What is the approach to managing lip lacerations?

Management of Lip Lacerations

For lip lacerations, immediately irrigate with copious amounts of water or sterile saline, then use tissue adhesive for low-tension wounds or layered suturing for high-tension injuries, ensuring precise vermilion border alignment to prevent permanent cosmetic deformity. 1, 2

Initial Assessment and Wound Preparation

Examination Priorities

• Assess the three anatomic layers: skin, muscle (orbicularis oris), and oral mucosa, as each requires separate consideration for repair 2
• Examine the vermilion border carefully under adequate lighting—misalignment by even 1mm creates visible permanent deformity 2, 3
• Check for through-and-through lacerations involving both external skin and intraoral mucosa 3
• Perform a digital examination to identify any embedded foreign material or tooth fragments 1

Wound Cleaning

• Irrigate with copious amounts of water or sterile normal saline (100-1000 mL) to remove debris and reduce infection risk 1, 4
• For mucosal-side lacerations, gentle cleaning with warm saline is sufficient and avoids tissue trauma 1
• Ensure the wound base is completely dry before applying any closure method 1
• Consider wound preparation with povidone-iodine or chlorhexidine before closure 5

Anesthesia

Local Anesthetic Options

• Topical anesthetics (EMLA cream or lidocaine/prilocaine combinations) can be applied directly into oral mucosal lacerations before suturing without risk of adverse tissue reaction 6
• Maximum lidocaine dose without epinephrine: 1.5-2.0 mg/kg in children 1
• Local anesthetic with epinephrine (1:100,000 to 1:200,000) is safe for use on the lips and face, contrary to older teaching 7
• For extensive or complex repairs, consider regional or general anesthesia 4

Critical Pitfall: Do not prescribe topical anesthetics for intraoral use in young children due to accidental ingestion risk 1

Repair Technique Selection

Low-Tension Lacerations

• Use tissue adhesive for essentially painless closure—apply the least amount necessary to seal the wound 1
• Tissue adhesives work effectively in low-tension skin areas and reduce procedure time significantly 4, 7
• This approach is associated with less pain and similar functional/cosmetic outcomes compared to suturing 4

High-Tension or Complex Lacerations

Employ layered suturing technique for wounds under tension or involving multiple tissue layers 1, 3:

1. Deep layer (muscle): Use 3-0 or 4-0 delayed absorbable sutures (polyglactin or poliglecaprone) with buried knots 5
2. Vermilion border: This is the most critical step—align this landmark first with a single precise suture before closing adjacent tissues 2, 3
3. Oral mucosa: Use 4-0 absorbable sutures 8
4. Skin: Use 6-0 monofilament non-absorbable sutures to reduce bacterial seeding 5, 8

• Use continuous, non-locking suture technique to distribute tension evenly and avoid tissue edema or necrosis 5
• Avoid locking sutures that cause excessive tension 5

Small Mucosal-Only Lacerations

• Many small intraoral lacerations heal well without suturing if hemostatic 1
• If closure is needed, use absorbable sutures only 3

Antibiotic Management

Do not routinely prescribe prophylactic antibiotics for simple traumatic lip lacerations 1. The evidence shows:

• Antibiotics should only be considered if there are signs of established infection (purulent discharge, fever, spreading erythema) 1
• For contaminated or bite wounds, consider combining primary closure with preemptive antibiotics 5
• If infection develops, prescribe appropriate systemic antimicrobials based on contamination level 5

Post-Repair Care

Wound Care

• Apply white soft paraffin ointment or petroleum jelly to the lips every 2 hours during the acute healing phase to prevent drying and cracking 1, 4
• Bacitracin ointment can be applied 1-3 times daily and covered with sterile bandage 9
• Encourage gentle oral hygiene with warm saline rinses after meals to keep the area clean 1
• Consider offering the child's favorite drinks for oral irrigation to improve compliance 1

Critical Pitfall: Avoid adhesive dressings on or near the lips—they cause additional trauma when removed 1

Pain Management

• Acetaminophen at 60 mg/kg/day divided into four doses provides effective analgesia 1
• Ibuprofen is an alternative option 5
• Reassess pain regularly and adjust as needed 1

Suture Removal

• Remove non-absorbable skin sutures at 5-7 days to minimize scarring on the face 5, 7
• Absorbable sutures in mucosa and muscle do not require removal 8

Tetanus Prophylaxis

• Administer Tdap if last dose was >10 years ago for clean wounds or >5 years for contaminated wounds 5

Follow-Up and Warning Signs

Instruct caregivers to watch for these signs requiring urgent reassessment 1:

• Increasing pain, redness, or swelling beyond 24-48 hours
• Purulent discharge
• Fever
• Wound dehiscence (separation)
• Difficulty eating or drinking due to worsening pain

Special Considerations

Timing of Repair

• There is no absolute "golden period"—depending on wound type, it may be reasonable to close even 18+ hours after injury 7
• However, earlier repair generally yields better outcomes 7

When to Consult

• Lacerations involving >25% of the lip require specialist consultation due to high risk of deformity 2
• Complex through-and-through lacerations may benefit from specialist repair 3
• Any uncertainty about vermilion border alignment warrants consultation 2

Healing Environment

• Wounds heal faster in a moist environment—use occlusive or semiocclusive dressings when appropriate 7
• Keep lips continuously moisturized throughout the healing process 1