Friday, March 11, 2011

Medical Myth: Lacerations need a Plastic Surgeon

Over the next three Fridays, I'm going to dispel some pretty popular medical myths that are perpetuated in books, on TV, and on film. Today we're focusing on the skill of the plastic surgeon.

Here's a common ER setup. A child comes in with a simple laceration to the face. Let's assume for the purpose of this blog post it's a one inch cut to the face that is not through any critical structures. I, your happy triage nurse, bring you into the triage room for your child's weight and vital signs and the first thing the parent says is, "We're going to need a plastic surgeon for this." My happiness bubble has burst.

First of all, anything that requires suturing is going to leave a scar, no matter who stitches it. It's the nature of how your body heals. The amount of scarring left after suturing depends more on you than the doctor assuming the doctor does a nice job stitching. Did the wound get infected? How does your body normally scar? Some people develop very heavy scars called keloids. Did you protect the skin from sun after the stitches were placed? All these factors play in to the amount of scar that is seen. It will take anywhere from 6-12months to know what the scar will look like.

 Secondly, there seems to be the general impression that if a plastic surgeon closes the cut, it will not scar. Let me pose this to you. If this were true, why do plastic surgeons hide their incisions up in the hairline, behind the ear, etc? Why not cut right down the middle of the forehead? They hide their incisions because they know a certain amount of scarring is going to happen. Surgical incisions are deep cuts. Just clean ones.

Lastly, plastic surgeons are generally unavailable to come to the ER for minor laceration repairs. We don't even have plastics on call for our ER. Emergency physicians are very adept at closing lacerations, even complicated ones.

The conflict arises when I begin to outline all of the above. What do you mean, there isn't a plastic surgeon? If you're unhappy with the repair, you can always consult a plastic surgeon at a later date for a scar revision. But, have some faith that the ER doctor will do a great job. They do stitches every day. If they think it is beyond their capability, they will let you know.

Are you afraid of your child having a simple scar on the face? Why?


  1. Jordyn - I actually have some experience with this topic.
    Thirty years ago I was in a serious car accident. I broke my nose on the steering wheel. It was after midnight, I had lost a lot of blood, and the bones in my nose were sticking out of my face (sorry if this is too graphic). The ER doctor decided that it was - as you phrased it - beyond her ability. She called in a plastic surgeon who put my nose back together at 3 am that night.
    Today I have a slight scar that is hardly noticeable, and I am grateful for an ER doctor who did the right thing!

  2. Thanks for your comment, Ava. Wow, how scary! So glad that you are all right now. And yes, kudos to your ER doctor for knowing her limits. Considering what you describe... I think she was right to do so. Sounds like you had a lot more going on than a simple laceration.

  3. Jordyn, can I ask a question? I was wondering about a scenario in my current book I'm working on. A character has a long cut down her forearm. She doesn't get it stitched up for a few days. After a few days, would a doctor still be able to stitch it up? Or would it already be healing in such a way that he couldn't? I realize this might have a lot to do with how deep the cut is, but I was wondering also how a cut would look after it starts to heal without stitches.
    I hope I'm making sense! :-)

  4. Melanie,

    Thanks so much for your comment and question.

    No, a doctor would not stitch a wound after a few days. There is a time limit for obtaining stitches. A good rule is 6-8 hours. An long outside shot may be 24 hours if the doctor felt the risk of wound contamination was relatively low.

    The reason for the short time of 6-8 hours is risk of infection. The longer the wound is open, the more chance it has for contamination. If we stitch something up that has been open longer than this... risk of infection is high (it really is high anyway) and may "trap" some bacteria into the wound.

    A cut that is not stitched and left gaping open is going to leave a pretty nasty scar. Your character can minimize scarring by perhaps using butterfly closures, tape, some other creative measure, to bring the edges of the wound close together. If you character can do this well, the scarring can be minimized.

    Infection into the wound increases visible scarring so if there is a way for her to wash it out with really clean water (say she boils water and lets it cool)... this will help decrease her chance of infection and help to minimize scarring.

    Hope this helps.


  5. Thanks, Jordyn! That really does help!

  6. True, if it is indeed the experienced ER physician himself closing a nasty deep laceration, and not some medical student "learning on the patient." Most patients/parents want the most experienced doctor to place those deep sutures, and throw those knots, which hopefully are not too tight (leading to tracking) or too loose (increasing risk of scar widening).

    Your premise does not account for today's increasing reality of paraprofessionals and medical students manning the ER and operating (without true informed consent or perhaps even specific permission) on the patient. This certainly can lead to a compromised or worse looking "scar".

    For large, non-linear, ragged lacerations with deep wounds, a plastic surgeon, surely a plastic surgeon has a duty to be consulted to close the cut. If none are on staff that is different. As the physician the question is "who can do the best job from experience level," not "who is available" or "who will pick up payment". Complications can and do arise, and the absence of calling a staff plastic surgeon on a prominent skin laceration may be folly.

    Sorry to disagree with you here. I believe as physicians one must always do that which is medically in the best interest of the patient from an experience point of view.

  7. To anonymous: Thank you so much for your comments. You bring up several good points for discussion.

    For the purpose of the post... I did qualify that it was a simple one inch cut not through any critical structures. Most experienced ER physicians will be able to close these with good outcomes without requiring plastics. In my experience, if the doc is uncomfortable they do consult a specialist. However, this is a very small percentage of cases which is what I think many people don't realize is how much an ED doctor is capable of doing well.

    You do bring up an excellent point about paraprofessionals and students "learning" and the outcome of the scar in those situations.

    A couple of points... I do think it is paramount to know the position and experience level of those doing the closure. If in doubt, the patient or parent should ask to be able to make an informed decision.

    However, I may persoanally choose the nurse practitoner who has been closing lacerations for ten years over the "attending" MD who just started his new job that day. I think some people are comforted by seeing the "doctor" not realizing the nurse practitioner may have years more experience. Again, all of these issues should be readily disclosed so patients and parents of patients can decide what is best for themselves.

    I'm all for disagreement and for respectfully arguing a point... which you did beautifully.

    And writing is all about conflict. The points you bring up can help add tension to any scene.

  8. Hi there. Good post. I just brought my 5 yo into an ED with a puncture wound to the center of the forehead though which you could see his skull. I thought the attending would close the wound, but the resident did under supervision. First year, and it was late July. What are the chances of a good outcome. The attending had to tell the resident that the knots were backwards, etc. Should I have insisted that the attending close, or that they call plastics? It was a large urban children's ER.

  9. Hi Jordyn,
    I know your post was some time ago now but I was wondering..I had a pretty nasty cut about an inch above my wrist awhile back and I had to stay in hospital until a plastic surgeon could do the job. I was totally confused and still am. After reading this am I right too assume they had a plastic surgeon do it too just reduce scarring?? As I said it was a bad cut, and damaged tendon. I have never understood why another surgeon couldn't just do it, they had to call plastics. The cut wasn't exactly in a place one would care about a scar, well not me anyway.
    The scar is barely noticeable though except when I'm cold it turns purple, pretty cool haha

    1. Hi Taryn,

      Thanks for leaving your comment.

      Each hospital system is different but my guess is the reason they called the plastic surgeon (although, I would have said hand surgeon if you had tendon damage) was likely the tendon damage. Or, just the fact that you cut deep enough to affect a tendon could have meant it was too extensive for the ER doctor. An ER doctor does have limits. They can't so up everything.

  10. The problem is this. The payment or reimbursement is based on the time of an emergency room doctor, who does not have office overhead, and does not have to drive in. A plastic surgeon does not get paid more, and has not only very high office overhead, but is on call, usually unpaid, and drives in and spends more time. The reimbursement from most insurance companies is the same as the emergency room doctor would get despite the extra time, training and costs. In addition plastic surgeons compete against many non plastic surgeons doing their work that pays the bills. The old rules of providing a service to the community has been broken by the community wanting competition. In other words, no one wants to pay for the plastic surgeon, the patient, the insurance company or society. For those reasons most plastic surgeons can no longer do them. The author is right on, there is no difference, there will be a scar, and they can be revised later under optimal conditions.
    If patients want this luxury someone needs to step forward and compensate fairly.

    1. This is a pretty interesting perspective, Ben, and an angle I hadn't really heard of. At least in pediatrics, we still do get requests for plastics. I think, sometimes, if parents could be guaranteed there would be no scar-- they might pay anything. Even if the scar doesn't disfigure the child in any way. Of course, nowadays, what I might call a simple scar is disfiguring to parents. Go figure.