sew what

Tuesday, November 30, 2010

Basketball players drive to the net all the time, elbows get in the way and a lip gets cut. Injuries are part of the game. But when the President of the United States busts a lip, it’s big news. And the press seems to be caught up in the fact that he got 12 stitches and that the docs used tiny thread to sew him up. Sewing is one of the fun parts of medicine. In the ER, it’s the one time that the doc can sit down and spend uninterrupted time with a patient. In the OR, it means that the operation is over and the sewing up the incision literally gives the surgeon closure.

There is often a disconnect between the expectations of the patient and the doctor when it comes to lacerations. The patient hopes to have no scar at all when a wound is repair. The physician would like to have minimal scarring but is more interested in making certain that there is no internal damage to stuff lying underneath the cut and that risk of infection is minimized.

First things first. All wounds will heal eventually and the priority is to learn how the injury occurred and what potential disasters might befall the patient. The risk of infection is pretty minimal for an incision made in the operating room under sterile conditions, compared to a dog bite to the face. In the OR, the surgeon is careful not to cut tendons, arteries and nerves but in the rest of the world, all those structures are fair game to be injured. It is perhaps most important that the doctor caring for the laceration be more interested that everything is working under the skin than to make the skin look pretty. That said, there is an art to making scars look good.

The key to good results starts with trying to minimize tension and inflammation at the wound edges. It is also important to try to get the layers of the skin to align at the same level to prevent step offs at the wound edge. This leads to shadowing and makes the scar appear more prominent. Sometimes the location of the cuts helps out with these goals but sometimes it isn’t so helpful. When you look at the skin, there are some natural creases called Langer’s Lines. Cuts that follow these lines tend to heal better than those that go across the grain. Burst lacerations are harder to hide than ones with a simple straight line.

Tension on the surface of the skin is decreased if the layers of the skin beneath the surface are lined up well and with deeper cuts, dissolvable sutures need to be placed to get those deep layers to come together. That allows the top layer of skin to come together and the sutures that are placed at skin level don’t have to do much work to hold the edges together. The less tension placed on those skin sutures allows thinner thread or suture material (often nylon or polypropylene) to be used.

People always want to know how many stitches are needed to close a wound. The answer is: it all depends. Usually, one starts sewing at one end of the cut and doesn’t know how many it will take to get to the end. No different than hemming a seam, you use enough to be done. That said, for the same laceration length, you need to put thinner sutures in place than if you use thicker ones. Thinner sutures placed closer together will leave less tension on the skin edge and potentially end up with a better scar. Sometimes, though, you need stout thread. If the laceration is located over part of the body that moves like a joint, the repair line has to be able to withstand the pulling apart of the skin and thicker thread is needed to prevent the wound from ripping open.

The interesting thing about wounds is like fine wine, they need time to mature. For the first three months there will be a red, raised healing ridge. It then flattens for the next three months and finally the scar begins to weather. It may take 6 or 8 months to appreciate the final product, which seems forever in out instant gratification world.

For the next few months, the President will be on display and we should all be able to view the handiwork of the doctor who sewed him up. I wonder what it was like at the bedside while the wound was cleaned and the sutures placed. It’s often a time for the doctor to visit and make small talk with the patient. Not often do you get real information when you ask your patient…so, what’s new in the world today.

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