Laceration — Repair Procedure — Clinical Pathway: Emergency

Laceration Clinical Pathway — Emergency Department

Repair Procedure

Suture repair is warranted in cases where laceration extends through the dermis and where apposition of wound edges promote wound healing and improve outcomes.

In general, the goal is to approximate wound edges with minimal compromise of skin integrity or function. In the majority of cases, ideal technique involves suture spaced evenly with each stitch of equal width and depth. Repairs should be within 18 hrs of injury for most uncomplicated wounds (24 hrs for facial wounds). Suture material should be chosen based on laceration depth and location, with consideration of age of patient.

Anatomical Specific Considerations

Location Materials Suture Size Methods
Face (General) Fast-absorbing gut – preferred 5.0/6.0
  • Simple interrupted
    • Consider wound closure strips for fine gauge
Vicryl Rapide 5.0/6.0
  • Topical skin adhesive
    • Clean laceration with minimal tension
Lip Fast-absorbing gut
Dry mucosa
 5.0/6.0 Approximate vermillion border first with anchor stitch
Chromic
Wet mucosa requiring repair		 5.0/6.0
Eyebrow Fast-absorbing gut 5.0/6.0 Simple Interrupted, approximate edge of eyebrow structure first
Ear (Spares Cartilage) Fast-absorbing gut 5.0/6.0 Simple interrupted
Tongue/Buccal mucosa Chromic 4.0/5.0 Most do not require repair
Vicryl 4.0/5.0
Scalp Staples Galea repairs should have pressure dressing applied after repair
Vicryl Rapide 4.0/5.0
Vicryl
Galea		 3.0/4.0
Body/Extremity Superficial layers
Absorbable:
  • Vicryl Rapide
  • Fast-absorbing gut
  • Plain gut
Non-absorbable:
  • Prolene
  • Ethilon
 4.0/5.0
  • Simple interrupted with inverted sub-dermal stitches when deep
  • Balance tissue reactivity and tensile strength of suture material vs age of patient and difficulty of follow-up when choosing absorbable vs non-absorbable sutures
Deep layers
  • Vicryl
 3.0

Suture Types and Methods

Closure Material Materials Methods Duration
Suture, Absorbable
Preferred
  • Chromic gut
  • Fast-absorbing gut
  • Monocryl
  • Vicryl
  • Vicryl Rapide
  • Match layers of skin
  • Properly align wound edges
  • Evert wound edge margins
  • Avoid in high tension wounds
  • Preferable to use a curved and tapered needle
 Will dissolve in 3-5 days
Suture,
Non-absorbable
  • Ethilon
  • Prolene
  • Match layers of skin
  • Properly align wound edges
  • Evert wound edge margins
  • Preferable to use a curved and tapered needle
  • Require removal by PCP
  • Eyelids: 3 days
  • Neck: 3-4 days
  • Face: 5 days
  • Scalp: 7-14 days
  • Nail beds: 10-14 days
  • Trunk and upper extremities: 7 days
  • Lower extremities: 8-10 days
Skin-glue Adhesive Dermabond
  • Non-gaping, low tension wounds
  • Apply 3-4 layers
  • Note: it can get hot as it dries (use LET)
 Will fall off in approx. 5-7 days
Steri-strips
  • 1/8 x 3"
  • 1/4x 4"
  • 1/2 x 4"
 Minor, low-tension wounds Allow to fall off on own, approx. 5-7 days
Staples   Scalp only
  • PCP will remove in 7-10 days
  • ED to provide staple removal kit

Laceration Closure Techniques
Approximate, Do Not Strangulate

Method Use Additional Consideration
Simple Interrupted
Preferred
  • Apposition of superficial cutaneous layer
  • Close space with inverted sub-dermal stitches
  • Most common method
  • Use absorbable or non-absorbable sutures
Subcutaneous
Deep sutures		 Approximate wound edges, reduce tension Use absorbable sutures
Horizontal Mattress
  • High tension, gaping wounds
  • Palms and soles
  • Potential for worse scarring, may devitalize tissue
  • Consider surgery consultation
Vertical Mattress
  • High tension in areas difficult to place subcutaneous stitch
  • Allows precise wound edge approximation with eversion
  • Potential for worse scarring, may devitalize tissue
  • Consider surgery consultation
Anchor Stitch
  • Initial stitch placed to ensure alignment of anatomic landmark
  
Subcuticular Used to minimize scarring
  • Consider with low tension wounds
  • Not commonly used in emergency setting
Running Long wounds with edges aligned easily Not commonly used in emergency setting

Post-Repair Care

  • An antibiotic ointment such as bacitracin may be applied after wound repair with instructions to apply 2 times a day at home until suture removal or dissolution.
  • Band-Aid or other non-adherent dressing may improve re-epithelialization.
  • Dressing is typically not necessary 24 hrs after repair of minor wounds.