Post-Burn and Surgical Scar Reconstruction with Tissue Expanders: Review of the Literature and Our Local Experience

Round 1

Reviewer 1 Report

Thank you to the authors for presenting this study report. The authors should consider what it is about the tissue expansion method that is unique or contemporary. Secondly, the use of different surveys before and after surgery limits the effective comparison of the results and therefore conclusions that can be reached about the benefit of the technique and the satisfaction of patients with the surgery, complications encountered and outcomes. The manuscript requires significant rework to be publishable.

Comments for author File: Comments.pdf

Minor issues of expression.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

The authors  focused on the significance of Tissue expansion (TE) as an important armamentarium and valid solution for the treatment of large and old post-burn scars, with good cosmetic and functional outcomes.

Moderate editing of English language required

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Thank you to the authors for improving their study report. The manuscript requires further adjustment to be publishable. In particular, the authors must please consider their broad statements of good outcomes and no complications in the face of the actual results. Further, the authors should consider how their results should be interpreted to direct future practice and clinician behaviours. Despite the assertions of the authors, this study is not all supportive of the use of tissue expanders in the context of the consumer voice and improvements can obviously be made to enhance the patient journey and the post-op outcomes. The authors must please reflect on the results with empathy for the patient opinion and alter their report accordingly. Please address individual comments in PDF attached.

Comments for author File: Comments.pdf

Some issues with duplicate words and expression to address please.

Author Response

Thank you for your comments. We have carefully reviewed the comments and have revised the manuscript accordingly. ‏ Our responses are given in a point-by-point manner below. Changes to the manuscript are shown in

1. Duplicate words have been removed from the highlighted text. Thank you for the detailed attention. 
2. Regarding the exact range, in our study ambulation with lower limb expanders was done between six months to one year. This has been adjusted in the article accordingly. 
3. Thank you for your valuable feedback on the results. Based on these findings, our primary focus for patient education is to enhance their understanding of skin expanders and the two-stage nature of the procedure. It is crucial for patients to be well-informed about each step of the surgery and the expected outcomes. We aim to reassure patients that the ultimate result of skin reconstruction using expanded tissue flaps can be more satisfactory compared to the initial scar.This was added to discussion and reconciled. 
4. Additionally, we appreciate the reviewer's insightful comment regarding the terminology used to describe the scars. Respondents in our study referred to the pre-operative scar as the "post-burn scar," which typically represents a wide scar. Conversely, the post-operative scar was described as the resultant scar after reconstruction with pre-expanded tissue flaps. We have incorporated this suggestion into the article accordingly. These revisions will help provide clarity and accuracy in communicating the information about the scars and their transformation throughout the surgical process.
5. Regarding your remark for Table 1; All scars treated excised in full or completely where patients referring to the scars that have been remaining after tissue expansion surgery. Of course, we will add this in our discussion as a point of limitation in our study.
6. Thank you for bringing up this important point. We appreciate your suggestion, and we have incorporated it into our discussion section. Patient satisfaction is a crucial aspect of our study, and we have assessed it through the patients' responses to our survey. Additionally, we have compared the pre- and post-operative statuses to evaluate the overall patient experience. Furthermore, the objective evaluation of the surgeon regarding the wound itself and the low complication rate associated with this surgical procedure also contribute to the high level of satisfaction observed. Both functional outcomes and cosmetic results have been assessed, further highlighting the positive outcomes of the surgery. We have made these additions to enhance the clarity and comprehensiveness of our discussion. By including these points, we aim to provide a more thorough understanding of the overall patient experience, as well as the objective measures of success in terms of both function and aesthetics. Thank you once again for your valuable input, which has helped us improve the quality of our manuscript.
7. Another limitation of the study was included; the inclusion of different parts in the study and we propose for other researchers in the future is to use such comparative studies with same design but specifically for upper limb, lower limb, trunk, or the breast. This may add extra knowledge that may add to the exciting literature for more information in the future. The summary and conclusion were adjusted accordingly.

We hope the revised version is now suitable for publication and look forward to hearing from you in due course.

Sincerely 

Reviewer 2 Report

The authors have answered correctly to my questions

Minor editing of English language required

Author Response

Thank you.

Round 3

Reviewer 1 Report

Thank you to the authors for their amiable response and efforts to improve the manuscript. This reviewer believes the manuscript requires minor adjustments to be publishable pending Editor's review.

Comments for author File: Comments.pdf

Minor adjustments and typo's to fix please.

Author Response

Dear Reviewer,

We would like to express our gratitude for your insightful comments and suggestions on our manuscript. Your feedback has been invaluable in improving the quality and clarity of our work, and we appreciate the time and effort you have dedicated to reviewing our study.

In response to your comments, we have carefully reviewed and addressed each of the concerns raised. We have made significant revisions to the manuscript to address the specific points you highlighted, aiming to enhance the overall coherence and impact of the study. We have highlighted the revised text in the manuscript In yellow highlight. We would like to outline the key amendments made in our response below:

1. Thank you for the important comment in section 2.4 about mobilization after surgery: Ranges of mobilization are as followed: Patient were able to fully mobilize after one to two months of insertion of the tissue expanders, similarly to full mobilization after removal of tissue expander and reconstruction of the old scar. The expectant restoration of full and normal mobilization after the whole process of insertion and removal, along with the period of filling was between 6 months to one year in patients of this study. This was also adjusted and made clear in the manuscript.
2. Thank you for your alertness about the formatting error in table 2. This was adjusted.
3. Regarding your feedback in the discussion section about complications of the statement about low complication in tissue expansion: the exposure of tissue expanders (TE) in 13% of patients is considered a low complication rate compared to other reconstructive surgeries. This can be attributed to the preservation of healthy tissue in most cases, even after the removal of the expanders. Both functional outcomes and cosmetic results have been assessed, further highlighting the positive outcomes of the surgery. We elaborated further on this point in the given section.
4. The typo “Out” was adjusted to “our” in the discussion, as well as your feedback regarding “the correct technique” was revised to “the best practice technique”. Thank you for these points of feedback. In addition, the word “Rather” was indeed removed, considering it not being a scientific term.
5. Finally, regarding your point about other lower burden techniques which should be considered and the standard of care regarding TE, we adjusted it to clarify it more, as we believe that using biological tissue expanders can be strongly considered as standard of care for scars with nearby healthy skin, where expansion can provide big amount of viable tissue that can replace the scar completely. This was adjusted accordingly.

Author Response File: Author Response.docx