eMedicine Specialties > Clinical Procedures > Soft Tissue Procedures

Complex Laceration, Lip

Gretchen S Lent, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Linda G Liu, MD, Attending Physician, Department of Emergency Medicine, Rochester General Hospital

Updated: Jul 27, 2009

Introduction

Laceration of the lip is an injury commonly seen in emergency departments. Careful repair is necessary to ensure the best cosmetic results.^1,2 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.^3,4 For a detailed discussion of lip anatomy, see Lips and Perioral Region Anatomy.

Illustration of the upper and lower vermilion border.

Lip laceration involving the lower vermilion border.

Lip laceration involving the upper vermilion border.

Indications

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.

Contraindications

• Certain wounds are best closed in consultation with a plastic surgeon. For more information, see Lip Reconstruction.
  • Large flaps
  • Large amounts of the vermilion border missing
  • Macerated wounds
  • Involvement of the commissure
  • Loss of more than 25% of the lip⁵
• 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.

Anesthesia

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.⁶

Lower lip nerve blocks

• Mental nerve
• Inferior alveolar nerve

• Infraorbital nerve
• Anterior superior alveolar nerve

Technique for extraoral infraorbital nerve block.

Intraoral approach for infraorbital nerve block.

Assess the adequacy of anesthesia.

Equipment

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 5-0⁷
• Nonabsorbable sutures (eg, Dexon, Vicryl), 6-0
• Suture tray
• Suture kit

Equipment for the anesthesia, irrigation, and closure of a lip laceration.

Positioning

• The supine position is preferred.

Technique

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.⁸ 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.

  
  

• 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.

  
  

• 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.

Pearls

• 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.⁹  Retained tooth fragments can be visualized on radiographs of the soft tissue.¹⁰  If not removed, such fragments may cause wound infections.
• Don't forget to update a patient's tetanus vaccination, when necessary. 

Complications

• The risks of contamination and resulting infection are considerable in intraoral lacerations.¹¹ 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.¹²

Multimedia

Media file 1: Equipment for the anesthesia, irrigation, and closure of a lip laceration.

Media file 2: Lip laceration involving the lower vermilion border.

Media file 3: Identification of intraoral skin laceration.

Media file 4: Lip laceration involving the upper vermilion border.

Media file 5: Deep intraoral lip laceration that needs repair.

Media file 6: Technique for extraoral infraorbital nerve block.

Media file 7: Intraoral approach for infraorbital nerve block.

Media file 8: Assess the adequacy of anesthesia.

Media file 9: Placement of the first suture through the vermilion border.

Media file 10: Assessing for mobile or broken teeth.

Media file 11: Further inspection of the anesthetized wound reveals a through-and-through laceration.

Media file 12: Extraoral approach to close the deep muscular layer.

Media file 13: Wound approximation after 2 deep sutures are placed.

Media file 14: Irrigation of lip laceration.

Media file 15: First suture aligning the vermilion border.

Media file 16: Placement of intraoral skin suture with buried knot.

Media file 17: Closure of an intraoral skin laceration.

Media file 18: Closure of an intraoral laceration.

Media file 19: Intraoral approach to close the deep muscular layer.

Media file 20: Wound approximation after placement of deep muscular sutures.

Media file 21: Placement of the first suture through the vermilion border.

Media file 22: Placement of the first suture through the vermilion border.

Media file 23: Complete closure of the facial skin.

Media file 24: Complete closure of the facial skin.

Media file 25: Illustration of the upper and lower vermilion border.

References

1. McCarn KE, Park SS. Lip reconstruction. Facial Plast Surg Clin North Am. May 2005;13(2):301-14, vii. [Medline].

2. Nabili V, Knott PD. Advanced lip reconstruction: functional and aesthetic considerations. Facial Plast Surg. Jan 2008;24(1):92-104. [Medline].

3. Galyon SW, Frodel JL. Lip and perioral defects. Otolaryngol Clin North Am. Jun 2001;34(3):647-66. [Medline].

4. Brown DJ, Jaffe JE, Henson JK. Advanced laceration management. Emerg Med Clin North Am. Feb 2007;25(1):83-99. [Medline].

5. Calhoun KH. Reconstruction of small- and medium-sized defects of the lower lip. Am J Otolaryngol. Jan-Feb 1992;13(1):16-22. [Medline].

6. Zide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg. Mar 1998;101(3):840-51. [Medline].

7. Horton CE, Adamson JE, Mladick RA, Carraway JH. Vicryl synthetic absorbable sutures. Am Surg. Dec 1974;40(12):729-31. [Medline].

8. Heintz WD. Dealing with dental injuries. Postgrad Med. Jan 1977;61(1):261-2, 264, 266. [Medline].

9. Rao D, Hegde S. Spontaneous eruption of an occult incisor fragment from the lip after eight months: report of a case. J Clin Pediatr Dent. Spring 2006;30(3):195-7. [Medline].

10. Pektas ZO, Kircelli BH, Uslu H. Displacement of tooth fragments to the lower lip: a report of a case presenting an immediate diagnostic approach. Dent Traumatol. Dec 2007;23(6):376-9. [Medline].

11. Baurmash HD, Monto M. Delayed healing human bite wounds of the orofacial area managed with immediate primary closure: treatment rationale. J Oral Maxillofac Surg. Sep 2005;63(9):1391-7. [Medline].

12. Parlin LS. Repair of lip lacerations. Pediatr Rev. Mar 1997;18(3):101-2. [Medline].

13. Bailey BJ, Nichols ML. Small defects (vermilion mucosa and less than one-third lower lips). In: Calhoun KH, Sternberg CM, eds. Surgery of the Lip. New York, NY: Thieme; 1992.

14. Calhoun KH. Lip anatomy and function. In: Calhoun KH, Sternberg CM, eds. Surgery of the Lip. New York, NY: Thieme; 1992:1-11.

15. Daver BM, Antia NH, Furnas DW. Lip and Cheek. In: Handbook of Plastic Surgery for the General Surgeon. 2^nd ed. New York, NY: Oxford; 2000:123-128 Chap 7.

16. Greer SE, Benhaim P, Lorenz HP, et al. Lip Reconstruction. In: Handbook of Plastic Surgery. New York, NY: Marcel Dekker; 2004:195-201 Chap 38.

17. Marks MW, Marks C. Reconstructive Procedures of the Face. In: Fundamentals of Plastic Surgery. Philadelphia, Pa: WB Saunders; 1997:240-242 Chap 13.

18. Marx JA, Hockberger RS, Walls RM. Rosen's Emergency medicine: concepts and clinical practice. St Louis, Mo: Mosby; 2002.

19. Reichman E, Simon RR. Management of Specific Soft Tissue Injuries. In: Emergency Medicine Procedures. New York, NY: McGraw-Hill; 2004:748-762 Chap 80.

20. Roberts J, Hedges J. Clinical Procedures in Emergency Medicine. 4^th ed. Portland, OR: WB Saunders; 2004.

21. Samo DG. A technique for parallel lacerations. Ann Emerg Med. Mar 1988;17(3):297-8. [Medline].

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

Contributor Information and Disclosures

Author

Gretchen S Lent, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Linda G Liu, MD, Attending Physician, Department of Emergency Medicine, Rochester General Hospital
Linda G Liu, MD is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

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
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Gretchen S Lent, MD, and Linda G Liu, MD, to the development and writing of this article.

Clinical guideline on management of acute dental trauma
American Academy of Pediatric Dentistry - Professional Association. 1991 (revised 2007 May). 14 pages. NGC:006230

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