Sutures vs staples
By reviewing the studies comparing sutures and staples, it may be
concluded that neither intervention results in any significant short
term cosmetic benefit. Oswal did note staples exhibited a small
advantage at 3 months (p=0.03). However, scar healing and remodelling
may take up to 12 months, meaning both groups could have had the
potential to recover over a more prolonged period of follow-up. Only dos
Santos followed-up patients beyond three months, meaning no studies
could accommodate for wound maturation or late scar complications such
as keloids.
Staples had a significantly faster closure time, a finding consistent
with systematic reviews across various specialties. Whilst prolonged
operative time is associated with an increased risk of post-operative
complications, it is debatable that a delay of seconds to minutes could
have a harmful influence on post-operative outcomes.
The choice of sutures and techniques across these studies is of
interest, as all made use of non-absorbable interrupted skin sutures.
Previous studies of facial lacerations found interrupted absorbable and
non-absorbable sutures have similar cosmetic outcomes and rates of
post-operative infection. However, non-absorbable sutures offer the
additional benefits not requiring removal and lower rates of wound
dehiscence; advantages that could be paralleled to a comparative study
with staples. The use of interrupted sutures may also confer another
source of bias, as systematic reviews have shown that this technique can
result in inferior cosmetic outcomes compared to subcuticular sutures.
Furthermore, in a systematic review of thyroid and parathyroid
surgeries, the cosmetic outcomes of subcuticular sutures were superior
to staples. This suggests the studies reviewed may be over-estimating
the cosmetic equivalency of sutures and staples by not comparing the
latter to a cosmetically superior suturing technique.
One study was weakly positive for a higher rate of wound complications
when closing with nylon sutures compared to staples (p=0.44), but this
was not documented in papers using silk sutures. This somewhat
contradicts established dogma that non-synthetic braided sutures may
generate a greater localised tissue reaction than synthetic
monofilaments, resulting in greater incidences of wound inflammation.
Notably, this paper does not describe use of post-operative intravenous
antibiotics or antiseptic wound dressings. Although a previous Cochrane
review could not draw any conclusions on the effectiveness of wound
dressings, meta-analyses have demonstrated post-operative intravenous
antibiotics can reduce the rate of surgical site infections in
non-contaminated wounds. Whilst the routine use of intravenous
antibiotics is not always indicated, it could be speculated that
infection rates could have been masked in those that used antibiotics in
their protocol.