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SRPS Volume 10, Number 7, Part 1 Simmons 224 recommend immediate Z-plasty for the repair of curved lacerations. Borges 225 disagrees, arguing that (1) most lacerations go beyond the skin and therefore it is difficult to decide what may be viable tissue; (2) patients may not like a zigzag scar if they have not had an opportunity to compare it with the scar produced by linear closure; and (3) the risk of infection or hematoma after a traumatic laceration is greater than after elective scar revision. WOUND PREPARATION Local anesthesia in the face is induced with a dilute anesthetic solution injected at key points over the nerve to the wounded area using a 25-gauge or smaller needle. 226 The syringe should be small and the pressure on the plunger no more than needed for a slow but steady flow. Traumatic wounds must be rid of all devitalized tissue and foreign material. Only minimal debridement is recommended in the head and neck because of the ample blood supply of the area and the mutilating consequences of overly aggressive debridement. After sharp debridement the wound should be thoroughly cleansed with normal saline or with povidone iodine for antisepsis. If primary closure is contemplated, the wound edges are trimmed to make them perpendicular to the bed. The exception is in hair-bearing areas, where they should parallel the hair shafts. Every effort should be made to preserve key anatomic landmarks—the vermilion border, eyelid, eyebrow, nostril, and auricular helix—by precisely aligning the wound edges during closure. SURGICAL TECHNIQUES Meticulous surgical technique is required to obtain an inconspicuous scar. Critical elements include the obliteration of dead space, layered tissue closure, and eversion of skin margins. Deep dermal sutures align the skin edges and help decrease tension on the skin closure. Everting skin sutures are placed by encompassing a larger amount of deep dermis than epidermis in the closure (Fig 8). They are tied under the minimal tension necessary to oppose the skin margins. Nonabsorbable synthetic monofilament sutures (nylon, Prolene, Novafil) are minimally reactive and Fig 8. Technique of layered wound closure everting the skin edges. (Modified from Spicer TE: Techniques of facial lesion excision and closure. J Dermatol Surg Oncol 8:551, 1982.) thus preferred for skin closure when cosmesis is essential. Absorbable synthetic braided sutures (Vicryl, Dexon) are ideal for deep dermal closure, acting as transient but necessary skin splints. Absorbable natural sutures (catgut, chromic catgut) induce inflammation as they are degraded by phagocytosis. They are useful where suture removal is difficult and cosmesis is not critical (eg, in the oral cavity, nasal cavity, and non-facial wounds in children). 227–233 The simple interrupted suture is the most common skin closure method. Horizontal mattress sutures facilitate tissue eversion with the use of 50% fewer sutures, whereas vertical mattress sutures are useful in wounds under significant tension. Running sutures speed the closure of uncomplicated, linear wounds. Unlike interrupted sutures, they do not allow the differential adjustment of suture tension that is required in complex wounds. Subcuticular running sutures yield cosmetically pleasing results in wounds under mild tension. 234–238 Tissue bonding with cyanoacrylate adhesives is becoming an increasingly popular method of wound closure in Canada and Europe. Mizrahi 239 reported the use of cyanoacrylate glue in more than 1500 simple pediatric lacerations, with a 2.4% complication rate. Applebaum 240 cites the advantages of rapid 19
SRPS Volume 10, Number 7, Part 1 and painless application at an average materials cost of $2.86 per patient. These products are not currently in mainstream use in the United States. A skin-stretching device has been developed recently by Hirschowitz. 241 Marketed in the U.S. as the Sure-Closure device, it uses the skin property of mechanical creep 242 to achieve primary closure of large wounds that would otherwise require grafts or flaps. Promising results have been demonstrated in the closure of fasciotomies, amputation stumps, and other wounds of the trunk and lower extremity. For difficult wound closure in the acute setting, Abramson and colleagues 243 describe a simple technique of intraoperative skin stretching with 18-gauge spinal needles placed parallel to the wound margins aided by a rib approximator. Markovchick 244 lists his recommendations for suture repair of soft-tissue injuries in an emergency department, including preferred anesthetic, suture material, surgical technique, wound dressing, and timing of suture removal (Table 6). POSTOPERATIVE CARE Immediately after completing the closure, antibiotic ointment is applied to the suture line without further occlusive covering. Most surgeons recommend that the wound be kept dry for the first 2 days, after which gentle washing is encouraged. Borges, 245 however, questions the wisdom of keeping a wound dry, and instead recommends immediate application of a light dressing to prevent scab formation and to maintain a moist wound environment. In support of this practice Noe and Keller 246 report no suture disruption, wound dehiscence, or infection in 100 patients who washed their wounds with soap and water twice a day beginning the morning after surgery. In the head and neck surgical sutures are removed in 3–5 days, while elsewhere they are left in place for 7–10 days. To remove it, the suture is cut close to the skin edge and its free end is pulled across the wound, not away from it. Crikelair 216 notes that the two most common causes of unsightly suture marks are delayed removal beyond 10 days and excessive tension of the closure. The size of the individual “bites”, type of needle, and suture material are not significant to the esthetic outcome. The eventual width of a scar is proportional to the force required for closure. Wray 247 suggests prolonged support of the wound edges with tape to effectively minimize scar width. Nonwoven microporous tape is superior in terms of breaking strength, extensibility, adhesive capacity, porosity, and resistance to infection. 248 For a wound to heal as a good scar without hypertrophy, adhesion, or contracture, the processes of scar formation and remodeling must follow a precisely chartered, finely tuned course. Parsons 249 makes the following points regarding scar prognosis: • A scar usually looks its worst between 2 weeks and 2 months after injury. Scar revision should await scar maturation, which can take from 4 to 24 months depending on the type of injury as well as on the patient’s age and genetic background. The only exception to this rule is when there is loss of function—eg, scars crossing concave surfaces or the flexor aspects of joints, which tend to contract into tethering bands that prevent full extension. • A scar becomes noticeable if it interrupts the homogeneous flow of tissue planes through color, contour, or texture differences—eg, hyperpigmented, depressed, or shiny scars. • The final appearance of a scar depends more on the type of injury than on the method of suture. Bruising and infection, traumatic tattooing, improper orientation of a laceration, tension, and beveling of edges on closure predict a poor outcome. • Differences among suture materials are of negligible importance to the result, but other technical factors of suture placement and removal do affect the final scar. • Immobilization is as important in soft-tissue healing as it is in bone fractures. Tension across the wound causes minute wound disruptions and subsequent excessive scarring. Adhesive strips across the suture line should be kept in place for 1 or 2 weeks after the sutures are removed. 20
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