1. Introduction

Scars of human body frequently determine aesthetic impairment and may cause itching, tenderness, pain, anxiety, depression and disruption of daily activities. Further to that psychological sequelae can lead to diminished quality of life. Scar contractures also can cause physical deformities. All these problems can become a real burden, particularly when the scar cannot be hidden by clothes. Considering the Oro-facial region, the effect of scars can greatly affect the aesthetics and functions in such a manner ^[1].

Oral cancer is a growing problem in many parts of the world. Oral and pharyngeal cancer are the sixth most common cancer in the world. ^[2] Oral cancers can be treated surgically, with irradiation, with chemotherapy, or with a combination of these. However in most cases, the primary treatment for oral cancers is the surgical excision of the lesion. Important anatomical structures of the face and oral cavity can be removed during tumour surgery, and this may be accompanied by severe problems related to mastication, swallowing and speech. Scar formation in the Oro-facial region can also be associated with the surgical management. When the tumour is presenting in the lip, the scar formation can be greatly affect the aesthetics ^[3].

Silicone gel contains long chain silicone polymer (polysiloxanes), silicone dioxide and volatile component. Those long chain polymers cross link with silicone dioxide and spread as an ultra-thin sheet. It has a self-drying technology and it dries within 4-5 minutes. It has been reported to be effective and produce 86% reduction in texture, 84% in colour and 68% in height of the scars. ^[4] Further Silicone gel reduces itching and discomfort associated with scars. The advantages of silicone gel include easy administration, even for sensitive skin and in children. It can be applied for any irregular scar surfaces, the face, joints and flexures or any size of scar ^[5].

Silicone gel exerts several actions which are beneficial in scars. It increases hydration of stratum corneum and thereby facilitates regulation of fibroblast production and reduction in collagen production. It results softer and flatter scar. It protects the scar tissue from bacterial invasion and prevents bacteria-induced excessive collagen production. ^[6] Further it could modulates the expression of growth factors such as transforming growth factor β (TGF β) (Figure and Fibroblast growth factor β (FGF β). TGF β stimulates fibroblasts to synthesize collagen and fibronectin. FGF β normalizes the collagen synthesis in an abnormal scar and increases the level of collagenases which breaks down the excess collagen. Proper balance of fibrillogenesis and fibrinolysis is ultimately restored. ^{[4, 5, 7]}

2. Case Report

A 62 years old male German citizen (living in Sri Lanka) with a histopathologically confirmed Squamous cell carcinoma (by incisional biopsy) in right side of the lower lip (more towards lateral aspect) presenting as an exophytic mass (Figure 1) was presented to Dental Hospital (Teaching) in June 2016. According to the TNM Classification, the condition was categorized as T4a (Lip), N0, MX (TNM Stage 4a). The treatment plan was the complete excision of the lesion with primary closure ^[8].

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Figure 1. Pre-operative view of the lesion

The patient had uncontrolled hypertension and Chronic Obstructive Pulmonary Disease. The anaesthesia team was not happy to do the case under the general anaesthesia. Therefore it was planned under local anaesthesia with sedation. Wide local excision of the lesion was done under LA. First tumour induration beyond the exophytic mass was marked. Then another 0.5cm safe margin was marked. Without compromising the safe margin “W” type of resection outline was drawn after that. The lesion was excised in W fashion from skin to mucosa including orbicularis oris muscle. The specimen was sent for frozen sections and reconstruction was delayed until the frozen section excisional biopsy report arrival. The biopsy report confirmed the initial diagnosis of squamous cell carcinoma and complete excision of the tumour with clear margins. A three layered closure of the defect was done. During reconstruction higher attention was given to repairing the orbicularis oris muscle ring by dissecting two ends of the muscle and suturing with 4/0 Proline. The skin, muscle and mucosa repaired separately giving special care to the Vermillion and Wet Dry junction.

Following reconstruction, the patient was reviewed after one week from the discharge for the purpose of observing wound healing and suture removal (Figure 2). The commercially available topical silicone gel elastomers (Dermatix®) was applied continuously for two weeks in order to reduce the scar formation. The procedure for gel application was as follows. The sutures were removed and the area was cleaned with normal saline. The area was massage gently. A very thin layer of Dermatix® was applied along with the scar tissues and left to dry for- minutes. The patient was advised to continue the procedure in the morning and evening for each day until two weeks. The patient was reviewed after 2 weeks and the scars were completely healed thus giving a normal contour of the tissue (Figure 3).

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Figure 2. After removing sutures (Post-operative view after one week form the surgery)

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Figure 3. Complete reduction of scar tissue (After two weeks of silicone gel application)

3. Discussion

Since the early 1990s, silicone gel sheeting has been widely used in the treatment of hypertrophic scars and keloids. Several studies have confirmed its efficacy. ^{[7, 9, 10]} Even though many treatments have been used in the management of scars, only a few have been supported by prospective studies with adequate control group. ^[11] Only two treatment methods have sufficient evidence for scar management; topical application of silicone gel sheeting and the intra- lesional injection of corticosteroids. The former is generally indicated as both preventive and therapeutic application. The latter is mainly as a therapeutic agent only ^[12].

Topical silicone gel sheeting is bit heavier and difficult to carry on the scar. Therefore the patient compliance often is low especially for lesions in visible areas. Tapes or bandaging is also not accepted. ^[12] It may also lead to skin irritation and discontinuation of treatment, especially in hot climates such as Sri Lanka. Gel sheeting is effective for scar control, but patient compliance of this method is not always satisfactory. Steroid injections are painful and may lead to skin atrophy and dyschromies. ^[12] They are usually contraindicated for large scars and for paediatric use. Use of topical silicone gel application can overcome some of these limitations. Self-drying silicone gel is more comfortable because it is effective and no fixation is required. Further, it is invisible when dry facilitating for application of sun blocks, makeup or any combinations.

Dermatix® is a Food and Drug Administration (FDA)-registered substantial equivalent to silicone gel sheeting for the prevention and management of hypertrophicscars and keloids. The effectiveness of Dermatix for reducing scar formation has been investigated with two prospective clinical studies. The results of those were suggestive of Silicone topical elastomer gel (Dermatix®) can offer an effective addition to the armamentarium of the physicians treating healing surgical wounds, traumatic wounds and as well as hypertrophic scars and keloids. ^{[13, 14]} As it was available in the Sri Lankan market this patient was also treated with Dermatix®. However, there were no conflict of interest with the manufacture or distributors with the authors.

Results from clinical trials and reviews have strongly suggested that use of silicone gel as an effective preventative and reduction therapy for excessive scarring. ^[12] However, a recent article by O’Brien et al. 2013 indicated that still there is a weak clinical evidence for the benefits of silicone gel in the prevention of abnormal scarring in high-risk individuals. ^[11] Although the exact mechanism of action is still not clearly understood, it is hypotheses that through occlusion of the scar site and hydration of the wound bed, the over activity of scar-related cells is suppressed, and their activity normalized.

Even though steroid injections offer significant positive impact on scarring, they remain a supporting treatment, due to the clinical impracticality and associated expense. Other existing treatments such as topical creams/gels and dressings containing active additives such as onion extract, vitamins C and E, and moisturizing agents are often seen to deliver little to no extra benefit than silicone gel itself. ^{[5, 6, 12]}.

However, use of silicone gel or other scar reducing application in the management of oral cancer patients are not so frequent. Reducing scar formation in the surgical site does not only depend on the supplementary treatments. The fine surgical margins with fine closure of the defects plays a massive role in this. In this patient, we have achieved a successful reduction of scar with the use of Dermatix® as an adjunctive. According to the clinical studies, the time taken to achieve best results with Dermatix® was 6 -12 weeks. ^{[13, 14]} However, in our case the patient responded well for the application and scar became invisible within a short period of time such as 2 weeks of its use.

4. Conclusion

Scar formation in the oro-facial region can also be associated with the surgical management of Oral Cancers. Care has to be taken to minimize the scar formation as it could affect aesthetic and functional outcome of an individual’s quality of life. It is quite true that surgical skill and technique play a pivotal role in aesthetic surgery. In our opinion it is very much worthwhile using the silicone gel, post operatively as it can deliver better outcome for the patient. Further studies including randomized controlled clinical trials are recommended in order to provide definitive scientific evidence.

Conflict of Interest

None to declare.

References

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