What is the recommended technique for repairing a deep nasal laceration?

Deep Nasal Laceration Repair Technique

For deep nasal lacerations, a layered repair approach is recommended, starting with identification and reapproximation of damaged cartilage structures using absorbable sutures, followed by subcutaneous tissue closure with continuous non-locking absorbable sutures, and finishing with skin closure using continuous non-locking subcuticular sutures for optimal cosmetic results. 1

Initial Assessment and Preparation

• 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 1
• For deeper lacerations, supplement topical anesthesia with local infiltration using buffered lidocaine 1
• Local anesthetic with epinephrine in a concentration of 1:200,000 is safe for use on the nose 2
• Ensure adequate lighting and proper positioning for optimal visualization 3
• Clean the wound thoroughly with irrigation using potable tap water or sterile saline 2

Structural Assessment

• Thoroughly examine for damage to underlying cartilage structures, as untreated septal injuries can lead to functional and cosmetic abnormalities 4
• Evaluate for septal hematoma or abscess formation which requires immediate evacuation to prevent cartilage resorption 4
• Document the extent of injury with photographs when possible 5

Repair Technique

Step 1: Cartilage Repair

• If septal involvement is present, repair the septum first as "the septum goes, so goes the nose" 1
• Use figure-8 sutures to stabilize adjacent cartilage segments and prevent overlap 1
• Consider batten-type grafts to reorient and straighten damaged cartilage when necessary 1

Step 2: Deep Tissue Repair

• Reapproximate subcutaneous tissues and muscle layers using continuous, non-locking absorbable sutures (e.g., 4-0 or 5-0 polyglactin 910) 1
• This distributes tension more evenly across the suture line and provides better support 1

Step 3: Skin Closure

• For optimal cosmetic results, use continuous non-locking subcuticular sutures for skin closure 1
• Alternatively, consider tissue adhesives for superficial aspects of the wound in low-tension areas 2

Special Considerations

• Ensure proper alignment of nasal cartilage to prevent future deformities 1
• For complex nasal lacerations involving multiple tissue layers or significant tissue loss, consider specialist consultation 6
• Wounds heal faster in a moist environment, so occlusive or semi-occlusive dressings should be considered 2

Infection Prevention and Follow-up Care

• Consider prophylactic antibiotics for deep lacerations, especially those involving cartilage 1
• Monitor for signs of infection including increasing pain, redness, swelling, or purulent discharge 1
• Schedule early follow-up within two weeks to assess wound healing 1
• Pain control can be achieved with acetaminophen, ibuprofen, and ice packs; opiates should be used only if needed 1

Common Pitfalls and How to Avoid Them

• Failure to identify septal hematoma can lead to cartilage necrosis and saddle nose deformity; always perform complete intranasal examination 4
• Inadequate cartilage repair can result in long-term functional and cosmetic issues; ensure proper alignment during initial repair 1
• Excessive tension on suture lines can lead to poor cosmetic outcomes; use layered closure to distribute tension 1
• Delayed repair may be appropriate in some cases, as there is no definitive "golden period" beyond which wounds cannot be safely closed 2, 7