The use of Steri-strips™ and quilting sutures for periocular full-thickness skin grafts: Avoiding a Frost suture or bolster

Abstract

Purpose:

To assess the early complications and functional and esthetic outcomes of using quilting sutures and Steri-strips for full-thickness skin grafts (FTSGs) in the periocular region.

Methods:

A retrospective, noncomparative, single-center review of patients who underwent FTSG with quilting sutures and Steri-strips splinting. Functional outcomes were assessed using MRD1 (margin reflex distance) and lagophthalmos on gentle closure for upper eyelid grafts, and MRD2 for lower eyelid grafts. Esthetic outcomes were determined using standardized photographs and a specific grading scale for eyelid FTSGs.

Results:

Our study included 67 patients (males: 42, females: 25) who underwent 70 FTSG procedures, with a mean age of 69.7 years (range: 18–96). The average initial postoperative visit was at 14.2 days, and patients had an average of 1.2 clinical visits in the first 6 weeks. The improvements in MRD1, MRD2, and lagophthalmos were 1.7 mm (P = 0.002), 1.9 mm (P < 0.001), and 2.5 mm (P = 0.015), respectively. Esthetic outcomes were graded as “perfect” to “good” in 52 (74%) patients for graft color and edge, 50 (71.4%) for graft contour, and 64 (91.4%) for graft size and lid margin contour. Graft survival was 98.6%. The complication rate was 14.3%, with a mean follow-up of 13 months (range: 3–50).

Conclusion:

Various techniques are described in the literature with good results, some requiring extra costs, theater time, or clinical visits. Our technique replaces Frost sutures and bolsters, minimizing immediate postoperative visits while achieving high graft success with favorable functional and esthetic outcomes.

The use of full-thickness skin grafts (FTSGs) in the periocular region for cicatricial conditions or reconstruction post-tumor excision is commonly practiced by oculoplastic surgeons. The robust blood supply in the region augments the prospects of graft survival.[1,2]

Several approaches have been described to increase FTSG survival rates with good esthetic outcomes.

Albert Frost described the use of a lower eyelid suspension suture in 1934 to appose the upper eyelid after ptosis surgery and to guard against corneal exposure. It was described as anchoring the lower to the upper eyelids using a silk suture before finally passing it to the brow.[3] This traction suture is also used to help prevent lower lid ectropion after lower lid blepharoplasty, which can occur due to swelling during the initial healing period,[4] to provide support to cervicofacial flaps,[5] and to counter the downward tension vectors on the lower eyelid margin after reconstructive procedures in the region.[6] Moreover, Frost sutures are used to enhance the survival rate of FTSG as well as restore or preserve the lower eyelid contour.[7] However, the use of such sutures obstructs the functional vision in that eye and impedes its examination. Frost sutures are usually removed between 3 and 12 days postoperatively.[6]

John Wolfe originally described the crucial role of applying a pressure dressing to FTSG taken from the forearm for eyelid reconstruction to ensure graft survival.[8] Tie-over bolsters were then introduced as an attempt to apply uniform pressure over FTSG to enhance their survival.[9] Simple dressings, rubber foam, stationer’s rubber bands, and pressure devices have all been used as different variants of the technique.[10,11,12] Bolsters are bulky, and they require more materials and time to apply. They may compromise the blood supply to the graft or even result in hematoma formation if uneven pressure is applied; therefore, some authors advise against their use.[13,14]

Quilting sutures were described by Hemant Mehta to secure FTSG in the periocular region, aiming to prevent hematoma formation and enhance graft survival rates.[15] This technique was advocated to shorten hospital stays to day case only and reduce the need to restrict patients’ early activities. Mehta then described 100% successful graft survival in all 109 patients, with excellent cosmetic results in terms of color match, texture, and surface contour in 99% of the cases.[16]

We present the functional and esthetic results of FTSG procedures in the periocular region employing quilting sutures and Steri-strips^® (3M, Saint Paul, Minnesota, USA) splinting, treated at a single center. This approach aims to demonstrate the viability of circumventing immediate postoperative visits while simultaneously reducing healthcare costs associated with both consumables and also early follow-up visits.

Methods

One hundred and thirteen FTSG procedures in the periocular region were performed by two different surgeons at The Corneoplastic Unit, Queen Victoria Hospital, East Grinstead, England, UK, on 108 patients between January 2019 and April 2023. This study was approved by the local Institutional Review Board as a retrospective audit and was conducted in accordance with the principles of the Declaration of Helsinki. A period of 3 months postoperatively was considered appropriate for the final outcome assessment, allowing sufficient time for graft integration, scar maturation, and stabilization of both esthetic and functional results. Therefore, patients with accessible standard preoperative photographs as well as photographs dated at least 3 months postoperatively were included in this study. Patients with photographs dating less than 3 months postoperatively or with unassessable photographs (e.g., large angle of globe deviation or gross globe pathology) were excluded. Therefore, 41 patients who underwent 43 FTSG procedures were excluded.

We retrospectively reviewed the results of 70 FTSG procedures in the periocular region performed for 67 patients (males 42, females 25). The mean age of the patients was 69.7 years (range 18–96). Eleven procedures were performed for the upper eyelids, and 59 for the lower eyelids. Two patients had both upper and lower eyelids grafts on the same side, and one patient had bilateral lower eyelids FTSG in the same setting. The harvest sites are detailed in Table 1.

Table 1.

Harvest sites for FTSG

FTSG harvest site:		Number of cases
Supraclavicular		27
postauricular		26
preauricular		4
inner arm		5
upper eyelid		3
Brow		3
Neck		1
Abdomen		1

Surgical technique

Local anesthetic (0.5% bupivacaine hydrochloride with adrenaline 1:200,000) is infiltrated at both skin harvest and grafting sites (upper or lower eyelid). For upper eyelid grafts, a supra-ciliary, stepped skin incision is made across the eyelid with a no. 15 blade. A downward stretch is then applied to the upper eyelid with 4-0 silk traction suture placed in the gray line. A skin flap is raised superiorly between the skin and the orbicularis until it lies on the muscle with minimal tension leaving an area of bare orbicularis. If a recession of levator is planned, the septum is then exposed and released to allow exposure, and the levator aponeurosis is recessed.

For lower eyelid grafts, a subciliary, stepped skin incision is made across the eyelid with a no. 15 blade. An upward stretch is then applied to the lower eyelid with 4-0 silk traction sutures placed in the gray line. A stepped-incision is made with a skin flap leaving the pretarsal orbicularis intact before a horizontal incision through preseptal orbicularis. The orbital septum is then released from canthus-to-canthus. If recession of the lower eyelid retractors is planned, then the retractors are exposed and recessed.

With the eyelid on stretch, the horizontal and vertical dimensions of the defect are then measured using a sterile ruler. An FTSG is harvested from preferred sites including post- or preauricular, supraclavicular, and contralateral upper eyelid. After preparing the harvest site, the skin is marked and incised to the level of dermis with a no. 10 blade. The graft is first thinned by trimming subcutaneous fat using Westcott scissors followed by further trimming to match the exact shape of the recipient site. The graft is then placed and secured with 6-0 Monocryl^® (Ethicon, Ohio, USA) continuous sutures. Grafts are quilted using central 6-0 Monocryl mattress sutures between graft and the recipient bed tied under moderate tension [Fig. 1a].

Figure 1.

(a) Multiple quilting sutures in the middle of the graft. (b) Overlapping half-inch Steri-strips® applied across the eyelid. (c) The process of applying overlapping Steri-strips™ is repeated for a splinting effect

Steri-strips^®, sized 12 mm × 50 mm, are applied on operated eyelid in an overlapping manner where every strip applied covers at least half of the other [Fig. 1b]. The process is repeated in layers over the graft area splinting it [Fig. 1c]. Over this, Jelonet^® (Smith and Nephew, UK) is applied and a double eye pad taped dressing for 1–2 days. The harvest site is closed using a 5-0 Monocryl continuous interlocking suture and Steri-strips dressing applied.

Patients are then advised to remove the dressing in 1–2 days and to remove the Steri-strips after 5 days. Patients are usually seen at 2 weeks.

To evaluate the functional outcomes, standard photographs taken by the hospital’s photography team were reviewed to obtain MRD1 and lagophthalmos on gentle closure for upper eyelids grafts, and MRD2 for lower eyelids FTSG. These measurements were determined by the first author as an independent assessor using a formula derived by Hashemi et al.[17] The esthetic outcomes were graded by an independent grader using standardized photographs and according to an eyelid-specific photographic grading scale (excluding the upper lid crease, which is only used for symmetry) proposed by Maqsood et al.[18] [Table 2].

Table 2.

Photographic grading scale[18]

Grade		Graft colour		Edge/interface		Skin surface contour		Size		Eyelid margin contour		Pretarsal lid show/upper lid skin crease
0, perfect		• Excellent colour match. • No hypopigmentation/ hyperpigmentation. • Graft not distinguishable.		• No visible scar. • No hypertrophy/ hypotrophy. • Flush interface.		• No contour alteration. • Perfect blend. • Imperceptible difference between graft and host.		• Perfect horizontal match. • Perfect vertical match.		• Perfect contour. • Perfect symmetry.		Excellent symmetry.
1, good		• Near normal colour match. • Subtle difference on scrutinising but no obvious redness/pallor/hypopigmentation or hyperpigmentation.		• No obvious scar. • Subtle white/pink scar on close scrutiny. • Not raised or dipped/no hypertrophy or hypotrophy.		• Smooth contour with minimal irregularities.		</=10% of horizontal or vertical oversize or undersize of graft.		• Smooth contour with imperceptible irregularities. • No scleral show/no lid retraction. • Minimal asymmetry.		Mild asymmetry (pretarsal show within 1 mm).
2, unsatisfactory		• Easily noticeable colour mismatch. • Pink or pale graft to adjacent tissue.		• Obvious scar. • Demarcated edges. • Raised or dipped/hypertrophy.		• Noticeable irregularities. • Visible folds and creases. • Graft fullness. • Localised lumps. • Sectoral oedema.		• 10%–25% of horizontal or vertical oversize or undersize of graft.		• Irregular lid margin. • Hyperemia. • Oedematous. • Lid retraction.		Moderate asymmetry (pretarsal show 1–2 mm).
3, unacceptable result		• Gross colour mismatch. • Obvious redness. • Excessive pigmentation/ hypopigmentation.		• Proud or excessive scar. • Excessive scar pigmentation (demarcated red, inflamed scar). • Hypopigmentation (white prominent scar, not pink). • Keloid.		• Raised, irregular, lumpy, thick/bulky graft. • Non-continuous. • Trap door effect. • Prominent folds. • Deep creases. • Hypertrichosis. • Haematoma/ gross oedema.		• Obvious size excess/contracted graft. • >25% of horizontal or vertical oversize or undersize of graft. • Secondary lid margin irregularities due to vertical graft excess/ defect.		• Full-length ectropion. • Convex eyelid margin. • Peaked margin. • Notched margin. • Gross lid retraction with >2 mm scleral show.		Severe asymmetry (pretarsal show >2 mm).

Statistical analysis

Parametric tests (paired t-test) were applied on normally distributed data, and Wilcoxon rank test was applied for nonparametric data. A P value of <0.05 was considered statistically significant.

Results

The mean initial postoperative visit was after 14.2 (range 4–90) days. Twenty-two (31.4%) patients were seen before the 10^th postoperative day. Of those, seven patients had undergone previous procedures on the operated side (e.g., previous FTSG or a flap procedure), and one patient was examined on the 6^th postoperative day due to donor site dehiscence. The remaining 14 patients had no documented concerns regarding their earlier-than-planned visits, according to e-records. The mean number of clinical visits in the first 6 weeks postoperatively was 1.2 times (range 0–2) with the highest number of visits reserved for complex cases that were also being followed up for other corneal pathologies. The mean follow-up period was 13 months (range 3–50 months).

The mean MRD1, lagophthalmos on gentle closure, and MRD2 preoperative measurements were 3.9 mm (SD = 2.3; 95% CI [2.57, 5.23]), 4.5 mm (SD = 2.8; 95% CI [2.91, 6.18]), and 7.8 mm (SD = 3.2; 95% CI [6.92, 8.6]), respectively, and the mean postoperative values were 1.4 mm (SD = 2.3; 95% CI [-0.01, 2.74]), 1.7 mm (SD = 1.7; 95% CI [0.63, 2.82]), and 5.9 mm (SD = 2.3; 95% CI [5.37, 6.53]), respectively. The mean improvement in MRD1 in upper eyelid grafts was 2.5 mm (SD = 2.1; 95% CI [1.12, 3.97]); (P = 0.002), while MRD2 for the lower eyelids and lagophthalmos on gentle closure have improved by an average of 1.9 mm (SD = 2.7; 95% CI [1.17, 2.58]); (P < 0.001), and 3.1 mm (SD = 2.3; 95% CI [1.62, 4.65]); (P = 0.015), respectively.

Esthetically, as per Maqsood et al.’s grading scale[18] [Table 2], “perfect” to “good” results were graded in 52 (74%) grafts in terms of color and edge, 50 (71.4%) grafts for graft contour, and 64 (91.4%) grafts for graft size and eyelid margin contour.

Out of the 70 grafts performed, 15 (21.4%) were conducted on patients who had previously undergone FTSG or flaps in the recipient region. Among these, 8 grafts (53.3%) exhibited at least one criterion that was deemed unsatisfactory or unacceptable. This percentage was only 36.4% (22 of 55 FTSGs) in patients with no history of previous procedures in the region.

To simplify the comparison of the overall esthetic outcome, we gave the final esthetic grade for each graft according to the worst grade recorded in any given criterion in the photographic scale [Table 2].[18] For example, if a graft was deemed “Perfect” in terms of graft color, edge/interface, skin surface contour, and size, but it was regarded as only “good” in terms of eyelid margin contour, the overall grade of “good” was given. “Perfect” to “good” results were achieved in all cases where upper eyelid (N = 3) or neck skin (N = 1) was used. The percentage of cases with similar esthetic outcomes was achieved in 57.7%, 51.9%, 50%, 40%, 33.3%, and 0% in grafts taken from postauricular (N = 26), supraclavicular (N = 27), preauricular (N = 4), inner arm (N = 5), brow (N = 3), and lower abdominal (N = 1) skin, respectively [Fig. 2]. The esthetic outcome results concerning donor sites were not statistically significant (P = 0.83).

Figure 2.

Graph depicting esthetic outcomes in relation to grafts’ donor sites

Complications

The overall incidence of complications was 14.3% [Table 3]. Of the 70 grafts, 69 (98.6%) demonstrated a complete survival without signs of necrosis. One graft (1.4%) showed signs of necrosis in 20% of its surface area. Six (8.5%) patients needed further interventions. Three of those patients had a complex medical history including severe vitamin deficiency (B1, Folate) and multiple graft failures, a renal transplant patient had a previous episode of severe infection in the periocular region predisposed by immunosuppression, and one patient had a history of ipsilateral lacrimal sac squamous cell carcinoma excision followed by radiotherapy. One patient needed graft debulking, and two patients received intra-graft triamcinolone or triamcinolone combined with 5-fluorouracil (5-FU).

Table 3.

Complications

Number of patients		Complications
3		Needed regrafting
2		Intralesional injections (Triamcinolone, 5-FU + Steroid)
1		Debulking and repositioning of graft
1		Moderate ectropion: observation
2		Donor-site infection
1		20% graft area necrosis

Two patients (2.9%) suffered from donor-site cellulitis that was treated with oral antibiotics. One patient (1.4%) had a residual lower eyelid ectropion that did not need further intervention.

Discussion

This study demonstrates that the use of quilting sutures combined with Steri-strips splinting for FTSG procedures in the periocular area results in good esthetic as well as functional results. After auditing our previous FTSG results, we found that the double eye pad dressing can be removed in 1–2 instead of 3–5 days postoperatively.[18] This intervention expedited the recovery of visual function in the operated eye for patients.

By avoiding the use of bolsters and Frost sutures, we effectively shortened the duration of the surgical procedure and the required theater time. Furthermore, this approach contributes to cost reduction in the healthcare system by minimizing the consumables (e.g., a bolster with its fixing suture material). Another noteworthy aspect is that our approach eliminates the requirement for an immediate follow-up visit for a bolster or Frost suture removal, thereby reducing the frequency of hospital visits for patients and alleviating clinic congestion. We plan for the first visit for our patients to be on day 14 postoperatively.

We also believe that using Monocryl (poliglecaprone 25) for fixing FTSG has played a role in reducing the rate of suture-related complications allowing the first postoperative visit to be after 14 days as planned. In comparison to Vicryl Rapide^®(Ethicon, Ohio, USA) sutures (polyglactin 910), a histological study showed that Monocryl had a better biological response with less inflammatory infiltrates and rapid healing.[19] Furthermore, braided sutures such as Vicryl Rapide can accommodate a greater number of bacteria.[20] Owing to maintaining 25% of its tensile strength after 14 days, the incidence of wound dehiscence is significantly lower by using Monocryl when compared to Vicryl Rapide, which loses its tensile strength completely by the 14^th day.[21] Moreover, we conducted a comparative analysis of the prices of the three most commonly used sutures. The prices were as follows: Monocryl at £3.03, Vicryl Rapide at £5.30, and Vicryl at £3.84. Our findings indicate that Monocryl is not only associated with a reduced rate of suture-related complications but also cost-effective.[22]

The FTSG healing process begins with the initial phase of graft revascularization. Minor movements within its recipient site are well tolerated, aligning with the typical facial mobility that occurs during normal activities without hindering the healing process. Partial immobilization of the surgical site is facilitated by the natural occurrence of graft edema and inflammation due to absorption of transudate from the recipient bed. This ‘plasmatic imbibition’ stage persists for a minimum of 48 hours, culminating in the fixation of the FTSG by a layer of fibrin that separates the graft from its bed. Notably, substantial graft adherence has been observed within 2 hours in an animal model.[23] Fibrin is then gradually replaced by granulation tissue.

Several adjunctive approaches have been used to potentiate the survival rate of FTSG:

Frost sutures

Originally described to support the upper eyelid after ptosis surgery and prevent corneal exposure,[3] Frost sutures evolved and utilized to oppose downward tension vectors that develop after reconstructive procedures involving the lower lid and cheek, therefore reducing the risk of developing ectropion following FTSG surgery in the region.[7] However, Frost sutures utilization comes with certain constraints, such as the inability to see with the eye while the suture is in position. Notably, the presence of the Frost suture impedes the examination of visual acuity, corneal integrity, and, possibly, even pupillary function. Additionally, there exists a theoretical risk of corneal abrasion and superficial skin erosion of the upper eyelid or brow due to the suture. The suture is usually removed between 3 and 12 days.[24]

Bolsters

Tie-over bolsters were introduced in the mid-twentieth century as an attempt to apply uniform pressure over FTSG to enhance their survival.[9] The use of a tie-over bolster introduces several drawbacks including the inherent bulkiness of the dressing. Furthermore, it has been proposed that the pressure applied should be a minimum of 25 mmHg to prevent hematoma and seroma formation. However, the pressure applied to the graft bed by the tie-over dressing has the potential of impeding normal blood flow at the wound edges, thereby hindering the healing process resulting in tissue necrosis.[25] Inspection of the wound becomes challenging until removal of the tie-over bolster. Achieving wound coverage and protection can be accomplished more simply with basic dressings. Additionally, practical disadvantages of tie-over bolster dressings include prolonged operative time and the use of more consumables.[26]

In a study involving 266 patients where tie-over bolster dressings were compared to cases with simple dressings, graft take, healing period, incidence of wound infection, and hematoma formation showed no significant differences between the two groups.[27]

Langtry et al.[28] described good FTSG take in 28/30 (93.3%) grafts where only light or no patching was used and without the use of bolsters. Moreover, Dhillon et al.[29] described a higher incidence rate of graft failure and infections in cases where bolsters were used.

Quilting sutures

When quilting sutures were compared to bolsters, there was no statistically significant difference in the rates of graft take or infection.[30,31]

Mehta reported quilting sutures to have a 100% survival rate in 109 FTSGs.[16] Central and paracentral quilting sutures were used to ensure FTSG approximation and immobility to their recipient beds, negating the need for bolsters. He proposed that the technique encouraged the survival of larger grafts as well as enhanced the survival of FTSG in irregular areas such as the medial canthus. His technique involved applying a pressure bandage at the end of the procedure; however, he described the use of only cartella shields with an overlying dressing to soak oozing secretions in 14 of his cases; two of those patients had only the shields as their dressings. The shield dressings were then removed after 48 hours, and quilting along with marginal sutures were removed by day 7–9 postoperatively. This is in contrast to our approach as we advise our patients to remove their pressure bandage dressing at home in 1–2 days postoperatively, remove the Steri-strips on day 5, and plan for the first clinical visit on day 14 after surgery, without the need for any suture removal.

Other studies described a high success rate for periocular FTSG without the use of bolsters, Frost, or quilting sutures, where the functional success rate ranged between 95% and 97% with a good graft color match of 85–94%.[32,33]

Eyelid splinting approaches

Splinting the eyelid to help prevent its malposition in the early postoperative period is essential. Cyanoacrylate to the host surrounding tissue has been described by Jackson et al.[34] in a small study group, which proved to be effective. Another larger study showed 96.9% complete graft take with the use of Steri-strips and Mepitel^® (Mölnlycke Health Care, Sweden) to splint the eyelids.[35]

On the other hand, several approaches other than Frost sutures were used to splint the eyelids to prevent their malposition, with or without FTSG. Jothi and Moe described splinting the lower eyelid with the help of a folded Xeroform^® gauze (Covidien, Minnesota, USA) which was sutured to the eyelid.[36] Table 4 summarizes outcomes of various techniques used for FTSG fixation in some of the studies mentioned above.

Table 4.

Summary of key studies in the literature reporting outcomes of FTSG utilizing different fixation techniques

Author		Aim		Number of patients		Follow-up		Outcome
Yuki et al. (2017)[27]		Comparing skin grafts’ outcomes with and without tie-over dressing groups.		Tie-over group: 148 patients. Non-tie-over group:118 patients Total n=266		From ≤10 to ≥31 days		No significant differences between the take rate, healing period, wound infection rate, and hematoma formation rate for the two groups.
Langtry et al.[28]		Describing outcomes of FTSG with a light or no dressing at all, without tie-over bolsters.		n=30		Two to three months.		100% graft take: First 2 weeks: 28/30 (93.3%) At 3 months: 30/30 (100%), 1 case with minimal contracture.
Dhillon et al.[29]		Comparing outcomes of FTSG with and without pressure dressing.		Thirty-five patients in each group. Total n=70		NA		Higher infection and graft failure rates with pressure dressing versus without pressure dressing. No statistically significant difference.
Akhavani et al.[30]		Comparing Tie-over dressing to quilting sutures for FTSG.		Twenty patients in each group. Total n=40		Two to three months.		Tie-over dressing group: 90% graft take. Quilting sutures group: 100% graft take. No statistically significant difference.
Keh et al.[31]		Comparing outcomes of through-and-through mattress suturing versus tie-over and pressure dressing for FTSG.		Through-and-through sutures group: n=100 Tie-over dressing: n=20 Total n=128		One week to 6 months.		Complete graft take rate: Through-and-through mattress suturing: 82%. Tie-over dressing: 76%. No significant difference between groups.
Armstrong et al.[35]		Outcomes of FTSG splinted with Mepitel™ and Steristrips™ without bolsters.		n=96		Two to 4 weeks		Complete graft success rate: 98%
Jothi and Moe[36]		Outcomes of eyelid splinting using Xeroform® gauze with suspension sutures.		n=10		One to 20 months		No reported eyelid malpositions, with one patient reported having restricted lid elevation on up gaze, which spontaneously resolved.

We performed a comparative cost analysis of the consumables used in eyelid splinting, comparing our technique with those documented in the literature. All costs were verified on February 20, 2024.[22] In our approach, we use two envelopes of 12 mm × 50 mm Steri-strips per graft, amounting to a total cost of £1.1. In contrast, employing Mepitel® (Mölnlycke Health Care, Sweden) adds an extra cost of £0.99.[35] Additionally, using a Xeroform gauze along with a 5-0 nylon suture for eyelid suspension results in a combined cost of £3.17.[36] Cyanoacrylate stands out as the most expensive consumable for eyelid splinting, with a cost of £6.49 per vial.[34] Therefore, we found our technique to be cost-effective when compared to other techniques in the literature.

The esthetic results in our study were very good overall. As per Maqsood et al.’s grading scale[18] [Table 2], “perfect” to “good” results were achieved in 52 (74%) grafts for their color and edge. Similar grades were achieved for graft contour in 50 (71.4%), and 64 (91.4%) grafts in terms of graft size and eyelid margin contour.

It was initially believed that donor sites may have played a role in the final esthetic outcomes for our patients. “Perfect” to “good” esthetic grades were documented in cases where donor sites were from upper eyelids, followed by neck, postauricular, supraclavicular, and preauricular skin. However, donor sites showed no statistical significance for the final esthetic outcome (P = 0.83).

We found that the least favorable results were for patients who had previous skin grafts in the region or underwent surgeries resulting in scarring requiring release in the recipient area, but this difference was not statistically significant (P = 0.2).

Our study demonstrates that simple Steri-strips – eyelid splinting provides high functional and esthetic success rates for FTSG in the periocular region. We believe using Monocryl sutures may have helped reduce the incidence of suture-related complications. Additionally, eliminating the need for an early postoperative hospital visit, coupled with the recovery of visual function in the operated eye in 1–2 days postoperatively, may enhance overall patient satisfaction.

A limitation of our study is its retrospective and noncomparative design. The costs associated with randomization and the ethical concerns regarding the random allocation of patients for this procedure in contrast to alternative options outlined above would preclude such a study. Even comparing the different uses of sutures would require a large study to achieve the required power for statistical analysis. It could also be argued that two or more assessors may be needed to grade the esthetic and functional outcomes rather than one assessor. However, according to Maqsood et al.,[18] the two assessors who used the grading scale had a strong level of agreement in their gradings (Kappa > 0.8); this is possibly because of the clear grading criteria shown in Table 2, allowing the assessment to be more objective rather than subjective. Also, all measurements obtained from patients’ photographs were repeated twice utilizing the same standardized level of high magnification for every patient during data collection. This is to minimize measurement variability and improve interobserver reliability.

Future studies could assess the Patient Reported Outcome Measures (PROMS) associated with this surgical approach, and compare them with those from other centers still employing Frost sutures and/or bolsters. Additionally, it would be greatly useful to conduct cost analyses of our surgical approach, including the required number of follow-ups for further evaluation.

Conclusion

The findings of this study offer substantiating evidence for the efficacy of utilizing quilting sutures, the use of Monocryl sutures, and in conjunction with Steri-strips splinting for periocular FTSG. This approach not only eliminates the need for Frost sutures and bolsters, thereby diminishing the necessity for immediate postoperative evaluation, but also achieves a high graft success rate and favorable functional and esthetic outcomes.

Patient consent

Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.