the general opinions on scars of the observer and the patient showed that the observer's opinion is influenced by vascularization, thickness, pigmentation, and relief, whereas the patient's opinion is mainly influenced by itching and the thickness of the scar. Such an impact of itching and thickness of the scar on the patient's opinion is an important and novel finding. The Patient and Observer Scar Assessment Scale offers a suitable, reliable, and complete scar evaluation tool.

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          Most cited references8

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          A new quantitative scale for clinical scar assessment.

          Wound healing in adult human skin results in varying degrees of scar formation, ranging clinically from fine asymptomatic scars to problematic hypertrophic and keloid scars, which may limit function and restrict further growth. At present, no good objective method of clinically assessing scars exists, which is problematic for the evaluation of scar prevention or treatment regimens. Similarly lacking are histologic correlates of what we consider good and bad clinical scars. The objective of this study was to quantitatively assess human scarring (1) clinically, by developing a comprehensive rating scale, (2) photographically, using an image capture system and a scar assessment panel, and (3) by histologic analysis following scar excision. We assessed 69 scars, with a wide clinical range of severity, in patients who were undergoing surgery, for whatever reason, that involved removal of an old scar. Preoperatively, patients had their scars assessed, clinically using our newly developed scale and photographically using a computerized image capture system. These photographs were then sent to a panel for assessment using similar criteria to those used clinically. Assessment of scars from photographs correlated well with the clinical scar evaluation, indicating its potential utility in multicenter scar prevention/treatment trials. Following excision, scars were processed and analyzed for histology. We also found a strong correlation between the macroscopic and microscopic appearance of scars, particularly between the clinical appearance and histologic scores of features in the epidermis and papillary dermis. This suggests that our clinical scale is a sensitive instrument in scar assessment, allowing validated quantification of the severity of a wide range of scars.
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            Reconstructive surgery with a dermal regeneration template: clinical and histologic study.

            Integra artificial skin was introduced in 1981 and its use in acute surgical management of burns is well established, but Integra has also been used in patients undergoing reconstructive surgery. Over a period of 25 months, the authors used Integra to cover 30 anatomic sites in 20 consecutive patients requiring reconstructive surgery and then analyzed the clinical and histologic outcomes. The most common reason for surgery was release of contracture followed by resurfacing of tight or painful scars. The authors assessed patients' satisfaction using a visual analog scale and scar appearance using a modified Vancouver Burn Index Scale. They evaluated the progress of wound healing by examining weekly punch-biopsy specimens with standard and immunohistochemical stains. Patients reported a 72 percent increase in range of movement, a 62 percent improvement in softness, and a 59 percent improvement in appearance compared with their preoperative states. Pruritus and dryness were the main complaints, and neither was improved much. Four distinct phases of dermal regeneration could be demonstrated histologically: imbibition, fibroblast migration, neovascularization, and remodeling and maturation. Full vascularization of the neodermis occurred at 4 weeks. The color of the wound reflected the state of neodermal vascularization. No adnexa, nerve endings, or elastic fibers were seen in any of the specimens. The new collagen was histologically indistinguishable from normal dermal collagen. The authors conclude that Integra is a useful tool in reconstructive surgery. The additional cost of its use can be justified by its distinct benefits compared with current methodology.
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              Rating the Resolving Hypertrophic Scar : Comparison of the Vancouver Scar Scale and Scar Volume

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