What to do for a 4 cm full thickness forehead laceration more than 12 hours old?

Management of a 4 cm Full-Thickness Forehead Laceration Presenting After 12 Hours

Despite the delayed presentation beyond 12 hours, this forehead laceration should be irrigated, debrided if necessary, and primarily closed with sutures, as evidence demonstrates that wounds can be safely repaired even 18 or more hours after injury without significantly increased infection risk. 1

Time-to-Repair Considerations

• There is no absolute "golden period" cutoff that prohibits primary closure of wounds based solely on time elapsed since injury. 1
• Studies demonstrate that depending on wound characteristics, it may be reasonable to close lacerations even 18 or more hours post-injury without increasing infection risk. 1
• In a large pediatric study, infections on presentation occurred only in patients who delayed care beyond 18 hours, but this represented less than 1% of cases (22/2,834), indicating that delayed presentation alone does not preclude repair. 2
• The forehead location is favorable for delayed closure due to excellent vascular supply, which reduces infection risk compared to extremity wounds. 2

Wound Assessment and Preparation

Before repair, perform a systematic evaluation:

• Assess for foreign bodies, as these were the most common complication (55 cases) in delayed presentations. 2
• Evaluate for signs of existing infection (erythema, purulence, warmth, lymphangitic streaking). 2
• Determine mechanism of injury to assess contamination risk—outdoor injuries and "street glass" are associated with higher infection rates. 2
• Check tetanus immunization status and provide prophylaxis if indicated. 1, 3

Wound Cleaning Protocol

Use the following evidence-based irrigation approach:

• Irrigate thoroughly with potable tap water, which does not increase infection risk compared to sterile saline and is cost-effective. 1
• Remove all visible debris and devitalized tissue through gentle irrigation and debridement if necessary. 3
• Clean the surrounding area with betadine or chlorhexidine over a large area of skin. 4
• Perform hand hygiene with antimicrobial soap or alcohol-based hand rub before touching the wound. 4

Anesthesia Administration

Provide adequate local anesthesia using these pain-reduction techniques:

• Consider topical anesthetic (LET: lidocaine, epinephrine, tetracaine) applied for 10-20 minutes until wound edges blanch, though this may be less practical for a 4 cm laceration requiring extensive repair. 4
• Inject lidocaine with epinephrine (1:100,000 or 1:200,000 concentration is safe for facial use) using a small-gauge needle. 4, 1
• Buffer the lidocaine with bicarbonate and warm it before injection to reduce pain. 4
• Inject slowly to minimize discomfort. 4

Repair Technique

For this full-thickness forehead laceration, use the following approach:

• Use sterile technique including sterile gloves, gown, equipment, and sterile towels (though non-sterile gloves do not increase infection risk, sterile technique is preferred for facial wounds). 4, 1
• Close in layers if the laceration extends through subcutaneous tissue: deep dermal layer with absorbable sutures, then skin closure. 5
• For skin closure, use either non-absorbable sutures (requiring removal in 5-7 days for facial wounds) or absorbable sutures to avoid removal-related anxiety. 4, 1
• Tissue adhesives are not appropriate for a 4 cm full-thickness laceration, as they are only suitable for low-tension, superficial wounds. 4, 1

Antibiotic Considerations

Prophylactic antibiotics are generally not indicated:

• A large pediatric study found no proven benefit of prophylactic antibiotics in reducing infection rates for any analyzed group. 2
• Consider antibiotics only if the wound is heavily contaminated or shows signs of infection on presentation. 4
• If infection is present, first-generation cephalosporins (cefazolin) are appropriate first-line agents. 5

Post-Repair Care

Provide the following wound care instructions:

• Apply a topical antibacterial agent (bacitracin ointment 1-3 times daily) and cover with a sterile bandage. 6
• Keep the wound clean and dry for 24-48 hours. 4
• Use occlusive or semiocclusive dressings when available, as wounds heal faster in moist environments. 1
• Recommend acetaminophen or ibuprofen for pain control. 4
• Remove non-absorbable sutures in 5-7 days for forehead lacerations (facial wounds heal faster than extremity wounds). 1
• Schedule follow-up within 5-7 days for suture removal and wound assessment. 4

Critical Pitfalls to Avoid

• Do not refuse closure based solely on the 12-hour delay—this outdated practice is not supported by current evidence. 1
• Do not use excessive force when injecting local anesthetic, as this increases pain. 4
• Do not assume all foreign bodies are visible on plain radiographs; some materials are radiolucent. 3
• Watch for signs of infection development (occurs in approximately 1.2% of repaired lacerations), which is more common with extremity wounds, outdoor injuries, and contaminated mechanisms. 2