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Clinical Procedures > Soft Tissue Procedures
Complex Laceration, Lip
Article Last Updated: Nov 19, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Gretchen S Lent, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Coauthor(s):
Linda Liu, MD, Attending Physician, Department of Emergency Medicine, Rochester General Hospital
Editors: Andrew K Chang, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
laceration, lip, suture technique, vermilion border, lip wound, lip laceration, complex lip laceration, chipped teeth, tooth fragment, laceration repair, lip wound repair, lip laceration repair, cosmetic lip repair, facial laceration, intraoral laceration, laceration closure, intraoral closure, mucosal laceration, maceration, lip commissure, puncture laceration, facial injury, lower lip nerve block, upper lip nerve block, lip wound irrigation, through-and-through lip wound, facial skin, intraoral skin
Laceration of the lip is an injury commonly seen in emergency departments. Careful repair is necessary to ensure the best cosmetic results.1 For more information, see Facial Soft Tissue Injuries and Facial Soft Tissue Trauma.
The lip is composed of the orbicularis oris muscle covered externally by the skin and internally by oral mucosa. The commissure is the lateral border of the oral cavity where the upper and lower lips join. The vermilion is the white roll that forms the free border of the lip at the cutaneous junction. This area is the focus of repair because even 1 mm of vermilion misalignment may be noticeable.2 For a detailed discussion of lip anatomy, see Lips and Perioral Region Anatomy. (For more information on wound management, please visit the Medscape Wound Management Resource Center.)
Illustration of the upper and lower vermilion border.
Lip laceration involving the lower vermilion border.
Lip laceration involving the upper vermilion border.
Unlike the cosmetically important facial lacerations that are almost always closed primarily, certain small intraoral lacerations may be left open without repair.
Indications for intraoral closure
- Mucosal laceration that creates a flap that interferes with chewing
- Mucosal laceration that is large enough to trap food particles
- Wounds longer than 2 cm
Identification of intraoral skin laceration.
Deep intraoral lip laceration that needs repair.
Certain wounds are best closed in consultation with a plastic surgeon.
- Large flaps
- Large amounts of the vermilion border missing
- Macerated wounds
- Involvement of the commissure
- Loss of more than 25% of the lip3
For more information, see Lip Reconstruction.
Small intraoral lacerations heal well without sutures. Small puncture lacerations through the lip may not require complete closure. The external portion may be repaired while the intraoral portion is allowed to heal without sutures.
Facial injuries give rise to understandable cosmetic concerns. Local infiltration of anesthesia into lip wounds often causes swelling and distortion of original landmarks. In order to obtain the best possible results, perform regional nerve blocks whenever possible.4
Lower lip nerve blocks
Upper lip nerve blocks
- Infraorbital nerve
- Anterior superior alveolar nerve
Pre-anesthetizing the mucosal area with a topical anesthetic 3 minutes prior to infiltrative injection is recommended.
Technique for extraoral infraorbital nerve block.
Intraoral approach for infraorbital nerve block.
Assess the adequacy of anesthesia.
Personal protective equipment - Gloves
- Sterile gloves
- Face shield
- Gown
Anesthesia equipment - Topical anesthetic
- Lidocaine
- Syringe, 10 mL
- Needle, 27 gauge (ga)
- Needle, 18 ga
Irrigation equipment - Sterile saline or water
- Syringe or irrigation device
- Splash shield
- Basin
Suture material - Absorbable sutures (eg, nylon, Ethilon, gut, chromic gut), 4-0 or 5-05
- Nonabsorbable sutures (eg, Dexon, Vicryl), 6-0
- Suture tray
- Suture kit
Equipment for the anesthesia, irrigation, and closure of a lip laceration.
- The supine position is preferred.
Inspection and irrigation
- Once the patient is anesthetized, inspect the wound carefully.
- Gentle probing may be required to visualize through-and-through lacerations.
- Check for concurrent chipped, missing, or mobile teeth.6 Tooth fragments may be lodged inside the wound and, if not removed, may serve as a nidus of infection.
- Intraoral wounds are prone to considerable contamination; therefore, thorough irrigation is necessary.
Irrigation of lip laceration.
Closure
Through-and-through lip wounds are closed in 3 layers.
- Muscular layer
The muscular layer is closed first. Use 4-0 or 5-0 absorbable sutures to anchor the fibrous tissue just underneath the anterior and posterior skin surfaces. In deep but not through-and-through lacerations, deep sutures can be placed using a simple interrupted technique that leaves the knot buried deep within the laceration.
Extraoral approach to close the deep muscular layer.
Wound approximation after 2 deep sutures are placed.
Intraoral approach to close the deep muscular layer.
Wound approximation after placement of deep muscular sutures. - Vermilion border
If the vermilion border is involved, approximate it with the first suture placed on facial skin. Use 6-0 nonabsorbable suture material. The approximation of the vermilion-cutaneous junction is the most crucial step in the closure of lip lacerations that involve the vermilion border. Misalignment of even 1 mm may cause a noticeable step-off when the wound is healed.
Placement of the first suture through the vermilion border.
Placement of the first suture through the vermilion border.
First suture aligning the vermilion border. - Intraoral skin
Intraoral skin may be closed either before or after the facial skin. Approximate the buccal wet mucosa with simple interrupted absorbable sutures (4-0 or 5-0). Secure each stitch with 4 knots to ensure that the stitches are not untied by the tongue. These sutures can be continued onto the wet and dry vermilion surface of the lip. Silk is best avoided in the mouth as it can irritate mucosal tissues. Any small intraoral flaps may be excised. Absorbable sutures fall out or absorb and do not require removal.
Closure of an intraoral skin laceration.
Placement of intraoral skin suture with buried knot.
Closure of an intraoral laceration. - Facial skin
Using 6-0 nonabsorbable sutures, approximate the skin with simple interrupted sutures. This suture material can be continued onto the lip; however, many prefer absorbable sutures on the dry vermilion surface.
Complete closure of the facial skin.
Complete closure of the facial skin.
Aftercare
- The use of prophylactic antibiotics in lip lacerations is controversial; however, antibiotics are generally prescribed in cases of intraoral and through-and-through lacerations.
- Antibiotic ointment may be placed daily over the skin surface of the laceration.
- Remove nonabsorbable sutures in 4-5 days to prevent scarring.
- Emphasis is advised to accurately approximate the vermilion border for cosmesis.
- The location of intraoral lacerations can make repair difficult without assistance for retraction. One option is to have the patient retract his or her own lip.
- If a patient with a lip or oral laceration also has a newly chipped tooth, search diligently for tooth fragments in the oral mucosa. Retained tooth fragments can be visualized on radiographs of the soft tissue. If not removed, such fragments may cause wound infections.
- Don't forget to update a patient's tetanus vaccination, when necessary.
- The risks of contamination and resulting infection are considerable in intraoral lacerations. These risks may be reduced by administration of prophylactic antibiotics. Patients should be educated to return if signs of infection develop. A wound check may be arranged within 48 hours.
- Wounds to the vermilion border may result in deep scars and tissue redundancy that may require later revision by a plastic surgeon.7
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Equipment for the anesthesia, irrigation, and closure of a lip laceration. |
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Lip laceration involving the lower vermilion border. |
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Lip laceration involving the upper vermilion border. |
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Deep intraoral lip laceration that needs repair. |
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Technique for extraoral infraorbital nerve block. |
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Intraoral approach for infraorbital nerve block. |
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Placement of the first suture through the vermilion border. |
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Further inspection of the anesthetized wound reveals a through-and-through laceration. |
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Extraoral approach to close the deep muscular layer. |
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Wound approximation after 2 deep sutures are placed. |
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Placement of intraoral skin suture with buried knot. |
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| Media file 19:
Intraoral approach to close the deep muscular layer. |
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Wound approximation after placement of deep muscular sutures. |
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Placement of the first suture through the vermilion border. |
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Placement of the first suture through the vermilion border. |
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| Media file 25:
Illustration of the upper and lower vermilion border. |
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Complex Laceration, Lip excerpt Article Last Updated: Nov 19, 2007
Topic originally published: Mar 4, 2006
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