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Preoperative and Postoperative Care of Facial Injuries
Preoperative and Postoperative Care of Facial Injuries EDWARD J. HILL, M.D., F.A.C.S. * HAVEN F. DOANE, D.D.S., F.A.C.D.**
THE specialties of plastic surgery and oral surgery are closely allied. In the authors' experience there have been many cases of serious facial injuries in which we are convinced the patient's general welfare has been better served by representation of the two specialties on a team, the team following through in surgery and postoperatively, than would have resulted if one or the other service had begun treatment and later sought consultation. There are, of course, many situations in which either the oral or the plastic surgeon is competent to handle the injury. However, here we are interested in the care of the more serious multiple face injury, rather than of a single isolated fracture or laceration. Facial injuries, which include soft tissue as well as bone injuries, are frequently associated with other damage, especially head and brain trauma. One must be prepared to evaluate the general condition of the patient quickly, including any possible injury to other parts of the body. The facial injury may be the primary concern but at times conditions require that it be treated secondarily. Treatment of facial injuries begins when the physician is called to see the patient in the hospital emergency room. We shall describe our management from the time of the first examination through the patient's admission to the hospital, the determination of the need for and the accomplishment at the right time of definitive surgery, and postoperative care. EMERGENCY ROOM TREATMENT AND ADMISSION
Control of Bleeding
One must first determine whether the bleeding is severe enough to require ligation of vessels or will be stopped immediately by pressure dressings. Digital pressure applied externally on the nose, perhaps supple-
* Department of Plastic Surgery,
Harper Hospital, Detroit, Michigan.
** Chief, Department of Oral Surgery, Harper Hospital, Detroit, Michigan. 1589
1590
Edward J. Hill, Haven F. Doane
mented by the addition of intranasal packing, will often control a profuse hemorrhage. Finger cots coated with petrolatum are often advantageous for this procedure since they will not adhere to any raw surface and cause bleeding when withdrawn. Prevention of Shock
Shock is treated in the routine manner with fluids, blood, plasma, and other measures which may be indicated. Pain is controlled with sedatives if these are not contraindicated. The use of Demerol or morphine intravenously is usually the method of choice for patients in shock and for those on whom repair is to be done immediately. Maintenance of Airway
The airway must be kept free of blood, mucus, dental restorations and bone or teeth fragments. The tongue must be retained in a position that assures a good airway. This may be done with an airway device or a silk suture placed through the tip of the tongue. Suction carefully used will assist in keeping the mouth free of mucus and blood. If the airway is endangered by edema a tracheotomy must be considered immediately but this should not be done without adequate assistance, usually available only after the patient is in the hospital. Oxygen may be administered through the nose when conditions warrant, such as cyanosis or shortness of breath from edema of the mouth or tongue. General Examination
One must be equipped to make a general examination of the patient for signs of other injuries. In skull injuries these may be bleeding from the ears, spinal fluid discharging from the nose, routine neurological signs of unconsciousness and localized paralysis or weakness. The cervical, thoracic and lumbar spines must be checked for possible fractures. The possibility of chest injury with rib fractures and contusions must be ruled out. The extremities and the pelvis should be palpated for fractures and the abdomen for possible ruptured viscera. The emergency room examination should be rapid but thorough. The important point to decide is whether priority must be given to the care of the body in general over that of the facial injury. Examination for Extent of Facial Injuries
The intra-oral and extra-oral areas can be checked by inspection for possible malocclusion of the teeth, extent of lacerations and involvement of soft tissue, which would include mucosa and skin, noting whether the facial nerve is severed. A digital examination is made, beginning on the forehead and continuing over the supra-orbital ridge, down along the lateral wall of the orbit, the zygomatic arch and into the infra-orbital
Pre- and Postoperative Care of Facial Injuries
1591
region and the nose. The patient is then asked to open and close the jaws. This procedure gives the examiner considerable information about the possible extent of injury. Lastly the examiner simultaneously places his hands on either side of the mandible near the angle, bringing the hands forward to the midline, and observes the general contour of the face and mandible. Obvious compound fractures of the mandible or maxilla are easily recognizable. Crepitation of the facial bones or nasal bones is not always present owing to edema and when possible x-rays are planned for further determination of bone fractures. Nasal bone fractures usually are determined by gross visual examination of the nose and easily by digital manipulation. Any deformity or fracture should be carefully noted in the emergency room record. Elllergency ROOlll Treatlllent
Repair of soft tissue injuries should be meticulous and careful. The most important consideration in repair of soft tissues about the face is the conservation of all possible tissue. With the excellent blood supply of the face, fragments of skin which appear cyanotic are frequently viable and should not be carelessly excised or discarded before providing an adequate chance for survival. Irrigation and cleansing of the wounds are done with pHisoHex and saline. Hydrogen peroxide diluted 50 per cent with water is excellent for separating large clots of blood from tissue, which is then irrigated with saline. Repair of soft tissue injuries and lacerations should be accomplished with a minimum of debridement and careful approximation with fine sutures. Surgery can usually be completed with local anesthesia. One to 2 per cent Xylocaine with epinephrine is used routinely for anesthesia. Fine sutures such as 5-0 and 6-0 nylon in conjunction with 4-0 plain catgut are employed for closure. The sutures are placed close to the wound edge and close together to obtain accurate approximation. The most important lacerations to close immediately are those of the eyelids, conjunctivae, lips, ears and skin over the ear cartilage. Stabilization of bone fragments sometimes can be done in the emergency room, the method depending on the general condition of the patient. If his general condition is poor, stabilization is done only with light pressure dressings carefully applied. Ace bandages can be dangerous and if used must be applied with much care, particularly over bony prominences and in the presence of edema about the face and neck. Barton or other tightly applied dressings may be injurious. History
If at all possible, a history of the patient's general health should be obtained from the patient or relatives. This may definitely influence treatment planning. Important factors concerning the accident include when, where and how it occurred and, if the patient was in a vehicle, its
1592
Edward J. Hill, Haven F. Doane
type. Also important is whether the patient has been unconscious, either immediately after the accident or later. The history also may reveal sensitization to drugs or other substances. Use of Anti-infective Agents
When indicated, tetanus and gas gangrene serum are given. Routine skin testing for possible sensitization and reading of the skin tests by the physician are always necessary. Of the antibiotics, Dicrysticin, 2 cc. daily, is preferred for most patients; when this is contraindicated oral antibiotics such as Terramycin or Achromycin are used if possible. Roentgen Exalllination
Good x-rays by a technician skilled in obtaining them from correct angles are most important. The basic views ordered are lateral, posteroanterior and Water's position. The latter is the view most frequently asked for when determining fractures about the maxilla and zygomatic arch. Possible fractures of the body and ascending ramus of the mandible must be demonstrated with the patient in the oblique lateral or the Townsend position. HOSPITAL CARE
Care following emergency treatment and admission depends on the severity of injury. Bed rest with slight elevation of the head should be employed. Ice bags are heavy and when placed on the face and nose add to the patient's discomfort and may depress bone fragments. The best cold compresses are gauze squares dipped into cold water. The patient must be observed closely, using temperature, pulse and respiration as guides to general condition. Suction must be available at the bedside at all times. Tracheotomy sets must be on the floor or in the patient's room. The patient may be allowed fluids if there is certainty that the airway and swallowing are not impaired. Fluids are usually best tolerated on the day after the injury, progressing to a high protein, high vitamin diet. Intravenous fluids may be required early following emergency surgery after the accident. Chemobiotic therapy also is continued. Sedation is governed by the patient's general condition, whether there was unconsciousness and the patient's age and neurological status. Heavy sedation is always avoided in serious head injuries. Dressings are changed daily or as the conditions warrant. Following initial emergency treatment and early subsequent care, when the patient requires surgical measures and his condition warrants a plan is outlined by therteam. The operation to be done, the approaches, anesthesia and methods to be used are discussed. If immobilization of the mandible or maxilla is indicated, arch bars are applied under local anesthesia one to two days before operation and may then be used at the time of operation as necessary.
Pre- and Postoperative Care of Facial Injuries
1593
Preoperative Definitive Care
Within seven to ten days after the accident the edema has usually subsided and the diagnosis is completed. Any fractures of the facial bones needing open reduction and internal fixation-and most do-are prepared. The patient has recovered sufficiently from initial injury and shock to allow general anesthesia, which is indicated. Preoperative care includes the usual preoperative medication, morphine, Demerol, atropine or scopolamine, varying with the physician or anesthetist. The patient's face should be washed with soap and water the evening before operation and his face shaved the following morning. The eyebrows are never shaved. Postoperative Definitive Care
The care given postoperatively is that following any elective operation. In most instances open reduction and internal fixation with wiring of fractures about the mandible, maxilla, orbit or zygomatic arch have been done. Suction is kept available at the bedside at all times. Dressings must be light and without pressure at any time. The position of the patient's head must not permit aspiration of mucus or blood. The house and nursing staffs are instructed in the method of releasing the elastic bands on the arch bars, which must be removed immediately if vomiting occurs. A small hemostat should be left at the bedside for this purpose. Chemotherapy, of course, is continued. Edema about the face can be treated with cold packs or the new drugs such as Varidase. In the first 24 or 48 hours intravenous fluids and blood are indicated. Because it is important to have the patient alert and cooperative, only minimum doses of sedatives are given. Oral hygiene in the form of mouth wash or mouth irrigations must be continued following operation. Sutures are removed from the face on the fourth day and all are removed by the sixth day. Following removal of sutures the wounds are supported with strips of fine mesh gauze soaked in plain collodion. These are maintained for at least two weeks. Postoperative General Care
The diet is influenced by the extent of surgery and whether the mandible is immobilized. A high protein, fluid diet with supplemental vitamins is ordered. If the arch bars are not in place the patient may be fed by spoon, cup or drinking tube. Nasal feeding tubes can be used but usually are not tolerated well. The patient's temperature, pulse and respiration are taken and recorded regularly. Food intake and excretion should be recorded. Laboratory rechecks of blood counts and hemoglobin are particularly important. Possible complications include bleeding about the mouth and nose and hematomas forming in the orbit, beneath the floor of the orbit and about the maxilla. Hematomas can cause pressure on the eye, and hematomas
1594
Edward J. Hill, Haven F. Doane
forming in and about the face occasionally may produce severe postoperative complications and infection which will require drainage. Early ambulation of these patients is essential. Small, fiat, rubber drains are occasionally left in wounds and removed on the second day. Any packing or drain inserted into the maxilla for support of the lateral walls of the maxillary sinus can occasionally be removed in the patient's room but may require removal in the operating room with the patient under anesthesia. Roentgen examinations can be. postponed for approximately a week after operation. Following complete healing the patient is a candidate for general dental care. Special Considerations in Children
Children usually are not cooperative after a severe injury about the face or mouth. Endotracheal general anesthesia facilitates repairs and prevents aspiration of mucus and blood. Teeth are molded into position if they are still in place and are fixed by wiring if necessary. At times, immediate consultation with the orthodontist is of great value in preserving the permanent teeth of a young child, especially if the front teeth are involved. If a general anesthetic will be required within a short time, the stomach is aspirated through a Levin tube in the emergency room. Aspiration with the Levin tube is repeated following operation to remove any blood, mucus or gastric juice which would tend to make the patient vomit after recovery from the anesthetic. The Levin tube may be inserted before the child is awakened and while the endotracheal tube is in place. CONCLUSIONS
There are many variations in injuries about the face and head which involve soft tissue and bone. The authors wish to stress again that in their experience close teamwork between the plastic surgeon and the oral surgeon is important in obtaining satisfactory results. The patient benefits from the care given by the two specialists from the very start of treatment in the emergency room. We also wish to stress the importance of meticulous care of lacerations and of thoughtful and precise attention to closure of facial wounds. Such care will, in many instances, eliminate the need for additional surgery and revision of scars. Proper reduction and alignment of facial bones and proper handling of the teeth will hasten the rehabilitation of the patient and make him feel that he has been given every possible chance for a good recovery. The kind of teamwork outlined may be a deterrent to the frequent lawsuits by patients who feel that they were mishandled by a single specialist and could have benefited more from care by physicians in one or several other specialties. 1536 David Whitney Building Detroit 26, Michigan (Dr. Hill)
THE specialties of plastic surgery and oral surgery are closely allied. In the authors' experience there have been many cases of serious facial injuries in which we are convinced the patient's general welfare has been better served by representation of the two specialties on a team, the team following through in surgery and postoperatively, than would have resulted if one or the other service had begun treatment and later sought consultation. There are, of course, many situations in which either the oral or the plastic surgeon is competent to handle the injury. However, here we are interested in the care of the more serious multiple face injury, rather than of a single isolated fracture or laceration. Facial injuries, which include soft tissue as well as bone injuries, are frequently associated with other damage, especially head and brain trauma. One must be prepared to evaluate the general condition of the patient quickly, including any possible injury to other parts of the body. The facial injury may be the primary concern but at times conditions require that it be treated secondarily. Treatment of facial injuries begins when the physician is called to see the patient in the hospital emergency room. We shall describe our management from the time of the first examination through the patient's admission to the hospital, the determination of the need for and the accomplishment at the right time of definitive surgery, and postoperative care. EMERGENCY ROOM TREATMENT AND ADMISSION
Control of Bleeding
One must first determine whether the bleeding is severe enough to require ligation of vessels or will be stopped immediately by pressure dressings. Digital pressure applied externally on the nose, perhaps supple-
* Department of Plastic Surgery,
Harper Hospital, Detroit, Michigan.
** Chief, Department of Oral Surgery, Harper Hospital, Detroit, Michigan. 1589
1590
Edward J. Hill, Haven F. Doane
mented by the addition of intranasal packing, will often control a profuse hemorrhage. Finger cots coated with petrolatum are often advantageous for this procedure since they will not adhere to any raw surface and cause bleeding when withdrawn. Prevention of Shock
Shock is treated in the routine manner with fluids, blood, plasma, and other measures which may be indicated. Pain is controlled with sedatives if these are not contraindicated. The use of Demerol or morphine intravenously is usually the method of choice for patients in shock and for those on whom repair is to be done immediately. Maintenance of Airway
The airway must be kept free of blood, mucus, dental restorations and bone or teeth fragments. The tongue must be retained in a position that assures a good airway. This may be done with an airway device or a silk suture placed through the tip of the tongue. Suction carefully used will assist in keeping the mouth free of mucus and blood. If the airway is endangered by edema a tracheotomy must be considered immediately but this should not be done without adequate assistance, usually available only after the patient is in the hospital. Oxygen may be administered through the nose when conditions warrant, such as cyanosis or shortness of breath from edema of the mouth or tongue. General Examination
One must be equipped to make a general examination of the patient for signs of other injuries. In skull injuries these may be bleeding from the ears, spinal fluid discharging from the nose, routine neurological signs of unconsciousness and localized paralysis or weakness. The cervical, thoracic and lumbar spines must be checked for possible fractures. The possibility of chest injury with rib fractures and contusions must be ruled out. The extremities and the pelvis should be palpated for fractures and the abdomen for possible ruptured viscera. The emergency room examination should be rapid but thorough. The important point to decide is whether priority must be given to the care of the body in general over that of the facial injury. Examination for Extent of Facial Injuries
The intra-oral and extra-oral areas can be checked by inspection for possible malocclusion of the teeth, extent of lacerations and involvement of soft tissue, which would include mucosa and skin, noting whether the facial nerve is severed. A digital examination is made, beginning on the forehead and continuing over the supra-orbital ridge, down along the lateral wall of the orbit, the zygomatic arch and into the infra-orbital
Pre- and Postoperative Care of Facial Injuries
1591
region and the nose. The patient is then asked to open and close the jaws. This procedure gives the examiner considerable information about the possible extent of injury. Lastly the examiner simultaneously places his hands on either side of the mandible near the angle, bringing the hands forward to the midline, and observes the general contour of the face and mandible. Obvious compound fractures of the mandible or maxilla are easily recognizable. Crepitation of the facial bones or nasal bones is not always present owing to edema and when possible x-rays are planned for further determination of bone fractures. Nasal bone fractures usually are determined by gross visual examination of the nose and easily by digital manipulation. Any deformity or fracture should be carefully noted in the emergency room record. Elllergency ROOlll Treatlllent
Repair of soft tissue injuries should be meticulous and careful. The most important consideration in repair of soft tissues about the face is the conservation of all possible tissue. With the excellent blood supply of the face, fragments of skin which appear cyanotic are frequently viable and should not be carelessly excised or discarded before providing an adequate chance for survival. Irrigation and cleansing of the wounds are done with pHisoHex and saline. Hydrogen peroxide diluted 50 per cent with water is excellent for separating large clots of blood from tissue, which is then irrigated with saline. Repair of soft tissue injuries and lacerations should be accomplished with a minimum of debridement and careful approximation with fine sutures. Surgery can usually be completed with local anesthesia. One to 2 per cent Xylocaine with epinephrine is used routinely for anesthesia. Fine sutures such as 5-0 and 6-0 nylon in conjunction with 4-0 plain catgut are employed for closure. The sutures are placed close to the wound edge and close together to obtain accurate approximation. The most important lacerations to close immediately are those of the eyelids, conjunctivae, lips, ears and skin over the ear cartilage. Stabilization of bone fragments sometimes can be done in the emergency room, the method depending on the general condition of the patient. If his general condition is poor, stabilization is done only with light pressure dressings carefully applied. Ace bandages can be dangerous and if used must be applied with much care, particularly over bony prominences and in the presence of edema about the face and neck. Barton or other tightly applied dressings may be injurious. History
If at all possible, a history of the patient's general health should be obtained from the patient or relatives. This may definitely influence treatment planning. Important factors concerning the accident include when, where and how it occurred and, if the patient was in a vehicle, its
1592
Edward J. Hill, Haven F. Doane
type. Also important is whether the patient has been unconscious, either immediately after the accident or later. The history also may reveal sensitization to drugs or other substances. Use of Anti-infective Agents
When indicated, tetanus and gas gangrene serum are given. Routine skin testing for possible sensitization and reading of the skin tests by the physician are always necessary. Of the antibiotics, Dicrysticin, 2 cc. daily, is preferred for most patients; when this is contraindicated oral antibiotics such as Terramycin or Achromycin are used if possible. Roentgen Exalllination
Good x-rays by a technician skilled in obtaining them from correct angles are most important. The basic views ordered are lateral, posteroanterior and Water's position. The latter is the view most frequently asked for when determining fractures about the maxilla and zygomatic arch. Possible fractures of the body and ascending ramus of the mandible must be demonstrated with the patient in the oblique lateral or the Townsend position. HOSPITAL CARE
Care following emergency treatment and admission depends on the severity of injury. Bed rest with slight elevation of the head should be employed. Ice bags are heavy and when placed on the face and nose add to the patient's discomfort and may depress bone fragments. The best cold compresses are gauze squares dipped into cold water. The patient must be observed closely, using temperature, pulse and respiration as guides to general condition. Suction must be available at the bedside at all times. Tracheotomy sets must be on the floor or in the patient's room. The patient may be allowed fluids if there is certainty that the airway and swallowing are not impaired. Fluids are usually best tolerated on the day after the injury, progressing to a high protein, high vitamin diet. Intravenous fluids may be required early following emergency surgery after the accident. Chemobiotic therapy also is continued. Sedation is governed by the patient's general condition, whether there was unconsciousness and the patient's age and neurological status. Heavy sedation is always avoided in serious head injuries. Dressings are changed daily or as the conditions warrant. Following initial emergency treatment and early subsequent care, when the patient requires surgical measures and his condition warrants a plan is outlined by therteam. The operation to be done, the approaches, anesthesia and methods to be used are discussed. If immobilization of the mandible or maxilla is indicated, arch bars are applied under local anesthesia one to two days before operation and may then be used at the time of operation as necessary.
Pre- and Postoperative Care of Facial Injuries
1593
Preoperative Definitive Care
Within seven to ten days after the accident the edema has usually subsided and the diagnosis is completed. Any fractures of the facial bones needing open reduction and internal fixation-and most do-are prepared. The patient has recovered sufficiently from initial injury and shock to allow general anesthesia, which is indicated. Preoperative care includes the usual preoperative medication, morphine, Demerol, atropine or scopolamine, varying with the physician or anesthetist. The patient's face should be washed with soap and water the evening before operation and his face shaved the following morning. The eyebrows are never shaved. Postoperative Definitive Care
The care given postoperatively is that following any elective operation. In most instances open reduction and internal fixation with wiring of fractures about the mandible, maxilla, orbit or zygomatic arch have been done. Suction is kept available at the bedside at all times. Dressings must be light and without pressure at any time. The position of the patient's head must not permit aspiration of mucus or blood. The house and nursing staffs are instructed in the method of releasing the elastic bands on the arch bars, which must be removed immediately if vomiting occurs. A small hemostat should be left at the bedside for this purpose. Chemotherapy, of course, is continued. Edema about the face can be treated with cold packs or the new drugs such as Varidase. In the first 24 or 48 hours intravenous fluids and blood are indicated. Because it is important to have the patient alert and cooperative, only minimum doses of sedatives are given. Oral hygiene in the form of mouth wash or mouth irrigations must be continued following operation. Sutures are removed from the face on the fourth day and all are removed by the sixth day. Following removal of sutures the wounds are supported with strips of fine mesh gauze soaked in plain collodion. These are maintained for at least two weeks. Postoperative General Care
The diet is influenced by the extent of surgery and whether the mandible is immobilized. A high protein, fluid diet with supplemental vitamins is ordered. If the arch bars are not in place the patient may be fed by spoon, cup or drinking tube. Nasal feeding tubes can be used but usually are not tolerated well. The patient's temperature, pulse and respiration are taken and recorded regularly. Food intake and excretion should be recorded. Laboratory rechecks of blood counts and hemoglobin are particularly important. Possible complications include bleeding about the mouth and nose and hematomas forming in the orbit, beneath the floor of the orbit and about the maxilla. Hematomas can cause pressure on the eye, and hematomas
1594
Edward J. Hill, Haven F. Doane
forming in and about the face occasionally may produce severe postoperative complications and infection which will require drainage. Early ambulation of these patients is essential. Small, fiat, rubber drains are occasionally left in wounds and removed on the second day. Any packing or drain inserted into the maxilla for support of the lateral walls of the maxillary sinus can occasionally be removed in the patient's room but may require removal in the operating room with the patient under anesthesia. Roentgen examinations can be. postponed for approximately a week after operation. Following complete healing the patient is a candidate for general dental care. Special Considerations in Children
Children usually are not cooperative after a severe injury about the face or mouth. Endotracheal general anesthesia facilitates repairs and prevents aspiration of mucus and blood. Teeth are molded into position if they are still in place and are fixed by wiring if necessary. At times, immediate consultation with the orthodontist is of great value in preserving the permanent teeth of a young child, especially if the front teeth are involved. If a general anesthetic will be required within a short time, the stomach is aspirated through a Levin tube in the emergency room. Aspiration with the Levin tube is repeated following operation to remove any blood, mucus or gastric juice which would tend to make the patient vomit after recovery from the anesthetic. The Levin tube may be inserted before the child is awakened and while the endotracheal tube is in place. CONCLUSIONS
There are many variations in injuries about the face and head which involve soft tissue and bone. The authors wish to stress again that in their experience close teamwork between the plastic surgeon and the oral surgeon is important in obtaining satisfactory results. The patient benefits from the care given by the two specialists from the very start of treatment in the emergency room. We also wish to stress the importance of meticulous care of lacerations and of thoughtful and precise attention to closure of facial wounds. Such care will, in many instances, eliminate the need for additional surgery and revision of scars. Proper reduction and alignment of facial bones and proper handling of the teeth will hasten the rehabilitation of the patient and make him feel that he has been given every possible chance for a good recovery. The kind of teamwork outlined may be a deterrent to the frequent lawsuits by patients who feel that they were mishandled by a single specialist and could have benefited more from care by physicians in one or several other specialties. 1536 David Whitney Building Detroit 26, Michigan (Dr. Hill)