Skin closure by metal staples is quick (at least four times faster than closure with sutures) and economical (slightly less total cost than suturing). 67 and 8 An additional advantage of staples is their low level of tissue reactivity; wounds with staple closure exhibit resistance to infection superior even to that of the least reactive suture. 9 These advantages of skin staples must be weighed against one notable drawback—the skin staple does not provide the same meticulous coaptation of lacerations with irregular skin edges that can be achieved with sutures. For staples to achieve accurate closure, the skin edges must be aligned before the staples are placed. Because accurate prepositioning of the wound edges is very difficult in many lacerations, staple implantation will often result in malapposition of wound edges, which is an invitation to the development of scar deformity. Consequently, skin staples are usually reserved for lacerations in anatomic sites where the healing scar is not readily apparent (e.g., scalp).

The basic shape of an applied cutaneous staple is an incomplete rectangle; the top bridges the laceration off the skin surface and the points are directed 90° inward off the side legs (Fig ,3..7..-9!). As staples are placed, the stapling device pushes the points toward each other; they impinge the skin and evert the wound edges. When placing staples, the wound edges should be held together with tissue forceps. The stapling device should be placed gently (not firmly or with pressure) against the skin surface before the trigger is slowly (not rapidly) squeezed. A properly placed staple should have its top side off the skin surface.

A variety of stapling devices that implant stainless steel staples are commercially available for use in the ED. There are several features of a stapling device to be considered in choosing a particular product:

1. The stapler should be designed so that it does not obstruct the physician's view of the wound edge.

2. The stapler should have a mechanism that holds the staple securely during its formation.

3. The stapler should have an ejection spring that automatically releases the staple.

4. The handling characteristics of the stapler should be such that the physician can easily implant a large number of staples without becoming fatigued.

Other features to be considered in choosing stapling devices include size (smaller ones are better for lacerations in tight areas) and quantity of staples (more are required when closing large lacerations).

Staples were originally developed to close surgical incisions, and there was initially a reluctance to use them for traumatic lacerations. 6 Clinical studies have found that for the scalp, neck, trunk, and extremities, staples produce a cosmetic result that is identical to that from sutures. 67 and 8 Staple removal requires a special instrument that deforms the top and spreads open the points. Staple removal is slightly more painful than suture removal.

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