How to repair a deep nose laceration?

Deep Nose Laceration Repair

Deep nose lacerations should be repaired immediately with a layered closure technique using appropriate anesthesia and wound preparation to minimize infection risk and optimize cosmetic outcomes.

Initial Assessment and Preparation

• Ensure adequate anesthesia before beginning repair. For deep nose lacerations, consider using lidocaine with epinephrine in a concentration of 1:200,000, which is safe for use on the nose 1.
• Apply topical anesthetics such as LET (lidocaine, epinephrine, and tetracaine) to the wound and allow it to soak for 10-20 minutes or until wound edges appear blanched 2.
• For deeper lacerations, supplement topical anesthesia with local infiltration using buffered lidocaine, warmed before injection, and injected slowly with a small-gauge needle for minimal pain 2.
• Clean the wound thoroughly with irrigation using potable tap water, which has been shown to be as effective as sterile saline and does not increase infection risk 1.

Repair Technique for Deep Nose Lacerations

Layered Closure Approach

1. Deep Layer Repair:

   • Identify and reapproximate any damaged cartilage structures using absorbable sutures 2.
   • For septal involvement, repair the septum first as "the septum goes, so goes the nose" 2.
   • Use figure-8 sutures to stabilize adjacent cartilage segments and prevent overlap 2.

2. Middle Layer Repair:

   • Reapproximate subcutaneous tissues and muscle layers using continuous, non-locking absorbable sutures 2.
   • This distributes tension more evenly across the suture line and provides better support 2.

3. Skin Closure:

   • For optimal cosmetic results, use continuous non-locking subcuticular sutures for skin closure 2.
   • Alternatively, consider tissue adhesives for superficial components in low-tension areas 1.
   • For facial wounds, use absorbable sutures to avoid the pain and anxiety of suture removal 2.

Special Considerations

• Timing of Repair: While immediate repair is ideal to achieve both functional and cosmetic restoration 3, evidence suggests that wounds may be safely closed even 18 or more hours after injury depending on wound type and contamination 1.
• Cartilage Involvement: If nasal cartilage is exposed or damaged, ensure proper alignment to prevent future deformities. Consider batten-type grafts to reorient and straighten damaged cartilage when necessary 2.
• Septal Hematoma: Always examine for septal hematoma, which requires immediate drainage to prevent cartilage necrosis and subsequent nasal deformity 4.
• Wound Dressing: Apply occlusive or semi-occlusive dressings as wounds heal faster in a moist environment 1.

Infection Prevention

• Consider prophylactic antibiotics for deep lacerations, especially those involving cartilage 2.
• For contaminated wounds (e.g., animal bites), aggressive irrigation and appropriate antibiotic coverage are essential 5.
• Ensure tetanus prophylaxis is provided if indicated based on immunization history 1.

Follow-up Care

• Monitor for signs of infection including increasing pain, redness, swelling, or purulent discharge 2.
• Pain control can be achieved with acetaminophen, ibuprofen, and ice packs; opiates should be used only if needed 2.
• Consider early follow-up within two weeks to assess wound healing 2.

Potential Complications

• Watch for wound dehiscence, infection, or poor cosmetic outcome requiring revision 6, 3.
• Long-term sequelae may include nasal deformity, scar formation, or functional impairment requiring secondary reconstruction 4, 3.