Effect of different degrees of wound eversion sutures on scar formation at donor site of anterolateral femoral flaps: A prospective randomized controlled study_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

HAN Jiansu , LI Fang ,  DENG Chengliang

Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563003, P. R. China;

Corresponding author：

DENG Chengliang, Email: cheliadeng@sina.com

Keywords：

Incision suturing; skin eversion; scar; anterolateral thigh flap; prospective randomized controlled study

DOI：

10.7507/1002-1892.202406028

Video：

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Objective To investigate the effect of different degrees of wound eversion on scar formation at the donor site of anterolateral femoral flaps by a prospective clinical randomized controlled study. Methods According to the degree of wound eversion, the clinical trial was designed with groups of non-eversion (group A), eversion of 0.5 cm (group B), and eversion of 1.0 cm (group C). Patients who underwent anterolateral femoral flap transplantation between September 2021 and March 2023 were collected as study subjects, and a total of 36 patients were included according to the selection criteria. After resected the anterior lateral thigh flap during operation, the wound at donor site of each patient was divided into two equal incisions, and the random number table method was used to group them and perform corresponding treatments. Thirty of these patients completed follow-up and were included in the final study (18 cases in group A, 23 cases in group B, and 29 cases in group C). There were 26 males and 4 females with a median age of 53 years (range, 35-62 years). The body mass index was 17.88-29.18 kg/m² (mean, 23.09 kg/m²). The incision healing and scar quality of three groups were compared, as well as the Patient and Observer Scar Assessment Scale (POSAS) score [the observer component of the POSAS (OSAS) and the patient component of the POSAS (PSAS)], Vancouver Scar Scale (VSS) score, scar width, and patient satisfaction score. Results In group C, 1 case had poor healing of the incision after operation, which healed after debridement and dressing change; 1 case had incision necrosis at 3 months after operation, which healed by second intention after active dressing change and suturing again. The other incisions on all groups healed by first intention. At 6 months after operation, the PSAS, OSAS, and patient satisfaction scores were the lowest in group B, followed by group A, and the highest in group C. The differences between the groups were significant (P<0.05). There was no significant difference between the groups in the VSS scores and scar widths (P>0.05). Conclusion Moderate everted closure may reduce hypertonic incision proliferative scar formation to some extent.

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2.	Mony MP, Harmon KA, Hess R, et al. An updated review of hypertrophic scarring. Cells, 2023, 12(5): 678. doi: 10.3390/cells12050678.
3.	Vorstandlechner V, Laggner M, Copic D, et al. The serine proteases dipeptidyl-peptidase 4 and urokinase are key molecules in human and mouse scar formation. Nat Commun, 2021, 12(1): 6242. doi: 10.1038/s41467-021-26495-2.
4.	Limandjaja GC, Niessen FB, Scheper RJ, et al. Hypertrophic scars and keloids: Overview of the evidence and practical guide for differentiating between these abnormal scars. Exp Dermatol, 2021, 30(1): 146-161.
5.	Zitelli JA, Moy RL. Buried vertical mattress suture. J Dermatol Surg Oncol, 1989, 15(1): 17-19.
6.	Sadick NS, D'Amelio DL, Weinstein C. The modified buried vertical mattress suture. A new technique of buried absorbable wound closure associated with excellent cosmesis for wounds under tension. J Dermatol Surg Oncol, 1994, 20(11): 735-739.
7.	Zhang X, Diao JS, Guo SZ, et al. Wedge-shaped excision and modified vertical mattress suture fully buried in a multilayered and tensioned wound closure. Aesthetic Plast Surg, 2009, 33(3): 457-460.
8.	Breuninger H, Keilbach J, Haaf U. Intracutaneous butterfly suture with absorbable synthetic suture material. Technique, tissue reactions, and results. J Dermatol Surg Oncol, 1993, 19(7): 607-610.
9.	陈珺, 章一新. 章氏超减张缝合在闭合高张力创面中的临床应用效果. 中华烧伤杂志, 2020, 36(5): 339-345.
10.	Kantor J. The set-back buried dermal suture: an alternative to the buried vertical mattress for layered wound closure. J Am Acad Dermatol, 2010, 62(2): 351-353.
11.	常树森, 莫小金, 魏在荣, 等. 遵义缝合法在股前外侧皮瓣供区缝合中的应用研究. 中国修复重建外科杂志, 2021, 35(4): 477-482.
12.	Alexanian CC, Zhuang AR, Crispin MK, et al. Wound eversion versus planar closure for wounds on the face or neck: A randomized split-wound comparative effectiveness trial. J Am Acad Dermatol, 2020, 83(5): 1439-1440.
13.	Bagheri M, von Kohout M, Fuchs PC, et al. How to evaluate scar colour after burn injuries—A clinical comparison of the Mexameter® and the subjective scar assessment (POSAS/VSS). Burns, 2024, 50(3): 691-701.
14.	Peng W, Zhang X, Kong X, et al. The efficacy and safety of fractional CO₂ laser therapy in the treatment of burn scars: A meta-analysis. Burns, 2021, 47(7): 1469-1477.
15.	孟繁君, 王莉, 王强, 等. 皮下埋没横向褥式缝合对减轻张力性切口瘢痕的临床效果观察. 组织工程与重建外科, 2023, 19(3): 236-241.
16.	裴芸琨, 程丽英, 张余光. 瘢痕张力相关性治疗的研究进展. 组织工程与重建外科杂志, 2019, 15(4): 266-267+274.
17.	夏云, 张红燕, 舒茂国, 等. 超减张缝合联合减张胶带在胸腹部增生性瘢痕中的临床应用效果. 中国美容整形外科杂志, 2023, 34(11): 669-671.
18.	陈立彬, 陈亚红, 高振, 等. 皮肤伤口减张器抑制切口瘢痕作用的临床观察. 组织工程与重建外科杂志, 2015, 11(5): 316-319.
19.	Wang AS, Kleinerman R, Armstrong AW, et al. Set-back versus buried vertical mattress suturing: results of a randomized blinded trial. J Am Acad Dermatol, 2015, 72(4): 674-680.
20.	Kappel S, Kleinerman R, King TH, et al. Does wound eversion improve cosmetic outcome?: Results of a randomized, split-scar, comparative trial. J Am Acad Dermatol, 2015, 72(4): 668-673.
21.	Chien WC, Tsai TF. The pressurized skin: A review on the pathological effect of mechanical pressure on the skin from the cellular perspective. Int J Mol Sci, 2023, 24(20): 15207. doi: 10.3390/ijms242015207.
22.	Khansa I, Harrison B, Janis JE. Evidence-based scar management: How to improve results with technique and technology. Plast Reconstr Surg, 2016, 138(3 Suppl): 165S-178S.

1. Clark RAF. To scar or not to scar. N Engl J Med, 2021, 385(5): 469-471.
2. Mony MP, Harmon KA, Hess R, et al. An updated review of hypertrophic scarring. Cells, 2023, 12(5): 678. doi: 10.3390/cells12050678.
3. Vorstandlechner V, Laggner M, Copic D, et al. The serine proteases dipeptidyl-peptidase 4 and urokinase are key molecules in human and mouse scar formation. Nat Commun, 2021, 12(1): 6242. doi: 10.1038/s41467-021-26495-2.
4. Limandjaja GC, Niessen FB, Scheper RJ, et al. Hypertrophic scars and keloids: Overview of the evidence and practical guide for differentiating between these abnormal scars. Exp Dermatol, 2021, 30(1): 146-161.
5. Zitelli JA, Moy RL. Buried vertical mattress suture. J Dermatol Surg Oncol, 1989, 15(1): 17-19.
6. Sadick NS, D'Amelio DL, Weinstein C. The modified buried vertical mattress suture. A new technique of buried absorbable wound closure associated with excellent cosmesis for wounds under tension. J Dermatol Surg Oncol, 1994, 20(11): 735-739.
7. Zhang X, Diao JS, Guo SZ, et al. Wedge-shaped excision and modified vertical mattress suture fully buried in a multilayered and tensioned wound closure. Aesthetic Plast Surg, 2009, 33(3): 457-460.
8. Breuninger H, Keilbach J, Haaf U. Intracutaneous butterfly suture with absorbable synthetic suture material. Technique, tissue reactions, and results. J Dermatol Surg Oncol, 1993, 19(7): 607-610.
9. 陈珺, 章一新. 章氏超减张缝合在闭合高张力创面中的临床应用效果. 中华烧伤杂志, 2020, 36(5): 339-345.
10. Kantor J. The set-back buried dermal suture: an alternative to the buried vertical mattress for layered wound closure. J Am Acad Dermatol, 2010, 62(2): 351-353.
11. 常树森, 莫小金, 魏在荣, 等. 遵义缝合法在股前外侧皮瓣供区缝合中的应用研究. 中国修复重建外科杂志, 2021, 35(4): 477-482.
12. Alexanian CC, Zhuang AR, Crispin MK, et al. Wound eversion versus planar closure for wounds on the face or neck: A randomized split-wound comparative effectiveness trial. J Am Acad Dermatol, 2020, 83(5): 1439-1440.
13. Bagheri M, von Kohout M, Fuchs PC, et al. How to evaluate scar colour after burn injuries—A clinical comparison of the Mexameter® and the subjective scar assessment (POSAS/VSS). Burns, 2024, 50(3): 691-701.
14. Peng W, Zhang X, Kong X, et al. The efficacy and safety of fractional CO₂ laser therapy in the treatment of burn scars: A meta-analysis. Burns, 2021, 47(7): 1469-1477.
15. 孟繁君, 王莉, 王强, 等. 皮下埋没横向褥式缝合对减轻张力性切口瘢痕的临床效果观察. 组织工程与重建外科, 2023, 19(3): 236-241.
16. 裴芸琨, 程丽英, 张余光. 瘢痕张力相关性治疗的研究进展. 组织工程与重建外科杂志, 2019, 15(4): 266-267+274.
17. 夏云, 张红燕, 舒茂国, 等. 超减张缝合联合减张胶带在胸腹部增生性瘢痕中的临床应用效果. 中国美容整形外科杂志, 2023, 34(11): 669-671.
18. 陈立彬, 陈亚红, 高振, 等. 皮肤伤口减张器抑制切口瘢痕作用的临床观察. 组织工程与重建外科杂志, 2015, 11(5): 316-319.
19. Wang AS, Kleinerman R, Armstrong AW, et al. Set-back versus buried vertical mattress suturing: results of a randomized blinded trial. J Am Acad Dermatol, 2015, 72(4): 674-680.
20. Kappel S, Kleinerman R, King TH, et al. Does wound eversion improve cosmetic outcome?: Results of a randomized, split-scar, comparative trial. J Am Acad Dermatol, 2015, 72(4): 668-673.
21. Chien WC, Tsai TF. The pressurized skin: A review on the pathological effect of mechanical pressure on the skin from the cellular perspective. Int J Mol Sci, 2023, 24(20): 15207. doi: 10.3390/ijms242015207.
22. Khansa I, Harrison B, Janis JE. Evidence-based scar management: How to improve results with technique and technology. Plast Reconstr Surg, 2016, 138(3 Suppl): 165S-178S.

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