Facial Laceration Repairs: Tips and Tricks

Special thanks to Dr. Andrew Hashikawa, MD, MS for working with Dr. Bauman on this post.

Pediatric facial lacerations are frequently encountered in acute care settings and present a unique set of challenges compared to adult cases. These often include:

1. Developmental considerations
2. Pain control
3. Resource constraints
4. Parental concerns

Below are a few tips to mitigate these challenges.

1. Challenge: Traditional laceration repair methods can be particularly difficult in young children, who often struggle to remain still or tolerate prolonged procedures due to their limited understanding and cooperation.

Tip: For linear, hemostatic scalp lacerations (where the hair is not too short), the hair apposition technique is an excellent option. The technique is quick, well-tolerated, has a lower infection rate than sutures, and does not require removal (compared to staples).

2. Challenge: Lidocaine injections are poorly tolerated by the young child.

Tips: Topical anesthesia is preferred for facial and scalp wounds and is effective in approximately 95% of cases when applied correctly. For non-mucosal lacerations, apply LET (Lidocaine-epinephrine-tetracaine) by placing half the dose directly into the wound and the other half on a cotton ball, secured with clear dressing tape, for ~30 minutes. Consider enlisting the parent to apply the LET via a cotton tip applicator every few minutes – this can decrease apprehension associated with physical touch at the site of injury.

3. Challenge: Wound irrigation is essential for reducing infection risk, but access to sterile saline or water can be limited or costly in resource-constrained environments.

Tip: Tap water is a safe, effective, and more cost-efficient alternative to saline, with equivalent infection rates. Consider using warm tap water to improve patient comfort! For high-pressure irrigation without additional equipment, puncture a water bottle cap with an 18-gauge needle.

4. Challenge: Parents are concerned about long-term cosmetic outcomes, especially for facial lacerations.

Tips: Set expectations early—explain that while all wounds leave some scarring, most pediatric facial lacerations heal well with minimal visible scarring. Absorbable sutures have been shown (via digital imaging analysis) to cause less tissue reaction than non-absorbable sutures, with no compromise in appearance. There is also no significant difference between braided and monofilament sutures regarding infection risk or cosmetic outcomes, offering flexibility in suture choice. Finally, remind parents that using sunscreen daily, year-round, can help reduce pigment changes and enhance the long-term appearance of scars.

Editor’s Note: First10EM did a great 12-part series several years ago looking at all the evidence around laceration repair in the emergency department. It’s worth a look to complement Dr. Bauman’s post! ~JB

Sources:

1. Forsch, R. T., Little, S. H., & Williams, C. (2017, May 15). Laceration repair: A practical approach. American Family Physician. https://www.aafp.org/pubs/afp/issues/2017/0515/p628.html
2. Karaduman S, Yürüktümen A, Güryay SM, Bengi F, Fowler JR Jr. Modified hair apposition technique as the primary closure method for scalp lacerations. Am J Emerg Med. 2009 Nov;27(9):1050-5. doi: 10.1016/j.ajem.2008.08.001. PMID: 19931749.
3. Kundu, S., & Achar, S. (2002, July 1). Principles of office anesthesia: Part II. topical anesthesia. American Family Physician. https://www.aafp.org/pubs/afp/issues/2002/0701/p99.html#afp20020701p99-b7
4. Migliaccio, D. (2024, September 1). An updated review of pediatric facial lacerations. Pediatric Emergency Medicine Reports . https://www.reliasmedia.com/articles/an-updated-review-of-pediatric-facial-lacerations
5. Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007 May;14(5):404-9. doi: 10.1197/j.aem.2007.01.007. PMID: 17456554.
6. Ozturk D, Sonmez BM, Altinbilek E, Kavalci C, Arslan ED, Akay S. A retrospective observational study comparing hair apposition technique, suturing and stapling for scalp lacerations. World J Emerg Surg. 2013 Jul 25;8:27. doi: 10.1186/1749-7922-8-27. PMID: 23885743; PMCID: PMC3745645.
7. Parara SM, Manios A, de Bree E, Tosca A, Tsiftsis DD. Significant differences in skin irritation by common suture materials assessed by a comparative computerized objective method. Plast Reconstr Surg. 2011 Mar;127(3):1191-1198. doi: 10.1097/PRS.0b013e3182043aa6. PMID: 21088646.

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