Facial Lacerations

Facial Lacerations represent a unique challenge in acute care medicine, sitting at the intersection of trauma management and cosmetic surgery. Unlike wounds elsewhere on the body, the primary goal is not just closure, but cosmetic excellence. The face is central to human identity and communication; even minor scarring can have profound psychological and social consequences for the patient.

The management of facial trauma requires a precise understanding of the complex 3D anatomy of the face. "Simple" lacerations can harbor occult injuries to critical structures such as the facial nerve, the parotid duct, or the lacrimal drainage system. A missed injury in these zones is catastrophic, leading to permanent paralysis, salivary fistulas, or chronic tearing.

The Golden Rule: The rich vascular supply of the face is a double-edged sword. It allows for "permissive" closure times (up to 24 hours) and the survival of narrow flaps that would die elsewhere. However, it also means profuse bleeding that can obscure deep pathology. Hemostasis and unhurried exploration are mandatory.

Critical Alerts (The "Do Not Miss" List)

1. Facial Nerve Palsy: Any laceration along the course of the facial nerve requires documented motor testing before local anaesthetic is injected.
2. Parotid Duct Injury: Lacerations crossing the middle third of the cheek may sever the duct.
3. Eyelid Margin Involvement: Failure to align the grey line results in notching and trichiasis (eyelashes scratching the cornea).
4. Vermilion Border Misalignment: A step-off of >1mm is visible from a conversational distance.
5. Septal Hematoma: Following nasal trauma, always look inside the nose. A hematoma can destroy the septal cartilage (Saddle Nose Deformity) within 24 hours.

The face is a topographical minefield. Safety depends on knowing where the "mines" are buried.

2.1 The Layers of the Face

1. Epidermis/Dermis: The cosmetic layer. Facial skin varies in thickness (Eyelid vs Forehead).
2. Subcutaneous Fat: Provides contour and mobility.
3. SMAS (Superficial Musculo-Aponeurotic System): A distinct fibrous layer enveloping facial muscles.
   • Surgical Relevance: This is the high-tension layer. Deep sutures must anchor here to take tension off the skin. If you close the skin under tension, the scar will widen.
4. Facial Nerve (CN VII): Runs DEEP to the SMAS (mostly) within the parotid gland, becoming more superficial as it branches distally.
5. Vascular Supply: The Facial Artery (from External Carotid) provides robust collateral flow.

2.2 The Muscles of Facial Expression (Detailed)

Unlike skeletal muscles, facial muscles insert into the skin, allowing for nuanced expression. Lacerations often transect these muscles, requiring deep repair.

2.3 The Danger Zones (Pitanguy's Lines)

The Temporal Danger Zone (Frontal Branch of CN VII)

The nerve that lifts the eyebrow runs superficially in the temple.

• Surface Landmark: Draw a line from the Tragus to the Lateral Canthus. Draw another line from the Tragus to the highest forehead crease. The "Danger Zone" is the triangle between these lines.
• Consequence: Interruption causes brow ptosis (inability to raise the eyebrow), leading to visual field obstruction and asymmetry.

The Mandibular Danger Zone (Marginal Mandibular Branch of CN VII)

This nerve powers the lip depressors.

• Course: It drops below the angle of the jaw before curving back up to the lip corner.
• Consequence: Asymmetric smile (inability to show lower teeth). The lip rides high on the affected side.

The Parotid Zone (Stenson's Duct & Buccal Branch)

• Surface Landmark: A line drawn from the Tragus to the Mid-Philtrum (middle of upper lip). The duct (and the Buccal branch of CN VII) runs along the middle third of this line.
• Anatomy: The duct is thick and distinct (like a macaroni noodle). The artery runs with it.
• Test: Cannulate the duct (the papilla is opposite the Upper 2nd Molar) or press on the gland to see if saliva leaks into the wound.

The Medial Canthal Zone (Lacrimal Apparatus)

• Anatomy: The Lacrimal Canaliculi drain tears from the eyelids to the nose. They run in the medial 5mm of the upper and lower lids.
• Rule: Any laceration medial to the punctum (tear duct opening) needs probing by ophthalmology. Missed injury causes permanent tearing (Epiphora).

3.1 History and Risk Stratification

• Mechanism:
  • Shear (Glass/Razor): Clean edges. Low energy. Best outcome.
  • Crush/Burst (Punch/Fall): Edges are exploded and devitalized. High energy. High scarring risk.
  • Avulsion (Dog Bite): Tissue loss. High infection risk.
• Timing:
  • Face: Primary closure acceptable up to 24 hours (if not grossly infected).
  • Body: usually < 12 hours.
• Tetanus Status:
  • If < 3 doses total: Needs Full Course + Immunoglobulin.
  • If Fully Immunised (>3 doses) but last booster > 10 years (clean) or > 5 years (dirty): Needs Booster.

3.2 Physical Examination (The Functional Exam)

CRITICAL STEP: You must assess nerve function BEFORE injecting local anaesthetic. Once numb, paralysis is iatrogenic until proven otherwise.

Cranial Nerve VII (Facial) Motor Exam

Test all 5 branches systematically:

1. Temporal: "Raise your eyebrows to the ceiling." (Check Frontalis).
2. Zygomatic: "Squeeze your eyes shut tight." (Check Orbicularis Oculi).
3. Buccal: "Show me your teeth" or "Puff out your cheeks." (Check Buccinator/Zygomatics).
4. Marginal Mandibular: "Show me your bottom teeth" or "Do a sad face." (Check Depressor Anguli Oris).
5. Cervical: "Clench your neck." (Check Platysma).

Cranial Nerve V (Trigeminal) Sensory Exam

Test sensation to light touch:

• V1 (Ophthalmic): Forehead.
• V2 (Maxillary): Cheek/Upper Lip. (Infraorbital nerve often injured).
• V3 (Mandibular): Chin/Lower lip. (Mental nerve).

Specific Structure Tests

• Levator Palpebrae (Upper lid): "Look up and down." Check for ptosis.
• Parotid Duct: Dry the wound. Massage the parotid gland. Look for saliva pooling in the wound.
• Orbital Rim: Palpate for "step-offs" (fractures) along the bony rim.
• Septal Hematoma: Look inside the nose for a boggy purple swelling on the septum.

Pain anxiety results in poor patient cooperation and poor cosmetic outcomes. Definitive anaesthesia (Total Facial Block) allows the operator to work with precision and calmness.

4.1 Pharmacology of Local Anaesthetics

Lidocaine (Lignocaine) - The Gold Standard

• Concentration: 1% or 2%.
• Onset: Rapid (< 2 minutes).
• Duration: 30-60 minutes (Plain) vs 2-4 hours (with Epinephrine).
• Max Dose: 3mg/kg (Plain) vs 7mg/kg (with Epinephrine).
• Role of Epinephrine (Adrenaline):
  • Vasoconstriction: Critical for hemostasis. Turns a bloody field into a dry field.
  • Safety Check: Safe for use in the nose, ear, and digit (unless profound vascular disease exists).
  • Contraindications: Pheochromocytoma, severe uncontrolled hypertension.

Bupivacaine (Marcaine) - The Long Actor

• Concentration: 0.25% or 0.5%.
• Onset: Slow (5-10 minutes).
• Duration: 4-8 hours.
• Use Case: Great for "painless discharge". Perform the repair with Lidocaine (fast onset), then infiltrate Bupivacaine at the end for sleep comfort.

The "Ouch-Less" Injection (Buffering)

Local anaesthetics are packaged at pH 3.5-5.0 (acidic) to preserve shelf life. This acid causes the "sting".

• Recipe: 9ml Lidocaine + 1ml Sodium Bicarbonate (8.4%).
• Effect: Neutralizes pH to ~7.4. Reduces pain scores by >50%.
• Technique: Even with buffering, inject slowly. Distention of tissue causes pain. Use a 30G needle.

4.2 Local Anaesthetic Systemic Toxicity (LAST)

Though rare in facial blocks properly performed, inadvertent intravascular injection into the Facial Artery can cause seizures and cardiac arrest.

Signs regarding Toxicity:

• Early: Perioral tingling, Metallic taste, Tinnitus (Ringing in ears).
• Intermediate: Visual disturbances, Slurred speech, Confusion.
• Late: Seizures, Coma, Cardiac Arrest (CV Collapse).

Management Protocol (Lipid Rescue):

1. Stop Injection immediately.
2. Airway: 100% Oxygen. Hyperventilate to prevent acidosis (acidosis worsens toxicity).
3. Benzodiazepines: Midazolam for seizures.
4. Intralipid 20% Emulsion:
   • Bolus: 1.5 ml/kg over 1 min.
   • Infusion: 0.25 ml/kg/min.
   • Effect: Acts as a "lipid sink" to absorb the lipophilic anaesthetic molecules from the heart/brain.

4.3 Regional Nerve Blocks (The "Master Class")

Infiltrating directly into a wound distorts the anatomy (ballooning) and hinders precise alignment. Nerve blocks provide wide-field anaesthesia with zero distortion.

1. Supraorbital & Supratrochlear Block (The "Forehead Field")

• Indication: Lacerations of the forehead, anterior scalp, or upper eyelid.
• Anatomy: Nerves exit the skull at the supraorbital rim.
  • Supraorbital Notch: Palpable on the rim, in line with the pupil (mid-pupillary line).
  • Supratrochlear Nerve: 1cm medial to the notch (near the nose).
• Technique:
  1. Palpate the Supraorbital Notch.
  2. Insert 27G needle just above the eyebrow, lateral to the notch.
  3. Advance medially towards the glabella, injecting a "band" of anaesthetic (3-4ml) subcutaneously across the entire brow.
• Result: Numbness of the entire hemiforehead up to the vertex.

2. Infraorbital Block (The "Mid-Face Mask")

• Indication: Lacerations of the cheek, upper lip, lateral nose, and lower eyelid.
• Anatomy: Nerves exit the Infraorbital Foramen.
  • Location: Mid-pupillary line, approx 1cm below the inferior orbital rim.
• Technique (Intra-Oral Approach):
  1. Lift the upper lip.
  2. Insert needle into the buccal mucosa (gum) just above the Canine (Eye tooth).
  3. Aim superiorly towards the pupil. You can palpate the foramen externally with your non-dominant hand to guide the needle tip.
  4. Inject 2-3ml near the bone (do not enter the foramen).
• Result: Profound numbness of the "snout" region.

3. Mental Nerve Block (The "Goatee Zone")

• Indication: Lacerations of the lower lip, chin, and mucosa.
• Anatomy: Nerves exit the Mental Foramen.
  • Location: Mid-pupillary line (in children) or between the 1st and 2nd Premolars (adults).
• Technique (Intra-Oral Approach):
  1. Pull the lower lip down and out.
  2. Insert needle into the buccal sulcus at the root of the 2nd Premolar.
  3. Inject 2ml.
• Result: Numbness of the lower lip and chin.

4. Auricular Block (The "Ring Block")

• Indication: Lacerations of the ear (pinna) or complex cartilage repairs.
• Anatomy: The ear is supplied by the Auriculotemporal (top), Lesser Occipital (back), and Great Auricular (lobe) nerves.
• Technique:
  1. You must block the entire base of the ear (360 degrees).
  2. Start below the lobule. Inject upwards behind the ear.
  3. Inject upwards in front of the (tragus).
  4. Inject over the top.
  • Shape: You are drawing a "Diamond" around the ear base.
• Volume: Requires ~5-8ml.

5. Dorsal Nasal Block (The Nose)

• Indication: Nasal tip or bridge lacerations.
• Technique:
  1. Inject down the midline of the nose (dorsum) from root to tip.
  2. Inject laterally at the alar bases (Infratrochlear nerves).

4.4 Procedural Sedation & Anxiolysis

For children or uncooperative adults, local anaesthesia alone may fail.

• Topical (LAT Gel): Lidocaine-Adrenaline-Tetracaine.
  • Action: Apply to wound 30 mins before repair. Often provides complete anaesthesia for scalp/face staples or glue without any needles.
• Nitrous Oxide (Entonox): Excellent for short procedural pain (breaking the pain anxiety cycle).
• Ketamine Dissociation: The procedure of choice for complex facial repairs in children.
  • Dose: 1-1.5 mg/kg IV or 3-4 mg/kg IM.
  • Benefit: Preserves airway reflexes while providing total dissociation.

5.1 Suture Material Science

Choosing the right material is a balance between tensile strength, reactivity, and handling.

Non-Absorbable (Skin Layer)

1. Nylon (Ethilon):
   • Pros: Monofilament (no bacterial wicking), high tensile strength, low cost, excellent knot security.
   • Cons: Stiff (memory), ends can poke the patient.
   • Verdict: The standard for facial skin. (6-0).
2. Polypropylene (Prolene):
   • Pros: Lowest reactivity (best for potential infection), bright blue color (easy to see), slippery (easy to remove).
   • Cons: Poor knot security (requires 4-5 throws), expensive.
   • Verdict: Best for Eyelids and Eyebrows.
3. Fast Absorbing Gut:
   • Pros: Falls out on its own (no removal visit), great for kids.
   • Cons: Higi reactivity (causes inflammation/redness), low strength.
   • Verdict: Use sparingly. Accepts a slightly worse scar for the convenience of no removal.

Absorbable (Deep Layer)

1. Polyglactin 910 (Vicryl):
   • Pros: Braided (easy to handle), holds tension well (2-3 weeks).
   • Cons: Braided (wicks bacteria).
   • Verdict: The standard for subcutaneous/muscle closure. (4-0, 5-0).
2. Poliglecaprone 25 (Monocryl):
   • Pros: Monofilament (less infection risk), non-reactive.
   • Cons: Harder to handle.
   • Verdict: Excellent for deep dermal, but harder to use than Vicryl.

5.2 Advanced Suture Techniques

The "Simple Interrupted" is not always enough.

1. The Deep Dermal Stitch (The "Money" Stitch)

   • Goal: To take 100% of the tension off the skin edges.
   • Technique: Enter the deep dermis from the bottom -> exit superficial dermis (below skin). Go to other side -> enter superficial dermis -> exit deep dermis. "Deep-to-Superficial, Superficial-to-Deep".
   • Result: The knot is buried at the bottom. The skin edges should naturally kiss.

2. The Vertical Mattress (The Evertor)

   • Goal: To force the wound edges to pout (evert).
   • Indication: Concave surfaces (neck, behind ear) where wounds naturally invert.
   • Pattern: "Far-Far, Near-Near".

3. The Corner Stitch (Half-Buried Horizontal Mattress)

   • Goal: To close a V-shaped flap tip without strangulating the blood supply.
   • Technique: Pass through the skin of the non-flap side -> pass horizontally through the dermis of the flap tip -> exit skin of the non-flap side.
   • Result: Pulls the tip into position without a knot sitting directly on the fragile apex.

6.1 The Lip (Vermilion Border)

Critical Anatomy: The "White Roll" is the ridge of pale skin just above the red lip. It reflects light. Even 1mm of misalignment breaks this reflection and is highly visible. Step-by-Step Repair:

1. Nerve Block: Use a Mental Block. Infiltration distorts the lip landmarks.
2. Mark: Use a surgical pen to mark the Vermilion Border before injection if possible.
3. The Key Stitch: Use 6-0 Nylon. Enter exactly at the border on one side, exit exactly at the border on the other. Tie loosely first to check alignment.
4. Deep Layer: If the Orbicularis Oris muscle is cut, it must be repaired with 5-0 Vicryl to prevent a divot/notch.
5. Mucosa: Close the wet mucosa with 5-0 Vicryl Rapide. These dissolve quickly.
6. Skin: Close the cutaneous lip with 6-0 Nylon.

6.2 The Eyelid

Anatomy: Skin -> Orbicularis Oculi -> Tarsal Plate -> Conjunctiva. Referral Red Flags:

• Lid Margin laceration (risk of notching).
• Ptosis (Levator injury).
• Fat Herniation (indicates septum breach -> orbital injury). ED Management:
• Linear lacerations of the eyelid skin (upper or lower) can be closed with 6-0 Prolene.
• Rule: Suture removal at 3-4 days to prevent cysts (milia).
• Tip: If the wound is parallel to the lid crease, it heals invisibly.

6.3 The Ear (Pinna)

Anatomy: Skin is tightly adherent to the underlying cartilage on the anterior side. Loose on the posterior side. The "Cover the Cartilage" Mandate:

• Exposed cartilage creates a path for Pseudomonas infection (Chondritis), which liquefies the ear scaffold (Cauliflower Ear).
• Technique: If skin is avulsed, undermine the surrounding skin to create laxity and slide it over the cartilage. Repairing the Cartilage:
• Avoid placing sutures through full-thickness cartilage if possible.
• Ideally, place 5-0 Vicryl bites into the Perichondrium (the skin of the cartilage) to align the edges. Dressing:
• Pressure dressing is MANDATORY.
• Place gauze behind the ear and molded gauze in front of the ear. Wrap head.
• Why? To prevent Hematoma.

6.4 The Nose

Anatomy: Thick sebaceous skin on the tip (nasal lobule); thin mobile skin on the bridge (dorsum). Management:

• Through-and-Through (Alar Rim): Hard to align. Refer if complex.
  • Layer 1: Vestibular lining (inside) -> 5-0 Vicryl Rapide.
  • Layer 2: Alar Cartilage -> 5-0 Vicryl.
  • Layer 3: Skin -> 6-0 Nylon.
• Septal Hematoma Check: Always look inside. If the septum is boggy/purple, incise and drain immediately to prevent saddle nose deformity.

6.5 The Eyebrow

The Landmark: The eyebrow is a key reference line for facial symmetry. Technique:

1. Do Not Shave: Regrowth is unpredictable.
2. Copious Irrigation: Scrub out road grit to prevent "traumatic tattooing".
3. Alignment: Use the hair follicles as graph paper to align the edges perfectly.
4. Sutures: Use Blue Prolene (so you can find them in the hair) or Nylon with long tails.

6.6 The Forehead

Anatomy: The Frontalis muscle runs vertically. Horizontal wrinkles are the RSTLs. Management:

• Horizontal Wounds: Heal well. Simple closure.
• Vertical Wounds: Gape widely (perpendicular to RSTL). Require significant deep tension-relieving sutures (4-0 Vicryl in SMAS/Frontalis).
• Galeal Laceration: If deep enough to hit bone, the Galea Aponeurotica is cut. You must close this layer (4-0 Vicryl) to restore the brow elevator mechanism and prevent a depressed scar.

6.7 The Cheek

Anatomy: Rich subcutaneous fat pad (Bichat's Fat Pad). Danger: The Facial Nerve (Buccal/Zygomatic) and Parotid Duct run here. Management:

• Check parotid duct integrity.
• Use layered closure (Deep Vicryl is essential to obliterate dead space).
• Unclosed dead space leads to hematoma -> infection -> abscess.

7.1 Antibiotic Prophylaxis Strategy

The routine use of antibiotics for non-bite facial lacerations is controversial and generally unsupported by evidence (Hollander et al). The infection rate of clean facial lacerations is <1% regardless of antibiotics.

Indications for Prophylaxis (The "High Risk" List):

1. Bite Wounds:
   • Dog/Cat/Human: Polymicrobial mix (Pasteurella, Eikenella, Anaerobes).
   • Drug: Co-amoxiclav (Augmentin) 625mg TDS for 5 days.
   • Penicillin Allergy: Doxycycline + Metronidazole OR Clindamycin + Ciprofloxacin.
2. Cartilage Involvement:
   • Risk: Pseudomonas chondritis.
   • Drug: Ciprofloxacin (Adults) or Co-amoxiclav.
3. Through-and-Through Lip:
   • Risk: Oral flora contamination.
   • Drug: Penicillin V or Amoxicillin.
4. Host Factors:
   • Diabetes (poor microcirculation).
   • Immunosuppression (Steroids, Chemo).
   • Valvular Heart Disease (Endocarditis prophylaxis for oral wounds).

7.2 Tetanus & Rabies

• Tetanus:
  • Clean Wounds: Booster if >10 years.
  • Dirty/Bite Implantation: Booster if >5 years. plus TIG if unknown history.
• Rabies:
  • Scenario: Unprovoked dog bite, bat exposure, or feral animal.
  • Action: Contact Public Health immediately. Post-Exposure Prophylaxis (PEP) includes Immunoglobulin infiltrated into the wound and a vaccine series (Day 0, 3, 7, 14).

7.3 Suture Removal Schedule (The "Railroad Track" Prevention)

Facial skin heals rapidly. Suture marks appear if stitches are left >5-6 days.

• Eyelids: 3-4 days (Healing is incredibly fast).
• Face/Lip: 5 days (Strict).
• Ear: 5-7 days.
• Scalp: 7-10 days (Under tension).
• Forehead: 5-7 days.

Facial lacerations are a high-risk area for litigation due to the cosmetic implications. Defensible documentation is your shield.

8.1 Photography

• Consent: Obtain verbal/written consent.
• Times: Take photos Pre-Repair (to show severity) and Post-Repair (to show alignment).
• Role: Patients often forget how "bad" the original cut was and blame the scar on the surgeon. The pre-op photo aligns expectations.

8.2 The "Perfect" Procedure Note Template

Copy and paste this into your notes:

Procedure: Repair of Facial Laceration

• Indication: Laceration to [Site], Length [X]cm.
• Neurovascular Status: Facial Nerve (Temporalis/Zygomatic/Buccal/Marginal) intact bilaterally. Sensation V1-V3 intact. Parotid duct patent/no leak.
• Consent: Risks of infection, bleeding, scarring, and need for revision discussed. Verbal consent obtained.
• Anaesthesia: [X]ml of Lidocaine 1% with Epinephrine (Buffered). Block: [Supraorbital/Infraorbital/Mental].
• Prep: Copious irrigation with [X]ml tap water. Chlorhexidine to surrounding skin.
• Exploration: No foreign bodies found. No fracture felt.
• Repair:
  • Deep Layer: [X] sutures of 5-0 Vicryl to SMAS/Subcut.
  • Skin Layer: [X] sutures of 6-0 Nylon (Simple Interrupted).
  • Alignment: Vermilion border aligned perfectly.
• Outcome: Hemostasis achieved. Edges everted.
• Plan: Suture removal in 5 days. Daily SPF 50 sun protection advised.

"The stitches are just the beginning. How you care for this wound over the next year determines the scar."

9.1 Immediate Care (Days 0-5)

• Cleaning: "Keep dry for 24h. Then gentle wash with soap/water. Pat dry."
• Ointment: "Apply Vaseline/Antibiotic ointment 2x daily. No scabs. If a scab forms, the scar will be a crater."
• Appearance: "It will look swollen and red. This is normal."

9.2 Intermediate Care (Weeks 2-12)

• Massage: "Once the wound is strong (2 weeks), massage it deeply with moisturizer for 5 minutes/day. This breaks up the hard scar tissue."
• Silicone: "Silicone sheets (Dermatix) applied overnight help flatten raised scars."

9.3 Long Term (Months 3-12)

• Sun Block (The #1 Rule): "New scar tissue has no protection against UV. It will turn permanently dark brown (hyperpigmentation) if exposed to sun. You MUST wear SPF 50 on the scar every day for a year."

1. "The Solution to Pollution is Dilution": You cannot suture a dirty wound. Irrigate with at least 500ml.
2. "Evert, Don't Invert": Use the Vertical Mattress stitch if edges are rolling in. Inverted edges cast a shadow and look like a canyon. Everted edges flatten out.
3. "Buffer your Lidocaine": 1ml Bicarb + 9ml Lide. It changes the injection from a "bee sting" to a "pressure".
4. "Respect the Vermilion": Take 5 minutes to align the first stitch on the lip. If you miss, start over.
5. "Don't Shave the Brow": It removes your landmarks and might not grow back.
6. "Glue the Kids": For a forehead laceration in a screaming 2-year-old, LAT gel + Dermabond gives a better result than wrestling with a needle.
7. "The Golden Period": Face wounds can be closed up to 24h. If it's 2am and you are tired/unskilled, clean it, dress it, and have the plastics team close it in the morning.
8. "Check the Septum": Every nose injury needs a speculum exam. A septal hematoma is a surgical emergency.
9. "Beware the Fight Bite": Any laceration over a knuckle (MCPJ) is a human bite until proven otherwise. Do not close primarily. washout + antibiotics.
10. "Tape Support": After removing sutures at day 5, apply Steri-Strips for another 5 days. The wound has only 5% tensile strength.

13.1 Anxiety Management (The Key to Success)

A terrified child is a moving target. Cosmetic precision is impossible on a moving target.

• The "Papoose" Board: Physical restraint is traumatic and controversial. Use only as a last resort.
• LAT Gel: Lidocaine-Adrenaline-Tetracaine.
  • Protocol: Apply to wound. Tape with Tegaderm. Wait 30-45 mins.
  • Result: Blanching (white ring) indicates success. Often allows Stapling or Gluing with ZERO pain.
• Intranasal Midazolam:
  • Dose: 0.3-0.5 mg/kg via mucosal atomizer.
  • Onset: 10 minutes.
  • Effect: Anxiolysis and Amnesia.

13.2 Ketamine Dissociation

For complex lip/eyelid repairs in children, Ketamine is the gold standard.

• Mechanism: Functional dissociation. The child is "awake" (eyes open, breathing) but the brain receives no sensory input.
• Dose:
  • IV: 1.5 mg/kg (Rapid onset, <1 min).
  • IM: 4 mg/kg (Onset 3-4 mins).
• Safety: Preserves airway reflexes. Risk of laryngospasm is rare (<0.3%).
• Emergence: Hallucinations possible on waking. Reduced by quiet environment.

13.3 Non-Accidental Injury (NAI)

Facial injuries can be a sign of abuse.

• Red Flags:
  • Delayed presentation (>24h).
  • Explanation does not fit the mechanism.
  • Bruising to the Ears, Neck, or Checks (soft tissues that don't bruise in normal tumbles).
  • Torn Frenulum (Upper lip) in a non-ambulatory infant (Forced bottle feeding).

14.1 The "Thin Skin" Challenge

Elderly skin is atrophic ("tissue paper" consistency).

• Problem: Suture wires simply slice through the skin (cheese-wire effect).
• Solution:
  • Steri-Strips: Often superior to sutures for linear tears.
  • Glue: Good option but avoid getting it in the wound.
  • Thicker Sutures: Paradoxically, using a thicker suture (4-0) rather than a fine one (6-0) prevents cutting through, but leaves marks.
  • Wide Bites: Take large bites of tissue to distribute tension.

14.2 Anticoagulation Management

• Warfarin: Check INR. If < 3.0, proceed with repair. Use adrenaline-soaked gauze for 10 mins. If bleeding persists, consider Tranexamic Acid (Topical or IV).
• DOACs (Apixaban/Rivaroxaban): No INR to check. Rely on mechanical pressure. Suture tightly.
• Prophylaxis: Elderly patients on thinners are high risk for delayed hematoma. Apply pressure dressing.

15.1 Growth Factors and Biologics

Current research is investigating the use of Platelet-Derived Growth Factor (PDGF) gels to accelerate closure.

• PRP (Platelet Rich Plasma): Used in private practice plastic surgery. Blood is spun, and the plasma layer (rich in factors) is injected into the wound margins.

15.2 Laser Treamtment

• Pulsed Dye Laser (PDL):
  • Target: Hemoglobin.
  • Use: Treats red, hypertrophic scars.
  • Timing: Can start as early as 2-3 weeks post-injury.
• Fractional CO2 Laser:
  • Use: Resurfacing of established, pitted scars.

15.3 Hyperbaric Oxygen Therapy (HBOT)

• Indication: Ischemic flaps (e.g., a large U-shaped avulsion on the cheek that is turning dusky blue).
• Mechanism: Forces Oxygen into plasma, bypassing hemoglobin. Can save a dying flap.

Missed foreign bodies (FB) are a primary cause of litigation and delayed infection.

16.1 Glass

• Scenario: Windshield shattering (MVA) or beer bottle assault.
• Problem: Glass is radiopaque (visible on X-ray) if >2mm.
• Protocol:
  • All glass lacerations need an X-ray mandated.
  • Ultrasound is excellent for detecting radiolucent glass.

16.2 Teeth Fragments

• Scenario: Punch to mouth ("Fight Bite") or fall onto chin.
• Danger: A fragment of the assailant's tooth can be embedded in the victim's knuckle. A fragment of the victim's tooth can be embedded in their own lip.
• Check: Count the teeth. If one is chipped, find the fragment. If you can't find it, X-ray the lip (Soft Tissue View).

16.3 Gravel/Dirt (Traumatic Tattooing)

• Scenario: Road rash or fall on pavement.
• Problem: If grit is healed into the dermis, the skin becomes permanently stained blue/grey. This is impossible to fix later without excision.
• Management: Aggressive scrubbing under anaesthesia with a stiff brush (chlorhexidine scrub brush). You must remove every black speck.

17.1 Infection Risk

• Pathogens: Pasteurella multocida (50%), Staphylococcus, Capnocytophaga (dangerous in asplenic patients).
• Risk Factors: Puncture wounds (cats) > Crush wounds (dogs). Hand > Face.
• Antibiotics: Mandatory for all significant bite wounds. Co-amoxiclav.

17.2 Closure Debate

• Old Dogma: "Never close a bite wound."
• New Evidence: Primary closure of facial dog bites is safe and yields better cosmetic results due to the rich blood supply.
• Protocol:
  1. Massive irrigation (Pressure washout).
  2. Debridement of crushed edges.
  3. Loose approximation sutures (allow drainage).
  4. Antibiotic cover.
  5. Review in 24 hours.

17.3 Breed Specifics (Medicolegal)

Case 1: The Missed Nerve

• Scenario: 20yo male, beer bottle to cheek. ED doctor documents "Neuro intact". Repairs wound.
• Outcome: Patient returns 2 weeks later with inability to smile on right. Plastic surgeon explores: cut Buccal branch.
• Verdict: Liability found. "Neuro intact" is vague. Must document specific branches (e.g., "Able to puff cheeks").

Case 2: The Retained Tooth

• Scenario: 4yo female, fell on chin. The laceration was closed.
• Outcome: 1 month later, firm lump in lip. X-ray shows incisor fragment. Required general anaesthetic removal.
• Lesson: Always palpate the lip for lumps and check the teeth for chips.

Case 3: The "Fight Bite" Infection

• Scenario: 25yo male punched a wall (actually a mouth). 5mm cut on knuckle. Closed with glue.
• Outcome: Septic arthritis of MCPJ. Finger amputation.
• Lesson: Never close a wound over a knuckle without an X-ray to rule out air in the joint (Clenched First Injury).

Q1: Will there be a scar?

• A: "Yes. Every cut that goes deeper than the surface leaves a scar. Our goal is to make it a fine line that hides in your natural wrinkles."

Q2: Can I go swimming?

• A: "No. No swimming (pool or ocean) until the stitches are out and the wound is sealed (approx 2 weeks). Risk of infection."

Q3: Can I wash my hair?

• A: "Yes, but keep the shampoo out of the wound. Do not soak the wound."

Q4: When can I wear makeup?

• A: "Not until the stitches are out and the scabs are gone (approx 10-14 days). Pigment in makeup can tattoo the healing wound."

Q5: What if the stitches pop?

• A: "If the wound opens up, come back immediately. We might be able to re-tape it."

Q6: Why is the scar red?

• A: "Redness means active healing (blood flow). It will fade to pink, then white over 6-12 months."

Q7: Can I take the stitches out myself?

• A: "Please don't. You risk infection or cutting the wrong thing. See your GP."

Q8: Does it hurt to take them out?

• A: "No. It feels like a tickle or a tiny pluck."

Q9: Do I need a plastic surgeon?

• A: "Emergency physicians repair 90% of facial cuts. We refer only complex cases involving nerves, ducts, or massive tissue loss."

Q10: Why do I need antibiotics for a dog bite but not a glass cut?

• A: "Dogs have bacteria in their mouths that cause rapid, nasty infections. Glass is usually 'cleaner'."

Q11: Can I shave?

• A: "Avoid shaving over the stitches. You can shave around them carefully."

Q12: Is numbness normal?

• A: "Yes. Small sensory nerves are often cut. Sensation usually returns over 3-6 months as they regrow."

Q13: What does a tetanus shot do?

• A: "It prevents Lockjaw, a fatal muscle spasm disease caused by soil bacteria."

Q14: Will my eyebrow grow back?

• A: "Usually yes, but scar tissue doesn't grow hair. You might have a thin bald line."

Q15: Can I go to the gym?

• A: "Avoid heavy lifting (straining) for 48 hours. It increases blood pressure and can cause the wound to bleed."

Q16: Why did you use blue stitches?

• A: "So they are easy to see and remove. We use clear/white ones for deep layers."

Q17: What is 'Keloid' scarring?

• A: "Genetic tendency to form thick, lumpy scars. If you have this history, tell us. We might use silicone sooner."

Q18: What signs of infection should I look for?

• A: "Spreading redness, heat, yellow pus, or fever."

Q19: Can I smoke?

• A: "Smoking constricts blood vessels and dramatically slows healing. It increases the risk of a bad scar."

Q20: When is the final result?

• A: "A scar takes 12 months to fully mature. Be patient."

Viva Questions

1. "Describe the surface anatomy of the Parotid Duct."
   • Answer: Middle third of a line drawn from the Tragus to the Mid-Philtrum.
2. "What are the indications for antibiotic prophylaxis in facial wounds?"
   • Answer: Bite wounds, cartilage involvement, through-and-through lip, immunocompromise.
3. "How long do you leave sutures in the face vs the scalp?"
   • Answer: Face 5 days (to prevent scarring). Scalp 7-10 days (high tension).
4. "What is the maximum dose of Lidocaine with Epinephrine?"
   • Answer: 7mg/kg.
5. "What is the first sign of Lidocaine Toxicity?"
   • Answer: Perioral tingling (circumoral paresthesia) and Tinnitus.

OSCE Station

• Scenario: "Repair this mannequin's lip laceration."
• Checklist:
  1. Check neurovascular status before injection.
  2. Verbalize Digital/Mental Block.
  3. Identify Vermilion Border.
  4. Place First Stitch at the border.
  5. Check alignment.
  6. Complete repair.
  7. Give discharge advice (Sunscreen/Removal timing).
  8. Document "No foreign body".