Laceration repair seemed to be the name of the game at work in the emergency department yesterday. Not only did I suture at least seven lacs, these were some pretty nasty cuts. From an extremity wound requiring nearly 30 sutures to lacerations on toddlers and intraoral injuries, my procedural skills were put to the test.
Lip lacerations once intimidated me, as did suturing almost any facial wound. When it comes to the face, I take my suturing skills particularly seriously as I want my patients to have the best possible cosmetic outcome. Even in elderly patients who laugh when I express concern for scarring, I use special care in placing the most perfect sutures possible.
When it comes to facial lacerations, the lip requires special care. Here are a few tips and tricks to keep in mind when suturing lip lacerations.
Line up the vermilion border with care
Lip lacerations crossing the vermillion-cutaneous border, the pink, contoured border between the lip tissue and surrounding skin, are especially prone to a poor cosmetic outcome. Misaligning this area by as little as 1mm can be noticeable once the wound has healed.
The first suture you place in lacerations crossing the vermilion border should go directly in this area to obtain proper laceration alignment. Use a small suture, such as 6-0 nylon, in simple interrupted fashion. Marking the edges of the vermilion border with a surgical marker can be helpful in placing this first suture properly. Make these markings prior to injecting anesthetic and irrigating the wound as these processes can distort wound margins. If you can’t locate a surgical marker, you can use the method for lining up the vermilion border outlined here.
Check for teeth!
As with any wound, lip lacerations need to be carefully explored for foreign bodies. Teeth are often involved in injuries to the mouth and are even the cause of many lip lacerations. If you notice dental involvement in a facial injury, don’t neglect exploring the wound for foreign bodies including fragments of damaged teeth. If in doubt, an X-ray will identify and potentially embedded tooth fragments.
Proceed with caution in wound prep
Copious irrigation is the name of the game in preparing most traumatic wounds. However, proceed with care when cleaning and irrigating wounds of the face. Copious irrigation may distort wound margins and cause further tissue damage. Some studies suggest that for clean lacerations of the scalp and face, copious irrigation has no impact on rate of infection.
Anesthetize with a nerve block
Lips can be difficult to anesthetize locally and doing so results in swelling distorting wound margins and making cosmetically appealing wound closure difficult. Use of a mental nerve block for the lower lip and an infraorbital nerve block to anesthetize the upper lip is often your best bet.
Check for a through-and-through laceration
Lip wounds may extend completely through the skin to the intraoral surface. Probe the wound gently as you explore it to check for a through-and-through laceration. Small intraoral lacerations may be left to heal on their own. Intraoral lacerations that are large enough to trap food particles or that interfere with chewing will need to be repaired with absorbable suture.
Look for associated injuries
Lip lacerations often go hand in hand with other injuries such as facial fractures and dental injuries. If you suspect a possible facial fracture, order appropriate imaging. Don’t let the obvious external laceration distract you from potential internal complications.
Don’t lose your sutures!
Suturing lip lacerations in patients with facial hair can be difficult. To further complicate the problem, the patient will not be able to shave the area for several days. This can make sutures difficult to locate for removal. In patients with dark facial hair, use sutures of a different color. You will thank yourself when the patient returns to have the sutures removed.
The following video shows basic lip laceration repair technique.
Do you have any lip laceration repair tips and tricks to share?
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