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Self-Treatment of Full-Thickness Traumatic Lip Laceration with Chicken Egg Shell Membrane
Wilderness and Environmental Medicine, 18, 230 231 (2007)
Letter to the Editor Self-Treatment of Full-Thickness Traumatic Lip Laceration with Chicken Egg Shell Membrane To the Editor: A 19-year-old patient who had emigrated from Ukraine 4 years previous presented for routine dental examination in the dental clinic. A ‘‘white-line’’ scar crossing the left side of his upper lip was noticed (Figure, a). The scar extended beyond the vermilion border and the intraoral portion of the lip (Figure, b), causing deformation of both aspects. According to the patient, 4 weeks earlier he had fallen and his lip was wounded. He barely managed to stop the bleeding by using a pad and applying pressure. He then topically bonded the margins of the wound by a fresh chicken egg membrane (‘‘egg-skin’’). Three days later, the patient removed the adhesive membrane. The patient did not seek professional treatment and did not take any medications. He reported no signs of inflammation, including pain, occurring immediately after the membrane application or during the 4 weeks after the event. No major change was observed in a reevaluation done 2 months later (3 months after the wound event). The patient is pleased with the current appearance of the lip and does not desire a cosmetic surgical correction of the scar. Lip wounds are among the most prevalent oral-maxillofacial injuries.1 Professional management of the wound is desirable to avoid contamination and to restore normal function and appearance of the lip. Lacerations extending through the entire thickness of the lip should be managed by use of copious irrigation, a triple-layered closure, and topical and/or systemic administration of antibiotics.2,3 The patient’s tetanus status should be ascertained.2 Of prime importance is the skillful mechanical approximation of the suture line for the avoidance of permanent unaesthetic lip deformation. Patients with facial wounds prioritize the cosmetic outcome as the most important aspect of their healing.4 According to Singer et al, optimal cosmetic outcome of laceration healing is characterized by elimination of step-off of borders, contour irregularities, wound margin separation, wound edge inversion, excessive wound distortion, and existence of good overall appearance.5 Corresponding author: Dr Yehuda Zadik, 16 Shlomo Zemach St, 96190 Jerusalem, Israel (e-mail: [email protected]).
Although this patient is satisfied with the outcome of his self-treatment, an objective examination of the scar according to Singer’s criteria reveals a failure of the cosmetic aspect of the healing. It is unknown whether the scar appearance is due to the material used (chicken egg membrane) or to an imprecise method of approximation. However, this full-thickness lip laceration was managed without irrigation, triple-layered suture, or antibiotics, as is indicated for such a condition with relative success. No infection and/or inflammation signs or symptoms were reported by the patient or clinically observed. However, as an anecdotal case, it is possible that the patient’s wound may have healed with similar results if just allowed to heal via secondary intention. In recent decades, tissue adhesives have become popular alternatives to sutures in treating surgical and traumatic wounds with good results.6 Tissue adhesives are cyanoacrylate and octylcyanoacrylate resins that polymerize to form a strong bond over the area of the wound. Rapid and painless application, antimicrobial effect, and self-removal are the advantages of adhesives over conventional sutures. The most prominent disadvantages of the adhesives are lower tensile strength and increased rate of dehiscence.7 Currently, there are only 1 published clinical trial and 1 case report supporting the usage of tissue adhesives for closure of congenital cleft lip8 and traumatic lip lacerations,9 respectively. Tissue adhesives are not yet recommended for closure over highly mobile areas or for areas in which precise alignment is a necessity, such as the lip.10,11 Adhesive strips can be
a. The white, linear scar crossing the left side of the patient’s upper lip and extending beyond the vermilion border. b. The intraoral aspect of the lip, 4 weeks after injury.
Letter to the Editor
231
placed at the time of suture removal to give external support to the healing wound.2 The chicken biologically active egg membrane contains types I, V, and X collagens, retains albumen, prevents penetration of bacteria, and is essential for the formation of eggshell.12 Ostrich egg membrane (with or without eggshell powder) has been offered as a facilitation to bone regeneration in cranial defects but with little adjunctive effect.13 However, as a skin graft donor site dressing, egg membrane possesses properties of pain relief, wound protection, promotion of healing, and low cost.14 It seems that chicken egg membrane is worthy of further research for surgical applications. Yehuda Zadik, DMD From the Medical Corps, Israel Defense Forces, Jerusalem, Israel References 1. Hill CM, Burford K, Martin A, Thomas DW. A one-year review of maxillofacial sports injuries treated at an accident and emergency department. Br J Oral Maxillofac Surg. 1998;36:44–47. 2. Ellis E. Soft tissue and dentoalveolar injuries. In: Peterson LJ, Ellis E, Hupp JR, Tucker MR, eds. Contemporary Oral and Maxillofacial Surgery. 3rd ed. St. Louis, MO: Mosby; 1998:583–586. 3. Zadik Y. Antibiotic coverage for lip wound. Dent Traumatol. 2006;22:56.
4. Singer AJ, Mach C, Thode HC Jr, et al. Patient priorities with traumatic lacerations. Am J Emerg Med. 2000;18: 683–686. 5. Singer AJ, Quinn JV, Thode HC Jr, Hollander JE. Determinants of poor outcome after laceration and surgical incision repair. Plast Reconstr Surg. 2002;110:429–437. 6. Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl J Med. 1997;337: 1142–1148. 7. Farion KJ, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations: a systematic review of randomized controlled trials. Acad Emerg Med. 2003;10:110– 118. 8. Magee WP Jr, Ajkay N, Githae B, Rosenblum RS. Use of octyl-2-cyanoacrylate in cleft lip repair. Ann Plast Surg. 2003;50:1–5. 9. de Blanco LP. Lip suture with isobutyl cyanoacrylate. Endod Dent Traumatol. 1994;10:15–18. 10. Penoff J. Skin closures using cyanoacrylate tissue adhesives. Plastic Surgery Educational Foundation DATA Committee. Plast Reconstr Surg. 1999;103:730–731. 11. Smith J, Maconochie I. Should we glue lip lacerations in children? Arch Dis Child. 2003;88:83–84. 12. Nakano T, Ikawa NI, Ozimek L. Chemical composition of chicken eggshell and shell membranes. Poult Sci. 2003; 82:510–514. 13. Durmus E, Celik I, Ozturk A, Ozkan Y, Aydin MF. Evaluation of the potential beneficial effects of ostrich eggshell combined with eggshell membranes in healing of cranial defects in rabbits. J Int Med Res. 2003;31:223–230. 14. Yang JY, Chuang SS, Yang WG, Tsay PK. Egg membrane as a new biological dressing in split-thickness skin graft donor sites: a preliminary clinical evaluation. Chang Gung Med J. 2003;26:153–159.
Letter to the Editor Self-Treatment of Full-Thickness Traumatic Lip Laceration with Chicken Egg Shell Membrane To the Editor: A 19-year-old patient who had emigrated from Ukraine 4 years previous presented for routine dental examination in the dental clinic. A ‘‘white-line’’ scar crossing the left side of his upper lip was noticed (Figure, a). The scar extended beyond the vermilion border and the intraoral portion of the lip (Figure, b), causing deformation of both aspects. According to the patient, 4 weeks earlier he had fallen and his lip was wounded. He barely managed to stop the bleeding by using a pad and applying pressure. He then topically bonded the margins of the wound by a fresh chicken egg membrane (‘‘egg-skin’’). Three days later, the patient removed the adhesive membrane. The patient did not seek professional treatment and did not take any medications. He reported no signs of inflammation, including pain, occurring immediately after the membrane application or during the 4 weeks after the event. No major change was observed in a reevaluation done 2 months later (3 months after the wound event). The patient is pleased with the current appearance of the lip and does not desire a cosmetic surgical correction of the scar. Lip wounds are among the most prevalent oral-maxillofacial injuries.1 Professional management of the wound is desirable to avoid contamination and to restore normal function and appearance of the lip. Lacerations extending through the entire thickness of the lip should be managed by use of copious irrigation, a triple-layered closure, and topical and/or systemic administration of antibiotics.2,3 The patient’s tetanus status should be ascertained.2 Of prime importance is the skillful mechanical approximation of the suture line for the avoidance of permanent unaesthetic lip deformation. Patients with facial wounds prioritize the cosmetic outcome as the most important aspect of their healing.4 According to Singer et al, optimal cosmetic outcome of laceration healing is characterized by elimination of step-off of borders, contour irregularities, wound margin separation, wound edge inversion, excessive wound distortion, and existence of good overall appearance.5 Corresponding author: Dr Yehuda Zadik, 16 Shlomo Zemach St, 96190 Jerusalem, Israel (e-mail: [email protected]).
Although this patient is satisfied with the outcome of his self-treatment, an objective examination of the scar according to Singer’s criteria reveals a failure of the cosmetic aspect of the healing. It is unknown whether the scar appearance is due to the material used (chicken egg membrane) or to an imprecise method of approximation. However, this full-thickness lip laceration was managed without irrigation, triple-layered suture, or antibiotics, as is indicated for such a condition with relative success. No infection and/or inflammation signs or symptoms were reported by the patient or clinically observed. However, as an anecdotal case, it is possible that the patient’s wound may have healed with similar results if just allowed to heal via secondary intention. In recent decades, tissue adhesives have become popular alternatives to sutures in treating surgical and traumatic wounds with good results.6 Tissue adhesives are cyanoacrylate and octylcyanoacrylate resins that polymerize to form a strong bond over the area of the wound. Rapid and painless application, antimicrobial effect, and self-removal are the advantages of adhesives over conventional sutures. The most prominent disadvantages of the adhesives are lower tensile strength and increased rate of dehiscence.7 Currently, there are only 1 published clinical trial and 1 case report supporting the usage of tissue adhesives for closure of congenital cleft lip8 and traumatic lip lacerations,9 respectively. Tissue adhesives are not yet recommended for closure over highly mobile areas or for areas in which precise alignment is a necessity, such as the lip.10,11 Adhesive strips can be
a. The white, linear scar crossing the left side of the patient’s upper lip and extending beyond the vermilion border. b. The intraoral aspect of the lip, 4 weeks after injury.
Letter to the Editor
231
placed at the time of suture removal to give external support to the healing wound.2 The chicken biologically active egg membrane contains types I, V, and X collagens, retains albumen, prevents penetration of bacteria, and is essential for the formation of eggshell.12 Ostrich egg membrane (with or without eggshell powder) has been offered as a facilitation to bone regeneration in cranial defects but with little adjunctive effect.13 However, as a skin graft donor site dressing, egg membrane possesses properties of pain relief, wound protection, promotion of healing, and low cost.14 It seems that chicken egg membrane is worthy of further research for surgical applications. Yehuda Zadik, DMD From the Medical Corps, Israel Defense Forces, Jerusalem, Israel References 1. Hill CM, Burford K, Martin A, Thomas DW. A one-year review of maxillofacial sports injuries treated at an accident and emergency department. Br J Oral Maxillofac Surg. 1998;36:44–47. 2. Ellis E. Soft tissue and dentoalveolar injuries. In: Peterson LJ, Ellis E, Hupp JR, Tucker MR, eds. Contemporary Oral and Maxillofacial Surgery. 3rd ed. St. Louis, MO: Mosby; 1998:583–586. 3. Zadik Y. Antibiotic coverage for lip wound. Dent Traumatol. 2006;22:56.
4. Singer AJ, Mach C, Thode HC Jr, et al. Patient priorities with traumatic lacerations. Am J Emerg Med. 2000;18: 683–686. 5. Singer AJ, Quinn JV, Thode HC Jr, Hollander JE. Determinants of poor outcome after laceration and surgical incision repair. Plast Reconstr Surg. 2002;110:429–437. 6. Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl J Med. 1997;337: 1142–1148. 7. Farion KJ, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations: a systematic review of randomized controlled trials. Acad Emerg Med. 2003;10:110– 118. 8. Magee WP Jr, Ajkay N, Githae B, Rosenblum RS. Use of octyl-2-cyanoacrylate in cleft lip repair. Ann Plast Surg. 2003;50:1–5. 9. de Blanco LP. Lip suture with isobutyl cyanoacrylate. Endod Dent Traumatol. 1994;10:15–18. 10. Penoff J. Skin closures using cyanoacrylate tissue adhesives. Plastic Surgery Educational Foundation DATA Committee. Plast Reconstr Surg. 1999;103:730–731. 11. Smith J, Maconochie I. Should we glue lip lacerations in children? Arch Dis Child. 2003;88:83–84. 12. Nakano T, Ikawa NI, Ozimek L. Chemical composition of chicken eggshell and shell membranes. Poult Sci. 2003; 82:510–514. 13. Durmus E, Celik I, Ozturk A, Ozkan Y, Aydin MF. Evaluation of the potential beneficial effects of ostrich eggshell combined with eggshell membranes in healing of cranial defects in rabbits. J Int Med Res. 2003;31:223–230. 14. Yang JY, Chuang SS, Yang WG, Tsay PK. Egg membrane as a new biological dressing in split-thickness skin graft donor sites: a preliminary clinical evaluation. Chang Gung Med J. 2003;26:153–159.