Lacerations to the head and neck form a large number of calls to the A+E department for SHO’s. Commonly these are small, often due to interpersonal violence, falls and RTC’s where they can simply be managed in the emergency department. However, occasionally these can require more complex treatment.


Careful assessment is required to ensure other underlying injuries are not missed. Initial assessment should be carried out by the A+E team and injuries to other body systems should have been completed or review arranged with other relevant teams. Make sure the patient is stable before accepting the referral!

Medical history – details sought as this may influence treatment pathways especially if the patient requires management under GA. Thorough history should include current tetanus immunisation status.

Injury details - mechanism of injury is important as it can suggest the level of contamination. Wounds inflicted by sharp weapons tend to be clean and non-contaminated, except when caused by glass weapons (which can contaminate the wound with glass fragments). Lacerations caused by falls and dog bites are often heavily contaminated therefore require more careful cleaning. High energy injuries may suggest underlying hard tissue injuries.

Examination - a full maxillofacial trauma assessment should be completed to assess for underlying injuries. Ensure the function of anatomically relevant underlying structures e.g. parotid duct, facial nerve. Complete an intra-oral examination as concurrent dental and soft tissue injuries are common. Careful assessment of the eye may be required (by the ophthalmology team if lacerations are closely situated to the eye as concurrent ocular injuries can occur).

Figure 1. Lower lip laceration [1]


Soft tissue injuries should be repaired as soon as possible, ideally within 24 hours. Often this can be done under effective local anaesthetic however some special circumstances may require management under a GA.

• Local anaesthetic (cartidge, syringe and handle)
• Gauze
• Saline
• Suture kit
• Sutures (e.g. vicryl rapide, ethilon etc.)
• Entonox (if treating paedatric patient)

Figure 2. Equipment for lacerations [2]

The tetanus status of the patient should be investigated. Tetanus is a life threatening condition. Tetanus prone wounds include:
• Puncture-type injuries acquired in a contaminated environment and likely therefore to contain tetanus spores e.g. gardening injuries
• Wounds containing foreign bodies
• Open fractures
• Wounds or burns with systemic sepsis
• Certain animal bites and scratches - although smaller bites from domestic pets are generally puncture injuries animal saliva should not contain tetanus spores unless the animal has been routing in soil or lives in an agricultural setting

High-risk tetanus-prone wounds include: Any of the above with either:
• Heavy contamination with material likely to contain tetanus spores e.g. soil, manure
• Wounds or burns that show extensive devitalised tissue
• Wounds or burns that require surgical intervention that is delayed for more than six hours are high risk even if the contamination was not initially heavy

Thorough cleaning of wounds is essential!
Public Health England (PHE) have produced guidelines regarding immunisation recommendations for clean and tetanus-prone wounds. See below.

Figure 3. Immunisation recommendations for clean and tetanus-prone wounds [3]

Wounds should be thoroughly cleaned to address wound contamination. This can result in increased infection risk or even tattooing of the skin when debris becomes impregnated into the dermis. The wound should be thoroughly inspected for foreign bodies (which should be removed) and underlying tissue damage, including important anatomical structures and underlying bony injury. If found, they may change your management strategy.
Wound closure:
• Very superficial and well approximated wounds may only require glue or steri-strips
• Wound edges should be debrided, and obviously necrotic skin removed
• Closure of wound in tissue layers (using resorbable sutures for the deeper layers)
• Use non-resorbable sutures (4/0 – 6/0) unless it is not practical to remove these sutures (e.g. children). In this case resorbable sutures should be used.
• Careful attention to re-alignment of the vermillion border should be employed when closing lip lacerations
• Wounds on the scalp can often be closed with staples

Figure 4. Suturing a lip laceration [4]

Post-op Care – Prophylactic antibiotics should be considered for:
• Contaminated wounds/bites
• Associated surgical emphysema
• Prolonged time prior to closure
The antibiotic choice will depend on local hospital policy and should continue for at least 5 days. The use of topical preparations (e.g. chloramphenicol) is contentious and you should be guided by your seniors and local protocol.
If non-resorbable sutures are placed, the patient should be instructed to see their GP practice for suture removal in 5-7 days. Simple wound care advice should be given, and appropriate dressing provided. Complex wounds, those at risk of significant infection or with tissue loss may require review in the maxillofacial clinic.

Special Considerations

Lacerations are common in children, but management can be difficult due to compliance. Children will often accept LA with careful patient management and positive parental engagement however other management strategies may need to be employed.
• LAT gel
• Entonox with LA
• GA
These management issues can also be encountered when dealing with special needs adults, where the same treatment strategies can be adopted.


These are becoming more common especially in children. These wounds require careful cleaning to prevent infections. Antibiotics should be prescribed. These wounds often involve tissue loss. If small, the wound can often be debrided and closed primarily. However, if extensive or involving certain anatomical locations, tissue grafting may be required. If determined that this is not the case, careful dressings (often with community/dressings clinic follow-up), should be arranged. It is often prudent to follow-up dog bites in clinic to ensure healing. Some units require you to report dog bites in children to safeguarding services within the hospital.

Figure 5. Dog-bite [5]

Dental Injuries

If teeth are unaccounted for a chest x-ray may need to be completed to ensure that they have not been inhaled. If lacerations (especially lips) are associated with missing tooth/restoration fragments soft tissue x-rays can help to determine if they are within the wound. These can also be useful in wounds involving glass or if heavily contaminated with gravel/metal shards.

Figure 6.Chest X-Ray - lost tooth [6]

Injuries to ear/nose

These injuries are often managed by either the ENT or maxillofacial team. Special attention should be paid to lacerations with involve cartilage as avascular necrosis can occur if not managed correctly. Lacerations involving cartilage may require debridement of loose fragments or re-approximation. Deformity of the ear (causing cauliflower ear) can also occur if local haematoma is not managed appropriately with pressure dressings.

Figure 7. Cauliflower ear [7]

Injuries involving the eye

As previously mentioned injuries close to the eye require careful assessment. Simple eyelid lacerations can often be closed by the maxillofacial team however if they involve the lacrimal or levator apparatus, require specialist input from the ophthalmology team. Any suspicion of intra-ocular injury or foreign body also requires special opinion

Figure 8. Laceration involving the eye [8]

Self-inflicted wounds

Patients who present with self-inflicted wounds (often to the neck) may or may not have underlying mental health concerns. Prior to discharge they should be assessed by the resident acute psychiatric team to assess if these patients are safe for discharge and their ongoing psychological support.

Figure 9. Penetrating neck wound due to
suicide attempt [9]

When to involve the registrar

Uncontrollable bleeding

The head and neck is a highly vascular region. Commonly vessels can be injured leading to uncontrollable bleeding, frequently superficial temporal artery or labial artery. Vessels may require tying off either in A+E or in theatre.
Initial management while waiting:
• A-E assessment (patients can become haemodynamically unstable)
• Local measures e.g. sit patient up, direct pressure
• Bloods (FBC, U+E, LFT, clotting/INR) + cannula
• If theatre is required arrange initial anaesthetic review and book emergency theatre

Figure 10. Blood supply of the head and neck [10]

Damage to underlying structures

Careful assessment is required to assess for damage to deeper/important structures. Wounds involving the parotid duct/parotid capsule or divisions of the facial nerve require exploration and repair in theatre to prevent long term complications. With respect to lacerations involving the facial nerve, if the wound is medial to a vertical line drawn from the lateral canthus of the eye, often the nerve to too small to re-anastomose. Always discuss these cases with the on call SpR.
Initial management while waiting:
• Prepare patient for admission/GA
• Dress the wound or tack closed to prevent oozing/infection
• If upper branches of the facial nerve are involved, preventing eye closure this requires eye dressing and lubrication

Figure 11. Facial nerve distribution [11]

Neck wounds

In some units these are managed by ENT. In others it is the maxillofacial team. Lacerations to the neck, even if superficial can involve several important anatomical structures and you should involve the registrar early. These include the following:
• Nerves (Marginal mandibular, vagus, accessory, hypoglossal)
• Vessels (External/Internal jugular, ICA)
• Other (trachea, oesophagus, thyroid, thoracic duct, parotid)

Figure 12. Zones of the neck [12]

Careful assessment is required to identify injury to these structures. If identified, they may require other teams to be involved e.g. ENT, vascular surgeons. Depending on the wound trajectory, mediastinal and chest injury can occur, requiring cardiothoracic input. Patients presenting with neck wounds if haemodynamically stable require CT angiography looking for occult vascular injury. If unstable, these patients require urgent transfer to the emergency theatre. Airway injuries and catastrophic bleeding require urgent treatment.

Often these patients arrive as a trauma call and the initial management has been completed, however things to consider while waiting:
• A-E assessment and management
• Bloods (FBC, U+E, clotting/INR, G+S x2) + cannula
• Ensure essential imaging arranged
• Contact emergency anaesthetist/theatres
• Contact other teams relevant to care e.g. ENT, vascular etc

Extensive/complex lacerations

These wounds often require a GA to manage effectively. The patient should be discussed with the SpR and admitted. Often due to the level of wound contamination the patient should be commenced on antibiotics. This also includes lacerations with tissue loss. Wounds can be temporarily tacked together to aid haemostasis and help reduce infection risk.

Figure 13. Complex laceration from dog bite [13]


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[2] ER Minor Laceration Tray, Adson Dressing Forceps Serrated [Internet]. BM Global Supply Corporation. Available from:
[3] Tetanus: advice for health professionals [Internet]. GOV.UK. Available from:
[4] Author unknown
[5] Ovais H, Adil H, MA D, Beenish M. Analysis of Dog Bite Injuries in Kashmir. Pulsus [Internet]. 2017. Available from:
[6] Bourcier J, Babinet M, Didier D. Lung Ultrasound Leading to a Diagnosis of Bronchial Foreign Body. Journal of Pulmonary and Respiratory Medicine [Internet]. 2016. Available from:
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[8] laceration E. Eyelid laceration [Internet]. American Academy of Ophthalmology. 2020. Available from:
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[10] HMA/Lectures/Anatomy of the peripheral vasculature [Internet]. StudyingMed. 2020. Available from:
[11] Image from: Lesser Petrosal Nerve - an overview | ScienceDirect Topics [Internet]. 2020. Available from:
[12] [Internet]. Available from:
[13] Pre-operative photograph showing extensive dog bite injury over the face. The official publication of the national postgradudate medical college of Nigeria. (Futher details unobtainable)