Is there a doctor in the house -- stitches

mikeland · Feb 7, 2008

Greatly appreciate insight on the following:

In my WIP, a five-year-old falls out of a tree and opens up a gash on his face from cheekbone to jaw. How many stitches would that require? The accident happens in the mid-90s, if that makes any difference.

Thanks in advance for any insight.

PattiTheWicked · Feb 7, 2008

Not a doctor, but a mom whose five year old ran into a fishtank and required stitches...

It's going to depend on the length of the laceration. My son had a fish-hook shaped avulsion on the bridge of his nose, with a total length of just under one inch. He had six stitches placed, and then Steri-strips over top of that.

ColoradoGuy · Feb 7, 2008

I've stitched up a lot of kid's faces over the years. As a general principle, we use as few stitiches as we can get away with in order to bring the tissues together without pulling or putting traction on the skin (this is key). The other way we allow the skin surface to have the cut edges gently touch one another is to use a second (or sometimes third) layer of dissolving stitches beneath the skin to absorb much of the tension. It is now common to use such subcutaneous stitches to hold things together and then use tissue glue to cement the skin edges together. Minor lacerations can often just be glued without any sutures at all.

The standard suture material for the face is called prolene (which looks like fishing line because it is) and the standard for dissolving suture is called vicryl. Suture comes in sizes ranging from 0 (huge) to 7-0 (cobweb size).

Facial stiches usually come out at 5 days or so.

The standard book about how and why to do this is Wounds and Lacerations by Alexander Trott. It's a good book.

mikeland · Feb 7, 2008

Thanks, Patti. That must have been scary. My son and daughter have had run-ins with playground equipment and a coffee table, respectively. But those cuts were stapled and glued -- no stitches.

Thanks, ColoradoGuy. That's a lot of helpful info and detail. And a great book recommendation. I always like to have go-to reference materials. Appreciate your insight.

Tsu Dho Nimh · Feb 7, 2008

For a facial laceration they will probably call a plastic surgeon to do the work ... it can be as complicated as you need.

Depends on how deep: every damaged layer gets aligned and stitched, nerves have to be found (maybe) and placed together so they can heal, the skin layers get stitched ... finally the visible layer is stitched or glued.

If it's stitched, you will see a lot of very fine stitches with very fine thread ... teeny little railroad tracks.

ColoradoGuy · Feb 7, 2008

Tsu Dho Nimh said:
For a facial laceration they will probably call a plastic surgeon to do the work ...

Actually--no, unless it is an especially complicated laceration. I've done this for many, many years and I'm not a plastic surgeon. This is often the case at smaller ERs.

johnnysannie · Feb 8, 2008

ColoradoGuy said:
Actually--no, unless it is an especially complicated laceration. I've done this for many, many years and I'm not a plastic surgeon. This is often the case at smaller ERs.

I agree and I'm just a mother

. My daughters stitches were done by the ER doctor. When I was a small child myself, I slit open my left eyelid in a swingset accident and the doctor at a small clinic sewed it up. Fortunately for me there was no eye damage.

Tsu Dho Nimh · Feb 8, 2008

ColoradoGuy said:
Actually--no, unless it is an especially complicated laceration. I've done this for many, many years and I'm not a plastic surgeon. This is often the case at smaller ERs.

All my work was in teaching hospitals and major trauma centers ...

johnnysannie · Feb 8, 2008

Tsu Dho Nimh said:
All my work was in teaching hospitals and major trauma centers ...

In smaller hospitals, there isn't a plastic surgeon available. Major facial lacerations would probably be referred to the next larger town or city where one is available but for a kid with a gash or cut, in smaller towns and rural areas, stitches are still the norm.

Maybe we're just backward.....

GeorgeK · Feb 8, 2008

Unfortunately if you are at a teaching hospital and ask for the "plastic surgeon On-Call" what you will get is the surgical intern rotating on Plastics. I'm sure there's a regional bias on which suture is more or less scar inducing. We would have used nylon on the face, with prolene a close second (probably since small nylon was cheaper rather than truly less reactive). Vicryl would be a no-no since it is braided and therefore more likely to get infected and hence more likely to induce scarring. For an absorbable subcutaneous layer we would have used chromic, but since non surgeons don't count the stitches you don't see, I'd suggest steri-strips on the skin and no external stitches. Fewer holes mean less scar tissue as long as you can somehow keep the edges together. Glue wasn't widely available in the mid 90's but would likely be a good choice if available. There was one intern that we ribbed for years about him using staples on somebody's face. We probably were like the surgeons of 100 AD looking down our noses at Galen for washing wounds instead of pouring boiling oil in stab wounds. Surprisingly, in follow up it didn't look bad.

reigningcatsndogs · Feb 8, 2008

This is maybe straying off topic, but may I please dip into the medical knowledge well? What about using scotch tape to close a wound? I ask because MANY years ago I took a 4" rusted spike in the back of the leg. The tear was down to the bone, and it went from the cheek to back of knee. We were rural and the 900 year old doctor there at the time said that using scotch tape was state of the art and left no scarring. He was DECIDEDLY wrong about the scar, especially since the wound became incredibly infected and developed sores around the entire perimeter.

I was just wondering, though, is it really something that was commonly practiced? Would a doctor use cellophane tape to close a wound and under what conditions would it work best? (the issue of facial wounds needing attention comes up in my WIP as well, and the scotch tape fleetingly crossed my mind)

Sorry Mikeland, I hope you don't mind the added question!

mikeland · Feb 8, 2008

Thanks again to all who have answered my question. Very helpful all around.

Reigningcatsanddogs, no worries about the hijack. Your issue is definitely more interesting than mine. I officially turn the thread over to you and look forward to hearing from the assembled medical personnel on this one.

(And just for the record, I'm having phantom pains in my leg thinking about that spike -- yikes!)

Tsu Dho Nimh · Feb 8, 2008

reigningcatsndogs said:
This is maybe straying off topic, but may I please dip into the medical knowledge well? What about using scotch tape to close a wound? I ask because MANY years ago I took a 4" rusted spike in the back of the leg. The tear was down to the bone, and it went from the cheek to back of knee. We were rural and the 900 year old doctor there at the time said that using scotch tape was state of the art and left no scarring. He was DECIDEDLY wrong about the scar, especially since the wound became incredibly infected and developed sores around the entire perimeter.

I was just wondering, though, is it really something that was commonly practiced? Would a doctor use cellophane tape to close a wound and under what conditions would it work best? (the issue of facial wounds needing attention comes up in my WIP as well, and the scotch tape fleetingly crossed my mind)

Sorry Mikeland, I hope you don't mind the added question!

With that sort of wound ... EWWWWW!!!! You need some careful debris removal, antiseptic washing, stitching of all the underlayers, and then good skin closure with whatever is suitable. Scotch tape was NEVER intended to be used on skin!

Something like that is going to scar - the only question being how much.

Tsu Dho Nimh · Feb 8, 2008

Living in rural Montana often means you ARE the closest and best source of help.

My sister slashed the webbing between her thumb and forefinger ... my dad, after finding out that she could move all fingers and had good sensation, did the stitching according to his (then) 10-year old WWII Navy medic training. By the time she was in high school, it was a faint scar line with a few tiny suture marks dotting along the side.

I have a few places he did the stitches for, and the reaction of surgeons is usually "wow, that's almost invisible!".

ColoradoGuy · Feb 8, 2008

GeorgeK said:
Unfortunately if you are at a teaching hospital and ask for the "plastic surgeon On-Call" what you will get is the surgical intern rotating on Plastics. I'm sure there's a regional bias on which suture is more or less scar inducing. We would have used nylon on the face, with prolene a close second (probably since small nylon was cheaper rather than truly less reactive). Vicryl would be a no-no since it is braided and therefore more likely to get infected and hence more likely to induce scarring. For an absorbable subcutaneous layer we would have used chromic, but since non surgeons don't count the stitches you don't see, I'd suggest steri-strips on the skin and no external stitches. Fewer holes mean less scar tissue as long as you can somehow keep the edges together. Glue wasn't widely available in the mid 90's but would likely be a good choice if available. There was one intern that we ribbed for years about him using staples on somebody's face. We probably were like the surgeons of 100 AD looking down our noses at Galen for washing wounds instead of pouring boiling oil in stab wounds. Surprisingly, in follow up it didn't look bad.

Not to derail and talk too much shop, George, but most of the folks I know use vicryl for the subQ now unless it's a real dirty wound (of course the wound needs to be cleaned out well first). I don't think I could even find chromic in the laceration cart anymore--someone would have to run and get it from somewhere. I've seen most folks gravitate from nylon to prolene over the last decade. My main gripe with prolene is that it's the same color as the blue towels and that 5-0 stuff is tough to see.

ColoradoGuy · Feb 8, 2008

reigningcatsndogs said:
This is maybe straying off topic, but may I please dip into the medical knowledge well? What about using scotch tape to close a wound? I ask because MANY years ago I took a 4" rusted spike in the back of the leg. The tear was down to the bone, and it went from the cheek to back of knee. We were rural and the 900 year old doctor there at the time said that using scotch tape was state of the art and left no scarring. He was DECIDEDLY wrong about the scar, especially since the wound became incredibly infected and developed sores around the entire perimeter.

I was just wondering, though, is it really something that was commonly practiced? Would a doctor use cellophane tape to close a wound and under what conditions would it work best? (the issue of facial wounds needing attention comes up in my WIP as well, and the scotch tape fleetingly crossed my mind)

Sorry Mikeland, I hope you don't mind the added question!

He was not only 900 years old--he was also an idiot.

chevbrock · Feb 8, 2008

Cats and Dogs - It was a wonder he didn't instruct you to drink half a bottle of whiskey and then pour the other half over the wound as well!

reigningcatsndogs · Feb 8, 2008

Tsu Dho Nimh said:
With that sort of wound ... EWWWWW!!!! You need some careful debris removal, antiseptic washing, stitching of all the underlayers, and then good skin closure with whatever is suitable. Scotch tape was NEVER intended to be used on skin!

Something like that is going to scar - the only question being how much.

Yeah, it scarred -- about two inches wide and about ten inches long.

He dumped alcohol on it and then taped it up. When all the sores started appearing around it, he thought perhaps I was allergic to tape, but he said there was nothing else he could do because it was a couple days later and he couldn't put stitches in then. I was six at the time, remember it very vividly (especially the alcohol) and spent the next three months pretty much on my stomach with heat lamps and something else that I can't remember pressed onto the back of my leg.

Glad I asked thought cause I honestly thought it might be okay in some cases. Guess I won't include it in the WIP!! Thanks so much for the feedback guys, and thanks Mike for the tiny derail. You guys are awesome.

ColoradoGuy · Feb 8, 2008

Nutty as the doc was, it is true you should not sew up an old, dirty wound, especially a deep one, because it just keeps the infection inside. Most folks use 24 hours or so post-injury as a cut-off for when it is safe to close it primarily. If it can't be closed it has to heal, slowly, as yours did by what's called "secondary intention." A plastic surgeon could probably help things quite a bit, even now, if you want the scar revised.

The scotch tape thing was insane, though.

reigningcatsndogs · Feb 8, 2008

ColoradoGuy said:
Nutty as the doc was, it is true you should not sew up an old, dirty wound, especially a deep one, because it just keeps the infection inside. Most folks use 24 hours or so post-injury as a cut-off for when it is safe to close it primarily. If it can't be closed it has to heal, slowly, as yours did by what's called "secondary intention." A plastic surgeon could probably help things quite a bit, even now, if you want the scar revised.

The scotch tape thing was insane, though.

I should be thankful then for small mercies! I imagine if he had decided to stitch it at that point it would have been a bit longer healing.

He really was older than dirt but he was all there was for about 100 miles. Thanks for the info, Colorado.

Shwebb · Feb 8, 2008

Our son had a facial laceration between the eyes when he was two years old. My husband, Mr. Paramedic, panicked a bit when our son hit his forehead on the table and got a 3/4 inch laceration that looked like someone sliced him open with a knife.

I tried butterflying it--I was rather proud of my handiwork, actually--but my son wouldn't leave the bandage alone. So my husband had to cart the toddler off to the ER, where the doc and he papoosed Ethan so the doc could put five stitches in him. He'd have used the glue, but it was an area of tension; he also knew my son would probably pick at it until it opened back up.

ColoradoGuy, you're right on the money, as usual. But then, who am I to tell you how to do your job?

GeorgeK · Feb 9, 2008

ColoradoGuy said:
Not to derail and talk too much shop, George, but most of the folks I know use vicryl for the subQ now unless it's a real dirty wound (of course the wound needs to be cleaned out well first). I don't think I could even find chromic in the laceration cart anymore--someone would have to run and get it from somewhere. I've seen most folks gravitate from nylon to prolene over the last decade. My main gripe with prolene is that it's the same color as the blue towels and that 5-0 stuff is tough to see.

Yeah, it's mostly the Urologists that seem to prefer the chromic. They didn't have it on the trays where I worked until I asked for it. It can be amusing to watch surgeons debate the vicryl vs chromic, braided vs monofilament until they are blue in the face, but the numbers do tend to work out about the same for like you said, the subcutaneous as long as there are no foreign implants. For external stitches I preferred chromic dipped in KY jelly. It really made a nicer scar and vicryl took too long to dissolve. People tend to not to sit still very well if you are having to take stitches out of their penis, so if they've all fallen out by the 3 week post op check it was a lot smoother.

5-0 on the skin...you must be doing peds stuff or face. Nylon is easier to tie and only needs 3 knots so it saves time and is cheaper. Proplene needs about 8 knots and tends to break a lot, but from a wound standpoint is the same. Tell whoever is ordering to get the green towels. They cost the same but make seeing everything easier. The smallest I've worked with was 12-0 chromic for a vas reversal. Those things are a real pain to see without a microscope.

Cellophane tape to close a wound? It's not designed to stick to skin, not sterile or even clean. If you are having to MacGyver it, I guess it might be better than nothing.

ColoradoGuy · Feb 10, 2008

GeorgeK said:
5-0 on the skin...you must be doing peds stuff or face . . .

Yep, often peds stuff on the face. And you're right, prolene takes a whole bunch of knots to stay tied. Off the face I use nylon mostly.

Sandi LeFaucheur · Feb 11, 2008

Glue wasn't widely available in the mid 90's

Isn't that odd? It was in use in England since the mid-to-late 80s at least. My son had a habit of falling of walls, chairs, etc, and so has had more glue sticking parts of his head together! I remember, though, watching US/Canadian medical programs and wondering why they didn't glue instead of stitches. I would have thought it's much less scary for the child. And regards scars, he only has one tiny scar on the back of his head where hair won't grow.

HeronW · Feb 11, 2008

Wouldn't the amt of stitches on a upper layer skin laceration also depend on the activity area--whether the cut was over bone or low-movement area vs lots of motion/stretching around the mouth?

Is there a doctor in the house -- stitches

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