Assessment and management of facial lacerations

INTRODUCTION — The assessment and management of facial lacerations will be reviewed here. Minor wound management, methods of suture placement, and repair of adjacent anatomic sites are discussed in detail separately:

●(See "Minor wound evaluation and preparation for closure".)

●(See "Skin laceration repair with sutures".)

●(See "Assessment and management of lip lacerations".)

●(See "Assessment and management of auricle (ear) lacerations".)

●(See "Evaluation and repair of tongue lacerations".)

●(See "Eyelid lacerations".)

●(See "Assessment and management of scalp lacerations".)

EVALUATION — Facial lacerations warrant a detailed and meticulous approach to evaluation due to their cosmetic importance. Patients are often concerned and disconcerted about the potential for scarring from facial lacerations [1-5].

In multiply injured patients, disfiguring or disconcerting facial lacerations should not distract from the initial primary survey and the focus on addressing immediately life-threatening injuries. Bleeding from facial lacerations should be controlled with direct pressure. (See "Trauma management: Approach to the unstable child", section on 'Primary survey' and "Initial management of trauma in adults".)

History — The clinician should identify the following aspects of the injury:

●Traumatic force (eg, high-speed motor vehicle collision with significant likelihood of associated injuries versus fall from standing height with no other symptoms)

●Associated symptoms of head injury (eg, altered mental status, vomiting, headache) (see "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'History' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'History')

●Age of wound

●Likelihood of wound contamination (eg, clean laceration from table edge with low risk of contamination versus bite wound with high risk of bacterial contamination and need for special prophylaxis)

●Potential presence of foreign body (eg, fall onto glass or gravel)

The history should also include a comprehensive review of underlying medical history (eg, diabetes mellitus, cancer, prior keloid formation), medication use (eg, immunosuppressive agents), and social habits (eg, tobacco use) that may negatively affect healing and increase the risk for a poor outcome. (See "Minor wound evaluation and preparation for closure", section on 'Risks for poor outcome'.)

The clinician should also inquire about allergies to any medications, especially local anesthetics, and the patient's tetanus immunization status. (See "Allergic reactions to local anesthetics", section on 'Evaluation' and 'Tetanus prophylaxis' below.)

Physical examination — The face should be examined carefully to evaluate for signs of injury to adjacent and/or underlying structures such as the orbits, eyes, nose, midface, teeth, maxilla, and mandible. (See "Initial evaluation and management of facial trauma in adults", section on 'General examination' and "Initial evaluation and management of facial trauma in adults", section on 'Examination of specific body parts'.)

Removal of all foreign debris and blood will permit proper assessment of facial lacerations. Local anesthesia using topical or infiltrated local anesthetic agents facilitates a comprehensive evaluation of the wound with minimal discomfort to the patient. In young children and other uncooperative patients, sedation may be necessary to perform optimal wound assessment and repair. (See 'Anesthesia and analgesia' below.)

Bleeding is a common problem with facial lacerations. Hemostasis permits an appropriate examination. Direct pressure for approximately 15 minutes with or without local injection of lidocaine with epinephrine can provide sufficient hemostasis. Clamping should be avoided to prevent tissue necrosis. Electrocautery should also be avoided in facial lacerations as this will likely delay healing or cause significant scarring.

The following attributes of the wound should be noted [6]:

●Location including the involved facial zone (eg, maxilla, chin, forehead, orbit, nose, temple, zygoma [cheek], lip) and side of the face (figure 1)

●Length of laceration in centimeters

●Depth of laceration (epidermis, dermis, subcutaneous fat, muscle, or bone)

●Shape of laceration (eg, linear, curvilinear, stellate, or corner)

●Presence of gross contamination or visible foreign bodies

●The presence of skin loss

●Whether the laceration is horizontal, vertical, or tangential to the lines of tension (Langer's lines) (figure 2). Skin tension lines and facial appearance during expression and emotion are important individual characteristics that contribute to overall cosmesis [7]. Relaxed skin tension lines run perpendicular to underlying facial muscle. The best outcomes and cosmesis with repairs involve wounds that parallel Langer's lines and are under minimal tension. Asking the patient to contract and exhibit facial emotions (ie, frowning, smiling, and puffing of cheeks) will allow for an appreciation of facial wrinkling and demonstrate the lines of least tension. However, children and adolescents will have less distinguishable features, whereas Langer's lines are more apparent in the older adult patient. Retraction of the wound edges with evaluation can help identify wounds under higher tension.

The clinician should also evaluate for the following associated injuries by facial region:

●Forehead – Deep lacerations may involve injury or complete laceration of the frontalis muscle of the forehead and possible bone exposure. Visible fractures or bony depressions warrant imaging with facial and head computed tomography (CT). Further, extensive bony injuries or facial trauma should prompt evaluation of the sinuses with CT.

●Eyelid – The lacrimal system, which begins at the upper and lower puncta and the nasolacrimal duct, should be inspected for injury. Injuries near the medial canthus can be associated with nasolacrimal duct injury (figure 3). Further, any injury to the eyelids or surrounding structures warrant a full ophthalmic evaluation, including an assessment of visual acuity, of the presence of ocular foreign bodies and the integrity of the globe. Injuries that involve the lacrimal system, full thickness eyelid injuries, eyelid margin lacerations, or wounds through the tarsal plate warrant ophthalmic consultation. (See "Eyelid lacerations", section on 'Indications for surgical subspecialty consultation or referral'.)

●Nose – Blunt trauma to the nasal bones should be suspected in patients with nasal lacerations, particularly those caused by marked blunt force trauma. The clinician should assess for drainage of cerebrospinal fluid secondary to a fracture through the cribriform plate (see "Initial evaluation and management of facial trauma in adults", section on 'Midface') and for injury to the nasal mucosa, septum and cartilage.

Septal abscesses can lead to necrosis and erosion of the septum from prolonged pressure. Therefore, it has traditionally been recommended that septal hematomas be drained, and this seems reasonable in many cases. Drainage of a septal hematoma involves aspiration through a large bore needle or an incision in the septal mucoperichondrium. Anterior nasal packing is placed for compression, along with a course of antibiotics to prevent sinus infection. Extensive or bilateral septal hematomas (picture 1) may warrant consultation with an otolaryngologist. (See "Nasal trauma and fractures in children and adolescents", section on 'Septal hematoma or abscess' and "Initial evaluation and management of facial trauma in adults", section on 'Nose'.)

Markedly displaced fractures in adolescents and adults may be reduced within six hours of injury. Otherwise, nasal septum deviation or fracture noted during initial evaluation can be referred for reduction by a surgical specialist within seven days. (See "Initial evaluation and management of facial trauma in adults", section on 'Nose'.)

Because the endpoint of reduction is difficult to appreciate in children, most pediatric nasal fractures are not immediately reduced in the emergency department. These injuries require evaluation and care by a pediatric otolaryngologist or other physician with similar expertise. Follow-up should occur within five to seven days because rapid healing makes the fractured elements difficult to mobilize after that time. (See "Nasal trauma and fractures in children and adolescents", section on 'Isolated nasal fracture'.)

●Cheek – Deep lacerations to the cheek and to areas anterior to the ear warrant careful evaluation for injury to the parotid gland, parotid duct and/or the facial nerve (figure 4 and figure 5):

•The opening of the parotid duct is located on the intra-oral mucosa adjacent to the second molar (figure 6). Injury to the duct can be difficult to diagnose; suspicion based upon the location of injury is critical. Facial nerve injury is suggestive. Occasionally, a sialocele may be evident in patients who present long enough after injury for salivary accumulation to occur.

Confirmation of a parotid duct injury, as performed by a surgical specialist, can often be performed at the bedside or in the operating room by cannulation of the parotid papilla using one of several potential probes (eg, epidural catheter, double-j catheter, lacrimal probes, silicone cuff cannula of an endotracheal tube), coupled with careful exploration of the wound bed to visualize the threaded material. The cannulation of the parotid duct serves as a stent to facilitate anastomoses of both ends of the duct [8-11].

The surgical specialist can also identify parotid duct injury by injecting fluorescein-stained normal saline through an intravenous catheter placed in the parotid papilla; extravasation is visualized using a Wood lamp [9].

•The facial nerve traverses the parotid gland. The function of the facial nerve and its branches (temporal, zygomatic, buccal, mandibular, and cervical) should be assessed (picture 2). The facial nerve function should be tested in all five branches as follows [12]: (1) temporal – contract the forehead and elevate the eyebrow; (2) zygomatic – open and shut eyes; (3) buccal – smile; (4) mandibular – frown; (5) cervical – contract the platysma muscle.

●Mouth – Lacerations of the intra-oral mucosa involve the buccal mucosa and mucosal reflections which connect the cheek to the mandibular and maxillary surfaces. These lacerations may be associated with injuries to the salivary glands (figure 6), parotid duct, submandibular duct, teeth, lips, and jaw. The lips, teeth, and mucosal anatomy must be thoroughly inspected with adequate lighting. Dental fractures, avulsions, gingival bleeding, lacerations or displacement of the alveolar margin may be associated with mandibular or maxillary fractures, particularly if there is discomfort at the temporomandibular joint or trismus. (See "Evaluation and management of dental injuries in children" and "Mandibular (jaw) fractures in children", section on 'Clinical features' and "Initial evaluation and management of facial trauma in adults", section on 'Temporomandibular joint'.)

Diagnostic imaging — Patients with clinical findings that suggest the presence of a foreign body not visible at the surface or bony injury warrant appropriate imaging, depending upon the type of facial trauma (see "Initial evaluation and management of facial trauma in adults", section on 'Diagnostic imaging'):

●Plain radiographs can identify most radiopaque foreign bodies (eg, glass, metal, rocks) while ultrasound can often locate many nonradiopaque foreign bodies. (See "Infectious complications of puncture wounds", section on 'Foreign body removal'.)

●Midface or orbital fractures are best evaluated by computed tomography (CT). Imaging is typically not necessary for the evaluation of isolated nasal fractures. (See "Initial evaluation and management of facial trauma in adults", section on 'Diagnostic imaging' and "Nasal trauma and fractures in children and adolescents", section on 'Imaging'.)

●Mandibular fractures are best identified by CT or, if available, panoramic plain radiographs (eg, Panorex).

INDICATIONS FOR SUBSPECIALTY CONSULTATION OR REFERRAL — Consultation with a surgical subspecialist (eg, plastic or maxillofacial surgeon, ophthalmologist), if available, is suggested in the following situations:

●Wounds to the zygoma (cheek) with associated injury to the facial nerve, facial artery, or parotid gland or ducts (see 'Physical examination' above)

●Lacerations that involve the nasal cartilage, ala, or columella (figure 7)

●Eyelid or orbital lacerations that involve the eyelid margin or tarsal plate, have protruding subcutaneous fat or involve the tear duct or lacrimal gland (figure 8) (see "Eyelid lacerations", section on 'Indications for surgical subspecialty consultation or referral')

●Complex wounds that require extensive revision or that have significant skin loss that may require grafting

●Wounds with associated fractures (eg, mandibular fracture, orbital fracture) that will require surgical subspecialty care (see "Initial evaluation and management of facial trauma in adults" and "Mandibular (jaw) fractures in children" and "Orbital fractures")

The majority of wounds may be closed by an emergency physician, a medical provider with appropriate expertise, or a surgical subspecialist, including:

●Lacerations through the vermillion border (see "Assessment and management of lip lacerations", section on 'Indications for subspecialty consultation or referral')

●Simple facial lacerations caused by animal or human bites

●Patients with a prior history of keloid formation

WOUND REPAIR

Indications for primary closure — Primary closure (ie, wound repair at the time of presentation) is usually the preferred treatment for facial lacerations that will lead to excess scarring if the wound edges are not opposed (ie, lacerations into or through the dermis). In general, facial lacerations without risk factors for infection can be closed within 24 to 48 hours if appropriate cleansing is performed [13].

Delayed primary closure (ie, cleansing and debridement at the time of initial presentation with definitive wound closure performed electively four to five days later) may be warranted for wounds that present after 24 hours and have increased risk for infection. Examples of such wounds include:

●Animal and human bites, which likely harbor high bacterial loads coupled with complex injuries to the soft tissue (ie, crushing, avulsions, and multiple perforations)

●Wounds that were insufficiently cleansed, debrided or decontaminated

●Wounds that present in the setting of advanced age, diabetes mellitus, renal impairment, impaired nutrition, hygiene, smoking, obesity, and chronic steroid use  

There is no definite time point after which wounds must be closed by delayed primary closure. In general, the decision should be based upon the time from injury, patient factors that increase the risk of infection (ie, vascular insufficiency), and wound factors (contamination or presence of a foreign body). (See "Minor wound evaluation and preparation for closure", section on 'Delayed primary closure'.)

Because of excellent blood flow to the face, wound infections are uncommon, even following repair of contaminated wounds or bites by animals or humans. (See "Animal bites (dogs, cats, and other mammals): Evaluation and management".)

Contraindications and precautions — Wounds with obvious signs of inflammation (redness, warmth, swelling, pus drainage) should not be closed primarily. Facial laceration closure should also not delay further evaluation and definitive care of more urgent traumatic injuries, including underlying facial fractures [14].

When closure is delayed, saline-soaked gauze packing (wet-dry closure) can be provided to enhance secondary healing. Appropriate antibiotic coverage (eg, amoxicillin-clavulanate, or in penicillin allergic patients, clindamycin) can be initiated in selected patients with non-bite wounds (eg, patient with diabetes mellitus, or other risk for poor healing). (See "Minor wound evaluation and preparation for closure", section on 'Type of closure'.)

Indications and empiric oral antibiotic regiments for patients with animal bites (table 1) and human bites (table 2) are discussed separately. (See "Animal bites (dogs, cats, and other mammals): Evaluation and management", section on 'Management' and "Human bites: Evaluation and management", section on 'Antibiotic prophylaxis'.)

Preparation — Preparation for the care of facial lacerations includes a discussion of the likely outcomes of repair, the choice of repair, assembly of the appropriate equipment, provision of anesthesia and analgesia, and wound debridement and cleansing.

General consent forms for treatment are commonly part of the registration process for all patients arriving into the emergency department (ED) and a separate written consent is not usually performed [15-17]. However, patients and caregivers should have a clear understanding that scarring is unavoidable and that the purpose of careful wound closure is to minimize, not eliminate, scarring. The clinician should also discuss the appropriate options for repair and explain the rationale for the chosen closure method. For example, parents of young children may request the use of tissue adhesives for lacerations ideally closed with simple interrupted sutures. In this circumstance, a basic explanation of the need for sutures to obtain the proper eversion and healing of the wound is warranted.

Anesthesia and analgesia — Wound débridement, cleansing, and closure are facilitated by local anesthesia, regional nerve block, or procedural sedation, depending upon the size and complexity of the laceration.

Local anesthesia — Local anesthesia typically provides adequate analgesia for the management of simple facial lacerations in children and adults. In children and apprehensive older patients, topical anesthesia with LET (4 percent lidocaine, 0.1 percent epinephrine, 0.5 percent tetracaine) available as an aqueous solution or methylcellulose based gel, either alone or prior to infiltration of local anesthesia facilitates repair for small (<4 cm) lacerations with minimal penetration into the dermis or subcutaneous tissue, especially when combined with concurrent nonpharmacologic interventions involving the use of biobehavioral and cognitive distraction. (See "Procedural sedation in children: Approach", section on 'Nonpharmacologic interventions' and "Clinical use of topical anesthetics in children", section on 'Lidocaine-epinephrine-tetracaine (LET)'.)

Nasal mucosal lacerations can be anesthetized by placing Q-tips or a nasal tampon soaked in 2 percent viscous lidocaine with epinephrine solution into the nostril for approximately 10 minutes [18].

When local infiltration of anesthetic is used, buffered lidocaine with epinephrine provides adequate analgesia and vasoconstriction to limit bleeding. (See "Subcutaneous infiltration of local anesthetics", section on 'Lidocaine' and "Subcutaneous infiltration of local anesthetics", section on 'Methods to decrease injection pain'.)

Lidocaine with epinephrine should be used with caution for large facial tissue flaps because of potential vasoconstriction with ischemia caused by the epinephrine [19-21]. Plain lidocaine (1 or 2 percent), bupivacaine, mepivacaine, or lidocaine with very dilute epinephrine (1:400,000 to 1:800,000) should be used in this instance [21]. Alternatively, a regional block can be performed. (See 'Facial nerve blocks' below and 'Forehead' below.)

Facial nerve blocks — Regional blocks are an alternative to local anesthesia and are preferable for large wounds (>4 cm) and wounds that require precise cosmetic approximation (eg, nasal ala, or columella) [22]. Regional nerve blocks commonly used for facial lacerations include [23]:

●Mental nerve block – This block anesthetizes the lower lip, skin below the lip, and chin and is performed as follows (figure 9):

•Locate the mental nerve foramen by palpation of the mandible in line with the infraorbital and supraorbital foramen as shown in the figure (figure 9).

•After cleansing and topical anesthesia with 2 percent viscous lidocaine that is applied to the inferior buccal mucosa, insert a small needle (eg, 25 or 27 gauge) intra-orally and just medial and directed towards the foramen. Alternatively, the needle may be inserted through the skin perpendicular to or at a 45 degree angle to the foramen.

•While palpating the foramen, insert the needle and inject one to two mL of local anesthetic (eg, buffered lidocaine 1 percent with epinephrine).

•If the patient reports paresthesias, withdraw the needle until paresthesias resolve prior to injection.

•Allow 5 to 10 minutes for complete anesthesia to occur.

●Infraorbital nerve block (intra-oral approach) – This block provides anesthesia to the upper lip, lateral nose, lower eyelid, and medial cheek (figure 10) and is performed as follows:

•Locate the infraorbital foramen with the middle finger and lift the upper lip with the index finger and thumb as shown in the figure (figure 10).

•Numb the upper gum line near the second bicuspid using topical anesthetic (eg, 2 percent viscous lidocaine on a Q-tip).

•Insert a small needle (gauge 25 or 27) through the gum line and at the second bicuspid as shown in the figure until the needle is palpated at the infraorbital foramen (approximately 2 cm in the adolescent or adult). Alternatively, insert the needle through the skin perpendicular or at a 45 degree angle to the foramen.

•If the patient reports paresthesias, withdraw the needle until paresthesias resolve prior to injection.

•Inject 1 to 2 mL of buffered lidocaine 1 percent with epinephrine.

•Allow 5 to 10 minutes for complete anesthesia to occur.

●Supraorbital nerve block (Supratrochlear nerve) – This block produces anesthesia in the forehead and anterior one third of the scalp and is performed as follows (figure 11):

•Locate the supraorbital nerve foramen in the medial aspect of the supraorbital ridge. The supratrochlear nerve is just medial to this site.

•After cleansing, insert a small needle (25 or 27 gauge) to a depth of 0.5 to 1 cm just medial and directed towards the foramen as shown in the figure (figure 11). After each pass, partially withdraw the needle, adjust the angle of entry, and then reinsert. This method, also called fanning, prevents laceration of tissue by avoiding excessive medial and lateral needle motion. Fanning out medially and laterally along the eyebrow while injecting also helps increase the efficacy of the block.

•Inject 1 to 3 mL of local anesthetic (eg, buffered lidocaine 1 percent with epinephrine).

•If the patient reports paresthesias, withdraw the needle until paresthesias resolve prior to injection.

•Allow 5 to 10 minutes for complete anesthesia to occur.

Methods to reduce the pain of facial blocks include buffering the anesthetic, decreasing the rate of infiltration, warming the anesthetic, and, for infraorbital and mental nerve blocks, intra-oral versus transcutaneous administration [24,25]. Although studies have described similar adult patient preference for an infraorbital regional block by either the intra-oral or extraoral approach, the intra-oral approach provides a longer duration of anesthesia [24].

Procedural sedation — Procedural sedation in children and adults is discussed in more detail separately. (See "Procedural sedation in children: Approach" and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

Procedural sedation is likely to maximize patient comfort and cosmetic outcomes in the following situations:

●Multiple large facial lacerations

●Wounds in young children that require precise approximation (eg, lacerations of the nasal ala or columella)

●Complex facial lacerations that require extensive revision or are associated with other injuries (eg, temporomandibular joint dislocation, displaced jaw fractures)

●Heavily contaminated lacerations that require aggressive cleaning

●Highly anxious or otherwise uncooperative patients, especially when clinician and staff safety may be compromised.

Wound debridement and cleansing — Local or regional anesthesia prior to initiating irrigation and wound cleansing improves patient comfort. In young children and patients with heavily contaminated wounds, procedural sedation may also be necessary so that wound preparation can be tolerated. (See 'Anesthesia and analgesia' above.)

The following are specific considerations for the preparation of facial lacerations:

●Irrigation – The volume of wound irrigation for facial lacerations is based upon wound size and degree of contamination. Moderate sized facial lacerations (>2.5 to 5.0 cm in length) with minimal contamination may be irrigated with 100 to 150 mL while contaminated wounds and wounds >5.0 cm in length may benefit from irrigation with 200 mL or more. (See "Minor wound evaluation and preparation for closure", section on 'Volume'.)

Due to the high vascularity of facial tissue, small, minimally contaminated facial lacerations (<2.5 cm) may not require irrigation if closed within six hours of injury. For example, a study of 1923 patients with small lacerations (median 2 cm in length) that were closed within six hours found that the 833 patients who did not undergo irrigation had no significant increase in wound infections (1.4 versus 0.9 percent infection rate) and better cosmetic appearance (82 versus 76 percent) at the time of suture removal when compared to those patients who received irrigation [26].

In general, facial lacerations can be irrigated with isotonic 0.9 percent normal saline. For clean wounds, running tap water is an acceptable alternative in regions where the local water supply is sanitary. Larger, more extensive lacerations (animal or human bites, contaminated wounds) can be irrigated with isotonic saline or a mixture of 1:10 povidone/iodine solution (Betadine solution) and isotonic 0.9 percent normal saline. (See "Minor wound evaluation and preparation for closure", section on 'Irrigation solution'.)

Povidone/iodine surgical scrub solution (Betadine surgical scrub) should not be used because it contains ionic detergent that may be toxic to wound tissue. The clinician should also avoid hydrogen peroxide solution due to its potential for dermatologic irritation and hair bleaching qualities. In addition, chlorhexidine solution should be avoided near the intra-oral mucosa or dentition to prevent staining. (See "Minor wound evaluation and preparation for closure", section on 'Irrigation'.)

●Facial hair – Heavy, dense beards should be clipped, but not shaved to the skin because shaving creates debris that can enter deep into the wound and is not easily removed.

●Eyebrows – Eyebrows should not be shaved or clipped as they provide an anatomic landmark for repair and may not fully grow back.

●Tissue excision – Due to the extensive amount of blood flow to facial tissue, devitalized or necrotic tissue is infrequently found. Tissue excision, when necessary, should be done carefully and cosmetically with respect to the surrounding tissue and underlying subcutaneous and muscle layers. Skin tension lines should be considered when debriding tissue. Patients whose lacerations require excision of large amounts of tissue typically warrant care by a plastic or maxillofacial surgeon. (See 'Indications for subspecialty consultation or referral' above.)

Wound debridement and irrigation are discussed in more detail separately. (See "Minor wound evaluation and preparation for closure", section on 'Irrigation' and "Minor wound evaluation and preparation for closure", section on 'Debridement'.)

Equipment — Depending upon the laceration, necessary equipment may include:

●Sterile gloves

●Surgical mask

●Eye protection

●Surgical or procedural gown

●Buffered 1 percent lidocaine with epinephrine or similar local anesthetic

●Small volume syringe (eg, 3 or 6 mL) with small gauge needle (eg, 27 or 30 gauge) for infiltration of local anesthetic

●Suture material (table 3)

●Needle holder

●Hemostat

●Scalpel with handle (#10 or 15 blade) if debridement or revision are planned

●Tissue forceps

●Scissors

●Surgical probe

●Sterile 4 x 4 gauze

●Absorbent towels

●Sterile field drapes

Emergency departments generally are well equipped with minor surgical or suture trays that contain the instruments, sterile gauze, towels, and drapes listed above.

Suture selection — Suggested suture material and size for facial lacerations are provided in the table (table 3). With the exception of wounds on the underside of the chin, the sutures used to close the skin in facial lacerations will usually be 6-0 in children and 5-0 to 6-0 in adults. Finer sutures on the face require a smaller and more sharply honed needle (P, PS, PC, and PRE series). (See "Skin laceration repair with sutures", section on 'Suture selection'.)

Nylon or similar synthetic nonabsorbable suture material (polypropylene, polybutester) is an excellent choice for facial skin closure due to its high-tensile strength and minimal inflammatory response (table 4). Fast-absorbing gut may be used for skin closure in selected situations without negatively impacting cosmetic outcome, such as in young children, to avoid the anxiety and difficulty of suture removal and in patients for whom follow-up for suture removal is not assured. As an example, cosmetic outcomes did not differ at nine months in 84 patients randomized to facial wound closure by fast-absorbing gut suture, nonabsorbable suture, or tissue adhesive [27]. (See "Skin laceration repair with sutures", section on 'Suture selection'.)

Chromic gut absorbable suture (4-0 or 5-0) is commonly used for closure of intra-oral mucosal lacerations because it is more rapidly absorbed in the oral environment than most synthetic sutures. It is less commonly used for dermal (subcutaneous) or muscle closure because it has increased tissue reactivity when compared to synthetic absorbable suture material. (See "Skin laceration repair with sutures", section on 'Suture selection'.)

Polyglactin 910 (Vicryl) and Poliglecaprone 25 (Monocryl) are often chosen for closure of muscle and subcutaneous layers in deep facial wounds because they provide good tensile strength with less tissue reactivity than chromic gut (table 5). Some surgical subspecialists prefer poliglecaprone 25 because it is easier to use and may theoretically have a lower chance for infection in contaminated wounds due to its monofilament structure. (See "Skin laceration repair with sutures", section on 'Suture selection'.)

Techniques — The table describes key aspects of wounds that impact the selection of a wound closure method (sutures, staples, tissue adhesives, or surgical tape) (table 6).

Simple interrupted suture placement — We suggest that superficial facial lacerations under tension and with subcutaneous fat exposure undergo closure with simple interrupted sutures rather than cyanoacrylate tissue adhesives alone or continuous suture placement. Closure with cyanoacrylate tissue adhesives in combination with interrupted buried dermal sutures is an acceptable alternative for such wounds.

Simple interrupted suture placement also provides good cosmetic skin closure for patients undergoing a multiple layered closure of deep lacerations into the muscle or subcutaneous tissue layer in combination with dermal sutures (figure 12). (See "Skin laceration repair with sutures", section on 'Dermal closure'.)

Evidence for simple interrupted sutures as the preferred method for closing superficial facial lacerations is primarily anecdotal. Placement of interrupted sutures allows for greater appreciation of the wound repair and can allow for correction as the procedure is underway. Sutures should be approximately 3 mm apart and 1 to 2 mm from the edges to allow for optimal approximation and cosmetic healing on the face. Low-tension areas of the face, areas where skin tension has been reduced by underlying muscular or dermal closure or wounds with irregular edges are appropriate for repair with interrupted sutures. For optimal healing and to minimize scarring, the edges of the wound should be everted (figure 13 and figure 14). (See "Skin laceration repair with sutures", section on 'Percutaneous closure'.)

Disadvantages of interrupted sutures include excessive time spent with placement of each individualized suture and the risk for crosshatched marks if sutures are not removed in a timely manner. However, techniques that require less time such as continuous suture placement or stapling are not appropriate for most facial laceration repairs. Running percutaneous sutures do not maintain wound integrity if the suture breaks and do not always result in optimal wound eversion. Staples may increase scarring and do not permit meticulous cosmetic repair. (See "Closure of minor skin wounds with staples", section on 'Contraindications' and "Skin laceration repair with sutures", section on 'Long, straight wounds'.)

Subcuticular running sutures are an option for straight lacerations of the face if the clinician is experienced in their placement; they may be reinforced with adhesive tape. (See "Skin laceration repair with sutures", section on 'Advanced repair of facial wounds'.)

Tissue adhesives — Cyanoacrylate tissue adhesives alone are effective in the closure of straight, low tensile facial lacerations with little dermal involvement and no subcutaneous exposure. For such wounds, tissue adhesives have equivalent cosmetic outcomes without increased infection or wound dehiscence when compared to standard wound closure [27-29].

Lacerations parallel to skin tension lines (figure 2) in the eyelids, above or below eyebrows, forehead, and cheek are optimal wounds for closure with tissue adhesives although care must be taken to avoid inadvertent ocular exposure when using tissue adhesives near the eye. Advantages of wound closure with tissue adhesives includes less pain, less time spent on wound repair, and no need for suture removal [27]. Tissue adhesives should be avoided for wounds in hair covered areas of the face (ie, eyebrows, beards, and mustache).

The application of tissue adhesives is discussed in detail separately. (See "Minor wound repair with tissue adhesives (cyanoacrylates)", section on 'Preparation'.)

Staples — Staples may cause greater scarring in patients who scar easily and are thus not appropriate for closure of cosmetic wounds on the face. Closure of minor skin wounds with staples is discussed in more detail separately. (See "Closure of minor skin wounds with staples".)

Adhesive tapes — The orientation of the laceration(s), its relationship to the skin tension lines, wound depth, and the condition of the wound should be taken into consideration, as well as the presence of underlying co-morbidities that may affect appropriate healing and the ultimate cosmetic result.

In selected children and adults, the use of adhesive tapes can be ideal as they are usually very cost effective, time saving and significantly less painful than sutures [30-32]. Furthermore, no significant differences between the results of adhesive tapes and tissue adhesives, as judged by both physicians and parents [33].

In general, the upper one-third to half of the face can be well managed with adhesive tapes when wounds are small (eg, <2.5 cm), uncomplicated, and, well approximated with low tension. However, lacerations on the lower third of the face will generally require suturing (ie, perioral region, mandibular and submental regions) due to higher tension and more movement [34]. The same considerations as for the use of tissue adhesives generally apply to the use of adhesives tape (ie, minimal tension, hairless surface, superficial epidermal closure without exposure of mucosa, absence of human or animal bite, and absence of moisture) (table 6). To augment the relative low-tensile strength of adhesive tapes, topical tincture of benzoin can be applied to aid adhesion, but one should be careful not to get it in the wound as it stings and may cause a local inflammatory reaction.

Adhesive tapes should be applied perpendicular to the length of the laceration with sufficient spacing between strips to allow drainage from the wound. Railroad tracking or placing additional adhesive tapes parallel to the wound to secure the distal edges of the perpendicular adhesive tapes improves adhesion (figure 15). Patients should be instructed to keep the wound clean and dry for 48 to 72 hours and that the tapes will fall off on their own in approximately five days.

WOUND-SPECIFIC CONSIDERATIONS — Additional cosmetic and wound management issues depend upon the site of the laceration.

Forehead — Prior to closure, facial expression and movements of the forehead should be elicited to appreciate the extent of muscle involvement [35]. Sensation should also be assessed. Vertical wounds are perpendicular to tension lines in this area. However, careful closure usually results in good cosmetic results.

In adults, the skin should be approximated with 5.0 or 6.0 nonabsorbable interrupted sutures [13]. In children, 6.0 absorbable fast-absorbing gut or nonabsorbable interrupted sutures should be used. With the exception of small children, close attention to wrinkles and facial lines are warranted. If needed, the subcuticular tissues and the muscle layer should be closed with as few 4.0 or 5.0 absorbable sutures as possible to prevent accumulation of material that can contribute to palpable nodules and scarring (table 3).

Trapdoor lacerations are round or elliptical partial avulsion injuries that are held in place by a small pedicle. During healing, these wounds commonly develop bulging within the flap, known as the "trapdoor effect" (figure 16) [35]. This effect can be minimized by approximation of the subcutaneous tissue layer to the base of the flap and careful apposition of the skin layers using simple interrupted sutures. Alternatively, small lacerations may be revised by removal of the flap and pedicle. Large lacerations typically warrant primary closure and referral to a plastic surgeon for elective Z-plasty after wound healing. Patients and caregivers should be advised of the likelihood of the trapdoor effect prior to repair of these wounds.

Eyebrow — The goal of eyebrow wound repair is to retain the natural curvature of the eyebrow and realign the hair margins. Thus, eyebrow hair should be left in place and debridement of hair or tissue should be minimal, conserving as much viable tissue as possible [36]. For lacerations partially within the eyebrow, the first suture should be placed at the edge of the eyebrow. Minimal malalignment is cosmetically obvious, similar to lip lacerations through the vermillion border [35].

Closure with 5.0 or 6.0 sutures in adults and 6-0 sutures in children should be performed while leaving long tails to allow for easier identification and removal (table 3). Use of blue or green colored nonabsorbable suture material also facilitates visualization during suture removal.

Eyelid — The eyelid and surrounding tissues are delicate structures which have cosmetic and functional importance. Lacerations involving the orbicularis oculi muscle, tarsal plate, the lacrimal apparatus, and the margin of the lids often warrant repair by a surgical subspecialist, if available. A careful assessment for ocular injuries, especially an open globe (which may be seen with orbital fat prolapse) (picture 3), should be performed and ophthalmology consultation obtained as needed. The closure of eyelid lacerations is covered in greater detail separately. (See "Eyelid lacerations".)

Nose — Nasal lacerations may be anesthetized with a combination of regional facial blocks and mucosal anesthesia. (See 'Facial nerve blocks' above and 'Local anesthesia' above.)

The clinician should use the alar margins at the entrance of the nares to guide wound repair and alignment. Nonabsorbable 6.0 suture material can be used to place interrupted sutures, with care used to maintain the curvatures and shape of the nose (table 3). Any exposed cartilage should be covered by approximation of the overlying tissue to prevent infection [35]. Full thickness lacerations of the nose can be repaired with 5.0, or in children, 6.0 nonabsorbable sutures. Mucosal lacerations can receive 5.0 or 6.0 absorbable sutures. Disruption of the nasal cartilage should be realigned by repairing the overlying tissue while avoiding direct suturing of the cartilage.

Cheek — Deep lacerations into the intra-oral mucosa require closure of the mucosa first with 4-0 or 5-0 chromic gut (table 3) [13]. After the mucosa is closed, the clinician should repeatedly irrigate the wound from the outside to prevent contamination from the oral flora. When closing the outer layers of the cheek wound, care must be taken to prevent placement of sutures into the parotid duct, gland or facial nerve. Muscle and subcutaneous layers should be closed with absorbable 4-0 suture. The skin should be closed with 5.0 or 6.0 sutures in adults and 6.0 sutures in children using interrupted sutures (table 3).

Intra-oral mucosal — Most buccal mucosa and gingival lacerations are not widely separated, heal rapidly without repair, and do not warrant primary closure. Intra-oral lacerations should be approximated when lesions are greater than 2 cm, considered large enough to retain food particles or other foreign debris, or become ensnared with mastication. Closure of intra-oral lacerations is covered in greater detail separately. (See "Assessment and management of intra-oral lacerations".)

Tongue — In most instances, outcomes for tongue lacerations are not improved by wound closure. Lacerations that should be considered for repair include (see "Evaluation and repair of tongue lacerations", section on 'Decision to repair'):

●Large lacerations (>1 cm in length) that extend into the muscular layers or pass completely through the tongue

●Deep lacerations on the lateral border of the tongue

●Large flaps or gaps in the tongue

●Lacerations with significant hemorrhage

●Lacerations that may cause dysfunction if improper healing occurs (anterior split tongue)

Lacerations that do not need repair include:

●Lacerations <1 cm in length

●Non-gaping lacerations

●Lacerations assessed to be minor in the clinical judgment of the examiner

Repair of tongue lacerations is discussed in greater detail separately. (See "Evaluation and repair of tongue lacerations", section on 'Laceration repair with sutures'.)

OTHER CONSIDERATIONS

Tetanus prophylaxis — Tetanus prophylaxis should be provided for all wounds as indicated (table 7). Pregnant women should receive immunization with tetanus and diphtheria toxoids. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination'.)

Prophylactic antibiotics — Most facial wounds do not warrant empiric antibiotic treatment. Prophylactic antibiotics may decrease the risk of wound infection in the following patients:

●Animal or human bites

●Intra-oral lacerations

●Wounds that extend into the nasal cartilage

●Patients with excessive wound contamination, vascular insufficiency (eg, peripheral artery disease), or immunodeficiency

Recommendations for the use of prophylactic antibiotics after the closure of skin wounds other than bite wounds are discussed in more detail separately. (See "Skin laceration repair with sutures", section on 'Prophylactic antibiotics'.)

Indications and empiric oral antibiotic regimens for patients with animal bites (table 1) and human bites (table 2) are discussed separately. (See "Animal bites (dogs, cats, and other mammals): Evaluation and management" and "Human bites: Evaluation and management".)

Bite wounds — Bites, scratches, abrasions, or contact with animal saliva via mucous membranes or a break in the skin all can transmit rabies. Early wound cleansing is an important prophylactic measure, in addition to timely administration of rabies immune globulin and vaccine (table 8). Indications for rabies prophylaxis are discussed separately. (See "Indications for post-exposure rabies prophylaxis" and "Rabies immune globulin and vaccine".)

Any unvaccinated patient or individual negative for anti-HBs antibodies who is bitten by an individual positive for HBsAg should receive both hepatitis B immune globulin (HBIG) and hepatitis B vaccine (table 9). In addition, although the risk for transmitting HIV through saliva is extremely low, infection is of concern if there is blood in the saliva. Counseling regarding postexposure HIV prophylaxis is appropriate in this setting. (See "Epidemiology, transmission, and prevention of hepatitis B virus infection", section on 'Post-exposure prophylaxis' and "HIV infection: Risk factors and prevention strategies", section on 'Bloodborne transmission risk factors'.)

AFTERCARE — Facial wounds benefit from a moist environment with nonadhesive dressings that will allow healing and prevent further irritation. Coverage with an antibiotic ointment and nonadherent gauze or a band aid suffices for most wounds. Dressings can be secured with paper or micropore tape to minimize further skin irritation. Wounds in areas covered with hair (eyebrow, beard, mustache) can be treated with antibiotic ointment alone. After 24 to 48 hours, wounds closed with nonabsorbable sutures can be left open to air and cleansed gently with soap and water. (See "Skin laceration repair with sutures", section on 'Topical antibiotics and wound dressing'.)

The timing for nonabsorbable suture removal depends upon the location of the laceration as follows (table 3):

●Forehead, cheek, and chin: Five days

●Eyebrow: Three to five days

●Eyelid: Three days

●Nose: Three to five days

Most clean facial wounds do not need to be seen by a physician until suture removal unless signs of infection develop. Highly contaminated wounds should be seen for follow-up in 48 to 72 hours. It is imperative that all patients or caregivers receive discharge instructions regarding the signs of wound infection.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Human bites" and "Society guideline links: Minor wound management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Stitches and staples (The Basics)").

SUMMARY AND RECOMMENDATIONS

●Evaluation – Patients with facial lacerations require careful evaluation to determine the presence of life-threatening associated injuries, historical features that increase the risk of complications after wound repair, and characteristics of the wound including extent, degree of contamination including the presence of foreign bodies, and injury to adjacent structures. (See 'Evaluation' above.)

●Indications for subspecialty consultation – Potential indications for facial wound repair by a surgical subspecialist include the following (see 'Indications for subspecialty consultation or referral' above):

•Deep wounds with damage to underlying nerves, arteries, or other important structures (eg, parotid gland or duct, lacrimal apparatus)

•Complex wounds that require extensive revision or grafting to achieve reasonable cosmetic results

•Wounds with associated injuries that require surgical subspecialty care

•Wounds that require precise cosmetic alignment (eg, lacerations through the columella, nasal ala)

●Primary closure indications and contraindications – Primary closure is usually the preferred treatment for facial lacerations that will lead to excess scarring if the wound edges are not opposed (ie, lacerations into or through the dermis). Wounds with obvious signs of inflammation (redness, warmth, swelling, pus drainage) should not be closed primarily. (See 'Indications for primary closure' above and 'Contraindications and precautions' above.)

●Anesthesia and analgesia – Local anesthesia typically provides adequate analgesia for the management of simple facial lacerations in children and adults. Regional blocks are an alternative to local anesthesia and are preferable for large wounds (>4 cm) and wounds that require precise cosmetic approximation (eg, nasal ala, or columella). Procedural sedation is appropriate for patients whose wounds require precise approximation, especially young children, patients with lacerations that are complex, multiple or heavily contaminated, and in anxious or uncooperative patients when clinician or other staff safety may be compromised. (See 'Anesthesia and analgesia' above.)

●Wound debridement and cleansing – Clean, small facial wounds do not routinely require wound irrigation. Large or contaminated facial wounds may be irrigated with normal saline or tap water. The volume of irrigation is based upon the wound size and degree of contamination. Eyebrows should be left intact. Facial hair other than eyebrows should be clipped rather than shaved until the full wound is visualized and hair does not impede suturing. Tissue excision should be minimal. (See 'Wound debridement and cleansing' above.)

●Suture selection – Suggested suture material and size for facial lacerations are provided in the table (table 3). (See 'Suture selection' above.)

●Choice of suturing versus other closure technique – In a patient with a facial laceration under tension that has subcutaneous fat exposure, we suggest closure with simple interrupted sutures rather than cyanoacrylate tissue adhesives alone or continuous suture placement (Grade 2C). Closure with cyanoacrylate tissue adhesives in combination with interrupted buried dermal sutures is an acceptable alternative for such wounds. (See 'Simple interrupted suture placement' above.)

●Tetanus and antibiotic prophylaxis – Patients should receive tetanus prophylaxis, as needed (table 7). Most facial wounds do not warrant empiric oral or intravenous antibiotic prophylaxis. Bite wounds from animals may warrant rabies prophylaxis. The need for viral prophylaxis for hepatitis B virus or human immunodeficiency virus should be assessed when treating human bites. (See 'Other considerations' above.)

●Aftercare – Facial wounds closed with sutures should be covered with a topical antibiotic ointment (eg, bacitracin zinc). They may also be dressed with a nonadhesive dressing for 24 to 48 hours. After 24 to 48 hours, all wounds closed with nonabsorbable sutures can be left open to the air and cleansed gently with soap and water. The timing for nonabsorbable suture removal depends upon the location of the laceration (table 3). (See 'Aftercare' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Martin Camacho, MSN, CRNP, ACNP-BC, ENP-BC, who contributed to an earlier version of this topic review.