Aesthetic and Functional Efficacy of Subcuticular Running Epidermal Closures of the Trunk and Extremity: A Rater-Blinded Randomized Control Trial
Alam M, Posten W, Martini MC, Wrone DA, Rademaker AW
Arch Dermatol. 2006;142:1272-1278
Summary
In this rater-blinded controlled trial, Alam and colleagues studied the scar outcome in patients with trunk and/or extremity lesions undergoing elliptical excision followed by 4 randomly assigned types of epidermal closure. Closure types were:
simple running polypropylene sutures (Prolene; Ethicon Inc., Somerville, New Jersey) removed after 14 days (control arm);
subcuticular running polypropylene sutures removed after 14 days;
subcuticular running polypropylene sutures left in place; and
subcuticular running polyglactin 910 (Vicryl; Ethicon Inc.) sutures left in place.
Outcome measures included scar-width measurement and blinded observer assessment of overall scar appearance at 3 and 9 months postoperatively. Secondary outcome measures included standardized scar ratings (Vancouver Scar Scale and the Hollander Scar Scale) and assessment of pruritus.
Three dermatologic surgeons operated on a total of 36 adult patients (age range, 18-65 years), and each patient was randomized to receive 2 elliptical excisions. All patients received methodologically standardized elliptical excisions with uniform deep dermal and subcutaneous closures. Surgical repairs differed only in the type of epidermal closure used, as outlined above.
Scar width did not differ significantly between different epidermal closure techniques. Nevertheless, subcuticular closure with running polyglactin 910 sutures left in place yielded the best overall scar appearance (blinded observer assessment, Vancouver and Hollander Scar Scale scores), followed by subcuticular closure with running polypropylene left in place. These differences lessened somewhat from 3 to 9 months. Of note, scar erythema and vascularity were more prominent in excisions closed by simple running polypropylene sutures (removed at 2 weeks) and least evident in excisions closed by subcuticular running polyglactin 910 sutures left in place. In order to control for variable skin tension at different sites, investigators matched high-tension anatomic sites such as the back and lower leg.
Viewpoint
This controlled clinical trial provides compelling evidence that subcuticular closures left in place can improve the cosmetic appearance of scars during the immediate postoperative period (follow-up of up to 9 months). The investigators did not report increased complication rates with this technique such as wound infection, "spitting sutures," and suture granuloma formation. Nevertheless, such theoretical concerns should be fully considered before advocating the standard use of subcuticular epidermal closures left in place for the repair of high-tension skin sites (eg, back and extremities).