The scalp and forehead (which includes eyebrows) are parts of the same anatomic structure (Fig. 11-1). Eyebrows are valuable landmarks for the meticulous reapproximation of the wound edges and should never be clipped or shaved. After the wound cleaning and hemostasis are achieved, the base of the wound always should be palpated for possible skull fracture. All depressed fractures should be evaluated by computed tomography.
The layers of the A. scalp, B. temporal region, and C. eyebrow. Key: TM = temporalis muscle.
When the edges of a laceration of the eyebrow or the scalp are devitalized, debridement is mandatory. Debride at an angle that is parallel to that of the hair follicles, to prevent subsequent alopecia. Occasionally direct pressure or vessel clamping may be needed to control hemorrhage at the wound edges. Begin wound closure with approximation of the galea aponeurotica using buried, interrupted absorbable 4-0 sutures. Close the divided edges of muscle and fascia with buried, interrupted, absorbable 4-0 synthetic sutures to prevent further development of depressed scars. Close the skin with staples or interrupted nylon sutures (sutures of a color different from the patient's hair should be considered).
Approximate the skin edges of anatomic landmarks on the forehead first with key stitches by using interrupted, nonabsorbable monofilament 5-0 synthetic sutures. Accurate alignment of the eyebrow, transverse wrinkles of the forehead, and the hairline of the scalp is essential. It may be necessary to have younger patients raise their eyebrows to create wrinkles for accurate placement of the key stitches. A firm pressure dressing placed around the head can close any potential dead space, encourage hemostasis, and prevent hematoma formation. Leave the pressure dressing in place for 24 hours. Scalp sutures and staples can be removed in 7 to 10 days, whereas facial sutures should be removed in 5 days.
A complete examination of the eye structure and function is essential, including an evaluation for foreign bodies (see Chapter 149). Examine the lid for involvement of the canthi, the lacrimal system, the supraorbital nerve, and the infraorbital nerve or penetration through the tarsal plate or lid margin (Fig. 11-2). The following wounds should be referred to an ophthalmologist: (a) those involving the inner surface of the lid, (b) those involving the lid margins, (c) those involving the lacrimal duct, (d) those associated with ptosis, and (e) those extending into the tarsal plate. Failure to recognize and properly repair the lacrimal system can result in chronic tearing.
Uncomplicated lid lacerations can be readily closed by using nonabsorbable 6-0 sutures, with removal in 3 to 5 days. Do not use tissue adhesive near the eye.