My comments on Jim Jolly's article is as follows:   Nurse Practitioners as well as other providers should think about cosmesis when doing any repair of a laceration regardless of the body site.  One should use the utmost skill to get best results even if in a scalp especially since many young men shave their heads as demonstrated in the photo.  Jim's repair of the scalp wound  did not show good approximation of the wound edges so this child will have a large scar.   As seen in the photo which was to demonstate proper wound closure, the stapes did not grab the other side of the wound which would  have given the wound edges a chance to heal properly.  If the first staple did not approximate the wound properly, then the wound should have been carefully held as the other staples were inserted,then the first staple could be removed and properly done.  Sometimes you can test the stapler first before using it on the patient in this way you can better estimate how the staple comes out of the device.  The editorial staff need to be more careful in the articles they choose especially when the photographs show improper placement of the staples which will result in poor skin closure and cosmesis.  Lucille Corva, RN, MSN, CPNP

Ms. Corva brings up two excellent points about the article. First, the photo in the article does appear to show a poor approximation of the wound. This is a demonstration of my poor photography skills rather than the wound closure itself The left side of the wound appears to be poorly approximated but I assure you this is an effect of the photo. There is actually some oozing blood which affects the appearance of the photo.

 Secondly Ms. Corva is absolutely correct when she points out that cosmetic outcome should be paramount in the consideration of wound closure technique. Especially in children, the most commonly asked questions I receive is "Will this hurt?" and "Will this scar?". Even a cursory search through the literature will reveal hundreds if not thousands of studies on the topic of scaring after wound closure. One that I found particularly helpful was in Pediatric Emergency Care (June 2002) Which specifically compared the cosmetic outcome of scalp repair in children with the use of staples versus traditional sutures. This particular study demonstrated "No significant difference" in cosmetic outcome after 1 year exam.

In fact, further research into the factors affecting outcome of laceration one would find that the actual closure of the wound is the least important part of the procedure. The most important part of the procedure is the exam, cleansing, and preparation prior to closure. Also the incredibly vascular nature of the scalp lends toward excellent healing which is why surgical staples have become so popular in this instance.