Cosmetic Outcomes of Three Skin Closure Techniques for Submandibular Surgical Incisions in a Nigerian Tertiary Hospital: A Comparative Cosmetic Outcomes of Three Skin Closure Techniques for Submandibular Surgical Incisions in a Nigerian Tertiary Hospital: A Comparative Study
Authors: Ogundele Abdulahi Ademola , Abdul Rasheed Dr. Suleiman , Olushola Ibiyinka Dr. Amole , Akinwale Adeyemi Dr. Efunkoya , Kelvin Uchenna Omeje 
Published: February 2025

ABSTRACT
Introduction
The face is an important part of the body for identification, communicative and adornment roles. Due to its prominence, Injuries and scars on the face have psychological impact on individuals living with them. Besides placement of incisions at the junction of the facial aesthetic units, orientation of surgical incisions along skin creases, and paying attention to surgical principles during wound closure to prevent unacceptable surgical scars, the technique used for closure of surgical wounds also influences the cosmetic outcome of their scars. There is paucity of studies on the cosmetic outcomes of different closure techniques in the maxillofacial region among Africans.
Aim of the study
This study aimed at comparing cosmetic outcomes following closure of submandibular incisions using subcuticular suturing, tissue adhesive, and percutaneous stapler - among maxillofacial surgical patients at the Aminu Kano Teaching Hospital, Kano (AKTH). Complications and duration of wound closure for each of the three techniques were also assessed.

Materials and methods
The study was a prospective cross-sectional study with a calculated size of 60 subjects recruited and randomly allotted into three groups A, B, and C at AKTH. Group A had subcuticular wound closure of submandibular incisions, while groups B and C had tissue adhesive and staples closures of submandibular incisions respectively. Intraoperatively, each wound’s length (centimeters) and closure time(minutes), were recorded, and the closure time per unit length (min/cm) for each wound was calculated and recorded. The Patient and Observer Scar Assessment Scale (POSAS) was used to assess cosmetic outcomes of the incision scars on postoperative days 10, 30 and 90 and comparisons of the POSAS scores and closure times per unit lengths of the wounds were done using Kruskal Wallis statistical test. The Subjects were also assessed for the presence of abscess and dehiscence on postoperative day (POD) 7. The level of statistical significance was set at p≤0.05.
Results
Fifty-six subjects with ages 18 to 60 years (mean=35±12years) and a male: female ratio of 2.3:1. completed the study. Patient scale scores of POSAS showed a significant statistical difference (p ≤ 0.05) in outcome scores on POD10 (p<0.001) and POD30 (p=0.04) with tissue adhesive scars having the best cosmetic rating on both days.
The Observer scale scores showed that wound closure with tissue adhesives had a significantly better outcome on POD10(p<0.001). There was no significant difference in observer outcome scores between the 3 closure techniques on POD30 (p=0.12) and POD90 (p=0.73)
Analysis of the closure time per unit wound length showed that the subcuticular technique had the longest closure time per unit length, mean = 2.01± 0.54min/cm. Tissue adhesive had a mean = 0.45± 0.65min/cm, while staple had the shortest closure time per unit length, mean=0.18±0.03min/cm. There was a statistically significant difference in closure time across all wound closure techniques (p < 0.001)
Two subjects had wound dehiscence in the tissue adhesive group while four subjects had wound dehiscence in the staple group. There was no wound dehiscence in the subcuticular group. The incidence of wound dehiscence was however not statistically significant. (p = 0.19).

Conclusion
In the early postoperative period, tissue adhesive yielded the best cosmetic outcome compared to subcuticular suturing and staples for surgical closures. However, irrespective of the wound closure type employed, the cosmetic outcome of the scar may eventually be similar. The staple was the fastest for wound closure among the three closure techniques and may help reduce the operation time if employed. The incidence of wound complications with the three different wound closure techniques was similar.