Chapter 118: Advanced Wound Closure Techniques

INTRODUCTION

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. 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 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.

ANATOMY AND PATHOPHYSIOLOGY

To have ...