Novel Use of Technology Helps Decrease Impact of Wounds of War

by U.S. Medicine

November 6, 2013

By Stephen Spotswood

SAN ANTONIO, TX – That soldiers come back from the battlefield bearing permanent reminders of their time there – scars they will live with for the rest of their lives – is taken as a heavy but inevitable cost of war.

Those scars need not be as permanent or debilitating as they have been in the past, however.

Military physicians are using healthcare technology designed for cosmetic purposes to help soften and decrease scar tissue in returning vets, and to help victims of limb loss have an easier transition to life with prosthetics. Their hope is that by creatively repurposing technology, they can ease the physical burden of wounded veterans.

Lt. Col. Chad Hivnor, MD, of the 59th Medical Wing, is the dermatology residency program director at Joint Base San Antonio-Lackland and was one of the first dermatologists who discovered the potential of fractionated laser technology in treating scar tissue.

Fractionated lasers use needlelike lasers to puncture the skin, creating patterns of thermal wounds that then begin to heal. The healing process creates an improvement in the tone and texture of skin.

The technology originally was used to treat facial lines and wrinkles and skin discoloration. As the technology improved, with the size of the beams shrinking from something measured in millimeters to something measured in microns, its ability to effectively impact the texture and flexibility of scar tissue rose significantly.

“When we started doing this, there was a dramatic softening of the scar and an increase in pliability and flexibility,” Hivnor said. “With that came an increased range of motion almost instantaneously.”

The improvement persisted for many months and, for the earliest patients, it has persisted for several years.

Sometimes this means patients have an easier time transitioning to civilian life. For others, it means they are able to return to service.

“I had one Marine special forces patient — ambidextrous in his ability to use his [weapons]. He was a very good sniper,” Hivnor said. “After an IED, he wasn’t able to pull the trigger with either hand. Using our laser, we were able to give him the ability to pull the trigger with both hands again.”

Lt. Col. Chad Hivnor uses a pulsed dye laser to help decrease redness on a wounded warrior’s scarred leg in the Dermatology Clinic at Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio-Lackland, Texas Aug 7. Hivnor will receive the 2013 Paul W. Myers Award for his work using lasers to improve the skin texture and flexibility on wounded warriors. (U.S. Air Force photo/Senior Airman Courtney Moses)

Focusing On Prosthetics

Initially, Hivnor focused on patients with burns, because the DoD burn center is headquartered in San Antonio. As military operations overseas wound down and the number of servicemembers returning with burns dropped off, Hivnor and his colleagues searched for other ways to study the technology.

Partnering with Massachusetts General Hospital and Shriner’s Hospital of Boston, Hivnor was awarded a $1.1 million grant to study improvement in range of motion, using lasers not only on burn scars, but also on amputation.

His work in helping treat the Marine sniper and demonstrating that the technology can be utilized beyond burn scars was instrumental in getting the grant, Hivnor said.

Amputations can result in severe scarring, not only from the initial trauma that resulted in the limb loss, but also from the multiple surgeries that follow.

“If you have bad trauma that causes amputation and you bring grafts together, that can [decrease] range of motion,” Hivnor pointed out. “By focusing the laser on that [scar tissue], we can get that range of motion back. It can also help decrease tension and helps with pliability around the wound, which helps [the wound] to heal.”

Laser technology also can be used to smooth the surface of the amputated limb, allowing for an easier prosthetic fit.

“If you have an undulating contour, the fractionated laser can help,” he said.

Hivnor also uses laser technology to remove hairs from amputated limbs — especially below-the-knee amputations. Friction created by the hair and prosthetic rubbing against one another can cause significant discomfort and potentially result in ulcers.

“That’s become quite common,” he said. “We do that on almost all of our patients.”

What’s less common is the use of Botox on amputated limbs to reduce sweating, but it’s a treatment that Hivnor has administered to those patients who feel the benefit is worth the discomfort of the procedure.

In the hot, humid climate of San Antonio, patients with below-the-limb amputations find sweat quickly accumulates in the Neoprene sleeve that fits the prosthetic to their limb.

“It creates pooling of sweat,” Hivnor said. “You can lose suction. The [prosthetic] leg can fall off in mid-stride.”

In 2010, Hivnor had an article published in the Archives of Dermatology documenting the case of a soldier treated with botulinum toxin to prevent sweating from his amputated leg. The injection decreased perspiration to the point where an adequate seal was created between skin and prosthetic.1

The process can be very painful, however, and must be done annually. Because effectiveness of the treatment peaks about two months after injection, patients begin coming in for treatment in March and April.

The number of patients returning for multiple treatments is highly variable. “It’s very helpful, but it’s also very painful,” Hivnor said, adding that he wishes there were a way to reduce the sweat painlessly.

Some other procedures, usually used in the underarm area, can permanently decrease perspiration, but Hivnor considers that to be too dangerous a proposition.

“What if 10 years down the road, we find out that sweat is important?” he mused.

Pushing the Boundaries

Hivnor said he recognizes that the potential of fractionated laser technology is at least partly a happy accident.

“These holes that are created with the laser devices — they don’t scar. And outside the first trimester of an embryo [that phenomenon] doesn’t exist,” he said. “We’re very fortunate the size of the laser beam was so small it didn’t create a scar, and it was just more luck than anything else. [The inventors] did not anticipate that.”

Now that the technology has been embraced and repurposed, Hivnor is searching for ways to push its boundaries. His goal for the near future is to finish a study on range of motion following treatment and provide further documentation of the technology’s benefits, providing an alternate to surgery.

“Surgery and laser treatment is probably going to be a nice combination, but where that balance is has yet to be determined,” he noted.

One innovation Hivnor is seeking is a way accurately determine the depth of a scar.

“Can we create an ultrasound device that’s attached to the laser that can tell the depth of the scar following multiple treatment protocols?” he wondered. “We know we have to go to a certain depth to get maximum improvement. That’s one of the limitations I’ve been [noting] since Day One.”

If that kind of technology were to be developed — something that made it easier for both civilian and military physicians to administer laser scar treatment — it would be a revolution, Hivnor said. “If a laser company figures that out, [the technology] is going to be highly sought after by the civilian realm, as well as DoD. It’s something a lot of people have been looking at.”

Lt. Col. Chad Hivnor uses a carbon dioxide fractional laser to help improve skin texture and flexibility on a wounded warrior’s scarred shoulder in the Dermatology Clinic at Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio-Lackland, Texas Aug. 7. Hivnor was awarded a 1.1 million dollar grant to study using lasers for improvement in range of motion on burn and amputee scars in a joint research project with Massachusetts General Hospital and Shriner’s Hospital of Boston. (U.S. Air Force photo/Senior Airman Courtney Moses)

1. Gratrix M, Hivnor C. Botulinum toxin A treatment for hyperhidrosis in patients with prosthetic limbs. Arch Dermatol. 2010 Nov;146(11):1314-5. doi: 10.1001/archdermatol.2010.326. PubMed PMID: 21079082. 

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