What is the recommended treatment for lacerations to the face?

Treatment of Facial Lacerations

For facial lacerations, skin adhesives or non-suturing approaches are recommended as first-line treatment due to better cosmetic outcomes, less pain, and shorter procedure time compared to traditional suturing. 1

Initial Assessment and Preparation

• Ensure adequate lighting and patient analgesia before repair

• For pain management:

  • Apply topical anesthetics such as LET (lidocaine, epinephrine, and tetracaine) to the wound for 10-20 minutes 1
  • For children: Consider buffered lidocaine for injection if needed (warmed, injected slowly with small-gauge needle) 1
  • For infants: Consider sucrose solution as adjunct for pain management 1

• Clean the wound thoroughly:

  • Irrigate under pressure to remove debris and contaminants
  • Prepare the site with betadine or chlorhexidine 1

Closure Method Selection

First-Line Options:

1. Skin Adhesives (e.g., octylcyanoacrylate/Dermabond)

   • Best for: Low-tension wounds, especially those oriented against Langer's lines 2
   • Benefits: Essentially painless closure, no need for removal, shorter ED length of stay (26 minutes shorter than sutures) 3
   • Technique: Apply after thorough wound cleansing, ensuring edges are well-approximated

2. Adhesive Strips (Steri-Strips)

   • Best for: Low-tension wounds
   • Benefits: Similar cosmetic outcomes to skin adhesives but lower cost 4
   • Technique: Apply perpendicular to the wound after ensuring wound is dry

Second-Line Options (for larger/deeper lacerations):

1. Absorbable Sutures

   • Best for: Facial wounds requiring suturing
   • Benefits: No need for removal, reducing pain and anxiety 1
   • Recommended material: Rapidly absorbing synthetic sutures like polyglactin 910 (VICRYL RAPIDE) 1

2. Non-absorbable Sutures

   • Best for: Complex facial lacerations with tension
   • Technique: Use continuous, non-locking suturing technique which distributes tension evenly 1
   • Material: Monofilament sutures preferred (less bacterial seeding) 1

Layered Closure Technique for Deeper Lacerations

1. Close the dermal layer first (provides wound strength) 5
2. Use continuous non-locking sutures for each layer 1
3. For skin closure, use subcuticular technique to avoid surface nerve damage 1

Special Considerations

• Location-specific approach:

  • For lacerations against Langer's lines: Skin adhesives provide better cosmetic outcomes than sutures 2
  • For high-tension areas: Consider layered closure with deep dermal sutures followed by superficial closure

• Wound size considerations:

  • Small lacerations (<5mm): Skin adhesive or adhesive strips
  • Medium lacerations (5-10mm): Consider absorbable sutures or skin adhesives
  • Large lacerations (>10mm): Layered closure with absorbable sutures

Post-Closure Care

• Clear documentation of laceration type and repair technique
• Patient education on wound care
• Pain control: acetaminophen, ibuprofen, ice packs
• Follow-up within two weeks for complex wounds 1

Common Pitfalls to Avoid

1. Using interrupted sutures instead of continuous technique (causes more pain and requires more suture removal) 1
2. Using locking sutures (can cause excessive tension leading to tissue edema and necrosis) 1
3. Neglecting the dermal layer (the skin's greatest strength is in this layer) 5
4. Placing full-thickness sutures in areas other than palmar and plantar surfaces 5