Resident Manual of Trauma to the Face, Head and Neck

6. Anterior Lamella Lacerations Anterior lamella lacerations typically only require skin repair. The orbicularis oculi fibers are densely adherent to the skin and will pas- sively approximate with skin closure. Deep sutures tend to accentuate intramuscular scarring and increase risk of lid malposition, retraction, and ectropion. 7. Lacrimal Canalicular Injury Lacrimal canalicular injury may require cannulation with repair or Crawford tube placement. This is best done in the operative setting and with ophthalmologic surgical guidance. 8. Canthal Injuries y y Medial canthal tendon avulsion and canthi laceration may denote naso-orbital-ethmoid fracture. See Chapter 3 for repair techniques. y y Lateral canthal repair must ensure resuspension of the canthal tendon to periosteum, approximating Whitnall’s tubercle and cantho- plasty with “gray line” approximation. 9. Closure at the Lid Margin Closure at the lid margin should be done with eversion of the skin edges to help prevent notching. 10. Lid Margin and Proximal Anterior Lamella Sutures All lid margin and proximal anterior lamella sutures should be cut with longer tails draped away from the lid margin. This helps prevent corneal irritation and abrasion. Tails can be secured with distally placed sutures or Mastisol® (Ferndale) skin adhesive and Steri-Strip™ dressings. 11. Superior Lid Lacerations In superior lid lacerations, particularly horizontal injuries, assessment of levator palpebrae superioris function is crucial. Muscle or aponeurosis separation from the superior tarsus will lead to traumatic ptosis. Reattachment can be established, depending on surgical skill and tissue quality. If bruising, edema, muscle contraction back into the orbit, or inexperience makes appropriate repair unlikely, the laceration should be repaired in a delayed setting in the operative theatre with ophthalmol- ogy assistance. 12. Visible Orbital Fat If orbital fat is visible within the wound, the orbital septum has been violated. This, too, is reason for further evaluation and repair in the operative setting.

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