Traumatic wounds or skin lacerations are among the most common
injuries, occurring in people of all ages, that require evaluation
and treatment in the Emergency Department. The result of many if
not all wound closures is scar formation. Although most wounds heal
with a surprisingly pleasing cosmetic transformation from their
initial presentations, it is not uncommon for some wounds to present
complications during the healing period as well as to produce an
undesirable scar. A systematic approach to wound management serves
to help in deciding how to close complicated wounds, reduce the
risk for infection, and minimize less favorable outcomes.
Wound management in the Emergency Department includes an assessment
of the mechanism and conditions that were present at the time of
injury. Initially, one must address the concerns of the patient,
family members, or friends with a concise explanation of how the
wound will be treated and what can be anticipated for aftercare.
Many lawsuits and concerns of poor care evolve from poor cosmetic
outcomes. It is recommended that verbal
wound care instructions be offered once wound closure is completed,
in addition to giving the patient written discharge instructions.1
Regardless of the severity of the wound or possible inherent
complications associated with the injury, many patients are primarily
concerned with the potential for scarring or disfigurement. Most
patients expect cosmetic and functional perfection as an ultimate
result after their wounds are treated and the healing process is
completed. These expectations are often not clearly expressed during
the evaluation and treatment in the Emergency Department. The Emergency Physician must openly explain
and discuss the fact that virtually no wound heals without a scar
following wound closure.1,2 A clear understanding
of this is not to be used as an explanation for a poor outcome but
to counter any misconception that a wound will heal to look exactly
like the previously intact skin. Treatment is rendered to offer
the best possible functional and esthetic outcome while reducing
the risk of potential soft tissue infection.
An overall plan of wound site preparation and closure will be
needed to provide the greatest likelihood of a pleasing cosmetic
result.1 The mechanism of injury, severity of the wound,
location of the wound, and the presence or risk of necrotic tissue
can all influence the risk of infection. Additionally, the decision
of how to approach wound closure will be affected by the patient’s
skin type, age, gender, occupation, and hobbies.
Wound healing ultimately takes place over at least 6 to
9 months. Any wound presenting with concerns for a poor outcome
or an obvious likelihood of wound revision in the future should
be evaluated and treated by a Plastic Surgeon when possible.1,2 All
other wounds requiring complex closures should be properly assessed
and treated by the Emergency Physician.
In order to have a better understanding of scar tissue formation
and the antecedent ...