Blunt and penetrating trauma can lead to a myriad of soft tissue injuries. The management of the majority of these injuries is discussed elsewhere in this text. Some specific soft tissue injuries require detailed explanations for their repair. These injuries are discussed below.
Forehead lacerations are common in all age groups, occurring most frequently during early childhood. While most forehead lacerations are not associated with any other significant injuries, their location demands a complete head and neck evaluation.1 Furthermore, their visibility requires meticulous attention to detail. Knowledge of the principles regarding their repair allows for good cosmesis. The repair of forehead lacerations differs from that of other soft tissue injuries due to the role of skin tension lines, the lack of extra tissue, and scarring promoted by too many deep dermal sutures.2–4 Forehead injury repair is governed by three principles: (1) skin tension lines run parallel to the skin creases and play a major role in the outcome of any forehead laceration; (2) lacerations running perpendicular to skin tension lines are more likely to result in a noticeable scar2,3; and (3) there is little excess tissue on the forehead to allow later wound revisions. Resist the temptation to excise ragged wounds.4 This leaves enough tissue for the Surgeon to work with if further revision is required. Place as few deep sutures as possible, as they tend to promote more tissue reaction and more noticeable scar formation.
Many forehead lacerations require repair in order to promote cosmesis and provide hemostasis. Perform primary repair at any time up to 24 hours after the initial insult. This allows referral to a consultant if there is any question about one's ability to achieve satisfactory cosmesis or if the wounds are so extensive as to take the Emergency Physician away from their departmental responsibilities for an unacceptably long time regardless of the level of complexity.
Laceration repair is dependent on the type of laceration. Small and uncomplicated lacerations can be closed with simple interrupted 6-0 nonabsorbable sutures (e.g., nylon or Prolene).1 Flaps smaller than 5 mm can be closed using simple interrupted 6-0 nonabsorbable sutures (e.g., nylon or Prolene). Larger flaps can be closed using the half-buried horizontal mattress stitch. Partial-thickness abrasions and gouges less than 1 cm wide and 2 mm deep should be allowed to heal by secondary intention.2,5,6 Bunched-up, small flap lacerations can be excised together and the resulting defect repaired primarily.6 This technique is described under “Multiple Small Skin Flaps” in this chapter.
Deeper transverse lacerations that involve the deep fascia, the frontalis muscle, and the periosteum should be repaired in layers using 5-0 absorbable suture (e.g., nylon or Prolene).1 The epidermal layer can be closed with either simple interrupted 6-0 nonabsorbable sutures (e.g., nylon or Prolene), skin closure strips over adhesive adjuncts, or with tissue adhesive. ...