A Meta-Analysis Of Outcomes Of Different Methods Of Linear Closure For Specific Cutaneous Defects

Objective:We assessed the level of evidence supporting different linear closure techniques of simple and specific cutaneous defects.Basically,we want to determine the optimal method used in closing specific skin defects,the effectiveness of different interventions,the risk of harmful events,patients' or patient caregivers' satisfaction,and whether individual or skin defects characteristics affect these outcomes.Specifically,we sought to find some "tips" to help surgeons clear their minds on choose the most appropriate method for their patient.Method:We searched PubMed,EMBASE,CNKI English Version,Cochrane Library systematically for relevant studies.We used a combination of keywords and clarify retrieval("cutaneous defect*" "linear closure*" "cosmetic outcomes*" or "scar assessment" "randomized controlled" "Meta")from 1990 to 18 October 2019 as our essential search strategy.We identified all available publications and reviewed the related references of overall included studies.In conducting this Meta-analysis,we reviewed the full text of all 69 randomized clinical trials(RCTs)comparing different techniques of linear closure to determine eligibility for the final inclusion.We extracted all exact data into Excel,assessed risk of bias according to Cochrane Handbook 6.0,evaluated the level of RCTs based on the 2011 Oxford scheme,and rated the strength of evidence for each recommendation by the GRADE scale.We performed the overall Meta-statistic-analysis in R(3.7.2).Results:Of 43 included random trials comparing two or more techniques to repair simple and specific cutaneous defects on face,neck,scalp,and body resulting from excision of benign neoplasms,extirpation of malignant cutaneous tumors,and traumatic lacerations.4 studies assessed single layer closure versus bilayer closure;6 studies assessed absorbable versus non-absorbable sutures for skin closure,2 studies assessed absorbable versus another absorbable suture,17 reviews compared different tissue adhesives with conventional skin closure techniques,6 articles compared SAS with sutures,5 studies compared sutures with closure devices,2 studies compared running cutaneous suture spacing,2 reviews compared simple transcutaneous stitching with running intradermal suture,one RCT revealed if eversion improves cosmetic outcome,one RCT compared dermal suture only with traditional bilayer closure.Principal Findings and GRADE:Suture techniques and materials1.There is evidence to support a single layer to reduce closure time with an equivalent cosmetic outcome and safety(A).2.Dermal suture only can be safely used compared to conventional bilayer closure(B);Superficial stitching provides no long-term benefits over BVMS alone(B).3.There is no adequate evidence to demonstrate the differences between absorbable and non-absorbable sutures for simple linear closure regarding cosmetic superiority(3mo),patient' satisfaction,or complications;Absorbable sutures are preferable for convenience,time and cost savings,and preventing uneasiness when equivalent remove(A).4.Compared with polyglactin-910,subcuticular poliglecaprone-25 can decrease the rate of the extruded suture(C).5.Evidence is needed to demonstrate whether eversion or high-density suture achieves a short-term or long-term superior scar outcome(C).6.There is no significant difference in complications between subcuticular sutures and conventional linear closure sutures(including simple interrupted sutures and running sutures(B).Tissue adhesives or surgical glue7.Adhesive strips(SAS)may be a cost-time-saving option for simple cutaneous repairs(B);Concerning the adjacent function of SAS,no statistical comparisons were performed,it provides no superior cosmesis over running subcuticular suture only(B).8.For surgical/tissue glue,no definite evidence of improved wound dehiscence,wound infection,or cosmetic outcomes(A).9.Compared to sutures,surgical/tissue or adhesives can save time(A).Staples10.Staples reduce the closure time compared to suture(B).11.In dermatologic surgery,there is no consistent evidence to conduct suture gives a lower risk of post-surgical complications or superior scar outcomes compared to staples(B).other closure devices12.Most closure devices have an advantage of time-saving,but no enough evidence to compare other results(C).Conclusion:A range of closure methods helps reduce closure time and material costs.Some interventions can increase patients' satisfaction with treatment.Few studies directly reveal one better than the other in cosmetic outcomes and risk of complications.Evidence to instruct surgeons to choose the optimal closure techniques and materials is likely best when implemented in the context of individual patient's characteristics,preferences,initial needs combined with surgeons' shinning.