Wound edge eversion: Tradition or science? To the Editor: Medicine in general, and dermatologic surgery in particular, is rich with concepts and dictums based on tradition and wisdom passed down from those who came before us. Unfortunately, tradition does not ensure truth or accuracy. Occasionally, ‘‘the emperor has no clothes.’’ Untested principles pertaining to undermining, prevention of flap pincushioning, and wound edge eversion continue to be taught as unquestioned surgical principles. The studies by Kappel et al and Wang et al attempt to clarify the mystique surrounding wound edge eversion with excellent analytic investigation. Apparently, however, elements of confusion persist. The study by Kappel et al1 concerning wound eversion concludes that eversion was not statistically associated with improved scar assessment. The technique employed permitted the use of a ‘‘dermal set-back or inverted vertical mattress suture, depending on surgeon preference.’’ There is no documentation regarding the distribution between these two everting techniques with respect to number or anatomic site. The Wang et al2 study by members of the same group compared the set-back suture to the buried vertical mattress suture and found superior cosmetic results with the set-back suture. How can this be? The take-home message from the Kappel et al1 study is that, regardless of everting technique (including the set-back suture), no cosmetic superiority was found compared with suturing without any eversion. Logically, this should make the subsequent study by Wang et al2 of little relevance. Eversion is of no assistance—why then worry about which everting technique to employ? How can one everting technique be superior to another when, in the end,

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eversion does not contribute to any cosmetic improvement? The contradiction is touched on by Trufant et al3 in their commentary. The initial study is confounded by the arbitrary nature of choice of everting technique and the widespread distribution of anatomic sites. Because cosmesis is primarily a concern on facial sites, perhaps a future investigation should be limited anatomically and exclude areas of higher tension such as trunk and extremities and should then be randomized between the 3 variable approaches to eversion. The water continues to be muddied, but there is every hope that future studies such as these will assist us in the transition from tradition to science. Leonard Dzubow, MD Private practice, Media, Pennsylvania Funding sources: None. Conflicts of interest: None declared. Correspondence to: Leonard Dzubow, MD, Private practice, 101 Chesley Drive, Media, PA 19063 E-mail: [email protected] REFERENCES 1. Kappel S, Kleinerman R, King TH, et al. Does wound eversion improve cosmetic outcome? Results of a randomized, split-scar, comparative trial. J Am Acad Dermatol. 2015;72:668-673. 2. Wang AS, Kleinerman R, Armstrong AW, et al. Set-back versus buried vertical mattress suturing: results of a randomized blinded trial. J Am Acad Dermatol. 2015;72:674-680. 3. Trufant JW, Leach BC. Commentary: wound edge eversion: surgical dogma or diversion? J Am Acad Dermatol. 2015;72: 681-682. http://dx.doi.org/10.1016/j.jaad.2015.04.042

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