Suture materials and techniques for optimal cutaneous wound cosmesis: A systematic review
Authors: Kevin Chao, Ashley N. Elsensohn, Gaurav Singh, Shang I. Brian Jiang
Journal: Journal of the American Academy of Dermatology (2021)

To the Editor: Wound cosmesis is the key to satisfaction in all patients undergoing surgery. While principles such as the preservation of function, free margins, contour, and the placement of scars in cosmetic subunit junction lines are widely accepted, the suture materials and techniques used to achieve an ideal scar vary. We performed a systematic review of the literature on how suture materials and techniques affect scar cosmesis. A primary literature search for peer-reviewed publications dated between January 1, 1976, and December 1, 2020, was conducted on December 12, 2020, using PubMed, Ovid Medline, Cochrane, and CINAHL. Two authors, K.C. and A.N.E., independently searched and cross-checked the following search terms: “suture” OR “scar” AND “cosmesis.” Any differences were resolved via discussion. The article types were limited to clinical trials and randomized controlled trials on humans published in English. Review articles without original data, studies that did not evaluate the aesthetic outcomes of the scar, studies that did not compare at least 2 different suture materials or techniques, and studies that only compared sutures with alternative closure materials (ie, adhesive, barbed sutures, and staples) were excluded. Four hundred ninety-nine articles were identified using the key search terms, and an additional 12 relevant records were identified using the bibliography review. After a full-text abstract screening, 43 publications were included (Supplemental Fig 1; available at https://www.jaad.com). Five studies evaluated deep suture material (Table I). For deep sutures, polyglactin-910 (PG910) was found to have cosmesis equivalent to that of poliglecaprone-25 and worse cosmesis than polydioxanone or poly-4-hydroxybutyrate. Although the cosmetic outcome was deemed equivalent, 1 study showed poliglecaprone-25 to have fewer extruded sutures than PG910. Twenty studies evaluated different superficial suture materials (Table II). Overall, polypropylene had cosmetic outcomes equivalent to those of absorbable sutures, whereas nylon had worse cosmetic outcomes. One study directly evaluated the superficial suture diameter and found no difference in the cosmesis between 5-0 and 6-0 fast-absorbing guts.1Pourang A. Crispin M.K. Clark A.K. Armstrong A.W. Sivamani R.K. Eisen D.B. Use of 5-0 fast absorbing gut versus 6-0 fast absorbing gut during cutaneous wound closure on the head and neck: a randomized evaluator-blinded split-wound comparative effectiveness trial.J Am Acad Dermatol. 2019; 81: 213-218Google ScholarTable IDeep suture material comparisonMaterial AMaterial BPG910PGC25PDSP4HBPG910211, 21PGC251PDS1, 2P4HB1Number of studies comparing each pair of deep suture material. The font color corresponds to the study's conclusions: black = equal cosmesis with material A and material B; red = better cosmesis with material A; blue = better cosmesis with material B (eg, 1 study found that cosmesis was equal with PDS and PG910; 2 studies found that cosmesis was better with PDS than with PG910).P4HB, Poly-4-hydroxybutyrate; PDS, polydioxanone; PG910, polyglactin-910; PGC25, poliglecaprone-25. Open table in a new tab Table IISuperficial suture material comparisonMaterial AMaterial BPPNylonPGC25PG910Fast-absorbing PG910Plain gutFGPGAPDSSilkPolyamidePolycaprolatePolyesterPolyglytonePP41121, 111Nylon31, 111111PGC2511, 111PG910121Fast-absorbing PG91021Plain gut1FG1, 112PGA111PDS111Silk1Polyamide1Polycaprolate1Polyester1Polyglytone1Number of studies comparing each pair of superficial suture material. The font color corresponds to the study's conclusions: black = equal cosmesis with material A and material B; red = better cosmesis with material A; blue = better cosmesis with material B (eg, 1 study found that cosmesis was equal with PP and FG; 1 study found that cosmesis was better with PP than with FG).FG, Fast-absorbing gut; PDS, polydioxanone; PGA, polyglycolic acid; PG910, polyglactin-910; PGC25, poliglecaprone-25; PP, polypropylene. Open table in a new tab Number of studies comparing each pair of deep suture material. The font color corresponds to the study's conclusions: black = equal cosmesis with material A and material B; red = better cosmesis with material A; blue = better cosmesis with material B (eg, 1 study found that cosmesis was equal with PDS and PG910; 2 studies found that cosmesis was better with PDS than with PG910). P4HB, Poly-4-hydroxybutyrate; PDS, polydioxanone; PG910, polyglactin-910; PGC25, poliglecaprone-25. Number of studies comparing each pair of superficial suture material. The font color corresponds to the study's conclusions: black = equal cosmesis with material A and material B; red = better cosmesis with material A; blue = better cosmesis with material B (eg, 1 study found that cosmesis was equal with PP and FG; 1 study found that cosmesis was better with PP than with FG). FG, Fast-absorbing gut; PDS, polydioxanone; PGA, polyglycolic acid; PG910, polyglactin-910; PGC25, poliglecaprone-25; PP, polypropylene. Seventeen studies evaluated the suture techniques used for scar cosmesis. In 5 studies directly comparing percutaneous and subcuticular techniques using the same suture material, the subcuticular technique showed improved cosmesis with polypropylene but worsened results with PG910. When subcuticular PG910 and polypropylene were compared with each other, subcuticular PG910 left in place was found to have superior cosmesis than polypropylene.2Alam M. Posten W. Martini M.C. Wrone D.A. Rademaker A.W. Aesthetic and functional efficacy of subcuticular running epidermal closures of the trunk and extremity: a rater-blinded randomized control trial.Arch Dermatol. 2006; 142: 1272-1278Google Scholar Continuous and interrupted sutures provide equivalent cosmesis,3Blouin M.M. Al Jasser M. Demanczuk A. Berkowitz J. Zloty D. Continuous versus interrupted sutures for facial surgery repair: a randomized prospective study.Dermatol Surg. 2015; 41: 919-928Google Scholar as do fewer and more widely spaced sutures (5 mm on the head and neck4Sklar L.R. Pourang A. Armstrong A.W. Dhaliwal S.K. Sivamani R.K. Eisen D.B. Comparison of running cutaneous suture spacing during linear wound closures and the effect on wound cosmesis of the face and neck: a randomized clinical trial.JAMA Dermatol. 2019; 155: 321-326Google Scholar and 10 mm on the trunk and extremities5Stoecker A. Blattner C.M. Howerter S. Fancher W. Young J. Lear W. Effect of simple interrupted suture spacing on aesthetic and functional outcomes of skin closures.J Cutan Med Surg. 2019; 23: 580-585Google Scholar). A single-layer closure without superficial sutures may provide cosmesis equivalent to that provided by a double-layered closure in the long term. Four studies found wound-everting methods and eversion to be beneficial for scar cosmesis, while 2 studies challenged this long-standing tenet of wound repair; given these conflicting results, further studies are required in this area. In conclusion, optimal cutaneous wound cosmesis can be achieved with different suture materials and suturing techniques. The limitations of our review include the fact that the surgical skills and techniques used vary, potentially resulting in different outcomes. Scar evaluations are subjective, and there is no universally accepted and validated scar-scoring system. The repairs in the studies varied from laceration repairs to cesarean sections, with variable applicability to excisional wounds under tension typically encountered in dermatologic surgeries. None disclosed.