
==== Front
Plast Reconstr Surg Glob Open
Plast Reconstr Surg Glob Open
GOX
Plastic and Reconstructive Surgery Global Open
2169-7574
Lippincott Williams & Wilkins Hagerstown, MD

GOX-D-24-00414
00030
10.1097/GOX.0000000000006148
3
Reconstructive
Original Article
Sabbath Observance and Delayed Primary Repair of Lacerations: Experience from a Plastic Surgery Practice
Scheinman Marcel MD, FACS *†
From the * Department of Surgery, Weill Medical College of Cornell University New York, N.Y.
† Private Practice, Lawrence, Nassau County, N.Y.
Marcel Scheinman, MD, 135 Rockaway Turnpike, Suite 108, Lawrence, NY 11559, E-mail: marcelsch1818@aol.com
9 2024
10 9 2024
12 9 e614816 4 2024
24 7 2024
Copyright © 2024 The Author. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background:

Despite public and medical professionals’ misconceptions about the timing of laceration repair and its consequences, it has been shown that the concept of the “golden period” has not been established, and in many uncomplicated wounds, may extend beyond 24 hours. This author presents his experience with delaying primary repairs, which may represent one of the largest published casuistries.

Methods:

A retrospective review of cases over a 14-year practice and review of the literature on the topic of the golden period and delayed primary repair of lacerations were performed.

Results:

Of a total of 6408 lacerations repaired, 313 were identified as planned delayed repairs (4.9%). The time of delay was estimated to be between 3 and 28 hours from the injury until treatment. There were no reported complications on the delayed repairs.

Conclusion:

Delayed repair of uncomplicated wounds does not increase the rate of infection or impact the final cosmetic outcome and may be applied safely by qualified professionals in carefully selected cases.

OPEN-ACCESSTRUE
COUNTRYUNITED STATES
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pmcTakeaways

Question: Can we safely primarily delay the repair of lacerations?

Findings: Planned delayed repairs (4.9% of our cases) estimated to be between 3 and 28 hours after injury until treatment showed no complications.

Meaning: Repair of uncomplicated lacerations may be safely postponed in a variety of situations including nighttime calls or understaffed facilities.

INTRODUCTION

Purposely delaying the primary repair of lacerations is not a foreign concept for many plastic surgeons. Often being called late at night for an uncomplicated wound when referring physicians or patient’s family1 prefer to have it repaired by a plastic surgeon, many choose to wait until the morning to do it, a practice that is known to be safe and uncompromising on results. Some would even argue that the inconvenience for the patient in waiting is offset by knowing that the surgeon performing the repair would be well rested and in prime form to do a meticulous job. The myth of the “golden period” of laceration repair has been long debunked by several publications as early as the 1980s,1 and it is well known to most plastic surgeons, albeit, still believed to be true by many practitioners and by the public at large.

The concept of delayed primary repair is also not foreign for people who practice the orthodox Jewish faith where the Sabbath (spanning from sundown on Friday until the beginning of nightfall on Saturday) is strictly observed as a holy day, for approximately 25 hours devoted to family time, prayers, and community gatherings and regulated by several religious restrictions that limit the use of modern energy-based appliances such as cell phones, TV, computers, and transportation by any means other than walking.2 These same rules apply to a few other days on the calendar year observed as Jewish religious holidays. It is noteworthy that nearly all these restrictions may be set apart in cases of medical emergencies given the high priority that the Jewish religion places on preservation of life and health in general. Therefore, it is a frequent practice within orthodox Jewish communities that healthcare personnel do carry and use their cell phones and drive if medically necessary on Sabbath, but the rest of the community do not. This unique dynamic was the driving force for the creation of Hatzalah (“rescue” in Hebrew), an organization comprised of volunteer trained emergency medical technicians and paramedics, created in Williamsburg in Brooklyn, New York, in 1965 and subsequently spread to other cities, states, and countries worldwide where orthodox Jewish communities have a presence, to facilitate urgent medical care 24/7, but most notably on the Sabbath and holidays when most of the people are present in their homes and synagogues.3 It is also a widespread practice for these volunteers to contact physicians and, notably, community-based plastic surgeons when faced with traumatic wounds of all sorts to streamline decision-making and access to treatment. Initial care will always be provided on site (such as bandaging or splinting), but definitive care may be delayed until after the Sabbath has concluded, when patients may drive themselves to a health-care facility or to a physician’s office, unless it is determined that such action could be detrimental, in which case the patient is immediately transported to a hospital.4 Having been in private practice as a plastic surgeon since 2003 in a community with a large Jewish orthodox presence, this author (who is also a practicing orthodox Jew) has often elected to delay the repair of lacerations deemed safe, which creates a unique experience with a larger than average casuistry and the first such report in the medical literature. Aside from presenting the author’s experience this article will focus on timing of laceration repair with a comprehensive review of the literature as well.

MATERIAL AND METHODS

This study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. IRB exemption was obtained with WCG Clinicals under # 1-1748663-1 (WCG North America, Princeton, N.J.). We reviewed our own database on Excel files of every procedure performed by this author either in office or hospitals beginning in January 2010 until April 2023 and performed a full chart review when necessary to obtain additional information. The data were gathered, including laceration repair; mechanism of injury; wound location in the body (face, scalp, neck, trunk, upper or lower extremities, hand, or foot); patient’s age; date and place of procedure; and estimated delay from injury to repair (when available). Given that this author does not routinely see elective patients on Saturdays and does not usually take plastic surgery or hand calls for hospitals on those days, all laceration repairs performed on Saturdays were identified and presumed to have been repaired at night after the completion of Sabbath as primary delayed repair, with the exception of 27 cases that were treated by the author on Friday night or Saturday daytime in his office and four cases that were treated in a hospital. The selection of candidates for delayed primary repair was based on history obtained over the phone and analysis of the photographs of the injury. Photographs were handled in a Health Insurance Portability and Accountabilty Act of 1996–compliant fashion: when texting or emailing pictures, patients are asked to not include their names or any identifiable information, which are only added to the file once in our secure and isolated server, and then pictures sent via text or emails are erased from the source. Patients were excluded (and therefore, referred for immediate repair) if they had one of the following characteristics: head and neck wound 5.0 cm or larger; extremity wounds 2.0 cm or larger; active bleeding not controlled by mild pressure bandages; surrounding abrasions with either embedded road rash or devitalized skin edges; crushing injuries to fingers; full thickness lip lacerations; eyelid lacerations involving the tarsal margin; and suspected associated fracture. Patients selected for delayed repair were instructed to rinse the wound with water and apply antibiotic ointment and occlusive bandage when appropriate. At the time of repair, the wound was cleaned with gauze and saline after local anesthesia or regional block was performed. Debridement was rarely necessary, and closure was done in one or two layers depending on depth and location. The type of sutures used (absorbable or not) also varied with type of wound, location, and patient’s age (it is this author’s preference to use absorbable sutures in young children regardless of the anatomical location). It is our protocol that patients who had sutures placed return for a single follow-up visit in our office between 4 and 10 days after facial or head and neck repairs and between 3 and 14 days for hand injuries, where simple lacerations require a single visit and lacerations involving nerves, tendons, nail bed, and associated fractures requiring between one and six additional visits thereafter. Patients who present any signs of infection are prescribed oral antibiotics and return for additional follow-up visits on an interval between 2 and 7 days until the infection is clinically resolved. Patients are encouraged to send pictures or return for more visits if any wound becomes wide or hypertrophic at any time during the healing process. Literature searches were conducted in four electronic databases (PubMed/Medline, the Cochrane Library, Embase, and Web of Science), with no initial time limit until May 2023. We limited it to human studies. The term golden period was combined with lacerations, wounds, injuries, sutures, or delayed repair. All available articles, book chapters, and abstracts were reviewed, and their references were reviewed as well for cross checking and to identify articles that were missed on the initial database search. Chapters that were not comprehensive or did not include concepts related to golden period or delayed repair were discarded as well as articles or studies deemed weak or that did not contain any new data as compared with previous publications. All abstracts and relevant articles were screened by the main author. Of the 16 articles chosen after screening, the bibliography was scrutinized in all to avoid potential misses or incorrect citations. Systematic review articles were included.

RESULTS

A total of 6408 lacerations were repaired by this author during the period reviewed, 4815 of them (75.1%) in hospital (emergency department or operating room) and 1593 of them (24.9%) in his office. We identified 313 cases of planned delayed primary repair (4.9% of all lacerations) treated either in hospital emergency department or in office. Included in this result were only those cases purposely delayed by the author due to religious observance. Cases that were presented to the emergency department or office more than 6 hours after the injury due to other causes were not identified in this search and therefore, not included in our analysis. The time of delay was estimated to be between 3 and 28 hours from the injury until treatment. The exact timing of delay in hours was documented only in a minority of cases (70 of 313 or 22.4%) and was estimated by the author in most cases. From the total, 249 were facial lacerations (79.6%), 59 hand lacerations (18.8%), four scalp lacerations (1.3%), and one foot laceration (0.3%). There were 283 patients younger than 18 years (90.4%) and 30 patients 18 years old or older (9.6%) (Table 1). No occurrence of wound infection or wound dehiscence was found among the 313 delayed repair cases.

Table 1. Delayed Repair of Lacerations

Patient’s Age (y)	Location of Wound	
<18 = 283 (90.4%)	Facial = 249 (79.6%)	
≥18 = 30 (9.6%)	Hand = 59 (18.8%)	
	Scalp = 4 (1.3%)	
	Foot = 1 (0.3%)	
N = 313	Total = 100%	

Our initial online review yielded 313 articles and/or chapters that were subsequently narrowed down to 42, and 16 of those were chosen as more significant to our analysis. From the initial search of 313 articles based on key words, the vast majority did not address traumatic lacerations repaired late and were immediately discarded. Of the 42 articles that did address it, many were overviews or repetitions of previous articles without new information or data, whereas some were judged by the author to be of low quality and were not included. The 16 articles chosen did address some form of delayed laceration repair and did offer substantial data deemed useful for comparison or as a historical importance on establishing the safety on delayed repairs. There were two systematic review articles that addressed the impact of delayed repair and possible complications.5,6 A summary of the most relevant studies is included in Table 2.

Table 2. Summary of Selected Studies on Laceration and Timing of Repair

Authors	Characteristics	Timing	Results	Study Type	
Berk et al7	372 patients in a public hospital in Jamaica	0–6 h
7–12 h
13–24 h
25–48 h
>48 h	No significant difference in healing between 0 and 19 h. Decrease in wound healing >19 h except for head.	Prospective observational	
Lammers et al8	5084 patients in a university medical center in the USA	<10 h
10–24 h	Overall infection rate 7.2% significant higher rate for >10 h and lower extremities.	Prospective observational	
Van den Baar et al9	425 patients in a level 1 trauma center in the Netherlands	0–6 h
>6 h	Overall infection rate of 2.8% not associated with wound age.	Prospective observational	
Waseem at al10	297 patients in a level 1 trauma center in the USA	0–6 h
>6 h	Overall 3.4% infection. Suggest increased infection rate beyond 15 h.	Prospective observational	
Quinn et al11	2663 patients in three different level 1 trauma centers in the USA	0–12 h
>12 h	Overall 2.6% infection rate. No difference in relation to timing of repair. Infection associated with lower extremity, diabetes and laceration greater than 5.0cm.	Multicenter prospective cohort	

DISCUSSION

To our knowledge, this article is likely the first to report a series of mutually agreed upon delayed repair of lacerations between physician and patients. Our results are consistent with the observations that delayed repair of uncomplicated lacerations (mostly on the facial area) does not result in increased complications and therefore, does not impact functional and aesthetic outcomes. The fact that we did not report any complication is not surprising considering the patient selection: all cases were screened by history and phone pictures and prospectively judged by the author to be of low risk for complications and amenable to delayed treatment. Comparing our results with some of the selected studies in Table 2, Van der Baar et al12 observed 36 cases of infection on the delayed repair cohort but only three of them were in repairs beyond 6 hours of injury. Quinn et al13 reported an overall low infection rate (2.6%), but it included all cases of consecutive repairs in 2662 patients. When stratified by location it only yielded 1.1% infection rate in facial wounds.

What is unique about our experience is that the delay was planned and agreed between the treating physician and patients (almost like a prospective study), but in almost all papers published on this topic, the treatment postponement was not due to the treating physician’s choice but rather attributed to extraneous circumstances causing the delay on repair, usually patient-related. The decision to delay the repair in our series was based on history, location of the wound (usually face and head), and cell phone pictures taken shortly after the onset of injury. This author has found that the main obstacle in planned delayed laceration repair, such as for religious observance, surgeon’s availability (or lack there of), or convenience (mostly on late nights or weekend cases), is the public perception that there are time limits for repair beyond which the risk of infection increases, or the cosmetic results get compromised. This perception, despite being erroneous, is not surprising given the fact that even some medical textbooks on emergency medicine suggest that a traumatic wound should not be closed after 6 hours.1 This dogma was likely coined by an animal study in 1898 by Paul Leopold Friedrich who lacerated the skin of guinea pigs, inoculated the wound with bacteria, and determined that if skin was excised at less than 6 hours, the animals survived, whereas if excised after 8 hours, the animals died.7,11 After Friedrich’s work, a general belief persisted that longer time elapsed from injury to repair correlated with increased infection rate; however, the exact golden period was never defined, albeit several publications state that it ranges from 3 to 24 hours, without any evidence to support this.5,6 One of the first papers to question and address the issue of the golden period was published in 1988 by Berk et al.14 It was a prospective study performed at Kingston Public Hospital emergency department in Jamaica, a high-volume casualty department to which many patients present with wounds older than 24 hours, where they were able to observe the effect of late primary closure on wound healing. They included 204 patients who returned to follow-up, 182 of whom had repair beyond 6 hours from injury. They concluded that their results indicated that a golden period does exist for certain primary repairs of traumatically induced wounds, and that its duration extends to approximately 19 hours from the injury. The healing of head wounds, however, was unaffected by the interval between injury and repair. In another study, Quinn et al13 conducted a multicenter prospective cohort of consecutive lacerations where 2663 patients completed the follow-up, and they found that the time between injury and closure had no association with infection. The overall infection rate was 2.6% and it did show an association with diabetes, wounds larger than 5 cm and location on the lower extremities. They concluded that the concept of a golden period no longer exists. Another prospective observational study by Baker and Lanuti15 looked at 2834 pediatric lacerations with a similar infection rate of 1.3%, but only 147 delayed repairs beyond 6 hours of injury. Chiang et al16 reviewed 143 patients with eyelid lacerations treated by the ophthalmology service at the Medical College of Wisconsin over a 38-month period, where 75% were repaired in an operating room and 54% had canalicular system involvement. Ninety-five patients (66.4%) underwent repair less than 24 hours after injury and 48 (33.6%) were repaired after 24 hours. No statistical difference in complications was found between the two groups, and no case of infection was found in either. Hollander et al17 in a prospective study looking at risk factors for infection in traumatic lacerations found a correlation with higher infection rates in older patients, presence of diabetes, and in complex or deeper wounds, but all subjects had a wound age less than 6 hours. In a study of hand wounds, Roberts et al8 found that patient age, wound age, number of sutures, and length of lacerations had no effect on healing or infection rates. Lammers and colleagues18 attempted to create a model for prediction of wound infection in uncomplicated, traumatic, sutured wounds on a prospective study with a total of 1142 wounds. The overall infection rate was 7.2%, but the study had flaws, a low follow-up rate (24%) and a small number of infections. From seven variables suggested to create a predictive model, wound location on legs and thigh was the strongest predictor. They mentioned that the wound age rule could be altered by a combination of other factors. For example, a contaminated laceration on the foot of an elderly diabetic individual who presents for care within 30 minutes is likely to be at higher risk of infection than a 24-hour-old, clean, facial laceration in a young, healthy patient. We found one article where delayed traumatic wound repair was systematically done. Akhtar et al19 audited the treatment of dog bite injuries in children at Sheffield Children’s Hospital in the United Kingdom. Of the 114 patients who required repair in an operating room, 57 (50%) were operated on within 12 hours of their injury and 57 (50%) after 12 hours to avoid nighttime operating according to their hospital guidelines. There were three cases of infection in the early group and none in the delayed group. Granted, in all patients who receive prophylactic antibiotics early on, these wounds are usually at a higher risk for infection given the bacterial inoculation. Moreira and Markovchick10 published a comprehensive review on traumatic wound management, which addresses that the concept of the golden period stems from the assumption that bacterial proliferation within wounds is dependent on time from initial insult to repair, but acknowledges the study from Jamaica14 that shows how a theoretical bacterial count does not correlate with clinical results. A meta-analysis of studies on wound age and infection was done by Zehtabchi et al.5 The objective was to answer if wounds closed via primary repair after the golden period had increased risk of infection. They identified 418 studies but excluded the ones with delayed primary repair or secondary closure; wounds requiring intraoperative repair, skin graft, drains, or extensive debridement; and those grossly contaminated or infected at presentation. They assessed the quality of the included trials, and four of them enrolling 3724 patients in aggregate met inclusion criteria. They concluded that the existing evidence does not support the existence of a golden period, nor does it support the role of wound age on infection rate in simple lacerations. A prospective study by Waseem et al9 found a minor increase in infection rate after 1000 minutes. However, they only had 297 participants with 10 of them with infection yielding a low power to their study. A Dutch prospective study on time to closure and infection12 had a relatively small cohort (408 patients in total with 36 infections) and included any redness as a sign of infection yet, on statistical analysis, they concluded that time of repair since trauma was not a factor, but lower limb wounds (regardless of time) had a significantly higher infection rate than wounds of the head. They hypothesized that the difference in thickness of the skin leads to differences in neo-angiogenesis. A weakness in our study was the lack of documentation of the exact timing of delay in hours, which was estimated by the author in most cases, and the lack of systematic long-term follow-up, although the presence of infection, or lack thereof, can be determined at the first visit 4 or more days following the repair. We would have liked to stratify the data in shorter time periods such as 3–12 hours, 12–24 hours, and greater than 24 hours but we lacked more detailed data on timing in our records. Furthermore, the definition of delay has not been defined. We included every patient who reached out almost immediately at the time of injury and could have had the repair done promptly; however, it is a reality that many patients who present to emergency departments with simple lacerations wait many hours to be treated. One of the key questions to be answered is “how long can we wait to repair uncomplicated lacerations?” and our data alone are insufficient to answer it. Given that the technique of wound closure does not vary for this author between early or delayed repairs, infection that could increase wound dehiscence would be the single variable determining a worse cosmetic result for delayed repair that was not observed, therefore allowing us to infer that no difference exists in cosmetic results between early versus delayed repair. The overall low complication rate for laceration repairs in general would require larger cohorts to obtain statistical significance, even though our findings are suggestive of a lower complication rate on selected cases for delayed repair, likely due to lower morbidity of the wounds and lower contamination rates at the onset. The selection bias by the author may be elusive for nonplastic surgeons or less-experienced practitioners but likely feasible and accessible to any trained plastic surgeon and other practitioners with trauma experience. We may suggest as future direction that a prospective study be designed to identify patients who present for late repair (eg, more than 6 hours from injury) with detailed documentation of number of hours and possibly a multicentric study to increase its power.

CONCLUSIONS

Our findings are consistent with the concept that delayed repair of uncomplicated wounds does not increase the rate of infection or impact the final cosmetic outcome. It is noteworthy that our casuistry is composed of mostly facial and hand injuries, and this experience may not be replicated in injuries of the lower extremities where multiple studies have shown a higher infection rate regardless of timing from injury to repair and also suggest increased morbidity with delay. It is also important to note that the mere location of the wound should not suffice for such a practice to take place, but other nuances should be addressed, such as size of the wound, mechanism, active bleeding, presence of foreign body, degree of discomfort, and associated injuries. The selection criteria should also consider the history, mechanism of injury and a visual exam. Our practice has a unique sociodemographic characteristic that created the experience of planned delayed repair of lacerations described here and depicted for the first time in a scientific publication, albeit likely practiced by other physicians. Based on our findings and practices herein described and with an analysis of other publications, it should not be difficult to any trained plastic surgeon or experienced emergency physician to determine the appropriateness of such an approach. It is likely that our results presented herein may serve as guidelines for other practitioners and for some emergency facilities (such as hospitals and urgent care centers) of the safety and appropriateness of delaying repair for uncomplicated lacerations (with the exception of ones on the lower extremities), most notably at late hours at night or when the facility may not be appropriately staffed with experienced practitioners to perform the repair and the patient would be better served by having the repair delayed.

DISCLOSURE

The author has no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENT

The author would like to thank Janice Lester, MLS, Northwell Health Librarian, for helping with the literature search.

Published online 10 September 2024.

Disclosure statements are at the end of this article, following the correspondence information.
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