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Madiedo et al. Plast Aesthet Res 2018;5:40 I http://dx.doi.org/10.20517/2347-9264.2018.40 Page 3 of 10

(affecting only the epidermis), partial-thickness (until papillary dermis layer) or full-thickness (complete
dermis and underlying tissue).

Patients were asked to sign an informed consent form to participate in the study and have their photos taken.
Patients showing additional comorbidities that could affect scarring, including malnutrition, high blood
pressure, diabetes mellitus, and coagulation disorders, were excluded. Patients having severe mental disorders
or exposed areas not suitable for graft coverage, including hypertrophic granulation tissues, edematous or pale
tissues, or the presence of discharge, were also excluded.

Procedures
Once the informed consent form was signed, the procedure was performed in operating rooms after the
administration of general anesthesia, patients were washed with water and chlorhexidine soap. Granulation
tissue curettage was executed for full removal, and wet compresses diluted in 500 cc of 0.9% saline were
applied, along with the use of a 1-mg adrenaline ampoule, to achieve hemostasis. In case bleeding was not
controlled, hemostasis was ensured by electrocautery. Subsequently, from the available donor sites, such as the
lower limbs, back or scalp, a split-thickness skin graft (between 0.25 mm and 0.30 mm) was harvested using an
electric dermatome. Following this, bupivacaine 0.25% with epinephrine at a dose of 2 mg/kg was administered
to manage postoperative pain at donor site. Upon verifying hemostasis at receptor site, the graft was placed
transversely in sheets, without expansion or meshing. Incisions for drainage were made, while ensuring that
no exposed spaces were left in between each sheet. Suture immobilization remained at the discretion of the
surgeon, but it was usually done on pediatric patients and at flexion creases sites. Next, the graft receptor site
was covered with nitrofurazone-impregnated gauzes and cotton padding bandages as secondary dressing.
Flexion areas were applied plaster splint intraoperatively. The first cleaning and dressing session took place
at postoperative day 5, and from then on, every third day until hospital discharge. Postoperative monitoring
varied in frequency, based on the surgeon’s judgment, until postoperative month 12. The same two surgeons
performed the monitoring.

On admission, all patients were evaluated and managed through physical and occupational therapies. Based
on the reported findings, the rehabilitation team planned activities aimed at lowering edema, reducing pain,
improving ROM, controlling positioning, and recovering sensitivity and strength, to promote the functionality
of affected areas and independence of physical and instrumental ADL. Rehabilitation treatment was suspended
immediately after surgery and was resumed at day 5 upon verification by the surgeon that there was proper
graft integration. Once the physical and occupational therapies were resumed, they were continued during
hospital admission and 3 months postoperatively (outpatient), through physical conditioning, digital pressure
on the scar, orthotic management, Lycra garments, silicone, moisturizers, and lubricants. The scars had no
medication infiltrated.

Scarring evaluation
The Vancouver Scar Scale (VSS) was used as follows: pigmentation and vascularity was examined visually,
pliability was assessed by palpation and digital pressure, and height/thickness was measured with a millimeter
[25]
ruler . Overall scores were categorized in three groups according to the following characteristics: (1) mild scar
(score 0-3): characterized by a flat scar having a similar appearance to normal skin. It is supple and elastic, and
has a few elements of pigmentation or vascularization; (2) moderate scar (score 4-7): characterized by a fairly
thick and wide scar or a slightly wide and raised scar. Pink to red pigmentation changes may be observed, but
there is yielding. Some areas may be fragile and less resistant; and (3) severe scar (score 8-13): characterized by
clear signs of hypertrophy or keloid. The scar has a red to purple pigmentation, and it is unstable, raised, bulky,
firm and indurated. Contractures and retractions may be present. Results were evaluated by a team of experts
consisting of two surgeons, who performed the procedures, and a burn specialist.