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Article 5
Article 5
Department of Burns, Plastic and Maxillofacial Surgery, Vardhaman Mahavir Medical College &
Safdarjung Hospital, New Delhi, India
KEYWORDS Summary Scars have multiple cosmetic and functional sequelae, and revision surgeries are
Scar revision; an attempt to ameliorate these effects. Reduction of spread of the revised scar is one of the
Polyglactin 910; main objectives of revision procedures. Provision of prolonged dermal support to wound can
Polydioxanone; theoretically reduce spread of the scar. We carried out a randomized controlled trial and ob-
Scar width; jectively evaluated the impact of two commonly used absorbable sutures, Polyglactin 910 and
Dermal support; Polydioxanone, on scar spread and quality. Sixty patients with post-traumatic scars of 1 year
Scar spread in duration were enrolled in the study and randomly divided into two groups of 30 each. Af-
ter recording the demographic data and baseline scar characteristics, revision of the scar was
carried out by elliptical excision and primary suturing. In Group 1, Polyglactin 910 6-0 suture
(Vicryl, Ethicon, Johnson and Johnson Ltd., India) was used for dermal suturing, whereas, in
Group 2, Polydioxanone 6-0 suture (PDS II, Ethicon, Johnson and Johnson Ltd., India) was used.
The scar spread in terms of scar width, and scar quality with Vancouver Scar Scale (VSS) was
evaluated at 1, 3 and 4 months postoperatively. The two groups were well matched for demo-
graphics and baseline scar characteristics. On follow-up, the mean scar width in Group 1 was
significantly more than that in Group 2. VSS score was significantly lower in Group 2 at the third
and fourth month follow up, signifying better scar quality. Suture extrusion was noticed in 3
cases in Group 1.
110009, India.
E-mail address: deepti2611@gmail.com (D. Gupta).
https://doi.org/10.1016/j.bjps.2018.03.021
1748-6815/© 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
1160 D. Gupta et al.
Compared to Polyglactin 910, Polydioxanone sutures, when used for intradermal suturing in
revision of facial scars, result in a significantly decreased scar spread and better scar quality.
© 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by El-
sevier Ltd. All rights reserved.
Fig. 1 Patient 1 belonging to Group 1 with scar on left cheek revised using Polyglactin 910 suture. a. Preoperative photograph,
lateral profile b. Postoperative photograph at 4 months, lateral profile.
Fig. 2 Patient 8 belonging to Group 2 with scar on forehead revised using Polydioxanone suture. a. Preoperative photograph, front
profile. b. Postoperative photograph at 4 months, front profile.
Table 1 Demographic data and baseline scar characteristics of patients in Group 1 and Group 2.
Group 1 (Polyglactin 910) Group 2 (PDS) p value
Gender (Male/Female) 9/21 14/16 0.184
Age∗ (years) 24.1 ± 6.8 22.9 ± 4.84 0.841
Scar duration† (years) 5.5 (4–8) 7 (5–9) 0.198
Scar width∗ (mm) 7.2 ± 1.93 6.7 ± 1.66 0.279
VSS score† 2 (2-2) 2 (1–3) 0.596
p value <0.05 considered as statistically significant.
∗ Expressed as mean ± standard deviation.
† Expressed as median (interquartile range).
(Table 2). In terms of the scar quality, the VSS score of the such prospective clinical study conducted by Guyuron et al.,
two groups were statistically comparable at 1 month follow- failed to demonstrate any statistically significant difference
up, but was significantly lower in Group 2 at 3 and 4 months in the scar spread with the use of 6-0 PDS and 6-0 polyglactin
follow-up, reflecting a better scar quality (Table 3). 910 sutures in patients undergoing facial rhytidectomy.19
Suture extrusion was noticed in three cases in Group 1 The scar spread in this study was noted as being present
subset, and was absent in group 2. None of the patients in (>5 mm) or absent (<5 mm). The authors did not take into
Group 2 showed suture extrusion. This difference was, how- account the actual difference in the mean scar width be-
ever, found to be statistically insignificant between the two tween the two groups. We quantitatively measured the scar
groups, with p value > 0.05. spread, and compared the mean scar width between the
two groups. Both our study groups showed spread of the
scar, as was noted by Guyuron et al., but the mean scar
Discussion spread was seen to be significantly more with the use of
Polyglactin 910 suture. The results in our study are in con-
Scar revision aims at providing optimal cosmetic results and cordance with those of Kia et al., who compared the spread
minimizing scar spread. There is a wide variety of suture of scar with the use of Poly-4-Hydroxybutyrate (P4HB) and
materials available for scar revision. The choice depends on Polyglactin 910. They used both these sutures for dermal ap-
the physical and biological properties of the suture mate- proximation in wounds resulting from excision of lesions on
rial, suturing technique and the healing properties of the the back.8 As P4HB is a longer acting suture in comparison
sutured tissues.15–17 This study was targeted to evaluate the to Polyglactin 910, the authors concluded that prolonged in-
role of prolonged dermal support in revision of facial scars. tradermal support results in decreased scar spread.
The slow reabsorbing PDS suture was compared to the early In our study, the scar quality, as assessed by VSS, was
reabsorbing Polyglactin 910 suture, and their impact on scar found to be comparable between Polyglactin 910 and PDS
spread and scar quality was assessed. The results of this group at 4 weeks of follow-up. This is because persistent
study show that scar spread, measured in terms of mean wound hyperemia at 4 weeks might have resulted in simi-
scar width at 1, 3 and 4 months follow-up was significantly lar scores in the vascularity sub-category of VSS, in both the
lower with the use of PDS sutures. The scar quality, as as- groups. With gradual maturation of the scar, the VSS score
sessed by median VSS score, showed a significantly lower was significantly lower in the PDS group at 3 and 4 month of
score at 3 and 4 months follow-up in the PDS group ver- follow-up. Our results differ from those of Guyuron et al.,
sus the Polyglactin 910 group, indicating better scar quality who labeled any raised scar as hypertrophic, and did not re-
with the use of PDS sutures for dermal support. veal any statistically significant difference in the incidence
Use of subcuticular nylon and other non-absorbable su- of hypertrophy with the use of Polyglactin 910 and PDS.19
tures for intradermal approximation has been shown to sig- We have scored the height of the scar according to the
nificantly decrease the stretching of scar in a wound sutured VSS, and found that compared to Polyglactin 910, PDS re-
under tension.6,18 This is associated with an increased risk of sulted in a significantly better scar quality at 3 and 4 months
wound inflammation and suture extrusion. Moreover, these follow-up.
sutures cannot be left in situ and need to be removed at a Our results corroborate with those of other studies that
later stage, which causes inconvenience to the patient and have shown better scar quality with the use of a longer act-
the surgeon. ing suture. When Polyglycolic Acid (PGA) and PDS subcu-
Studies comparing the characteristics of a scar result- ticular sutures were compared in a prospective study, PDS
ing from suturing a wound with absorbable versus delayed was found to cause scar hypertrophy in significantly lesser
absorbable sutures have reported varying conclusions. One number of wounds.7 Similarly, compared to Polyglactin 910,
Improved outcomes of scar revision with the use of polydioxanone suture in comparison to polyglactin 910 1163
the use of a longer acting suture (P4HB) for dermal support References
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