This post was written by Nick Szugye, a resident at Cincinnati Children’s, and it answers several common questions that arise when approaching lacerations of the lip.
What are some of the most important anatomic and technical considerations when repairing a lip laceration?
- Be aware that the layers of the lip (see figure below) must be well aligned and brought together. Always align deep layers first obviously.
- Close approximation is important, but the sutures shouldn’t be too tight as to pucker the skin.
- Close approximation of the vermilion border is the key to a good cosmetic repair. Remember, the human eye can see even 1mm of misalignment at the lip.
- Use absorbable suture if possible- especially if removal will be challenging
- For deep sutures this can be 5-0 or 6-0 chromic gut
- Superficial sutures 6-0 fast absorbing gut or 6-0 Prolene. Note though that there may be a higher rate of dehiscence for fast gut. If you think that the child will bite at or lick the suture choose non-absorbable.
- Irrigate the wound with 100 ml Normal Saline per cm of laceration
- Do not close primarily if there is a sign of infection or if the wound is older than 24 hours (ideally 12 hours)
- Be aware that lidocaine plus epinephrine (injection or LET) can cause blanching that may obscure your landmarks. However it is completely safe to apply LET to the lip. Regional blocks (submental or infraorbital can be used, but in lacerations close to the midline a bilateral block may be necessary)
- Consider oral flora coverage with antibiotics for lacerations caused by an animal bite or if it extends intraorally
What about those lacerations that involve the vermilion border?
There are two things to consider when encountering vermillion-cutaneous border lacerations:
- First, place deep sutures for through-and-through lacerations, or those that are in the deep dermis/muscle layer to bring the tissue together. Deep sutures will decrease wound tension and make it harder for the wound to experience dehiscence if the child chews out one of the external sutures.
- Place the first superficial stitch is always at the level of the vermillion border (or 1 mm adjacent). Make sure that the vermilion border is well aligned before placing any other stitches. Consider marking with a fine tip pen at each side of the laceration right at the vermilion border.
When should you consult a Plastic Surgeon?
- Tissue Loss/Devitalized Tissue
- Complex laceration (if you anticipate > 30 minutes to repair)
- Dental injury
- Signs of facial fractures or mandibular fracture
- Facial nerve injury (be sure to do a cranial nerve exam!)
Which patients require sedation?
Remember, the two main considerations are pain control and anxiolysis. The choice of sedation depends upon many factors.
- Midazolam can be your friend. Use for children to help facilitate local anesthesia. A dose of 0.7 to 0.8mg/kg (max 20mg) is appropriate for a child who is a toddler or preschooler.
- Use moderate/procedural sedation (ketamine) if:
- Repair will take > 30 minutes
- If the child will not be able to hold still with minimal physical restraint
- The wound is extensive or complex (includes multiple wounds)
- Always, always use a holder!
What should I include in the discharge instructions?
- Soft diet for 2-3 days
- Follow up for suture removal in approximately 5 days
- Make sure the child doesn’t chew on the sutures (or suck their thumb, use a pacifier etc,.) until the local anesthetic has worn off.
Parlin LS. Repair of Lip Lacerations. Pediatrics in Review 1997; 18(3): 101-102
Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl J Med 1997; 337:1142.
Grunebaum LD, Smith JE, Hoosien GE. Lip and perioral trauma. Facial Plast Surg 2010; 26:433.