Silicone Gel versus Combination of Silicone Gel and a 577-nm Diode Laser in the Treatment of Post-surgery Hypertrophic scar (Comparative Study) 

Silicone Gel versus Combination of Silicone Gel and a 577-nm Diode Laser in the Treatment of Post-surgery Hypertrophic scar (Comparative Study) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Silicone Gel versus Combination of Silicone Gel and a 577-nm Diode Laser in the Treatment of Post-surgery Hypertrophic scar (Comparative Study) Essam-Elden M. Mohamed, Hazem Lotfy Abd-Elaleem, Samar Ali A. Zahran This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5233207/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Hypertrophic scars, resulting from alterations in the normal processes of cutaneous wound healing, are characterized by proliferation of dermal tissue with excessive deposition of fibroblast-derived extracellular matrix proteins, especially collagen, over long periods, and by persistent inflammation and fibrosis. The present study aim to compare the efficacy of silicone gel versus combination of a 577-nm diode laser and silicone gel in the treatment of post-surgery hypertrophic scar. Methods: This study is a randomized comparative study In the period from 14 January 2021 up to the end of January 2023. 30 patients with post-surgery hypertrophic scar divided into two groups: A: one half of scar was managed with 577 nm diode laser 3 sessions monthly combined with application of silicone gel at home. A + B: the entire scar was treated with silicone gel within six months who admitted to the Laser unit of the Dermatology and Andrology Department at Al-Azhar University Hospital, Assiut during the study period. Results: significant improvement in pigmentation, pliability, height and total Vancouver score. By comparing between silicone gel and combination of silicone gel and a 577 nm diode laser, the combination shows significant improving than silicone gel alone. The scar in the lip and breast area showed a significant higher improvement rate with yellow laser plus silicone gel compared to the other site. Conclusion: combination of silicone gel and yellow laser has significant effect in making surgical scars less distinct Silicon Gel Yellow Laser Scar Surgical Scar 577nm Diode Laser Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Post-operative scar forms as a result of a highly conserved cascade of events following surgery that seeks to restore skin integrity and is influenced by the wound environment. Mechanical forces including tension, depth and epidermal closure all influence scarring. [ 1 ] Excessive scarring can have unpleasant physical, psychologicaland social consequences. Physicalsymptoms may include itching, stiffness, scar contractures,tenderness and pain. The psychosocial effects include diminished self-esteem, disruption of daily activities, anxiety anddepression. [ 2 ] Several treatments are used to reverse scar formation and emulate normal wound healing and remodelling, including transdermal injections, biomaterial based approaches and non-pharmacological approaches. [ 3 ] Silicone gels are universally considered as the gold standard in scar management and the only non-invasive preventive and therapeutic measure for which there is enough supporting data to make evidence-based recommendations. Silicone gel is applied in a thin layer to the skin where it dries to form a transparent, flexible, gas-permeable, water-impermeable silicone sheet. Silicone gel exerts several actions; scar more softer and flatter by reduction collagen production, protect scar tissue from bacterial invasion, restore balance between fibrogenesis and fibrolysis. [ 4 ] Laser therapy is an option which can be used to treat the surface texture of abnormal scars and may also be suitable for the treatment of residual redness, telangiectasias or hyperpigmentation. Laser therapy uses focused beams of light that can improve the appearance of scars. Diode laser targets chromophore haemoglobin, both destroy and inhibit the formation of small vessels within the scar as it interrupts the increased blood flow before it reaches the scar. [ 5 ] The aim of the present study is to compare the efficacy of silicone gel versus combination of a 577-nm diode laser and silicone gel in the treatment of post-surgery hypertrophic scar. Methods This study is a randomized comparative study In the period from 14 January 2021 up to the end of January 2023. 30 patients with post-surgery hypertrophic scar within six months who admitted to the Laser unit of the Dermatology and Andrology Department at Al-Azhar University Hospital, Assiut during the study period. Ethical considerations: This study was approved by the Committee of Local Institutional Ethics of Faculty of Medicine, Al-Azhar University. An informed consent was taken from the participants after illustrating the nature and duration of the study. Inclusion criteria: Patients aged more than 18 years old, Both sex, Patients with post-surgery hypertrophic scar either immediate after suture removal up to 6 months after surgery. Co-operative patient who accept to participate in the current study. Exclusion criteria: Patients with infections, rashes, or discharge producing wound, with underlying diseases such as diabetes mellitus, systemic lupus erythematosus, dermatomyositis, systemic sclerosis, and other autoimmune diseases, who on systemic or topical corticosteroids 1 month prior to the study, treated with immunosuppressive drugs, chemotherapy, radiation therapy, or diagnosed with cancer, who on anticoagulants medications and with allergy to silicone gel. Eligible patients were evaluated according to the following steps: Personal history, Past history of any associated disease involving the skin, Family history of keloid or other general diseases, General examination for general condition of the patients, Local examination and evaluation of scar. Treatment protocol: All the scars divided into two halves and designated “A” and “B.” A: one half of scar was managed with 577 nm diode laser 3 sessions monthly combined with application of silicone gel at home. A + B: the entire scar was treated with silicone gel. During treatment, the patient and physician wear specific goggles to guard against the harmful effects of laser on eyes.The treatment was performed at 1-month intervals and carried out with a single pass of 577-nm pro-yellow laser (QuadroStar PRO YELLOW® Asclepion Laser Technologies) on half of the scar and the wavelength used was 577 nm. In post-surgical scars treated patients, fluence was started from 16 J/cm 2 and increased gradually to 18 J/cm 2 and pulse duration was 32 ms.Immediately after the session, panthenol was applied and if the scar on face, sunscreen with SPF more than 30 was applied. The number of sessions is varied between individuals from 3 up to 6 sessions. Silicone gel: The patient was asked to apply Scaro gel two times daily and after shower for 3 months. The patient put the Scaro gel on whole post-surgical scar. Post session advice: After the session of pro yellow laser, the patients were prescribed topical emollient (panthenol) for 5 – 7 days. The patient who had post-surgical scar on face was advised avoiding sun exposure with regular use of sunscreen and emollient. Scar assessment: Photographs of patients: we used mobile phone to photos the studied participants before the start of treatment, after each session and after the last session. The level of improvement of the scars was evaluated by using the modified Vancouver Scar Scale (VSS) at the baseline and after 3 to 6 months of the final session. Safety assessments: At each visit, all possible side effects and complications, such as erythema, pain, edema, and post-inflammatory hyperpigmentation was recorded Statistical analysis: Statistical analysis was performed using GraphPad Prism version 8.0.2 (GraphPad Software, La Jolla, CA). Descriptive statistics for quantitative data were expressed in tables as the mean ± SD, while qualitative data were expressed as number and percentage. P-value was considered significant if < 0.05. Results The mean age was 28.60 ± 6.59 years ranging between 19 and 42 years. Out of these patients, 27 (90 %) patients were females, and only three patients were male. The duration of the scar ranged between one to four months with mean duration 2.57 ± 1.18 months as shown in Table 1 . Table 1 - Demographic data of the patients. Age (years) Mean ± SD Range 28.60 ± 6.59 19-42 Sex (%) Female 27 (90.0) Male 3 (10.0) Duration of the scar (Months) Mean ± SD Range 2.57 ± 1.18 1-4 Skin photo type III 19 (63.3) IV 11 (36.7) Site Abdomen 19 (63.3) Breast 3 (10.0) Neck 3 (10.0) Lip 3 (10.0) Forearm 2 (6.7) Residence Urban 22 (73.3) Rural 8 (26.7) We found that, there was a statistically significant differences as regard the percentage difference of the side underwent the combination therapy versus silicone gel alone treated side with p-value = 0.039, as shown in Table 2. Table 2: The mean percentage difference of Vancouver scoreafter application of both techniques Mean percentage Silicone gel + Yellow laser Silicone gel alone P- value Mean ± SD 59.81 ± 21.14 48.29 ± 21.31 0.039* According to the quartile grading scale 6 (20%) of the silicone gel plus yellow laser side treated scar showed excellent improvement, whereas no scar underwent silicone gel alone achieved excellent improvment. On the other hand, 4 (13.3%) silicone treated side showed mild improvement less than 25%, however no scar underwent the combination therapy revealed this grading with significant p-value =0.018 as shown in table 3 Table 3 - Quartile grading scale according to the percentage difference of Vancouver score of both techniques Silicone gel + Yellow laser Silicone gel alone P- value Excellent 25% 0 (0.0) 4 (13.3) As regard to the items of Vancouver score there were a significant difference in the pigmentation, vascularity, pliability, height and the total value of Vancouver score after application of silicone gel plus yellow laser as shown in table 4. Table 4 - Comparison between Vancouver score items before and after application of silicone gel plus yellow laser. Silicone gel + Yellow laser Before After P-value Pigmentation 1.67± 0.80 1.00 ± 0.64 <0.001* Vascularity 1.37± 0.81 0.53± 0.51 <0.001* Pliability 2.10±0.55 0.90 ± 0.71 <0.001* Height 1.37±0.49 0.37 ± 0.49 <0.001* Vancouver score 6.80±1.06 2.80 ± 1.60 <0.001* Also, for the side of the scar treated with silicone gel alone there was a statistically significant difference of Vancouver score compared to the baseline score as shown in table 5. Table 5 - Comparison between Vancouver score items before and after application of silicone gel alone. Silicone gel alone Before After P-value Pigmentation 1.67± 0.80 1.20± 0.61 0.008* Vascularity 1.17± 0.87 0.80± 0.41 0.019* Pliability 2.10±0.55 0.90 ± 0.84 <0.001* Height 1.23± 0.43 0.57± 0.68 <0.001* Vancouver score 6.30±1.29 3.47±1.70 <0.001* The scar in the lip and breast area showed a significant higher improvement rate with yellow laser plus silicone gel when compared to the other site as shown in table 6. Table 6 - Relation between improvement and demographic data of patients. Silicone gel + Yellow laser p-value Silicone gel alone p-value Mean ± SD Mean ± SD Sex Female 57.19 ±20.68 0.040* 45.32 ±20.37 0.019* Male 83.33 ±0.00 75.00 ±0.00 Residence Urban 66.78 ±20.37 0.001* 55.29 ±19.75 0.001* Rural 40.62 ±5.79 29.02 ±11.52 Skin phototypes III 58.64 ±17.94 0.699 51.50 ±21.79 0.285 IV 61.82 ±26.64 42.73 ±20.21 Site Abdomen 50.75 ±16.17 <0.001* 41.62 ±22.19 0.051 Breast 83.33 ±0.00 75.00 ±0.00 Lip 100.00 ±0.00 66.67 ±0.00 Neck 60.00 ±0.00 46.67 ±11.55 Forearm 50.00 ±0.00 46.43 ±5.05 Correlation of Vancouver score with patients’ age and duration of the scar revealed no statistically significant correlation on both sides as shown in table 7. Table 7 - Correlation of Vancouver scores with patients’ age and duration of the scar. Silicone gel + Yellow laser p-value Silicone gel p-value R R Vancouver score Age (years) 0.16 0.409 0.24 0.198 Duration (months) -0.25 0.181 -0.28 0.138 Discussion Post-surgical scarring with its physical sequelae (pain, itching, and unattractive appearance) and resultant psychological stress can dramatically impact a patient’s quality of life. These scars are a constant reminder of the patient’s past or present disease and the related surgery and can be associated with extensive functional and psychosocial morbidities. [6] These endogenous factors were well controlled in this trial as this study was designated as a split-scar study, in which each scar was divided into two equal portions, and each half was assigned treatment with either silicone gel or silicone gel with yellow laser. As a result, microvasculature and collagen play crucial roles in hypertrophic scars formation, which is characterized by two important clinical features: redness and thickening. Therefore, targeting microvasculature and collagen is pivotal in the prevention and treatment of hypertrophic scars Yuan et al. [7] Silicone gel has demonstrated positive effects on hypertrophic scars and keloids in many previous studies Wang et al. [8] The authors hypothesized that the positive effects of the silicone gel at the cellular level would translate to newly created surgical scars. Moreover, the positive effect of the silicone gel has been most frequently reported for the induction of good scar maturation among many adjunctive methods Song et al. [9] We also suppose that the mechanism of action of both the laser and the silicone gel is based on a non-traumatic gentle reduction of the vascularization of the keloid and hypertrophic scar. A novel 577-nm emits yellow light of comparable wavelengths. It was shown to effectively treat various vascular and pigmented skin conditions Mohamed et al. [10] Few studies are available in the literature that investigates the effectiveness of the pro-yellow laser for the therapy of vascular disorders Ataseven et al. [11] ; Mohamed et al. [10] ; Mohamed et al. [12] ; Sarac et al. [13] To the best of our knowledge there is no study has been assessed the efficacy of yellow laser in the treatment of hypertrophic scar. So, in this study we aimed to evaluate the efficacy of silicone gel alone versus silicone gel combined with 577-nm ND-Yag laser. Our result showed that the combination of silicone gel and yellow laser showed asignificant effectin making surgical scars less distinct as regards the total Vancouver score, also the side treated with yellow laser plus silicone gel revealed a significant difference in the vascularity after treatment when compared to the side treated with silicone gel alone. The neodymium-doped yttrium garnet lasers have been proposed for the treatment of pathologic scars and shown to effectively reduce the Vancouver Scar Scale (VSS) score, with a notably greater effect on hypertrophic scars Pan et al. [14] Another recent study investigating the use of a 1470-nm bare-fiber diode laser found an overall VSS score improvement of 42% for hypertrophic scars and 37.9% for keloids, with no reported adverse events or recurrence Li et al. [15] Recent evolutions in laser treatments point to more favorable outcomes and higher patient satisfaction for combination laser therapy over monotherapy for pathologic scars Frech et al. [16] In the study conducted by Cohen and Geronemus [17] comparing outcomes on 25 patients randomized to four treatment groups (PDL alone, CO 2 laser alone, a combined treatment of these two, and another combination with CO 2 ablative fractional resurfacing on the day of surgery) found that the best outcomes in scar appearance were seen for scars that underwent a combination treatment. In a study performed by Waibel et al. [18] comparing no laser treatment, CO2 laser treatment alone, and intense pulsed light (IPL) + CO2 laser, both treatment groups had statistically significant improvements in POSAS score and Manchester scar scale (MSS) score compared to the placebo, without significant difference between the treatment groups. The only significant difference between treatment groups was in favor of the combination therapy for scar color and texture, indicating that CO2 alone is sufficient, and IPL can be used for an additional benefit for these specific factors. In this study we found the scar in the lip and breast area showed a significant higher improvement rate when compared to the other site. This can be explained that the more skin tension is stimulus for the excessive production of collagen, citing sites of keloid predilection in areas of so-called tension on the chest, deltoid and back. Skin tensionwas believed to be the reason why keloids occurred in young people and was almost absent in the elderly Cassuto et al. [19] Conclusion The results of this study provide evidence that combination of silicone gel and yellow laser has significant effect in making surgical scars less distinct. Recommendation Further studies with larger sample size are needed to confirm the current finding. Longer follow-up period are recommended to provide additional information about the sequel of both studied techniques. Application ofyellow laser plus topical silicone gel or silicone gel alone is safe but the combination is more effective for post-surgical scars. Limitations The lack of long-term follow-up and smaller sample size is considered a limitation for this study. Further studies, incorporating a larger number of subjects and a longer follow-up period are recommended to provide additional information. Declarations Author Contribution Department of Dermatology, Andrology and Venerology, Faculty of Medicine, Al-Azhar University (Assiut) References Namazi, M.R., Fallahzadeh, M.K. & Schwartz, R.A. (2011) Strategies for prevention of scars: what can we learn from fetal skin? International Journal of Dermatology , 50(1), 85-93 Bakker, A., Maertens, K.J., Van Son, M.J. & Van Loey, N.E. (2013) Psychological consequences of pediatric burns from a child and family perspective: a review of the empirical literature . Clinical psychology review , 33(3), 361-371 Coentro, J.Q., Pugliese, E., Hanley, G., Raghunath, M. & Zeugolis, D.I. (2019) Current and upcoming therapies to modulate skin scarring and fibrosis. Advanced drug delivery reviews , 146, 37-59 De Decker, I., Hoeksema, H., Verbelen, J., Vanlerberghe, E., De Coninck, P., Speeckaert, M.M., Blondeel, P., Monstrey, S. & Claes, K.E. (2022) The use of fluid silicone gels in the prevention and treatment of hypertrophic scars: a systematic review and meta-analysis. Burns, 48(3), 491-509 De Las Alas, J.M.G., Siripunvarapon, A.H. & Dofitas, B.L. (2012) Pulsed dye laser for the treatment of keloid and hypertrophic scars: a systematic review. Expert review of medical devices , 9(6), 641-650 Safra, T., Shehadeh, W., Koren, A., Salameh, F., Friedman, O., Sprecher, E. & Artzi, O. (2019) Early intervention with pulse dye and CO 2 ablative fractional lasers to improve cutaneous scarring post-lumpectomy: a randomized controlled trial on the impact of intervention on final cosmesis. Lasers in Medical Science , 34, 1881-1887 Yuan, B., Upton, Z., Leavesley, D., Fan, C. & Wang, X.-Q. (2023) Vascular and collagen target: a rational approach to hypertrophic scar management. Advances in Wound Care , 12(1), 38-55 Wang, F., Li, X., Wang, X. & Jiang, X. (2020) Efficacy of topical silicone gel in scar management: A systematic review and meta-analysis of randomised controlled trials. Int Wound J , 17(3), 765-773 Song, T., Kim, K.H. & Lee, K.W. (2018) Randomised comparison of silicone gel and onion extract gel for post-surgical scars. Journal of Obstetrics and Gynaecology , 38(5), 702-707 Mohamed, E.M ., Tawfik, K.M., Elsayed, I.B., Bölke, E. & Gerber, P.A. (2021) 577-nm high-power optically pumped semiconductor laser is safe and effective in the treatment of inflammatory acne: a prospective, single-center, split-face comparative study. European Journal of Medical Research , 26(1), 103 Ataseven, A., Temiz, S.A. & Özer, İ. (2023) An Investigation of the Effectiveness of the 577-nm Pro-yellow Laser in Patients with Vascular Disorders. European Journal of Therapeutics , 29(1), 49-54 Mohamed, E.E.M., Mohamed Tawfik, K. & Hassan Ahmad, W. (2019) Successful treatment of facial vascular skin diseases with a 577 nm pro yellow laser. Journal of Cosmetic Dermatology , 18(6), 1675-1679 Sarac, G. & Kapicioglu, Y. (2019) Efficacy of 577‐nm Pro‐Yellow laser in port wine stain treatment . Dermatologic therapy , 32(6), e13078 Pan, L., Qin, H., Li, C., Zhang, G., Yang, L. & Zhang, L. (2022) Efficacy of the neodymium-doped yttrium aluminum garnet laser in the treatment of keloid and hypertrophic scars : a systematic review and meta-analysis. Aesthetic Plastic Surgery , 46(4), 1997-2005 Li, K., Nicoli, F., Cui, C., Xi, W.J., Al-Mousawi, A., Zhang, Z., Balzani , A., Neill, L., Sorge, R. & Tong, Y. (2020) Treatment of hypertrophic scars and keloids using an intralesional 1470 nm bare-fibre diode laser: a novel efficient minimally-invasive technique. Scientific Reports , 10(1), 1-11 Frech, F.S., Hernandez, L., Urbonas, R., Zaken, G.A., Dreyfuss, I. & Nouri, K. (2023) Hypertrophic Scars and Keloids: Advances in Treatment and Review of Established Therapies. American Journal of Clinical Dermatology , 1-21 Cohen, J.L. & Geronemus, R. (2016) Safety andEfficacy Evaluation of Pulsed Dye Laser Treatment, CO 2 Ablative Fractional Resurfacing, and Combined Treatment for Surgical Scar Clearance. Journal of drugs in dermatology: JDD , 15(11), 1315-1319 Waibel, J.S., Wulkan, A.J., Rudnick , A. & Daoud, A. (2019) Treatment of hypertrophic scars using laser-assisted corticosteroid versus laser-assisted 5-fluorouracil delivery. Dermatologic Surgery , 45(3), 423-430 Cassuto, D.A., Scrimali, L. & Siragò, P. (2010) Treatment of hypertrophic scars and keloids with an LBO laser (532 nm) and silicone gel sheeting. Journal of Cosmetic and Laser Therapy , 12(1), 32-37. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 21 Nov, 2024 Reviews received at journal 21 Nov, 2024 Reviews received at journal 18 Nov, 2024 Reviewers agreed at journal 18 Nov, 2024 Reviewers agreed at journal 14 Nov, 2024 Reviewers agreed at journal 22 Oct, 2024 Reviewers invited by journal 17 Oct, 2024 Editor assigned by journal 14 Oct, 2024 Submission checks completed at journal 14 Oct, 2024 First submitted to journal 09 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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The right side treated with silicone gel and 577 nm diode laser and the left side with silicone gel only\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-5233207/v1/a7eb73d285ea9a22c2b8dd4a.png"},{"id":71925015,"identity":"f2532de8-c6ec-4b63-84c8-fccb533403bb","added_by":"auto","created_at":"2024-12-19 18:31:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":693668,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure (4) - \u003c/strong\u003eFemale patient 42 years old presented with post cleft lip surgery scar for 1 month the left photo pre-treatment and the right one post treatment. 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The right side treated with silicone gel and 577 nm diode laser and the left side with silicone gel only\u003c/p\u003e","description":"","filename":"33.png","url":"https://assets-eu.researchsquare.com/files/rs-5233207/v1/c6e1d0f91de994d4337ea88d.png"},{"id":71925017,"identity":"5fabfeca-ba45-46fe-be12-c4bda0f26014","added_by":"auto","created_at":"2024-12-19 18:31:31","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":474696,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure (6) - \u003c/strong\u003eFemale patient 26 years presented with post benign breast mass removal surgury scar for 4 months the upper photo pre-treatment and the lower one post treatment. The right side treated with silicone gel and 577 nm diode laser and the left side with silicone gel only.\u003c/p\u003e","description":"","filename":"44.png","url":"https://assets-eu.researchsquare.com/files/rs-5233207/v1/e6e22629fd3545bdd4c10dfd.png"},{"id":71925941,"identity":"7da5bae8-440f-4f28-95ca-12d8113073c4","added_by":"auto","created_at":"2024-12-19 18:47:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4532433,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5233207/v1/6ec6a90c-8638-4091-b557-2e19d8305a1a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Silicone Gel versus Combination of Silicone Gel and a 577-nm Diode Laser in the Treatment of Post-surgery Hypertrophic scar (Comparative Study) ","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePost-operative scar forms as a result of a highly conserved cascade of events following surgery that seeks to restore skin integrity and is influenced by the wound environment. Mechanical forces including tension, depth and epidermal closure all influence scarring.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eExcessive scarring can have unpleasant physical, psychologicaland social consequences. Physicalsymptoms may include itching, stiffness, scar contractures,tenderness and pain. The psychosocial effects include diminished self-esteem, disruption of daily activities, anxiety anddepression.\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSeveral treatments are used to reverse scar formation and emulate normal wound healing and remodelling, including transdermal injections, biomaterial based approaches and non-pharmacological approaches.\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSilicone gels are universally considered as the gold standard in scar management and the only non-invasive preventive and therapeutic measure for which there is enough supporting data to make evidence-based recommendations. Silicone gel is applied in a thin layer to the skin where it dries to form a transparent, flexible, gas-permeable, water-impermeable silicone sheet. Silicone gel exerts several actions; scar more softer and flatter by reduction collagen production, protect scar tissue from bacterial invasion, restore balance between fibrogenesis and fibrolysis.\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eLaser therapy is an option which can be used to treat the surface texture of abnormal scars and may also be suitable for the treatment of residual redness, telangiectasias or hyperpigmentation. Laser therapy uses focused beams of light that can improve the appearance of scars. Diode laser targets chromophore haemoglobin, both destroy and inhibit the formation of small vessels within the scar as it interrupts the increased blood flow before it reaches the scar.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe aim of the present study is to compare the efficacy of silicone gel versus combination of a 577-nm diode laser and silicone gel in the treatment of post-surgery hypertrophic scar.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study is a randomized comparative study In the period from 14 January 2021 up to the end of January 2023. 30 patients with post-surgery hypertrophic scar within six months who admitted to the Laser unit of the Dermatology and Andrology Department at Al-Azhar University Hospital, Assiut during the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Committee of Local Institutional Ethics of Faculty of Medicine, Al-Azhar University. An informed consent was taken from the participants after illustrating the nature and duration of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria:\u0026nbsp;\u003c/strong\u003ePatients aged more than 18 years old, Both sex, Patients with post-surgery hypertrophic scar either immediate after suture removal up to 6 months after surgery. Co-operative patient who accept to participate in the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria:\u0026nbsp;\u003c/strong\u003ePatients with infections, rashes, or discharge producing wound, with underlying diseases such as diabetes mellitus, systemic lupus erythematosus, dermatomyositis, systemic sclerosis, and other autoimmune diseases, who on systemic or topical corticosteroids 1\u0026nbsp;month prior to the study, treated with immunosuppressive drugs, chemotherapy, radiation therapy, or diagnosed with cancer, who on anticoagulants medications and with allergy to silicone gel.\u003c/p\u003e\n\u003cp\u003eEligible patients were evaluated according to the following steps: Personal history, Past history of any associated disease involving the skin, Family history of keloid or other general diseases, General examination for general condition of the patients, Local examination and evaluation of scar.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment protocol:\u0026nbsp;\u003c/strong\u003eAll the scars divided into two halves and designated \u0026ldquo;A\u0026rdquo; and \u0026ldquo;B.\u0026rdquo; A: one half of scar was managed with 577 nm diode laser 3 sessions monthly combined with application of silicone gel at home. A + B: the entire scar was treated with silicone gel. During treatment, the patient and physician wear specific goggles to guard against the harmful effects of laser on eyes.The treatment was performed at 1-month intervals and carried out with a single pass of 577-nm pro-yellow laser (QuadroStar PRO YELLOW\u0026reg; Asclepion Laser Technologies) on half of the scar and the wavelength used was 577\u0026nbsp;nm. In post-surgical scars treated patients, fluence was started from 16\u0026nbsp;J/cm\u003csup\u003e2\u003c/sup\u003e and increased gradually to 18 J/cm\u003csup\u003e2\u003c/sup\u003e and pulse duration was 32 ms.Immediately after the session, panthenol was applied and if the scar on face, sunscreen with SPF more than 30 was applied. The number of sessions is varied between individuals from 3 up to 6 sessions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSilicone gel:\u0026nbsp;\u003c/strong\u003eThe patient was asked to apply Scaro gel two times daily and after shower for 3 months. The patient put the Scaro gel on whole post-surgical scar.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePost session advice:\u0026nbsp;\u003c/strong\u003eAfter the session of pro yellow laser, the patients were prescribed topical emollient (panthenol) for 5 \u0026ndash; 7 days. The patient who had post-surgical scar on face was advised avoiding sun exposure with regular use of sunscreen and emollient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eScar assessment:\u0026nbsp;\u003c/strong\u003ePhotographs of patients: we used mobile phone to photos the studied participants before the start of treatment, after each session and after the last session. The level of improvement of the scars was evaluated by using the modified Vancouver Scar Scale (VSS) at the baseline and after 3 to 6 months of the final session.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSafety assessments:\u0026nbsp;\u003c/strong\u003eAt each visit, all possible side effects and complications, such as erythema, pain, edema, and post-inflammatory hyperpigmentation was recorded\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis:\u0026nbsp;\u003c/strong\u003eStatistical analysis was performed using GraphPad Prism version 8.0.2 (GraphPad Software, La Jolla, CA). Descriptive statistics for quantitative data were expressed in tables as the mean \u0026plusmn; SD, while qualitative data were expressed as number and percentage. P-value was considered significant if \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age was 28.60 \u0026plusmn; 6.59 years ranging between 19 and 42 years. Out of these patients, 27 (90 %) patients were females, and only three patients were male. The duration of the scar ranged between one to four months with mean duration 2.57 \u0026plusmn; 1.18 months as shown in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 - Demographic data of the patients.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"462\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 462px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e28.60\u0026nbsp;\u0026plusmn; 6.59\u003c/p\u003e\n \u003cp\u003e19-42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 462px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e27 (90.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e3 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 462px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of the scar (Months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e2.57\u0026nbsp;\u0026plusmn; 1.18\u003c/p\u003e\n \u003cp\u003e1-4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 462px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSkin photo type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e19 (63.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e11 (36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 462px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSite\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eAbdomen\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e19 (63.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eBreast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e3 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eNeck\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e3 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eLip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e3 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eForearm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e2 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 462px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e22 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e8 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eWe found that, there was a statistically significant differences as regard the percentage difference of the side underwent the combination therapy versus silicone gel alone treated side with p-value = 0.039, as shown in \u003cstrong\u003eTable 2.\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"\"\u003e\u003cstrong\u003e\u003cspan dir=\"\"\u003eTable 2: The mean percentage difference \u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"\"\u003eof Vancouver scoreafter application of both techniques\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eMean percentage\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSilicone gel + Yellow laser\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSilicone gel alone\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eP- value\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eMean \u0026plusmn; SD\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e59.81 \u0026plusmn; 21.14\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp; 48.29 \u0026plusmn; 21.31\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp; 0.039*\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAccording to the quartile grading scale 6 (20%) of the silicone gel plus yellow laser side treated scar showed excellent improvement, whereas no scar underwent silicone gel alone achieved excellent improvment. On the other hand, 4 (13.3%) silicone treated side showed mild improvement less than 25%, however no scar underwent the combination therapy revealed this grading with significant p-value =0.018 as shown in \u003cstrong\u003etable 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"\"\u003e\u003cstrong\u003e\u003cspan dir=\"\"\u003eTable 3 - Quartile grading scale according to the percentage difference of Vancouver score of both techniques\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSilicone gel + Yellow laser\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSilicone gel alone\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eP- value\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eExcellent \u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026lt;\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e75%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e6 (20.0)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0 (0.0)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 0.018*\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003emarked (50-75%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e15 (50.0)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e16 (53.3)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003emoderate (25-49%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e9 (30.0)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e10 (33.3)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003emild \u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026gt;\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e 25%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0 (0.0)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e4 (13.3)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAs regard to the items of Vancouver score there were a significant difference in the pigmentation, vascularity, pliability, height and the total value of Vancouver score after application of silicone gel plus yellow laser as shown in table 4.\u003c/p\u003e\n\u003cp dir=\"\"\u003e\u003cstrong\u003e\u003cspan dir=\"\"\u003eTable \u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"\"\u003e4 - Comparison between Vancouver score items before and after\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eapplication of silicone gel plus yellow laser.\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"594\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 594px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSilicone gel\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;+ Yellow laser\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\u0026nbsp;\u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eBefore\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eAfter\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eP-value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003ePigmentation\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1.67\u0026plusmn; 0.80\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1.00 \u0026plusmn; 0.64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e\u0026lt;0.001*\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eVascularity\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1.37\u0026plusmn; 0.81\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.53\u0026plusmn; 0.51\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e\u0026lt;0.001*\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003ePliability\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e2.10\u0026plusmn;0.55\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.90 \u0026plusmn; 0.71\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e\u0026lt;0.001*\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eHeight\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1.37\u0026plusmn;0.49\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.37 \u0026plusmn; 0.49\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e\u0026lt;0.001*\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eVancouver score\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e6.80\u0026plusmn;1.06\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e2.80 \u0026plusmn; 1.60\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e\u0026lt;0.001*\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAlso, for the side of the scar treated with silicone gel alone there was a statistically significant difference of Vancouver score compared to the baseline score as shown in table 5.\u0026nbsp;\u003c/p\u003e\n\u003cp dir=\"\"\u003e\u003cstrong\u003e\u003cspan dir=\"\"\u003eTable 5 - Comparison between Vancouver score items before and after application of silicone gel alone.\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 600px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Silicone gel\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e alone \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eBefore\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eAfter\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eP-value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003ePigmentation\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1.67\u0026plusmn; 0.80\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1.20\u0026plusmn; 0.61\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e0.008*\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eVascularity\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1.17\u0026plusmn; 0.87\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.80\u0026plusmn; 0.41\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e0.019*\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003ePliability\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e2.10\u0026plusmn;0.55\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.90 \u0026plusmn; 0.84\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e\u0026lt;0.001*\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eHeight\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1.23\u0026plusmn;\u0026nbsp;\u003c/span\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e0.57\u0026plusmn; 0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e\u0026lt;0.001*\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eVancouver score\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e6.30\u0026plusmn;1.29\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e3.47\u0026plusmn;1.70\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e\u0026lt;0.001*\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe scar in the lip and breast area showed a significant higher improvement rate with yellow laser plus silicone gel when compared to the other site as shown in table 6.\u003c/p\u003e\n\u003cp dir=\"\"\u003e\u003cstrong\u003e\u003cspan dir=\"\"\u003eTable 6 - Relation between improvement and demographic data of patients.\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSilicone gel + Yellow laser\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003ep-value\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSilicone gel alone\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003ep-value\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMean \u0026plusmn; SD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMean \u0026plusmn; SD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 638px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSex\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eFemale\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e57.19 \u0026plusmn;20.68\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.040*\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e45.32 \u0026plusmn;20.37\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.019*\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eMale\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e83.33 \u0026plusmn;0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e75.00 \u0026plusmn;0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eResidence\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eUrban\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e66.78 \u0026plusmn;20.37\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.001*\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e55.29 \u0026plusmn;19.75\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.001*\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eRural\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e40.62 \u0026plusmn;5.79\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e29.02 \u0026plusmn;11.52\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 638px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSkin phototypes\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eIII\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e58.64 \u0026plusmn;17.94\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.699\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e51.50 \u0026plusmn;21.79\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.285\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eIV\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e61.82 \u0026plusmn;26.64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e42.73 \u0026plusmn;20.21\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSite\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eAbdomen\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e50.75 \u0026plusmn;16.17\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"5\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026lt;0.001*\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e41.62 \u0026plusmn;22.19\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.051\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eBreast\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e83.33 \u0026plusmn;0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e75.00 \u0026plusmn;0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eLip\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e100.00 \u0026plusmn;0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e66.67 \u0026plusmn;0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eNeck\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e60.00 \u0026plusmn;0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e46.67 \u0026plusmn;11.55\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eForearm\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e50.00 \u0026plusmn;0.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e46.43 \u0026plusmn;5.05\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCorrelation of Vancouver score with patients\u0026rsquo; age and duration of the scar revealed no statistically significant correlation on both sides as shown in table 7.\u003c/p\u003e\n\u003cp dir=\"\"\u003e\u003cstrong\u003e\u003cspan dir=\"\"\u003eTable 7 - Correlation of Vancouver scores with patients\u0026rsquo; age and duration of the scar.\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSilicone gel + Yellow laser\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003ep-value\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSilicone gel\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003ep-value\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eVancouver score\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eAge (years)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.16\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.409\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.24\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.198\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eDuration (months)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e-0.25\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.181\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e-0.28\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.138\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003ePost-surgical scarring with its physical sequelae (pain, itching, and unattractive appearance) and resultant psychological stress can dramatically impact a patient\u0026rsquo;s quality of life. These scars are a constant reminder of the patient\u0026rsquo;s past or present disease and the related surgery and can be associated with extensive functional and psychosocial morbidities.\u003csup\u003e[6]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThese endogenous factors were well controlled in this trial as this study was designated as a split-scar study, in which each scar was divided into two equal portions, and each half was assigned treatment with either silicone gel or silicone gel with yellow laser.\u003c/p\u003e\n\u003cp\u003eAs a result, microvasculature and collagen play crucial roles in hypertrophic scars formation, which is characterized by two important clinical features: redness and thickening. Therefore, targeting microvasculature and collagen is pivotal in the prevention and treatment of hypertrophic scars \u003cstrong\u003eYuan et al.\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e[7]\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSilicone gel has demonstrated positive effects on hypertrophic scars and keloids in many previous studies \u003cstrong\u003eWang et al.\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e[8]\u003c/sup\u003e\u003c/strong\u003e The authors hypothesized that the positive effects of the silicone gel at the cellular level would translate to newly created surgical scars. Moreover, the positive effect of the silicone gel has been most frequently reported for the induction of good scar maturation among many adjunctive methods \u003cstrong\u003eSong et al.\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e[9]\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe also suppose that the mechanism of action of both the laser and the silicone gel is based on a non-traumatic gentle reduction of the vascularization of the keloid and hypertrophic scar.\u003c/p\u003e\n\u003cp\u003eA novel 577-nm emits yellow light of comparable wavelengths. It was shown to effectively treat various vascular and pigmented skin conditions \u003cstrong\u003eMohamed et al.\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e[10]\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFew studies are available in the literature that investigates the effectiveness of the pro-yellow laser for the therapy of vascular disorders\u003cstrong\u003e Ataseven et al.\u003csup\u003e[11]\u003c/sup\u003e; Mohamed et al.\u003csup\u003e[10]\u003c/sup\u003e; Mohamed et al.\u003csup\u003e[12]\u003c/sup\u003e ; Sarac et al.\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e[13]\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo the best of our knowledge there is no study has been assessed the efficacy of yellow laser in the treatment of hypertrophic scar. So, in this study we aimed to evaluate the efficacy of silicone gel alone versus silicone gel combined with 577-nm ND-Yag laser. \u003c/p\u003e\n\u003cp\u003eOur result showed that the combination of silicone gel and yellow laser showed asignificant effectin making surgical scars less distinct as regards the total Vancouver score, also the side treated with yellow laser plus silicone gel revealed a significant difference in the vascularity after treatment when compared to the side treated with silicone gel alone.\u003c/p\u003e\n\u003cp\u003eThe neodymium-doped yttrium garnet lasers have been proposed for the treatment of pathologic scars and shown to effectively reduce the Vancouver Scar Scale (VSS) score, with a notably greater effect on hypertrophic scars \u003cstrong\u003ePan et al.\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e[14]\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnother recent study investigating the use of a 1470-nm bare-fiber diode laser found an overall VSS score improvement of 42% for hypertrophic scars and 37.9% for keloids, with no reported adverse events or recurrence \u003cstrong\u003eLi et al.\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e[15]\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRecent evolutions in laser treatments point to more favorable outcomes and higher patient satisfaction for combination laser therapy over monotherapy for pathologic scars \u003cstrong\u003eFrech et al.\u003csup\u003e[16]\u003c/sup\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the study conducted by \u003cstrong\u003eCohen and Geronemus\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e[17]\u003c/sup\u003e\u003c/strong\u003ecomparing outcomes on 25 patients randomized to four treatment groups (PDL alone, CO\u003csub\u003e2\u003c/sub\u003e laser alone, a combined treatment of these two, and another combination with CO\u003csub\u003e2\u003c/sub\u003e ablative fractional resurfacing on the day of surgery) found that the best outcomes in scar appearance were seen for scars that underwent a combination treatment.\u003c/p\u003e\n\u003cp\u003eIn a study performed by \u003cstrong\u003eWaibel et al.\u003csup\u003e[18]\u003c/sup\u003e \u003c/strong\u003ecomparing no laser treatment, CO2 laser treatment alone, and intense pulsed light (IPL) + CO2 laser, both treatment groups had statistically significant improvements in POSAS score and Manchester scar scale (MSS) score compared to the placebo, without significant difference between the treatment groups. The only significant difference between treatment groups was in favor of the combination therapy for scar color and texture, indicating that CO2 alone is sufficient, and IPL can be used for an additional benefit for these specific factors.\u003c/p\u003e\n\u003cp\u003eIn this study we found the scar in the lip and breast area showed a significant higher improvement rate when compared to the other site. \u003c/p\u003e\n\u003cp\u003eThis can be explained that the more skin tension is stimulus for the excessive production of collagen, citing sites of keloid predilection in areas of so-called tension on the chest, deltoid and back. Skin tensionwas believed to be the reason why keloids occurred in young people and was almost absent in the elderly \u003cstrong\u003eCassuto et al. \u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e[19]\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of this study provide evidence that combination of silicone gel and yellow laser has significant effect in making surgical scars less distinct.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFurther studies with larger sample size are needed to confirm the current finding. Longer follow-up period are recommended to provide additional information about the sequel of both studied techniques. Application ofyellow laser plus topical silicone gel or silicone gel alone is safe but the combination is more effective for post-surgical scars. \u003c/p\u003e"},{"header":"Limitations ","content":"\u003cp\u003eThe lack of long-term follow-up and smaller sample size is considered a limitation for this study. Further studies, incorporating a larger number of subjects and a longer follow-up period are recommended to provide additional information. \u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDepartment of Dermatology, Andrology and Venerology, Faculty of Medicine, Al-Azhar University (Assiut)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eNamazi, M.R., Fallahzadeh, M.K. \u0026amp; Schwartz, R.A. (2011)\u003c/strong\u003e Strategies for prevention of scars: what can we learn from fetal skin? \u003cem\u003eInternational Journal of Dermatology\u003c/em\u003e, 50(1), 85-93\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBakker, A., Maertens, K.J., Van Son, M.J. \u0026amp; Van Loey, N.E. (2013)\u003c/strong\u003e Psychological consequences of pediatric burns from a child and family perspective: a review of the empirical literature\u003cspan dir=\"RTL\"\u003e.\u0026nbsp;\u003c/span\u003e\u003cem\u003eClinical psychology review\u003c/em\u003e, 33(3), 361-371\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCoentro, J.Q., Pugliese, E., Hanley, G., Raghunath, M. \u0026amp; Zeugolis, D.I. (2019)\u003c/strong\u003e Current and upcoming therapies to modulate skin scarring and fibrosis. \u003cem\u003eAdvanced drug delivery reviews\u003c/em\u003e, 146, 37-59\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDe Decker, I., Hoeksema, H., Verbelen, J., Vanlerberghe, E., De Coninck, P., Speeckaert, M.M., Blondeel, P., Monstrey, S. \u0026amp; Claes, K.E. (2022)\u003c/strong\u003e The use of fluid silicone gels in the prevention and treatment of hypertrophic scars: a systematic review and meta-analysis. Burns, 48(3), 491-509\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDe Las Alas, J.M.G., Siripunvarapon, A.H. \u0026amp; Dofitas, B.L. (2012)\u003c/strong\u003e Pulsed dye laser for the treatment of keloid and hypertrophic scars: a systematic review. \u003cem\u003eExpert review of medical devices\u003c/em\u003e, 9(6), 641-650\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSafra, T., Shehadeh, W., Koren, A., Salameh, F., Friedman, O., Sprecher, E. \u0026amp; Artzi, O. (2019)\u003c/strong\u003e Early intervention with pulse dye and CO 2 ablative fractional lasers to improve cutaneous scarring post-lumpectomy: a randomized controlled trial on the impact of intervention on final cosmesis. \u003cem\u003eLasers in Medical Science\u003c/em\u003e, 34, 1881-1887\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eYuan, B., Upton, Z., Leavesley, D., Fan, C. \u0026amp; Wang, X.-Q. (2023)\u0026nbsp;\u003c/strong\u003eVascular and collagen target: a rational approach to hypertrophic scar management. \u003cem\u003eAdvances in Wound Care\u003c/em\u003e, 12(1), 38-55\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eWang, F., Li, X., Wang, X. \u0026amp; Jiang, X. (2020)\u003c/strong\u003e Efficacy of topical silicone gel in scar management: A systematic review and meta-analysis of randomised controlled trials. \u003cem\u003eInt Wound J\u003c/em\u003e, 17(3), 765-773\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSong, T., Kim, K.H. \u0026amp; Lee, K.W. (2018)\u003c/strong\u003e Randomised comparison of silicone gel and onion extract gel for post-surgical scars. \u003cem\u003eJournal of Obstetrics and Gynaecology\u003c/em\u003e, 38(5), 702-707\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMohamed, E.M\u003cspan dir=\"RTL\"\u003e.,\u0026nbsp;\u003c/span\u003eTawfik, K.M., Elsayed, I.B., B\u0026ouml;lke, E. \u0026amp; Gerber, P.A. (2021)\u003c/strong\u003e 577-nm high-power optically pumped semiconductor laser is safe and effective in the treatment of inflammatory acne: a prospective, single-center, split-face comparative study. \u003cem\u003eEuropean Journal of Medical Research\u003c/em\u003e, 26(1), 103\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAtaseven, A., Temiz, S.A. \u0026amp; \u0026Ouml;zer, İ. (2023)\u003c/strong\u003e An Investigation of the Effectiveness of the 577-nm Pro-yellow Laser in Patients with Vascular Disorders. \u003cem\u003eEuropean Journal of Therapeutics\u003c/em\u003e, 29(1), 49-54\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMohamed, E.E.M., Mohamed Tawfik, K. \u0026amp; Hassan Ahmad, W. (2019)\u003c/strong\u003e Successful treatment of facial vascular skin diseases with a 577 nm pro yellow laser. \u003cem\u003eJournal of Cosmetic Dermatology\u003c/em\u003e, 18(6), 1675-1679\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSarac, G. \u0026amp; Kapicioglu, Y. (2019)\u003c/strong\u003e Efficacy of 577‐nm Pro‐Yellow laser in port wine stain treatment\u003cspan dir=\"RTL\"\u003e.\u0026nbsp;\u003c/span\u003e\u003cem\u003eDermatologic therapy\u003c/em\u003e, 32(6), e13078\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePan, L., Qin, H., Li, C., Zhang, G., Yang, L. \u0026amp; Zhang, L. (2022)\u003c/strong\u003e Efficacy of the neodymium-doped yttrium aluminum garnet laser in the treatment of keloid and hypertrophic scars\u003cspan dir=\"RTL\"\u003e:\u0026nbsp;\u003c/span\u003ea systematic review and meta-analysis. \u003cem\u003eAesthetic Plastic Surgery\u003c/em\u003e, 46(4), 1997-2005\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLi, K., Nicoli, F., Cui, C., Xi, W.J., Al-Mousawi, A., Zhang, Z., Balzani\u003cspan dir=\"RTL\"\u003e,\u0026nbsp;\u003c/span\u003eA., Neill, L., Sorge, R. \u0026amp; Tong, Y. (2020)\u003c/strong\u003e Treatment of hypertrophic scars and keloids using an intralesional 1470 nm bare-fibre diode laser: a novel efficient minimally-invasive technique. \u003cem\u003eScientific Reports\u003c/em\u003e, 10(1), 1-11\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFrech, F.S., Hernandez, L., Urbonas, R., Zaken, G.A., Dreyfuss, I. \u0026amp; Nouri, K. (2023)\u003c/strong\u003e Hypertrophic Scars and Keloids: Advances in Treatment and Review of Established Therapies. \u003cem\u003eAmerican Journal of Clinical Dermatology\u003c/em\u003e, 1-21\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCohen, J.L. \u0026amp; Geronemus, R. (2016)\u0026nbsp;\u003c/strong\u003eSafety andEfficacy Evaluation of Pulsed Dye Laser Treatment, CO 2 Ablative Fractional Resurfacing, and Combined Treatment for Surgical Scar Clearance. \u003cem\u003eJournal of drugs in dermatology: JDD\u003c/em\u003e, 15(11), 1315-1319\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eWaibel, J.S., Wulkan, A.J., Rudnick\u003cspan dir=\"RTL\"\u003e,\u0026nbsp;\u003c/span\u003eA. \u0026amp; Daoud, A. (2019)\u003c/strong\u003e Treatment of hypertrophic scars using laser-assisted corticosteroid versus laser-assisted 5-fluorouracil delivery. \u003cem\u003eDermatologic Surgery\u003c/em\u003e, 45(3), 423-430\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCassuto, D.A., Scrimali, L. \u0026amp; Sirag\u0026ograve;, P. (2010)\u003c/strong\u003e Treatment of hypertrophic scars and keloids with an LBO laser (532 nm) and silicone gel sheeting. \u003cem\u003eJournal of Cosmetic and Laser Therapy\u003c/em\u003e, 12(1), 32-37.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Silicon Gel, Yellow Laser, Scar, Surgical Scar, 577nm Diode Laser","lastPublishedDoi":"10.21203/rs.3.rs-5233207/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5233207/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eHypertrophic scars, resulting from alterations in the normal processes of cutaneous wound healing, are characterized by proliferation of dermal tissue with excessive deposition of fibroblast-derived extracellular matrix proteins, especially collagen, over long periods, and by persistent inflammation and fibrosis. The present study aim to compare the efficacy of silicone gel versus combination of a 577-nm diode laser and silicone gel in the treatment of post-surgery hypertrophic scar.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis study is a randomized comparative study In the period from 14 January 2021 up to the end of January 2023. 30 patients with post-surgery hypertrophic scar divided into two groups: A: one half of scar was managed with 577 nm diode laser 3 sessions monthly combined with application of silicone gel at home. A + B: the entire scar was treated with silicone gel within six months who admitted to the Laser unit of the Dermatology and Andrology Department at Al-Azhar University Hospital, Assiut during the study period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003esignificant improvement in pigmentation, pliability, height and total Vancouver score. By comparing between silicone gel and combination of silicone gel and a 577 nm diode laser, the combination shows significant improving than silicone gel alone. The scar in the lip and breast area showed a significant higher improvement rate with yellow laser plus silicone gel compared to the other site.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003ecombination of silicone gel and yellow laser has significant effect in making surgical scars less distinct\u003c/p\u003e","manuscriptTitle":"Silicone Gel versus Combination of Silicone Gel and a 577-nm Diode Laser in the Treatment of Post-surgery Hypertrophic scar (Comparative Study) ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-19 18:31:26","doi":"10.21203/rs.3.rs-5233207/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-21T18:50:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-21T06:46:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-18T14:17:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52749758484432506707217091016914688248","date":"2024-11-18T12:43:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225857002090122904401792297013545171080","date":"2024-11-15T00:22:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89390267630366231798612142127605239370","date":"2024-10-22T12:58:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-17T05:43:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-14T07:51:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-14T07:48:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Dermatological Research","date":"2024-10-09T13:52:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6846ef33-e0fb-4cc4-a97a-59b79905fc02","owner":[],"postedDate":"December 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-12-20T22:08:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-19 18:31:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5233207","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5233207","identity":"rs-5233207","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}