For many patients with scalp and forehead lacerations, the wound may be a minor part of the overall injury; prior to definitive wound care, airway, breathing, circulation, hemorrhage control, and spinal and neurologic injury should be addressed. In some cases, it may be necessary to control scalp hemorrhage urgently by applying direct pressure or clamping the involved vessel(s) at the wound edges (e.g., using Raney clips).

Routine lacerations should be inspected and gently palpated to their depth, noting whether the galea is lacerated or if there is an underlying depressed skull fracture. Palpable depressions in the outer table of the skull should be evaluated further by computed tomography. The orientation of forehead lacerations has important cosmetic implications. In general, wounds that fall along the lines of skin tension have better cosmetic results. Skin tension lines are always perpendicular to the underlying muscles. As an obvious example, the horizontal lines seen on the forehead when the brow is raised are perpendicular to the frontalis muscle underneath

(Fig 38-2). Forehead lacerations that extend to other structures, such as the eyebrow, nose, or ear must be evaluated and managed with the cosmetic result of these structures in mind.

FIG. 38-2. Skin tension lines are perpendicular to underlying muscles.
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