- Email: [email protected]
Injuries to the soft tissues of the face
Injuries
to the Soft Tissues HERBERT CONWAY, M.D., New York,
From tbe Department of Surger.y (Plastic) York Hospital-Cornell Medical Center, New I7ork.
A
of The New New York,
the widespread institution of safety measures has reduced the incidence of injuries caused by industria1 hazards, there has been an actual rise in the incidence of facia1 injuries due to the increased use of automotive and other forms of transportation. The primary care of such injuries usually must be managed by the genera1 practitioner or bv the members of the resident staff of hospitals. Since the knowledge of and the adherence to a few basic principles of faciaI surgery are rewarded with primary healing without significant deformity in the majority of cases, it is timeIy that these principles be reiterated and that attention he caIIed to those surgica1 technics which have been developed in recent years. In cases of injury to soft facia1 tissues only, there is no need for the empIoy of specialist help for the management of intracranial, intrathoracic or skeIeta1 injuries. Thus there is no need for haste in the execution of detaiIed surgery, although emphasis on Iimitation of the time interva1 between accident and surgica1 repair is most important. CareIessness or ignorance of the basic principres of facia1 repair resuIt in excessive cicatrix and deformities of contour which require extensive corrective surgery later or which may never be eradicated completely. FaciaI repair must be unhurried and deliberate. The abundant circulatory suppIy of the facia1 tissues is such that, even in this regard, repair may be carried out effectiveIy after greater time elapse than for exampie in the management of injuries to the extremities. In the majority of cases the patient with faciaI injury receives primary care within four hours. Suture can be executed with IittIe concern for complication, however, as late as tweIve or even sixteen hours after injury. This LTHOUGH
of the Face* New
1’ork
presentation deaIs with the management of injuries to soft tissues onIy, aIthough these may occur either with or without injury to the underlying bony structures or the speciahzed organs such as the eye and the brain. In the emergency care of injuries to the soft tissues the need for attention to maintenance of the pharyngeal airway is not encountered except in the unusua1 circumstance in which through and through Iaceration of the cheek may be compIicated by brisk hemorrhage into the ora cavity and the pharynx with formation of obstructive cIot. Injuries to the soft tissues aIone do not require the use of tracheostomy. As in the management of facial fractures, the patient should be transported in the prone position, treated for shock, and hemorrhage from the wound should be controlled by application of hemostats or snug packing. Barton’s bandage is the time-honored type of emergency dressing. If the degree of shock or the inadvertent swaIIowing of Iarge amounts of bIood is accompanied by nausea, this type of bandage is contraindicated. Once the patient has arrived at the doctor’s surgery or the emergency room of the hospital, definitive management of the injury is undertaken. Shock is combated by conventional therapy, i.e., externa1 warming of the body by the use of bIankets, elevation of the foot of the operating tabIe, intravenous administration of physiologic saline, plasma or whole bIood and intramuscuIar injection of morphine. In severe shock it is we11 to give a Iessened dose of morphine intramuscuIarIy, for the ineffrciency of the capiIIary circulation during shock is such that the drug may not be absorbed promptIy. It is a mistake to empIoy successive fuI1 doses of morphine intramuscuIarIy in order to obtain the desired effect of the opiate because on recovery from shock rapid uptake of the drug may be followed by signs of overdosage. Definitive facial repair requires that the
* Read at the AnnuaI Meeting of the American Society of MaxilIofaciaI
Surgeons,
May 8 to I I, ,955, Louisville,
Kentucky.
891
American Journal of Surgery, Volume 90, December, 1931
Conway
IA
IB
FIG. I. A, severe abrasion of the face suffered when patient tripped on a curbstone and fell against the asphaIt pavement. Numerous minute particIes of dirt and foreign materiai were embedded into the dermis. B, appearance eight days after emergency treatment by abrasion using novocain injection to the Doint of tense rkiditv of the tissue, the application of the rotary steel brush kd Vaseline gauge d&sings.
extent and type of the injury be assayed accurateIy. FolIowing the cIeansing of the skin with soap, water and a detergent the wound should be irrigated copiousIy with warm physioIogic saIine soIution. This reduces the amount of bacteria1 contamination, removes cIots and Ioose foreign bodies, and allows for the evaIuation of the degree and type of trauma. Injuries to the soft tissues of the face are classified as follows: (I) abrasions and contusions; (2) simpIe Iacerations; (3) Iacerations with avuIsion flaps; (4) lacerations with Ioss of soft tissue; (5) lacerations into the ora cavity; (6) Iacerations with injury to the eye or with associated fractures of the underIying facial bones. Genera1 measures which are necessary incIude the administration of tetanus antitoxin or booster dose of toxoid and IiberaI treatment with peniciIIin. FortunateIy, penicilIin is very effective against mouth organisms. Abrasions and contusions formerly were treated with simpIe cIeansing and the appIication of a vaseIine dressing. This treatment faiIed to take care of the problem of foreign materia1 imbedded in the dermis. Injury by scraping on macadam, brick or other objects resuIts invariabIy in traumatic tattoo. It has been deveIoped that in such instances it is justifiable and correct to treat the cutaneous area of foreign body embedment by the abrasive technic using fine sandpaper supported
on wooden bIocks or the rotary steel brush powered by a dental driI1 apparatus or conventiona1 motor. AIthough this method recognizes that further trauma is being added, the results justify the technic. (Figs. I, 2 and 3.) Simple lacerations are cIeansed by strong brushing of the floor of the wound if necessary, loose coaptation of fascial structures by catgut sutures, and approximation of cutaneous margins with sutures of 6-o fine silk starting at key points in the irregular laceration. Dead space is obIiterated by the pressure of Firm head dressings. Debridement of margins of the wound is contraindicated, for facia1 tissue is precious and the Iikelihood of complicating infection is remote. There is no authentic case report in the Iiterature of gas gangrene developing in a wound of the face. Just as infection by partiaI tension organisms such as the gonococcus is not encountered in the mouth, the rich oxygenation of facial tissues due to the abundant blood suppIy protects against infection foIIowing trauma except in the very rare instance in which there is massive devitaIization of tissue or in which the interva1 of time between injury and repair is unduly proIonged. If simple facial lacerations are paraIIe1 to the wrinkIe Iines of the skin, primary suture is rewarded with an unnoticeabIe scar of heaIing. On the other hand, violent trauma does not always respect laws or lines of physiologic
892
Injuries
to Soft Tissues
2A FIG. 2. A and B, several grades of fine sandpaper wooden blocks.
of Face
ZB supported
on wide and narrow
3A
3c 3D FIG. 3. Buncke safety sIeeve with rotary steel brush. A, the sleeve is detached and the rotary steel brush (which is power driven) is exposed. B, the safety sIeeve is in place so that the bristles of the brush project onIy through the small opening in the cylindric sIeeve. C, without the safety sleeve the bristles of the brush cause heaping up of the skin to one side and there is no protection against penetration of the compIete thickness of the skin. D, with the safety sleeve in pIace the rotary action of the stee1 brush does not alIow for tenting up of the skin. Moreover, protection is offered against too deep penetration of the dermis and centrifuga1 spray of bIood and ceIIuIar amterial is prevented. (From BUNCKE, H. J. Plast. G Reconstruct. Surg., 16: 65, 1955.)
Conway
FIG. 4. WrinkIe lines of the face. Note that they aIways are at right angIes to the line of contractiIe pull of the underlying muscles. Facial lacerations parallel to these lines heaI ideahy after primary suture. (From KRAISSL, C. J. and CONWAY, H. Surgery, 25: 592, 1949.)
FIG. 5. A, severe faciaI laceration incurred in automobiIe accident. B, after primary suture (without debridement) it was apparent that the verticaI hypertrophic scar paraIIeIing the nose on the Ieft was due to the fact that the Iaceration was not paraIIe1 to the wrinkIe Iines of the face. C, appearance after secondary excision of scar and shifting of tissue by the Z plastic technic.
tension, and Iacerations may be at right angIes to the wrinkle lines or at variance with them. In such cases primary suture resuIts in minima1 cicatrix which may be corrected at a Iater date by excision and revision of the tissue by the Z pIastic technic. In this cIassic procedure two incisions are made at an angIe of 60 degrees with the Iong axis of the scar which itseIf forms the obIique Iine of the Z. The horizonta1 arms of the Z are created by incision paraIIe1 to the wrinkIe lines which aIways run at right angIes to the Iine of contractiIe force of the underlying pIatysma. (Figs. 4 and 3.) Lacerations with avulsion flap of soft tissue are treated by gentIe cIeansing with saIine sponges, irrigation of the wound, remova of bIood cIots, accurate hemostasis and replacement of the ffap by Ioose fascia1 suture and minute (6-o siIk) cutaneous sutures even though the Ilap is SignificantIy cyanotic. It is the ruIe rather than the exception that posttraumatic, cyanotic flaps of soft facia1 tissue regain their viability after suture due to the abundant vascuIarity of this anatomic region. At any rate, the recovery of circuIation invariably saves more of a severeIy damaged
flap than would be saved by conservative debridement or amputation of portions of such flap. Lacerations witb loss of soft tissue are best treated by the surgica1 measures mentioned previously, foIlowed by the immediate appIication of a temporary thick-spIit graft of skin. This measure effects primary heaIing and prevents infection and subsequent cicatrix. The graft may be excised Iater by pIastic procedure and the area covered by the wide undercutting and advancement of a Aap of facia1 and cervica1 skin and subcutaneous tissue. In the case of loss of soft tissue of the eyelid fuI1 attention must be given to the protection of the gIobe. Freeing of the conjunctiva from the remainder of the Iid or Iids wiI1 aIIow for its closure over the eyebalI with a running suture of catgut appIied so that suture materia1 does not rub on the cornea. The externa1 wound is covered with a thick894
Injuries
to Soft Tissues
split graft of skin. Loss of soft tissue of the nose can be compensated for by the application of a skin graft. Through and through defects of the nasal alae (up to I cm. in diameter) may be corrected immediately by the use of a composite graft of skin and cartilage taken from the ear. More extensive Iosses must be corrected by the use of a pedicIed flap taken preferably from the temporal region. Through and through loss of tissue from the ear shouId be treated by suture of the aural remnant down to the skin of the mastoid area. Such a step avoids infection and readies the defect for correction by subcutaneous buriaI of cartilage and its subsequent elevation from the mastoid area and backing by skin graft. This method employs the first operative step at the time of repair of primary injury. If simple suture only of cutaneous margins of aural remnant is done, the aural reconstruction may require six or more reconstructive operative steps. It is intriguing to consider the abdominal burial of a compIetely detached portion of auricuIar cartiIage after excision of the overIying skin if such detached specimen has been saved. Manual carving of cartitage for aura1 repIacement never has been rewarded by contoural result which is equa1 to the scuIptured effect of the naturaI auricuIar cartilage. The onIy case in which I have had the opportunity to carry out this technic was a late disappointment due to the excessive formation of fibrous tissue over the cartiIaginous transplant. Lacerations into the oral cavity require thorough cleansing, irrigation with hydrogen peroxide or sodium perborate and Ioose suture of the mucous membranes, after which the details of closure of musculature and skin are carried out as listed heretofore. If there is sizabIe loss of tissue, infection can be avoided by the immediate suture of mucous membrane to skin, thus creating a temporary fistula of the cheek. Injury to Stensen’s duct must be searched for in lacerations of the cheek. If divided, its proximal end should be brought into the oral cavity at a position posterior to its normal aperture. If this is not feasibIe, the duct should be Iigated even though parotid atrophy foIIows this step. Minor injuries to the duct of the parotid gIand may cause Iocalized subcutaneous or submucous accumuIation of saliva. Usually this condition responds to successive aspirations. Lacerations in association with underlying
of Face
FIG. 6A. Example of a severe soft tissue wound in association with horizontar fracture of the maxilla. Patient had been struck by a taxicab. Emergency care included maintenance of airway by upward pressure on the upper jaw and the institution of tracheostomy. BIood transfusion was required as an emergency procedure. (From CONWAY, H. Rocky Mt. M. J., 50: 469, 19s)
severe fractures of the facial bones are treated just as other injuries to soft tissues, after reduction of the fractures has been accomplished. (Fig. 6.) SUMMARY
This presentation reiterates the principles of the management of soft tissue injuries of the face and emphasizes the vaIue of preservation of tissue rather than its wanton dkbridement. Attention to the basic principles of soft tissue repair at the time of emergency suture avoids the crippling deformities which follow infection of facial wounds or which mav on occasion be caused by excision of marginal tissue. The responsibiIity appears to be at the doorstep of the medical profession to influence the manufacturers of motor vehicles to incorporate into their construction of automobiles safety factors which wil1 limit the incidence of injuries to the face foIIowing automobite coIlisions. Most often injured is the occupant of 895
Conway
FIG. 6B to E. B, IateraI x-ray foIlowing the dispIacement of the fractured maxilla. C, IatereI x-ray foIIowing direct wiring of the fracture, the institution of fixation by intermaxillary wires. The wound was irrigated copiously with physioIogic saline and the margins of the jigsaw puzzIe, which the jagged Iaceration presented, were approximated by interrupted sutures of No. 5 zero and 6 zero bIack siIk. Margins of the wound were not excised, nor was it necessary to cut away any of the soft tissues. There was compIete absence (traumatic loss) of the nasa1 septum. D, appearance of the patient after primary heaIing. E, appearance after subsequent admission to the hospital, at which time a free graft of cartilage was inserted for support of the dorsum nasi. (From CONWAY, H. Rocky Mt. M. J., 50: 469, 1953.)
2. BUNCKE, H. J. Safety sleeve for wire brush abrasive
the right side of the front seat. The use of safety beIts, generousIy padded dashboards, recessed controk and some type of firm but transparent and moderately elastic materia1 in substitution for gIass for windshields unquestionably wouId be rewarded with a diminished incidence of facia1 injury due to automobile accidents.
therapy. Plast. CTReconstruct. Surg. (in press). 3. KRAISSL, C. J. and CONWAY, H. Excision of small tumors of the skin of the face with special reference to the wrinkle Iines. Surgery, 25: 592, 1949. 4. BROWN, J. B. and CANNON, B. Composite free grafts of skin and cartilage from the ear. Surg., Gynec. @ Obst., 82: 253, 1946. 5. CONWAY, H., STARK, R. B. and KAVANAUGH, J. D. Variations of the tempora1 Aap. Ph. w Reconstruct. Surg., g: 410, 1952. 6. PIERCE, G. W. Reconstruction of the externa1 ear. Surg., Gynec. u Obst., 50: 601, 1930. 7. CONWAY, H., NEUMANN, C. G., GELB, J., LEVERIDGE, L. L. and JOSEPH, J. M. Reconstruction of the external ear. Ann. Surg., 128: 226, 1948.
REFERENCES I. IVERSON, P. C. Further developments in the treatment of skin Iesions by surgical abrasion. Plast. u Reconstruct. Surg., 12: 27, 1953.
896
to the Soft Tissues HERBERT CONWAY, M.D., New York,
From tbe Department of Surger.y (Plastic) York Hospital-Cornell Medical Center, New I7ork.
A
of The New New York,
the widespread institution of safety measures has reduced the incidence of injuries caused by industria1 hazards, there has been an actual rise in the incidence of facia1 injuries due to the increased use of automotive and other forms of transportation. The primary care of such injuries usually must be managed by the genera1 practitioner or bv the members of the resident staff of hospitals. Since the knowledge of and the adherence to a few basic principles of faciaI surgery are rewarded with primary healing without significant deformity in the majority of cases, it is timeIy that these principles be reiterated and that attention he caIIed to those surgica1 technics which have been developed in recent years. In cases of injury to soft facia1 tissues only, there is no need for the empIoy of specialist help for the management of intracranial, intrathoracic or skeIeta1 injuries. Thus there is no need for haste in the execution of detaiIed surgery, although emphasis on Iimitation of the time interva1 between accident and surgica1 repair is most important. CareIessness or ignorance of the basic principres of facia1 repair resuIt in excessive cicatrix and deformities of contour which require extensive corrective surgery later or which may never be eradicated completely. FaciaI repair must be unhurried and deliberate. The abundant circulatory suppIy of the facia1 tissues is such that, even in this regard, repair may be carried out effectiveIy after greater time elapse than for exampie in the management of injuries to the extremities. In the majority of cases the patient with faciaI injury receives primary care within four hours. Suture can be executed with IittIe concern for complication, however, as late as tweIve or even sixteen hours after injury. This LTHOUGH
of the Face* New
1’ork
presentation deaIs with the management of injuries to soft tissues onIy, aIthough these may occur either with or without injury to the underlying bony structures or the speciahzed organs such as the eye and the brain. In the emergency care of injuries to the soft tissues the need for attention to maintenance of the pharyngeal airway is not encountered except in the unusua1 circumstance in which through and through Iaceration of the cheek may be compIicated by brisk hemorrhage into the ora cavity and the pharynx with formation of obstructive cIot. Injuries to the soft tissues aIone do not require the use of tracheostomy. As in the management of facial fractures, the patient should be transported in the prone position, treated for shock, and hemorrhage from the wound should be controlled by application of hemostats or snug packing. Barton’s bandage is the time-honored type of emergency dressing. If the degree of shock or the inadvertent swaIIowing of Iarge amounts of bIood is accompanied by nausea, this type of bandage is contraindicated. Once the patient has arrived at the doctor’s surgery or the emergency room of the hospital, definitive management of the injury is undertaken. Shock is combated by conventional therapy, i.e., externa1 warming of the body by the use of bIankets, elevation of the foot of the operating tabIe, intravenous administration of physiologic saline, plasma or whole bIood and intramuscuIar injection of morphine. In severe shock it is we11 to give a Iessened dose of morphine intramuscuIarIy, for the ineffrciency of the capiIIary circulation during shock is such that the drug may not be absorbed promptIy. It is a mistake to empIoy successive fuI1 doses of morphine intramuscuIarIy in order to obtain the desired effect of the opiate because on recovery from shock rapid uptake of the drug may be followed by signs of overdosage. Definitive facial repair requires that the
* Read at the AnnuaI Meeting of the American Society of MaxilIofaciaI
Surgeons,
May 8 to I I, ,955, Louisville,
Kentucky.
891
American Journal of Surgery, Volume 90, December, 1931
Conway
IA
IB
FIG. I. A, severe abrasion of the face suffered when patient tripped on a curbstone and fell against the asphaIt pavement. Numerous minute particIes of dirt and foreign materiai were embedded into the dermis. B, appearance eight days after emergency treatment by abrasion using novocain injection to the Doint of tense rkiditv of the tissue, the application of the rotary steel brush kd Vaseline gauge d&sings.
extent and type of the injury be assayed accurateIy. FolIowing the cIeansing of the skin with soap, water and a detergent the wound should be irrigated copiousIy with warm physioIogic saIine soIution. This reduces the amount of bacteria1 contamination, removes cIots and Ioose foreign bodies, and allows for the evaIuation of the degree and type of trauma. Injuries to the soft tissues of the face are classified as follows: (I) abrasions and contusions; (2) simpIe Iacerations; (3) Iacerations with avuIsion flaps; (4) lacerations with Ioss of soft tissue; (5) lacerations into the ora cavity; (6) Iacerations with injury to the eye or with associated fractures of the underIying facial bones. Genera1 measures which are necessary incIude the administration of tetanus antitoxin or booster dose of toxoid and IiberaI treatment with peniciIIin. FortunateIy, penicilIin is very effective against mouth organisms. Abrasions and contusions formerly were treated with simpIe cIeansing and the appIication of a vaseIine dressing. This treatment faiIed to take care of the problem of foreign materia1 imbedded in the dermis. Injury by scraping on macadam, brick or other objects resuIts invariabIy in traumatic tattoo. It has been deveIoped that in such instances it is justifiable and correct to treat the cutaneous area of foreign body embedment by the abrasive technic using fine sandpaper supported
on wooden bIocks or the rotary steel brush powered by a dental driI1 apparatus or conventiona1 motor. AIthough this method recognizes that further trauma is being added, the results justify the technic. (Figs. I, 2 and 3.) Simple lacerations are cIeansed by strong brushing of the floor of the wound if necessary, loose coaptation of fascial structures by catgut sutures, and approximation of cutaneous margins with sutures of 6-o fine silk starting at key points in the irregular laceration. Dead space is obIiterated by the pressure of Firm head dressings. Debridement of margins of the wound is contraindicated, for facia1 tissue is precious and the Iikelihood of complicating infection is remote. There is no authentic case report in the Iiterature of gas gangrene developing in a wound of the face. Just as infection by partiaI tension organisms such as the gonococcus is not encountered in the mouth, the rich oxygenation of facial tissues due to the abundant blood suppIy protects against infection foIIowing trauma except in the very rare instance in which there is massive devitaIization of tissue or in which the interva1 of time between injury and repair is unduly proIonged. If simple facial lacerations are paraIIe1 to the wrinkIe Iines of the skin, primary suture is rewarded with an unnoticeabIe scar of heaIing. On the other hand, violent trauma does not always respect laws or lines of physiologic
892
Injuries
to Soft Tissues
2A FIG. 2. A and B, several grades of fine sandpaper wooden blocks.
of Face
ZB supported
on wide and narrow
3A
3c 3D FIG. 3. Buncke safety sIeeve with rotary steel brush. A, the sleeve is detached and the rotary steel brush (which is power driven) is exposed. B, the safety sIeeve is in place so that the bristles of the brush project onIy through the small opening in the cylindric sIeeve. C, without the safety sleeve the bristles of the brush cause heaping up of the skin to one side and there is no protection against penetration of the compIete thickness of the skin. D, with the safety sleeve in pIace the rotary action of the stee1 brush does not alIow for tenting up of the skin. Moreover, protection is offered against too deep penetration of the dermis and centrifuga1 spray of bIood and ceIIuIar amterial is prevented. (From BUNCKE, H. J. Plast. G Reconstruct. Surg., 16: 65, 1955.)
Conway
FIG. 4. WrinkIe lines of the face. Note that they aIways are at right angIes to the line of contractiIe pull of the underlying muscles. Facial lacerations parallel to these lines heaI ideahy after primary suture. (From KRAISSL, C. J. and CONWAY, H. Surgery, 25: 592, 1949.)
FIG. 5. A, severe faciaI laceration incurred in automobiIe accident. B, after primary suture (without debridement) it was apparent that the verticaI hypertrophic scar paraIIeIing the nose on the Ieft was due to the fact that the Iaceration was not paraIIe1 to the wrinkIe Iines of the face. C, appearance after secondary excision of scar and shifting of tissue by the Z plastic technic.
tension, and Iacerations may be at right angIes to the wrinkle lines or at variance with them. In such cases primary suture resuIts in minima1 cicatrix which may be corrected at a Iater date by excision and revision of the tissue by the Z pIastic technic. In this cIassic procedure two incisions are made at an angIe of 60 degrees with the Iong axis of the scar which itseIf forms the obIique Iine of the Z. The horizonta1 arms of the Z are created by incision paraIIe1 to the wrinkIe lines which aIways run at right angIes to the Iine of contractiIe force of the underlying pIatysma. (Figs. 4 and 3.) Lacerations with avulsion flap of soft tissue are treated by gentIe cIeansing with saIine sponges, irrigation of the wound, remova of bIood cIots, accurate hemostasis and replacement of the ffap by Ioose fascia1 suture and minute (6-o siIk) cutaneous sutures even though the Ilap is SignificantIy cyanotic. It is the ruIe rather than the exception that posttraumatic, cyanotic flaps of soft facia1 tissue regain their viability after suture due to the abundant vascuIarity of this anatomic region. At any rate, the recovery of circuIation invariably saves more of a severeIy damaged
flap than would be saved by conservative debridement or amputation of portions of such flap. Lacerations witb loss of soft tissue are best treated by the surgica1 measures mentioned previously, foIlowed by the immediate appIication of a temporary thick-spIit graft of skin. This measure effects primary heaIing and prevents infection and subsequent cicatrix. The graft may be excised Iater by pIastic procedure and the area covered by the wide undercutting and advancement of a Aap of facia1 and cervica1 skin and subcutaneous tissue. In the case of loss of soft tissue of the eyelid fuI1 attention must be given to the protection of the gIobe. Freeing of the conjunctiva from the remainder of the Iid or Iids wiI1 aIIow for its closure over the eyebalI with a running suture of catgut appIied so that suture materia1 does not rub on the cornea. The externa1 wound is covered with a thick894
Injuries
to Soft Tissues
split graft of skin. Loss of soft tissue of the nose can be compensated for by the application of a skin graft. Through and through defects of the nasal alae (up to I cm. in diameter) may be corrected immediately by the use of a composite graft of skin and cartilage taken from the ear. More extensive Iosses must be corrected by the use of a pedicIed flap taken preferably from the temporal region. Through and through loss of tissue from the ear shouId be treated by suture of the aural remnant down to the skin of the mastoid area. Such a step avoids infection and readies the defect for correction by subcutaneous buriaI of cartilage and its subsequent elevation from the mastoid area and backing by skin graft. This method employs the first operative step at the time of repair of primary injury. If simple suture only of cutaneous margins of aural remnant is done, the aural reconstruction may require six or more reconstructive operative steps. It is intriguing to consider the abdominal burial of a compIetely detached portion of auricuIar cartiIage after excision of the overIying skin if such detached specimen has been saved. Manual carving of cartitage for aura1 repIacement never has been rewarded by contoural result which is equa1 to the scuIptured effect of the naturaI auricuIar cartilage. The onIy case in which I have had the opportunity to carry out this technic was a late disappointment due to the excessive formation of fibrous tissue over the cartiIaginous transplant. Lacerations into the oral cavity require thorough cleansing, irrigation with hydrogen peroxide or sodium perborate and Ioose suture of the mucous membranes, after which the details of closure of musculature and skin are carried out as listed heretofore. If there is sizabIe loss of tissue, infection can be avoided by the immediate suture of mucous membrane to skin, thus creating a temporary fistula of the cheek. Injury to Stensen’s duct must be searched for in lacerations of the cheek. If divided, its proximal end should be brought into the oral cavity at a position posterior to its normal aperture. If this is not feasibIe, the duct should be Iigated even though parotid atrophy foIIows this step. Minor injuries to the duct of the parotid gIand may cause Iocalized subcutaneous or submucous accumuIation of saliva. Usually this condition responds to successive aspirations. Lacerations in association with underlying
of Face
FIG. 6A. Example of a severe soft tissue wound in association with horizontar fracture of the maxilla. Patient had been struck by a taxicab. Emergency care included maintenance of airway by upward pressure on the upper jaw and the institution of tracheostomy. BIood transfusion was required as an emergency procedure. (From CONWAY, H. Rocky Mt. M. J., 50: 469, 19s)
severe fractures of the facial bones are treated just as other injuries to soft tissues, after reduction of the fractures has been accomplished. (Fig. 6.) SUMMARY
This presentation reiterates the principles of the management of soft tissue injuries of the face and emphasizes the vaIue of preservation of tissue rather than its wanton dkbridement. Attention to the basic principles of soft tissue repair at the time of emergency suture avoids the crippling deformities which follow infection of facial wounds or which mav on occasion be caused by excision of marginal tissue. The responsibiIity appears to be at the doorstep of the medical profession to influence the manufacturers of motor vehicles to incorporate into their construction of automobiles safety factors which wil1 limit the incidence of injuries to the face foIIowing automobite coIlisions. Most often injured is the occupant of 895
Conway
FIG. 6B to E. B, IateraI x-ray foIlowing the dispIacement of the fractured maxilla. C, IatereI x-ray foIIowing direct wiring of the fracture, the institution of fixation by intermaxillary wires. The wound was irrigated copiously with physioIogic saline and the margins of the jigsaw puzzIe, which the jagged Iaceration presented, were approximated by interrupted sutures of No. 5 zero and 6 zero bIack siIk. Margins of the wound were not excised, nor was it necessary to cut away any of the soft tissues. There was compIete absence (traumatic loss) of the nasa1 septum. D, appearance of the patient after primary heaIing. E, appearance after subsequent admission to the hospital, at which time a free graft of cartilage was inserted for support of the dorsum nasi. (From CONWAY, H. Rocky Mt. M. J., 50: 469, 1953.)
2. BUNCKE, H. J. Safety sleeve for wire brush abrasive
the right side of the front seat. The use of safety beIts, generousIy padded dashboards, recessed controk and some type of firm but transparent and moderately elastic materia1 in substitution for gIass for windshields unquestionably wouId be rewarded with a diminished incidence of facia1 injury due to automobile accidents.
therapy. Plast. CTReconstruct. Surg. (in press). 3. KRAISSL, C. J. and CONWAY, H. Excision of small tumors of the skin of the face with special reference to the wrinkle Iines. Surgery, 25: 592, 1949. 4. BROWN, J. B. and CANNON, B. Composite free grafts of skin and cartilage from the ear. Surg., Gynec. @ Obst., 82: 253, 1946. 5. CONWAY, H., STARK, R. B. and KAVANAUGH, J. D. Variations of the tempora1 Aap. Ph. w Reconstruct. Surg., g: 410, 1952. 6. PIERCE, G. W. Reconstruction of the externa1 ear. Surg., Gynec. u Obst., 50: 601, 1930. 7. CONWAY, H., NEUMANN, C. G., GELB, J., LEVERIDGE, L. L. and JOSEPH, J. M. Reconstruction of the external ear. Ann. Surg., 128: 226, 1948.
REFERENCES I. IVERSON, P. C. Further developments in the treatment of skin Iesions by surgical abrasion. Plast. u Reconstruct. Surg., 12: 27, 1953.
896