Essentials of Skin Laceration Repair RANDALL T.

FORSCH, MD, MPH, Department of Family Medicine, University of Michiga n Medical School, Ann Arbor, Michigan Am Fam Physician. 2008 Oct 15;78(8):945-951. Patient information: See related handout on taking care of healing cuts, writt en by the author of this article. Skin laceration repair is an important skill in family medicine. Sutures, tissue adhesives, staples, and skin-closure tapes are options in the outpatient settin g. Physicians should be familiar with various suturing techniques, including sim ple, running, and half-buried mattress (corner) sutures. Although suturing is th e preferred method for laceration repair, tissue adhesives are similar in patien t satisfaction, infection rates, and scarring risk in low skin-tension areas and may be more cost-effective. The tissue adhesive hair apposition technique also is effective in repairing scalp lacerations. The sting of local anesthesia injec tions can be lessened by using smaller gauge needles, administering the injectio n slowly, and warming or buffering the solution. Studies have shown that tap wat er is safe to use for irrigation, that white petrolatum ointment is as effective as antibiotic ointment in postprocedure care, and that wetting the wound as ear ly as 12 hours after repair does not increase the risk of infection. Patient edu cation and appropriate procedural coding are important after the repair. Although the emergency department routinely treats acute trauma, family physicia ns should be prepared to manage acute lacerations. This requires knowledge of wo und evaluation, preparation, and appropriate repair techniques; when to refer fo r surgical treatment; and how to provide follow-up care. SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation Evidence rating References Saline or tap water may be used for wound irrigation, whereas povidone-iodine, d etergents, and hydrogen peroxide should be avoided. B 3,5 The sting from a local anesthetic injection can be decreased by slow administrat ion and buffering the solution. B 8 Suturing is the preferred technique for skin laceration repair. C 5 Tissue adhesives are comparable with sutures in cosmetic results, dehiscence rat es, and infection risk.

arteries. B = inconsistent or limi ted-quality patient-oriented evidence. the extent and location of the wound. go to http://www. exper . Lacerat ions that expose underlying tissue or continue bleeding should be repaired.1 The goals of laceration repair are to achieve hemostasis. good-quality patient-oriented evidence. Table 1 Guidelines for Seeking Surgical Consultation for Laceration Repair Deep wounds of the hand or foot Full-thickness lacerations of the eyelid.xml. simple hand lacerations that are less than 2 cm long) may heal well with conservative management. usual practice. nerves. refe rral decisions are ultimately based on the physician's level of expertise. tape. A patient history should be obtained. Baseline neurovascular and functi onal status of the involved body part should be evaluated before repair. blood vessels. and achieve optimal cosmetic results with m inimal scarring. or antibiotics). bones. or joints Penetrating wounds of unknown depth Severe crush injuries Severely contaminated wounds requiring drainage Wounds leading to a strong concern about cosmetic outcome note: Surgical consultation should be considered for these wounds. or ear Lacerations involving nerves. Definitive laceration management depends on the time since inju ry. and the skill of the physician.g.aafp. B 25 A = consistent. Guidelines for seeking surgical consultation fo r laceration repair are presented in Table 1. tendons. A careful exploration of the laceration should be performed to determine severity and whether it involves mu scle. tetanus immunization history. allergies to latex. or case series. a laceration should be evaluated and the bleeding controlled using direct pressure. resto re function to the involved tissues. includi ng mechanism and time of injury and personal health information (e. lip. expert opinion.. human imm unodeficiency virus and diabetes status. local anesthesia.A 14–17 Applying white petrolatum to a sterile wound to promote wound healing is as effe ctive as applying an antibiotic ointment. avoid infection. or bone. disease-oriented evidence.g. available laceration repair materials. Wound Evaluation and Preparation Immediately upon presentation.. For information about the SORT evidence rating system. however. C = alth ough some less severe wounds (e.

9 Laceration Repair Techniques Laceration repair options in the outpatient setting include sutures.5 mg per mL) is appropriate for small wounds. Areas with low skin tension. which is used to decrease w ound bleeding through vasoconstriction.ience. Local hair should be clipped. Alternatively. especially in children and in patients w ho cannot tolerate injections. Warmed irrigation solution is more comfortable for the patient. including how to choose the correct closure method and ho w to perform closures to obtain optimal results. In persons who are allergic to amide forms of local anesthetics. a nd wound contamination factor into the decision about when to repair the lacerat ion.4 Povidone-iodin e solution. and earlobes. Copious wound irrigation with normal saline or tap water 3 washes away foreign m atter and dilutes the bacterial concentration to decrease post-repair infection. staples. a nd up to 3 mg per kg with epinephrine). The cream is applied to intact skin and covered w ith an occlusive dressing one to four hours before the repair procedure. . if needed. and detergents should not be used because their t oxicity to fibro-blasts impedes healing. Epinephrine. Anatomic location of the wound.8 warming the anesthetic solution. Physicians should have a working knowledg e of these techniques. Large wo unds occurring on limbs may require a regional block to prevent toxic doses of t he local anesthetic (lidocaine 3 to 5 mg per kg without epinephrine. injecting slowly. nerves. Both method s take into account potential wound infection and offer the potential for an acc eptable cosmetic result. Local anesthesia with lidocaine 1% (Xylocaine. and skin-closure tape. such as the face an d scalp. 50 mg per mL solution. such as lidocaine/pri locaine cream (EMLA). should be avoided when wounds involve an atomic areas with end 60-mL syringe and 18-gauge needle or angiocatheter. bupivacaine 1 to 2 mg per kg without epinephrine. can be closed successfully even later in healthy patients. clipping of the eyebrows should be avoided because o f unpredictable regrowth and to prevent uneven reapproximation. and surgica l referral should be considered. Areas of high skin tension. If infection occurs. such as over joints. and joints should be removed with caution. should be repaired with sutures or staples. The optimal time interval from injury to laceration repair is not clearly define d. Regardless of location. tissue adhe sives. such as the digits.5 The wound should be irrigated copiousl y with a 30. Foreign bodies ne ar blood vessels. mechanism of injury. a maximum application of one hour is suggested to avoid the theoretic risk of acquired methemoglobinemia. which can cl eanse at 5 to 8 lb per square inch of pressure without damaging the tissue. or buff ering the solution with sodium bicarbonate 8. not shaved. the wound may be packed for three to five days followed by delayed primary closure. to pr event wound contamination7. if no wound infection develops. nose.2 Clean lacerations involving well-vascularized tissue. health of the patient. also may be used. Noncontaminated wounds have been successfully closed up to 12 hours post-in jury. In newb orns. hydrogen peroxide.6 Any visible foreign matter should be removed with forceps. single interrupted sutures that are sufficient to close the wound. The sting of local anesthetic injections may be reduced by using a smaller need le (25 to 30 gauge). and devitalized tissue r emoved with sharp debridement to reduce the risk of infection. these older laceration s can be repaired with loose. although ris k of infection must be minimized. 2. or areas with a thick dermis.4% (1 mL of sodium bicarbonate per 10 mL of local anesthetic). and up to 7 mg per kg with epinephrine. such as on the back. and comfort with managing the laceration. Topical anesthetics. the wound should be allowed to heal by secondary intention. Wounds requiring extensive debr idement or multiple-layer closure are best repaired with a suture.25 % (Marcaine. 10 mg per mL) or bupivacaine 0. penis. intradermal diphenhydramine 1% (created by adding 1 mL of diphenhyd ramine. to 4 mL of sterile saline) may be substituted bec ause it has local anesthetic effects.

monofilament nonabsorbable sutures (e. The wound dehiscence rate. may be effectively repaired with tis sue adhesives. Figure 1. Figure 2. After the wound is prepped. and poliglecaprone 25 (Monocryl). they all usually absorb within four to eight weeks. (A) Single interrupted closure. Aseptic techniques must be used. single interrupted sutures. In general.13 Traditionally. such as polyglactin 910 (Vicryl). Blue-colored sutures may be beneficial for scalp lacerations in appropriate p opulations to differentiate the suture from the hair. such as a split tongue. genitalia) with significant hemorrhage or depth that involve muscular layers. single interru pted sutures (Figure 1A). or that may have significant functional or cosmetic outcomes. . (B) Run ning (“baseball”) closure. Most other wounds can be closed effectively with nonab sorbable. polyglycolic acid (Dexon).such as on the face.g. SUTURING Suturing is the preferred technique for laceration repair. shin. Optimal cosmetic results can be achieved by using the finest suture possible. Proper technique of a single interrupted stitch for wound eversion and closure. including sterile f ields and gloves and universal body fluid precautions. the suture begins in the middle of the wound. which is accomplished by twisting the wrist. The needle should pierce the skin at a 90-degree angle with the trailing suture following the curve of the needle.12 Silk sutures are no longer used t o close the skin because of their poor tensile strength and high tissue reactivi ty. A multiple-layer closure c an improve cosmetic results by bringing opposing wound edges closer together and decreasing wound tension. multiple-layer wounds should be repaired using absorbable.10 Laceration repair techniques follow common principles. multiple-layer lacerations. tongue. Nylon. regardless of laceration location or closure method. This technique will cause eversion of the wound edges (Figure 2). are used to close deep. and absorbable sutures are more cost-effect ive because there is no need for removal. Mucosal lacerations (e. (C) Subcuticular running closure. which i s accomplished by twisting the wrist. 4–0 or 5–0 on the extremities and scalp. Suture techniques for laceration repair. cosmetic results.5 Absorbable sutures. Although thes e sutures absorb at varying rates. de pending on skin thickness and wound tension. with the remaining stitches placed symmetrically until the wound is closed. should be repaired. The needle should pierce the skin at a 90degree angle with the trailing suture following the curve of the needle. especially in children. and infection risk of absorbable sutures appear to be comparab le to that of nonabsorbable sutures. the appropriate suturing technique must be selected. compensating for the eventual retraction of the scar dur ing healing... a 3–0 or 4–0 suture is appr opriate on the trunk.11. and 5–0 or 6–0 on the fac e. Deep wounds require a mul tiple-layer closure with an absorbable suture and possibly a temporary drain to reduce the risk of hematoma or subsequent infections. polypropylene [Prolene]) must eventually be removed. mouth. The role of absorbable sutures in the closure of ar eas with low skin tension continues to be evaluated. Deep.g. and dorsal hand. An absorbable 3–0 or 4–0 suture should be used.

such as 2-octylcyanoacrylate (Dermabond).. The vertical mattress technique (Figure 4) is best for everting wound edges in areas that tend to invert.20 Figure 6 shows the proper technique. and should not be used for contaminated. such as over joints. They should also be avoided on mucosal surfaces an d areas that maintain moisture. t issue adhesives can be applied more quickly. The en ds of this suture do not need to be tied. Figure 5.15 Effective application of tissue adhesives is a quickly learned skill compared wi th suturing. theoretically decreasing tip necrosis. such as the posterior nec k or concave skin surfaces. Lacerations over joints may be splinted temporarily for comfort and to promote healing.18 Although tissue adhesives have a higher direct cost per uni t than sutures. but they may be secured with slip knot s or tape. are comparable with sutures in cosmetic results. Note that the suture remains subcuticular in the flap to avoid cutting off the blood supply. co mplex. using caution around the eyes.15–17 However.19 Tissue adhesives' low tensile strength makes them inappropriate fo r high-tension areas. Vertical mattress suture technique. unless the area is immobilized. such as the groin or axillae. therefore. require no anesthesia. and eliminat e the need for follow-up because they slough off spontaneously within five to 10 days.The horizontal mattress technique (Figure 3) may be the best option for closing gaping or high-tension wounds or wounds on fragile skin because it spreads the t ension along the wound edge. those who are immunosuppressed or have diabetes). The wound edges are approximated using gloved fingers. They form a protective barrier to promote wound healing and may have anti microbial effects. and infection risk.5 minutes. whereas a s ubcuticular running suture (Figure 1C) is ideal for closing small lacerations in low skin-tension areas where cosmesis is important. they are more cost-effective because of quick application and no follow-up. TISSUE ADHESIVES Tissue adhesives. After the repair is complete. Figure 4. patie nts must be instructed to avoid using them on the repaired wound. such as on the face. Half-buried mattress (corner) suture for laceration repair. the wound should be cleaned with sterile saline an d dressed appropriately. A runni ng (“baseball”) suture (Figure 1B) is used for long.g. called the half-buried mattress (corn er) suture (Figure 5). or jagged lacerations.14 A variation. After irrigation. . Three to four layers are applied with 30 seconds b etween applications. then the adhesive is applied in a thin layer over the wound with a 5-mm overlap on each side. Tissue adhesives are contraindicated in patients at higher risk of poor healing (e. the wound should be dried with sterile gauze and placed in a horizontal position to preven t runoff. Antibi otic and white petrolatum ointments can remove tissue adhesive. dehiscence rates. is ideal for closure of a triangular edge because it does not compromise the blood supply. Full tensile strength is achieved after 2. Horizontal mattress suture technique. low-tension wounds. They may be ideal for simple lacerations under a cast or splint. Figure 3.

22 Figure 7. Automatic staplers. Hair apposition suture technique. Traditionally. can cause a local inflammatory reaction. OTHER TECHNIQUES Stainless steel or absorbable staples and skin-closure strips (e. are recommended for closing thick skin on the extrem ities. leading to faster wound healing and less necrosis. Stainless s teel staples should not be used for scalp wounds if computed tomography or magne tic resonance imaging of the head is anticipated. The t echnique can be performed by nonphysicians and causes less scarring. skin-closure strips have a r ole in the repair of pretibial lacerations.. The hair apposition technique (Figure 7) may be used for closing scalp wounds. such as tincture of benzoin . The quick application of stapl es makes them a good choice for patients who have multiple traumas or who are in toxicated. on e study showed that leaving the wound uncovered and wetting it after 12 hours di d not increase infection rates. adhesive adjuncts. Table 2 Timing of Suture or Staple Removal Wound location Timing of removal (days) Face Three to five Scalp Seven to 10 . their lack of tensile strength ca n lead to wound dehiscence. and feet. has fewer c omplications.25.Figure 6. but not on the face. hands. patients have been told to keep the wound clean and dry using a p rotective dressing for at least 24 hours after the repair procedure. trunk. Opposing strands of hair are brought to gether with a simple twist and are secured with a drop of tissue adhesive. Antibiotic and white petrolatum ointments are equally effective. No te the wound edge approximation and thin layer of tissue adhesive. neck. and scalp. However. simple lacerations in l ow-tension areas with well-approximated edges. Although skin-closure strips can be effective for small.26 The timing of suture or staple removal varies with wound locati on (Table 2).23 Follow-up Care and Billing Follow-up for repaired lacerations is similar regardless of the technique used. Also. Steri-strip s) are also commonly used to repair lacerations. However. T he technique is best for non-actively bleeding wounds that are less than 10 cm l ong when scalp hair is longer than 3 cm.24 To prevent infection and promote healing. Proper technique for the application of tissue adhesive in laceration repair. an a ntibiotic or white petrolatum ointment can be applied daily to wounds not repair ed with tissue adhesives.21 and is more cost-effective than a scalp suture.g. usually use d in surgical wound repair.

patients should receive instructions on signs of infection and when follow-up should be perform ed (see accompanying patient education handout).Arms Seven to 10 Trunk 10 to 14 Legs 10 to 14 Hands or feet 10 to 14 Palms or soles 14 to 21 Tetanus immunization status should be assessed in patients with lacerations.27 After laceration repair. Tab le 3 summarizes the Centers for Disease Control and Prevention guidelines for te tanus pro-phylaxis in these patients. Table 3 Guidelines for Tetanus Prophylaxis in Adults Receiving Routine Wound Management History of absorbed tetanus toxoid Clean. minor wound All other wounds * Tdap or Td TIG Tdap or Td TIG Unknown or less than three doses Yes No Yes Yes More than three doses No† No .

Simple laceration repair includes superficial. Table 4 includes codes for common procedures. Billing for laceration repair depends on the size and location of the wound and on the complexity of the repair. reduced tetanus toxo ids. MMWR Recomm Rep. and other wound preparation (e. Td = tetanus-diphtheria toxoids vaccine. Cortese MM. avulsions. et al. wounds contaminated with dirt. if it has been five years or more since the last dose of tetanus toxoid–contain ing vaccine. or sal iva. TIG = tetanus immune globulin. limbs 2. *— Such as. and complex laceration repair includes multiple-layer clo sures. staples. soil. reduced diphtheria t oxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP. Adhesive strip s alone should be categorized using the appropriate evaluation and management co de. trunk. Broder KR. but not limited to.6 to 7. 2006. feces.g. puncture wound. ears. bu rns or frostbite. but can be billed if the repair was performed elsewhere. such as i n the emergency department. and tissue adhesives are all billable methods. for use of Tda p among health-care personnel. if it has been 10 years or more since the last dose of tetanus toxoid–containi ng vaccine.No‡ No note: Guidelines apply to adults 19 to 64 years of age. ‡—Yes. intermediate laceration repair includes multiple-layer closures or extensive cleaning. and pertussis among adults: use of tetanus toxoid.5 12002 Face. crushing. dip htheria. Preventing tetanus.. debridement. Tdap = diphtheria. †— Yes. single-layer closures with lo cal anesthesia. Table 4 CPT Codes for Laceration Repairs Location of wound Length of wound (cm) CPT Code Simple repairs Scalp. and acellular pertussis vaccine.28 Sutures.5 or less 12001 2.55(RR-17):25. and wounds resulting from missiles. undermining of skin for b etter wound edge closure). Adapted from Kretsinger K. eyelids . Follow-up suture removal is included in the laceratio n repair fee. supported by the He althcare Infection Control Practices Advisory Committee (HICPAC).

5 or less 12031 2.5 12034 Neck.5 12014 Intermediate repairs Scalp.5 or less 12011 2.5 12042 . limbs 2.6 to 7.1 to 7. trunk.6 to 12. feet 2.2. hands.0 12013 5.5 12032 7.5 or less 12041 2.6 to 5.6 to 7.

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