A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study)

doi:10.1067/mem.2002.125928

Annals of Emergency Medicine

Volume 40, Issue 1, July 2002, Pages 19-26

Presented at the American College of Emergency Physicians Research Forum , Chicago, IL, October 2001, and at the Second Society for Emergency Medicine in Singapore (SEMS) Annual Scientific Meeting, Singapore, February 2001.

https://doi.org/10.1067/mem.2002.125928 Get rights and content

Abstract

Study objective: We evaluate a new technique of treating scalp lacerations, the hair apposition technique (HAT). After standard cleaning procedures, hair on both sides of a laceration is apposed with a single twist. This is then held with tissue adhesives. HAT was compared with standard suturing in a multicenter, randomized, prospective trial. Methods: All linear lacerations of the scalp less than 10 cm long were included. Severely contaminated wounds, actively bleeding wounds, patients with hair strand length less than 3 cm, and hemodynamically unstable patients were excluded. Patients were randomized to receive either HAT or standard suturing, and the time to complete the wound repair was measured. All wounds were evaluated 7 days later in a nonblinded manner for satisfactory wound healing, scarring, and complications. Results: There were 96 and 93 patients in the study and control groups, respectively. Wound healing trended toward being judged more satisfactory in the HAT group than standard suturing (100% versus 95.7%; P =.057; effect size 4.3%; 95% confidence interval 0.1% to 8.5%). Patients who underwent HAT had less scarring (6.3% versus 20.4%; P =.005), fewer overall complications (7.3% versus 21.5%; P =.005), significantly lower pain scores (median 2 versus 4; P <.001), and shorter procedure times (median 5 versus 15 minutes; P <.001). There was a trend toward less wound breakdown in the HAT group (0% versus 4.3%; P =.057). When patients were asked whether they were willing to have HAT performed in the future, 84% responded yes, 1% responded no, and 15% were unsure. Conclusion: HAT is equally acceptable and perhaps superior to standard suturing for closing suitable scalp lacerations. Advantages include fewer complications, a shorter procedure time, less pain, no need for shaving or removal of stitches, similar or superior wound healing, and high patient acceptance. HAT has become our technique of choice for suitable scalp lacerations. [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). Ann Emerg Med. July 2002;40:19-26.]

Introduction

The ideal management of a scalp laceration would be a procedure that is painless, can be performed quickly, has a low complication rate, leaves a good functional and cosmetic result, and requires minimal follow-up care.¹ In the United States, more than 12 million traumatic wounds are treated in emergency departments every year.² Of these, many are traumatic lacerations of the scalp.³

Traditional treatment of scalp lacerations has been wound cleansing and suturing. However, patients perceive this method to be painful and slow; in addition, in cases when the hair is shaved, a bald patch results. The patient also requires a return visit for the removal of sutures.

Alternative techniques described have included stapling,4, 5, 6, 7, 8 use of tissue adhesives,9, 10, 11 and knotting of hair.¹² Knotting of hair involves using hair on either side of the wound to throw a knot, thus apposing the wound. However, because hair is smooth, the knot often slips. In addition, once the knot is tied, it can only be removed by cutting the affected hairs off. Stapling4, 5, 6, 7, 8 is probably faster but has similar disadvantages of pain and the requirement of the removal of sutures.

Tissue glue is a recent innovation in wound care that has been found to be useful for skin wounds.9, 10, 11, 13 Morton et al¹⁰ described a case series of 50 patients having scalp wounds closed by tissue adhesive. Applebaum et al⁹ described a series of 30 patients with scalp wounds that were closed with knotting of the hair, which was then secured with adhesives, thus avoiding the problem of slippage of knots. Wang et al¹¹ reported a series of 83 scalp incisions closed with adhesives in neurosurgical patients. However, manufacturers currently do not recommend shaving of hair and applying tissue adhesives because this may impede subsequent hair growth. Furthermore, no randomized trials have been conducted to compare adhesives with sutures in scalp lacerations.

We describe a new technique for closing scalp lacerations using apposition of hair with tissue adhesives. No knotting of hair is involved. We conducted a prospective, randomized, multicenter clinical trial to compare the hair apposition technique (HAT) with standard suturing, looking specifically at wound healing, complication rates, duration of procedure, pain perception, and patient satisfaction.

Section snippets

Materials and methods

Prospective patients presenting with scalp lacerations to the EDs of 2 tertiary level hospitals were enrolled in this trial. The study began in December 1999 and ended in March 2001. The study was approved by the hospital ethics committee of both institutions involved in the trial.

A scalp laceration was defined as a break of the skin on the hair-bearing area of the head resulting usually from blunt trauma. Patients of all ages were included in the trial. Other inclusion criteria included

Results

One hundred eighty-nine patients with scalp lacerations were enrolled in the trial (Figure 5).

. Profile of the randomized controlled trial.

Ninety-six were randomized to the HAT group and 93 to standard suturing. Of these, 188 patients were available for follow-up. One patient in the HAT group did not return for his review and was lost to follow-up. Two patients were randomized to the standard suturing group but were given HAT instead because of noncompliance to protocol. They were analyzed under

Discussion

In this study, we found HAT to be an effective alternative treatment for patients with suitable scalp lacerations. Patients undergoing HAT were less likely to have scarring or any complications (ie, infection, scarring, bleeding, wound breakdown) and were just as likely to have satisfactory wound healing. Infection and bleeding rates were not significantly different. Wound breakdown occurred in 4 patients in the suturing group but did not occur in the HAT group. Procedure time was significantly

Acknowledgements

We thank Peter Manning, MD, National University of Singapore, for coining the term “HAT” and Chan Yiong Huak, PhD, Clinical Trials and Epidemiology Research Unit, Ministry of Health, for his advice.

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^*: Histoacryl Blue was provided by B. Braun (Melsungen, Germany).

^☆☆: Address for reprints: Marcus Ong Eng Hock, MBBS, FRCS(A&E), Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608; 65-3213590, fax 65-3214873; E-mail [email protected]

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Wound Care/Original ContributionA randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study)*,☆☆

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Ann Emerg Med

J Pediatr

Ann Emerg Med

Ann Emerg Med

J Pediatr Surg

Clin Plast Surg

J Emerg Med

Surgery

J Pediatr

Evaluation and management of traumatic lacerations

N Engl J Med

National Hospital Ambulatory Medical Care Survey: 1994 emergency department summary

Wound registry: development and validation

Ann Emerg Med

Staples versus sutures in the closure of scalp wounds: a prospective, double-blind, randomized trial

Injury

Skin wound closure with staples in the accident and emergency department

J R Coll Surg Edinb

Comparison of staples and sutures for closure of scalp lacerations

Acad Emerg Med

Wound Care/Original Contribution
A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study)*,☆☆