The scalp and forehead have thick skin and little cushioning fat (Fig. 11-1). Wounds of the scalp and forehead can usually be repaired with primary closure when they are not visibly infected, regardless of the time since the injury and even if the injury was secondary to a bite. After performing wound cleansing and achieving hemostasis, palpate the base of the wound to assess for possible skull fracture. CT scan can be used to further evaluate an injury when an underlying fracture is suspected.
Examine the wound edges for signs of devitalized tissue that may require debridement. When hemostasis is not easily achieved, use direct pressure or vessel clamping to control bleeding at the wound edges. Irrigate the wound well to remove contamination and reduce the risk of wound infection. Close scalp lacerations with surgical staples or simple interrupted sutures using nonabsorbable monofilament or rapidly absorbable material. Consider a pressure dressing over deep scalp lacerations for the first 24 hours to reduce the chance of hematoma formation.
Superficial forehead lacerations are not associated with injury to the frontalis muscle, while deep lacerations do have damage to the frontalis muscle. Close superficial forehead lacerations with 6-0 nonabsorbable interrupted suture, rapidly absorbable suture, or tissue adhesive. Close the muscular layer of deep forehead lacerations with buried 5-0 absorbable suture, and then close the epidermal layer with 6-0 nonabsorbable suture, skin closure strips, or tissue adhesive. Eyebrows are important landmarks to assist with reapproximation of wound edges. When wounds involve the eyebrows, minimize skin debridement and leave suture tails long to facilitate removal. Remove scalp staples or sutures in 10 to 14 days, while forehead nonabsorbable sutures can be removed in 5 to 7 days.
The eyelids are thin and offer limited protection from injuries to the globe and surrounding structures. Examine lid injuries for involvement of the canthi, the lacrimal system, or penetration through the tarsal plate or lid margin (Fig. 11-2). Eyelid injuries within 6 to 8 mm of the medial canthus are at risk for canalicular laceration, particularly when associated with medial wall blow-out fractures. Consider consultation with an ophthalmologist when ptosis is present or for complex eyelid wounds such as those involving the inner surface of the lid, lid margins, lacrimal duct, and tarsal plate. Close uncomplicated eyelid lacerations with nonabsorbable 6-0 or 7-0 simple interrupted percutaneous sutures. Avoid the use of tissue adhesive near the eye. Remove nonabsorbable sutures in 3 to 5 days.
Examine nasal lacerations to determine depth and involvement of deep tissue layers. Exposed cartilage or deep involvement of the ...