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Injuries to no other area of the body illicits more of an emotional response than those to the face. Patients fear permanent scarring and facial disfigurement. Patient expectations are high. It is imperative that the surgeon dealing with facial injuries has a thorough understanding and systematic method of dealing with facial trauma
Patients with facial injuries often have sustained multiple trauma. Assessment of the basic ABC’s (Airway, Breathing, and Circulation) take priority over facial injuries. The cervical spine must be stabilized until it has been evaluated for fracture. Evaluation must also be made for any neurologic, chest, abdominal or extremity injuries.
The mechanism of injury is important. High-speed motor vehicle accidents and gun shot wounds result in more extensive injuries than those initially appreciated. Human and animal bites differ from those created from sharp objects such as knives and glass. The degree of contamination must be ascertained as well. Careful evaluation of the wound for foreign bodies must be performed to prevent further infection.
Because of their high vascularity, facial wounds can be safely closed primarily well beyond the standard 12 – 24 hours applied to other wounds without increasing the risk of infection. If facial fractures are co-existent, they should be reduced before soft tissue repair.
Deep cheek and eyelid injuries
Injuries to certain facial regions require particular attention. Deep cheek lacerations should alert the surgeon to the possibility of injury to the facial nerve, parotid duct and gland. Eyelid injuries should be evaluated for corneal lacerations and globe injuries. Scars will heal inconspicuously if they are parallel to or concealed in natural skin creases (RSTL or relaxed skin tension lines, which are perpendicular to the underlying facial musculature).
These are important considerations especially during secondary scar revisions. Formation of hypertrophic scars or keloids are possible depending upon patient skin type or if repairs are made under tension.
All facial wounds are potentially contaminated. Tetanus-prone wounds are those with heavy contamination from soil or manure, devitalized tissue, or deep puncture wounds. In the tetanus-prone wound, all patients should receive tetanus toxoid unless they have been immunized in the past five years. Adequate anesthesia must be obtained before the wound can be cleaned, explored and repaired. Most of the time this can be accomplished in the emergency room using local anesthesia.
In areas where careful tissue realignment is essential (the vermilion border of the lip), injecting away from the wound edge prevents distortion of the tissues. When larger areas are involved, regional nerve blocks are helpful. At times, wound repair must be accomplished in the operating room using general anesthesia, especially with younger children and more extensive trauma.
The wound must be prepared and cleansed to remove any foreign material, such as glass, clothing, road tar and dirt. The wound should be copiously irrigated to remove embedded foreign material as well as to reduce the bacterial counts. The wound edges should be debrided and only obviously devitalized tissue should be removed. Even tissues that appear cyanotic may survive because of the excellent vascularity of the face.
The surgeon performing facial plastic repairs must adhere to the following general principles: delicate handling of tissue, use of small needles and suture material, layered closure of tissue to eliminate dead space, and careful eversion of skin edges with a cutaneous suture to avoid depression of the scar.
Most commonly the deep and subcutaneous layers are repaired with absorbable suture such as chromic catgut or vicryl. Each anatomic layer that has been violated should be repaired as a separate entity (muscle, fascia, and periosteum). The superficial skin edges should be carefully approximated with as little tension as possible. Final skin closure is accomplished with a fine monofilament synthetic material such as 5-0 or 6-0 nylon or Prolene.
On younger children . . .
For younger children, the use of dissolvable suture or tissue glue obviates the need for suture removal. Most abrasion injuries are superficial and heal spontaneously with proper wound care. Many have dirt or grease embedded in them and if not adequately removed, may result in traumatic tattooing. After cleaning, the wound should be covered with an antibiotic ointment to prevent drying and crusting.
Contusions occur from blunt trauma or crush injuries. Swelling, bruising, and occasionally a hematoma may form. Generally these wounds do not require any specific treatment except for recognition of any underlying injuries and drainage of the hematoma. Wounds with contusion at the edges may develop pigmentary changes and soft tissue atrophy.
Sharp objects . . .
Sharp clean objects such as knives and glass cause linear lacerations. They should be explored fully and injury to underlying nerves and muscle should be suspected. A layered plastic closure with attention to reapproximation of facial landmarks is essential.
Explosive or crush injuries . . .
Stellate lacerations, seen with explosive or crush injuries, have more significant contusion at the edges. Avulsion lacerations are broad and tangential; they have lifted up flaps of tissue. They may develop into a trap-door deformity if they are curvilinear in shape. The contraction forces of scar tissue, as well as obstruction of lymphatic and venous drainage cause this.
Wound edge modification at time of repair, as well as pressure dressing, can minimize its formation. Facial wounds will rarely involve areas of actual tissue loss. Small areas may be repaired by undermining and primary closure. Care must be taken in undermining traumatized tissue so as not to further compromise its vascularity. Other management options include split-thickness skin grafts, local flaps, and healing by secondary intention.
Dog bites . . .
Dog bites account for 85% of animal bites requiring medical attention.Children are especially prone, with the most common area being the central portion of the face. These wounds are polymicrobial, with many containing anaerobic organisms.
Management includes forced irrigation, debridement of wound edges and primary closure. Th exception is bite wounds greater than 12-24 hours old or those already grossly infected. In these situations, local wound care, followed by delayed primary closure 4-7 days later is advisable. If tissue is avulsed, the conservative approach involves local wound care followed by delayed repair at 4-7 days.
Most clinicians advocate antibiotics. Rabies prophylaxis is advisable if the animal is a suspected carrier. Tetanus immunization should be updated. Human bites are generally believed to be more serious than animal bites with a higher incidence of infection.
Lips and ears are the most commonly involved facial structures. Primary closure of fresh human bites is preferable because of its cosmetic importance. However, because of its higher incidence of infection, wounds greater than 12 hours old, avulsion injuries, and grossly infected wounds should undergo delayed repair. Antibiotics are essential, with parenteral route of administration considered to those high-risk patients, those with grossly infected wounds, and those bites that involve cartilage.
Gunshot wounds . . .
Gunshot wounds are particularly traumatic to soft tissue. The missile’s energy creates a temporary conical cavity up to 40X the diameter of the bullet. This cavity collapses, leaving the permanent pathway surrounded by a much larger zone of traumatized tissue. The potential for tissue destruction is proportional to the bullet mass and exponentially proportional to its velocity. Therefore, velocity is the greatest determinant of tissue damage.
Low velocity missile-entry wounds (speeds less than 610 m/s) are small with well-demarcated edges and frequently no exit wounds. Tissue destruction is limited to a small area around the bullet’s path. Because of its low kinetic energy, they may also have their course altered by the interface of tissue planes. They may actually go around vascular and nerve structures. Civilian gunshot wounds are usually of the low-velocity type. Management consists of local wound care and debridement, with primary closure when needed.
High velocity wounds are seen with military type rifles. More tissue destruction exists at the entrance site, and a large exit wound is present. The kinetic energy of such a wound creates a large cavity resulting in extensive damage to surrounding areas without direct contact by the bullet. Management involves wide debridement, drainage and packing the wound open. A delayed primary repair can be performed when the wound can be fully evaluated.
Shotgun wounds pose a different problem. They have a muzzle velocity of 1000 m/s; however it drops off rapidly with time, and the wound is created by a spray of pellets. Gunshot wounds create devastating injuries only at close range. Beyond 6m, only superficial penetration of the pellets and minimal destruction is seen. Injuries from less than 3 m result in large gaping wounds with massive tissue destruction. Management involves meticulous debridement and removal of shot and wadding. Attempts at primary closure can be made, but infection and wound breakdown is common. Areas of tissue loss can be reconstructed secondarily. Facial nerve repair is best delayed for 2-3 weeks after tagging the ends of the nerve at the initial procedure.
Eyelid injuries . . .
All eyelid injuries must be inspected carefully. Injuries may involve the globe, lacrimal system and canthal tendons. The orbital septum may be violated if fat is in the wound. Deep upper lid wounds may violate the levator aponeurosis, resulting in lid ptosis.
Ophthalmologic evaluation is mandatory if injury to the globe is suspected. The lid margin should be carefully approximated. The remainder of the laceration is closed in two layers: the tarsus-conjunctiva (deeper) layer is repaired with fine absorbable suture, burying the knots to prevent corneal irritation; the skin-muscle (superficial) layer is repaired with fine silk or nylon. Avulsion injuries can be repaired with local advancement flaps or skin grafts from the opposite eyelid or post-auricular area.
Defects less than 1/3 of the lid can be closed primarily; those up to one half the lid can be repaired with the addition of a lateral canthotomy. Larger defects require more extensive flap procedures.
Lacerations of the nose . . .
Lacerations of the nose should undergo a layered plastic repair. Absorbable suture is used to repair the intranasal lining first. The perichondrium is sutured to realign the cartilaginous elements and the nasal tip. It is essential that the alar rim is realigned to avoid notching. If a septal hematoma is identified, it must be drained and stented. More pronounced scarring may result in the nasal tip region because of the thicker sebaceous skin.
Lacerations of the lip . . .
Full thickness lacerations of the lip bleed profusely because of its rich blood supply. A three layered repair is performed, approximating mucosa, muscle, and skin. The vermilion must be realigned accurately. Proper closure of the muscle layer helps preserve its important sphincter function.
Abrasions of the ear . . .
Abrasions of the ear are treated with topical antibiotic ointment and light non-compressive dressings. Lacerations may involve the cartilage. Exposed edges of cartilage are trimmed back and reapproximated with fine absorbable sutures. Crushed or shredded cartilage should be debrided. The skin is repaired to ensure that all cartilage is buried to help prevent infection. Accurate reapproximation of the landmarks, especially the helical rim, is important. Contusion may result in an auricular hematoma, when blood collects between the perichondrium and cartilage. This is best managed by evacuation and application of a pressure dressing to prevent reaccumulation and eventual formation of a cauliflower ear.
Partial and total avulsion injuries of the ear commonly occur from human or animal bites. Any tissue that is still attached should be preserved and reapproximated. The missing piece, if available, may be: conservatively debrided and re-implanted as a free composite graft for immediate reconstruction; denuded of its epithelium and buried in a post-auricular subcutaneous pocket to be used weeks later for delayed reconstruction; or used for microsurgical revascularization. When the amputated piece is unavailable for repair, the existing skin should be closed and the defect reconstructed secondarily.In any laceration to the lateral cheek region, injury to the parotid gland, its duct, and facial nerve must be suspected and evaluated.
Before administration of anesthetic, facial nerve function must be assessed and documented. Facial nerve injuries anterior to a vertical line from the lateral canthus do not require repair, as primary wound closure allows for nerve regeneration by neurotization of the muscle. Posteriorly, severed branches should be identified with the operating microscope and reapproximated. Repair within 48 to 72 hours, while the nerve is stimulatable, is recommended.
Clear fluid and saliva in the wound is indicative of a parotid gland or duct injury. The wound is closed in layers and a pressure dressing helps avoid a salivary fistula. The buccal branch of the facial nerve runs with the duct. Ductal injuries may be repaired by reanastomosis or re-routing of the duct.Optimal results from soft tissue trauma repair require meticulous attention to wound care and follow-up. Hematomas are prevented by appropriate use of drains and conforming pressure dressings. Wound care involves prevention and removal of crusts with hydrogen peroxide followed by application of topical antimicrobial ointment.
Infections are rare in facial wounds because of its excellent blood supply. Residual foreign bodies should be suspected when a wound continues to drain or drains after a period of satisfactory healing. Skin sloughs and necrosis are managed conservatively to allow the wound to declare itself. Local wound care to allow for secondary healing is adequate for small areas of skin slough. Larger areas of necrosis may require debridement and closure with a local flap when the wound has stabilized. Facial sutures are removed between 4-7 days, depending upon the region of the face. The use of steri-strips for anti-tension taping may help reduce scar widening. It takes up to one year for a scar to mature. Sun protection is essential for the first three months to reduce the possibility of post-inflammatory hyperpigmentation.
Author: Todd A. Morrow, MD, FACS
e-mail: info@tomorrowsface.com
Phone: (973) 243-0600
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Surgical Department
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