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Facial Plastic Surgery

Smaller lacerations can often be repaired satisfactorily in the emergency

room. Larger, more complex lacerations may be better repaired in the

operating room, where the patient can be made more comfortable and the

wound thoroughly cleaned. Pay particular attention to deep wounds that

traverse the course of the

facial nerve

parotid duct,

as these structures

may be injured as well. Lacerations that involve the eyelid may have

injured the globe, and ophthalmic consultation should be considered.

Once these other considerations have been satisfied and the wounds are

ready to be repaired, several principles may be helpful. First is careful

reapproximation of all remaining tissue. After the wound has been anes-

thetized and cleansed, it becomes more obvious where the tissue needs to

go. It is important to be meticulous when you are repairing these wounds,

somewhat like putting together a jigsaw puzzle. Line up known lines first:

the vermilion border of the lips,

free margins of the nose and eyelids

edges of eyebrows, and parts of the pinna must be perfectly aligned.

Second, careful handling of soft tissue is important to avoid crushing the

delicate tissue edges further. It may take more than one effort to repair

some of these wounds properly, and removing any misplaced sutures and

starting over is not uncommon. Buried resorbable sutures of material,

such as polyglactan or monocaproic acid, help to reduce the tension

placed on the wound (which is an important determinant of reducing scar

formation). Last, when closing the final layer, it is important to be sure

that the skin edges are everted and not inverted, as this will lead to a

depressed scar that is more visible.

On the face, 5-0 or 6-0 suture is usually adequate, and resorbable mild

suture, such as fast-absorbing gut, or a permanent suture, such as nylon or

polypropylene, is best. Immediately after a wound is closed, it fills with

serum, which clots. This serum prevents water from entering the wound.

Wounds may be allowed to get wet within a few minutes of closure as long

as the microscopic clot is not disrupted. Thus, you may tell patients they

can get their wound wet, as long as they do not scrub it and the water is

reasonably clean. Showering is fine; swimming in a lake probably is not.

Instruct them to keep antibiotic ointment or petrolatum jelly on the

wound. This will help it retain moisture and reduce crusting until the skin

has healed (usually about a week on the face).

Sutures on the face should be removed at three to five days, while those on

the ear and scalp should be allowed to remain somewhat longer, usually

around seven days. It is important for patients to realize that scars take a

minimum of one year to cosmetically mature. The time course usually

involves the scar turning red, with the maximum redness occurring at