What is the best approach for repairing deep forehead lacerations?

Best Approach for Repairing Deep Forehead Lacerations

For deep forehead lacerations, a layered closure technique using monofilament sutures (5-0 or 6-0) for skin closure provides optimal cosmetic outcomes while minimizing infection risk and maximizing wound strength. 1

Anesthesia Management

• Use adequate anesthesia before repair:
  • For adults: Consider local anesthesia with buffered lidocaine
  • For children: Consider topical anesthetics like LET (lidocaine, epinephrine, and tetracaine) applied 10-20 minutes before procedure 2
  • For extensive lacerations: Regional nerve blocks may provide better anesthesia with less tissue distortion 1

Wound Preparation

1. Clean thoroughly with irrigation under pressure
2. Prepare wound site with appropriate antiseptic (povidone-iodine or chlorhexidine if iodine allergic) 1
3. Debride any devitalized tissue
4. Explore for deeper injuries (frontal bone fractures, foreign bodies)

Layered Closure Technique

Deep Layer Closure

• Close deep tissue layers with absorbable sutures (e.g., 3-0 or 4-0 polyglactin/Vicryl)
• Use continuous non-locking sutures to distribute tension evenly 1
• Consider triclosan-coated sutures in higher-infection risk scenarios 1

Skin Closure

• Use monofilament sutures (5-0 or 6-0) for skin closure to minimize bacterial seeding and tissue reaction 1
• Options for skin closure:
  1. Preferred method: Continuous subcuticular closure for minimal scarring and pain 1
  2. Interrupted sutures with precise eversion of wound edges
  3. For small, low-tension areas: Consider tissue adhesives (octylcyanoacrylate) or Steri-Strips 1

Special Considerations for Forehead Lacerations

• Align with relaxed skin tension lines (horizontal on forehead) for optimal cosmetic outcome
• Ensure precise edge approximation with slight eversion of wound edges
• Consider the frontalis muscle function when repairing deeper lacerations
• For wounds crossing eyebrows, align hair follicles precisely to maintain natural appearance

Post-Repair Care

• Apply occlusive or semi-occlusive dressings to maintain moist wound environment 3
• Provide tetanus prophylaxis if indicated 3
• Remove sutures in 5-7 days for facial wounds 1
• Consider applying Steri-Strips for additional support for 3-5 days after suture removal 1
• Advise patient on scar care: sun protection, silicone-based products after healing

Pitfalls to Avoid

• Excessive tension on closure leading to tissue necrosis and poor healing
• Inadequate deep tissue closure resulting in depressed scars
• Misalignment with relaxed skin tension lines causing more visible scarring
• Improper suture removal timing (too early: wound dehiscence; too late: suture track marks)
• Neglecting to address deeper structure injuries (frontalis muscle, periosteum)

By following this structured approach to forehead laceration repair, optimal functional and cosmetic outcomes can be achieved while minimizing complications and scarring.