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Leaker BD, Sojoodi M, Tanabe KK, Popov YV, Tam J, Anderson RR. Increased susceptibility to ischemia causes exacerbated response to microinjuries in the cirrhotic liver. FASEB J 2024; 38:e23585. [PMID: 38661043 DOI: 10.1096/fj.202301438rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 03/07/2024] [Accepted: 03/18/2024] [Indexed: 04/26/2024]
Abstract
Fractional laser ablation is a technique developed in dermatology to induce remodeling of skin scars by creating a dense pattern of microinjuries. Despite remarkable clinical results, this technique has yet to be tested for scars in other tissues. As a first step toward determining the suitability of this technique, we aimed to (1) characterize the response to microinjuries in the healthy and cirrhotic liver, and (2) determine the underlying cause for any differences in response. Healthy and cirrhotic rats were treated with a fractional laser then euthanized from 0 h up to 14 days after treatment. Differential expression was assessed using RNAseq with a difference-in-differences model. Spatial maps of tissue oxygenation were acquired with hyperspectral imaging and disruptions in blood supply were assessed with tomato lectin perfusion. Healthy rats showed little damage beyond the initial microinjury and healed completely by 7 days without scarring. In cirrhotic rats, hepatocytes surrounding microinjury sites died 4-6 h after ablation, resulting in enlarged and heterogeneous zones of cell death. Hepatocytes near blood vessels were spared, particularly near the highly vascularized septa. Gene sets related to ischemia and angiogenesis were enriched at 4 h. Laser-treated regions had reduced oxygen saturation and broadly disrupted perfusion of nodule microvasculature, which matched the zones of cell death. Our results demonstrate that the cirrhotic liver has an exacerbated response to microinjuries and increased susceptibility to ischemia from microvascular damage, likely related to the vascular derangements that occur during cirrhosis development. Modifications to the fractional laser tool, such as using a femtosecond laser or reducing the spot size, may be able to prevent large disruptions of perfusion and enable further development of a laser-induced microinjury treatment for cirrhosis.
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Affiliation(s)
- Ben D Leaker
- Health Sciences and Technology, Harvard-Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mozhdeh Sojoodi
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth K Tanabe
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Yury V Popov
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Tam
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts, USA
| | - R Rox Anderson
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts, USA
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Ma Y, Barnes SP, Chen YY, Moiemen N, Lord JM, Sardeli AV. Influence of scar age, laser type and laser treatment intervals on paediatric burn scars: a systematic review and meta-analysis. BURNS & TRAUMA 2024; 12:tkad046. [PMID: 38312741 PMCID: PMC10838059 DOI: 10.1093/burnst/tkad046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/24/2023] [Indexed: 02/06/2024]
Abstract
Background Laser therapy has emerged to play a valuable role in the treatment of paediatric burn scars; however, there is heterogeneity in the literature, particularly concerning optimal timing for initiation of laser therapy. This study aims to investigate the effect of factors such as scar age, type of laser and laser treatment interval on burn scar outcomes in children by meta-analysis of previous studies. Methods A literature search was conducted across seven databases in May 2022 to understand the effects of laser therapy on burn scar outcomes in paediatric patients by metanalysis of standardized mean difference (SMD) between pre- and post-laser intervention. Meta-analyses were performed using the Comprehensive Meta-Analysis software version 4.0. Fixed models were selected when there was no significant heterogeneity, and the random effects model was selected for analysis when significant heterogeneity was identified. For all analyses, a p-value < 0.05 was considered significant. Results Seven studies were included in the meta-analysis with a total of 467 patients. Laser therapy significantly improved Vancouver Scar Scale (VSS)/Total Patient and Observer Scar Assessment Scale (Total POSAS), vascularity, pliability, pigmentation and scar height of burn scars. Significant heterogeneity was found between the studies and thus subgroup analyses were performed. Early laser therapy (<12 months post-injury) significantly improved VSS/POSAS scores compared to latent therapy (>12 months post-injury) {SMD -1.97 [95% confidence interval (CI) = -3.08; -0.87], p < 0.001 vs -0.59 [95%CI = -1.10; -0.07], p = 0.03} as well as vascularity {SMD -3.95 [95%CI = -4.38; -3.53], p < 0.001 vs -0.48 [95%CI = -0.66; -0.30], p < 0.001}. Non-ablative laser was most effective, significantly reducing VSS/POSAS, vascularity, pliability and scar height outcomes compared to ablative, pulse dye laser and a combination of ablative and pulse dye laser. Shorter treatment intervals of <4 weeks significantly reduced VSS/POSAS and scar height outcomes compared to intervals of 4 to 6 weeks. Conclusions Efficacy of laser therapy in the paediatric population is influenced by scar age, type of laser and interval between laser therapy application. The result of this study particularly challenges the currently accepted initiation time for laser treatment. Significant heterogeneity was observed within the studies, which suggests the need to explore other confounding factors influencing burn scar outcomes after laser therapy.
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Affiliation(s)
- Yangmyung Ma
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Sabrina P Barnes
- Hull York Medical School, University Rd, Heslington, York YO10 5DD, United Kingdom
| | - Yung-Yi Chen
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Naiem Moiemen
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
- Department of Burns and Plastic Surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- Scar Free Foundation Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Janet M Lord
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
- Scar Free Foundation Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Amanda V Sardeli
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
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Ma Y, Barnes SP, Chen YY, Moiemen NS, Lord JM, Sardeli AV. Influence of scar age, laser type and laser treatment intervals on adult burn scars: A systematic review and meta-analysis. PLoS One 2023; 18:e0292097. [PMID: 37756273 PMCID: PMC10529539 DOI: 10.1371/journal.pone.0292097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
AIM The study aims to identify whether factors such as time to initiation of laser therapy following scar formation, type of laser used, laser treatment interval and presence of complications influence burn scar outcomes in adults, by meta-analysis of previous studies. METHODS A literature search was conducted in May 2022 in seven databases to select studies on the effects of laser therapy in adult hypertrophic burn scars. The study protocol was registered with PROSPERO (CRD42022347836). RESULTS Eleven studies were included in the meta-analysis, with a total of 491 patients. Laser therapy significantly improved overall VSS/POSAS, vascularity, pliability, pigmentation and scar height of burn scars. Vascularity improvement was greater when laser therapy was performed >12 months (-1.50 [95%CI = -2.58;-0.42], p = 0.01) compared to <12 months after injury (-0.39 [95%CI = -0.68; -0.10], p = 0.01), the same was true for scar height ((-1.36 [95%CI = -2.07; -0.66], p<0.001) vs (-0.56 [95%CI = -0.70; -0.42], p<0.001)). Pulse dye laser (-4.35 [95%CI = -6.83; -1.86], p<0.001) gave a greater reduction in VSS/POSAS scores compared to non-ablative (-1.52 [95%CI = -2.24; -0.83], p<0.001) and ablative lasers (-0.95 [95%CI = -1.31; -0.59], p<0.001). CONCLUSION Efficacy of laser therapy is influenced by the time lapse after injury, the type of laser used and the interval between laser treatments. Significant heterogeneity was observed among studies, suggesting the need to explore other factors that may affect scar outcomes.
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Affiliation(s)
- Yangmyung Ma
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | | | - Yung-Yi Chen
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Naiem S. Moiemen
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Department of Burns and Plastic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Scar Free Foundation Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Janet M. Lord
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Scar Free Foundation Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Amanda V. Sardeli
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
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Worley B, Kim K, Jain-Poster K, Reynolds KA, Merkel EA, Kang BY, Dirr MA, Anvery N, Christensen RE, Hisham FI, Ibrahim SA, Asadbeigi SN, Poon E, Alam M. Treatment of traumatic hypertrophic scars and keloids: a systematic review of randomized control trials. Arch Dermatol Res 2023; 315:1887-1896. [PMID: 36781457 DOI: 10.1007/s00403-023-02535-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/08/2022] [Accepted: 01/12/2023] [Indexed: 02/15/2023]
Abstract
Exaggerated healing and remodeling after skin injury may cause hypertrophic and keloidal scars, which are associated with functional and quality of life impairment. There is limited guidance available regarding the relative effectiveness of therapies for hypertrophic scars and keloids. In this review, we aim to compare the effectiveness of treatments for hypertrophic scars and keloids. MEDLINE, Embase, Scopus, and the Cochrane Collaboration database were searched from inception to March 2019 for randomized control trials of treatments for hypertrophic and keloid scars that included 20 or more patients. Outcomes evaluated included the standardized mean reduction in scarring and adverse events. The type of scar and the demographic features were analyzed for their effect on clinical outcome. Based on 25 included clinical trials, intralesional injection (64.1% [95% CI 60.8-67.5%]) may be more effective than physical (29.9% [95% CI 28.9-30.9%]) or topical treatments (34% [95% CI 31.8-36.8%]). Combination of 5-fluorouracil and triamcinolone (9:1 dilution) appeared superior among intralesional treatments for keloids. Ablative laser and pulsed-dye laser were the most useful laser treatments. Regression modeling showed laser treatment response was linked to Fitzpatrick skin type (p = 0.002). Adverse events were uncommon for all treatments and mostly transient. Intralesional treatments for keloid and hypertrophic scars may be the most reliable treatment option to improve pathologic scars, while laser treatment may have specific benefits for Fitzpatrick skin types I-III over types IV-VI. Management of pathological scars is an area of critical need, where appropriate treatment can have a significant impact on quality of life.
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Affiliation(s)
- Brandon Worley
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
| | - Kathyrn Kim
- University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Ketan Jain-Poster
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
| | - Kelly A Reynolds
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Emily A Merkel
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
| | - Bianca Y Kang
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
| | - McKenzie A Dirr
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
| | - Noor Anvery
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
| | - Rachel E Christensen
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
| | - Farhana Ikmal Hisham
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
| | - Sarah A Ibrahim
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
| | - Sepideh Nikki Asadbeigi
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
| | - Emily Poon
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA
| | - Murad Alam
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Suite 1600, Chicago, IL, 60611, USA.
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Department of Otolaryngology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Lin MJ, Dubin DP, Torbeck RL, Bernstein DM, Nabatian A, Dolan CK, Bacigalupi R, Zade J, Zheng Z, Desman G, Khorasani H. Early Fractional Ablative Laser for Skin Cancer Excision Scars: A Randomized Split-Scar Study. Dermatol Surg 2023; 49:338-342. [PMID: 36763896 DOI: 10.1097/dss.0000000000003720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
BACKGROUND Fractional ablative laser resurfacing has been shown to improve the final cosmetic appearance of surgical scars, but optimal timing is unknown. OBJECTIVE To compare surgical scars treated with fractional carbon dioxide (CO 2 ) laser performed on Day 0 and Day 14. METHODS Prospective, randomized, split-scar, physician-blinded study of 30 surgical scars on the limbs. Scars halves received fractional CO 2 laser on either Day 0 or Day 14. Scar assessment at 6 months evaluated patient preference, physician modified Manchester Scar Scale (MMSS) score, and quantitative scar analysis on histology (fractal dimension [F D ] and lacunarity [L] analysis). RESULTS There was no significant difference in patient assessment (54% preferred Day 0 side, 46% preferred Day 14 side, p = .58) or physician assessment (mean MMSS 8.4 for Day 0 vs 8.7 for Day 14, p = .28). Fractal dimensions were similar for both interventions (mean 1.778 for Day 0 vs 1.781 for Day 14, p = .80). Lacunarity was similar for both interventions (mean 0.368 for Day 0 vs 0.345 for Day 14, p = .44). LIMITATIONS Single-center study with wounds limited to limbs of skin Phototype I-II subjects; 4 of whom were lost to follow-up. CONCLUSION Intraoperative CO 2 laser is noninferior to Day 14 laser resurfacing for surgical scar treatment.
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Affiliation(s)
- Matthew J Lin
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Danielle P Dubin
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Richard L Torbeck
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Daniel M Bernstein
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Adam Nabatian
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christopher K Dolan
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert Bacigalupi
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John Zade
- Private Practice, Fort Smith, Arkansas
| | - Zhong Zheng
- School of Dentistry, University of California, Los Angeles, California
| | - Garrett Desman
- Division of Anatomic Pathology & Clinical Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
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Magni G, Piccolo D, Bonan P, Conforti C, Crisman G, Pieri L, Fusco I, Rossi F. 1540-nm fractional laser treatment modulates proliferation and neocollagenesis in cultured human dermal fibroblasts. Front Med (Lausanne) 2022; 9:1010878. [PMID: 36330058 PMCID: PMC9623312 DOI: 10.3389/fmed.2022.1010878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/29/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Giada Magni
- Istituto di Fisica Applicata “Nello Carrara”, Consiglio Nazionale delle Ricerche (IFAC-CNR), Florence, Italy
| | | | - Paolo Bonan
- Laser Cutaneous Cosmetic and Plastic Surgery Unit, Villa Donatello Clinic, Florence, Italy
| | - Claudio Conforti
- Department of Dermatology and Venereology, Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | | | | | - Irene Fusco
- El.En Group, Calenzano, Italy
- *Correspondence: Irene Fusco
| | - Francesca Rossi
- Istituto di Fisica Applicata “Nello Carrara”, Consiglio Nazionale delle Ricerche (IFAC-CNR), Florence, Italy
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7
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Maninder K, Richa R, Dinesh AP, Suman P. Factors affecting the outcome of fractional carbon dioxide laser resurfacing of various types of scars in skin of color. J Cosmet Dermatol 2022; 21:3842-3847. [PMID: 34932873 DOI: 10.1111/jocd.14698] [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: 06/10/2021] [Revised: 09/23/2021] [Accepted: 12/10/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Fractional laser resurfacing has been used widely in management of scars. However, data for post-traumatic and post-burn scar are limited in skin of color. AIMS This retrospective study assessed the efficacy of fractional ablative carbon dioxide laser in treatment of various types of scars other than acne scars. We also tried to find out the effect of different factors like skin type, duration, shape, location, and color of the scars on the outcome. MATERIALS AND METHODS Forty-two patients with 67 scars including post-traumatic (43), post-burn (15), post-surgical (5), and post-folliculitis (5) scars treated during 2019-2020 were analyzed. The improvement was graded according to investigator and patient global assessment (IGA & PGA) through percentage improvement and quartile scale. RESULTS Overall, there was 45.4% and 32.7% of improvement according to PGA and IGA, respectively. Scars with >50% improvement were recorded in 13.43% of the scars with IGA and 41.78% with PGA. Early scars, scars without hyperpigmentation, lighter skin type, post-traumatic scars had better results. There was no significant difference for other parameters like atrophic versus hypertrophic, facial versus extra facial, linear versus non-linear, or the number of sessions. CONCLUSION Fractional carbon dioxide laser efficacious for non-acne facial and extra facial scars in the skin of color. Early intervention could yield more satisfactory results.
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Affiliation(s)
- Kaur Maninder
- Department of Dermatology, All India Institute of Medical Sciences, Bhopal, India
| | - Rupla Richa
- Department of Dermatology, All India Institute of Medical Sciences, Bhopal, India
| | - Asati P Dinesh
- Department of Dermatology, All India Institute of Medical Sciences, Bhopal, India
| | - Patra Suman
- Department of Dermatology, All India Institute of Medical Sciences, Bhopal, India
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THE IMPORTANCE OF BIOMECHANICS AND THE KINETIC CHAINS OF HUMAN MOVEMENT IN THE DEVELOPMENT AND TREATMENT OF BURN SCARS – A NARRATIVE REVIEW WITH ILLUSTRATIVE CASES. Burns 2022; 49:707-715. [PMID: 36127224 DOI: 10.1016/j.burns.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 08/11/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Burn scars are a major clinical sequelae of severe burn wound healing. To effectively establish a successful treatment plan and achieve durable results, understanding the pathophysiology of scar development is of utmost importance. METHODS A narrative review of the principles of the kinematic chain of movement and the hypothesised effect on burn scar development based on properties of burn scars was performed. An examination of the literature supporting these concepts is presented in conjunction with illustrative cases, with a particular focus on the effect of combination treatments that include ablative fractional resurfacing with surgical contracture releases. DISCUSSION Ablative fractional resurfacing combined with the surgical release of contractures are an effective treatment modality for burn scar reconstruction. This treatment approach seems particularly effective because it is one of the only approaches where the principles of functional kinematics can be addressed when tailoring a reconstructive approach to an individual burn patient. The presented cases illustrate the importance of recognising and including the principles of functional kinematic chains in any reconstructive treatment approach for burn scars. Further, epifascial contracture bands are cord like structures which can be found underneath the subcutaneous fat of scar contractures which follow the principles of functional kinematics. Contractures can be more efficiently released if these structures are divided as well. CONCLUSION Ablative fractional resurfacing combined with local tissue re-arrangements is a promising approach to address the underlying forces leading to hypertrophic burn scarring. To achieve an optimal outcome, it is essential to recognise and address the origin of the pathology when treating burn scars. Ablative fractional laser resurfacing allows a different scar approach as it is not limited to one surgical site and thus enables for effective treatment at the cause of the pathology.
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9
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Scarcella G, Pieri L, Fusco I. Skin Fractional Scar Treatment with a New Carbon Dioxide Scanner: Histological and Clinical Evaluation. Photobiomodul Photomed Laser Surg 2022; 40:424-432. [DOI: 10.1089/photob.2021.0165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Giuseppe Scarcella
- General Secretary and National Head of Laser Department of ISPLAD, International-Italian Society of Plastic-Regenerative and Oncologic Dermatology, Verona, Italy
| | | | - Irene Fusco
- Department of Pharmacology, University of Florence, Florence, Italy
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10
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Li J, Ng SKH, Xi W, Zhang Z, Wang X, Li H, Su W, Wang J, Zhang Y. Efficacy and safety of a dual-scan protocol for carbon dioxide laser in the treatment of split-thickness skin graft contraction in a red Duroc pig model. BURNS & TRAUMA 2022; 9:tkab048. [PMID: 34988232 PMCID: PMC8720306 DOI: 10.1093/burnst/tkab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 10/29/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Fractional CO2 laser plays an important role in scar management post split-thickness skin graft by loosening the graft contracture and restoring the smoothness of the surface. However, the optimal treatment protocol remains unknown. This study applied a dual-scan protocol to achieve both releasing and ablation of contracted skin graft. We comprehensively describe this treatment method and compare the efficacy and safety between this dual-scan method and the conventional mono-scan mode. METHODS A hypercontracted scar model after split-thickness skin grafting in red Duroc pigs was established. All scars meeting the inclusion criteria were randomly divided into four groups: high fluence-low density (HF-LD), low fluence-high density (LF-HD), combined group and control group. The energy per unit area was similar in the HF-LD and LF-HD groups. Two laser interventions were performed at a 6-week interval. The efficacy of the treatment was evaluated by objective measures of scar area, release rate, elasticity, thickness and flatness, while the safety was evaluated based on adverse reactions and melanin index. Collagen structure was observed histologically. The animals were followed up for a maximum of 126 days after modeling. RESULTS A total of 28 contracted scars were included, 7 in each group. At 18 weeks postoperatively, the HF-LD and the combined groups showed significantly increased scar release rate (p = 0.000) and elasticity (p = 0.036) and decreased type I/III collagen ratio (p = 0.002) compared with the control and LF-HD groups. In terms of flatness, the combined group was significantly better than the HF-LD group for elevations <1 mm (p = 0.019). No significant skin side effects, pigmentation or scar thickness changes were observed at 18 weeks. CONCLUSIONS Dual-scan protocol could achieve superficial ablation and deep release of contracted split-thickness skin graft in a single treatment, with similar contraction release and texture improvement compared to a single deep scan. Its main advantage is to restore a smoother scar appearance. Adequate laser penetration was necessary for the release of contracted scars.
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Affiliation(s)
- Jie Li
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Sally Kiu-Huen Ng
- Department of Plastic Surgery, Austin Health, Melbourne 3084, Australia.,Victorian Adult Burns Service, Alfred Health, Melbourne 3181, Australia
| | - Wenjing Xi
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Zheng Zhang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Xiaodian Wang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Hua Li
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Weijie Su
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Jingyan Wang
- Department of Plastic and Reconstructive Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
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Clinical and histological evaluation of a dual sequential application of fractional 10,600 nm and 1570 nm lasers, compared to single applications in a porcine model. Lasers Med Sci 2021; 37:1983-1992. [PMID: 34741658 PMCID: PMC8971156 DOI: 10.1007/s10103-021-03460-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/01/2021] [Indexed: 11/10/2022]
Abstract
The sequential application of fractional ablative/10,600 nm/CO2 followed by 1570 nm non-ablative laser treatment might produce better results than applying either laser treatment alone. However, histological data regarding the safety of this combination is lacking. This study aimed to assess and compare clinical effects, histological tissue damage, and wound healing after monochromatic and sequential fractional laser treatments. In this prospective porcine model study, three adult female pigs were each irradiated using three different wavelengths: (a) monochromatic fractional ablative CO2 laser; (b) monochromatic fractional non-ablative 1570 nm laser; (c) sequential fractional 10,600 nm/CO2 followed by 1570 nm laser treatment. There were six power levels in the monochromatic 1570 nm laser, five in the 10,600 nm/CO2, and five in the sequential treatment. The immediate skin reaction (ISR), crusting and adverse effects, was evaluated across different time points throughout the healing process. Wound biopsies were taken at immediately after (0) and at 3, 7, and 14 days after irradiation. Depth and width of craters, and width of coagulation zone were measured and compared. Similar ISR and crusting score values were obtained following the monochromatic and sequential irradiation in a similar dose–response manner. During 14 days of follow-up, the skin looked intact and non-infected with no signs of necrosis. The mean depth and width of craters were comparable only at the maximal energy level (240 mJ) of CO2 laser, with the coagulation size greater after the sequential treatment. In histology, a similar wound healing was evident. On day 3, crusts were observed above all lesions as was epithelial regeneration. The sequential irradiation with 10,600 nm/CO2 and 1570 nm lasers did not pose any additional risk compared to the risk of each laser alone.
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12
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Wyss N, Graf N, Hafner J, Imhof L. Fractional CO 2 laser to improve noticeable scars after skin cancer surgery: An appraisal by the patients, laypersons, and experts. Dermatol Ther 2021; 34:e14999. [PMID: 34022110 PMCID: PMC8459294 DOI: 10.1111/dth.14999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/12/2021] [Indexed: 12/01/2022]
Abstract
Ablative fractionated carbon dioxide (fCO2) laser may be a useful tool to improve noticeable scars after skin cancer surgery. Therefore we evaluated 40 patients who have been treated with fCO2 laser for facial scars after skin cancer surgery. This retrospective study is based on blinded evaluation of pre‐ and postoperative photographs. Patients (n = 40), laypersons (n = 5) and experts (n = 5) evaluated the esthetics and the Vancouver scar scale as primary endpoints. Secondary endpoints included patient satisfaction and treatment safety. Patients, laypersons and experts consistently assessed a significant improvement of scar quality and appearance after fCO2 laser treatment, which was paralleled by high patient satisfaction. In conclusion, ablative fCO2 laser is effective in improving noticeable postsurgical scars. Patients are highly satisfied with post‐laser results.
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Affiliation(s)
- Nina Wyss
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | | | - Juerg Hafner
- Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Laurence Imhof
- Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
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13
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Asuku M, Yu TC, Yan Q, Böing E, Hahn H, Hovland S, Donelan MB. Split-thickness skin graft donor-site morbidity: A systematic literature review. Burns 2021; 47:1525-1546. [PMID: 33781633 DOI: 10.1016/j.burns.2021.02.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 12/08/2020] [Accepted: 02/02/2021] [Indexed: 12/21/2022]
Abstract
The purpose of this systematic literature review is to critically evaluate split-thickness skin graft (STSG) donor-site morbidities. The search of peer-reviewed articles in three databases from January 2009 to July 2019 identified 4271 English-language publications reporting STSG donor-site clinical outcomes, complications, or quality of life. Of these studies, 77 met inclusion criteria for analysis. Mean time to donor-site epithelialization ranged from 4.7 to 35.0 days. Mean pain scores (0-10 scale) ranged from 1.24 to 6.38 on postoperative Day 3. Mean scar scores (0-13 scale) ranged from 0 to 10.9 at Year 1. One study reported 28% of patients had donor-site scar hypertrophy at 8 years. Infection rates were generally low but ranged from 0 to 56%. Less frequently reported outcomes included pruritus, wound exudation, and esthetic dissatisfaction. Donor-site wounds underwent days of wound care and were frequently associated with pain and scarring. Widespread variations were noted in STSG donor-site outcomes likely due to inconsistencies in the definition of outcomes and utilization of various assessment tools. Understanding the true burden of donor sites may drive innovative treatments that would reduce the use of STSGs and address the associated morbidities.
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Affiliation(s)
- Malachy Asuku
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Tzy-Chyi Yu
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA.
| | - Qi Yan
- Oxford PharmaGenesis Inc., 4 Caufield Place, Suite 201, Newtown, PA, 18940, USA
| | - Elaine Böing
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Helen Hahn
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Sara Hovland
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Matthias B Donelan
- Shriners Hospital for Children-Boston, 51 Blossom Street, Suite 930, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02114, USA; Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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14
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Ablative fractional laser treatment of hypertrophic burn and traumatic scars: a systematic review of the literature. Arch Dermatol Res 2020; 313:301-317. [PMID: 32926192 DOI: 10.1007/s00403-020-02135-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/13/2020] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
Hypertrophic scars (HTS) following burns and other trauma and are associated with significant functional and psychosocial impairment. Ablative fractional lasers (AFLs) are increasingly being applied in the treatment of HTS supported by a rapidly expanding multidisciplinary base of literature. The multidisciplinary authors sought to evaluate existing literature, provide context and identify gaps, and make recommendations for a path forward. A systematic review was conducted to identify literature pertinent literature through September 2019. Retrospective cohort, randomized controlled trials, quasi-randomized controlled trials, observational prospective cohort, or case series with five or more subjects with hypertrophic scars incurred from burns and related trauma were considered. Twenty-two of the 23 evaluated studies documented statistically significant and/or meaningful qualitative improvements in nearly all outcome measures. Adverse events were generally infrequent and minor. Significant heterogeneity was observed among the studies included in this systematic review, precluding metaanalysis of pooled data. There is abundant existing literature on the use of AFLs in the management of HTS but study heterogeneity limits generalizability. Future studies should prioritize standardized protocols including assessments of function and quality of life.
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15
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Letter to the Editor: Fractional CO2 laser ablation of porcine burn scars after grafting. Burns 2020; 47:492-493. [PMID: 32900548 DOI: 10.1016/j.burns.2020.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/22/2020] [Indexed: 11/23/2022]
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16
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Chen B, Hou J, Song H, Gao Q, Xu M, Wang F, Wang J, Wu J, Chai J. Using rational strategies for children's scars based on more than 5 years assessment after burn. Burns 2020; 47:190-197. [PMID: 32713827 DOI: 10.1016/j.burns.2020.06.036] [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: 03/12/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Paediatric patients with scars after burn are regularly encountered. Discussion of rational strategies for management are of value. The objective of the study was to describe development and utilisation of strategies for paediatric burn scars up to five years after injury. METHODS We included 164 cases aged from 5 to 8 years old in our study; all had burn scar deformities. RESULTS Assessments were made up to December 31, 2019. The following strategies were used: sequential treatment, reconstruction based on facial aesthetic units, predicting the effect of surgery on development, releasing skin tension and application of photoelectric technology or other non-surgical measures. CONCLUSIONS Using rational strategies for paediatric burn scars is very important.
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Affiliation(s)
- Baoguo Chen
- The Fourth Medical Center of Chinese People's Liberation Army General Hospital, China.
| | - Jian Hou
- The Fourth Medical Center of Chinese People's Liberation Army General Hospital, China
| | - Huifeng Song
- The Fourth Medical Center of Chinese People's Liberation Army General Hospital, China.
| | - Quanwen Gao
- The Fourth Medical Center of Chinese People's Liberation Army General Hospital, China
| | - Minghuo Xu
- The Fourth Medical Center of Chinese People's Liberation Army General Hospital, China
| | - Fang Wang
- The Fourth Medical Center of Chinese People's Liberation Army General Hospital, China
| | - Jue Wang
- The Fourth Medical Center of Chinese People's Liberation Army General Hospital, China
| | - Jiang Wu
- The Fourth Medical Center of Chinese People's Liberation Army General Hospital, China
| | - Jiake Chai
- The Fourth Medical Center of Chinese People's Liberation Army General Hospital, China
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17
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Seago M, Shumaker PR, Spring LK, Alam M, Al-Niaimi F, Rox Anderson R, Artzi O, Bayat A, Cassuto D, Chan HH, Dierickx C, Donelan M, Gauglitz GG, Leo Goo B, Goodman GJ, Gurtner G, Haedersdal M, Krakowski AC, Manuskiatti W, Norbury WB, Ogawa R, Ozog DM, Paasch U, Victor Ross E, Tretti Clementoni M, Waibel J. Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus Recommendations. Lasers Surg Med 2020; 52:96-116. [PMID: 31820478 DOI: 10.1002/lsm.23201] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2019] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Meghan Seago
- Department of Dermatology, Naval Medical Center, San Diego, California, 92134
- Fellow, Micrographic Surgery and Surgical Oncology, Scripps Clinic, La Jolla, California, 92037
| | - Peter R Shumaker
- Department of Dermatology, Naval Medical Center, San Diego, California, 92134
| | - Leah K Spring
- Fellow, Micrographic Surgery and Surgical Oncology, SkinCare Physicians, Chestnut Hill, Massachusetts, 02467
| | - Murad Alam
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, 60611
| | | | - R Rox Anderson
- Department of Dermatology, Harvard Medical School, and Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, 02114
| | - Ofir Artzi
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ardeshir Bayat
- Division of Dermatology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Henry Hl Chan
- Private Practice and Department of Medicine (Dermatology), University of Hong Kong, People's Republic of China
| | | | - Matthias Donelan
- Department of Surgery, Massachusetts General Hospital, Shriners Hospitals for Children-Boston, Harvard Medical School, Boston, Massachusetts, 02114
| | - Gerd G Gauglitz
- Department of Dermatology and Allergy, Ludwig Maximillian University, Munich, Germany
| | - Boncheol Leo Goo
- Naeum Dermatology and Aesthetic Clinic/Skin Rehabilitation Center, Seoul, Korea
| | - Greg J Goodman
- Department of General Practice, Monash University, Clayton, Victoria, Australia
| | - Geoffrey Gurtner
- Department of Surgery, Stanford University School of Medicine, Stanford, California, 94305
| | - Merete Haedersdal
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Andrew C Krakowski
- Division of Dermatology, St. Luke's University Health Network, Bethlehem, Pennsylvania, 18015
| | | | - William B Norbury
- Department of Surgery, University of Texas Medical Branch, Shriners Hospital for Children-Galveston, Galveston, Texas, 77550
| | - Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - David M Ozog
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan, 48202
| | - Uwe Paasch
- Department of Dermatology, Venereology, and Allergy, University of Leipzig, Leipzig, Germany
| | | | | | - Jill Waibel
- Miami Dermatology and Laser Institute, Miami, Florida, 33173
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18
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New Developments for Fractional CO2 Resurfacing for Skin Rejuvenation and Scar Reduction. Facial Plast Surg Clin North Am 2020; 28:17-28. [DOI: 10.1016/j.fsc.2019.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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19
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Ablative fractional resurfacing for burn scar management affects the number and type of elective surgical reconstructive procedures, hospital admission patterns as well as length of stay. Burns 2020; 46:65-74. [DOI: 10.1016/j.burns.2019.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/21/2018] [Accepted: 01/01/2019] [Indexed: 11/20/2022]
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20
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Klifto KM, Asif M, Hultman CS. Laser management of hypertrophic burn scars: a comprehensive review. BURNS & TRAUMA 2020; 8:tkz002. [PMID: 32346540 PMCID: PMC7175764 DOI: 10.1093/burnst/tkz002] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 08/28/2019] [Indexed: 12/15/2022]
Abstract
Hypertrophic scars often develop following burn-related injuries. These scars can be cosmetically unappealing, but associated symptoms of pruritus, pain and restricted range of motion can impair a person’s quality of life. Laser and light therapies offer a minimally invasive, low-risk approach to treatment, with a short postoperative recovery period. As laser technology developed, studies have shown decreased scar thickness, neuropathic pain and need for surgical excision, as well as improved scar pigmentation, erythema, pliability, texture, height and pruritus. In this review, we present the evolution of laser therapy for hypertrophic burn scars, how different types of lasers work, indications, perioperative considerations and guidelines for practice management.
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Affiliation(s)
- Kevin M Klifto
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, Maryland, USA, 21205.,Johns Hopkins Burn Center, The Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, Maryland, USA, 21224
| | - Mohammed Asif
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, Maryland, USA, 21205.,Johns Hopkins Burn Center, The Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, Maryland, USA, 21224
| | - C Scott Hultman
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, Maryland, USA, 21205.,Johns Hopkins Burn Center, The Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, Maryland, USA, 21224
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21
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Labadie JG, Kosche C, Kyllo R, Johnson T, Shumaker PR, Alam M, Choi JN. Fractional CO 2 laser for the treatment of sclerodermatous cGVHD. J COSMET LASER THER 2020; 22:49-51. [PMID: 31893961 DOI: 10.1080/14764172.2019.1710537] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Sclerodermatous graft versus host disease (sclGVHD) is a debilitating complication of hematopoietic stem cell transplant and is characterized by skin thickening and fibrosis that can result in severe contractures. While immunosuppressive therapy remains a mainstay of treatment, the disease course often progresses and, in severe cases, renders patients immobile and wheelchair-bound. Lasers that can target sclerotic lesions to improve tissue pliability and restore range of motion are a promising potential treatment for sclGVHD. Fractional CO2 lasers promote selective collagen remodeling by creating microcolumns of thermal injury that stimulate a wound healing response. Here, we present 2 patients with sclGVHD who underwent treatment with fractional ablative CO2 laser. In this pilot case series demonstrating the novel use of CO2 laser for severe, refractory sclGVHD, two patients were treated with fractional ablative CO2 laser to a focal area of sclerosis. One patient also received clobetasol ointment under occlusion in between treatments. Both patients reported marked subjective improvement in pain and mobility. Objective measurements were recorded for patient 2 who gained roughly 10 degrees of extension and 2 degrees of flexion, as well as a 10% reduction in skin thickness in the treated area. CO2 laser therapy with or without clobetasol ointment under occlusion is a promising treatment modality for sclGVHD.
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Affiliation(s)
- Jessica G Labadie
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cory Kosche
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rachel Kyllo
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Tyler Johnson
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Peter R Shumaker
- Department of Dermatology, Naval Medical Center San Diego, San Diego, California, USA
| | - Murad Alam
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jennifer N Choi
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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22
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Zhang C, Yin K, Shen YM. Efficacy of fractional carbon dioxide laser therapy for burn scars: a meta-analysis. J DERMATOL TREAT 2019; 32:845-850. [PMID: 31865824 DOI: 10.1080/09546634.2019.1704679] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Cong Zhang
- Department of Burn, Beijing Jishuitan Hospital, Beijing, China
| | - Kai Yin
- Department of Burn, Beijing Jishuitan Hospital, Beijing, China
| | - Yu-ming Shen
- Department of Burn, Beijing Jishuitan Hospital, Beijing, China
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23
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Leaker BD, Fuchs C, Tam J. When Wounds Are Good for You: The Regenerative Capacity of Fractional Resurfacing and Potential Utility in Chronic Wound Prevention. Adv Wound Care (New Rochelle) 2019; 8:679-691. [PMID: 31750016 DOI: 10.1089/wound.2019.0945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/03/2019] [Indexed: 12/24/2022] Open
Abstract
Significance: Fractional resurfacing involves producing arrays of microinjuries on the skin, by thermal or mechanical means, to trigger tissue regeneration. Originally developed for cosmetic enhancement, fractional resurfacing induces a broad array of improvements in the structural and functional qualities of the treated skin and is especially effective at returning defective skin to a more normal state. In addition to fascinating questions about the nature of this remarkable regenerative capacity, there may be potential utility in ulcer prevention by halting or even reversing the progressive decline in overall skin quality that usually precedes chronic wound development. Recent Advances: Photoaging and scarring are the two skin defects most commonly treated by fractional resurfacing, and the treatment produces profound and long-lasting improvements in skin quality, both clinically and at the cellular/histologic level. Chronic wounds usually occur in skin that is compromised by various pathologic factors, and many of the defects found in this ulcer-prone skin are similar to those that have seen improvements after fractional resurfacing. Critical Issues: The mechanisms responsible for the regenerative capacity of fractional resurfacing are mostly unknown, as is how ulcer-prone skin, which is usually afflicted by stressors external to the skin tissue itself, would respond to fractional resurfacing. Future Directions: Better understanding of the cellular and molecular mechanisms underlying the unique healing response to fractional resurfacing could reveal fundamental information about adult tissue regeneration, lead to improvements in current applications, as well as new therapies in other pathologic conditions.
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Affiliation(s)
- Ben D. Leaker
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- The Harvard-MIT Program in Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Christiane Fuchs
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Joshua Tam
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
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24
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Baumann ME, Blackstone BN, Malara MM, Clairmonte IA, Supp DM, Bailey JK, Powell HM. Fractional CO 2 laser ablation of porcine burn scars after grafting: Is deeper better? Burns 2019; 46:937-948. [PMID: 31767253 DOI: 10.1016/j.burns.2019.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 10/01/2019] [Accepted: 10/04/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Fractional CO2 lasers have been used in clinical settings to improve scarring following burn injury. Though used with increasing frequency, the appropriate laser settings are not well defined and overall efficacy of this therapy has not been definitively established. As it has been proposed that for thick hypertrophic scars proportionally greater fluence and thus deeper ablation into the scar tissue would be most effective, the goal of this study was to examine the role of ablation depth on scar outcomes in a highly-controlled porcine model for burn scars-after grafting. METHODS Properties of laser ablated wells were quantified on ex vivo pig skin as a function of laser energy (20, 70 or 150mJ). Full-thickness burn wounds were created on the dorsum of red Duroc pigs with the eschar excised and grafted with a split-thickness autograft meshed and expanded 1.5:1. After four weeks of healing, sites were treated with either 20, 70, or 150mJ pulse energy from a fractional CO2 laser at 5% density or left untreated as a control. Sites were treated every four weeks with three total sessions. Scar area, pigmentation, erythema, roughness, histology, and biomechanics were evaluated prior to each laser treatment at day 28, 56, and 83, as well as four weeks after the final laser treatment, day 112. Additional biopsies were collected at day 112 for gene expression analysis. RESULTS The depth of the laser ablated wells increased with increasing pulse energy while the width of the wells was smaller in the 20mJ group and not significantly different in the 70 and 150mJ groups. Scar properties (area, color, biomechanics) were not significantly altered by laser therapy at any of the laser energies tested versus controls. Average scar roughness was improved by laser therapy in a dose dependent manner with scars treated with 150mJ of energy having the smoothest surface; however, these changes were not statistically significant. Assessment of matrix metalloproteinase 9 gene expression showed a slight upregulation in scars treated with 70 or 150mJ versus control scars and scars treated with 20mJ pulse energy. CONCLUSION The current study demonstrated that the properties of the ablative well (depth and width) are not linearly correlated with laser pulse energy, with only a small increase in well depth at energies between 70 and 150mJ. Overall, the study suggests that there is little difference in outcomes as a function of laser energy. Fractional CO2 laser therapy did not result in any statistically significant benefit to scar properties assessed by quantitative, objective measures, thus highlighting the need for additional clinical investigation of laser therapy efficacy with non-treated controls and objective measures of outcome.
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Affiliation(s)
- Molly E Baumann
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, United States
| | - Britani N Blackstone
- Department of Materials Science and Engineering, The Ohio State University, Columbus, OH, United States
| | - Megan M Malara
- Department of Materials Science and Engineering, The Ohio State University, Columbus, OH, United States
| | - Isabelle A Clairmonte
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, United States
| | - Dorothy M Supp
- Research Department, Shriners Hospitals for Children, Cincinnati, OH, United States; Department of Surgery, University of Cincinnati, Cincinnati, OH, United States
| | - J Kevin Bailey
- Research Department, Shriners Hospitals for Children, Cincinnati, OH, United States; Department of Surgery, Division of Critical Care, Trauma and Burns, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Heather M Powell
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, United States; Department of Materials Science and Engineering, The Ohio State University, Columbus, OH, United States; Research Department, Shriners Hospitals for Children, Cincinnati, OH, United States.
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25
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Kauvar AN, Kubicki SL, Suggs AK, Friedman PM. Laser Therapy of Traumatic and Surgical Scars and an Algorithm for Their Treatment. Lasers Surg Med 2019; 52:125-136. [DOI: 10.1002/lsm.23171] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2019] [Indexed: 01/03/2023]
Affiliation(s)
- Arielle N.B. Kauvar
- Department of DermatologyNew York Laser & Skin Care1044 Fifth Avenue (between 85th and 86th St.) New York New York 10028
- Department of DermatologyNew York University School of Medicine240 E 38th St. New York New York 10016
| | - Shelby L. Kubicki
- Department of Dermatology, University of Texas MD Anderson Cancer CenterUniversity of Texas, McGovern Medical School6655 Travis St. #700 Houston Texas 77030
| | - Amanda K. Suggs
- Department of Dermatology, University of Texas MD Anderson Cancer CenterUniversity of Texas, McGovern Medical School6655 Travis St. #700 Houston Texas 77030
- Department of DermatologyDermatology & Laser Surgery Center6400 Fannin St., Suite 2720 Houston Texas 77030
| | - Paul M. Friedman
- Department of Dermatology, University of Texas MD Anderson Cancer CenterUniversity of Texas, McGovern Medical School6655 Travis St. #700 Houston Texas 77030
- Department of DermatologyDermatology & Laser Surgery Center6400 Fannin St., Suite 2720 Houston Texas 77030
- Department of Dermatology, Weill Cornell Medical CollegeHouston Methodist Hospital6550 Fannin St., Suite 1001 Houston Texas 77030
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Fractional Ablative Laser Therapy is an Effective Treatment for Hypertrophic Burn Scars. Ann Surg 2019; 274:e574-e580. [DOI: 10.1097/sla.0000000000003576] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Burn injury: Challenges and advances in burn wound healing, infection, pain and scarring. Adv Drug Deliv Rev 2018; 123:3-17. [PMID: 28941987 DOI: 10.1016/j.addr.2017.09.018] [Citation(s) in RCA: 291] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 09/15/2017] [Accepted: 09/18/2017] [Indexed: 12/18/2022]
Abstract
Severe burn injuries are the most traumatic and physically debilitating injuries affecting nearly every organ system and leading to significant morbidity and mortality. Early burn wound excision and skin grafting are common clinical practices that have significantly improved the outcomes for severe burn injured patients by reducing mortality rate and days of hospital stay. However, slow wound healing, infection, pain, and hypertrophic scarring continue to remain a major challenge in burn research and management. In the present article, we review and discuss issues in the current treatment of burn injuries; the advances and novel strategies developed in the past decade that have improved burn management; and also, pioneer ideas and studies in burn research which aims to enhance burn wound care with a focus on burn wound infection, pain management, treatments for scarring and skin tissue engineering.
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Issler-Fisher AC, Waibel JS, Donelan MB. Laser Modulation of Hypertrophic Scars. Clin Plast Surg 2017; 44:757-766. [DOI: 10.1016/j.cps.2017.05.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gokalp H. Evaluation of nonablative fractional laser treatment in scar reduction. Lasers Med Sci 2017; 32:1629-1635. [DOI: 10.1007/s10103-017-2303-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 08/06/2017] [Indexed: 10/19/2022]
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Willows BM, Ilyas M, Sharma A. Laser in the management of burn scars. Burns 2017; 43:1379-1389. [PMID: 28784339 DOI: 10.1016/j.burns.2017.07.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 05/10/2017] [Accepted: 07/05/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Burn scars are associated with significant morbidity ranging from contractures, pruritus, and disfigurement to psychosocial impairment. Traditional therapies include silicone gel, compression garments, corticosteroid injections, massage therapy, and surgical procedures, however, newer and advanced therapies for the treatment of burn scars have been developed. Lasers, specifically ablative fractional lasers, show potential for the treatment of burn scars. METHODS Both MeSH and keyword searches of the PubMed, Medline and Embase databases were performed and relevant articles were read in full for the compilation of this review. RESULTS Fifty-one relevant observational studies, clinical trials, and systematic reviews published in English from 2006 to 2016 were reviewed and summarized. CONCLUSION Laser therapy is effective for the treatment of burn scar appearance, including measures such as pigmentation, vascularity, pliability, and thickness. Ablative fractional laser therapy, in particular, shows significant potential for the release of contractures allowing for improved range of motion of affected joints. Patients may benefit from the use of lasers in the treatment of burn scars, and the safety profile of lasers allows the benefits of treatment to outweigh the risks. Laser therapy should be included in burn scar treatment protocols as an adjuvant therapy to traditional interventions.
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Affiliation(s)
- Brooke M Willows
- School of Medicine, University of Arizona, Phoenix, AZ, United States
| | - Muneeb Ilyas
- Department of Dermatology, Mayo Clinic Arizona, 13400 E. Shea Blvd. Scottsdale, AZ 85259, United States.
| | - Amit Sharma
- Department of Dermatology, Mayo Clinic Arizona, 13400 E. Shea Blvd. Scottsdale, AZ 85259, United States
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Karmisholt KE, Taudorf EH, Wulff CB, Wenande E, Philipsen PA, Haedersdal M. Fractional CO 2 laser treatment of caesarean section scars-A randomized controlled split-scar trial with long term follow-up assessment. Lasers Surg Med 2016; 49:189-197. [PMID: 27862066 DOI: 10.1002/lsm.22606] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Caesarean section (c-section) scars can be pose functional and cosmetic challenges and ablative fractional laser (AFXL) treatment may offer benefit to patients. We evaluated textural and color changes over time in AFXL-treated versus untreated control scars. MATERIALS AND METHODS A randomized, controlled, intra-individual split-scar trial with three sessions of AFXL-treatments for mature c-section scars. Settings of AFXL were adjusted to each individual scar. End-points were blinded on-site clinical evaluations at 1, 3, and 6 months follow-up (Patient and Observer Scar Assessment Scale [POSAS] and Vancouver Scar Scale [VSS]), blinded photo-evaluations, reflectance measurements, tissue histology, and patients satisfaction. RESULTS Eleven of 12 patients completed the study. At 1 month follow-up, AFXL-treated scars were significantly improved in pliability (POSAS P = 0.01 VSS P = 0.02) and smoother in surface relief (POSAS P = 0.03) compared to control scars. At 1-3 months, overall scar appearance was dominated by transient erythema and hyperpigmentation, confirmed by reflectance measurements (erythema% and pigmentation% peaked at 1 and 3 month follow-up, respectively). At 6 months follow-up, AFXL-treated scars improved on POSAS-total score though not significantly (P = 0.06). Correspondingly, blinded photo-evaluation found AFXL-treated scars significantly improved compared to controls (VAS P = 0.02). Histology indicated new dermal collagen and elastic fibers on AFXL-treated scars. At 6 months follow-up, a majority of patients (64%) favored subsequent AFXL-treatment of their untreated control scar tissue. CONCLUSIONS Scar remodeling is initiated 1 month after AFXL treatment, but overall scar improvement is concealed until laser-induced color changes resolve. At 6 months follow-up, the benefit of AFXL treatment on c-section scars emerges. Lasers Surg. Med. 49:189-197, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Katrine E Karmisholt
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth H Taudorf
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Camilla B Wulff
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Emily Wenande
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter A Philipsen
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Merete Haedersdal
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Issler-Fisher AC, Fisher OM, Smialkowski AO, Li F, van Schalkwyk CP, Haertsch P, Maitz PKM. Ablative fractional CO 2 laser for burn scar reconstruction: An extensive subjective and objective short-term outcome analysis of a prospective treatment cohort. Burns 2016; 43:573-582. [PMID: 27707636 DOI: 10.1016/j.burns.2016.09.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/13/2016] [Accepted: 09/13/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The introduction of ablative fractional CO2 lasers (CO2-AFL) for burn scar management shows promising results. Whilst recent studies have focused on objective scar outcomes following CO2-AFL treatment, to date no data on patient subjective factors such as quality of life are available. METHODS A prospective study was initiated to analyze the safety and efficacy of the CO2-AFL. Various objective and subjective outcome parameters were prospectively collected from the date of first consultation and follow-up following treatment. Objective factors include the Vancouver Scar Scale (VSS), the Patient and Observer Scar Assessment Scale (POSAS), and ultrasound measurements of the thickness of the scar. Subjective parameters included the assessment of neuropathic pain and pruritus, as well as the evaluation of improvement of quality of life following CO2-AFL with the Burns Specific Health Scale (BSHS-B). For treatment effect analysis, patients were stratified according to scar maturation status (> or <2 years after injury). RESULTS 47 patients with 118 burn scars completed at least one treatment cycle. At a median of 55 days (IQR 32-74) after CO2-AFL treatment all analyzed objective parameters decreased significantly: intra-patient normalized scar thickness decreased from a median of 2.4mm to 1.9mm (p<0.001) with a concomitant VSS-drop from a median of 7 to 6 (p<0.001). The overall POSAS patient scale decreased from a median of 9 to 5 (p<0.001) with similar effects documented in POSAS observer scales. Both pain and pruritus showed significant reduction. Quality of life increased significantly by 15 points (median 120 to 135; p<0.001). All of the identified changes following CO2-AFL were equally significant irrespective of scar maturation status. CONCLUSION Our preliminary results confirm significant improvement in thickness, texture, colour, and symptoms following treatment with CO2-AFL. Foremost, quality of life of patients with both immature and mature scars (up to 23 years after injury) improved significantly after just one treatment session. To our knowledge, this is the first study to document such holistic treatment effects in burn patients treated by CO2-AFL.
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Affiliation(s)
| | - Oliver M Fisher
- St. Vincent's Centre for Applied Medical Research, Sydney, Australia
| | | | - Frank Li
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia
| | | | - Peter Haertsch
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia
| | - Peter K M Maitz
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
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Lee SJ, Suh DH, Lee JM, Song KY, Ryu HJ. Dermal Remodeling of Burn Scar by Fractional CO2 Laser. Aesthetic Plast Surg 2016; 40:761-8. [PMID: 27519176 DOI: 10.1007/s00266-016-0686-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 07/29/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Ablative CO2 fractional lasers have recently been introduced for burn scar treatment because of pronounced clinical outcomes with fewer treatment sessions than nonablative fractional laser. OBJECTIVE This study was conducted to observe clinical as well as histologic changes of burn scars after treatment with CO2 fractional laser. MATERIALS AND METHODS Eleven patients (one female and 10 males, aged 31-59 years) with skin phototypes III to V with burn scars received 10 sessions of fractional CO2 laser treatments (UltraPulse(®) Encore; Lumenis, Santa Clara, CA, USA) over an average 5-week interval. Two passes were performed using the following parameters: deep FX mode, 12.5-30 mJ, with a density setting of 5-10 %. Clinical evaluations by three blinded dermatologists were obtained at baseline and at 6 months after the final treatment via photographs using the Vancouver scar scale (VSS). Skin biopsies were done on four patients before and after treatment. RESULTS All patients showed clinical improvement in their scars with significant decrease in VSS. Histologic findings showed the changes in the upper dermis with newly formed dermal papilla. This characteristic upper dermis change was presented as improvement in surface smoothness and skin tension clinically. Postinflammatory hyperpigmentation and itching sensation were the most common adverse effects. CONCLUSION Burn scar treatment by fractional CO2 laser is effective by forming new collagen fibers mainly in the upper dermis. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Sang-Jun Lee
- Dermatology, Arumdaun Nara Dermatologic Clinic, Seoul, Korea
| | - Dong-Hye Suh
- Dermatology, Arumdaun Nara Dermatologic Clinic, Seoul, Korea
| | - Ji Min Lee
- Department of Dermatology, Korea University College of Medicine, Inchon-ro 73(Anam-dong 5ga), Seongbuk-gu, Seoul, 136-705, Korea
| | - Kye-Yong Song
- Department of Pathology, College of Medicine Chung-Ang University, Seoul, Korea
| | - Hwa Jung Ryu
- Department of Dermatology, Korea University College of Medicine, Inchon-ro 73(Anam-dong 5ga), Seongbuk-gu, Seoul, 136-705, Korea.
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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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Khetarpal S, Dover JS, Arndt K. The Evolution and Current Best Treatments for Traumatic, Surgical, and Burn Scars. CURRENT DERMATOLOGY REPORTS 2016. [DOI: 10.1007/s13671-016-0146-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Krakowski AC, Totri CR, Donelan MB, Shumaker PR. Scar Management in the Pediatric and Adolescent Populations. Pediatrics 2016; 137:e20142065. [PMID: 26743819 DOI: 10.1542/peds.2014-2065] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2015] [Indexed: 11/24/2022] Open
Abstract
For most children and adolescents who have developed symptomatic scars, cosmetic concerns are only a portion of the motivation that drives them and their caregivers to obtain treatment. In addition to the potential for cosmetic disfigurement, scars may be associated with a number of physical comorbidities including hypertrichosis, dyshidrosis, tenderness/pain, pruritus, dysesthesias, and functional impairments such as contractures, all of which may be compounded by psychosocial factors. Although a plethora of options for treating scars exists, specific management guidelines for the pediatric and adolescent populations do not, and evidence must be extrapolated from adult studies. New modalities such as the scar team approach, autologous fat transfer, and ablative fractional laser resurfacing suggest a promising future for children who suffer symptomatically from their scars. In this state-of-the-art review, we summarize cutting-edge scar treatment strategies as they relate to the pediatric and adolescent populations.
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Affiliation(s)
- Andrew C Krakowski
- Division of Pediatric and Adolescent Dermatology, Rady Children's Hospital, San Diego, California;
| | - Christine R Totri
- Department of Dermatology, SUNY Downstate Medical Center, Brooklyn, New York
| | - Matthias B Donelan
- Department of Plastic Surgery, Shriner's Hospital for Children, Boston, Massachusetts; and
| | - Peter R Shumaker
- Department of Dermatology, Naval Medical Center, San Diego, California
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Finney R, Torbeck R, Saedi N. Non-ablative fractional resurfacing in the treatment of scar contracture. Lasers Surg Med 2015; 48:170-3. [PMID: 26251257 DOI: 10.1002/lsm.22400] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES A 28-year-old female presented with extensive scarring after a traumatic injury to her right lower extremity. She had been hit by a vehicle one year prior to presentation and had several open fractures with extensive overlying cutaneous damage, which required multiple surgeries and skin grafts. She had limited range of motion of the affected limb secondary to scar contracture. STUDY DESIGN/MATERIALS AND METHODS The patient received 6 treatments with a non-ablative fractional resurfacing (NAFR) device with two wavelengths (Fraxel DUAL, Solta Medical, Hayward, CA) spaced 4-8 weeks apart. The patient received two treatments with the 1927 nm NAFR thulium laser (10 mJ, 30% density, 8 passes) and two treatments with the 1550 nm NAFR laser (40 mJ, 17-26% density, 8 passes). Before and after treatment photographs were taken, as well as range of motion measurements with respect to her right ankle. RESULTS The patient had 50-75% improvement in the texture and discoloration. There was both subjective and objective improvement in the range of motion of her right lower extremity. The patient experienced mild erythema and edema, both of which resolved after 7-10 days. CONCLUSION Recent studies have shown great functional improvement in scar contractures with ablative fractional laser treatments; however, these treatments are accompanied by significant downtime along with risk of further scarring and infection. NAFR is an accessible treatment with a low side effect profile and to our knowledge has not been reported as efficacious in the treatment of scar contracture. This case report is novel in its demonstration of the utility of a dual wavelength NAFR in the treatment of scar contracture and functional impairment.
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Affiliation(s)
- Robert Finney
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, 833 Chestnut St., Ste. 740, Philadelphia, Pennsylvania, 19107
| | - Richard Torbeck
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, 833 Chestnut St., Ste. 740, Philadelphia, Pennsylvania, 19107
| | - Nazanin Saedi
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, 833 Chestnut St., Ste. 740, Philadelphia, Pennsylvania, 19107
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A Randomized Controlled Pilot Study on Ablative Fractional CO2 Laser for Consecutive Patients Presenting With Various Scar Types. Dermatol Surg 2015; 41:371-7. [DOI: 10.1097/dss.0000000000000306] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Krakowski AC, Goldenberg A, Eichenfield LF, Murray JP, Shumaker PR. Ablative fractional laser resurfacing helps treat restrictive pediatric scar contractures. Pediatrics 2014; 134:e1700-5. [PMID: 25367535 DOI: 10.1542/peds.2014-1586] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Conventional management of debilitating pediatric scar contractures, including hand therapy and surgery, may often be beset by delayed treatment, suboptimal results, and additional surgical morbidity. Ablative fractional laser resurfacing is an emerging adjunctive procedural option for scar contractures because of its promising efficacy and safety profile. However, its use to improve function has not been studied in the pediatric population. Herein we report 2 pediatric patients with recalcitrant scar contractures, causing persistent functional deficits, treated with an ablative fractional laser protocol. Both patients experienced rapid and cumulative subjective and objective improvements in range of motion and function as measured by an independent occupational therapist without reported complications. We highlight ablative fractional laser resurfacing as a novel and promising tool in the management of function-limiting scar contractures in children and propose that the technique be incorporated into existing scar treatment paradigms, guided by future research.
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Affiliation(s)
| | - Alina Goldenberg
- University of California San Diego School of Medicine, San Diego, California; and
| | | | - Jill-Peck Murray
- Occupational Therapy, Rady Children's Hospital, San Diego, California
| | - Peter R Shumaker
- Department of Dermatology, Naval Medical Center, San Diego, California
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40
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Perry A, Elston J, Reynolds H, Hawley L, Kroonen L, Uebelhoer NS, Shumaker PR. Ablative fractional photothermolysis in the treatment of scar contractures of the wrists and forearms: A retrospective data analysis. J Am Acad Dermatol 2014; 71:841-2. [DOI: 10.1016/j.jaad.2014.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 05/27/2014] [Accepted: 06/02/2014] [Indexed: 11/29/2022]
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41
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Yoon H, Chung YK, Kim J. Efficacy of Early Application of Ablative Fractional CO 2Laser on Secondary Skin Contracture after Skin Graft. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2014. [DOI: 10.14730/aaps.2014.20.2.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Hyungwoo Yoon
- Department of Plastic and Reconstructive Surgery, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Yoon-kyu Chung
- Department of Plastic and Reconstructive Surgery, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Jiye Kim
- Department of Plastic and Reconstructive Surgery, Yonsei University, Wonju College of Medicine, Wonju, Korea
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42
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Krakowski AC, Admani S, Uebelhoer NS, Eichenfield LF, Shumaker PR. Residual scarring from hidradenitis suppurativa: fractionated CO2 laser as a novel and noninvasive approach. Pediatrics 2014; 133:e248-51. [PMID: 24323993 DOI: 10.1542/peds.2012-3356] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Hidradenitis suppurativa (HS) is a chronic, relapsing, inflammatory skin condition that can have a significant psychosocial impact, both with the active disease and with residual scarring. Although a wide variety of treatment options exist for HS, to our knowledge there are no reported modalities aimed specifically at treating HS scarring. We describe the case of an adolescent female who received medical management of intramammary HS followed by successful treatment with fractionated 10,600-nm carbon dioxide laser for her residual cribriform scarring. We believe there is great potential for the use of fractionated carbon dioxide laser to improve short- and long-term psychosocial outcomes of HS, promote physical scar remodeling, and possibly alter the disease process itself.
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Affiliation(s)
- Andrew C Krakowski
- Scar Treatment and Revision (S.T.A.R.) Program, Pediatric and Adolescent Dermatology, Rady Children's Hospital, 8010 Frost St, Suite 602, San Diego, CA 92123.
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Kroonen L, Shumaker PR, Kwan JM, Uebelhoer N, Hofmeister E. Treatment of split-thickness skin graft-related forearm scar contractures with a carbon dioxide laser protocol: 3 case reports. J Hand Surg Am 2013; 38:2164-8. [PMID: 24021742 DOI: 10.1016/j.jhsa.2013.06.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 06/19/2013] [Accepted: 06/21/2013] [Indexed: 02/02/2023]
Abstract
Split-thickness skin grafts in the forearm can lead to motion restriction and disability through the dense scarring of the skin and formation of graft-tendon adhesions. Three patients were referred for laser treatment of motion-limiting scar-associated split-thickness skin grafts to the forearm. All patients had reached a plateau in range of motion despite aggressive hand therapy and underwent serial laser scar treatments at 6- to 8-week intervals. Treatments were performed in a clinic setting and were initiated 2 to 5 months after reconstructive surgery. Rapid subjective functional and objective improvements in range of motion were noted after laser therapy. Results were cumulative and durable at final follow-up ranging from 10 to 15 months after the initial treatment. No complications were noted. Fractionated carbon dioxide laser therapy is a promising adjunct to hand therapy when the main restraint to motion is superficial skin scarring and skin-tendon adhesions.
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Affiliation(s)
- Leo Kroonen
- Departments of Orthopedics and Dermatology, Naval Medical Center San Diego, San Diego, California.
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