Laser Scar Rehabilitation Transforms Wounded Warriors

"That was the last thing I remembered, before I woke up laying on the ground."  

On November 20, 2011, Burgess was in Afghanistan, attached to a mission heading into a village where at least 50 known improvised explosive devices (IEDs) had been found and cleared. That morning, the team had already found four IEDs -- each of them marked with something red, like a rock or a piece of cloth. As the team waited in an alley for another IED to be blown in place, they didn't know that inches from where they waited, lay a legacy IED, marked in blue. Burgess' right foot made contact. 

At the blast, Burgess suffered a traumatic amputation. "They said the only thing they could find were quarter-size and half-dollar-size pieces of my boot. I'm not going to lie, I'm still mad to this day! Those boots were heaven." Burgess was MEDEVACed out of the country with his sense of humor intact. He credits the Corpsman on patrol with him for saving his life. "I was his first traumatic hit, phenomenal kid, did a great job. I ended up with like four tourniquets on me. Most of the care on the battlefield, I don't remember. I got a lot of morphine. Once I got on the bird, I asked the flight medic to put me to sleep and I passed out."  

Eventually he was flown to the States to start his rehab process at Joint Base San Antonio-Fort Sam Houston. That was where he first met Dr. Chad Hivnor and Dr. Thomas Beachkofsky, military doctors at the time who now work for VA.  

"We were seeing a lot of patients coming back from the war as amputees with traumatic scarring and burns," says Dr. Thomas Beachkofsky, Staff Dermatologist at the James A. Haley Veterans' Hospital (JAHVH, Tampa VA). "Caring for the skin of residual limbs following limb loss is absolutely critical. It is the interface between the patient and prosthesis and an area of significant pressure, friction, sweating, skin irritation and often scarring.  If undermanaged, it can lead to devastating skin disease that causes pain, infections, and the inability to wear prosthetic devices. That negative impact on quality of life is where trauma dermatologists can provide significant support to help them return to their functional goals.”  

Even with scar massage, Burgess' skin graft scars on his left leg healed slowly and tight. "You couldn't bend it," he says. Dr. Chad Hivnor, now Chief of Dermatology for the San Antonio VA, had a solution he thought might work. By using microablative fractional resurfacing -- microscopic laser beams -- and initiating a small re-wounding process, patients see and feel improvement in skin collagen, elasticity, blood flow, and reduced pain and itch. Dr. Beachkofsky, a resident with Dr. Hivnor at the time and who continues the work at Tampa VA explains, "While not completely accurate, I liken this procedure to mechanical lawn aeration in terms of its ability to it stimulate growth and improve quality. We use light to generate heat and make microscopic holes in scar tissue to stimulate a rehabilitative wound healing process, resulting in healthier skin and happier patients."  

It's a treatment that has worked for Daniel Burgess. "You could see the improvement. Other people who didn't have it done, their scars looked like thick, nasty, uncared for scars. Mine started looking nice, and there was progress."  

Now part of the Veteran Interdisciplinary Combat Trauma Outreach and Rehabilitation Project (VICTORY Project) Drs. Hivnor and Beachkofsky along with Dr. Peter Shumaker, Chief of Mohs Surgery at San Diego VA, bring this specialized approach nationwide, with planned development of centers of excellence within the San Antonio, Tampa, and San Diego Veterans' Hospitals. Having collaborated and cultivated this area of trauma dermatology and scar care for years, they are now unified as VA employees and bring their expertise to Veteran patients every day. Burgess is one of few patients treated by all three at once, united to simultaneously accomplish the largest laser procedure they'd ever done outside of an OR.  

"I've already changed how I've thought about different patients," says Dr. Elana Hartman, Office of Academic Affiliations Advanced Fellow in Amputation Rehabilitation, JAHVH. "Even patients who aren't trauma related, who come in because they had delayed healing and now have a scar that's adhesive and not moving, when we try to fit them with a prosthesis, they're not able to fit well and they end up with another open wound. We now have something to offer them. We have more options." Skin and scar condition causes a domino effect in recovery. Without a strong and pliable scar, it can cause a patient to have to be fitted in a less-than-optimal prosthetic design. Laser scar rehabilitation can provide improvement, quickly. Hartman has seen the results. "Even after one treatment, a patient's knee range of motion went from a pretty significant contracture to pretty minimal degrees." This results in being able to wear a prosthesis longer, be more active, use a wheelchair less, and achieve lifestyle goals.  

"This can only exist at a VA where that system of training, the support system, the laser devices, and funding can support this work. There's no other institution doing this kind of work," says Dr. Eugene Sanik, Assistant Chief of Dermatology at Tampa VA. With the unique care-team approach, patients have access to teams of specialists including prosthetics, dermatology, plastic surgery, physical therapy and more. "This doesn't exist in the civilian world—the intimate interdisciplinary collaboration that occurs between medical and surgical specialties that might never interact on a day-to-day basis is the foundation of our success with these wounded warrior patients," says Dr. Brooke Baldwin, Chief of Dermatology at Tampa VA. Dr. Joe Lezama, Associate Chief of Staff for Medicine and Specialty Care, "This is where all of Haley's Heroes get to come together, almost like a big cinematic blockbuster movie to provide outstanding, innovative care to a Veteran. That truly, is very exciting." 

For patients with scarring considering the treatment, a consult with Dermatology is a good first step. Scars don't need to be new, to benefit. According to Dr. Jeffrey Heckman, Medical Director of the Regional Amputation Center, "Folks who were injured in the late 60s, in the Vietnam era, have been living with these scars and contractures, and all of these skin issues, chronic wounds, for a long time and now we're saying now -- we think we can do something! So come back and let's talk about this and think about what your goals are and where we think we can get you to."  

While the treatment might be pioneering, Daniel Burgess knows, "It drastically works," and urges patients to seek it out. "It's your life, and your life is important. Something that's non-invasive that you would never expect, can change your life. That's what happened to me." Being on the cutting edge is a great place to be. "We cannot fully control wound healing to prevent scarring, we're simply not there yet," says Dr. Beachkofsky, "However, we are absolutely successful with scar rehabilitation through the use of medical lasers and other adjunctive treatments.  I am proud that we can provide a multidisciplinary approach for our patients. The VICTORY Project aims to provide personalized care for each veteran and is dedicated to reducing symptoms and restoring function." 

Today, Daniel Burgess travels, runs with his kids at school events, and is glad he took the chance on the therapy. "Go in with an open mind. The knowledge that's at James Haley for some of these injuries, you're going to get to somebody that can help you."