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No Closure

As any experienced practitioner knows, we see many lacerations present to the ED that we really don’t need to see.  That is to say, without primary closure, these wounds will do very well, with minimal scarring.  In fact, it’s arguable that the increase in inflammation and infection risk that comes along with suturing will be of more detriment to the final cosmetic outcome.

I think the hardest time for us to make this call is when dealing with pediatric lacerations on the face.  Lacerations are common in the rambunctious toddler age group,  and of course this is the same age group that doesn’t sit still for even a small lac repair, leading to the added risks of procedural sedation in many cases.

The truth is, kiddie skin heals like gangbusters.  Thus many lacerations, even those that you really want to try to repair, will heal fantastically if you do nothing besides clean the wound and give good supportive care/return precautions.  Again, experienced practitioners already know this–the hardest part is often convincing parents this is the case.

I have therefore developed this library of pediatric facial lacerations with follow up images in which no primary closure was performed.  I invite you to share these images with your patients and parents when you are all staring at a laceration trying to decide what the right thing to do is.  Many many thanks to the incredibly kind parents and children who gave permission to let these more sensitive images be published–my hope is that they will save some future toddler the ordeal of some unnecessary stitches.

Day of injury.  Swollen nose, upper lip abrasion, and a short but deep laceration to the upper lip.

Day of injury. Swollen nose, upper lip abrasion, and a short but deep laceration to the upper lip.

On closer inspection, the laceration does not cross the vermillion border, but does abut it.  It is short but deep and bleeding a fair amount.

On closer inspection, the laceration does not cross the vermillion border, but does abut it. It is short but deep and bleeding a fair amount.

This pretty young girl fell and hit her face, sustaining a nose contusion and a laceration of the upper lip. The laceration was freshly bleeding in this photo but deeper than the photo gives credence to.  On careful inspection the laceration did not cross the vermillion border, but did abut it.  After a discussion with her parents about the different options (primary closure was offered, but not recommended), we agreed on a plan of supportive management.

One week after the injury.

One week after the injury.

Her parents contacted me one week after the injury as I requested and send along this picture. It’s healing but the scar is still prominent.  At this point, it’s important to counsel parents to be patient, as scar formation and remodeling doesn’t happen overnight.

One month after the injury.

One month after the injury.

But low and behold, one month later, only a very faint scar remains.  I am pretty confident in another few months, it will be essentially invisible. No repair was definitely the right decision for this little girl!

For lacerations in less cosmetic areas, there is even evidence to support the “no closure” approach.  I encourage you to take a look at this great article from 2002, showing no difference in cosmetic outcomes for small hand lacerations closed primarily or managed conservatively:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124590/

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