Scrub out the wound
When I started my surgical training in 2006, I would splash some betadyne on a laceration and then suture it up. Yeah, thats the brown liquid that makes a mess.
Now I regularly scrub the wound with betadyne or another cleanser prior to closure. This minimize bacterial load and removes foreign bodies.
When treating a hand injury on somebody who works in construction, I don’t think that’s enough. After numbing up their hand, I will have them scrub it with soap and water to remove grease and oil. Only then do I use a surgical sterilizer. No point to sterilize a greasy hand.
Remove non-viable tissue
When the skin and deeper layers of tissue are in tatters, their blood supply has been diminished. This is especially true for crush injuries.
If skin edges are dark from a lack of blood supply, suturing dead skin to dead skin does not heal well. Thats why I will typically excise necrotic (nonviable) wound edges to prepare the wound for closure.
Excision of necrotic tissue is very important below the neck. The skin above the neck has a robust blood supply and can tolerate injury that other areas can’t.
Close in layers
I think a difference that plastic surgeons offer in wound closure is that we are comfortable placing deep stitches. I use vicryl or monocryl (both dissolvable) for deep sutures. This decreases “dead space” that could exist if just the skin was closed. I believe that “dead space” is a risk for fluid collection, infection, and a sunken scar.
Deep sutures also reduce tension on the superficial skin closure. This allows plastic surgeons to use small sutures on the skin layer.
Evert wound edges
Because all scars contract, by pushing the skin edges upward during wound closure, we are planning for the scar to contract and become less prominent. If a laceration is closed flat to the skin today, at six months there is increased risk of a sunken or wide scar.
Minimize the use of external sutures
The frankestein deformity is when we see large suture marks on the skin next to the scar. If I can use all internal sutures, then the needle as never passed through the outside of the skin, and there is no risk of this. Occasionally this is not possible such as in the case of a very jagged laceration.
