A Plastic Surgeon's Approach to Facial Lacerations

Facial laceration repair is mostly about anatomy, tension management, and knowing when specialist consultation actually changes care. Forehead and scalp wounds have different closure priorities, and many facial lacerations do not require immediate plastic surgery repair if fractures, nerve injury, and major tissue loss are absent.

Facial Laceration Repair Principles

• Consult triggers that matter: Hard reasons to involve plastics or ENT are devastating tissue loss, facial fracture, and vascular or nerve injury; many other facial lacerations can be repaired safely in the ED.
• Wound visualization first: Copious irrigation is the first step because it defines what structures are involved and exposes deeper injuries before you commit to a closure plan.
• Tension lives in depth: Multilayer closure is the core cosmetic principle: deep dermal sutures should carry the wound tension, while the epidermal layer is mainly for edge approximation and appearance.
• Running skin closure advantage: Running sutures are often faster than interrupted closure and can improve cosmesis by distributing tension evenly across the full length of the laceration, a distinction we get into in the episode.
• Skin suture material choices: On the face, fast-absorbing gut suits minor low-tension wounds, while PROLENE remains a low-reactivity nonabsorbable option when follow-up for removal is realistic.
• Absorbable tradeoffs on skin: Chromic gut holds strength longer but is generally avoided on the face because its slower absorption and greater tissue reactivity can work against cosmetic goals.

Forehead and Scalp Closure

• Linear forehead closure plan: A straightforward forehead laceration usually gets buried 4-0 MONOCRYL for the dermis, with the deep layer doing the real work of keeping the wound closed.
• Forehead skin options: Common skin-layer choices are a 5-0 PROLENE running stitch, fast-absorbing gut running closure, or a running intracuticular MONOCRYL when skin edges are pristine.
• Bone exposure changes layers: If a forehead wound exposes bone, inspect for fracture and think in three layers; the deepest muscular layer is commonly reapproximated with 3-0 VICRYL.
• Scalp hemostasis and galea: Scalp wounds bleed impressively, so hemostasis matters early; if the laceration reaches galea, 2-0 VICRYL is the classic repair suture.
• Staples for most scalp wounds: Staples are appropriate for most scalp lacerations because they are fast and reliable, while a bald patient may be a better cosmetic fit for chromic gut instead.
• Hair management pitfalls: Do not trap hair in the closure because buried hair can seed infection or epidermal inclusion cysts. We walk through the practical scalp prep details in the episode.