Aesthetic and functional efficacy of subcuticular running epidermal closures of the trunk and extremity - A rater-blinded randomized control trial

Objective: To ascertain whether subcuticular epidermal closures of elliptical excisions of the trunk and extremities result in better functional and cosmetic outcomes than simple running epidermal closures of the same sites. Design: Randomized controlled trial, with allocation of epidermal closure of elliptical excisions to 4 arms, including 1 control arm ( simple running polypropylene sutures removed after 14 days) and 3 experimental arms ( subcuticular running polypropylene sutures removed after 14 days, subcuticular running polypropylene sutures left in place, and subcuticular running polyglactin 910 sutures left in place). All experimental interventions were preceded by deep dermal closure with simple interrupted polyglactin 910 sutures. Interventions were delivered by 3 surgeons, who underwent 2 training sessions to minimize intersurgeon technique variability. Setting: Institutional referral practice providing ambulatory care in an urban environment. Patients: A consecutive sample of 36 adult patients ( ages 18- 65 years), each referred for concurrent elliptical excision of at least 2 clinically atypical nevi of the trunk and/ or extremity, were included in the study. Main Outcome Measures: Primary outcome measures obtained at 3 and 9 months included scar width in millimeters and blinded observer ordinal scale assessment of overall scar appearance. Secondary outcome measures included ratings on the standardized Vancouver Scar Scale and the Hollander Scar Scale; an additional nonstandard item was added to assess pruritus. Results: No difference among groups was found in scar width at 3 or 9 months. Differences among groups were detected in overall scar appearance ( 3 months, P <. 001; 9 months, P <. 001), vascularity ( 3 months, P=. 001; 9 months, P <. 001), excessive distortion ( 3 months, P=. 04; 9 months, P=. 02), contour irregularity ( 3 months, P <. 001), and edge inversion ( 3 months, P=. 01). The best overall appearance was with a subcuticular running polyglactin 910 suture left in place, and the next best was with a subcuticular running polypropylene suture left in place; differences across groups persisted but decreased in intensity at 9 months. A secondary analysis that matched high- tension anatomic sites ( back and lower leg), and high and moderate tension sites ( also chest and shoulder) yielded the same main effects and mostly the same results in pairwise comparisons. Conclusion: While scar width does not appear to vary significantly based on choice of epidermal closure, bi-layered closures of the trunk and extremity have better overall appearance and less associated erythema at 3 and 9 months after surgery with the use of a subcuticular running polyglactin 910 suture left in place.