Comparing Cosmetic Outcomes of Straight-Line Versus W-Plasty Techniques for Linear Postauricular Wound Closure: A Randomized Evaluator Blind Split-Scar Trial.

BACKGROUND: Surgeons' opinions vary on the cosmetic outcome of straight-line (SL) versus broken-line (W-plasty) closure methods. To date, no studies have compared the 2 techniques in the split-scar design model that resolves the confounding individual patient factors that affects the scar outcome. OBJECTIVE: Compare outcomes and wound cosmesis with SL versus W-plasty closure techniques. METHODS: This clinical trial was conducted with 50 linear surgical wounds randomized to SL closure on half and W-plasty on the other half. At 3 months, patients and 2 masked observers evaluated each scar using the Patient and Observer Scar Assessment Scale (Patient Observer Scar Assessment Scale [POSAS]). RESULTS: The mean (SD) sum of the POSAS observer component scores were 16.6 (6.18) for the SL side and 15.5 (6.37) for the W-plasty side ( p = .49). The mean (SD) sum of the POSAS patient scores were 14.4 (6.8) in SL and 15.1 (8.2) in W-plasty ( p = .59). The mean (SD) complications were 0.08 (0.06) for SL and 0.02 (0.14) for W-plasty ( p = .18). CONCLUSION: No statistically significant difference in wound cosmesis or complications was noted between SL versus W-plasty closure techniques. Surgeons may want to consider whether the extra time involved in placing zigzag W-plasty lines is worthwhile.

Aesthetic outcome of intermediate closure versus intermediate closure followed by 2-octyl cyanoacrylate: A randomized evaluator-blinded split-wound comparative effectiveness trial.

BACKGROUND: Dermatologic surgeons are increasingly using surgical adhesives in their practice. Studies comparing sutured wounds to those that utilize a combination of suturing and skin adhesive have not been previously conducted. OBJECTIVE: To compare the cosmetic outcome and patient wound care satisfaction of an intermediate suture closure with an intermediate suture closure followed by the application of 2-octyl cyanoacrylate (2-OCA). METHODS: Fifty patients were enrolled in a randomized, evaluator-blinded, split-scar study. Following intermediate sutured closure of a surgical defect, one side of the wound was randomized to receive an additional application of 2-OCA. After 3 months, the scar was assessed using the POSAS tool and patients reported wound care preferences. RESULTS: As the primary outcome measure, the mean sum of observer POSAS was 12.80 for sutured closure alone versus 12.40 for sutured closures followed by 2-OCA (P = .49). LIMITATIONS: Single-center study of a relatively homogenous population. CONCLUSION: Although there were no significant differences in scar cosmesis, both patients and observers tended to prefer the side with an additional application of 2-OCA in most POSAS components, in overall opinion, and in patient wound care satisfaction. Dermatologic surgeons may add this to their practice without sacrificing scar outcomes or patient satisfaction.

Update of penetrance estimates in Birt-Hogg-Dubé syndrome.

BACKGROUND: Birt-Hogg-Dubé (BHD) syndrome is a rare genetic syndrome caused by pathogenic or likely pathogenic germline variants in the FLCN gene. Patients with BHD syndrome have an increased risk of fibrofolliculomas, pulmonary cysts, pneumothorax and renal cell carcinoma. There is debate regarding whether colonic polyps should be added to the criteria. Previous risk estimates have mostly been based on small clinical case series. METHODS: A comprehensive review was conducted to identify studies that had recruited families carrying pathogenic or likely pathogenic variants in FLCN. Pedigree data were requested from these studies and pooled. Segregation analysis was used to estimate the cumulative risk of each manifestation for carriers of FLCN pathogenic variants. RESULTS: Our final dataset contained 204 families that were informative for at least one manifestation of BHD (67 families informative for skin manifestations, 63 for lung, 88 for renal carcinoma and 29 for polyps). By age 70 years, male carriers of the FLCN variant have an estimated 19% (95% CI 12% to 31%) risk of renal tumours, 87% (95% CI 80% to 92%) of lung involvement and 87% (95% CI 78% to 93%) of skin lesions, while female carriers had an estimated 21% (95% CI 13% to 32%) risk of renal tumours, 82% (95% CI 73% to 88%) of lung involvement and 78% (95% CI 67% to 85%) of skin lesions. The cumulative risk of colonic polyps by age 70 years old was 21% (95% CI 8% to 45%) for male carriers and 32% (95% CI 16% to 53%) for female carriers. CONCLUSIONS: These updated penetrance estimates, based on a large number of families, are important for the genetic counselling and clinical management of BHD syndrome.

Performing research and publishing in the peer-reviewed medical literature should be a requirement for completion of post-graduate residency and fellowship training.

Graduate medical education (GME) in the USA is an increasingly organized and formalized process overseen by regulatory bodies, notably the American Council of Graduate Medical Education (ACGME), and associated specialty-specific Residency Review Committees (RRCs) to ensure that trainees, including residents and fellows, receive comprehensive, high-quality didactic education, clinical training, and research experience. Among the required elements of GME, performance of independent research is emphasized less than clinical and didactic education. In general, there are no ACGME requirements that trainees successfully publish papers in the peer reviewed. Indeed, unlike as is the case with procedure case logs, there are no minimum thresholds for specific numbers of abstracts presented, posters accepted, or manuscripts published. As such, while residencies and fellowships in certain disciplines or institutions may require considerable, documented research activity, others may not. Since future attending physicians are expected to be experts in their fields, able to digest relevant medical knowledge, critically evaluate emerging findings in the literature, and lead multi-professional healthcare teams, they must have a level of facility with the medical literature than can only be acquired by having performed research and having published papers themselves. Publishing one paper during training is easily attainable for all trainees. Having this be an ACGME requirement will necessitate protected time, research methods education, and mentorship for trainees. This can be accomplished without disrupting the other elements of resident and fellow training. From an ACGME perspective, required scholarly activity will support the competencies of practice-based learning and improvement as well as professionalism. In lay terms, benefits will be a higher level of education and attainment for trainees, and a potentially higher standard of health care for our patients.

Focused update: Guidelines of care for the management of actinic keratosis.

BACKGROUND: Actinic keratoses (AKs) are rough scaly patches that arise on chronically UV-exposed skin and can progress to keratinocyte carcinoma. OBJECTIVE: In 2021, the American Academy of Dermatology published guidelines to assist in clinical decision-making for the management of AK. The purpose of this focused guideline update is to incorporate recently available evidence on the use of topical tirbanibulin to treat AK. METHODS: A multidisciplinary work group conducted a systematic review to evaluate data on the use of tirbanibulin for AK and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of the evidence and formulating and grading a clinical recommendation. The graded recommendation was voted on to achieve consensus. RESULTS: Two trials were identified, and analysis of the evidence resulted in 1 recommendation. LIMITATIONS: This analysis is based on the best available evidence at the time it was conducted. Long-term efficacy and safety data are not currently available. CONCLUSIONS: A strong recommendation for the use of topical tirbanibulin to join the currently recommended list of topical therapies for AK was made on the basis of the available evidence.

Interrupted subcuticular suture spacing during linear wound closures and the effect on wound cosmesis: a randomized evaluator-blinded split-wound comparative effectiveness trial.

BACKGROUND: Surgical reconstructions following Mohs micrographic surgery and standard surgical excisions are often closed with two layers of sutures: a deep subcuticular layer and a superficial cuticular layer. Some surgeons feel the need to place many deep sutures in order to reduce tension on cuticular sutures, as they believe this may decrease incidence of track marks and dehiscence, and lead to better cosmetic outcomes. However, others feel that a higher number of subcuticular sutures increases the risk of a suture reaction, which leads to patient anxiety and poorer wound cosmesis. To our knowledge, there are no studies published on the effect of subcuticular suture spacing on wound cosmesis. OBJECTIVES: To determine whether suturing with 1-cm interval subcuticular sutures results in better cosmetic outcomes than suturing with 2-cm interval subcuticular sutures. METHODS: Fifty patients were enrolled in a randomized clinical trial using a split-wound model, where half of the wound was repaired with sutures spaced 2 cm apart and the other half was repaired with sutures spaced 1 cm apart (ClinicalTrials.gov identifier NCT03327922). Both the evaluators and patients were blinded as to which side received which treatment. The scar was evaluated 3 months post-surgery by two blinded observers and the patients themselves using the Patient and Observer Scar Assessment Scale (POSAS), a validated scar assessment instrument. RESULTS: The total mean POSAS score for observers for the sides that received 1-cm interval subcuticular sutures and the sides that received 2-cm interval subcuticular sutures did not differ significantly at 3 months (P = 0·34). There was also no significant difference in the patient assessment scale score between the two sides at 3 months (P = 0·084). CONCLUSIONS: We found that 1-cm suture spacing was not significantly associated with improved overall cosmetic outcome compared with 2-cm suture spacing when evaluated by blinded observers or the patients themselves. Our results support the use of either interval. What is already known about this topic? Surgeons have differing opinions on the ideal frequency of subcuticular sutures for optimizing cosmetic outcomes and minimizing suture reactions. The effect of subcuticular suture spacing on wound cosmesis has not been previously explored in the literature. What does this study add? There was no significant difference in cosmetic outcome between 1-cm suture spacing and 2-cm suture spacing when evaluated by blinded observers and patients. Dermatology surgeons can use 2-cm suture spacing for increased efficiency, without significantly different cosmetic outcomes, detected by blinded observers and patients.

Evidence-Based Clinical Practice Guidelines for Extramammary Paget Disease.

IMPORTANCE: Extramammary Paget disease (EMPD) is a frequently recurring malignant neoplasm with metastatic potential that presents in older adults on the genital, perianal, and axillary skin. Extramammary Paget disease can precede or occur along with internal malignant neoplasms. OBJECTIVE: To develop recommendations for the care of adults with EMPD. EVIDENCE REVIEW: A systematic review of the literature on EMPD from January 1990 to September 18, 2019, was conducted using MEDLINE, Embase, Web of Science Core Collection, and Cochrane Libraries. Analysis included 483 studies. A multidisciplinary expert panel evaluation of the findings led to the development of clinical care recommendations for EMPD. FINDINGS: The key findings were as follows: (1) Multiple skin biopsies, including those of any nodular areas, are critical for diagnosis. (2) Malignant neoplasm screening appropriate for age and anatomical site should be performed at baseline to distinguish between primary and secondary EMPD. (3) Routine use of sentinel lymph node biopsy or lymph node dissection is not recommended. (4) For intraepidermal EMPD, surgical and nonsurgical treatments may be used depending on patient and tumor characteristics, although cure rates may be superior with surgical approaches. For invasive EMPD, surgical resection with curative intent is preferred. (5) Patients with unresectable intraepidermal EMPD or patients who are medically unable to undergo surgery may receive nonsurgical treatments, including radiotherapy, imiquimod, photodynamic therapy, carbon dioxide laser therapy, or other modalities. (6) Distant metastatic disease may be treated with chemotherapy or individualized targeted approaches. (7) Close follow-up to monitor for recurrence is recommended for at least the first 5 years. CONCLUSIONS AND RELEVANCE: Clinical practice guidelines for EMPD provide guidance regarding recommended diagnostic approaches, differentiation between invasive and noninvasive disease, and use of surgical vs nonsurgical treatments. Prospective registries may further improve our understanding of the natural history of the disease in primary vs secondary EMPD, clarify features of high-risk tumors, and identify superior management approaches.

Undermining during cutaneous wound closure for wounds less than 3 cm in diameter: a randomized split wound comparative effectiveness trial.

Undermining is thought to improve wound outcomes; however, randomized controlled data regarding its efficacy are lacking in humans. The objective of this randomized clinical trial was to determine whether undermining low to moderate tension wounds improves scar cosmesis compared to wound closure without undermining. Fifty-four patients, 18 years or older, undergoing primary linear closure of a cutaneous defect with predicted postoperative closure length of ≥ 3 cm on any anatomic site were screened. Four patients were excluded, 50 patients were enrolled, and 48 patients were seen in follow-up. Wounds were divided in half and one side was randomized to receive either no undermining or 2 cm of undermining. The other side received the unselected intervention. Three months, patients and 2 masked observers evaluated each scar using the Patient and Observer Scar Assessment Scale (POSAS). A total of 50 patients [mean (SD) age, 67.6 (11.5) years; 31 (64.6%) male; 48 (100%) white] were enrolled in the study. The mean (SD) sum of the POSAS observer component scores was 12.0 (6.05) for the undermined side and 11.1 (4.68) for the non-undermined side (P = .60). No statistically significant difference was found in the mean (SD) sum of the patient component for the POSAS score between the undermined side [15.9 (9.07)] and the non-undermined side [13.33 (6.20)] at 3 months. For wounds under low to moderate perceived tension, no statistically significant differences in scar outcome or total complications were noted between undermined wound halves and non-undermined halves.Trail Registry: Clinical trials.gov Identifier NCT02289859. https://clinicaltrials.gov/ct2/show/NCT02289859 .

Aesthetic outcome of simple cuticular suture distance from the wound edge on the closure of linear wounds on the head and neck: A randomized evaluator blinded split-wound comparative effect trial.

BACKGROUND: Little data support the optimal distance of cuticular suture placement from the wound edge to achieve the most cosmetically appealing scar. OBJECTIVE: To compare Patient and Observer Scar Assessment Scale (POSAS) scores for cutaneous sutures spaced 2 mm versus 5 mm from the wound edge in head and neck defects repaired via linear closure. METHODS: Fifty patients were enrolled in this randomized, evaluator blinded, split-scar study. Surgical wounds were repaired with cuticular sutures 2 mm from the wound edge on one side and 5 mm on the other. POSAS scores and scar width were compared 3 months postoperatively. RESULTS: The sum observer POSAS score for this study had a mean (SD) of 16.06 (6.49) on the 2-mm side and 15.82 (6.83) on the 5-mm side (P = .807). Similarly, no difference was seen between scar width with a mean (SD) of 0.100 cm (0.058 cm) on the 2-mm side and with mean (SD) 0.100 cm (0.076 cm) on the 5-mm side (P = .967). LIMITATIONS: Linear repairs were studied on head and neck defects after extirpation of cutaneous malignancies, resulting in a homogeneous elderly white patient population. CONCLUSION: Cuticular sutures placed 2 or 5 mm from the wound edge did not result in different cosmetic outcomes in linear closures on the head and neck.