Facial Lacerations
Summary
Facial lacerations are common ED presentations. While the robust vascular supply of the face promotes rapid healing and resistance to infection, it also causes profuse bleeding. The primary goal is cosmetic and functional restoration. Key underlying structures (Facial nerve, Parotid duct, Lacrimal apparatus) must be excluded from injury before any closure is attempted. [1,2]
Key Facts
- Blood Supply: Excellent. This allows for "primary closure" (stitching) even up to 24 hours after injury (unlike 6-12 hours for limbs).
- Suture Removal: The face heals fast. Sutures must be removed in 3-5 days. Leaving them longer causes "train-track" scarring (epithelialisation of the needle holes).
- Vermilion Border: The junction between the red lip and skin. Even a 1mm misalignment here is visually obvious. This landmark must be the first stitch placed.
Clinical Pearls
Don't Shave Eyebrows: Never shave an eyebrow to suture a wound. Re-growth is unpredictable and slow, and the hairless patch is cosmetically disfiguring. Use lube or soap to smooth the hair out of the way.
The "Through-and-Through" Lip: If a tooth has gone through the lip, search the wound for tooth fragments. If you stitch a fragment inside, it causes a severe infection. X-ray if in doubt.
Eyelid Fat: If you see yellow globules of fat in an eyelid laceration, the Orbital Septum has been breached. This is not a simple skin cut; it puts the orbit at risk of infection. Refer to Ophthalmology/Oculoplastics.
Causes
- Adults: Assaults (glassings), Falls, RTCs.
- Children: Falls against furniture (forehead), Dog bites.
Anatomy of Danger Zones
- Temporal Region: The Temporal Branch of the Facial Nerve runs from the tragus to the lateral eyebrow. It is superficial (just under temporoparietal fascia). Injury causes inability to raise the eyebrow (forehead paralysis).
- Cheek: The Parotid Duct runs on a line from the tragus to the mid-upper lip. Deep lacerations here can cut the duct, leading to a salivary fistula/sialocele.
- Medial Canthus: The Lacrimal Canaliculi drain tears. Lacerations here cause permanent tearing (epiphora) if not repaired with stents.
Assessment
- Facial Nerve: Ask patient to:
- Raise eyebrows (Frontal branch).
- Close eyes tight (Zygomatic branch).
- Show teeth/Smile (Buccal/Marginal Mandibular).
- Pucker lips/Whistle (Buccal).
- Parotid Duct: If cheek wound is deep, press on the parotid gland and look inside the mouth (at the duct orifice opposite the 2nd upper molar) for saliva flow. Or see if saliva leaks from the wound.
- Sensory: Check infraorbital nerve (sensation to cheek/lip) often damaged in orbital floor fractures.
Imaging
- X-Ray:
- Facial Views (OM): If fracture suspected (Zygoma/Mandible/Orbit).
- Soft Tissue: To detect glass or tooth fragments.
- CT Face: For complex deep trauma.
Management Algorithm
FACIAL LACERATION
↓
EXCLUDE DEEP INJURY
(Nerve? Duct? Bone? Eyelid margin?)
↓
┌───────────┴───────────┐
SIMPLE COMPLEX
(Skin/Muscle only) (Nerve/Duct/Margin)
↓ ↓
ED CLOSURE REFER PLASTICS
(See below) / MAXFAX
Suture Selection
- Face: 6-0 Nylon or Prolene (Monofilament, Non-absorbable).
- Lips/Mucosa: 5-0 Vicryl Rapide (Absorbable).
- Scalp: 3-0 or 4-0 Nylon/Staples.
- Deep Layer: If muscle involved, close with 5-0 Vicryl to take tension off the skin.
Techniques
- Cleaning: Copious irrigation. Debridement should be minimal on the face (preserve tissue).
- Glue (Dermabond): Excellent for linear, non-tension wounds in children (scared of needles).
- Suturing: Evert the wound edges. Inverted edges cast a shadow and look like a valley scar.
- Tetanus: Boost if >10 years since last dose.
Aftercare
- Antibiotics: Only for bite wounds (Co-amoxiclav) or heavily contaminated wounds. Not for clean glass/knife cuts.
- Removal: Day 5 (Face). Day 7 (Scalp).
- Sun Protection: UV light causes scar hyperpigmentation. Use Factor 50 on the scar for 12 months.
- Scarring: Hypertrophic or Keloid (especially on earlobes/jawline in darker skin).
- Infection: Rare on the face (less than 5%).
- Trapdoor Deformity: U-shaped flaps of skin contract and bulge up like a pincushion. May need surgical revision.
- Cosmesis: Usually excellent if aligned well.
- Maturation: Scars take 12-18 months to fully mature (fade from red to white).
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Wound Management | NICE / BAPRAS | Primary closure up to 24h on face. Use of non-absorbable fine sutures. |
| Bites | Cochrane | Prophylactic antibiotics for mammalian bites. |
Landmark Evidence
1. Suture vs Glue
- Studies confirm that for low-tension linear wounds, tissue adhesive (Glue) gives equivalent cosmetic results to sutures, with less pain and no removal visit.
Will it scar?
Every cut that goes through the full thickness of the skin leaves a scar. However, we will stitch it carefully to make the line as thin and hidden as possible. It will look red and lumpy for a few months before fading to a pale line.
Why take stitches out so soon?
On the legs or back, stitches stay in for 2 weeks. On the face, we take them out in 5 days because if we leave them longer, the needle holes themselves leave permanent dot-scars ("train tracks"). The face heals fast enough to hold together by day 5.
Can I put makeup on it?
Wait until the stitches are out and the scab has fallen off completely (usually 10-14 days).
Primary Sources
- Singer AJ, et al. Lacerations and acute wounds: An evidence-based guide. Emerg Med Clin North Am. 2007.
- Hollander JE, et al. Wound registry: development and validation. Ann Emerg Med. 1995.
Common Exam Questions
- Anatomy: "Landmark for Parotid Duct?"
- Answer: Line from Tragus to Philtrum (Mid-lip). The middle third is the danger zone.
- Technique: "Lip repair priority?"
- Answer: Align the Vermilion Border first.
- Structure: "Fat in eyelid wound?"
- Answer: Orbital Septum breach.
- Management: "Eyebrow laceration?"
- Answer: Do NOT shave.
Viva Points
- Trapdoor Effect: Explain why U-shaped lacerations bulge. The lymphatic drainage is cut on three sides, causing lymphoedema in the flap, plus the scar contracture "pursestrings" it, popping it up.
- Local Anaesthetic: Where to inject? Through the wound edges (less painful) or nerve block (Infraorbital/Mental) to avoid distorting the tissue with fluid volume.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.