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Facial

Lacerations
Nima Shemirani
Eos Rejuvenation
Lasky Clinic, Beverly Hills CA

Objectives

Basic principles of wound healing


Suture and needle choices
Techniques of effective closure to
optimize scar outcomes
Wound preparation
Comparison of suture types
Role of antimicrobials

Evaluation of patient

After ABCs, anesthetize laceration and


explore locally
Thoroughly clean all debris and blood
from face to avoid missing a laceration
Surgilube is a great way to clean
dried blood leave on for 2 minutes
and wipe with 4x4
Assess depth of wound, layers affected,
and look for fractures which may be at
the base of the laceration

Principles of wound
management

Thoroughly cleanse the wound with


copious irrigation
If there is any debris it must be
removed, residual debris will leave
tatoos within the dermis (may need
to use scrub brush)

Reference

Wound physiology and


healing

Only the dermis is capable of


regeneration, not the epidermis
Wounds will contract as they heal
A tension-free closure is essential to
help avoid widened scars
Remove foreign bodies, devitalized
tissue

Features involving face

Can be up to 9 degrees warmer than


extremities
High relative blood flow aids in
preventing infection without the use
of antibiotics
Sutures to be left in 5-7 days to
avoid tracking

Anatomy of a needle

3 parts: point,
body and
swage
Needle is
rounded at
swage end
Needle is flat
within body
(best place to
grab with
needle driver

Anatomy of a needle
(cont)

A = swage
(needle
rotates)
B= body
(needle
secure)
C= point
(point is
blunted)

Needle choices

Taper stretches tissue, good for deep,


soft and elastic tissue
Conventional cutting 3rd edge along inner
aspect of needle can pull needle through
tissue inadvertantly
Reverse cutting 3rd edge along outer
aspect of needle to minimize pulling the
needle through

Needle driver choice

Jaws of needle driver should approximate 3035% of the length of the needle
A= just right
B= too big C= too small

Suture choices

Ideal suture: absorbable, minimal


reactivity, minimal memory, and
ease of use
Absorbable - Fast gut, chromic gut,
cat gut, Vicryl, Monocryl, PDS
Non-absorbable Nylon, Prolene

Sutures and strengths

Costs of suture (hospital


wholesale)

Black nylon (5-0) = $3.22


Blue Prolene (5-0) = $4.28
Fast gut (6-0) = $4.78
Dermabond capsule = $25

Deep suture technique

Suture is tied on deep side of knot


Important to enter and exit tissue at same
levels
Formation of box type knot

Matching uneven skin


edges

Use layer of skin to match levels (dermis


to dermis)
This will help ensure a even edge closure

Importance of eversion
Wound will
contract over
time
Need to evert
wound edges
to prevent
depressions
and widening
of scar

For proper eversion

Penetrate skin and tissue at 90


degree angles
Form a box with the suture

Injection

Topical anesthetic may help


For kids, give a dose of benadryl with
topical
Use 1% lido with epi (hemostasis) and
bicarb in a 1cc bicarb to 9cc of lidocaine
+ epi
For abscesses use 2% lido+epi (8cc) and
bicarb (2cc)
Use 30g needle and inject SLOWLY
Try to enter the laceration in areas that
are already anesthetized

Forehead

Simple interrupted sutures should only be


left in place for 3-4 days to prevent track
marks
Usually this is not enough time for
adequate healing and wound strength
Alternatively, use a sub-cuticular running
suture with prolene or nylon and use steristrips so you can leave sutures in longer
Very important to get good deep closure

Example of SubCuticular

Eyelid

Look for fat in the wound


This is a sign that the orbital septum
(continuous with the periosteum) has
been violated - call occuloplastics
Suture skin only with small bites, do
not need to reapproximate orbicularis
oculi - this may lead to scar contracture
and inability to close eye

Example of a bad
outcome

Example of a bad
outcome

Lip

Extremely important to realign the


vermillion
A 1mm step-off in the closure will be
noticeable
Reaproximate the orbicularis oris
musle to relieve tension in this
active area

Lip Closure

Scars change over time

Regional Blocks

Work well in areas such as the lip whose


anatomy can be altered with local injections
To approximate the lip, align the red border
Lido with epi may blanch the skin so realigning the lip can be difficult
Infra-orbital block for upper lip, mental nerve
3-4-5 rule, use the 3rd tooth from the midline
for upper, in between 4 and 5 for lower
How to block and tackle the face - Zide

Ear

Skin is adherent to underlying


cartilage
Difficult to suture cartilage together
and the overlap may lead to a
deformity
Just need to suture the overlying
skin, the cartilage does not need to
be sutured

Timing of repair

Berk et al looked at 372 patients,


204 of whom had followed up 7 days
later in 2004
They concluded that wounds that
were closed within 24 hours had no
increased risk of infection if it is a
clean laceration

Visual analog scale (0100mm)


Quinn et al 1995

Cosmetic appearance
score
From Wound Registry:
Hollander Wound
Evaluation Scale

Assessing outcomes in
facial plastic surgery
(Rhee
et
al
2008)
Review of all outcomes in facial

Review of all outcomes in facial


plastic surgery
Other than the Quinn VAS and
Hollender Wound Evaluation Score,
there are 4 other scales
Of note the Quinn and Hollander
scales are reliable (good inter and
intra rater reliability), and validated
(use of lit reviews, expert opinions)

Ethibond vs
Monofilament (Quinn
1998)
Paid for by manufacturers of Ethibond

136 randomized patients to pediatric


ER to either 5-0/6-0 closure or ethibond
Reassess wound at 10days, 3mos, 1
year
Use of Hollander wound score and VAS
by 2 research RNs on follow-up and a
validated wound VAS by a cosmetic
plastic surgeon (based on photographs)

Results of Ethibond
closure

No significant difference in optimum


wound scores (73% for Ethibond, 68%
suture) or VAS
No correlation between 10 days and 3 mos,
but excellent correlation between 3 mos
and 1 year in appearance of wound
Essentially all future studies use 3 mos f/u
in their methods based on the results of
this study
Consideration: application of Ethibond
cannot be within wound, cannot use on lips

Cochrane review of
tissue adhesives (2001,
updated 2007)
Used VAS and cosmetic wound score to

examine a total of 889 lacerations, with 364


having follow-up 9-12 mos out from 9 studies
No difference in wound scores noted
Less pain involved with application and
absence of suture removal
Time to apply adhesive was ~5 minutes
shorter than suturing
There was a slightly higher risk of
dehicience with adhesive (6.6% vs 2.2%)
which was stat sig

Fast gut vs Nylon closure


(Luck 2008)

Pediatric ED patients comparing suture


choices
Wounds 1-5cm without irreg borders, 12 layer closure
Follow-up at 5-7days and 3 months
Use validated VAS for cosmesis by 3
blinded observers (peds ED attendings)
based on photographs, and parental
VAS
90 patients total randomized with 60%
f/u rate at 3 months

Luck et al. results

Mean VAS was 92mm (FG) and 93mm (N)


Parental VAS was 86mm (FG) and 91mm (N)
Parental survey found fast gut to be more
convenient (91% vs 75%) and were more
likely to request it in the future (96% vs
79%)
3 parents (13%) perceived complications in
fast gut group compared to nylon (1 large
scar after dehiscience, 2 with premature
unraveling)

Limitations

70% of fast gut patients had at least


one suture that needed to be removed
at 5-7d follow-up
Photographs do not show 3D anatomy
Only 60% follow-up rate
Note that the parental VAS was 5mm
higher for the nylon group - this was
statistically insignificant based on the
study, but is it clinically insignificant?

Comparison of nylon,
fast gut and Dermabond
(Holger
2004)

146 patients randomized to each


group
9-12 mos of follow-up, ~60% followup rate
VAS used to assess wound
No significant differences between 3
groups in wound outcome

Metanalysis of
absorbable vs nonabsorbable suture (AlAbdullah 2007)

2 studies from Holger (2004) and


Karounis (2004) showed no difference
in long term cosmetic outcome scores
when results were pooled together
3 studies pooled showed no difference
in hypertrophic scarring
7 studies pooled together revealed no
difference in infection rate

Choice of closure method

Whatever method you choose, make sure


you perform it correctly (dermabond, steri
strips)
Fast gut may have an unpredictable
absorption rate, if it stays in too long, track
marks may form as well as prolonged
erythema
Dermabond cannot get into the wound
6-0 Prolene is a good choice, gives control
over wound closure and suture removal

Choice of
irrigant/cleanser

Normal saline, water, Shur-Clens shown to


be least toxic to fibroblasts and
keratinocytes in vitro (Wilson et al 2005)
Povidine-iodine and hydrogen peroxide
among the most toxic, but iodine not shown
to prevent infection (Gravett et al 1987)
Since commercial detergents and normal
saline have been shown to be equally
effective in preventing infection, normal
saline is adequate for cleaning of the wound

Role of antimicrobials

In animal models 105 colonies/g tissue


Typical ED laceration (clean) has 102/g
tissue
Systemic antimicrobials for
complicated wounds (next slide)
Dire et al found a decreased infection
rate with the application of triple abx
ointment (4.5%) vs bacitracin (5.5%) vs
silvadene (12%) vs petrolatum (17%)

Assess risk factors

Extremes of age
DM, renal disease
Immunocompromised state
Malnutrition
Obesity
Bite injuries (Amox/clav x 3-5 days to cover Eikenella,
Pasturella)
Crush injuries
Grossly contaminated wounds
Laceration involving muscle
Open fractures
Intraoral lacerations (5 days of PCN adequate)

Appropriate use of
antibiotics

Nakamura and Daya did a review of


clinical trials involving the use of
anitbiotics
They concluded that antimicrobials should
be used in open fractures, intra-oral
wounds and bites
In addition, since there are no randomized
trials for assessing risk factors, it is
accepted that it would be appropriate to
use antimicrobials for the previously
mentioned risk factors

Pearls and techniques

Zen-like - need to visualize and practice


entering and exiting the skin at 90
degree angles
Formation of a square with the suture
Wound eversion is necessary
Have the proper equipment - need fine
instruments with delicate lacerations,
small children
Most of all, be patient and achieve a
correct closure, spending an extra 10
minutes will make for a better outcome

Practice

Carry a needle driver in your pocket


Practice opening and closing without
using your fingers
This will make it more efficient and
help prevent inadvertently pulling
the needle out

Conclusions

Proper suture placement and eversion of wound


is essential for optimum scar outcome
Antibiotics have not been shown to be effective
in non-contaminated wounds
Closure with fast gut appears to have similar
wound outcomes when compared with nonabsorable sutures at 1 year
Dermabond has similar wound outcomes, but
requires special attention when applying
Cleaning of the wound with normal saline is
adequate to prevent infection