Facial laceration pointers

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EM/CC_23

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Hi, im a 4th year med student. I recently repaired a 3cm facial laceration secondary to a tree hitting the face (landscaping accident). I spent a lot of time trying hard to repair this as best I could, and was told by my ED attending he wouldnt have done it any differently.

I used 10 5-0 nylon sutures on a p-13 needle. Anesthesia with 8cc 1% lidocaine. 1000cc sterile water irritation under pressure. Multiple tiny wood chips removed from wound with kelly forceps.

im sure there is alot to improve considering it is literally my 4th lac repair. I particularly regret the slight gap left of wound center, and also wonder if i everted the wound enough. I also think sutures could have been straighter and more evenly spaced.

Id love any and all feedback from you experts on what i should have done better.

Also, I wish i had used lido w/ epi due to constant bloody ooze, but resident told me no--is that your practice? (I thought it was just avoid epi w/ end circulation areas like nose/penis/fingertips?)

Thanks for your time, i know you are busy!

Ps. Permission obtained from patient to photograph wound and show picture to teaching doctors for feedback.

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So first off, there is a good thread on facial lac repair pearls somewhere in this forum and I would suggest looking it up

Second, these are just random pointers and I welcome anyone else to chime in with additional/differing viewpoints.

So when I see a lac in the ED I first run through a mental checklist.
1. Region - forehead, cheek, chin lacs there better be a damn good reason why the ED can't repair these. These are regions with few aesthetic landmarks and basically anything you do is probably going to be fine. Versus Lip, nasal, or ear lacs where the ER may be freaking out but I know that with aligning a few key points I'll get a good result. Eyelid lacs, there better be a good reason why we aren't going to the OR.
2. Collateral damage - in the face, I want to know three things before I start sewing. Is there a facial nerve branch out? Is the parotid duct involved? Is the lacrimal system ok? I literally ask myself these three questions before suturing any facial lac because it's REALLY easy to miss an injury. Goes without saying you should document all of these exams.
3. Plan for anesthesia - you gotta know your local blocks for the face, as you can repair some gnarly lip lacs with an infra orbital or mental nerve block. Aesthetic landmarks have to be lined up before you infiltrate any local in the region of the lac, and again this is where blocks can help. In the scalp, forehead, or ear (or literally ANYWHERE) local with epi can cut down on bleeding. Sometimes I like to do a regional block for pain and then infiltrate the lac with local for hemostasis.
4. Cleaning. This is where the ER messes up ALWAYS. You have to irrigate the bejesus out of these wounds, and then do it again. At minimum, I use a liter of Bernadine/saline mix followed by a liter of saline. 3 liters is probably safer. Retained debris leads to tattooing and infection.
5. Repair. So you have assured yourself that there is no facial nerve injury, the lac doesn't involve the eyelid, and you're 100% sure the parotid duct isn't involved. General principles - minimize buried suture and align anatomical landmarks. For a cheek lac this may mean just putting a bunch of interrupted 5-0 or 6-0 prolene. For the lip, you want to put the mucosa together with something quick absorbing : 4-0 chromic or plain gut. Then the muscle with 4-0 cicely. Aligning the vermilion-cutaneous junction and wet-dry lip is something your resident should probably check, since a step off of 2mm can be noticed at conversation distance, but get that aligned before you infiltrate local for sure. For the ear, if the lac goes through the cartilage, don't go crazy with cartilage sutures - you only need them if there is displacement of cartilage and even then, just place a couple slow absorbing (4-0 or 5-0 monocryl or odd) in the cartilage to re-align. Bolstering an ear lac is the biggest thing to remember.

Don't forget that any permanent suture you place will need to be removed, and if it's a small kid or drug-addict street fighter you may want to just place absorbable sutures to avoid the need for suture removal.
 
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So first off, there is a good thread on facial lac repair pearls somewhere in this forum and I would suggest looking it up

Second, these are just random pointers and I welcome anyone else to chime in with additional/differing viewpoints.

So when I see a lac in the ED I first run through a mental checklist.
1. Region - forehead, cheek, chin lacs there better be a damn good reason why the ED can't repair these. These are regions with few aesthetic landmarks and basically anything you do is probably going to be fine. Versus Lip, nasal, or ear lacs where the ER may be freaking out but I know that with aligning a few key points I'll get a good result. Eyelid lacs, there better be a good reason why we aren't going to the OR.
2. Collateral damage - in the face, I want to know three things before I start sewing. Is there a facial nerve branch out? Is the parotid duct involved? Is the lacrimal system ok? I literally ask myself these three questions before suturing any facial lac because it's REALLY easy to miss an injury. Goes without saying you should document all of these exams.
3. Plan for anesthesia - you gotta know your local blocks for the face, as you can repair some gnarly lip lacs with an infra orbital or mental nerve block. Aesthetic landmarks have to be lined up before you infiltrate any local in the region of the lac, and again this is where blocks can help. In the scalp, forehead, or ear (or literally ANYWHERE) local with epi can cut down on bleeding. Sometimes I like to do a regional block for pain and then infiltrate the lac with local for hemostasis.
4. Cleaning. This is where the ER messes up ALWAYS. You have to irrigate the bejesus out of these wounds, and then do it again. At minimum, I use a liter of Bernadine/saline mix followed by a liter of saline. 3 liters is probably safer. Retained debris leads to tattooing and infection.
5. Repair. So you have assured yourself that there is no facial nerve injury, the lac doesn't involve the eyelid, and you're 100% sure the parotid duct isn't involved. General principles - minimize buried suture and align anatomical landmarks. For a cheek lac this may mean just putting a bunch of interrupted 5-0 or 6-0 prolene. For the lip, you want to put the mucosa together with something quick absorbing : 4-0 chromic or plain gut. Then the muscle with 4-0 cicely. Aligning the vermilion-cutaneous junction and wet-dry lip is something your resident should probably check, since a step off of 2mm can be noticed at conversation distance, but get that aligned before you infiltrate local for sure. For the ear, if the lac goes through the cartilage, don't go crazy with cartilage sutures - you only need them if there is displacement of cartilage and even then, just place a couple slow absorbing (4-0 or 5-0 monocryl or odd) in the cartilage to re-align. Bolstering an ear lac is the biggest thing to remember.

Don't forget that any permanent suture you place will need to be removed, and if it's a small kid or drug-addict street fighter you may want to just place absorbable sutures to avoid the need for suture removal.

Thank you so much for taking the time to write that. Ill definitely keep those suggestions in mind--particularly the part about irrigation, im definitely not doing nearly enough of that.
 
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Keep it up....the more you do the more you learn:..also if optho or plastics gets called for something make sure you watch what they do and take notes. Your repair looks fine btw. :)
 
http://forums.studentdoctor.net/thr...n-er-resident-face-lacs.924095/#post-12684390

I answered a couple of times in the above thread. It has the basics of what I did in residency and continue to do in practice now.
The only thing I've changed in the past 3 years is that I use a lot more 4-0 monocryl or 5-0 monocryl in the deep dermis and 5-0 plain gut (NOT fast gut) for the skin. The plain gut is a lot tougher, easier to sew without breaking, and a lot harder to find in an ED. You will have to go to an OR to get that stuff. I tend to use prolene (never nylon) less often because it's sometimes hard to make a perfect 5 day followup for suture removal coincide with my available clinic days. I can pick the remains of 5-0 plain gut out in 7-8 days in the clinic and not get the railroad tracks I would with prolene.

Regarding the use of epic in liodcaine, 1% lido 1:100,000 is safe to use anywhere. Penis/toes/fingers/nose is a completely outdated concept, based on erroneous data from the 50's. There are a lot of good studies with high levels of evidence on the safety of lidocaine even in digital blocks. Look up Don Lalonde's excellent work in the plastic surgery literature. Wait a LONG time for maximal vasoconstriction - 20 min if you can help it - and you will have very good hemostasis.
 
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And EM/CC, here's some specific feedback:

You did a fine job. Learn to close in multiple layers and you'll be better than 90% of your colleagues, who usually do a fine job too. The strength layer of your repair is in the deep dermal closure - 4-0/5-0 monocryl buried deep dermal sutures, even 2 or 3 of them, can provide the bulk of your closure. I would have run a simple over and over running 5-0 prolene or 5-0 plain gut to perfectly close the skin after just a couple of monocryls.

And 1000cc of sterile saline in a 3cm is lac is plenty.

Find every opportunity to sew, and don't worry about taking too much time. Work on the basic mechanics of suturing, watch plastics close something, etc. Once you become facile with simple lacs you can work on ones with extra difficulty, like trimming ragged edges and undermining a little. That's the next level. Then, learn how to do good horizontal mattress sutures for hand (4-0 nylon) and you'll earn a lot of respect; they evert a lot better. Hand nerds like me will appreciate it.

After that, work on your setup and efficiency. Little things like injecting your local first (with epi, right?) and letting it sit for hemostasis while you irrigate, set up, prep and drape go a long way towards eventually building speed into your successful procedures.

bb
 
I'd also add that not every lac is appropriate for closing "like a plastic surgeon". Some wounds are just too dirty and spending hours on a perfect closure will only lead to an infected wound that has to be re-opened. Sometimes loose approximation is better than a 3 layer tight closure that looks great initially.
 
Hi all,
I was wondering if I could get some feedback on this lac repair. Female was struck by a piece of sheet metal. As you can see by photo, it got her pretty good. Plastic surgery was unable to come suture so I had to do it in the ER. I'm still worrying that I should have focused more on a running subcuticular. What are your thoughts on running subcuticular vs interrupted on the face? I did both on this repair, but again, I am second guessing my decision. She's a younger girl with no medical comorbidities. I irrigated the wound well. The laceration did not extend into oral cavity. I used 6-0 ethilon for external and vicryl for internal.
Any advice for future reference is much appreciated!
Thank you!! :)
 

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http://forums.studentdoctor.net/thr...n-er-resident-face-lacs.924095/#post-12684390

I answered a couple of times in the above thread. It has the basics of what I did in residency and continue to do in practice now.
The only thing I've changed in the past 3 years is that I use a lot more 4-0 monocryl or 5-0 monocryl in the deep dermis and 5-0 plain gut (NOT fast gut) for the skin. The plain gut is a lot tougher, easier to sew without breaking, and a lot harder to find in an ED. You will have to go to an OR to get that stuff. I tend to use prolene (never nylon) less often because it's sometimes hard to make a perfect 5 day followup for suture removal coincide with my available clinic days. I can pick the remains of 5-0 plain gut out in 7-8 days in the clinic and not get the railroad tracks I would with prolene.

Regarding the use of epic in liodcaine, 1% lido 1:100,000 is safe to use anywhere. Penis/toes/fingers/nose is a completely outdated concept, based on erroneous data from the 50's. There are a lot of good studies with high levels of evidence on the safety of lidocaine even in digital blocks. Look up Don Lalonde's excellent work in the plastic surgery literature. Wait a LONG time for maximal vasoconstriction - 20 min if you can help it - and you will have very good hemostasis.

Lalonde's from Canadia and does thangs like carpal tunnel releases under local in the office. Love it. And yes, to reiterate the point - I've lido + epi all sorts of things with no issues. In reality, epi lasts may be a couple hours if you're lucky. We routinely put entire limbs on ischemia for 1-2 hours via tourniquet. So... that prohibition makes of epi doesn't make sense to me at all.
 
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Hi all,
I was wondering if I could get some feedback on this lac repair. Female was struck by a piece of sheet metal. As you can see by photo, it got her pretty good. Plastic surgery was unable to come suture so I had to do it in the ER. I'm still worrying that I should have focused more on a running subcuticular. What are your thoughts on running subcuticular vs interrupted on the face? I did both on this repair, but again, I am second guessing my decision. She's a younger girl with no medical comorbidities. I irrigated the wound well. The laceration did not extend into oral cavity. I used 6-0 ethilon for external and vicryl for internal.
Any advice for future reference is much appreciated!
Thank you!! :)

So one thing that you guys are doing in the ED that you're forgetting is that... with these permanent sutures, someone's gotta take em out in about 5-7 days or they can leave nasty train-track scars on people. Hope she's got good follow up. Otherwise, honestly, it's the face and a light skin kid, it's probably gonna heal beautifully as long as you approximate the edges. Just fyi, that lac is horrible because it runs right through a few of asesthetic subunits, especially the cheek. May require a scar revision in the future to hide it better.

Oh - and your closure looks fine. Lots of people hem and haw about what kind of suture etc etc. Just follow the principles stated a few posts above and you should be a-okay. On your particular laceration, I'd also have asked the patient about sensation in the upper lip, and explored the wound to make sure that it didn't bang the distal part of the infraorbital nerve.
 
So one thing that you guys are doing in the ED that you're forgetting is that... with these permanent sutures, someone's gotta take em out in about 5-7 days or they can leave nasty train-track scars on people. Hope she's got good follow up. Otherwise, honestly, it's the face and a light skin kid, it's probably gonna heal beautifully as long as you approximate the edges. Just fyi, that lac is horrible because it runs right through a few of asesthetic subunits, especially the cheek. May require a scar revision in the future to hide it better.

Oh - and your closure looks fine. Lots of people hem and haw about what kind of suture etc etc. Just follow the principles stated a few posts above and you should be a-okay. On your particular laceration, I'd also have asked the patient about sensation in the upper lip, and explored the wound to make sure that it didn't bang the distal part of the infraorbital nerve.


Thanks so much for your reply!! That makes me feel a little better about things. Her lip sensation was all intact. Thankfully. We had follow-up all set up for her in a few days so that should be no problem. I just wish our plastics docs or residents were more willing to help in situations like this. They expected us to fix her all up when we, as ER people, are not used to this delicate suturing.
Thanks again!
 
Your knots are waaaaaay too tight there. You can already see the swelling being created. That's something you have to learn to compensate for, that you kind of learn in following up these patients. As that's a straight line lac, I would have made life simpler and used a 5-0 or 6-0 prolene for speed and ease of suture removal.

I am not a fan of gut sutures in visible locations. It's mostly something for someone in the ER if you don't think they will follow up reliably or someone like a nursing home patient you don't want to have to have transported by ambulance to have sutures out. I also hate mattress sutures as they are a bitch to remove (particularly in the palm of the hand) from swelling and it's complete bulls**t that they make anything heal any better.
 
4. Cleaning. This is where the ER messes up ALWAYS. You have to irrigate the bejesus out of these wounds, and then do it again. At minimum, I use a liter of Bernadine/saline mix followed by a liter of saline. 3 liters is probably safer. Retained debris leads to tattooing and infection.

EM intern here - so, when I was a scribe the older docs used betadine 1:10, and I sort of just adopted that as a med student and intern because it makes intuitive sense to me to use a disinfectant; however, every time a 'younger' EM senior resident or attending has seen me do this they kind of roll their eyes that it is unnecessary and not evidence based. Is there plastics literature to support betadine or is it more of an old-school wisdom type thing?
 
Hi all,
I was wondering if I could get some feedback on this lac repair. Female was struck by a piece of sheet metal. As you can see by photo, it got her pretty good. Plastic surgery was unable to come suture so I had to do it in the ER. I'm still worrying that I should have focused more on a running subcuticular. What are your thoughts on running subcuticular vs interrupted on the face? I did both on this repair, but again, I am second guessing my decision. She's a younger girl with no medical comorbidities. I irrigated the wound well. The laceration did not extend into oral cavity. I used 6-0 ethilon for external and vicryl for internal.
Any advice for future reference is much appreciated!
Thank you!! :)

Rae Liz - That's a pretty straight and clean lac. I would have irrigated that out, and then closed it with a few 5-0 monocryl simple buried sutures at the dermis, and then run a subcuticular 5-0 prolene pull-out stitch, applied dermabond, and then pulled out the 5-0 prolene. Dermabond is secure, requires no suture removal, and the patient has no dressing care. The patient can shower immediately.
 
EM intern here - so, when I was a scribe the older docs used betadine 1:10, and I sort of just adopted that as a med student and intern because it makes intuitive sense to me to use a disinfectant; however, every time a 'younger' EM senior resident or attending has seen me do this they kind of roll their eyes that it is unnecessary and not evidence based. Is there plastics literature to support betadine or is it more of an old-school wisdom type thing?

No evidence to support that. Normal saline is enough.
 
You guys use anything but monocryl for deep sutures? Vicryl?
 
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