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Three Part Question

In [patients with scalp lacerations] does [hair apposition or suturing] produce [the best cosmetic outcome]

Clinical Scenario

A small child with a scalp laceration presents to the Emergency Department. You wonder whether the less painful technique of closing wounds with hair apposition will produce as good as a result as suturing.

Search Strategy

PUbMed for MEDLINE 1966-
[wound. ti,ab OR lac*. ti,ab OR laceration. ti,ab] AND [scalp. ti,ab OR head. ti,ab] AND [hair. ti,ab]

Search Outcome

60 papers found, of which 58 were irrelevant. In addition, 1 paper sourced from references

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ong Eng Hock, M. Et al 2002 Singapore	Randomisation of 189 patients of all ages to either hair apposition and glue (95 pts.) or suturing (93 pts.)at 2 tertiary level EDs in Singapore. Inclusion criteria of wound length <10cm, hair length>3cm. Exclusion criteria of active bleeding not stopping after 5/60 of pressure, unstable patients requiring resuscitation, heavily contaminated wounds.	Prospective Randomised controlled trial analysed by intention to treat		HAT and glue vs sutures	Well conducted trial, albeit with relatively small sample size. No documentation of wound depth or characteristics. Non-blinding of study group-including at review; hair shaved in suture group leading to better visualisation of wound at review and possible bias towards poorer appearance. However, wounds were only considered satisfactory if no further treatment was needed-'wounds with recovery of epithelial integrity but with excessive scar tissue...were considered to have healed satisfactorily'. Small follow up period of 7 days, those with complications were followed every week until healed, although no results documented for this group. Longer followup would give a better estimation of cosmetic appearance.
			infection rates	1.1% vs 1.1% (p=1.0)
			scarring rates	6.3% vs 20.4% (p=0.04)
			bleeding rates	0% vs 1.1% (p=0.49)
			wound breakdown	0% vs 4.3% (p=0.057)
			wound healing	100% vs 95.7% (p=0.057)
			pain score during treatment	2 vs 4 (p<0.001)
			duration of procedure	5min vs 15min (p<0.001)
Davies, MJ 1989 UK	Prospective cohort of 25 children aged 11months to 8 years treated by hair-tying and then reviewed at 2 days.	Prospective cohort	wound infection	no cases	Very small study, aims and methods poorly stated, no publication of raw data, no quantifiable results ('wounds appeared to be healing well').
			wound separation (2-4mm)	2 cases
Aoki, N 1996 Japan	Case series of 12 'head trauma' patients with 'superficial scalp wounds'	Case series		'excellent wound healing in all patients'	Paper only seeks to describe closure technique. No inclusion of patient or wound demographics/blinding/methods. No raw data-sweeping conclusion 'In all patients, excellent wound healing was achieved, without infection or unfavourable approximation'.

Comment(s)

Hair braiding has obvious advantages over suturing, namely the speed of the procedure, acceptability to patients and the absence of any possible needle-stick injury; however, questions still remain regarding wound healing. Without prior local anaesthetic infiltration some would argue that a wound can not be fully explored and successfully irrigated leading to an increased risk of infection and later wound dehiscence. Similarly, when using sutures one can oppose deeper layers of skin and evert wound edges in order to avoid possible haematomas or depressed scar formation. Nevertheless, the well-designed RCT by Ong Et al shows that at one week post injury, when most sutured wounds will be reviewed by a GP, hair braiding produces a better cosmetic appearance than suturing with no increase in the infection rate. However, as many emergency departments are moving away from suturing wounds and tending towards the use of tissue adhesives, a more relevant study is needed comparing use of tissue adhesives alone, or in addition to hair braiding.

Clinical Bottom Line

More research is needed comparing hair apposition to closure with adhesives given that the majority of paediatric EDs have moved away from using sutures. Longer-term follow up is required before hair apposition could be considered in full thickness scalp wounds with regards to possible wound dehiscence.

References

1. Ong Eng Hock M, Ooi SBS, Saw SM, Lim SH A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study) Am J EM Jul;40(1):19-26
2. Davies, MJ Scalp wounds. An alternative to suture Inj 1988; 19(6):375-6
3. Aoki N, Oikawa A, Saki T Hair-braiding closure for superficial wounds Surg Neurol 1996; 46(2)150-1