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Prospective clinical trial comparing barbed dermal suture and interrupted suture closure of the anterolateral thigh flap donor site in a Taiwanese population based on the Vancouver scar scale and the patient and observer scar assessment scale

      Dear sir,
      The anterolateral thigh (ALT) flap is ideal for soft tissue reconstruction. Most of donor sites can be primarily closed. Boca
      • Boca R.
      • Kuo Y.R.
      • Hsieh C.H.
      • Huang E.Y.
      • Jeng S.F.
      A reliable parameter for primary closure of the free anterolateral thigh flap donor site.
      showed that flap width–to–thigh circumference (WtTC) ratio is reliable parameter. All cases can be primarily closed if flap WtTC ratio is <16%.
      Unsatisfied hypertrophic scar occurs around 19%
      • Kimata Y.
      • Uchiyama K.
      • Ebihara S.
      • Sakuraba M.
      • Iida H.
      • Nakatsuka T.
      • Harii K.
      Anterolateral thigh flap donor-site complications and morbidity.
      . Theoretically, possible risk factors include tension, suture material, body mass index (BMI), and WtTC. Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment scale (POSAS) are scientific tools for linear scar evaluation
      • Durani P.
      • McGrouther D.A.
      • Ferguson M.W.
      Current scales for assessing human scarring: a review.
      . However, there is no study demonstrated predominant factor of scar formation in ALT flap donor site based on VSS and POSAS. Nylon is traditionally available suture material, and barbed suture is newly time-saving one.
      This study was designed to compare the esthetic results between 4 - 0 nylon and 3–0 V-Loc 90 barbed suture (VLoc, Covidien, North Haven, CT, USA). The VLoc was used in closing donor site of ALT flap for head and neck cancer reconstruction. All deep sutures were made with interrupted 2–0 and 3–0 vicryl in same tension-free method. Prospective clinical trials comparing VLoc and nylon for 92 ALT flaps in 90 consecutive patients were performed (May 2016–February 2017). Patient profile included age, sex, BMI, and width and length of ALT flap.
      The desired flap width, midpoint between anterior superior iliac spine and superior lateral border of patella (M point circumference), midpoint of designed ALT flap (m point circumference), and WtTC ratio were recorded before surgery. This study hypothesized that greater WtTC ratio will cause more tension and contribute to worse scar based on the study by Boca
      • Boca R.
      • Kuo Y.R.
      • Hsieh C.H.
      • Huang E.Y.
      • Jeng S.F.
      A reliable parameter for primary closure of the free anterolateral thigh flap donor site.
      . Therefore, circumferences of the M and m points were recorded before harvesting of ALT flap. The flap width was evaluated by pinch test. Every case was prospectively enrolled if WtTC ratio (<16%) meets criteria. Post-operative care includes sterile tape coverage and neomycin with gauze dressing. The sterile tapes and nylon were removed in postoperative week 2. Patients were asked to use sterile tape for scar care for 6 months. All cases were followed up in postoperative months 1–6 and 7–12. Two well-trained plastic surgeons recorded widest scar width, completing VSS and POSAS questionnaire. The outcome assessment was not double-blinded. Statistical Analysis were conducted using Pearson correlation test for risk factors, and independent t-test for numerical data. The China Medical University Hospital Ethics Committee approved this study, and patients gave written informed consent.
      Included in this study were 92 ALT flaps in 90 patients (May 2016 to February 2017). The VLoc (72.0%; 36/50) and nylon groups (76.2%; 32/42) completed two-stage follow-up. Factors in basic patient profile were normally distributed except for sex (female predominated VLoc group). One flap failure occurred and no donor site complications (e.g., wound infection, dehiscence, and seroma) existed.
      No significant correlation existed between scar score and age, BMI, ALT width, and M and m point circumferences. Neither flap width to M (W/M ratio) nor to m ratio (W/m ratio) was found to correlated with final scar (Table 1). The result does not support the initial hypothesis wherein greater tension was derived from higher BMI, wider ALT width, and higher WtTC ratio which does not contribute to the worsening of thigh scar in ALT flap donor site. VLoc showed significantly better cosmetic results (Table 2). In VSS, results in postoperative 1–6 months (VLoc vs. nylon, 3.72 ± 2.15 vs. 6.59 ± 1.84; p = 0.000) and postoperative 7–12 months (VLoc vs. nylon, 2.75 ± 2.44 vs. 5.19 ± 2.73; p = 0.000) showed significant difference. When using POSAS, VLoc also achieved better score either by patient (P_POSAS) or observer (O_POSAS). P_POSAS (VLoc vs. nylon, 11.56 ± 3.24 vs. 18.79 ± 7.61; p = 0.000) and O_POSAS (VLoc vs. nylon, 15.51 ± 6.66 vs. 26.44 ± 8.83; p = 0.000) at postoperative 1–6 months, P_POSAS (VLoc vs. nylon, 11.42 ± 6.12 vs. 16.41 ± 5.31; p = 0.001) and O_POSAS (VLoc vs. nylon, 14.83 ± 8.45 vs. 26.81 ± 11.21; p = 0.000) at postoperative 7–12 months were also significantly better in the VLoc group. The mean final scar width at postoperative 7–12 months in VLoc group is significantly reduced around 3 mm than nylon group.
      Table 1Determining Factors Contributing to The Scores of Vancouver Scar Scale and Patient and Observer Scar Assessment Scale.
      VLoc (6–12 month)N = 36
      VSS (Correlation)p valueP_POSAS (Correlation)p valueO_POSASp valueScar Width (Correlation)p value
      Age−0.2460.108−0.0360.818−0.1590.301−0.2870.059
      Body mass index0.1910.2150.2210.150.1380.371−0.0270.861
      ALT width−0.2420.113−0.280.065−0.1210.436−0.1620.294
      ALT length−0.310.041−0.2890.057−0.2070.177−0.1550.316
      M point circumference0.1910.2140.0810.6010.0280.856−0.1960.202
      m point circumference0.1180.4440.150.33−0.0090.955−0.1460.344
      W/M ratio−0.2880.058−0.2580.09−0.0910.5580.0080.957
      W/m ratio−0.2610.087−0.3120.04−0.0880.57−0.010.951
      Nylon (6–12 month)N = 32
      VSS (Correlation)p valueP_POSAS (Correlation)p valueO_POSASp valueScar Width (Correlation)p value
      Age−0.0040.981−0.0550.74−0.0550.738−0.2770.087
      Body mass index−0.0250.879−0.1020.535−0.0330.841−0.0620.708
      ALT width0.0110.948−0.1160.481−0.040.81−0.0370.823
      ALT length−0.1030.533−0.1220.461−0.1840.262−0.2070.205
      M point circumference−0.0480.7710.852−0.3010.0010.9960.070.673
      m point circumference0.0080.961−0.030.8550.030.8560.0840.609
      W/M ratio0.0450.786−0.0490.769−0.0140.931−0.0530.748
      W/m ratio0.0010.995−0.0580.724−0.0510.759−0.0830.617
      # VSS: Vancouver Scar Scale.
      # POSAS: patient and observer scar assessment scale.
      # P_POSAS: POSAS scores provided by patient.
      # O_POSAS: POSAS scores provided by observer.
      # W/M ratio: WtTC of M point.
      # W/m ratio: WtTC of m point.
      # Statistics: Pearson Correlation test.
      Table 2Two Staged Follow-up for Scar Evaluation.
      VLocNylon95% Confidence Intervalp- value
      0–6 monthN = 39N = 34
      Mean ± SD (Range)Mean ± SD (Range)
      VSS score3.72 ± 2.15 (0–8)6.59 ± 1.84 (2–9)(-3.81–-1.93)0.000
      P_POSAS11.56 ± 3.24 (7–24)18.79 ± 7.61 (7–38)(-10.06–-4.40)0.000
      O_POSAS15.51 ± 6.66 (7–38)26.44 ± 8.83 (8–42)(-14.63–-7.22)0.000
      7–12 monthN = 36N = 32
      Mean ± SD (Range)Mean ± SD (Range)
      VSS score2.75 ± 2.44 (0–10)5.19 ± 2.73 (1–11)(-3.69–-1.19)0.000
      P_POSAS11.42 ± 6.12 (7–33)16.41 ± 5.31 (7–28)(-7.78–-2.20)0.001
      O_POSAS14.83 ± 8.45 (7–49)26.81±11.21 (9–59)(-16.75–-7.20)0.000
      Scar width (mm)5.31 ± 3.42 (2–14)8.28 ± 3.26 (1–15)(-4.60–-1.35)0.000
      # VSS: Vancouver Scar Scale.
      # POSAS: patient and observer scar assessment scale.
      # P_POSAS: POSAS scores provided by patient.
      # O_POSAS: POSAS scores provided by observer.
      # Statistics: independent t-test. SD: standard deviation.
      Limitations include small sample size and significant selection bias (female predominated and additional financial burden 60 USD in VLoc group). Also, patients were excluded if pinch test indicated primary closure impossible.
      In conclusions, VLoc is a safe, cosmetic, and time-saving material in the closure of ALT flap donor site. Based on VSS and POSAS, this is the first study providing an objective evaluation of thigh scar. Two-staged follow-up in a year significantly provide better scar scores both by the patient and physicians.

      Funding

      None.

      Ethical approval

      Not required.

      Declaration of Competing Interest

      None.

      Reference

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        • Kuo Y.R.
        • Hsieh C.H.
        • Huang E.Y.
        • Jeng S.F.
        A reliable parameter for primary closure of the free anterolateral thigh flap donor site.
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        • Uchiyama K.
        • Ebihara S.
        • Sakuraba M.
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        • Nakatsuka T.
        • Harii K.
        Anterolateral thigh flap donor-site complications and morbidity.
        Plast. Reconstr. Surg. 2000; 106: 584-589
        • Durani P.
        • McGrouther D.A.
        • Ferguson M.W.
        Current scales for assessing human scarring: a review.
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