33 FACIAL LACERATIONS
Lawrence L. Ketch M.D.

1. What distinguishes facial from other lacerations?

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Appearance is clearly of primary importance. Quality of the final result depends on strict adherence to basic principles of wound management and painstaking technique. Copious irrigation, judicious debridement, gentle tissue handling, meticulous hemostasis, and minimization of sutures combined with early stitch removal are critical to an optimal result. Fine suture and sharp instruments should be used; eversion of the wound margin with layered closure, obliteration of dead space, and lack of tension are mandatory.

2. What factors influence treatment for the wound?

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The mechanism of injury, the clinical assessment of contamination, and the time elapsed since wounding dictate treatment. Clean lacerations, heavily contaminated wounds, crush injuries, and bites are treated very differently.

3. How are clean lacerations repaired?

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They should be irrigated with normal saline or Ringer’s lactate. Only the surrounding skin should be prepared, and no antiseptic should be introduced into the wound. Regional anesthesia is preferred because of the potential for spread of contamination with direct injection of the wound margin. Epinephrine should be avoided because it devitalizes tissue and potentiates infection. Wounds should be repaired in layers with absorbable suture in deep tissue. The smallest number of sutures necessary to overcome the natural resting wound tension should be used. Sutures should be removed within 3-5 days, and the wound margin should be subsequently supported with Steri-strips.

4. How are dirty lacerations repaired?

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Heavily contaminated wounds should remain open after irrigation and debridement to undergo delayed closure. Because of cosmetic considerations, however, this approach is unacceptable in the face. For this reason, meticulous debridement of devitalized tissue and removal of all foreign material is essential. The wound should be cultured before copious irrigation, and a broad-spectrum antibiotic should be instituted prophylactically. The patient must be informed of the potential of a postrepair infection.
KEY POINTS: FACIAL LACERATIONS

1. Appearance is of paramount importance.
2. Clean lacerations are treated with minimal, tension-free, fine monofilament suture placement and early suture removal (3-5 days).
3. Heavily contaminated wounds are irrigated, debrided, and repaired with administration of antibiotics.
4. Human and animal bites are highly prone to infection; therefore, antibiotics and delayed closure are necessary.
5. N-butyl-2-cyanoacrylate (Dermabond) is used to repair pediatric facial lacerations.

5. What factors influence suture selection?

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Any method of suturing provokes tissue damage, impairs host defense, increases scar proliferation, and invites infection. Presence of a single silk suture in a wound lowers the infective threshold by a factor of 10,000. Therefore, fine, monofilament suture, just strong enough to overcome the resting wound tension, should be used. Use as few sutures as possible. Wounds with little or no retraction may be closed with tape alone.

6. Which wounds are suitable for closure with tissue adhesives?

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N-butyl-2-cyanoacrylate may suffice for cutaneous closure of low-tension lacerations in children (preferred method) and adults. This adhesive effectively closes low-tension lacerations. This method is fast and relatively painless. It has a low complication rate and produces excellent cosmetic outcomes. In many instances, if initial wound orientation is against Langer’s lines, it may, in fact, offer an advantage over conventional manual suturing.

7. Should eyebrows be shaved when facial lacerations are repaired?

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No. They provide a landmark for realignment of disrupted tissue edges and do not always grow back.
8. How should crush avulsion injuries with associated skin loss be repaired? Show answer
Nonviable elements must be surgically excised because they predispose to infection and lead to excessive scarring. If viability is in doubt, the wound should be irrigated thoroughly and left open with moist dressings. A delayed closure can be accomplished when the questionable areas have declared themselves. It is often prudent to close facial tissue as it lies; this technique often produces a less obtrusive scar than straight-line debridement and closure.

9. How should bites be treated?

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Both animal and human bite wounds are big-time contaminated and prone to infection. The wound should be left open and closed in a delayed fashion. Antibiotic prophylaxis is indicated. If the wound becomes infected, the sutures must be removed and the wound allowed to drain and heal. The patient should be informed that a scar revision will be necessary.

10. Should skin grafts or flaps be used for primary closure of a wound?

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Complicated tissue transfer techniques have no place in the acute treatment of facial wounds. Closure should be achieved in the simplest way possible and complex reconstructive efforts should be deferred until the scar has matured (months). When tissue loss prevents closure, it may be necessary to use a thin split-thickness skin graft for coverage.

11. When are antibiotics indicated in the treatment of facial lacerations?

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Copious irrigation, debridement, and gentle tissue handling are more pertinent to the prevention of infection than the use of antibiotics in clean and clean-contaminated wounds. Antibiotic coverage is indicated, however, in crush avulsion injuries, bites, and heavily contaminated injuries.

12. What determines the quality of the scar?

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Location of the wound, age of the patient, and type and quality of skin determine it. Lesser determinants are the type and quantity of suture material and wound care. Final appearance depends little on the method of suture. Contusion, infection, retained foreign body, improper orientation of laceration, tension, and beveling of edges predict a poor outcome. Differences among suture materials are negligible; however, the technical factors of suture placement to produce wound eversion and time to removal affect the final result.

13. When should scars be revised?

A scar usually has its worst appearance at 2 weeks to 2 months after suturing. Scar revision should await complete maturation, which may take 4-24 months. A good rule of thumb is to undertake no revisions for at least 6-12 months after initial repair. The maturation of the wound may be assessed by its degree of discomfort, erythema, and induration.