Resident Manual of Trauma to the Face, Head and Neck

a. Deep-Tissue Alignment and Reapproximation y y Align and reapproximate deeper tissues (muscle, fascia) to abolish dead space and relieve wound tension. y y Use 3-0 or 4-0 resorbable suture (e.g., Monocryl™, Vicryl™). Using undyed or clear suture will prevent surface visibility. y y Place sutures in a simple, interrupted, inverted fashion with a buried knot. b. Dermis Closure y y Close dermis with 4-0 or 5-0 resorbable suture (i.e., Vicryl™ or chromic) in a similar inverted, interrupted fashion, thereby burying the knot. y y Pay particular attention to needle entry and exit points in the dermis to precisely realign skin edges. y y Work to avoid height discrepancies on either side of the wound. c. Skin Closure Skin closure may be undertaken with 5-0 or 6-0 either absorbable (i.e., fast-absorbing gut) or permanent (i.e., nylon or Prolene™) suture. In patients for whom follow-up is questioned or in children where compli- ance with removal is often limited, absorbable material is frequently chosen. d. Shallow Lacerations If skin edges are precisely approximated under no tension, wound adhesives, such as a topical skin adhesive like 2-octyl-cyanoacrylate (Dermabond®), may also be applied for small, shallow lacerations. e. Suture Options y y In general, sutures in the face and neck should be placed ~2 mm from the skin edge and 3 mm between each suture as to provide good eversion and avoid resultant depressed scarring. y y If skin eversion is difficult, intermittent placement of vertical mattress sutures is an excellent option. y y Typically, closure is accomplished with either simple interrupted or running (locked or unlocked) sutures, with some debate existing between these options. A running-locked stitch provides excellent eversion of the skin edge and favorable cosmesis. Careful attention must be paid to avoid strangulation of the skin edges. If lacerations are significantly jagged making alignment more difficult, simple interrupted sutures are ideal. Additionally, where concern for infec- tion is high, one may defer to interrupted sutures, so as to allow for individual removal to provide drainage if infection does ensue, rather than reopening the entire wound with resultant poorer cosmesis.

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