What is the management of a galea (fibrous tissue layer) laceration?

Management of Galea Laceration

The management of galea lacerations requires thorough wound cleansing, appropriate debridement, and meticulous layered closure to prevent complications such as infection, hematoma formation, and alopecia. Galea lacerations involve the fibrous tissue layer between the scalp skin and periosteum, requiring specific attention to anatomical repair.

Initial Assessment and Preparation

• Ensure adequate lighting and patient analgesia before repair 1
• Clean the wound thoroughly with:
  • Sterile saline solution or tap water for irrigation 1
  • Antiseptic solution for skin preparation 1
• Remove any foreign bodies and debris to reduce infection risk
• Assess the extent of the laceration and involvement of deeper structures

Anesthesia Options

• Local anesthesia with lidocaine is typically sufficient
  • Consider buffering lidocaine with bicarbonate to reduce pain during injection 2
  • Use the smallest gauge needle possible and inject slowly 2
• For larger lacerations, consider topical anesthetic/vasoconstrictor combinations:
  • LET (lidocaine, epinephrine, tetracaine) provides excellent wound anesthesia in 20-30 minutes 2
  • Apply LET directly to the wound and allow to soak for 10-20 minutes until wound edges appear blanched 2
  • Dose: 3 mL for children >17 kg; 0.175 mL/kg in children <17 kg 2

Wound Closure Technique

1. Layered closure is essential for galea lacerations:

   • First, identify and reapproximate the galea layer with absorbable sutures (e.g., 3-0 or 4-0 polyglactin or poliglecaprone)
   • This deep layer closure is critical to prevent wound dehiscence and abnormal healing

2. Subcutaneous tissue closure:

   • Use absorbable sutures to close the subcutaneous layer
   • This reduces tension on the skin closure and improves cosmetic outcome

3. Skin closure options:

   • Interrupted or continuous non-locked sutures for skin closure
   • Consider absorbable sutures for facial wounds to avoid the pain of suture removal 2
   • Tissue adhesives (e.g., octyl cyanoacrylate) or Steri-Strips can be used for low-tension areas 2
   • Monofilament sutures cause less bacterial adherence and tissue reaction

Post-Repair Management

• Apply an appropriate dressing based on wound characteristics 1
• Provide adequate pain management with acetaminophen and/or NSAIDs
• Patient education on wound care:
  • Keep the wound clean and dry
  • Watch for signs of infection (increasing pain, redness, swelling, purulent drainage)
  • Follow-up for suture removal if non-absorbable sutures were used

Antibiotic Considerations

• Universal antibiotic prophylaxis is not recommended for all wounds 1
• Reserve antibiotics for specific cases:
  • Heavily contaminated wounds
  • Immunocompromised patients
  • Wounds with established infection
  • Deep or extensive galea lacerations with high risk of infection

Common Pitfalls and Complications

• Inadequate hemostasis: Can lead to hematoma formation under the galea
• Improper galea closure: May result in wound dehiscence or widened scars
• Excessive tension: Can cause tissue necrosis and poor cosmetic outcome
• Inadequate debridement: Increases risk of infection and poor healing
• Hair entrapment in sutures: Can lead to inflammation and poor healing

Follow-up Recommendations

• Evaluate the wound at 24-48 hours after initial treatment to detect early signs of infection 1
• Timing of suture removal depends on location:
  • Scalp sutures typically removed after 7-10 days
  • Consider longer duration if wound is under tension

By following these guidelines, galea lacerations can be effectively managed to achieve optimal functional and cosmetic outcomes while minimizing the risk of complications.