Fast Absorbing Gut Sutures in Dermatologic Surgery - A Systematic Review and Meta-Analysis

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Seger, Spencer P McClure, Brett C. Neill, Atieh Jibbe This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3854900/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Jun, 2024 Read the published version in Archives of Dermatological Research → Version 1 posted 7 You are reading this latest preprint version Abstract Introduction Fast gut cutaneous sutures have become more prominent due to their low tissue reactivity, rapid absorption, and elimination of suture removal visits. It is not known how fast gut sutures compare to other closure modalities. Methods A comprehensive literature review was conducted to identify randomized controlled trials comparing fast gut sutures to alternative closure methods during dermatologic surgery. Data collected included patient and physician assessed cosmetic outcome as well as standardized complication rates. Results Six studies were included in final analysis and reported on 208 patients. Fast gut sutures were associated with lower physician opinions of final scar when compared to polyproline sutures (SMD 0.438; 95% CI: 0.082–0.794). No differences existed between physician opinion of fast gut sutures and cyanoacrylate tissue adhesive (SMD − 0.024; 95% CI: -0.605–0.556). Complications with fast gut suture placement were rare, and included infection, dehiscence, and hematomas. Fast gut sutures were less likely to experience wound dehiscence than tissue adhesive (p = 0.01). Conclusion If no contraindications to non-absorbable sutures exist, they may provide superior cosmetic outcomes compared to fast gut sutures. Further research is required to better quantify cosmetic outcomes and optimal use of fast gut sutures. Dermatology Surgery Suture Mohs Reconstruction Figures Figure 1 Introduction Dermatologists perform the vast majority of benign and malignant surgical excisions. On a yearly basis they perform more than 15 times as many intermediate and complex repairs as the next most productive specialist group, plastic and reconstructive surgeons. 1 With Mohs micrographic surgery (MMS) increasingly recognized as a superior treatment option for melanoma and non-melanoma skin cancers, the number of complex repairs performed by dermatologists will likely increase in the future. 2–4 Final wound cosmesis is among the biggest determinants of patient satisfaction for skin cancer surgeries, and accordingly is a major factor for physicians when deciding what materials and techniques to use for defect closures. 5,6 Most dermatologic repairs are performed using non-absorbable cutaneous sutures such as monofilament nylon and polyproline (PP). Although tensile strength of these sutures is high and they are generally well tolerated, they require patients to return to the clinic for suture removal. In children (due to factors such as anxiety related to suture removal and inability to remain still), and in those who do not live close to the surgical office, this removal step can be difficult. 7 Alternative options meant to eliminate this step include dissolvable sutures and tissue adhesives, however many dermatologic surgeons were not trained in these modalities and may be hesitant to incorporate them into practice. 8,9 Moreover, there is a lack of definitive large-scale studies establishing their efficacy. One type of dissolvable cutaneous suture is the fast absorbing gut (FG). These sutures are created using submucosal layers of sheep small intestine or serosal layers of cattle small intestine. Given their biologic origin, they are noted to have less tissue reactivity than other sutures which is beneficial for skin grafts and in patients with a history of suture reactivity. 10 Compared to other gut variants, FG sutures are heat treated and provide effective wound support for approximately 1 week (losing 50% of tensile strength over 3–5 days). They dissolve more rapidly than other sutures, and completely absorb after 21–42 days. 11 Their tensile strength is lower than most other cutaneous sutures which may limit use to low tension areas, however they are frequently used for complex closures where suture removal would be difficult. 12 Despite the frequency that Mohs surgeons perform complex procedures, FG sutures are used less often during MMS when compared to other specialties. This may be due to a lack of definitive data demonstrating their efficacy or non-inferiority in MMS and dermatologic surgeries. The purpose of this systematic review is to identify well controlled research trials which targeted clinical and cosmetic outcomes following the use of fast-gut sutures for cutaneous wound closures during MMS and dermatologic surgeries. By providing a comprehensive review and analysis of the current FG suture literature, practicing dermatologic surgeons will better be able to assess their utility in future practice. Methods Search Strategy A systematic literature search was performed on May 17, 2020 to identify randomized controlled trials comparing the use of fast-gut sutures to other closure modalities during dermatologic surgery or Mohs micrographic surgery. This search was conducted by 2 independent reviewers (E.W.S and N.L) in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines for Network Meta-Analysis (PRISMA-NMA). 13 Databases searched included PubMed, Embase, Medline and the Cochrane central registry of controlled trials. Search terms included (in isolation and combination): “Mohs”, “sutures”, “dermatologic surgery”, “fast gut”, “gut sutures”, and “closures”. Any discrepancies between decisions related to inclusion/exclusion were resolved by a third independent reviewer (B.C.N). Inclusion Criteria To be included in the final analysis studies were required to be ( 1 ) level 1 evidence randomized controlled trials; ( 2 ) published in the English language and with the use of human subjects; ( 3 ) reporting data based on surgical procedures performed by dermatologists or Mohs micrographic surgeons; ( 4 ) reporting a minimum of 3 months follow up data, as this timeframe has become an established criteria for evaluating post-surgical scar cosmesis; and ( 5 ) include outcome data related to complication rates and overall cosmesis of the study groups. Defect closure comparisons Defect outcomes following placement of fast-gut sutures were compared to those undergoing placement of non-absorbable PP sutures or cyanoacrylate tissue adhesive (CA). All studies were performed using split scar comparisons, and all studies first placed buried sutures to both assist with approximation of wound edges as well as to relieve skin tension. Suture pattern and surgeon skill or training level were not reported by all studies, however all surgeons closed both sides of the split-scar design which was thought to minimize cross-study bias associated with different techniques. Post-operative wound care management in all studies consisted of petroleum jelly and gauze pressure dressings which is considered to be standard protocol for dermatologic surgical excisions. Outcome data Final tissue cosmesis was compared using established variables within the patient and observer scar assessment scale (POSAS). 14 When final cosmetic outcomes were reported using custom visual analog scales, results were standardized with POSAS variables when possible. Complication rates following surgical procedures were standardized across all reports and included any case of ( 1 ) surgical site infection or abscess; ( 2 ) surgical site hematoma; ( 3 ) wound dehiscence; or ( 4 ) surgical site reactions including skin inflammation or pruritus beyond what would be normally expected Risk of bias and statistical analysis Studies were assessed for potential bias using the Cochrane Risk of Bias 2.0 tool designed for randomized controlled trials. 15 Factors considered in this assessment included design of the randomization process, deviations from the intended result, outcome data collected, selection of the desired result, and measurement of outcome data. For each variable, a score of either “low risk”, “some concerns” or “high risk” was determined by 2 reviewers (E.W.S and B.C.N) and final risk of bias was determined as a summation of these scores. Outcome data was systematically extracted from studies meeting inclusion criteria and recorded in an electronic database (Microsoft Excel; Redmond, WA). Statistical comparisons were made using Open Meta-Analyst software. 16 Scar cosmesis was compared between closure techniques using a continuous random effects model performed using the DerSimonian and Laird method, and standardized mean difference (SMD) was reported. 17 Chi-Squared tests were used to compare complication rates. Statistical significance was defined as p < 0.05. Results Literature search and risk of bias assessment Six hundred and thirty-three manuscripts were identified during the literature search. Following preliminary screening, 48 manuscripts were read in full (Figure 1). Eight manuscripts were related to FG sutures and dermatologic surgery and 6 were included in the final analysis. Of the excluded studies, one analyzed the placement of FG sutures without a corresponding excision, and one was a case report on the use of FG sutures. 18 , 19 Three studies which were included in the final analysis compared the use of fast-gut sutures to cyanoacrylate adhesive, two studies compared FG to traditional PP sutures, and one compared different sized (5-0 and 6-0) FG sutures together. 8 , 9 , 20-23 Risk of bias was considered low across all studies with regards to the randomization process, deviations from the intended result, outcome data, and selection of the desired result (Supplementary 1). Although overall risk was believed to be low, some concerns were present with measurement of outcome data as patients were unable to be blinded during the randomization process and were aware of their treatment group in 3 manuscripts. 21-23 Concurrent grading by blinded physicians during these studies was thought to minimize the potential impact of this bias. Patient Population Two hundred and eight patients were enrolled in the included studies, with outcome data reported on 198 patients after the follow up period of 3 months (4.8% lost to follow up, Table 2). The average age of patients was 64 years, and 66.3% were male. Procedures were performed on HEENT regions in 169 cases (81.3%), 24 cases were on the trunk (11.5%), and 15 were on the extremities (7.2%). MMS was used in 144 cases (69.2%), with the remainder being wide local excision (WLE, 64 cases, Table 2). All defects were closed with linear repairs. FG sutures were used in 196 closures (50 closures included in this cohort were split repairs using both 5-0 FG and 6-0 FG), 74 were with PP and 96 with CA. Comparison with polyproline sutures The use of FG sutures was associated with a lower overall physician opinion of final scar when compared to PP sutures (SMD 0.438; 95% CI: 0.082 - 0.794, Supplementary Table 2)). Individually, Eisen et al. reported physician preference for PP when compared to FG sutures (POSAS for overall opinion 2.49±1.45 with FG vs 1.88±1.04 with PP, p<0.006, Table 3). 21 There was no significant difference between individual physician graded POSAS components (vascularity, pigmentation, thickness, relief, pliability, and scar surface area) when comparing FG to PP sutures, however the sum of all physician graded POSAS components was also significantly better in favor of PP (12.74±5.82 with FG vs 10.26±4.16 with PP, p<0.001, Table 3). 21 In contrast, there was no difference in physician opinion between FG and PP when comparing scars after bilateral upper lid blepharoplasty (1.67±0.64 with FG vs 1.48±0.73 with PP, p=0.46; Modified scale: 1-5 with 1 being highest). 9 Patient preference was only reported in one study, and they had a higher overall opinion of their scars following closure with PP when compared with FG using POSAS criteria (3.14±2.01 with FG vs 2.41±1.66 with PP, p=0.043). 21 There was no significant difference in additional patient specific POSAS variables (pain, itching, color, stiffness, thickness, or irregularity, Table 3). Comparison with cyanoacrylate tissue adhesive There was no difference in final tissue cosmesis between FG and CA when pooling physician opinions (SMD -0.024; 95% CI -0.605 - 0.556, Supplementary 3). There was no difference in physician opinion of final scars favored those closed with FG when compared to CA in studies by Kim et al. (7.97±1.25 with FG vs 7.47±0.81 with CA, p=0.23; Modified scale: 1-10 with 10 being highest) or Zhuang et al. (2.26±1.37 with FG vs 2.5±1.28 with CA, p=0.29; POSAS scale). 8 , 22 In comparison, Tierney et al. reported superior physician graded cosmetic outcome with FG sutures (3.56 with FG vs 3.19 with CA, p=0.05; Modified scale: 1-4 with 4 being highest) and Kouba et al. reported significantly improved scar cosmesis following CA placement for upper lid blepharoplasty (1.67±0.64 with FG vs 1.26±0.45 with CA, p=0.03; Modified scale: 1-5 with 1 being highest). 9 , 23 Two studies reported data related to patient opinion of final cosmetic outcome and there was no difference between closures using FG vs. CA (Table 3). 22 , 23 Complications A total of 40 complications were reported across all wound closures (Table 4). The most common complication noted with FG sutures was infection (n=8, 3.3% of overall cases, Table 4). There was no difference in rates of infection when comparing FG closures to PP (p=0.72) or CA (p=1.00, Table 5). Dehiscence was seen more frequently with CA than FG sutures (p=0.01); there was no difference in dehiscence rates between FG and PP (p-0.39, Table 4). Tissue hematomas and localized tissue reactions were both rare with FG sutures (n=2 for hematomas and n=1 for tissue reaction), and no difference in frequency of these complications was noted between PP or CA closures (Table 4). Discussion A multifactorial approach is ultimately required when selecting closure materials. In the current review, FG sutures may be inferior to non-absorbable PP sutures in regard to final tissue cosmesis. Conversely, cosmetic outcome is similar between FG and CA tissue adhesives, although tissue adhesives are more likely to experience wound dehiscence. FG and CA sutures allow for avoidance of return visits; however, they are also notably more expensive than more traditional non-absorbable sutures. In patients who can return for suture removal, or for wounds in high tension areas, PP sutures may be a superior treatment option. Overall adverse events were rare, therefore if concerns such as tissue reactivity or inability to tolerate suturing exist, then the provider can make a case by case decision on what modality to use. In particular FG sutures are often considered useful for skin grafts, however the current review did not include any grafting procedures. One factor which may limit the utility of FG sutures during dermatologic surgery is their low tensile strength. Although all studies included in our analysis included absorbable deep sutures which reduce tension on epidermal sutures, there remains a risk of wound dehiscence with a reduction in suture tensile strength. This was not noted in any of the studies in this review, including one by Pourang et al. which compared the 5 − 0 vs 6 − 0 FG variants. 20 Common post closure wound care regimens may increase their degradation rates (and reduction in tensile strength) even further. 24 Modifications to surgical techniques may reduce risk of suture breakage, and utilizing several non-absorbable interrupted cutaneous sutures alongside FG sutures may help reduce suture tension further. 12,25 Unfortunately the use of 2 cutaneous sutures simultaneously is less cost or time efficient and may have limited clinical utility. Tissue adhesives are also an increasingly used for low tension defects. They can be applied rapidly and may provide more uniform results for dermatologists less skilled with cutaneous sutures. Other non-suture alternatives include surgical glue and cutaneous staples. 26,27 While staples do not alleviate the need for a return visit, they are quickly applied and provide more support for high tension areas. They also remain in the skin for longer periods of time which may prevent dehiscence and improve cosmesis. For optimal cosmetic outcome, particularly for Mohs surgeons who primarily operate on head and neck regions, sutures will likely still be preferable to these alternative options provided patients can return for suture removal. Recent literature suggests that this removal step may not even be necessary, as many patients are willing and capable of self-removal for cutaneous wounds. 28 There are several limitations of the current review, notably the difficulty in establishing true complication rates from a relatively small overall cohort size. Complication rates of the current studies may have more variability due to factors such as individual surgeon skill as well as each authors threshold for reporting events as complications. FG sutures are also significantly more expensive than many other sutures, so rates of suture breakage and wound dehiscence will likely play a role in surgeons determining their utility. Another limitation is the lack of comparison to additional suture modalities. While PP is a common epidermal suture, dermatologic surgeons often have different preferences for their defects which were not necessarily compared in the current review. A larger scale study comparing closures using FG sutures alongside multiple different epidermal sutures would be beneficial for surgeons looking to optimize cosmetic outcomes. In conclusion, FG sutures appear to be similar to tissue adhesives for cosmetic outcome of linear defect closures, however they are likely inferior to non-absorbable sutures such as PP. The cost of materials, desire for patient to avoid returning for suture removal, and risk of adverse events should all be considered when selecting a method of closure. Ultimately, non-absorbable sutures, FG sutures, and tissue adhesives all have potential utility for defects closures, and final decision should be based on physician preference and comfort using each modality. Declarations Author Contribution E.S: Manuscript writing, editing, design, conceptualization S.M.: Manuscript writing, editingB.N.: Manuscript editing, conceptualizationA.J: Manuscript editing, conceptualization, oversight The authors report no conflicts of interest to disclose There were no funding sources for this research IRB Status: Exempt References Kantor J. Dermatologists perform more reconstructive surgery in the Medicare population than any other specialist group: A cross-sectional individual-level analysis of Medicare volume and specialist type in cutaneous and reconstructive surgery. J Am Acad Dermatol. 2018;78(1):171–173 e171. Hanson J, Demer A, Liszewski W, Foman N, Maher I. Improved overall survival of melanoma of the head and neck treated with Mohs micrographic surgery versus wide local excision. J Am Acad Dermatol. 2020;82(1):149–155. Xiong DD, Beal BT, Varra V, et al. Outcomes in intermediate-risk squamous cell carcinomas treated with Mohs micrographic surgery compared with wide local excision. J Am Acad Dermatol. 2020;82(5):1195–1204. Siscos SM, Neill BC, Seger EW, Hooton TA, Hocker TLH. The Current State of Mohs Surgery for the Treatment of Melanoma: A Nationwide Cross-Sectional Survey of Mohs Surgeons. Dermatol Surg. 2020. Leonard AL, Hanke CW. Second intention healing for intermediate and large postsurgical defects of the lip. J Am Acad Dermatol. 2007;57(5):832–835. Asgari MM, Warton EM, Neugebauer R, Chren MM. Predictors of patient satisfaction with Mohs surgery: analysis of preoperative, intraoperative, and postoperative factors in a prospective cohort. Arch Dermatol. 2011;147(12):1387–1394. Luck RP, Flood R, Eyal D, Saludades J, Hayes C, Gaughan J. Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care. 2008;24(3):137–142. Kim J, Singh Maan H, Cool AJ, Hanlon AM, Leffell DJ. Fast Absorbing Gut Suture versus Cyanoacrylate Tissue Adhesive in the Epidermal Closure of Linear Repairs Following Mohs Micrographic Surgery. J Clin Aesthet Dermatol. 2015;8(2):24–29. Kouba DJ, Tierney E, Mahmoud BH, Woo D. Optimizing closure materials for upper lid blepharoplasty: a randomized, controlled trial. Dermatol Surg. 2011;37(1):19–30. Regula CG, Yag-Howard C. Suture Products and Techniques: What to Use, Where, and Why. Dermatol Surg. 2015;41 Suppl 10:S187-200. Ethicon. 1916G Fast absorbing surgical gut suture (plain). https://www.ethicon.com/na/epc/code/1916g?lang=en-default . Published 2020. Accessed August 6, 2020, 2020. Joshi AS, Janjanin S, Tanna N, Geist C, Lindsey WH. Does suture material and technique really matter? Lessons learned from 800 consecutive blepharoplasties. Laryngoscope. 2007;117(6):981–984. Shamseer L, Moher D, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;350:g7647. Draaijers LJ, Tempelman FR, Botman YA, et al. The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg. 2004;113(7):1960–1965; discussion 1966–1967. Sterne JAC, Savovic J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. Wallace BC, Dahabreh IJ, Trikalinos TA, Lau J, Trow P, Schmid CH. Closing the Gap between Methodologists and End-Users: R as a Computational Back-End. 2012. 2012;49(5):15. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–188. Susong JR, Neiner JR. Effect of petrolatum coating on fast-absorbing gut suture. J Am Acad Dermatol. 2018;79(5):952–953. Todd PS, Gordon SC, Rovner RL, Tung R. Eruptive Penile Syringomas in an Adolescent: Novel Approach with Serial Microexcisions and Suture-Adhesive Repair. Pediatr Dermatol. 2016;33(2):e57-60. Pourang A, Crispin MK, Clark AK, Armstrong AW, Sivamani RK, Eisen DB. Use of 5 – 0 Fast Absorbing Gut versus 6 – 0 Fast Absorbing Gut during cutaneous wound closure on the head and neck: A randomized evaluator-blinded split-wound comparative effectiveness trial. J Am Acad Dermatol. 2019;81(1):213–218. Eisen DB, Zhuang AR, Hasan A, Sharon VR, Bang H, Crispin MK. 5 – 0 Polypropylene versus 5 – 0 fast absorbing plain gut for cutaneous wound closure: a randomized evaluator blind trial. Arch Dermatol Res. 2020;312(3):179–185. Zhuang AR, Beroukhim K, Armstrong AW, Sivamani RK, Eisen DB. Comparison of 2-Octylcyanoacrylate Versus 5 – 0 Fast-Absorbing Gut During Linear Wound Closures and the Effect on Wound Cosmesis. Dermatol Surg. 2020;46(5):628–634. Tierney EP, Moy RL, Kouba DJ. Rapid absorbing gut suture versus 2-octylethylcyanoacrylate tissue adhesive in the epidermal closure of linear repairs. J Drugs Dermatol. 2009;8(2):115–119. Athre RS, Park J, Leach JL. The effect of a hydrogen peroxide wound care regimen on tensile strength of suture. Arch Facial Plast Surg. 2007;9(4):281–284. Bloom R, Do D. Practical needle driver cleaning technique when using fast-absorbing plain gut sutures for facial defect repair. J Am Acad Dermatol. 2019;80(6):e147-e148. Al-Mubarak L, Al-Haddab M. 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Tables Table 1: Randomized trials including fast absorbable gut sutures Study Design Comparison n Wound Site Wound Size Follow up Measure Outcome Eisen et al. 2019 RCT Split Scar 5-0 FG a vs 5-0 PP b 50 HEENT Trunk Extremities 5.8 cm 3 months POSAS PP resulted in better cosmetic outcomes than FG Kim et al. 2015 RCT Split Scar 5-0/6-0 FG vs Cyanoacrylate adhesive 14 HEENT 4.2 cm 3 months 10 Item VAS Similar cosmetic outcomes between FG and CA Kouba et al. 2011 RCT Split Scar * 6-0 FG vs 6-0 PP vs CA 36 Upper Eyelid - 3 months 5 Item VAS Similar cosmetic outcomes between FG and PP; CA resulted in better cosmetic outcomes than FG Pourang et al. 2019 RCT Split Scar 5-0 FG vs 6-0 FG 46 HEENT > 3 cm 3 months POSAS No difference in cosmetic outcomes between 5-0 FG and 6-0 FG Tierney et al. 2009 RCT Split Scar 5-0/6-0 FG vs Cyanoacrylate adhesive 8 Trunk Extremities - 3 months 4 Item VAS FG resulted in significantly better cosmetic outcomes than CA Zhuang et al. 2019 RCT Split Scar 5-0 FG vs Cyanoacrylate adhesive 44 HEENT Trunk Extremities 5.9 cm 3 months POSAS No difference in cosmetic outcomes between FG and CA FG – Fast gut suture; PP – Polyproline suture; CA - cyanoacrylate tissue adhesive; POSAS - patient and observer scar assessment scale; VAS – Visual analog scale Table 2: Patient Demographics Overall FG PP CA n 208 a 196 b 74 96 Gender (% male) 66.3 - - - Age (y) 64 - - - Procedure, n (%) MMS 144 (69.2) 144 (73.5) 34 (45.9) 60 (62.5) WLE 64 (30.8) 52 (26.5) 40 (54.1) 36 (37.5) Anatomic Site, n (%) HEENT 169 (81.3) 157 (80.1) 58 (78.4) 73 (76.0) Trunk 24 (11.5) 24 (12.2) 10 (13.5) 14 (14.6) Extremities 15 (7.2) 15 (7.7) 6 (8.1) 9 (9.4) FG – Fast gut suture; PP – Polyproline suture; CA - cyanoacrylate tissue adhesive; a Value reported is of initial enrollment, outcome data ultimately reported for 198 patients. b Pourang et al. reported 50 patients enrolled in RCT (n=50 used in calculations), however each defect was closed with 2 unique FG sutures, so treatment for FG is n=100 (not reported in calculations) Table 3: Physician and patient outcome comparisons POSAS Outcomes Eisen et al. Pourang et al. Zhuang et al. FG PP FG5 FG6 FG CA Physician Overall Opinion 2.49 (1.45) 1.88 (1.04) 2.64 (1.24) 2.49 (1.31) 2.26 (1.37) 2.5 (1.28) Patient Overall Opinion 3.14 (2.01) 2.41 (1.66) 2.37 (1.40) 2.59 (1.68) 3.43 (2.36) 3.45 (2.34) POSAS - Physician Vascularity 2.47 (1.62) 2 (1.23) 2.34 (1.09) 2.10 (0.99) 2.22 (1.33) 2.39 (1.37) Pigmentation 1.91 (1.33) 1.61 (0.83) 1.76 (0.84) 1.62 (0.77) 1.79 (0.80) 1.98 (0.91) Thickness 1.96 (1.31) 1.61 (1.06) 2.26 (1.32) 2.11 (1.32) 1.73 (0.95) 1.75 (1.00) Relief 2.08 (1.33) 1.56 (0.85) 2.36 (1.30) 2.12 (1.04) 1.73 (0.73) 1.87 (0.81) Pliability 2.09 (1.37) 1.72 (1.04) 2.11 (1.39) 2.00 (1.17) 1.84 (0.85) 1.92 (0.91) Surface area 2.38 (1.59) 1.79 (1.12) 2.28 (1.09) 2.09 (0.98) 2.31 (1.51) 2.4 (1.28) Sum of components 12.74 (5.82) 10.26 (4.16) 13.11 (5.74) 12.03 (5.03) 11.6 (4.36) 12.3 (4.72) POSAS - Patient Pain 1.02 (0.15) 1 (0) 1.39 (1.56) 1.22 (1.33) 1.32 (1.29) 1.32 (1.29) Itching 1.11 (0.44) 1.09 (0.36) 1.46 (1.72) 1.26 (1.38) 1.27 (0.79) 1.48 (1.37) Color 3.55 (2.42) 3.25 (2.43) 2.63 (1.83) 2.63 (1.87) 4.14 (2.68) 4.07 (2.71) Stiffness 2.95 (2.27) 2.57 (2.29) 2.20 (1.75) 2.74 (2.07) 2.59 (2.29) 2.91 (2.21) Thickness 2.86 (2.26) 2.20 (1.73) 2.00 (1.43) 2.17 (1.89) 2.41 (2.01) 2.48 (1.81) Irregularity 2.84 (1.96) 2.18 (1.77) 2.20 (1.56) 2.59 (2.10) 3.16 (2.71) 3.02 (3.17) Sum of components 14.34 (8.14) 12.3 (7.63) 11.87 (6.05) 12.61 (6.87) 14.6 (8.90) 14.9 (8.67) Modified Scoring Outcomes Kim et al. a Kouba et al. b Tierney et al. c FG CA FG CA PP FG CA Physician Overall Opinion 7.97 (1.25)* 7.47 (0.81) 1.67 (0.64) 1.26 (0.45) 1.48 (0.73) 3.56 3.19 Patient Overall Opinion - - - - - 3.5 3.56 FG – Fast gut suture; PP – Polyproline suture; CA - cyanoacrylate tissue adhesive; FG5 – 5-0 fast gut suture; FG6 – 6-0 fast gut suture; a Scale from 1-10 (With 10 being highest opinion); b Scale from 1-5 (with 1 being highest opinion); c Scale from 1-4 (with 4 being highest opinion) Table 4: Wound closure complications FG PP CA Closures (n) a 246 74 96 Complications (n) 16 8 16 Dehiscence 5 3 8 Infection b 8 3 3 Hematoma 2 1 2 Reaction c 1 1 3 a Closure defined as half of wound closure for split scar studies, n=246 for FG sutures as Pourang et al. reported as n=100; b Infection defined as author reported infection or abscess; c Reaction defined as cutaneous skin finding or localized pruritus to wound area Additional Declarations No competing interests reported. Supplementary Files Supplementary.docx Cite Share Download PDF Status: Published Journal Publication published 08 Jun, 2024 Read the published version in Archives of Dermatological Research → Version 1 posted Editorial decision: Revision requested 07 Apr, 2024 Reviews received at journal 10 Feb, 2024 Reviewers agreed at journal 09 Feb, 2024 Reviewers invited by journal 07 Feb, 2024 Submission checks completed at journal 11 Jan, 2024 Editor assigned by journal 11 Jan, 2024 First submitted to journal 11 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Seger","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYFCCBAjFD2YXkKJFsgHENiBFi8EBMEmEBn72BOYPH37Z5BufX5344YEBgzy/2AH8WiR7HrBJzuxLs9x24+1mCaDDDGfOTsCvxeBGAhszb89hA7MbZzeAtCQY3Cagxf5GAvPnvz3/DYxnnN38gygtBhIJDNIMPw4YGPD3biPOFokzD9skexuSDSRu8G6zSDCQIOwX/vbkwx9+/LEz4O8/u/nmjwobeX5pAloYGBgbGBjbQPaBVUoQUg4Df0D2HSBW9SgYBaNgFIw0AAAgwEXVGBsonAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Kansas Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Edward","middleName":"W.","lastName":"Seger","suffix":""},{"id":266615657,"identity":"b0915d31-44de-494d-92f0-c99589943d3c","order_by":1,"name":"Spencer P McClure","email":"","orcid":"","institution":"University of Kansas Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Spencer","middleName":"P","lastName":"McClure","suffix":""},{"id":266615658,"identity":"03e2b6ae-0617-4721-8896-9575a1842054","order_by":2,"name":"Brett C. Neill","email":"","orcid":"","institution":"University of Kansas Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Brett","middleName":"C.","lastName":"Neill","suffix":""},{"id":266615659,"identity":"4354cc36-bea8-426d-882e-ff819351d7bc","order_by":3,"name":"Atieh Jibbe","email":"","orcid":"","institution":"University of Kansas Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Atieh","middleName":"","lastName":"Jibbe","suffix":""}],"badges":[],"createdAt":"2024-01-11 22:01:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3854900/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3854900/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00403-024-02973-7","type":"published","date":"2024-06-08T14:49:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":49632847,"identity":"62cbabe3-db70-4d73-8427-372526630da0","added_by":"auto","created_at":"2024-01-15 16:02:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41279,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSearch Methodology\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3854900/v1/d1d9c1614fd7cd81b987f41b.png"},{"id":58822142,"identity":"3a88977e-b37d-461e-920d-13bdec56f1b7","added_by":"auto","created_at":"2024-06-21 16:33:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":714800,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3854900/v1/313b342b-2c1f-4fbb-ac1f-e5e18e8b4fb9.pdf"},{"id":49632049,"identity":"dfc732cf-d84b-4912-b6af-4c5102e712db","added_by":"auto","created_at":"2024-01-15 15:54:17","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":86476,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary.docx","url":"https://assets-eu.researchsquare.com/files/rs-3854900/v1/b5f3374a91df137b6c126cf6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fast Absorbing Gut Sutures in Dermatologic Surgery - A Systematic Review and Meta-Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDermatologists perform the vast majority of benign and malignant surgical excisions. On a yearly basis they perform more than 15 times as many intermediate and complex repairs as the next most productive specialist group, plastic and reconstructive surgeons.\u003csup\u003e1\u003c/sup\u003e With Mohs micrographic surgery (MMS) increasingly recognized as a superior treatment option for melanoma and non-melanoma skin cancers, the number of complex repairs performed by dermatologists will likely increase in the future.\u003csup\u003e2\u0026ndash;4\u003c/sup\u003e Final wound cosmesis is among the biggest determinants of patient satisfaction for skin cancer surgeries, and accordingly is a major factor for physicians when deciding what materials and techniques to use for defect closures.\u003csup\u003e5,6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMost dermatologic repairs are performed using non-absorbable cutaneous sutures such as monofilament nylon and polyproline (PP). Although tensile strength of these sutures is high and they are generally well tolerated, they require patients to return to the clinic for suture removal. In children (due to factors such as anxiety related to suture removal and inability to remain still), and in those who do not live close to the surgical office, this removal step can be difficult.\u003csup\u003e7\u003c/sup\u003e Alternative options meant to eliminate this step include dissolvable sutures and tissue adhesives, however many dermatologic surgeons were not trained in these modalities and may be hesitant to incorporate them into practice.\u003csup\u003e8,9\u003c/sup\u003e Moreover, there is a lack of definitive large-scale studies establishing their efficacy.\u003c/p\u003e \u003cp\u003eOne type of dissolvable cutaneous suture is the fast absorbing gut (FG). These sutures are created using submucosal layers of sheep small intestine or serosal layers of cattle small intestine. Given their biologic origin, they are noted to have less tissue reactivity than other sutures which is beneficial for skin grafts and in patients with a history of suture reactivity.\u003csup\u003e10\u003c/sup\u003e Compared to other gut variants, FG sutures are heat treated and provide effective wound support for approximately 1 week (losing 50% of tensile strength over 3\u0026ndash;5 days). They dissolve more rapidly than other sutures, and completely absorb after 21\u0026ndash;42 days.\u003csup\u003e11\u003c/sup\u003e Their tensile strength is lower than most other cutaneous sutures which may limit use to low tension areas, however they are frequently used for complex closures where suture removal would be difficult.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite the frequency that Mohs surgeons perform complex procedures, FG sutures are used less often during MMS when compared to other specialties. This may be due to a lack of definitive data demonstrating their efficacy or non-inferiority in MMS and dermatologic surgeries. The purpose of this systematic review is to identify well controlled research trials which targeted clinical and cosmetic outcomes following the use of fast-gut sutures for cutaneous wound closures during MMS and dermatologic surgeries. By providing a comprehensive review and analysis of the current FG suture literature, practicing dermatologic surgeons will better be able to assess their utility in future practice.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch Strategy\u003c/h2\u003e \u003cp\u003eA systematic literature search was performed on May 17, 2020 to identify randomized controlled trials comparing the use of fast-gut sutures to other closure modalities during dermatologic surgery or Mohs micrographic surgery. This search was conducted by 2 independent reviewers (E.W.S and N.L) in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines for Network Meta-Analysis (PRISMA-NMA).\u003csup\u003e13\u003c/sup\u003e Databases searched included PubMed, Embase, Medline and the Cochrane central registry of controlled trials. Search terms included (in isolation and combination): \u0026ldquo;Mohs\u0026rdquo;, \u0026ldquo;sutures\u0026rdquo;, \u0026ldquo;dermatologic surgery\u0026rdquo;, \u0026ldquo;fast gut\u0026rdquo;, \u0026ldquo;gut sutures\u0026rdquo;, and \u0026ldquo;closures\u0026rdquo;. Any discrepancies between decisions related to inclusion/exclusion were resolved by a third independent reviewer (B.C.N).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion Criteria\u003c/h2\u003e \u003cp\u003eTo be included in the final analysis studies were required to be (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) level 1 evidence randomized controlled trials; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) published in the English language and with the use of human subjects; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) reporting data based on surgical procedures performed by dermatologists or Mohs micrographic surgeons; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) reporting a minimum of 3 months follow up data, as this timeframe has become an established criteria for evaluating post-surgical scar cosmesis; and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) include outcome data related to complication rates and overall cosmesis of the study groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDefect closure comparisons\u003c/h2\u003e \u003cp\u003eDefect outcomes following placement of fast-gut sutures were compared to those undergoing placement of non-absorbable PP sutures or cyanoacrylate tissue adhesive (CA). All studies were performed using split scar comparisons, and all studies first placed buried sutures to both assist with approximation of wound edges as well as to relieve skin tension. Suture pattern and surgeon skill or training level were not reported by all studies, however all surgeons closed both sides of the split-scar design which was thought to minimize cross-study bias associated with different techniques. Post-operative wound care management in all studies consisted of petroleum jelly and gauze pressure dressings which is considered to be standard protocol for dermatologic surgical excisions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcome data\u003c/h2\u003e \u003cp\u003eFinal tissue cosmesis was compared using established variables within the patient and observer scar assessment scale (POSAS).\u003csup\u003e14\u003c/sup\u003e When final cosmetic outcomes were reported using custom visual analog scales, results were standardized with POSAS variables when possible. Complication rates following surgical procedures were standardized across all reports and included any case of (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) surgical site infection or abscess; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) surgical site hematoma; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) wound dehiscence; or (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) surgical site reactions including skin inflammation or pruritus beyond what would be normally expected\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eRisk of bias and statistical analysis\u003c/h2\u003e \u003cp\u003eStudies were assessed for potential bias using the Cochrane Risk of Bias 2.0 tool designed for randomized controlled trials.\u003csup\u003e15\u003c/sup\u003e Factors considered in this assessment included design of the randomization process, deviations from the intended result, outcome data collected, selection of the desired result, and measurement of outcome data. For each variable, a score of either \u0026ldquo;low risk\u0026rdquo;, \u0026ldquo;some concerns\u0026rdquo; or \u0026ldquo;high risk\u0026rdquo; was determined by 2 reviewers (E.W.S and B.C.N) and final risk of bias was determined as a summation of these scores. Outcome data was systematically extracted from studies meeting inclusion criteria and recorded in an electronic database (Microsoft Excel; Redmond, WA). Statistical comparisons were made using Open Meta-Analyst software.\u003csup\u003e16\u003c/sup\u003e Scar cosmesis was compared between closure techniques using a continuous random effects model performed using the DerSimonian and Laird method, and standardized mean difference (SMD) was reported.\u003csup\u003e17\u003c/sup\u003e Chi-Squared tests were used to compare complication rates. Statistical significance was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eLiterature search and risk of bias assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSix hundred and thirty-three manuscripts were identified during the literature search. Following preliminary screening, 48 manuscripts were read in full (Figure 1). Eight manuscripts were related to FG sutures and dermatologic surgery and 6 were included in the final analysis. Of the excluded studies, one analyzed the placement of FG sutures without a corresponding excision, and one was a case report on the use of FG sutures.\u003csup\u003e18\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e19\u003c/sup\u003e Three studies which were included in the final analysis compared the use of fast-gut sutures to cyanoacrylate adhesive, two studies compared FG to traditional PP sutures, and one compared different sized (5-0 and 6-0) FG sutures together.\u003csup\u003e8\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e9\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e20-23\u003c/sup\u003e \u003c/p\u003e\n\u003cp\u003eRisk of bias was considered low across all studies with regards to the randomization process, deviations from the intended result, outcome data, and selection of the desired result (Supplementary 1). Although overall risk was believed to be low, some concerns were present with measurement of outcome data as patients were unable to be blinded during the randomization process and were aware of their treatment group in 3 manuscripts.\u003csup\u003e21-23\u003c/sup\u003e Concurrent grading by blinded physicians during these studies was thought to minimize the potential impact of this bias. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePatient Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo hundred and eight patients were enrolled in the included studies, with outcome data reported on 198 patients after the follow up period of 3 months (4.8% lost to follow up, Table 2). The average age of patients was 64 years, and 66.3% were male. Procedures were performed on HEENT regions in 169 cases (81.3%), 24 cases were on the trunk (11.5%), and 15 were on the extremities (7.2%). MMS was used in 144 cases (69.2%), with the remainder being wide local excision (WLE, 64 cases, Table 2). All defects were closed with linear repairs. FG sutures were used in 196 closures (50 closures included in this cohort were split repairs using both 5-0 FG and 6-0 FG), 74 were with PP and 96 with CA. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eComparison with polyproline sutures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe use of FG sutures was associated with a lower overall physician opinion of final scar when compared to PP sutures (SMD 0.438; 95% CI: 0.082 - 0.794, Supplementary Table 2)). Individually, Eisen et al. reported physician preference for PP when compared to FG sutures (POSAS for overall opinion 2.49\u0026plusmn;1.45 with FG vs 1.88\u0026plusmn;1.04 with PP, p\u0026lt;0.006, Table 3).\u003csup\u003e21\u003c/sup\u003e There was no significant difference between individual physician graded POSAS components (vascularity, pigmentation, thickness, relief, pliability, and scar surface area) when comparing FG to PP sutures, however the sum of all physician graded POSAS components was also significantly better in favor of PP (12.74\u0026plusmn;5.82 with FG vs 10.26\u0026plusmn;4.16 with PP, p\u0026lt;0.001, Table 3).\u003csup\u003e21\u003c/sup\u003e In contrast, there was no difference in physician opinion between FG and PP when comparing scars after bilateral upper lid blepharoplasty (1.67\u0026plusmn;0.64 with FG vs 1.48\u0026plusmn;0.73 with PP, p=0.46; Modified scale: 1-5 with 1 being highest).\u003csup\u003e9\u003c/sup\u003e Patient preference was only reported in one study, and they had a higher overall opinion of their scars following closure with PP when compared with FG using POSAS criteria (3.14\u0026plusmn;2.01 with FG vs 2.41\u0026plusmn;1.66 with PP, p=0.043).\u003csup\u003e21\u003c/sup\u003e There was no significant difference in additional patient specific POSAS variables (pain, itching, color, stiffness, thickness, or irregularity, Table 3).\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eComparison with\u003c/strong\u003e \u003cstrong\u003ecyanoacrylate tissue adhesive\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no difference in final tissue cosmesis between FG and CA when pooling physician opinions (SMD -0.024; 95% CI -0.605 - 0.556, Supplementary 3). There was no difference in physician opinion of final scars favored those closed with FG when compared to CA in studies by Kim et al. (7.97\u0026plusmn;1.25 with FG vs 7.47\u0026plusmn;0.81 with CA, p=0.23; Modified scale: 1-10 with 10 being highest) or Zhuang et al. (2.26\u0026plusmn;1.37 with FG vs 2.5\u0026plusmn;1.28 with CA, p=0.29; POSAS scale).\u003csup\u003e8\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e22\u003c/sup\u003e In comparison, Tierney et al. reported superior physician graded cosmetic outcome with FG sutures (3.56 with FG vs 3.19 with CA, p=0.05; Modified scale: 1-4 with 4 being highest) and Kouba et al. reported significantly improved scar cosmesis following CA placement for upper lid blepharoplasty (1.67\u0026plusmn;0.64 with FG vs 1.26\u0026plusmn;0.45 with CA, p=0.03; Modified scale: 1-5 with 1 being highest).\u003csup\u003e9\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e23\u003c/sup\u003e Two studies reported data related to patient opinion of final cosmetic outcome and there was no difference between closures using FG vs. CA (Table 3).\u003csup\u003e22\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e23\u003c/sup\u003e \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 40 complications were reported across all wound closures (Table 4). The most common complication noted with FG sutures was infection (n=8, 3.3% of overall cases, Table 4). There was no difference in rates of infection when comparing FG closures to PP (p=0.72) or CA (p=1.00, Table 5). Dehiscence was seen more frequently with CA than FG sutures (p=0.01); there was no difference in dehiscence rates between FG and PP (p-0.39, Table 4). Tissue hematomas and localized tissue reactions were both rare with FG sutures (n=2 for hematomas and n=1 for tissue reaction), and no difference in frequency of these complications was noted between PP or CA closures (Table 4). \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eA multifactorial approach is ultimately required when selecting closure materials. In the current review, FG sutures may be inferior to non-absorbable PP sutures in regard to final tissue cosmesis. Conversely, cosmetic outcome is similar between FG and CA tissue adhesives, although tissue adhesives are more likely to experience wound dehiscence. FG and CA sutures allow for avoidance of return visits; however, they are also notably more expensive than more traditional non-absorbable sutures. In patients who can return for suture removal, or for wounds in high tension areas, PP sutures may be a superior treatment option. Overall adverse events were rare, therefore if concerns such as tissue reactivity or inability to tolerate suturing exist, then the provider can make a case by case decision on what modality to use. In particular FG sutures are often considered useful for skin grafts, however the current review did not include any grafting procedures.\u003c/p\u003e \u003cp\u003eOne factor which may limit the utility of FG sutures during dermatologic surgery is their low tensile strength. Although all studies included in our analysis included absorbable deep sutures which reduce tension on epidermal sutures, there remains a risk of wound dehiscence with a reduction in suture tensile strength. This was not noted in any of the studies in this review, including one by Pourang et al. which compared the 5\u0026thinsp;\u0026minus;\u0026thinsp;0 vs 6\u0026thinsp;\u0026minus;\u0026thinsp;0 FG variants.\u003csup\u003e20\u003c/sup\u003e Common post closure wound care regimens may increase their degradation rates (and reduction in tensile strength) even further.\u003csup\u003e24\u003c/sup\u003e Modifications to surgical techniques may reduce risk of suture breakage, and utilizing several non-absorbable interrupted cutaneous sutures alongside FG sutures may help reduce suture tension further.\u003csup\u003e12,25\u003c/sup\u003e Unfortunately the use of 2 cutaneous sutures simultaneously is less cost or time efficient and may have limited clinical utility.\u003c/p\u003e \u003cp\u003eTissue adhesives are also an increasingly used for low tension defects. They can be applied rapidly and may provide more uniform results for dermatologists less skilled with cutaneous sutures. Other non-suture alternatives include surgical glue and cutaneous staples.\u003csup\u003e26,27\u003c/sup\u003e While staples do not alleviate the need for a return visit, they are quickly applied and provide more support for high tension areas. They also remain in the skin for longer periods of time which may prevent dehiscence and improve cosmesis. For optimal cosmetic outcome, particularly for Mohs surgeons who primarily operate on head and neck regions, sutures will likely still be preferable to these alternative options provided patients can return for suture removal. Recent literature suggests that this removal step may not even be necessary, as many patients are willing and capable of self-removal for cutaneous wounds.\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere are several limitations of the current review, notably the difficulty in establishing true complication rates from a relatively small overall cohort size. Complication rates of the current studies may have more variability due to factors such as individual surgeon skill as well as each authors threshold for reporting events as complications. FG sutures are also significantly more expensive than many other sutures, so rates of suture breakage and wound dehiscence will likely play a role in surgeons determining their utility. Another limitation is the lack of comparison to additional suture modalities. While PP is a common epidermal suture, dermatologic surgeons often have different preferences for their defects which were not necessarily compared in the current review. A larger scale study comparing closures using FG sutures alongside multiple different epidermal sutures would be beneficial for surgeons looking to optimize cosmetic outcomes.\u003c/p\u003e \u003cp\u003eIn conclusion, FG sutures appear to be similar to tissue adhesives for cosmetic outcome of linear defect closures, however they are likely inferior to non-absorbable sutures such as PP. The cost of materials, desire for patient to avoid returning for suture removal, and risk of adverse events should all be considered when selecting a method of closure. Ultimately, non-absorbable sutures, FG sutures, and tissue adhesives all have potential utility for defects closures, and final decision should be based on physician preference and comfort using each modality.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eE.S: Manuscript writing, editing, design, conceptualization S.M.: Manuscript writing, editingB.N.: Manuscript editing, conceptualizationA.J: Manuscript editing, conceptualization, oversight\u003c/p\u003e\u003cp\u003eThe authors report no conflicts of interest to disclose\u003c/p\u003e\n\u003cp\u003eThere were no funding sources for this research\u003c/p\u003e\n\u003cp\u003eIRB Status: Exempt\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKantor J. Dermatologists perform more reconstructive surgery in the Medicare population than any other specialist group: A cross-sectional individual-level analysis of Medicare volume and specialist type in cutaneous and reconstructive surgery. J Am Acad Dermatol. 2018;78(1):171\u0026ndash;173 e171.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanson J, Demer A, Liszewski W, Foman N, Maher I. Improved overall survival of melanoma of the head and neck treated with Mohs micrographic surgery versus wide local excision. J Am Acad Dermatol. 2020;82(1):149\u0026ndash;155.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiong DD, Beal BT, Varra V, et al. Outcomes in intermediate-risk squamous cell carcinomas treated with Mohs micrographic surgery compared with wide local excision. J Am Acad Dermatol. 2020;82(5):1195\u0026ndash;1204.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiscos SM, Neill BC, Seger EW, Hooton TA, Hocker TLH. The Current State of Mohs Surgery for the Treatment of Melanoma: A Nationwide Cross-Sectional Survey of Mohs Surgeons. Dermatol Surg. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeonard AL, Hanke CW. Second intention healing for intermediate and large postsurgical defects of the lip. J Am Acad Dermatol. 2007;57(5):832\u0026ndash;835.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsgari MM, Warton EM, Neugebauer R, Chren MM. Predictors of patient satisfaction with Mohs surgery: analysis of preoperative, intraoperative, and postoperative factors in a prospective cohort. Arch Dermatol. 2011;147(12):1387\u0026ndash;1394.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuck RP, Flood R, Eyal D, Saludades J, Hayes C, Gaughan J. Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care. 2008;24(3):137\u0026ndash;142.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim J, Singh Maan H, Cool AJ, Hanlon AM, Leffell DJ. Fast Absorbing Gut Suture versus Cyanoacrylate Tissue Adhesive in the Epidermal Closure of Linear Repairs Following Mohs Micrographic Surgery. J Clin Aesthet Dermatol. 2015;8(2):24\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKouba DJ, Tierney E, Mahmoud BH, Woo D. Optimizing closure materials for upper lid blepharoplasty: a randomized, controlled trial. Dermatol Surg. 2011;37(1):19\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRegula CG, Yag-Howard C. Suture Products and Techniques: What to Use, Where, and Why. Dermatol Surg. 2015;41 Suppl 10:S187-200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEthicon. 1916G Fast absorbing surgical gut suture (plain). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ethicon.com/na/epc/code/1916g?lang=en-default\u003c/span\u003e\u003cspan address=\"https://www.ethicon.com/na/epc/code/1916g?lang=en-default\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2020. Accessed August 6, 2020, 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoshi AS, Janjanin S, Tanna N, Geist C, Lindsey WH. Does suture material and technique really matter? Lessons learned from 800 consecutive blepharoplasties. Laryngoscope. 2007;117(6):981\u0026ndash;984.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShamseer L, Moher D, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;350:g7647.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDraaijers LJ, Tempelman FR, Botman YA, et al. The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg. 2004;113(7):1960\u0026ndash;1965; discussion 1966\u0026ndash;1967.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSterne JAC, Savovic J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWallace BC, Dahabreh IJ, Trikalinos TA, Lau J, Trow P, Schmid CH. Closing the Gap between Methodologists and End-Users: R as a Computational Back-End. 2012. 2012;49(5):15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177\u0026ndash;188.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSusong JR, Neiner JR. Effect of petrolatum coating on fast-absorbing gut suture. J Am Acad Dermatol. 2018;79(5):952\u0026ndash;953.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTodd PS, Gordon SC, Rovner RL, Tung R. Eruptive Penile Syringomas in an Adolescent: Novel Approach with Serial Microexcisions and Suture-Adhesive Repair. Pediatr Dermatol. 2016;33(2):e57-60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePourang A, Crispin MK, Clark AK, Armstrong AW, Sivamani RK, Eisen DB. Use of 5\u0026thinsp;\u0026ndash;\u0026thinsp;0 Fast Absorbing Gut versus 6\u0026thinsp;\u0026ndash;\u0026thinsp;0 Fast Absorbing Gut during cutaneous wound closure on the head and neck: A randomized evaluator-blinded split-wound comparative effectiveness trial. J Am Acad Dermatol. 2019;81(1):213\u0026ndash;218.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEisen DB, Zhuang AR, Hasan A, Sharon VR, Bang H, Crispin MK. 5\u0026thinsp;\u0026ndash;\u0026thinsp;0 Polypropylene versus 5\u0026thinsp;\u0026ndash;\u0026thinsp;0 fast absorbing plain gut for cutaneous wound closure: a randomized evaluator blind trial. Arch Dermatol Res. 2020;312(3):179\u0026ndash;185.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhuang AR, Beroukhim K, Armstrong AW, Sivamani RK, Eisen DB. Comparison of 2-Octylcyanoacrylate Versus 5\u0026thinsp;\u0026ndash;\u0026thinsp;0 Fast-Absorbing Gut During Linear Wound Closures and the Effect on Wound Cosmesis. Dermatol Surg. 2020;46(5):628\u0026ndash;634.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTierney EP, Moy RL, Kouba DJ. Rapid absorbing gut suture versus 2-octylethylcyanoacrylate tissue adhesive in the epidermal closure of linear repairs. J Drugs Dermatol. 2009;8(2):115\u0026ndash;119.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAthre RS, Park J, Leach JL. The effect of a hydrogen peroxide wound care regimen on tensile strength of suture. Arch Facial Plast Surg. 2007;9(4):281\u0026ndash;284.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBloom R, Do D. Practical needle driver cleaning technique when using fast-absorbing plain gut sutures for facial defect repair. J Am Acad Dermatol. 2019;80(6):e147-e148.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Mubarak L, Al-Haddab M. Cutaneous wound closure materials: an overview and update. J Cutan Aesthet Surg. 2013;6(4):178\u0026ndash;188.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSouza SC, Briglia C, Costa SR. Repair of cutaneous wounds with the use of low cost surgical glue. An Bras Dermatol. 2012;87(2):241\u0026ndash;249.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacdonald P, Primiani N, Lund A. Are patients willing to remove, and capable of removing, their own nonabsorbable sutures? CJEM. 2012;14(4):218\u0026ndash;223.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Randomized trials including fast absorbable gut sutures\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"1008\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.69047619047619%\"\u003e\n \u003cp\u003e\u003cstrong\u003eComparison\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.5714285714285716%\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWound Site\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.119047619047619%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWound Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30952380952381%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeasure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"25\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" rowspan=\"2\"\u003e\n \u003cp\u003eEisen et al. 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003cp\u003eSplit Scar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.69047619047619%\" rowspan=\"2\"\u003e\n \u003cp\u003e5-0 FG \u003csup\u003ea\u003c/sup\u003e vs\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5-0 PP \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.5714285714285716%\" rowspan=\"2\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\" rowspan=\"2\"\u003e\n \u003cp\u003eHEENT Trunk Extremities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.119047619047619%\" rowspan=\"2\"\u003e\n \u003cp\u003e5.8 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30952380952381%\" rowspan=\"2\"\u003e\n \u003cp\u003ePOSAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" rowspan=\"2\"\u003e\n \u003cp\u003ePP resulted in better cosmetic outcomes than FG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"NaN%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" rowspan=\"2\"\u003e\n \u003cp\u003eKim et al. 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003cp\u003eSplit Scar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.69047619047619%\" rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e5-0/6-0 FG vs Cyanoacrylate adhesive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.5714285714285716%\" rowspan=\"2\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\" rowspan=\"2\"\u003e\n \u003cp\u003eHEENT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.119047619047619%\" rowspan=\"2\"\u003e\n \u003cp\u003e4.2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30952380952381%\" rowspan=\"2\"\u003e\n \u003cp\u003e10 Item VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" rowspan=\"2\"\u003e\n \u003cp\u003eSimilar cosmetic outcomes between FG and CA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"NaN%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" rowspan=\"2\"\u003e\n \u003cp\u003eKouba et al. 2011\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003cp\u003eSplit Scar\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.69047619047619%\" rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e6-0 FG vs 6-0 PP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; vs CA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.5714285714285716%\" rowspan=\"2\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\" rowspan=\"2\"\u003e\n \u003cp\u003eUpper Eyelid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.119047619047619%\" rowspan=\"2\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30952380952381%\" rowspan=\"2\"\u003e\n \u003cp\u003e5 Item VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eSimilar cosmetic outcomes between FG and PP; CA resulted in better cosmetic outcomes than FG\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"NaN%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" rowspan=\"2\"\u003e\n \u003cp\u003ePourang et al. 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003cp\u003eSplit Scar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.69047619047619%\" rowspan=\"2\"\u003e\n \u003cp\u003e5-0 FG vs 6-0 FG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.5714285714285716%\" rowspan=\"2\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\" rowspan=\"2\"\u003e\n \u003cp\u003eHEENT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.119047619047619%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026gt; 3 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30952380952381%\" rowspan=\"2\"\u003e\n \u003cp\u003ePOSAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" rowspan=\"2\"\u003e\n \u003cp\u003eNo difference in cosmetic outcomes between 5-0 FG and 6-0 FG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"NaN%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" rowspan=\"2\"\u003e\n \u003cp\u003eTierney et al. 2009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003cp\u003eSplit Scar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.69047619047619%\" rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e5-0/6-0 FG vs Cyanoacrylate adhesive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.5714285714285716%\" rowspan=\"2\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\" rowspan=\"2\"\u003e\n \u003cp\u003eTrunk Extremities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.119047619047619%\" rowspan=\"2\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30952380952381%\" rowspan=\"2\"\u003e\n \u003cp\u003e4 Item VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" rowspan=\"2\"\u003e\n \u003cp\u003eFG resulted in significantly better cosmetic outcomes than CA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"NaN%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" rowspan=\"2\"\u003e\n \u003cp\u003eZhuang et al. 2019\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003cp\u003eSplit Scar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.69047619047619%\" rowspan=\"2\"\u003e\n \u003cp\u003e5-0 FG vs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Cyanoacrylate adhesive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.5714285714285716%\" rowspan=\"2\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.523809523809524%\" rowspan=\"2\"\u003e\n \u003cp\u003eHEENT Trunk Extremities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.119047619047619%\" rowspan=\"2\"\u003e\n \u003cp\u003e5.9 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30952380952381%\" rowspan=\"2\"\u003e\n \u003cp\u003ePOSAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" rowspan=\"2\"\u003e\n \u003cp\u003eNo difference in cosmetic outcomes between FG and CA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"NaN%\" height=\"38\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFG \u0026ndash; Fast gut suture; PP \u0026ndash; Polyproline suture; CA - cyanoacrylate tissue adhesive; POSAS - patient and observer scar assessment scale; VAS \u0026ndash; Visual analog scale\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Patient Demographics\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"617\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.058441558441558%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.85064935064935%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ePP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.058441558441558%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.85064935064935%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e208\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e196\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.90909090909091%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender (% male)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e66.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.90909090909091%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (y)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.90909090909091%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eProcedure, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.058441558441558%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"36.85064935064935%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMMS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e144 (69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e144 (73.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e34 (45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\"\u003e\n \u003cp\u003e60 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.058441558441558%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"36.85064935064935%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eWLE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e64 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e52 (26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e40 (54.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\"\u003e\n \u003cp\u003e36 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.90909090909091%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnatomic Site, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.058441558441558%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"36.85064935064935%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eHEENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e169 (81.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\"\u003e\n \u003cp\u003e157 (80.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\"\u003e\n \u003cp\u003e58 (78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\"\u003e\n \u003cp\u003e73 (76.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.058441558441558%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"36.85064935064935%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrunk\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e24 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e24 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e10 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e14 (14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.058441558441558%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.85064935064935%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eExtremities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e15 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e15 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e6 (8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.772727272727273%\" valign=\"bottom\"\u003e\n \u003cp\u003e9 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFG \u0026ndash; Fast gut suture; PP \u0026ndash; Polyproline suture; CA - cyanoacrylate tissue adhesive; \u003csup\u003ea\u0026nbsp;\u003c/sup\u003eValue reported is of initial enrollment, outcome data ultimately reported for 198 patients. \u003csup\u003eb\u003c/sup\u003e Pourang et al. reported 50 patients enrolled in RCT (n=50 used in calculations), however each defect was closed with 2 unique FG sutures, so treatment for FG is n=100 (not reported in calculations)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Physician and patient outcome comparisons\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePOSAS Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"833\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.369747899159663%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eEisen et al.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.009603841536613%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePourang et al.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.56902761104442%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eZhuang et al.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFG5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFG6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.051620648259302%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003ePhysician Overall Opinion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.49 (1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.88 (1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e2.64 (1.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e2.49 (1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.26 (1.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.5 (1.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.051620648259302%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003ePatient Overall Opinion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;3.14 (2.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.41 (1.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e2.37 (1.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e2.59 (1.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.43 (2.36)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.45 (2.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.051620648259302%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003ePOSAS - Physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003eVascularity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.47 (1.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e2 (1.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e2.34 (1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e2.10 (0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.22 (1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.39 (1.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003ePigmentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.91 (1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.61 (0.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e1.76 (0.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e1.62 (0.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.79 (0.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;1.98 (0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003eThickness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.96 (1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.61 (1.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e2.26 (1.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e2.11 (1.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.73 (0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.75 (1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003eRelief\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.08 (1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.56 (0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e2.36 (1.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e\u0026nbsp;2.12 (1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.73 (0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.87 (0.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003ePliability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.09 (1.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.72 (1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e2.11 (1.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e2.00 (1.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;1.84 (0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.92 (0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003eSurface area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.38 (1.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.79 (1.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e2.28 (1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e2.09 (0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.31 (1.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.4 (1.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003eSum of components\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e12.74 (5.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e10.26 (4.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e\u0026nbsp;13.11 (5.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e12.03 (5.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e11.6 (4.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e12.3 (4.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.051620648259302%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003ePOSAS - Patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.02 (0.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e1.39 (1.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e1.22 (1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.32 (1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.32 (1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003eItching\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;1.11 (0.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.09 (0.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e1.46 (1.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e1.26 (1.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.27 (0.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.48 (1.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003eColor\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.55 (2.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.25 (2.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e2.63 (1.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e2.63 (1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e4.14 (2.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e4.07 (2.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003eStiffness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.95 (2.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.57 (2.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e2.20 (1.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e2.74 (2.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.59 (2.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;2.91 (2.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003eThickness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.86 (2.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.20 (1.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e2.00 (1.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e2.17 (1.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.41 (2.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.48 (1.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003eIrregularity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.84 (1.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.18 (1.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e2.20 (1.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e2.59 (2.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.16 (2.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.02 (3.17)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8415366146458583%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.210084033613445%\" valign=\"bottom\"\u003e\n \u003cp\u003eSum of components\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.004801920768307%\" valign=\"bottom\"\u003e\n \u003cp\u003e14.34 (8.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\" valign=\"bottom\"\u003e\n \u003cp\u003e12.3 (7.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.364945978391356%\"\u003e\n \u003cp\u003e11.87 (6.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\"\u003e\n \u003cp\u003e12.61 (6.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.644657863145259%\" valign=\"bottom\"\u003e\n \u003cp\u003e14.6 (8.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.92436974789916%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;14.9 (8.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eModified Scoring Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"836\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.966507177033492%\" colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"26.555023923444978%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eKim et al.\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.62200956937799%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eKouba et al.\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85645933014354%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTierney et al.\u003csup\u003ec\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.497005988023952%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.497005988023952%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.011976047904191%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.574850299401197%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.179640718562874%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.179640718562874%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.179640718562874%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.137724550898204%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.74251497005988%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.994011976047904%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003ePhysician Overall Opinion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.011976047904191%\"\u003e\n \u003cp\u003e7.97 (1.25)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.574850299401197%\"\u003e\n \u003cp\u003e7.47 (0.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.179640718562874%\"\u003e\n \u003cp\u003e1.67 (0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.179640718562874%\"\u003e\n \u003cp\u003e1.26 (0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.179640718562874%\"\u003e\n \u003cp\u003e1.48 (0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.137724550898204%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.74251497005988%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.994011976047904%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003ePatient Overall Opinion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.011976047904191%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.574850299401197%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.179640718562874%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.179640718562874%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.179640718562874%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.137724550898204%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.74251497005988%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFG \u0026ndash; Fast gut suture; PP \u0026ndash; Polyproline suture; CA - cyanoacrylate tissue adhesive; FG5 \u0026ndash; 5-0 fast gut suture; FG6 \u0026ndash; 6-0 fast gut suture; \u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e Scale from 1-10 (With 10 being highest opinion); \u003csup\u003eb\u003c/sup\u003e Scale from 1-5 (with 1 being highest opinion); \u003csup\u003ec\u003c/sup\u003e Scale from 1-4 (with 4 being highest opinion)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Wound closure complications\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"415\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.9879518072289155%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.602409638554217%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3855421686747%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.879518072289155%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ePP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.14457831325301%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.59036144578313%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eClosures (n) \u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3855421686747%\"\u003e\n \u003cp\u003e246\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.879518072289155%\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.14457831325301%\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.59036144578313%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplications (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3855421686747%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.879518072289155%\" valign=\"bottom\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.14457831325301%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.9879518072289155%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"30.602409638554217%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eDehiscence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3855421686747%\" valign=\"bottom\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.879518072289155%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.14457831325301%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.9879518072289155%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"30.602409638554217%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfection \u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3855421686747%\" valign=\"bottom\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.879518072289155%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.14457831325301%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.9879518072289155%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"30.602409638554217%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eHematoma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3855421686747%\" valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.879518072289155%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.14457831325301%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.9879518072289155%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.602409638554217%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eReaction \u003csup\u003ec\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3855421686747%\" valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.879518072289155%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.14457831325301%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003eClosure defined as half of wound closure for split scar studies, n=246 for FG sutures as Pourang et al. reported as n=100;\u003cstrong\u003e\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/strong\u003e Infection defined as author reported infection or abscess; \u003csup\u003ec\u0026nbsp;\u003c/sup\u003eReaction defined as cutaneous skin finding or localized pruritus to wound area\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Dermatology, Surgery, Suture, Mohs, Reconstruction","lastPublishedDoi":"10.21203/rs.3.rs-3854900/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3854900/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eFast gut cutaneous sutures have become more prominent due to their low tissue reactivity, rapid absorption, and elimination of suture removal visits. It is not known how fast gut sutures compare to other closure modalities.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA comprehensive literature review was conducted to identify randomized controlled trials comparing fast gut sutures to alternative closure methods during dermatologic surgery. Data collected included patient and physician assessed cosmetic outcome as well as standardized complication rates.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSix studies were included in final analysis and reported on 208 patients. Fast gut sutures were associated with lower physician opinions of final scar when compared to polyproline sutures (SMD 0.438; 95% CI: 0.082\u0026ndash;0.794). No differences existed between physician opinion of fast gut sutures and cyanoacrylate tissue adhesive (SMD \u0026minus;\u0026thinsp;0.024; 95% CI: -0.605\u0026ndash;0.556). Complications with fast gut suture placement were rare, and included infection, dehiscence, and hematomas. Fast gut sutures were less likely to experience wound dehiscence than tissue adhesive (p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIf no contraindications to non-absorbable sutures exist, they may provide superior cosmetic outcomes compared to fast gut sutures. Further research is required to better quantify cosmetic outcomes and optimal use of fast gut sutures.\u003c/p\u003e","manuscriptTitle":"Fast Absorbing Gut Sutures in Dermatologic Surgery - A Systematic Review and Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-15 15:54:12","doi":"10.21203/rs.3.rs-3854900/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-07T04:14:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-10T23:44:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9c9c579f-39a8-4ed2-8ec9-2697a37c07c8","date":"2024-02-10T00:28:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-07T20:10:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-12T04:47:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-12T04:47:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Dermatological Research","date":"2024-01-11T21:45:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8e34338f-6868-45a0-8fbb-3ff58feb0de2","owner":[],"postedDate":"January 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T14:49:09+00:00","versionOfRecord":{"articleIdentity":"rs-3854900","link":"https://doi.org/10.1007/s00403-024-02973-7","journal":{"identity":"archives-of-dermatological-research","isVorOnly":false,"title":"Archives of Dermatological Research"},"publishedOn":"2024-06-08 14:49:09","publishedOnDateReadable":"June 8th, 2024"},"versionCreatedAt":"2024-01-15 15:54:12","video":"","vorDoi":"10.1007/s00403-024-02973-7","vorDoiUrl":"https://doi.org/10.1007/s00403-024-02973-7","workflowStages":[]},"version":"v1","identity":"rs-3854900","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3854900","identity":"rs-3854900","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}