Treatment of Forehead Lacerations Presenting After 12 Hours

Wound Assessment and Preparation

• Grossly contaminated wounds require more extensive irrigation and may need delayed closure 1, 2

Wound Cleaning Protocol

• Remove superficial debris carefully, avoiding aggressive debridement that enlarges the wound 4
• Prepare the wound site with betadine or chlorhexidine antiseptic solution 5, 6

Anesthesia Options

• Topical anesthetics (LET solution) should be applied with lidocaine-epinephrine-tetracaine for 10-20 minutes until wound edges blanch; contraindicated if gross contamination present 1, 2
• Injectable lidocaine should be buffered with bicarbonate, warmed before injection, and injected slowly with small-gauge needle to minimize pain 1, 2

Closure Technique Selection

• Facial wounds can be closed primarily if seen by an experienced provider, provided there has been meticulous wound care and copious irrigation 4

Preferred Closure Methods

• Tissue adhesives (octyl cyanoacrylate) provide essentially painless closure for low-tension facial wounds, associated with 26-minute shorter procedure time and less pain 1, 2
• Wound closure strips (Steri-Strips) offer painless closure, are less expensive than adhesives, and are appropriate for low-tension areas 1, 2
• Absorbable sutures should be considered for facial wounds requiring suturing to avoid pain and anxiety of suture removal 1, 2

Suturing Approach When Required

• Use continuous non-locking subcuticular technique to distribute tension evenly and minimize pain 7
• Avoid transcutaneous interrupted sutures on facial skin as they damage nerve endings and increase pain 7

Critical Timing Considerations

• Facial wounds have better blood supply and lower infection risk 4

Antibiotic Considerations

• Prophylactic antibiotics are NOT routinely indicated for clean facial lacerations, even when presenting late 8
• Consider antibiotics only if signs of established infection are present 8
• If antibiotics are used, first-generation cephalosporins (cefazolin 2g) are appropriate 7

Post-Closure Management

• Tetanus prophylaxis if status is outdated or unknown (0.5 mL intramuscularly) 4

Common Pitfalls to Avoid

• Avoid aggressive debridement that enlarges the wound and impairs closure 4
• Never close infected wounds primarily - these require delayed closure after infection resolution 4