Time to wound closure in facial soft tissue injuries following road traffic accidents

Abstract

The 6‐hour (6‐h) time to wound closure was a controversial issue as studies have shown that time was not a substantial factor. Wounds in the face are often considered to have a lower infection risk. Despite this, the cause of injury was not extensively discussed in relation to this context. The primary objective was to investigate the association between the 6‐h time to wound closure and wound complications following emergency management of facial soft tissue injuries (STIs). Additionally, the secondary objective was to explore other factors contributing to wound complications. A retrospective record review was conducted in our hospital in Kuala Lumpur, Malaysia, from 1 January 2017 to 31 December 2021. Medical records of patients with facial STIs due to road traffic accidents were included. Simple random sampling was used to select records meeting inclusion criteria. Data on demographic, injury, and treatment characteristics were collected using a standardized proforma. Descriptive, univariate and multivariate analyses were performed, including chi‐square tests and binary logistic regression. A total of 295 patient records were included, with most patients being males (77.3%) and of Malay ethnicity (54.9%). The median age was 31.0 years. Majority of patients were treated within 6 h of injury (93.9%). Complications were documented in 6.1% of cases, including wound dehiscence and infection. Multivariate analysis revealed a significant association between 6‐h time to closure and wound complications (OR: 7.53, 95% CI: 1.90–29.81, p = 0.004). Grade of surgeon on duty (OR: 4.61, 95% CI: 1.25–16.95, p = 0.02) and diabetes mellitus (OR: 6.12, 95% CI: 1.23–30.38, p = 0.03) were also shown to have a statistically significant association with wound complications. A 6‐h time to wound closure, grade of surgeon on duty and diabetes mellitus were three major factors involved in facial wound complications following road traffic accidents.

1. INTRODUCTION

Wound closure of traumatic facial soft tissue injuries (STIs) has to be performed as soon as possible to reduce the risk of infection. ¹ However, life‐threatening injuries or serious comorbidity, social issues, poor compliance or patient's fear or lack of understanding have been identified as factors that could lead to delayed treatment. ² Ideal closure within 6 h or a maximum of 12 h has been proposed, with the aims to reduce the rate of infection, enhance aesthetic outcomes and prevent subsequent swelling from obscuring important landmarks. ³ The 6‐h timing for wound closure was described as the ‘golden period’ as closure performed beyond 6 h would increase the risk of bacterial contamination. ⁴ This is a concept popularized by Friedrich (1898) after his experiment on the guinea pigs' skin. ⁵ He demonstrated that wounds that were left for more than 6 h were significantly associated with infection compared to those treated in less than 6 h. ⁵

Despite the historical 6‐h concept, studies in this era reported findings that were not supportive or with limited data about the timing of wound closure and infection. ⁶ , ⁷ , ⁸ , ⁹ Waseem et al. reported longer period, that is, after 1000 min for the wounds to be associated with infection. ⁶ Quinn et al., who analysed 2663 patients, showed infection in 1.2% wounds that were closed after 12 h, compared to 2.9% in wounds that were closed earlier than 12 h. ⁷ Another study did not show any statistical difference between wounds that were treated within 6 h and after 6 h. ⁸ Therefore, most researchers concluded that time was not a substantial factor in the decision to close a wound. ⁸ , ⁹

Time factor in the management of surgical conditions has been widely underscored. In 2015, The Lancet Commission on Global Surgery (LCoGS) highlighted the time factor in its report titled ‘Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development’. ¹⁰ The LCoGS proposed a target of a minimum of 80% coverage of essential surgical and anaesthesia services per country by 2030 as one of their six core surgical indicators in achieving health, welfare and economic development. ¹⁰ Timely availability of surgical services is critical to quality care of the injured patients, which includes common conditions requiring emergency procedures such as wound care and debridement. ¹⁰ , ¹¹

Well‐organized emergency care is therefore a key factor for achieving a range of sustainable development goal (SDG) targets, which among others include road traffic injuries. ¹² Target 3.6 within the SDG3 emphasizes on reducing the number of global deaths and injuries due to road traffic accidents (RTAs). ¹² Mortality and morbidities associated with RTA are global health burden, especially in the underdeveloped countries compared to the developed nations. ¹³ In Malaysia, the number of RTA has been on the increasing trend for decades. ¹⁴ , ¹⁵

Incorporating the concerns of LCoGS and SDG3 into our setting, we hypothesized that timely closure of wounds resulting from RTAs was essential to mitigate the occurrence of complications. The objectives of the study were, therefore, two‐fold. The primary objective was to investigate the association between 6‐h time to wound closure and wound complications following emergency management of the facial STIs. The secondary objective was to explore other factors that were associated with the wound complications.

Many authors agreed that the location of the wound was one of the risk factors of infection, with the head, face and trunk showing lower occurrence of infection compared to the limbs. ⁶ , ⁸ , ⁹ We selected the facial wounds because they are one of the commonest injuries in the RTA in Malaysia. ¹⁶ We also would like to show that regardless of the anatomical region, timing of repair is still a crucial factor in RTA‐related wounds. It was shown that road accident wounds were contaminated with various microorganisms such as Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, Bacillus sp. and others. ¹⁷ , ¹⁸ , ¹⁹ Acceptable time interval for wound repair should, therefore, be based on the individual situation. ²⁰

2. METHODS

The study protocol adhered to the ethical guidelines of the Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects and received the ethical approval from the Research Ethics Committee, Universiti Kebangsaan Malaysia (UKM PPI/111/8/JEP‐2021‐736 dated 1 November 2021).

2.1. Study design

The study design was a retrospective record review.

2.2. Patients and setting

The source population for this study was patients with facial injury due to RTA who attended the emergency department (ED), Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from 1 January 2017 to 31 December 2021. The ED of UKMMC in Kuala Lumpur, Malaysia, provides facial trauma treatment coverage for about one‐third of the Klang Valley, which has a population of about 3 million. UKMMC is one of the main hospitals in Kuala Lumpur city, receiving more than 72 000 patients annually or at the average of 200 patients per day observed at the ED. ²¹

The inclusion criteria comprised completed medical records of facial STI cases, which consisted the diagnosis, treatment provided and review appointments documentation (for the assessment of complications). The exclusion criteria were patients who were treated elsewhere at any phase of the STI treatment.

2.3. Sampling method

The records were selected using a simple random sampling method. Records that fulfilled the inclusion and exclusion criteria were selected and given a number. The estimated number of facial injury cases due to RTA during the 5‐year period was 1300 in UKMMC. Random numbers were assigned to all facial injury records. The sample size was calculated using the epidemiological statistics application Open Epi, which was available online at https://www.openepi.com/. ²² Reference from Najib Majdi ²³ was used, and the calculation yielded 292 samples at a 95% confidence interval (CI).

2.4. Study tool and definitions

A standard proforma was used to assist in data collection. This comprised the independent and dependent variables.

1. Independent variables

The following are the list of the independent variables that were investigated.

1. Demographic profile: gender, age and ethnic groups.

2. Comorbidity: history of medical disease/s.

3. Grade of surgeon: the first officer that attended to the patient in the ED whether they were doctors in training or non‐training.

4. Vehicle involved in RTA: car, motorcycle or others.

5. STI characteristics: type, location and severity using the Abbreviated Injury Scale (AIS© 2005 Update 2008). ²⁴ In addition, concomitant injuries, such as facial fractures, dental injuries and other body part injuries, wound contamination and tissue loss were included as the independent variables.

6. Time to wound closure: defined as time interval from the time of injury to completion of wound repair. ⁶ In this study, we categorized time to closure into less or equal to 6 h (≤6 h) and more than 6 h (>6 h).

• 2Dependent variable

The dependent variable was complication of STI treatment.

The complications assessed were infection, wound dehiscence and unfavourable scar. The infection was assessed using the following clinical signs as described by Graan and Balogh. ²⁵

1. Pain

2. Local erythema

3. Local swelling

4. Increased local temperature

5. Fever

2.5. Statistical analysis

The data were analysed quantitatively using the Predictive Analytics Software (PASW: formerly SPSS) statistics version 16.0 (SPSS Inc., Chicago, IL). Descriptive, univariate and multivariate statistics were employed in this study, where appropriate.

The sociodemographic, facial injury, treatment completion and complication characteristics as well as the outcomes of interest were shown as frequencies, percentage, mean, standard deviation (SD), median and interquartile range (IQR) where appropriate.

The associations between the variables and the outcomes of interest were initially examined using univariate analysis. All variables were in the form of categorical data and were analysed using the chi‐square test. The level of significance was set at 5%.

Following initial examination, and where appropriate, the data were then included in multivariate analyses. Binary logistic regression was used in the models where the dependent variable was dichotomous. Binary logistic regression analysis was employed to examine the association between the independent and dependent (outcome) variables. The method used was ‘enter’.

The multivariate analysis is presented in the form of odds ratios (OR) with 95% CI. If the OR is larger than 1.00, the risk is greater in the exposed group and when the OR is less than 1.00, the risk is less in the exposed group. An OR less than 1.00 is sometimes referred to as a protective effect and if the OR is equal to 1.00, the risk is the same in both groups and this is known as null value, indicating no difference. ²⁶ The width of the CI indicates the amount of variability in the estimate, and it reflects the size of the sample. ²⁶ Larger sample size tends to show less variability, and narrow interval is associated with a more precise estimate. On the contrary, smaller sample size has wider interval, indicating more variability and less precision.

The logistic regression model underwent numerous tests before being declared fit. Goodness‐of‐fit was assessed using the Hosmer and Lemeshow test and the classification table. Obtaining a non‐significant result in the Hosmer Lemeshow test would indicate that the model was well calibrated, and therefore was considered as fit. In the classification table, models with percentage of overall correctly classified closer to 100% were considered as more accurate.

3. RESULTS

Between 1 January 2017 and 31 December 2021, a total of 1875 medical records of patients with facial injuries were initially screened from the Emergency Department and Medical Information Department, UKMMC. However, a total of 650 records were initially removed due to incomplete information. The remaining complete records were randomly selected and based on the sample size calculation, records of 295 patients with facial STIs were selected.

3.1. General patient, doctor and vehicle characteristics

A total of 228 (77.3%) males and 67 (22.7%) females were included in the study, with the Malay ethnic group having the highest involvement with 162 (54.9%) patients, followed by Chinese, 77 (26.1%) patients, Indians, 36 (12.2%) patients and others with 20 (6.8%) patients. The median age of patients was 31.0 with IQR of 20. The youngest patient was 3‐year‐old while the oldest was 82‐year‐old at the time of injury.

Of the 295 patients, 53 (18.0%) presented with pre‐existing comorbidity at the time of injury. 16 (5.4%) patients presented with history of diabetes mellitus, while 41 (13.9%) patients presented with other co‐morbidities such as hypertension, asthma, ischemic heart diseases and dyslipidemia. With regards to grade of surgeon, the doctors or health personnel who first attended the patients in the ED can be grouped into (i) oral and maxillofacial surgery (OMFS) residents who were in training to become the OMFS specialists and (ii) OMFS residents who were not in the training posts.

A total of 131 (44.4%) patients were attended to by the in‐training residents and 164 (55.6%) by the non‐training residents. All the in‐training and non‐training residents were supervised by a consultant on duty.

To address Target 3.6 of the SDG3, the RTA characteristics were included. This involved information regarding the vehicle and the driver or passenger. The most common involvement was motorcycle users (86.1%), followed by car driver or passengers (9.5%) and others such as van, lorry or bicycle rider (2.0%). In addition, seven (2.4%) patients were pedestrians. Table 1 summarized the demographic, the health personnel involved in the initial management of the injury and the vehicle characteristics.

TABLE 1.

General patient, doctor and vehicle characteristics.

Demographic factor		Total number of patients, n (%), N = 295
Age	Range (years)	3–82
	Median age (IQR)	31.0 (20.0)
Gender	Male	228 (77.3)
	Female	67 (22.7)
Race	Malay	162 (54.9)
	Chinese	77 (26.1)
	Indian	36 (12.2)
	Others	20 (6.8)
Comorbidity	No co‐morbid	242 (82.0)
	Diabetes mellitus (DM)	12 (4.1)
	Others	37 (12.5)
	Multiple comorbidity	4 (1.4)
Grade of surgeon	In‐training residents	131 (44.4)
	Non‐training residents	164 (55.6)
Vehicle involved in RTA	Motorcycle	254 (86.1)
	Car	28 (9.5)
	Pedestrian	7 (2.4)
	Others	6 (2.0)

Abbreviations: DM, diabetes mellitus; IQR, interquartile range; RTA, road traffic accident.

3.2. Injury characteristics

3.2.1. Type of STI

Of all the STIs sustained, laceration wounds accounted for 79.0%, followed by contusion (41.7%), abrasion wounds (40.3%) and avulsion wounds (0.3%). Most of the STIs were located at the periorbital area (40.3%), followed by the cheek (33.2%), upper lip (32.5%), lower lip (27.8%), forehead (25.4%), chin (25.1%), philtrum (14.2%), nose (10.2%) and temple (1.4%). Table 2 summarized the location of STIs.

TABLE 2.

Distribution of STI and their location.

Location of STI	Total number of patients, n (%)
Forehead	75 (25.4)
Periorbital	119 (40.3)
Cheek	98 (33.2)
Temple	4 (1.4)
Nose	30 (10.2)
Philtrum	42 (14.2)
Chin	74 (25.1)
Upper lip	96 (32.5)
Lower lip	82 (27.8)

3.2.2. Single versus multiple wounds

Based on the number of STI sustained, 140 (47.5%) patients sustained only a single type of STI, either contusion, abrasion, laceration or avulsion while 155 (52.5%) patients sustained a combination of at least two types of STIs.

3.2.3. Severity of the soft tissue wounds

A total of 293 (99.3%) patients had AIS 1 for their facial injuries, that is, contusion, abrasion and avulsion injuries. Only two patients (0.7%) presented with AIS 2, these were laceration wounds that measured about 11 cm in length.

3.2.4. Concomitant injuries

STI was shown to occur concurrently with a facial bone fracture (14.9%), dental trauma (16.3%), and a combination between facial bone fractures and dental trauma (6.1%). A total of 142 (48.1%) patients sustained combined facial injury with other injuries such as head, orthopaedic, thoracic and abdominal injuries.

3.2.5. Wound contamination

Wound contamination was observed in 12 patients (4.1%) and this required vigorous cleansing prior to closure. The contaminants documented were road debris and tar.

3.2.6. Tissue loss

Partial thickness tissue loss was observed in two patients (0.7%).

3.2.7. Time to wound closure

The range of time to wound closure (time of injury to treatment completion) was between 30 min to 8 h and 30 min, with a median of 3.5 (IQR = 1.5) hours. A total of 277 (93.9%) patients were treated within 6 h from injury.

Table 3 shows overall treatment completion and time to closure.

TABLE 3.

Injury characteristics.

Injury characteristics		Total number of patients, n (%), N = 295
Number of STI	Single	140 (47.5)
	Multiple	155 (52.5)
Severity of STI	AIS 1	293 (99.3)
	AIS 2	2 (0.7)
Concomitant STI with facial bone fracture	Yes	44 (14.9)
	No	251 (85.1)
Concomitant STI with dental trauma	Yes	48 (16.3)
	No	247 (83.7)
Concomitant STI with facial fractures and dental trauma	Yes	18 (6.1)
	No	277 (93.9)
Concomitant STI with other body part injuries	Yes	142 (48.1)
	No	153 (51.9)
Wound contamination	Yes	12 (4.1)
	No	283 (95.9)
Tissue loss	Yes	2 (0.7)
	No	293 (99.3)
Time to wound closure	≤6 h	277 (3.9)
	>6 h	18 (6.1)

Abbreviations: AIS, Abbreviated Injury Scale; STI, soft tissue injury.

3.3. Facial STI: wound complications

A total of 18 (6.1%) patients were documented with complications related to STI. Median (IQR) duration of follow‐up was 7.0 (4.0) days, with a range of 1–30 days. Most of the complications were wound dehiscence with the involvement of 11 (3.7%) patients, 4 (1.4%) patients with infection, 2 (0.7%) patients with wound dehiscence and infection and 1 (0.3%) patient with infection and scar.

Among the factors examined in the association with wound complications were (i) age, (ii) gender, (iii) single versus multiple wounds, (iv) time to wound closure, (v) presence of comorbidity, particularly (vi) diabetes mellitus, (vii) grade of surgeon and finally, (viii) wound factors such as presence of contamination with foreign body and (ix) tissue loss.

Based on the univariate analyses, there were statistically significant associations between (i) number of STI (p = 0.03), (ii) time to wound closure (p = 0.02), (iii) grade of surgeon (p = 0.02), (iv) wound contamination (p = 0.000) and (v) tissue loss (p = 0.004) and wound complications (Table 4).

TABLE 4.

Association of various factors and wound complication.

Variables		Number of patients, n (%)		p‐value
		Had complication	No complication
Gender	Male	12 (4.1)	216 (73.2)	0.26
	Female	6 (2.0)	61 (20.7)
Age	≤45	15 (5.1)	218 (73.9)	0.77
	>45	3 (1.0)	59 (20.0)
Number of STI	Single	4 (1.4)	136 (46.1)	0.03
	Multiple	14 (4.7)	141 (47.8)
Time to wound closure	≤6 h	14 (4.7)	263 (89.2)	0.02
	>6 h	4 (1.4)	14 (4.7)
Comorbidity	Yes	3 (1.0)	50 (16.9)	1.00
	No	15 (5.1)	227 (76.9)
Diabetes mellitus	Yes	3 (1.0)	13 (4.4)	0.07
	No	15 (5.1)	264 (89.5)
Grade of surgeon	In‐training residents	3 (1.0)	128 (43.4)	0.02
	Non‐training residents	15 (5.1)	149 (50.5)
Wound contamination	Yes	12 (4.1)	0 (0.0)	0.000
	No	6 (2.0)	277 (93.9)
Tissue loss	Yes	2 (0.7)	0 (0.0)	0.004
	No	16 (5.4)	277 (93.9)

Abbreviation: STI, soft tissue injuries.

3.4. Multivariate analysis

Binary logistic regression was performed to investigate the association between age, pre‐existing diabetes mellitus, grade of surgeon, time to wound closure or 6‐h time to closure and the number of STI sustained and wound complication. The final model is shown in Table 5. The findings are:

1. More than 6‐h time to closure had the odds of 7.53 (95% CI 1.90–29.81) of developing wound complications (p = 0.004).

2. The non‐training residents showed four times the likelihood of getting a wound complication when compared to the in‐training residents (p = 0.02).

3. Comorbidity, that is, diabetes mellitus had the odds of 6.12 (95% CI 1.23–30.38) of being associated with wound infection (p = 0.03).

4. Multiple STI had the odds of 2.67 (95% CI 0.81–8.82) of having a complication, however, this association was not statistically significant (p = 0.11).

TABLE 5.

Adjusted association between various factors with wound complication.

Wound complication a
Factors		Odds ratio (95% CI)	p‐value
Time to wound closure	≤6 h >6 h	1.00 7.53 (1.90–29.81)	0.004
Grade of surgeon	In‐training residents Non‐training residents	1.00 4.61 (1.25–16.95)	0.02
Comorbidity	No diabetes mellitus With diabetes mellitus	1.00 6.12 (1.23–30.38)	0.03
Number of STI	Single Multiple	1.00 2.67 (0.81–8.82)	0.11

Abbreviation: STI, soft tissue injury.

^a Controlled for age.

The logistic regression model was considered to be a good fit with Hosmer and Lemeshow test of χ ²(7) = 3.66, p = 0.82. The Nagelkerke R² was 0.19, and the model was correctly classified at 93.9%.

4. DISCUSSION

One of the LCoGS indicators for the preparation of surgical and anaesthesia care is access to timely essential surgical care. ¹⁰ With regards to the context of this study, this can be defined as timely emergency care of the facial STI. Our study showed that the range of duration of STI treatment was between 30 min to 8 h and 30 min (median = 3.5; IQR = 1.5 h). In addition, 277 (93.9%) patients were treated within the ideal ‘golden period’ of 6 h from injury. All patients (100%) from this study were attended to and treated within 24 h. Repair or closure of the facial STI without additional injuries has been advocated to be carried out as soon as possible. ³ , ²⁷ On the other hand, delayed treatment had been shown to be associated with concomitant injuries, decreased Glasgow Coma Scale (GCS) and other social factors. ² , ²⁷ In addition, hospital emergency response time (ERT) was another factor, which could contribute to delayed in overall trauma management. In some parts of Malaysia, the ambulance response time or the ERT was shown to be below the international standards. ²⁸ , ²⁹ Factors contributing to late ERT were highly related to the congested traffic conditions, bad weather such as heavy rain and vehicle accidents. ²⁸ , ²⁹ Among these factors, traffic congestion, especially at junctions with traffic signal control, had a significant influence on the ERT. ²⁸ , ²⁹

With regards to overall facial injuries, STIs accounted for 98.3% of all the injuries, followed by facial bone fracture (54.3%), and dental trauma (37.7%). Our findings were comparable with similar studies performed in this country as well as in the South‐East Asian region. ³⁰ , ³¹ , ³² , ³³

Many literatures from the past and present advocated that wounds of the face and scalp should be primarily closed as soon as they are seen, and as long as active infection is not present. ³⁴ , ³⁵ , ³⁶ , ³⁷ Both our univariate and multivariate analyses showed significant association between the 6‐h time to closure and wound infection. In the multivariate analysis, we showed that treating a facial wound of more than 6 h following RTA had seven times likelihood to be involved in wound complication. The nature of the STIs in RTA is different from other aetiology depending on the surface the face had in contact with. The mechanism of injury for abrasion wound or also known as road rash involves dragging the skin over the rough and uneven surface such as the road surface, soil and others. Abrasion wounds are mostly superficial but, in some RTAs, extreme dragging can produce extensive form of injuries, which can involve the skin, muscles and sometimes bone. ³⁸

A laceration wound, which is another type of blunt object injury, results in tearing of the skin and adjacent tissue. A laceration often presented with irregular wound margins and damage to the surrounding tissues and this type of wound has a moderate risk of infection and scarring. ⁹ , ³⁹ In addition, direct compression injuries, for example, a blow to the head, typically result in a stellate laceration, which has the highest risk of infection. ⁹ , ³⁹

In this study, 6.1% of patients presented with wound complications, 11 (3.7%) patients with wound dehiscence, 4 (1.4%) patients with infection, 2 (0.7%) patients with wound dehiscence and infection and 1 (0.3%) patient with infection and scar. All complications were promptly managed and further follow‐ups were scheduled for reassessment. Wound dehiscence results from increase in tension on the skin layer and this opens up the wound. Local tissue ischemia, necrosis and infection are factors that could result in wound dehiscence. ⁴⁰ Factors such as suture materials and different surgical techniques have been shown not to be responsible for these complications. ⁴¹ In addition, surgeon's experience, general characteristics of the patients (sex and age), wound length and site seemed to have some association with these complications. ⁴²

All lacerations in this study were approximated using sutures. A study comparing two types of material for facial wound approximation and scar formation found that wound tape was more effective than sutures for wound lengths less than 20 mm. ⁴³ However, scar formation was similar between sutures and wound tape for wounds between 20 and 50 mm. ⁴³ In another study, which involved the minipigs, skin adhesives showed the most wound dehiscence while absorbable sutures were more inclined to produce a scar compared to the non‐absorbable sutures. ⁴⁴

In relation to infection, the literature showed a range between 1.1% and 3.7% infection occurred following facial wound treatment. ⁴⁵ , ⁴⁶ , ⁴⁷ Due to low rate of infection (less than 5%), studies have not recommended routine use of antibiotics in patients with facial lacerations and abrasions. ³⁷ , ⁴⁸ , ⁴⁹ However, there was a disagreement as complicated facial wounds were prone for infection. ¹⁷

A position paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of Emergency Surgery (WSES) outlined the criteria for risk assessment and this was based on (i) type of wound, (ii) location of the wound and (iii) characteristics of the wounded patient. ⁵⁰ Wounds observed in our study were in accordance to the description in the position paper under the category of type of wound, that is, tears/bruises/contusion wounds, wounds contaminated with soil and dirt or mineral oil and contaminated wounds with foreign bodies. These wounds were regarded as high risk for infection. In relation to the location of the wound, the facial region was regarded as low risk for infection as it has abundant blood supply; however, the oral mucosa wounds were considered as high risk for infection due to its high concentration of commensal flora. Finally, regarding the characteristics of the wounded patients, children, young patients and adults have low risk for infection compared to elderly (>65 years old), immunocompromised patients and patients with vascular disease and diabetes mellitus. All these factors are important as, if one or two high‐risk variables are present, the AcEMC and WSES position paper advocated for antibiotics administration. ⁵⁰ Our results were in line with the AcEMC and WSES position paper, and all our patients received antibiotics following wound closure.

Apart from infection, other complications related to STI include keloids, hypertrophic, atrophic and flat scars. ⁵¹ , ⁵² One of our patients (0.3%) had scar‐related complications. Although the number was small, the psychosocial effect on the patient can be very significant. Factors such as age, overall skin quality, systemic diseases (diabetes and chronic kidney diseases) and mechanism of injury contributed to facial wound complication. ⁵² In addition, location of injury, the onset and cause of the scar affect the characteristics of the scars. ⁵¹

Our multivariate analysis showed that other factors are significantly associated with wound complications. The non‐training residents in our department contributed four times likelihood of developing wound complications (95% CI 1.25–16.95). Facial lacerations, which are among the common injuries presented to the ED, warrant optimal wound repair skills for favourable outcomes. ⁵³ , ⁵⁴ They were mostly treated either by residents or officers in plastic surgery, OMFS or the emergency physicians. ⁵⁵ There are very few studies comparing the outcomes of facial wound repair when treated by different operators. ⁵⁵ Lee et al. reported that there was no significant difference in patient's satisfaction between emergency physician and plastic surgeon for repair of facial laceration in the ED. ⁵⁶

While the literature for the grade of surgeon is limited, studies on diabetes mellitus and complications of healing are abundant. Diabetes mellitus contributed significantly to complications of facial wound with the odds of 6.12 (95% CI 1.23–30.38). Many studies showed that diabetes mellitus is one of the risk factors for acute wound healing. ² , ⁷ , ⁹ It is a known fact that diabetic patients are susceptible to infection due to impaired leukocyte function, poor glucose control and altered host response. ⁵⁷ , ⁵⁸ The impairment of wound healing involved all the phases of wound healing, namely the inflammatory, proliferative and remodelling phases. ⁵⁹ In addition, diabetic skin has been shown to have higher colonization of both S. aureus and S. epidermidis ⁶⁰ and this makes wound easily infected by these microorganisms.

The timing of first follow‐up and review visit and complication following STI treatment were documented. The median (IQR) duration of follow‐up and review appointment following the initial treatment date was 7.0 (4.0) days, with a range between 1 and 30 days. Follow‐up visits were generally scheduled to assess the healing of injuries and the presence of complications. Lee et al. reported average follow‐up time of 9.8 days to assess wound healing following facial laceration wounds treated in the emergency setting. ⁵² They also recommended that follow‐up visits be performed on 1, 3 and 5 days after primary repair, and to remove the sutures on Day 4 after primary repair when wound healing was rapid. ⁵³ Subsequent follow‐up treatments were recommended 14 days after primary repair for patient education on wound care. ⁵³ Scar management follow‐up visits afterward were recommended monthly until satisfactory wound healing. ⁵³

The findings of our study strengthen the timely surgical care as an indicator in the context of Global Surgery as reported by the LCoGS. Systematic reviews performed between 2003 and 2021 showed mixed results. Cheng et al. showed that the increase in operative time was associated with increase in complication. ⁶¹ However, this association was not statistically significant. ⁶¹ Jaman et al. could not establish the exact time frame for primary closure of wounds due to non‐availability of high‐quality studies while Lammers et al. reported significant differences in wound age between the infected and uninfected group. ⁶² , ⁶³ Wound location has been determined to be the strongest predictor, while wound age beyond 10–24 h was also an important risk factor with 14% rate of infection. ⁶³ Our study is different from the others as we focused on wounds related to RTAs. These wounds are entirely different from other aetiologies as they are likely to be contaminated with soil, dirt and foreign body.

Our findings highlight the importance of prompt evaluation and management of facial STIs in patients presenting to the ED following RTAs. Early wound closure within 6 h should be prioritized to minimize the risk of complications and optimize patient outcomes. However, it is essential to recognize that individual patient factors, such as the presence of co‐morbidities or the extent of tissue damage, may influence the decision‐making process regarding wound closure timing. Clinicians should use their judgement to balance the benefits of early closure with the risks of potential complications.

4.1. Limitations

Our study has several limitations. First, it is a retrospective study, which is subject to inherent biases and limitations associated with retrospective data collection. Being a retrospective study, details of the wounds and impact of associated injuries and co‐morbidities could not be highlighted much. Second, the study was conducted at a single centre, which may limit the generalizability of the findings to other settings. Third, we relied on clinical documentation to identify wound complications, which may have resulted in underestimation or misclassification of complications.

5. CONCLUSION

In conclusion, our study demonstrates that early wound closure within 6 h following the onset of the injury was associated with a lower likelihood of wound complications in patients with facial STIs due to RTAs. Timely evaluation and management of these injuries are essential to optimize patient outcomes and minimize the risk of complications. Future research should focus on prospective studies to validate the findings and identify strategies to further improve the management of facial STIs in the emergency setting.

CONFLICT OF INTEREST STATEMENT

The authors report there are no competing interests to declare regarding this study.

Hamzah MA, Rahman NA, Ramli R. Time to wound closure in facial soft tissue injuries following road traffic accidents. Int Wound J. 2024;21(6):e14910. doi: 10.1111/iwj.14910

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable requests.