What are the steps for stitching a forehead laceration in a patient, considering factors such as depth, length, contamination, and patient demographics, including age and past medical history (e.g. bleeding disorders, anticoagulant therapy)?

Forehead Laceration Repair: Evidence-Based Approach

For forehead lacerations, use tissue adhesives or wound closure strips as first-line closure methods when appropriate, reserving sutures for deeper or high-tension wounds, with absorbable sutures preferred to avoid painful removal. 1, 2

Initial Assessment and Patient Risk Stratification

Evaluate Contraindications to Closure

• Anticoagulation status: Patients on warfarin with INR >3.0 or those on anticoagulants with bleeding disorders require careful assessment, as they are at increased risk for wound complications 3
• Timing: Facial wounds presenting even after 12 hours can be closed primarily due to excellent blood supply and lower infection risk, provided meticulous wound care is performed 1
• Contamination level: Grossly contaminated wounds require more extensive irrigation and may need delayed closure 1
• Signs of infection: Never close infected wounds primarily—these require delayed closure after infection resolution 1

Patient Demographics Considerations

• Pediatric patients: Children are often uncooperative and benefit from painless closure methods like tissue adhesives or strips 4
• Elderly patients: Those on anticoagulation (common in this age group) may require dose adjustment or bridging, though minor procedures like laceration repair are generally low bleeding risk 3

Wound Preparation Protocol

Anesthesia Selection

• Topical anesthetics (LET solution): Apply lidocaine-epinephrine-tetracaine for 10-20 minutes until wound edges blanch; contraindicated if gross contamination present 1
• Injectable lidocaine: Buffer with bicarbonate, warm before injection, and inject slowly with small-gauge needle to minimize pain 1

Wound Cleansing

• Irrigation: Use sterile normal saline or potable tap water with high pressure and volumes (100-1000 mL) for contaminated wounds 2
• Antiseptic preparation: Prepare wound site with betadine or chlorhexidine antiseptic solution 1, 2
• Debridement: Remove superficial debris carefully, avoiding aggressive debridement that enlarges the wound 1

Closure Technique Algorithm

First-Line: Non-Suture Methods (Low-Tension Wounds)

Tissue adhesives (octyl cyanoacrylate) are preferred for:

• Low-tension facial wounds 1
• Pediatric or uncooperative patients 4
• Benefits: 26-minute shorter procedure time, essentially painless, less pain than sutures 1

Wound closure strips (Steri-Strips) are appropriate for:

• Low-tension areas 1
• Cost-conscious settings (less expensive than adhesives) 1
• Duration: Remove at 5-7 days for facial wounds after assessing complete wound edge approximation and absence of infection 2, 5

Second-Line: Suturing (Deeper or High-Tension Wounds)

Layered closure technique when suturing is required:

• Deep layer: Use 3-0 or 4-0 delayed absorbable sutures (polyglactin or poliglecaprone) to approximate the dermis, as the dermal layer provides the skin's greatest strength 2, 6
• Superficial layer: Use continuous non-locking subcuticular technique with absorbable sutures to distribute tension evenly and minimize pain 1
• Avoid: Transcutaneous interrupted sutures on facial skin as they damage nerve endings and increase pain 1

Absorbable sutures are strongly preferred for facial wounds to avoid pain and anxiety of suture removal, with cosmetic outcomes equivalent to nonabsorbable sutures 1, 7

Anticoagulation Management

Low Bleeding Risk Procedure

• Forehead laceration repair is a low bleeding risk procedure (0-2% risk of major bleeding) 3
• Warfarin patients: Can proceed with INR in therapeutic range (2.0-3.0); if INR 3.0-5.0 without active bleeding, can proceed with caution or hold 1-2 doses 3
• DOAC patients: May consider holding dose day of procedure to avoid peak anticoagulant effects, but generally can proceed 3
• No bridging required for minor procedures like laceration repair 3

Antibiotic and Tetanus Prophylaxis

Antibiotic Use

• Prophylactic antibiotics are NOT routinely indicated for clean facial lacerations, even when presenting late 1
• Consider antibiotics only if: Signs of established infection are present 1
• If used: First-generation cephalosporins (cefazolin 2g) are appropriate 1
• Bite wounds: Require copious irrigation, cautious debridement, and preemptive antibiotics 2

Tetanus Prophylaxis

• Administer 0.5 mL intramuscularly if status is outdated or unknown 1
• Tdap if last dose: >10 years ago for clean wounds or >5 years for dirty wounds 2

Critical Pitfalls to Avoid

• Never aggressively debride facial wounds, as this enlarges the wound and impairs closure 1
• Never use full-thickness sutures on facial skin except palmar/plantar surfaces, as they damage nerve endings 6
• Never leave Steri-Strips on facial wounds beyond 7 days to prevent skin irritation or adhesive dermatitis 2, 5
• Never close infected wounds primarily—these require delayed closure 1
• Avoid removing closure materials too early (before 5 days) as this may result in wound dehiscence due to inadequate tensile strength 5

Post-Closure Wound Care

• Initial 48 hours: Keep wound dressing undisturbed unless leakage occurs 5
• Days 1-7: Change sterile dressing daily with local disinfection until granulation occurs 5
• After initial healing: Wound cleansing and dressing every 2-3 days 5
• Washing: After 1-2 weeks, washing with soap and water or showering is possible; remove dressings before washing, rinse away residual soap, dry well before applying new dressing 5