Hair apposition technique is better than suturing scalp lacerations - Patient-Oriented Evidence that Matters - Brief Article

Journal of Family Practice, Oct, 2002 by Raymond Weick, James J. Stevermer

Hock MO, Ooi SB, Saw SM, Lira SH. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study). Ann Emerg Med 2002: 40:19-26.

* BACKGROUND Suturing scalp lacerations can be a painful, time-consuming procedure. It often requires shaving a portion of the scalp and subsequent suture removal. The search for a less invasive means of wound closure led the authors to develop the hair apposition technique. After cleaning the wound, and without anesthesia, about 4 to 5 strands of hair from each side of the laceration are twisted together once and a drop of tissue adhesive is placed on the twist to hold it in place. A series of twists are placed over the laceration to appose the wound. Patients are instructed not to wash their hair for 2 days. This study compared the hair apposition technique with standard suturing methods.

* POPULATION STUDIED This study was performed at emergency departments at 2 tertiary care centers in Singapore. The authors enrolled 189 patients who had linear, nonstellate scalp lacerations less than 10 cm in length. They did not include patients with severely contaminated wounds, arterial bleeding not controlled with 5 minutes of pressure, hair length less than 3 cm, and medically unstable patients.

* STUDY DESIGN AND VALIDITY This study was a randomized, controlled clinical trial. In a concealed fashion, 93 patients were randomized to suturing and 96 patients to the hair apposition technique. Both groups had their wounds irrigated and cleansed in a similar fashion. The control group was shaved according to local practice and received an injection of local anesthetic; young children sometimes received oral sedation. Hair washing was discouraged for 1 week in the suture group. No subject in the study group received anesthesia or sedation. A senior physician who was not involved in the initial treatment evaluated subjects after 1 week; sutures were removed at that time as well. If complications were noted, the patient was followed weekly for as long as 4 weeks.

This study used reasonable methods. Because blinding was not possible in this study, subjective assessments, such as scarring, might have been biased. Follow-up was nearly complete, with only 1 person not completing the study. Two patients were randomized to the suture group but were treated with the hair apposition technique because of protocol noncompliance. These 2 patients were analyzed as part of the suture group according to the intention-to-treat principle.

* OUTCOMES MEASURED Primary outcome measures were wound healing and the presence of complications including infection, scarring, bleeding, wound breakdown, and allergy. Secondary outcome measures were duration of procedure, pain perception, and patient preference.

* RESULTS Overall, complications were reduced by the hair apposition technique (7.4% vs 21.5%; P = .005, NNT = 7). Most of the difference in complication rates can be attributed to the decreased scarring (at 1 week) found in the hair apposition technique group. Wound breakdown, bleeding, and infection rates were similar in both groups. The hair apposition technique was quicker than suturing (median time of 5 vs 15 minutes; P < .001). Less pain was reported in the hair apposition technique group (median score 2 vs 4 [out of 10 possible]); P < .001). In the hair apposition technique group, 84% claimed they would be willing to have the procedure in the future compared with only 10% in the suture group.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Using hair apposition with tissue adhesive appears to be an effective technique for closing simple scalp lacerations. It is faster and better tolerated than suturing, and appears to result in less scarring. The superficial apposition provided by this technique will not be adequate in those cases were deep sutures are required. Using the hair apposition technique appears to be a practical method of treating scalp lacerations.

Raymond Weick, MD
James J. Stevermer, MD, MSPH
Department of Family and Community Medicine
University of Missouri-Columbia
E-mail: weickr@health.missouri.edu