P APERS OF THE 134TH ASA ANNUAL MEETING Laser Resurfacing and Remodeling of Hypertrophic Burn Scars The Results of a Large, Prospective, Before-After Cohort Study, With Long-term Follow-up C. Scott Hultman, MD, MBA, FACS, ∗ † Jonathan S. Friedstat, MD, ∗ Renee E. Edkins, DNP, NP, ∗ † Bruce A. Cairns, MD, FACS,† and Anthony A. Meyer, MD, PhD† Objectives: Hypertrophic burn scars produce significant morbidity, including itching, pain, stiffness, and contracture, but best management practices remain unclear. We present the largest study to date that examines long-term impact of laser therapies, a potentially transformative technology, on scar remodeling. Methods: We conducted a prospective, before-after cohort study in burn pa- tients with hypertrophic scars. Pulsed-dye laser was used for pruritus and erythema; fractional CO 2 laser was used for stiffness and abnormal texture. Outcomes included (1) Vancouver Scar Scale (VSS), which documents pig- mentation, erythema, pliability, and height, and (2) University of North Car- olina “4P” Scar Scale (UNC4P), which rates pain, pruritus, paresthesias, and pliability. Results: A total of 147 burn patients (mean age, 26.9 years; total body surface area, 16.1%) received 415 laser sessions (2.8 sessions/patient), 16 months (median) after injury, including pulsed dye laser (n = 327) and CO 2 (n = 139). Laser treatments produced rapid, significant, and lasting improvements in hypertrophic scar. Provider-rated VSS dropped from 10.43 [standard deviation (SD) 2.37] to 5.16 (SD 1.92), by the end of treatments, and subsequently decreased to 3.29 (SD 1.24), at a follow-up of 25 months. Patient-reported UNC4P fell from 5.40 (SD 2.54) to 2.05 (SD 1.67), after the first year, and further decreased to 1.74 (SD 1.72), by the end of the study period. Conclusions: For the first time, ever, in a large prospective study, laser ther- apies have been shown to dramatically improve both the signs and symptoms of hypertrophic burn scars, as measured by objective and subjective instru- ments. Laser treatment of burn scars represents a disruptive innovation that can yield results not previously possible and may displace traditional methods of operative intervention. Keywords: Burn injury, hypertrophic scar, laser treatment (Ann Surg 2014;260:519–532) R ecovery after burn injury involves the coordinated restoration of form and function, to maximize patient outcomes. Over the past few decades, we have witnessed major advances in the resusci- tation and rehabilitation of patients with significant thermal injury, but reconstructive efforts may be limited by the development and per- sistence of pathologic scar formation. Abnormal healing that results From the ∗ Division of Plastic Surgery; and †The NC Jaycee Burn Center, University of North Carolina Health Care System, Chapel Hill. Disclosure: This study was supported in part by the Ethel and James Valone Plas- tic Surgery Research Endowment, University of North Carolina. The authors report no conflict of interest and have not received any consulting fees, stock options, research funding, capital equipment, or educational grants from any laser companies. Presented at the 134th Annual Scientific Meeting of the American Surgical Asso- ciation, April 2014, Boston, MA. Reprints: C. Scott Hultman, MD, MBA, FACS, Division of Plastic Surgery, The University of North Carolina, Chapel Hill, NC 27516. E-mail: cshult@med.unc.edu. Copyright C  2014 by Lippincott Williams & Wilkins ISSN: 0003-4932/14/26003-0519 DOI: 10.1097/SLA.0000000000000893 in hypertrophic scars or keloids may produce significant morbidity and impair quality of life, due to intense pruritus, neuropathic pain, stiffness and contracture, loss of thermoregulation, and decreased protection from mechanical trauma. 1 Treatment of hypertrophic burn scars involves different ap- proaches, depending upon the severity and type of patient signs and symptoms. 2–5 Conventional management has included observation, massage, moisturizing agents, compression garments, silicone sheet- ing, steroid injection, and direct excision. However, laser therapies have recently emerged as an attractive modality to treat hypertrophic burn scars, 6–25 with a limited complication profile. 26–29 Utilizing the principles of selective photothermolysis and fractional ablation of tissue, new laser- and light-based technologies permit targeted ma- nipulation of the burn scar. The ability to remodel thickened, disor- ganized dermis may accelerate burn scar maturation and yield results not previously possible. In a large, prospective, before-after cohort study, we demon- strated that laser treatment of hypertrophic burn scars produces rapid, significant, short-term improvement in both objective and subjective measures. 30 However, long-term results have not been reported, and recurrence of hypertrophic scars remains a legitimate concern for the patient, the provider, and payers. The purpose of this project was to document the long-term efficacy of laser therapies on hypertrophic burn scar formation, using provider-rated and patient-reported instru- ments. Secondary goals included determining (1) the optimal timing of treatment after burn injury and (2) the impact of treatment in chil- dren compared with adults. A growing body of evidence indicates that laser therapies can improve and even prevent hypertrophic scar formation, but best practices regarding timing, duration, and type of treatment have yet to be elucidated. METHODS Study Design After obtaining approval from the University of North Car- olina (UNC) biomedical institutional review board (IRB Study No. 11-0946, “Laser and/or Light Based Therapy for the Management of Hypertrophic, Hyperemic, or Dyschromic Burn Scars”), we con- ducted a prospective, before-after, single-cohort study of all burn patients who underwent laser treatment of hypertrophic burn scars, in 2011. All procedures were performed at a single institution, by the first author (C.S.H.), over this 12-month period. Hypertrophic burn scars were assessed immediately before and 4 to 6 weeks after each treatment, using patient-reported and provider-rated scar scales. Burn patients served as their own controls in this model. All symptomatic scars were treated until both the patient and the provider agreed that scar improvement had plateaued. For long-term follow-up, pa- tients who returned for a scheduled clinic visit in 2013 underwent reassessment of their burn scars, using the same instruments from 2011. Patient satisfaction was also measured, 2 years later, using a willingness-to-pay questionnaire. Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Annals of Surgery  Volume 260, Number 3, September 2014 www.annalsofsurgery.com | 519