Lacerations to the face and scalp are grouped together because
of their proximity but have important differences regarding repair.
Facial, including forehead, wounds are the most cosmetically apparent
of all wounds and therefore warrant careful evaluation and meticulous
repair technique. The emergency physician can repair the majority
of facial lacerations, but consultation with specialists is encouraged
when the technical aspects of closure exceed the physician’s
ability. Wounds to the face that involve areas of tissue avulsion
may best be repaired primarily in the operating room so flaps or
grafts can be applied.
There are several common principles to repair of facial and scalp
lacerations. As with any wound, cleaning and removal of foreign
debris is important. Keep debridement of skin edges to a minimum.
Because of the excellent blood supply to the face, tissue that appears
nonviable will often recover and heal. For small lacerations <3
cm, infiltration of local anesthetics along the wound edges is usually
adequate. But infiltration can distort the anatomy and hinder alignment
of the wound edges during repair. One alternative is to inject the
local anesthetic several millimeters from the wound edges and wait
longer than normal for the swelling to subside. Another alternative
is regional nerve blocks, which are especially useful for larger
Nonabsorbable monofilament is recommended for the skin, with
rapidly absorbable suture and tissue adhesives useful alternatives
in selected locations. Mucosa and muscle/facial layers
are closed with absorbable suture. To minimize scarring, percutaneous
sutures on the face are typically placed 1 to 2 mm from the wound
edges, 3 to 4 mm apart, with everted edges. Mucosal sutures should
be 2 to 3 mm from the wound edges, 5 to 7 mm apart, and superficial
so as to only include the mucosa and not the underlying muscle or
fascia. Use of magnification with surgical loupes is encouraged
for facial wounds, as they allow for more accurate suture placement
and wound edge alignment. Most facial lacerations are superficial
and can be closed in a single layer with percutaneous sutures.
A common injury sustained by domestic violence victims is facial
trauma.1 Patients with facial trauma should be
questioned about the possibility of domestic violence, and appropriate
authorities should be notified (Table 46-1).
Table 46-1 Maxillofacial
Injuries and Domestic Violence in the ED |Favorite Table|Download (.pdf)
Table 46-1 Maxillofacial
Injuries and Domestic Violence in the ED
|Most victims of domestic violence have maxillofacial injuries.|
|Women are more commonly affected than men.|
|Fist is most common weapon.|
|Left side of face is most common site of injury.|
|Nasal bone is commonly fractured.|
Facial and scalp wounds are most often caused by a combination
of sharp and blunt mechanisms. Lacerations caused by sharp objects
are likely to have discrete edges but may extend deeply and involve underlying
structures, such as the muscles of facial expression, nerves, and
arteries. Wounds caused by blunt forces burst the skin open, damage
cells, and produce tissue edema, which slows the wound-healing process.
As a result, it takes an average of 10 times fewer bacteria to cause
an infection in a blunt wound compared with a sharp wound. Blunt
forces are also more likely to cause diffuse underlying damage,
such as fractures of the facial bones or ...