Does taping torso scars following dermatologic surgery improve scar appearance?

Background: Studies show that patients are significantly less satisfied with torso scars than scars elsewhere. Though not an uncommon practice, it is unknown if application of adhesive tapes following dermatological surgery help improve cosmesis. Objective: To determine the effect of taping sutured torso wounds on overall scar appearance, scar width and patient satisfaction with the scar. Patients/Methods: Participants having elliptical torso skin excisions in a primary care setting in regional Australia were randomized in a single-blinded, controlled trial to 12 weeks taping (intervention) or usual care (control) following deep and subcuticular suturing. A blinded assessor reviewed scars at three and six months. Results: Of 195 participants recruited, 136 (63 taped, 73 controls) completed six months of follow-up. Independent blinded assessment of overall scar appearance was significantly better in taped participants (p= 0.004). Taping reduced median scar width by 1 mm (p=0.02) and when stratified by gender, by 3.0 mm in males (p=0.04) and 1.0 mm in females (p=0.2). High participant scar satisfaction was not further improved by taping. Conclusion: Taping elliptical torso wounds for 12 weeks after dermatologic surgery improved scar appearance at six months.

The study nurse phoned participants within five days of surgery and then fortnightly for 12 weeks to ascertain analgesia requirements, wound complications and intervention compliance. Wound assessment was encouraged at three and six months even if participants had not been fully compliant with the intervention protocol.
Every participant gave signed informed consent and received written postoperative wound care information.

Eligibility criteria
Patients aged 18 to 80 years requiring elliptical skin excisions on the torso were eligible for the study provided they could easily reach the wound or had someone available to help with taping. Exclusion criteria included known tendency to keloid scarring; allergy to the sutures or skin tapes; flap surgery; and prescribed immunosuppressive drugs. Participants requiring a second wider excision for residual tumor or melanoma were subsequently excluded from the study.

Surgical wound management protocol
We used a standardized surgical procedure ( Figure 1). In addition to deep and subcuticular sutures, an occasional superficial interrupted 3/0 nylon suture was used where necessary to improve wound edge apposition.

Intervention
Adhesive tapes 100 mm long and 10 mm wide (Leukostrips, Smith and Nephew Medical Ltd, Hull, UK) were applied perpendicularly to the sutured wound, in parallel without overlapping, prior to the dressing ( Figure 2). It has been shown that tapes adhere to skin for longer with this technique [15]. Participants and carers were shown how to apply and remove tapes as well as receiving written instructions and a descriptive photo of the taping technique ( Figure 3).
Instructions were given to change tapes on the same day each week for 12 consecutive weeks and to trim tape ends if they lifted. If no more than 4 cm extending either side of the scar, instructions were given to replace this tape and still change all tapes on the scheduled weekday.

Introduction
Dermal postoperative repair produces scar tissue that can cause significant psychological and physical consequences [1,2]. With an estimated 55 million elective operations occurring each year in the developed world alone [3] and confirmation that most patients (irrespective of age, gender and ethnicity) believe that even a small improvement in scarring is worthwhile [4], any research that may help improve scar outcome is meaningful.
Research has confirmed a positive correlation between tension and increased scar tissue formation [5,6]. The great range of movement afforded by the spine renders scars on the trunk particularly vulnerable to tension and subsequent disfigurement. It may therefore not be surprising that patients are significantly more dissatisfied with torso scars than other scars [7][8][9]. Dermatologic surgery on the trunk is common worldwide, and in Australia 27% of all basal cell carcinomas (BCCs), 8% of all squamous cell carcinomas (SCCs), 25% of all invasive melanoma in men and 11% of all invasive melanoma in women are excised from the torso [10,11].
Evidence shows that prolonged use of adhesive tapes applied along a scar following surgery may reduce scar volume and improve cosmetic outcome [12,13]. Though shortterm taping following dermatological surgery may be standard protocol for many practices, the optimal duration and mechanism of action of this intervention remains unclear [12,14].
The aim of this study was to determine the impact of 12 weeks of tape application perpendicular to sutured torso wounds on overall aesthetic appearance and width of the scars, as well as patient scar satisfaction at six months following surgery.

Materials and methods
This was a randomized controlled assessor blinded trial involving patients having elliptical skin excisions on the torso in a primary health care setting. The study was approved by the University of Queensland ethics committee (approval number #2008000535 April 2008). All patients gave written informed consent.

Setting & participants
Consecutive eligible patients were recruited by two general practitioners (including the prin cipal researcher, HR), at a primary health skin cancer clinic in Townsville, North Queensland, Australia from June 2008 to January 2010.
Baseline demographic data, relevant medical history, degree of torso movement anticipated during the study period and lesion histology were documented (Table 1).
Excision sites were recorded on body maps. The principal

Randomization and blinding
The allocation sequence was generated using a computerized randomization schedule at the Discipline of General

Clinical outcomes
Maximal scar width was recorded to the nearest millimeter.
Overall scar appearance and participant satisfaction with their scar were both appraised using five-point categorical scales.
Outcome assessment was undertaken by an independent blinded research nurse three and six months postoperatively.
Overall scar appearance was evaluated and documented along with presence of scar elevation, depression and dyschromia. Reference photographs taken and categorized by the principal investigator (HR) before commencement of the trial helped ensure consistency of this assessment.
Participants completed adapted questionnaires [16] at the assessment visits. Participant satisfaction with the scar was ascertained as well as how perceived cosmetic results compared to their expectation and whether they would use tapes for future torso scars if our study results proved favorable.

Sample size
It was hypothesized that a minimum mean difference of 2 mm in wound width between taped participants and controls would be clinically significant. To show this with statistical confidence (power in excess of 80%; significance level 0.05), 29 participants were required in each study group.
For overall scar appearance and patient scar satisfaction (both measured on categorical scales), it was hypothesized that a difference of at least one category between the two

Characteristics of non-participants
Forty-five patients declined participation, mainly due to a lack of interest (73.3%). Participants were more likely to be female (p=0.005), less likely to take anticoagulants or inhaled steroids (p=0.049) and reported more exercise in their leisure time (p=0.042) than non-participants. Those who enrolled in but did not complete the study (41) were more likely to be younger (p<0.001), female (p=0.01) and more physically active at work (p=0.036).

Main outcome measures
The overall scar rating given by the blinded assessor at six months was significantly better in the intervention group (p=0.004) (

Statistical analysis
Participant data were analyzed according to allocated study group, irrespective of protocol violation or non-compliance.
Success of randomization was ascertained by comparing baseline information between groups. This included age, gender, diabetes, smoking history, degree of torso movement at work and in leisure time, body mass index, histology of lesion, torso site and wound dimensions.
Numerical data were described using mean values and standard deviations when approximately normally distributed or median values and inter-quartile ranges when skewed.

Chi-square tests, t-tests and non-parametric Wilcoxon tests
were used for baseline comparisons between participants and non-participants and between the study groups. Wound assessments and patient satisfaction scores were compared using non-parametric Wilcoxon tests.
Statistical analysis was conducted using SPSS version 18 (PASW; SPSS Inc., Chicago, Illinois). P-values of less than 0.05 were considered statistically significant.

Treatment and complications
There was no difference between study groups in the number of deep sutures used (p=0.93; median number three; range from two to ten) or postoperative pain relief require-

Discussion
Twelve weeks of taping torso scars postoperatively significantly improved independent assessment of overall scar appearance at six months. There was no significant difference in the number of participants with at least some scar depression, elevation or dyschromia in the two study groups. Since degree of these three variables was not evaluated, however, these observations may have little clinical relevance.
Taping reduced median scar width by a modest 1 mm, which, though statistically significant, was thought not to be clinically relevant. When stratified by gender, however, the observed 3 mm reduction in scar width in taped males may be of clinical as well as statistical significance. In nontaped controls, scars were significantly wider in males than females, possibly because men subject the torso to more ten-  (Table 3).
Though trends suggested that median scar width and overall scar appearance was better in the intervention group three months postoperatively, this did not reach statistical significance. Median scar width was 1 mm less in taped participants (3.0 mm, IQR = 2.0, 5.0) than controls (4.0 mm, IQR = 2.5,6.0) (p=0.064), while overall scar appearance rated good/ very good in 53% taped participants compared to 43% controls (p=0.259) at three months following surgery. Similar to other studies [17,18], we found that the independent assessor was less satisfied with the scar than the It has been postulated that the following three interventions help prevent excessive scar formation: supporting the healing wound to reduce tension (which results in increased collagen synthesis); covering the wound to improve hydration and hasten scar maturity (by down regulating collagen and fibroblast production); and applying pressure to the wound (causing local hypoxia and subsequent fibroblast and collagen degradation) [12, 14,19]. In our study long tapes applied close together perpendicular to the wound edges is likely to have reduced wound tension and provided at least intermittent wound pressure (with torso movement).
Though the tapes we employed were only partially occlusive, this may also have played a role in improving scar hydration.
Though the trend in our study suggested that taping torso wounds was beneficial at three months, statistical significance was only seen at six months. Any intervention for torso scars might therefore be best followed up for at least six months before discounting its effectiveness. A longer term observational study mapping the natural progress of torso scars is needed to establish just how long they are vulnerable to stretch, as it may well be much longer than six months.
The 12-week period of taping in our study was an arbitrary decision. Perhaps a shorter period of taping is equally effective, or conversely, more prolonged taping gives a superior result. We have outlined several potential reasons for patient satisfaction being high and in particular being equally high in both study groups. Despite this, 82.4% taped participants specified they would tape a future scar if our results proved favorable, indicating that many patients are motivated to improve scar appearance and that 12 weeks of taping is not too onerous.

Conclusion
This study has shown that 12 weeks taping of sutured torso scars is a safe, effective and well-tolerated intervention that may significantly improve scar appearance at six months.