Comparison of Running Cutaneous Suture Spacing During Linear Wound Closures

Comment: This paper compares spacing of sutures and found no difference between those placed 2 mm and 5 mm apart. The closures examined were from surgical fusiform wounds. Of course, this is not analogous to the traumatic wounds encountered on call, but is food for thought, especially considering the time involved in placement of very fine sutures with no obvious cosmetic benefit (at least at three months).—Jennifer A. Villwock, MD

What are the outcomes and wound cosmesis achieved with running cutaneous sutures spaced 2 mm vs. 5 mm apart?

Bottom Line: No statistically significant difference in wound cosmesis or total complications were noted between running cuticular sutures spaced 2 mm vs. 5 mm apart. Both suturing techniques resulted in similar cosmetic outcomes and complication rates. Surgeons may want to consider whether the extra time involved in placing very closely spaced cuticular sutures is worthwhile.

Background: Surgeons have varying opinions on the ideal cutaneous suture spacing for optimal cosmetic outcomes. To date, no studies concerning the effect of suture spacing on cosmetic outcomes exist in the literature.

Study design: Randomized clinical trial.

Setting: University of California, Davis dermatology clinic.

Synopsis: The trial was conducted from November 28, 2017, to June 15, 2018. Fifty-six patients 18 years or older with surgical fusiform wounds (from Mohs procedure or surgical excision) on the head or neck with assumed closure lengths of at least 3 cm were screened. Resarchers excluded six patients, enrolled 50 patients, and followed up with 48 patients. Fifty surgical fusiform wounds were randomized to running cuticular closure with 2-mm spacing on half and 5-mm spacing on half. At three months, patients and two masked observers evaluated each scar using the patient and observer scar assessment scale (POSAS). A total of 50 patients (mean [SD] age, 71.1 [11.4] years; 43 [86%] male; 50 [100%] white) were enrolled in the study. The mean (SD) sum of the POSAS observer component scores was 10.7 (4.3) for the 2-mm interval side and 10.8 (3.5) for the 5-mm side at three months. No statistically significant difference was found in the mean (SD) sum of the patient component for the POSAS score between the 2-mm interval side (10.2 [4.7]) and the 5-mm interval side (11.5 [6.4]) at three months. No statistically significant difference was observed in mean (SD) scar width between the 2-mm side (0.9 [0.6] mm) and the 5-mm side (0.8 [0.4] mm).

Citation: Sklar LR, Pourang A, Armstrong AW, et al. Comparison of running cutaneous suture spacing during linear wound closures and the effect on wound cosmesis of the face and neck: a randomized clinical trial [published January 16, 2019 online ahead of print]. JAMA Dermatol. doi: 10.1001/jamadermatol.2018.5057.

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Should the Contralateral Tonsil Be Removed in Cases of HPV-Positive Squamous Cell Carcinoma of the Tonsil?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

Human papillomavirus-positive (HPV+) head and neck squamous cell carcinomas (SCC) are increasing in incidence worldwide. The palatine tonsils are the most commonly involved anatomical subsite, followed by the base of tongue and then the soft palate. Secondary primary malignancy (SPM) is a well-established phenomenon among patients with head and neck SCC and can present in up to 36% of patients within 20 years of their original diagnosis. Furthermore, synchronous tumors are defined as those that occur simultaneously with the index cancer; these tumors are present in approximately 4% of cases.

SPM is thought to arise secondary to field cancerization, a biological process by which prolonged exposure to carcinogens leads to independent malignant transformation at multiple sites. The prevalence of synchronous bilateral HPV+ SCC of the tonsil (SBTC) is largely unknown, and there is much controversy regarding routinely removing the contralateral tonsil. Fear of increased pain, bleeding, circumferential scarring, and functional impairment have all been cited as reasons to avoid contralateral tonsillectomy in these scenarios. Proponents of contralateral tonsillectomy, however, raise concerns over the potentially fatal consequences of missing occult contralateral disease. Another advantage is the resulting symmetric appearance of the palatal arches, which allows for improved oncologic surveillance and easier detection of tumor recurrence.

Given the important prognostic and therapeutic implications of identifying a SBTC, should the contralateral tonsil routinely be removed in cases of HPV+ squamous cell carcinoma of the tonsil (TSCC)?

Best Practice

The contralateral tonsil should routinely be removed in cases of suspected or known unilateral HPV+ TSCC. Furthermore, preoperative clinical exam findings and imaging studies including PET-CT should not be used to exclude the possibility of SBTC. Although there are reports of significant complications resulting from bilateral radical surgery, performing a routine contralateral tonsillectomy does not appear to increase rates of morbidity or complications, and the resulting symmetric palatal arch could potentially improve oncologic surveillance and detection of recurrence.

Furthermore, identifying a contralateral TSCC can dramatically alter treatment and prognosis. The patient may need further surgery and/or radiation therapy to the contralateral oropharynx and neck, which otherwise would not be indicated in unilateral disease. Although the true incidence of SBTC remains unknown, the oncologic outcome of missing the second primary and delaying treatment can be devastating and even fatal. Future prospective studies should be performed to identify any clinical disparities or differences in tumor characteristics that could improve preoperative identification of SBTC patients (Laryngoscope. 2019;129:1257–1258).

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Is Core Needle Biopsy Effective for Assessment of Head and Neck Lesions?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

Ultrasonography in combination with fine needle aspiration (FNA) has served as the primary line of investigation for head and neck lesions. In the 10% to 15% of cases for which FNAs yield nondiagnostic material, the next option is often excisional biopsy under general anesthesia. In patients who are poor surgical candidates, core needle biopsy (CNB) with a larger gauge needle under ultrasound guidance has emerged as a simple, minimally invasive, and accurate method for the diagnosis of head and neck lesions, especially when conservative treatment is likely. CNB has been shown to yield a higher sensitivity and specificity compared to FNA in head and neck lesions, including malignant lymphoma. Surveys show physicians are reluctant to incorporate this diagnostic method into practice due to concerns regarding bleeding, infection, nerve injury, and tumor cell seeding. This article reviews the evidence for the safety of CNB in the diagnosis of head and neck lesions, with an emphasis on the risk of tumor cell seeding and bleeding.

Best Practice

Based on current studies, ultrasound guided CNB is a minimally invasive and accurate diagnostic option for the assessment of head and neck lesions, including lymphoma. In comparison to FNA, CNB has achieved a higher accuracy in providing specific diagnoses, detecting malignancy, and identifying true neoplasms. CNB should be the procedure of choice in patients with multiple nondiagnostic FNAs prior to excisional biopsy. These studies have shown that CNB has enhanced accuracy and equivalent safety compared to FNA and lower rates of complications as compared to excisional biopsy (Laryngoscope. 2018;129:2669–2670)

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