Battlefield lessons arm clinicians with new treatment for burn scars
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Dermatologists in the armed forces help pioneer new use for laser therapy to help wounded soldiers

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 cost-prohibitive 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.

Improved survival rate creates need for better scar treatments

The development of laser therapy for burn scars became necessary due to a general improvement in soldier survival, according to dermatologist Chad Hivnor, MD, a lieutenant colonel in the United States Air Force. He said the lifesaving potential of battlefield 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.

“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.)[pagebreak]

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.

Ablative lasers and scar treatment

Dr. Hivnor and Navy dermatologists Lt. Cmdr Nathan Uebelhoer, DO, and Cmdr. Peter Shumaker, MD, from the Naval Medical Center in San Diego, have worked alongside University of Miami dermatologist Jill Waibel, MD, 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.

“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.”

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.[pagebreak]

“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.”

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.

“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.”[pagebreak]

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.

Future civilian potential

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.

“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 difficult; 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.”

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.”

Military dermatology

For dermatologists in the military, most often the goal is to get troops with dermatologic injuries back into action. Dermatologist Yang Xia, MD, a Mohs surgeon and major in the Army who is currently deployed in Afghanistan, said that much of his work involves utilizing the systems and equipment in place to quickly and effectively treat and release soldiers back to duty.

“We have the necessary support, staff, and equipment to deliver care, but it can take a toll on a lot of the physicians here because it is a 24/7 operation. Our biggest goal is to quickly return soldiers back to the fight. Usually, dermatologic injuries shouldn’t be a hindrance to being in battle,” Dr. Xia said.

Dr. Xia said he has done 20-30 Mohs surgeries in Afghanistan in a recent four-month period. For these he uses a modified procedure in which he is able to have the slides processed in Germany and is sent a high-resolution photograph of the margins via email.

“I take a small margin around the tumor, send it to Germany, it gets processed there, and they send the pictures of the specimen via email back to me. If the margins are negative, I am then able to close up the wound. As a result, we’re able to send the patients back to the battle almost 100 percent of the time.”

The possibility of serious injury is a constantly present danger for troops deployed to Iraq and Afghanistan. Dr. Xia said that for wounded troops, there is a tiered system designed to deliver care to the most critically wounded in a systematic and expedient manner. Injured soldiers, he said, are first transported to a Forward Operating Base (FOB), which are scattered throughout the campaign theater. In most cases, Dr. Xia said, wounded soldiers reach the FOB within an hour.

“They stabilize the patient at the FOB,” Dr. Xia said. “If there’s a below-knee amputation or anything of that nature, it usually happens there.”

Patients who reach a hospital with vital signs intact, according to dermatologist Chad Hivnor, MD, a lieutenant colonel in the Air Force, have an extremely high rate of survival. Dr. Xia attributes this to lessons learned during recent campaigns in the Middle East.

“Having been in the war in Afghanistan for the past 10 years, military medicine has learned a lot about trauma,” Dr. Xia said. “[A wounded soldier] usually gets to the FOB very quickly, and they usually do extremely well.”

From FOBs in Afghanistan, patients in need of evacuation and further treatment are sent to Bagram Airfield, a military complex in the Parwan province. The base serves as the point of departure for wounded soldiers in need of further treatment.

“At Bagram, soliders are further assessed by our surgical team to make sure they remain clinically stable,” Dr. Xia said.

From Bagram, patients who need further attention are flown to Germany, where they’re able to receive specialized care and be sent back to the U.S. for continued treatment. Dr. Xia said that for the most critical patients, the evacuation process to Germany can happen extremely quickly.

“Once the soldier gets injured, we have a military triage system that determines how fast the patient gets evacuated to Germany. Let’s say a patient was injured by an IED. They’ve probably lost a limb from the explosion, and within an hour, they’re likely at a Forward Operating Base to get stabilized,” Dr. Xia said. “If their injuries exceed the FOB’s capabilities they are transferred from their FOB to Bagram within a couple of hours. You do sometimes have patients who are more clinically stable they could spend a few days at the FOB before coming to Bagram, then be evacuated to Germany.”

Military setting may make medical breakthroughs more likely

In addition to groundbreaking treatment for severe burn scars, dermatologists in the armed services have extended laser breakthroughs to other therapies. Chad Hivnor, MD, a lieutenant colonel in the Air Force, said a study by Nathan Uebelhoer, M.D., a lieutenant commander in the Navy, helped him connect ongoing military dermatologic breakthroughs to a new treatment for his wounded patients in San Antonio. His patients with amputations were experiencing problems with the climate. The heat and humidity would cause the skin under their prostheses to become damp and break the seal between skin and prosthetic, leading to many of them losing suction and falling unexpectedly. Laser treatment and botulinum toxin injections, he said, offered a solution.

“In a journal that I’d read, Dr. Uebelhoer did a study looking at laser hair removal and a decrease in sweat in the areas treated. And I’d certainly noticed it in regard to amputations as well. If you live in a humid or hot climate, like San Antonio, soldiers with prosthetic legs will be walking along and lose suction because of sweat, often falling flat on their face,” Dr. Hivnor said. “They also get traumatic folliculitis with the neoprene sleeves that they wear for the amputation — it rubs back and forth and the hair follicles get inflamed or infected.” To resolve both problems, he said, “What we’ve done is 300-400 units of botulinum toxin and laser hair removal. Because of the hair removal you get a better fit, and because of the decrease in normal sweat [due to the botulinum toxin] you don’t see the loss of suction.”

The idea to try both treatments in combination illustrates the difference between civilian and military dermatology, according to Dr. Uebelhoer. He said that military physicians have the ability to utilize new treatments, medications, and combinations of therapies without the need to seek prior approval from private insurers. Wounded soldiers receive whatever care is necessary without regard to cost. This policy, he said, allows him to work with the most cutting-edge technology available and pioneer new treatments.

“We don’t have the same insurance restrictions that a civilian dermatologist might have in terms of what procedures and what medications to use. Our patients are similar, but they can also be very different because we’re dealing with patients with certain injuries to the skin more specific to the types of jobs we’re dealing with,” Dr. Uebelhoer said. “The reason why I stay in the Navy is because we’re doing some very exciting, cutting-edge work that is really dramatically helping wounded warriors. That’s just very satisfying and exciting work.”

Burn lasers in the civilian world

Despite the lack of a CPT code for fractional ablative laser treatment for burn scars, University of Miami dermatologist Jill Waibel, MD, has been able to offer treatment to a number of civilian patients with severe scarring.

For Dr. Waibel, the inspiration to use fractional ablative lasers for severe burn scars was spurred by a patient who had suffered burns on more than 80 percent of her body. Dr. Waibel quickly became enamored of the potential of fractional ablative treatment to help the patient.

“In 2004, I treated my first burn patient with fractional. Before that, lasers weren’t being used on burn patients and severe traumatic patients, because the laser technology we had prior to 2004 could actually make some of these scars worse. If you look in the literature from the the early 1990s, there were studies performed and published that the continuous CO2 and erbium could actually make scars worse,” Dr. Waibel said. “When fractional ablative lasers came out for wrinkles in 2004, people were using them for acne scars. And I had one patient — she was my inspiration — who was in a horrible grease fire and almost died. She found me and asked me to help her, and so we attempted these treatments with the non-ablative fractional laser. She ended up getting somewhere around a 98 percent improvement. It was just amazing.”

Publication followed, and soon Dr. Waibel was fielding calls from across the country from patients who wanted the treatment. Among those were the Berns triplets, sisters who survived a fire at 17 months of age that left them without a mother and with disfiguring third-degree burns. Their story was featured on Good Morning, America; The Today Show; and ABC’s 20/20.

“I remember one time we were at this public pool swimming, and this mother, her kids were playing with us in the pool and she grabbed her kids up and she was like Don’t play with these kids. This is what happens when you play with fire,’” Trae Berns said during an interview with ABC’s 20/20.

Dr. Waibel, along with the laser manufacturer, agreed to perform the procedure for free. The results were dramatic.

“We’re noticing every day more and more improvement,” Chandra Berns said during the interview with Roberts. “Already I feel more confident.”

Following successful results and positive publicity for the procedure and the device manufacturers, there is hope that this effective treatment will one day be available to all the victims of severe burns.



Military dermatology
Military setting may make medical breakthroughs more likely
Burn lasers in the civilian world