Commentor Question: Lacerations and Plastic Surgeons

This blog is generated from a comment on this post: Medical Myth: Lacerations Need a Plastic Surgeon.

I do read each and every comment to the blog. Usually, I don't comment on real life medical scenarios but I thought this had several good teaching points that could serve the public good.

The comment:

I just brought my 5 y/o into an ED with a puncture wound to the center of his forehead through 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 knots were backward, etc. Should I have insisted that the attending close, or that they call plastics? It was a large urban Children's ER.

Jordyn Says:

Thanks so much for leaving this comment and I hope you see this post.

As a mother and a nurse, I get the parental anxiety around closing lacerations. The truth is that anything that requires sutures is going to leave a scar. That's life. Now, how big or thick the scar is depends on many factors. How it was closed. There is a learning curve to closing the skin. Lacerations can actually be closed too tightly which can be as problematic as not bringing the edges close enough together.

That being said, there are many other factors that determine how the scar will look. Does it become infected? How does the patient normally scar? Some people genetically develop very heavy scarring (called keloid scarring) and there's nothing we can really do about that. Also, after healing, how much is it exposed to the sun?

Now, should you have allowed a resident to suture your child?

From the medical side-- students need to learn and must practice, at some point, on live patients. I'm glad this first year was being monitored during the procedure. That's what should have happened. Knots being tied backwards and needing to be redone doesn't mean you'll have a bad outcome. Experienced physicians redo sutures all the time. It's more the final closure that's important.

From my nursing/mother standpoint-- you have the right to refuse a resident practicing on your child. If you are uncomfortable then absolutely speak up and state your request plainly-- "I'm sorry, but I'd like an attending to close this laceration."

Some people are uncomfortable with a nurse practitioner or physician's assistant doing a laceration repair and request an attending. Keep in mind, that mid-level provider may have more experience than your attending physician. They may have been in practice four times as long! So maybe ask how many years they've been practicing as an attending before you pass over on a mid-level provider.

If you feel that you can't make this request to the doctor directly, then you need to tell your nurse who should advocate for you.

Should you have insisted on a plastic surgeon? The truth is that pediatric ER providers close lacerations every day on moving targets-- we don't commonly sedate kids for simple laceration repairs. Plastic surgeons are generally only utilized for complex laceration repairs and would honestly be annoyed to come to the ER for a simple repair.

If you don't like how the wound healed and the scar it left behind then you can consult a plastic surgeon to investigate a scar revision.

Hope this helps.

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?