Chapter 11. Lacerations to the Face and Scalp

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.

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.

Lacerations of the nose may be limited to skin or involve the deeper structures (sparse nasal musculature, cartilaginous framework, and nasal mucous membrane). Each tissue layer must be accurately approximated. Inexperienced operators should refer such cases to an otolaryngologist or a plastic surgeon. Local anesthesia of the nose can be difficult because of the tightly adhering skin. Topical anesthesia may be successful with lidocaine.

When the laceration extends through all tissue layers, begin closure with a nonabsorbable, monofilament 5-0 synthetic suture that aligns the skin surrounding the entrances of the nasal canals to prevent malposition and notching of the alar rim. Traction on the long, untied ends of this suture approximates the wounds and aligns the anterior and posterior margins of the divided tissue layers. Repair the mucous membrane with interrupted, braided, absorbable 5-0 synthetic sutures, burying the knots in the tissue. Re-irrigate the area gently from the outside. Rarely, the cartilage may need to be approximated with a minimal number of 5-0 absorbable sutures. In sharply marked linear lacerations, closure of the overlying skin is usually sufficient. Close the cut edges of the skin, with its adherent musculature, using interrupted, nonabsorbable, monofilament 6-0 synthetic sutures. Remove external sutures in 3 to 5 days.

Inspect the septum for hematoma formation with a nasal speculum. The presence of bluish swelling in the septum confirms the diagnosis of septal hematoma. Treatment of the hematoma is evacuation of the blood clot. Drainage of a small hematoma can be accomplished by aspiration of the blood clot through an 18 gauge needle. A larger hematoma should be drained through a horizontal incision at the base. Bilateral hematomas should be drained in the operating room by a specialist. Reaccumulation of blood can be prevented by nasal packing. Antibiotic treatment is recommended to prevent infection that may cause necrosis of cartilage. Use an oral penicillin, cephalosporin, or macrolide (in penicillin-allergic patients).

The technique of closure will depend largely on the type of lip wound. Isolated intraoral lesions may not need to be sutured. Through and through lacerations that do not include the vermilion border can be closed in layers. Begin repair with 5-0 absorbable suture for the mucosal surface, reirrigate and then close the orbicularis oris muscle with 4-0 or 5-0 absorbable suture. Close skin with 6-0 nonabsorbable suture or tissue adhesive. Remove sutures in 5 days.

Begin closure of a complicated lip laceration at the junction between the vermilion and the skin with a nonabsorbable, monofilament 6-0 synthetic suture (Fig. 11-3). The orbicularis oris muscle is then repaired with interrupted 4-0 or 5-0 absorbable sutures. Approximate the junction between the vermilion and the mucous membrane with a braided, absorbable 5-0 synthetic suture. Close the divided edges of the mucous membrane and vermilion with interrupted absorbable 5-0 synthetic sutures in a buried knot construction. Skin edges of the laceration may be jagged and irregular, but they can be fitted together as the pieces of a jigsaw puzzle by using interrupted, nonabsorbable, monofilament 6-0 synthetic sutures with their knots formed on the surface of the skin. Patients with sutured intraoral lacerations should receive prophylactic antibiotics, penicillin or clindamycin.

Close superficial lacerations of the ear with 6-0 nylon suture. Cover exposed cartilage. Debridement of the skin is not advisable because there is very little excess skin. In most through and through lacerations of the ear, the skin can be approximated and the underlying cartilage will be supported adequately (Fig. 11-4). After repair of simple lacerations, place a small piece of nonadherent gauze over the laceration only and apply a pressure dressing. Place gauze squares behind the ear to apply pressure, and wrap the head circumferentially with gauze. Remove sutures in 5 days. Consult an otolaryngologist or plastic surgeon for more complex lacerations, ear avulsions, or auricular hematomas.

In general, facial lacerations are closed with 6-0 nonabsorbable, simple interrupted sutures and are removed after 5 days. Tissue adhesive may also be used. Attention to anatomic structures including the facial nerve and parotid gland is necessary (Fig. 11-5). If these structures are involved, operative repair is indicated.