Interrupted subcuticular suture spacing during linear wound closures and the effect on wound cosmesis: a randomized evaluator-blinded split-wound comparative effectiveness trial.

BACKGROUND: Surgical reconstructions following Mohs micrographic surgery and standard surgical excisions are often closed with two layers of sutures: a deep subcuticular layer and a superficial cuticular layer. Some surgeons feel the need to place many deep sutures in order to reduce tension on cuticular sutures, as they believe this may decrease incidence of track marks and dehiscence, and lead to better cosmetic outcomes. However, others feel that a higher number of subcuticular sutures increases the risk of a suture reaction, which leads to patient anxiety and poorer wound cosmesis. To our knowledge, there are no studies published on the effect of subcuticular suture spacing on wound cosmesis. OBJECTIVES: To determine whether suturing with 1-cm interval subcuticular sutures results in better cosmetic outcomes than suturing with 2-cm interval subcuticular sutures. METHODS: Fifty patients were enrolled in a randomized clinical trial using a split-wound model, where half of the wound was repaired with sutures spaced 2 cm apart and the other half was repaired with sutures spaced 1 cm apart (ClinicalTrials.gov identifier NCT03327922). Both the evaluators and patients were blinded as to which side received which treatment. The scar was evaluated 3 months post-surgery by two blinded observers and the patients themselves using the Patient and Observer Scar Assessment Scale (POSAS), a validated scar assessment instrument. RESULTS: The total mean POSAS score for observers for the sides that received 1-cm interval subcuticular sutures and the sides that received 2-cm interval subcuticular sutures did not differ significantly at 3 months (P = 0·34). There was also no significant difference in the patient assessment scale score between the two sides at 3 months (P = 0·084). CONCLUSIONS: We found that 1-cm suture spacing was not significantly associated with improved overall cosmetic outcome compared with 2-cm suture spacing when evaluated by blinded observers or the patients themselves. Our results support the use of either interval. What is already known about this topic? Surgeons have differing opinions on the ideal frequency of subcuticular sutures for optimizing cosmetic outcomes and minimizing suture reactions. The effect of subcuticular suture spacing on wound cosmesis has not been previously explored in the literature. What does this study add? There was no significant difference in cosmetic outcome between 1-cm suture spacing and 2-cm suture spacing when evaluated by blinded observers and patients. Dermatology surgeons can use 2-cm suture spacing for increased efficiency, without significantly different cosmetic outcomes, detected by blinded observers and patients.

The Pinch Stitch: A Pearl for Suturing Wounds Under Tension.

Closing defects under tension in areas such as the scalp and back may be challenging during dermatologic surgery. Different techniques have been advocated to ease the placement of the first deep suture under tension, including the slip-knot stitch, pully stitch, horizontal mattress suture, pulley set-back dermal suture, and tandem pulley stitch.

Surgical and Noninvasive Modalities for Scar Revision.

Scar revision is of premier importance to the dermatologic surgeon. Some of the least invasive modalities include use of silicone gel sheets, resurfacing with electrosurgical instruments, dermabrasion, chemical peels, and subcision. Laser technology also has been implemented to selectively target and ablate fibrous scar tissue via selective thermolysis. Other lasers have been used to target dyschromia associated with scar formation. Lastly, invasive modalities of scar revision include excisional modalities and/or rearrangement of skin to enhance cosmesis of unsightly or morbid scars. Herein is a discussion of the multiple modalities of scar revision as well as advantages and disadvantages of each.

Comparison of Running Cutaneous Suture Spacing During Linear Wound Closures and the Effect on Wound Cosmesis of the Face and Neck: A Randomized Clinical Trial.

Importance: Surgeons have varying opinions on the ideal cutaneous suture spacing for optimal cosmetic outcomes. To date, no studies concerning the effect of suture spacing on cosmetic outcomes exist in the literature. Objective: To compare outcomes and wound cosmesis achieved with running cutaneous sutures spaced 2 vs 5 mm apart. Design, Setting, and Participants: This randomized clinical trial was conducted at the University of California, Davis dermatology clinic from November 28, 2017, to June 15, 2018. Fifty-six patients 18 years or older with surgical fusiform wounds (from Mohs procedure or surgical excision) on the head or neck with assumed closure lengths of at least 3 cm were screened. Six patients were excluded, 50 patients were enrolled, and 48 patients were followed up. Interventions: Fifty surgical fusiform wounds were randomized to running cuticular closure with 2-mm spacing on half and 5-mm spacing on half. Main Outcomes and Measures: At 3 months, patients and 2 masked observers evaluated each scar using the Patient and Observer Scar Assessment Scale (POSAS). Results: A total of 50 patients (mean [SD] age, 71.1 [11.4] years; 43 [86%] male; 50 [100%] white) were enrolled in the study. The mean (SD) sum of the POSAS observer component scores was 10.7 (4.3) for the 2-mm interval side and 10.8 (3.5) for the 5-mm side at 3 months (P = .77). No statistically significant difference was found in the mean (SD) sum of the patient component for the POSAS score between the 2-mm interval side (10.2 [4.7]) and the 5-mm interval side (11.5 [6.4]) at 3 months (P = .24). No statistically significant difference was observed in mean (SD) scar width between the 2-mm side (0.9 [0.6] mm) and the 5-mm side (0.8 [0.4] mm; P = .15). Conclusions and Relevance: No statistically significant difference in wound cosmesis or total complications were noted between running cuticular sutures spaced 2 vs 5 mm apart. Both suturing techniques resulted in similar cosmetic outcomes and complication rates. Surgeons may want to consider whether the extra time involved in placing very closely spaced cuticular sutures is worthwhile. Trial Registration: ClinicalTrials.gov identifier: NCT03330041.

Blueberry muffin rash secondary to hereditary spherocytosis.

The term blueberry muffin rash is used to describe the clinical presentation of dermal extramedullary hematopoiesis. The common culprits of this rash include a TORCH (toxoplasmosis, other agents, rubella, cytomegalovirus, herpes) infection or hematologic dyscrasia. Association of this rash with hereditary spherocytosis is extremely rare. We present a unique case of a neonate born with a blueberry muffin rash secondary to hereditary spherocytosis.

An Atypical Case of Warfarin-Induced Skin Necrosis.

Skin necrosis is a relatively rare, potentially fatal side effect of warfarin. It is most commonly reported within 10 days of initiation of therapy in warfarin-naïve patients. We report an atypical case of warfarin-induced skin necrosis upon recommencement of warfarin in a non-naïve warfarin patient.

Laser assisted drug delivery: a review of an evolving technology.

BACKGROUND: Topically applied drugs have a relatively low cutaneous bioavailability. OBJECTIVE: This article reviews the existing applications of laser assisted drug delivery, a means by which the permeation of topically applied agents can be enhanced into the skin. RESULTS: The existing literature suggests that lasers are a safe and effective means of enhancing the delivery of topically applied agents through the skin. The types of lasers most commonly studied in regards to drug delivery are the carbon dioxide (CO2 ) and erbium:yttrium-aluminum-garnet (Er:YAG) lasers. Both conventional ablative and fractional ablative modalities have been utilized and are summarized herein. LIMITATIONS: The majority of the existing studies on laser assisted drug delivery have been performed on animal models and additional human studies are needed. CONCLUSIONS: Laser assisted drug delivery is an evolving technology with potentially broad clinical applications. Multiple studies demonstrate that laser pretreatment of the skin can increase the permeability and depth of penetration of topically applied drug molecules for both local cutaneous and systemic applications.

Use of transcutaneous ultrasound for lipolysis and skin tightening: a review.

UNLABELLED: Several ultrasonic devices have recently been investigated for their ability to decrease areas of focal adiposity and tighten small areas of the skin. Studies show that ultrasound technology offers a safe, reliable, and predictable means to sculpt the body of nonobese patients, but its efficacy remains uncertain. Although most studies claim statistically significant results, the clinical significance of ultrasound technology has yet to be determined. Most studies use waist circumference measurements to determine statistical significance and efficacy. The majority of the current studies also have a relatively a short follow-up period of 3 months. More studies are needed to assess the true efficacy of ultrasound technology using more reliable measurements such as diagnostic ultrasound and computed tomography (CT) imaging and to include a follow-up period longer than 6 months to obtain more valid results. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effects of ultraviolet radiation, visible light, and infrared radiation on erythema and pigmentation: a review.

The effects of ultraviolet radiation, visible light, and infrared radiation on cutaneous erythema, immediate pigment darkening, persistent pigment darkening, and delayed tanning are affected by a variety of factors. Some of these factors include the depth of cutaneous penetration of the specific wavelength, the individual skin type, and the absorption spectra of the different chromophores in the skin. UVB is an effective spectrum to induce erythema, which is followed by delayed tanning. UVA induces immediate pigment darkening, persistent pigment darkening, and delayed tanning. At high doses, UVA (primarily UVA2) can also induce erythema in individuals with skin types I-II. Visible light has been shown to induce erythema and a tanning response in dark skin, but not in fair skinned individuals. Infrared radiation produces erythema, which is probably a thermal effect. In this article we reviewed the available literature on the effects of ultraviolet radiation, visible light, and infrared radiation on the skin in regards to erythema and pigmentation. Much remains to be learned on the cutaneous effects of visible light and infrared radiation.