Dermatology World August 2011 : Page 18

arm clinicians with new treatment for burn scars 18 DERMATOLOGY WORLD // August July 2011 2011 www.aad.org

BATTLEFIELD LESSONS

JOHN CARRUTHERS

<br /> Dermatologists in the armed forces help pioneer new use for laser therapy to help wounded soldiers<br /> <br /> Burn scars are a challenge for dermatologists, burn surgeons, and their patients — even when they heal well, they can remain unsightly and often restrict motion. In the past decade, military dermatologists, working with private practitioners and researchers, have been able to pioneer revolutionary advances in burn scar therapy for wounded soldiers. While the treatments and technologies are currently costprohibitive for most in the civilian market, the pioneers behind them believe that they will eventually enhance dermatologists’ ability to offer patients with burn scars the possibility of significant improvement in both appearance and range of motion.<br /> <br /> IMPROVED SURVIVAL RATE CREATES NEED FOR BETTER SCAR TREATMENTS<br /> <br /> The development of laser therapy for burn scars became necessary due to a general improvement in soldier survival, according to dermatologist Chad Hivnor, M.D., a lieutenant colonel in the United States Air Force. He said the lifesaving potential of battle field medicine has reached unprecedented levels during the wars in Iraq and Afghanistan, with advances in body armor, en route treatment, and surgical technology bringing the survival figure for injured troops successfully transported to mobile field hospitals to 98 percent. As a result, Dr. Hivnor said, much of the focus is now on treatment and rehabilitation for wounded veterans.<br /> <br /> “We’re saving trauma victims more than any other war in the past — we’ve become very efficient at protecting our troops from abdominal and chest wounds. We’re not losing people to lung shots and heart shots,” Dr. Hivnor said. But as a consequence, he said, military physicians are seeing surviving soldiers who are left with different injuries. “We’re seeing a lot of different things that we haven’t seen before, including a lot of amputations.” (See sidebar on the use of lasers and botulinum toxin to help military amputees with prosthetics.)<br /> <br /> Many of the injured soldiers who arrive to field hospitals are suffering from serious burns caused by the improvised explosive devices (IEDs) used by enemy combatants, and subsequently incur severe scarring. In response to this, military dermatologists have employed new uses for fractional ablative lasers that have helped greatly in the rehabilitation of these wounded soldiers. This, Dr. Hivnor said, is an important step, as it has offered welcome surcease to many who would, in the past, have had to live with painful constricting scars for the rest of their lives.<br /> <br /> ABLATIVE LASERS AND SCAR TREATMENT<br /> <br /> Dr. Hivnor and Navy dermatologists Lt. Cmdr Nathan Uebelhoer, D.O., and Cmdr. Peter Shumaker, M.D., from the Naval Medical Center in San Diego, have worked alongside University of Miami dermatologist Jill Waibel, M.D., to push the envelope of scar revision treatment. As a treatment, Dr. Uebelhoer said, there’s nothing even comparable that existed as little as 10 years ago.<br /> <br /> “We’re finding that these lasers can have dramatic effects on scars. Improving them not just cosmetically, but from a functional standpoint, which is the most exciting part,” Dr. Uebelhoer said. “Taking a scar that would have otherwise restricted some sort of movement and reducing that restriction is a tremendous advance.”<br /> <br /> Dr. Uebelhoer remains astounded by the potential of laser treatment for burn scars, but maintains that rather than a replacement for traditional burn therapies, fractional ablative laser treatment is an adjunct to surgery and physical therapy.<br /> <br /> “We are now treating patients who were burn-injured, blast-injured, with major scarring that occurred three months earlier,” Dr. Uebelhoer said. “They’ve had all sorts of major reconstructive surgeries on their limbs, their skin, and now are having this restrictive scarring set in. And we’re lasering them and seeing good results. A few years ago — and really, even today — most experts would say that you shouldn’t really be addressing a scar until it matures, which can be six months at least, possibly 12. And we find that we’re not improving the cosmetic look of a scar so much at three months, but we are clearly reducing the restriction that scar is going to have over time.”<br /> <br /> With the use of ablative lasers achieveing success under such trying conditions, many of the lessons from their military applications have begun to successfully transfer into civilian dermatology. Though Dr. Waibel began her work with these lasers outside of the military setting (see sidebar), her close partnership with Dr. Hivnor and Dr. Uebelhoer has allowed for a fruitful collaboration that has benefitted both patient groups.<br /> <br /> “Surgery does one thing, and the lasers do a second. It’s given new hope to a lot of these patients. It’s really quite rewarding to treat these patients because they’re so grateful. I can treat anywhere from infants to 90-year olds, and it’s an outpatient treatment,” Dr. Waibel said. “It’s a fraction of the cost of surgery, and it treats the color and the texture of scars and contractures as well.”<br /> <br /> In September, Dr. Hivnor and Dr. Waibel will join Dr. Uebelhoer in San Diego to present at the first-ever military symposium on burn scar treatment with fractional ablative lasers. Key medical personnel will be brought in from all branches of the armed services in an effort to extend the benefits of this treatment to all American soldiers.<br /> <br /> FUTURE CIVILIAN POTENTIAL<br /> <br /> For the moment, scar revision with fractional ablative lasers remains prohibitive for most private citizens. Though cheaper than many surgical options, the treatment has not been assigned a CPT code, and it remains uncovered by private insurance.<br /> <br /> “I’m hoping that at some point we’ll have a study out that will allow insurance companies to cover this. There are burn scars occurring every day in the U.S., and every one of those scars would benefit from this treatment done properly,” Dr. Uebelhoer said. “I’m hoping that soon we can get some sort of coding so that regular insurance companies can recognize it as a very important modality. It’s diffficult; large burns sometimes require general anesthesia. It takes significant expense and time to treat a patient. It’s not going to be easy to get reimbursement, but that’s how I see this trickling down.”<br /> <br /> Dr. Waibel said that the current federal budget issues and health reform debate make the possibility of reimbursement a remote one at present. “I’ve worked with burn reconstructive surgeons and the AMA coding committee, and right now, with the budget crisis in Washington new codes are not being added. New laser scar resurfacing codes are unlikely in the short term — but we have at least planted the seeds for a future code for functional improvement in burn patients,” she said. “If the laser scar revision procedure is done in the office the costs usually range from a few hundred dollars to a few thousand dollars. Our experience has been that a combination of surgical reconstruction from burn reconstructive surgeons and laser resurfacing gives optimal scar revision results,” she said. “The risks are minimal, and the healing is very fast with laser.”<br /> <br />

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