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The Donati Stitch Revisited: Favorable Cosmetic Results in a Randomized Clinical Trial
Journal of Surgical Research 107, 131–134 (2002) doi:10.1006/jsre.2002.6486
The Donati Stitch Revisited: Favorable Cosmetic Results in a Randomized Clinical Trial J. B. Trimbos, M.D., Ph.D.,* ,1 R. Mouw, M.D.,* G. Ranke,* K. B. Trimbos,* and K. Zwinderman, Ph.D.† Departments of *Gynaecology and †Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands Submitted for publication January 24, 2002; published online July 24, 2002
INTRODUCTION Background. Literature on the cosmetic results of various surgical methods to close the skin is scarce. We sought to compare the cosmetic results of two different surgical techniques of skin closure after lower midline laparotomy Materials and methods. A randomized clinical trial compared a running nylon skin suture to interrupted Donati stitches in 58 patients undergoing gynecological surgery. Scar hypertrophy, scar width, scar color, the presence of cross-hatching marks, and a total scar score were assessed in all patients at 2 weeks, 6 months, and 12 months postoperatively. Results. On average closing the wounds with Donati stitches took 5 min longer than using a running suture (P > 0.001). The Donati sutures caused sifnificantly less cross-hatching at 2 weeks and 6 months postoperatively. At 1 year, the scar color following Donati closure was also significantly less pronounced than in the running suture arm. The total scar score was significantly better in the Donati arm at each of the three time periods of assessment. The difference at 6 months was equal to the difference at 1 year. Conclusions. Closing the skin of lower midline laparotomy wounds with Donati stitches resulted in a cosmetically better scar. Scar cosmetics of lower midline laparotomies could be improved by using interrupted Donati stitches instead of a running suture. The difference was significant at 2 weeks, 6 months, and 12 months postoperatively, but the magnitude of the difference was the same at 6 and at 12 months. © 2002 Elsevier Science (USA) Key Words: scar cosmetics; skin closure; Donati’s stitch; vertical mattrass suture; wound healing; laparotomy scar; wound eversion. 1 To whom correspondence should be addressed at Department of Gynaecology, Leiden University Medical Center, POB 9600, 2300RC, Leiden, The Netherlands. FAX: ⫹31.71.5248181. E-mail: [email protected].
The laparotomy scar is the only part of the operation that remains visible to the outer world and it carries the “signature of the surgeon” [1]. Considerations on scar cosmetics in the gynecological literature are scarce and the experience of plastic surgeons has to be looked at instead [2]. In benign gynecological surgery transverse Pfannenstiel or Maylard incisions are frequently used and they usually result in acceptable scars. Lower midline incisions, however, have to resist more strain on the scar because of the course of Langer’s elastic tension lines [3]. Lower midline incisions are frequently closed by means of a running over-and-over skin suture. Interrupted vertical mattrass sutures have been described by Donati [4]. These sutures serve three goals. First, they give a very precise adaptation of the opposite wound edges. Second, they are able to resist more tension on the wound edges, and third, they cause eversion of the incision line. This eversion might compensate for the effect of scar retraction during the further course of wound healing. This wound retraction might eventually lead to a cosmetically problematic, retracted scar. The present study was initiated to determine whether interrupted Donati skin sutures would result in a better cosmetic scar compared to the standard running suture. MATERIALS AND METHODS Patients undergoing lower midline laparotomy for a gynecological condition were randomized into an interrupted Donati group and a running suture group closing the skin. Donati skin stitches are also referred to as vertical mattress stitches. They have a far–far–near– near structure as the initial bites pass through skin and subcutaneous fat and the last two bites only comprise the dermal layer of the skin. By this composure a meticulous adaptation of the wound occurs as well as eversion of the edges. Randomization was done at the time
131
0022-4804/02 $35.00 © 2002 Elsevier Science (USA) All rights reserved.
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JOURNAL OF SURGICAL RESEARCH: VOL. 107, NO. 1, SEPTEMBER 2002
TABLE 1 Scoring System Used for Clinical Assessment of Laparotomy Scars Score
Hypertrophy
Width (mm)
Color
Cross-hatching
1 2 3 4
No elevation above surrounding skin Minimal elevation Hypertrophic but acceptable Distinct hypertrophy
⬍1 1–2 3–5 ⬎5
No difference from surrounding skin Minimal difference Marked difference Purple-blue scar, unacceptably different
Absent Slightly visible Clearly present but acceptable Unacceptable
of fascial closure by the method of sealed eveloppes. Negroid patients were excluded because of their tendency to produce hyperthropic scars and patients were stratified according to parity: nulliparous versus nonnulliparous. The study was approved by the local ethical committee and in all cases informed consent of the patient was obtained. In both arms, 4-O USP monofilament nylon (Ethilon; Ethicon; Johnson & Johnson, Sommerville, NJ) suture was used for skin closure. The peritoneum was left open and the fascia was closed with running 1 USP degradable polydioxanon suture (PDS; Ethicon; Johnson & Johnson). No stitches in the subcutaneous tissue were used and the skin sutures were removed on the 8th postoperative day. All sutures used were intended for operating room use. In all instances, closure of the abdominal wall was performed by a 4th-year resident under supervision of a staff gynecologist. Various clinical characteristics of the patients and the operations were registrated. Postoperatively, the wounds were assessed by means of a semiquantitative scar score (Table 1). Validation of this score has been described previously [1]. All patients received prophylactic antibiotics and subcutaneous low-dose heparine for prophylaxis of thromboembolism. The scars were assessed at three different time periods following surgery: at discharge (2nd postoperative week), 6 months, and 12 months, by an independent investigator (G.R.), blinded to the surgical technique used. The width of the scar was measured with calipers. Each of the four items of the score was assessed separately, together with a total sum score. Two-sided chi-square, Student’s t, or Mann–Whitney tests were used to assess statistically significant differences between randomization groups at a P level of ⬍0.05. The repeated measures of the sum score of the hypertrophy, width, color, and cross-hatching grades were analyzed with mixed-model ANOVA.
RESULTS
Twenty-seven patients were included in the Donati suture arm and 31 in the running suture arm. The two treatment arms were comparable with respect to various clinical characteristics (Table 2). Skin closure took significantly longer in the Donati arm (P ⬍ 0.001). There was a difference of the average closure time of 5.3 min. No patients were lost to follow-up, and in all cases a wound assessment shortly after surgery, after 6 months, and after 12 months was obtained. Of the various components of the scar score cross-hatching was significantly more prominent in the running suture arm at the early assessment as well as at 6 months following surgery. Color was significantly more pronounced in the running suture group at 12 months following surgery and scar width showed a trend of difference (P ⫽ 0.08; Table 3). The total scar scores are summarized in Table 4. In the Donati group the mean scores were significantly lower and indicative of a cosmetically superior scar at all three time points, and this was also true for the average scores of all the time periods combined (P ⫽ 0.004). The amount of difference between the scar scores of the running suture and the Donati group was not significantly different when the three time periods were compared (P ⫽ 0.87; Fig. 1). The decrease
TABLE 2 Distribution of Various Clinical and Surgical Characteristics among Patients in the Running Suture Arm (n ⴝ 31) and the Donati Suture Arm (n ⴝ 27)
Age (yrs): mean (SD) Length (m): mean (SD) Weight (kg): mean (SD) Diabetes mellitus: n (%) Chronic pulmonary disease: n (%) Use of corticosteroids: n (%) Use of cytostatic drugs: n (%) Postoperative radiation: n (%) Operating time (min): mean (SD) Blood loss (ml): median (range) Duration of skin closure (min): mean (SD) Contaminated wound: n (%)
Running suture
Donati suture
P value
52 (10) 1.67 (0.056) 75 (14) 2 (7%) 2 (7%) 0 (0%) 6 (19%) 4 (13%) 119 (54) 500 (10–2500) 7.9 (2.5) 1 (3%)
52 (12) 1.66 (0.089) 70 (13) 1 (4%) 2 (7%) 1 (4%) 6 (22%) 2 (7%) 103 (36) 400 (10–3000) 13.2 (4.8) 1 (4%)
0.98 0.62 0.19 0.64 0.89 0.28 0.79 0.49 0.19 0.31 ⬍0.001 0.92
TRIMBOS ET AL.: COSMETICS OF DONATI SKIN CLOSURE
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TABLE 3 Individual Scores of Scar Assessment Elements at 1 Year Postoperatively Parameter and score Hypertrophy 1 2 3 4 Width 1 2 3 4 Color 1 2 3 4 Cross-hatching 1 2 3 4
Running suture (n ⫽ 31)
Donati suture (n ⫽ 27)
17 (55%) 13 (42%) 1 (3%) —
20 (75%) 6 (22%) 1 (4%) —
5 (16%) 13 (42%) 8 (26%) 5 (16%)
7 (26%) 15 (56%) 3 (11%) 2 (7%)
4 (13%) 22 (71%) 5 (16%) —
11 (41%) 14 (52%) 2 (7%) —
24 (77%) 5 (16%) 2 (7%) —
23 (85%) 4 (15%) — —
P value
0.20
0.08
0.02
0.22
of the scar score during the first 6 months following surgery (running suture arm: 0.22, P ⫽ 0.63; Donati arm: 0.52, P ⫽ 0.15) was not significant. The decrease after 1 year was statistically significant in both arms (running suture arm: 1.0, P ⫽ 0.05; Donati arm: 1.22, P ⫽ 0.004). DISCUSSION
This study shows that the use of Donati skin sutures to close lower midline laparotomy wounds results in cosmetically better scars compared to a standard running suture. This difference was significant at the 2nd week following surgery, at 6 months, and after 1 year. The magnitude of the difference however was larger at 6 months and 1 year than at the early wound assessment. The price for a nicer scar was an extra operating TABLE 4 Mean Total Scar Scores (SD) among Patients in the Running Suture Arm (n ⴝ 31) and the Donati Suture Arm (n ⴝ 27)
Second week postoperatively Six months postoperatively One year postoperatively
Running suture
Donati suture
P value
8.29 (2.04) 8.06 (2.05) 7.29 (1.87)
7.33 (1.52) 6.81 (1.84) 6.11 (1.67)
0.050 0.018 0.015
FIG. 1. Mean difference between the running suture and Donati suture group regarding the total scar score (⫾ 95% confidence interval).
time of 5.3 min on average and this seems a negligible drawback with respect to a long-term improvement of cosmetics of the scar. Furthermore, a new method has been described in which vertical mattress stitches are tied with the same amount of eversion as the classic technique but in half the time [5]. The average improvement of the total scar score among the three time periods of assessment amounted to about 1.0. The question is whether this is of clinical significance. A difference of 1.0 in our semiquantitative assessment could mean the difference between minimal or marked color difference to the adjacent skin or between minimal elevation of the scar and hypertrophic scarring. Therefore, we believe that a consistent difference of this magnitude will definitely be of significance to the individual patient. In a broader perspective this study emphasizes the importance of wound eversion and precise adaptation of the wound edges for a better cosmetic result. Both phenomena are characteristics of vertical mattrass sutures [6]. Furthermore, these sutures have been associated with the capacity of reducing tension on the wound edges [7]. In addition, our findings indicate that wound assessment at 6 months after surgery is as reliable as assessment after 1 year. This has also been demonstrated by others [2]. Even a period of 3 months has been advocated as sufficiently long to assess the long-term healing profiles of the wound [8]. In conclusion interrupted vertical mattrass sutures give more favorable cosmetic results compared to a running suture in skin closure of lower midline laparotomy wounds. These sutures deserve more attention in view of their properties of wound eversion, meticulous adaptation, and the relieving of tension of the wound edges. REFERENCES 1.
Trimbos, J. B., Smeets, M., Verdel, M., and Hermans J. Cosmetic result of lower midline laparotomy wounds: Polybutester and nylon skin suture in a randomized clinical trial. Obstet. Gynecol. 82: 390, 1993.
134 2.
3. 4. 5.
6.
JOURNAL OF SURGICAL RESEARCH: VOL. 107, NO. 1, SEPTEMBER 2002 Niessen, F. B., Spauwen, P. H. M., and Kon, M. The role of suture material in hyperthrophic scar formation: Monocryl versus Vicryl-rapide. Ann. Plast. Surg. 39: 254, 1997. Langer, K. On the anatomy and physiology of the skin (1861). Translation by Tibson T. Br. J. Plast. Surg. 31: 93, 1978. Nockemann, P. F. Die chirurgische naht. 1st ed. Stuttgart: Georg Thieme Verlag, 1968, P. 101. Jones, J. S., Gartner, M., Drew, G., and Pack, D. S. The short hand vertical mattress stitch: Evaluation of a new suture technique. Am. J. Emerg. Med. 11: 483, 1993. Snow, S., Goodman, M. M., and Lemke, B. N. The shorthand
vertical mattress stitch—A rapid skin everting suture technique. J. Dermatol. Surg. Oncol. 15: 379, 1989. 7.
Hohenleutner, U., Egner, N., Hohenleutner, S., and Landthaler, M. Intradermal buried vertical mattress suture as sole skin closure: evaluation of 149 cases. Acta Derm. Venereol. 80: 344, 2000.
8.
Quinn, J., Wells, G., Sutcliffe, T., Jarmuske, M., Maw, J., Stiell, I., and Johns, P. Tissue adhesive versus suture wound repair at 1 year: Randomized clinical trial correlating early, 3 month, and 1 year cosmetic outcome. Ann. Emerg. Med. 32: 645, 1998.
The Donati Stitch Revisited: Favorable Cosmetic Results in a Randomized Clinical Trial J. B. Trimbos, M.D., Ph.D.,* ,1 R. Mouw, M.D.,* G. Ranke,* K. B. Trimbos,* and K. Zwinderman, Ph.D.† Departments of *Gynaecology and †Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands Submitted for publication January 24, 2002; published online July 24, 2002
INTRODUCTION Background. Literature on the cosmetic results of various surgical methods to close the skin is scarce. We sought to compare the cosmetic results of two different surgical techniques of skin closure after lower midline laparotomy Materials and methods. A randomized clinical trial compared a running nylon skin suture to interrupted Donati stitches in 58 patients undergoing gynecological surgery. Scar hypertrophy, scar width, scar color, the presence of cross-hatching marks, and a total scar score were assessed in all patients at 2 weeks, 6 months, and 12 months postoperatively. Results. On average closing the wounds with Donati stitches took 5 min longer than using a running suture (P > 0.001). The Donati sutures caused sifnificantly less cross-hatching at 2 weeks and 6 months postoperatively. At 1 year, the scar color following Donati closure was also significantly less pronounced than in the running suture arm. The total scar score was significantly better in the Donati arm at each of the three time periods of assessment. The difference at 6 months was equal to the difference at 1 year. Conclusions. Closing the skin of lower midline laparotomy wounds with Donati stitches resulted in a cosmetically better scar. Scar cosmetics of lower midline laparotomies could be improved by using interrupted Donati stitches instead of a running suture. The difference was significant at 2 weeks, 6 months, and 12 months postoperatively, but the magnitude of the difference was the same at 6 and at 12 months. © 2002 Elsevier Science (USA) Key Words: scar cosmetics; skin closure; Donati’s stitch; vertical mattrass suture; wound healing; laparotomy scar; wound eversion. 1 To whom correspondence should be addressed at Department of Gynaecology, Leiden University Medical Center, POB 9600, 2300RC, Leiden, The Netherlands. FAX: ⫹31.71.5248181. E-mail: [email protected].
The laparotomy scar is the only part of the operation that remains visible to the outer world and it carries the “signature of the surgeon” [1]. Considerations on scar cosmetics in the gynecological literature are scarce and the experience of plastic surgeons has to be looked at instead [2]. In benign gynecological surgery transverse Pfannenstiel or Maylard incisions are frequently used and they usually result in acceptable scars. Lower midline incisions, however, have to resist more strain on the scar because of the course of Langer’s elastic tension lines [3]. Lower midline incisions are frequently closed by means of a running over-and-over skin suture. Interrupted vertical mattrass sutures have been described by Donati [4]. These sutures serve three goals. First, they give a very precise adaptation of the opposite wound edges. Second, they are able to resist more tension on the wound edges, and third, they cause eversion of the incision line. This eversion might compensate for the effect of scar retraction during the further course of wound healing. This wound retraction might eventually lead to a cosmetically problematic, retracted scar. The present study was initiated to determine whether interrupted Donati skin sutures would result in a better cosmetic scar compared to the standard running suture. MATERIALS AND METHODS Patients undergoing lower midline laparotomy for a gynecological condition were randomized into an interrupted Donati group and a running suture group closing the skin. Donati skin stitches are also referred to as vertical mattress stitches. They have a far–far–near– near structure as the initial bites pass through skin and subcutaneous fat and the last two bites only comprise the dermal layer of the skin. By this composure a meticulous adaptation of the wound occurs as well as eversion of the edges. Randomization was done at the time
131
0022-4804/02 $35.00 © 2002 Elsevier Science (USA) All rights reserved.
132
JOURNAL OF SURGICAL RESEARCH: VOL. 107, NO. 1, SEPTEMBER 2002
TABLE 1 Scoring System Used for Clinical Assessment of Laparotomy Scars Score
Hypertrophy
Width (mm)
Color
Cross-hatching
1 2 3 4
No elevation above surrounding skin Minimal elevation Hypertrophic but acceptable Distinct hypertrophy
⬍1 1–2 3–5 ⬎5
No difference from surrounding skin Minimal difference Marked difference Purple-blue scar, unacceptably different
Absent Slightly visible Clearly present but acceptable Unacceptable
of fascial closure by the method of sealed eveloppes. Negroid patients were excluded because of their tendency to produce hyperthropic scars and patients were stratified according to parity: nulliparous versus nonnulliparous. The study was approved by the local ethical committee and in all cases informed consent of the patient was obtained. In both arms, 4-O USP monofilament nylon (Ethilon; Ethicon; Johnson & Johnson, Sommerville, NJ) suture was used for skin closure. The peritoneum was left open and the fascia was closed with running 1 USP degradable polydioxanon suture (PDS; Ethicon; Johnson & Johnson). No stitches in the subcutaneous tissue were used and the skin sutures were removed on the 8th postoperative day. All sutures used were intended for operating room use. In all instances, closure of the abdominal wall was performed by a 4th-year resident under supervision of a staff gynecologist. Various clinical characteristics of the patients and the operations were registrated. Postoperatively, the wounds were assessed by means of a semiquantitative scar score (Table 1). Validation of this score has been described previously [1]. All patients received prophylactic antibiotics and subcutaneous low-dose heparine for prophylaxis of thromboembolism. The scars were assessed at three different time periods following surgery: at discharge (2nd postoperative week), 6 months, and 12 months, by an independent investigator (G.R.), blinded to the surgical technique used. The width of the scar was measured with calipers. Each of the four items of the score was assessed separately, together with a total sum score. Two-sided chi-square, Student’s t, or Mann–Whitney tests were used to assess statistically significant differences between randomization groups at a P level of ⬍0.05. The repeated measures of the sum score of the hypertrophy, width, color, and cross-hatching grades were analyzed with mixed-model ANOVA.
RESULTS
Twenty-seven patients were included in the Donati suture arm and 31 in the running suture arm. The two treatment arms were comparable with respect to various clinical characteristics (Table 2). Skin closure took significantly longer in the Donati arm (P ⬍ 0.001). There was a difference of the average closure time of 5.3 min. No patients were lost to follow-up, and in all cases a wound assessment shortly after surgery, after 6 months, and after 12 months was obtained. Of the various components of the scar score cross-hatching was significantly more prominent in the running suture arm at the early assessment as well as at 6 months following surgery. Color was significantly more pronounced in the running suture group at 12 months following surgery and scar width showed a trend of difference (P ⫽ 0.08; Table 3). The total scar scores are summarized in Table 4. In the Donati group the mean scores were significantly lower and indicative of a cosmetically superior scar at all three time points, and this was also true for the average scores of all the time periods combined (P ⫽ 0.004). The amount of difference between the scar scores of the running suture and the Donati group was not significantly different when the three time periods were compared (P ⫽ 0.87; Fig. 1). The decrease
TABLE 2 Distribution of Various Clinical and Surgical Characteristics among Patients in the Running Suture Arm (n ⴝ 31) and the Donati Suture Arm (n ⴝ 27)
Age (yrs): mean (SD) Length (m): mean (SD) Weight (kg): mean (SD) Diabetes mellitus: n (%) Chronic pulmonary disease: n (%) Use of corticosteroids: n (%) Use of cytostatic drugs: n (%) Postoperative radiation: n (%) Operating time (min): mean (SD) Blood loss (ml): median (range) Duration of skin closure (min): mean (SD) Contaminated wound: n (%)
Running suture
Donati suture
P value
52 (10) 1.67 (0.056) 75 (14) 2 (7%) 2 (7%) 0 (0%) 6 (19%) 4 (13%) 119 (54) 500 (10–2500) 7.9 (2.5) 1 (3%)
52 (12) 1.66 (0.089) 70 (13) 1 (4%) 2 (7%) 1 (4%) 6 (22%) 2 (7%) 103 (36) 400 (10–3000) 13.2 (4.8) 1 (4%)
0.98 0.62 0.19 0.64 0.89 0.28 0.79 0.49 0.19 0.31 ⬍0.001 0.92
TRIMBOS ET AL.: COSMETICS OF DONATI SKIN CLOSURE
133
TABLE 3 Individual Scores of Scar Assessment Elements at 1 Year Postoperatively Parameter and score Hypertrophy 1 2 3 4 Width 1 2 3 4 Color 1 2 3 4 Cross-hatching 1 2 3 4
Running suture (n ⫽ 31)
Donati suture (n ⫽ 27)
17 (55%) 13 (42%) 1 (3%) —
20 (75%) 6 (22%) 1 (4%) —
5 (16%) 13 (42%) 8 (26%) 5 (16%)
7 (26%) 15 (56%) 3 (11%) 2 (7%)
4 (13%) 22 (71%) 5 (16%) —
11 (41%) 14 (52%) 2 (7%) —
24 (77%) 5 (16%) 2 (7%) —
23 (85%) 4 (15%) — —
P value
0.20
0.08
0.02
0.22
of the scar score during the first 6 months following surgery (running suture arm: 0.22, P ⫽ 0.63; Donati arm: 0.52, P ⫽ 0.15) was not significant. The decrease after 1 year was statistically significant in both arms (running suture arm: 1.0, P ⫽ 0.05; Donati arm: 1.22, P ⫽ 0.004). DISCUSSION
This study shows that the use of Donati skin sutures to close lower midline laparotomy wounds results in cosmetically better scars compared to a standard running suture. This difference was significant at the 2nd week following surgery, at 6 months, and after 1 year. The magnitude of the difference however was larger at 6 months and 1 year than at the early wound assessment. The price for a nicer scar was an extra operating TABLE 4 Mean Total Scar Scores (SD) among Patients in the Running Suture Arm (n ⴝ 31) and the Donati Suture Arm (n ⴝ 27)
Second week postoperatively Six months postoperatively One year postoperatively
Running suture
Donati suture
P value
8.29 (2.04) 8.06 (2.05) 7.29 (1.87)
7.33 (1.52) 6.81 (1.84) 6.11 (1.67)
0.050 0.018 0.015
FIG. 1. Mean difference between the running suture and Donati suture group regarding the total scar score (⫾ 95% confidence interval).
time of 5.3 min on average and this seems a negligible drawback with respect to a long-term improvement of cosmetics of the scar. Furthermore, a new method has been described in which vertical mattress stitches are tied with the same amount of eversion as the classic technique but in half the time [5]. The average improvement of the total scar score among the three time periods of assessment amounted to about 1.0. The question is whether this is of clinical significance. A difference of 1.0 in our semiquantitative assessment could mean the difference between minimal or marked color difference to the adjacent skin or between minimal elevation of the scar and hypertrophic scarring. Therefore, we believe that a consistent difference of this magnitude will definitely be of significance to the individual patient. In a broader perspective this study emphasizes the importance of wound eversion and precise adaptation of the wound edges for a better cosmetic result. Both phenomena are characteristics of vertical mattrass sutures [6]. Furthermore, these sutures have been associated with the capacity of reducing tension on the wound edges [7]. In addition, our findings indicate that wound assessment at 6 months after surgery is as reliable as assessment after 1 year. This has also been demonstrated by others [2]. Even a period of 3 months has been advocated as sufficiently long to assess the long-term healing profiles of the wound [8]. In conclusion interrupted vertical mattrass sutures give more favorable cosmetic results compared to a running suture in skin closure of lower midline laparotomy wounds. These sutures deserve more attention in view of their properties of wound eversion, meticulous adaptation, and the relieving of tension of the wound edges. REFERENCES 1.
Trimbos, J. B., Smeets, M., Verdel, M., and Hermans J. Cosmetic result of lower midline laparotomy wounds: Polybutester and nylon skin suture in a randomized clinical trial. Obstet. Gynecol. 82: 390, 1993.
134 2.
3. 4. 5.
6.
JOURNAL OF SURGICAL RESEARCH: VOL. 107, NO. 1, SEPTEMBER 2002 Niessen, F. B., Spauwen, P. H. M., and Kon, M. The role of suture material in hyperthrophic scar formation: Monocryl versus Vicryl-rapide. Ann. Plast. Surg. 39: 254, 1997. Langer, K. On the anatomy and physiology of the skin (1861). Translation by Tibson T. Br. J. Plast. Surg. 31: 93, 1978. Nockemann, P. F. Die chirurgische naht. 1st ed. Stuttgart: Georg Thieme Verlag, 1968, P. 101. Jones, J. S., Gartner, M., Drew, G., and Pack, D. S. The short hand vertical mattress stitch: Evaluation of a new suture technique. Am. J. Emerg. Med. 11: 483, 1993. Snow, S., Goodman, M. M., and Lemke, B. N. The shorthand
vertical mattress stitch—A rapid skin everting suture technique. J. Dermatol. Surg. Oncol. 15: 379, 1989. 7.
Hohenleutner, U., Egner, N., Hohenleutner, S., and Landthaler, M. Intradermal buried vertical mattress suture as sole skin closure: evaluation of 149 cases. Acta Derm. Venereol. 80: 344, 2000.
8.
Quinn, J., Wells, G., Sutcliffe, T., Jarmuske, M., Maw, J., Stiell, I., and Johns, P. Tissue adhesive versus suture wound repair at 1 year: Randomized clinical trial correlating early, 3 month, and 1 year cosmetic outcome. Ann. Emerg. Med. 32: 645, 1998.