Absorbable versus Non-Absorbable Sutures in Paediatric Facial Trauma - A Cosmetic Assessment

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Jemds.com Original Research Article
J Evolution Med Dent Sci / eISSN - 2278-4802, pISSN - 2278-4748 / Vol. 9 / Issue 36 / Sept. 07, 2020 Page 2601
Absorbable versus Non-Absorbable Sutures in Paediatric Facial Trauma
- A Cosmetic Assessment
Pinki Pargal1,
1Department of Plastic Surgery, Christian Medical College & Hospital, Ludhiana, Punjab, India
AB S TR AC T
BACKGROUND
Paediatric age group is most vulnerable to trauma. Children often suffer facial
injuries. Though many topical skin adhesives and strips are available in the market
which have given excellent cosmetic results, deeper injuries especially along the lines
of high tension need suturing both with buried and skin sutures. Different variety of
sutures are available in the market which are used as per the choice of the surgeon.
Children are more apprehensive when it comes to suture removal. So use of
absorbable sutures in place of non-absorbable sutures in skin can save the children
from this fear factor.
METHODS
A prospective study was done in the department of plastic surgery from May 2012 to
Dec. 2013 with an objective of studying the outcome of plain catgut suture as skin
sutures versus non-absorbable skin suture Nylon in facial trauma in the paediatric
age group. Chromic catgut was used as buried suture in both groups. All the patients
presenting in emergency department with facial trauma with age 10 years or less
were included in the study. Skin sutures, where needed removal, were removed on
5th post-operative day followed by follow up on 7th post-operative day, 3rd month and
8th month during which cosmetic assessment of scar was done. 25 patients who
presented first in emergency and fulfilled the study criteria were sutured with 5 - 0
chromic catgut buried sutures and skin suture used was 6 - 0 Nylon and this group
was labelled group A. Next 25 patients who presented in emergency for suturing were
sutured with 5 - 0 chromic catgut as buried and plain catgut as skin suture. This group
was labelled as Group B. Cosmetic outcome was assessed on 7th post-operative day,
3rd month and 8th month by using Beusang E cosmetic scar assessment scale based on
two parameters which included colour and texture of scar.1 Statistical analysis was
done with continuous variables expressed as Mean ± S.D. and categorical variables
were expressed as count (percentage). Chi-square was used to compare the
categorical variables between groups or Fisher exact test was used.
RESULTS
On 7th post-operative day follow up, out of 50 patients, 25 patients (50 %) in whom
nylon was used as skin suture, 4 patients (16 %) had mismatch of colour. All scars
were smooth in texture. In rest 25 patients (50 %) in whom plain catgut was used as
a skin suture, 1 (4 %) patient had mismatch of the colour. None of the patients had
frank pus in both groups & hypertrophic scar was seen in one patient. On 3rd month
follow up, Group A patients with nylon as skin suture, 1 (4 %) patient showed
hypertrophic scar whereas in Group B (8 %) patients had hypertrophic scar. On 8th
month follow up, both group A & B had colour mismatch of 12% with firm texture of
scar in 8% patients.
CONCLUSIONS
There is no long-term differences in cosmetic outcomes and complication rates
between absorbable catgut suture and commonly used nylon sutures in the repair of
facial trauma in paediatric age groups. So, absorbable sutures are acceptable
alternative to non-absorbable suture especially in paediatric age group, keeping in
mind their apprehensive nature and fear of suture removal.
KEY WORDS
Absorbable Suture, Plain Catgut, Buried Suture, Chromic Catgut, Non-Absorbable
Suture, Nylon, Facial Trauma, Suturing, Paediatric Age Group
Corresponding Author:
Dr. Pinki Pargal.
Gateway Terrace 10,
Opp. CMC Hospital, Doctor’s Colony,
Ludhiana, Pinjab, India.
E-mail: pinkipargal@gmail.com
DOI: 10.14260/jemds/2020/566
How to Cite This Article:
Pargal P. Absorbable versus non-
absorbable sutures in paediatric facial
trauma - a cosmetic assessment. J Evolution
Med Dent Sci 2020;9(36):2601-2604, DOI:
10.14260/jemds/2020/566
Submission 02-06-2020,
Peer Review 26-07-2020,
Acceptance 03-08-2020,
Published 07-09-2020.
Copyright © 2020 JEMDS. This is an open
access article distributed under Creative
Commons Attribution License [Attribution
4.0 International (CC BY 4.0)]

Jemds.com Original Research Article
J Evolution Med Dent Sci / eISSN - 2278-4802, pISSN - 2278-4748 / Vol. 9 / Issue 36 / Sept. 07, 2020 Page 2602
BA C KG RO UN D
Egyptian scrolls described the art of suturing wounds as early
as 3500 BC. Suture materials used in the past centuries
consisted of horsehair, animal tendons, vegetable fibers and
human hair.3 since then with advancement of modern
techniques in processing of suture material resulted in wide
variety of suture material in the market which included both
absorbable and non - absorbable sutures. Trauma anywhere in
the body needs suturing especially suturing of the outermost
layer of the skin with non-absorbable sutures which needs
removal once wound is healed.
Ideally non-absorbable Nylon suture is used for skin
closure.4 However in past few decades different approaches
have evolved where the skin suturing is replaced by Topical
skin adhesives like butyl cyanoacrylate and octyl
cyanoacrylate which are easy to apply and gave good results in
superficial wounds.5 Adhesive strips have also come in
market.6 All the superficial injuries in any part of the body gave
good results with these techniques but deeper wounds always
required suturing Skin suturing is the only treatment in such
cases, in addition to skin sutures buried sutures played
important to obliterate the dead space.7
Various sutures used for skin suturing are available in
market, they are either absorbable or non-absorbable. Various
studies available have shown no significant differences with
respect to wound appearance and infection rates between
absorbable and non - absorbable sutures8. Among the non-
absorbable suture most often used is Nylon. Its sterile,
synthetic monofilament which provide good tensile strength
and low tissue reactivity, dyed black or green for better
visibility Non absorbable sutures on the face need removal
between 4 and 6 days. Catgut suture available as plain catgut
or chromic catgut. It’s derived from processed sheep or cattle
intestines and was first described for use in suturing in 1870s.
It’s degraded by proteolytic enzymes in the tissues and when
pretreated with heat produces a fast absorbing material that
dissolves between 3 to 10 days 9.
These sutures when used needs no removal, only
unraveled suture were removed keeping in mind this quality
of suture this can be used in skin suturing of paediatric age
group. Children are apprehensive of pain associated with
suture removal, especially if they have unpleasant memories
of their initial suturing. This suture if used lessens the number
of hospital visits and costs associated with follow up can be
minimized. The present study was done to compare the
cosmetic results of absorbable suture Plain catgut with non-
absorbable Nylon suture and also to compare complications
rates in these suture material. So that in future absorbable
suture can be used in paediatric age group if its long-term
cosmetic results were comparable with non-absorbable
suture.
Objectives
To compare the long-term cosmetic outcome of Absorbable
Versus Non - Absorbable Suture in Paediatric Facial Trauma &
Comparison of complication rates.
ME T HO DS
A prospective study was done in the department of plastic
surgery from May 2012 to Dec 2013 after obtaining
institutional ethic committee clearance. All the patients
presenting in emergency with facial trauma with age 10 year
or less were included in study. Exclusion criteria included 1)
all those facial injuries presented late, that is after 8 hours of
trauma. 2) Grossly contaminated wounds. 3) Wounds with
associated abrasions 4) all superficial wounds where topical
adhesives or strips can be applied. Out of the 80 patients who
presented for facial suturing during the study period, only 50
patients were enrolled as they fulfilled the criteria. Informed
consent was taken from the patient parent / guardian. Once
agreed a detailed history which included demographic profile
and mode of injury were noted.
A photographic record was maintained in follow up period
with same digital camera with same settings. Non - absorbable
skin sutures when used removal was done on on 5th post -
operative day followed by follow up on 7th post - operative day,
3rd month and 8th month during which cosmetic assessment
of scar was done. Randomization of the patients was done by
dividing patients into two groups. 25 patients who presented
first in emergency and fulfilled the study criteria were sutured
with 5 - 0 or 6 - 0 Nylon skin sutures and this group was
labelled group A. Next 25 patients who presented in
emergency with facial injury 5-0 plain catgut was used as skin
suture and this group was labelled as Group B. Cosmetic
outcome was again assessed on 7th post -operative period, 3rd
month and 8th month. Cosmetic Assessment of scar was done
using Beusang E cosmetic scar assessment scale based on two
parameters which included Colour and texture of scar. In
Colour it was noted whether the scar matched the surrounding
skin or there was any mismatch. Similarly in texture it was
noted whether scar site was smooth or firm.
Presence or absence of wound infection was noted taking
four parameters into account which included presence or
absence of Redness, Serosanguinous collection, frank pus,
Oedema, Presence of hypertrophic scar during the follow up
visit was also noted. In case of patients where plain catgut was
used as skin suture, premature unravelling of sutures was also
noted. Simple interrupted suturing technique using a cutting
needle was used in both groups. Injuries on the face which had
deep wounds, requiring multilayer closure 5 - 0 chromic catgut
was used as buried suture. In both the groups Steristrips were
used after suturing to optimize wound approximation9
Patients were discharged with standardized wound care
instructions.
Statistical Analysis
In the descriptive analysis, continuous variables were
expressed as Mean ± S.D. and categorical variables were
expressed as count (percentage). Chi-square was used to
compare the categorical variables between groups or Fisher
exact test was used when expected count was < 5. Independent
t-test was used to compare continuous variables between two
groups. The significance level was set at p < 0.05. All statistical
analysis was performed using SPSS, version 21.0. Armonk, NY:
IBM corp.

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RE S UL T S
A total of 50 children was enrolled in the study in the age group
of 0 - 10 years. Male: female ratio was 3:1. The Mean (SD) age
of patients in Nylon group 4.4 (2.1) years was comparable with
Catgut group 3.9 (2.5) years, p = 0.442. The cause of injury was
fall for 28 (56 %) of the patients and RTA for 22 (44 %) of the
patients.
On 7th Post - Operative Day follow up, Out of 50 patients,
25 patients (50 %) in whom nylon was used as skin suture, 4
patients (16 %) had mismatch of colour, 3 (12 %) patients had
redness of the scar, 2 (8 %) patients had serosanguinous
collection, 3(12 %) patients had oedema of the scar. None of
the patients had frank pus or hypertrophic scar. All the scars
were smooth in texture. In rest 25 patients (50 %) in whom
plain catgut was used as a skin suture, 1 (4 %) patient had
mismatch of the colour 1 (4 %) patient had firm texture, 2 (8
%) patients had the redness of the scar, 2 (8 %) patients had
serosanguinous collection and 1 (4 %) patient had oedema.
None of the patient had frank pus and hypertrophic scar was
seen in one patient.
Cosmetic Assessment of
Scar & Complications
Nylon
Catgut
Statistical
Outcome
n (%)
n (%)
P-Value
Colour
Perfect
21 (84.0)
24 (96.0)
0.349
Mismatch
4 (16.0)
1 4.0)
Texture
Smooth
25 (100.0)
24 (96.0)
1.000
Firm
0 (0)
1 (4.0)
Redness
3 (12.0)
2 (8.0)
0.637
Serosanguinous Collection
2 (8.0)
2 (8.0)
1.000
Frank Pus
0 (0)
0 (0)
------
Hypertrophic Scar
0 (0)
1 (4.0)
1.000
Oedema
3 (12.0)
0 (0)
0.235
Table 1. During 7th Post-Operative Day Follow Up
On 3rd Month follow up, patients with nylon as skin suture,
4 (16 %) patients had mismatch of the colour of the scar, 1
(4 %) patient had firm texture and rest all had smooth texture.
Redness was seen in 3 (12 %) patients, Serosanguinous
discharge was seen in 2 (8 %) patients. None of the patient had
frank pus, 2 (8 %) patients had oedema of the scar, with 1 (4
%) patient showing hypertrophic scar. The patients sutured
with plain catgut on 3rd month showed 1 (4 %) patient with
mismatch of the colour, 2 (8 %) patients had firm texture, 1
(4 %) patient had redness and frank pus, 2 (8 %) patients
showed serosanguinous collection, 2 (8 %) patients had
hypertrophic scar.
Cosmetic Assessment of
Scar & Complications
Nylon
Catgut
Statistical
Outcome
n (%)
n (%)
P - Value
Colour
Perfect
21 (84.0)
24 (96.0)
0.349
Mismatch
4 (16.0)
1 (4.0)
Texture
Smooth
24 (96.0)
23 (92.0)
0.552
Firm
1 (4.0)
2 (8.0)
Redness
3 (12.0)
1 (4.0)
0.297
Serosanguinous Collection
2 (8.0)
2 (8.0)
1.000
Frank Pus
0 (0)
1 (4.0)
1.000
Hypertrophic Scar
1 (4.0)
2 (8.0)
0.552
Oedema
2 (8.0)
1 (4.0)
0.552
Table 2. During 3rd Month Follow Up
On 8th Month follow up, patients with the nylon skin suture
had mismatch of the colour of the scar in 3 (12 %) patients,
firm texture was seen in 2 (8 %) patients, hypertrophic scar
was seen in 2 (8 %) patients. In catgut skin suture patients, 3
(12 %) patients had mismatch of the colour of the scar, 2 (8 %)
patients had firm texture, 1 (4 %) patient showed both redness
and frank pus. None of the patient had hypertrophic scar or
oedema. Unraveled Plain Catgut Sutures were seen in 5 (20 %)
patients.
Cosmetic Assessment of
Scar & Complications
Nylon
Catgut
Statistical
Outcome
n (%)
n (%)
P - Value
Colour
Perfect
22 (88.0)
22 (88.0)
1.000
Mismatch
3 (12.0)
3 (12.0)
Texture
Smooth
23 (92.0)
23 (92.0)
1.000
Firm
2 (8.0)
2 (8.0)
Redness
1 (4.0)
1 (4.0)
0.297
Serosanguinous Collection
0 (0)
0 (0)
------
Frank Pus
0 (0)
1 (4.0)
1.000
Hypertrophic Scar
2 (8.0)
0 (0)
0.490
Oedema
0 (0)
0 (0)
------
Table 3. During 8th Month Follow Up
DI S CU SS IO N
The present study comparing absorbable suture Plain catgut
with Non-absorbable Nylon suture material was done in
paediatric age group between 0 to 10 years. M: F ratio was 3 :
1 in the study done by Karounis et al,10 number of females
outnumbered males. In our study 56 percent of patients had
history of fall comparable to this study. The cosmetic outcome
results of our study were also consistent with previously
published reports evaluating the use of absorbable sutures in
laceration repair. Holger et al,11 using VAS scores, compared
the cosmetic outcomes at 9 to 12 months of adult and
paediatric patients with facial lacerations repaired using
nylon, FAC, and octyl cyanoacrylate. Their results also showed
no clinically important differences in VAS scores between the
3 groups. Karounis et al10 also did not detect any clinical
difference in cosmetic scores between plain catgut versus
nylon sutures in paediatric lacerations at 4 to 5 months. Rates
of infection and dehiscence between the two groups were
comparable, with infection rate 0 vs 2 with p = 0.3, and wound
dehiscence 2 % vs 11% with p = 0.07. The two study group had
similar gender distribution in contrast to our study where
male outnumbered females. Lubitz and Coyne12 did not detect
any difference in cosmetic outcomes between FAC and non-
absorbable sutures at 4 to 12 months. In our study
Complication rates were similar in both the group, similar
results were seen by Start et al,13 where a total of 100 children
were studied, 50 had chronic catgut skin suture and 50
repaired with silk. In our study there was no significant
difference in both groups of number of hypertrophic scars.
Similar results were seen with studies done by Helen et al and
H. Choudhary et al,14 who concluded that the absorbable
sutures designed to degrade rapidly led to lesser scar
formation. In our study we had hypertrophic scar in two
patients treated with Nylon, similar results were seen by
Raemma et al15 in their study where one patient had keloid at
3rd month follow up. For those patients in whom Plain Catgut
skin sutures were applied in our study, the sutures that were

Jemds.com Original Research Article
J Evolution Med Dent Sci / eISSN - 2278-4802, pISSN - 2278-4748 / Vol. 9 / Issue 36 / Sept. 07, 2020 Page 2604
still intact or unraveled were removed at 5th post - operative
day. Out of 25 patients, 17 (68 %) had at least one suture
remaining on 5th post-operative day which was removed.
Present finding is comparable to study done by Raemma et al15
where out of 23 patients 16 patients (70 %) had one suture
which needed removal. Only two patients in the Catgut group
had premature unraveling of the suture comparable with
study done by Raemma et al.15
CO N CL US IO NS
Absorbable sutures are acceptable alternatives to non-
absorbable sutures in paediatric facial trauma as there are no
long-term differences in cosmetic outcome and complication
rates between the two sutures.
Financial or Other Competing Interests: None.
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