Burn Scar Management with Ablative Fractional Laser Resurfacing

Concord Repatriation General Hospital (CRGH) has one of the largest and most extensive prospective databases on burn patients treated with ablative fractional CO₂ laser to date. It focuses on both objective health outcomes as well as subjective factors such as quality of life and patient symptoms during treatment.

Aim

To improve the health and wellbeing of patients with extensive burn scars treated at CRGH and to continue to evaluate the effects and functional outcomes of this novel treatment.

Benefits

Interim and short-term outcomes of burn patients treated with ablative fractional CO₂ laser reveal:

• significant improvement in quality of life
• significant improvement in thickness, texture and colour of scars
• enhanced range of motion, function and appearance of scars
• significant reduction of symptoms such as pain, itchiness and heat intolerance
• significant reduction in hospital length of stay compared to traditional elective reconstructive procedures.

Background

Burn injuries often have negative physical, aesthetic and social effects on the patient. They can lead to itchiness, pain, reduced range of motion, heat intolerance, inability to sweat, social stigma and mental health issues. Patients often cannot work and have a reduced quality of life, resulting in substantial costs for the healthcare system. These issues have become more pronounced in recent years with advances in burn care and increased survival rates following extensive burn injuries. Patients often survive horrific burn injuries, but end up in a lifelong cage of scars.

To release tension and improve the range of motion in contracted and hypertrophic burn scars, traditional reconstructive surgery is the main approach. Reconstructive surgery includes scar excisions, release and grafting, expanders and the whole range of flaps. However, these procedures are often lengthy, complex and painful. They are also associated with lengthy hospital admissions and significant morbidity, which has a psychological impact on the patient and involves time off work.

The use of ablative fractional CO₂ laser for burn scar reconstruction has shown promising results. However, in addition to the lack of clinical data available, there is also a lack of evidence about subjective factors such as quality of life — the ultimate outcome of a burn survivor.

The underlying mechanisms leading to scar modulation following laser treatment are still poorly understood. As such, the project is analysing clinical, molecular and histopathological outcomes of burn victims treated with this laser therapy to help clinicians improve their understanding of this new treatment and potentially develop best practice guidelines for future treatment algorithms, by identifying patients who may benefit most from this treatment.

Implementation

• The Burns Unit of CRGH runs a fortnightly scar clinic for the assessment and development of individual treatment plans for patients who need burn scar management. A fortnightly laser list has been introduced, where patients are treated under local anaesthetic. More complex cases (patients with larger scars or those combined with other reconstructive procedures) are operated on the regular bi-weekly burns lists.
• Since December 2015, the Burns Unit of CRGH has been prospectively maintaining a database of all patients treated with the ablative fractional CO₂ laser. All information about patient demographics, burn mechanism and the treatment itself (including settings, adverse reactions and type of anaesthesia) are collected. Multiple objective and subjective outcome parameters are collected on the day of enrolment and 6-8 weeks after every treatment, including:
  • Vancouver Scar Scale (VSS)
  • Patients and Observer Scar Assessment Scale (POSAS)
  • ultrasound measurements of scar thickness
  • range of motion measured with a goniometer
  • DN4 questionnaire measuring neuropathic pain
  • Modified 5D itch scale to measure pruritus (a desire to scratch)
  • Burns Specific Health Scale (BSHS-B) to measure quality of life
  • subjective overall improvement (change of the scar evaluated by patients themselves).
• The collection of tissue samples has been implemented into the routine protocol to evaluate the molecular and histological mechanisms involved in the scar remodelling process, by analysing histology, immunohistochemistry and RNA expression patterns.

Status

Sustained – The project has been implemented and is sustained in standard business.

Dates

• October 2014: Ethics application started
• December 2014: Start date of prospective data collection
• September 2016: Publication of first short-term outcome analysis
• June 2017: Ethics application approved
• June 2017: Implementation of tissue sample collections: ethics application approved and sample collection started
• October 2018: Publication of clinical long-term outcomes data
• February 2019: Completion of pilot project: molecular and histological analysis

Implementation sites

Burns Unit, Concord Repatriation General Hospital, Sydney Local Health District (SLHD)

Partnerships

• ANZAC Research Institute, Concord Repatriation General Hospital, SLHD
• University of Sydney

Results

• As of December 2017, 42 patients with 65 burn scars were treated with the M22 laser system. 241 patients with 675 scars were treated with the ablative fractional CO₂ laser.  40 patients (16.6 per cent) were combined procedures, of which 34 cases (85 per cent) were Z-plasties – a technique used to improve the functional and cosmetic appearance of scars.
• In an interim analysis performed in April 2017, 41 patients with 93 scars completed their full treatment with the ablative fractional CO₂ laser. All measurements had improved significantly, regardless of scar maturation status. All these analysis remained statistically significant if immature (less than two years post injury) and mature (more than two years post injury) scars were evaluated individually.
• There was also a positive economic impact on CRGH as a result of the project. An audit conducted in June 2017 found that while the number of outpatient visits and admissions had increased substantially, the introduction of the ablative fractional CO₂ laser led to a reduction in average hospital length of stay for elective reconstructive procedures.
• The data suggests that with early treatment of ablative fractional CO₂ laser, the entire rehabilitative process may be enhanced and accelerated, which may help patients return to work quicker and allow them to enjoy a better quality of life. The implementation of this procedure does not replace reconstructive surgery but reduces the extent needed and in some cases might even allow the patient to avoid surgery.

Awards

Winner of the 2017 Premier's Award for Public Service Anthea Kerr Award and Improving Service Levels in Hospitals category.

Lessons learnt

This process requires a full team approach with many different specialties and skills required for its successful implementation. Surgeons, anaesthetists, operating theatre and burn nurses, administration staff and patients all have to be willing to invest in the project for it to be successful.

Further reading

• Anderson RR, Donelan MB, Hivnor C et al. Laser treatment of traumatic scars with an emphasis on ablative fractional laser resurfacing: consensus report. JAMA Dermatology 2014; 150(2):187-93.
• Cervelli V, Gentile P, Spallone D et al. Ultrapulsed fractional CO2 laser for the treatment of post-traumatic and pathological scars. Journal of Drugs in Dermatology 2010;9(11):1328-31.
• Donelan MB. Principles of Burn Reconstruction. 6th Edition. Philadelphia, USA: Grabb and Smith's Plastic Surgery; 2007.
• Hultman CS, Friedstat JS, Edkins RE et al. Laser resurfacing and remodeling of hypertrophic burn scars: the results of a large, prospective, before-after cohort study, with long-term follow-up. Annals of Surgery 2014;260(3):519-29.
• Issler-Fisher AC, Fisher OM, Smialkowski AO et al. Ablative fractional CO2 laser for burn scar reconstruction: An extensive subjective and objective short-term outcome analysis of a prospective treatment cohort. Burns 2017;43(3):573-82.
• Issler-Fisher AC, Waibel JS, Donelan MB. Laser Modulation of Hypertrophic Scars: Technique and Practice. Clinics in Plastic Surgery 2017;44(4):757-66.
• Rumsey N, Clarke A, White P. Exploring the psychosocial concerns of outpatients with disfiguring conditions. Journal of Wound Care 2003;12(7):247-52.
• Uebelhoer NS, Ross EV, Shumaker PR. Ablative fractional resurfacing for the treatment of traumatic scars and contractures. Seminars in Cutaneous Medicine Surgery 2012;31(2):110-20.
• Waibel J, Beer K. Ablative fractional laser resurfacing for the treatment of a third-degree burn. Journal of Drugs in Dermatology 2009;8(3):294-7.

Contact

Andrea Issler-Fisher
Burns and Reconstructive Surgery Fellow
Concord Repatriation General Hospital
Sydney Local Health District
02 9767 7775 / 0409 858 820
andrea.isslerfisher@gmail.com