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.