Facial Lac
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There are excellent chapters in Fonseca's Oral and Maxillofacial Trauma, Peterson's Oral and Maxillofacial Surgery, and Booth's Maxillofacial Trauma and Aesthetic Facial Reconstruction... I'm sure you could find good articles in their "references" section if you need a specific journal.
I just read these two a couple weeks ago:Bifid Uvula said:
British Journal of OMFS; The Management of Soft Tissue Facial Wounds; 1995: 33, 76-85
Journal of OMFS; Management of Injuries to the Auricle; 1997: 55, 732-739
The references at the end of the chapter are great. Usually, I start with Peterson (the two-volume edition). I read a chapter and then look over the references to find articles that I'd like to read more about.
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I agree that the major textbooks are good enough...the rest is learning as you go. Just remember the principles:
1) Through-and-through lacs into the mouth get a mucosal closure first, then close remaining layers with skin last. Inside---->out.
2) Line up any important landmarks in the beginning. Lip vermillion, eyebrows, etc.
3) Always consider which anatomic injuries you have to rule out. For cheek lacs think about facial nerve and parotid duct, for brow lacs the frontal branch of facial nerve. For preauricular lacs you should try to see if the parotid fascia is violated because if you don't close that layer they'll get a sialocele a few days later. For intraoral lacs you should be on the lookout for the parotid and submandibular ducts. For tongue lacs in an unconscious patient, I throw a 2-0 silk through the anterior tongue, stretch the damn thing out and clip it to his drape of c-collar or something. Now they are sticking their tongue out at you and you don't have to sew inside a hole. With gingival lacs, you should be suspicious of an underlying mandibular fx.
4) For ears, consider a bolster when you get done to prevent a hematoma which can give a "cauliflower ear" deformity long-term. There are many ways to do this. You can just mattress some resorbable sutures through-and-through the injured areas to tack down the skin to the cartilage to eliminate potential dead-spaces. Some people tape or sew a bulky gauze dressing or dental cotton-rolls to both the front and back of the ear to achieve the same thing.
I'm just thinking out loud here. I'm sure there are many more pearls out there.
If you're starting out, you also need to know how to numb/block the entire head & neck in the ER. A GREAT article is:
How to block and tackle the face. Plast Reconstr Surg. 1998 Mar;101(3):840-51
I have it in PDF format. PM me your email address if you want it. Make sure your email can receive a 6MB file.
1) Through-and-through lacs into the mouth get a mucosal closure first, then close remaining layers with skin last. Inside---->out.
2) Line up any important landmarks in the beginning. Lip vermillion, eyebrows, etc.
3) Always consider which anatomic injuries you have to rule out. For cheek lacs think about facial nerve and parotid duct, for brow lacs the frontal branch of facial nerve. For preauricular lacs you should try to see if the parotid fascia is violated because if you don't close that layer they'll get a sialocele a few days later. For intraoral lacs you should be on the lookout for the parotid and submandibular ducts. For tongue lacs in an unconscious patient, I throw a 2-0 silk through the anterior tongue, stretch the damn thing out and clip it to his drape of c-collar or something. Now they are sticking their tongue out at you and you don't have to sew inside a hole. With gingival lacs, you should be suspicious of an underlying mandibular fx.
4) For ears, consider a bolster when you get done to prevent a hematoma which can give a "cauliflower ear" deformity long-term. There are many ways to do this. You can just mattress some resorbable sutures through-and-through the injured areas to tack down the skin to the cartilage to eliminate potential dead-spaces. Some people tape or sew a bulky gauze dressing or dental cotton-rolls to both the front and back of the ear to achieve the same thing.
I'm just thinking out loud here. I'm sure there are many more pearls out there.
If you're starting out, you also need to know how to numb/block the entire head & neck in the ER. A GREAT article is:
How to block and tackle the face. Plast Reconstr Surg. 1998 Mar;101(3):840-51
I have it in PDF format. PM me your email address if you want it. Make sure your email can receive a 6MB file.
I would also say to make sure you line up the margins. Nothing looks worse than a stepoff, even if you are just stapling the scalp. Also, make sure you evert the margins if possible. If you are doing a funky scalp lac consider a suction drain. DON'T, I repeat DON'T, staple the suction. It is a biznitch to get out if you do. Learn how to do a vertical/horizontal mattress to help you evert margins. Learn how to suck little corners into stellate wounds. Learn how to tie like a man. DO use resorbables or glue on little kids if you know how to do it. You will keep your hair from going gray during your intern year (taking OUT sutures is much worse than putting them in. They are usually sedated when you put them in). Don't go nuts on the sutures, just enough to keep the wound closed without tension. Every suture you put under the skin will have an inflammatory response than may lead to increased scarring, particularly if they pus. If you see gingival lacs get a pano and a PA ceph (that way Eddy doesn't kill you 😀 ). Don't be afraid to pick up the scalpel and give yourself a better wound to deal with. If the skin looks thin, it probably is and will necrose on you and look like AR$E when the attending looks at it ten hours later. It really is a matter of experience. You just have to do some and screw things up to get good at it (see above mention of stapling drains in 
).
You will go look up some articles on "wound management" and then get to the ED and think, "How did this guy manage to get gored in the face by a bull and not break any bones?". Then you will think, "This wound don't look nuthin' like that fancy picture in the article." Then you will realize it is 4:45 AM and you round in an hour and fifteen minutes and so you will improvise. It will look like crapola the first couple you do, and then you will get better. Happens to everyone (unless you gotz no skilz.)
). You will go look up some articles on "wound management" and then get to the ED and think, "How did this guy manage to get gored in the face by a bull and not break any bones?". Then you will think, "This wound don't look nuthin' like that fancy picture in the article." Then you will realize it is 4:45 AM and you round in an hour and fifteen minutes and so you will improvise. It will look like crapola the first couple you do, and then you will get better. Happens to everyone (unless you gotz no skilz.)
toofache32 said:
OMFS2B said:
There are a million articles on lacerations. The above advice is excellent. I will add a few things. Aside from the physical skill of bringing a laceration together in a timely fashion, (watching an intern or dental student sew can be painful-something akin to watching a dog hump over trying to crap at the park) and the intelligence to understand what else could possibly be wrong beside the laceration (ie leaving glass/debris in the wound, not picking up a subtle fracture such as a pediatric patient where fractures running through developing tooth follicles are as difficult to follow at times as my loquatious replys 🙂 ) there are issues of antimicrobial adjunctive therapy which apply to different situations. From training 3 go rounds of new residents, this can be frusterating; when and when not to give antibiotics. While everyone has their own reasons, may I suggest studying about human and animal bite lacerations, communicating cutaneous lacerations with the oral cavity or sinus. Lacerations exposing cartilage (especially laceration of cartilage) and bone (especially bony fractures). Nothing like a perfect repair (the skill) to accompany an assinine medical therapy (the brains/understanding of what is going on). These are the pearls to think about. This separates the technicians from the doctors. Enough material to last you from now until way into your residency. There is good evidency based research, so the blanket statement of every laceration gets antibiotics is incorrect! Additionally, look at some ED research on lacerations. They have done some good stuff with questions like "how long can a laceration sit without increasing the risks of scar/infection. That makes it nice to tell an ED doc to put a moist dressing on the lac and send it to the clinic in the morning... as I go back to sleep.
One thing I also learned is that if you cannot attend to the face lac right away (be it that you have to do your chief's b!tch work or you absolutely must attend to your bathroom emergency 
), you should keep a wet gauze in the wound to keep it moist. I dont remember the precise scientific/clinical reason, but one of my attending mentioned that it had something to do with reducing(?) the amount of serum(?) that forms within the wound. I dont remember if that's even the correct reason.
I may have heard from my attending or one of the upper guys that wounds can be left open for hours (8+) without any ill complications.
Also, make sure their tetanus immunization is up to date........but the ED should have taken care of that already.
), you should keep a wet gauze in the wound to keep it moist. I dont remember the precise scientific/clinical reason, but one of my attending mentioned that it had something to do with reducing(?) the amount of serum(?) that forms within the wound. I dont remember if that's even the correct reason.I may have heard from my attending or one of the upper guys that wounds can be left open for hours (8+) without any ill complications.
Also, make sure their tetanus immunization is up to date........but the ED should have taken care of that already.
Your staff saw your lacs!? Damn.Jediwendell said:
Only on the rare occasion when they got put in the unit or when they were in the ED when we were rounding. Our staff is a little anal since the San Antonio hospital got hosed by medicaid for something like 50 million bones. Translation: If they see it, they can bill for it. 😉
toofache32 said:
This thread suddenly made me remember why I never ever desire to pursue OMFS.
griffin04 said:
What part of this thread is revolting? This thread is actually dealing with something a touch more important than if the teeth are straight. Management of cutaneous wounds is important to just about anyone who is ANY kind of surgeon-even a dental surgeon. Don't tell me that looking at a carpule of local anesthetic makes you queezy! Even for an ortho wannabe if someone gets popped in the mouth and you can see your brackets through the laceration-nice to know you might have a basic idea of how to triage if not treat it.
the other day i had a kid come in who was wearing braces and had run into the wall while playing basketball.. Needless to say his max. anterior teeth were kicked back, comminuted dental alveolar fx;yet the braces held the teeth in their respective sockets. Lucky guy.. anyway, i was thinking of bonding them back into place...but decided to cut off his thousand dollar braces and i strapped on a beautiful shiny arch bar to hold those teeth in place... maybe i can make money doing ortho with arch bars..
hmm
hmm
Facial lacerations are not revolting and I don't get queasy from lidocaine. But, I'd rather not be the one lining up landmarks, suturing ears, stapling scalps. I'm pretty sure that is not within the realm of your ordinary general dentist, unless the dentist has a special interest in facial lacerations/ER, lives in boonies and is the only DDS in a 100 mile radius, or is an oral surgeon.
I did a GPR. I saw enough crazy facial lacerations/trauma and did my time in rounds, treating crazies, shucking teeth, ER visits at 12 am, OR cases at 12 am, definitely more so than your average orthowannabe who goes straight from dental school right into ortho residency. I'm not afraid to pick up a suture kit and use it if necessary, but I'd rather not do it on a regular basis. I'll be sure triage and send them to the local hospital with an OMS residency - "don't worry mom, they are specialists, they'll take wonderful care of your little angel and his busted lip there."
Heck if I had a facial laceration, I'd want an OMS to suture me up, not my general dentist buddies.
I did a GPR. I saw enough crazy facial lacerations/trauma and did my time in rounds, treating crazies, shucking teeth, ER visits at 12 am, OR cases at 12 am, definitely more so than your average orthowannabe who goes straight from dental school right into ortho residency. I'm not afraid to pick up a suture kit and use it if necessary, but I'd rather not do it on a regular basis. I'll be sure triage and send them to the local hospital with an OMS residency - "don't worry mom, they are specialists, they'll take wonderful care of your little angel and his busted lip there."
Heck if I had a facial laceration, I'd want an OMS to suture me up, not my general dentist buddies.
griffin04 said:
Translation (where I work): "Don't worry mom, they are specialists, they'll ketamine dart his ass, sew like hell before it wears off, and hand him back to the ER docs to take care of the rest. And any loose teeth will buy him an ugly arch-bar."
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I give an arch bar to the luxated teeth same as a dentoalveolar fx. Avulsed teeth in the ER are a tough call for me because of the poor follow-up of these people. If I knew they would go to a dentist in the next week, I would splint them just like in the real world. But usually the only dentist anyone in their family has seen is me in the ER, so they aren't always good candidates for re-implantation. At least that's what I tell myself to feel better about throwing a 10-year-old's #8 in the trash. But then again, these types of people are always missing some teeth so I guess it's not as big of a deal to them.tx oms said:
Ditto. It is kinda an ethical dilemma. With luxated teeth I try to convince the patients to extract the teeth by telling them how much root canals cost. It doesn't work too often. Most people are just unwilling to face the reality of their situation right after a trauma. They think they'll get the root canal even though it costs three months of welfare.toofache32 said:
At our hospital we don't have any of our equipment in the ER so we have to take the patient up stairs to our clinic for x-rays and treatment. That sucks at 2:00am. I'd like to just tell them, "I don't treat tooth trauma. You need to see a general dentist first thing in the morning."
Same here. At Children's hospital the ER has a hard time getting the pediatric dental residents to answer their pages in the middle of the night, and we're the default backup since we're in-house anyway. Sometimes they just call us from the start.tx oms said:
