CELESTE, Neill Sebastien D.

Date of Rotation: June 9-15, 2023

APMC Midyear Intern

Journal Title:
Scar Prevention With Prolonged Use of Tissue Adhesive Zipper Immediately After Facial
Surgery: A Randomized Controlled Trial

Zongan Chen, PhD ; Yunbo Jin, PhD; Yun Zou, MD; Yajing Qiu, MD;
Li Hu, PhD; Lei Chang, PhD; Hui Chen, PhD; and Xiaoxi Lin, PhD

INTRODUCTION
I. BACKGROUND
A. Anatomy and Physiology of the Skin
The skin is the largest organ of the body, covering an area of approximately 2 m2. The
skin is composed of the cutis (including the dermis and epidermis), subcutaneous tissue,
and skin appendages. The epidermis, which is derived from ectoderm, is the outermost
layer of the skin and is mainly composed of keratinocytes. The dermis, which is derived
from mesoderm, is located underneath the epidermis and is mainly composed of elastic
fibers, type I collagen, and connective tissue. It is formed by the papillary dermis and the
reticular dermis. The subcutaneous tissue, which is derived from the mesoderm, is the
innermost layer of the skin and is mainly composed of fat and connective tissue. Skin
appendages are derived from the skin and include hair, nails, and glands. The main
functions of the skin are protection (barrier against ultraviolet radiation, microorganisms,
and water loss), the synthesis of vitamin D, detection of sensation (e.g., touch, temperature,
pain), and the regulation of body temperature.

Structure of the Skin

The skin is composed of several layers, which are categorized as follows (from
superficial to deep).

CUTIS
EPIDERMIS
- Derived from the ectoderm, the epidermis is the outermost and non vascularized layer
of the skin that maintains the skin’s barrier function. It is primarily composed of
keratinocytes, which constantly regenerate approximately every 30 days.
- There are 5 layers of the epidermis, which are categorized as follows (from superficial
to deep);

a. Stratum corneum - the outer layer of the epidermis; consists of dead (anuclear),
keratin filled cells. This layer is constantly being sloughed off.
b. Stratum lucidum - a thin, translucent layer that is located only on thick skin
(palms and soles); composed of a homogeneous layer of keratinocytes with no
nuclei or organelles.
c. Stratum granulosum - also known as the granular layer, this layer has waterproof
properties. It also contains keratohyalin.
d. Stratum spinosum - this layer is the one that produces keratin and thus induces
keratinization. This layer is composed of actively dividing keratinocytes with

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

spinous-like projections (also known as prickle cells). Langerhans cells (bone

marrow derived dendritic cells) are also located in this layer.
e. Stratum basale - also called the basal layer of the epidermis; The stratum basale
is regenerative, wherein basal keratinocytes proliferate to fill skin defects. This is
where stem cells of the epidermis are found (their daughter cells migrate
upwards and differentiate into other cells). Melanocytes and Merkel cells are also
located in this layer.

DERMAL-EPIDERMAL JUNCTION
- Composed of the basement membrane which anchors the epidermis to the dermis. It
consists of 2 layers;
a. Lamina lucida (superficial)
b. Lamina densa (deeper)
- Hemidesmosomes: connects the epidermis to the basement membrane
- Collagen fibrils: connects the stratum basale to the papillary layer

DERMIS
- Derived from the mesoderm; this layer contains blood vessels and provides structural
integrity to the skin

a. Papillary Dermis
i. Consists of fine, loosely arranged collagen fibers
ii. Supplies the epidermis with nutrients
iii. Plays an important role in temperature regulation
iv. Forms dermal ridges, which connect dermal papillae (extension of the
papillary dermis into the epidermis) to epidermal downgrowths known as
epidermal ridges or rete ridges
v. Contains the Meissner corpuscles (for fine-touch and two-point
discrimination) and free nerve endings
vi. Contains immune cells (mast cells and macrophages)

b. Reticular Dermis
i. Consists of thick, densely packed fibers (e.g. reticular, elastic, and
collagenous) that provide structure and support to the skin and its
components
ii. Contains Ruffini corpuscles (mechanoreceptors); responsible for
mechanical pressure and the sensation of distortion
iii. Contains sweat glands, sebaceous glands, and the roots of hair follicles
iv. Langer lines - topographic lines that correlate with the natural orientation
of the reticular fibers of the reticular dermis; important for wound healing
and for guiding surgical incisions

SUBCUTIS (also called hypodermis)

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

- Derived from the mesoderm; consists mainly of subcutaneous fat that protects from
cold and trauma
- Contains superficial veins and free nerve endings
- Contains Pacinian corpuscles (mechanoreceptors) that are responsible for the
sensations of vibration and pressure
- Collagenous and elastic fibers in this area anchor the skin (epidermis, dermis) to the
deep fascia.
- Allows for the subcutaneous administration of medications

CELLS OF THE SKIN

KERATINOCYTES
DEFINITION Principal cells of the epidermis

LOCATION Found throughout the whole epidermis; mitotically active in the basal layer
(basal cells); connected to the basement membrane via hemidesmosomes

FUNCTION / Primarily protects against environmental damage and form a barrier against
CHARACTERISTICS
pathogens; protects against UV radiation by storing melanin produced by
melanocytes; produce proinflammatory mediators to activate the immune
system when exposed to pathogens; aids in the process of wound healing;
form tight junctions with nerve endings and hold lymphocytes and
Langerhans cells in place

CLINICAL (1) Abnormal keratinocyte desquamation contributes to the development

SIGNIFICANCE
of acne;
(2) apoptosis of keratinocytes in sunburn;
(3) blistering skin disorders (e.g. pemphigus vulgaris, staphylococcal
scalded skin syndrome) results to loss of intercellular junctions and
desquamation of keratinocytes

MELANOCYTES
DEFINITION Melanin-producing cells derived from neural crest cells

LOCATION Hair, iris, and choroid of the eye; stratum basale of the skin

FUNCTION / Melanin synthesis and storage

CHARACTERISTICS
- Melanin is a dark pigment synthesized and stored in melanosomes
(organelles within melanocytes)
- Dendritic processes transfer melanosomes to adjacent and distant
keratinocytes
- Melanocytes are stimulated by MSH, ACTH, and sunlight (UV-A): MSH
and ACTH share the same precursor, proopiomelanocortin (POMC)

CLINICAL (1) Pigmented skin disorders (vitiligo, albinism, melasma, tinea

SIGNIFICANCE
versicolor)
(2) Potential tumors (benign - nevus, mole; malignant - melanoma)

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

LANGERHANS CELLS
DEFINITION Macrophages of the skin; a type of dendritic cell

LOCATION Stratum spinosum

FUNCTION / - Acts as antigen presenting cells (APC)

CHARACTERISTICS
- Express the following proteins: MHC Class II, Fc receptors, S-100,
CD1a
- Mesodermal origin
- Stains positive for S-100 and CD1a
- Contain Birbeck granules

CLINICAL (1) Langerhans cell histiocytosis

SIGNIFICANCE
(2) HIV transmission
(3) HPV transmission

MERKEL CELLS
DEFINITION Mechanoreceptors for deep static touch features (e.g shapes and edges)

LOCATION Mainly located in the stratum basale

They surround richly innervated areas of connective tissue, such as fingertips

FUNCTION / - Rich in keratin filaments, desmosomes, and small dense blue

CHARACTERISTICS
granules
- Merkel cells are connected to enlarged axon terminals via
synapse-like junctions
- The merkel cell-neurite complex is known as a Merkel disc receptor

SKIN APPENDAGES
NAIL AND ITS PARTS
● Perionychium: epidermal tissue surrounding the root and base of the nail
● Eponychium: proximal layer of the epidermis extending over the nail base
● Hyponychium: epidermal tissue immediately underlying the free distal edge of the nail
● Nail plate (nail body)
○ Covers the nail bed
○ Proximally: consists of the matrix unguis or onychostroma (responsible for new
nail growth) and the lunula (the white, crescent-shaped, poorly vascularized
portion of the nail)
○ Distally: sterile matrix (provides the nail with bulk and strength)
● Nail fold: depression proximal to the nail plate from which the nail grows
● Vascular Supply
○ Arterial: two terminal branches of the volar digital artery
○ Venous: drains into a network in the proximal nail bed and the skin proximal to
the nail fold
● Innervation: trifurcation of the dorsal volar digital nerve (supplying the nail fold, pulp,
and distal tip of the finger)

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

HAIR FOLLICLES
● Definition: invaginations of the epidermis into the deep dermis, forming a cavity where
the hair grows and develops
● Composition
○ Hair - a skin appendage that grows from follicles in the dermis; functions include
conservation of body heat, sensation, and protection of the skin
○ Hair shaft - extends above the epidermis; connects to the hair root in the deep
dermis
○ Hair bulb - root of the hair follicle; located deep in the dermal papilla; receives
blood and nutrients from a capillary network of vessels to sustain hair growth
○ Arrector pili muscle
■ Description: obliquely directed smooth muscle fibers that attach to the dermal
sheath surrounding hair follicles
■ Function: contraction (piloerection or goosebumps), conservation of body
heat; innervated by the sympathetic autonomic nervous system
○ TYPES
■ Vellus hair follicle - extends into the reticular dermis and is found all
throughout the body. During puberty, vellus hairs in the axilla and the genital
area become terminal hairs
■ Terminal hair follicle - extends into the subcutaneous fat; found on the scalp,
eyebrows, and eyelashes

GLANDS
SEBACEOUS SWEAT GLANDS
GLANDS
ECCRINE SWEAT GLANDS APOCRINE SWEAT GLANDS

DESCRIPTION - Exocrine - Composed of a secretory unit called glomerulum or

(holocrine) acrosyringium; surrounded by myoepithelial cells
branched glands - The combination of sebaceous gland, arrector pili
muscle, and hair follicle is known as the
pilosebaceous unit

LOCATION AND - Dermis - Deep in the dermis and hypodermis

DISTRIBUTION - Predominantly
located on the - Most areas of the Mostly axilla, perineum,
face and scalp body areola of the nipple, and
- Absent on - Absent in lips, ear external ear
palms and soles canal, clitoris, labia
minora, and glans
penis

FUNCTION - Secretion of - Secretion of sweat Modified apocrine cells

sebum (an oily, (thermoregulation) produce ear wax or breast
waxy substance milk; no significant role in
which is a thermoregulation
lubricant and a
waterproof layer

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

for the skin and

hair)

REGULATION - Stimulated by Stimulated by acetylcholine Stimulated by epinephrine

OF SECRETION androgens, esp via muscarinic receptors and norepinephrine from
dihydrotestostero adrenergic nerve fibers
ne
- Inhibited by - Circulating hormones may also affect the secretion of
estrogens sweat
- Growth hormone: increased size of sweat glands
- Thyroid hormone: increased secretion of sweat (i.e.
hyperthyroidism is characterized by warm and moist skin

Functions of the Skin

The main functions of the skin include:
a. Barrier and protection against the external environment
b. Thermoregulation (e.g. perspiration, regulation of blood circulation)
c. Sensory function: sensations of pressure, vibration, touch, pain, and temperature
d. Hormone synthesis of vitamin D
e. Melanin synthesis: provides protection against ultraviolet (UV) radiation and
determines the color of the skin and iris

B. Principles of Wound Healing

1. Zones of the Skin
a) ZONE I: Macrocirculatory System
Blood supply: Blood vessels travel by one of two main routes to terminate in the
cutaneous circulation.

- Musculocutaneous arteries (MC)

- Pass through and provide nutrition to overlying muscle
- Leave the muscle and enter the subcutaneous tissue to supply a smaller
region of skin.
- Septocutaneous arteries / direct cutaneous arteries (SC)
- Travel through fascial septa that divide the muscular segments
- The cutaneous portion of a septocutaneous artery typically runs parallel
to the skin surface, providing nutrition to a large area of skin
- Usually accompanied by pairs of veins and run above the superficial
muscular fascia.

Venous Drainage: Network of dermal and subdermal plexuses

- Provides a redundancy in the vascular supply to the skin
- A collateral blood supply supports the vascular territory of each artery.

Lymphatics: form a plexus running parallel and deep to the network of blood
capillaries.

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

- The lymphatic capillaries, which end in blind sacs, conduct extracellular

fluid back into the bloodstream.

Nerve Supply
- The neural supply to the skin originates from sensory nerves and
sympathetic nerves.
- Sensory nerves are distributed in segmental fashion, forming
dermatomes, and participate in the skin’s protective function.

b) ZONE II: Capillary System

- The cutaneous capillary system and arteriovenous shunts, serves the two
important functions: nutritional support and thermoregulation
- The rate of blood flow through the skin is highly variable. Blood flow can
increase to 20x this value with maximal vasodilation.
- When the body is exposed to extreme cold, blood flow can be reduced to levels
that are marginal for cutaneous nutrition.
- Before entering the capillary bed, the arterioles branch into small vessels (e.g.
terminal arterioles or metarterioles) that are surrounded by a discontinuous
layer of smooth muscle
- Even in areas of the skin that have lost their sympathetic innervation, a mass
discharge of the sympathetic system (epinephrine and norepinephrine) still
results in intense vasoconstriction in the skin.
- The precapillary sphincter is the one that controls the amount of nutritive blood
flow to the skin. It responds to local hypoxemia and increased metabolic
byproducts by dilating.

c) ZONE III: Interstitial System

- The interstitial space is filled with proteoglycans and collagen.
- Hyaluronic acid filaments
- Make up the interstitial ground substance in many tissues
- These filaments are normally woven through the interstitium, producing a
medium that exhibits high resistance to fluid movement unless the tissue
is well-hydrated.
- Lymphatic system: 2 functions that affect Zone III
(1) To remove excess fluid
(2) To remove interstitial fluid

d) ZONE IV: Cellular System

- Intracellular space
- The endpoint for nutrient transport
- The origin of metabolic waste

2. Wound Healing

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

- Wound healing occurs as a result of several processes including coagulation,

inflammation, matrix synthesis and deposition, angiogenesis, fibroplasias,
epithelialization, contraction, remodeling, and scar maturation.
- Depends on the type of wound and the manner of wound closure.

2.1 Types of Wound Healing

- Primary Intention / Primary Closure / Primary Healing
- When wound edges are apposed properly, healing is rapid.
- Secondary Intention / Secondary Closure / Secondary Healing
- The open wound (i.e. soft tissue loss) spontaneously closes with
contraction, after undergoing the same process of wound healing,
where angiogenesis and fibroblast proliferation produces granulation
tissue which then contracts to cover the open wound.
- Usually, healing by secondary intention would give the worse
aesthetic outcome, thus efforts must be done to achieve primary
closure if possible.
- Tertiary Healing
- Delayed wound closure after several days.
- Distinguishing feature of this type of healing is the intentional
interruption of healing begun as secondary intention and can occur
anytime after granulation tissue has formed in the wound.
- Delayed closure - performed when the wound is not infected.
- One example of this type is the healing of wounds using tissue grafts.

2.2 Phases of Wound Healing

- Primary Injury / Coagulation Phase
- Vasoconstriction is the first response to tissue injury; helps in
hemostasis
- Primary hemostasis: when platelets, together with fibrinogen, fibrin,
and fibronectin form a plug that reestablishes hemostasis
- Secondary hemostasis occur simultaneously with the primary
hemostasis and occurs when additional coagulation factors are
released to strengthen the platelet plug
- Tissue mast cells: release bradykinin, serotonin, and histamine
- Platelets
- Chemotaxis: releases chemotactic factor which releases which
attract inflammatory infiltrates
- Platelet-derived growth factor: a chemotactic agent for
macrophages and fibroblasts, macrophage activation,
fibroblast proliferation, matrix production, and
angiogenesis.
- Transforming-growth factor B: involved in keratinocyte
invasion, chemotaxis for macrophages and fibroblasts, and
fibroblasts matrix synthesis and remodeling.

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

- Epidermal growth factor: active in keratinocyte migration

and replication
- The clot covers the wound and provides an initial matrix for cell
attachment and migration.

- Inflammatory Phase
- Within hours, polymorphonuclear neutrophils (PMN) arrive at the site
of the injury and predominate the population of inflammatory cells in
the wound; the neutrophils phagocytize bacteria and debris
- Influx of monocytes after 48 hours, which phagocytize other
phagocytes, bacteria, and damaged tissues.
- Macrophages also stimulate cells to form granulation tissue and form
an extracellular matrix
- Persists for 72-96 hours

- Proliferative Phase (Fibroplasia)

- Consists of re-epithelialization, formation of granulation tissue, and
wound contraction.
- Re-epithelialization begins within hours of injury and is the result of
keratinocyte migration and proliferation.
- Keratinocyte proliferation occurs 1-2 days after injury.
- Granulation tissue replaces fibrin clot 3-4 days after injury.
- Wound contraction occurs at the 2nd week of healing, wherein
myofibroblasts provide the contractile forces produced in wound
granulation tissue
- Epithelialization - 7 to 10 days after, as epithelial cells, fibroblasts, and
capillary endothelial cells cover and fill the wound.
- Collagen, hyaluronic acid, fibronectin, and chondroitin sulfate also fill
the wound that forms an extracellular matrix.

- Maturation Phase (Remodeling)

- Collagen synthesis and degradation are in balance.
- Myofibroblasts, vascular cells undergo apoptosis and are removed.
- Granulation tissue is turned into a scar.
- Wound maturation is a dynamic process lasting for up to 2 years.
- Initially, immature collagen and ground substances dominate the
wound. As maturation proceeds, proteases and collagenases degrade
immature collagen at the same time it is replaced (balance between
collagen synthesis and lysis occurs)
- Ground substance decreases and the wound is filled with mature
collagen.

3. Factors affecting Wound Healing

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

LOCAL FACTORS

Dessication
- a moist environment allows wounds to heal faster and less painful than in a dry
environment in which cells typically dehydrate and die
- this causes a scab or crust to form over the wound site, which impedes healing
- if the wound is kept hydrated with a moisture-retentive dressing, epidermal cell
migration is enhanced, encouraging epithelialization

Infection / Abnormal Bacterial Presence

- if an infection is present, as evidenced by purulent drainage or exudate,
induration, erythema, or fever, a wound culture should be obtained to identify the
offending bacteria and guide antibiotic therapy
- when a pressure ulcer or full-thickness wound extending to the bone fails to
heal, the patient should be assessed for signs of osteomyelitis

Necrosis
- dead, devitalized (necrotic) tissue can delay healing
- Two types:
(1) Slough: moist, loose, stringy necrotic tissue that is typically yellow
(2) Eschar: appears as dry, thick, leathery tissue that may be black. In most
cases, necrotic tissue must be removed before repair and healing can
occur

Pressure
- when the pressure in the wound site is excessive or sustained, the blood supply
to the capillary network may be disrupted
- this impedes blood flow to the surrounding tissue and delays healing

Trauma and Edema

- wounds heal slowly and may not heal at all in an environment in which they are
repeatedly traumatized or deprived of local blood supply by edema.

SYSTEMIC FACTORS

Age
- wounds in older patients may heal more slowly than those in younger patients,
mainly because of comorbidities that occur as a person ages
- Older patients may have inadequate nutritional intake, altered hormonal
responses, poor hydration, and compromised immune, circulatory, and
respiratory systems, any of which can increase the risk of skin breakdown and
delay wound healing

Body Type
- Obese patients may experience compromised wound healing due to poor blood
supply to adipose tissue; some may have protein malnutrition that may further
impede healing
- Emaciated patients may have lack of oxygen and depleted nutritional stores

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

that may interfere with wound healing

Chronic Disease
- Diseases that may compromise wound healing include coronary artery disease,
peripheral vascular disease, cancer, diabetes mellitus
- Patients with chronic diseases should be followed closely through their course
of care to provide the best plan

Immunosuppression and Radiation Therapy

- Suppression of the immune system by disease, medication (corticosteroids), or
age can delay wound healing
- Radiation therapy: causes ulceration, or change in the skin, either immediately
after a treatment or after all treatment has ended

Laboratory Values
- Nutritional markers are not the only laboratory values that must be considered
when evaluating healing
- Measuring the hemoglobin level helps assess the oxygen-carrying capacity of
the blood; however it may also be necessary to assess renal, hepatic, and
thyroid functions to determine the patient’s healing capacity

Smoking
- Nicotine is vasoconstrictive and it decreases proliferation of erythrocytes,
macrophages, and fibroblasts
- Carbon monoxide competes with oxygen in hemoglobin because of its high
affinity to it
- Hydrogen cyanide (also present in cigarette smoke) is a toxic by-product and is
associated with cardiovascular disease.

Nutritional Status
- Ongoing nutritional assessment is necessary because the visual appearance of
the patient or the wound is not a reliable indicator of whether the patient is
receiving the proper amount of nutrients.
- Markers of malnutrition:
(1) Albumin and pre-albumin levels
(2) Total lymphocyte count
(3) Transferrin levels

Vascular Insufficiency
- Various wounds or ulcers such as arterial, diabetic, pressure, and venous
ulcers can affect the lower extremities
- Decreased blood supply is a common cause of these ulcers
- The clinician must identify the type of ulcer to ensure appropriate topical and
supportive therapies.

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

II. Journal Discussion

A. Introduction
The goals of wound closure are to enable rapid skin healing and prevent infection, and
to facilitate early mobilization while achieving a good cosmetic result. A variety of
materials including sutures, skin staples, tissue adhesives, and surgical tapes have
been used in surgical wound closure.

Post surgical scar formation, particularly the cosmetic aspects of scar appearance, is
an object of focus for patients and clinicians alike. Physiologic dysfunction due to
serious scars notwithstanding, some atrophic scars following physiologic wound repair
may cause psychosocial distress and dissatisfaction among patients due to their
unsightly appearance.

The concept of scar outcomes being improved by minimizing wound tension by means
of techniques ranging from external equipment to internal suture materials and
techniques is widely accepted, and improves scar appearance effectively.
Mechanomodulatory therapy is the practical application of this concept, and makes use
of various devices and methods.

B. Objective
The objective of this study is to determine the efficacy and safety of using tissue
adhesive zippers in postsurgical scar prevention among patients undergoing surgical
excision of the face. The primary outcome was a reduction in scar width, which was
evaluated 1, 3, 6, and 12 months postoperatively. Scar width at Month 12 was
considered the final outcome.

C. Results
Statistical analysis revealed that prolonged use of this device reduced scar width and
improved scar appearance at 12 months post operation in younger individuals,
especially pediatric patients.

The complication rates of the 2 groups (the control group and zip group) did not differ
significantly, indicating that clinical application of this wound-closure device is feasible.

Interventions during the early stages of wound healing reportedly improve final scar
outcomes. The results of this study indicated that scar spreading was most
pronounced in the first month post operation, which is consistent with observations
reported in previous studies. The same effect may be achieved with the use of this
device at an early stage for a short period of time.

The study has several limitations. Variations in wound tension among different patients
may result in different outcomes. This study only enrolled patients who had undergone
the same surgical excision of skin mass with an incision length of 3 to 6 cm to reduce

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CELESTE, Neill Sebastien D. Date of Rotation: June 9-15, 2023
APMC Midyear Intern

the number of individual variables. However, the original incision width of enrolled
patients varied, which greatly affected postoperative scar width.

D. Advantages and Disadvantages of using Tissue Adhesives

ADVANTAGES DISADVANTAGES

- Sterile, adjustable, hydrocolloid - Not widely available in the

adhesive based current setting
- Less pain - applicable for - More well‐designed studies are
pediatric patients needed to confirm the reliability
- Does not cover wound surface of the results of present studies
(may be used in early wound
healing)
- Adjustable zipper function
facilitates its use in wounds with
different tensions / provides
uniform force along the wound
edge
- Proven safe and may be used as
a replacement for epidermal
sutures
- Decreased incidence of SSI as
compared to sutures
- Shorter wound closure time -
better scar score

E. Conclusions and Recommendations

The present study demonstrated that prolonged use of a tissue adhesive zipper
improves the subjective and cosmetic outcomes of scars. The prolonged use of this
device did not cause significant side effects. This study also showed that scars
develop more rapidly during the first month, indicating that early intervention benefits
wound healing results, and suggests that reliable support will benefit scar
management.

However, 53 enrolled patients are not sufficient to draw concrete conclusions from, and
in this study most enrolled individuals were pediatric patients, which may have caused
age-related bias. A self-controlled design with a larger sample size can further
minimize variation and is needed to confirm the results further.

In addition, a single-center study consisting solely of individuals of Asian descent with

wounds on the face may reduce the generalizability of the conclusions; therefore,
studies on other populations and body sites may be required.

Lastly, the choice between the zipper and sutures should be based on factors such as
local availability, cost, surgeon preference, and individual constitution and wishes of
patients.

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