Journal of Plastic, Reconstructive & Aesthetic Surgery (2018) 71, 1159–1163

Improved outcomes of scar revision with

the use of polydioxanone suture in
comparison to polyglactin 910: A
randomized controlled trial
Deepti Gupta∗, Upendra Sharma, Shashank Chauhan,
Shamendra Anand Sahu

Department of Burns, Plastic and Maxillofacial Surgery, Vardhaman Mahavir Medical College &
Safdarjung Hospital, New Delhi, India

Received 22 January 2018; accepted 30 March 2018

KEYWORDS Summary Scars have multiple cosmetic and functional sequelae, and revision surgeries are
Scar revision; an attempt to ameliorate these effects. Reduction of spread of the revised scar is one of the
Polyglactin 910; main objectives of revision procedures. Provision of prolonged dermal support to wound can
Polydioxanone; theoretically reduce spread of the scar. We carried out a randomized controlled trial and ob-
Scar width; jectively evaluated the impact of two commonly used absorbable sutures, Polyglactin 910 and
Dermal support; Polydioxanone, on scar spread and quality. Sixty patients with post-traumatic scars of 1 year
Scar spread in duration were enrolled in the study and randomly divided into two groups of 30 each. Af-
ter recording the demographic data and baseline scar characteristics, revision of the scar was
carried out by elliptical excision and primary suturing. In Group 1, Polyglactin 910 6-0 suture
(Vicryl, Ethicon, Johnson and Johnson Ltd., India) was used for dermal suturing, whereas, in
Group 2, Polydioxanone 6-0 suture (PDS II, Ethicon, Johnson and Johnson Ltd., India) was used.
The scar spread in terms of scar width, and scar quality with Vancouver Scar Scale (VSS) was
evaluated at 1, 3 and 4 months postoperatively. The two groups were well matched for demo-
graphics and baseline scar characteristics. On follow-up, the mean scar width in Group 1 was
significantly more than that in Group 2. VSS score was significantly lower in Group 2 at the third
and fourth month follow up, signifying better scar quality. Suture extrusion was noticed in 3
cases in Group 1.

The work has not been presented earlier in any conference.

∗ Corresponding author. Department of Burns, Plastic and Maxillofacial Surgery, Safdarjung Hospital, B-38, Derawal Nagar, New Delhi,

110009, India.
E-mail address: deepti2611@gmail.com (D. Gupta).

https://doi.org/10.1016/j.bjps.2018.03.021
1748-6815/© 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
1160
Compared to Polyglactin 910, Polydioxanone sutures, when used for intradermal suturing in
revision of facial scars, result in a significantly decreased scar spread and better scar quality.
© 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by El-
sevier Ltd. All rights reserved.
Introduction
Scars have multiple cosmetic and functional sequelae, but
more importantly, they have a lasting impact on the psycho-
logical and social well-being of an individual.1 Facial scars
are linked to a high level of self-consciousness and anxiety,
and therefore, a large number of patients seek removal of
these scars.2 Various surgical approaches for revising a scar
include fusiform elliptical excision, serial excision, Z-plasty,
W-plasty and geometric broken line closure.3–5 After a facial
scar revision, the epidermal sutures are usually removed
early to prevent formation of visible suture marks. There-
after, underlying dermal sutures support the revised scar to
resist the tensile forces. Therefore, the type of suture ma-
terial used for dermal closure has a definitive bearing on the
eventual scar spread.
Precise subdermal approximation with an absorbable
suture material that provides prolonged support to the
wound has been found to reduce scar spread.6,7 This pro-
tracted support should ideally be continued until the scar
gains adequate strength to resist the shearing forces acting
on it. Studies that have compared the effect of different
suture materials on scar spread and quality have shown
discordant results. Several reports reveal significant benefit
with the use of delayed absorbable over rapidly absorbable
sutures.6–8 At the same time, numerous research papers do
not prove the superiority of one suture material over the
other.9,10
Polyglactin 910 (Vicryl, Ethicon, Johnson and Johnson
Ltd., India) is synthetic, absorbable, braided and one of the
most commonly used suture for dermal suturing.11 It is com-
posed of a copolymer made from 90% glycolide and 10% L-
lactide. Sixty-five percent of its strength is retained at 2
weeks, 40% at 3 weeks, and 25% at 4 weeks, and the suture
is completely absorbed by hydrolysis in 56–72 days.12 It thus
supports the wound healing effectively for around 3 weeks
by which time there is approximately 20% gain in the wound
tensile strength. On the other hand, Polydioxanone (PDS II,
Ethicon, Johnson and Johnson Ltd., India), is a monofila-
ment absorbable suture material composed of a polyester,
poly (p-dioxanone). It retains 70% of its strength at 2 weeks,
40% at 4 weeks, and 35% at 6 weeks and is completely ab-
sorbed by hydrolysis within 180 to 230 days.13,14
This study aimed to compare the scar spread with the use
of Polyglactin 910 versus PDS sutures in patients undergoing
facial scar revision and to evaluate and compare the quality
of the final scar.
Materials and methods
After obtaining clearance from Institutional Ethics Commit-
tee, this prospective randomized controlled trial was con-
D. Gupta et al.
ducted at a tertiary care center over a period of 18 months.
The trial was registered with the Clinical Trials Registry-
India (CTRI) (CTRI/2017/01/007659). Sixty patients aged
18–60 years, with one or more post-traumatic facial scars
of more than 1 year in duration that required scar revi-
sion were included in the trial. Patients having scars with
width more than 1 cm, those with hypertrophic scars or
keloids, and those with known history of bleeding, colla-
gen or elastin disorder were excluded from the trial. A writ-
ten informed consent was obtained from all the enrolled
patients.
The envelope method was used to randomly allocate
all the patients to either Group 1 or Group 2. Demo-
graphic details, duration of scar, scar sub-site, width and
Vancouver Scar Scale (VSS) score were documented for all
patients. Elliptical excision was carried out for all scars
under local anesthesia by a single surgeon in all cases.
The cut edges were undermined to facilitate primary clo-
sure, and hemostasis was achieved. In Group 1 (n = 30),
coated Polyglactin 910 6-0 suture (Vicryl, Ethicon, Johnson
and Johnson Ltd., India) was used for interrupted dermal-
subdermal closure of the defect. In Group 2 (n = 30), Poly-
dioxanone 6-0 suture (PDS II, Ethicon, Johnson and Johnson
Ltd., India) was used is the same way. In both the groups,
Nylon 6-0 (Ethilon, Ethicon, Johnson and Johnson Ltd., In-
dia) simple interrupted sutures were used to close the skin
followed by application of adhesive tapes. The skin sutures
were removed on the 5th postoperative day. As maximum
scar spread is known to occur in the initial months, patients
were followed-up at 1 month, 3 months and 4 months post-
operatively for scar assessment. At each visit, an assessor
blinded to the type of suture material used, measured the
scar width using a digital Vernier caliper with a least count
of 0.01 mm, and calculated the VSS score. Patients were
assessed for complications like suture extrusion, infection,
skin bruising, bleeding and wound dehiscence. Preoperative
and postoperative photograph at 4 months were taken for
patient record (Figure 1, 2 ).
Sample size was calculated based on previous studies,
and the required number of subjects in each group was
calculated to be a minimum of 26. All data were entered
into MS Excel sheet and subsequently analyzed with the
help of computer software (SPSS statistical software, ver-
sion 21.0, for Microsoft Windows, SPSS Inc. Chiacgo, IL). All
values are expressed as mean plus/minus standard devia-
tion (mean ±SD), median, interquartile (25%–75%) or per-
centage as appropriate. Discrete variables were compared
by the Chi-square test or Fisher’s exact test, and continu-
ous variables with independent sample t-test (for paramet-
ric data) or Mann-Whitney U test (for nonparametric data).
Statistical significance was attributed to p-value of lower
than or equal to 0.05.
Improved outcomes of scar revision with the use of polydioxanone suture in comparison to polyglactin 910 1161

Fig. 1 Patient 1 belonging to Group 1 with scar on left cheek revised using Polyglactin 910 suture. a. Preoperative photograph,
lateral profile b. Postoperative photograph at 4 months, lateral profile.

Fig. 2 Patient 8 belonging to Group 2 with scar on forehead revised using Polydioxanone suture. a. Preoperative photograph, front
profile. b. Postoperative photograph at 4 months, front profile.

Table 1 Demographic data and baseline scar characteristics of patients in Group 1 and Group 2.
Group 1 (Polyglactin 910) Group 2 (PDS) p value
Gender (Male/Female) 9/21 14/16 0.184
Age∗ (years) 24.1 ± 6.8 22.9 ± 4.84 0.841
Scar duration† (years) 5.5 (4–8) 7 (5–9) 0.198
Scar width∗ (mm) 7.2 ± 1.93 6.7 ± 1.66 0.279
VSS score† 2 (2-2) 2 (1–3) 0.596
p value <0.05 considered as statistically significant.
∗ Expressed as mean ± standard deviation.
† Expressed as median (interquartile range).

Results from 18–48 years. The maximum number of patients be-

All 60 patients included in the study were successfully fol-
lowed up for the entire study period. The patient demo-
graphics and baseline scar characteristics such as duration
of scar, scar width and VSS score were well matched in both
the groups (Table 1). The age of study population ranged
longed to the age group of 21–30 years in each group. A total
of 23 (38.33%) patients had a scar on the cheek, making it
the most common subunit of the face involved in the study
population.
The mean scar width at 1, 3 and 4 months follow-up,
in Group 1 was significantly wider than that in Group 2
1162
Table 2 Mean scar width in Group 1 and Group 2.
Group 1 (Polyglactin 910)
Scar width∗ (mm) 1 month 0.7 ± 0.24
3 months 1.82 ± 0.43
4 months 2.85 ± 0.57
p value <0.05 considered as statistically significant.
∗ Expressed as mean ± standard deviation.
Table 3 Vancouver scar scale score in Group 1 and Group 2.
Group 1 (Polyglactin 910)
∗
VSS Score 1 month 2 (1–2)
3 months 2 (1–3)
4 months 1 (0–2)
p value <0.05 considered as statistically significant.
∗ Expressed as median (interquartile range).
(Table 2). In terms of the scar quality, the VSS score of the
two groups were statistically comparable at 1 month follow-
up, but was significantly lower in Group 2 at 3 and 4 months
follow-up, reflecting a better scar quality (Table 3).
Suture extrusion was noticed in three cases in Group 1
subset, and was absent in group 2. None of the patients in
Group 2 showed suture extrusion. This difference was, how-
ever, found to be statistically insignificant between the two
groups, with p value > 0.05.
Discussion
Scar revision aims at providing optimal cosmetic results and
minimizing scar spread. There is a wide variety of suture
materials available for scar revision. The choice depends on
the physical and biological properties of the suture mate-
rial, suturing technique and the healing properties of the
sutured tissues.15–17 This study was targeted to evaluate the
role of prolonged dermal support in revision of facial scars.
The slow reabsorbing PDS suture was compared to the early
reabsorbing Polyglactin 910 suture, and their impact on scar
spread and scar quality was assessed. The results of this
study show that scar spread, measured in terms of mean
scar width at 1, 3 and 4 months follow-up was significantly
lower with the use of PDS sutures. The scar quality, as as-
sessed by median VSS score, showed a significantly lower
score at 3 and 4 months follow-up in the PDS group ver-
sus the Polyglactin 910 group, indicating better scar quality
with the use of PDS sutures for dermal support.
Use of subcuticular nylon and other non-absorbable su-
tures for intradermal approximation has been shown to sig-
nificantly decrease the stretching of scar in a wound sutured
under tension.6,18 This is associated with an increased risk of
wound inflammation and suture extrusion. Moreover, these
sutures cannot be left in situ and need to be removed at a
later stage, which causes inconvenience to the patient and
the surgeon.
Studies comparing the characteristics of a scar result-
ing from suturing a wound with absorbable versus delayed
absorbable sutures have reported varying conclusions. One
D. Gupta et al.
Group 2 (Polydioxanone) p value
0.46 ± 0.13 <0.005
1.1 ± 0.3 <0.005
1.96 ± 0.58 <0.005
Group 2 (Polydioxanone) p value
2 (1–2) 0.541
1 (1-1) 0.004
0 (0–1) 0.024
such prospective clinical study conducted by Guyuron et al.,
failed to demonstrate any statistically significant difference
in the scar spread with the use of 6-0 PDS and 6-0 polyglactin
910 sutures in patients undergoing facial rhytidectomy.19
The scar spread in this study was noted as being present
(>5 mm) or absent (<5 mm). The authors did not take into
account the actual difference in the mean scar width be-
tween the two groups. We quantitatively measured the scar
spread, and compared the mean scar width between the
two groups. Both our study groups showed spread of the
scar, as was noted by Guyuron et al., but the mean scar
spread was seen to be significantly more with the use of
Polyglactin 910 suture. The results in our study are in con-
cordance with those of Kia et al., who compared the spread
of scar with the use of Poly-4-Hydroxybutyrate (P4HB) and
Polyglactin 910. They used both these sutures for dermal ap-
proximation in wounds resulting from excision of lesions on
the back.8 As P4HB is a longer acting suture in comparison
to Polyglactin 910, the authors concluded that prolonged in-
tradermal support results in decreased scar spread.
In our study, the scar quality, as assessed by VSS, was
found to be comparable between Polyglactin 910 and PDS
group at 4 weeks of follow-up. This is because persistent
wound hyperemia at 4 weeks might have resulted in simi-
lar scores in the vascularity sub-category of VSS, in both the
groups. With gradual maturation of the scar, the VSS score
was significantly lower in the PDS group at 3 and 4 month of
follow-up. Our results differ from those of Guyuron et al.,
who labeled any raised scar as hypertrophic, and did not re-
veal any statistically significant difference in the incidence
of hypertrophy with the use of Polyglactin 910 and PDS.19
We have scored the height of the scar according to the
VSS, and found that compared to Polyglactin 910, PDS re-
sulted in a significantly better scar quality at 3 and 4 months
follow-up.
Our results corroborate with those of other studies that
have shown better scar quality with the use of a longer act-
ing suture. When Polyglycolic Acid (PGA) and PDS subcu-
ticular sutures were compared in a prospective study, PDS
was found to cause scar hypertrophy in significantly lesser
number of wounds.7 Similarly, compared to Polyglactin 910,
Improved outcomes of scar revision with the use of polydioxanone suture in comparison to polyglactin 910
the use of a longer acting suture (P4HB) for dermal support
was reported to result in better scores on Hollander wounds
evaluation scale.8
Suture extrusion occurred in three cases in our study
(10.0%) with the use of Polyglactin 910, which was lesser
than that shown in an experimental study by Drake et al.
They reported a mean cumulative incidence of suture ex-
trusion of 31% with coated Polyglactin sutures.20 Increased
rate of suture reaction in the postoperative period has also
been described with the use of a longer acting suture like
P4HB.8 We, however, did not notice any suture reaction with
the use of longer lasting suture material, PDS. This can be
attributed to the fact that PDS has low tissue reactivity, and
therefore, its presence in the dermis for a longer time does
not result in increased inflammatory reaction.
The assessment by Guyuron et al. of intraoperative han-
dling of both the sutures is also endorsed by us.19 Slight dif-
ficulty was faced in visualizing the PDS 6-0 suture because
of its transparency, and that led us to leave a longer suture
tail during suture placement. We employed 5 to 6 knots for
tying PDS sutures and 3 to 4 knots for Polyglactin 910. With
repeated use and practice, the ease of suturing increased
and the initial difficulties faced for tying the PDS reduced.
This study is limited by its short duration of follow-up.
As scars continue to mature over a period of 1 year, out-
comes could have been better analyzed over a longer pe-
riod of observation after scar revision. The other drawback
is that the scar assessment at follow-up was single-sided and
performed only by the caregivers. No patient reported out-
comes or patient satisfaction scores were included for scar
quality analysis.
Conclusions
Scars are often a cause of psychological distress for the pa-
tient, and revision surgeries are aimed at improving the aes-
thetic appearance of the scar. Our objective should be to
minimize the spread of the revised scar. Prolonged dermal
support in the form of a delayed absorbable suture can help
us achieve the desired result. As seen in our study, PDS pro-
vides a better alternative to Polyglactin 910 for dermal su-
turing in scar revision, as its use is associated with lesser
spread and better quality of the revised scar.
Conflict of interest and funding
There were no conflicts of interest or source of funding that
need to be disclosed.
1163
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