Drs. Miletta and Hivnor are from the Laser Surgery and Scar Center, San Antonio Military Health System, Texas. Dr. Donelan is from Shriners Hospitals for Children, Boston, Massachusetts.
Dr. Miletta reports no conflict of interest. Drs. Donelan and Hivnor have received travel expenses and honoraria for lectures and seminars from Lumenis.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, Department of the Air Force, or the Department of Defense.
Correspondence: Nathanial R. Miletta, MD, Laser Surgery and Scar Center, 2200 Bergquist Dr, San Antonio, TX 78236 (nathanmiletta@gmail.com).
Recent advances in laser surgery and our understanding of wound healing have ushered in a new era of trauma and burn scar management. Traditional therapy has centered around scar excision followed by primary closure or tissue replacement with flaps and grafts. This approach represents a perpetuation of the common fallacy that extensive scar improvement requires extensive surgical intervention. Laser surgery in conjunction with pharmacotherapy and minor tissue-conserving surgery produces well-healed and remodeled existing tissue that provides the most natural appearance and function of the skin. Now, patients’ hypertrophic, contracted, and disfiguring scars represent their most valuable reconstructive anatomy. With this paradigm shift, dermatologists are uniquely positioned to provide transformative and cost-effective scar therapy due to their proficiency in the necessary treatment modalities and expertise in the utilization of local anesthesia. We hope to further expand military and civilian patient access to such care in their local community through peer education and advocacy. We present a brief overview and outline of scar treatment practices that can be performed by dermatologists in office using devices and techniques they often already possess.
Burn and trauma scarring represents a major source of morbidity in both the civilian and military populations worldwide and often is mechanically, aesthetically, and symptomatically debilitating.
Advances in laser surgery and our understanding of wound healing have resulted in a scar therapy paradigm shift from large scar excisions and repair to a multimodal, tissue-conserving approach that relies on remodeling of the existing tissue.
Dermatologists are uniquely positioned to increase patient access to cost-effective, outpatient-based burn and trauma scar care utilizing devices and techniques that they currently possess.
References
Hypertrophic scarring secondary to trauma, burns, and surgical interventions is a major source of morbidity worldwide and often is mechanically, aesthetically, and symptomatically debilitating. Modern advances in acute trauma care protocols have resulted in survival rates greater than 90% in both civilian and military populations.1,2 Patients with wounds that have historically proven fatal are now surviving and are confronted with the long-term sequelae of their injuries. With more than 52,000 service members injured in military engagements from 2001 to 2015 and 8.5 million civilians presenting annually with injury patterns at risk for hypertrophic scarring, it is paramount that we ensure access to safe and effective long-term scar care.2,3
At its simplest level, hypertrophic scarring is believed to result from a disequilibrium between collagen production and degradation. This failure to properly transition through the stages of wound healing results in bothersome symptoms, a disfigured appearance, and mechanical dysfunction of the skin (Figure, A). Decreased elasticity and extensibility, increased dermal thickness, and scar contractures impair patient range of motion and functional mobility. Those affected commonly experience varying degrees of pruritus and dysesthesia along the scar. Combined with aesthetic variations in pigmentation, erythema, texture, and thickness, hypertrophic scarring often leads to long-term psychosocial impairment and decreased health-related quality of life.4
Hypertrophic burn scar contractures of the left dorsal forearm, wrist, and hand before (A) and after serial treatment with pulsed dye laser, ablative fractional CO2 laser, and an individual Z-plasty to the dorsal hand (B).
Treatment Approach
Treatment of hypertrophic scars requires a multimodal approach due to the spectrum of associated concerns and the natural recalcitrance of the scar to therapy. Protocols should be tailored to the individual but generally begin with tissue-conserving surgical interventions followed by selective photothermolysis of the scar vasculature. Subsequently, deep and superficial ablative fractional laser (AFL) treatment and local pharmacotherapy also are employed. Treatment can be accomplished in the outpatient setting under local anesthesia in a serial fashion. In the authors’ experience, these therapies behave in a synergistic fashion, achieving outcomes that far exceed the sum of their parts, often obviating the need for scar excision in the majority of cases (Figure, B).
Tissue-Conserving Surgical Intervention
Z-plasty is an indispensable surgical tool due to its ability to lengthen scars and reduce wound tension. Treatment is easily customizable to the patient and can be performed using the individual or multiple Z-plasty techniques. Undermining and step-off correction while suturing allow the physician to lower raised scars, elevate depressed scars, and obscure scar presence by minimizing the straight lines that draw the eye to the scar. Z-plasties rely on the creation and transposition of 2 triangular flaps and permit a 75% increase in length along the desired tension vector. As such, Z-plasties decrease wound tension and facilitate scar maturation.
Selective Photothermolysis of the Vasculature
Although there are several devices available to treat vascular and immature hypertrophic scars, the majority of studies have been conducted with the 595-nm pulsed dye laser. By preferentially heating oxyhemoglobin within the dermal microvasculature, the pulsed dye laser irreparably injures the vascular endothelium. The subsequent tissue hypoxia and collagen fiber heating results in collagen fiber realignment, normalization of collagen subtypes, and neocollagenesis.5 Pulsed dye laser therapy most effectively reduces erythema and pruritus; however, improvements in scar volume, pliability, and elasticity also have been reported.5 When targeting the fine vasculature of the scar, thermal confinement is critical to prevent injury to the surrounding dermis. As such, pulse widths of 0.45 to 1.5 milliseconds are routinely utilized with a fluence just sufficient to elicit transient purpura lasting 3 to 5 seconds. Employing a spot size of 7 to 10 mm, typical fluences range from 4.5 to 6.5 J/cm2. Engagement of the dynamic cooling device reduces the risk for complications, allowing the patient to proceed to the next step in their therapy regimen: the AFL.
