Marsena Collins, FNP-C, ENC-C
Knowing how to repair a laceration is an essential skill for almost any provider to have. People will always injure themselves and likewise, they will need our skills. Let’s briefly discuss the process of laceration closure.
Step 1: Wound Anatomy
Prior to closure it’s important to understand basic wound anatomy. Remember that the skin is the body’s largest organ. The epidermis, dermis, and subcutaneous layers are the 3 tissue layers of concern during a skin laceration repair. The epidermis and dermis are also attached together. Together they constitute the skin tissue as we know it. Dermal approximation provides the strength and the alignment of skin during laceration closure process. Adipose tissue composes the majority of the subcutaneous layer. Nerve fibers, blood vessels, and hair follicles are also located in this layer). Sutures placed in the subcutaneous layer may decrease the tension of the wound and improve the overall cosmetic overall
Step 2: Wound Evaluation
Proper evaluation and assessment of the wound has to occur prior to closure. This evaluation includes: assessment of injury, age of wound, and also the degree of contamination. Foreign body presence, size, depth, tetanus vaccination status, injury to adjacent structures (ex. tendons, bones, ligaments, etc.), neurovascular status, and proper wound preparation (irrigation, debridement, hemostasis) are also important considerations.
Step 3: Closure Method
Next, you should consider how will you plan to close the wound and also what your options are for closure. Sutures are usually a method of choice for closures through the dermis that require careful wound approximation and also if a wound is under tension.
Staples are a great alternative for a wound if in a non-cosmetic region, linear, and especially long. Staples are also a method for laceration located on the scalp. Tissue Adhesive is also a painless closure option. It is fast and usually placed in less tense and dry regions of the body. Don’t use tissue adhesive in areas with hair. Tissue adhesive is becoming standard in certain locations. These areas include nail bed repairs and larger lacerations. Adhesives also show improved healing outcomes with reduced scarring.
Step 4: Setup
Organizing everything needed for your anticipated repair will make you very efficient. Suture kits usually contain the basic supplies needed for wound repair. These include forceps, a needle driver, and scissors. Usually, there will also be gauze pads, a drape, and a towel. Be familiar with your suture kit before you use it. Plan ahead and have extra equipment ready if you think it may be needed! A typical single suture packet will allow for 3-4 single simple interrupted sutures.
In general, a list of basic supplies you will need for wound repair includes the following:
- Suture Material (enough for entire wound, including different layers)
- Irrigation liquid
- Needle Driver
- 4×4 gauze pads (10)
- 18g angiocath needle or saline bottle irrigation adaptor
- Gloves, face shield, and gown
Normal Saline Solution is the standby for wound irrigation. An 18 gauge syringe and catheter should be used for irrigation. This catheter size delivers optimal stream size and pressure for small debris irrigation and removal. Remember to maximize your facial protection when irrigating your patients.
If you have suction readily available, irrigating over a fracture pain and taping a yankauer suction into the pan can also make cleanup very easy!
Choose the anesthesia with your patient. Patients who cannot tolerate lidocaine may also benefit from locally injected Benadryl. Lidocaine provides 15-20 minutes of anesthesia. It can be mixed with epinephrine. Marcaine lasts 45 minutes to 2 hours and can also be combined with epinephrine.
Topical LET solution is also a great option for pediatric patients. It takes 60 minutes after application for maximum effect. Once applied, it provides superficial skin sensory relief.
Local anesthesia is very effective. It is also effective in combination with LET. Injected anesthesia can also provide a regional nerve block. These blocks allow for effective regional anesthesia without deforming the wound. Blocks also permit a wide area of anesthesia without using a large amount of anesthetic. Remember that lidocaine is potentially cardiotoxic, and therefore should be used sparingly.
The addition of epinephrine allows the anesthesia to last longer. It also potentiates the anesthesia, meaning you won’t need to use as much when it is combined with epinephrine. Recent data has validated that anesthesia with epinephrine is safe to use in the fingers and toes. Don’t use epinephrine around the nose, ears, or genitals.
Sutures are absorbable or non-absorbable. The location and type of wound should guide suture selection. Absorbable sutures are used in locations that will not require removal.
Sutures come in a variety of sizes, thicknesses, and colors. Needle also vary by shape, size, and curve. We discuss these in more detail in a separation article. In general, 6-0 needle size and non-absorbable suture material such as prolene or nylon work well for closing the epidermis on the face or where scarring should be minimized. 4-0 needles are acceptable for closing most other locations.
Deep wounds closure should start from the deepest injury. Closure should progress towards the skin surface. In these instances, absorbable sutures such as vicryl are a great choice for approximating tissue layers.
Step 5: Planning the Closure
There are many suturing techniques that can be used on a single laceration. The technique you choose will depend on the type of wound. For example, a straight laceration may be brought together with simple interrupted sutures. Likewise, an irreguarly shaped or stellate laceration may need combination of Interrupted and running sutures. Wound that require tension (such as over the knee) may need mattress sutures. It’s important to have your plan in mind and use the correct technique for the laceration you are repairing. For a deep dive into the types of sutures and techniques, check our our suturing blog!
Step 6: Closure
Once you have your plan of attack, it’s time to get to work. First, begin by positioning your patient in a position good for your procedure and also for their comfort. Wash your hands and put on gloves. Wounds should be cleaned with Betadine. Next, anesthesia should be injected to allow 5-10 minutes to take effect. While the anesthesia is taking effect, you should take this opportunity to set up your suture tray. Use sterile technique to open the suture kit onto a table and drop in the suture materials. Take care not to touch the sutures with your bare hands. Any sterile cups in the kit should be filled with additional betadine. When you are ready to begin, put on your gloves, face shield, and mask.
Wounds require extensive irrigation. Remove visible debris. You may also scrub the wound with betadine as needed. Once the wound is clean, it should be inspected to identify which tissue layers are injured. These will need to be brought back together. Deeper tissue structures such as fascia should be tacked together. Closure continues until the final tissue layer left is the epidermis.
When closing the epidermis, avoid closing the skin too tightly. An old rule says that wounds “should be approximated but not strangulated.” In general, wound edges should be brought together close enough to remain in tight contact. These should not be too tight to impair blood flow. After the wound is closed, all needles should be accounted for. Needles should be safely discarded.
Step 7: Inspection and Dressing
Once closed, the wound should be inspected for any areas of poor approximation. A suture count, by layer, should also be documented. The procedure note should comment on the indication for the procedure, amount of contamination, degree of irrigation, length and depth of wound, layers involvled, type of suture material used for each layer, and the color of the suture material. A non-stick dressing or sterile gauze dressing with a fine line of bateriostatic ointment should also be applied.
Counsel your Patient
Giving your patients a good summary of what you did goes a long way. Likewise, this explanation can help them identify complications before they become a big problem. Always mention that you irrigated the wound and did not see any visible foreign bodies. It’s also a good idea to explain to them that small debris not visible to the eye can still cause irritation, and that irrigation may never be 100% effective.
Educating your patient is very important. Reasons for immediate professional evaluation include redness, drainage, and breakdown (wound separation). Ensure that their tetanus vaccine status is up to date. Well healed sutures should be safely removed in 10-14 days.
Lots of Personal Closure Experience
DeLemos. D (Dec 2020) Skin Laceration repair with sutures: UptoDate. RetrivedJanuary2021from https://www.uptodate.com/contents/skin-laceration-repair-with-sutures#topicContent