David A. Wrone

Techniques for Cutaneous Sutured Closures: Variants and Indications

Many different suture techniques are routinely used by cutaneous surgeons for the closure of surgical wounds. This paper reviews several common suture techniques and their associated subtypes. In particular, for each technique, we discuss the method for placement, generally accepted indications, controversies regarding utility, and objective evidence of efficacy.

Outcomes Research/Evidence‐Based Medicine: A New Feature

OURS IS a pragmatic and open-minded field. Dermatologic surgeons are doers who appropriate rapidly evolving technologies to best serve their patients. Thus, it is natural that this journal should initiate a new feature devoted to ‘‘Outcomes Research/EvidenceBased Medicine.’’ Like new materials and methods in the operating suite, the results of outcomes research can be useful tools for improving surgeries. Several types of outcomes investigations are particularly relevant to dermatologic surgery: (1) structured reviews and meta-analyses of the literature, which pose a clinically relevant question and then mine the information in previously published articles to produce answers and treatment recommendations; (2) analyses of existing databases, which use statistical methods to process information about large numbers of patients; (3) survey studies, which use questionnaire measures to elicit patient or physician opinions; (4) prospective trials, which enroll human subjects and use sound methods to address pressing questions; and (5) philosophical articles, which aim to determine the questions worth asking. The overarching goal is to organize information intelligently. Given the volume of research currently being conducted, we require techniques to extract the information that is most salient. For prospective studies, easily implementable improvements in method can greatly improve the reliability of the data. Among the questions amenable to outcomes research are which surgical technique or basket of techniques for achieving a particular result is (1) more cost-effective or lower cost, (2) associated with an objectively higher quality result, (3) most likely to have a long-lasting effect, (4) likely to induce greater patient satisfaction, (5) least painful or inconvenient, and (6) safest. Pertinent issues in clinical epidemiology, such as the incidence and prevalence of diseases or the current volume of specific procedures, are also a part of evidence-based medicine. This inaugural article in this section critically reviews the literature pertaining to the effectiveness of cryotherapy for basal cell carcinomas. English language articles from several databases are evaluated. A formal meta-analysis, which would entail statistically combining all of the individual cases observed by the various authors, was rendered impractical because of the significant methodologic differences among articles. Indeed, the conclusions of this review are humbling: Even for so long-standing, ubiquitous, and mundane a therapy as cryotherapy of basal cell carcinoma, there is a dearth of convincing information about efficacy. However, this is no cause for discouragement. It is always better with the truth, for acceptance of deficiency is a prerequisite to subsequent correction. Cryotherapy is popular among many patients and physicians because it is an easily applied and widely available modality. However, in the absence of convincing data about cryotherapy’s usefulness for basal cell carcinoma, its scope of relevance for this indication should be re-evaluated. Currently, we have some data suggesting that cryotherapy works well in experienced hands. The role of cryotherapy in a stateof-the-art dermatologic surgeon’s office is less clear. Logically, the absence of margin control, the inability to be actively tissue sparing, and the many other difficult-to-control treatment variables (e.g., skin thickness, duration of freeze, angle and dispersion of coolant, tumor-specific factors) suggest that cryotherapy is difficult to standardize. Moreover, successful deep freezes are likely to be associated with significant discomfort, recovery time, and scarring. New trials are needed to provide a better answer regarding cryotherapy for basal cell carcinoma. Such studies should include (1) an extremely well-defined, replicable treatment technique; (2) the training of relative novices in this technique to make sure that it is reliably teachable; (3) pretreatment and posttreatment biopsy confirmation; (4) sufficient numbers to achieve statistical significance. An ideal trial would be a side-by-side comparison with excision or some other standard treatment approach. In the future, Dermatologic Surgery will be actively soliciting manuscripts for the ‘‘Outcomes Research/ Evidence-Based Medicine’’ section. Articles should meet the journal’s general guidelines for submissions. Additionally, prospective authors are encouraged to contact the feature editors (e-mail: murad@alam.com) to discuss questions and concerns as well as possible topics.