Facial Lacerations
Nima Shemirani
Eos Rejuvenation
Lasky Clinic, Beverly Hills CA
Objectives
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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
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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
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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
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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
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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
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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)
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A = swage
(needle rotates)
B= body (needle
secure)
C= point (point
is blunted)
Needle choices
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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
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Jaws of needle driver should approximate 3035% of the length of the needle
A= just right B= too big
C= too small
Suture choices
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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
Suture
Type
Chromic Gut
Natural
Tensile
Strength
(50%)
5 days
Absorption
Rate
Fast Gut
Natural
2-3 days
Complete by
day 5-10
Coated
Vicryl
Braided
3 weeks
Complete by
day 50-70
Monocryl
Monofilament
1 week
Complete by
day 90-120
PDS II
Monofilament
4 weeks
Complete by
180 days
Complete by
day 90
Costs of suture (hospital wholesale)
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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 (width=length)
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
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Penetrate skin and tissue at 90 degree angles
Form a “box” with the suture
Injection
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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
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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 steri-strips so you
can leave sutures in longer
Very important to get good deep closure
Example of Sub-Cuticular
Eyelid
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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
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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
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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 re-aligning
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
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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
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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 (0-100mm)
Quinn et al 1995
Cosmetic appearance score
From Wound Registry: Hollander
Wound Evaluation Scale
Assessing outcomes in facial
plastic surgery (Rhee et al 2008)
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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)
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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
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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)
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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)
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Pediatric ED patients comparing suture choices
Wounds 1-5cm without irreg borders, 1-2 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
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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
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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)
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146 patients randomized to each group
9-12 mos of follow-up, ~60% follow-up rate
VAS used to assess wound
No significant differences between 3 groups in
wound outcome
Metanalysis of absorbable vs nonabsorbable suture (Al-Abdullah
2007)
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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
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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
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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
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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
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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
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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
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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
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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
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Proper suture placement and eversion of wound is essential for
optimum scar outcome
Antibiotics have not been shown to be effective in noncontaminated wounds
Closure with fast gut appears to have similar wound outcomes
when compared with non-absorable 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