- Best Results9-24 months
- Treatment Recovery3-12 days
- Procedure Time30-120 minutes
- Skin SpecialistDavin Lim
- Duration of ResultsPermanent
- AnaestheticBlocks, numbing, sedation
- Back to Work0-8 days
- Cost$- $$ Medicare
Lasers can be useful as adjunctive therapy to burn scars. Lasers provided controlled thermal energy. This stimulates collagen cells to remodel established scar tissue. This improves scar thickness & reduces symptoms. The laser of choice is the Lumenis Ultrapulse carbon dioxide or CO2 laser.
FactsFacts on treating burns scars
- Lasers are not a substitute for surgery, silicone, & compression
- They can be a useful adjunct to the above
- A short pulse duration CO2 is the Gold Standard for burn scarring
- Lasers can reduce symptoms such as itch, pain, & tightness
- Laser resurfacing can improve mobility, contraction & improve range of motion
- CO2 & thulium lasers can also potentiate absorption of topicals
What is the concept of burn scar revision?
Logically scars are textural, contour changes, & colour changes or a mixture of three. For burns scars the aim of treatment is to –
- Improve skin texture & pliability.
- Normalise pigment within the scar (re-pigment white areas).
- Reduce scar thickness.
- Reduce symptoms such as itch or pain
- Improve range of movement & function
- Restore normal contours
How should one approach burn scars?
Burns scars are unique because the normal components of skin including pigment cells, hair follicles, & sweat glands are either damaged or markedly attenuated. Additionally, scar tissue can give rise to thickened areas with abnormal collagen. Thick areas of scar tissue may lead to scar contractures with reduced function & sensitivity.
Treatment is aimed at reducing thickness & improving function, as well as decreasing scar contractures. I need to work with a plastic surgeon, physiotherapists & an occupational therapist for the best results. Lasers are not a substitute for surgical procedures, compression, silicone & mobility exercises. Fractional lasers are adjunctive therapy.
What is the logic of using lasers for burns?
I get it, it sounds counterintuitive to cause thermal damage (burn) for tissue that has experienced a thermal burn. The fundamental differences of lasers for burn scarring are the generation of low density but deep controlled thermal damage. It works by-
- Modifying cytokine & growth factor release. This results in scar remodelling. As it normalises the ratio of type 1 to 3 collagen within the burn scar.
- Allows for anti-inflammatory penetration of corticosteroids. This improves the pliability & softens scar tissue.
- Reduces redness through inflammatory modulation.
- Stimulates pigmentation in some scars, providing there are viable melanocytes present.
What lasers do I use?
I use the gold stand of CO2 lasers for burns – the Lumenis Ultrapulse SCAAR FX. Look it up. This laser is ancient, however with a recent software update it can produce a lot of power. In the context of deep scars, I can go down to 4,000 microns or 4 mm. This does not sound that deep, but in reality, it is 30 to 40 times the thickness of epidermis.
The concept of treating burn scars is easy to understand– if I push up the power, I reduce the density of CO 2 laser. Hence for 4mm depth penetration, my density level is 1-2. For more superficial scars, my density level is 3-6. In some cases, I use a Lutronic laser as it has an even shorter pulse duration (fire a Lumenis side by side with the same depth of penetration to compare & you will understand the PD).
Lasers also help with dermal drug delivery. In this context I may use a combination of deep CO2, with low density, & superficial thulium 1927 lasers. The drug of choice is triamcinolone as this can improve scar pliability. I also deliver other drugs such as PG analogues, tacrolimus & others to stimulate pigment production.
Is the treatment painful?
Treatments are comfortable. I use a mixture of numbing gel, injections & in some cases sedation. Post laser, there is no pain.
How many laser sessions are required?
It really depends on the extent of scarring, both in surface area & thickness. Typically, 3-12 sessions are required over a course of 6 to 24 months.
Progress is marked in the first few sessions. Patients will receive a noticeable improvement in texture, as well as range of movement. Most patients will also experience reduced symptoms such as itch.
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What are pulse dye lasers?
This laser (I use both the V Beam Prima & Perfecta) does not break the epidermis as it has an inbuilt cooling system that protects the upper layers of skin. I employ this laser to treat thinner scars (not hypertrophic). This laser works by reducing redness. It also works by non-selectively modulating cytokine expression. This means it makes scars softer (as compared to selective photo thermolysis that targets red).
How many laser sessions will you need?
About 3-8, it really depends. If you have mild hypopigmentation, 1-3 sessions will do. For more extensive areas, additional sessions may be required.
Lasers can stimulate melanin production via increased absorption of chemicals that stimulate these cells. Addition of medical phototherapy can compound pigment production.
Will my burn scar look better after the treatment?
Recovery takes 6-14 days. In many cases, scars will decrease in thickness. Skin will become more flexible and less red. But we caution patients to set realistic expectations. Your scar will only soften, not disappear. Your scar will be softer & in most cases symptoms such as itch will improve.
Are there any risks associated with laser treatment for burn scars?
You may also experience bleeding, infection & skin pigment changes. In exceptionally rare cases scars may feel tighter after a laser treatment. If you are not compliant with silicone dressings, I may not treat your scars as this may worsen with treatments.
What can be done for white scars?
White or hypopigmented scars have a lack of pigment, this means that pigment cells known as melanocytes are either low in number or non-existent. In order to improve pigment, I must either transfer new melanocytes or awaken sleeping cells in the scars. This is the only way to get pigment back.
Melanocytes account for one in thirty-five cells that form the basal layer of skin. Their job is to produce pigment. Pigment packets are then transferred to the keratinocytes. In hypopigmented burn scars the number is reduced. Hence pigment is either greatly diminished or non-existent.
Melanocyte transfer in burns is much more complicated than in vitiligo or traumatic scarring. This is due to poor wound healing due to lack of hair follicles in burns.
What is my preferred method of treating white/hypopigmented burn scars?
My preferred method is micrografting with autologous melanocytes. This is an involving treatment as it requires surgery with healing times. Micrografting is successful in most, but not all cases. This treatment cannot be conducted aggressively in scar tissue that lacks hair follicles.
This procedure transfers pigment cells from a donor site (most commonly the inner arm, upper thigh or buttock) to the recipient site (hypopigmented scar). This is a form of autologous cell transfer.
In more detail-
- A sliver of skin including melanocytes & keratinocytes are harvested by hand using a blade.
- Donor site harvesting is painless as I use local analgesia
- Pigment cells are processed into small units
- Recipient site is prepared with either manual dermabrasion or laser
- Cells are placed on the hypopigmented scars
- Pigment cells populate the recipient site over the next 10 days
- Pigment starts to develop at week 3
- Maximal pigment is achieved at 9 to 12 months after the surgery
What can be done for hair loss in burn scars?
FUE or follicular unit extraction is my preferred method of repurposing hair. Scar tissue is very difficult compared to normal tissue. My preferred method is to normalize scar tissue as much as possible before hair transplantation. This allows a better recipient bed for transplanted hair follicles. This increases the survival rate.
This can be done on scalp & eyebrow hair. Most often I conduct test spots to check for follicular viability prior to full transplantation. PRP can be used as adjunctive therapy post transplant to improve survival rates.
What is ReCell, & is it effective for burn scars?
ReCell is marketed as a spray on skin. It can be useful for acute burns, but in the context of what I do (remodel & revise established scars) it has limited value. In my hands, limited micrografts are better.
ReCell uses your own skin cells as a donor & transfers both keratinocytes & melanocytes to the burnt areas. A special enzymatic process breaks down the donor skin into small pieces. This is then sprayed or painted on to the affected sites.
Do I use microneedling for burns scars?
Unlike normal tissue, burn tissue has extensive fibrosis. This means scar tissue is compact & hard. Even with super powerful motor driven pens devices, penetration is limited. CO2 lasers with very short pulse durations can penetrate dense scar tissue with ease, hence they are my preferred method of revision. Needling devices come in a distant second.
OK, let’s say I don’t have access to lasers, my next choice is a derma roller. Why? Because I can generate more force with roller & stamps over pens. In this context needling is only useful to allow steroid penetration. This will gradually soften the scar.
Why is Medicare backward & unfair with their ruling?
Don’t get me started on this. The idiots who decide on Medicare item number should really understand (experience) the physical & psychological effects of burn scars.
Medicare subsides many skin conditions. For example, if you have a patch of dry skin that resembles psoriasis on your elbows or knees, treatments are available. Medicare subsides over $6000 worth of phototherapy a year, for many, many years. A psoriasis patient can accumulate up to $30,000 worth of subsidised Medicare & PBS bills within 5 years. They are entitled to a lifetime of subsidised (often fully paid treatments by Medicare). A patient with full thickness burns that finds it difficult to swallow has zero subsidy. Talk about retardation of our medical system.
The evidence that fractional lasers, in particular CO2 lasers have on burn scarring is irrefutable. All burn units throughout the world recognise this as a treatment that gives unparalleled improvements, both psychologically & physically. Despite this, Medicare does not recognise fractional CO2 laser as an appropriate treatment for scarring. I have lobbied, written, & faced committee panels. I have provided them with evidence, I have also got other senior dermatologists to do the same. Despite all our efforts the idiots at the top won’t listen.
How much are treatments?
Depending on the severity of your scars, some treatments are covered under Medicare. The medical insurance system in Australia, in the context of scarring, has illogical reasoning as fractional lasers are not covered. As a guide, for the treatment of burns, I charge about one third the costs compared to lasers for cosmetics.
- Micrografting & split grafts- POA, depending on area.
- Fractional lasers – from $490
- Microneedling & topicals- from $440
- Phototherapy – no charge. Bulk billed under Medicare
Where to get treated publicly?
The Royal Brisbane Hospital has an Ultrapulse SCAAR FX Lumenis CO2 laser. You can book an appointment with the Plastics team for an assessment. They do run this laser intermittently.
Davin’s Viewpoint on treating burn scars
Lasers are useful as adjunctive treatment for surgical, traumatic, & burn scarring. In the context of burns, the traditional approaches of surgical revision with grafts, Z-pasties, tissue expanders, & contracture release all applies. Laser is not a substitute for surgical management. Additionally, the use of silicone sheeting & compression garments still forms the foundation of treatment. Occupational & physiotherapy plays a vital role in rehabilitation as it aids mobility & range of movement.
The role of fractional lasers for burn scarring is relatively new, pioneered by dermatologists & plastic surgeons in the United States & in Italy. There have been many papers over the past 5-10 years demonstrating efficacy & safety. My goal is to improve-
- Symptoms, including itch & pain. Lasers can modify the inflammatory response, including histamine release & mast cells, thereby reducing itch & pain.
- Improve range of motion. This occurs as a result of scar remodelling as the ratio of type 1 & 3 collagen changes with CO2 lasers.
- Contour changes can be improved with collagen remodelling. Scars are less thick.
- Color changes are harder to correct with lasers. Fractional CO2, coupled with topicals may induce hyperpigmentation if there are viable pigment cells/melanocytes.
Inflammation & trauma (scratch, accident, burn) can reduce melanocyte numbers. If this happens, I need to transfer pigment cells from one area to another. This is surgical. There is no other way to reliably replace melanocytes.
Hypopigmented scars take time to heal & re-pigment, especially with lasers, microneedling & topicals. Melanocyte transfer is faster, I often get re-pigmentation within 3-8 weeks of surgery. The scar-recipient site looks somewhat patchy for many months before evening up at 12 months. You are in it for the long haul. Unlike pigment transfer for vitiligo, melanocyte transfer is more stable in scar tissue. In the context of burn scars, this transfer is more complex. The primary reason is that I cannot aggressively dermabrade or resurface the scar. This is due to the lack of pilosebaceous units. In 2022 I am researching the viability of FUE (follicular unit extraction & translation) for burns. This will increase melanin production as I transfer viable hair follicles in the burn scar itself. This has to be performed when scar thickness normalizes as this will give the highest survival rate for follicles.
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