Vol. 34. No. 1


In 2008, Dr. Jill Waibel encouraged me to try a new laser technique in treating restrictive scars. She envisioned its benefit on the wounded warriors that we managed at the Naval Medical Center in an Diego, California, USA. Over the following few years we saw this technique grow into what we consider the standard of care as an adjunctive procedure in the scar rehabilitation of all patients with hypertrophic disabling scars. The management of burn and traumatic scars requires a multidisciplinary effort. Even with the most ideal protocols of the burn and trauma teams, various plastic surgeons, orthopedic surgeons, and then long-term physical therapy and subsequent surgical revisions, outcomes are often still lacking. With the addition of this specific type of laser surgery using a high-energy, low-density, submillisecond-pulsed ablative laser fractionated to roughly 200- 400 microns, more optimization of function can be achieved in the majority of cases. It can be safely applied in almost all phases of scar rehabilitation. Beginning within the first months post injury and at intervals of 6 to 12 weeks, these treatments have a low-risk profile and can be applied 20 or more times to a scar, seeing benefits with each treatment that are often persistent. In the US Navy, along with CDR Peter Shumaker, we had the privilege to treat hundreds of sailors and soldiers who had sustained injuries in combat. But we have also seen a positive effect of this treatment in children, pregnant women, scarring genetic diseases, connective tissue diseases, and many other conditions. Furthermore, we’ve been able to use it safely and effectively on medical missions into underserved areas of the world. This experience has connected dermatologists with the burn and trauma community in a new way and is the impetus for this edition on the laser treatment of scars. But most importantly, we had the opportunity to watch first-hand how meticulously applied laser technology could improve the quality of life in our wounded service members – whether the restrictive scar was just forming or was decades old. The purpose of this issue of Seminars in Cutaneous Medicine and Surgery is to convey the importance of understanding the latest treatment of scars. In this issue, we highlight the approach in treating burn and traumatic scars and how to optimize their functionality. I would like to express my thanks to the authors who worked so diligently to put their expertise in writing so that the millions of patients that need this treatment may benefit.

An idiosyncratic history of burn scars

Jane A Petro, MD
The ability to detect early melanoma remains of paramount importance in our efforts to curtail deaths related to this malignancy. Fortunately, our clinical skills at recognizing the varied clinical presentation of early melanomas are continuously improving. Our enhanced clinical acumen together with improved awareness of the danger signs of melanoma has resulted in a greater proportion of thin melanomas being diagnosed today as compared to the past. The implementation and utilization of in vivo imaging technologies in clinical practice promises to further enhance our ability to detect melanoma while this cancer is still thin and easily curable. This article describes the utility and application of the in vivo imaging technologies that are currently in clinical use today including dermoscopy, total body photography, individual lesion photography, and reflectance confocal microscopy. Semin Cutan Med Surg 27:2-10 © 2008 Elsevier Inc. All rights reserved.

Microstructural and molecular considerations in the treatment of scars with ablative fractional lasers

Cerrene N Giordano, MD | David Ozog, MD
Fractional ablative lasers have recently proven to be an effective modality for improving the clinical appearance and minimizing the morbidity associated with restrictivetype scars. Their tolerable safety profile on nonfacial sites and darker Fitzpatrick skin types provides an advantage over its fully ablative counterpart in treating facial rhytides, photodamaged skin, and acne scars. However, despite its increasing usage in clinical practice, the mechanism behind the observed clinical benefit remains complex and has yet to be fully elucidated. This paper reviews the work on the histological mechanism of action of ablative fractional lasers, and the molecular changes that occur posttreatment on restrictive scars, with an emphasis on mature burn and postsurgical scars. As the majority of research has been on the carbon dioxide laser, a natural focus on this wavelength is presented. Semin Cutan Med Surg 34:7-12 © 2015 Frontline Medical Communications

Current trends and future considerations in scar treatment

Ashley Rudnick | Jill S Waibel, MD
The goal of scar therapy is the restoration of the patient to their preinjury state. A combination of injected antimetabolites, surgery, laser, and laser-assisted delivery of drugs is needed for minimally invasive surgical correction of scars. As a result, laser therapy is emerging as an essential treatment element. It has been noted that fractional lasers normalize both the clinical and histological appearance of scars. Laser- and light-based therapies complement existing approaches of surgery and physical therapy, resulting in significant gains with minimal associated morbidity. Emerging and future laser technologies are creating a new paradigm in the management of scar rehabilitation. Semin Cutan Med Surg 34:13-16 © 2015 Frontline Medical Communications

Laser treatment of traumatic scars: a military perspective

Peter R Shumaker, MD

Advancements in medical treatment and transport over more than a decade of conflict have resulted in unprecedented survival rates for service members despite catastrophic injuries. Enhanced survival has created an unprecedented need for comprehensive rehabilitation and transition services. Though far from the exclusive domain of military dermatologists, military medicine has had a prominent role in integrating cutaneous procedural techniques into the rehabilitation of traumatically injured patients for a variety of reasons. The introduction of fractional laser technology in the mid-2000’s has stimulated a revolution in scar treatment, and is gradually remodeling the fields of procedural dermatology and trauma rehabilitation both inside and outside of the military. This manuscript will provide a brief review of common cutaneous procedures applicable to rehabilitation, with an emphasis on ablative fractional laser resurfacing of scars and contractures. Semin Cutan Med Surg 34:17-23 © 2015 Frontline Medical Communications


Multidisciplinary, multimodal approach for a child with a traumatic facial scar

Amanda Gosman, MD | Andrew C Krakowski, MD | Jeffery W Gertner, MD | Nathan S Uebelhoer, DO | Peter R Shumaker, MD | Shehla Admani, MD

The treatment of disfiguring and disabling scars remains a field of active study, reinvigorated with recent advances in techniques and technologies. A variety of approaches can be utilized depending on scar characteristics, location, degree of tissue loss, and associated contractures. Just as traumatic scars can be complex and heterogeneous, the corresponding paradigm for treatment must also be flexible and multimodal for optimal improvement. This report describes a 3-year-old girl with a “mixed” (atrophic/hypertrophic), violaceous, contracted facial scar from a dog bite. It was treated with a novel approach utilizing a multidisciplinary pediatric scar team to combine autologous fat grafting, ablative fractional laser resurfacing, pulsed-dye laser, and laser-assisted delivery of a corticosteroid as concurrent, multimodal therapy to optimize the outcome. Semin Cutan Med Surg 34:24-27 © 2015 Frontline Medical Communications