Comparison Between Using Monocryl Suture and Polypropylene Suture in Closure of Alar Base Excision in Rhinoplasty

Abstract

Background:

Rhinoplasty is one of the most common procedures that act as a challenge for consistent outstanding results. Alar base reduction is a technique of rhinoplasty that is prescribed in many conditions. Wound closure requires using of sutures and there are several types of sutures for this purpose; however, good scar results are necessary for patients’satisfaction.

Aim:

To evaluate alar base resection scar results after surgical resection using different types of suturing material.

Methods:

This is a retrospective cohort study that was conducted at King Abdulaziz University Hospital, Riyadh, Kingdom of Saudi Arabia. The study was performed by reviewing patient’s records and performing post-operative photography for patient who underwent alar base resection. The patients were divided into 2 groups, the first group of patients had the alar base wound closed with interrupted Polypropylene 6/0 and the other group wound was closed with monocryl 6/0 sutures. Visual analog scale was used to investigate basal views.

Results:

The study included 80 patients divided into 2 groups, each group included 40 patients, in the first group (Polypropylene group) there were 25% males and 75% females, whereas in the second group (monocryl) there were 15% and 85% males and females, respectively. There were 85% and 82.5% unnoticeable scar reported by the first and second group, respectively; however there was no significant difference between the 2 groups (P = .75).

Conclusion:

Both Polypropylene and monocryl sutures result in the same result for closing alar base wound post surgically.

Introduction

Rhinoplasty is one of the most common surgeries, but it is a challenge for consistent outstanding results ¹ as it should result in an aesthetic balance for the nose with normal function. ² Alar base reduction is a well described technique of rhinoplasty. ³ Alar base reduction should be considered when the interalar distance exceeds the intercanthal distance. ³ Also, it is required to correct the sidewall flaring that may be caused by retrodisplacement of the nasal tip. ^4,5 Good scar results are essential for patient satisfaction. ⁶ Non absorbable and absorbable suture materials are used for wound closure in surgical operations. ^7,8 Absorbable sutures are used for the wound that rapidly heals and requires temporary support. ⁹ Poliglecaprone 25 (Monocryl) was introduced in 1993 and is formed of a copolymer of glycolide and epsilon-caprolactone. It retains, 60% to 70% of its tensile strength in 1 week, whereas the complete loss occurs at 3 weeks and complete absorption occurs between 91 to 119 days. ¹⁰ Poliglecaprone 25 is an absorbable monofilament ¹¹ reported as the second preferred suture, with only 11% preferring it. ¹² Poliglecaprone has minimal rates of complications regardless of presence or absence of comorbid factors. ¹³ Non absorbable sutures are required for the wound that needs longer support, polyproplene is non absorbable synthetic suture material that has non-adherent property to tissue, so it is a good material for closure, however it can cause suture sinus formation, palpable knots, wound pain, dehiscence and wound sepsis, incisional hernia, and stitch granuloma. ⁹ The ideal suture should have these characteristics, allow secure knots, be sterile, non-allergenic, non-electrolytic, cheap, atraumatic, have adequate tensile strength, and have good handling characteristics. ¹⁴ This study aimed to evaluate alar base resection scar results after surgical resection in our patients using different types of suturing material, and to analyze the scar results that help the surgeon to better choose suturing material to maximize scar cosmesis and reduce discomfort to patients.

Patients and Methods

This is a retrospective cohort study that was performed at King Abdulaziz University Hospital, Riyadh, Kingdom of Saudi Arabia. The study was performed by reviewing patient’s records and performing post-operative photography for patients who underwent alar base resection to compare scar outcomes between patients who underwent surgical resection and wound closure by using monocryl suture or Polypropylene suture in closure of resection site. To standardize the procedure and exclude the effect of skill differences, all patients were operated by the same surgeon. The inclusion criteria for patients were as follows: patients aged older than 18 years, primary cases, patients who underwent open alar base resection and wound closure with monocryl or Polypropylene 6-0 and, patients with more than 1-year follow up. The exclusion criteria were patients less than 18 years, those who suffer trauma, revision, and congenital cases, and patients less than 1 year post-operatively. The alar base resection was used for all patients in same surgical technique. The patients included were divided into 2 groups; the first group of patients had the alar base wound closed with interrupted Polypropylene 6/0 and the other group wound was closed with absorbable monocryl sutures. The Polypropylene 6/0 suture was removed 5 days post-operatively, whereas the monocryl group did not require suture removal. Scar results were assessed by asking patent verbally by telephone after 1 year of surgery using visual analogue scale (VAS) score which categorize scar result to 3 categories: unnoticeable, noticeable but acceptable, and noticeable and not acceptable. Objective assessment was done by assessing patient photography (basal, right, and left lateral view) after 1 year of surgery by 2 rhinoplasty surgeons using Stony Brook Scar Evaluation Scale (SBSES). Total scar scores were then categorized into 3 groups: poor (0-1 point), moderate (2-3 points), and good (4-5 points).

Statistical Analysis

SPSS program was used to analyze data, χ² test was used to calculate statistical significance between the 2 groups, P-value at ≤ .05 was considered significant.

Results

The present study included 80 patients who were divided into 2 groups; the first group included 40 patients who performed the alar base wound closed with interrupted Polypropylene 6/0 suture, the study included 10 (25%) males and 30 (75%) females with age range of 20 to 44 years and a mean age of 32 years and standard deviation (SD) of ±6 years. The second group included 40 patients who underwent wound closer with absorbable monocryl 6/0 sutures, the group included 6 (15%) males and 34 (85%) females with mean of age range of 31 years and SD of ±6 years, Table 1.

Table 1.

Demographics of Patients in the 2 Groups.

Variables	First group (Polypropylene group)	Second group (monocryl group)
Age, mean (SD)	32 (±6)	31 (±6)
Sex
Male	10 (25%)	6 (15%)
Female	30 (75%)	34 (85%)

Abbreviation: SD, standard deviation.

By using VAS, in the first group (Polypropylene group) there were 34 (85%) patients who had unnoticeable scar, 5 (12.5%) patients who had noticeable but acceptable scar, and only 1 (2.5%) patient who had noticeable and not acceptable scar. In the second group, there were 33 (82.5%) patients who had unnoticeable scar and 7 (17.5%) patients who had noticeable but acceptable scar, Figure 1.

Figure 1.

Objective scar evaluation.

Another method (SBSES) of evaluation was used, and it was performed by SPSS program using a scoring system, where unnoticeable scar referred to good, noticeable but acceptable scar referred to moderate, and noticeable and not acceptable scar referred to poor, so in the first group there were 33 (82.5%), 6 (15%), and 1 (2.5%) of patients who had good, moderate, and poor satisfaction, respectively. In the second group, there were 35 (87.8%) patients who had good satisfaction and 5 (12.5%) patients who had moderate satisfaction, Figure 2.

Figure 2.

Subjective scar evaluation.

The differences in views and satisfaction of patients were investigated between the 2 groups, Table 2. There were no significant differences between the 2 groups regarding VAS (P = .75) and SBSES (P = .75).

Table 2.

Comparison Between the 2 Groups.

Group	P value of VAS	P value of SBSES
First group Second group	0.75	0.75

Abbreviations: SBSES, Stony Brook Scar Evaluation Scale; VAS, visual analogue scale.

Discussion

The present study was conducted to compare between 2 types of sutures in alar base wound closing. In 2005, Kridel et al ¹⁵ reported in their study that alar base wedge excision showed 17% need dermabrasion while in our study no patient from either group needed it. In the present study, there was no significant difference in using Polypropylene or monocryl suture regarding closing of alar base wound, subjectively patients did not notice a difference in outcome based on suture type. A study by Ashraf et al ¹⁶ was conducted on 100 patients who underwent open rhinoplasty and closure of the trans columellar incision by using and absorbable vicryl and non-absorbable prolene suture; the study showed that there was no significant differences in scar scores between the 2 groups of patients (P = .39). This is in agreement with our study, where the 2 groups showed no significant difference in scar score. Another study by Alijanpur et al ¹⁷ revealed that there was no significant difference between the use of absorbable and non-absorbable suture in terms of scar in rhinoplasty; however, the using of absorbable suture resulted in comfort for patients and saved time for removal. A study by Foda on alar base reduction showed that the scar was inconspicuous and well hidden by using boomerang-shaped excision with 6-0 prolene suture, also no keloid or hypertrophic scar formation was encountered; however, dermabrasion of that scar was needed in 3 (6.5%) cases to eliminate apparent suture track marks. ¹⁸ Another study by Foda ¹⁹ showed that using 5-0 polyglactin suture for alar base excision resulted in inconspicuous and well-hidden scars with no keloid or hypertrophic scar formation was encountered; however, dermabrasion of that scar was needed in 6 cases to eliminate apparent suture track marks. It was stated that non-absorbable suture have the ability to result in late complications such as foreign body reaction, infection, and extrusion ²⁰ ; however in the current study, there were no complications reported in either of the 2 groups. A study conducted to compare 3 types of sutures including poliglecaprone 25, polyglacin 910, and polyamide in post cesarean women found that the results were similar for poliglecaprone 25 and polyglacin 910 except for discomfort, ²¹ and poliglecaprone 25 was found to be better than polyglactin-910 as it resulted in less extruded suture. ²² In a randomized trial, it was found that poliglecaprone 25 resulted in significant patient satisfaction. ²³

Conclusion

In our study, the usage of either Polypropylene or monocryl sutures in closing alar base woulds post-surgical resection didn’t result in a major difference in scar result but using a monocryl suture was more comfortable to the patient avoiding patient discomfort during suture removal and saving physician time.