What is the treatment for a forehead laceration that occurred more than 12 hours ago?

Treatment of Forehead Lacerations Presenting After 12 Hours

Forehead lacerations presenting more than 12 hours after injury can still be safely closed primarily with meticulous wound preparation, as there is no definitive "golden period" beyond which closure becomes unsafe. 1

Wound Assessment and Preparation

The initial evaluation should focus on:

• Contamination level - Grossly contaminated wounds require more extensive irrigation and may need delayed closure 2
• Depth and tissue involvement - Assess for involvement of deeper structures including muscle, fascia, or bone 1
• Signs of infection - Look for erythema, purulent discharge, warmth, or systemic signs that would contraindicate primary closure 1

Wound Cleaning Protocol

• Irrigate copiously with 100-1000 mL of potable tap water or sterile saline - both are equally effective and tap water does not increase infection risk 3, 1
• Remove superficial debris carefully, avoiding aggressive debridement that enlarges the wound 2
• Prepare the wound site with betadine or chlorhexidine antiseptic solution 2

Anesthesia Options

Adequate pain control is essential before wound manipulation:

• Topical anesthetics (LET solution) - Apply lidocaine-epinephrine-tetracaine for 10-20 minutes until wound edges blanch; contraindicated if gross contamination present 2
• Injectable lidocaine - Buffer with bicarbonate, warm before injection, and inject slowly with small-gauge needle to minimize pain 2
• Epinephrine-containing anesthetics are safe for facial use at concentrations up to 1:200,000 1

Closure Technique Selection

For forehead lacerations presenting late, facial wounds can be closed primarily if seen by an experienced provider, provided there has been meticulous wound care and copious irrigation. 2

Preferred Closure Methods

• Tissue adhesives (octyl cyanoacrylate) - Provide essentially painless closure for low-tension facial wounds, associated with 26-minute shorter procedure time and less pain 2, 4
• Wound closure strips (Steri-Strips) - Offer painless closure, less expensive than adhesives, appropriate for low-tension areas 2, 3
• Absorbable sutures - Should be considered for facial wounds requiring suturing to avoid pain and anxiety of suture removal 2

Suturing Approach When Required

• Use continuous non-locking subcuticular technique to distribute tension evenly and minimize pain 2
• Avoid transcutaneous interrupted sutures on facial skin as they damage nerve endings and increase pain 2

Critical Timing Considerations

The traditional 12-hour "golden period" is not evidence-based - depending on wound characteristics, closure may be reasonable even 18+ hours after injury. 1 The decision should be based on:

• Contamination level rather than time alone 1
• Presence or absence of infection signs 1
• Anatomic location - facial wounds have better blood supply and lower infection risk 2

Antibiotic Considerations

• Prophylactic antibiotics are NOT routinely indicated for clean facial lacerations, even when presenting late 2
• Consider antibiotics only if signs of established infection are present 2
• If antibiotics are used, first-generation cephalosporins (cefazolin 2g) are appropriate 2

Post-Closure Management

• Pain control with acetaminophen and/or ibuprofen 3
• Ice packs to reduce swelling 3
• Moist wound environment with occlusive or semi-occlusive dressings promotes faster healing 1
• Tetanus prophylaxis if status is outdated or unknown (0.5 mL intramuscularly) 2
• Monitor for infection signs including increased pain, redness, swelling, or purulent discharge 3

Common Pitfalls to Avoid

• Do not refuse closure based solely on time elapsed - assess wound characteristics instead 1
• Avoid aggressive debridement that enlarges the wound and impairs closure 2
• Do not use sterile gloves unnecessarily - nonsterile gloves do not increase infection risk 1
• Never close infected wounds primarily - these require delayed closure after infection resolution 2