Emergency physicians can also employ hair apposition technique in addition to suturing and stapling in the treatment of scalp lacerations. In our study, hair apposition technique was associated with a higher rate of satisfaction than other techniques 7 days and 15 days after the procedure.
Hock et al., in a study where they used techniques of suturing and hair apposition in patients with scalp laceration, included lacerations up to 10 cm but did not mentioned about any relationship between the technique used and laceration length . Both our study and previous studies suggested that a hair length of at least 1 cm is essential for application of hair apposition technique in scalp lacerations [7, 8]. In our study there was no significant difference between the technique used and hair length.
Hock et al. compared complication and healing rates 7 days after treatment of scalp lacerations with suturing or hair apposition techniques and reported that wound healing and scar formation occurred more commonly in suturing whereas rates of infection or bleeding were not different in both groups . Karaduman et al. used all three techniques in scalp lacerations and reported no cases of infection 7 days after the procedure. They reported abnormal hair growth in a patient who was treated with hair apposition, which was attributed by the authors to excess amount of glue used in the procedure, causing spread of glue in the wound . Ong et al. used suturing or hair apposition in scalp lacerations and reported fewer complications 7 days after the procedure with the hair apposition technique . Kanegaye et al., in a study on pediatric scalp lacerations, compared stapling and suturing with respect to complication rates 7 days after the procedure and reported fewer complications in stapling group . We also found that the highest complication rate was with suturing. The most common complications 7 days after the procedure included redness, pain, and hair loss, which occurred most commonly with suturing followed by stapling and hair apposition techniques. The highest rate of infection was associated with suturing technique followed by stapling technique. Hair loss, an important cosmetic problem, occurred most commonly with suturing followed by stapling technique whereas hair apposition technique was not associated with hair loss 7 days after the procedure. Hock et al. reported a higher rate of satisfaction in patients treated with hair apposition technique compared with those treated with suturing technique. This high rate of satisfaction was related by the authors to the properties of the technique including quick application, less painful nature due to absence of need for anesthesia, and absence of need for shaving and suture removal . Karaduman et al. applied all three techniques to their patients with scalp laceration and looked at patient satisfaction on day 30th. They reported a high rate of satisfaction in those who were applied hair apposition technique and 97% of patients would prefer this method in the event they sustained a scalp laceration in the future . The rate of satisfaction was related with the technique used, such that patients were dissatisfied with stapling and suturing while dissatisfaction rate was quite low. In our study, Assessment of 7th and 15th day satisfaction rates revealed significant differences in favor of hair apposition technique. The painless nature of the technique and absence of suture removal may have increased patient satisfaction. In our study there was a significant association between the technique used and emergence of cosmetic problems 15 days later. We found that cosmetic problems were most prevalent in patients treated with suturing while they were least common in those managed with hair apposition technique. We think that this is because there was no need to shave hairs in this technique and we carefully placed only one drop of glue on the crossed strands without bringing the glue into contact with the wound. Otherwise excessive amount of glue will result in hair knots, leading to haircut while contact of tissue adhesive with laceration will result in decreased hair growth . Kanegaye et al. compared the cosmetic outcomes of stapling or suturing in pediatric scalp lacerations 1 week after the procedure when they removed suture materials. They reported no cosmetic problems in stapling group .
In literature there are plenty of studies on application time of these techniques. Hock et al. compared suturing and hair apposition techniques with respect to application time and found that hair apposition technique was applied in a shorter time than other technique . Kanegaye et al. reported that stapling technique was applied in a shorter time compared to suturing in pediatric patients with scalp laceration . In a surgical study stapling and suturing techniques used in the treatment of long lacerations were compared in terms of application times. Stapling technique was reported to be associated with five-to-seven times shorter times compared with the suturing technique [12–15]. Karaduman et al., in a study examining the hair apposition and suturing techniques in emergency department patients with scalp laceration in terms of application times, reported that hair apposition technique was associated with shorter procedure time . As our study was retrospective, we could not gather any information on application times. However, experience from our daily practice suggests that stapling method can be performed in a relatively shorter time.
Ong et al. compared hair apposition and suturing techniques in terms of treatment cost in scalp lacerations and reported that hair apposition technique had a significantly lower cost. They related that result to a shorter time of the procedure, absence of need for anesthesia and suture removal, and low complication rates. They expressed that the rate of scalp lacerations in EDs remain high and this technique would provide considerable cost saving . Orlinsky et al., in a general study on costs of treatment of scalp lacerations in emergency departments, found that stapling was considerably advantageous with respect to overall cost . We did not perform a cost analysis.
Hair apposition technique may be used more commonly in daily practice by virtue of its low complication and cosmetic problem rate coupled with high patient satisfaction rate. Determination of the ideal wound closure technique requires more prospective, randomized controlled studies with larger sample size that investigate factors effective on wound healing and satisfaction level.