Abstract Background Optimizing scar aesthetics is a key objective in upper blepharoplasty. Although nylon 6-0 sutures are widely used, the ideal skin closure technique remains debated. Objectives The aim of this study was to compare early and long-term aesthetic outcomes of intradermal and continuous external suturing techniques using a randomized intrapatient design. Methods This prospective, randomized, intraindividual clinical trial included 50 patients undergoing bilateral upper blepharoplasty performed by a single oculoplastic surgeon at a university-affiliated tertiary center. Each eyelid was randomly assigned to receive either an intradermal or a continuous external running suture using 6-0 nylon. Standardized photographs were evaluated at postoperative day 7 and 6 months by 2 blinded oculoplastic surgeons. Patients completed the Global Aesthetic Improvement Scale, and scar quality was assessed using the Observer component of the Patient and Observer Scar Assessment Scale (POSAS Observer). Results At postoperative day 7, 1 evaluator favored intradermal sutures in 60% of cases (P = .013), whereas the second evaluator found no significant difference between techniques. At 6 months, both methods demonstrated comparable aesthetic outcomes. Patient satisfaction was high, with 80% of patients reporting “much improved” or “very much improved” results. Quantitative analysis using the POSAS Observer scale showed no statistically significant differences between suturing techniques at either postoperative time point. No suture-related complications were identified. A single case of unilateral wound dehiscence occurred, which could not be attributed to either suturing technique. Conclusions Intradermal and continuous external suturing techniques provide equivalent long-term aesthetic outcomes in upper blepharoplasty. Although intradermal sutures may offer modest early advantages, final scar quality is comparable, supporting technique selection based on surgeon preference and workflow. Level of Evidence: 3 (Therapeutic) For image description, please refer to the figure legend and surrounding text.
Soares et al. (2026) studied this question.