Article selection

The initial literature search across PubMed, Scopus, Web of Science, and Google Scholar yielded a total of 312 records. After removing 48 duplicates, 264 unique records remained for screening.

1.

Title and Abstract Screening: Two independent reviewers evaluated the 264 records against the predefined inclusion and exclusion criteria. Studies were excluded if they:

Did not involve cutaneous closure in upper (or lower) eyelid blepharoplasty.

Were non-comparative (e.g., single-arm studies, laboratory/animal research).

Focused on other periocular or facial procedures unrelated to blepharoplasty.

Compared only closure techniques (e.g., running vs. interrupted) without evaluating both absorbable and non-absorbable sutures.

Were case reports, reviews, commentaries, or editorials.

This step resulted in the exclusion of 231 records, leaving 33 articles for full-text assessment.

2.

Full-Text Review: The 33 articles were thoroughly evaluated for eligibility. An additional 22 articles were excluded due to:

Lack of direct comparison between absorbable and non-absorbable sutures (n = 15).

Insufficient outcome data (n = 5).

Non-English full-text or incomplete abstracts (n = 2).

A total of 11 articles were included for data extraction and synthesis. The primary evidence base for comparing suture materials consists of 8 studies that provided a direct comparison of absorbable versus non-absorbable sutures [5,6,7,8, 15,16,17,18]. Separately, three additional studies [11,12,13] that compared only suturing techniques (e.g., running vs. interrupted) were included post hoc. These were incorporated solely to provide essential contextual data on the impact of suturing technique, which was identified as a major confounding variable during analysis. These technique-only studies do not contribute data to the primary suture material comparison but are vital for interpreting its results. Consequently, the results are synthesized in two distinct parts:

The PRISMA flow diagram (Fig. 1) summarizes the selection process, detailing the number of records identified, screened, and excluded at each stage.

The included studies comprised randomized controlled trials (RCTs), prospective cohort studies, and retrospective analyses, all of which provided direct comparisons of absorbable and non-absorbable sutures in upper eyelid blepharoplasty. Key outcomes such as scar quality, complications, patient satisfaction, and follow-up burden were extracted and synthesized to address the research questions.

Fig. 1

PRISMA Flow Diagram of Study Selection

Results of data extraction and synthesis

We systematically extracted data from all studies meeting predefined inclusion criteria, focusing on direct comparisons of absorbable versus non-absorbable skin sutures in upper (and lower, if applicable) eyelid blepharoplasty, as well as studies examining suture-related outcomes in periocular plastic surgery. Our standardized extraction captured study design, sample size and demographics, suture details, outcome domains (scar quality, complications, patient discomfort, follow-up/resource use), follow-up metrics, and main results (including statistical data where reported). Given the clinical and methodological heterogeneity, synthesis was primarily qualitative, with quantitative details summarized where reported. For clarity, key study characteristics and primary findings are summarized in Table 2.

Table 2 Summary of included studiesComparative clinical outcomes of absorbable vs. non-absorbable sutures in upper eyelid blepharoplasty

The comparative clinical outcomes of absorbable versus non-absorbable sutures for cutaneous wound closure in upper eyelid blepharoplasty are consistently found to be equivalent in the robust studies available (Table 3). Randomized, split-eyelid and prospective comparative trials [5, 7, 8] report no meaningful differences in final scar quality, wound healing, or overall aesthetic appearance between the two suture classes when modern materials and standardized closure protocols are used. Both absorbable and non-absorbable sutures yield similarly low rates of serious complications such as wound dehiscence, infection, and granuloma. Short-term differences—such as early edema or ecchymosis—appear to be more affected by suturing technique (e.g., interrupted vs. running) than by whether the suture is absorbable or not [7]. Importantly, absorbable sutures offer the secondary benefits of obviating the need for suture removal and reducing associated discomfort, though quantitative data on this are limited.

While some studies suggest a slight aesthetic preference or marginal reduction in removal-related discomfort favoring absorbable sutures, these effects do not alter the overall equivalence in clinically important outcomes [5, 8]. Large observational case series and additional direct comparisons [16, 17] further reinforce this consensus, although detailed outcome data are limited by lack of full abstracts. In summary, with appropriate technique and follow-up, both suture types deliver safe, effective, and cosmetically acceptable results for upper eyelid blepharoplasty.

Table 3 Comparative clinical outcomes of absorbable vs. Non-Absorbable sutures in upper eyelid blepharoplastyImpact of suture type on postoperative Follow-Up burden and resource utilization

The type of suture used has a clear theoretical implication for postoperative follow-up burden, as non-absorbable sutures require a dedicated clinic visit for removal, while absorbable sutures do not. However, the available literature does not quantitatively measure this outcome. Non-absorbable sutures require patients to return for a dedicated clinic visit for suture removal—typically on postoperative day 5–7. It is therefore logical that this would increase both patient inconvenience and the utilization of clinical resources [5, 8]. Conversely, it is hypothesized that absorbable sutures, which dissolve spontaneously, could reduce follow-up demands. Notably, none of the retrieved studies provided explicit quantitative data on the number of follow-up visits, time expenditure, or associated costs. The requirement for a removal visit is inherent to non-absorbable sutures, but its quantitative impact on healthcare systems and patients remains unmeasured in the available literature on blepharoplasty.

Regarding patient discomfort, it is frequently suggested that absorbable sutures avoid the discomfort associated with suture removal, but this has rarely been measured quantitatively [5, 8]. While one prospective study [5] indicated a qualitative preference for absorbables due to less discomfort, the actual magnitude was not reported. Similarly, none of the comparative studies detailed explicit cost/resource analyses. Therefore, while the theoretical advantages of absorbable sutures are clear, this review found no quantitative evidence to confirm a reduction in follow-up burden or resource utilization (Table 4).

Table 4 Effect of suture type on postoperative Follow-Up burden, discomfort, and resource utilizationInfluence of suture technique on aesthetic outcomes, complications, and patient satisfaction

Different suture techniques, specifically running versus interrupted closure, can have distinct impacts on early postoperative healing and short-term aesthetics in upper eyelid blepharoplasty, though these differences generally do not translate into significant variations in long-term scar quality or patient satisfaction (Table 5). For example, Aydemir et al. (2022) [7] conducted a split-eyelid prospective study and found that within both absorbable (vicryl) and non-absorbable (polypropylene) suture groups, interrupted sutures were associated with less ecchymosis and edema in the first postoperative week compared to running sutures. However, by three months postoperatively, scar quality as assessed by the Manchester Scar Scale was equivalent regardless of technique or suture type.

Other studies, including larger randomized trials focused on technique [11, 12], similarly report that while running and subcuticular (a variation of running) techniques may offer theoretical efficiency, neither technique consistently outperforms the other in patient-reported satisfaction or blinded scar outcome grading. Adverse events and complication rates, such as infection, significant edema, or poor healing, are also low and do not differ significantly between running and interrupted closures [11,12,13]. These findings suggest that suture technique choice can be tailored to the surgeon’s preference and clinical context, with either approach yielding safe and cosmetically satisfactory results in the long term.

Table 5 Impact of suture technique (Running vs. Interrupted) on outcomes in upper eyelid blepharoplastyContextual findings from studies on suture technique

To contextualize the findings from the primary suture material analysis, the influence of suturing technique was examined separately. As noted, three technique-only studies provided robust evidence on this relationship [11,12,13]. It is important to reiterate that these studies did not compare suture materials but were included to assess technique as a potential confounder.

As shown in Table 5, Aydemir et al. [7] (a study also included in the primary analysis) and others [11, 12] consistently found that while technique (e.g., interrupted vs. running) can significantly influence short-term outcomes like edema and ecchymosis, it does not result in significant differences in long-term scar quality or patient satisfaction. For instance, Told et al. [12] and Vasović et al. [11] both used non-absorbable sutures in all patients and found no difference in outcomes between different closure techniques. It demonstrates that the suturing technique is a more significant determinant of early healing than the choice of suture material. Therefore, the equivalent long-term outcomes observed between absorbable and non-absorbable sutures in the primary analysis are likely genuine and not masked by technical variations between studies.

Predictors and risk factors for adverse outcomes in upper eyelid blepharoplasty

Adverse outcomes following upper eyelid blepharoplasty—such as significant postoperative edema, infection, or hypertrophic scarring—are uncommon, but several clinical series and recent studies have identified important predictors and risk factors (Table 6). The largest and most contemporary series, such as Park et al. (2024) [13], found that surgical technique plays a major role: specifically, blepharoplasty accompanied by mini crease enhancement or use of closure techniques incorporating the levator aponeurosis was associated with a substantially higher rate of clinically significant eyelid edema (CSEE). Logistic regression confirmed that these technical modifications, rather than suture material, were independent predictors of persistent swelling. Additionally, the study controlled for race, another variable that can influence healing and adverse event risk, but found technique to be a stronger predictor in their cohort.

Studies such as Joshi et al. (2007) [17]—an 800-case series—support that while suture material is less often implicated, surgeon experience, meticulous technique, and perioperative care are key to preventing infection, wound dehiscence, or abnormal scarring. Rare complications like granuloma or milia may also be affected by materials and closure style, though large series do not identify consistent patient-level predictors. Broader observational and qualitative evidence [6, 18] further emphasize that early suture removal can lower the risk of track marks or skin irritation, while delayed removal or poorly executed closure can increase minor adverse outcomes. Overall, patient-specific predictors are seldom highlighted, while surgical technique and perioperative management features (timely suture removal, avoidance of excessive tension, and minimizing foreign body load) predominate as identified risk factors in the literature.

Table 6 Predictors and risk factors for adverse outcomes in upper eyelid blepharoplasty