There is an ongoing search for the ideal option in the surgical treatment of PSD. After treatment, recurrence and loss of workforce constitute the major problems. Expectations from surgical treatment are low recurrence rates, return to daily life as soon as possible, and acceptable cosmetic outcomes. The Cochrane review published in 2010 reported that the extra-midline closure was much more beneficial than the midline closure technique[11]. The consensus among the recently published German, American and Italian guidelines is that midline closure should not be performed[3, 5, 12]. There are many studies in the literature comparing different surgical techniques. Some studies have compared primary closure and flap procedures, while others evaluated different flap types. However, to our knowledge, our study is the first in the literature to compare the BPEF and KF techniques. In addition, we assessed the short and long-term outcomes of patients who underwent surgery with BPEF and KF, which are both non-midline closure techniques. In terms of the VAS score and early return to work, BPEF was found to be much more advantageous than KF, and this was statistically significant.
In this study, BPEF was applied similar to the technique described by Yuksel et al.[6]. In their study, the authors reported the rates of postoperative complications WSI, WD, and seroma to be 3.5%, 3.5%, and 5.7%, respectively. In the current study, we determined the rates of WSI, WD, and seroma as 2%, 2%, and 14.2%, respectively. Thus, although WSI and WD were observed at similar rates, the rate of seroma was higher in our patients. Yuksel et al. reported the mean time to return to work as 12.6 days, while this duration was much higher in our study (21.06 days). Lastly, Yuksel et al. found the recurrence rate to be 1.7% after an average of 21.4 months of follow-up. In contrast, we determined the recurrence rate to be 4% after an average of 39.9 months of follow-up. The higher recurrence rate in our study can be attributed to the longer follow-up period.
PSD is mostly seen in young adults. This means that the longer the time to return to work/school after surgery, the greater the loss of workforce. Therefore, the time to return to work emerges as a very important factor in the choice of treatment. In the literature, the mean time to return to work after surgery with the KF technique has been reported to vary between 14.4 and 23.29 days[13–15]. In the current study, the mean time to return to work was 27.04 days for the patients who underwent surgery with the KF technique. Compared to the literature, the longer period taken to return to work in our study may be because the patients in our study waited until complete recovery. For the BPEF group, we found the mean time to return to work as 21.06 days, which was statistically significant compared to the KF group (p < 0.005).
Postoperative pain affects the quality of life of patients and their early return to daily activities. The surgical procedure to be preferred should have a minimal effect on the quality of life in the early postoperative period. In previous studies, the degree of postoperative pain has been generally evaluated with VAS. Bali et al.[16] reported a mean postoperative VAS score of 4 among patients that underwent surgery with the KF technique, while the mean VAS score was determined as 4.11 by Alvandipour et al. [8] and 5.58 by Ates at al.[17] on the postoperative 15th day. In our study, the mean postoperative VAS score was found to be 3.57 for the KF group and 2.47 for the BPEF group, and the difference was statistically significant (p < 0.005).
Early wound complications and long-term recurrence continue to be troubling possibilities in all procedures. Therefore, the search for a gold standard treatment method still continues. A review of the literature in terms of wound complications and recurrence among patients that underwent surgery with the KF technique shows that the rates of postoperative WSI, WD, seroma and recurrence were reported to be 8.1%, 2.7%, 35.1%, and 2.7%, respectively by Alvandipour et al.[8]; 1.8%, 5.6%, 3.7%, and 1.8%, respectively by Caliskan et al.[18]; and 3%, 10%, 5%, and 2%, respectively by Bessa[19]. In the current study, postoperative WSI, WD, seroma and recurrence were detected at the rates of 5.6%, 5.6%, 15%, and 5.6%, respectively among the patients who underwent surgery with the KF technique, and 2%, 2%, 14.2%, and 4%, respectively in the BPEF group. There was no statistically significant difference between the two groups. We consider that the higher rate of seroma in our study is due to our routine use of drains. Other complications and recurrence were observed at similar rates to the literature.
In the literature, the complaints of patients are described as pain, discharge (clear fluid or pus), and local swelling[11, 20]. In our study, patient complaints were similar. We determined the mean length of hospital stay as 1.45 and 1.41 days for the KF and BPEF groups, respectively, indicating no statistically significant difference. Previous studies reported similar results in terms of the mean hospital stay[8, 14, 15].