Question for the pros.... from an ER resident - face lacs

[pinipig523]

Hey guys -

I figured I'd ask the pros, the specialists. Keep in mind this is just so I can provide my patients with better laceration outcomes.

I'm only asking about face lacerations.

What advice would you give a 4th year ER resident with regards to face lacs? I've done my share of lac repairs and have worked with several plastic residents and have gotten some feedback from them.

But I wanted to really know - tips for repairing face lacs? What suture technique? What type of sutures do you prefer?

I usually use 6.0 ethilon/nylon in either simple or running stitches. I asked a few plastic residents about subcuticulars and they were against it.

Any tips from you pros would be very helpful to me. Thanks!

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[maxheadroom]

Subcuticular probably doesn't evert enough for a face lac. I would do some sort of deep dermal with 5-0 Monocryl (I think it spits less than Vicryl) and 6-0 nylon or prolene. I prefer prolene on guys who have facial hair -- not many blue whiskers when it's time to take out sutures.

Also, I excise the laceration edge if it isn't really clean. Mostly it just needs a 1-2 mm trim to get clean, non-traumatized skin for a nicer closure.

 

[bottombracket]

I agree completely with Max above, with the following additions:

Preparation: Irrigate the wound copiously with NSS. I poke two holes in the top of a 250 or 500cc bottle of NSS with an 18ga needle, and use that to irriagate. I prep with betadine and use sterile towels - not paper, as they get all wet and fall apart. I wear sterile gloves, no mask or gown, and loupes just because I have them.

Technical considerations: Cut ragged edges back like Max said.

I don't put braided sutures in traumatic wounds- monocryl or biosyn only. Use as few sutures as possible that obliterates any dead space and brings the dermis together. Reduce the burden of suture in the wound whenever possible.

Run the skin with 5-0/6-0 prolene because blue is easy to see under hair, scabs, or general wound yuck.

For kids: if it takes sedation to put the sutures in, it's gonna take sedation to get them out. 5-0 fast and then hide those stitches from the patient and their parents with a single longitudinal steri-strip.

Occasionally I will use skin glue on top of the fast gut sutures, but only if it's a clean, fresh wound. If I glue it, I won't put a steri on top- that can make the whole construct impossible to get off.

If the patient is unlikely to follow up (ie, drunk as a skunk in the trauma bay): they get absorbable sutures only. 5-0 fast for you, too.

For eyelid lacs: I never use interrupted 6-0 prolenes in a lid lac. I only made that mistake once as a junior resident, as the attending called me into clinic to take each and every one out. Use a pullout 6-0 prolene or interrupted 6-0 fast.

For intraoral lacs: 4-0 chromic interrupted sutures spaced 2-3mm apart (you really don't need a ton) with 5 square knots (they really come undone fast otherwise), 5-0 chromic on the wet and dry vermillion.

Lips: When crossing the vermillion border, line it up with one stitch, then step back and look from multiple angles. Ask others in the room (nurses, parents, spouses) if you are unsure, or if you want to show them how it lines up. A 1mm stepoff can be seen from across the room- get it right the first time.

The aftermath: I will admit that I probably overprescribe antibiotics. Dog or human bites: always. My rule of thumb is that if I pick any foreign material out of a wound, they get abx.

These general principles have served me well in residency and will hopefully be useful for you, too.

bb

 

[bottombracket]

Oh yeah, I forgot this key move:

Prep the whole face out because it's amazing how claustrophobic a little towel can be.

Then, take two moistened 4x4's and put them over the patient's eyes for two reasons: one, those lights are bright, and two, then your med student or junior resident can sew away without the patient seeing you gesticulate wildly when they do something you don't want them to do.

bb

 

[pinipig523]

Awesome recs man... see the red for my questions... thanks!!

I agree completely with Max above, with the following additions:

Preparation: Irrigate the wound copiously with NSS. I poke two holes in the top of a 250 or 500cc bottle of NSS with an 18ga needle, and use that to irriagate. I prep with betadine and use sterile towels - not paper, as they get all wet and fall apart. I wear sterile gloves, no mask or gown, and loupes just because I have them.

Technical considerations: Cut ragged edges back like Max said.
Got it... will do. I've heard that before, but I'll make sure I do now.

I don't put braided sutures in traumatic wounds- monocryl or biosyn only. Use as few sutures as possible that obliterates any dead space and brings the dermis together. Reduce the burden of suture in the wound whenever possible.
So you're saying the less deeps I do, the better? Just as long as I obliterate the dead space?

Run the skin with 5-0/6-0 prolene because blue is easy to see under hair, scabs, or general wound yuck.
When you say "RUN", do you mean a simple running stitch?

For kids: if it takes sedation to put the sutures in, it's gonna take sedation to get them out. 5-0 fast and then hide those stitches from the patient and their parents with a single longitudinal steri-strip.
Gotcha.

Occasionally I will use skin glue on top of the fast gut sutures, but only if it's a clean, fresh wound. If I glue it, I won't put a steri on top- that can make the whole construct impossible to get off.

If the patient is unlikely to follow up (ie, drunk as a skunk in the trauma bay): they get absorbable sutures only. 5-0 fast for you, too.

For eyelid lacs: I never use interrupted 6-0 prolenes in a lid lac. I only made that mistake once as a junior resident, as the attending called me into clinic to take each and every one out. Use a pullout 6-0 prolene or interrupted 6-0 fast.
So no interrupteds - what do you mean by "Pullout" and Interrupted FAST"?

For intraoral lacs: 4-0 chromic interrupted sutures spaced 2-3mm apart (you really don't need a ton) with 5 square knots (they really come undone fast otherwise), 5-0 chromic on the wet and dry vermillion.
Do you mean you use chromic as a deep stick on the vermillion or do you use it as a surface stitch?

Lips: When crossing the vermillion border, line it up with one stitch, then step back and look from multiple angles. Ask others in the room (nurses, parents, spouses) if you are unsure, or if you want to show them how it lines up. A 1mm stepoff can be seen from across the room- get it right the first time.
Fantastic to know.

The aftermath: I will admit that I probably overprescribe antibiotics. Dog or human bites: always. My rule of thumb is that if I pick any foreign material out of a wound, they get abx.
Dog or human for sure. Even ortho hand has me give Keflex for clean hand wounds.

These general principles have served me well in residency and will hopefully be useful for you, too.
THANKS!!

bb

 

[danzman]

This should be a sticky in the EM forums..

Couple of things though.

I was always told not to use prolene on white skin as there was a chance it could stain. I got yelled at once because "somebody got sued for that one time."

What do you think of 6-0 fast chromic for minor lacs that do not require any deep sutures?

I have also seen a running 5-0 Vicryl Subcuticular followed by a 6-0 fast chromic for deeper facial lacs in drunks with no F/U.

 

[maxheadroom]

I use lots of prolene and I've never seen it stain anything. That sounds like total BS to me.

"Fast" and "Chromic" are two different things. Chromic sticks around for 10-14 days, depending on where you used it. Fast sticks around for 4-7 days.

A running subcuticular is not good enough without some sort of interrupted deep dermal sutures -- it won't off-load tension for very long and the scar will spread.

 

[danzman]

That is correct, I misspoke. Have you ever used a simple or runnung fast to close a minor facial lac?

 

[maxheadroom]

I would use 5-0 Fast on something very superficial as an interrupted. If there is a lac that needs sutures, running a Fast is probably insufficient.

 

[pinipig523]

Thread's looking good guys... Can someone address my questions in red above?

Thanks!

 

[bottombracket]

I don't know how to quote a quote, but here goes:

1. For deep or layered sutures, in general, I think that if you obliterate dead space, repair any deeper anatomic structures (galea in scalp, orbicularis in lip, etc), and evert your skin edges, you have done the majority of the work. Remember, the real strength layer is your deep dermal layer -- the skin closure is only the icing on the cake.

Repair the skin in any way you see fit after you've done the deep stuff.

2. Yes, 'running' the skin is a colloquial term for a simple over-and-over running stitch.

3. Pullouts. A 'pullout' suture is just a unknotted running subcuticular suture which is started outside of the laceration on the skin surface a couple of mm away, then brought into the lac, sutured in the subcuticular pattern you've always done, and then at the end of the lac, the last bit is brought back outside the wound and left long.

If you use a permanent suture (usually prolene as it's 'slippery' and easy to pull out), you wait 5 days then pull it out from one end or another. This is common in elective blepharoplasties and I will occasionally use it in linear simple lid lacs.

You can also use an unknotted pullout absorbable monofilament suture for the final skin closure, but that's less likely in traumatic wounds.

4. 'Interrupted fast' means interrupted sutures of fast absorbing gut.

5. In the mouth, just a simple stitch of chromic (on a taper) through the mucosa will do just fine.

6. I too have never heard of prolene staining skin.

7. Also, I agree that if it's a real, full-thickness laceration, it probably needs two layers of closure if the superficial closure is done with a fast gut suture. Fast gut seems to dissolve by the time you put bacitracin on the patient's face.

bb

bb

 

[pinipig523]

BB -

So basically -

For face - running it is ok, use blue (prolene) 6.0.

For eyelid lac - run it if possible.

For lips - 5.0 chromic on wet/dry vermillion, line up the border first and check and double check.

Now - is it common practice to repair all intraoral mucosal lacs? I've also heard that repairing it may cause food particulates to get stuck and cause infection. Sometimes I've heard it advocated not to close intraoral lacs for this reason. Opinions and thoughts?

What about ear lacs? No suturing of the cartilage and ok to use chromic on the skin and perichondral layers? Then pressure dress w/ xeroform and gauze? Do any of you guys use paper to act as buttress of sorts?

Thanks guys... so awesome.

 

[PAGuy77]

Great thread guys, very informative! I'm a fast track PA and would love to improve my suturing skills. So you feel pretty confident using fine fast sutures on kids? I'm guessing you restrict the bathing to the face? Do you consider plain gut fast?

I'm always second guessing myself, I recently had a forehead flap that I closed with 6.0 vicryl and 6.0 prolene and it came out great. Based on what I've read, is Monocryl preferable due to its unbraided nature? --> less chance to spit?

Also, I've been using a technique on shin lacs, as they tend to splay. I will throw on vertical mattress suture in the middle to bring the wound edges closer together, and then throw superficial sutures around it to approximate. Any thoughts on that?

I've also cut back on my Abx, I used to give EVERYONE with a lac Abx, now I reserve it for really dirty wounds.

Great post again, thanks so much

Matt

 

[45408]

Preparation: Irrigate the wound copiously with NSS. I poke two holes in the top of a 250 or 500cc bottle of NSS with an 18ga needle, and use that to irriagate. I prep with betadine and use sterile towels - not paper, as they get all wet and fall apart. I wear sterile gloves, no mask or gown, and loupes just because I have them.

I basically do the same thing, although I wear a mask, because I've gotten splashed during enough irrigations. I've also never worn my loupes, but that makes a lot of sense actually, especially since the lighting in the ED isn't as good as the OR, and I can use the help.

3. Pullouts. A 'pullout' suture is just a unknotted running subcuticular suture which is started outside of the laceration on the skin surface a couple of mm away, then brought into the lac, sutured in the subcuticular pattern you've always done, and then at the end of the lac, the last bit is brought back outside the wound and left long.

Do you just put Steristrips over the wound the long way and tape down the pullout ends?

 

[Winged Scapula]

Do you just put Steristrips over the wound the long way and tape down the pullout ends?

I know you weren't asking me, but that's what I do - leave the ends long without knots, tape the ends down and then put Proxi-strips over top along the long axis of the wound.

 

[armybound]

I know you weren't asking me, but that's what I do - leave the ends long without knots, tape the ends down and then put Proxi-strips over top along the long axis of the wound.

for every subcuticular or only certain sites? I was taught this method by one general surgeon, but every other surgeon I've worked with has preferred to anchor it at the apex on either end. I like leaving it without knots, partially because it's easier to do and partially because I tend to make a decent little suture-oma in their apex when I try to anchor it.

 

[Winged Scapula]

for every subcuticular or only certain sites? I was taught this method by one general surgeon, but every other surgeon I've worked with has preferred to anchor it at the apex on either end. I like leaving it without knots, partially because it's easier to do and partially because I tend to make a decent little suture-oma in their apex when I try to anchor it.

Every site (albeit my range of sites is somewhat restricted now, although I'll assist PRS on flaps). As a general surgery resident, I was trained to do the Aberdeen hitch and that's what I did when I first started out until I decided what I preferred to do.

If you are regularly creating a "suture-oma" you are either not lying your knots flat, throwing too many or aren't burying them deep enough.

 

[armybound]

Every site (albeit my range of sites is somewhat restricted now, although I'll assist PRS on flaps). As a general surgery resident, I was trained to do the Aberdeen hitch and that's what I did when I first started out until I decided what I preferred to do.

If you are regularly creating a "suture-oma" you are either not lying your knots flat, throwing too many or aren't burying them deep enough.

Probably all of the above 🙂