Pediatric emergency medicine trisk 3399 3399

Blunt injuries to the nose are much more common than lacerations. When a nasal
laceration results from blunt trauma, careful evaluation of underlying nasal bones
and examination for a nasal septal hematoma are essential. Other associated
injuries, such as facial bone fractures or injuries to the orbit, should also be ruled
out.
The skin overlying the nose is taut and stiff. Approximating the edges of
simple, nongaping nasal wounds, mostly along the upper half of the nose, is
usually straightforward. Wounds with any gaping, commonly in the lower part of
the nose, can be difficult to coapt because of the nature of the skin in this
location. The suture material can tear through the skin easily. Absorbable
subcutaneous stitches are recommended before skin closure to relieve tension and
prevent tearing through the wound edges. Skin closure should be with simple
interrupted 6-0 absorbable material. Early removal of the sutures is advised for
the same reason.
Full-thickness nasal lacerations involving the alae nasi or entering the vestibule
require layered closure. The procedure should start with the nasal mucosa, using
absorbable material and finish with the skin, preferably using continuous
subcuticular suture technique.
The nasal cartilage, when involved, rarely requires sutures. When alignment is
difficult, a few fine sutures (Vicryl or plain catgut) will help hold it in place.
When the free rim of the nare is involved, precise alignment is imperative for
good cosmetic outcome. For complex nasal lacerations, lacerations associated
with fractures, or when there is tissue loss, consultation with a surgical specialist
is recommended.

Lip Lacerations
Lip lacerations are a particular concern because of the importance of the lip as a
facial landmark. The lip is a vascular structure with multiple layers. The
vermilion border, the junction of the dry oral mucosa and facial skin, serves as an
important landmark for proper repair when involved. The vermilion border is
easily identified by its relative pallor compared to the neighboring lip and skin.

Therefore, the use of epinephrine with local anesthesia should be avoided so the
landmark is not obscured. When parted, the vermilion border should be precisely
reapposed using a 6-0 suture. The buccal mucosal surface is then closed with 5-0
absorbable material, followed by the skin, using 6-0 nonabsorbable sutures. Fastabsorbing gut is also an alternative when suture removal is likely to be
challenging. The parents should be warned that, while the lip is still anesthetized,
there is a chance that the child will bite the sutures off and that they should
distract the child from doing so.