A Plastic Surgeon's Approach to Ear, Nose and Lip Lacs

Facial laceration repair is an anatomic problem, not just a skin-closure problem. Forehead, scalp, ear, nose, and lip wounds need layered closure, careful structure identification, and selective specialty consultation when fractures, nerve injury, or tissue loss are in play.

Facial laceration repair principles

• Consultation red flags: Immediate plastics or ENT involvement is most justified for devastating injuries, facial fractures, and clear vascular or nerve injury; many other facial lacerations can be repaired safely in the ED.
• Irrigation and structure check: Copious irrigation is the first step because the real decision point is which structures are involved, not how long the skin cut looks.
• Layered closure strategy: For most facial wounds, multilayer closure is the key move because the deep dermal layer should carry the tension while the skin layer is mainly cosmetic.
• Running skin sutures: Running closure is often faster than interrupted sutures and can improve cosmesis by distributing tension evenly across the wound, a technique nuance we get into in the episode.
• Skin suture selection: Fast-absorbing gut works well for small low-tension facial wounds, while PROLENE remains a low-reactivity nonabsorbable option when follow-up for removal is reliable.
• Buried suture selection: MONOCRYL is the fastest-absorbing buried monofilament, while VICRYL is the workhorse for deeper tissue under tension, especially muscle and galea.

Forehead and scalp lacerations

• Forehead closure framework: A linear forehead laceration usually needs buried 4-0 MONOCRYL to do the real work of closure, with the superficial layer chosen mainly for edge approximation and cosmesis.
• Deep forehead injuries: When a forehead wound exposes bone, look for fracture and convert to a 3-layer repair; the deepest muscular layer is commonly reapproximated with 3-0 VICRYL.
• Intracuticular skin option: A running intracuticular MONOCRYL closure is reserved for clean, undamaged skin edges where a buried cosmetic skin closure is feasible. We cover when that choice pays off on the show.
• Scalp hemostasis and exposure: Scalp lacerations bleed impressively, so cleaning away matted hair and securing hemostasis are prerequisite steps before judging depth or planning closure.
• Galea repair trigger: If the scalp wound reaches the galea or bone, repair the galea with 2-0 VICRYL before addressing the skin because deep support matters more than the outer closure.
• Staples and scalp aftercare: Staples are appropriate for most scalp wounds, though bald patients may be better served with chromic gut; keep the closure moist and avoid trapping hair in the repair.

References:

1. Semer, Nadine. Chapter 16: Facial Lacerations. In: Practical Plastic Surgery for Nonsurgeons.  Hanley & Belfus, Inc; 2001: 145-160