Assessment and management of lip lacerations

INTRODUCTION — This topic will discuss the assessment and management of lip lacerations. Assessment and management of other facial lacerations, tongue lacerations, and general discussions on wound preparation and suturing are provided separately:

●(See "Assessment and management of facial lacerations".)

●(See "Evaluation and repair of tongue lacerations".)

●(See "Minor wound evaluation and preparation for closure".)

●(See "Skin laceration repair with sutures".)

BACKGROUND — Minor wound management should reduce the likelihood of infection and be performed to achieve minimal scarring [1]. It is especially critical that lip lacerations are repaired correctly to preserve the cosmetic appearance and functionality of the lip. When interacting with people, our vision is immediately directed towards the eyes and lips highlighting the aesthetic importance of lip structure. The lip also serves a critical role in speech articulation, food ingestion, and tactile sensation. Most lacerations can be repaired by the emergency clinician; however, there are rare circumstances where specialist referral may be necessary. (See 'Indications for subspecialty consultation or referral' below.)

ANATOMY — The lip is a unique structure in the body and in cross section is composed of three layers: the mucosal layer (within the oral cavity), the middle muscular layer (orbicularis oris muscle), and the outer mucosal layer consisting of the wet vermillion (internal oral) and the dry vermillion (external oral) or the "red lip" (figure 1). The cosmetic outline of the lip where the facial skin meets the vermillion is referred to as the vermillion border. Aesthetically the vermillion border is crucial as light reflects at this juncture and misalignment by 1 mm will cause a noticeable scar.

The blood supply to the lip arises from the superior and inferior labial arteries which are branches of the facial artery (figure 2).

The lip is innervated by the infraorbital and inferior alveolar nerves which arise from the trigeminal nerve (cranial nerve V) (figure 3).

EVALUATION — In most instances, lip lacerations result from isolated trauma. However, as for all trauma patients, the initial clinical assessment should focus on rapid identification of potentially fatal conditions. For victims of major trauma, there should be immediate evaluation for airway compromise (while maintaining cervical spine immobilization) including the presence of midface (LeFort) injuries and dental or jaw fractures with oral hemorrhage, impaired breathing, hemorrhagic shock, and altered level of consciousness. Systematic evaluation helps ensure that potentially life-threatening injuries are promptly detected.

The approach to the injured child or adult is discussed in detail separately (table 1). (See "Trauma management: Approach to the unstable child", section on 'Primary survey' and "Initial management of trauma in adults".)

In victims of major trauma, lip lacerations should be assessed during a careful and organized secondary survey. (See "Trauma management: Approach to the unstable child", section on 'Secondary survey'.)

History — The clinician should identify the following aspects of the injury:

●Traumatic force (eg, high-speed motor vehicle collision with significant likelihood of associated injuries versus fall from standing height with no other symptoms)

●Associated symptoms of head injury (eg, altered mental status, vomiting, headache) (see "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'History' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'History')

●Age of wound

●Presence of tooth looseness, pain, or sensitivity to hot or cold (see "Evaluation and management of dental injuries in children", section on 'Evaluation' and "Initial evaluation and management of facial trauma in adults", section on 'History and physical examination')

●Jaw pain (see "Mandibular (jaw) fractures in children", section on 'Clinical features' and "Initial evaluation and management of facial trauma in adults", section on 'Examination of specific body parts')

●Difficulty in opening and closing the mouth, suggesting displaced teeth, jaw, or facial fracture (see "Evaluation and management of dental injuries in children", section on 'Evaluation' and "Initial evaluation and management of facial trauma in adults", section on 'History and physical examination')

●Foreign body sensation (eg, embedded tooth, glass, or gravel)

The history should also include a comprehensive review of the underlying medical history (eg, diabetes mellitus, cancer, prior keloid formation), medication use (eg, immunosuppressive agents), and social habits (eg, tobacco use) that may negatively affect healing and increase the risk for a poor outcome. (See "Minor wound evaluation and preparation for closure", section on 'Risks for poor outcome'.)

The clinician should also inquire about allergies to latex, any medications (especially local anesthetics), and the patient's tetanus immunization status. (See "Allergic reactions to local anesthetics", section on 'Evaluation' and "Assessment and management of facial lacerations", section on 'Tetanus prophylaxis'.)

Physical examination — Wound assessment should identify the following:

●Location of the injury (figure 1)

●Depth of the injury

●Length of the laceration in centimeters

●Whether the laceration extends through the vermillion border

●Whether the laceration passes through all layers of the lip ("through-and-through" injury)

●Presence of a foreign body

●Ongoing bleeding

The clinician should also evaluate for the following associated injuries to the face, teeth, and jaw:

●Dental fractures (see "Evaluation and management of dental injuries in children", section on 'Examination' and "Initial evaluation and management of facial trauma in adults", section on 'Dental injury')

●Loose, displaced, or missing teeth (see "Evaluation and management of dental injuries in children", section on 'Examination' and "Initial evaluation and management of facial trauma in adults", section on 'Dental injury')

●LeFort fracture suggested by malocclusion, midface instability, ecchymosis over the cheek, anesthesia of the region supplied by the infraorbital nerve (upper lip, alveolar ridge, lateral nose, lower eyelid) (figure 3) or enophthalmos (see "Initial evaluation and management of facial trauma in adults", section on 'Midface' and "Nasal trauma and fractures in children and adolescents", section on 'Physical examination')

●Jaw fracture suggested by malocclusion, trismus (unable to open jaw more than 5 cm), pain over the temporomandibular joint, or jaw tenderness (see "Mandibular (jaw) fractures in children" and "Initial evaluation and management of facial trauma in adults", section on 'Temporomandibular joint')

Ancillary studies — Patients with clinical features suggestive of associated injuries warrant additional studies as follows:

●Midface fractures – When suspected, visualization of fractures among the complex curves of facial bones is best achieved using computed tomography (CT). CT scans of the face should include fine cuts and both coronal and sagittal reconstructions. CT angiography may be useful if the patient has a significant or expanding facial hematoma or if injury to or dissection of the carotid artery is a concern. (See "Initial evaluation and management of facial trauma in adults", section on 'Facial injury'.)

●Mandibular and dental fractures – Computed tomography (CT) accurately detects mandible fractures. The U-shape of the mandible and the presence of adjacent bony structures make it impossible to isolate the mandible on a flat x-ray film. Therefore, simple radiographs of the mandible are less sensitive for detecting fractures than panoramic radiographs (ie, Panorex) and can miss fractures of the condyle. If available, Panorex imaging can be used for isolated mandibular fractures, dental fractures, or fractures of the alveolar ridge instead of CT. (See "Initial evaluation and management of facial trauma in adults", section on 'Mandibular injury'.)

INDICATIONS FOR SUBSPECIALTY CONSULTATION OR REFERRAL — Consultation with an appropriate specialist (eg, plastic or maxillofacial surgeon, dentist), if available, is suggested in the following situations:

●Crush wounds or other wounds with significant amounts of devitalized tissue

●Wounds with large defects, particularly of the upper lip

●Luxation injuries in which the teeth are extruded or laterally displaced with malocclusion (see "Evaluation and management of dental injuries in children", section on 'Other luxation injuries')

●Permanent (secondary) tooth avulsion (see "Evaluation and management of dental injuries in children", section on 'Avulsions')

●Mandibular fracture (see "Mandibular (jaw) fractures in children", section on 'Management')

●LeFort fracture (see "Initial evaluation and management of facial trauma in adults", section on 'Midface')

WOUND REPAIR

Indications for primary closure — Primary closure (ie, wound repair at the time of presentation) is the preferred treatment for most lip lacerations.

Delayed primary closure (ie, cleansing and debridement at the time of initial presentation with definitive wound closure performed electively four to five days later) may be appropriate for wounds of the lip that present after 24 hours and have increased risk for infection. In general, the decision should be based upon the time from injury, patient factors that increase the risk of infection (eg, vascular insufficiency or in adults, diabetes mellitus), and wound factors (bite wound, other contamination, or foreign body potential). (See "Minor wound evaluation and preparation for closure", section on 'Type of closure'.)

Contraindications and precautions — Wounds with obvious signs of inflammation (redness, warmth, swelling, pus drainage) should not be closed primarily. Lip laceration repair should also not delay further evaluation and definitive care of more urgent traumatic injuries, including underlying midface or jaw injuries.

When using delayed primary closure, saline-soaked gauze packing (wet-dry closure) can be provided to enhance secondary healing. Appropriate antibiotic coverage (eg, amoxicillin-clavulanate or in penicillin-allergic patients, clindamycin) aimed at the flora of the skin and possibly upper respiratory tract can be initiated in selected patients with wounds other than bite wounds (eg, patient with diabetes mellitus, or other risks for poor wound outcome), although there is no direct evidence supporting any benefit. (See "Minor wound evaluation and preparation for closure", section on 'Type of closure'.)

Indications and empiric oral antibiotic regimens for patients with animal bites (table 2) and human bites (table 3) are discussed separately. (See "Animal bites (dogs, cats, and other mammals): Evaluation and management", section on 'Management' and "Human bites: Evaluation and management", section on 'Antibiotic prophylaxis'.)

Preparation — Preparation for the care of lip lacerations includes a discussion of the likely outcomes of repair, the choice of repair, assembly of the appropriate equipment, provision of anesthesia and analgesia, and wound debridement and cleansing. The patient and/or caregiver must be aware of the general risks of laceration repair, which include infection, pain and scarring.

Anesthesia and analgesia

Regional block — Regional nerve blocks are the anesthetic method of choice for lip laceration repair. Direct infiltration of local anesthetic into lip lacerations should be avoided as this can distort the lip tissue, making it more difficult to complete an optimal cosmetic repair. Infraorbital (figure 4) and mental nerve blocks (figure 5) anesthetize the skin and mucosal surfaces of the upper and lower lips respectively. If the laceration crosses the midline, bilateral nerve blocks should be performed.

The techniques for infraorbital and mental nerve blocks are discussed in detail separately. (See "Assessment and management of facial lacerations", section on 'Facial nerve blocks'.)

Nonpharmacologic interventions such as the use of biobehavioral and cognitive distraction may be useful when performing regional blocks in children and other apprehensive patients. (See "Procedural sedation in children: Approach", section on 'Nonpharmacologic interventions'.)

Procedural sedation — Procedural sedation is likely to maximize patient comfort and cosmetic outcomes in the following situations:

●Lip lacerations in young or uncooperative children that require precise approximation (eg, lacerations of the vermillion border)

●Complex lip lacerations that require extensive revision

●Highly anxious or otherwise uncooperative patients, especially when the safety of clinician and staff may be compromised

Procedural sedation in children and adults is discussed in more detail separately. (See "Procedural sedation in children: Approach" and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

Irrigation and debridement — Local or regional anesthesia prior to initiating irrigation and wound cleansing improves patient comfort. In young children and patients with heavily contaminated wounds, procedural sedation may also be necessary so that wound preparation can be tolerated. (See "Assessment and management of facial lacerations", section on 'Anesthesia and analgesia'.)

Oral and perioral wounds are contaminated wounds since saliva typically contains one million bacteria per milliliter [2]. Local wound inoculums of 100,000 bacteria per gram of tissue are sufficient to cause wound infection. Although irrigation with normal saline has not been shown to decrease rates of infection, the authors and others still perform irrigation of lip lacerations to enhance removal of gross contaminants within the wound [3,4]. The suggested volume of irrigation solution is approximately 50 to 100 mL per centimeter of laceration. Particularly in sedated patients, care should be taken to frequently perform oral suction and to maintain patients in a head-up position so that aspiration of irrigation solution is prevented.

Antiseptics, such as chlorhexidine, povidone-iodine solution (Betadine), or hydrogen peroxide, should be avoided because they are cytotoxic and can cause tissue injury [3,4].

The presence of nonviable tissue increases the rate of infection after wound closure and such tissue should therefore be removed. However, debridement of lip lacerations and oral wounds should not routinely be performed by emergency clinicians because it distorts the original architecture and alters the cosmetic appearance. The presence of crushed, devitalized or necrotic tissue is a potential indication for surgical specialty consultation. (See 'Indications for subspecialty consultation or referral' above and "Minor wound evaluation and preparation for closure", section on 'Debridement'.)

The clinician should not shave facial hair near the laceration because shaving is associated with the deposition of bacteria into the wound [4]. If facial hair impedes visualization of the wound, it can be clipped with scissors or smoothed down away from the wound edge with normal saline or petrolatum.

Equipment — The following equipment should be assembled for facial laceration repair:

●Sterile gloves

●Surgical mask

●Eye protection

●Buffered 1 or 2 percent lidocaine (with or without epinephrine) or similar local anesthetic (table 4); lidocaine with epinephrine is preferable for patients with ongoing bleeding and for most regional blocks; plain lidocaine is preferred for the patient undergoing direct infiltration so that blanching does not obscure the vermillion border

●Small volume syringe (eg, 3 or 6 mL) with small gauge needle (eg, 25 or 27 gauge) for infiltration of local anesthetic; a short needle (eg, 0.625 inch) is preferable for young children or other patients in whom movement is anticipated

●Nonabsorbable suture for skin closure (table 5): 5.0 or 6.0; absorbable suture (eg, fast-absorbing gut) can also be used, avoiding the need for suture removal. Absorbable as well as 6.0 sutures are preferred in young children.

●Absorbable suture for submucosal closure: 4.0 or 5.0 absorbable suture (5.0 in children), such as polyglactin 910 (Vicryl) or poliglecaprone 25 (Monocryl)

●Absorbable suture for muscle layer closure: 5.0 absorbable suture such as polyglactin 910 (Vicryl) or poliglecaprone 25 (Monocryl)

●Absorbable for surface mucosal closure: 5.0 or 6.0 absorbable suture (6.0 in children), chromic gut

●Needle holder

●Hemostat

●Tissue forceps

●Scissors

●Surgical probe

●Sterile 4 x 4 gauze

●Absorbent towels

●Sterile field drapes

Emergency departments generally are well-equipped with minor surgical or suture trays that contain the instruments, sterile gauze, towels, and drapes listed above.

Techniques

●Superficial dry vermillion lacerations – Superficial lacerations of the dry vermillion (visible part of the lip when the mouth is closed (figure 1)) that extend to the submucosa and do not involve the vermillion border should be closed with 5.0 or 6.0 chromic or fast-absorbing gut (6.0 in children) using simple interrupted sutures. (See "Skin laceration repair with sutures", section on 'Percutaneous closure'.)  

●Superficial wet vermillion lacerations – Most small, superficial lacerations of the wet vermillion (inner portion of the lip when the mouth is closed (figure 1)) do not require closure.

However, lacerations that have ongoing oozing of blood and that are longer than 2 cm or have a gaping defect or flap should be closed so that food particles do not get stuck in the wound. The clinician should repair these wounds with 5.0 or 6.0 chromic gut using deep buried stitches to avoid irritation of the gums, mucosa, and tongue and suture dislodgement (figure 6). Suture knots should be secured with at least four square knots. Nonabsorbable sutures should not be placed within the oral mucosa as they are irritating to adjacent structures.

●Lacerations through the vermillion border – Precise repair of the vermillion border is essential for a good cosmetic outcome. When repairing the vermillion border, the clinician should first place a "stay stitch" at the vermillion border to ensure proper alignment using 6-0 nonabsorbable suture (eg, polypropylene [Prolene] or nylon [Ethilon]) (figure 7).

Once the vermillion border is approximated, simple skin lacerations should be closed with simple interrupted stitches using 5.0 or 6.0 (6.0 in children) nonabsorbable suture (eg, polypropylene [Prolene] or nylon [Ethilon]). In children and older patients for whom follow-up is not assured, skin closure may be accomplished with 6.0 fast-absorbing gut.

Lacerations of the vermillion and the oral mucosa should be repaired with 5-0 or 6-0 absorbable (chromic gut) sutures as described above.

●Through-and-through lip lacerations – Lacerations that extend through all layers of the lip (figure 1) should be closed in stepwise fashion as follows (figure 8) [5]:

•Prepare the wound as described above. (See 'Irrigation and debridement' above.)

•Debride any obviously traumatized minor salivary glands to avoid delayed formation of a mucocele.

•Align the vermillion border using 6-0 nonabsorbable suture (eg, polypropylene [Prolene] or nylon [Ethilon]) (figure 7).

•Close the inner fibrofatty junction with 4.0 or 5.0 absorbable suture such as polyglactin 910 (Vicryl) or poliglecaprone 25 (Monocryl) suture (5.0 in children) as shown in plate B of the figure (figure 8).

•Re-irrigate the wound from the outside.

•Close the outer fibrofatty junction with 4.0 or 5.0 absorbable suture such as polyglactin 910 (Vicryl) or poliglecaprone 25 (Monocryl) suture (5.0 in children) as shown in plate C of the figure (figure 8).

•Identify and close any laceration to the orbicularis muscle layer located beyond the vermillion border with 5.0 absorbable suture such as polyglactin 910 (Vicryl) using deep buried sutures (figure 6).

•Close the wet and dry vermillion as described above.

•Close the skin beyond the vermillion border with 5.0 or 6.0 (6.0 in children) using nonabsorbable suture (eg, polypropylene [Prolene] or nylon [Ethilon]). In children and older patients for whom follow-up is not assured, skin closure may be accomplished with 6.0 fast-absorbing gut.  

OTHER CONSIDERATIONS

Tetanus prophylaxis — Tetanus prophylaxis should be provided for all wounds as indicated (table 6). Tetanus prophylaxis for pregnant women depends upon their immunization history and is discussed in detail separately. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination'.)

Prophylactic antibiotics — We suggest that patients with through-and-through lip lacerations as well as those with significant mucosal involvement receive prophylactic antibiotics selected to cover oral flora (eg, penicillin, amoxicillin, cephalexin, or in penicillin-allergic patients, clindamycin). However, evidence does not support administration of antibiotics to all patients with lip lacerations, especially clean wounds that do not involve wet mucosal surfaces.

The risk of wound infection following lip laceration varies from 9 to 27 percent [6-11], and one single center observational study suggests that there is significant practice variation for the prescribing of prophylactic antibiotics to patients with oral lacerations [11]. Randomized trials have not shown a significant benefit of empiric antibiotics but have enrolled low numbers of patients and have not been blinded [12]. One study did find fewer infections in compliant patients and in patients with more extensive lacerations (eg, through-and-through lip lacerations) versus no treatment (0 versus 18 percent and 7 versus 27 percent, respectively) although these results were not statistically significant [9].

Taken together, the evidence suggests that antibiotics may decrease the rate of wound infection after repair of lip lacerations with significant mucosal involvement and that this is a reasonable therapy given that oral and perioral lacerations are contaminated by abundant facultative species and obligate anaerobes. However, clean lacerations that do not involve wet mucosal surfaces and occur in healthy patients do not require antibiotic prophylaxis.

Indications and empiric oral antibiotic regimens for patients with animal bites (table 2) and human bites (table 3) are discussed separately. (See "Animal bites (dogs, cats, and other mammals): Evaluation and management", section on 'Management' and "Human bites: Evaluation and management", section on 'Antibiotic prophylaxis'.)

Bite wounds — Bites, scratches, abrasions, or contact with animal saliva via mucous membranes or a break in the skin all can transmit rabies. Early wound cleansing is an important prophylactic measure, in addition to timely administration of rabies immune globulin and vaccine (table 7). Indications for rabies prophylaxis are discussed separately. (See "Indications for post-exposure rabies prophylaxis" and "Rabies immune globulin and vaccine".)

In general, the risk of contracting HIV, hepatitis B, or hepatitis C from a human bite is negligible unless blood exposure has also occurred. If the biter has been exposed to blood from an infected bite victim, then prophylaxis may be appropriate as discussed separately. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults".)

AFTERCARE — Once the wound is repaired, the clinician should apply a topical antibiotic ointment (eg, bacitracin) to the dry vermillion or perioral skin, as indicated. Occlusive dressings are difficult to maintain around the lip and are unnecessary.

Some patients (eg, those with through-and-through lacerations or risk factors for infection) should undergo reevaluation 48 to 72 hours after repair to ensure proper healing. Patients capable of self-assessment might not need physician evaluation at this time.

Patients with intraoral lip lacerations should be advised as follows:

●Eat soft foods for two to three days.

●Rinse the mouth with water after eating.

●Avoid spicy or salty foods until the wound is healed.

●Avoid the use of straws (negative pressure may increase ecchymosis or bleeding at the wound site).

Nonabsorbable sutures should be removed by a health care provider in three to five days, as should any simple interrupted absorbable sutures of the wet or dry vermillion that have not dissolved by five days.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Human bites" and "Society guideline links: Minor wound management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Stitches and staples (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Anatomy – The lip is a unique structure in the body and in cross section is composed of three layers: the mucosal layer (within the oral cavity), the middle muscular layer (orbicularis oris muscle), and the outer mucosal layer consisting of the wet vermillion (internal oral) and the dry vermillion (external oral) or the "red lip" (figure 1). The cosmetic outline of the lip where the facial skin meets the vermillion is referred to as the vermillion border. Aesthetically, the vermillion border is crucial as light reflects at this juncture and misalignment by 1 mm may cause a noticeable cosmetic defect. (See 'Anatomy' above.)

●Evaluation – Patients with lip lacerations require careful evaluation to determine the location and depth of the wound, whether the laceration involves the vermillion border or extends entirely through the lip, or is associated with significant trauma to the midface, dentition, or mandible. (See 'Evaluation' above.)

●Indications for subspecialty consultation – Surgical specialty consultation, if available, is appropriate for crush wounds, wounds with large defects, wounds with devitalized or necrotic tissue, and wounds with associated tooth avulsion, dental extrusion or lateral displacement with malocclusion, mandibular fracture, or LeFort fracture. (See 'Indications for subspecialty consultation or referral' above.)

●Anesthesia – Regional nerve blocks are the anesthetic method of choice for lip laceration repair. Direct infiltration of local anesthetic into lip lacerations should be avoided, as this can distort the lip tissue making it more difficult to complete an optimal cosmetic repair. Infraorbital (figure 4) and mental nerve blocks (figure 5) anesthetize the skin and mucosal surfaces of the upper and lower lips respectively. If the laceration crosses the midline, bilateral nerve blocks should be performed. (See 'Anesthesia and analgesia' above.)

●Irrigation – Irrigate oral and perioral wounds with approximately 50 to 100 mL per centimeter of laceration. Although irrigation with normal saline has not been shown to decrease rates of infection, the authors and others still perform irrigation of lip lacerations. Oral and perioral wounds are essentially contaminated wounds, and irrigation enhances removal of gross contaminants within the wound. Antiseptics, such as chlorhexidine, povidone-iodine solution (Betadine), or hydrogen peroxide, should be avoided because they are cytotoxic and can cause tissue injury. Do not shave facial hair near the laceration. Debridement of lip lacerations and oral wounds should not be performed by inexperienced clinicians because it distorts the original architecture and alters the cosmetic appearance. (See 'Irrigation and debridement' above.)

●Wound repair – Primary closure (ie, wound repair at the time of presentation) is the preferred treatment for most lip lacerations. Wounds with obvious signs of inflammation (redness, warmth, swelling, pus drainage) should not be closed primarily. Lip laceration repair should also not delay further evaluation and definitive care of more urgent traumatic injuries, including underlying midface or jaw injuries. (See 'Wound repair' above.)

The suggested equipment and techniques for closure of lip lacerations are provided. (See 'Equipment' above and 'Techniques' above.)

●Prophylactic antibiotics – In a patient with a through-and-through lip laceration or significant mucosal involvement, we suggest administering prophylactic antibiotics (Grade 2C). The antibiotic should cover oral flora (eg, penicillin, cephalexin, or in penicillin-allergic patients, clindamycin). Prophylactic antibiotics may also decrease the risk of wound infection in patients with animal or human bites. However, evidence does not support administration of antibiotics to all healthy patients with lip lacerations, especially those with clean wounds that do not involve wet mucosal surfaces. (See 'Prophylactic antibiotics' above and 'Bite wounds' above.)

●Tetanus prophylaxis – Patients should receive tetanus prophylaxis, as needed. (See 'Tetanus prophylaxis' above.)

●Aftercare – Instruct the patient in the following (see 'Aftercare' above):

•Application of topical antibiotic (eg, bacitracin) to external wounds

•Re-evaluation in 48 to 72 hours

•Soft diet, mouth rinsing after eating, and avoidance of irritating foods or straw use in patients with intraoral lip lacerations

•Removal of nonabsorbable sutures in three to five days