From the Cochrane Library: Subcuticular sutures for skin closure in nonobstetric surgery

To the Editor: Dermatologic surgeons must choose from an array of surgical wound closure techniques and materials that may be poorly supported by evidence—many suture trials have been at high risk of bias or underpowered to detect the superiority of any one modality.1Veitch D. Broderick C. Wernham A.G.H. et al.National survey demonstrates significant variation in suture use for dermatological procedures.Clin Exp Dermatol. 2020; 45: 742-745https://doi.org/10.1111/ced.14238Google Scholar A thorough understanding of the effect of the suture choice on wound healing is critical to minimize postsurgical complications, including tissue necrosis, peri-wound edema, hematomas, and dehiscence. However, a recent national survey of dermatologists and plastic surgeons in the United Kingdom found that the choice of epidermal suture (eg, absorbable or non-absorbable, subcuticular only, skin glue/adhesive) varied widely, with the majority of surgeons guided by personal experience rather than evidence.1Veitch D. Broderick C. Wernham A.G.H. et al.National survey demonstrates significant variation in suture use for dermatological procedures.Clin Exp Dermatol. 2020; 45: 742-745https://doi.org/10.1111/ced.14238Google Scholar Although the application of subcuticular sutures is uptrending, coinciding with the increased availability of synthetic absorbable filaments, few studies have assessed the complications associated with subcuticular wound closure.2Goto S. Sakamoto T. Ganeko R. Hida K. Furukawa T.A. Sakai Y. Subcuticular sutures for skin closure in non-obstetric surgery.Cochrane Database Syst Rev. 2020; 4: CD012124https://doi.org/10.1002/14651858.CD012124.pub2Google Scholar A 2020 Cochrane review, “Subcuticular Sutures for Skin Closure in Non-obstetric Surgery,” offers a comprehensive review of the efficacy and acceptability of subcuticular sutures for skin closure in nonobstetric surgery.2Goto S. Sakamoto T. Ganeko R. Hida K. Furukawa T.A. Sakai Y. Subcuticular sutures for skin closure in non-obstetric surgery.Cochrane Database Syst Rev. 2020; 4: CD012124https://doi.org/10.1002/14651858.CD012124.pub2Google Scholar Data were compiled from 66 studies (7487 participants) comparing subcuticular sutures with transdermal sutures, skin staples, or tissue adhesives, primarily in patients undergoing Centers for Disease Control class 1 (clean) surgeries in hospital-based and office-based settings. The results are summarized in Table I.Table ISummary of treatment comparisons with respective results, risk ratios, mean differences, and confidence intervalsComparisonOutcomeFindingRelative effectQuality of evidence∗The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. High certainty: very confident that true effect is close to the estimate; moderate certainty: moderately confident that true effect is close to the estimate, but possibility of substantial difference; low certainty: limited confidence in effect estimate, true effect may be substantially different; very low certainty: very little confidence in effect estimate, true effect is likely to be substantially different.Subcuticular sutures vs. transdermal suturesIncidence of SSILittle or no differenceRR 1.10; 95% CI 0.80-1.52; n = 3107 (20 RCTs)Low-certainty evidenceSubcuticular sutures vs. transdermal suturesIncidence of wound complicationsUncertainRR 0.83; 95% CI 0.40-1.71; n = 1489 (9 RCTs)Very low-certainty evidenceSubcuticular sutures vs. transdermal suturesIncidence of wound dehiscenceUncertainRR 0.35; 95% CI 0.08-1.54; n = 866 (6 RCTs)Very low-certainty evidenceSubcuticular sutures vs. transdermal suturesPatient satisfaction assessed by 10-point patient survey 30 days postprocedureSubcuticular sutures are superiorMD 1.60; 95% CI 1.32-1.88; n = 290 (1 RCT)Moderate-certainty evidenceSubcuticular sutures vs. transdermal suturesWound closure timeTransdermal sutures are superiorMD 5.81 min; 95% CI 5.13-6.49 min; n = 585 (2 RCTs)Moderate- certainty evidenceSubcuticular sutures vs. skin staplesIncidence of SSILittle or no differenceRR 0.81; 95% CI 0.64-1.01; n = 4163 (14 RCTs)Moderate-certainty evidenceSubcuticular sutures vs. skin staplesIncidence of wound complicationsSubcuticular sutures are superiorRR 0.79; 95% CI 0.64-0.98; n = 2973 (9 RCTs)Moderate-certainty evidenceSubcuticular sutures vs. skin staplesIncidence of wound dehiscenceSubcuticular sutures are superiorRR 0.63; 95% CI 0.43-0.94; n = 1984 (7 RCTs)Low-certainty evidenceSubcuticular sutures vs. skin staplesPatient satisfaction assessed by 5-point patient survey 30 days postprocedureSubcuticular sutures are superiorMD 0.20; 95% CI 0.10-0.30; n = 1232 (1 RCT)High-certainty evidenceSubcuticular sutures vs. skin staplesWound closure timeSkin staples are superiorMD 0.30-5.50 min; further analyses not pursued due to statistical heterogeneity of results; n = 1384 (4 RCTs)Low-certainty evidenceSubcuticular sutures vs. tissue adhesivesIncidence of SSINo clear differenceRR 0.77; 95% CI 0.41-1.45; n = 869 (10 RCTs)Moderate-certainty evidenceSubcuticular sutures vs. tissue adhesivesIncidence of wound complicationsNo clear differenceRR 0.62; 95% CI 0.35-1.11; n = 1058 (11 RCTs)Low-certainty evidenceSubcuticular sutures vs. tissue adhesivesIncidence of wound dehiscenceSubcuticular sutures are superiorRR 0.23; 95% CI 0.07-0.74; n = 1155 (11 RCTs)Low-certainty evidenceSubcuticular sutures vs. tissue adhesivesPatient satisfaction assessed by 10-point patient survey within 30 days postprocedureTissue adhesives are superiorMD ₋2.05; 95% CI ₋3.05 to ₋1.05; n = 131 (1 RCT)Low-certainty evidenceSubcuticular sutures vs. tissue adhesivesWound closure timeUncertainMD range ₋0.34 to 10.39 min.; n = 895; further analyses not pursued due to statistical heterogeneity of results; n = 895 (11 RCTs)Very low-certainty evidenceMD, Mean difference; n, number of participants; RCT, randomized controlled trial; RR, risk ratio; SSI, surgical site infection.∗ The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. High certainty: very confident that true effect is close to the estimate; moderate certainty: moderately confident that true effect is close to the estimate, but possibility of substantial difference; low certainty: limited confidence in effect estimate, true effect may be substantially different; very low certainty: very little confidence in effect estimate, true effect is likely to be substantially different. Open table in a new tab MD, Mean difference; n, number of participants; RCT, randomized controlled trial; RR, risk ratio; SSI, surgical site infection. There was no clear difference in the incidence of surgical site infection between subcuticular sutures and other closure types. Subcuticular sutures were associated with greater patient satisfaction but longer wound closure time than transdermal sutures. Compared to staples, subcuticular sutures were associated with higher patient satisfaction, longer closure time, and lower wound complications. Tissue adhesives were associated with higher patient ratings versus subcuticular sutures; however, subcuticular sutures were associated with a marginally lower incidence of dehiscence. A 2021 systematic review evaluating sutures, tissue adhesives, and tapes for pediatric wound closure found similar rates of infection among all 3, analogous to the results of this review, but reported similar rates of dehiscence2Goto S. Sakamoto T. Ganeko R. Hida K. Furukawa T.A. Sakai Y. Subcuticular sutures for skin closure in non-obstetric surgery.Cochrane Database Syst Rev. 2020; 4: CD012124https://doi.org/10.1002/14651858.CD012124.pub2Google Scholar,3Tandon S. Smale M. Pacilli M. Nataraja R.M. Tissue adhesive and adhesive tape for pediatric wound closure: a systematic review and meta-analysis.J Pediatr Surg. 2021; 56: 1020-1029https://doi.org/10.1016/j.jpedsurg.2020.07.037Google Scholar; tape was associated with improved cosmesis versus adhesives (though the included studies were at high risk of bias). Another study found cyanoacrylate provided faster wound closure, shorter stitch-out time, and superior wound margin coaptation during the early postoperative period, with similar safety and efficacy to subcuticular sutures.4Choi K.Y. Koh I.J. Kim M.S. Park D.C. Sung Y.G. In Y. 2-Octyl cyanoacrylate topical adhesive as an alternative to subcuticular suture for skin closure after total knee arthroplasty: a randomized controlled trial in the same patient.J Arthroplasty. 2021; 36: 3141-3147https://doi.org/10.1016/j.arth.2021.04.033Google Scholar Given the broad, global subject base of this review, we expect its results to be highly generalizable.2Goto S. Sakamoto T. Ganeko R. Hida K. Furukawa T.A. Sakai Y. Subcuticular sutures for skin closure in non-obstetric surgery.Cochrane Database Syst Rev. 2020; 4: CD012124https://doi.org/10.1002/14651858.CD012124.pub2Google Scholar However, although it excluded no particular patient groups and encompassed a wide range of surgery types, due to the variety of included procedures, interpreting the overall effects with respect to dermatologic surgery must be performed cautiously. The limitations of the evidence in this Cochrane review include incomplete outcome reporting, highlighting the need for future trials to follow the Consolidated Standards of Reporting Trials statement and report outcomes of patient satisfaction and cosmesis using standardized intervals, facilitating pooled analysis. Six-month or longer follow-up would assess the durability of outcomes, particularly important in assessing cosmesis—this was recently emphasized by the results of an observer-blinded study of scar outcomes, in which traditional bilayered closure yielded better cosmesis versus buried dermal sutures alone at 3 months, yet no statistical difference remained after 12 months.5Joo J.S. Zhuang A.R. Tchanque-Fossuo C. et al.Dermal suture only versus layered closure: a randomized, split wound comparative effectiveness trial.J Am Acad Dermatol. 2019; 81: 1346-1352https://doi.org/10.1016/j.jaad.2019.08.040Google Scholar Dr Dellavalle is Editor in Chief of the Journal of Medical Internet Research (JMIR) Dermatology, a Joint Coordinating Editor for Cochrane Skin, a dermatology section editor for UpToDate, a Social Media Editor for the Journal of the American Academy of Dermatology (JAAD), and a Podcast Editor for the Journal of Investigative Dermatology (JID). He is a coordinating Editor Representative and Co-Chair of Cochrane Council. Dr Sivesind is a Section Editor for JMIR Dermatology. Drs Oganesyan, Goto and Szeto have no conflicts of interest to declare.