Ablative Fractional Laser Resurfacing: A Promising Adjunct to Surgical Reconstruction

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1 MILITARY MEDICINE, 181, 6:e616, 2016 Ablative Fractional Laser Resurfacing: A Promising Adjunct to Surgical Reconstruction LT David Griffin, MC USN*; LCDR Megan Brelsford, MC USN ; CDR Eamon O Reilly, MC USN ; CDR Sean P. Stroup, MC USN*; CDR Peter Shumaker, MC USN ABSTRACT Ablative fractional laser resurfacing (AFLR) is emerging as a safe and effective treatment option for the mitigation of cosmetic and functional deficits resulting from traumatic scars and scar contractures. Military centers of excellence engaged in the multidisciplinary rehabilitation of wounded warriors have been instrumental in the widening acceptance of the technique in both the military and civilian realms. Despite the end of large-scale combat operations, AFLR remains a promising complement to surgical reconstruction and a novel option in challenging clinical situations that defy resolution with traditional methods. Herein, we present the case of a man in his 50s who underwent extensive genital and perineal debridement related to Fournier s gangrene. Despite successful reconstruction including extensive skin grafting, the patient suffered from intractable discomfort related to developing scar contractures that responded rapidly to a course of AFLR. This case serves to highlight the potential benefits of AFLR for postoperative wound management, and the importance of a multidisciplinary approach for the care of complex injuries. INTRODUCTION Fournier s gangrene is a life-threatening necrotizing fasciitis of the male genitalia and perineum first described in 1764 by Baurienne and eponymously named after Jean Alfred Fournier described the condition in Untreated, this mono- or polymicrobial infection spreads rapidly along the superficial fascia system and onto the anterior abdominal wall. Initial treatment involves resuscitation, broad-spectrum antibiotics, and, of paramount importance, aggressive surgical debridement. Subsequently, reconstructive goals of the perineum and genitalia include both functional (urination and sexual function) and cosmetic (restoration of premorbid appearance) outcomes. Acceptable results are challenging because of significant skin loss. 2 Muscle flaps and full- and split-thickness skin grafts are crucial for wound coverage, but are frequently prone to contracture and hypertrophic scar formation leading to functional and cosmetic impairments. Effective treatment options are limited, particularly in the early postoperative period before full scar maturation and a consideration of surgical revision. Nonsurgical interventions, such as compression therapy and gel sheeting, may have a modest role in scar prevention but offer little improvement *Department of Urology, Naval Medical Center San Diego, San Diego, CA. Department of Dermatology, Naval Medical Center San Diego, San Diego, CA. Department of Plastic Surgery, Naval Medical Center San Diego, San Diego, CA. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. The authors are military service members. This work was prepared as part of their official duties. Title 17, USC, 105 provides that Copyright protection under this title is not available for any work of the United States Government. Title 17, USC, 101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person s official duties. doi: /MILMED-D for existing scars. Surgical revision is associated with additional surgical morbidity, frequently limited benefits, and relatively high recurrence rates. 3,4 Additional effective yet minimally invasive treatment options are clearly needed. Since its introduction for primarily cosmetic applications in 2007, ablative fractional laser resurfacing (AFLR) has emerged as a safe and effective treatment option in the management of traumatic scars and contractures. 5 9 Military centers of excellence including the Naval Medical Center San Diego have had a significant role in advancing the technique in the setting of multidisciplinary rehabilitation of wounded warriors and other traumatically injured patients. 10 Herein we present a case in which AFLR was employed successfully in the early postoperative period to complement surgical reconstruction after extensive debridement in the management of Fournier s gangrene. Although this case report is from our civilian experience, this technique holds promise to optimize outcomes and improve patient satisfaction in a multitude of challenging clinical situations whether derived on or off the battlefield. CASE REPORT A man in his 50s presented to the Emergency Department with fever and several days of increasing pain, pruritis, and swelling in the perineum and genitalia accompanied by leukocytosis and lactic acidosis on laboratory evaluation. Members of the Department of Urology diagnosed the patient with Fournier s gangrene and he was taken to the operating room for debridement of the scrotum and perineum. Multiple serial procedures were required to remove necrotic tissue, with negative pressure wound therapy employed between debridements. Approximately 5 weeks after his initial procedure, members of the Departments of Urology and Plastic Surgery reconstructed his scrotum using bilateral gracilis muscle flaps and a split-thickness skin graft to the e616

2 scrotum, full-thickness skin graft to the proximal shaft of the penis, and split-thickness skin grafts to the suprapubic area. Despite satisfactory wound healing at his 3-month follow-up evaluation, the patient complained of increasing and intractable pain and tightness in his scrotum and penis, as well as decreased range of motion in his lower extremities. Erections and intercourse were also painful, and the patient complained of loss of length and width during penile tumescence. Given previous positive experience with AFLR in the setting of traumatic scarring, the patient was referred to Dermatology for consideration of treatment. On physical examination, circumferential cicatrix bands (corresponding to the edges of the full-thickness skin graft) were noted just proximal to the glans and at the base of the penis, causing significant edema. The split-thickness skin grafts overlying the suprapubic area and scrotal reconstruction were firm with limited pliability. In addition, mild-to-moderate hypertrophic scarring was noted on the donor-site incisions of the gracilis flaps on the bilateral medial thighs (Fig. 1). After informed consent, a course of AFLR was initiated approximately 4 months after his initial debridement. Because of early concern over tolerability resulting from the location and total area of involvement, the procedure was performed under general anesthesia in a multidisciplinary setting. Laser treatment parameters were selected to include a low microcolumn density and a treatment depth according to anatomical considerations and in proportion to the estimated scar thickness in a particular area. The initial treatment and 3 of 4 subsequent AFLR treatments were performed with a 10,600-nm carbon dioxide (CO 2 ) laser (Deep FX Handpiece; Lumenis Ultrapulse, Yokneam, Israel). Microcolumn diameter and pulse width are generally fixed and are dependent on the particular laser platform; in this case, approximately 120 μm and250μs, respectively. The selected treatment depth ranged from approximately 0.8 to 2 mm. In areas with hypertrophic scarring, topical triamcinolone acetonide suspension at a concentration of 40 mg/ml was applied immediately after treatment. During the initial treatment, a clear transudate was immediately noted over the skin of the edematous penile shaft (Fig. 2). Postprocedure wound care included the application of topical petrolatum ointment in the treatment areas until re-epithelialization, in approximately 1 to 2 days. Postoperative pain medications were not necessary, and there were no activity restrictions except for basic wound care and no water submersion for 24 hours. Immediately on recovery from anesthesia after the first treatment, the patient noted a significant reduction in subjective tightness and discomfort in the treated areas, particularly in the vicinity of the reconstructed scrotum. Approximately 6 weeks after his initial treatment, the patient estimated a 50% improvement in overall pain, tightness, range of motion, and swelling in the reconstructed areas. Examination revealed corresponding interval enhancements in texture, pliability, erythema, and edema. The patient received total of 5 AFLR treatments at 6- to 8-week intervals using similar treatment parameters and technique (Table I). Of note, one fractional treatment session was performed with an FIGURE 1. Patient at presentation in Dermatology approximately 4 months after reconstruction. There is generalized erythema, constricting cicatrix bands at the base and middle portion of the penile shaft with associated edema, and adherent split-thickness skin grafts of the reconstructed scrotum and suprapubic area. FIGURE 2. Patient on the same day as in Figure 1 approximately 5 minutes after his initial ablative fractional laser treatment. A serous transudate is visible on the dorsal aspect of the penile shaft. e617

3 TABLE I. Treatment Parameters Laser Suprapubic Setting Scrotal Setting Penile Shaft Setting Medial Thigh Setting Triamcinolone Treatment 1 CO 2 40 mj, 20 mj, 20 mj, 50 mj, Yes Treatment 2 CO 2 40 mj, 40 mj, 20 mj, 40 mj, Yes Treatment 3 CO 2 Not Treated 30 mj, 20 mj, BBL Treatment No 5% Density 5% Density (for Erythema) Treatment 4 Er:YAG Not Treated 800 microns, 700 microns, 800 microns, Yes 11% Density 11% Density 11% Density Treatment 5 CO mj, 30 mj, 25 mj, mj, No BBL, broadband light. All laser settings are single pass. ablative fractionated 2,940-nm erbium:yttrium aluminum garnet (Er:YAG) laser (Contour TRL ProFractional-XC; Sciton Joule, Palo Alto, CA), and the hypertrophic scars of his medial thighs were treated with vasculature-targeting broadband light rather than AFLR in the same session. With each treatment, there were cumulative objective enhancements with a corresponding improvement in subjective symptoms. Approximately 1 year after his initial AFLR treatment, the patient reported an 80 to 90% improvement in symptoms and function with corresponding enhancements in texture, pliability, erythema, and edema (Fig. 3). Interestingly, the patient also noted improvement in penile length and width during tumescence in additional to other described findings. No additional treatments were performed having reached therapeutic goals. DISCUSSION The patient in this report underwent life-saving surgical debridement and other related medical care, followed by FIGURE 3. Patient after a series of 5 ablative fractional laser treatments, approximately 1 year after his initial treatment. Notable reductions in erythema, edema, and restriction are evident. Note the relaxation and lack of ridging and cobblestoning of the reconstructed scrotum compared to the baseline in Figure 1. successful genital and perineal reconstruction. Despite optimal surgical technique and an unremarkable postoperative course, he developed predictable postoperative sequelae including restrictive scarring that had a severely negative impact on this patient s recovery and overall quality of life. Hypertrophic scars can cause a variety of challenges for patients and their physicians including symptoms such as pruritus and pain, restricted movement and decreased overall function, and disfigurement. 2,4 Conventional management includes therapy and surgical revision techniques (e.g., Z-plasty, W-plasty, small-wave incisions, etc.) or scar excision, with or without graft or flap placement. 3 Unfortunately, the recurrence rate with surgical intervention is noted to be high, and surgical revision is often delayed to allow for scar maturation. 11 Multiple minimally invasive modalities are available that may augment or sometimes obviate surgical correction including compression therapy, gel sheeting, corticosteroid injections, microdermabrasion, and vascular-specific laser devices. 12 However, the efficacy of these interventions is often limited in the face of large scar contractures. The concept of fractional photothermolysis, the generation of narrow pixelated columns of thermal injury to controlled depths by water-targeting lasers to stimulate dermal remodeling, emerged more than a decade ago. 13,14 Originally applied in nonablative platforms to various cosmetic indications such as photoaging, dyschromia, and acne scarring; AFLR is rapidly gaining acceptance for the management of debilitating traumatic scars and contractures. 9,10,15 Multidisciplinary military centers of excellence in rehabilitation such as the Naval Medical Center San Diego have proven fertile ground for these advances, combining unprecedented need over more than a decade of conflict with a collaborative approach to care. 8,16 This environment has welcomed nontraditional specialties such as dermatology into the routine care of traumatically injured patients and helped advance the state of the art. As planned combat operations cease, this case helps illustrate the potential utility of AFLR for the millions of patients worldwide with disabling scars and contractures from injuries not received on the battlefield. e618

4 The mechanism of action of AFLR appears to be gradual laser-induced dermal remodeling, with a relative normalization of architecture and collagen subtypes reported in one study involving burn scars. 17 Penetration depths unavailable to previous platforms combined with relatively large areas of intervening untreated skin between ablated columns likely contribute to the reported efficacy and safety in early studies. 18 The tolerability of the procedure in a sensitive location on compromised skin in this case is promising for its potential suitability for treatment in virtually any location (Fig. 4). Interestingly, the patient noted an immediate improvement in symptoms after his initial treatment. Clearly this was not because of collagen remodeling, as this is a gradual process over weeks, months, and years after injury. In the experience of one of the authors (PS), immediate improvement in range of motion is a frequent observation associated with AFLR, particularly in areas reconstructed with split-thickness skin grafts. 16 This observation likely results from photomechanical fenestration of the scar sheet, similar to the meshing of a split-thickness skin graft after harvesting. Durable improvements follow with subsequent remodeling. This immediate photomechanical effect is illustrated in Figure 2, with a serous transudate visible over ablated columns within minutes of treatment. Enhanced lymphatic outflow because of remodeling and decreased edema likely accounted for the lack of a similar effect after the second treatment despite similar settings. While promising, there are several limitations to this report that must be addressed. There was no control, so it is possible, and likely, that spontaneous improvement accounted for a portion of the improvements observed in this case. However, the rapidity and degree of improvement far exceeded that which would have been observed with spontaneous improvement alone. Furthermore, enhancements were incremental and cumulative with each treatment. Also, it is FIGURE 4. AFLR involves using a laser pattern generator to create multiple microscopic treatment zones. In the treatment area, the laser contacts a relatively small portion of the skin allowing the uncontacted portion to assist in rapid wound healing and remodeling. Treatment depth and density settings are adjustable by the laser surgeon. possible that the topical corticosteroid suspension applied in focal areas during 3 of the treatment sessions accounted for a portion of the observed improvements. However, it is unlikely that 3 applications of corticosteroid suspension would have had significant effects on intact skin. Laserassisted corticosteroid delivery has been previously reported to be efficacious in the treatment of hypertrophic scars, and laser-mediated channels through the epidermal barrier would have been instrumental to any substantial effects in this case. 19 Also of note, one of the treatment sessions involved the use of an ablative fractionated 2,940-nm Er:YAG laser rather than the CO 2 laser. This choice was based on convenience rather than the availability of any comparative studies in the literature. There was a reduction in the treatment depth, accounting for the larger microcolumn diameter of approximately 430 μm for the Er:YAG platform compared to 120 μm fortheco 2 platform in this case. Finally, the patient received a single treatment of broadband light for the linear hypertrophic scars of his medial thighs. This would have had negligible effects on the treated areas of the genitals and perineum. CONCLUSIONS On the basis of the observations in this case, AFLR is a promising complement to surgical reconstruction including, but not limited to, the genital area. With the increasing number of survivable injuries in our military service members and the high percentage of service members who have suffered trauma to their external genitalia in recent conflicts, there is an increasing need to address genital and sexual restoration. AFLR may be a useful adjunct in the perioperative management of these patients and warrants consideration in the management of difficult perineal and genital scars. Further research including controlled trials is warranted to confirm efficacy in various clinical contexts, establish appropriate timing for the initiation and interval of treatment, and establish appropriate combination therapies. Though not necessarily appropriate in all circumstances, there are likely other conditions to which this technique could be applied in Urology, Plastic Surgery, and other surgical disciplines. Applied safely approximately 4 months after reconstruction in this case, AFLR may offer a powerful new tool in difficult clinical situations for which there are few current options. This case also illustrates that multidisciplinary collaboration can enhance the care of our patients. REFERENCES 1. Roghmann F, von Bodman C, Loppenberg B, Hinkel A, Palisaar J, Noldus J: Is there a need for the Fournier s gangrene severity index? Comparison of scoring systems for outcome prediction in patients with Fournier s gangrene. BJU Int 2012; 110: Lee SH, Rah DK, Lee WJ: Penoscrotal reconstruction with gracilis muscle flap and internal pudendal artery perforator flap transposition. Urology 2012; 79: Watson D, Reuther MS: Scar revision techniques-pearls and pitfalls. Facial Plast Surg 2012; 28: e619

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