Modern Burn Scar Treatment
Extensive burns are still the most devastating injury known. Nowadays mortality from burn injuries has diminished considerably. However some burn injuries leave serious scars after healing. These scars were untreatable until recently. Today we have considerable improvement for their treatment.
Classical treatment of burn scars
Historical treatment options of burn scars can be summarized as follows:
Excision of the scar and primary closure
If the scar is narrow and there is loose skin around, it is possible to remove the scar by cutting and then closing the adjacent normal skin to push together and suture. It creates a linear scar. But there is always a possibility being enlarged, hypertrophied and getting reddish color for this scar.
Removing the scar and putting skin graft
Large burn scars can be excised and resultant open wounds can be closed by skin graft taken from the patient. Skin grafts must be taken from certain parts of the body and ugly scars may happen in these donor areas. Donor area scar after skin graft harvesting is related to the thickness of the graft. Thin thickness grafts leave less scar. On the other hand, the quality of the healed graft area may not be nice enough. It may seem different from the adjacent normal skin and not acceptable enough in terms of aesthetic appearance. Thick skin grafts result in better appearance in the recipient areas but cause ugly scars in their donor areas. Application of skin grafts are limited to the available donor areas. It is impossible to find adequate donor areas for extensive scars like these covering the whole torso and extremities. In these cases repeated graft harvesting from limited areas is necessary and results are poor.
Full thickness skin graft application
Extensive burn scars of the face can be treated by total excision of the whole face skin and putting one piece full thickness skin graft. But the area of the full face is larger than the imagined and the only treatment for such a large donor area is putting another thin skin graft over them. Because large full thickness skin defects can not heal primarily. Although the appearance of the face is somewhat acceptable, the appearance of the donor area is not.
Face transplantation is a promising treatment for devastating face scars but it is a complicated procedure and can not be used for the large burn scars out of the face.
Improving the appearance of the burn scars
All the topics mentioned above are still valid treatment options for today. On the other hand do we have another option if none of the classical scar treatments are applicable? For example if we can not excise a large scar can we improve the appearance without removing it? This is the most researching subject nowadays. Following paragraphs explain how can it be done.
Special laser treatments
Certain fractional lasers especially Fraxel Dual ™ are useful in all kinds of scars including burn scars. Fraxel Dual works with 1550 nm and 1927 nm wavelengths and is effective in both hypertrophy and discoloration (red or dark pigmentation) of the scar. Downside of this treatment is that only limited improvement is obtained after one session. Treatment must be repeated with one month (sometimes 2 or 3 months) intervals. Also it is not possible to predict how many sessions will be adequate. Fraxel treatment is somewhat painful. Because of this some pain relief cream could be applied over the treatment area and wait at least 2 hours. This treatment is an outpatient procedure. Usually ıt doesn’t leave any wound over the skin. Patients can wash the treated area immediately after treatment. However extra trauma and direct sunshine should be avoided. Moisturizers can be applied over the treatment area a couple of times daily. Some mild pain and redness can happen for one or two days. Some mild skin texture changes may happen but all of them disappear approximately in one month. So the treatment can be repeated within one month or more intervals. It is not easy to apply this treatment to children. Some kind of minimal anesthesia must be used. Fraxel laser is one of the most effective tools for burn scar treatment.
Drug injections into the burn scar, ointments, silicon and pressure treatments
Most burn scars are hard, tight, red and bulged (hypertrophied). Certain drugs may reduce the hardness and bulging resulting softening after injection into the scar. Some cancer drugs and cortisone solutions are among them. But if they are injected into the wrong places may result in damage. They must be employed by qualified doctors. Also their dosages are very important. If the scar area is very large it is not safe to inject whole areas. In this case only some part of the wound is injected in every session. Average interval for injections is one to three months. It can not be predicted how many sessions would be enough. Some drugs can be injected directly but some need anesthesia. Drug injections are same day and outpatient procedures. Topical application of steroid ointments and some scar softening ointments may cause some benefits. Silicon sheet and pressure applications are also useful.
Stem cell enriched autologous fat injections
This treatment is one of the most promising and effective treatments of burn scars. Fat is harvested from the patient and stem cells are concentrated. This concentrate and fat tissue is injected into the burn scar. Injection into the scar is not too painful. It can be done under sedation as a same day procedure. On the other hand harvesting fat tissue is painful. Small amount of fat can be sucked under the skin by a large syringe and small cannula. If a large amount of fat is necessary liposuction is done and all fat is collected in a sterile jar. Later fat tissue is processed and injected into the scar with a syringe and needle. Usually one session fat injection is not enough. It should be repeated every 3 months. How many sessions will be needed can not be calculated. It is not logical to harvest the fat for every session. Instead we harvest as much fat as should be needed in the future in one session. After injecting adequate fat the excess amount is quickly frozen in liquid nitrogen and stored in -80 degree deep freeze. When needed in the future an adequate amount is melted and injected under local and sedation anesthesia as same day outpatient procedure. There is no wound except some needle punctures so no special wound care is needed. The only problem of this treatment is difficulties in very thin patients who have not enough fat to harvest and children.
Abrasion of the scar and ultra thin skin graft
The last step of the burn scar treatment is this procedure. Some burn scars are seen only white areas after complete healing or treatment. There is no sign of scar except hypopigmentation. Treatments described above can not correct hypopigmentation. We developed a special treatment for hypopigmentation. The white areas are abraded very superficially and ultra thin partial thickness skin grafts are layed down over this area. Since the thickness of the graft is ultra thin usually no scar is resulted on the graft donor area. After complete take of the graft some pigmentation appears on the white areas. The downside of this treatment is sometimes the pigmentation can not match the color of the normal skin.
The success rate and duration of the treatment
The most frequent question from the patients is success rate. Unfortunately it is not a miracle treatment and the success rate never reaches 100%. On the other hand this is the most successful treatment in the world of this time. Success rate differs from patient to patient, sometimes more than 70% and in some patients only 40%. However even the small amount of improvement makes a patient very happy. Because there is no other alternative treatment for patients with large burn scars. Also this treatment doesn’t leave any irreversible unwanted changes that could cause problems for future new treatments. The duration of the treatment is variable. Generally more than a year. We continue the treatment as long as the patient has benefit. Some patients decide to stop the treatment after some time saying “this improvement is enough for me”. On the other hand in some other patients the benefit of the treatment reaches a limit and we stop the treatment to prevent unnecessary costs.
Today a large burn scar can be treated better than before and leaving with burn scars is not a destiny for these patients.