Facial lacerations warrant a detailed and meticulous approach to evaluation due to their cosmetic importance. The final appearance of the scar depends partly upon the orientation of the wound and its relation to natural skin tension lines, but also upon initial management. In multiply injured patients, disfiguring or disconcerting facial lacerations should not distract from the initial primary survey and the focus on addressing immediately life-threatening injuries.

Assessment

• History
  • Mechanism of injury
  • Associated symptoms of head injury
  • Age of wound
  • Likelihood of wound contamination
  • Potential presence of foreign body
  • Past medical history, drug history, social history to identify risk factors for poor wound healing
• Examination
  • The face should be examined carefully to evaluate for signs of injury to adjacent and/or underlying structures such as the orbits, eyes, nose, midface, teeth, maxilla, and mandible
  • Removal of all foreign debris and blood will permit proper assessment of facial lacerations.
  • Local anaesthesia using topical or infiltrated local anaesthetic agents facilitates a comprehensive evaluation of the wound with minimal discomfort to the patient.
  • Bleeding is a common problem with facial lacerations. Haemostasis permits an appropriate examination. Direct pressure for approximately 15 minutes with or without local injection of lidocaine with epinephrine can provide sufficient haemostasis.
  • The following attributes of the wound should be noted:
    • Location including involved facial wound
    • Length of laceration
    • Depth of laceration (epidermis, dermis, subcutaneous fat, muscle, bone)
    • Shape of laceration (e.g. linear, curvilinear, stellate, corner)
    • Presence of gross contamination or visible foreign bodies
    • Presence of skin loss
    • Whether laceration is horizontal, vertical or tangential to the lines of tension (Langer's lines)
• Specific considerations by facial region
  • Forehead
    • Deep lacerations may involve injury or complete laceration of the frontalis muscle of the forehead and possible bone exposure.
    • Visible fractures or bony depressions warrant imaging with facial and head computed tomography (CT).
  • Eyelid
    • The lacrimal system, which begins at the upper and lower puncta and the nasolacrimal duct, should be inspected for injury. Injuries near the medial canthus can be associated with nasolacrimal duct injury.
    • Any injury to the eyelids or surrounding structures warrant a full ophthalmic evaluation, including an assessment of visual acuity, of the presence of ocular foreign bodies and the integrity of the globe.
    • Injuries that involve the lacrimal system, full thickness eyelid injuries, eyelid margin lacerations, or wounds through the tarsal plate warrant ophthalmic consultation.
  • Nose
    • Blunt trauma to the nasal bones should be suspected in patients with nasal lacerations, particularly those caused by marked blunt force trauma.
    • The clinician should assess for drainage of cerebrospinal fluid secondary to a fracture through the cribriform plate and for injury to the nasal mucosa, septum and cartilage.
  • Cheek
    • Deep lacerations to the cheek and to areas anterior to the ear warrant careful evaluation for injury to the parotid gland, parotid duct and/or the facial nerve. Refer for exploration in theatre if there is any clinical suspicion of involvement of any of these structures.
    • The parotid duct runs transversely forwards from the anterior portion of the gland, parallel and inferior to the zygomatic arch, before entering the mouth opposite the second upper molar. Injury to the duct can be difficult to diagnose; suspicion based upon the location of injury is critical. Facial nerve injury is suggestive. Occasionally, a sialocele may be evident in patients who present long enough after injury for salivary accumulation to occur.
    • The facial nerve traverses the parotid gland to supply the muscles of facial expression. The function of the facial nerve and its branches should be assessed: (1) temporal – contract the forehead and elevate the eyebrow; (2) zygomatic – open and shut eyes; (3) buccal – smile; (4) mandibular – frown; (5) cervical – contract the platysma muscle. Unrepaired injury may result in permanent disfigurement.
  • Mouth
    • Lacerations of the intra-oral mucosa involve the buccal mucosa and mucosal reflections which connect the cheek to the mandibular and maxillary surfaces. These lacerations may be associated with injuries to the salivary glands, parotid duct, submandibular duct, teeth, lips, and jaw.
    • The lips, teeth, and mucosal anatomy must be thoroughly inspected with adequate lighting. If there are any fractured or avulsed teeth, consider obtaining soft tissue lateral x-rays of the lips to look for embedded fragments.
    • Dental fractures, avulsions, gingival bleeding, lacerations or displacement of the alveolar margin may be associated with mandibular or maxillary fractures, particularly if there is discomfort at the temporomandibular joint or trismus.

Imaging

Patients with clinical findings that suggest the presence of a foreign body not visible at the surface or bony injury warrant appropriate imaging, depending upon the type of facial trauma:

• Plain radiographs can identify most radiopaque foreign bodies (e.g. glass, metal, rocks) while ultrasound can often locate many non-radiopaque foreign bodies.
• Midface or orbital fractures are best evaluated by computed tomography (CT).
• Imaging is typically not necessary for the evaluation of isolated nasal fractures.
• Mandibular fractures are best identified by CT or, if available, panoramic plain radiographs.

Indications for subspeciality referral

Consultation with a surgical subspecialist (e.g. plastic or maxillofacial surgeon, ophthalmologist), if available, is suggested in the following situations:

• Wounds to the zygoma (cheek) with associated injury to the facial nerve, facial artery, or parotid gland or ducts
• Lacerations that involve the nasal cartilage, ala, or columella
• Eyelid or orbital lacerations that involve the eyelid margin or tarsal plate, have protruding subcutaneous fat or involve the tear duct or lacrimal gland
• Lip lacerations through the vermillion border
• Complex auricular lacerations
• Complex wounds that require extensive revision or that have significant skin loss that may require grafting
• Wounds with associated fractures (e.g. mandibular fracture, orbital fracture) that will require surgical subspecialty care

Management

• Cleaning is crucial but do not debride with tissue excision in the ED.
• Local anaesthesia typically provides adequate analgesia for the management of simple facial lacerations. Regional blocks are an alternative to local anaesthesia and are preferable for large wounds (> 4 cm) and wounds that require precise cosmetic approximation.
• Type of closure
  • Primary closure (i.e. wound repair at the time of presentation) is usually the preferred treatment for facial lacerations that will lead to excess scarring if the wound edges are not opposed (i.e. lacerations into or through the dermis). In general, facial lacerations without risk factors for infection can be closed within 24 to 48 hours if appropriate cleansing is performed.
  • Delayed primary closure (i.e. cleansing and debridement at the time of initial presentation with definitive wound closure performed electively four to five days later) may be warranted for wounds that present after 24 hours and have increased risk for infection.
• Suturing
  • Suturing is indicated for any laceration through the dermis, especially wounds that require careful wound approximation.
  • Most facial wounds should be closed with simple interrupted suture placement.
  • With the exception of wounds on the underside of the chin, the sutures used to close the skin in facial lacerations will usually be 6-0 in children and 5-0 to 6-0 in adults.
  • Most nonabsorbable suture removal from the face should take place at 3 - 5 days, depending on the location of the laceration.
• Other methods of closure
  • Tissue adhesives are effective in the closure of straight, low tensile facial lacerations with little dermal involvement and no subcutaneous exposure. Lacerations parallel to skin tension lines in the eyelids, above or below eyebrows, forehead, and cheek are optimal wounds for closure with tissue adhesives although care must be taken to avoid inadvertent ocular exposure when using tissue adhesives near the eye.
  • Adhesive tapes (e.g. Steri-Strips) can be ideal in some cases as they are usually very cost effective, time saving and significantly less painful than sutures. In general, the upper one-third to half of the face can be well managed with adhesive tapes when wounds are small (e.g. <2.5 cm), uncomplicated, and, well approximated with low tension.
  • Staples may cause greater scarring in patients who scar easily and are thus not appropriate for closure of cosmetic wounds on the face. Staples are ideal for scalp wounds and wounds in non-cosmetic areas, especially long-linear wounds.
• Other considerations
  • Tetanus prophylaxis
  • Prophylactic antibiotics
  • Bite wound management