Upper Eyelid Blepharoplasty: Using Interrupted Suture or Running Suture?
Aging is an inevitable process that causes noticeable changes throughout the body, with the face and eyes being particularly affected. These changes, which include sagging eyebrows, excess eyelid skin, wrinkles around the eyes, and fat accumulation under the eyes, can cause significant physical and psychological issues. To address these concerns, blepharoplasty has become a popular surgical procedure that involves removing or reshaping the eyelid skin, muscle, and fat to improve the patient's appearance and rejuvenate the face.
If blepharoplasty is performed for the appropriate reasons, it can be successful, but it can also have complications that are rare but critical for patient satisfaction, such as swelling, infection, asymmetry caused by too much or too little removal of skin, muscle, or fat, and unsightly scarring. Scarring is one of the most prevalent and undesirable side effects of blepharoplasty that can impact patient satisfaction. However, there is no consensus in the literature on the specific cutting method or instruments used, or the techniques and materials used to close blepharoplasty incisions. Closure materials such as vicryl, polypropylene, nylon, fast-absorbing gut, and ethyl cyanoacrylate adhesives, and techniques such as subcutaneous continuous, interrupted cutaneous, and running cutaneous, can all be used safely. However, it appears that the choice of technique and material is mostly based on the surgeon's personal preference.
Although blepharoplasty generally results in high patient satisfaction, the methods used to close the incisions can impact the outcome. Previous studies have examined the complications and scarring associated with various suture materials and techniques, but the effects of interrupted cutaneous and running cutaneous techniques on postoperative swelling, bruising, and scarring have not been investigated. In light of this, the objective of this article is to compare the outcomes of patients who underwent upper eyelid blepharoplasty with interrupted cutaneous sutures in one eye and running cutaneous sutures in the other eye, with regards to swelling, bruising, and scarring.
Methodology
The Department of Ophthalmology at the Adyaman University Training and Research Hospital conducted a prospective cross-sectional study. To participate in the study, patients had to have upper eyelid blepharoplasty and their suture methods had to be interrupted cutaneous in one eye and running cutaneous in the other. Patients having a history of blepharoplasties, conditions like diabetes that may impair wound healing, connective tissue disorders, and those taking anticoagulants or anti-inflammatory medications were also disqualified. Patients without missing data and those who did not show up for their control visits were also disqualified from the trial.
The same surgeon used the same surgical method for all blepharoplasty procedures. Incision lines were marked using a waterproof pencil prior to surgery. All procedures were carried out while under local anesthesia. Following skin disinfection, skin infiltration using lidocaine 2% with 1:100,000 epinephrine was carried out. High-frequency radiosurgery was used to make incisions in the skin and subcutaneous tissue. Monopolar coagulation was used to meticulously achieve hemostasis. The septum was then either buttonholed to reveal the nasal and medial fat pads or simply cauterized using unipolar needlepoint cautery. Fat was removed by needlepoint cautery if necessary. The onset of hemostasis.
Finally, the wound was stitched shut using the same suture material, either 6-0 polypropylene sutures or 6-0 vicryl sutures, using a running cutaneous style in one eye and an interrupted cutaneous style in the other. To determine which upper eyelid the suture was running and which upper eyelid it was interrupted, randomization was used. Both eyelids received cold packs following the procedure. After seven days, the sutures were removed. The illustration below depicts the preoperative and immediate postoperative appearance of a patient who underwent upper eyelid blepharoplasty:
See below the figure where the preoperative and immediate postoperative image of a patient who has undergone upper eyelid blepharoplasty. The suturing was performed as interrupted in the right upper eyelid and running in the left upper eyelid (From Beyoglu Eye J. 2022)
The patients were extensively evaluated before and after the surgery, and photographs were taken at various time points: 1 day, 1 week, 1 month, 3 months, and 6 months after the surgery, and every 6 months thereafter. Each patient was evaluated for swelling and bruising using a Likert scale that was independent of postoperative days 1, 7, and 30 and 3 months. The scars were also evaluated after 1 month and 3 months using the Manchester Scar Scale, which assesses color, shininess, contour, distortion, and texture. The study also assessed for complications such as wound infections, milia, dehiscence, lagophthalmos, ptosis, xerophthalmia, and upper eyelid anomalies. All these measurements were examined and compared statistically. Additionally, the patients were divided into two groups based on the suture material used (polypropylene or vicryl), and each group was analyzed separately.
For the analysis, they used SPSS, version 22 (IBM Corp., Armonk, NY). The independent t-test was used to examine edema and ecchymosis on postoperative days 1, 3, 7, 14, and 30. To examine the Manchester Scar Index results, a separate t-test was also employed. The outcomes were then examined using IBM Corp.'s SPSS, version 22 (Armonk, NY). Statistics were considered significant if P 0.05.
Difference of Running and Interrupted Suture
Running suture is a continuous stitch that is used to close the wound. This technique involves placing a single thread through the tissue, which is then tied at the end. Running suture is quick to perform, but it can increase the risk of wound dehiscence (where the wound re-opens), especially in areas where there is a lot of tension. Furthermore, running sutures may not be as precise as interrupted sutures since they involve placing a single thread through the tissue, which can lead to uneven tension on the wound edges. This uneven tension can increase the risk of wound dehiscence, which is when the wound re-opens.
Interrupted sutures, on the other hand, involve placing multiple individual stitches through the tissue and tying each one separately. This technique takes longer to perform, but it allows for more precise wound closure, especially in areas where there is a lot of tension. Interrupted sutures also provide better wound stability and decrease the risk of wound dehiscence.
While running sutures are quick to perform, they may not be as secure as interrupted sutures, which provide better wound closure and stability, especially in areas where there is tension. Ultimately, the choice of suture technique depends on the surgeon's preference and the individual patient's needs.
Patient Evaluation
Out of the patients who had undergone upper eyelid blepharoplasty, 38 patients in the vicryl group and 48 patients in the polypropylene group were suitable for the study. However, 4 patients from the vicryl group and 2 from the polypropylene group were excluded due to missing medical records. In the end, 34 patients (22 female, 12 male) in the vicryl group and 46 patients (27 female, 19 male) in the polypropylene group were included for statistical comparison. The average age in the vicryl group was 56.7±5.7 years (ranging from 50 to 69), while the average age in the polypropylene group was 58.8±5.4 years (ranging from 49 to 67).
Edema comparison: Only the edema in the first week in the vicryl group was superior to interrupted sutured eyelids (p=0.011). There were no appreciable differences in edema between the two eyelids in the polypropylene group (p>0.05 for all).
Ecchymosis comparison: During the first week in the Vicryl group, the amount of ecchymosis in the interrupted sutured eyelid was considerably lower than that in the running sutured eyelid (p=0.001). In the polypropylene group, interrupted sutured eyelids had considerably less ecchymosis than running sutured eyelids at the first day and first week postoperatively (p=0.025 and p=0.001, respectively). The figure below displays the amounts of edema and ecchymosis in both groups:
See below the postoperative alterations in edema and ecchymosis between interrupted and running suture techniques in both suture materials (From Beyoglu Eye J. 2022)
See below the postoperative complications in interrupted and running suture techniques in both vicryl and polypropylene groups (From Beyoglu Eye J. 2022):
Surgical Techniques
Upper eyelid blepharoplasty is a frequently performed surgical procedure worldwide, and the techniques and materials used for wound closure vary based on surgeons' preferences. In the study mentioned above, they have prospectively examined the outcomes of patients who underwent the procedure with interrupted cutaneous sutures in one eye and running cutaneous sutures in the other. They have found that the suture technique used had an effect on postoperative swelling, bruising, and scarring.
Upper eyelid blepharoplasty is a popular cosmetic surgery that aims to achieve excellent results with minimal complications and discomfort. To achieve this goal, surgeons have tried various methods and techniques. One study compared the results of subcuticular closure with a 5-0 polypropylene suture to closure with a running 6-0 fast-absorbing catgut approximation in the other eye in upper eyelid blepharoplasty. They found that the running 6-0 fast-absorbing catgut suture may offer slightly better results than a subcuticular permanent suture for closure of the upper eyelid blepharoplasty incision, with no significant differences in postoperative discomfort levels. Another study investigated whether an internal intradermal suture technique affects the occurrence of suture abscess formation and focal inflammation in upper eyelid blepharoplasty. They found that starting the suture in the medial side of an upper eyelid blepharoplasty wound resulted in a statistically significant reduction in the incidence of medial wound inflammation and suture abscess formation. As upper eyelid blepharoplasty is mainly performed for aesthetic purposes, any complications such as scar formation or postoperative discomfort are not desirable.
Different types of suture materials and techniques can be used to close incisions in upper eyelid blepharoplasty, including nonabsorbable and absorbable sutures, as well as simple, running, running locking, and subcuticular closure. One study compared various suture materials and techniques, such as a running subcuticular Prolene suture, a running-locking cutaneous 5-0 Prolene suture, a running cutaneous 6-0 plain gut suture, two interrupted 6-0 Prolene sutures, and a running 6-0 fast-absorbing gut suture, and found that closure with two interrupted 6-0 Prolene sutures and a running 6-0 fast-absorbing gut suture resulted in the lowest rates of complications and revisions postoperatively. Another study compared the use of 6-0 polypropylene sutures, 6-0 fast-absorbing gut sutures, and ethyl cyanoacrylate tissue adhesive for wound closure and found that tissue adhesive appeared to provide greater cosmesis than absorbable suture material over short- and intermediate-term follow-up. However, there was no significant advantage of tissue adhesive over polypropylene sutures. While tissue adhesives are a good option, they may not be available at every clinic.
Running and interrupted cutaneous suture techniques with either an absorbable or non-absorbable material are the typical methods utilized to close the upper eyelid blepharoplasty incision. We may be able to compare the postoperative outcomes of running and interrupted suture procedures in the same patient who underwent upper eyelid blepharoplasty more effectively by eliminating the various skin texture disparities. The purpose of the study's design is to first assess postoperative scar index, ecchymosis, and edema.
When to Choose Interrupted or Running Sutures
Different suture materials showed varying results in postoperative edema comparison. In the vicryl group, the interrupted sutured eyelid had better postoperative edema in the first week, whereas there were no significant changes between both eyelids in the polypropylene group. This suggests that edema levels are similar in both suture techniques. When it comes to ecchymosis levels, the interrupted sutured eyelid had significantly less ecchymosis than the running sutured eyelid in the first week in the vicryl group. In the polypropylene group, there was significantly less ecchymosis in the interrupted sutured eyelid than the running sutured eyelid in the first day and first week postoperatively. However, there was no difference in the long term. Therefore, the interrupted suture technique can be considered as an option for patients who may be disturbed by early ecchymosis. However, it is always more important to inform the patient that this situation can be seen to prevent these problems in the early postoperative period.
The formation of postoperative scars is an unwanted complication in cosmetic surgeries, such as blepharoplasty. In the vicryl group, the scar index was better in the interrupted sutured group than the running suture group at the first postoperative month, but differences in texture and contour were reduced by the third postoperative month. In the polypropylene group, while color, contour, and distortion indexes were better in the interrupted sutured eyelid at the first postoperative month, only color differences remained at the same level at the third postoperative month. The total scores of the scar index in both groups were significantly better in the interrupted sutured eyelid at both the first and third postoperative months. The better results in the interrupted sutured eyelid may be due to the better tissue approximation of the interrupted suture technique, which prevents tissue overlapping and pronouncing that can negatively affect tissue healing. Therefore, the interrupted suture technique may be superior in terms of scar formation after upper eyelid blepharoplasty. In the study, they have found that milia and wound dehiscence were the most common minor complications associated with blepharoplasty. In the vicryl group, while 5 patients had milia, 2 patients had wound dehiscence in running sutured eyelid, 2 patients had milia, and 3 patients had wound dehiscence in interrupted sutured eyelid. In the polypropylene group, while 6 patients had milia and 4 patients had wound dehiscence, 2 patients had an infection in running sutured eyelid, 4 patients had milia, and 4 patients had wound dehiscence in interrupted sutured eyelid. As seen, milia formation is seen more common in running suture technique. Wound dehiscence rates were similar in both suture techniques. A report has concluded a higher rate of milia formation (7.5%) after using the running subcuticular polypropylene. A study found nearly equal rates of milia formation with subcuticular polypropylene (2.5%) and with 6-0 running-fast absorbing gut, 5-0 simple interrupted Prolene (2%). Similarly, they have observed no significant difference in milia formation after using a permanent subcuticular and an absorbable skin suture. Another observed higher rates of milia (6.7%) with a running 6-0 plain suture and a running cutaneous locked Prolene (17%) when compared with either a subcuticular closure or a running closure with fast-absorbing gut suture. Milia are believed to result from the entrapment of epithelial cells along suture line tracts. Tissue–tissue overlapping and pronouncing that resulted in entrapment of epithelial cells along suture line tracts is prominent with the running suture technique. That could be an explanation for higher rates of milia formation of running suture technique. Overall, the findings suggest that the interrupted suture technique may be superior in reducing the risk of milia formation after blepharoplasty.
Limitations
The study has several limitations. The small sample size may affect the validity of our results. These points may be evaluated in future prospective studies with longer follow-up periods. On the other hand, we preliminarily evaluated the suture techniques that do not suture materials. Therefore, we did not compare the results of suture materials. However, the comparison of suture materials on different patients may not be as effective as the comparison in the same patient. These ideas could be a subject for future studies with a prospective design.
Conclusion
In this study, we report a sizable group of individuals who had upper eyelid blepharoplasty. In terms of edema, ecchymosis, and scar development, we have seen a substantial difference between suture approaches. The approach with the lowest incidence of edema, ecchymosis, and scarring appears to be interrupted suturing. Despite the fact that our research does not suggest that surgeons should alter their suturing methods, we can state that in these particular surgeries, an interrupted suture produces better results.
Reference
Comparison of Clinical Outcomes of Upper Eyelid Blepharoplasty Using Two Different Suture Techniques (2022)
Novel approach with fractional ultrapulse CO2 laser for the treatment of upper eyelid dermatochalasis and periorbital rejuvenation (2013)
Comparison of clinical outcomes of CO2 laser-assisted blepharoplasty using two different methods (2020)
Improved upper blepharoplasty outcome using an internal intradermal suture technique:a prospective randomized study (2015)
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