Effectiveness of different non-surgical scar reduction methods in post-operative scars: a systematic review and meta-analysis

Introduction

Surgical scars are a common and often unavoidable consequence of operative interventions. While typically benign, they may be associated with pain, pruritus, restricted mobility, and significant psychosocial distress, particularly when located on visible or functionally sensitive areas such as the face, hands, or perineum. These effects can substantially impact a patient’s quality of life, affecting both physical function and psychological well-being (1).

Abnormal scarring, including hypertrophic scars and keloids, arises from dysregulated wound healing. Although the formation of scar tissue is a natural reparative process, it often results in compromised tensile strength, disrupted skin architecture, and poor aesthetic outcomes (2). Given this, numerous interventions have been developed to minimize scarring and promote optimal healing. These include silicone gel sheets, pulsed dye laser (PDL), fractional CO₂ laser therapy, and botulinum toxin A (BTX-A), each aiming to improve scar pliability, reduce pigmentation and thickness, and alleviate associated symptoms.

Scar formation is a natural and inevitable physiological response during the healing process of wounds and traumas. Scars represent a form of aberrant tissue that lacks the structure, physiological function, and vitality of normal skin. Beyond their impact on aesthetic appearance, scars can impair the function of adjacent tissues or organs and may lead to deformities. Patients with scars, particularly those resulting from burns or severe trauma, often experience significant physical discomfort and psychological distress. The severity of scarring is influenced by factors such as the nature and characteristics of the scar, as well as any subsequent interventions affecting deeper tissues. Scars serve as an imperfect substitute for the original healthy skin: mechanically, they exhibit reduced strength; nutritionally, they compromise oxygen and nutrient exchange; functionally, they can cause deformity and dysfunction; and aesthetically, they disrupt the skin’s appearance. Consequently, effective scar management is crucial for improving cosmetic outcomes, restoring physiological function, and enhancing both physical and mental well-being (1).

Scarring not only affects cosmetic appearance, causing pain and discomfort, but also the impairment of skin function and significant impacts on patients’ psychological wellbeing (2), especially for patients that have scars located on visible or intimate areas of their body such as the face, hands and perineum. According to the biopsychosocial model of medicine (3), it is crucial for plastic surgeons to consider patients’ psychological states together with physical scar repair through surgical or alternative methods. Scar management encompasses a prolonged process aimed at both physical and psychological recovery. Evaluating patients’ psychological status is essential for facilitating a more holistic and comprehensive journey. To achieve objective assessments, it is recommended to establish a systematic evaluation of patients’ somatic function, sleep quality and chronic symptoms such as itchiness and pain during consultations. Rehabilitation for patients with scars should include professional healthcare as well as mutual support from peers with similar experiences. Additionally, with the rise of cosmetic dermatology, integrating healthcare, laser treatments and traditional physical and chemical therapies, addresses not only scar repair but also its complications such as hyperpigmentation and keloids. This multidisciplinary approach will then meet the aesthetic needs of patients with scars and play a significant role in their overall physical and psychological health.

Despite the widespread use of these modalities, there is a lack of consensus regarding their relative efficacy. Past reviews have largely focused on burn scars or addressed individual therapies in isolation (4,5). Few have quantitatively compared multiple treatment strategies for post-surgical scarring adults using standardised outcome measures to discuss the effectiveness of each respective scar reduction techniques and compared them.

This systematic review and meta-analysis aims to address this gap by evaluating the comparative effectiveness of four used scar reduction techniques—PDL, silicone gel, fractional CO₂ laser, and BTX-A—in adult patients with surgical scars (6). The primary outcomes assessed include scar pigmentation, surface area, thickness, and pliability, which are key contributors to functional and aesthetic recovery. By synthesizing current evidence, this review seeks to inform clinical practice and guide future scar management strategies. We present this article in accordance with the PRISMA reporting checklist (available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-25-59/rc).

Methods

Search strategy and study selection

The systematic search was performed in the three months from July 2024 to October 2024 on the databases PubMed (Medline), Springer Link, National University of Singapore (NUS) Library and ResearchGate (Figure S1, Tables S1,S2). Each of them was last reviewed on 30^th October 2024, 29^th October 2024 and 27^th September 2024 respectively. It was conducted using a specific combination of selected general keywords (scar reduction, scar reduction techniques, wound repair, post-surgical scars, scar formation) (Table 1). The search reached saturation when combining various keywords and adding new terms yielded no additional unique articles beyond those already selected. Applying the systematic search strategy, 84 potential articles on the five effects studied, namely the effects of PDL, silicone gel sheets, fractional CO₂ laser and BTX-A were found. The reference lists of all included studies and related systematic reviews were manually reviewed to identify any additional relevant publications.

Only full-text articles published in English and peer-reviewed journals were included. The study selection was limited to articles that clearly explored the patient’s progress with non-surgical scar reduction techniques. Thus, we restricted the search to longitudinal studies. Details of each search strategy for the respective databases are available in Appendix A.

The set inclusion criteria composed of: (I) randomised controlled trials, non-controlled trials, self-controlled trials, cohort studies, cross sectional studies, case control studies, case series and thematic analyses; (II) English full-text availability; (III) human participants; (IV) any kind of scar tissue management; (V) post-surgical patients; (VI) control intervention or no treatment; (VII) outcome consisting of subjective and/or objective scar tissue evaluations.

For the set exclusion criteria, it consisted of: (I) no English full text availability; (II) non-human subjects; (III) non-scar tissue management; (IV) pre-surgical patients; (V) no control intervention; (VI) outcomes that do not assess subjective or objective scar tissue outcomes; (VII) duplicate publications; (VIII) burn scars.

All articles were screened by the same independent researchers in two stages. Titles and abstracts were screened to assess their potential relevance for full review, then relevant full texts of potentially relevant articles were retrieved and screened. Any discrepancies were resolved through discussion between the two independent researchers. The reference lists of all relevant studies were also screened to ensure no study had been missed. The study selection process was documented using a PRISMA flow diagram (Figure 1). In instances where publications by the same researchers reported overlapping data or sources, duplicates were carefully identified and excluded to avoid redundancy in the review.

Figure 1 PRISMA flowchart of selection of studies for systematic review and meta-analysis.

Data extraction

Relevant data were manually extracted from the included studies by one reviewer. Collected information included year of publication, total number of patients, and the number of patients in the control group and those who received the scar reduction intervention under study. Results were organized according to the outcome variables and assessment tools used. All extracted data were subsequently verified by a second reviewer to ensure accuracy and consistency.

Critical appraisal

To assess the studies identified by the search, a system proposed by Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence was used. The quality of the studies was evaluated using the PRISMA statement. The level of evidence was assessed as level 1–5 using the guide derived by OCEBM Levels of Evidence. Risk of bias was assessed using the Cochrane risk-of-bias assessment tool (7), and was done at a study and outcome level.

Statistical analysis

A quantitative synthesis of the results was performed using available outcome data and effect sizes were plotted using forest plots. The effect measures for each outcome can be found in Tables 2-5. However, due to limited data availability and reporting heterogeneity across studies, a formal meta-analysis model (fixed or random effects), heterogeneity measures (I²/τ²), sensitivity or influence analyses and publication bias assessment could not be reliably conducted.

For studies with paired split-scar designs, effect sizes were extracted as reported without adjustment for within-subject correlation as these details were not consistently available. We did not formally assess the risk of bias for each syntheses as each intervention included less than 10 studies (five studies for each outcome). Tests for funnel plot asymmetry are unreliable with small number of studies, and results could be misleading. Therefore, the risk of bias due to missing results could not be formally determined.

Results

Summary

A total of 20 studies met the inclusion criteria for this review. These studies were published between 1995 to 2024.

General characteristics

Characteristics of the included studies are shown in Tables 6,7. Seven studies were conducted in China including 2 conducted in Taiwan, five studies in the USA, four studies in South Korea, and one study each in Egypt, Turkey, Iran and Germany. Most of the papers were prospective randomised controlled trials with the exception of six prospective split-scar trials and one prospective cohort study. The study characteristics of each paper can be found in Appendix A.

Level of evidence

Two studies were rated as providing level 4 evidence (8,9), one study with level 2b evidence (10) and the rest of the papers level 1b evidence.

Risk of bias assessment

The results of risk-of-bias assessment for the included studies are summarised in Table 8.

Summary of characteristics and risk of bias in contributing studies

Silicone gel studies consisted of randomised controlled trials (RCTs) with sample sizes ranging between 40–120 participants. Their follow-up periods were varied between 3 to 12 months. Risk of bias was low to moderate.

PDL consisted of small RCTs with fewer than 80 participants. Risk of bias was moderate due to limited reporting of adverse effects of the treatment.

Fractional CO₂ consisted of RCTs and cohort studies, with its sample sizes being fewer than 30 participants for each study. Risk of bias was moderate due to unclear blinding of outcome assessment.

BTX-A consisted of RCTs with its sample sizes being less than 60 participants. Its risk of bias was moderate due to some studies having selective reporting.

Forest plots

Figure 2 comprises of forest plots that were created with the help of ChatGPT, GPT-5 to show the benefit across studies, if confidence intervals do not cross zero, there is statistically significant improvement in scar reduction and appearance.

Figure 2 Pooled forest plots comparing the effectiveness of four non-surgical scar management modalities (PDL, silicone gel, fractional CO₂ laser, and BTX-A) versus control in improving postoperative scar outcomes. (A) Forest plot of the meta-analysis showing the overall weighted effect size of PDL versus control on scar improvement. (B) Forest plot of the meta-analysis showing the overall weighted effect size of silicone gel versus control on scar severity. All studies favored silicone gel over no treatment. (C) Forest plot of the meta-analysis showing the overall weighted effect size of fractional CO₂ laser therapy compared to control in improving surgical scars. (D) Forest plot of the meta-analysis illustrating the overall weighted effect size of BTX-A versus control in scar appearance outcomes. BTX-A, botulinum toxin A; CO₂, carbon dioxide; PDL, pulsed dye laser.

Each plot of Figure 2 shows:

• Effect sizes (Hedges’ g) for each study.
• 95% confidence intervals.
• A red dashed line at 0 =no effect.

All five studies (11-15) assessed the impact of PDL on scar appearance using measures such as the Vancouver Scar Scale (VSS), with some incorporating Visual Analogue Scales (VAS) and objective photographic evaluations. The reported effect sizes ranged from −0.20 to −1.54 as seen in Figure 2A, with three of the five studies demonstrating statistically significant improvements. The largest effect was observed in the study by Nouri et al. [2003] (11), which evaluated early intervention with PDL immediately after suture removal. While one study (16) reported a smaller, non-significant difference compared to fractional CO₂ laser, the overall trend favored PDL over control.

All five studies (17-21) evaluated the effects of silicone gel on postoperative scars using validated outcome measures, primarily the VSS and VAS. The studies consistently demonstrated improvement in scar severity compared to control groups, with effect sizes ranging from −0.35 to −0.50 as seen in Figure 2B. Notably, none of the 95% confidence intervals crossed zero, indicating statistically significant benefits across all studies.

Five studies (9,10,22-24) investigated the effectiveness of fractional CO₂ laser therapy for improving postoperative scar outcomes. Effect sizes ranged from −0.25 to −0.70, with all studies demonstrating confidence intervals that did not cross zero as seen in Figure 2C, indicating statistically significant improvements in scar characteristics such as pigmentation, texture, and pliability. The studies consistently favored CO₂ laser over control interventions, regardless of anatomical site or surgical context.

The five studies (8,24-27) evaluating BTX-A demonstrated consistent efficacy in reducing scar severity and improving cosmetic outcomes. Effect sizes ranged from −0.42 to −0.75, with all confidence intervals indicating statistical significance as seen in Figure 2D. The strongest effects were reported in studies targeting high-tension surgical sites, such as the face and cleft lip repairs. The meta-analysis by Zhang et al. [2020] (24) contributed the highest weight at 23%, due to its pooled data from multiple RCTs.

Discussion

This meta-analysis demonstrates that all four non-invasive interventions—PDL, silicone gel, fractional CO₂ laser, and BTX-A—are associated with measurable improvements in scar appearance, as evidenced by negative effect sizes and narrow confidence intervals in the majority of included studies.

PDL

The PDL group had greater variability in their study outcomes (Figure 2A), likely due to differences in wavelength, timing of application, and target scar type (Keloid vs. Hypertrophic). Notably, studies (11,15) highlighted that very early intervention—immediately post-suture removal or within days of post-operation—yields optimal cosmetic outcomes, likely due to early modulation of angiogenesis and inflammatory cascades. By contrast, delayed initiation (12,13) showed less consistent benefit, particularly in keloid-prone individuals where fibroblast hyperactivity dominates pathology (28). Furthermore, skin type and ethnicity are critical: darker phototypes (Fitzpatrick IV-VI) absorb laser energy less efficiently and are more prone to dyspigmentation (29). Thus, patient selection and intervention timing are key determinants of efficacy.

Timing when scar treatment is initiated plays a crucial role. For example, PDL therapy shows variable outcomes depending on when it is applied. Initiating treatment immediately in the post-suture phase often results in greater reductions in scar thickness, vascularity and overall scar appearance. Whereas delayed applications after scar maturation may produce less significant results (13). Early intervention having a higher efficacy can likely be attributed to heightened cellular activity during the initial phase of wound healing—fibroblast proliferation and collagen deposition, thus, modulating scar formation more effectively.

Silicone gel

Silicone gel showed consistent low-to-moderate effectiveness which supports its role as a first-line topical therapy. This aligns with previous systematic reviews showing benefit in hydration, stratum corneum barrier restoration and modulation of collagen production (16,30,31). While individual trials (17-19) varied in formulation and application protocols, the overall outcome of the effect was largely uniform. Some studies also suggested that efficacy becomes more apparent only after 6 months (31) which may explain why short-term follow up RCTs often report insignificant differences across placebo or corticosteroid groups (20). Silicone gel remains a cost-effective, safe and accessible option for all patients, though longer treatment windows are crucial to realise its full clinical benefit.

Furthermore, accessibility and cost considerations may influence treatment choices, especially in resource-limited settings, underscoring the need for tailored, evidence-based decision-making for patients. Current silicone gel sheets are designed to be worn up to 24 hours, washed and reused. However, this approach can be inconvenient and can even increase the risk of skin infections. Single-use silicone gel sheets on the contrary are more hygienic and convenient while remaining cost effective. Therefore, they provide patients with the access to products that can be used safely at home (30).

Fractional CO₂ laser

Fractional CO₂ laser appears effective regardless of anatomical location or surgical origin. Fractional CO₂ laser was associated with robust and consistent improvements in scar pliability, texture and overall cosmesis across several high-quality RCTs (10,21,32) seen in Figure 2C. Its mechanism of action is fractional photothermolysis (22) which promotes neocollagenesis and dermal remodeling—explaining its relatively durable outcomes recorded at 6-12 months compared to other modalities. Studies employing split-scar designs (9,33) demonstrated clear differences within the patient which further supports its efficacy. However, fractional CO₂ laser requires technical expertise and carries the risk of transient erythema and hyperpigmentation as side effects, especially in patients with skin of colour (34). Despite these considerations, its reproducible effect profile suggests a pivotal role for reduction in post-operative scars refractory to topical therapy.

Ethnicity, skin type and scar subtypes are key factors influencing scar treatment outcomes. Individuals with Fitzpatrick skin types IV-VI exhibit altered responses to laser therapies. This is due to melanin which acts as a competing chromophore absorbing laser energy and reducing treatment efficacy. It can also increase the risk of complications such as hyper or hypopigmentation (29). Moreover, people of colour are more prone to hypertrophic scars and keloids, likely due to genetic predispositions involving hyperactive fibroblasts (28,35), which can affect scar pathophysiology and response to such therapies. These differences highlight the importance of tailoring treatment protocols to the patient’s skin type and genetic background.

BTX-A

Meanwhile, BTX-A showed moderate-to-strong efficacy seen in Figure 2D, particularly in high-tension areas like the face and chest (22,32). BTX-A reduces mechanical stress at wound edges and modulates fibroblast activity, making it an attractive adjunct to surgical closure. In a recent paper by Zhang et al. 2020 (20), showed significant improvement in scar width and pigmentation, supporting the previous claim. Overall, the outcome of the treatment depends largely on the dosage administered (27) as well as the time of intervention (8) which demonstrated that immediate post-closure injection had the most consistent benefit. However, its only limitation is its high cost and limited accessibility—restricting widespread use in routine scar prevention. Additionally, the efficacy of the treatment is highly dependent on timing of administration, dosage and injection technique, making it operator-dependent and potentially vary between patients (27). Some patients may also experience local side effects such as pain, bruising or transient muscle weakness temporarily. Despite these limitations, the cumulative evidence from multiple studies indicates that BTX-A is effective in reducing scar width and improving cosmesis. Thus, while cost and operator-dependent constraints exist, its ultimate clinical benefits make it a valuable adjunct in select cases where optimal scar outcomes are desired.

While therapeutic efficacy is influenced by biological and procedural factors, the interpretation of each outcome is equally dependent on scar assessment tools used to quantitatively and qualitatively measure the improvements. The differences between each scar assessment tool affects significantly the homogeneity in the reported treatment effects. The Patient and Observer Scar Assessment Scale (POSAS) includes patient-reported symptoms such as pain and itchiness in addition to observer evaluations of scar physical characteristics. These provide a more holistic and widely validated measurement compared to the VSS, which focuses on vascularity, pigmentation, pliability, and height (36). The VAS, while simple and helpful in measuring subjective parameters, is less comprehensive as well. The choice of assessment tool therefore affects sensitivity to clinical changes and patient-centered outcomes, influencing effect size estimates and comparability across studies (12,19,22,25).

Scar maturation and remodeling extend over several months, thus, follow-up duration critically impacts the assessment of treatment efficacy. For instance, ablative fractional laser-treated scars showed significant pliability improvements at one month but only trends toward overall scar improvement at six months, emphasizing the need for adequate follow-up to capture its true clinical effect (21). Additionally, topical silicone gel’s efficacy appears to manifest significantly only after six months postoperatively, suggesting that shorter follow-up periods may underestimate its effectiveness (31).

Differences in intervention specifics—such as laser wavelength, BTX-A dosing, or silicone formulation—also affect outcomes. Certain treatments are also preferred based on scar type and severity. For example, minor keloids often respond well to combined silicone gel and intralesional corticosteroids, while major keloids may require more aggressive approaches such as corticosteroids with cryotherapy (37).

Given the multifactorial nature of scar treatment response, early multimodal therapy combining physical (e.g., silicone gel), pharmacologic (e.g., corticosteroids, BTX-A), and procedural (e.g., laser) approaches may yield better outcomes. This is done by holistically targeting different aspects of scar pathophysiology all at once. The current literature supports such combined regimens, especially for challenging scars like keloids (38).

Conclusions

Summary

Overall, there is a wide variety of non-surgical scar management options for post-surgical scars with each showing measurable improvements in scar appearance especially in reduction and pigmentation. The adoption of the same consistent scar assessment tools to evaluate the outcome utilised as well as the incorporation of patient-centred measures such as quality of life and psychosocial impact is therefore recommended in future publications to provide a more holistic outcome of the treatments as well as fair comparison. Despite the variability in study designs and intervention methods, current literature reflects promising potential in scar reduction through diverse approaches and combinations. Future research should explore the effects of integrating scar management with surgical technique and wound care methods.

In conclusion, future research should prioritize standardized outcome measures like POSAS and carefully planned follow-up schedules to enable consistent comparisons and improve clinical guidance. Additionally, stratifying patients by ethnicity, skin type, and scar characteristics can tailor treatment algorithms and optimize efficacy while minimizing adverse effects.

Strengths and limitations

Strengths of this analysis include the inclusion of recent RCTs and estimation of study weights based on confidence intervals. However, variability in scar assessment tools (VSS, POSAS, VAS), patient populations, and follow-up durations introduce some heterogeneity. Especially patient compliance with regards to their consistency in application of silicone gels or following up in the clinic on a regular basis and at regular intervals. Additionally, several studies lacked full reporting of standard deviations, requiring estimation in some cases.

Furthermore, while forest plots were used to summarise key effect sizes, key meta-analytic methods such as model declaration, heterogeneity testing and publication bias assessment were not performed due to insufficient data. Therefore, the results should be interpreted as a descriptive quantitative synthesis rather than a full meta-analysis.

Future research

The paucity of current literature still remains, especially in the standardisation of scar assessment tools, as heterogeneity in VSS, POSAS, and VAS can complicate direct comparison and data pooling. Long-term follow-up periods to assess the durability of treatment effects should be considered to help determine the efficacy of the treatments not only in early healing but beyond it. Furthermore, cost-effectiveness analyses of each treatment would be also vital to determine clinical applicability and sustainability in routine surgical aftercare. Lastly, future trials should stratify data by scar type (hypertrophic, keloids) and anatomical locations (flexural, extensor regions) as these factors can significantly influence treatment response.

Acknowledgments

The authors thank Dr. Clement Chia, Senior Consultant at Khoo Teck Puat Hospital for his guidance with the curation of our research paper. During the preparation of this work the authors used ChatGPT, GPT-5 to edit language and the creation of Forest Plots. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-25-59/rc

Peer Review File: Available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-25-59/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-25-59/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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