Facial Lacerations

1

What distinguishes facial lacerations from other?

After facial trauma, restoration of the appearance of the face is of the utmost concern. Successful primary closure of a facial laceration can be best achieved with irrigation, minimal debridement, gentle handling of the tissue, and eversion of the skin edges. Adherence to these principles gives the best chance for the least noticeable scar.

The face has abundant blood supply, when compared to the rest of the body. Thus, lacerations on the face should be closed even after more than 6 hours from injury. Furthermore, as the face has laxity of skin, most wounds may be primarily repaired. In the majority of cases, the use of local flaps should be avoided immediately after injury and once the wound is stable used in a secondary procedure.

2

How do you anesthetize a wound for repair?

If the wound is small, lidocaine with epinephrine may be injected into the wound directly. However, the infusion may distort the anatomy.

For larger wounds, the following nerve blocks may be performed. The advantage of this technique is that it allows adequate analgesia without the confounding distortion/edema of a local infusion. One must be careful to not inject the nerves directly, and remember to withdraw while inserting. The following are the nerve blocks for the face:

• Mental nerve block (for ipsilateral lower lip and the chin): The mental nerve is a branch of the inferior alveolar nerve, which is a branch of cranial nerve (CN) V3. The mental nerve exits the mental foramen, which is usually located at the second premolar, about 2 cm inferior to the alveolar ridge.

• Studies have found that an intraoral injection is less painful than a percutaneous injection, but care must be taken to not directly inject the nerve or inject into the foramen. This may be done by retracting the cheek and inserting the needle along the lower gum line where there is a buccal mucosal fold around the premolar teeth, this is a shallow injection about 5 mm deep. One to 2 mL of local anesthetic is slowly injected. If a percutaneous approach is taken, insert the needle midway between the oral commissure and the inferior mandible.

• Infraorbital nerve (for ipsilateral upper lip, lateral nose, cheek, and lower eyelid): The infraorbital nerve is a branch of the second division of CNV, the maxillary nerve. The maxillary nerve exits the foramen rotundum and branches prior to exiting the infraorbital canal where it becomes the infraorbital nerve.

• An infraorbital nerve block can be done with 1–3 mL of anesthetic agent. The infraorbital foramen is best located by having the patient look straight ahead and imagine a line extending from the pupil down to the inferior border of the infraorbital ridge (midpupillary line). Retract the lip, and insert the needle near the second bicuspid, keeping the needle parallel with the tooth. Protect the foramen by placing a finger on the inferior orbital rim, and slowly inject 2–3 mL of local anesthetic.

• Alternatively, a percutaneous injection can be done by sterilely inserting the needle approximately 1 cm below the infraorbital rim at the midpupillary line at a perpendicular angle. Again, one should take care not to enter the foramen.

• Supraorbital nerve and supratrochlear nerves (ipsilateral forehead): The supraorbital and supratrochlear nerve is located at the superior medial orbital rim and 1.5 cm medial respectively. To block the forehead, identify the supraorbital foramen where you can feel the notch at the superior orbital rim and inject just lateral to that. Inject 2 mL of lidocaine.

• Furthermore, for children, eutectic mixture of local anaesthetics (EMLA) cream may be applied, but the cream takes 60 minutes for optimal analgesia.

3

How do you clean a wound?

Irrigate wound with normal saline after local anesthesia, taking care to remove all foreign bodies and devitalized tissue.

4

What sutures should one use?

For clean lacerations, the deep dermal layer should be reapproximated with interrupted buried 4-0 Vicryl or PDS. For skin, 5-0 or 6-0 interrupted nylon or another type of monofilament suture such as Prolene should be used to close a wound on the face. For mucosal lacerations, Chromic or Vicryl should be used.

N-Butyl-2-cyanoacylate (Dermabond) or fast absorbing gut (absorbable suture) may be used on a child who would not tolerate suture removal, or a patient who will likely not return for suture removal. Skin adhesive, like N-Butyl-2-cyanoacylate should only be used if it is a low-tension laceration without concern for infections.

5

How do you place sutures?

Sutures on the face should be placed a little closer together than usually recommended because of cosmetic concerns. The sutures should be placed 1–2 mm from the skin edge and 3 mm apart to achieve better tissue approximation.