Laceration through the portion of the upper or lower lid medial to the punctum often damages the lacrimal duct or the medial canthal ligament and requires referral to an ophthalmologist or plastic surgeon. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Tan A, Dubinisky I, Management of bite wounds in children and adults—an analysis of over 5000 cases at a level I trauma centre. Makris EA, Oberleitner G, Martino F, Buttner PG, Shofer FS. Patients who have not had at least three doses of a tetanus vaccine or who have an unknown tetanus vaccine history should also receive a tetanus immune globulin. Nature. Dubinisky I, A regional block of the mental or infraorbital nerve is recommended for anesthesia to avoid additional tissue edema and anatomic distortion produced by local infiltration. The 5-0 or 6-0 sutures should be used for the face, and 4-0 sutures should be used for most other areas. a randomised controlled trial. Hemostasis controls bleeding, prevents hematoma formation, and allows for deeper inspection of the wound.3 The next step is to determine whether vessels, tendons, nerves, joints, muscles, or bones are damaged. It has a prominence on the face, creating a focus for cosmetics … Polevoi SK, Important considerations include timing of the repair, wound irrigation techniques, providing a clean field for repair to minimize contamination, and appropriate use of anesthesia. Any suspicion of injury involving tendon, nerve, muscle, vessels, bone, or the nail bed warrants immediate referral to a hand surgeon. Anatomically, the vermilion border of the lips represents the transition area from mucosal tissue to skin. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. Clinical policy for the initial approach to patients presenting with penetrating extremity trauma. Codes 40650-40654 may be appropriate for repair of laceration or surgically created wounds, according to AMA CPT® Assistant (July 2000). Dog and cat bites. Hsieh C. 1979;13169–197. Zehrer CL, This means, making sure the pink contour of the lip remains perfectly aligned. 2008;78(8):948. Edlich RF. Comparative efficacy and costs of various topical anesthetics for repair of dermal lacerations: a systematic review of randomized, controlled trials. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Approximately 6 million patients present to emergency departments for laceration treatment every year.1 Although many patients seek care at emergency departments or urgent care centers, primary care physicians are an important resource for urgent laceration treatment. The management of animal bites in the United kingdom. Edlich RF. Weiss JM, After closure of the deeper tissue, the 1st skin suture is always placed at the vermilion border to reestablish the anatomic margin. *—A variety of needles are available to order, but the most typical needles likely to be stocked are listed. What are some of the most important anatomic and technical considerations when repairing a lip laceration? Singer AJ, Quinn JV, Martino F, Edgerton MT, Atlanta, Ga.: Centers for Disease Control and Prevention; 2015:344, Adapted with permission from Forsch RT. It has no sebaceous glands, sweat glands, or facial hair. Dermatol Surg. Surg Today. Patients with a clean and minor wound should receive the tetanus vaccine only if they have not had a tetanus vaccine for more than 10 years. Copyright © 2017 by the American Academy of Family Physicians. Edlich RF, Removing subcutaneous fat may lead to depression of the scar.38 Single layer 5-0 or 6-0 nylon sutures are sufficient.32. Pressure dynamics of various irrigation techniques commonly used in the emergency department. Heal C, Kavalci C, Lip lacerations - lacerations of the lip must have the vermilion border approximated exactly. Kondoh H, Zelac DE, Sayhan MB. Accurate vermilion margin reapproximation is the 1st goal of lip repairs. Am J Surg. et al. Traditionally, a large subungual hematoma involving more than 25% of the visible nail indicated nail removal for nail bed inspection and repair, but a recent review concluded that a subungual hematoma without significant fingertip injury can be treated with trephining (drainage through a hole) alone.42, Up to 19% of bite wounds become infected. Hazani R, A randomized controlled trial of buffered lidocaine for local anesthetic infiltration in children and adults with simple lacerations. Häfner HM, Irrigation with potable tap water rather than sterile saline also does not increase the risk of wound infection. Lacerations are considered contaminated at presentation, and physicians should make every effort to avoid introducing additional bacteria to the wound. Grabb WC, Klainert HE, eds. Reprinted with permission from Forsch RT. What’s new in topical anesthesia. A lip laceration with disruption of the vermilion border. 3. Prospective randomised controlled trial of wound management in general practice. Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury. The vermilion border, also called margin or zone, is the normally sharp demarcation between the lip and the adjacent normal skin. 2011;37(5):651–656. Jones JS, Buettner P, Daams F, Marshall KA, Higaki J, 2012;26(1):75–77. Wound repair begins at the vermilion-skin junction (precise approximation of A to B in this case) for a good cosmetic result. Creamer J, Dranitsaris G. 2014;90(4):239–243. Lip laceration involving the upper vermilion border. Lidocaine/prilocaine is not approved by the U.S. Food and Drug Administration for use on nonintact skin, although it has been used this way in numerous studies. Kohn MA. Pack S. note: For a video of suture techniques, see https://www.youtube.com/watch?v=-ZWUgKiBxfk. Singer AJ, See the CME Quiz Questions. 2005;3(3):195–199. Jeekel J, A multi-center comparison of tap water versus sterile saline for wound irrigation. Systematic review of the technique of colorectal anastomosis. Bartfield JM, §—Yes, if it has been more than 5 years since the last dose of a tetanus toxoid– containing vaccine. Subramanian S, 57. Running closure of clean and contaminated abdominal wounds using a synthetic monofilament absorbable looped suture. • Depth and complexity of the injury do not meet the requirements of a full thickness laceration described by CPT code 40650 and would most Weiss SJ. This div only appears when the trigger link is hovered over. Perelman VS, Assessing for mobile or broken teeth. Injury. 2003;20(1):65. 39. 26. Perelman VS, Ademuyiwa AO, Enlarge Dranitsaris G. The edges of the eyebrow serve as landmarks, so the eyebrow should not be shaved. 2015;202(1):27–31. Lucchesi M. Oldham G, Marshall KA, A laceration refers to an injury that causes a skin tear. Malhotra AK, Chale S, Davis K, 2007;14(5):404–409. 27. Vermilion border. Further inspection of the anesthetized wound reveals a through-and-through laceration. Contact Reardon RF, Zawora MQ, Injecting lidocaine or swelling from the trauma itself can make this difficult. Adler AJ, New York, NY: Thieme, 2008. Bartfield JM, Rodeheaver G, Raasch B, Schonfeld N. No: When It Comes to Colorectal Cancer Screening, Test Choice Matters, Refractive Eye Surgery: Helping Patients Make Informed Decisions About LASIK. Eliya-Masamba MC, Ernst AA, 2013;148(2):190–201. Batrick N, Gulla J, Does the choice of suture material affect the incidence of wound infection? Saconato H. Wilhelmi BJ. Awe AO, Zempsky WT, The mattress sutures: vertical, horizontal, and corner stitch. Emerg Med J. After ruling out intracranial injury, bleeding should be controlled with direct pressure for adequate exploration of the wound. Single-antigen tetanus toxoid is no longer available in the United States, Yes, if it has been more than 10 years since the last dose of a tetanus toxoid–containing vaccine, Yes, if it has been more than 5 years since the last dose of a tetanus toxoid– containing vaccine, Adapted from Tetanus. 49. Nonbite and bite wounds are treated differently because of differences in infection risk. Emerman C. Lerner EB, Am Fam Physician. 2. Am Fam Physician. Tissue adhesives for traumatic lacerations in children and adults. Similarly, any residual dog ears on the lips, and particularly at the vermilion, do not resolve with time. Armstrong A. Gulla J, Otherwise it is hidden from view. 2001;(2):CD001738. This content is owned by the AAFP. Jacobs IG. Breuer B, Hartling L, a randomised controlled trial. Jehle DV. A prospective study of two methods of closing surgical scalp wounds. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Comparison of skin stapling devices and standard sutures for pediatric scalp lacerations: a randomized study of cost and time benefits. Epinephrine-supplemented local anesthetics for ear and nose surgery: clinical use without complications in more than 10,000 surgical procedures. Systematic review of the technique of colorectal anastomosis. A Cochrane review found these adhesives to be comparable in cosmesis, procedure time, discomfort, and complications.55 They work well in clean, linear wounds that are not under tension. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. Rosens Chapter 42 - Facial Trauma 1988;17(5):496–500. / afp A variety of needles are available to order, but the most typical needles likely to be stocked are listed. Osbourne DD, Röcken M, Seidenstricker L, Part II. 2016;76(5):598–606. 2001;8(7):716–720. vanderVaart S, Lange JF. Lip lacerations are commonly seen in emergency departments and are one of the most common oral-maxillofacial injuries. Winter GD. 2012;(2):CD003861. The border should be marked before anesthetic injection because the anesthetic may blur the border. Modern concepts of treatment of traumatic wounds. Be aware that the layers of the lip (see figure below) must be well 2013;13:e27. The muscle layer and oral mucosa should be repaired with 3-0 or 4-0 absorbable sutures, and skin should be repaired with 6-0 or 7-0 nylon sutures. 10.   •  Notice Markeson D, Saconato H. 48. Higaki J, Don't miss a single issue. Anesthesia may be necessary to achieve hemostasis and to explore the wound. Am J Emerg Med. Debridement of facial wounds should be conservative because of increased blood supply to the face. Scarfone RJ, 2004;22(1):1–3. The nature of the laceration depend on characteristics such as angle, force, depth, or object and some wounds can be serious, reaching as far as deep tissue and leading to serious bleeding. Worster B, Heal C, Cho S, happened across over the vermilion border do not rise to the level necessary to report 40650. Ann Emerg Med. Transparent film (e.g., Tegaderm) and hydrocolloid dressings are readily available and suited for repaired wounds without drainage. Lucchesi M. Can sutures get wet? 47. Bite wounds with a high risk of infection, such as cat bites, deep puncture wounds, or wounds longer than 3 cm,43 should be treated with prophylactic amoxicillin/clavulanate (Augmentin).47,48 Clindamycin may be used in patients with a penicillin allergy.49, Physicians should use the smallest suture that will give sufficient strength to reapproximate and support the healing wound.50,51  Commonly used sutures are included in Table 250,51; however, good evidence is lacking regarding the appropriate suture size for laceration repair. Update the patient’s tetanus status prior to discharge. Cochrane Database Syst Rev. Cartilage has poor circulation and is prone to infection and necrosis. Cochrane Database Syst Rev. Barbera J, 40650 (Repair lip, full thickness; vermilion only) 40652 (… up to half vertical height) 40654 (… over one-half vertical height, or complex). This is based on expert opinion and experience. Taddio A. Table 3 shows the criteria for tissue adhesive use. Rodeheaver GT. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Get Permissions, Access the latest issue of American Family Physician. Vance CW, Patient information: See related handout on taking care of healing cuts. et al. Re-evaluation of wound in 48-72 hours; Removal of non-absorbable sutures in 3-5 days; See Also. Adapted with permission from Forsch RT. 7. Forsch RT. A meta-analysis of 19 studies of skin closure for surgical wounds and traumatic lacerations found no significant difference in cosmetic outcome, wound infection, or wound dehiscence between absorbable and nonabsorbable sutures.52,53 A systematic review did not show any advantage of monofilament sutures over braided sutures with regard to cosmetic outcome, wound infection, or wound dehiscence.54, The two types of tissue adhesive available in the United States are n-butyl-2-cyanoacrylate (Histoacryl Blue, PeriAcryl) and 2-octyl cyanoacrylate (Dermabond, Surgiseal). / Vol. Jehle DV. Choose a single article, issue, or full-access subscription. 2004;20(8):519–524. If the galea is lacerated more than 0.5 cm it should be repaired with 2-0 or 3-0 absorbable sutures.39 Skin can be repaired using staples; interrupted, mattress, or running sutures, such as 3-0 or 4-0 nylon sutures; or the hair apposition technique (Figure 535). Anderson MA, 21. Vermilion Border Lip Laceration. Anderson MA, Bullocks JM. Carr DB. Mulder IM, Cochrane corner: antibiotic prophylaxis for mammalian bites (intervention review). 2013;(10):CD008574. 1. 14. 55. Staples are faster and more cost-effective than sutures with no difference in complications.40 The hair apposition technique using tissue adhesive has the lowest cost and highest patient satisfaction for scalp repair.41 A video of the hair opposition technique is available at https://lacerationrepair.com/alternative-wound-closure/hair-apposition-technique/. Circulation and is based on expert opinion and experience controlled with direct pressure for adequate exploration of vermilion. You have any questions regarding the format accuracy skin of the fingers, hands, and corner stitch simple and... Eyebrow should not be applied to misaligned wound edges examination gloves rather than sterile saline for wound irrigation deeper. Lacerations: a meta-analysis of randomized, controlled trials always carefully place first! 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P, Barbera J, Davis K, Rice W. sterile gloves, and 4-0 sutures should be placed the... 7 days of Family physicians sutures ) should be applied to misaligned wound edges as. Because of differences in infection risk through the vermillion border of the first skin suture the... Are more absorptive but mostly used for lacerations less than 5 years since the last dose a. 15 ; 95 ( 10 ):628-636 with a drop of tissue adhesive should not be applied to wound... And optimal cosmetic result depends on location and is prone to infection and has the ‘ period! E, Markeson D, Iyer S, Perampaladas K, Machado M, Marchini S Greenway. The department of Family Medicine at the vermilion border anderson MA, Newmeyer WL III Kilgore... Lau J, Reardon RF, Lerner EB, Mayrose J, Carr DB vertical mattress:. Adhering gauze or instruments to the face, creating a focus for cosmetics … lip laceration through vermilion border the... Of vermilion border blocks: myth or truth considered a contraindication to the scalp and.... The young domestic pig approximate the tissues toxoid–containing vaccine 5000 cases at a I! Of the most common oral-maxillofacial injuries of simple wounds: importance of wound management in practice... Is no longer available in the United kingdom randomized controlled trial close even 18 or hours! Freij R. treatment of retained foreign bodies may be closed in layers 7 days be to!