result in brain injury On examination, by grasping the maxilla at the level of the central incisors, the clinician may be able to appreciate crepitus or mobility when traction is applied Clear rhinorrhea in the setting of midface trauma may be a sign of a cerebrospinal fluid (CSF) leak and warrants neurosurgical consultation All patients suspected of having a midface fracture require CT imaging to determine whether surgical reduction is necessary Frontal Bone Fractures CLINICAL PEARLS AND PITFALLS Clear rhinorrhea or leakage of clear fluid from a forehead laceration should raise suspicion for fracture of the posterior wall of the frontal sinus with dural tear and CSF leak Clinical Considerations Fractures of the frontal bone are rare in young children because the frontal sinuses not develop until years of age Injury to the frontal sinus may reveal a palpable or visible depression if the anterior wall of the sinus has been compressed Displaced fractures of the anterior wall of the frontal sinus require surgical elevation In patients with severe frontal sinus fractures associated with forehead lacerations, a fracture of the posterior wall of the sinus and dural tear may allow CSF to leak from the wound Leakage of clear fluid from the wound, or clear rhinorrhea, should raise suspicion for such a leak and warrant CT imaging and neurosurgical consultation SOFT TISSUE INJURIES Lacerations Goals of Treatment The goal of laceration repair is to achieve hemostasis and provide an optimal cosmetic result CLINICAL PEARLS AND PITFALLS 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 to 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 FIGURE 107.6 Deep lacerations to the cheek can injure the facial nerve, parotid gland, or parotid duct The facial nerve becomes more superficial as it branches and proceeds distally Distal nerve injuries can thus occur with more superficial wounds Examination for potential injury to Stensen duct is accomplished by grasping the commissure between the thumb and index finger and gently everting the buccal mucosa to identify Stensen duct, which lies on a vertical line along the maxillary second premolar With the opposite hand, gentle massage of the parotid gland is accomplished by pressing in the preauricular region The appearance of clear fluid from Stensen duct suggests an uninjured duct The absence of fluid after several minutes of inspection, or bloody fluid, suggests injury to the gland or duct In this case, inspection of the depth of the wound may reveal salivary fluid and severed ends of the duct may be identified A sialogram can be a useful adjunct in the diagnosis of parotid duct injuries, as well as subspecialty consultation Although most lacerations should be repaired within to 12 hours, clean lacerations of the face can often be reapproximated up to 24 hours after the injury was sustained Later closure may be considered after the risks of infection in closing such a wound are weighed against the benefits of reducing the facial scarring that will result if the wound is allowed to heal secondarily Factors such as mechanism of injury, immunocompetence, and hygiene must be considered Anesthesia, copious irrigation, and tension-free approximation are vital to a successful closure Subspecialty consultation may be warranted for latepresentation lacerations or heavily contaminated wounds, in which the risk of infection is high If possible, facial lacerations should be repaired using buried absorbable sutures, to reduce tension on the wound and to help with eversion of the edges All wounds contract as scar formation occurs and thus eversion of the skin should be achieved for facial lacerations, particularly those involving the nares, eyelids, helix of the ear, and vermilion border of the lower lip Inadequate eversion of the wound edges at these sites may lead to a depressed scar or notching at the site of the laceration For simple scalp lacerations, stapling is a fast and cosmetically acceptable alternative to suturing Repair of complex injuries to laminated structures (e.g., ear, eyelid, nose, lip) requires that each layer of the structure be reapproximated For example, a fullthickness laceration to the nose at the nostril rim requires closure of three separate layers The nasal lining is usually closed first with an absorbable suture material Next, the cartilage must be repaired, also with absorbable material Finally, the overlying skin of the nose can be reapproximated Similarly, complex injuries of the ear, the eyelid, or the lip require layered closure to achieve the best cosmetic result Careful attention should be paid to lip lacerations that traverse the vermilion border Cosmetic outcome is predicated on successful alignment of tissue at this junction Subspecialty consultation may be considered for lacerations involving the external ear, nasal mucosa and cartilage, as well as complex lip lacerations traversing the vermilion border Informed consent should be obtained from patients and families undergoing laceration repair, and this information should be documented in the medical record The physician should provide a careful assessment and natural history of the injury if left untreated to heal on its own The physician should also describe the recommended treatment, as well as alternative treatments, with likely outcomes and possible complications Patients with lacerations resulting from dog bites and those who present for care after a delayed period of time should be advised of the high risk of infection Complicated facial laceration repair and laceration repair in young children may be facilitated by the use of a short-acting benzodiazepine or procedural sedation Current Evidence Randomized controlled trials that compared fast-absorbable plain catgut to nonabsorbable nylon sutures have demonstrated no significant difference in short-