Whether at the playground, reaching for something high on a shelf, or just running into a coffee table, childhood lacerations are a part of everyday life. When my boys were little, I used to joke that I would follow them around with pillows. The wonderful news is that small children usually heal very well. Most falls leave only bumps and bruises but occasionally a child will need stitches or sutures.
What should I do first?
Faced with a crying child and oozing blood can be very alarming. The most important thing to do is to apply pressure so that the bleeding stops. Find a clean towel and hold pressure directly over the wound for five minutes. Most bleeding will stop in a few minutes. Then clean the wound with warm water and examine it. Make sure there is no foreign material in the wound like glass, dirt, wood or metal which could lead to an infection later.
Do I need stitches?
Once you examine the wound, try to assess if the bleeding is from an abrasion (scratch) or if the skin has a true defect. If there is only an abrasion, then clean the wound with soap and water and apply a thin coat of bacitracin ointment and a band-aid to it. Repeat this daily until a scab forms. If there is a skin defect, the edges of the skin are spread apart from each other and you see fatty tissue, then you should seek medical attention. You can apply ice to the wound to help decrease the swelling.
Should I request a plastic surgeon?
Of course I am biased. There is a broad range of specialties among emergency doctors and pediatricians. Not everyone feels as comfortable as a surgeon to place sutures. The ultimate goal is to close the laceration by re-approximating the skin edges with minimal tension. Although many emergency room physicians can close a simple laceration, there are some subtleties that elevate an adequate repair into an excellent one. When a wound is jagged, uneven, or when there is skin missing, a plastic surgeon is more likely to revise the wound edges and close the wound in multiple layers to give you the best possible outcome.
What type of anesthesia will my child require?
Almost all wounds can be closed under local anesthesia. Lidocaine will be injected into the wound prior to any stitches being placed. I use a mixture of lidocaine with the vasoconstricting agent epinephrine when I repair most lacerations. The epinephrine not only reduces bleeding but also blanches the skin around the wound so that even though the child may be crying because he/she is scared, I know that the area is numb. It is always upsetting to see a small child frightened but it gives me peace of mind knowing that I am not hurting him.
Sutures or Glue?
My preference is usually sutures. I know that I will be able to control the re- approximation of the wound edges by placing individual sutures. With that said, if the wound is only a skin defect and the skin edges are not spread apart, then dermabond or surgical glue is a good option. Dermabond is fast and does not require any local anesthesia.
Dissolvable or Non-Dissolvable sutures?
Different sutures are used for different areas of the body. Dissolvable sutures are often used for inside the mouth, parts of the lip and in young children who will not tolerate having the sutures removed. Dissolvable sutures will fall out in a few days once they have been wet. Unfortunately, they are not as strong as permanent sutures and could possibly fall out too quickly. In most cases, I will use dissolvable sutures deep in the wound to remove tension from the wound’s surface and then use permanent sutures on the skin.
When should I take out the sutures?
Sutures on the face should be removed in a week and on the body in 10-14 days.
Can my child bathe?
Do not allow the wound to get wet for 24 hours on the face and two days on the body. Do not soak the wound in a bathe or swimming pool for two weeks.
Will there be a scar?
If the cut is through the skin and you see fatty tissue, then there will be a scar. The trick to plastic surgery is to decrease the width of the scar. We improve the appearance of scars by closing the wound in multiple layers to decrease the tension of the skin’s surface leading to a thin line instead of a wide depression.
How can I improve the scar?
The scar takes up to a year to mature. The wound will be red for three to four months after the sutures are removed. I find that placing a silicone ointment twice a day once the sutures are removed is helpful to reduce redness and flatten the scar faster. Silicone strips can also be useful. It is important to wear strong sunscreen when outside. I recommend using an SPF of 45 or 50 on the scar for six months. Scars can also be revised when your child is older. It is easier to make a beautiful scar with a scalpel than with pavement. Lasers are helpful in improving texture and pigmentation.