PONE-D-24-50779Non-surgical treatments for post-burn scars: a network meta-analysisPLOS ONE

Dear Dr. Li,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 18 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Steven E. Wolf, MD

Academic Editor

PLOS ONE

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For every excluded study, the table should list the reason(s) for exclusion. 

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Well done on your hard work in producing this paper.

The paper includes impressive statical analysis and offers new evidence that would add towards burn scar care. However, I feel this paper is written poorly and needs thorough revisions to improve its overall message and strength its evidence.

The paper feels informal in nature, and I would advise the authors to remove ‘we’ in the context of the authors decision throughout the paper. Please note not to start sentences with a number. Furthermore, I feel the authors writing style could be more concise to allow for more characters to defend and boarded their discussion points.

Please note: ‘hyperplastic scar’ is the umbrella terminology for keloid, hypertrophic and cheloid scars. When the authors refer to keloid and hyperplastic scars in the text they should discuss as just hyperplastic scarring or keloid and hypertrophic scars.

Finally, despite referencing Table 1 (characteristics) and 3 – no tables have been attached to the submission. These would have to be reviewed before final acceptance. I would also hope a table offering a brief overview of each paper would add to the understanding of the paper.

Please find some more specific points of guidance per section:

Abstract

Background and aim: ‘This study aims to compare the outcomes of non-surgical treatmentS for post-burn scars using network meta-analysis.’ This will correlate to your title.

Introduction

I feel the first paragraph should be re-written to deliver a more gripping and comprehensive overview of burn scar care.

More explanation concerning the benefits of non-surgical technique should be explored to highlight the importance of what your evidence will influence in burn care.

Many sweeping statements are made addressing the reliability and validity of VSS and VAS. These tools are widely debated as to their reliability and validity and this is the main reason centres now choose the POSAS score to objectively measure scar care. The authors need to add more evidence to support their conclusion concerning VSS and VAS.

Again, a statement has been made concerning previous studies have ‘some limitations’ with no supporting discussion. If the authors want to improve from previous literature, they must first comment and address previous literature limitations thoroughly.

Overall, I feel the introductions is still in draft form and should be strengthen to provide a clearer picture of current burn scar care.

Method

Please could the authors reflect on why they did not include ‘keloid’ and ‘hypertrophic’ within their key word search despite this being the topic of the paper. It may be sensible to re-run a search and ensure no texts have been missed.

Did the author attempt to contact the papers’ authors if full text was unavailable? If no, why not? If yes, please state in the manuscript.

Please clarify why the authors choose to extract data at the 6-month point. What statistical guidance in burn care pointed to this being the optimum treatment efficacy?

Correct the references for software and Cochrane Manual to be included in the reference list.

Please state how the authors disputed differing opinions for RoB analysis.

Results

I felt the results were written extremely well, offering concise and clear information for a somewhat confusing presentation.

I would note the authors have not commented on treatment practical techniques, patient demographics or side effects. The authors chose to mention scar location, days post-burn until enrolment but did not expand on the significance of mentioning this data.

I would expect two tables in the results section offering patient characteristics and brief overview of the papers.

Discussion

Again, I feel the discussion could be re-written to produce a more concise manuscript with more in-depth explanation. All discussion points only scratch the surface of the debates, therefore limiting the impact of the study findings.

For example, the authors only commented on one element of the VSS (scar pliability) and related this to scar massage. For the overall results of VSS to improve, scar massage must also influence scar vascularity, pigmentation and height. These characteristics must also be justified by the authors.

Again, I do not feel the authors have portrayed their understanding of the topic well when writing ‘positive effects on pain receptor physiology, leading to scar remodelling, tissue repair and pain relief’. Pain receptor physiology has no implication on scar remodelling and tissue repair ONLY pain relief. Please clarify.

Please note that any burn can result in scarring irrespective of depth.

Finally, I would remove point of allocation concealment from the limitation paragraph as this cannot be achieved with these treatment methods.

Figures

Flowchart:

Please state the other sources either in the manuscript or on the flowchart.

The authors will need to upload again in a high resolution for printing.

Add figure labels to figures document.

Please consider this revisions carefully, with improvement the paper could add to burn scar care.

Reviewer #2: Manuscript PONE-D-24-50779

Title: Non-surgical treatments for post-burn scars: a network meta-analysis

Thank you to the authors for this review of an important topic.

The review has significant issues to be resolved before it can be considered publishable. There are fundamental questions for the authors to consider in relation to possible bias introduced in searches and missing key research as well as challenges to interpretation of results, due to choices in the study design:

1. Frequentist approach - It seems that the nodes of the network model are identified using a frequency of text mentions within the included study reports? How do the authors justify this method as a way to provide valid comparison between intervention methods that do not have direct comparison to a standardized intervention such as SMC? Following on, was AI used to complete the assimilation of searches? If so, how so?

2. The lack of searching of PEDRO physiotherapy evidence database. Not all scar management and research are conducted by occupational therapists. Please apply all updated searches to this online repository.

3. The omission of POSAS as a valid and contemporary objective scar outcome. The use of VSS only is controversial as the literature is conflicting in supporting the scale as a valid and reliable measure of scar outcome.

4. The omission of the more contemporary ‘modified VSS’ as a scar outcome. Was this used in addition to VSS?

5. The choice to include only one timepoint for scar outcomes is challengeable. Treatments may be applied to influence the rate of scar maturation across time eg PT or MT and the change in trajectory of scar maturation (and symptoms) may not be reflected using a snapshot timepoint of outcome at 6 months post-burn.

6. Lastly, the authors need to explain and justify why they accept (ablative) CO2 laser and microneedling therapies as non-surgical treatments please. Both are invasive and may be applied under general anesthetic. Thus, these techniques have a different risk / benefit profile compared to other non-surgical treatments which may not be considered a valid and reasonable comparison particularly with the objective outcome measure compared only at 6 months post-burn.

In addition to addressing these major queries, please adjust the manuscript and, or respond to the specific comments below.

Abstract:

1. Please update after revision of the manuscript.

Introduction:

2. Requires major adjustment to justify the chosen inclusions, methods of rating treatments against each other and outcomes. (Ack: some responses may be better added to Methods.)

Methods:

3. Please define and explain how a network meta-analysis is conducted. For the naïve reader, please provide a clear explanation of how to interpret the results presented. For instance, how is the ‘inconsistency test’ result to be interpreted?

4. Why was online repository PEDRO not searched? It is allied health specific and there must be justification as to why it was not included please.

5. Why was POSAS not included as an acceptable (primary) scar outcome? This requires consideration and justification as to why it is not included, please.

6. Section 2.3, Eligibility Criteria – please adjust the outcomes statement to remove reference to RCT which is not an outcome – it is a design feature which has already been screened for if the inclusion criteria have been applied appropriately.

7. Section 2.3, please explain why conference abstracts were excluded if they described a RCT.

8. Section 2.5, was data only included in the meta-analysis if VSS was available at 6 months after injury? Please be clear in earlier methods statements as to the primary outcome.

9. Were any Artificial Intelligence techniques applied in any parts of the Methods? If so, please describe clearly.

Results

10. Section 3.3, microneedling is mentioned for the first time in the manuscript in this section. As with CO2 ablative laser treatment, microneedling needs to be explained and justified as a non-surgical treatment prior to this mention in Results.

11. It is unclear how the authors justify the weighting of various treatments and their effect size to determine a relative ranking of efficacy. The direct and indirect comparison methods needs far better explanation so that the reader can be assured which intervention is best.

Discussion

12. Please start with the main result that the authors wish to highlight, not a repeat of Introduction statements.

13. Please adjust after revising Intro, Methods and Results.

Conclusions

14. The authors have not qualified the conclusions in relation to the single timepoint of VSS. Please clarify the interpretation of the results in respect to the scar maturation timeline.

Figures

15. Figure 3a – How are readers to interpret the results associated with interventions eg microneedling and PDL, that are not networked (compared) to a standardised intervention such as SMC?

16. Figure 3b – How is the reader to interpret these graphs?

17. Figure 3c – the legend is uninterpretable and does not relate to the included studies or NMA plot. Please clarify.

18. Similar queries for Figures 4 and 5.

Tables – there is a table referred to in text but not provided or in Supplementary Material?

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Reviewer #1: No

Reviewer #2: Yes:  Dale Wesley Edgar

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PONE-D-24-50779R1Non-surgical treatments for post-burn scars: a network meta-analysisPLOS ONE

Dear Dr. Li,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 19 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Steven E. Wolf, MD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: Manuscript PONE-D-24-50779R1

Title: Non-surgical treatments for post-burn scars: a network meta-analysis

Thank you to the authors for their amiable and comprehensive approach to the review comments. The explanations of the NMA methods and inconsistency assessment are enlightening and provide significant clarification. Many of the review issues have been resolved and, or explained and this reviewer believes the report has moved much closer to a publishable standard.

There remain several major questions to be addressed:

1. POSAS – the authors’ arguments about POSAS exclusion are weak. They demonstrate that the authors do not appreciate the subjectivity and ambiguity of the scoring of the VSS. The limitations of the VSS were the very premise of and impetus to develop the POSAS as an alternative scar outcome measure. To further exclude POSAS on the basis of redundancy with VAS, also suggests a lack of understanding of the foibles of groupwise ‘quantitative’ pain measures. That said, if the authors are unable to extend the scope of this study (and NMA) then please add text to affirm the direction that future reviews of this type and, or studies should be going.

2. How do the authors reconcile that by excluding the studies using the more contemporary POSAS outcome measure also more than likely excludes the more contemporary scar treatments? The authors confirm that <15% of potentially eligible studies reported POSAS results which is an indication of the point made above, and there is a likely bias introduced to the NMA by excluding more recent studies as per the review methodology.

3. Lastly, after the comments made by multiple reviewers, why were sensitivity analyses not conducted in this revision? In particular, why were studies with possible or confirmed application of (ablative) CO2 laser and microneedling therapies under general anaesthetic, not removed from the NMA corpus to confirm the effect size of these techniques in a way that is much more comparable to other non-surgical techniques with a far lower risk and complication profile? The invasive techniques and general anaesthetic have much more pronounced risk compared to other non-surgical treatments and this issue of relative benefit must be explored so that readers can make an informed decision as to the interpretation of results for their practice.

In addition to addressing these major queries, please adjust the manuscript and, or respond to the specific comments below.

Abstract:

1. Much improved. Why is SMC only mentioned in presentation of some results eg associated with ECSWT? Isn’t SMC implied in most studies as the control condition for all treatments included regardless of whether there is a stated comparison with routine care? Please drop it and be consistent with terminology in Abstract as well as the remainder of the manuscript. Consider that SMT differs between studies and is not necessarily the same for each study where that condition is stated. Perhaps ‘routine local treatment’ or similar is a better generic terminology?

Introduction:

2. Much improved. Thank you.

Methods:

3. Please confirm that CO2LT only refers to the ablative procedure, and does not include pooled results from the non-ablative intervention (which is referred to in Discussion).

4. Please add a short summary of the response points to justify conference abstract exclusion in Section 2.3.

Results

5. Well done. Section 3.3.1, sentence 3 - ….therefore the consistency model was used for the NMA….’ Please change ‘was used’ to ‘was applicable’ or similar.

6. Section 3.2 and Discussion (Strengths and Limitations) still refers to Table 1, 3.31 refers to Table 2, Section 3.3.2 refers to Table 3, Section 3.3.3 refers to Table 4 – all of which have not been included in the revised submission. Please remove reference to all tables from the text if they are not going to be part of the manuscript.

Discussion

7. With respect to Limitations - Please consider and comment on whether the choice of timeframe for the primary study outcome impacts the comparison of effect size. For instance, how many burn services apply ablative CO2LT prior to 6 months post-burn? Does the study (review) method therefore bias or impact the volume of studies that support the effect size of various interventions?

8. Consider specifically identifying the gaps in the research literature, framed by the Global Top 10 Research Priorities (Richards et al, Lancet Global Health, 2025) and directions for future research based on the review findings.

Conclusions

9. Remove the reference to SMT as it is confusing.

Figures

10. Remove SMC from ALL figures please, except where it is itself the defined group or comparison.

11. How is the reader supposed to interpret Figures 3B, 4B, 5B. Footnotes or explanations in captions are required to help the reader.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: Yes:  Dr Sabrina Poppy Barnes

Reviewer #2: Yes:  Dale W. Edgar

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

PONE-D-24-50779R2Non-surgical treatments for post-burn scars: a network meta-analysisPLOS ONE

Dear Dr. Li,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

ACADEMIC EDITOR:  Additional issues should be carefully clarified.

==============================

Please submit your revised manuscript by Aug 28 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Vincenzo Lionetti, M.D., PhD

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Manuscript PONE-D-24-50779R2

Title: Non-surgical treatments for post-burn scars: a network meta-analysis

Thank you again to the authors for their amiable responses to the latest review and the substantial improvements which have been made to the manuscript.

In relation to the comments and latest text, please adjust the following:

a) Please adjust this added sentence to Limitations to include ‘contemporary’: In addition, one limitation of this NMA is the exclusion of studies reporting only POSAS outcomes, which may have led to the omission of more recent, CONTEMPORARY interventions that adopt this more comprehensive and patient-centered assessment tool.

b) Unfortunately, the additional tables provided are unformatted and uninterpretable. It is fair that the authors are avoiding a sensitivity analysis which removes combined results from (ablative) CO2 laser and microneedling under general anaesthetic studies due to statistical power. However, in reply (2)(clinical heterogeneity), the authors contradict themselves and confirm the fundamental differences between the CO2 laser and needling sub-set of techniques in comparison with all others, basically justifying the request for a sensitivity analysis. However, so as not to create an impasse, if the authors choose not to include a sensitivity analysis (perhaps only removing CO2 laser studies), please instead add a statement in Discussion or Limitations which reiterates to the reader the reasons for applying the definition of non-surgical techniques in this review.

In addition, please tweak the manuscript as per the specific comments below:

Methods:

1. Data Extraction, page 8 – Please change adjective to ‘closest’ if this is an accurate description to: For outcomes reported at multiple time points, only data CLOSEST to 6 months were extracted.

Figures

2. Please note, the previous comment was not a request to remove SMC from the figures, it was a reference to remove the title which was confusing. In that, SMC has now been changed to RT appropriately, thank you.

3. Please adjust the last sentence of the footnotes added in the last version: A higher curve indicates a greater likelihood of being ranked higher. This explanation is confusing and needs additional clarification and tweak of expression which removes duplication of the word ‘higher’.

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Reviewer #2: Yes:  Dale W Edgar

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PONE-D-24-50779R3Non-surgical treatments for post-burn scars: a network meta-analysisPLOS ONE

Dear Dr. Li,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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ACADEMIC EDITOR: The text should be revised in order to avoid typos.

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Please submit your revised manuscript by Sep 08 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Vincenzo Lionetti, M.D., PhD

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Manuscript PONE-D-24-50779R3

Title: Non-surgical treatments for post-burn scars: a network meta-analysis

Thank you again to the authors for their respectful and considered responses to the last review. I think your methods demonstrate a potential option for all future reviews to be made more interpretable and place greater weight on less popular (less cited) works.

Apologies, I have noticed two text errors which will need to be addressed in the Abstract please:

1. Define (or remove) the acronym SUCRA.

2. To rebalance the word count – remove sentence about risk of bias, it is not necessary.

Other than that, this reviewer believes that this version is of publishable standard. Well done!

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #2: Yes:  Dale W Edgar

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Non-surgical treatments for post-burn scars: a network meta-analysis

PONE-D-24-50779R4

Dear Dr. Li,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support .

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Vincenzo Lionetti, M.D., PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Thank you to the authors, all comments addressed. This reviewer happy to accept and believes that the manuscript is ready for publication if the editor agrees.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #2: Yes:  Dale W Edgar

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