An international clinician survey CompAring Nonabsorbable Vs. Absorbable sutures for Skin surgery: the CANVAS study.

dear editor, Skin lesion excision is performed frequently, and the clinical and health economic burdens are increasing commensurate with skin cancer incidence. , Absorbable sutures (AS), including rapidly absorbable sutures or nonabsorbable sutures (NAS), can be used for epidermal closure following excisional skin surgery. There is low‐quality evidence supporting suture choice in this circumstance, which may be influenced by various factors, including clinician/patient preference, access to suture removal, anatomical site, cosmesis, complication risk and cost. The CANVAS clinician survey assessed current opinions on suture use in the UK/Republic of Ireland and Australia/New Zealand as part of the feasibility work for a randomized controlled trial (RCT) comparing AS and NAS.

The online survey (available at https://is.gd/CanvasStudy) was developed by a steering group (n = 7) of plastic surgeons and dermatologists. It was distributed via UK and Australasian collaborator networks using REDCap©. Data collection occurred between 1 September 2020 and 15 April 2021. Respondents were asked about factors influencing suture choice and suture preferences, including the impact of COVID‐19. Data were analysed using descriptive statistics (Stata, StataCorp LLC, College Station, TX, USA).

In total, 375 surveys were completed [UK/Republic of Ireland, n = 297 (79%)]. Most respondents were consultants or associate specialists (n = 206, 55%; modal age group 36–50 years). The three highest represented specialties were Dermatology (n = 165, 44%), Plastic Surgery (n = 112, 30%) and General Surgery (n = 28, 7%). Subsequent interspecialty comparisons focus on the two largest respondent groups, Dermatology and Plastic Surgery.

The importance of various factors that influence suture choice was ranked by respondents on a scale of 0–100. The highest‐ranked factors were anatomical location [median score 88, interquartile range (IQR) 78–98], tension across wound (87, IQR 76–97), wound dehiscence (87, IQR 76–97) and long‐term scar appearance (87, IQR 78–98).

Prior to the COVID‐19 pandemic, most clinicians preferred NAS for epidermal closure on the face (n = 274, 73%) and body (n = 205, 55%) (Table 1). Preference for NAS was higher among clinicians from Australia/New Zealand than from the UK/Republic of Ireland, for both the face (84% vs. 72%; P < 0·05) and body (77% vs. 52%; P < 0·001). Significantly more dermatologists preferred NAS for epidermal closure on the body than plastic surgeons (81% vs. 19%, P < 0·001). When AS was chosen, the preferred suture material for the face was rapidly absorbable (n = 51, 54%), and for the body was absorbable monofilament (n = 104, 66%). However, there was significant specialty variation. For example, regardless of anatomical site, most plastic surgeons preferred absorbable monofilaments (face, 40%; body, 77%), and most dermatologists preferred rapidly absorbable sutures (face, 82%; body, 47%). The preferred suture for securing a full‐thickness skin graft to a facial wound was AS overall (n = 215, 58%) and by plastic surgeons (n = 81/112, 72%), but not dermatologists, who preferred NAS (n = 84/161, 52%); P < 0·001. Many respondents reported changing suture preference during COVID‐19 towards using more AS (n = 191, 51%) and planned to maintain this change after easing of restrictions (n = 126, 66%). This change was more common in the UK/Republic of Ireland than Australia/New Zealand (59% vs. 22%); P < 0·001.

Table 1

Pre‐COVID‐19 suture preferences for epidermal closure following skin lesion excision by anatomical location

Suture preference	Anatomical location of the lesion, n (%)
	Face	Body
Epidermal suture material
None	6 (2)	13 (3)
Absorbable	95 (25)	157 (42)
Nonabsorbable	274 (73)	205 (55)
Absorbable suture material used for epidermal closure
Braided	9 (9)	5 (3)
Braided antimicrobial	6 (6)	9 (6)
Monofilament	29 (31)	104 (66)
Rapidly absorbable	51 (54)	39 (25)
Securing full‐thickness skin graft to facial wounda
Nonabsorbable sutures	141 (38)
Absorbable (all types)	215 (58)
Braided	45 (12)
Braided antimicrobial	12 (3)
Monofilament	33 (9)
Monofilament antimicrobial	5 (1)
Rapidly absorbableb	120 (32)
None (e.g. glue or tape)	9 (2)
Staples	6 (2)

Bold text indicates the most frequent response. aMissing data, n = 4 (dermatology responses). bEither braided or nonbraided.

Respondents also compared AS vs. NAS with respect to patient outcomes, using a scale of 0 (AS inferior) to 100 (AS superior). On average, they rated AS equivalent to NAS with regard to cosmetic outcome (median score 50%, IQR 25–50) and complications (50%, IQR 25–50), but superior for patient satisfaction (61%, IQR 50–79).

Most clinicians (n = 308, 82%) indicated a willingness to randomize patients to an RCT comparing AS and NAS. Most were willing to randomize for excisions on the body and face (n = 190, 62%), followed by the body only (n = 99, 32%) and face only (n = 19, 6%). When asked to select the earliest possible time to assess scar outcome, most respondents chose 3 months (n = 146, 39%) followed by 6 months (n = 92, 25%) and 12 months (n = 60, 16%).

In conclusion, the COVID‐19 pandemic has led to clinicians reporting a change in epidermal suture preference from NAS to AS, particularly in the UK/Republic of Ireland, possibly due to geographical variation in COVID‐19 rates. Further work is required to see if this change is sustained. One potential limitation of this work (and all self‐reported surveys) is response bias, limiting generalizability. There is significant individual, interspecialty and geographical variation in clinician opinion regarding suture choice (AS vs. NAS) for epidermal closure, and the impact of suture type on clinical and patient‐reported outcomes. Some series have reported equal cosmetic results with AS or NAS for superficial closure on the face at 4 months. This highlights the need for a definitive RCT; if noninferior, using AS may reduce healthcare costs associated with suture removal or supply (when used for both deep and superficial closure).

Author contributions

Alice Lee: Data curation (lead); formal analysis (lead); project administration (lead); writing – original draft (lead); writing – review and editing (lead). Guy Stanley: Conceptualization (supporting); data curation (equal); methodology (supporting); project administration (equal); writing – review and editing (equal). Matthew Gardiner: Conceptualization (supporting); methodology (lead); project administration (equal); software (lead); supervision (lead); writing – review and editing (supporting). Jonathan M. Batchelor: Conceptualization (lead); methodology (equal); supervision (equal). Rachel Angharad Abbott: Conceptualization (lead); methodology (equal); supervision (equal). Aaron Wernham: Conceptualization (lead); methodology (lead); supervision (lead); visualization (lead); writing – review and editing (equal). David Veitch: Conceptualization (lead); methodology (lead); supervision (lead); visualization (lead); writing – review and editing (equal).

Appendix S1 Full list of CANVAS Collaborators (in alphabetical order).

Appendix S2 Full list of participating institutions.

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