The Donati Stitch Revisited: Favorable Cosmetic Results in a Randomized Clinical Trial J. B. Trimbos, M.D., Ph.D.,* ,1 R. Mouw, M.D.,* G. Ranke,* K. B. Trimbos,* and K. Zwinderman, Ph.D.† Departments of *Gynaecology and †Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands Submitted for publication January 24, 2002; published online July 24, 2002 Background. Literature on the cosmetic results of various surgical methods to close the skin is scarce. We sought to compare the cosmetic results of two dif- ferent surgical techniques of skin closure after lower midline laparotomy Materials and methods. A randomized clinical trial compared a running nylon skin suture to interrupted Donati stitches in 58 patients undergoing gynecologi- cal surgery. Scar hypertrophy, scar width, scar color, the presence of cross-hatching marks, and a total scar score were assessed in all patients at 2 weeks, 6 months, and 12 months postoperatively. Results. On average closing the wounds with Donati stitches took 5 min longer than using a running suture (P > 0.001). The Donati sutures caused sifnificantly less cross-hatching at 2 weeks and 6 months postoper- atively. At 1 year, the scar color following Donati clo- sure was also significantly less pronounced than in the running suture arm. The total scar score was signifi- cantly better in the Donati arm at each of the three time periods of assessment. The difference at 6 months was equal to the difference at 1 year. Conclusions. Closing the skin of lower midline laparot- omy wounds with Donati stitches resulted in a cosmeti- cally better scar. Scar cosmetics of lower midline lapa- rotomies could be improved by using interrupted Donati stitches instead of a running suture. The difference was significant at 2 weeks, 6 months, and 12 months postop- eratively, but the magnitude of the difference was the same at 6 and at 12 months. © 2002 Elsevier Science (USA) Key Words: scar cosmetics; skin closure; Donati’s stitch; vertical mattrass suture; wound healing; lapa- rotomy scar; wound eversion. INTRODUCTION The laparotomy scar is the only part of the operation that remains visible to the outer world and it carries the “signature of the surgeon” [1]. Considerations on scar cosmetics in the gynecological literature are scarce and the experience of plastic surgeons has to be looked at instead [2]. In benign gynecological surgery trans- verse Pfannenstiel or Maylard incisions are frequently used and they usually result in acceptable scars. Lower midline incisions, however, have to resist more strain on the scar because of the course of Langer’s elastic tension lines [3]. Lower midline incisions are fre- quently closed by means of a running over-and-over skin suture. Interrupted vertical mattrass sutures have been described by Donati [4]. These sutures serve three goals. First, they give a very precise adaptation of the opposite wound edges. Second, they are able to resist more tension on the wound edges, and third, they cause eversion of the incision line. This eversion might compensate for the effect of scar retraction during the further course of wound healing. This wound retraction might eventually lead to a cosmetically problematic, retracted scar. The present study was initiated to de- termine whether interrupted Donati skin sutures would result in a better cosmetic scar compared to the standard running suture. MATERIALS AND METHODS Patients undergoing lower midline laparotomy for a gynecological condition were randomized into an interrupted Donati group and a running suture group closing the skin. Donati skin stitches are also referred to as vertical mattress stitches. They have a far–far–near– near structure as the initial bites pass through skin and subcutane- ous fat and the last two bites only comprise the dermal layer of the skin. By this composure a meticulous adaptation of the wound occurs as well as eversion of the edges. Randomization was done at the time 1 To whom correspondence should be addressed at Department of Gynaecology, Leiden University Medical Center, POB 9600, 2300RC, Leiden, The Netherlands. FAX: +31.71.5248181. E-mail: J.B.M.Z.Trimbos@lumc.nl. Journal of Surgical Research 107, 131–134 (2002) doi:10.1006/jsre.2002.6486 131 0022-4804/02 $35.00 © 2002 Elsevier Science (USA) All rights reserved.