Response to letter from Verdura et al.

To the Editor: We appreciate the thoughtful commentary provided by Verdura et al to our article on the use of a novel adhesive retention suture (ARS) device for closure of wounds during the COVID-19 pandemic.

Verdura et al cited important benefits of the ARS as closure of wounds with large substance loss and avoidance of flaps, grafts, and dermal substitutes. These benefits allow more primary closures of skin tumors that may have grown due to COVID-19-related delay in care. COVID-19 lock-downs have also affected upstream care of vascular and diabetic patients and resulted in a dramatic increase in the rate of amputations., Of note, the ARS is particularly useful for the closure of these lower limb amputations, where the rate of wound dehiscence and other complications is over 20%.

Verdura et al also suggested that the ARS is a unique hybrid method of wound closure in that it allows a large caliber (eg, 2-0 nylon) suture to be placed in the middle of the wound to manage tension, while the adhesive portion protects the skin. This protection is valuable for wound closures under intraoperative or postoperative tension.

We acknowledge that consensus documents, including those from NCCN, are in place to manage patients with cutaneous tumors during the COVID-19 pandemic and agree that there are many closure options that can limit postoperative patient visits including absorbable sutures and adhesives. We also agree that strict compliance to cleanliness and sterility are important when patients are removing their own sutures or ARS devices at home. To that end, patients should be given instructions to use scissors that can tolerate immersion in boiling water for 5 minutes and carefully cut one side of the knot in the percutaneous suture. For some patients, we use telemedicine to guide the patient in real time through the removal.

For facial defects closed with the ARS hybrid closure, Verdura et al found that central scarring was unacceptable due the percutaneous suture entry points. They solved this issue with higher-density absorbable dermal sutures and superficial adhesives. We agree that facial wounds present a unique challenge in restoring volume loss in an aesthetically pleasing manner without visible scarring. In many facial wound closures, the use of absorbable sutures and adhesives can avoid postoperative visits and provide good outcomes without the ARS. In facial closures for which we have used the ARS hybrid methods, patients chose this option because it was easy to understand and it avoided complications of a flap. While these patients have had acceptable results, we acknowledge that patient expectations for facial wound healing and cosmesis are generally higher than for truncal or extremity wounds.

The ARS hybrid method affords surgeons in all specialties as a new option for skin wound closure. While particularly useful for managing skin loss, it can also be helpful in cases in which there is an expectation of postoperative complications or swelling. Judicious use of the ARS can also allow for reduced patient visits in times of lock-down or other restrictions.

Conflict of interest

Founder, shareholder, officer and director of SUTUREGARD Medical, Inc (maker of HEMIGARD ARS in article).