Facial Facial LacerationsLacerations

Nima ShemiraniNima Shemirani

Eos RejuvenationEos Rejuvenation

Lasky Clinic, Beverly Hills CALasky Clinic, Beverly Hills CA

ObjectivesObjectives

Basic principles of wound healingBasic principles of wound healing Suture and needle choicesSuture and needle choices Techniques of effective closure to Techniques of effective closure to

optimize scar outcomesoptimize scar outcomes Wound preparationWound preparation Comparison of suture typesComparison of suture types Role of antimicrobialsRole of antimicrobials

Evaluation of patientEvaluation of patient

After ABCs, anesthetize laceration and After ABCs, anesthetize laceration and explore locally explore locally

Thoroughly clean all debris and blood Thoroughly clean all debris and blood from face to avoid missing a lacerationfrom face to avoid missing a laceration

Surgilube is a great way to clean Surgilube is a great way to clean dried blood – leave on for 2 dried blood – leave on for 2 minutes and wipe with 4x4minutes and wipe with 4x4

Assess depth of wound, layers affected, Assess depth of wound, layers affected, and look for fractures which may be at and look for fractures which may be at the base of the lacerationthe base of the laceration

Principles of wound Principles of wound managementmanagement

Thoroughly cleanse the wound with Thoroughly cleanse the wound with copious irrigationcopious irrigation

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

ReferenceReference

Wound physiology and Wound physiology and healinghealing

Only the dermis is capable of Only the dermis is capable of regeneration, not the epidermisregeneration, not the epidermis

Wounds will contract as they healWounds will contract as they heal A tension-free closure is essential to A tension-free closure is essential to

help avoid widened scarshelp avoid widened scars Remove foreign bodies, devitalized Remove foreign bodies, devitalized

tissuetissue

Features involving faceFeatures involving face

Can be up to 9 degrees warmer than Can be up to 9 degrees warmer than extremitiesextremities

High relative blood flow aids in High relative blood flow aids in preventing infection without the use preventing infection without the use of antibioticsof antibiotics

Sutures to be left in 5-7 days to Sutures to be left in 5-7 days to avoid trackingavoid tracking

Anatomy of a needleAnatomy of a needle 3 parts: point, 3 parts: point,

body and body and swageswage

Needle is Needle is rounded at rounded at swage endswage end

Needle is flat Needle is flat within body within body (best place to (best place to grab with grab with needle driverneedle driver

Anatomy of a needle Anatomy of a needle (cont)(cont)

A = swage A = swage (needle (needle rotates)rotates)

B= body B= body (needle (needle secure)secure)

C= point C= point (point is (point is blunted)blunted)

Needle choicesNeedle choices

Taper – stretches tissue, good for deep, Taper – stretches tissue, good for deep, soft and elastic tissuesoft and elastic tissue

Conventional cutting – 3Conventional cutting – 3rdrd edge along edge along inner aspect of needle – can pull needle inner aspect of needle – can pull needle through tissue inadvertantlythrough tissue inadvertantly

Reverse cutting – 3Reverse cutting – 3rdrd edge along outer edge along outer aspect of needle to minimize pulling the aspect of needle to minimize pulling the needle throughneedle through

Needle driver choiceNeedle driver choice

Jaws of needle driver should approximate 30-Jaws of needle driver should approximate 30-35% of the length of the needle35% of the length of the needle

A= just rightA= just right B= too bigB= too big C= too smallC= too small

Suture choicesSuture choices

Ideal suture: absorbable, minimal Ideal suture: absorbable, minimal reactivity, minimal “memory,” and reactivity, minimal “memory,” and ease of useease of use

Absorbable - Fast gut, chromic gut, Absorbable - Fast gut, chromic gut, cat gut, Vicryl, Monocryl, PDScat gut, Vicryl, Monocryl, PDS

Non-absorbable – Nylon, ProleneNon-absorbable – Nylon, Prolene

Sutures and strengthsSutures and strengths

Suture Type Tensile Strength

(50%)

Absorption Rate

Chromic Gut Natural 5 days Complete by day 90

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

Costs of suture (hospital Costs of suture (hospital wholesale)wholesale)

Black nylon (5-0) = $3.22Black nylon (5-0) = $3.22 Blue Prolene (5-0) = $4.28Blue Prolene (5-0) = $4.28 Fast gut (6-0) = $4.78Fast gut (6-0) = $4.78 Dermabond capsule = $25Dermabond capsule = $25

Deep suture techniqueDeep 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 Matching uneven skin edgesedges

Use layer of skin to match levels (dermis to dermis)

This will help ensure a even edge closure

Importance of eversionImportance of eversion

Wound will contract over time

Need to evert wound edges to prevent depressions and widening of scar

For proper eversionFor proper eversion

Penetrate skin and tissue at 90 Penetrate skin and tissue at 90 degree anglesdegree angles

Form a “box” with the sutureForm a “box” with the suture

InjectionInjection

Topical anesthetic may helpTopical anesthetic may help For kids, give a dose of benadryl with For kids, give a dose of benadryl with

topicaltopical Use 1% lido with epi (hemostasis) and Use 1% lido with epi (hemostasis) and

bicarb in a 1cc bicarb to 9cc of lidocaine bicarb in a 1cc bicarb to 9cc of lidocaine + epi+ epi

For abscesses use 2% lido+epi (8cc) and For abscesses use 2% lido+epi (8cc) and bicarb (2cc)bicarb (2cc)

Use 30g needle and inject SLOWLYUse 30g needle and inject SLOWLY Try to enter the laceration in areas that Try to enter the laceration in areas that

are already anesthetizedare already anesthetized

ForeheadForehead

Simple interrupted sutures should only be Simple interrupted sutures should only be left in place for 3-4 days to prevent track left in place for 3-4 days to prevent track marksmarks

Usually this is not enough time for Usually this is not enough time for adequate healing and wound strengthadequate healing and wound strength

Alternatively, use a sub-cuticular running Alternatively, use a sub-cuticular running suture with prolene or nylon and use suture with prolene or nylon and use steri-strips so you can leave sutures in steri-strips so you can leave sutures in longerlonger

Very important to get good deep closureVery important to get good deep closure

Example of Sub-Example of Sub-CuticularCuticular

EyelidEyelid

Look for fat in the woundLook for fat in the wound This is a sign that the orbital septum This is a sign that the orbital septum

(continuous with the periosteum) has (continuous with the periosteum) has been violated - call occuloplasticsbeen violated - call occuloplastics

Suture skin only with small bites, do Suture skin only with small bites, do not need to reapproximate orbicularis not need to reapproximate orbicularis oculi - this may lead to scar contracture oculi - this may lead to scar contracture and inability to close eyeand inability to close eye

Example of a bad Example of a bad outcomeoutcome

Example of a bad Example of a bad outcomeoutcome

LipLip

Extremely important to realign the Extremely important to realign the vermillion vermillion

A 1mm step-off in the closure will be A 1mm step-off in the closure will be noticeable noticeable

Reaproximate the orbicularis oris Reaproximate the orbicularis oris musle to relieve tension in this musle to relieve tension in this active areaactive area

Lip ClosureLip Closure

Scars change over timeScars change over time

Regional BlocksRegional Blocks Work well in areas such as the lip whose Work well in areas such as the lip whose

anatomy can be altered with local injectionsanatomy can be altered with local injections To approximate the lip, align the red borderTo approximate the lip, align the red border Lido with epi may blanch the skin so re-Lido with epi may blanch the skin so re-

aligning the lip can be difficultaligning the lip can be difficult Infra-orbital block for upper lip, mental nerveInfra-orbital block for upper lip, mental nerve 3-4-5 rule, use the 3rd tooth from the midline 3-4-5 rule, use the 3rd tooth from the midline

for upper, in between 4 and 5 for lowerfor upper, in between 4 and 5 for lower ““How to block and tackle the face” - ZideHow to block and tackle the face” - Zide

EarEar

Skin is adherent to underlying Skin is adherent to underlying cartilagecartilage

Difficult to suture cartilage together Difficult to suture cartilage together and the overlap may lead to a and the overlap may lead to a deformitydeformity

Just need to suture the overlying Just need to suture the overlying skin, the cartilage does not need to skin, the cartilage does not need to be suturedbe sutured

Timing of repairTiming of repair

Berk et al looked at 372 patients, Berk et al looked at 372 patients, 204 of whom had followed up 7 days 204 of whom had followed up 7 days later in 2004later in 2004

They concluded that wounds that They concluded that wounds that were closed within 24 hours had no were closed within 24 hours had no increased risk of infection if it is a increased risk of infection if it is a clean lacerationclean laceration

Visual analog scale (0-Visual analog scale (0-100mm)100mm)

Quinn et al 1995Quinn et al 1995

Cosmetic appearance Cosmetic appearance scorescore

From Wound Registry: From Wound Registry: Hollander Wound Hollander Wound Evaluation ScaleEvaluation Scale

Assessing outcomes in Assessing outcomes in facial plastic surgery facial plastic surgery

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

plastic surgeryplastic surgery Other than the Quinn VAS and Other than the Quinn VAS and

Hollender Wound Evaluation Score, Hollender Wound Evaluation Score, there are 4 other scalesthere are 4 other scales

Of note the Quinn and Hollander Of note the Quinn and Hollander scales are reliable (good inter and scales are reliable (good inter and intra rater reliability), and validated intra rater reliability), and validated (use of lit reviews, expert opinions)(use of lit reviews, expert opinions)

Ethibond vs Ethibond vs Monofilament (Quinn Monofilament (Quinn

1998)1998) Paid for by manufacturers of EthibondPaid for by manufacturers of Ethibond 136 randomized patients to pediatric ER to 136 randomized patients to pediatric ER to

either 5-0/6-0 closure or ethibondeither 5-0/6-0 closure or ethibond Reassess wound at 10days, 3mos, 1 yearReassess wound at 10days, 3mos, 1 year Use of Hollander wound score and VAS by Use of Hollander wound score and VAS by

2 research RNs on follow-up and a 2 research RNs on follow-up and a validated wound VAS by a cosmetic plastic validated wound VAS by a cosmetic plastic surgeon (based on photographs)surgeon (based on photographs)

Results of Ethibond Results of Ethibond closureclosure

No significant difference in optimum No significant difference in optimum wound scores (73% for Ethibond, 68% wound scores (73% for Ethibond, 68% suture) or VASsuture) or VAS

No correlation between 10 days and 3 mos, No correlation between 10 days and 3 mos, but excellent correlation between 3 mos but excellent correlation between 3 mos and 1 year in appearance of woundand 1 year in appearance of wound

Essentially all future studies use 3 mos f/u Essentially all future studies use 3 mos f/u in their methods based on the results of in their methods based on the results of this studythis study

Consideration: application of Ethibond Consideration: application of Ethibond cannot be within wound, cannot use on lipscannot be within wound, cannot use on lips

Cochrane review of Cochrane review of tissue adhesives (2001, tissue adhesives (2001,

updated 2007)updated 2007) Used VAS and cosmetic wound score to Used VAS and cosmetic wound score to examine a total of 889 lacerations, with 364 examine a total of 889 lacerations, with 364 having follow-up 9-12 mos out from 9 studieshaving follow-up 9-12 mos out from 9 studies

No difference in wound scores notedNo difference in wound scores noted Less pain involved with application and Less pain involved with application and

absence of suture removalabsence of suture removal Time to apply adhesive was ~5 minutes Time to apply adhesive was ~5 minutes

shorter than suturingshorter than suturing There was a slightly higher risk of There was a slightly higher risk of

dehicience with adhesive (6.6% vs 2.2%) dehicience with adhesive (6.6% vs 2.2%) which was stat sigwhich was stat sig

Fast gut vs Nylon closure Fast gut vs Nylon closure (Luck 2008)(Luck 2008)

Pediatric ED patients comparing Pediatric ED patients comparing suture choicessuture choices

Wounds 1-5cm without irreg borders, Wounds 1-5cm without irreg borders, 1-2 layer closure1-2 layer closure

Follow-up at 5-7days and 3 monthsFollow-up at 5-7days and 3 months Use validated VAS for cosmesis by 3 Use validated VAS for cosmesis by 3

blinded observers (peds ED blinded observers (peds ED attendings) based on photographs, attendings) based on photographs, and parental VASand parental VAS

90 patients total randomized with 90 patients total randomized with 60% f/u rate at 3 months60% f/u rate at 3 months

Luck et al. resultsLuck et al. results

Mean VAS was 92mm (FG) and 93mm (N)Mean VAS was 92mm (FG) and 93mm (N) Parental VAS was 86mm (FG) and 91mm (N)Parental VAS was 86mm (FG) and 91mm (N) Parental survey found fast gut to be more Parental survey found fast gut to be more

convenient (91% vs 75%) and were more convenient (91% vs 75%) and were more likely to request it in the future (96% vs likely to request it in the future (96% vs 79%)79%)

3 parents (13%) perceived complications in 3 parents (13%) perceived complications in fast gut group compared to nylon (1 large fast gut group compared to nylon (1 large scar after dehiscience, 2 with premature scar after dehiscience, 2 with premature unraveling)unraveling)

LimitationsLimitations

70% of fast gut patients had at least 70% of fast gut patients had at least one suture that needed to be removed one suture that needed to be removed at 5-7d follow-upat 5-7d follow-up

Photographs do not show 3D anatomyPhotographs do not show 3D anatomy Only 60% follow-up rateOnly 60% follow-up rate Note that the parental VAS was 5mm Note that the parental VAS was 5mm

higher for the nylon group - this was higher for the nylon group - this was statistically insignificant based on the statistically insignificant based on the study, but is it clinically insignificant?study, but is it clinically insignificant?

Comparison of nylon, Comparison of nylon, fast gut and Dermabond fast gut and Dermabond

(Holger 2004)(Holger 2004) 146 patients randomized to each 146 patients randomized to each

groupgroup 9-12 mos of follow-up, ~60% follow-9-12 mos of follow-up, ~60% follow-

up rateup rate VAS used to assess woundVAS used to assess wound No significant differences between 3 No significant differences between 3

groups in wound outcomegroups in wound outcome

Metanalysis of Metanalysis of absorbable vs non-absorbable vs non-

absorbable suture (Al-absorbable suture (Al-Abdullah 2007)Abdullah 2007)

2 studies from Holger (2004) and 2 studies from Holger (2004) and Karounis (2004) showed no Karounis (2004) showed no difference in long term cosmetic difference in long term cosmetic outcome scores when results were outcome scores when results were pooled togetherpooled together

3 studies pooled showed no 3 studies pooled showed no difference in hypertrophic scarringdifference in hypertrophic scarring

7 studies pooled together revealed 7 studies pooled together revealed no difference in infection rateno difference in infection rate

Choice of closure methodChoice of closure method

Whatever method you choose, make sure Whatever method you choose, make sure you perform it correctly (dermabond, steri you perform it correctly (dermabond, steri strips)strips)

Fast gut may have an unpredictable Fast gut may have an unpredictable absorption rate, if it stays in too long, track absorption rate, if it stays in too long, track marks may form as well as prolonged marks may form as well as prolonged erythemaerythema

Dermabond cannot get into the woundDermabond cannot get into the wound 6-0 Prolene is a good choice, gives control 6-0 Prolene is a good choice, gives control

over wound closure and suture removalover wound closure and suture removal

Choice of Choice of irrigant/cleanserirrigant/cleanser

Normal saline, water, Shur-Clens shown to Normal saline, water, Shur-Clens shown to be least toxic to fibroblasts and be least toxic to fibroblasts and keratinocytes in vitro (Wilson et al 2005)keratinocytes in vitro (Wilson et al 2005)

Povidine-iodine and hydrogen peroxide Povidine-iodine and hydrogen peroxide among the most toxic, but iodine not shown among the most toxic, but iodine not shown to prevent infection (Gravett et al 1987)to prevent infection (Gravett et al 1987)

Since commercial detergents and normal Since commercial detergents and normal saline have been shown to be equally saline have been shown to be equally effective in preventing infection, normal effective in preventing infection, normal saline is adequate for cleaning of the woundsaline is adequate for cleaning of the wound

Role of antimicrobialsRole of antimicrobials

In animal models 10In animal models 1055 colonies/g tissue colonies/g tissue Typical ED laceration (clean) has 10Typical ED laceration (clean) has 1022/g /g

tissuetissue Systemic antimicrobials for Systemic antimicrobials for

complicated wounds (next slide)complicated wounds (next slide) Dire et al found a decreased infection Dire et al found a decreased infection

rate with the application of triple abx rate with the application of triple abx ointment (4.5%) vs bacitracin (5.5%) vs ointment (4.5%) vs bacitracin (5.5%) vs silvadene (12%) vs petrolatum (17%)silvadene (12%) vs petrolatum (17%)

Assess risk factorsAssess risk factors Extremes of ageExtremes of age DM, renal diseaseDM, renal disease Immunocompromised stateImmunocompromised state MalnutritionMalnutrition ObesityObesity Bite injuries (Amox/clav x 3-5 days to cover Eikenella, Bite injuries (Amox/clav x 3-5 days to cover Eikenella,

Pasturella)Pasturella) Crush injuriesCrush injuries Grossly contaminated woundsGrossly contaminated wounds Laceration involving muscleLaceration involving muscle Open fracturesOpen fractures Intraoral lacerations (5 days of PCN adequate)Intraoral lacerations (5 days of PCN adequate)

Appropriate use of Appropriate use of antibioticsantibiotics

Nakamura and Daya did a review of Nakamura and Daya did a review of clinical trials involving the use of clinical trials involving the use of anitbioticsanitbiotics

They concluded that antimicrobials They concluded that antimicrobials should be used in open fractures, intra-should be used in open fractures, intra-oral wounds and bitesoral wounds and bites

In addition, since there are no In addition, since there are no randomized trials for assessing risk randomized trials for assessing risk factors, it is accepted that it would be factors, it is accepted that it would be appropriate to use antimicrobials for the appropriate to use antimicrobials for the previously mentioned risk factorspreviously mentioned risk factors

Pearls and techniquesPearls and techniques

Zen-like - need to visualize and practice Zen-like - need to visualize and practice entering and exiting the skin at 90 entering and exiting the skin at 90 degree anglesdegree angles

Formation of a “square” with the sutureFormation of a “square” with the suture Wound eversion is necessaryWound eversion is necessary Have the proper equipment - need fine Have the proper equipment - need fine

instruments with delicate lacerations, instruments with delicate lacerations, small childrensmall children

Most of all, be patient and achieve a Most of all, be patient and achieve a correct closure, spending an extra 10 correct closure, spending an extra 10 minutes will make for a better outcomeminutes will make for a better outcome

PracticePractice

Carry a needle driver in your pocketCarry a needle driver in your pocket Practice opening and closing without Practice opening and closing without

using your fingersusing your fingers This will make it more efficient and This will make it more efficient and

help prevent inadvertently pulling help prevent inadvertently pulling the needle outthe needle out

ConclusionsConclusions Proper suture placement and eversion of wound Proper suture placement and eversion of wound

is essential for optimum scar outcomeis essential for optimum scar outcome Antibiotics have not been shown to be effective Antibiotics have not been shown to be effective

in non-contaminated woundsin non-contaminated wounds Closure with fast gut appears to have similar Closure with fast gut appears to have similar

wound outcomes when compared with non-wound outcomes when compared with non-absorable sutures at 1 yearabsorable sutures at 1 year

Dermabond has similar wound outcomes, but Dermabond has similar wound outcomes, but requires special attention when applyingrequires special attention when applying

Cleaning of the wound with normal saline is Cleaning of the wound with normal saline is adequate to prevent infectionadequate to prevent infection