Sutures Make Differences in Complications, Revision of Blepharoplasties

MARCO ISLAND, FL-In performing blepharoplasty, the type of suture materials used by the surgeon may make a difference in outcome, researchers suggested at the first combined sections meeting of the Triological Society.

Doctors scrutinized the complication rates, the need for revision, and other factors among more than 800 patients who were treated by a single surgeon during a five-year period.

During the preoperative evaluation, patients were assigned one of four established techniques for incision closure based on the senior author’s experience, reported Arjun Joshi, MD, resident in the division of otolaryngology-head and neck surgery at The George Washington University in Washington, DC.

Dr. Joshi said that the study was undertaken because despite the prevalence of the surgery-performed for cosmetic reasons or to improve a patient’s field of vision-there is a paucity of information regarding suture techniques not only in blepharoplasty, but in other aesthetic facial surgeries.

He noted that upper eyelid blepharoplasty is one of the most common procedures performed for facial rejuvenation. It is a very successful treatment when patients are carefully chosen. The risks in the procedure are fairly low, he said, but asymmetry and scarring can occur.

Results of the Study

From 2001 to 2005, Dr. Joshi said that 866 patients underwent blepharoplasty. Patients who had skin resurfacing procedures such as lasers or peels were excluded from the study.

He said 198 of the surgeries were closed with 5-0 subcuticular polyprolene; 45 patients were closed with 5-0 running, locking polyprolene; 177 patients were closed with 6-0 running plain gut; and 466 patients were closed with 6-0 fast-absorbing gut, 2-0 simple interrupted 5-0 polyprolene sutures at the lateral ends of the incisions. All the patients underwent evaluation of the procedure at one, two, four, and six weeks, and then they were surveyed after three months.

Dr. Joshi said that among those whose blepharoplasty was closed with 5-0 subcuticular polyprolene, there were 5 (2.5%) who developed milia-the white bumps that often occur in healing skin, which are usually temporary; 11 patients (5.5%) had standing cone deformities that required revision; none of the patients had scarring; 4 patients (2%) had erythema; none of the patients had suture marks; and minor hematoma occurred in 2 patients (1%).

Among the individuals whose surgery was closed with 5-0 running, locking polyprolene, 8 patients (17%) developed milia; 2 patients (4.4%) had standing cone deformities; no patient had scarring; 1 patients (2.2%) had erythema; none of the patients had suture marks; and minor hematoma was absent.

Among the persons whose surgery was closed with 6-0 running plain gut, 12 patients (6.7%) developed milia; none had standing cone deformities; 5 patients (2.8%) had scarring; 16 patients (9%) had erythema; 3 patients (1.6%) had suture marks; and minor hematoma occurred in 1 patient (0.5%).

Of the patients whose surgery was closed with 6-0 fast-absorbing gut, 2-0 simple interrupted 5-0 polyprolene, 9 (2%) developed milia; none had standing cone deformities; 1 patient (0.2%) had scarring; 10 patients (2.1%) had erythema; 2 patients (0.4%) had suture marks; and minor hematoma occurred in 2 patients (0.4%).

None of the patients in any of the groups developed a major hematoma, infection, or dehiscence, Dr. Joshi said.

Interpretation of the Data

We found that there were significant [p < 0.05] differences between materials used in the development of milia, persistent scarring, and erythema. The results that saw erythema associated with plain gut were similar to our clinical experience. We found that the erythema was enhanced by the use of Neosporin use postoperatively in these patients. We now tell our patients not to use Neosporin postoperatively.

This is a large series of more than 800 patients who underwent upper lid blepharoplasty. We found significant differences between sutures. The study was performed by the same author using similar technique to try to minimize variations in terms of techniques, Dr. Joshi said.

Milia and standing cone deformity were the most common complications of upper lid blepharoplasty, he said in discussing the study. Subcuticular Prolene and running fast-absorbing gut resulted in nearly equal rates of milia, and the lowest of the four groups. Standing cone deformity rates were highest with subcuticular Prolene and running locking Prolene. Erythema and scarring appear to be associated with plain gut sutures versus the other sutures.

Dr. Joshi said that the study results are not expected to change general clinical practice. We don’t expect that facial plastic surgeons or surgeons who perform these aesthetic procedures are going to change their material or technique. We just offer this as a topic for consideration for further studies. Whether we can apply these results to other areas of the face remains to be seen, he said. He noted that one of the confounding factors in the study is that the primary author was able to classify groups into whatever type of closure they should get; additionally, scarring could have been affected by the method of fat excision used by the investigator.

It is an interesting topic, and the proper suture material is something we wrestle with all the time, said John Rhee, MD, Associate Professor of Otolaryngology at the Medical College of Wisconsin in Milwaukee.

This is a very large study of different materials in performing blepharoplasty. There have been other studies of these materials in other parts of the body but I’m not aware of other studies that have been performed that specifically look at blepharoplasty.

The problem with this study is that it is not randomized. It allows for the senior author to determine which patients would receive which suture, and any time that a study is not randomized it allows for the possibility of bias in selecting patients for each form of treatment, said Dr. Rhee, who moderated the session at which Dr. Joshi’s paper was presented.

If this study could be accomplished in a randomized fashion, it is the type of information we need in the medical literature, he said.

©2007 The Triological Society