Abstract
Objective
To determine the beneficial effects of cosmetic tension-reducing suturing techniques in repairing maxillofacial trauma.
Methods
A retrospective study was conducted on 120 patients with maxillofacial trauma, who presented to outpatient departments and emergencies from March to September 2024. Patients were divided into two groups equally. The experimental group (n = 60) was subjected to cosmetic tension-reducing suturing. The control group (n = 60) was subjected to traditional suturing. Evaluations targeted clinical outcomes, adverse event rates, patient satisfaction, and scar width and characteristics using the Scar Score- Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS).
Results
Longer procedure times were noted in the experimental group, but there was less than 5% adverse event rate compared to 27% of the control group. By the fourth postoperative day, three patients in the experimental group exhibited localized inflammation and infection, which were resolved with secondary cleaning and closure, while all other wounds healed primarily. The experimental group showed a significant improvement of P < 0.05 in aesthetic-functional scores and the scar thickness reduced significantly.
Conclusion
The application of cosmetic tension-reducing suturing techniques in maxillofacial trauma helps reduce complications and scar formation during the healing period, improves aesthetic outcomes and increases patient satisfaction. Therefore, it enhances the clinical applicability of these techniques.
Keywords: Maxillofacial trauma, Tension-reducing technique, Vancouver Scar Scale, Postoperative complications, Patient satisfaction
Introduction
The etiology of injury to the jaws and face is very complex and diverse. It is mostly due to traffic accident, mechanical trauma, animal bites [1]– [2]. Clinical studies show that when only basic suturing techniques are used in the emergency stage, the affect wound often undergoes a considerable increase in scar tissue and structural deformation of the local tissue [3]. In spite of the fact that post-operative combied therapies (e.g., local corticosteroid injections, pressure therapy and phototherapy) can effectively control the scar formation, the initial debridement and suturing technique quality are also important factors affecting the wound healing [4]– [5].
The field of plastic and aesthetic surgery is advancing fast, which has led to the ever more frequent application of cosmetic tension-reducing suturing techniques in the emergency management of maxillofacial trauma. Cosmetic tension-reducing suturing techniques is a technique of suturing following the plastic surgery principles with aseptic operation to align the tissue precisely to reduce the tension and minimize the scar. This method follows aseptic techniques and precise tissue alignment but also focuses on maintaining tension and ensures accurate apposition of wound margins and consistency of the skin texture. While it ensures the wound is functionally restored, it greatly reduces the incidence of scarring which promotes the aesthetic satisfaction of the patients with the postoperative outcome [6]. This method shows specific therapeutic benefits, particularly in the crucial aesthetic areas of the face, namely the maxillofacial area and periorbital area, which greatly influences facial appearance [7–9].
According to studies, it has been reported that complications and hypertrophic scarring were reduced whilst patient satisfaction was increased through cosmetic tension-reducing suturing [10]. For instance, Chen et al. (2024) reported that tension-reducing techniques improved maxillofacial trauma scars [11]. This approach integrates emergency medicine with plastic surgery to optimize outcomes. The aim of this study is to compare the efficacy of optimized cosmetic tension-reducing suturing and traditional suturing in maxillofacial surgery when judged by scar width and complication occurrence and satisfaction. The aim is to check the clinical utility of optimized cosmetic tension-reducing suturing. The method is intended to be standardized for emergency management of Maxillofacial trauma with improved layered suturing and microsurgical assistance.
Patients and methods
Patients information
This retrospective study was carried out on a total of 120 cases of maxillofacial plastic and reconstructive surgery performed at outpatient department and emergency department of Changsha Economic and Technological Development Zone Hospital from March to September 2024. The researcher systematically reviewed patients’ medical records and collected as well as analysed relevant clinical information regarding cosmetic or reconstructive surgery performed on the patients at outpatient department and emergency department.
A total of 120 patients were reviewed back in time using electronic medical record (EMR) system. The assignment of patients to either the experimental group (n = 60, cosmetic tension-reducing suturing) or control group (n = 60, traditional suturing) was done in a non-randomized manner based on the technique used for suturing. Grouping was based on past data so there was no bias. The research aimed at collating and analysing relevant clinical data of patients who underwent cosmetic or reconstructive surgeries as outpatients and emergency department patient.
The data was obtained from the hospital EMR system, which records all outpatient and emergency patients’ clinical information. The parameters of the survey include patient particulars such as age and sex trauma particulars like length and site of incision surgical parameters like suturing technique cost of procedure duration of procedure post-operative parameters like duration of swelling length of healing complications follow-up parameters like width of scar VSS and POSAS score. The new EMR system has standardized data entry templates. One of the operating surgeon or medical officer completes it soon after the end of the surgery. The quality of data entry is further ensured by regular auditing with adherence built into the system. The built-in SQL query tool of the EMR system of the hospital was used for extracting relevant data, as per the diagnostic codes (maxillofacial trauma), treatment type (cosmetic tension-reducing suturing or traditional suturing), and time frame (March–September 2024).
Please refer to the Results section for detailed information on the patient’s baseline characteristics. This information typically includes: sample size, age, sex, and statistical analysis of these three characteristics. The results showed that there were no statistically significant differences (P > 0.05) between the experimental and control group in age (P = 0.068) and sex (P = 0.451). This retrospective study was approved by the Medical Ethics Committee of Changsha Economic and Technological Development Zone Hospital (Approval No.: JKYY-SOP-009). As this was a retrospective analysis involving only anonymized historical medical records with no additional interventions or risks to patients, informed consent was waived by the ethics committee. All clinical procedures adhered to standard diagnostic and therapeutic protocols at the time of treatment, and patients had signed routine surgical consent forms for their procedures during their original visits; these consents were unrelated to this subsequent retrospective study and were not obtained prospectively for research purposes.
Inclusion criteria were standardized as follows: (1) Patients aged ≥ 18 years who provided written informed consent (or via legal guardians for those requiring family consent) and were able to comply with postoperative follow-up and evaluation; (2) Patients with fresh maxillofacial soft tissue injuries (within 6 h of trauma), characterized by clean wound edges, minimal contamination (no visible signs of infection or heavy debris), controllable bleeding, and intact consciousness (Glasgow Coma Scale score of 15).
Exclusion criteria are as follows: Patients with significant cardiovascular or cerebrovascular dysfunction, or impaired liver or kidney function; individuals with coagulation disorders; those with extensive maxillofacial trauma involving deep tissue destruction or open fractures; cases requiring complex maxillofacial reconstructive surgery for specific deformities; patients with psychiatric disorders, cognitive impairments, or insufficient postoperative compliance; Individuals who have recently undergone maxillofacial treatments or interventions that may interfere with efficacy assessment (e.g., any facial treatments received within the past 3 months, such as hormone injections, laser/light-based procedures, chemical peels, microneedling/radiofrequency treatments, Botox, fillers/thread lifts, retinoid medications, silicone-based treatments); patients with unrealistically high expectations for cosmetic outcomes or who are unable to comply with the treatment process.
Surgical methods for the experimental group
Wound preparation and debridement
The wound was cleaned with 0.9% sterile saline followed by 3% hydrogen peroxide to remove debris & clotted blood. To assist access, the hair around wounds was removed. The devitalized or ischemic tissue was excised while leaving the functional structures under anaesthesia. Protocol for managing bleeding was established. foreign body removal was done using precision tools, with enhanced visualization, to minimize damage to surrounding tissue [12]– [13].
Addressing tissue loss
Wounds with tissue defects in cosmetically sensitive areas such as the forehead or eyelid were thoroughly decontaminated and the edges realigned to achieve a better cosmetic result, especially around the nasal alae or lip areas. Tension was minimized during closure to avoid distortion. Preservation of tissues surrounding the object. Wherever the laxity of the skin allowed, flap techniques were applied along the lines of natural skin; methods like V-Y advancement were used based on anatomy [14].
Suturing methodology
The closure was done in layers, meaning that we closed the muscle, subcutaneous layer, and epidermis in the same anatomical planes from deep to superficial. ①Muscle Layer: The muscle layer consisted of absorbable 5 − 0 sutures arranged either continuously or interruptedly for their accurate alignment. For larger defects, V-Y flaps or Z-plasties were used to restore continuity (Figs. 1 and 2, 3 A). ②Subcutaneous Layer: The subcutaneous layer was sutured with 5 − 0 or 6 − 0 absorbable suture. The needle was inserted parallel to the tissue plane to avoid tension and preserve blood vessels. 0.5–1 cm spaced stitches were placed using non-toothed forceps to gently approximate the adipose tissue for tension-free closure. The appropriate length of suture was chosen according to the thickness of tissue for alignment and dead space (Figs. 1, 2 and 3B). ③Epidermal Layer: The suture material employed for the epidermal layer were non-absorbable 7 − 0 nylon or prolene suture that used a needle of 3 to 5 mm and the entry was made 2–3 mm from the wound edge [15]. Suturing started at the incision’s mid-point and proceeded to the sides for balanced apposition of edges. The tension of knots was adjusted to ensure proper alignment of the skin without any eversion or inversion. Moreover, the distance between sutures was determined to reduce tension. This was done to prevent the dehiscence of the wound (Figs. 1 and 2, 3 C).
Fig. 1 .
Fig. 1-3 Cosmetic tension-reducing suturing technique: Illustrate real cases of cosmetic tension-reducing suturing following maxillofacial trauma. The sterile surgical procedures were photographed anonymously. For details on the surgical procedure, please refer to the aforementioned suturing method
Fig. 2.
Fig. 1-3 Cosmetic tension-reducing suturing technique: Illustrate real cases of cosmetic tension-reducing suturing following maxillofacial trauma. The sterile surgical procedures were photographed anonymously. For details on the surgical procedure, please refer to the aforementioned suturing method
Fig. 3.
Fig. 1-3 Cosmetic tension-reducing suturing technique: Illustrate real cases of cosmetic tension-reducing suturing following maxillofacial trauma. The sterile surgical procedures were photographed anonymously. For details on the surgical procedure, please refer to the aforementioned suturing method
Postoperative management
Post-surgery care included taking care of the wound, infection control and scar management. The sterile gauze should be changed every two days until the removal of the stitches, which should be done 5–7 days later. The wound has to be kept dry and clean. For contaminated wounds, 48 h of sterile intravenous antibiotics like cefaclor 500 mg twice daily orally or intravenously was given followed by adjustment according to culture sensitivity thereafter. All patients were given subcutaneous tetanus toxoid (0.5 mL, intramuscularly) before surgery and patients with animal bite injuries were given rabies vaccine according to WHO schedule (day 0, day 3, day 7, day 14, and 28). Scar management involved applying silicone gel on the wound twice daily for at least 12 h each application for at least three months or until stable. Furthermore, patients were instructed to utilize custom-fitted pressure bandages (15–25 mmHg) for 8–12 h/day for 3–6 months to improve scar flexibility [16]. Follow-up evaluations were performed at 1, 3, 6, and 12 months, including clinical assessment (e.g. swelling, infection), clinical photography, and scar assessment using the VSS and the POSAS [17]. Changes to the treatment protocol were made on the presence of scar hypertrophy (VSS score > 5) or symptoms reported by the patient (e.g. itching or pain, POSAS patient score > 10).
Surgical methods for the control group
The control group employed traditional suturing techniques, using sterile saline and 3% hydrogen peroxide irrigation during initial closure to clear tissue debris and coagulated blood, without requiring specialized minimally invasive instruments. Nerve and vascular integrity were assessed using standard techniques and bleeding was controlled by electrocoagulation or ligation. Through a layered technique, suturing was carried out for functional wound closure without major concern for details. This is the accepted practice in emergency departments. The closure of the deep muscular layer with interrupted absorbable sutures (e.g., 3 − 0 polylactic acid) allows for tissue approximation. The absorbable suture (e.g. 3 − 0 or 4 − 0 polyglactin) layers of the subcutaneous layer are sutured every 1–2 cm with basic alignment only without special measures to relieve tension and dead space. The epidermal layer is closed using larger, non-absorbable sutures (for example, size 2 − 0 or 3 − 0 nylon or Prolene sutures) in an interrupted fashion at intervals of 1–2 cm. The suturing technique used is a basic emergency one with rapid closure and advanced tension-reducing techniques are not employed.
Postoperative care included: Patients in the control group were given standard emergency wound care. Changing a sterile gauze every two days until suture removal at 5–7 operative days. The antibiotic regimen for contaminated wounds was the same as that of the experimental group (e.g., cefuroxime 500 mg twice daily for 48 h). Tetanus prophylaxis and rabies vaccination protocols were identical to those of the experimental group .Unlike the experimental group, the control group refrained from using silicone dressing with compression; traditional focus of emergency suturing care on dressing and observing the wound and not on complex treatment. The patients underwent follow-up assessments at 1, 3, 6, and 12 months postoperatively; which consisted of clinical examinations (i.e., infection, wound dehiscence) and VSS/POSAS scoring with no scar management applied.
Observation indicators
Perioperative metrics
Data were collected on patient demographics (age, gender), incision dimensions, procedure length, duration of postoperative swelling, time to wound closure, and treatment expenses. These variables underwent statistical analysis. Clinical assessments were performed by the surgeon or designated medical personnel, according to protocol in the literature, and included observation of tissue edema, stiffness on palpation, and objective measurement of the extent of swelling (diameter in centimeters). Standard anatomical landmarks were selected at the injury site to ensure the repeatability of the measurement results. For the forehead/periorbital region, vertical distance from the nasal root point to the hairline midpoint and vertical distance from the eyebrow midpoint to the lower eyelid margin midpoint; horizontal distance between bilateral temporal ridges were measured. The middle portion of the face analyzed by the horizontal distance from the tragus to the alar base. The vertical distance from the tragus to the infraorbital rim. The lower face is determined by measuring the horizontal distance from the tragus to the corner of the mouth and the vertical distance from the tragus to the soft tissue anterior chin point. Prior to local anaesthesia, baseline measurements are taken. In order to quantify the changes after the surgery, baseline values at these landmarks are recorded (diameter of postoperative swelling = postoperative value – baseline value). Subjective symptoms reported by patients like discomfort or tightness are also recorded. Postoperative assessment is done regularly (on Day 1, 3, 5 and 7) until swelling goes down with photographic evidence for assessment consistency [18–20]. The duration of edema (days) was defined as the number of days from surgery to complete clinical resolution, based on the objective swelling measurements in cm. Complete clinical resolution was defined as: the daily measured diameter of swelling (Δcm) returning to ≤ 0.2 cm from the preoperative baseline, no visible/palpable edema, and confirmation by two independent clinicians. Measurements were taken daily using standardized markers until this endpoint was reached, and the last day was recorded as the duration. Wound healing time (days) was defined as the duration from surgery to complete epithelialization without exudation or crusting, confirmed by clinical examination and continuous photographic imaging. Both duration indicators were recorded in the electronic medical record system for statistical analysis.
Postoperative complications
Occurrences of surgical complications, including infection, hematoma, suture reactions, cavity formation, and wound separation, were recorded, with incidence rates calculated for both groups.
Patient satisfaction assessment
Post-treatment contentment was evaluated using a 10-point visual analog scale (VAS), with scores ≤ 6 indicating dissatisfaction, 7–9 reflecting moderate contentment, and 10 denoting high contentment. The overall contentment rate was calculated as the combined percentage of moderate and high contentment.
Scar width measurement
Scar Width Measurement: Scar width was measured at its widest point using a digital caliper (e.g., Mitutoyo Absolute Digimatic Caliper, accuracy ± 0.01 mm) at 1, 3, 6, and 12 months post-procedure.
Vancouver scar scale evaluation
Scar quality was assessed at 1, 3, 6, and 12 months post-procedure using the VSS, which evaluates pigmentation, vascularity, pliability, and height on a 0–15 scale, where lower scores indicate less noticeable scars [21].
Patient and observer Scar assessment scale evaluation
At 1, 3, 6, and 12 months post-procedure, scar severity was evaluated by patients and clinicians using the POSAS scale, comprising patient-reported metrics (pain, itching, color, thickness, softness, self-perception; 6–60 points) and observer-rated metrics (vascularity, color, thickness, roughness, softness, surface area; 6–60 points). The final POSAS score is the average of both perspectives, with lower scores indicating better scar outcomes [22]– [23].
Data analysis method
Data analysis was performed using SPSS 25.0 software(IBM Corp., Armonk, NY). Continuous variables were confirmed normal by the Shapiro-Wilk test and expressed as mean ± standard deviation (x ± s). Such variables included scar width, VSS score, operation time, edema duration and healing time. Parametric comparisons among groups were applied using the independent sample T test for normally distributed data. The Mann-Whitney U test was employed for continuous variables with a non-normal distribution. Categorical variables (e.g., complication rates, satisfaction rates) were expressed as percentages (%) and compared using the chi-square (χ²) test or Fisher’s exact test when expected frequencies were low (< 5). Statistical significance was set at P < 0.05.
Results
Patient information
The experimental group (n = 60; 20 males, 40 females) underwent layered cosmetic tension-reducing suturing. Participants varied in age ranging from 20 to 57 years (mean ± SD: 34.1 ± 6.7 years). The control group (n = 60; 25 males, 35 females) underwent traditional suturing techniques, with ages ranging from 22 to 61 years (mean ± SD: 32.0 ± 6.2 years). No statistically significant differences were observed between groups in age (P = 0.068) or gender (P = 0.451) (P > 0.05).
Results analysis
Perioperative indicators
Statistical analysis showed no significant difference in incision length (mm) between the two groups (P > 0.05). The experimental group had significantly longer operative time (minutes) than the control group (P < 0.05), and treatment costs (RMB) were significantly higher in the experimental group (P < 0.05). However, the duration of edema (days) and wound healing time (days) in the experimental group were significantly shorter than those in the control group, with statistically significant differences in all indicators (P < 0.05). Detailed results are shown in Table 1.
Table 1.
Comparison of perioperative parameters between the two groups
| Group | Incision length (mm) | Operation time (min) | Duration of edema (d) | Wound healing time (d) | Treatment cost (RMB) |
|---|---|---|---|---|---|
| Experimental group(n = 60) | 30.5 ± 18.4 | 96.4 ± 24.9 | 5.7 ± 1.6 | 5.2 ± 1.3 | 1915.6 ± 640.6 |
| Control group(n = 60) | 30.7 ± 16.9 | 38.0 ± 10.4 | 7.2 ± 1.6 | 6.5 ± 1.4 | 294.5 ± 33.7 |
| P-value | 0.962 | < 0.001 | < 0.001 | < 0.001 | < 0.001 |
Surgical complications
Analysis of postoperative adverse events revealed that the incidence rate of related issues in the experimental group was 5%, significantly lower than the 27% observed in the control group. Statistical analysis using the chi-square test demonstrated a statistically significant difference between the two groups (P < 0.05) (Table 2). The data indicates that the experimental group protocol can effectively reduce the risk of postoperative complications.
Table 2.
Comparison of complications between the two groups [n (%)]
| Group | Hematoma | Infection | knot reaction | Wound dehiscence | dead space formation | overall incidence (%) |
|---|---|---|---|---|---|---|
| Experimental group(n = 60) | 3 | 0 | 0 | 0 | 0 | 3(5%) |
| Control group(n = 60) | 4 | 3 | 2 | 3 | 4 | 16(27%) |
Treatment overall satisfaction survey
During the research process, a standardized scale was used to conduct a survey of 120 participants. Analysis of the obtained data revealed that the overall satisfaction rate in the experimental group reached 95%. Among them, 40 participants highly approved of the treatment efficacy, 17 participants reported satisfactory results, and only 3 participants raised objections due to postoperative infections. In contrast, the control group showed an overall satisfaction rate of merely 70%. Chi-square test verification demonstrated that the experimental group had a statistically significant advantage in complication control. Detailed data can be found in Table 3.
Table 3.
Comparison of the total treatment satisfaction rate between the two groups [n (%)]
| Group | Very satisfied | Satisfied | Dissatisfied | Overall satisfaction rate |
|---|---|---|---|---|
| Experimental group(n = 60) | 40(67.00) | 17(28.00) | 3(5.00) | 57(95.00) |
|
Control group (n = 60) |
12(20.00) | 30(50.00) | 18(30.00) | 42(70.00) |
Scar width
Observations at different time points (1, 3, 6, and 12 months post-surgery) revealed that scar width in the experimental group was significantly reduced compared to the control group (P < 0.05). The detailed data is presented in Table 4. Statistical analysis show a statistically significant difference in scar width of both groups with the experimental group maintaining a narrower scar morphology. The experimental group was effective in controlling the scar width as evidenced by this result.
Table 4.
Comparison of postoperative scar width between the experimental group and the control group
| Group | One month after surgery (mm) | Three months after surgery (mm) | Six months after surgery (mm) | 12 months after surgery (mm) |
|---|---|---|---|---|
| Experimental group(n = 60) | 0.17 ± 0.07 | 0.28 ± 0.05 | 0.31 ± 0.06 | 0.32 ± 0.06 |
| Control group(n = 60) | 2.77 ± 1.23 | 4.23 ± 1.58 | 4.85 ± 1.41 | 5.90 ± 1.82 |
| P-value | < 0.001 | < 0.001 | < 0.001 | < 0.001 |
Vancouver scar scale
Based on the clinical observation data obtained at the 1, 3, 6, and 12-month of the follow-up period, statistical analysis revealed that the VSS scores of the experimental group were lower than those of the control group, with the difference between the two groups reaching a statistically significant level. The detailed data can be found in Table 5. The observations revealed that the scar condition in the experimental group patients remained consistently superior to that in the control group over time, a trend validated at all postoperative time points.
Table 5.
Comparison of VSS Scores between the experimental group and the control group
| Group | One month after surgery | Three months after surgery | Six months after surgery | 12 months after surgery |
|---|---|---|---|---|
| Experimental group(n = 60) | 1.65 ± 0.68 | 2.35 ± 0.58 | 2.67 ± 0.71 | 1.98 ± 0.43 |
| Control group(n = 60) | 2.65 ± 1.22 | 4.75 ± 0.97 | 6.30 ± 1.24 | 4.55 ± 1.43 |
| P-value | < 0.001 | < 0.001 | < 0.001 | < 0.001 |
Patient and observer scar assessment scale
At 1, 3, 6, and 12 months postoperatively, the experimental group demonstrated significantly lower POSAS scores compared to the control group (P < 0.05) (Table 6).
Table 6.
Comparison of POSAS Scores between the experimental group and the control group
| Group | One month after surgery | Three months after surgery | Six months after surgery | 12 months after surgery |
|---|---|---|---|---|
| Experimental group(n = 60) | 16.11 ± 1.24 | 15.35 ± 0.87 | 13.15 ± 1.32 | 11.38 ± 0.66 |
| Control group(n = 60) | 25.87 ± 1.45 | 23.56 ± 1.70 | 19.56 ± 1.35 | 16.86 ± 2.56 |
| P-value | < 0.001 | < 0.001 | < 0.001 | < 0.001 |
Discussion
The cosmetic tension-reducing suture technique takes “the tension-reducing suture” concept and implements it specifically and accurately. The gradual closure of subcutaneous tissue, dermis and epidermis distributes tension on the wound evenly, with a considerable decrease in mechanical stress at the edges of the wound. In this research, the cosmetic tension-reducing suture method outcomes were good. The scar width and VSS score of the experimental group significantly reduced (12 months: 1.98 ± 0.43 vs. 4.55 ± 1.43, P < 0.001). Similarly, POSAS score (11.38 ± 0.66 vs. 16.86 ± 2.56, P < 0.001), complication (5% vs. 27%, P < 0.05), and patient satisfaction (95% vs. 70%, P < 0.05) improved significantly. These better outcomes may be due to certain techniques involved in cosmetic tension-reducing suturing such as layered closure of deep and subcutaneous tissues using fine absorbable sutures (5 − 0/6 − 0) and epidermal approximation using non-absorbable sutures (7 − 0). This method provides precise alignment of tissue whilst limiting the mechanical stress on the edges of the wound [7, 11]. Furthermore, there is evidence supporting an agreement that silicone gel (twice-daily for 3 months) and pressure therapy (8–12 h/day for 3–6 months at 15–25 mmHg) decrease hypertrophic scarring postoperatively. On the other hand, the control group used thicker sutures (2 − 0/3 − 0), larger stitch intervals (1–2 cm), and enabled aesthetic tension-reducing techniques and scar management. The risk of complications such as dehiscence and wound infection was significantly higher, leading to a wider scar. These findings corroborate earlier studies. The experimental group that utilized accurate suturing along with complete postoperative care played an important role in the betterment of the scar quality and the reduction of the complications during the emergency repair of a case of maxillofacial trauma.
The procedure of cosmetic suturing refers to: first, the subcutaneous closure using absorbable sutures to lessen the deep tension; next, the dermis is precisely put together with fine sutures; and lastly, the epidermis is closed by various options like continuous intraderm suture. The procedure is tailored to the anatomical features of the wound location. One notable example of this is that, if the suture is made along Langer’s lines (skin tension lines), the stress induced on the suture is less when dynamic facial movements are made. This is especially true for highly mobile areas such as the eyelids or lips [24].This approach significantly reduces the chances of wound splitting or opening. Research has shown that using cosmetic tension-reducing suturing techniques in dynamic areas present less scar hyperplasia than non-elastic stitching techniques [25] .
Cosmetic tension-reducing suturing has proven to be better than other methods. For example, Capek et al. (2012) showed that the use of classical suturing techniques on facial wounds produced a scar hyperplasia rate that was 25% greater than the rate associated with layered cosmetic tension-reducing suturing [26]. Likewise, According Zhang et al. (2024), the average incision scar width in the stepped suture group (1.62 ± 0.36) was significantly lower than that in the control group (1.87 ± 0.42, p = 0.0004), suggesting that cosmetic tension-reducing suturing techniques are a highly promising option for reducing incision scarring. Furthermore, this technique optimizes postoperative aesthetics and reduces scar visibility by tailoring suturing strategies to the specific movement characteristics of areas such as the eyelids and lips [27].
Tension is important in scar tissue formation [28]. In the control group that employed conventional suturing techniques, thicker suture material (2 − 0/3 − 0) and wider needle spacing (1–2 cm) were used, sustaining higher tension. It may lead to the formation of scars with unsightly cosmetic result, wound edges misaligned, localized ischemic necrosis, and subsequent hypertrophic scarring (higher VSS score: 4.55 ± 1.43 vs. 1.98 ± 0.43 at a year, P < 0.001). Improperly applied excessive force and faulty control of tension during traditional suturing often lead to further complications. In comparison, the technique of cosmetic suturing in the experimental group reduced the traction of the tissue and prevented the compression of the vascular by optimizing the steps. The use of micro-absorbable sutures such as 5 − 0 and 6 − 0 is aimed at minimising trauma and scar concealment. Clinical data indicate that the use of precision surgical instruments combined with standardized suture procedures significantly reduces tissue damage in the surgical area and improves healing results [29].
For a comprehensive assessment of the efficacy of the wound healing, two assessment tools were used, VSS and POSAS. The VSS give the numbers on how much the scars are getting better by checking on how pigmented they are, how blood goes around them, how deep they are and how flexible they are without bias. At the same time, the POSAS include the more subjective check up of the patient feeling things like pain, itch, colour and hardness and the check up of the doctor on things like how the vessels are, the colour, how tall and how flexible it is for a more thorough check on how the scar gets better. From the study’s findings, VSS ratings in the experimental group at one, three, six, and twelve months post-procedure stood at 1.65 ± 0.68, 2.35 ± 0.58, 2.67 ± 0.71, and 1.98 ± 0.43, respectively. Comparatively, the control group recorded 2.65 ± 1.22, 4.75 ± 0.97, 6.30 ± 1.24, and 4.55 ± 1.43. Group variances were notable from the initial month onward (p < 0.001). At the one-year mark, the experimental group’s VSS value was 1.98 ± 0.43 versus 4.55 ± 1.43 in the control group. Complementing this, POSAS metrics for the experimental group were 16.11 ± 1.24, 15.35 ± 0.87, 13.15 ± 1.32, and 11.38 ± 0.66 at the same intervals, while the control group showed 25.87 ± 1.45, 23.56 ± 1.70, 19.56 ± 1.35, and 16.86 ± 2.56, with consistent statistical relevance from month one (p < 0.001). These results suggest that stepwise tension-reducing approaches effectively curb scar overgrowth and elevate overall scar attributes through balanced stress allocation across the injury site [30]. The experimental group’s use of silicone gel and pressure therapy, absent in the control group, likely contributed to the significantly reduced scar width and lower VSS/POSAS scores (P < 0.05). Previously silicone-based treatments have been found to prevent hypertrophic scarring[4]. In comparison with 5% evidence of complications in the experimental group, evidence of 27% complications as well as inferior aesthetic outcomes in the control group justify the significance of integral scar management in the emergency repairs of facial trauma. Furthermore, in mobile area such as perioral and periorbital areas, both VSS and POSAS indicators for cosmetic tension-reducing suturing techniques were superior to conventional suturing techniques [11]. The incorporation of a stepwise approach to cosmetic tension-reducing suturing into clinical practice is strongly validated by these findings. Clinicians can use it to design patient-specific interventions to enhance satisfaction and optimize healing.
Despite its numerous advantages, cosmetic tension-reducing suturing techniques present limitations that warrant consideration. This technique needs extra skill and better surgical ability which means it cant be used where the resources are lacking. The layered suturing technique is hard and takes more time for the surgeon to do. So, it can be hard and a bit tricky for a busy hospital. Also, these cosmetic tension-reducing suturing techniques give bad results when used on wounds that are uneven or large because its hard to put the right amount of tension on them. Risks of complications—including exposed sutures, infection, or recurrent scarring—may arise from dead space or improper tension management. Using tiny sutures and more care after the operation (like using silicone gel and pressure) add to the cost and need the patient to follow the treatment plan, which may be a problem for some groups. These limits show why there needs to be a standard way to teach, better sutures to use, and more study on this topic to make cosmetic tension-reducing suturing better suited for different patient needs and situations. To fix these issues in the future, the key goals should be: (I) To make barbed sutures that take longer to break down and are made of smart material so scars are less. (II) To add robotic surgery help and 3D models for better surgery. (III) To use better treatments, like botulinum toxin or gels, to make scars look better after surgery. (IV) To do studies with many centers and longer follow-up times (like 24 36 months) to check how well the method works in the long run for different kinds of wounds and patients. V.To set standards for teaching so this can be used more easily where resources are fewer. These ideas, once put into practice, will make the use of different methods for cosmetic tension-reducing suturing work better and easier in tough and busy maxillofacial trauma cases.
Conclusion
In maxillofacial reconstructive procedures, refined cosmetic tension-reducing suturing techniques outperform traditional methods by promoting balanced stress distribution across wound layers, thereby reducing scar formation and postoperative complications. This technique not only improves functional recovery but also enhances aesthetic effects, thus becoming an ideal choice for clinical adoption in managing facial injuries.
Acknowledgements
Not applicable.
Authors’ contributions
(I)Concept and design: Jiang N.Yang, Yang Du, De Y.Fu; (II)Acquisition, analysis, or interpretation of data: Jiang N.Yang, Yang Du, Zhi G. Liao; (III) Drafting of the manuscript: Jiang N.Yang, Yang Du; (IV)Critical review of the manuscript for important intellectual content: Jiang N.Yang, Shuai Chen, De Y.Fu; (V)Supervision: Shuai Chen, De Y.Fu; (VII) final approval of manuscript: all authors.
Funding
Not applicable.
Data availability
The data used in the study can be obtained from the corresponding author of this study. This data will not be made public due to privacy or ethical constraints.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of Changsha Economic Development Hospital: No.JKYY-SOP-009. Informed consents were obtained from all participants. Clinical trial number: Not applicable. All patients received treatment in accordance with clinical standards. The care protocols for both the control and experimental groups (excluding suturing techniques) followed identical standard operating procedures (SOPs) to ensure patient safety and rights.
Consent for publication
All authors have approved of the consents of this manuscript and provided consent for publication. The images are a partial picture, so the participants will not be recognized. Consent for publication from participants is not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Jiang N. Yang and Yang Du are contributed equally to this work and are co-first authors.
Contributor Information
De Y. Fu, Email: 18051060677@yzu.edu.com
Shuai Chen, Email: shuaige419@qq.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used in the study can be obtained from the corresponding author of this study. This data will not be made public due to privacy or ethical constraints.