Pediatric emergency medicine trisk 3302 3302
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Deep lacerations to the cheek or lateral periorbital region should raise
suspicion for facial nerve injury.
Lacerations to the medial periorbital region near the medial canthus
should be evaluated for injury to the lacrimal canaliculi.
Fast-absorbing plain gut sutures have demonstrated equivalent
cosmetic outcome compared to nonabsorbable sutures in repair of
facial lacerations.
Clinical Considerations
The goal of laceration repair is to achieve hemostasis and provide an optimal
cosmetic result. Knowledge of the deep structures of the face, particularly the
facial nerve and the lacrimal apparatus, will aid in the evaluation and
management of children with deep facial lacerations. Lateral periorbital
lacerations should raise suspicion of injury to the frontal branch of the facial
nerve, which travels superficially along a line from just above the tragus to a
point 1.5 cm above the lateral eyebrow. Lacerations in the medial periorbital
region near the medial canthus should raise suspicion for lacrimal duct injury.
Because 85% of tears are drained via the lower canaliculus, failure to repair a
laceration to the lacrimal duct may result in excessive tearing (epiphora). If deep
lacerations are present in the cheek region, the clinician must determine whether
injury to the buccal branch of the facial nerve and to the parotid duct has occurred
( Fig. 107.6 ).
When injury to the facial nerve is suspected, function can be tested by having
the patient move specific muscles of facial expression. This testing should take
place before infiltration with local anesthetic. The frontal branch of the facial
nerve can be tested by asking the patient to frown in order to look for symmetry
of frontalis muscle action. The marginal mandibular (motor) branch may course
as much as 1 to 2 cm below the border of the mandible and is responsible for the
depression and eversion of the lower lip. Injury to this branch results in a
characteristic inward rotation of the lower lip on the affected side as a result of
unopposed orbicularis oris tone on that side. The buccal branches are in close
proximity to Stensen (parotid) duct, usually close to a line between the tragus of
the ear and the mid upper lip. Pure motor injuries to the facial nerve are quite
amenable to microsurgical repair if detected and repaired in a timely fashion.
Therefore, all suspected motor nerve injuries warrant appropriate surgical
consultation to allow for the best functional recovery.
