Outcomes of cosmetic suturing for facial trauma in medically underserved counties of western China: A retrospective observational cohort study

Abstract

Facial trauma is frequent in medically underserved regions of western China, where lack of access to specialized surgical care contributes to infection, hypertrophic scarring, and psychosocial distress. Although cosmetic suturing is widely used in plastic surgery, its systematic application in rural hospitals has not been well characterized. We conducted a single-center, retrospective, non-comparative observational cohort study at the Qingyang Hospital of Traditional Chinese Medicine from January to December 2024. Sixty consecutive patients (mean age 30.7 ± 13.6 years; 38 males, 22 females) with acute facial lacerations closed by direct approximation were included. Outcomes were evaluated at 6 months using the Vancouver Scar Scale (VSS) and patient satisfaction via the Visual Analog Scale. Logistic regression was performed to identify independent predictors of satisfaction. Falls (46.7%) and road traffic accidents (31.7%) were the leading causes of trauma. Mean scar length was 7.35 ± 5.02 cm, with 23.3% of patients presenting with multi-site lacerations. Superficial infection occurred in 2 cases (3.3%) and partial dehiscence in 3 cases (5.0%). At 6 months, 91.7% of patients reported satisfaction with cosmetic outcomes. The satisfied group demonstrated higher mean Visual Analog Scale scores (8.65 ± 1.03 vs 7.20 ± 0.45, P = .004) and lower mean VSS scores (1.74 ± 0.61 vs 2.90 ± 0.22, P < .001). Multivariate regression identified 2 independent predictors of satisfaction: lower VSS scores (odds ratio = 0.12, 95% confidence interval: 0.02–0.68, P = .016) and adherence to silicone therapy (odds ratio = 5.42, 95% confidence interval: 1.10–26.81, P = .038). In this non-comparative cohort, cosmetic suturing with layered closure and tension-reducing techniques, supplemented by scar management strategies, produced favorable short-term aesthetic outcomes in a rural Chinese hospital. However, interpretation is limited by the small sample size, 6-month follow-up period, and potential selection bias. Broader multicenter studies with longer follow-up are warranted to validate these findings.

1. Introduction

Facial trauma remains a pressing public health concern in medically underserved regions of western China, where incidence rates are disproportionately high in rural and remote areas. The face, with its constant exposure and complex anatomy, is particularly vulnerable to injury.^[1] Even seemingly minor wounds can impair speech, vision, or mastication, while visible scars impose lasting psychosocial consequences. In children, trauma is typically activity-related, most often due to falls (17%) or bicycle accidents (28.5%), whereas in adults, agricultural injuries, traffic collisions, and interpersonal violence predominate.^[2–5]

Specialized surgical services in these regions are scarce. Many local facilities lack physicians trained in cosmetic closure, and limitations in surgical materials and sterility further heighten the risks of infection, hypertrophic scarring, and functional impairment. Geographic isolation and financial constraints compound delays in accessing care, frequently culminating in disfiguring outcomes and chronic disability.

The psychosocial burden of facial scarring in these communities is considerable.^[6] Cultural norms emphasizing facial harmony and unblemished skin render scars stigmatizing, particularly for women, with negative repercussions for self-esteem, social participation, and marital prospects. The scarcity of mental health resources exacerbates these effects, leaving many patients without adequate support. Addressing these challenges requires a multifaceted approach, one that combines reliable surgical techniques, preventive strategies, and accessible rehabilitation to mitigate both functional deficits and psychosocial impact in this vulnerable population.

2. Patients and methods

This single-center, retrospective observational cohort study was conducted at the Qingyang Hospital of Traditional Chinese Medicine between January 1 and December 31, 2024. Institutional review board approval was obtained, and informed consent was provided by all patients or their legal guardians.

2.1. Patient selection

Eligible patients were those aged ≥4 years who presented within 24 hours of acute facial soft-tissue laceration and were managed by direct approximation without concomitant orbital rim entrapment or sensory organ injury.

Exclusion criteria included: full-thickness tissue loss requiring flap or graft reconstruction; craniofacial fractures requiring open reduction and internal fixation; preexisting facial scars, keloids, or dermatologic disorders affecting wound healing; and incomplete 6-month follow-up.

Among 68 patients initially screened, 8 (11.8%) were found to have mandibular or zygomatic fractures on computed tomography. Five underwent open reduction and internal fixation with titanium miniplates and screws, and 3 were treated conservatively with intermaxillary fixation for 2 weeks. These cases were excluded, leaving 60 patients (38 males, 22 females; mean age 30.7 ± 13.6 years) for analysis.

2.2. Injury assessment

On admission, all patients underwent structured clinical evaluation. Physical examination assessed swelling, contusions, abrasions, lacerations, and facial symmetry. Palpation of facial bones identified tenderness, step-offs, or instability. The oral cavity was examined for malocclusion, lacerations, and foreign bodies, and ocular and cranial nerve function were documented. Thin-slice, non-contrast computed tomography imaging was performed to exclude fractures and detect retained foreign material. Foreign body contamination (gravel, dirt, or glass shards) was identified in 7 patients (11.7%) and managed successfully with irrigation and meticulous debridement.

2.3. Timing of debridement and antibiotic prophylaxis

Wound debridement and closure were performed within 6 to 12 hours of injury whenever feasible. All patients received prophylactic oral first-generation cephalosporins for 3 to 5 days. Two patients (3.3%) who developed infection received extended antibiotic therapy guided by culture and sensitivity testing.

2.4. Cosmetic suturing technique

All procedures were performed by the same surgeon, a general surgeon with fellowship training in plastic surgery, to ensure consistency across cases. Closure followed a standardized protocol:

1. Subcutaneous tension reduction with absorbable sutures (4-0 or 5-0 Vicryl).

2. Deliberate eversion of wound edges.

3. Interrupted epidermal closure with fine non-absorbable monofilament sutures (6-0 or 7-0 polypropylene).

Sutures were removed between postoperative days 5 and 7 depending on anatomical site, with earlier removal for perioral and periorbital regions.

2.5. Postoperative management

Patients were instructed to minimize facial movement and avoid sun exposure during early healing. Daily wound care included saline irrigation and topical antimicrobials. Scar prevention measures (micropore tape and silicone gels or sheets) were recommended to all patients, although adherence varied and contributed to outcome differences. Follow-up at 6 months included scar assessment by Vancouver Scar Scale (VSS), objective scar width and length measurements, and patient-reported satisfaction using the Visual Analog Scale (VAS).

2.6. Statistical analysis

Data were analyzed using SPSS 26.0 (IBM Corp., Armonk). Continuous variables were expressed as mean ± SD and compared with Student t test; categorical variables were compared using chi-square or Fisher exact tests. Scar length was categorized as small (<5 cm), medium (5–10 cm), or large (>10 cm). Wound locations were classified as perioral, periorbital, frontal, nasal, chin, cheek/zygomatic, or auricular. Variables with P < .10 in univariate analysis, as well as clinically relevant factors (age, scar length, location, infection, silicone use), were included in binary logistic regression. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported.

3. Results

A total of 60 patients were included. Clinical characteristics and outcomes are summarized in Table 1. The mean age was 30.7 ± 13.6 years, with a male predominance (63.3%). Falls (46.7%) and road traffic accidents (31.7%) were the most common causes of trauma. Mean scar length was 7.35 ± 5.02 cm, with 20.0% of patients presenting with large scars (>10 cm). Multi-site lacerations, often associated with longer wounds, were observed in 14 patients (23.3%).

Table 1.

Clinical characteristics and outcomes of patients with facial trauma (n = 60).

Variable	Value
Demographics
Age, mean ± SD (yr)	30.7 ± 13.6
Male sex, n (%)	38 (63.3)
Female sex, n (%)	22 (36.7)
Injury etiology, n (%)
Falls	28 (46.7)
Road traffic accidents	19 (31.7)
Collisions (sports/impacts)	10 (16.7)
Others (animal/violence)	3 (5.0)
Scar length, mean ± SD (cm)	7.35 ± 5.02
Scar length categories, n (%)
Small (<5 cm)	22 (36.7)
Medium (5–10 cm)	26 (43.3)
Large (>10 cm)	12 (20.0)
*Wound location, n (%)
Perioral	18 (30.0)
Periorbital	14 (23.3)
Frontal	12 (20.0)
Nasal	8 (13.3)
Chin	7 (11.7)
Cheek/zygomatic	9 (15.0)
Auricular	3 (5.0)
Clinical outcomes, n (%)
Infection	2 (3.3)
Wound dehiscence	3 (5.0)
Foreign body contamination	7 (11.7)
Hypertrophic scar requiring steroid injection	2 (3.3)
Reoperation	0
Mean dressing changes (per patient)	3.2 ± 1.1
Mean outpatient visits (per patient)	2.5 ± 0.8

^*Percentages exceed 100% because some patients presented with wounds involving multiple anatomical subunits, particularly in cases of longer lacerations.

3.1. Baseline characteristics

Of the 60 patients (38 males, 22 females), trauma etiologies included falls (46.7%), road traffic accidents (31.7%), collisions (16.7%), and other causes (5.0%). Scar lengths were distributed as small (<5 cm, 36.7%), medium (5–10 cm, 43.3%), and large (>10 cm, 20.0%).

3.2. Clinical outcomes

All patients received prophylactic oral cephalosporins for 3 to 5 days. Two (3.3%) developed superficial wound infections and 3 (5.0%) experienced partial wound dehiscence; no seromas, hematomas, or reoperations were recorded. Foreign body contamination was identified in 7 patients (11.7%), mostly gravel or glass shards, and was managed successfully with debridement. Two patients (3.3%) developed hypertrophic scars requiring intralesional triamcinolone.

Sutures were removed between postoperative days 5 and 7 according to anatomical location (earlier in perioral and periorbital regions). No patients developed railroad tracking, ischemic indentation, or localized necrosis. On average, each patient underwent 3.2 ± 1.1 dressing changes and 2.5 ± 0.8 outpatient follow-up visits. All operations were performed by the same surgeon, a general surgeon with formal fellowship training in plastic surgery, ensuring consistency of technique.

3.3. Aesthetic outcomes

At 6 months, the mean VAS satisfaction score was 8.65 ± 1.03 in the satisfied group and 7.20 ± 0.45 in the dissatisfied group (P = .004). Mean VSS score was 1.74 ± 0.61 versus 2.90 ± 0.22, respectively (P < .001). Aesthetic outcomes and predictors of satisfaction are detailed in Table 2 (Figs. 1–4).

Table 2.

Aesthetic outcomes and predictors of patient satisfaction.

Variable	Satisfied group (n = 48)	Dissatisfied group (n = 12)	P-value	Logistic regression, OR (95% CI)	P-value
Age (yr), mean ± SD	29.9 ± 14.1	33.8 ± 11.9	.42	1.04 (0.91–1.18)	.58
Male sex, n (%)	30 (62.5)	8 (66.7)	.78	–	–
Scar length (cm), mean ± SD	6.49 ± 5.12	10.00 ± 4.30	.04	1.11 (0.95–1.30)	.19
Multi-site involvement (≥2 subunits), n (%)	10 (20.8)	4 (33.3)	.33	1.74 (0.39–7.80)	.47
Wound location (high mobility, perioral/periorbital), n (%)	18 (37.5)	6 (50.0)	.40	–	–
Foreign body contamination, n (%)	5 (10.4)	2 (16.7)	.61	–	–
Infection, n (%)	1 (2.1)	1 (8.3)	.29	–	–
Silicone tape adherence, n (%)	38 (79.2)	5 (41.7)	.01	5.42 (1.10–26.81)	.038*
VAS score, mean ± SD	8.65 ± 1.03	7.20 ± 0.45	.004	–	–
VSS score, mean ± SD	1.74 ± 0.61	2.90 ± 0.22	<.001	0.12 (0.02–0.68)	.016*

VAS = Visual Analog Scale, VSS = Vancouver Scar Scale.

^*Significant predictors in logistic regression: lower VSS score (better scar quality); adherence to silicone tape therapy.

Figure 1.

(A and B) Preoperative images depicting facial trauma with multiple lacerations. (C) Follow-up image at 2 months post-injury, showing scar maturation with minimal hypertrophy and pigmentation. Mild left eyelid edema and subtle ptosis compared with the contralateral side are also visible, raising the possibility of partial levator palpebrae involvement. Despite this, the patient reported high satisfaction with the aesthetic outcome and declined further intervention.

Figure 4.

(A) Preoperative photograph of a patient with facial trauma from a road traffic accident, showing an open laceration with irregular edges and surrounding soft-tissue injury. (B) Postoperative image taken on the second day following multilayered cosmetic suturing with absorbable and non-absorbable materials, demonstrating meticulous wound edge approximation and tension-reduction strategies to promote healing. (C) One-month follow-up reveals a well-healed wound with minimal scarring and narrow scar width. The patient reported high satisfaction with the cosmetic outcome. Although no obvious deficits in facial mobility or sensation were noted on clinical examination, objective sensory testing (e.g., Semmes–Weinstein monofilament or PSSD) was not performed; therefore, subtle hypesthesia in the supraorbital or supratrochlear distributions cannot be excluded.

Figure 2.

(A) Preoperative images of facial lacerations resulting from a road traffic accident, showing avulsion injury with clean, well-defined wound margins, and no tissue loss. (B–D) Sequential postoperative photographs on days 3, 5, and 7, demonstrating progressive wound healing marked by precise edge approximation and eversion. These features are critical for promoting optimal re-epithelialization and reducing hypertrophic scar formation. The use of multilayered closure combined with tension-relieving techniques facilitates rapid tissue repair and restoration of natural facial contours. (E) Two-month postoperative follow-up reveals a mature scar exhibiting minimal pigmentation, contracture, and hypertrophy.

Figure 3.

(A) Preoperative image of a pediatric female patient presenting with an irregular eyelid laceration sustained from a fall, demonstrating complex wound morphology. (B) Postoperative photograph on day 5 shows optimal wound edge eversion and alignment, essential for effective healing and improved scar quality. (C) Two weeks post-surgery, the wound is well-healed with inconspicuous scarring and preservation of eyelid shape and function.

3.4. Subgroup analyses

• Age: younger patients demonstrated a tendency toward more exuberant scarring; however, logistic regression did not identify age as an independent predictor (OR = 1.04, 95% CI: 0.91–1.18, P = .58).

• Scar length: longer scars correlated with lower satisfaction in univariate analysis (10.0 ± 4.3 cm vs 6.5 ± 5.1 cm, P = .04), but significance was lost after adjustment.

• Anatomical location: no significant differences in outcomes were observed between facial subunits, though perioral and periorbital wounds required earlier suture removal.

• Multi-site involvement: patients with multi-site lacerations had slightly higher dissatisfaction rates (33.3% vs 20.8%), but this difference was not significant. Regression confirmed that multi-site injury was not an independent predictor (OR = 1.74, 95% CI: 0.39–7.80, P = .47).

3.5. Predictors of favorable outcome

Multivariate logistic regression identified 2 independent predictors of higher patient satisfaction:

• Lower VSS score (OR = 0.12, 95% CI: 0.02–0.68, P = .016);

• Adherence to silicone tape therapy (OR = 5.42, 95% CI: 1.10–26.81, P = .038).

Age, sex, scar length, wound location, and multi-site involvement were not significant predictors after adjustment.

4. Discussion

This study provides new evidence on the role of cosmetic suturing for facial trauma in medically underserved regions of western China. Our findings demonstrate that meticulous layered closure, combined with tension-reducing techniques and structured postoperative care, can achieve low complication rates, favorable scar quality, and high patient satisfaction, even in resource-limited settings. While these techniques are not novel in plastic surgery, their systematic application by a general surgeon with formal plastic surgery training represents an important step toward improving outcomes in rural populations where specialist access is scarce.

4.1. Comparison with previous literature

Gillanders et al^[7] reported no significant difference in cosmetic results or complication rates between absorbable and non-absorbable sutures for primary facial closure, reinforcing that surgical precision outweighs suture choice. Similarly, randomized trials using adhesive strips or fast-absorbing gut sutures also found equivalent aesthetic outcomes.^[8,9] Taken together, these data suggest that technique is the critical determinant of long-term cosmesis, consistent with our results.

4.2. Tension reduction and scar quality

Scar optimization was closely linked to effective tension management. Layered closure and deliberate edge eversion, augmented in some cases with adjunctive tension-relieving methods, improved both VSS and VAS scores. This aligns with recent Chinese studies showing that tension-reducing strategies significantly narrow scar width and raise patient satisfaction.^[10] Such measures are particularly valuable in mobile or tension-prone regions of the face.

4.3. Training and early complication rates

Provider expertize remains pivotal. De et al^[11] emphasized the role of standardized trauma protocols and trained teams in minimizing complications. In our series, complications were limited to minor infections and partial dehiscence, with no reoperations required. This low rate reflects the benefits of consistent technique, even when advanced infrastructure is lacking, underscoring the importance of training general surgeons in cosmetic suturing principles in rural hospitals.

4.4. Postoperative care and patient education

Adherence to postoperative recommendations, particularly the use of silicone-based scar therapies, emerged as an independent predictor of satisfaction. This highlights the importance of patient education, daily wound hygiene, sun avoidance, and scar prevention measures. Literature consistently supports silicone gel sheets and micropore tape as effective tools in reducing hypertrophic scarring.^[12] In rural China, these products are widely available through online platforms, making them feasible even in resource-limited contexts.

4.5. Study limitations and shortcomings

Several limitations should be acknowledged. First, although follow-up extended to 6 months, scar maturation continues for 12 to 18 months, and hypertrophic scars may improve over time, whereas keloids may appear later. Longer follow-up is therefore needed to distinguish transient hypertrophy from pathological scarring. Second, our cohort was relatively small, limiting the ability to detect rare complications such as keloid formation, which is more prevalent in Asian populations (0.6%–16%).^[13] Larger multicenter studies would provide more generalizable estimates. Third, objective sensory testing was not available in our setting, and complications such as transient hypesthesia (as in the case shown in Fig. 4) were evaluated clinically rather than with standardized methods. Finally, cosmetic suturing is a fundamental principle of plastic surgery and not novel; our contribution lies in its systematic implementation in a rural hospital by a general surgeon with plastic surgery fellowship training, demonstrating feasibility in underserved regions.

4.6. Economic considerations

The use of polypropylene and silicone-based materials raised concerns about cost. In our setting, however, these sutures are readily available through hospital procurement channels and reimbursed by national health insurance, minimizing patient burden. Adjunctive scar therapies, such as silicone gels and tapes, are inexpensive and easily purchased online. Thus, while costs are a relevant consideration, they do not represent a prohibitive barrier in rural western China.

4.7. Broader implications

Our findings parallel experiences in other low-resource settings, where training, education, and standardized protocols have improved outcomes.^[14] Expanding such approaches in western China could mitigate disparities in trauma care. Furthermore, cultural sensitivity remains essential: in rural communities, visible scars are strongly stigmatized, impacting marriage prospects, social integration, and psychological well-being.^[15,16] In contrast, urban Chinese populations and Western societies increasingly frame cosmetic interventions as expressions of autonomy and self-care.^[17–21] Tailored patient education that addresses local cultural values while emphasizing the psychosocial benefits of scar optimization is therefore essential.

5. Conclusion

This study underscores that the quality of facial trauma repair in underserved regions depends less on advanced materials or technology than on meticulous technique, standardized protocols, and patient adherence to postoperative care. Even in resource-limited hospitals, systematic application of cosmetic suturing principle (layered closure, tension reduction, and precise wound edge alignment) can yield outcomes comparable to those reported in higher-resource settings.

Author contributions

Conceptualization: Tao Xie, Yuan Qin.

Data analysis: Tao Xie.

Methodology: Yuan Qin.

Writing – original draft: Yuan Qin, Tao Xie.

Writing – review & editing: Tao Xie.