Goals are to optimize wound strength, reduce inflammation, avoid infection, and minimize scar formation

    Time to wound cleaning is the most important factor

    To preserve viable tissue and restore continuity and function of tissue

CONTRAINDICATIONS

 Heavily contaminated wounds

 Presentation time for primary closure is after 12 hours for standard lacerations

 Presentation time for primary closure is after 24 hours for lacerations of the face, scalp, or other highly vascular areas

 Wounds under high tension should not be closed by skin adhesives alone

 Animal or human bite and most puncture wounds should not be closed on initial presentation

RISK/CONSENT ISSUES

 Cleaning and repair of wounds cause pain

    Local anesthetics are indicated for all wound repairs in conscious, alert patients

 Infection is always a risk in wound repair

 Wound repair always results in some scarring and can affect cosmetic appearance permanently

 Tendon, nerve, and vascular injuries can occur at time of initial injury or at time of repair

 Risk of retained foreign body exists despite best methods of foreign body identification and removal, such as local exploration, radiographs, ultrasonography, and irrigation

    Thorough exploration for foreign bodies must be performed and documented

TECHNIQUE

 Patient and Wound Preparation

    Position the patient to prevent falling or fainting during wound repair

    Practice universal precautions

    Prepare the surrounding skin with povidone–iodine solution and cover with sterile drapes before manipulation of any kind

 Local Anesthesia: Lidocaine (1% or 2%) with or without epinephrine

    Epinephrine is contraindicated in areas of high risk for ischemia, such as fingers, ears, nose, toes, and penis

    Use small-gauge needle (25 or 27 gauge) to directly inject into subcutaneous (SQ) tissue within the laceration

    To decrease pain, inject through the wound and not through the skin

    Use adequate amount for anesthesia but avoid high volumes that will lead to significant tissue distortion, possible cosmetic embarrassment, or systemic toxicity

       Maximum dose: 3 to 5 mg/kg 1% lidocaine, 7 mg/kg 1% lidocaine with epinephrine.

    Consider regional blocks for repairs in cosmetically important areas (face, hands, etc.) to avoid distortion of tissue

 Wound Cleansing

    Copious amounts of sterile water or sterile saline via high-power irrigation with a large syringe and splatter shield or an 18-gauge catheter. Tap water equally effective.

 Wound Exploration

    After cleansing, the true depth of the wound is appreciated

    Look for deeper tissue involvement and explore the wound

    If tendon or vascular structures are visualized, inspect through full range of motion, test for state of function, and document findings

 Radiography and/or Sonography

    If the possibility of underlying fracture and/or foreign body exists, image the affected area and document

 Select Method of Repair

    2-Octyl cyanoacrylate

    Staples

    Sutures

DERMABOND (LIQUID ADHESIVE)

 Indicated for simple wounds under low tension

 Advantages

    Ease of use, speed, and safety

    No return visit necessary (sloughs off in 5 to 10 days and serves as own dressing)

    Much less painful

 Disadvantages

    Moderate closure strength—cannot be used on joints or areas with high tension

    Cannot be used in areas with excessive hair

 Caution when using around eyes to prevent accidental runoff into eyes

 Equivalent tensile strength at 7 days when compared to sutures

 Procedure

    Clean the wound

    Approximate wound edges with forceps or fingers

    Apply three to four layers along the wound length or perpendicularly to it (as strips)

    Maintain manual support for 60 seconds

STAPLES

 Indicated for superficial scalp lacerations, linear lacerations on extremities, trunk, and wounds under low tension

 Advantages

    Ease of use, speed, and safety

    Easily removed and excellent tensile strength

 Disadvantages

    Less refined closure

    Possible greater scarring

    Uncomfortable removal (TABLE 69.1)

 No significant differences found with infection, healing, or patient acceptance when compared to suturing

 Procedure

    Anesthetize, clean, and debride wound as necessary

    If necessary, close deep fascia with absorbable sutures with a buried knot

    Evert wound edges before placing staple, if possible utilizing the services of an assistant with forceps. Do not press too hard.

    Allow the staple crossbar to sit 1 to 2 mm above wound edge

    Place enough staples to adequately appose tissue edges

SUTURES

 General Rules

    Deep stitches require 3-0 or 4-0 absorbable sutures

    Skin closure requires 4-0 or 5-0 nonabsorbable sutures

    Face, lips, and eyelid wounds: Consider 6-0 sutures

    High skin tension areas: Consider 3-0 or 4-0 sutures

    Always select the smallest size that will hold the skin edges together

 Nonabsorbable Sutures

    Silk: Has the best knot security, the best tie ability, the least tensile strength, and causes significant tissue reactivity. Used in intraoral mucosa.

    Ethilon: Has good knot security, good tensile strength, minimal tissue reactivity, and good tie ability. Best suited suture material for typical wound closure.

    Prolene: Poorest knot security, best tensile strength, least tissue reactivity, and fair tie ability

 Absorbable Sutures

    Vicryl: Good knot security, good tensile strength, minimal tissue reactivity, best tie ability, and 30-day suture duration. Used for deep repair to reduce wound tension.

    Surgical and chromic gut: Fair knot security, fair tensile strength, greatest tissue reactivity, poor tie ability, and 5- to 7-day suture duration. Used for intraoral wounds.

 Procedure

    Anesthetize, clean, and debride wound as necessary

    Prepare the skin with povidone–iodine or chlorhexidine solution

    Minimize trauma by handling skin with toothed forceps and by using small sutures

    Relieve tension by undermining with a scissor and by using layered sutures (FIGURE 69.1)

    Subcutaneous Layer Closure

       Reapproximate fascia as needed

       Close the SQ layer in sections, starting in the middle and then bisecting adjacent sections until adequate tension has been relieved from the skin edges

       Insert the suture at the bottom of the layer and draw it through to just beneath the dermis on the same side of the wound

       Reenter beneath the dermis on the adjacent side and draw through to the bottom of the SQ layer

       Tie the knot such that it remains at the bottom of the wound, thereby preventing a palpable knot near the skin surface

    Interrupted Stitch

       Most commonly used stitch. If one fails, the rest will maintain closure.

       Insert the needle at 90 degrees to the skin surface and include sufficient SQ tissue in the bite and carry the suture through to the opposite side

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