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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 lacerations.


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).

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Table 46-1 Maxillofacial Injuries and Domestic Violence in the ED

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 ...

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