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Liu XJ, Liu WH, Fang SW, Zhou XL, Xu JX, Li GS. Lasers and Intense Pulsed Light for the Treatment of Pathological Scars: A Network Meta-Analysis. Aesthet Surg J 2022; 42:NP675-NP687. [PMID: 35762934 DOI: 10.1093/asj/sjac175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Laser and intense pulsed light (IPL) therapies have shown promising effects on pathological scars, but the comparative effectiveness of laser and IPL therapies has not yet been studied. OBJECTIVES The aim of this study was to compare and rank the efficacy of laser and IPL therapies to determine the most effective treatment method for pathological scars. METHODS Relevant studies published up to February 2022 were identified by searching PubMed, Web of Science, Cochrane Library, CNKI, and Wanfang databases. We defined Vancouver Scar Scale score as the primary outcome. Both frequentist and Bayesian approaches were used to perform a network meta-analysis. RESULTS We included 25 trials with a total of 1688 participants. The rankings based on the surface under the cumulative ranking curve for the Vancouver Scar Scale score based on the Bayesian approach suggested IPL + CO2 (96.43%) > pulsed dye laser (PDL) + 1064-nm Nd:YAG (yttrium aluminum garnet) laser (86.21%) > PDL + CO2 (82.15%) > CO2 (58.97%) > 1064-nm Nd:YAG (57.03%) > PDL (52%) > 532-nm Nd:YAG (33.28%) > Er:YAG + IPL (28.38%) > Er:YAG (26.56%) > IPL (15.03%) > control (13.97%). The ranking results based on the frequentist approach were basically consistent with those based on the Bayesian approach. CONCLUSIONS The results of the network meta-analysis showed that the combination of IPL and CO2 laser has the highest probability of being the most effective intervention. However, our conclusions must be interpreted with caution due to the relatively few evaluation indicators included in our study. Future well-designed randomized controlled trials with large sample sizes are required to confirm our conclusions. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Xuan-Jun Liu
- Department of Plastic and Reconstructive Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wen-Hui Liu
- Department of Plastic and Reconstructive Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shao-Wen Fang
- Department of Plastic and Reconstructive Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin-Long Zhou
- Department of Plastic and Reconstructive Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jia-Xiang Xu
- Department of Plastic and Reconstructive Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guang-Shuai Li
- Department of Plastic and Reconstructive Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Treatment of hyperpigmentation after burn: A literature review. Burns 2022; 48:1055-1068. [PMID: 35537921 DOI: 10.1016/j.burns.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 03/31/2022] [Accepted: 04/20/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIFY Skin pigmentation disorders are one of the most frequent sequelae after burn injury. While these conditions often improve over time, some are permanent and cause severe psychological disorders (especially on the face). Given the frequency of these disorders and their benign nature, the scientific community has great difficulty postponing these patient follow-ups. Publications on their management are rare, and there is no consensus on the gold standard treatment for skin dyschromia. Herein, we performed a literature review including the various treatments currently proposed to manage these hyperpigmentations. METHODS All reported articles up to February 2021 were reviewed on Pubmed. Studies on the treatment of hyperpigmented scars were included if they were secondary to burn injuries. Excluded articles evaluated transient treatments, such as makeup, and articles on inflammatory hyperpigmentation without etiological details or not secondary to burns. RESULTS 201 articles were identified, and 13 studies were included. Topical creams used in inflammatory hyperpigmented lesions such as hydroquinone and first-line retinoids are controversial due to their inconstant efficacy. Various types of laser and pulsed light treatments have shown their effectiveness but can also aggravate pigmentation. CONCLUSION Dyschromia after burn remains a therapeutic challenge. Hyperpigmentations after burn should be treated on a case-by-case basis, using data from the literature, clinical experience and measuring the risk/benefit ratio.
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Zhang CQ, Gogal C, Gaugler T, Blome-Eberwein S. A 6-Year Experience of Laser Treatments for Burn Scars in a Regional Burn Center-Safety, Efficacy, and Quality Improvement. J Burn Care Res 2021; 42:74-81. [PMID: 32681723 DOI: 10.1093/jbcr/iraa118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Laser treatments have long been used as a treatment method for burn scars. Since 2012, more than 1800 laser treatments were performed at Lehigh Valley Health Network Burn Center, far exceeding any previous cohort in studies exploring laser treatments for burn scars. Although previous research has looked at improving scar appearance and physiology with laser treatments, very few have focused on safety. The purpose of the study was to determine whether laser treatments are a safe treatment option for burn scars. Four hundred and fourteen patients who had undergone at least one laser treatment in the outpatient burn center since 2012 were analyzed. Electronic medical records (EPIC) were reviewed. The data were entered in REDCap and later exported to Microsoft Excel and R Studio for statistical analysis. Most of the complications found were related to the moderate sedation during the procedures and were mild, ie, nausea. The most common adverse effect was prolonged recovery time, which can affect practice flow. The overall postoperative complication rate for laser treatments with and without moderate sedation was minimal at 2.2% and 1.4%, respectively. Pain during and after the procedure averaged 3.9 and 1.7, respectively, on a 1 to 10 scale. The Vancouver Scar Scale showed modest improvement in scar appearance over time with an average improvement of 1.4. The high variability of the Vancouver Scar Scale observed in this series underlines its lack of sensitivity. The study results show that laser treatments for burn scars in the outpatient setting generally are safe for patients in need of burn scar intervention. Some practice flow adjustments need to be taken into consideration when offering these procedures in an outpatient setting.
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Fractionally Ablative Er: YAG Laser Resurfacing for Thermal Burn Scars: a Split-Scar, Controlled, Prospective Cohort Study. Dermatol Surg 2021; 46:1577-1582. [PMID: 32740214 DOI: 10.1097/dss.0000000000002650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thermal burn scars can have catastrophic impact on the quality of life and personal image, and over time can lead to profound physical and psychological debilitation. There are no established treatments to significantly improve burn scars. OBJECTIVE To demonstrate the safety, efficacy, and tolerability of fractionally ablative Er:YAG resurfacing of mature burn scars. METHODS Sixteen subjects were enrolled and received 3 treatments of fractionally ablative Er:YAG resurfacing at monthly intervals. Twelve completed the study. Scars were scored with the Vancouver Scar Scale (VSS) by the patient and physician before and after treatment. Blinded photographic analysis (Visual Analog Scale [VAS]) and blinded histologic analysis of tissue before and after treatment was also performed. RESULTS Significant Improvement in VSS scores were seen in all 12 patients, reported by patients and the evaluating physician alike. Photographic analysis demonstrated subjective improvement in all 12 patients. Histologically, there was significant improvement in collagen architecture and the number of vessels per high-power field. The treatments were tolerated well by patients, and 1 superficial skin infection occurred. CONCLUSION Fractionally ablative Er:YAG laser resurfacing is a safe and effective modality in the treatment of thermal burn scars with subjective and objective improvement as seen from the patient and physician.
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Madni TD, Lu K, Nakonezny PA, Imran JB, Cunningham HB, Clark AT, Taveras L, Hoopman JE, Wolf SE, Kenkel JM, Phelan HA. Treating Hypertrophic Burn Scar With 2940-nm Er:YAG Laser Fractional Ablation Improves Scar Characteristics as Measured by Noninvasive Technology. J Burn Care Res 2020; 40:416-421. [PMID: 31046088 DOI: 10.1093/jbcr/irz056] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Their group previously demonstrated high-patient satisfaction for the treatment of hypertrophic burn scar (HBS) with the erbium: yttrium aluminum garnet (Er:YAG) laser, but this and other literature supporting the practice suffer from a common weakness of a reliance on subjective assessments by patients or providers. Herein, they sought to prospectively study the effects of Er:YAG fractional ablation on HBS using noninvasive, objective technologies to measure outcomes. Patients with HBS had identical regions of scar designated for treatment by the Er:YAG laser (TREAT) or to be left untreated (CONTROL). They prospectively collected scar measurements of TREAT and CONTROL regions preoperatively, 3 weeks, and 3 months after Er:YAG treatment. Scar measurements included viscoelastometry, transepidermal water loss, optical coherent tomography, and high-frequency ultrasound. Outcomes were measured for the aggregate difference between the TREAT group vs the CONTROL group, as well as within each group in isolation. Seventeen patients were seen preoperatively, followed by n = 15 at 3 weeks and n = 11 at 3 months. A mixed-model repeated measures analysis showed no significant effect of fractional ablation when comparing the overall TREAT group measurements with those of the CONTROL group. However, when considered as within-group measurements, TREAT scars showed significant improvement in viscoelastic deformity (P = .03), elastic deformity (P = .004), skin roughness (P = .05), and wrinkle depth (P = .04) after fractional ablation, whereas CONTROL scars showed no such within-group changes. HBS treated by the Er:YAG laser showed objective improvements, whereas no such changes were seen within the untreated scars over the same time frame.
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Affiliation(s)
- Tarik D Madni
- UT Southwestern Department of Surgery, Division of Biostatistics Dallas, Texas
| | - Karen Lu
- UT Southwestern Department of Plastic Surgery, Division of Biostatistics Dallas, Texas
| | - Paul A Nakonezny
- UT Southwestern Department of Clinical Sciences, Division of Biostatistics, Dallas, Texas
| | - Jonathan B Imran
- UT Southwestern Department of Surgery, Division of Biostatistics Dallas, Texas
| | - Holly B Cunningham
- UT Southwestern Department of Surgery, Division of Biostatistics Dallas, Texas
| | - Audra T Clark
- UT Southwestern Department of Surgery, Division of Biostatistics Dallas, Texas
| | - Luis Taveras
- UT Southwestern Department of Surgery, Division of Biostatistics Dallas, Texas
| | | | | | - Jeffrey M Kenkel
- UT Southwestern Department of Plastic Surgery, Division of Biostatistics Dallas, Texas
| | - Herb A Phelan
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas, Texas
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Nonsurgical Management of Hypertrophic Scars: Evidence-Based Therapies, Standard Practices, and Emerging Methods. Aesthetic Plast Surg 2020; 44:1320-1344. [PMID: 32766921 DOI: 10.1007/s00266-020-01820-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Accepted: 01/05/2007] [Indexed: 12/12/2022]
Abstract
Hypertrophic scars, resulting from alterations in the normal processes of cutaneous wound healing, are characterized by proliferation of dermal tissue with excessive deposition of fibroblast-derived extracellular matrix proteins, especially collagen, over long periods, and by persistent inflammation and fibrosis. Hypertrophic scars are among the most common and frustrating problems after injury. As current aesthetic surgical techniques become more standardized and results more predictable, a fine scar may be the demarcating line between acceptable and unacceptable aesthetic results. However, hypertrophic scars remain notoriously difficult to eradicate because of the high recurrence rates and the incidence of side effects associated with available treatment methods. This review explores the various treatment methods for hypertrophic scarring described in the literature including evidence-based therapies, standard practices, and emerging methods, attempting to distinguish those with clearly proven efficiency from anecdotal reports about therapies of doubtful benefits while trying to differentiate between prophylactic measures and actual treatment methods. Unfortunately, the distinction between hypertrophic scar treatments and keloid treatments is not obvious in most reports, making it difficult to assess the efficacy of hypertrophic scar treatment.
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Madni TD, Hoopman JE, Li X, Imran JB, Clark AT, Cunningham HB, Wolf SE, Kenkel JM, Phelan HA. Impact of a Laser Service Line for Burn Scar on a Dedicated Burn OR's Flow and Productivity. J Burn Care Res 2020; 39:811-814. [PMID: 29789856 DOI: 10.1093/jbcr/irx056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Our group began performing erbium-YAG 2940 wavelength fractional resurfacing of burn scar in our burn center's dedicated burn operating room (OR) in January 2016. The impact of these procedures on the performance of a mature, dedicated burn OR is unknown. All burn OR cases performed between January 1, 2015 and December 31, 2015 served as a pre-laser (PRE-LSR) historical control. A postintervention cohort of laser-only cases (LSR) performed between January 1, 2016 and August 17, 2016 was then identified. PRE-LSR and LSR cases were retrospectively reviewed for OR component times, and work relative value units (wRVU) billed. A total of 628 burn OR cases were done in 2015 (PRE-LSR), while 488 burn OR cases were done between January 1 and August 17, 2016. Of these 488, 59 cases were LSR (12.1%). Calculated on a monthly basis, significantly more cases were done per day in the LSR era (2.2 ± 0.4 cases/d) than PRE-LSR (1.6 ± 2.0 cases/d; P < .0001). The LSR group was significantly shorter than the PRE-LSR group for all OR component times (induction, prep, and procedure all P < .0001; transport out, P = .01; room turnover, P = .004). Aggregate OR component time was 79.2 ± 33.4 minutes for LSR and 157.5 ± 65.0 minutes for PRE-LSR (P < .0001). LSR yielded 6.9 ± 3.2 wRVU/h, while PRE-LSR generated 12.2 ± 8.9 wRVU/h (P < .0001). Despite significantly shorter OR component times and more cases being done per day, laser treatment of burn scar using a single 17108 Current Procedural Terminology code cuts wRVUs generated per hour in a mature burn OR roughly in half.
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Affiliation(s)
- Tarik D Madni
- UT Southwestern Department of Surgery, Dallas, Texas
| | | | - Xingchen Li
- UT Southwestern Department of Plastic Surgery, Dallas, Texas
| | | | - Audra T Clark
- UT Southwestern Department of Surgery, Dallas, Texas
| | | | - Steven E Wolf
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas
| | | | - Herb A Phelan
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas
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Kant SB, Colla C, van den Kerckhove E, Piatkowski de Grzymala A. Clinical effects of transparent facial pressure masks: A literature review. Prosthet Orthot Int 2019; 43:349-355. [PMID: 30860443 PMCID: PMC6557006 DOI: 10.1177/0309364619836023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Severe facial hypertrophic scars are known to severely impact emotional well-being. Pressure therapy by means of transparent face masks has been used for almost 40 years, but evidence about the clinical effects remains sparse. OBJECTIVES To provide a summary on the efficacy of transparent face masks in the treatment of facial hypertrophic scars. METHODS A literature search was conducted in PubMed, MEDLINE, and Cochrane databases through 1 January 2018. Articles describing the clinical effects of facial pressure therapy for remodeling the face after trauma or surgery with a validated tool were included. This review included studies of participants treated with facial hypertrophic scars, both minors and adults. RESULTS Three articles involving 33 patients were selected for inclusion. Two studies described statistically significant improvement in facial scars measured by durometer, ultrasound, and the Patient and Observer Scar Assessment Scale (POSAS). CONCLUSIONS Facial pressure masks have been shown to deliver significant improvement in facial scars, measured by both subjective and objective tools. However, only three studies could be included in this literature review. Also, because of considerable limitations of the studies, it remains difficult to draw substantial conclusions about the efficacy of transparent face masks. CLINICAL RELEVANCE This literature review provides a summary of the current evidence on the subjectively and objectively measured clinical effects of transparent face masks in the treatment of facial scars, highlighting the need for further research on this topic.
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Affiliation(s)
- Sander B Kant
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, The Netherlands,Sander B Kant, Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, P Debyelaan 25, 6229 HX Maastricht, The Netherlands.
| | - Carlo Colla
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, The Netherlands
| | - Eric van den Kerckhove
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, The Netherlands,Department of Rehabilitation Sciences (Faber), Universitaire Ziekenhuizen Leuven, KU Leuven, Leuven, Belgium,Department of Physical Medicine and Rehabilitation and Burns Center, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
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Madni TD, Nakonezny PA, Imran JB, Clark AT, Cunningham HB, Hoopman JE, Arnoldo BD, Wolf SE, Kenkel JM, Phelan HA. Patient satisfaction after fractional ablation of burn scar with 2940nm wavelength Erbium-Yag laser. Burns 2018; 44:1100-1105. [PMID: 29627130 DOI: 10.1016/j.burns.2018.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/11/2017] [Accepted: 02/05/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Fractional laser therapy is a new treatment with potential benefit in the treatment of burn scars. We sought to determine patient satisfaction after burn scar treatment with the Erbium-Yag laser. METHODS We performed a telephone survey of all patients who underwent fractional resurfacing of burn scars with the Erbium-Yag 2940 wavelength laser at Parkland Hospital from 01/01/2016 to 05/01/2017. Subjects were asked to rate their satisfaction with their scars' after treatment characteristics on a scale from 1 (completely unsatisfied) to 10 (completely satisfied). Subjects were also asked to assess their treatment response using the UNC 4P Scar Scale before and after treatment. RESULTS Sixty-four patients underwent 156 treatments. A survey response rate of 77% (49/64) was seen (age: 36.8+21 years; surface area treated=435+326cm2; 35% of burn scars were >2 years old; mean scar age of 1.02+0.4 years). Overall, 46/49 (94%) of patients reported some degree of scar improvement after treatment. Patient satisfaction scores were 8.3+2.3. Number of laser treatments included: 1 (31%), 2 (33%), 3 (18%), 4(10%), >5 (8%). Treatment depth, scar age, and number of laser procedures were not significant predictors of satisfaction or UNC 4P Scar scores. The paired t-test showed a significant reduction on each of the UNC 4P Scar scale items (pain, pruritus, pliability, paresthesia). One subject reported that she felt that the laser treatment made her scar worse (2%). CONCLUSION Burn patients treated with the Erbium-Yag laser are highly satisfied with changes in their burn scars.
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Affiliation(s)
- Tarik D Madni
- UT Southwestern Department of Surgery, Dallas, TX, United States.
| | - Paul A Nakonezny
- UT Southwestern Department of Clinical Sciences, Division of Biostatistics, Dallas, TX, United States.
| | - Jonathan B Imran
- UT Southwestern Department of Surgery, Dallas, TX, United States.
| | - Audra T Clark
- UT Southwestern Department of Surgery, Dallas, TX, United States.
| | | | - John E Hoopman
- UT Southwestern Medical Center, Dallas, TX, United States.
| | - Brett D Arnoldo
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas, TX, United States.
| | - Steven E Wolf
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas, TX, United States.
| | - Jeffrey M Kenkel
- UT Southwestern Department of Plastic Surgery, Dallas, TX, United States.
| | - Herb A Phelan
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas, TX, United States.
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Żądkowski T, Nachulewicz P, Mazgaj M, Woźniak M, Cielecki C, Wieczorek AP, Beń-Skowronek I. A new CO2 laser technique for the treatment of pediatric hypertrophic burn scars: An observational study. Medicine (Baltimore) 2016; 95:e5168. [PMID: 27759650 PMCID: PMC5079334 DOI: 10.1097/md.0000000000005168] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Treatment of hypertrophic scars arising as a result of thermal burns in children is still a big problem. The results of the treatment are not satisfactory for patients and parents, and new methods of treatment are still investigated.We present the use of one of the most modern carbon dioxide (CO2) lasers (Lumenis Encore laser equipped with a Synergistic Coagulation and Ablation for Advanced Resurfacing module) in the treatment of hypertrophic scars in children after burns.From March to April of 2013, a group of 47 patients aged 6 to 16 years underwent 57 laser surgery treatments. The average time from accident was 7.5 years. The results of treatment were investigated in 114 areas. The assessed areas were divided into 2 groups: 9-cm area 1, where the thickness of the scar measured by physician was the lowest and 9-cm area 2, where the thickness of the scar was the biggest. The results were considered on the Vancouver Scar Scale (VSS) independently by the surgeon and by parents 1, 4, and 8 months after the procedure. In addition, ultrasound evaluation of the scar thickness before and after laser procedure was made.VSS total score improved in all areas assessed by both the physician and parents. The biggest change in total VSS score in area 1 in the evaluation of the investigator was obtained at follow-up after the 1st month of treatment (average 7.23 points before and 5.18 points after the 1st month after surgery-a difference of 2.05 points). Scar ratings by parents and the physician did not differ statistically (P < 0.05). In the ultrasound assessment, the improvement was statistically significant, more frequently for both minimum and maximum thickness of the scars (B-mode measures) (P < 0.05).The use of a CO2 laser in the treatment of hypertrophic scars in children is an effective and safe method. The use of a CO2 laser improves the appearance and morphology of scarring assessed using the VSS by both the parents and the physician. The treatment also reduced the thickness of scars evaluated by ultrasound.
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Affiliation(s)
- Tomasz Żądkowski
- Department of Paediatric Surgery
- Correspondence: Tomasz Żądkowski, Medical University of Poland, Lublin, Poland (e-mail: )
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Abstract
INTRODUCTION Although lasers can improve burn scars, such treatment has not been adopted universally, due to operational challenges starting a practice and the perception that such a program is not financially viable. We report the logistics of building a laser practice for the treatment of hypertrophic burn scars. METHODS We analyzed the clinical, operational, and financial components of our laser practice, focusing on treatment of hypertrophic burn scars, using pulsed dye laser, fractional CO2 laser, and intense pulsed light. Cases were performed in an operating room, with anesthesia, after preauthorization. We examined professional charges and collections, case time, variable and indirect expenses, and breakeven volumes. RESULTS Our practice grew as follows: 2008, 1 case; 2009, 44 cases; 2010, 169 cases; and 2011, 415 cases. Overall collection rate was 32.1%. Expenses incurred by the provider, per 8-hour session, included laser rental/lease ($2375), personnel salaries ($1900), and physician overhead ($808), for a total cost of $5083. Mean charge was $1642 per case; mean collection was $527 per case. Median case time (procedure plus turnover) was 40 minutes. In this model, breakeven volume is 9.7 cases per day; breakeven time is 49.7 minutes. Provider profit margin for 10 cases per day, or 83% capacity utilization, is $187 per day (income - expenses = $5270 - $5083). CONCLUSIONS Despite high costs associated with starting and operating a laser practice for the treatment of hypertrophic burn scars, a sustainable enterprise can be achieved when the provider has accrued enough volume to batch cases over an entire day. Critical to achieving breakeven is preauthorization, controlling overhead, and efficient throughput.
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Prospective, before-after cohort study to assess the efficacy of laser therapy on hypertrophic burn scars. Ann Plast Surg 2013; 70:521-6. [PMID: 23542846 DOI: 10.1097/sap.0b013e31827eac5e] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Hypertrophic burn scars produce significant morbidity, including itching, pain, stiffness, and contracture. Best practices for management continue to evolve. Lasers have recently been added to treatment algorithms, but indications and efficacy have not been fully defined. We studied the impact of laser therapies on hypertrophic burn scars. METHODS We conducted a prospective, before-after study in burn patients with hypertrophic scars. Procedures were performed more than 6 months after burn injury and were repeated monthly. The pulsed-dye laser was used for pruritus and erythema, whereas the fractional CO2 laser was used for stiffness and abnormal texture. All procedures were performed in the OR, with anesthesia. Outcomes are as follows: (1) Vancouver Scar Scale (objective changes in pigmentation, erythema, pliability, height; range, 0-15) and (2) UNC Scar Scale (subjective changes in pain, itching, tingling, stiffness; range, 0-12). Before-after scores were compared by Student t test, with significance assigned to P values of <0.05. RESULTS During 2011, we treated 147 patients (mean age, 26.9 years; mean TBSA, 16.1%) over 415 sessions (2.8 sessions/patient), including pulsed dye laser (n = 327) and CO2 (n = 139), mean surface area of 83 cm. Etiology included flame (75), scald (37), and other (35). Treatments occurred 16 months (median) and 48 months (mean) after burn injury. Vancouver Scar Scale decreased from 10.4 (SD, 2.4) to 5.2 (1.9) (P < 0.0001). UNC Scar Scale decreased from 5.4 (2.5) to 2.1 (1.7) (P < 0.0001). Mean length of follow-up was 4.7 months. CONCLUSIONS Laser therapies significantly improve both the signs and symptoms of hypertrophic burn scars, as measured by objective and subjective instruments.
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Narinesingh S, Lewis S, Nayak BS. Use of 1540nm fractionated erbium:glass laser for split skin graft resurfacing: a case study. J Wound Care 2013; 22:510-3. [PMID: 24005785 DOI: 10.12968/jowc.2013.22.9.510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The field of laser skin resurfacing has evolved rapidly over the past two decades from ablative lasers, to nonablative systems using near-infrared, intense-pulsed light and radio-frequency systems, and most recently fractional laser resurfacing. Although fractional thermolysis is still in its infancy, its efficacy in in the treatment of skin disorders have been clearly demonstrated. Here we present a case report on the safety and efficacy of a 1540nm erbium:glass laser in the treatment of the waffle pattern of a meshed skin graft in a 38-year-old patient with type V skin in the Caribbean.
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Affiliation(s)
- S Narinesingh
- Registrar, Department of Surgery, North Central Regional Health Authority, EWMSC, Trinidad
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Incidence and Management of Adverse Events After the Use of Laser Therapies for the Treatment of Hypertrophic Burn Scars. Ann Plast Surg 2013; 70:500-5. [DOI: 10.1097/sap.0b013e31827eac79] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shine on: Review of Laser- and Light-Based Therapies for the Treatment of Burn Scars. Dermatol Res Pract 2012; 2012:243651. [PMID: 22778719 PMCID: PMC3388335 DOI: 10.1155/2012/243651] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 03/09/2012] [Indexed: 11/18/2022] Open
Abstract
Restoration of form and function after burn injury remains challenging, but emerging laser and pulsed light technologies now offer hope for patients with hypertrophic scars, which may be associated with persistent hyperemia, chronic folliculitis, intense pruritis, and neuropathic pain. In addition to impairing body image, these scars may limit functional recovery, compromise activities of daily living, and prevent return to work. Three different platforms are now poised to alter our reconstructive algorithm: (1) vascular-specific pulsed dye laser (PDL) to reduce hyperemia, (2) ablative fractional CO(2) laser to improve texture and pliability of the burn scar, and (3) intense pulsed light (IPL) to correct burn scar dyschromia and alleviate chronic folliculitis. In this paper, we will provide an overview of our work in this area, which includes a systematic review, a retrospective analysis of our preliminary experience, and interim data from our on-going, prospective, before-after cohort trial. We will demonstrate that laser- and light-based therapies can be combined with each other safely to yield superior results, often at lower cost, by reducing the need for reconstructive surgery. Modulating the burn scar, through minimally invasive modalities, may replace conventional methods of burn scar excision and yield outcomes not previously possible or conceivable.
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Hautier A, Ould Ali D, Salem M, Magalon G. [Burn contractures of the extremities]. ANN CHIR PLAST ESTH 2011; 56:444-53. [PMID: 21917370 DOI: 10.1016/j.anplas.2011.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 08/08/2011] [Indexed: 10/17/2022]
Abstract
Burn contractures are common after deep burns of the limbs. When rehabilitation fails to restore joint function and normal range of motion, surgical contracture release should be performed. Different plastic surgery techniques can be used, from Z-plasty to skin grafts, artificial dermis and flaps. Surgery can also be used in case of esthetic concerns. Available surgical techniques and indications are presented.
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Affiliation(s)
- A Hautier
- Centre des brûlés inter-régional méditerranée, CHU de la Conception, 147, boulevard Baille, 13005 Marseille, France.
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Haedersdal M, Moreau KE, Beyer DM, Nymann P, Alsbjørn B. Fractional nonablative 1540 nm laser resurfacing for thermal burn scars: A randomized controlled trial. Lasers Surg Med 2009; 41:189-95. [DOI: 10.1002/lsm.20756] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Prevention and management of hypertrophic scars and keloids after burns in children. J Craniofac Surg 2008; 19:989-1006. [PMID: 18650721 DOI: 10.1097/scs.0b013e318175f3a7] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hypertrophic scars and keloids are challenging to manage, particularly as sequelae of burns in children in whom the psychologic burden and skin characteristics differ substantially from adults. Prevention of hypertrophic scars and keloids after burns is currently the best strategy in their management to avoid permanent functional and aesthetical alterations. Several actions can be taken to prevent their occurrence, including parental and children education regarding handling sources of fire and flammable materials, among others. Combination of therapies is the mainstay of current burn scar management, including surgical reconstruction, pressure therapy, silicon gels and sheets, and temporary garments. Other adjuvant therapies such as topical imiquimod, tacrolimus, and retinoids, as well as intralesional corticosteroids, 5-fluorouracil, interferons, and bleomycin, have been used with relative success. Cryosurgery and lasers have also been reported as alternatives. Newer treatments aimed at molecular targets such as cytokines, growth factors, and gene therapy, currently in developing stages, are considered the future of the treatment of postburn hypertrophic scars and keloids in children.
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Armour A, Scott PG, Tredget EE. Cellular and molecular pathology of HTS: basis for treatment. Wound Repair Regen 2007; 15 Suppl 1:S6-17. [PMID: 17727469 DOI: 10.1111/j.1524-475x.2007.00219.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Hypertrophic scar and keloids are fibroproliferative disorders of the skin which occur often unpredictably, following trauma and inflammation that compromise cosmesis and function and commonly recur following surgical attempts for improvement. Despite decades of research in these fibrotic conditions, current non-surgical methods of treatment are slow, inconvenient and often only partially effective. Fibroblasts from these conditions are activated to produce extracellular matrix proteins such as collagen I and III, proteoglycans such as versican and biglycan and growth factors, including transforming growth factor-beta and insulin like growth factor I. However, more consistently these cells produce less remodeling enzymes including collagenase and other matrix metalloproteinases, as well as the small proteoglycan decorin which is important for normal collagen fibrillogenesis. Recently, the systemic response to injury appears to influence the local healing process whereby increases in Th2 and possibly Th3 cytokines such as IL-2, IL-4 and IL-10 and TGF-beta are present in the circulating lymphocytes in these fibrotic conditions. Finally, unique bone marrow derived cells including mesenchymal and endothelial stem cells as well as fibrocytes appear to traffic into healing wounds and influence the healing tissue. On this background, clinicians are faced with patients who require treatment and the pathophysiologic basis as currently understood is reviewed for a number of emerging modalities.
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Affiliation(s)
- Alexis Armour
- Department of Surgery, University of Alberta Hospital, Edmonton, Alberta, Canada
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Atiyeh BS. Nonsurgical management of hypertrophic scars: evidence-based therapies, standard practices, and emerging methods. Aesthetic Plast Surg 2007; 31:468-92; discussion 493-4. [PMID: 17576505 DOI: 10.1007/s00266-006-0253-y] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Accepted: 01/05/2007] [Indexed: 01/10/2023]
Abstract
Hypertrophic scars, resulting from alterations in the normal processes of cutaneous wound healing, are characterized by proliferation of dermal tissue with excessive deposition of fibroblast-derived extracellular matrix proteins, especially collagen, over long periods, and by persistent inflammation and fibrosis. Hypertrophic scars are among the most common and frustrating problems after injury. As current aesthetic surgical techniques become more standardized and results more predictable, a fine scar may be the demarcating line between acceptable and unacceptable aesthetic results. However, hypertrophic scars remain notoriously difficult to eradicate because of the high recurrence rates and the incidence of side effects associated with available treatment methods. This review explores the various treatment methods for hypertrophic scarring described in the literature including evidence-based therapies, standard practices, and emerging methods, attempting to distinguish those with clearly proven efficiency from anecdotal reports about therapies of doubtful benefits while trying to differentiate between prophylactic measures and actual treatment methods. Unfortunately, the distinction between hypertrophic scar treatments and keloid treatments is not obvious in most reports, making it difficult to assess the efficacy of hypertrophic scar treatment.
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Affiliation(s)
- Bishara S Atiyeh
- Division Plastic and Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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