Lacerations and Plastic Surgery

Plastic surgery is not only for cosmetic enhancement. Interestingly, plastic surgery originated with repairing war injuries, particularly disfiguring hand injuries. The main goal was to restore functionality from devastating trauma. Of course, today plastic surgery consists of all types of cosmetic and aesthetic corrections. Currently, in trauma cases plastic surgeon specialists are used to help with the aesthetic and functional outcomes. Even “minor” lacerations can leave lasting scars and may benefit from the expertise of a plastic surgeon specialist.

All cuts heal on their own, even if sutures, bandages or tissue glue aren’t used. But the scar might not heal well; it might get infected; it could lead to scar tissue that impairs movements; it could lead to pain; or it might not have a pleasant cosmetic outcome. For example, if a laceration overlies a joint, such as on the fingers, the resultant scar tissue can compromise range of motion. For these types of delicate lacerations, instead of an emergency medical provider repairing the laceration, it is often better to get a specialist to close them.

There are many types of medical providers who are proficient in repairing lacerations. Many times the specialist is a medical provider with extensive training and expertise. In the emergency room it is common to have a nurse practitioner or physician assistant be the most proficient at suturing. This is because in ERs NPs and PA’s usually perform most of the suturing, while the MD’s and DOs are usually handling other medically-complex patients, and in the ER minor trauma such as fractures and lacerations are not considered high acuity. The way emergency departments stratify patients, in degrees of urgency and emergency, often leave many hands-on cases to PA’s and NPs. this is because lacerations and fractures are not as serious as, for example, heart attacks and strokes.

Associated complications

The main goal of closing a wound is to ensure that the wound heals without complications, which include: infections, loss of functioning and a satisfactory cosmetic outcome.

Depending on the cause of the laceration, the wound will need a medical evaluation to rule out other injuries associated with the initial injury that caused the laceration. Chin lacerations can have associated jaw and dental fractures. While face lacerations to the face and scalp have low risk of infections, face lacerations need extra caution to ensure satisfactory cosmetic outcomes. Lacerations to the extremities have a higher risk of infection. And lacerations to the hands can have tendon and nerve involvement, which require specialist consultation. Crush injuries can lead to irregular shaped lacerations and flaps of skin that can be challenging to repair. Abrasions can lead to devitalized tissue with contamination and loss of tissue.

Lacerations need to be examined and explored if there is a suspicion of a foreign body inside the laceration. If a person feels as if something is inside the wound this should be taken seriously. Most times people are correct that there is a foreign body stuck in the wound.

Depending on the nature of the mechanism of injury an extensive work up will be performed to rule out fractures, contaminations, infections, and tendon or nerve involvement. Contamination needs to be properly irrigated to ensure the wound is clean enough for closure.

If a person has an underlying medical condition that increases their risk of infection or poor healing they need to be medically evaluated. Conditions such as diabetes, peripheral vascular disease, malnutrition, morbid obesity. In these types of patients even simple laceration can get infected and lead to poor outcomes.

Golden period

Lacerations have a “golden period” when they must be repaired. This time frame is somewhat variable, and specific lacerations need to be evaluated individually, but as a guideline the accepted period for closure of a non-face/scalp laceration is between 6 to 10 hours. Some new research has shown that in clean wounds it might be safe to close lacerations up to 19 hours. Hand lacerations usually need to be closed within 8 hours. Facial wounds can be closed up to 36 hours after injury. As the length of time to closure increases so does the risk of infection.

Urgent Care Specialists

For many years it has been fairly easy to get a plastic surgeon or specialist to repair a laceration in the emergency department. But lately, due to changes in insurance reimbursement, it is becoming increasingly difficult. Luckily, there are plastic surgeon specialists who practice in urgent care centers that are able to provide similar high-quality laceration repair. If you feel that a skin injury needs professional medical attention it probably does. And due to the time-sensitive nature of repairing such an injury it should be taken care of as soon as possible.

Written by: Jacob Gerlitz