12 Years of ablative fractional CO2 laser Practice: Logistics, lessons and evolving model of care

• Ablative fractional CO 2 laser (AFCO 2 L) services improve equity of access to scar treatment. • AFCO 2 L service resulted in reduced burn scar operative reconstructive cases. • Younger, female patients more likely to receive AFCO 2 L. • Patients with slower healing burns more likely to receive surgery and AFCO 2 L. Ablative fractional CO 2 lasers (AFCO 2 L) have been shown to improve burn hypertrophic scars significantly. In this paper we describe the journey of setting up the laser service for burns patients, considerations in patient selection, treatment algorithms, and lessons learned. This study is a retrospective cohort study including all patients who received AFCO 2 L at the Western Australian (WA) Statewide Adult Burn Unit since the start of the program in 2013–2024. Descriptive statistics present the number, timing and settings of AFCO 2 L events, as well as patient, injury, and treatment characteristics. Further, the profile of patients who underwent laser treatment was compared to those who did not, during the study period. Since the introduction of the AFCO2L, a total of 4005 laser sessions involving 837 burns patients has been completed in WA. The majority were performed as an outpatient (66 %), with the proportion and total numbers increasing with time to 2021. Compared to those not receiving laser for their scars, AFCO2L was more likely applied to younger (p < 0.0001), female (p < 0.0001) patients with higher %TBSA burns (p < 0.0001) involving multiple anatomic areas (p = 0.001), more often requiring surgery (p < 0.0001) and longer times to heal (p < 0.0001). In 2013, 100 % of all lasers were provided as an inpatient, under general anesthetic with an average age of scar > 5000 days. By 2023/4, only 18 % required an inpatient stay and the average age of scar was 111 days. The SABU team evolved AFCO 2 L therapy into the model of care over time to achieve earlier, more equitable delivery of laser treatments to 80 % of patients as outpatients, supported by extensive multidisciplinary team involvement.