Chapter 42: Face and Scalp Lacerations

INTRODUCTION AND EPIDEMIOLOGY

Lacerations of the face and scalp are proximate in location but have important differences regarding repair. Facial wounds are the most cosmetically apparent of all wounds and therefore warrant careful evaluation and meticulous repair technique for the best possible outcome. Scalp wounds are less visible and are typically closed with less attention to detail. Most facial and scalp lacerations can be closed by the emergency physician, but consult with specialists if the technical aspects of closure are complex.

Three common principles guide repair of facial and scalp lacerations.¹ First, cleanse, irrigate, and remove foreign material to minimize infection. Second, limit debridement of skin edges because the excellent blood supply enables tissues to recover that initially appear nonviable. And third, if local anesthetic infiltration distorts anatomy and hinders wound edge alignment, use regional nerve blocks (see chapter 36, "Local and Regional Anesthesia").²

Use nonabsorbable monofilament suture for facial skin. Rapidly absorbable suture and tissue adhesives are alternatives in selected locations and for children.^3,4 Use absorbable suture for mucosa and facial layers. To minimize scarring, place percutaneous sutures on the face 1 to 2 mm from the wound edges, 3 to 4 mm apart, with everted edges. Place mucosal sutures 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 may facilitate more accurate suture placement in facial wounds.

Ask about the possibility of domestic violence in patients with facial injuries, and notify appropriate authorities if violence is suspected (Table 42-1).^5,6,7

PATHOPHYSIOLOGY

Facial and scalp wounds are most often caused by a combination of sharp and blunt mechanisms. Lacerations caused by sharp objects likely 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, all of which slow 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 skull.

In most patients with isolated facial trauma resulting in lacerations, the ...