Assessment and management of facial lacerations
- Judd E Hollander, MD
Judd E Hollander, MD
- Professor and Vice Chair Department of Emergency Medicine
- Thomas Jefferson University
- Martin Camacho, MSN, CRNP, ACNP-BC, ENP-BC
Martin Camacho, MSN, CRNP, ACNP-BC, ENP-BC
- Manager Department of Emergency Medicine
- The Reading Hospital and Medical Center
- Section Editors
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
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]. While the majority of emergency care providers are adept at the repair of facial lacerations, the technical nature of a repair related to the underlying anatomy and normal function may occasionally warrant a specialized consultation.
As with all lacerations, a proper evaluation and exploration of the wound is essential. Prior to closure, the clinician should perform an overall trauma assessment, and identify any adjacent bony injuries and disrupted anatomy (especially muscle laceration or neurovascular compromise) or involvement of specialized structures (eg, eyes, teeth). 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.
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:
- Rankin M, Borah GL. Perceived functional impact of abnormal facial appearance. Plast Reconstr Surg 2003; 111:2140.
- Glynn SM, Shetty V, Elliot-Brown K, et al. Chronic posttraumatic stress disorder after facial injury: a 1-year prospective cohort study. J Trauma 2007; 62:410.
- Glynn SM, Asarnow JR, Asarnow R, et al. The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital. J Oral Maxillofac Surg 2003; 61:785.
- Singer AJ, Mach C, Thode HC Jr, et al. Patient priorities with traumatic lacerations. Am J Emerg Med 2000; 18:683.
- Levine E, Degutis L, Pruzinsky T, et al. Quality of life and facial trauma: psychological and body image effects. Ann Plast Surg 2005; 54:502.
- Lee RH, Gamble WB, Robertson B, Manson PN. The MCFONTZL classification system for soft-tissue injuries to the face. Plast Reconstr Surg 1999; 103:1150.
- Moss AL. Facial laceration repairs revisited. Am J Emerg Med 2005; 23:420.
- Lammers RL. Methods of wound closure. In: Clinical Procedures in Emergency Medicine, 5th ed, Roberts JR, Hedges JR (Eds), Saunders Elsevier, Philadelphia 2010. p.592.
- Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999; 34:356.
- Rui-feng C, Li-song H, Ji-bo Z, Li-qiu W. Emergency treatment on facial laceration of dog bite wounds with immediate primary closure: a prospective randomized trial study. BMC Emerg Med 2013; 13 Suppl 1:S2.
- Saigal K, Winokur RS, Finden S, et al. Use of three-dimensional computerized tomography reconstruction in complex facial trauma. Facial Plast Surg 2005; 21:214.
- Moskop JC. Informed consent in the emergency department. Emerg Med Clin North Am 1999; 17:327.
- Code of ethics for emergency physicians. American College of Emergency Physicians. Ann Emerg Med 1997; 30:365.
- Tsai AK, Schafermeyer RW, Kalifon D, et al. Evaluation and treatment of minors: reference on consent. Ann Emerg Med 1993; 22:1211.
- Häfner HM, Röcken M, Breuninger H. Epinephrine-supplemented local anesthetics for ear and nose surgery: clinical use without complications in more than 10,000 surgical procedures. J Dtsch Dermatol Ges 2005; 3:195.
- Wu G, Calamel PM, Shedd DP. THe hazards of injecting local anesthetic solutions with epinephrine into flaps: experimental study. Plast Reconstr Surg 1978; 62:396.
- Reinisch J, Myers B. The effect of local anesthesia with epinephrine on skin flap survival. Plast Reconstr Surg 1974; 54:324.
- Atabey A, Galdino G, El-Shahat A, Ramirez OM. The effects of tumescent solutions containing lidocaine and epinephrine on skin flap survival in rats. Ann Plast Surg 2004; 53:70.
- Lacroix G, Meaudre E, Prunet B, et al. [Appreciation of the role of regional anaesthesia in managing facial wounds in the emergency unit]. Ann Fr Anesth Reanim 2010; 29:3.
- Cimpello LB, Deutsch RJ, Dixon C, et al. Illustrated techniques of pediatric emergency procedures. In: Textbook of Pediatric Emergency Medicine, 6th ed, Fleisher GR, Ludwig S (Eds), Lippincott, Williams & Wilkins, Philadelphia 2010. p.1744.
- Lynch MT, Syverud SA, Schwab RA, et al. Comparison of intraoral and percutaneous approaches for infraorbital nerve block. Acad Emerg Med 1994; 1:514.
- Syverud SA, Jenkins JM, Schwab RA, et al. A comparative study of the percutaneous versus intraoral technique for mental nerve block. Acad Emerg Med 1994; 1:509.
- Hollander JE, Richman PB, Werblud M, et al. Irrigation in facial and scalp lacerations: does it alter outcome? Ann Emerg Med 1998; 31:73.
- Holger JS, Wandersee SC, Hale DB. Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorbable sutures. Am J Emerg Med 2004; 22:254.
- Singer AJ, Quinn JV, Clark RE, et al. Closure of lacerations and incisions with octylcyanoacrylate: a multicenter randomized controlled trial. Surgery 2002; 131:270.
- Lo S, Aslam N. A review of tissue glue use in facial lacerations: potential problems with wound selection in accident and emergency. Eur J Emerg Med 2004; 11:277.
- Zempsky WT, Parrotti D, Grem C, Nichols J. Randomized controlled comparison of cosmetic outcomes of simple facial lacerations closed with Steri Strip Skin Closures or Dermabond tissue adhesive. Pediatr Emerg Care 2004; 20:519.
- Göktas N, Karcioglu O, Coskun F, et al. Comparison of tissue adhesive and suturing in the repair of lacerations in the emergency department. Eur J Emerg Med 2002; 9:155.
- Simon HK, Zempsky WT, Bruns TB, Sullivan KM. Lacerations against Langer's lines: to glue or suture? J Emerg Med 1998; 16:185.
- Mattick A, Clegg G, Beattie T, Ahmad T. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emerg Med J 2002; 19:405.
- Ong TK, Dudley M. Craniofacial trauma presenting at an adult accident and emergency department with an emphasis on soft tissue injuries. Injury 1999; 30:357.
- Kim H, Kim J, Choi J, Jung W. The Usefulness of Leukosan SkinLink for Simple Facial Laceration Repair in the Emergency Department. Arch Plast Surg 2015; 42:431.
- Lammers RL. Methods of wound closure. In: Clinical Procedures in Emergency Medicine, 5th edition, Roberts JR, Hedges JR (Eds), Saunders Elsevier, Philadelphia 2010. p.592.
- Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl J Med 1997; 337:1142.
- Physical examination
- Diagnostic imaging
- INDICATIONS FOR SUBSPECIALTY CONSULTATION OR REFERRAL
- WOUND REPAIR
- Indications for primary closure
- Contraindications and precautions
- - Anesthesia and analgesia
- Local anesthesia
- Facial nerve blocks
- Procedural sedation
- - Wound debridement and cleansing
- - Equipment
- Suture selection
- - Simple interrupted suture placement
- - Tissue adhesives
- - Staples
- - Adhesive tapes
- - Combination of adhesives and adhesive tape
- WOUND SPECIFIC CONSIDERATIONS
- Intra-oral mucosal
- OTHER CONSIDERATIONS
- Tetanus prophylaxis
- Prophylactic antibiotics
- Bite wounds
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS