Patients with severe burn or traumatic scars benefit from a multidisciplinary approach involving burn and trauma teams, orthopedic and plastic surgeons, dermatologic laser therapy, and long-term physical therapy. Such a multimodal approach is most likely to increase functionality, improve cosmesis, and provide symptom relief. In recent years, scar rehabilitation with minimally invasive and noninvasive laser therapy has evolved and can now provide significant benefit to a wide range of scar patients.
When evaluating a patient with severe traumatic and restrictive scars, such as burn scars, multiple factors need to be considered, including improving functionality, cosmesis, and symptom relief.1 Often, to help achieve these outcomes, a multidisciplinary effort is required that may involve orthopedic and plastic surgeons, burn and trauma teams, dermatological laser therapy, and long-term physical therapy.2 Recently, advances in laser technology have played a significant role in optimizing function. It is crucial to set realistic expectations with patients during the process of addressing their concerns, and appropriate patient selection is an integral part of the process.1
Much of our knowledge regarding the treatment of traumatic scars with laser surgery has been derived from treating hundreds of wounded warriors who sustained combat injuries,2 such as burns from blasts associated with improvised explosive devices.3 The successful outcomes associated with treating this specific patient population have been extrapolated to a broader patient base, like those who have developed scars after tumor extirpation or developed restrictive scars from accidents.3 In general, each scar is slightly different, and the individual characteristics of the scar and the patient are used to guide therapy.1 In this chapter, we will focus on patient selection as it relates to all scar improvement therapies, but particularly with a focus on laser therapies, as these are more novel and less well-understood than traditional scar revision approaches.
Scars can be graded based on several characteristics: dyschromia (erythematous, hyperpigmented, or hypopigmented), scar type (hypertrophic, flat, or atrophic), and body location.1 These factors can help guide initial treatment selection and treatment parameters. Erythematous and hypertrophic scars are usually seen within the first year of injury. Generally, vascular laser treatment combined with fractional ablative laser therapy is most effective for scars with associated erythema and hypertrophy, respectively. Hyperpigmented scars are more challenging and do not respond as quickly or effectively to laser treatment. Atrophic scars are also challenging; however, previous studies have demonstrated that fractional laser therapy can stimulate neocollagenesis and remodeling in these patients.1 The patient’s Fitzpatrick skin type (I to VI), age, pain tolerance, comorbid conditions, functional restrictions related to the scar, psychosocial anxiety, and scar-related hyperhidrosis and/or hypertrichosis4 are also important to consider when developing a comprehensive treatment plan.
While traumatic scars can be disfiguring, they can also cause pain, burning, and itching, as well as decreased function and reduced range of motion ...