Lacerations can occur anywhere on the skin surface and can be any length or depth. Many lacerations are easily repaired in the Urgent Care Centers or Emergency Rooms by physicians manning these departments. But when the lacerations involve larger areas, deeper structures, or are located in cosmetically sensitive areas, plastic surgeons are usually asked to take care of the wounds. The lacerations can be due to any number of causes e.g. dog bites, knife injuries, skill saw injuries, motor vehicle accidents. Regardless of the cause of the injury the tissues are treated very specially.
The key to remember is to maintain a blood supply to the injured tissue. This is not only the skin tissue but the deeper structures that may also be injured with a laceration. Plastic surgeons are very familiar with issues of blood supply to the skin and deeper structures like tendons, nerves and bones. Each injured structure needs to be repaired with the idea of maintaining blood supply.
Another consideration is the prevention of infections associated with lacerations. The skin is a barrier that protects the internal environment of the body from the external environment. When the skin is lacerated, a passage or portal exists from the external environment to the internal environment exists. This passage allows bacteria, fungus, viruses, and foreign bodies to enter the internal environment of the body. Infections are the number one reason for wounds not healing.
When plastic surgeons are asked to help close a laceration, a quick history and physical examination (H&P) is obtained.
- What was the mechanism of injury?
- How long was the laceration open?
- What level of pain exist?
- Are there any allergies to medicines?
- What medicines does the patient take?
These are just a few of the questions a plastic surgeon (or any other physician) will ask. The laceration will be examined to determine what tissues are involved and how contaminated the wound is among many other observations.
Injured underlying structures, like tendons, bones, muscles, and nerves are repaired (if possible) as soon as reasonable. Sometimes delayed repairs are needed for these deeper structures when there are medical conditions present requiring delay. If the laceration involves only the skin and subcutaneous tissue, these can be repaired hopefully before 12 hours after the injury. After 12 hours, the infection rate is higher. The wounds are debrided and closure begins. Debridement usually involves removal of non-viable tissue e.g. tissue which has no blood supply. Debridement also removes any foreign bodies in the wound. Consider an injury around the 4th of July. Many times there are black areas in the dermis of the skin which are actually the powder from a firecrackers. This needs to be removed or the dermis can be tattooed
When the wound has been debrided, the skin is closed. There are different ways to close the skin. Current Procedural Terminology (CPT) uses simple, intermediate and complex closures which are based upon the anatomic area of the laceration. For example, a 5 cm laceration on the buttock is not usually the same as a 5 cm laceration on the lip or nose or ear. These determinations are made by the treating surgeon.
After the laceration is closed, the decision to place the patient on antibiotic and pain medicines is also determined by the treating surgeon. The information gathered at the H&P and during the closure of the laceration will often guide the physician on these decisions.
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