Improving Comfort and Throughput for Patients Undergoing Fractionated Laser Ablation of Symptomatic Burn Scars

Surgical Management of Chronic Neuropathic Burn Pain

Burn-related chronic neuropathic pain can contribute to a decreased quality of life. When medical and pharmacologic therapies prove ineffective, patients should undergo evaluation for surgical intervention, consisting of a detailed physical examination and elective diagnostic nerve block, to identify an anatomic cause of pain. Based on symptoms and physical examination findings, particularly Tinel's sign, treatments can vary, including a trial of laser therapies, fat grafting, or nerve surgeries (nerve decompression, neuroma excision, targeted muscle reinnervation, regenerative peripheral nerve interfaces, and vascularized denervated muscle targets). It is essential to counsel patients to establish appropriate expectations prior to treatment with a multidisciplinary team.

How to evaluate scar colour after burn injuries - A clinical comparison of the Mexameter® and the subjective scar assessment (POSAS/VSS)

INTRODUCTION

Scarring after burn injuries remains one of the major challenges in burn medicine and is the subject of current research. Accurate and high-quality assessment of scars is needed to enable exact outcome evaluation of different treatments. Our aim was to evaluate the most common subjective scar evaluation scores-the POSAS (Patient and Observer Scar Assessment Scale) and VSS (Vancouver Scar Scale)-in comparison with the objective device Mexameter® for colour evaluation.

METHODS

A prospective monocentre study was performed, which included 120 examined scar areas of 60 patients with third degree burns who had received skin grafts between 1975 and 2018 with a total burned surface area (TBSA) > 2%. Two different scar areas in comparison with one healthy skin area concerning 'colour', 'pigmentation', and 'vascularization' were evaluated by the Mexameter® MX 18, the OSAS, and the VSS by the same examiner, as well as the PSAS by the patient.

RESULTS

The mean TBSA of the 60 patients was 24.3%. In the OSAS, 61% of the scars were evaluated as 'hyper-', 19% as 'hypo-', and 19% as 'mix-pigmented'. Furthermore, 65% of the scars were estimated as highly vascularized. In the Mexameter®, the melanin index values of the scar areas compared to the healthy skin areas showed a small difference of 12 (p < 0.05). The mean difference of erythema between the scar and the healthy skin areas was 84 (p < 0.001). For the Mexameter®, moderate correlations were found when comparing 'erythema' with the OSAS category 'vascularization' (r = 0.33, p < 0.05) and 'melanin' with the OSAS parameter 'pigmentation' (r = 0.28, p < 0.05). When comparing the Mexameter® measurements to the OSAS questionnaire, 27% of the scars were wrongly evaluated as 'hyperpigmented' by the observer and 21% as 'hypervascularized', while showing low measurements in the device. Additionally, a novel Mexameter® ordinal scare scale was calculated.

CONCLUSION

In this study, we were able to show on a relatively large patient population that with the Mexameter®, the subjectivity of the scar colour assessment by examiner/patient can be overcome, but precise differentiation can still be ensured with subjective evaluation tools. We further introduced a novel Mexameter® Scar Scale. It is necessary to further investigate the vast range of objective devices and develop scar panels for with an incorporation of objective and subjective devices to further improve reliability with reduced bias in terms of scar assessment.

Treatment of Chronic Hypertrophic Burn Scars With a Fractional CO 2 Laser Is Well Tolerated in an Outpatient Clinic Setting

INTRODUCTION

The necessity of treating hypertrophic burn scars has expanded significantly with increased burn survivorship. Ablative lasers, such as carbon dioxide (CO 2 ) lasers, have been the most common nonoperative option for improving functional outcomes in severe recalcitrant hypertrophic burn scars. However, the overwhelming majority of ablative lasers used for this indication require a combination of systemic analgesia, sedation, and/or general anesthesia due to the painful nature of the procedure. More recently, the technology of ablative lasers has advanced and is more tolerable than their first-generation counterparts. Herein, we hypothesized that refractory hypertrophic burn scars can be treated by a CO 2 laser in an outpatient clinic.

METHODS

We enrolled 17 consecutive patients with chronic hypertrophic burn scars that were treated with a CO 2 laser. All patients were treated in the outpatient clinic with a combination of a topical solution (23% lidocaine and 7% tetracaine) applied to the scar 30 minutes before the procedure, Cryo 6 air chiller by Zimmer, and some patients received a mixture of N 2 O/O 2 . Laser treatments were repeated every 4 to 8 weeks until the patient's goals were met. Each patient completed a standardized questionnaire to assess tolerability and patient satisfaction of functional results.

RESULTS

All patients tolerated the laser well in the outpatient clinic setting, with 0% indicating "not tolerable," 70.6% "tolerable," and 29.4% "very tolerable." Each patient received more than 1 laser treatment for the following complaints: decreased range of motion (n = 16, 94.1%), pain (n = 11, 64.7%), or pruritis (n = 12, 70.6%). Patients were also satisfied with the results of the laser treatments ("no improvement or worsened" = 0%, "improved" = 47.1%, and "significant improvement" = 52.9%). The age of patient, type of burn, location of burn, presence of skin graft, or age of scar did not significantly affect the tolerability of treatment or satisfaction of outcome.

CONCLUSIONS

The treatment of chronic hypertrophic burn scars with a CO 2 laser is well tolerated in an outpatient clinic setting in select patients. Patients reported a high level of satisfaction with notable improvement in functional and cosmetic outcomes.

A 6-Year Experience of Laser Treatments for Burn Scars in a Regional Burn Center-Safety, Efficacy, and Quality Improvement

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.

Impact of a Laser Service Line for Burn Scar on a Dedicated Burn OR's Flow and Productivity

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.

Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus Recommendations

BACKGROUND AND OBJECTIVES

There is currently intense multidisciplinary interest and a maturing body of literature regarding laser treatments for traumatic scars, but international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the tremendous potential of laser techniques, offer recommendations for safe and efficacious treatment, and promote wider patient access guided by future high-quality research.

STUDY DESIGN/MATERIALS AND METHODS

An international panel of 26 dermatologists and plastic and reconstructive surgeons from 13 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the laser treatment of traumatic scars. A three-step modified Delphi method took place between March 2018 and March 2019 consisting of two rounds of emailed questionnaires and supplementary face-to-face meetings. The panel members approved the final manuscript via email correspondence, and the threshold for consensus was at least 80% concurrence among the panel members.

RESULTS

The manuscript includes extensive detailed discussion regarding a variety of laser platforms commonly used for traumatic scar management such as vascular lasers and ablative and non-ablative fractional lasers, special considerations such as coding and laser treatments in skin of color, and 25 summary consensus recommendations.

CONCLUSIONS

Lasers are a first-line therapy in the management of traumatic scars and contractures, and patients without access to these treatments may not be receiving the best available care after injury. Updated international treatment guidelines and reimbursement schemes, additional high-quality research, and patient access should reflect this status. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Patient satisfaction after fractional ablation of burn scar with 2940nm wavelength Erbium-Yag laser

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.

Peri-Procedure Laser Scar Therapy Protocol: A Pilot Survey of Plastic Surgeons' Practices

BACKGROUND

Scar management using laser phototherapy continues to evolve as it gains wide acceptance among patients and providers. Despite widespread use of laser therapy, there are no guidelines or consensus published regarding optimal pre- and post-procedure patient management. Our objective is to gain insight into the best laser practices; we decided to poll colleagues nationwide.

METHODS

An online survey was distributed to members of the American Society of Plastic Surgeons. The survey consisted of 34 questions regarding pre- and post-procedure protocols related to laser scar therapy.

RESULTS

Forty plastic surgeons responded to the survey. The survey demonstrated that ten types of lasers are currently used to treat scars. The most commonly used lasers are fractional Er:YAG (44.7%), pulsed dye (42.1%), and fractional CO₂ (36.8%). On a Likert 3-point scale, providers favored the use of pre-procedural sunblock (2.12), topical analgesics (1.91), and oral antivirals (1.83). They also preferred the use of topical moisturizer (2.45), oral analgesics (2.29), and oral antivirals (1.97) as a part of the post-laser treatment regimen.

CONCLUSION

The study verified there is no consensus regarding peri-procedure laser scar therapy regimens. As laser scar management continues to grow in popularity, this lack of consensus suggests the need for experts in the field to come together and propose agreeable protocols to be used as guidelines.

LEVEL OF EVIDENCE V

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