Upper Blepharoplasty: Permanent vs Dissolving Sutures

Two topics come up almost every time we prepare for upper blepharoplasty: Why don’t I use dissolving stitches? And is having stitches removed going to hurt? Both are fair questions, and both deserve a real answer.

The upper eyelid incision is closed under some tension, and the closure has one job during the first week: hold the wound edges together precisely while the tissue begins to heal. Lower tension on the wound means better healing, and the more tension the suture can bear, the less tension the wound itself has to carry. Because the eyelid moves constantly, there are countless small opportunities for stress on the fresh wound. A suture that holds full strength for the entire healing week does that job without asking anything of the tissue around it.

Nylon and polypropylene (Prolene) are inert synthetic materials. The body essentially ignores them. They lose no meaningful strength between the moment they are placed and the moment they are removed.

Plain gut, the common dissolving option for eyelid skin, works differently. It is broken down by the body’s own enzymatic and inflammatory response. The suture does not simply disappear on its own. The body has to mount an inflammatory reaction to digest it, and that reaction happens directly within the healing wound. Inflammation is not a friend to scars. A quieter wound environment generally heals with less redness and a finer line. So when I choose a permanent stitch, I am choosing a material whose strength does not fade across the vulnerable healing week and whose presence adds essentially nothing to the inflammatory burden in the scar.

There is a practical point as well. Routine wound care, cleaning the incision and applying antibiotic ointment, softens gut suture and speeds its breakdown. The material may be weakening earlier than anyone intended.

Here is the way I think about it that makes the most sense to me, and it matches what I have seen in practice. Imagine the same surgeon operating on the same eyelid in two different rooms, Room A and Room B.

Room A is stocked only with dissolving plain gut. The surgeon knows the suture will begin losing strength over the coming days and may have less confidence that the closure holds. In some cases, that can subtly push a surgeon toward taking less skin.

Room B is stocked only with permanent suture. The excision is limited only by the things that should limit it: the anatomy and the small details that determine the best cosmetic outcome. The surgeon has no insecurity about what will hold the incision together and no need to compensate for it. Suture performance over the next week is simply not part of the equation. The permanent stitch will hold.

Dehiscence means a wound edge that separates. Eyelid skin is the thinnest on the body, the scar sits in a visible and expressive location, and a separated wound can heal with a wider or irregular line and create asymmetry with the other side.

The largest review of wound dehiscence after upper blepharoplasty, covering 2,376 cases, found that dehiscence was associated with the use of fast-absorbing plain gut suture. I have done a lot of eyelid surgery. Dehiscence is not common, and it can happen with permanent stitches too. This is about reducing the likelihood. If it can be avoided, I will do everything I can to avoid it. I have seen it happen more often with dissolving sutures, and for the reasons above that are unique to the eyelid, I prefer a stitch I can count on.

To be fair to both sides, the broad literature on facial skin closure finds absorbable and nonabsorbable sutures roughly equivalent in many settings (Parell 2003, Rosenzweig 2010, systematic review 2025). This is debated from the first day of surgical training onward. I have seen excellent results with both, and a patient whose surgeon prefers absorbable sutures should not read this as a criticism. Risk tolerance, experience, and differences in technique all play a role. What follows is my experience.

Three findings do support the decision I have arrived at through that experience.

First, a randomized split-wound trial, in which each half of the same wound received a different suture, compared polypropylene directly against fast-absorbing plain gut. Blinded physicians rated the polypropylene side better on a validated scar assessment scale at three months.

Second, in a series of 149 upper blepharoplasty patients, slightly more of those closed with absorbable suture needed reoperation, most often for asymmetry or insufficient skin resection. The difference was small and did not reach statistical significance, and the authors concluded that both sutures work well. Still, the authors themselves suggested that the gradual loss of tensile strength in absorbable material might contribute, and the trend fits what I have seen in my own patients.

Third, the one randomized trial in upper blepharoplasty that compared closure materials side by side within the same patient found that fast-absorbing gut produced the least favorable cosmetic scores of the options tested.

None of these is a definitive verdict. Together with my own experience, they are enough to make me comfortable with a preference I already held for mechanical reasons.

The removal appointment is the part patients dread in advance and then, almost universally, find uneventful. Before removal, a strong, quick-acting topical numbing cream is applied to the incision line. Most patients feel nothing during the removal itself. Truly.

Upper blepharoplasty itself is such a quick and easy procedure that coming back a week later for suture removal can feel like a relative inconvenience. But the visit is brief and comfortable, and it lets me inspect the incision and counsel you on next steps so it heals the best way possible.

There is a single exception, at the very corner of the lid. The incision comes to a point there, and it needs its own stitch to let the skin sit flat and even. Tension at that spot is minimal, and a permanent knot can physically bother the patient during the healing week. So in that one location I use gut, if a suture is needed at all. At the one week visit, the knot usually just gets trimmed rather than the whole suture pulled out, and the body quietly handles the small amount that remains.

None of this overrides individual judgment. Skin quality, healing tendencies, prior surgery, and the specifics of each eyelid all factor into the plan, and no suture choice guarantees a particular scar. Healing timelines vary from person to person, and the approach described here reflects my general practice rather than a promise about any individual outcome.