Textbook on Scar Management. State of the Art Management and Emerging Technologies

Foreword
Preface
Contents
Contributors
I: Biology and Scar Formation
	1: Fetal Wound Healing
		1.1	 Background
		1.2	 Inflammation
		1.3	 Extracellular Matrix
		1.4	 Angiogenesis
		1.5	 Keratinocytes
		1.6	 Fibroblasts
		1.7	 Mechanical Forces
		1.8	 Remodeling
		1.9	 Skin Appendix Formation
		1.10 Conclusions
		References
	2: Mechanobiology of Cutaneous Scarring
		2.1	 Background
		2.2	 Role of Mechanobiology in Cutaneous Scarring
		2.3	 Cellular and Tissue Responses to Mechanical Forces
		2.4	 Role of Mechanobiology in the Development of Pathological Scars
		2.5	 A Pathological Scar Animal Model that Is Based on Mechanotransduction
		2.6	 Mechanotherapy for Scar Prevention and Treatment
			2.6.1	 Stabilization Materials
			2.6.2	 Sutures
			2.6.3	 Z-Plasty, Skin Grafting, and  Local Flaps
		2.7	 Conclusion
		References
	3: Scar Formation: Cellular Mechanisms
		3.1	 Background
		3.2	 Introduction
		3.3	 General Mechanisms of Scar Formation
		3.4	 Morphological and Biochemical Characteristics of Myofibroblast Phenotype
		3.5	 Cellular Origins of Myofibroblasts
		3.6	 Regulation of Myofibroblast Phenotype
		3.7	 Role of Myofibroblasts in Pathological Scarring and Fibrosis
		3.8	 The Role of Mechanical Tension
		3.9	 Role of Innervation in Skin Healing
		3.10 Therapeutic Options
		3.11 Conclusion
		References
II: Epidemiology of Scars and Their Consequences
	4: The Epidemiology of Keloids
		4.1	 Background
		4.2	 Demographic Risk Factors That Shape Keloid Rates
		4.3	 Genetic Risk Factors That Shape Keloid Rates
		4.4	 Environmental Risk Factors That Shape Keloid Rates
		4.5	 Conclusion
		References
	5: Epidemiology of Scars and Their Consequences: Burn Scars
		5.1	 Burn Injuries and Their Treatment
			5.1.1	 Burn Care
			5.1.2	 Acute Phase
		5.2	 Prevalence of Burn Scars and Their Consequences
			5.2.1	 Definition of Scars
			5.2.2	 Prevalence of Hypertrophic Scarring
			5.2.3	 Prevalence of Contractures
			5.2.4	 Scar Quality Assessment
			5.2.5	 Prevalence of Reconstructive Surgery
			5.2.6	 Maturation Pattern
		5.3	 Factors Predicting Scar Outcome After Burns
			5.3.1	 Patient Characteristics
			5.3.2	 Injury and Treatment Characteristics
			5.3.3	 Patient, Injury and Treatment Characteristics Combined
		5.4	 Clinical Relevance
		5.5	 Conclusion
		References
			Further Reading
	6: Scar Epidemiology and Consequences
		6.1	 Introduction and Background
		6.2	 Reminder of the Spectrum of Scars
			6.2.1	 Contractures
			6.2.2	 Extended Scar
			6.2.3	 Atrophic Scar
			6.2.4	 Hypertrophic Scar
			6.2.5	 Keloid Scar
		6.3	 Hypertrophic Scars
		6.4	 Basic Epidemiology
			6.4.1	 Risk Factors
		6.5	 Keloid Scars
			6.5.1	 Basic Epidemiology
			6.5.2	 Risk Factors
		6.6	 Specific Situation: The Burnt Patient Healing
			6.6.1	 Scarred Hypertrophy in Burned Patients: Epidemiology
			6.6.2	 Retracted Scars
		6.7	 Impact of Scars
		6.8	 Conclusion
		References
	7: Other Scar Types: Optimal Functional and Aesthetic Outcome of Scarring in Cleft Patients
		7.1	 Background
		7.2	 Objectives of Cleft Lip Surgery
		7.3	 Treatment Protocol
		7.4	 Cleft Lip Reconstruction: Surgical Techniques
			7.4.1	 Unilateral Cleft Lip
				7.4.1.1	 Millard Lip Closure
				7.4.1.2	 Fisher Lip Closure
			7.4.2	 Bilateral Cleft Lip
			7.4.3	 Additional Measures to Improve Scarring
				7.4.3.1	 Perioperative Botulinum Toxin
				7.4.3.2	 Sutureless Skin Closure
				7.4.3.3	 Silicone Application
				7.4.3.4	 Postoperative Laser Therapy
				7.4.3.5	 Hair Transplantation
		7.5	 Secondary Cleft Lip Reconstruction
		7.6	 Evaluation of Aesthetic Outcome
			7.6.1	 Palatal Scarring
				7.6.1.1	 Palatal Closure
				7.6.1.2	 Timing of Palatal Closure
				7.6.1.3	 Maxillary Growth
				7.6.1.4	 Speech Development
		7.7	 Conclusion
		Further Reading
III: Hypertrophic and Keloid Scar: Genetics and Proteomic Studies
8: Genetics of Keloid Scarring
	8.1 Background
	8.2 HLA Immunogenetics
	8.3 Linkage
	8.4 Large-Scale Population Single-Nucleotide Polymorphism (SNP)
	8.5 Gene Expression
	8.6 MicroRNAs (miRNA)
	8.7 Long noncoding RNA (lncRNA)
	8.8 Small Interfering RNA (siRNA)
	8.9 Microarray Analysis
	8.10 Epigenetics
		8.10.1 Methylation
		8.10.2 Histone Modifications
	8.11 Mutations
	8.12 Copy Number Variation
	8.13 FISH (Fluorescence In Situ Hybridization)
	8.14 Conclusions
	Further Readings/Additional Resources
		References
IV: International Scar Classifications
9: International Scar Classification in 2019
	9.1	 Immature Scar
	9.2	 Mature Scar
	9.3	 Atrophic Scar
	9.4	 Linear Hypertrophic Scar
	9.5	 Widespread Hypertrophic Scar
	9.6	 Keloid
		9.6.1	 Minor Keloid
		9.6.2	 Major Keloid
	Bibliography
V: Scar Symptoms
10: Scar Symptoms: Pruritus and Pain
	10.1 Pain: Definition and Subtypes
	10.2 Pain Pathway
		10.2.1 Peripheral Receptor Activation
		10.2.2 Ascending Pathway
		10.2.3 Descending Pathway
		10.2.4 Peripheral Sensitization
		10.2.5 Central Sensitization
		10.2.6 Pruritus: Definition and Subtypes
		10.2.7 Pruritic Pathway
			10.2.7.1 Peripheral Receptor Activation
				Histamine
				Acetylcholine
				Bradykinin
				Proteinases
		10.2.8 Peripheral Nerve Fibers (PNF)
		10.2.9 Spinal Cord/Itch Specific Neurons
		10.2.10 Thalamocortical Level
			10.2.10.1 Incidence/Prevalence of Pain and Itch in Scars
			10.2.10.2 Management of Symptoms
		10.2.11 Non-pharmacological Adjuncts
			10.2.11.1 Psychological Support
			10.2.11.2 Cooling
			10.2.11.3 Hydration/Moisturization
			10.2.11.4 Massage
			10.2.11.5 Silicone Gels/Sheets
		10.2.12 Transcutaneous Electrical Nerve Stimulation (TENS)
		10.2.13 Pharmacological Adjuncts
			10.2.13.1 Capsaicin
			10.2.13.2 Antihistamines
			10.2.13.3 Gabapentin/Pregabalin
			10.2.13.4 Steroids
			10.2.13.5 Botulinum Toxin
		10.2.14 Emerging Modalities
			10.2.14.1 Autologous Fat Grafting
			10.2.14.2 Lasers
	10.3 Conclusion
	References
11: Scar Symptom: Erythema and Thickness
	11.1 Mechanisms of Erythema in Scar
		11.1.1 Inflammation-Induced Capillary Perfusion Is Crucial for Erythema Initiation
		11.1.2 Vascularization Dynamically Participates in the Erythema Development
		11.1.3 Thinner Epidermis Is Directly Responsible for the Transparency in Erythematous Scars with Skin Barrier Defect
	11.2 Contributions of Erythema to Scar Development and Associated Clinical Symptoms
	11.3 Scar Erythema and Scar Thickness
	11.4 Clinical Measurement of Scar Redness and Thickness
	11.5 Clinical Relevance
		11.5.1	 Clinical Treatment Strategies of Erythema in Scars
			11.5.1.1 Anti-inflammation Strategies to Alleviate Erythema and Hinder Scars Development
			11.5.1.2 Laser Treatments to Interfere with Erythema from Multiple Perspective
			11.5.1.3 Compression Therapy
			11.5.1.4 Medical Needling
	11.6 Clinical Treatment for Thick Scar
	11.7 Conclusion
	References
12: Scar Symptoms: Pigmentation Disorders
	12.1 Pathophysiology and Epidemiology
		12.1.1 Hypopigmentation
		12.1.2 Hyperpigmentation
		12.1.3 Maturation
	12.2 Measurement Techniques
		12.2.1	 Objective Measurement Instruments
		12.2.2 Scar Assessment Scales
	12.3 Therapies
		12.3.1	 Hypopigmentation
			12.3.1.1 Nonsurgical Techniques
				Laser Therapy
				Dermatography
				Camouflage Therapy
			12.3.1.2 Surgical Techniques
				Dermabrasion
				Skin Grafting
				Cell Therapy
				Microneedling
				Excision
		12.3.2 Hyperpigmentation
			12.3.2.1 Nonsurgical Treatment
				Topical Treatments
				Chemical Peels
				Laser Therapy
			12.3.2.2 Surgical Treatment
				Dermabrasion
				Excision
	12.4 Conclusion
	References
13: Scar Contractures
	13.1 Introduction
	13.2 General Features
	13.3 Contractures of the Neck
	13.4 Axillar Contractures
	13.5 Hand Contractures
	13.6 Other Anatomical Sites of Scar Contractures
	13.7 Rehabilitation Programs
	13.8 Surgical Strategies
	13.9 Z Plasties
	13.10 Skin Grafts
	13.11 Dermal Substitutes
	13.12 Flaps
	13.13 Conclusion
	References
VI: Scar Assessment Scales
14: Scar Assessment Scales
	14.1 Background
	14.2 Domains
	14.3 Scar Assessment Scales
	14.4 Measurement Properties/Clinimetrics
	14.5 Conclusion
	References
15: Japan Scar Workshop (JSW) Scar Scale (JSS) for Assessing Keloids and Hypertrophic Scars
	15.1 Background
	15.2 JSW Scar Scale (JSS) 2015
	15.3 Classification Table
	15.4 Evaluation Table
	15.5 Clinical Suitability and Usefulness of the JSS
	15.6 Conclusion
	References
VII: Objective Assessment Technologies (Cutometer, Laser Doppler, 3D Imaging, Stereophotogrammetry)
16: Objective Assessment Technologies: General Guidelines for Scar Assessment
	16.1 Background
	16.2 Choosing the Right Tools for Each Scar
	16.3 Optimizing the Measurement Process
		16.3.1 Preparing the Surroundings
		16.3.2 Configuring and Calibrating the Assessment Tools
		16.3.3 Preparing the Patient
		16.3.4 Performing the Measurements
	16.4 Interpreting Therapeutic Success with Objective Scar Assessment Technologies
		16.4.1 Data Assessment and Evaluation
		16.4.2 Clinically Important Difference
	16.5 Conclusion
	References
17: Objective Assessment Tools: Physical Parameters in Scar Assessment
	17.1 Clinimetrics
	17.2 Color
		17.2.1	 Erythema and Pigmentation
		17.2.2 Reflectance Spectroscopy
			17.2.2.1 Tristimulus Colorimetry
			17.2.2.2 Narrow-Band Spectrophotometry
		17.2.3 Spectrophotometric Analysis (SIA)
	17.3 Elasticity
		17.3.1 Cutometer
			17.3.1.1 Clinimetric Properties
		17.3.2 DermaLab
		17.3.3 Tonometers
	17.4 Perfusion
		17.4.1 Laser Doppler Imaging
		17.4.2 Laser Speckle Imaging
	17.5 Conclusion
	References
		Further Reading
18: Objective Assessment Techniques: Physiological Parameters in Scar Assessment
	18.1 Background
	18.2 Skin Hydration
		18.2.1 Skin Hydration in the Epidermis
		18.2.2 Dermal Water Content
		18.2.3 How to Measure Skin Hydration?
			18.2.3.1 Trans-Epidermal Water Loss: Measuring Principle
			18.2.3.2 Open-Chamber Method
			18.2.3.3 Semi-Open-Chamber Method
			18.2.3.4 Closed-Chamber Method
			18.2.3.5 Stratum Corneum Hydration Level: Measuring Principle
			18.2.3.6 Corneometer CM825®
			18.2.3.7 Skicon-200EX
			18.2.3.8 General Recommendations for Skin Hydration Measurements
		18.2.4 Dermal Water Content Measurement
			18.2.4.1	 Confocal Raman Spectroscopy
			18.2.4.2 Near-Infrared Spectroscopy
	18.3 Transcutaneous Oxygen Tension
	18.4 Tactile Sensitivity
	Bibliography
19: Structural Assessment of Scars Using Optical Techniques
	19.1 Introduction
		19.1.1 Volumetric Analyses
		19.1.2 Surface Topology
		19.1.3 Thickness
	19.2 Experimental Techniques
		19.2.1 Optical Coherence Tomography
		19.2.2 Confocal Microscopy
		19.2.3 Nonlinear Optical Microscopy
			19.2.3.1	 Introduction
			19.2.3.2 Two-Photon Excited Autofluorescence (2PEF)
			19.2.3.3 Second Harmonic Generation (SHG) Microscopy
			19.2.3.4 Third Harmonic Generation (THG) Microscopy
			19.2.3.5 Coherent Anti-Stokes Raman Spectroscopy (CARS)
	19.3 Future Perspectives
	References
20: Ethical Considerations: Scar Management
	20.1 Is there Truly a Need to Invoke Ethics When the Clinician Is Faced with Managing a Patient’s Scar?
	20.2 What Are the Dilemmas that a Clinician Will Confront in Their Daily Practice When Managing a Patient’s Scar?
	References
VIII: Treatment of Immature Scars: Evidence-Based Considerations
21: Ideal Wound Closure Methods for Minimizing Scarring After Surgery
	21.1 Background
	21.2 Cutaneous Wound Healing and Mechanobiology
	21.3 Surgical Techniques that Can Minimize Dermal Tension
	21.4 Z-Plasty
	21.5 Conclusion
	References
22: Treatment of Immature Scars: Evidence-Based Techniques and Treatments
	22.1 Techniques for the Treatment of Immature Scars
		22.1.1	 Pressure Therapy
		22.1.2 Silicone-Based Products
		22.1.3 Onion Extract
		22.1.4 Pulsed Dye Laser (PDL)
		22.1.5 Fractional Ablative Carbon Dioxide (CO2) Laser
		22.1.6 Nonablative Erbium Glass (Er:Glass) Laser
	22.2 Conclusion
	References
23: Silicone Gel for Scar Prevention
	23.1 History
	23.2 The Role of the Epithelium in Scar Formation
		23.2.1 Delay in Epithelization
		23.2.2 Clinical Studies
		23.2.3 Sheets Versus Creams
	Bibliography
24: Onion Extract
	24.1 Onion Extract
	24.2 Conclusion
	References
25: Treatment of Immature Scars: Manual Massages
	25.1 Background
	25.2 Introduction
	25.3 Indications of Manual Massages
	25.4 Description of the Techniques
		25.4.1	 Morice Orthodermic Stretching
		25.4.2 Punctual Crushing
		25.4.3 Static Fold
		25.4.4 Palpate-Rolling
		25.4.5 Efficacy
	25.5 Conclusion
	Bibliography
26: Treatment of Immature Scars with Botulinum Toxin
	26.1 Background
	26.2 Chapter Introduction
	26.3 Botulinum Exotoxin, Structure, and Mechanism of Action
		26.3.1 Structure of BoNTA
		26.3.2 Neuronal Mechanism of Action of BoNTA and Effects on Immature Scars
		26.3.3 Nonneuronal Mechanisms of Action of BoNTA and Effects on Immature Scars
			26.3.3.1 Effects of BoNTA on the Inflammatory Cascade
			26.3.3.2 Effects of BoNTA on Fibroblasts and Keratinocytes
			26.3.3.3 Effects of BoNTA on Vascular Endothelium
	26.4 Clinical Application of BoNTA for Treatment of Scars
		26.4.1 Timing of BoNTA Injections
		26.4.2 Choosing BoNTA Preparation
		26.4.3 Reconstituting BoNTA
		26.4.4 Dose of BoNTA for Scar Treatment
		26.4.5 BoNTA for Treatment of Keloid and Hypertrophic Scars
		26.4.6 Summary of Practical Guidelines for the Application of BoNTA in the Treatment of Scars
	26.5 Conclusions
	References
27: Compression Therapy and Conservative Strategies in Scar Management After Burn Injury
	27.1 Conclusion
	References
IX: Minimal-Invasive Technologies for Treatment of HTS and Keloids
28: Minimally Invasive Technologies for the Treatment of Hypertrophic Scars and Keloids: Intralesional Cryosurgery
	28.1 Background
	28.2 The Technology: Treatment Technique – CryoShape [5, 10]
	28.3 When to Use Contact or Intralesional Cryosurgery?
	28.4 How Many Cryosessions Are Needed for Contact or Intralesional Cryosurgery?
	28.5 Combined Treatment
	28.6 Conclusion
	References
29: Minimal-Invasive Technologies for Treatment of HTS and Keloids: Corticosteroids
	29.1 Background
	29.2 The Corticosteroids
	29.3 Pharmacology and Mechanism of Action
	29.4 Corticosteroid in Scar Treatment
	29.5 Topical Steroids
	29.6 Intralesional Injection
		29.6.1 Administration
		29.6.2 Side Effects and Complications
	29.7 Further Applications
		29.7.1 Enhancing the Effect of Intralesional Corticosteroid
	29.8 Conclusion
	References
30: Minimally Invasive Technologies for Treatment of HTS and Keloids: Low-Dose 5-Fluorouracil
	30.1 Introduction
		30.1.1 Hypertrophic Scar and Keloid Information
		30.1.2 Chemotherapy for Keloids and Hypertrophic Scar
		30.1.3 5-FU and Its Combined Use of Steroids
	30.2 The Rational of Using Low-Dose 5-FU Injection for Keloid Treatment
		30.2.1 Background
	30.3 Clinical Protocol of Low-Dose 5-FU Injection Therapy
	30.4 Low-Dose 5-FU-Based Injection Therapy for HTS and Keloids
		30.4.1 Important Concepts of Keloid Curing and Relapse Rate for Low-Dose 5-FU-Based Therapy
	30.5 5-FU-Based Injection Therapy for Recurrence Prevention of Surgically Removed Keloids
		30.5.1 Surgical Procedure for Keloid Excision
		30.5.2 Postsurgical Monitoring and Preventive Injection of 5-FU
	30.6 Anti-indications of Low-Dose 5-FU Injection Therapy Combined with Steroids
	30.7 Representative Case Reports
		30.7.1 Case 1. Remodeling of Keloid into Normal-Looking Skin [7] (. Fig. 30.2)
		30.7.2 Case 2. Intralesional Injection of Low-Dose 5-FU and Steroid for a Large-Sized Keloid
		30.7.3 Case 3. Sufficient Therapy Is Essential for Curing Keloids
		30.7.4 Case 4. Low-Dose 5-FU for Preventing Keloid from Reoccurrence After Surgical Excision
		30.7.5 Case 5. Low-Dose 5-FU for Combined Chemoradiotherapy to Prevent Keloid from Postsurgical Reoccurrence
	30.8 Conclusion
	References
31: Minimally Invasive Technologies for Treatment of HTS and Keloids: Pulsed-Dye Laser
	31.1 Historical Development
	31.2 Technique of a Laser
	31.3 Tissue Interaction of Laser
	31.4 Selective Photothermolysis
	31.5 The PDL and Its Application on Hypertrophic Scars and Keloids
	31.6 Selected Studies and Evidence
	31.7 Clinical Relevance
	31.8 Conclusion
	References
		Further Reading
32: Long-Pulsed 1064 nm Nd:YAG Laser Treatment for Keloids and Hypertrophic Scars
	32.1 Background
	32.2 Laser Therapies for Keloids and Hypertrophic Scars
	32.3 Indications and Limitations of Long-Pulsed 1064 nm Nd:YAG Laser for Keloids and Hypertrophic Scars
	32.4 Treatment Settings of Long-Pulsed 1064 nm Nd:YAG Laser for Keloids and Hypertrophic Scars
	32.5 Follow-Up of Keloids and Hypertrophic Scars
	32.6 Conclusion
	References
33: Minimally Invasive Technologies for Treatment of HTS and Keloids: Fractional Laser
	33.1 Introduction
	33.2 Method of Action
	33.3 Fractioned Laser Platforms
	33.4 Fractioned CO2 Laser
	33.5 Settings for Ablative Fractional CO2 Laser
	33.6 Fractioned Erbium:YAG
	33.7 Fractional Non-ablative Laser
	33.8 Picosecond, Fractioned, 1064 nm Nd:YAG
	33.9 Cautions and Contraindications
	33.10 Preoperative and Postoperative Regimes
	33.11 Expected Outcomes
	33.12 Potential Complications
	33.13 Fractioned CO2 Laser as a Method for Potentiating Transdermal Laser-Assisted Drug Delivery (LADD)
	33.14 Consensus Practice
	References
34: Minimal Invasive Technologies for Treatment of HTS and Keloids: Medical Needling
	34.1 Background
	34.2 Introduction
	34.3 Method
	34.4 Effects of Medical Needling
	34.5 Needling Techniques
	34.6 Postinterventional Treatment Measures
	34.7 Induction of the Post-Needling Wound-Healing Cascade
	34.8 Effects of Medical Needling Regarding Different Parameters
	34.9 Dermal Remodeling
	34.10 Improved Perfusion
	34.11 Dermal Thickness and Erythema
	34.12 Richness of Moisture
	34.13 Conclusion
	References
X: Invasive Techniques in Scar Management
35: Usefulness of Local Flaps for Scar Contracture Release
	35.1 Background
	35.2 Selection of Local Flaps
	35.3 Transposition Flaps
	35.4 The Square Flap Method
	35.5 Propeller Flaps
	35.6 Conclusion
	References
36: Scar Resurfacing
	36.1 Overview
	36.2 The Mechanism of the Initial Skin Injury and Clinical Pathway of Healing
	36.3 The Timing of the Intervention
	36.4 The Techniques for Preparing the Scar Wound Bed for Resurfacing
	36.5 The Techniques of Wound Repair for Resurfacing
	36.6 Post-Intervention Scar Management
	36.7 Conclusion
	References
37: Invasive Techniques in Scar Management: Skin Substitutes
	37.1 Background
	37.2 Permanent Wound Coverage
		37.2.1 Epidermal Cells/Cultured Epidermal Autografts CEA
		37.2.2 Dermal Substitutes
			37.2.2.1 Tissues
			37.2.2.2 Dermal Scaffolds
		37.2.3 Cellular Dermal Substitutes
	37.3 Full-Skin Substitutes
	37.4 Subcutaneous Fat
	37.5 Regulatory/Safety Issues
	37.6 Conclusion
	References
38: Facial Scars Reconstruction
	38.1 Objectives of the Chapter
	38.2 Techniques
	38.3 Critical Analysis of the Literature
	References
39: Invasive Techniques in Scar Management: Fat Injections
	39.1 Adipose-Derived Stem Cells: Their Biological Properties
	39.2 The Guidelines
	39.3 The Procedure
	39.4 The Free Fat Grafting and Scars [3–9] (. Figs. 39.5, 39.6, 39.7, and 39.8)
		39.4.1 The Skin Texture, Thickness, and Pliability
		39.4.2 The Fibrosis
		39.4.3 The Volume and Contour
		39.4.4 Pain: The Analgesic Effect
		39.4.5 The Possible Applications
	39.5 The Ancillary Procedures to Increase the Overall Survival of Adipose Cells
		39.5.1 The Plasma-Rich Platelet [10]
		39.5.2 The External Volume Expansion [11]
		39.5.3 The Future
	39.6 Something to Discuss: The Oncological Point of View
	39.7 Conclusion
	References
40: Additional Invasive Techniques in Scar Management
	40.1 Background
	40.2 Introduction
	40.3 Types of Radiation Therapy
		40.3.1 External Beam Radiation Therapy (EBRT)
		40.3.2 Brachytherapy (Internal Radiation)
	40.4 Excision and Radiation Type
	40.5 Recurrence
		40.5.1 Complications
	40.6 Safety Concerns
	40.7 Additional Thoughts on the Biomechanisms of Radiotherapy in Keloid Treatment
	40.8 Conclusions
	References
XI: Specific Attention Areas in Scar Management
41: Specific Attention Areas in Scar Management: Management of Atrophic Scars
	41.1 Background
		41.1.1 Common Principles
	41.2 Atrophic Acne Vulgaris Scarring
		41.2.1 Resurfacing and Tightening Techniques
			41.2.1.1 Microdermabrasion
			41.2.1.2 Chemical Peels and Microneedling
		41.2.2 Dermal Lift Techniques
			41.2.2.1 Punch Excision
			41.2.2.2 Subcutaneous Incision
		41.2.3 Volume-Imparting Techniques
			41.2.3.1 Filling Techniques
			41.2.3.2 Dermal and Fat Autografting
		41.2.4 Isotretinoin Treatment
		41.2.5 State-of-the-Art and Combinatorial Approaches
			41.2.5.1 Fractional Radiofrequency (FRF)
			41.2.5.2 High-Pressure Dermal Filler Deposition
			41.2.5.3 Laser
	41.3 Striae Albae
	41.4 Burn Atrophic Scars
	41.5 Conclusion
	References
42: Specific Attention Areas in Scar Management: Specific Scar Management Depending on Anatomical Features (Face, Hair, Breast, Hand, Joints, Foot)
	42.1 Scar Treatment Options for Different Anatomical Localizations
		42.1.1 Face
		42.1.2 Hair
		42.1.3 Hands
		42.1.4 Feet
		42.1.5 Joints
	42.2 Conclusion
	References
43: Management of Scars in Skin of Color
	43.1 Background
	43.2 How Scars Evolve Differently in Skin of Color?
	43.3 Management of Scars in the Skin of Color
		43.3.1 Nonsurgical
			43.3.1.1 Intralesional Steroid Injections
			43.3.1.2 Silicone Gel/Sheet
			43.3.1.3 Radiotherapy
			43.3.1.4 Photodynamic Therapy (PDT)
			43.3.1.5 Electrical Stimulation
		43.3.2 Surgical
			43.3.2.1 Surgical Excision and Adjuvant Therapy
			43.3.2.2 Cryosurgery
		43.3.3 Response Rates and Side Effects in Skin of Color
		43.3.4 Recurrence Rate
	43.4 Management of Scars in Asian Skin
	43.5 Conclusions
	References
44: Scar and Scarring in the Elderly
	44.1 Introduction
	44.2 Epidemiology of the Elderly: A Factor to Consider
	44.3 Definition of Elderly in Medicine: Should We Make Distinctions?
	44.4 From Skin Aging to Dermatoporosis
	44.5 Consequences of Age on Wound Healing
	44.6 Frequent Comorbidities Altering Wound Healing in the Elderly
	44.7 What Scarring Problems Are Usually Observed in the Elderly?
	44.8 Conclusion
	References
45: Management of Scarring Following Aesthetic Surgery
	45.1 Introduction
	45.2 Patient Selection for Cosmetic Surgery
		45.2.1 Evaluating Medical Risks
		45.2.2 Assessment of Constitutional and Genetic Risks
		45.2.3 Modification of Lifestyle
		45.2.4 Psychological Assessment and Expectations Management
	45.3 Prophylactic Measures in Cosmetic Surgery to Reduce Excessive Scarring
		45.3.1 Choice of Surgical Techniques
		45.3.2 Methods to Control Better Healing
	45.4 Treatment of Scars Following Aesthetic Surgery
		45.4.1 Surgical Treatments
		45.4.2 Non-surgical Treatments
		45.4.3 Long-Term Management of Patients with Scars After Cosmetic Surgery
	45.5 Conclusion
	References
46: Scars in Pediatric Patients
	46.1 Introduction/Background
	46.2 Healing Specificities in Children
		46.2.1 Fetal Healing
		46.2.2 Pediatric Peculiarities in Healing
		46.2.3 How to Manage Wound Healing in Children
	46.3 Pathological Scars
		46.3.1 Clinical and Histological Aspects
		46.3.2 Easing Factors
		46.3.3 Prevention and Treatment [13]
	46.4 Defective or Disgracious Scars
	46.5 Scars and Growth
	46.6 Conclusion
	References
47: Genital Scars
	47.1 Epidemiology and Etiology of Genital Wounds
	47.2 Genital Skin Anatomy and Microstructure
		47.2.1 Development of Genital Organs and Homology Between Sexes
		47.2.2 Anatomy of Male and Female Genitalia
		47.2.3 Microstructure of the Genital Skin
	47.3 Pathophysiology of Genital Wound Healing, Lymphedema and Scarring
		47.3.1 Skin Architecture and Biomechanics
		47.3.2 Moist Environment and Bacterial Colonialization
		47.3.3 Hormonal Influences
			47.3.3.1 Increased Aromatase Activity and Intracrine Estrogen Production
			47.3.3.2 Androgen and Estrogen Receptor Expression in Genital Skin
	47.4 Acute Wound Repair of Genital Skin After Trauma
	47.5 Chronic Inflammatory Diseases of the External Genitalia and Tissue Fibrosis
		47.5.1 Lichen Sclerosus et Atrophicus/Balanitis Xerotica Obliterans
		47.5.2 Behçet’s Disease
		47.5.3 Chronic Inflammation due to Foreign Body Reaction
		47.5.4 Congenital and Acquired Genital Lymphedema and Tissue Fibrosis
	47.6 Treatment of Genital Wounds and Scars
		47.6.1 Treatment of Acute Wounds and Tissue Defects
		47.6.2 Treatment of Genital Wounds and Scars After Burn Injury
		47.6.3 Gender Reassignment Surgery
		47.6.4 Treatment of Chronic Genital Skin Diseases
		47.6.5 Lymphedema Treatment
	47.7 Postoperative Management for Scar Prevention
	47.8 Conclusion
	References
		Further Reading
XII: Psychological Impact of Burn Injuries
48: Psychological Impact of Living with Scars Following Burn Injury
	48.1 Background
	48.2 Psychological Problems After a Burn Injury
	48.3 Psychological and Social Impact of Living with Scars
		48.3.1 Body-Esteem and Self-Esteem Concerns
		48.3.2 Social Self-Consciousness of Appearance
	48.4 Factors Impacting Adjustment
		48.4.1 Burn Severity and Scarring
		48.4.2 Facial Involvement
		48.4.3 Concealed Scars
		48.4.4 Gender
		48.4.5 Importance of Appearance
	48.5 Interference of Psychological Problems with the Perception of the Scar
	48.6 Management
	48.7 Conclusion
	References
49: Makeup Therapy for Scars
	49.1 Definition
	49.2 Characteristics
	49.3 The Benefits of Medical Makeup
		49.3.1 Psychological Impact
		49.3.2 Social Impact
	49.4 Medical Makeup
		49.4.1 Step-by-Step Process
			49.4.1.1 Evaluation of Needs
			49.4.1.2 Makeup Base
			49.4.1.3 Color Correction
		49.4.2 Using Color Correction Is the Best Solution to This Issue
		49.4.3 Complementary Colors
		49.4.4 The Value of Colors
			49.4.4.1 Corrective Foundations
		49.4.5 Compact Foundation Creams
		49.4.6 Fluid Foundation Correctors
			49.4.6.1 How to Decide on a Shade of Foundation
				Powder
				Corrector Pencils
					Eyebrows
					Lips
				Ensure Makeup Lasts longer
				Makeup Removal
	49.5 Medical Makeup Classes
	References
XIII: Emerging Technologies in Scar Management
50: Emerging Technologies in Scar Management: Laser-Assisted Delivery of Therapeutic Agents
	50.1 Background
	50.2 Laser Systems Used for Laser-Assisted Delivery
	50.3 Carbon Dioxide (CO2) Laser and Erbium:Yttrim-Aluminum-Garnet (Er:YAG) Laser
	50.4 Mechanism of Ablative Fractional Laser-Assisted Drug Delivery
	50.5 Technique and Parameters
		50.5.1 Main Parameters: MTZ Density and Depth
			50.5.1.1 MTZ Density and Coverage
			50.5.1.2 MTZ Depth and Energy
		50.5.2 Clinical Application in Scar Treatment: Drugs and Bioactive Molecules
			50.5.2.1 Corticosteroid
			50.5.2.2 Other Agents for Scar Treatment
		50.5.3 Other Modalities to Enhance the Effect of Laser-Assisted Delivery
			50.5.3.1 Emerging Devices
			50.5.3.2 Limitations
	50.6 Conclusion
	References
51: Emerging Technologies in Scar Management: The Role of Allogeneic Cells
	51.1 Background
	51.2 Allogenic Cell Therapy Studied in Scar Management Field
	51.3 Human Allogeneic Epidermal Sheets
	51.4 Cellular Dermal Substitutes and Human Dermal Fibroblasts Therapy
	51.5 Human Skin Equivalent
	51.6 Bioprinting of Skin
	51.7 Injections of Mesenchymal Stromal Cells (MSCs) for Skin Regeneration
	51.8 Promising Embryonic(-Like) Stem Cells Therapy for Scar Treatment
	51.9 Conclusion/Discussion
	References
52: New Drugs for Scar Treatment
	52.1 Background
	52.2 Objectives of the Proposed Chapter
	52.3 Description of the State-of-the-Art Historical Evolution: Recent Data
	52.4 Transforming Growth Factor-β (TGF-β)
	52.5 Interleukins (IL)
	52.6 Mechanotransduction Pathway Inhibitors
	52.7 Supportive Articles in the EBM Literature
	52.8 Clinical Relevance
	52.9 Conclusion
	References
53: Emerging Technologies in Scar Management: Remodeling of Post-surgical Linear Scar Using Microplasma Radiofrequency
	53.1 Introduction
		53.1.1 Fractional Microplasma Radiofrequency Technology
	53.2 Procedures: Clinical Protocol for Microplasma-Based Tissue Remodeling (. Fig. 53.3)
		53.2.1 Pre-therapy Preparation
		53.2.2 Microplasma Treatment
		53.2.3 Post-therapy Wound Care
	53.3 Application Areas for FMRT-Mediated Tissue Remodeling
		53.3.1 Microplasma Therapy for Post-scar Revision Skin to Enhance Cosmetic Result
		53.3.2 Microplasma for Early Wound Intervention to Prevent Scar Formation
		53.3.3 Microplasma Remodeling for an Existing Linear Scar
	References
54: Vacuum Massage in the Treatment of Scars
	54.1 Working Mechanism of Vacuum Massage in Relation to Pathological Scarring
	54.2	 The Effects of Vacuum Massage on Scars
		54.2.1	 General Effects [1, 10–12]
		54.2.2	 Physical Effects [13–16]
		54.2.3	 Physiological Effects [2, 10, 13, 15, 17]
		54.2.4	 Mechanical Effects
	54.3	 Conclusion
	Bibliography
55: Shock Wave Therapy for Wound Healing and Scar Treatment
	55.1 Working Mechanism of SWT in Relation to Skin Defects
	55.2 SWT Dose Effect Relationship
	55.3 The Effects of Shock Wave Therapy in Soft Tissue Defects
		55.3.1 The Effects of SWT in Wound Healing
		55.3.2 The Effects of SWT in Scar Management
	55.4 Conclusion
	Bibliography
56: Effectiveness of Corticosteroid Tapes and Plasters for Keloids and Hypertrophic Scars
	56.1 Introduction
	56.2 Difference Between Steroid Tapes/Plasters and Steroid Injection
	56.3 Typical Usage of Steroid Tapes/Plasters
	56.4 Difference Between Deprodone Propionate Plaster and Deprodone Propionate Ointment
	56.5 Therapeutic Effect and Usage of Steroid Tape Preparations
	56.6 Side Effects of Steroid Tapes and Plasters
	References
57: Suture Edge Tension Control Technologies for Scar Improvement
	57.1 Background
	57.2 Introduction/Objectives
	57.3 Description of the State of the Art, Historical Evolution, and Recent Data
		57.3.1 Silicone Devices
		57.3.2 Reinforced Suture Materials
		57.3.3 Adjustable Tensors
		57.3.4 Closed Incision Negative Pressure Therapy
	57.4 Conclusion
	References
XIV: Scars from a Clinical Perspective: Commented Clinical Cases
58: Hyperpigmented Scar
	58.1 Medical History
	References
59: Clinical Case Reports: Scar Prevention by Laser Treatment in Mastopexy With Implant
	59.1 Introduction
	59.2 Case Report Number 1
	59.3 Case Report Number 2
	59.4 Discussion
	References
60: Burn Hypertrophic Scar in Pediatric Patients: Clinical Case
	60.1 Background
		60.1.1 Incidence of Hypertrophic Scars
		60.1.2 Prevention
		60.1.3 Burn Depth
		60.1.4 Chapter Objectives
	References
61: Clinical Case: Earlobe Keloid
	61.1 Medical History
	Further Readings
62: Scars After Breast Reconstruction
	62.1 Conclusion
	References
63: Atrophic Scars: Reinforcing the Flap Mattress Using Adipocyte Transfer in Paraplegic Patients at Risk of Pressure Ulcer Recurrence
	63.1 Medical History
	References
64: Secondary Lip Correction in a Cleft Lip Patient
	Suggested Reading
Index