By Stephen Spotswood
SAN DIEGO NAVAL MEDICAL CENTER, CA — Thanks to the work of physicians here and at a select number of facilities around the country, the paradigm of how scars are treated might be shifting.
Whereas, in the past, the use of fractional lasers on scar tissue has been relegated mostly to cosmetic repairs, new techniques are allowing for more functional improvements. After these treatments, wounded warriors are able to more freely maneuver digits and limbs, which they previously had been unable to do because of the tightness of scar tissue.
A decade ago, when dermatologists Cmdr. Peter Shumaker, MD and Cmdr. Nathan Uebelhoer, MD, were new to the Naval Medical Center (NMCSD), lasers already were being utilized to mitigate scarring on injured servicemembers.
“Even in 2001, a lot of the current technology was around. It was being used to improve the redness and brown aspects of scars,” Uebelhoer said. “Treating the actual texture of the scar tissue was not easy. Often we would treat the texture, but the color would change poorly — the color would actually get worse, and the skin would get whiter. Treating the texture wasn’t a great option.”
Over the next decade, however, the technology improved swiftly. In 2004, the dermatologists started noticing that some of the newer laser technology could affect the texture without making the scar tissue look cosmetically worse. That same year, Rox Anderson, MD, a professor of dermatology at Harvard Medical School, developed fractional laser technology.
The technology he developed took the lasers being used by dermatologists and shrank the size of the beam from something measured in milligrams to something measured in microns. The needle-like laser was originally developed specifically for wrinkles. But over the next few years, dermatologists working on scar and burn victims found that fractionated lasers improved scars in terms of texture better than anything previously available.
|Cmdr. Peter Shumaker, left, and Lt. Cmdr. Nathan Uebelhoer, top right, perform a fractional carbon dioxide laser surgery on Lance Cpl. Juan Dominquez, assigned to Wounded Warrior Battalion-West, NMCSD detachment. Navy photo by Mass Communication Specialist Seaman Joseph A. Boomhower.|
“Fractional technology is really one of the big breakthroughs,” Shumaker said. “I would describe it as a lawn aerator. It creates a controlled injury, like little plugs of turf, separated by untreated areas. These untreated areas are reservoirs of normal skin. By treating these microcolumns of skin, we can achieve depths that were unavailable to previous lasers.”
The reservoir of untreated skin also seems to improve healing time and the margin of safety of the procedure. “The treatment appears to be very well tolerated in terms of complication rates,” Shumaker said.Novel Use of Fractional Lasers for Scarring Improves Quality of Life for Injured Troops
The dermatology community is slowly coming to accept this application of the technology, Shumaker said. The two have published some articles in the last year and expect to conduct more extensive studies in the future.
“Up to this point, we’ve been determining what’s possible,” Shumaker said. “In the near future, we need to prove, in scientifically rigorous prospective studies, that it works. We need research into optimal combinations of treatment and into when the best time to intervene is.”
In the meantime, Shumaker and Uebelhoer say they are hoping the number of facilities using this kind of treatment will grow quickly and are doing what they can to make that happen. Last year, NMC San Diego hosted its First Annual Scar Symposium. The goal that year was to train other military physicians in this treatment.
At the second symposium this September, they are looking to create a world-class symposium on the treatment of scars, bringing in experts not only from dermatology but from plastic surgery, orthopedics and burn centers to share a variety of perspectives.
They also will use the symposium to teach physicians how to employ the treatment. “It’s important that people are well trained and familiar with the technique before they employ it,” Shumaker said. “But it’s certainly possible and very feasible to train people on devices they already have in their centers.”
They are especially hoping to attract VA physicians to the symposium. “We know there are hundreds, if not thousands, of burn and scar patients who could benefit from this — many of whom are out of the military but still have [veterans] benefits,” Uebelhoer said.
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Novel Use of Fractional Lasers for Scarring Improves Quality of Life for Injured Troops
Uebelhoer and Shumaker have been employing ablative fractional laser technology for traumatic scars and other types of injuries at NMCSD since 2009. They were among the first and remain one of the most prolific users of the treatment — showing that not only cosmetic benefits, but also functional improvements can result from these treatments.
“Early on, we started very conservatively,” Uebelhoer said. “We used settings we knew would not hurt anyone, because we knew this was a new frontier. We started on a few individuals and saw them begin to move their hands better or their arms better. The timing of this improvement was too closely associated with the time we lased them to be just a coincidence of their scar rehab suddenly improving.”
Physical therapists told the dermatologists that patients who had reached a plateau in their rehabilitation suddenly showed dramatic improvements following the laser treatment.
The improvements can appear subtle, the dermatologists explained, but they make a big difference in terms of a patient’s quality of life.
One patient who had a blast injury to the lips and cheeks had difficulty putting large bites of food into his mouth. Within a few weeks after the treatment, he was taking big bites out of a hamburger.
Another patient had injured his hand while defusing a bomb. He’d lost several fingers, and the scar tissue on the remaining fingers was so tight that he was unable to bring his thumb and middle finger together.
“He said he couldn’t even get change out of his pocket,” Uebelhoer said.
Following several laser treatments, he was able not only to grasp things with those fingers but also to lift weights using that hand again.
“This gentleman has been able to go back onto full duty,” Uebelhoer said. “Though he’s missing fingers, he’s able to function enough to be on active duty again.”
Uebelhoer and Shumaker are quick to note that this treatment is in no way a replacement for surgery or existing scar rehab treatment.
“That’s critical to make clear,” Uebelhoer said. “This is not a monotherapy. We need physiotherapists and plastic surgeons. We’re just adding this little adjunct therapy.”
The treatment goes against some of the current treatment paradigms for traumatic scars. For decades, it’s been common practice to leave traumatic scars untreated until they have “matured,” which can take as long as a year.
“For people who were brought up with surgical training, there’s a rule of thumb that you let a scar mature before you do any procedural intervention,” Shumaker said. “And when we only had earlier iterations of laser technology and surgical treatment, that was true.”
Using ablative fractional laser technology before a scar has finished maturing has been able to change the trajectory of the scar for the better, the dermatologists pointed out.
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