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Two-Point Technique
Place both hands on the tissue, “sink in,” then
gently pull outwards (point A moves away from
point B) (Fig.18; Video 8).
Three-Point Technique
The three-point technique is basically identical to
the two-point technique.
The therapist places the hands in such a way
that he can place a xed point (third point)
between points A and B with his index nger
(Fig.19; Video 9). This prevents the tissue in the
concavity that is under tension from lifting off.
T. Koller
Clinical Tip
– A specic scar assessment precedes the
appropriate treatment techniques. The
aim is to determine the current phase of
wound healing, the quality of the scar or
scar surface, potential limitations, and
general mobility. This information
forms the basis for manual scar therapy
and individual therapeutic measures.
– It is particularly important to start with
an adequately dosed manual scar therapy at the beginning of the proliferation
phase. This ensures functional alignment at the tissue level and is crucial for
the best possible maintenance of function later.
– The treatment of large, deep dermal
scars requires a lot of time and specic
knowledge about pathophysiological
processes during wound healing or scar
formation.
Fig. 18 Two-point extension technique for convex surfaces.
(Figure: Bellikon Rehabilitation Clinic)
Fig. 19 Three-point extension technique for concave surfaces with xed point in the center. (Figure: Bellikon
Rehabilitation Clinic)
Conclusion
To be able to initiate the correct processes at the
cellular level, adequate manual dosing is a basic
requirement. Overloading the tissue inevitably
leads to cellular damage and triggers a new
inammatory reaction with all cardinal symptoms. Understrain, on the other hand, leads to the
formation of crosslinks and reduced elasticity
and resilience.
In the follow-up treatment of deep dermal
defects and hypertrophic scars, additional parameters must be considered. Compression, silicone,
vacuum massage, tape, and splint therapy offer
valuable support here.
Physical Therapy
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Management ofHypertrophic
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Scars inPediatric Burn Patients
AlenPalackic, RobertP.Duggan,
CamilaFranco- Mesa, andLudwikK.Branski
Introduction
Wound healing is a complex, physiologic ballet
that requires precise convergence of numerous
cellular and humoral cascades in harmony [1].
Physiologic requirements and demands change
as we age [1, 2]. Thus, it should be no surprise
that children and adults differ in notable aspects
when considering wound healing [3]. Even
within the pediatric population, healing and scar
physiology have certain peculiarities [1]. Factors
such as the inammatory response, characteristics of extracellular components, and the environment surrounding the injured tissue are essential
to understand the scarring discrepancies between
these patient populations [4, 5].
A. Palackic · L. K. Branski (*)
Department of Surgery, University of Texas Medical
Branch, Galveston, TX, USA
Division of Plastic, Aesthetic and Reconstructive
Surgery, Department of Surgery, Medical University
of Graz, Graz, Austria
e-mail: alpalack@utmb.edu; lubransk@utmb.edu
R. P. Duggan · C. Franco-Mesa
Department of Surgery, University of Texas Medical
Branch, Galveston, TX, USA
e-mail: rpduggan@utmb.edu; camfranc@utmb.edu
Pathophysiology
We will detail the differences in scarring exhibited by each pediatric age group. For general
information, see the respective chapter(s).
Fetal
During the fetal period, skin wounds heal without
scar formation [6]. Although the mechanism
responsible for this is still unclear, several theories have been described [3, 6]. At 8weeks of ges-
tation, skin cells exist as a single layer, but by
24weeks, the epidermis is indistinguishable from
that of a newborn. The dermis, however, is thin
and is progressively lling with extracellular
matrix components [6]. There is a lack of inammatory response attributed to a markedly
decreased macrophage migration. Without the
major inux of these cells, the healing process is
carried out in a noninammatory environment.
Growth factors expressed in the fetal period are
also different from adults. Lower levels of TGF-β
1, TGF-β 2, and platelet-derived growth factor
(PDGF) accompanied by elevated levels of TGF-β
3 have been described. Ferguson etal. conrmed
that mimicking these growth factor ratios outside
the fetal period improved the quality of resulting
scars. The fetal environment contains high levels
of adhesion molecules and selective growth factors in a hyaluronic acid-rich amniotic uid [6].
These conditions provide an amplied noninam-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
S. P. Nischwitz et al. (eds.), Scars, https://doi.org/10.1007/978-3-031-24137-6_15
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matory setting that allows scarless or minimum
scarring. As gestational age increases, so does the
inammatory response, and the resulting scars
become more visible [4, 6].
Neonates andInfants (−12Months)
Neonatal and infant skin have unique properties
attributed to their transition period [2]. The
decreased inammatory response seen in the
fetal period persists in a less dramatic state
throughout the neonatal stage and, to an even
lesser degree, into infancy. As a result, scarring
is only barely noticeable under most conditions
during this time. Wounds tend to close quickly
due to the accelerated granulation tissue formation rate and extracellular matrix deposition.
Topical absorption is exaggerated at these ages
due to an immature stratum corneum. These
patients are more vulnerable when exposed to
irritating environmental substances such as
adhesives, feces, urine, tape, and continuous
pressure [2].
Toddlers andChildren (1–12Years)
The scarring process in this age group tends to be
quite unpredictable. After age two, the inammatory response begins to strengthen and only
intensies with age [3]. Pajulo etal. reported an
elevated concentration of interleukin 6 (IL-6) and
metalloproteinase 9 (MMP-9) associated with
increased neutrophil inltration in early stage
wounds (Pajulo). In the acute phase, the extracellular matrix modication is related to the intensity of the proinammatory response [7].
Children have a rapid healing phase with a robust
remodeling phase. This combination can result in
hypertrophic scarring or keloid formation [3].
Thus, children are more prone to develop hypertrophic scarring, to the point that it is not an
uncommon result for wounds sustained in this
age group. In burned children less than 5years of
age, a 50% hypertrophic scarring rate was
reported by Spurr et al. in 1990 [8]. Lawrence
etal. would evaluate the prevalence of hypertro-
phic scarring after burn injury in 2012, reporting
a rate of 32–75% [9]. Risk factors for pathologic
scarring included darker skin, female gender,
neck and upper extremity injury, more severe
burns, prolonged healing time, and surgical interventions [9]. Ten years later, and despite advances
in treatment, pathologic scarring is still frequent,
with a 30–90% incidence of keloids or hypertrophic scars, according to Barone et al. [10]
Mechanism of injury and quality of treatment
also impact scar formation [3]. Traumatic
wounds, such as burns, often have protracted
healing times, increasing the risk for hypertrophic scarring [11]. Injuries closed under high
degrees of tension experience an increased inux
of inammatory mediators, promoting pathologic scar formation [3, 12].
Adolescence (12–18Years)
As age increases, so does the possibility of excessive wound healing [5]. In other words, adolescent skin has a greater capacity to scar than
younger counterparts. Cytokine response during
this period is quite different; TGF-β 1, TGF-β 2,
and interleukins 6 and 8 are noticeably increased.
Hyaluronic acid is decreased, and collagen type I
is present to a greater extent than collagen III [5,
6]. By adolescence and early adulthood, the scar-
ring process can be divided into the well-known
three stages of inammation, proliferation, and
remodeling [13]. Overall, the adolescent wound
healing mechanisms are virtually the same as
those in young adults [3, 5, 6].
Nonsurgical Approaches
The best treatment for hypertrophic scarring is
prevention. Optimal management of the initial
wound environment decreases mortality and will
lessen the burden of hypertrophic scarring as the
wound heals and as the patient ages. Whether or
not hypertrophic scarring occurs is dramatically
inuenced by the duration of wound healing.
Wounds that heal in under 21days are markedly
less likely to become hypertrophic, whereas those
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wounds taking longer than 25days to heal are at
risk [14]. Prompt debridement and wound coverage promote timely wound healing and, in turn,
decrease the reconstructive burden later in life.
Attention to wound tension at the time of closure
will foster more rapid and organized healing.
Avoiding local or systemic factors that impair
wound healing, such as wound infection or corticosteroid usage, will speed wound closure and
diminish future pathological scarring [15, 16].
Compression Garments
Persistent physical compression of burn scars has
been reported and recommended since the 1970s
[17, 18]. Dr. Duane L.Larson and his team at the
Galveston Shriners Hospital for Children
observed that scars under thermoplastic splints
used in preventing contractures were soft and
smooth and rarely became hypertrophic. Later, in
conjunction with plastic surgeon Ted Huang at
the neighboring University of Texas Medical
Branch, it was reported that a pressure of at least
15 mmHg applied continuously for at least
6months was required to cause the changes that
were being observed clinically [18]. No single
pathway for the efcacy of compression garments has been elucidated. External compression
has been shown to affect the scar extracellular
matrix, making it more rigid. This rigidity then
stimulates increases in mechanoreceptor number
and increases in apoptotic signaling. Local
hypoxia due to compression also is thought to
play a role in decreasing collagen overproduction
[19, 20]. Clinical reports and series would be
published over the decades exhibiting the efcacy of compression bandages and other garments [21–25]. Results were encouraging, but
randomized studies were lacking [26].
Chang et al. conducted a trial randomizing
burn patients to compression garment therapy
versus no compression garments. Their early
ndings in 122 patients were contrary to the
widespread trend of the time, nding no benet
in compression garments [27]. Future randomized studies did, however, indicate that compression therapy improved scar quality [28, 29].
Investigation into optimal degree and duration of
compression has occurred since its initial popularization [29–31]. Engrav etal. enrolled patients
aged 7–65 over 12 years to be randomized to
low- or normal-pressure garments applied over
forearm burns. Patients were instructed to wear
their garments for 23hours a day, removing only
to bathe, and were taught the proper application
of the garment by their manufacturer. Wide pressure ranges in both the low (mean 6.4mmHg)
and normal (mean 25mmHg) groups were present, highlighting the difculty of applying a consistent and prescribed pressure “dose” for the
treatment of hypertrophic scars. Their rigorous
study design and follow-up conrmed the efcacy of compression garments and highlighted
the difculty of applying controlled compression over tissue for the duration required to modify scars. Importantly, they strongly recommend
the use of compression garments in children and
adolescents. In the same year, Candy et al.
reported the results of a trial randomizing adult
burn patients to normal (10–15 mmHg) versus
high (20–25 mmHg) compression. All patients
demonstrated improved scar thickness at
5months, but high-pressure scars, those under at
least 20mmHg of pressure, improved more consistently. Controlling pressure application again
was noted to be difcult, with pressure loss
being more signicant in the high compression
group [30].
Additional randomized clinical trials are
needed to prove the efcacy of pressure therapy
more denitively. However, the current body of
evidence supports their use as rst-line therapy to
prevent hypertrophic burn scars. Compression
garments may be fashioned out of numerous
materials with or without splints, and a multidisciplinary approach involving occupational and
physical therapists is necessary to fashion ergonomic devices. Certain body areas are more
receptive to compression therapy. Areas of exion in the limbs likely receive less consistent
pressure for the duration of treatment. As such,
the overlying scar is less affected. The ideal duration of wear for maximal benet has yet to be
determined. Clinical trials begin with daily wear
after reepithelization has occurred and advise at
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least 6months of therapy. However, recent trials
have shown that at this time, there is little difference between compression, silicone, or no therapy at all [32].
Any intervention over most of a day will have
compliance issues. Loose pressure garments may
be more comfortable for daily wear but provide
little long-term benet. More restrictive garments
that provide over 40mmHg of compression may
seem appealing, offering a higher dose of pressure while patients are compliant. However, these
pressures risk paresthesias and can decrease
overall compliance. Restrictive garments may
also be uncomfortable in warmer and humid climates, and compression and moisture may macerate the underlying skin and foster dermatologic
reactions. In young patients who cannot dress
themselves, caregivers may struggle with tting
garments daily. As children rapidly grow, garments may become too restrictive, and replacements may be needed, an unforeseen cost that
ultimately promotes discontinuation. Adolescents
may be reluctant to wear compression garments
in social situations. In children, particularly those
prone to hypertrophic scarring or with a family
history of pathogenic scarring, compression therapy is a cost-effective treatment for hypertrophic
scarring. Treatment can be initiated once wounds
have re-epithelized and will likely occur for at
least 12months. Caregivers and patients should
be counseled on the importance of daily wear,
and replacement garments should be readily
available as the child ages.
Silicone
Silicone was rst described as a treatment for
burn scars in the 1980s [33]. At that time, potential mechanisms of action had yet to be described.
Like compression therapy, there is no single unifying pathway that accounts for silicone’s efcacy. Silicone products have been described as
mediating their scar-modulating effects through
altering tissue oxygenation, scar polarization,
increased temperature, decreased tension, and
direct effects of the silicone molecule itself. The
most plausible mechanism involved silicone’s
ability to create an occluded and hydrated environment. This environment decreases broblast
activity and diminishes scarring. Furthermore, a
hydrated and occluded environment may decrease
nociceptor activity in the scar and decrease neurogenic inammation driving hypertrophic scarring [19, 34]. Silicone sheeting may also reduce
tension by transmitting forces to the edge of the
sheet, away from the forming scar.
Despite widespread use, the evidence supporting silicone is less robust than desired, and ndings are conicting [31, 35, 36]. Many silicone
products are available in diverse applications
ranging from silicone sheets to sprays and foams
applied to scars. No one product is clearly more
efcacious than others, and the ideal duration of
therapy has not been established [32]. In a randomized trial with intraindividual comparisons,
Steinstraesser etal. compared the addition of silicone sheeting versus silicone spray to pressure
therapy. At 18months, their results did not suggest any additive benet due to either silicone
product when compared to compression therapy
alone [35]. Wiseman et al. randomized patients
18 and under to silicone gel, pressure therapy, or
combined therapy; at 6 months of therapy, the
silicone-only patients had signicantly thinner
scars than the combined therapy group. Still, no
other differences in scar quality were found
between groups [32]. Inherent in the study design
is the practice of compression therapy and silicone products in the pediatric population despite
the lack of high-level evidence for either product
or their use in conjunction.
Caregivers and patients may have fewer compliance issues with silicone products than with
pressure garments. Sheets and strips may be
placed directly over scarred areas rather than
compressing entire limbs. More self-conscious
wearers may nd silicone products to draw less
attention than compression garments. Most products tend to be single-use, and costs may accumulate over the recommended therapy duration.
Patients may develop folliculitis or other dermatological reactions secondary to the occlusive
nature of the dressings. Both are widely recom-
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mended and well-tolerated despite lacking highlevel evidence for either compression garments
or silicone products [37]. Further investigations
are needed to determine the optimal timing for
initiation of therapy and the duration of wear to
achieve maximal benet.
Scar Massage
Scar massage is employed globally to manage
not only hypertrophic scars but also well-healing
traumatic or surgical scars [37–39]. Its reported
benets include alterations to the scar appearance
and quality, including increased pliability and
decreased scar thickness. Essential patient quality of life improvements related to their scar has
been reported as well, including decreased pruritis and decreased hypersensitivity and pain [38,
40–44]. A systematic review by Ault etal. ana-
lyzed scar massage in hypertrophic burn scarring
[38]. Only two reviewed studies focused on pediatric populations [43, 44]. Morien etal. prospectively enrolled pediatric burn survivors to receive
scar massage by trained therapists once a day for
20–25min. Patients were over 2years postburn
with well-matured scars. In their small series of
eight patients, range of motion throughout the
scarred area improved within 3–5 sessions [43].
Patiño etal. randomized 30 pediatric patients to
receive 10min of massage by their primary caregiver for 3months or to receive no massage. At
the conclusion of the study, the massage intervention failed to show improvements in scar
quality; however, pruritis was improved [44].
Unlike silicone or compression therapy, scar
massage may have no associated costs for
patients. Furthermore, it can be performed by the
patient themselves once properly instructed and
by caregivers. The potential psychosocial benet
of scar massage, including decreased depression
and anxiety, is enough to recommend this relatively benign intervention for the pediatric population. Future investigations into the idea
techniques and their implementation will help
provide more evidence-based recommendations
to parents and caregivers.
Injections ofCorticosteroids
The intralesional injection with corticosteroids
into the hypertrophic scar is another nonsurgical
approach commonly applied in pediatric burn
patients. Intralesional injections have long been
shown to reduce scar height, volume, pain, and
pruritis and improve pliability [16, 45].
Triamcinolone acetonide is the most used corticosteroid for pathological scarring in pediatric
patients postburn. On a cellular level, injections
work to inhibit collagen production; suppress
inammation; attenuate the proliferation of broblasts and keratinocytes; limit oxygen and nutrient delivery; and halt the migration and
phagocytosis by immunoregulatory cells [41,
46]. In pediatric patients, the intralesional injec-
tion may be accompanied by pain and discomfort, which can be minimized when combined
with topical lidocaine cream prior to injection. In
pediatric burn patients, corticosteroids can be
combined with other preventive therapies, including silicone gel therapy, pulsed dye laser treatment, and cryotherapy [45, 47]. Corticosteroid
injections can be done several times; however,
there should be at least a 2-month interval
between two injections as overloading the scar
with steroids can result in epidermal thinning and
the appearance of telangiectasia.
Autologous Fat Transfer (AFT)
AFT or also widely known as fat lipolling may
be benecial as an adjuvant treatment option for
postburn scarring in children [48]. The adiposederived stem cells have a variety of regenerative
and metabolic properties and growth factors
involved in the remodeling process, promoting
rapid revascularization and a decrease in brosis
[49]. Using the Coleman technique, fat adiposederived stem cells can be harvested and reinjected
at 2–4week intervals until healing [48]. Applying
the same technique, reinjections may also be performed at a 12weeks interval after healing [50].
AFT may also alleviate pruritis and neuropathic
pain associated with hypertrophic scars. Despite
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these positive ndings, more research is needed
to determine the efcacy of AFT and its combination with other treatment options such as laser
therapy in this population [51, 52].
Laser and Surgical Approaches
Laser andLight Therapy
There have been signicant advancements in
laser and light therapy technology in recent
decades. These therapies are now used with conventional surgical options or exclusively to avoid
more invasive procedures [53]. Compared to the
previously described nonsurgical treatment
options, a core advantage of lasers is the improvement of the scar in a few sessions, rather than the
gradual improvement only after months or years
of therapy. Different lasers have been utilized in
pathological and nonpathological burn scars,
including the 585–595nm pulsed dye laser, the
585nm short-pulsed dye laser, the Er:Yag laser,
and the ablative and non-ablative fractional CO2
laser [54]. Briey, laser therapies are based on
selective thermolysis, which permits the targeted
application of energy into tissues with minimal
damage to surrounding areas. Lasers emit different wavelengths of light targeting different chromophores, compounds within the body, such as
melanin, hemoglobin, and water. Energy in the
form of photons excites the target chromophore
and ultimately leads to selective tissue damage
[55]. Numerous studies have shown scar size and
quality improvement following laser therapy sessions [56]. Furthermore, it has been shown that
laser therapy improves erythema, texture, contracture, neuropathic pain, function, and overall
quality of life [57–60]. However, most of these
ndings have been shown in the adult burn population; the literature on laser use in pediatric
patients is scarce. Nevertheless, there are studies
reporting their experiences with laser therapy,
showing improvement in scar quality in pediatric
burn patients.
Two commercially available lasers are most
widely reported in the literature [61]. The rst is
the 585 nm short-pulsed dye laser (Syneron
Candela VBeam Perfecta, Wayland, MA), whose
target chromophore is hemoglobin. Destruction
of hemoglobin-containing tissues leads to necrosis in capillaries and the reduction of scar erythema, and improvements in pliability and
pruritus [62]. Next is the fractional carbon dioxide laser (The UltraPulse® Lumenis) which is an
ablative fractional resurfacing (AFR) machine
with different setting options; ActiveFXTM (lowest energy and highest density) and DeepFXTM
(balance between energy and density). These two
settings are commonly applied for supercial and
deep treatments, respectively. In contrast to the
pulsed dye laser, an ablative fractional laser
improves the scar’s height, volume, thickness,
and overall texture [56, 60, 61]. Both mechanisms can be used to treat hypertrophic scars. In
a retrospective review, Zuccaro etal. report that
using a pulsed dye laser in conjunction with an
ablative fractional carbon dioxide laser signicantly improved scar pigmentation, vascularity,
pliability, and height. Also signicant was the
nding that the two lasers could be safely combined in a single case [62]. A recent prospective
cohort study by Patel et al. would conrm the
efcacy of carbon dioxide laser in pediatric burn
survivors. The authors suggested that laser treatment of scars provides an excellent alternative to
more invasive therapies and a more immediate
alternative to more conservative scar treatments
[54]. The treatment with ablative fractional laser
can be combined with reconstructive surgical
techniques, which has become a popular and efcacious treatment approach [59]. However, once
a scar is fully matured, treatment with laser therapy alone is not a replacement for surgical reconstruction, which will be discussed in the following
section.
In the pediatric population, it is crucial to individualize the use of lasers and consider each scar
as its own clinical problem to optimize results.
Once a wound is healed, the treatment team
should consider laser treatment in the early phase
to prevent scar contracture and increase other
treatments’ responses using the ActiveFXTM
CO2 laser. At our institution, Shriners Children’s
Texas, recently matured scars with red or raised
appearance are commonly treated with intense
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pulsed light (IPL). These patients also may benet from the intralesional corticosteroid injections, typically with Kenalog 10 mg or 40 mg
(Bristol Myers Squibb, NewYork City, NewYork,
USA). Scars with intense pruritis are also considered for IPL therapy or fat grafting. While benets may be apparent after a single session, scars
typically require multiple rounds of laser therapy
before a treatment plateau is reached. The scar
should be allowed to heal between treatments,
6–8weeks, so the response to treatment can begin
to be observed and documented. More extensive
scars will require more sessions than limited
ones. Depending on the scar quality and
symptoms, ActiveFXTM and DeepFXTM fractional CO2 laser can be applied in one single session for supercial and deep treatment,
respectively. This approach is primarily applied
in thicker scars with erythema and pruritus. Every
session should be performed under intravenous
sedation to reduce discomfort and pain. Regarding
pain management, additional intradermal injections or regional nerve blocks can be utilized in
pediatric patients, which has also been reported
in the literature [63].
Surgical Scar Revision
Although there have been advancements in conservative treatment approaches, surgical treatment remains integral in the management of
excessive scarring postburn. No two scars are the
same, and every case needs to be considered individually to match the surgical plan with the
patient’s complaints and goals. The timing of
scar revision surgeries should be considered carefully, and children should be monitored throughout their growth and development. The scar tissue
does not grow as fast as the child during the
growth period, leading to asymmetric growth and
motor impairment. Therefore, it is crucial to
anticipate the need for potential scar surgery
prior to the development of permanent sequelae.
Furthermore, surgeries should be considered at
least 1 year after healing to allow for scar
maturation.
If surgery is required, our approach generally
follows the reconstructive ladder, carefully considering where laser or corticosteroid-based therapies may be employed as a complement. Patients
presenting to our clinic have a detailed surgical
plan in place, including areas of possible surgical
intervention and laser therapy, including previous
laser settings and treatment response. Still,
patients and caregivers guide our approach; care
is taken to address the most pressing complaints
rst, whether or not they were part of the surgical
plan beforehand.
Local tissue rearrangements are a workhorse
for burn reconstruction. The most common and
valuable techniques for contracture release
include various forms of Z-, W-, V-Y, or Y-Vplasty, which every reconstructive burn surgeon
should master. These techniques elongate tissue
along a contracture, camouage scar tissue in
favor of cosmesis, and release tension, resulting
in decreased inammation and hypertrophic
scarring [64]. Based on the hypertrophic scar
location, local aps can be utilized in various
forms. Hypertrophic scars of the face are commonly released with multiple Z-plasty in combination with ablative CO2 laser treatment. Local
V-Y advancement aps release the commissures
around the mouth. In the hand, small scarring
bands and mild forms of scarring in the palm
can be released by Z-plasty. Within the web
spaces, the jumping man Z-plasty, STAR-plasty,
or Y-V aps have been established as valuable
techniques for scar release, as they create concavity and length [65]. In the region of the nose,
the nasal turndown ap, consisting of the dorsal
surface of the nose and made up of skin graft
and scar, has been established as a useful surgical technique [66].
Depending on the severity of contracture and
location, skin grafts may be needed to introduce
unscarred tissue where local tissue rearrangement
is insufcient. For the reconstruction of eyelids,
we always use a full-thickness skin graft for the
lower lid and a thick split-thickness skin graft
(STSG) for the upper lids. In the axillary and popliteal regions, we frequently use fasciocutaneous
transposition aps. To prevent contracture in these
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