Wound Healing – Scar Minimization · Wound Healing – Scar Minimization ... Optimization of...
Transcript of Wound Healing – Scar Minimization · Wound Healing – Scar Minimization ... Optimization of...
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Wound Healing –Scar Minimization
Ben McIntire, MDFaculty Mentor: Harold Pine, MD, FAAP, FACS
The University of Texas Medical BranchDepartment of Otolaryngology
Grand Rounds PresentationMarch 28, 2014
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Scar management
“Put sunscreen on it”
“If it feels hard, you can massage it”
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Objectives
• Describe the phases of wound healing
• Identify factors which can optimize wound healing
• Understand the goals of scar management
• Describe techniques and products which can aid in scar minimization
• Understand how to apply these techniques and products in the pediatric population
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Disclosure
• I have no financial incentive on behalf of any of the products mentioned in this presentation
• All pictures used without permission
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Phases of wound healing
1 Inflammatory
– Hemostatic– Cellular
2 Proliferative
– Reepithelialization– Neovascularization– Collagen deposition
3 Remodeling/maturation
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Phases of wound healing
1 Inflammatory (hemostatic):
– Convergence of coagulation cascade, complement cascade, and platelet activation
1. Vasoconstriction vasodilation
2. Platelet degranulation TGF-β + others
3. Platelet plug formation – activated platelets + fibrin + exposed collagen
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Phases of wound healing
1 Inflammatory (cellular):
– Neutrophils – dominant cell type at 1-2 days• Phagocytosis of debris and bacteria
– Macrophages – dominant cell type at 2-4 days• Regulatory role is essential for wound healing• Secrete TNF-α, TNF-β, IGF-1, and IL-1
– Fibroblasts – dominant cell type at 15 days• Myofibroblasts wound contraction• Produce collagen
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Phases of wound healing
2 Proliferative (reepithelialization):
– Collagenase, plasmin, and MMPs begin remodeling wound bed
– Fibroblasts begin migration from wound edge into wound bed
– Cellular migration occurs at 12-21 μm/hr
• Rate is moisture dependent
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Phases of wound healing
2 Proliferative (neovascularization):
– Granulation tissue formation – serves as scaffold for cellular migration
– Angiogenesis – via migration of endothelial cells; mediated by VEGF
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Phases of wound healing
2 Proliferative (collagen deposition):
– Early formation of type III collagen
– Late formation of type I collagen
• Hydroxylation is vit. C dependent
• Tensile strength due to cross-linking of collagen fibers
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Phases of wound healing
3 Remodeling/maturation:
– Increase in type I collagen deposition
• Decreased scar dimensions
• Increased tensile strength
– 3 weeks – 15% original strength– 6 weeks – 60% original strength– 6 months – 80% original strength
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Optimization of wound healing
• Surgical principles
• Local factors
• Systemic factors
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Optimization of wound healing
• Surgical principles:
– Proper planning of incision
– Appropriate tissue handling
– Minimization of wound tension
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Optimization of wound healing
• Local factors:
– Desiccation
– Infection
In general, addressed with proper dressing and ABX as indicated
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Optimization of wound healing
• Systemic factors:
– Comorbidities
– Hypovolemia
– Malnutrition
In general, addressed with proper medical management, adequate hydration, and nutritional repletion as indicated
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Scar management
• Goals:
– Maintain moisture
– Minimize tension
– Avoid inflammation
– Optimize molecular environment of scar
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Sunscreen
• Rationale – to prevent postinflammatoryhyperpigmentation
– Early scars are composed of disorganized tissue, relative to the well defined, layered, composition of adjacent non-wounded skin
– Therefore UV light can penetrate more deeply into tissue and affect melanogenesis
– UV light shown to upregulate NO and histamine, which are known stimulators of melanogenesis
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Sunscreen
• Efficacy for immature scars is ubiquitously documented
• Evidence is predominately, if not entirely, anecdotal
• Recommendations not established for minimum SPF and duration of treatment
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Sunscreen
• “Rubor perseverans”
– Physiologic, non-inflammatory redness of normal scar
– Due to vascular elements in the immature scar
– Typically resolves in 7 months following incisional wounding, but may persist beyond 12 months
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Sunscreen
Bond et al. (2008)
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Sunscreen
• Recommendations - U. Michigan (2010):
– SPF ≥ 35
– Any time sun exposure is anticipated for ≥ 1 year
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Sunscreen
http://www.amazon.com
Unit price: $3.60/oz
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Scar massage
• Rationale – to optimize the molecular environment of scar
– Mechanical forces induce changes in expression of MMPs and proteases
– Dissolution of fibrotic tissue which increases scar pliability
– Release of beta-endorphins resulting in relief of pain
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Scar massage
• Ubiquitously advised
• Anecdotally effective
• Recommendations not well established regarding time to treatment onset, technique, frequency, and duration of therapy
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Scar massage
• Evidence – Shin and Bordeaux (2012):
– Weak evidence supports use of scar massage in treatment of routine postsurgical scars
– Study design: systematic review (10 articles, total of 144 patients)
– Onset:
• Begin massage after nonabsorbable suture removal (approximately POD#10-14)
• Avoid massage before POD#10-14
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Scar massage
• Evidence – Shin and Bordeaux (2012):
– Method:
• Use enough pressure to blanch scar
• Use nonirritating emollient
• Massage for 10 minutes BID
– Not enough evidence to recommend technique or duration of therapy
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Scar massage
• Evidence - Bodian (1969):
– Study design: case series (14 patients with eyelid/periorbital incisions)
– Technique – rotary movements
– Duration – 1-2 months https://handtherapy.wordpress.com
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Hydration ointments/dressings
• Rationale – maintain moisture
– Moist healing promotes rapid epithelialization
– Retain important molecular messengers within the wound bed
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Hydration ointments/dressings
• Ex: mineral oil, petrolatum-based ointments, semi occlusive dressings (Steri-Strip™), occlusive dressings (Tegaderm™)
• Used to speed healing of fresh surgical wounds
• Ointments used over a longer period of time to improve appearance of surgical scars
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Hydration ointments/dressings
• Evidence – Winter and Scales (1963):
– In wounds covered with an occlusive dressing, reepithelialization is 2x as rapid when compared to wounds without a dressing
– Study design: porcine model
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Hydration ointments/dressings
• Evidence – Jackson and Shelton (1999):
– Applying a petrolatum-based ointment to postsurgical scars resulted in a significant reduction of scar erythema between pre- and post-treatment evaluation (endpoint ~1 month)
– Study design: RCT
– Onset: day of suture removal
– Duration: TID x1 month
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Hydration ointments/dressings
Unit price: $2.00/oz
http://www.amazon.com
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Adhesive microporous hypoallergenic paper tape
• Rationale – maintain moisture, minimize tension, optimize molecular environment of scar
• Use in scar minimization is not common
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Adhesive microporous hypoallergenic paper tape
• Evidence – Atkinson et al. (2005):
– Application of Micropore™ tape to postsurgical scars significantly decreased scar volume and decreased risk of hypertrophic scar formation when compared to untreated scars (endpoint 12 weeks)
– Study design: RCT (cesarean scars)
– Onset: after suture removal
– Duration: 12 weeks (tape changed 2x per week)
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Adhesive microporoushypoallergenic paper tape
Unit price: $0.01/in.
http://www.amazon.com
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Silicone gel/sheeting
• Rationale – maintain moisture, therapeutic effect of silicone?
• Often recommended to patients for treatment of existing keloids and hypertrophic scars
– Mixed evidence exists to support this recommendation
• Not often mentioned for prophylaxis of postsurgical scars
– Relatively well studied
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Silicone gel/sheeting
• Evidence - Signorini and Clementoni (2007):
– Silicone gel application to postsurgical scars resulted in significant improvement in scar appearance when compared to untreated scars (endpoint 6 months)
– Study design: RCT
– Onset: POD#10-21
– Duration: BID x4 months
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Silicone gel/sheeting
• Evidence - Chan et al. (2005):
– Silicone gel application to postsurgical scars demonstrated significant improvement in pigmentation, vascularity, pliability, and height when compared to scars treated with a water-based gel (endpoint 3 months)
– Study design: double-blinded RCT
– Onset: POD#14
– Duration: BID x3 months
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Silicone gel/sheeting
• Evidence - Gold et al. (2001):
– Silicone sheet application to postsurgical scars resulted in a significant decrease in abnormal scar formation, in high-risk patients, when compared to untreated scars (endpoint 6 months)
– Study design: RCT
– Onset: POD#2
– Duration: ≥ 12 hrs/d x6 months
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Silicone gel/sheeting
• Evidence - Niessen et al. (1998):
– Neither silicone gel nor silicone sheets demonstrated significant improvement in height/width/color of postsurgical scars when compared to scars treated with Micropore™ tape (endpoint 12 months)
– Study design: RCT
– Onset: POD#3
– Duration: 24 hrs/d x3 months
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Silicone gel/sheeting
Unit price: $90.00/oz
http://www.amazon.com
http://www.amazon.comUnit price: $0.71/sq. in.
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Moist exposed burn ointment (MEBO)
• Rationale – maintain moisture, therapeutic effect of plant extracts?
• Patented in 1995 in USA
• 6 herbal extracts in a base of beeswax and sesame oil
• Active ingredient – β-sitosterol
• Characteristics – strong smell
• Side effects: acne exacerbation
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Moist exposed burn ointment (MEBO)
• Evidence - Atiyeh et al. (2003):
– STSG donor sites treated with MEBO demonstrated significantly faster reepithelialization and better scar quality when compared to treatment with a Tegadermdressing (endpoint 6 months)
– Study design: RCT
– Onset: POD#0
– Duration: daily application until reepithelializationoccured
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Moist exposed burn ointment (MEBO)
• Evidence - Atiyeh et al. (2003):
– Postsurgical facial incisions treated with MEBO demonstrated cosmetically better scars when compared to incisions with no treatment or those treated with ABX ointment (endpoint 6 months)
– Study design: controlled trial
– Onset: POD#0 or after steri-strip removal
– Duration: TID-QID x6 weeks
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Moist exposed burn ointment (MEBO)
Unit price: $21.00/oz
http://www.amazon.com
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Pressure dressing
• Rationale – to optimize the molecular environment of scar
– Compression induces apoptosis and modulates cytokine expression to prevent scar hypertrophy
• Ubiquitous use in management of hypertrophic scars and burn scars
– Anecdotally effective
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Pressure dressing
http://www.dentalhypotheses.com
• Evidence – Russell et al. (2001):
– Zimmer splints, along with a single corticosteroid injection, resulted in ≥50% reduction in keloid size in each patient studied (endpoint 12 months)
– Study design: case series
– Onset: not stated; patients with keloids following ear piercing
– Duration: ≥12 hrs/d x6 months
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Pressure dressing
• Evidence:
– No evidence to support the use of pressure dressings to improve the appearance of keloids in other parts of the body
– No evidence to support the use of pressure dressings to improve the appearance of normal postsurgical scars
http://www.colonialmedical.com
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Vitamin E
• Rationale – antioxidant properties reduce the amount of reactive oxygen species during the inflammatory phase of wound healing
• Topical α-tocopherol in an oil base
• Role as an antioxidant is well studied in-vitro
• Anecdotally effective to speed wound healing and improve scar appearance
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Vitamin E
• Evidence - Baumann and Spencer (1999):
– Topical Vitamin E application did not demonstrate a significant difference in the cosmetic appearance of postsurgical scars when compared to scars treated with a petrolatum-based ointment (endpoint 12 weeks)
– Topical Vitamin E application resulted in an increased incidence of contact dermatitis when compared to application of a petrolatum-based ointment
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Vitamin E
• Evidence - Baumann and Spencer (1999):
– Study design: double-blinded RCT
– Onset: POD#0
– Duration: BID x4 weeks
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Vitamin E
http://www.amazon.com
Unit price: $5.50/oz
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Vitamin D
• Rationale – decrease the risk of hypertrophic scars due to its role as an anti-inflammatory molecule and its ability to decrease keratinocyte proliferation
• Calcipotriol (synthetic Vitamin D derivative)
– Currently used in topical treatment of psoriasis
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Vitamin D
• Evidence - van der Veer et al. (2009):
– Application of topical calcipotriol to postsurgical scars demonstrated no significant difference in the prevalence of hypertrophic scars, when compared to placebo treated scars (endpoint 12 months)
– Study design: double-blinded RCT (did not study scar appearance or content of placebo ointment)
– Onset: POD#10
– Duration: BID x3 months
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Vitamin D
http://www.ioffer.com
http://www.amazon.com
Unit price: $5.00/oz
Unit price: $50.00/oz
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Mederma®
• Rationale – the anti-inflammatory properties of Quercetin could improve raised, erythematous, or otherwise symptomatic scars
• Very popular OTC product aimed at scar minimization
• Active ingredient – allium cepa (onion extract)
– Derivative is Quercetin
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Mederma®
• Evidence - Jackson and Shelton (1999):
– Application of Mederma® to postsurgical scars demonstrated no significant difference between pre- and post-treatment evaluation of scar erythema
– Study design: RCT
– Onset: day of suture removal
– Duration: TID x1 month
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Mederma®
• Evidence - Chung et al. (2006):
– Application of Mederma® to postsurgical scars demonstrated no significant difference in scar appearance or symptomatology, when compared to treatment with petrolatum-based ointment (endpoint 12 weeks)
– Study design: double-blinded RCT
– Onset – day of suture removal
– Duration – TID x8 weeks
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Mederma®
http://www.amazon.com
Unit price: $29.00/oz
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Product summary
• Remember fundamentals:
– Maintain moisture and decrease tension
– Reasonable to use Steri-Strips™ at time of wound closure
– Reasonable to begin topical therapy after sloughing of Steri-Strips™ or removal of nonabsorbablesutures
– Reasonable to continue topical therapy 6-12 months
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Product summary
• Sunscreen – Overwhelming opinion recommends use in treatment of routine postoperative scars– SPF ≥ 35 for ≥ 1 year
• Scar massage – Weak evidence to support use in treatment of routine postoperative scars– 10 min BID x1-2 months
• Hydration (petrolatum-based) ointment – Evidence supports use in treatment of routine postoperative scars– TID x1 month
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Product summary• Micropore™ tape – Evidence supports use in
treatment of routine postoperative scars– continuous x12 weeks; change 2x per week
• Silicone gel – Mixed evidence supports use in treatment of routine postoperative scars– BID x3-4 months
• Silicone sheets – Mixed evidence supports use in treatment of routine postoperative scars– ≥ 12 hrs/d x3-6 months
• MEBO – Evidence supports use in treatment of routine postoperative scars– TID-QID x6 weeks
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Product summary
• Pressure dressing – no evidence to support use in treatment of routine postsurgical scars
• Vitamin E – no evidence to support use in treatment of routine postoperative scars; some authors discourage use in treatment of routine postoperative scars
• Vitamin D – no evidence to support use in treatment of routine postoperative scars
• Mederma® – no evidence to support use in treatment of routine postoperative scars
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Pediatric pearls
• Infants have immature epidermal-dermal bond
• Protect epidermis with proper dressing:
– Opt for ointment rather than adhesive dressing
– If using adhesive dressing, opt for latex-free hypoallergenic paper tape (Micropore™) to decrease skin trauma
– Foam dressings (Mepilex®) are more absorptive than plain gauze, allowing for decreased frequency of dressing changes
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Pediatric pearls
• Prevent pain:
– In infants, consider distraction technique or oral sucrose administration during dressing changes
– In children, always pre-medicate with analgesics before dressing changes
– For painful wounds or difficult locations, consider anxiolytic administration along with analgesics before dressing changes
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Thank you!
https://peerj.com/articles/37/
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Scar management
“Put sunscreen on it”
“If it feels hard, you can massage it”
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References• Atiyeh, B., Amm, C., & El Musa, K. (2003). Improved Scar Quality Following Primary and Secondary
Healing of Cutaneous Wounds. Aesth Plast Surg, 27, 411-417.• Atkinson, J., McKenna, K., Barnett, A., McGrath, D., & Rudd, M. (2005). A Randomized, Controlled Trial to
Determine the Efficacy of Paper Tape in Preventing Hypertrophic Scar Formation in Surgical Incisions that Traverse Langer’s Skin Tension Lines. Plast Reconstr Surg, 116, 1648-1656.
• Baumann, L., & Spencer, J. (1999). The Effects of Topical Vitamin E on the Cosmetic Appearance of Scars. Dermatol Surg, 25, 311-315.
• Bodian, M. (1969). Use of massage following lid surgery. Eye Ear Nose Throat Mon, 48, 542-547.• Bond, J., Duncan, J., Mason, T., Sattar, A., Boanas, A., O’Kane, S., et al. (2008). Scar Redness in Humans:
How Long Does It Persist after Incisional and Excisional Wounding? Plast Reconstr Surg, 121, 487-496.• Chadwick, S., Heath, R., & Shah, M. (2012). Abnormal pigmentation within cutaneous scars: A
complication of wound healing. Indian J Plast Surg, 45, 403-411.• Chan, K., Lau, C., Adeeb, S., Somasundaram, S., & Nasir-Zahari, M. (2005). A randomized, placebo-
controlled, double-blind, prospective clinical trial of silicone gel in prevention of hypertrophic scar development in median sternotomy wound. Plast Reconstr Surg, 116, 1013-1022.
• Chen, M., & Davidson, T. (2005). Scar management: prevention and treatment strategies. Curr OpinOtolaryngol Head Neck Surg, 13, 242-247.
• Chung, V., Kelley, L., Marra, D., & Jiang, S. (2006). Onion Extract Gel Versus Petrolatum Emollient on New Surgical Scars: a Prospective Double-Blinded Study. Dermatol Surg, 32, 193-197.
• Costa, A., Peyrol, S., Porto, L., Comparin, J., Foyatier, J., & Desmouliere, A. (1999). Mechanical Forces Induce Scar Remodeling: Study in Non-Pressure-Treated versus Pressure-Treated Hypertrophic Scars. Am J Pathol, 155, 1671-1679.
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References• Gauglitz, G., Korting, H., Pavicic, T., Ruzicka, T., & Jeschke, M. (2011). Hypertrophic Scarring and Keloids:
Pathomechanisms and Current and Emerging Treatment Strategies. Mol Med, 17, 113-125. • Gold, M., Foster, T., Adair, M., Burlison, K., & Lewis, T. (2001). Prevention of hypertrophic scars and
keloids by the prophylactic use of topical silicone gel sheets following a surgical procedure in an office setting. Dermatol Surg, 27, 641-644.
• Jackson, B., & Shelton, A. (1999). Pilot Study Evaluating Topical Onion Extract as Treatment for Postsurgical Scars. Dermatol Surg, 25, 267-269.
• Li, J., Chen, J., & Kirsner, R. (2007). Pathophysiology of acute wound healing. Clinics in dermatology, 25, 9-18.
• Liu, A., Moy, R., & Ozog, D. (2011). Current Methods Employed in the Prevention and Minimization of Surgical Scars. Dermatol Surg, 37, 1740-1746.
• McCord, S., & Levy, M. (2006). Practical Guide to Pediatric Wound Care. Semin Plast Surg, 20, 192-200.• Morganroth, P., Wilmot, A., & Miller, C. (2009). Over-the-counter scar products for postsurgical patients:
Disparities between online advertised benefits and evidence regarding efficacy. J Am Acad Dermatol, 61, e31-47.
• Niessen, F., Spauwen, P., Robinson, P., Fidler, V., & Kon, M. (1998). The use of silicone occlusive sheeting (sil-K) and silicone occlusive gel (epiderm) in the prevention of hypertrophic scar formation. Plast ReconstrSurg, 102, 1962-1972.
• Pasha, R., & Golub, J. (2014). Otolaryngology Head and Neck Surgery: Clinical Reference Guide (4th ed.). San Diego, CA: Plural Publishing.
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References• Regents of the University of Michigan. (2010). Scar Care Instructions. Retrieved March 24, 2014, from
http://surgery.med.umich.edu/plastic/patient/forms/instructions/scar_care_postop.shtml.• Russell, R., Horlock, N., & Gault, D. (2001). Zimmer splintage: a simple effective treatment for keloids
following ear-piercing. British Journal of Plastic Surgery, 54, 509-510.• Shih, R., Waltzman, J., & Evans, G. (2007). Review of Over-the-Counter Topical Scar Treatment Products.
Plast Reconstr Surg, 119, 1091-1095.• Shin, T., & Bordeaux, J. (2012). The Role of Massage in Scar Management: A Literature Review. Dermatol
Surg, 38, 414-423.• Signorini, M., & Clementoni, M. (2007). Clinical evaluation of a new self-drying silicone gel in the
treatment of scars: a preliminary report. Aesthetic Plast Surg, 31, 183-187.• Van der Veer, W., Jacobs, X., Waardenburg, I., Ulrich, M., & Niessen, F. (2009). Topical Calcipotriol for
Preventive Treatment of Hypertrophic Scars. Arch Dermatol, 145, 1269-1275. • Winter, G., & Scales, J. (1963). Effect of Air Drying and Dressings on the Surface of a Wound. Nature, 197,
91-92.