Available online at www.sciencedirect.

com

ScienceDirect

British Journal of Oral and Maxillofacial Surgery 62 (2024) 642–650

Randomised controlled trial of resorbable versus non-

resorbable sutures for lacerations of the face (TORN Face)
Shadi Basyuni 1,2,⇑, Ashley Ferro 1, Ian Jenkyn 1, Gareth Nugent 1, Maryam Bennani 1,3,
Henry Bennett 3, Jonathan Chu 3, Matthew Davies 1, Clarissa Hjalmarsson 3, Keri Moorhouse 1,
Robert Bosley 1,3, Roxanne Mehdizadeh 1,3, Navin Pancharatnam 1, Malcolm Cameron 1,
Chang-Bon Man 1, Kanwalraj Moar 1, Mark Thompson 1, Christopher Fowell 1,2,
Vijay Santhanam 1
1
Department of Oral and Maxillo-Facial Surgery, Cambridge University Hospitals, Cambridge, UK
2
Department of Surgery, School of Clinical Medicine, University of Cambridge, Cambridge, UK
3
School of Clinical Medicine, University of Cambridge, Cambridge, UK

Received 9 May 2024; accepted in revised form 30 May 2024

Available online 18 June 2024

Abstract

Facial lacerations are commonly encountered in emergency departments and require effective management to optimise aesthetic out-
comes. Non-resorbable sutures are traditionally favoured for their tensile strength and minimal inflammatory response, despite the inconve-
nience of the required follow up for removal. This single-centre, single-blinded randomised controlled trial aimed to compare the clinical
efficacy and cost-effectiveness of resorbable (Vicryl Rapide) versus non-resorbable (Ethilon) sutures for the closure of facial lacerations
in adults. Between November 2021 and February 2023, 200 adult patients presenting with facial lacerations were randomly allocated to either
resorbable or non-resorbable sutures. Outcomes assessed included aesthetic results via the Visual Analogue Scale (VAS) and Hamilton Scar
Scale, patient-reported satisfaction using the Patient Scar Assessment Questionnaire (PSAQ), complication rates, and cost analysis. No sig-
nificant differences were found in mean VAS scores between the two groups in both modified intention-to-treat and per-protocol analyses.
The majority of patients reported high satisfaction levels. Early complication rates were significantly higher in the non-resorbable group at
the one-week follow up, with no long-term differences noted. Preliminary cost analysis indicated a more than five-fold cost saving with
resorbable sutures. Resorbable sutures provide a viable and cost-effective alternative to non-resorbable sutures for adult facial lacerations,
with comparable aesthetic outcomes and patient satisfaction. Their use could reduce healthcare burdens by eliminating the need for
follow-up suture removal, supporting broader adoption in clinical practice.
Ó 2024 The Author(s). Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons. This is an open
access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Keywords: facial trauma; lacerations; suture; resorbable; non-resorbable

Introduction a broad age range of patients presenting with facial lacera-

tions, with falls presenting as the most common mechanism
Facial wounds are frequently encountered in the emergency of injury (64%), especially in under-18 and elderly popula-
department (ED), accounting for approximately 4–7% of all tions. Of the identified injuries, laceration repair was required
ED attendances in the UK.1 An epidemiological survey of in 70% of cases.2 One of the primary aims of surgical wound
over five million cases of head and neck trauma confirmed management is optimal aesthetic outcome, irrespective of
where the wound is sited. This is more important still in
⇑ Corresponding author at: Department of Oral and Maxillo-Facial
the repair of facial wounds, where the consequence of poor
cosmetic outcome may have significant implications on
Surgery, Cambridge University Hospitals, Cambridge, CB2 0QQ, UK.
E-mail address: [email protected] (S. Basyuni). social functioning and mental wellbeing.3,4 Wound closure

https://doi.org/10.1016/j.bjoms.2024.05.012
0266-4356/Ó 2024 The Author(s). Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
 S. Basyuni et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 642–650 643

techniques vary according to the characteristics of the Primary and secondary outcomes
laceration. Topical skin adhesives and tissue-adhesive tapes
effectively manage simple and superficial lacerations.5–7 The primary outcome was aesthetic outcome at six-months’
However, sutures are required for the effective management post closure as assessed using the Visual Analogue Scale
of more complex lacerations, such as those that are deeper, (VAS).13 Secondary outcomes were cosmetic outcome
gaping, contaminated, or span natural lines of tension. assessed using the Hamilton Scar Scale (as a means of further
Currently there is no universal consensus on the most validating the primary outcome),14 patient-reported out-
appropriate suture material for facial wound repair.8 Tradi- comes, assessed using the Patient Scar Assessment Question-
tionally, non-resorbable suture materials have been preferred naire (PSAQ) Satisfaction with Appearance subscale,15
on the face for their higher tensile strength and lower inflam- complications and cost.
matory response, which were thought to yield better out-
comes. However, non-resorbable sutures present several Randomisation, blinding, and recruitment
disadvantages, notably necessitating a follow up visit for
removal, which can disrupt patient flow and add inconve- The study was a single centre, single-blinded randomised
nience. Additionally, this requirement may lead to unneces- controlled trial with two treatment arms. Participants were
sary patient-clinician interactions, burdening already randomly allocated to resorbable (Vicryl Rapide) or non-
pressured healthcare systems. resorbable (Ethilon) based on a computer-generated random
Several trials suggest that resorbable sutures are at least as allocation sequence. Block randomisation was used, with a
effective as non-resorbable sutures in paediatric patients.9,10 block size of 4 and allocation ratio 1:1, and subjects were
Given the additional considerations for this population, such allocated randomly within each block. The allocation
as difficulty with suture removal and missed school time, sequence was created before study commencement by a
resorbable sutures have become the standard for facial lacer- member of the trial team not involved in recruitment. Alloca-
ations in paediatric care. tion was concealed in sequentially numbered opaque envel-
There is less clear evidence in adult patient populations opes. Recruiting clinicians were blinded until after the
supporting the use of resorbable sutures in traumatic facial participant gave their consent for recruitment to the trial.
injuries. Previous work in adult populations have focused Study personnel involved in outcome assessment were
on the cosmetic outcomes following operative incisions,11 blinded to group allocation until study completion. Assessors
which is a fundamentally different type of injury to that com- were not involved in patient care and did not access the med-
monly experienced in the emergency department. The ical records.
included injuries lack the complexity of lacerating injuries, A trial database was created within the EPIC Electronic
which may exhibit shelving, tissue loss, tissue maceration, Health Record (Epic Systems Corporation). Eligible patients
and contamination.12 were contacted by a trained clinician or member of the trial
The aim of the present randomised controlled trial (RCT) team to introduce the study. Patients interested in trial partic-
was to compare the clinical efficacy of resorbable sutures ipation provided written consent in person, prior to the pro-
versus non-resorbable sutures in the management of facial cedure taking place under local anaesthetic.
lacerations occurring in the adult population.
Operative management
Methods
All recruiting clinicians received study instructions and a
Study population flowchart describing the study procedures as part of their
research training. Standard department procedures were fol-
The trial had national ethics approval and was registered on lowed for the closure of facial lacerations. Wounds were first
NIHR Clinical Research Network (CRN) Portfolio (CPMS inspected for evidence of non-viable tissue and contamina-
ID: 48907) and ISCRTN (55795740). The study was caried tion. Contamination was managed as per standard procedure
out in accordance with the Declaration of Helsinki. This with washout and appropriate debridement of non-viable tis-
manuscript includes all components of the Consolidated sue as required. Washout was performed with normal saline
Standards of Reporting Trials (CONSORT). (0.9% saline) only. Lidocaine (2%) with 1:80,000 adrenaline
Between November 2021 and February 2023, patients was employed as an anaesthetic in all cases, using blocks
aged 18 years, with facial lacerations presenting to the where appropriate (so as not to distort tissue architecture)
Emergency Department of Cambridge University Hospitals or direct infiltration with caution to volume used. Layered
were evaluated for eligibility. Exclusion criteria included closure using resorbable sutures was performed to minimise
complex lacerations requiring closure under general anaes- tension at the skin. Skin closure was performed using a stan-
thetic, significant wound contamination, animal or human dard interrupted instrument tie approach. Post procedure, all
bites, and patients with a medical history remarkable for fac- patients, irrespective of treatment arm received 1% chloram-
tors that contribute to poor wound healing (appendix). Writ- phenicol ointment to apply topically to the wound three times
ten informed consent was provided by all enrolled patients. daily for five days. Deep suturing was performed only with
644 S. Basyuni et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 642–650

Vicryl Rapide 3-0. Skin closure was performed with a suture patients (63 non-resorbable; 65 resorbable) and 161 patients
size of 5-0 only – participants received either Vicryl Rapide provided complete PSAQ data at the trial end point (82 non-
or Ethilon as per randomisation. resorbable; 79 resorbable). A modified intention to treat anal-
ysis (mITT) was undertaken including all patients providing
Postoperative study procedures complete data at the six-month trial end point. Eleven
patients who provided final photographic data deviated from
Patients were provided with a standardised questionnaire protocol: seven underwent suture removal of resorbable
through telephone consultation at one week and three months sutures, and four patients were prescribed antibiotics follow-
post injury to enquire on progress and complications (ap- ing closure. A per-protocol analysis was thus undertaken on
pendix). At six months’ post injury patients were asked to photographic data from 117 patients (58 in the non-
complete the ‘Satisfaction with Appearance’ domain of the resorbable arm; 59 in the resorbable treatment arm.
Patient Scar Assessment Questionnaire (PSAQ). This ques- Baseline characteristics were similar between treatment
tionnaire comprises 10 items enquiring on patient satisfac- arms (Table 1). Baseline characteristics were also similar
tion on various aesthetic aspects of the wound in question between treatment arms for patients included in mITT and
and was chosen in light of independent validity of individual PP analyses (Supplementary Tables S1 and S2, online only).
subscales and reasonable inter-rater reliability.16,17 Addition-
ally, patients were asked to provide three clinical pho- Visual analogue score
tographs of the healed wound at the six-month end-point
post closure, according to a standardised series of instruc- The mean VAS for all patients providing complete data
tions (appendix). These photographs were assessed using (n = 128; mITT) was 84.05 (SD 8.11). In the resorbable
both the Visual Analogue Score (VAS) and the Hamilton group, the mean (SD) VAS was 85.12 (7.62), compared to
Scar Scale (a scar assessment tool developed for use specif- 82.94 (8.5) in the non-resorbable group for those providing
ically on clinical photographs).14 Each clinical photograph complete photographic data. For protocol-compliant
was assessed for VAS by two independent Consultant asses- patients, the resorbable group had a mean (SD) VAS of
sors who were not involved in patient care and were blinded 85.66 (7.54), while the non-resorbable group scored 83.84
to treatment allocation. (8.21). No significant differences in mean VAS were
observed between the treatment arms in both mITT and
Statistical analysis per-protocol (PP) analyses (p = 0.213 and p = 0.320, respec-
tively; Fig. 2).
Normality of continuous variables was assessed first visually
using density and qq-plots, before quantitative evaluation Hamilton scar scale
using Shapiro-Wilk test. Levene’s test was used to assess
for homoscedasticity between groups. Given breach of The Hamilton scar scale, designed specifically to assess scar
assumptions, Wilcox Rank Sum test was used to compare outcomes from clinical photographs, was also used to evalu-
continuous variables between treatment arms. The chi ate aesthetic results. Among 128 patients with complete pho-
squared test of independence was used to assess association tographic data, the median total Hamilton score was 1 [IQR
between categorical variables, with pair-wise post-hoc com- 0-2] in the resorbable group and 1 [IQR 0-3] in the non-
parisons using Bonferroni correction for multiple testing, if resorbable group. No significant differences in scores were
appropriate. found between treatment groups (W = 2306, p = 0.2068;
It has previously been determined that the minimal Fig. 3). This was also true in the per-protocol analysis
clinically-important difference in the visual analogue scale (W = 1922, p = 0.237).
is 10–15 mm.13 The standard deviation of the cosmesis
scores was estimated at 14mm. To detect a difference in Patient reported outcomes (PROMS)
cosmesis of 10mm, with a power of 90% (alpha 0.05), 43
patients are required per group. A recruitment target of 100 Patient-reported outcomes were assessed at the trial’s end-
participants for each arm was set to accommodate the unpre- point using the ‘Satisfaction with Appearance’ domain of
dictable rate of loss to follow-up. Statistical analyses were the Patient Scar Assessment Questionnaire (PSAQ). At this
performed using R version 4.0.0, and p values <0.05 were endpoint, 161 patients provided complete PSAQ data - 79
accepted as significant. in the resorbable treatment arm and 82 in the non-
resorbable arm. Across both groups, the majority of patients
Results expressed satisfaction, with 64.3% reporting ‘Very Satisfied’
and 30.0% ‘Satisfied’ (Fig. 4). The median total PSAQ score
The 200 patients were recruited over a period between 13 was 11 [IQR 9-15] in both the resorbable and non-resorbable
November 2021 and 27 February 2023. The final six- arms, with a slightly higher upper range in the non-
month follow up was completed on 27 August 2023. The resorbable group (IQR 9-15.75) (Fig. 5). There was no sig-
trial flow profile is presented in Figure 1. Of the 200 recruited nificant difference in the total PSAQ scores between the
patients, complete photographic data were obtained for 128 treatment groups (W = 3367, p = 0.66).
 S. Basyuni et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 642–650 645

Fig. 1. Consolidated Standards of Reporting Trials (CONSORT) flow chart for trial recruitment.

Complications the initial encounter cost from this preliminary cost analysis.
Therefore, the analysis focuses solely on the cost differences
All complications reported by patients and clinicians were between treatments due to the unit cost of suture materials
documented, irrespective of whether they were expected out- and any necessary follow ups in the non-resorbable treatment
comes of laceration injuries. Throughout the study, 58 com- arm. According to the ‘Unit Costs of Health and Social Care
plications were noted during follow ups at one week, three Programme’ (2022–2027), the estimated unit cost for a gen-
months, and six months post injury, affecting 48 patients eral practitioner is £41 for a 9.22-minute patient consultation,
(24% of participants; Table 2). Swelling was the most com- and £52 per hour for a GP practice nurse, which translates to
mon complication, occurring in 12 cases, followed by £13 per interaction for the required 15-minute appointment
paraesthesia and infection, each with nine instances. In the to remove sutures.18 At time of writing, the NHS supply
resorbable treatment arm, there were seven cases of delayed chain cost of a single Ethilon suture was £1.79 compared
suture resorption requiring removal. with £2.77 for a single Vicryl Rapide suture. The estimated
No statistically significant difference in overall complica- cost of material and required follow up across this trial was
tions was observed between groups (v2(1) = 0.685, thus at least £1479 for the non-resorbable group (assuming
p = 0.408). However, a significant association was found nurse practitioner suture removal and excluding the addi-
between early complications at the 1-week follow-up and tional expense of equipment required for suture removal),
the non-resorbable treatment arm (v2(1) = 5.50, p = 0.019; compared to £277 to the resorbable group.
Supplementary Table S4; Fig. 5). No significant differences
were noted in complication rates at the three- and six-month Discussion
follow ups between groups (v2(1) = 0.16, p = 0.688 and
v2(1) = 1.998e-32, p = 1, respectively). The TORN Face trial was designed to evaluate the efficacy of
resorbable (Vicryl Rapide) versus non-resorbable (Ethilon)
Brief cost evaluation sutures in managing adult facial lacerations. This study fills
a notable gap in the literature, as previously, there was a lack
It is assumed there were no differences in the time required of high-quality evidence comparing these suture materials
for wound closure between treatment arms, thus excluding and their outcomes in this specific population. Traditional
646 S. Basyuni et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 642–650

Table 1
Baseline characteristics of recruited patients. Data are mean (SD) unless otherwise stated.
Variable Non- Resorbable Total p value
resorbable (n = 100) (n = 200)
(n = 100)
Age (years) 45.6 (19.1) 45.8 (20.0) 45.7 (19.5) 0.96
Sex:
F 30 (30.0) 41 (41.0) 71 (35.5) 0.139
M 70 (70.0) 59 (59.0) 129 (64.5) 0.335
Fitzpatrick:
i 15 (15.0) 19 (19.0) 34 (17.0)
ii 69 (69.0) 58 (58.0) 127 (63.5)
iii 11 (11.0) 13 (13.0) 24 (9.0)
iv 2 (2.0) 7 (7.0) 9 (4.5)
v 2 (2.0) 3 (3.0) 5 (2.5)
vi 1 (1.0) 0 (0.0) 1 (0.5)
Significant PMH:
No 59 (59.0) 57 (57.0) 116 (58.0) 0.886
Yes 41 (41.0) 43 (43.0) 84 (42.0)
Immunosuppression:
No 97 (97.0) 99 (99.0) 196 (98.0) 0.621
Yes 3 (3.0) 1 (1.0) 4 (2.0)
Smoking:
No 87 (87.0) 89 (89.0) 176 (88.0) 0.828
Yes 13 (13.0) 11 (11.0) 24 (12.0)
Alcohol >14 units/week:
No 84 (84.0) 81 (81.0) 165 (82.5) 0.71
Yes 16 (16.0) 19 (19.0) 35 (17.5)
Illicit drug use:
No 100 (100.0) 99 (99.0) 199 (99.5) 1
Yes 0 (0.0) 1 (1.0) 1 (0.5)
Laceration site:
Cheek 7 (7.0) 10 (10.0) 17 (8.5) 0.054
Chin 21 (21.0) 7 (7.0) 28 (14.0)
Eyebrow 26 (26.0) 40 (40.0) 66 (33.0)
Forehead 23 (23.0) 22 (22.0) 45 (22.5)
Lip 18 (18.0) 16 (16.0) 34 (17.0)
Nasal 5 (5.0) 5 (5.0) 10 (5.0)
Mechanism
Accidental 9 (9.0) 8 (8.0) 17 (8.5) 0.717
Fall 37 (37.0) 41 (41.0) 78 (39.0)
Fall from bike 32 (32.0) 24 (24.0) 56 (28.0)
IPV 6 (6.0) 8 (8.0) 14 (7.0)
Occupational 5 (5.0) 3 (3.0) 8 (4.0)
RTC 4 (4.0) 5 (5.0) 9 (4.5)
Seizure 1 (1.0) 0 (0.0) 1 (0.5)
Sport related 6 (6.0) 11 (11.0) 17 (8.5)
Admission:
No 94 (94.0) 94 (94.0) 188 (94.0) 1
Yes 6 (6.0) 6 (6.0) 12 (6.0)
Deep suture placed:
No 28 (28.0) 25 (25.0) 53 (26.5) 0.749
Yes 72 (72.0) 75 (75.0) 147 (73.5)
PMH, past medical history; IPV, interpersonal violence; RTC, road traffic collision

guidelines have favoured non-resorbable sutures for skin clo- modified intention-to-treat and per-protocol analyses, sug-
sure, citing their higher tensile strength and lower inflamma- gesting that with regards to cosmetic outcome, resorbable
tory response. However, these preferences were established sutures offer a viable and non-inferior alternative to non-
prior to the advent of advanced fast-absorbing materials resorbable sutures in adult populations. Moreover, the high
and have not been rigorously tested in clinical trials. patient satisfaction rates reported in both groups further sup-
Our findings indicate no significant difference in aesthetic port the clinical acceptability of resorbable sutures. The ‘Sat-
outcomes between Vicryl Rapide and Ethilon sutures when isfaction with Appearance’ domain of the Patient Scar
measured by both the Visual Analogue Scale (VAS) and Assessment Questionnaire (PSAQ) demonstrated that the
the Hamilton Scar Scale. These results are consistent across majority of patients were either ‘Very Satisfied’ or ‘Satisfied’
 S. Basyuni et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 642–650 647

100 100

90 90
Visual Analogue Score (mITT)

Visual Analogue Score (PP)

80 80

70 70

60 60

50
p = 0.213 50
p = 0.320
e

e
bl

bl
e

e
ba

ba
bl

bl
ba

ba
or

or
es

es
or

or
es

es
−r

−r
on

on
R

R
N

N
Suture Material

Fig. 2. Summary of modified intention to treat (mITT) and per-protocol (PP) analyses for visual analogue score (VAS); Left panel, mITT; Right panel, PP. P
values reflect result of two-tailed independent samples T test of mean VAS scores between treatment groups.

Score 0 1 2 3 4

10.0
Scar Vascularity p = 0.2068
Non−resorbable

Scar Pigmentation

7.5
Scar Irregularity
Hamilton Component

Total Hamilton

Apparent Height

5.0
Scar Vascularity

Scar Pigmentation
Resorbable

2.5
Scar Irregularity

Apparent Height
0.0

0% 25% 50% 75% 100%

e
bl

Proportion
e
ba

bl
ba
or
es

or
es
−r
on

R
N

Suture Material

Fig. 3. Summary plots of Hamilton scar scale14 scoring across all patients providing complete photographic data. In summary lower score is favourable with 0
being attributed to ‘normal’ in that domain; Left panel, proportions of scoring using Hamilton scar scale in each domain according to treatment allocation; Right
panel, summary of total Hamilton scar scale scoring according to treatment allocation. P value reflects Wilcox Rank Sum Test in mITT analysis.

with their surgical outcomes, which underscores the potential The complication rates observed in this study further rein-
for resorbable sutures to be used more broadly in clinical force the safety of using resorbable sutures. Again, there was
practice without compromising patient perceptions of cos- no significant difference between overall complication rates.
metic success. However, a detailed analysis revealed a significant associa-
648 S. Basyuni et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 642–650

Q9
Q8
35 p = 0.66
Q7

Non−resorbable
Q6
Q5 30
Q4
Q3
Q2 25
Question

Q1

PSAQ Total
Q9
Q8 20
Q7

Resorbable
Q6
15
Q5
Q4
Q3
10
Q2
Q1

0% 25% 50% 75% 100% 5

Proportion

le
ab

e
bl
Patient Response VS S D VD

rb

ba
so

or
−re

es
on

R
N
Suture Material

Fig. 4. Patient-reported outcomes; Left panel, Overview of patient responses to each item of the PSAQ ‘Satisfaction with Appearance’ domain (VS = very
satisfied; S = satisfied; D = dissatisfied; VD = very dissatisfied); Right panel, PSAQ total score according to treatment allocation

Non−resorbable Resorbable

1 week 3 months 6 months

p = 0.408 p = 0.019 p = 0.688 p=1

75
Frequency

50

25

No Yes No Yes No Yes No Yes

Complication
Fig. 5. Overview of frequency of complications at 1-week, 3-month and 6-month follow up time points.
 S. Basyuni et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 642–650 649

Table 2 In the paediatric population, the benefits of using resorb-

Overview of complications between treatment groups. able sutures are well recognised. Specifically, the challenges
Complication Suture material associated with suture removal in children shift the focus of
Non- Resorbable Total clinical decision-making. A greater emphasis is placed on
resorbable avoiding the additional anxiety and risks of a second proce-
Bleeding 3 0 3 dure, thus the balance shifts towards resorbable sutures,
Dehiscence 1 0 1 which offer more benefits than risks. While the advantages
Delayed suture removal (NR) 6 0 6 might not be as immediately apparent, the benefits of resorb-
Delayed suture resorption (R) 0 2 2
Delayed suture resorption requiring 0 7 7
able sutures for adults are also present. By necessitating only
removal (R) a single patient encounter, resorbable sutures not only
Erythema 0 1 1 enhance convenience but also reduce healthcare costs. They
Infection 7 2 9 help streamline patient flow in busy healthcare settings and
Pain 0 2 2 minimise unnecessary patient-clinician interactions, provid-
Paraesthesia 5 4 9
Pruiritis 2 1 3
ing benefits to both the health system and patients. Previous
Redness 1 0 1 studies, albeit in different populations, have demonstrated
Retained foreign body 1 0 1 the non-inferiority of resorbable sutures.9–11 The TORN
Revision of sutures 0 1 1 Face trial results demonstrate comparable efficacy, good
Swelling 8 4 12 safety profile, and cost-effectiveness; thus, our findings sug-
Total 34 24 58
gest that resorbable sutures are a good option for the closure
NR, non-resorbable; R, resorbable. of facial lacerations in adults. This could lead to a shift in
clinical practice norms and potentially reduce the burden
tion between early complications and non-resorbable sutures on healthcare resources.
at the one-week follow up, though no long-term differences
were evident at three and six months. The higher rate of early Conclusion
complications in the non-resorbable group may be attributed
to the differing handling properties or the requirement for In conclusion, the TORN Face trial supports the use of
suture removal, which can itself increase the risk of discom- resorbable sutures for facial lacerations in adults, with no
fort and infection. It is important to note that we inclusively compromise in aesthetic outcomes or patient satisfaction
recorded all complications reported by patients and clini- when compared to non-resorbable sutures. The additional
cians, and thus, caution is advised in interpreting these early benefit of lower costs provides a strong argument for their
complication rates, especially since the non-resorbable group adoption in routine clinical practice.
required an additional clinician encounter. Perhaps the more
important conclusion, is that the resorbable group did not Acknowledgements
experience an increase in complication rates, effectively dis-
pelling previous concerns about heightened inflammation The TORN Face trial acknowledges primarily the patients
and infection. and the families and friends who supported them for partic-
While a comprehensive and systematic economic evalua- ipating in this study. Also, to: the recruiters and wider staff
tion was beyond the scope of this manuscript, we conducted of the Department of Oral and Maxillo facial Surgery at
a preliminary cost analysis focused on readily measurable vari- Cambridge University Hospitals for their general support
ables, independent of assumptions. This analysis provides in the running of the study; the Department of Emergency
compelling economic evidence supporting the use of resorb- Medicine at Cambridge University Hospitals for their sup-
able sutures, revealing a cost saving of more than five times port with research administration and delivery; the Depart-
compared to non-resorbable sutures. It is important to note that ment of Surgery at the School of Clinical Medicine,
our analysis primarily covered direct costs, such as healthcare University of Cambridge for their support and guidance.
provider time and materials, and did not account for indirect
costs, including patient inconvenience and potential produc- Conflict of interest
tivity loss. Therefore, we anticipate that a planned more
detailed cost analysis will reveal even greater cost savings. We have no conflicts of interest.
As with any study, consideration must be given to the
trial’s limitations. The sample size was sufficient to detect
differences in aesthetic outcomes but may not have fully cap- Funding
tured less common complications. Additionally, as the study
was conducted in a single centre, this may limit the general- This work was funded by a grant supported by the British
isability of the findings. However, the baseline characteris- Association of Oral and Maxillofacial Surgeons (BAOMS).
tics of our sample were representative of the broader UK The funders of the study had no role in study design, data
population, supporting the relevance of our results across dif- collection, data analysis, data interpretation, or writing of
ferent settings. the report.
650 S. Basyuni et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 642–650

Ethics statement/confirmation of patient permission 7. Zempsky WT, Parrotti D, Grem C, et al. Randomized controlled
comparison of cosmetic outcomes of simple facial lacerations closed
with steri strip skin closures or Dermabond tissue adhesive. Pediatr
The trial had national ethics approval and was registered on Emerg Care 2004;20:519–524.
NIHR Clinical Research Network (CRN) Portfolio (CPMS 8. Singer AJ, Hollander JE, Quinn JV. Evaluation and management of
ID: 48907) and ISCRTN (55795740). Patient consent traumatic lacerations. N Engl J Med 1997;337:1142–1148.
obtained for trial. No identifying information presented. 9. Luck R, Tredway T, Gerard J, et al. Comparison of cosmetic outcomes
of absorbable versus nonabsorbable sutures in pediatric facial lacera-
tions. Pediatr Emerg Care 2013;29:691–695.
10. Karounis H, Gouin S, Eisman H, et al. A randomized, controlled trial
Appendix A. Supplementary material comparing long-term cosmetic outcomes of traumatic pediatric lacer-
ations repaired with absorbable plain gut versus nonabsorbable nylon
Supplementary material to this article can be found online at sutures. Acad Emerg Med 2004;11:730–735.
https://doi.org/10.1016/j.bjoms.2024.05.012. 11. Guyuron B, Vaughan C. A comparison of absorbable and nonab-
sorbable suture materials for skin repair. Plast Reconstr Surg
1992;89:234–236.
References 12. Milroy CM, Rutty GN. If a wound is “neatly incised” it is not a
laceration. BMJ 1997;315:1312.
1. Allonby-Neve CL, Okereke CD. Current management of facial wounds 13. Quinn JV, Wells GA. An assessment of clinical wound evaluation
in UK accident and emergency departments. Ann R Coll Surg Engl scales. Acad Emerg Med 1998;5:583–586.
2006;88:144–150. 14. Crowe JM, Simpson K, Johnson W, et al. Reliability of photographic
2. Sethi RK, Kozin ED, Fagenholz PJ, et al. Epidemiological survey of analysis in determining change in scar appearance. J Burn Care
head and neck injuries and trauma in the United States. Otolaryngol Rehabil 1998;19:183–186.
Head Neck Surg 2014;151:776–784. 15. Durani P, McGrouther DA, Ferguson MW. The patient scar assessment
3. Tebble NJ, Adams R, Thomas DW, et al. Anxiety and self- questionnaire; a reliable and valid patient-reported outcomes measure
consciousness in patients with facial lacerations one week and six for linear scars. Plast Reconstr Surg 2009;123:1481–1489.
months later. Br J Oral Maxillofac Surg 2006;44:520–525. 16. Choo AM, Ong YS, Issa F. Scar assessment tools: how do they
4. Rankin M, Borah GL. Perceived functional impact of abnormal facial compare? Front Surg 2021;8 643098.
appearance. Plast Reconstr Surg 2003;111:2140–2146. 17. Economopoulos KP, Petralias A, Linos E, et al. Psychometric
5. Mattick A, Clegg G, Beattie T, et al. A randomised, controlled trial evaluation of patient scar assessment questionnaire following thyroid
comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips and parathyroid surgery. Thyroid 2012;22:145–150.
(Steristrips) for paediatric laceration repair. Emerg Med J 18. Jones KC, Weatherly H, Birch S, et al. Unit costs of health and social
2002;19:405–407. care 2022 manual. Available from URL: https://www.pssru.ac.uk/pub/
6. Singer AJ, Hollander JE, Valentine SM, et al. Prospective, randomized, uc/uc2022/Unit_Costs_of_Health_and_Social_Care_2022.pdf (last
controlled trial of tissue adhesive (2-Octylcyanoacrylate) vs standard accessed 17 June 2022).
wound closure techniques for laceration repair. Acad Emerg Med
1998;5:94–99.