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Burns 31 (2005) 15–24
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Erbium:YAG laser treatment of post-burn scars:
potentials and limitations
Aletta Eberleina,*, Hadrian Scheplerb, Gerald Spilkera,
Peter Altmeyerc, Bernd Hartmannd
a
Department of Plastic Surgery and Burn Center, Cologne City Hospital, Teaching Hospital of University of
Witten-Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany
b
Department of Hand and Plastic Surgery, Klinikum Lu¨denscheid, Teaching Hospital of University of Bonn,
Paulmannsho¨her Str. 14, 58515 Lu¨denscheid, Germany
c
Department of Dermatology, Ruhr-University of Bochum, St. Josef-Hospital, Gudrunstr. 56, 44791 Bochum, Germany
d
Department of Plastic Surgery and Burn Center, Unfallkrankenhaus Berlin, Warener Str. 7, 12683 Berlin, Germany
Accepted 1 June 2004
Abstract
Erbium:YAG lasers are successfully used to treat a variety of epidermal and dermal lesions, including rhytides, dyschromias, and certain
types of scars. To date, however, no report has focused on the experiences with this laser in reconstructive burn surgery.
Since 2001, the Erbium:YAG laser has become an integral part of the treatment of postburn scars at the Berlin Burn Center. This paper
presents the techniques applied and clinical experiences obtained. In addition, a new stripe technique is introduced, which avoids healing
disturbances in scars following deep burns.
In conclusion, the Erbium:YAG laser has proven to be a valuable supplementary tool for the improvement of cosmetically disturbing mild
postburn scars. It is particularly handy in areas difficult to treat, such as the eyes, nose, lips, and fingers. The individual advantages of the
Erbium:YAG laser, other laser systems, and dermabrasion for the treatment of burn scars are compared in a brief survey.
# 2004 Published by Elsevier Ltd and ISBI.
Keywords: Erbium:YAG laser; Scars; Burns; Wound-healing; Review
1. Introduction
The classic procedure for improving the superficial
appearance of scars is dermabrasion. In addition, advancements in laser technology have provided several new tools
for scar revision [1–5].
Ablative laser systems like the Erbium:YAG laser and the
pulsed CO2 laser deepithelialize similarly to dermabrasion
without direct wound contact. The laser energy is mainly
absorbed by water and proteins of tissue cells. High-peak
power and short-pulse durations are used to optimize
vaporization of targeted tissue with minimal surrounding
damage [6,7]. Both lasers are successfully used in cosmetic
* Corresponding author.
0305-4179/$30.00 # 2004 Published by Elsevier Ltd and ISBI.
doi:10.1016/j.burns.2004.06.004
surgery and for a large variety of dermatologic indications
[7–12].
The erbium:YAG laser in its traditional configuration
emits infrared light with a wave length of 2.94 mm and uses
250–350 ms pulse durations in laser skin resurfacing. As a
rule, a single pulse of the Er:YAG laser at 5 J/cm2 will ablate
about 20–25 mm of tissue with an additional 5–10 mm zone
of thermal necrosis [6,13,14]. The necrotic layer is
completely removed during each new pass, and even after
multiple passes, the residual necrotic layer does not exceed
10–50 mm [7,12,15] (Fig. 1).
The defined depth of ablation and constantly low thermal
necrosis are two favourable conditions considering the
often-impaired healing potential of burn scars. While normal
skin will reepithelialize quickly and evenly from hair
follicles and dermal glands after dermabrasion or laser
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A. Eberlein et al. / Burns 31 (2005) 15–24
Fig. 1. Histological finding after application of 600 mJ three times on the same 3 mm spot = 25.5 J/cm2. The epidermis is completely ablated and a very narrow
zone of thermal necrosis is apparent in the papillary dermis.
ablation, burn scars are often partially or completely
deprived of their epidermal appendages, especially after
deep burns [3]. During resurfacing of such scars, it is
advisable to save spots of intact epidermal basal layer, which
can serve as islands for reepithelialization. As the
Erbium:YAG laser provides ideal options to maintain such
calculated procedures, this laser was added to the equipment
in our burn center in May 2001.
2. Patients and methods
2.1. Laser and technique
The laser in use was the Dermablate1 (Aesclepion,
Jena, Germany). This laser provides pulse energies of
100–1000 mJ. The spot size on the skin can be varied
between 1–6 mm using different spacers on the handpiece. A
high-power smoke vacuum (Safe SystemTM, Edge Systems
Corp., USA) is directly attached to the handpiece (Fig. 2).
We mostly used the 3-mm spot size in a freehand mode.
The single spots were placed slightly overlapping in circles,
meander or any other pattern on the skin (Fig. 3), while a
constant spot overlap of 30–40% was maintained. At a speed
of 8 Hz, working with the laser beam is similar to working
with a paint brush. The speed was reduced to 2–4 Hz in more
delicate areas such as the periorbital region, or accelerated
for larger areas such as the trunk.
For an even subtotal deepithelialization of larger areas,
we applied two passes of a fluency of about 11–12 J/cm2 as
provided by the 3-mm spot, a single spot energy of 600 mJ
and 30–40% spot overlap. In order to level down single
nodules or prominent parts of larger scar areas, higher spot
energies (800–1000 mJ), higher pulse repetition, and
increased overlaps, close to the point of pulse stacking,
were used depending on the individual clinical situation.
In larger scar areas containing multiple prominent bands
and lines, the elevations were first cleared away selectively
using high power (Figs. 4 and 8b). Preoperative marking of
the elevated scar lines and points using a sterile skin marker
was often helpful during this procedure (Fig. 4b). In a second
step, the whole scar area was subtotally deepithelialized
using the above described energy mode in order to obtain an
even regeneration and optical blending. In the face,
complete aesthetical subunits were treated whenever
possible. All procedures were performed under either local
infiltration anaesthesia, regional nerve blocks or under
general anaesthesia.
In some cases, thicker scar boards needed to be thinned.
In these cases, deep ablation was performed in a channellike manner, leaving narrow stripes of healthy epidermis in
between (Fig. 8b). These provided rapid postoperative
A. Eberlein et al. / Burns 31 (2005) 15–24
17
Fig. 2. Different spacers on the laser handpiece can be chosen for different spot sizes. The wide opening on the handpiece is part of the integrated smoke
vacuum.
healing. As soon as repigmentation was restored, the other
still untreated stripe-like scar areas were selectively levelled
down in a second step (Fig. 8d).
2.2. Patients and perioperative care
During May 2001 and December 2002, a total of 96 scars
were treated in 24 patients aged 16–55 years. The scars to be
treated had developed either after spontaneously healed
superficial burns or after autologous skin grafting secondary
to burn injuries. Most of the scars were mature scars, only
few scars showed prolonged redness, indicating persistent
scar proliferation. No keloids were treated.
Thirty-eight scars with irregular profiles were larger than
4 cm 4 cm or covered a complete aesthetic unit in the face.
Thirty of these scars were located in the face, neck or low
neckline, eight on the hands. Twenty-four additional scar
areas were treated for hyperpigmentation, four of these cases
contained deep spotted powder tattoos that had to be
removed (Fig. 5). Thirty-four scars were single nodules or
cords or transplant borders (Fig. 6). The results of treatment
were evaluated for changes of skin texture and colour after a
follow-up period of at least 6 months.
All patients gave their informed consent before treatment. Patients treated for hyperpigmentation were informed
about alternative treatments such as ruby lasers. Patients
who had received blood transfusions or who presented other
risk factors were asked to be screened for HIV and Hepatitis.
As the intended clinical laser treatment was not a part of an
approved study, a human studies committee was not
involved.
After full-face procedures, the entire face was covered by
Silon-TSRTM (Bio Med Sciences Inc. Allentown, PA),
which is a very thin and flexible perforated silicone sheet
specially produced for laser-resurfacing. In all other cases,
we chose MepitelTM (Mo¨ lnycke Health Care AB, Sweden), a
different silicone wound dressing, which we use regularly
for the treatment of superficial second-degree burn injuries.
The dressings were changed first on postoperative days 2 or
3, and thereafter every 1 to 3 days depending on the
individual healing progress. During the postoperative
period, special attention was paid concerning the possibility
of herpes reactivation by laser treatment. However, no
perioral antivirals were given prophylactically, as none of
the patients presented a positive history of herpes simplex in
the area to be treated. After complete healing, patients
switched to the application of a moisturizing sunscreen
during daylight (SPF 30 or greater) and pathenol cream until
complete resolution of erythema.
3. Results
3.1. Clinical improvement
All profile treatments of larger areas in the face, neck,
lower neckline and hands showed improvement (Fig. 7).
Grafted area could be smoothed in all cases (Fig. 6).
Single nodes or cords, which were levelled down, showed
partial recurrence of hypertrophy in 42% of the treatments.
Some of these cases responded to a second treatment
session.
Results after treatment of hyperpigmented scars varied.
Black powder tattoos could be cleared away in all cases
(Fig. 5). Smaller dark spots or freckle-like lesions improved
in 93% of the cases. One Russian patient who underwent
multiple treatment sessions for large hyperpigmentation on
both hands, returned to her country after healing and could
not be further followed up. After treatment of nine other
larger hyperpigmented areas on other patients, recurrence of
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A. Eberlein et al. / Burns 31 (2005) 15–24
Fig. 3. Application of the laser beam on the skin: single spots may be lined up in circles creating round planes (a) or in meander-like patterns forming
rectangular areas (b).
hyperpigmentation occurred in five cases. The other
four laser-treated areas remained hypopigmented, which,
however, were intended and improved the overall appearance.
3.2. Complications
No intraoperative complications occurred. None of the
patients developed local infections or herpetic reactivation.
Reepithelialization was completed after 7–14 days postoperatively in all cases where the technical treatment
modalities described above were used. However, delayed
healing-up to 5 weeks was observed in three other cases,
where the applied laser energy exceeded the threshold of
25 J/cm2 in larger areas for other reasons. One of the latter
patients showed local infection and subsequent hypertrophic
scarring. The second patient developed long-lasting
erythema and itching, and the third patient could not be
followed up.
Unwanted hypopigmentation was not seen, especially not
in darker skin types. Hyperpigmentation was seen in one
female patient of darker skin type III. As the healing process
A. Eberlein et al. / Burns 31 (2005) 15–24
Fig. 4. Typical profile irregularities after mesh graft transplantation
of the hand (a): elevated scar components are pen-marked prior to selective
ablation (b) and subsequent superficial treatment of the complete
region.
was completely inconspicuous after the first two treatment
sessions, this patient became less compliant regarding the
use of her sun blocker after the third treatment. Shortly after
reepithelialization, she developed blotchy hyperpigmentation, most of which resolved spontaneously within several
months.
4. Discussion
4.1. Safety of the Erbium:YAG laser in burn scar treatment
Reepithelialization of a large ablated skin surface
depends on intact adnexal structures, such as hair follicles
and dermal glands. However, in deeper second-degree and
third-degree burns, those adnexal structures are partially or
completely destroyed. In such cases, spontaneous healing
can take place only from the surrounding healthy skin. This
19
Fig. 5. (a) Residual powder-tattoo secondary to superficial burn injury
caused by a gunshot. (b) The pigmented spots were removed using the 1-mm
spot size and short-pulse stacking.
procedure usually goes along with delayed healing time
depending on the wound size and wound contraction. In such
spontaneously healed skin only the epidermis is restored
without adnexal structures. In other burns, where the wound
has been covered by thin split-thickness skin grafts, adnexal
glands are lacking as well. In conclusion, areas with thin or
atrophic skin, such as burn scars, must be treated with
caution [3]. In such cases, the possibility of a highly
controlled laser ablation as provided by the Er:YAG laser is a
great advantage. In addition, this laser causes only minimal
thermal necrosis, which even after multiple passes does not
exceed 10–50 mm using ablative energy modes [7,12,15]
(Fig. 1).
As a single pulse of the Er:YAG laser at 5 J/cm2 will
ablate about 20–25 mm of tissue, one would expect complete
ablation of a thin epidermal layer of about 125 mm after
delivering a fluence of 25 J/cm2 and more [13,14]. Our own
previous clinical observations and histological findings in
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A. Eberlein et al. / Burns 31 (2005) 15–24
Fig. 6. Full-thickness skin transplant at the lower eyelid before (a) and after
laser treatment of the transplant borders and the small nodule at the medial
border (b).
discarded human dog-ear skin have shown that this
treatment mode causes gross ablation into the dermal layer
but leaves small islands of basal epidermis intact.
Accordingly, for an even subtotal deepithelialization of
larger areas, we usually applied no more than two passes of a
fluency of 11–12 J/cm2 as provided by the 3-mm spot and a
single spot energy of 600 mJ. In fact, in all cases where the
above energy mode was used, we found a regular course of
healing within 1–2 weeks postoperatively. In addition, all
areas treated with higher energy flow according to the stripe
technique proved regular healing time as well. Hence, we
consider the Erbium:YAG laser as a safe tool for scar
treatment in reconstructive burn surgery (Table 2).
4.2. Technical advantages of the Erbium:YAG laser
Working with the laser beam is similar to working with a
paint brush if a 3–6 mm spot size and a medium speed like
4–8 Hz is chosen. For larger areas like the trunk, larger spot
sizes may be preferable. For this special indication,
Fig. 7. A 28-year-old female burn patient who had received mesh graft
transplants in the entire face abroad 2 years before and who is in the
multistep secondary reconstruction program in our clinic. Among others,
she had received full-thickness skin grafts of the eyelid, upper cheeks, and
upper lip in the meantime. (a) Presently, hypertrophic scar ropes lateral to
the nasolabial fold are causing a bulky appearance of the midface. (b)
Improved appearance after levelling prominent scars in the nasolabial fold
and on the distal part of the nose.
additional scanner devices, as promoted for cosmetic skin
resurfacing, may also have a place in reconstructive burn
surgery.
Particularly fine parts of a scar can be revised using even
smaller spot sizes so that the laser beam can be guided like a
pen. In delicate areas like the periorbital region or the nose,
the speed can be easily reduced to 2–4 Hz (Figs. 6 and 7).
A. Eberlein et al. / Burns 31 (2005) 15–24
Table 1
Burn scars susceptible to Erbium:YAG laser treatment
Table 3
Disadvantages of the Erbium:YAG laser
Mildly prominent scars
Mesh-graft pattern
Overgrafting
Edges of skin transplants
Fine scar lines and filigree findings
Pigmentation irregularities
Traumatic dotted tattoos
Selective levelling of elevated scar components necessary
Time consuming treatment of larger areas
Missing hemostasis (not relevant in scar tissue)
Smoke development
High costs
21
as well as higher costs for purchase, storage and service
(Table 3).
In conclusion, the Erbium:YAG laser is particularly
handy for very small and fine scars (Table 1). In addition, in
areas difficult to work on like the eye-lids, the nose, the lips
or the fingers, the laser was found to be comparably safe, as
it is not subject to the special risks of dermabrasion such as
slipping or rolling up soft tissue like the eye-lid.
Furthermore, the flexibility and handyness of this laser
allow special applications like the stripe technique, as
described above.
4.3. Disadvantages of ablative lasers in comparison to
dermabrasion
There is an important difference between dermabrasion
and laser ablation of irregular scar surfaces like mesh-graft
pattern. While dermabrasion first clears away the elevated
layers of scars, the laser beam will level ‘‘hills’’ and
‘‘valleys’’ equally. Only some minor irregularities may
smooth away secondarily due to new mild scarring.
However, this secondary shrinking effect, which is desired
in the so-called ‘‘laser lifting’’ of normal aged skin, may be
unwanted in the face of burn patients, where the scarred skin
is already contract. Therefore, we feel, that an even twodimensional lasering of a complete area should be advised
only for very mild scar irregularities after spontanously
healed superficial burns.
In all other scars showing more prominent profile
irregularities, single elevations must be levelled down
selectively. In such cases, preoperative ink-marking of the
elevated scar lines and points is helpful during the operation,
especially in larger scar areas (Fig. 4). Nevertheless, clearing
away elevations selectively remains time-consuming and
exhausting, especially in mesh-graft pattern. This general
disadvantage concerns all ablative laser systems such as the
Erbium:YAG lasers and CO2 lasers. Other disadvantages of
ablative lasers include the development of smoke and smell
Table 2
Advantages of the Erbium:YAG laser in burn scars
Minimal thermal necrosis (‘‘cold ablation’’)
Predictability of ablation depth and healing time
Variable spot sizes and speed
Precise ablation of filigree scars
No mechanical wound contact
No risk of slipping or rolling up soft tissue
Easy handling around eyes, nose, lips
Low rate of complications
4.4. Advantages and disadvantages of the Erbium:YAG
laser in comparison to the CO2 laser
The CO2 laser produces deeper thermal necrosis, which
increases with each pass and may reach about 180 mm
[11,16–18]. Therefore, the risk of wound healing disturbances and destruction of already atrophic dermis in burn
scars by CO2 lasers is generally higher in comparison to the
Erbium:YAG laser. However, in cosmetic resurfacing
procedures for the aged skin, a deeper zone of necrosis
and collagen shrinking is desired, as it is thought to be
essential for wrinkle reduction and smoothed skin surface
[17,19,20].
The more distinct thermal necrosis produced by CO2
lasers causes hemostasis, which simplifies cosmetic resurfacing procedures. The ‘‘cold’’ Erbium:YAG laser ablation,
however, causes no coagulation, which is why ablation is
normally stopped as soon as pinpoint bleeding from dermal
vessels occurs and most of the laser energy is absorbed from
the exuding blood. However, this is only true for healthy
skin. Interestingly, pinpoint bleeding is not apparent in scar
tissue and therefore, deep ablation using the Erbium:YAG
laser is not limited by bleeding in burn scars (Fig. 8d).
In conclusion, we consider the Erbium:YAG laser to be
more suitable for the treatment of scars due to lesser thermal
necrosis, while CO2 lasers seem to be more effective for
smoothing aged skin.
4.5. Additional laser systems offering treatment
options for burn scars
Hypertrophic scars, which show prolonged redness and
activity, can be improved by laser systems targeting
treatment to the vascular component of the scar tissue.
One of these lasers is the pulsed dye laser (585 nm), which
has hemoglobin as target chromophore and thus penetrates
the epidermis without deepithelialization. In several studies,
it has been shown to be effective for longstanding
hypertrophic and erythematous scars and for some cases
of keloids [21–23]. In addition, itching of scars may be
reduced [21,22]. Again, multiple treatment sessions in 8week-intervals are required. Early initiation of PDLtreatment for abnormally proliferative scars and concomitant administration of intralesional corticisteroids and
silicone gel sheets are suggested.
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A. Eberlein et al. / Burns 31 (2005) 15–24
Pigmented lesions caused by burn trauma may respond to
treatment by the Q-switched Ruby laser [24]. Its 694 nm
wavelength with a very short 20–40 ns pulse duration is
selectively absorbed by melanosomes and other dark
pigments, and its long wavelength allows penetration into
the dermis. Like with all other lasers, the Ruby laser may
cause unwanted pigmentation disturbances such as transient
or permanent hypopigmentation or hyperpigmentation.
However, the incidence of scarring or atrophy is comparatively low [25].
Unfortunately, postinflammatory hyperpigmentation, a
frequent problem seen after second-degree burns and splitthickness skin grafting, is not consistently responsive to the
ruby laser [26,27], but may be improved by the pigmented
lesion dye laser (510 nm) [28–30]. Other laser systems,
proven effective in the treatment of epidermal and dermal
Fig. 8. Same patient as in Fig. 7. For deeper ablation of a thick scar board on the forehead (a) the two step stripe technique is applied (b–d). The first laser session
was performed in supraorbital nerve block. The first pass of stripe-wise ablation (b) with single pulse energies of 800 mJ, 3 mm spot size and 80–90%
spot overlap is followed by a second pass in the same lines. In between the laser-treated stripes, narrow bands of healthy skin are preserved as basis for a
rapid and undisturbed reepithelialization, which is completed after 10 days (c). After 2 months, the still untreated skin bands are laser-treated selectively,
while the formerly treated stripes are pen-marked and preserved (d). In addition, multiple scar bands in the nasal and nasolabial area were treated during
the same operation. Note typical lack of bleeding within the scar tissue. (e) Clinical outcome on the forehead. There is some improvement of gross appearance.
However, additional superficial dermabrasion or selective laser levelling of the numerous small scar elevations prior to stripe-wise treatment may have led
to a better result.
A. Eberlein et al. / Burns 31 (2005) 15–24
23
Fig. 8. (Continued ).
pigmented lesions, are the Q-switched Alexandrite laser
(755 nm) and the Q-switched Nd:YAG laser (1054 nm)
[25,30].
5. Conclusion
In our experience, the Erbium:YAG laser is a valuable
supplementary tool in reconstructive burn surgery. It is a
very handy instrument for the improvement of cosmetically
disturbing postburn scars, especially in areas that are
difficult to treat such as hands, face, and neck. Its predictable
rate of ablation along with very low thermal necrosis allows
very careful procedures in large scars with impaired healing
potentials. The Erbium:YAG laser can effectively improve
fine profile irregularities as well as certain kinds of
hyperpigmentations and dotted tattoos, which often occur
during burn trauma.
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