Ideal Method for Closing Head Lacerations
For head lacerations, primary closure with sutures is the preferred method, as facial and scalp wounds have excellent blood supply allowing safe closure even with delayed presentation, and should be managed with copious irrigation, cautious debridement, and appropriate wound approximation to optimize cosmetic outcomes. 1
Wound Assessment and Preparation
Initial Evaluation
- Ensure adequate lighting and patient analgesia before beginning repair 1
- Perform thorough wound cleansing with sterile normal saline or potable tap water (both are equally effective and do not increase infection risk) 1
- Assess wound depth, location, and contamination level to guide closure technique 2
Timing Considerations
- There is no absolute "golden period" for head laceration repair - depending on wound type, closure may be reasonable even 18+ hours after injury due to the excellent vascular supply of the head 2
- Clean facial and scalp lacerations presenting within 6 hours can be safely closed primarily 3
Closure Technique Selection
Primary Closure with Sutures
- Layered closure is essential for optimal strength and cosmetic results - the dermis provides the skin's greatest tensile strength and must be accurately approximated to the opposite dermal layer 4
- Use 3-0 or 4-0 delayed absorbable sutures (polyglactin or poliglecaprone) for deeper layers 1
- Epidermal approximation provides cosmetic refinement but does not contribute to wound strength 4
Alternative Closure Methods for Low-Tension Wounds
- Tissue adhesives (cyanoacrylate) or Steri-Strips are effective alternatives for low-tension facial wounds and offer essentially painless closure with excellent cosmetic outcomes 5, 2
- Steri-Strips should remain in place for 5-7 days on facial wounds (shorter than other body areas due to rapid healing from excellent blood supply) 5
- These methods provide shorter procedure time, less pain, and similar functional outcomes compared to suturing 1
Critical Wound Management Steps
Irrigation Controversy
- For clean, noncontaminated facial and scalp lacerations, irrigation does not significantly reduce infection rates (0.9% with irrigation vs 1.4% without, P=0.28) 3
- However, for contaminated wounds or bite wounds to the face, copious irrigation with cautious debridement remains recommended 1
- When irrigation is performed, higher pressures and volumes (100-1000 mL) are more effective than lower pressures 1
Infection Prevention
- Primary closure of facial wounds is recommended (unlike other bite wounds where closure is generally avoided), but should be combined with copious irrigation, cautious debridement, and preemptive antibiotics 1
- Use of nonsterile gloves does not increase infection risk compared to sterile gloves 2
- Wound preparation with povidone-iodine or chlorhexidine is reasonable before closure 1
Post-Closure Care
Suture Removal Timing
- Facial sutures should be removed earlier than other body locations due to rapid healing from excellent vascular supply 2
- Steri-Strips on facial wounds should be removed at 5-7 days, assessing for complete wound edge approximation and absence of infection 5
Wound Care Instructions
- Patients may wash head and neck wounds with soap and water as early as 8 hours after closure without affecting healing or increasing infection risk 6
- Occlusive or semiocclusive dressings promote faster healing in moist environments and should be considered 2
Common Pitfalls to Avoid
- Do not delay closure excessively - while head wounds tolerate delayed closure better than other locations, earlier repair still provides optimal outcomes 2
- Avoid leaving Steri-Strips on facial wounds beyond 7 days - prolonged application may cause skin irritation or adhesive dermatitis 5
- Do not rely on epidermal sutures alone for wound strength - proper dermal layer approximation is essential 4
- Ensure tetanus prophylaxis - administer Tdap (preferred over Td if not previously given) if last dose was >10 years ago for clean wounds or >5 years for dirty wounds 1