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Lacerations of the head and neck
Link to instructional video on suture technique.
Overview
The care of head and neck soft tissue wounds including lacerations, avulsions, and abrasions, is a crucial skill for the ENT resident in order to maximize functional and aesthetic outcomes. General principles of facial laceration and avulsion repair include detailed physical exam for additional injuries and damaged critical structures (facial nerve, salivary ducts etc.), copious irrigation and cleaning of wounds, minimal tissue debridement or removal in the acute period, and closure as soon as possible after injury (i.e., at least within 24 hours for grossly non-contaminated wounds). While typically ordered by the emergency department provider, always ensure tetanus and rabies vaccinations are given when indicated. Antibiotics are not routinely prescribed for head and neck lacerations but should be considered in immunosuppressed patients, in ear or nasal lacerations with exposed cartilage, any open fracture, through and through lip lacerations or any laceration crossing mucosal barriers, and grossly contaminated wounds or bite wounds. Common mistakes to avoid during laceration repair are inadequate irrigation of wounds, failure to meticulously remove foreign debris, inadequate examination of wound extent especially in puncture wounds, wound closure under tension, and assumption of missing tissue in widely gaping or macerated lacerations.
Evaluation & Cleaning of Lacerations
Always begin with detailed history; important considerations include injury timing, any loss of consciousness, mechanism of injury, social context (domestic abuse and assault are common causes of facial trauma making documentation especially important from a medicolegal standpoint). Physical exam as in all traumas should start with focus on the ABCs (airway, breathing, circulation) and should then include a general head and neck physical exam avoiding the pitfall of concentrating on obvious or “distracting” injuries at the neglect of being thorough. Underlying bony injuries to the face, cervical spine, or skull as well as intracranial injuries should be ruled out by proper exam and imaging when indicated. After appropriate attention to more critical injuries, wounds should be thoroughly cleaned and assessed. Cleaning of wounds involves copious irrigation with saline, frequently 1-2 liters depending on wound size and degree of contamination. In wounds with dry bloody crusts or hair throughout the wound, it may be necessary to add a small amount of hydrogen peroxide to aid in cleaning. Hydrogen peroxide is not routinely added to irrigation solutions due to concern of impaired wound healing but should be selectively used in order to facilitate wound inspection and closure. Similarly, antimicrobial cleansers such as povidone iodine and chlorhexidine are not necessary after irrigation in most facial wounds though should be used if the wound is contaminated or had a “dirty” mechanism.
Local Anesthesia
Local anesthesia of wounds allowing complete wound evaluation and relatively painless closure can typically be obtained by one of three methods: topical anesthetic, direct infiltration, or nerve blocks. While a wide range of local anesthetics are commercially available for any of these methods, the selection can typically be simplified to a few common choices. Topical anesthetic may make closure more comfortable in all patients but is commonly utilized only in cases where a patient is unable to tolerate injections, such as children or mentally disabled adults and usually is achieved through application of LET (4%lidocaine, 1:2000 epinephrine, and 1%tetracaine) or TAC (0.5% tetracaine, 1:2000 adrenalin, 11.8% cocaine) directly in the wound bed with overlying occlusive dressing application. Downsides to topical anesthetics include time requirements (may take 30 minutes for full anesthetic effect), additional cost, and potential toxicity when additional local anesthetics are required given difficulty of calculating total dosage. The most common injectable anesthetic choices are listed below.
Direct infiltration of wounds with local anesthetic is an easy method for achieving sufficient anesthesia in small wounds but can distort local tissues or compromise macerated tissue with tenuous blood supplies if the solution contains epinephrine. In large wounds or wounds where tissue distortion is to be avoided, nerve blocks may provide anesthesia with decreased total anesthetic dosage and without the tissue distortion. There are 8 primary blocks important in facial anesthesia: supraorbital/ supratrochlear, infraorbital, dorsal nasal, zygomaticofacial, zygomaticotemporal, inferior alveolar, mental, and great auricular nerve blocks. The precise method to achieve these individual blocks is beyond our scope here but should be reviewed by residents as needed prior to complex laceration repairs. If patients remain combative or non amenable to any of the methods discussed above, sedation may be required via MAC in the ED or occasionally in the OR with general anesthesia.
Suture Selection
The table below outlines the most commonly used sutures in facial laceration repair as well as possible options for suture selection based on subsite or structure. All closures should involve meticulous closure with minimal wound tension on the dermis/epidermis and eversion of the skin edges. Generally, deep sutures for approximation of subcutaneous tissue and reduction of surface tension should be placed any time a laceration is deep enough to allow them while still placing as few as necessary to relieve the surface tension in order to minimize the inflammatory reaction. Suture selection for the skin edges should be made with consideration of likelihood of patient follow up and ease of removal; choose absorbable sutures if the patient is unlikely to return to care in a timely manner or unable to tolerate suture removal. Traditionally, it has been thought that non-absorbable suture with planned early removal leads to best aesthetic results, though many believe fast absorbing gut sutures yield comparable results and may be routinely used. The most important factors are optimal technique and minimizing tension on the closure.
Key Supplies for Laceration Repair
Headlight
PPE (Eyewear, gloves, mask, +gown)
Normal saline bottles for wound irrigation
Iodine swabs
1% Lidocaine 1:100,000 with epinephrine
18-gauge and 27-gauge needles with 12ml syringe
4x4 Gauze
Laceration tray with forceps, needle driver, and scissors
Sterile towels and gloves
Sutures or stapler
15-blade scalpel
Vaseline or bacitracin ointment
Abrasions
The management of the most superficial of these injuries, an abrasion, is thorough cleaning and light debridement (critical to avoid traumatic tattooing) followed by meticulous wound care while healing. Wound care for abrasions involves keeping the site moist with bacitracin or petroleum-based ointment and avoidance of drying/crusting of the surface and strict sun avoidance or protection.
Specific Facial Subsite Considerations
These subsites outline basic closure with the expectation that a comprehensive history and physical are completed prior to laceration closure with prioritization of more critical injuries first. The scope of the discussion herein is narrowed to lacerations typically closed by junior residents in the emergency department setting without significant loss of tissue or complexity requiring advanced reconstructive techniques.
Scalp
Unique to the scalp due to its distinctly layered anatomy is the propensity of lacerations to create large flaps or avulsion injuries that may require a drain/compression wrap to prevent hematoma formation. Scalp wounds also tend to collect debris and congealed blood in the tissue requiring a slightly more aggressive washout and manual debridement prior to closure.
Small lacerations of the scalp can frequently be closed with a quick staple or two without any local anesthetic as their rapid application is usually less painful and traumatic than an injection. Moderate sized lacerations involving multiple layers of the scalp should be closed by layers and a head wrap considered if concerned for hematoma formation. Very large lacerations to the scalp are frequently still closed at bedside with frequent drain requirements and may require large doses of anesthetic making it critical to calculate maximum weight-based doses of local anesthetics before injection. Scalp wounds with tissue defects and especially defects that involve pericranium leaving a segment of calvarium exposed should typically be closed in the OR with reconstructive techniques such as local flaps, grafts, and free flaps that are beyond our scope for this discussion.
Gentle inspection of the wound and consideration for need to go to the operating room for closure (severely contaminated or large macerated wounds, wounds requiring complex reconstructive methods, lacerations in patients unable to tolerate bedside closure, or patients with other injuries that require operative intervention)
Anesthetize the wound (the scalp is highly vascular making anesthetic preparations that contain epinephrine especially beneficial) by injecting circumferentially into the tissue around the laceration
Slide the patient to the top of the bed or gurney and, while an assistant holds the patient’s head off the bed as well a basin below, wash the wound out thoroughly while using one hand to gently scrub the wound, ensure all hematoma has been removed and no foreign bodies are present, may lightly paint the wound with iodine swabs if contaminated
Slide the patient back down gurney into a comfortable position with towels under the head and proper lighting
If a suction drain is needed, make a small stab incision with 11 blade 1-2 cm away from the posterior or most dependent portion of the laceration while the patient is supine. Push a Kelly or Mayo clamp through the incision and grasp the end of your 7 French JP drain and pull through the incision into the wound bed. Cut the end of the drain so it is not coiled in the wound bed and secure drain with a 2-0 Nylon suture
Close the laceration by layers. S.C.A.L.P. mnemonic: Skin, Connective tissue, Aponeurosis, Loose Areolar tissue, Periosteum. Use buried interrupted Vicryl sutures to close the deep layers (being cautious not to suture through the drain), place your deep dermal sutures until the skin edges are well approximated and the drain holds suction. Close the skin with staples (hair bearing), Ethilon/Prolene, or fast absorbing suture, typically in a running fashion
Apply vaseline or bacitracin to the incision. If placing a head wrap: apply Xeroform gauze to laceration, cover with fluffs then wrap the head using Kerlix followed by Coban ensuring the wrap is appropriately tight. May need to wrap under the chin if the laceration is on the vertex of the scalp in order to apply downward pressure
Ear
The blood supply to the ear is robust, but the cartilage derives its blood supply from the overlying skin and perichondrium and must be fully covered in order to survive. The cartilage is also fragile and easily torn if passing suture, especially with cutting needles. Because of the thin skin and easily distorted architecture of the ear, most lacerations of the ear are best anesthetized with a nerve block of the external ear as opposed to direct infiltration of wounds (though direct injection may be necessary for the concha cavum and tragus). The external auditory canal may be involved in some lacerations with the risk of scarring leading to canal stenosis. These lacerations can usually be managed with stenting of the canal during healing by use of an otowick placed after detailed exam.
Anesthetize the ear with a nerve block by injecting appropriate local anesthetic targeting the Auriculotemporal (anterior superior course to the ear), the Greater Auricular (posterior inferior to the ear), and Lesser Occipital Nerve (posterior mid ear)
Thoroughly irrigate the wound with saline and meticulously remove any foreign bodies or debris
Ensure sufficient laxity in skin to close over the cartilage or judiciously trim small amount of exposed cartilage back to allow closure of skin
Complete the deep closure of the laceration using 5-0 Monocryl or undyed PDS interrupted deep sutures through dermis and perichondrium with sparing use of cartilaginous sutures
Close the skin with interrupted Ethilon or Fast Absorbing Gut sutures (5-0 or 6-0 typically)
If there was significant separation of the skin/perichondrium from the cartilage or concern of auricular hematoma, an ear bolster dressing may be applied. Patients are often placed on a prophylactic antibiotic while the bolster is in place for 5-7 days
Consider fluroquinolone if dirty wound or significant cartilage exposure
Explain return precautions including warning signs of hematoma formation
Follow up in 5-7 days for bolster and suture removal
Periorbital
The skin around the eye is some of the thinnest skin in the body and is both aesthetically and functionally important especially when involving the eyelids, the lid margins, and the canthi. Closure of periorbital lacerations requires detailed orbital exam first and foremost ensuring no injury to the globe or lacrimal system while always maintaining a high level of suspicion for involvement of underlying structures and a low threshold for ophthalmology consultation if suspected. The lids are comprised of the anterior lamella (skin and orbicularis oculi), middle lamella (orbital septum) and posterior lamella (tarsus, levator palpebrae superioris in the upper lid, and conjunctiva). The medial and lateral canthal tendons maintain the tension and position of the lids respective to the bony orbit and injury should be suspected with lacerations that pass through or near the canthi and when increased lid laxity is found on exam. The medial canthus attaches to the frontal process of the maxilla and lacrimal bones and surrounds the lacrimal sac which is often injured concomitantly. If concerns for lacrimal system injury, Ophthalmology should be consulted. The closure of the eyelid margins with full thickness defects must be exact to prevent entropion or ectropion and is usually accomplished with a three-suture technique where approximation of the meibomian glands, grey line, and lash line by individual sutures is used. The finding of ptosis in a patient with an upper eyelid laceration may indicate injury to the levator palpebrae superioris muscle and Ophthalmology should be consulted. Lacerations involving the lateral brow can involve the frontal branch of the facial nerve which must be carefully examined prior to anesthetic injection. The eyebrow should be carefully reapproximated and should never be shaved as regrowth is unpredictable and can take 6 months or more. Additionally, minimal dermal sutures should be placed in the brow to minimize the risk of alopecia secondary to follicle damage though this may be unavoidable, and patients should be warned of this possibility.
Inject the tissue surrounding the laceration with 1% lidocaine with 1:100,000 epinephrine
Thoroughly irrigate the laceration with saline
Consider applying eye ointment and corneal protector if suturing close to the globe to avoid corneal abrasion
Repair the laceration deep to superficial typically avoiding suture placement in the septum or conjunctiva (risk of corneal abrasion from sutures)
Approximate the tarsus with 5-0 PDS or 6-0 Vicryl simple interrupted sutures with the knot on the superficial side of the tarsus to avoid corneal irritation
Place a vertical mattress suture with 7-0 Ethilon or Prolene through the meibomian gland line
A 7-0 Ethilon or Prolene is then used to approximate the grey line with either a vertical mattress or simple interrupted
A third margin suture in then placed at the line of the lash follicles with the 7-0 Ethilon or Prolene suture
The remainder of the skin layer is closed with 6-0 fast absorbing suture
Tuck the tails of the margin sutures away from the eye by passing the tails under a skin suture
Apply antibiotic ointment (typically erythromycin ointment) and remove the corneal protector if placed
Follow up scheduled 5-7 days after repair for suture removal
Nasal
Injuries to the nose should be approached with consideration of its important form and function with the goal to restore these through appropriate management of wounds. Lacerations that extend fully through the nose and nasal mucosa are at higher risk of leading to collapse of the internal or external nasal valve and therefore are more likely to lead to nasal obstruction and future need for functional rhinoplasty or scar revision. The repair of nasal cartilage is critical to long term results of repair and usually is best accomplished with sutures such as an undyed PDS or Monocryl. The alar rim is frequently involved in lacerations and has a propensity to retract with healing leading to external nasal valve collapse or notching if the wound is not well approximated. These complications are avoided by silastic stenting of the involved vestibule for one week following repair and meticulous re-approximation during closure.
Thoroughly wash and inspect the laceration
Ensure no underlying nasal bone or septal fracture/hematoma
Achieve sufficient anesthesia either through direct injection or a nasal block
Injections to dorsal nasal nerves, lateral nasal area, and intranasal pledgets soaked in anesthetic
Repair laceration deep to superficial
Approximate skin of vestibule or nasal mucosa with 5-0 Fast Absorbing Gut or Chromic Gut suture
If laceration involves alar rim, consider first approximating the laceration at the rim with a vertical mattress 5-0 Fast Absorbing Gut or Nylon suture
Selectively place undyed 5-0 PDS or Monocryl sutures to approximate nasal cartilage
Lastly close the skin with gentle approximation with 5-0or 6-0 Fast Absorbing Gut or Nylon (sebaceous rich skin of the nose tears easily if using a cutting needle or if under any tension)
If significant laceration involving alar rim or external nasal valve, consider placement of a silicone nasal splint sutured in place
Apply bacitracin ointment
Follow up scheduled 5-7 days after repair
Intraoral/Lip
Lacerations to the tongue, buccal mucosa, and wet lip are commonly caused by the teeth and are therefore frequently puncture wounds in nature. These lacerations, like all lacerations, should be thoroughly irrigated which may be best accomplished with warm water and an angio-catheter on a 20cc syringe or by simply having an alert patient gargle with water or chlorhexidine rinse. The buccal mucosa and lip have the tendency to swell more than other subsites leading small lacerations, that would otherwise not need any closure, to splay open and take longer to heal if not sutured. The long-term healing of oral lacerations left to heal by secondary intention is typically satisfactory though hypertrophic scarring in the buccal vestibules can lead to chronic irritation from the occluding teeth and can be avoided by primary closure. The parotid and submandibular ducts are important structures to examine prior to any attempted closure. If in doubt, these ducts can be probed to ensure no injury or Sialography performed if high suspicion of injury. Chromic gut is a common absorbable suture with properties ideal for the oral environment as the chromium salts help maintain tensile strength for 5-7 days. Vicryl may be used both for deep buried sutures as well as for mucosal surface closure if tensile strength is desired for a longer period (may take up to 4 weeks in the mouth for breakdown). Lacerations to the dry lip that extend through the vermillion border should be approximated starting with the vermillion border prior to local anesthetic distorting tissue followed with deep sutures to approximate the orbicularis oris, deep dermal sutures, and lastly skin closure usually with Fast Absorbing Gut or Ethilon suture. The vermillion border suture must be extremely precise as a 1mm discrepancy in the approximation can be noticeable. Avulsion injuries with loss of up to 1/3 of the lip can be closed primarily with low risk of microstomia, any larger loss of tissue should lead to consideration of closure with local flaps (i.e. Abbe or Gillies flaps).
Thoroughly clean all intraoral wounds by having conscious and alert patients gargle and rinse with chlorhexidine oral rinse (altered patients should be topically cleaned with syringe flushes or a tooth brush dipped in chlorhexidine with suction ready to prevent aspiration)
Achieve local anesthesia, commonly with direct infiltration though avoid direct infiltration with wounds crossing the vermillion border as can obscure this landmark
Ensure critical structures (e.g. Stenson’s and Wharton’s ducts) are not involved, look for dental fractures and ensure no palate or alveolar ridge mobility
Close wound deep to superficial (if wound crosses the Vermillion Border consider first passing one suture through this border to mark exact location prior to additional layers)
Approximate orbicularis oris with 4-0 Vicryl sutures
Intraoral mucosa and wet lip closed with 4-0 Chromic Gut
Dry lip and external skin closed with interrupted 5-0 Fast Absorbing Gut or Ethilon sutures
Apply bacitracin to external wound
Chlorhexidine mouth rinses TID for 2 weeks for intraoral lacerations
Follow up scheduled 5-7 days after repair
Cheek
Primary concerns with cheek lacerations is damage to the facial nerve, especially the buccal branch, as well as the parotid gland and duct. Lacerations to the lateral cheek or preauricular area that extend deep to the SMAS are likely to involve the parotid gland and any clear fluid in the wound bed should be suspected to be saliva. These gland injuries can be closed primarily by layers with attention to close approximation with low risk of salivary fistula when well closed if no associated ductal injury. Injuries to the parotid duct and/or buccal branch of the facial nerve should be suspected when an injury crosses a line drawn from the tragus to the middle of the upper lip and should be thoroughly explored. Both these structures are most vulnerable as they cross the masseter superficially in the mid cheek. Repair techniques for the parotid duct are beyond the scope of this discussion. Facial nerve injury repair is similarly beyond our discussion here, but the primary responsibility of the junior resident is a thorough facial nerve exam with documentation of the affected branches as well as quantification of the paresis with House-Brackmann classification as well as ensuring protective measures for the eye if lagophthalmos is noted (moisture chamber, lacrilube, artificial tears etc.). If the injury is medial to an imaginary line drawn from the lateral canthus inferiorly, exploration of the wound with intent to repair the nerve is not usually attempted. When lateral to the imaginary line from the lateral canthus, the wounds are explored in the operating room with attempt to locate and repair by primary neurorrhaphy, transposition grafting, or interposition grafting as soon as possible as Wallerian degeneration leads to poorly stimulating distal branches by 72 hours.
Thoroughly irrigate and inspect the laceration
Detailed facial nerve exam prior to any local anesthetic injection and careful examination for any exposed parotid tissue or possible injury to parotid duct
Inject local anesthetic, commonly direct infiltration though infraorbital blocks may be helpful or even sufficient if wound is medial
Close laceration from deep to superficial with special attention to approximation especially if concern of parotid salivary gland tissue damage with goal to decrease risk of salivary fistula
Approximate the facial muscles and subcutaneous tissue with 4-0 Vicryl sutures
Deep dermal suture with buried 4-0 Vicryl sutures
Close the skin surface with 5-0 Fast Absorbing Gut, Prolene, or Ethilon suture
Apply ointment
Follow up scheduled 5-7 days after repair
Aftercare
Routine care after laceration repair includes petroleum-based ointment for one week to keep moist, prevention of drying and crusting, chlorhexidine rinse after meals for 1 week for intraoral lacerations, scar massage beginning at 3 weeks, and avoidance of sun exposure to the scar for minimum of 6 months.
References
Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. Am Fam Physician. 2017;95(10):628-636.
Hill, J.D., et al (2020). Facial Trauma: Soft Tissue Lacerations and Burns. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 269-287). Philadelphia, PA: Elsevier.
Shadfar, S., Shockley, W.W. (2013). Management of Soft Tissue Injuries of the Face. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1108-1130). Baltimore, MD: Lippincott Williams & Wilkins.