Laceration Repair, Wound Closure & Suturing
Comprehensive fast-track emergency guide to laceration repair and wound closure. Details local anesthetic selection and modern safety of epinephrine on digits, suture material sizing by anatomical location, simple interrupted vs. horizontal/vertical mattress techniques, tissue adhesives (Dermabond), and exact suture removal timelines.
Resuscitation Quick Actions • First 2 Minutes
Local Anesthesia
1% Lidocaine (max 4.5 mg/kg without epi, 7 mg/kg with epi); buffer 9:1 with 8.4% Sodium Bicarbonate to eliminate injection pain.
Wound Cleansing
Copious high-pressure irrigation (7-8 psi using 18G angiocatheter on 35 mL syringe) with tap water or sterile saline; povidone-iodine and hydrogen peroxide are cytotoxic to exposed tissue and must NOT be used inside wounds.
Suture Sizing
Face: 6-0 Nylon/Fast Gut; Scalp/Extremities: 4-0 or 5-0; Over Joints: 3-0 or 4-0; Subcutaneous/Deep dermal: 4-0 or 5-0 Vicryl.
Tissue Adhesive (Dermabond)
Indicated only for low-tension linear lacerations with cleanly apposed edges; DO NOT place inside the wound or near the eyes.
Suture Removal Timelines
Face: 3-5 days (prevents railroad tracking); Scalp: 7-10 days; Upper extremities: 7-10 days; Lower extremities/Over joints: 10-14 days.
Bottom-Line Clinical Pearl
Modern medical evidence has thoroughly debunked the myth that epinephrine cannot be used in digital or extremity blocks: 1% lidocaine with epinephrine (1:100,000) is completely safe on fingers, toes, ears, and nose in patients without severe active peripheral vascular disease, doubling anesthetic duration and providing superior hemostasis.
| Anatomical Site | Suture Material & Size | Deep Layer (Tension Relief) | Suture Removal Timing |
|---|---|---|---|
| Face & Eyelids | 6-0 Non-absorbable Nylon/Polypropylene OR 6-0 Fast-Absorbing Gut | 5-0 Vicryl (absorbable) deep dermal | 3 to 5 days (strictly remove early to avoid permanent cross-hatch scarring) |
| Scalp | 4-0 Nylon/Prolene OR Skin Staples | 3-0 Vicryl for galea aponeurotica (mandatory to close galea defect) | 7 to 10 days |
| Trunk (Chest/Abdomen) | 4-0 or 5-0 Nylon/Polypropylene | 3-0 or 4-0 Vicryl deep dermal | 10 to 14 days |
| Upper Extremities & Hands | 5-0 Nylon (hand/fingers) or 4-0 Nylon (forearm/arm) | 4-0 or 5-0 Vicryl deep dermal | 7 to 10 days (hand: 10 days) |
| Lower Extremities & Feet | 4-0 Nylon/Polypropylene (5-0 on dorsal foot) | 3-0 or 4-0 Vicryl deep dermal | 10 to 14 days (foot soles: 14 days) |
| Over Joint/High-Tension (Knee, Elbow) | 3-0 or 4-0 Nylon (Horizontal/Vertical Mattress) | 3-0 Vicryl inverted dermal sutures | 12 to 14 days |
| Oral Cavity/Tongue/Lip Mucosa | 4-0 or 5-0 Chromic Gut/Fast Gut (absorbable) | Mandatory 3-layer closure for through-and-through lip lacerations | Absorbs spontaneously in 5-7 days; no removal needed |
| Technique | Primary Indication | Mechanics & Biomechanical Advantage |
|---|---|---|
| Simple Interrupted | Standard linear, low-to-moderate tension lacerations | Basic wound apposition; allows selective suture removal if localized hematoma or infection develops. |
| Vertical Mattress | Deep wounds with tendency to invert; excellent edge eversion | 'Far-far, near-near' stitch. Maximizes wound edge eversion and relieves dead space in thick skin (back, extensor joints). |
| Horizontal Mattress | High-tension wounds, fragile elderly skin, or hemostatic closure | Distributes lateral tension across a broad area; promotes eversion. Can cause tissue ischemia if tied too tightly. |
| Deep Dermal/Subcutaneous | Wounds with dermal gaping or significant tension | Buried absorbable suture (Vicryl) tied with knot at the base of the wound. Relieves surface tension so skin sutures can be tied loosely. |
| Corner/Half-Buried Mattress | V-shaped flaps, stellate lacerations | Passes through deep subcutaneous tissue of flap tip without piercing skin surface; preserves capillary microperfusion to flap apex, preventing flap tip necrosis. |
Practice Recommendation
The 1-mm Cosmetic Rule: In lacerations crossing the vermilion border of the lip, a misalignment of even 1 millimeter produces a visible, permanent cosmetic defect noticed across a room. Always place your FIRST suture precisely at the vermilion border to achieve exact anatomical alignment before closing the remainder of the lip. For full-thickness lip wounds, perform a meticulous 3-layer closure: (1) Oral mucosa (4-0 chromic gut); (2) Orbicularis oris muscle layer (4-0 Vicryl); (3) Skin (6-0 nylon).
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