- Email: [email protected]
Management of soft-tissue trauma to the face
Operative Techniques in Otolaryngology (2008) 19, 90-97
Management of soft-tissue trauma to the face Krishna G. Patel, MD, PhD, Jonathan M. Sykes, MD From the Department of Otolaryngology–Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California. KEYWORDS Soft tissue trauma; Facial trauma; Facial injury
The management of acute soft-tissue trauma can be very challenging for the facial plastic surgeon. The goals of management of facial trauma are the preservation of form and function. These goals are particularly important in facial soft-tissue trauma, where injuries can cause not only esthetic deformities but also can affect neural function, normal mastication, visual fields, and salivary outflow. This article outlines the evaluation and treatment of acute soft-tissue facial trauma. The key components include allowing for the stabilization of the patient, complete examination of the injury and face, thorough wound irrigation and debridement of necrotic tissue, preservation of all viable tissue, tension-free closure, and realignment of important facial esthetic structures. Special consideration must be given to injuries of functional structures such as the facial nerve, ductal systems or organs, and ensuring appropriated management of these structures. © 2008 Elsevier Inc. All rights reserved.
In the United States, more than 146,000 patients per year are treated for soft-tissue trauma in emergency centers.1 The most common cause for soft-tissue trauma is motor vehicle accidents. Other common etiologies of trauma include falls, assault/altercations, sports, industrial accidents, self-inflicted trauma, and bites (both human and animal).1,2 The appropriate initial management of soft-tissue trauma during the acute phase can be invaluable for the long-term esthetic and functional outcomes. Given that many patients with soft-tissue trauma present with multiple injuries, the patient must first undergo a thorough evaluation under the standard guidelines of the Advance Trauma Life Support (ATLS) system.3,4 This evaluation allows the trauma patient to be stabilized if there are life-threatening injuries. However, soft-tissue trauma of the face can contribute to airway compromise if there is significant edema or oral bleeding.4 Mandible fractures that avulse the tongue’s attachment to the lingual mandible or mobilize the central mandible, such as bilateral parasymphyseal fractures, can reposition the tongue base posteriorly causing airway compromise. In addition to the airway, facial trauma can also play a role in circulatory compromise if
Address reprint requests and correspondence: Krishna G. Patel, Department of Otolaryngology–Head and Neck Surgery, University of California, Davis Medical Center, 2521 Stockton Blvd, Suite 7200, Sacramento, CA 95817. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2008.05.004
significant hemorrhage occurs. In the setting of hemorrhage, initially packing and applying pressure allows for the temporary tamponade of the vascular injury until the lacerated vessel can be identified and ligated, repaired, or embolized. If epistaxis is present, temporary nasal packing often sufficiently manages the bleeding.
Evaluation Once the initial assessment has been performed and the patient stabilized, the soft-tissue facial trauma can be carefully evaluated. Obtaining the patient’s history, such as the time and mechanism of the injury, aides in the management
Table 1
Tetanus prophylaxis in wound management
History of tetanus immunization (doses)
Clean, minor wounds, Td TIG
All other wounds, Td TIG
Unknown or ⬍3 doses 3 or more doses
Yes, No No,* No
Yes, Yes No,† No
Recommendations are based upon the CDC, Department of Health and Human Services Center for Disease Control and Prevention (www. cdc.gov/vaccines/). Td, diphtheria-tetanus toxoid; TIG, tetanus immune globulin. *Yes, if ⬎10 years since last dose. † Yes, if ⬎5 years since last dose.
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Figure 1 A photograph displaying a lateral view of an intubated patient involved in a motor vehicle accident. Note the extensive asphalt tattooing over the cheek and multiple contaminated lacerations and abrasions. (Color version of figure is available online.)
of care. If the mechanism of injury involved armory often there is deep tissue destruction and burn injury.5 Injuries involving motor vehicles or gunshots often require exploration and removal of foreign body material. Human and animal bites and contaminated wounds require extensive irrigation to prevent wound infection. Obtaining past medical history and social history can help identify factors that may affect wound healing. Comorbidities such as diabetes,
Figure 3 A postoperative photograph displaying a lateral view of the patient from Figure 1 after high-pressure pulsatile irrigation, debridement of necrotic tissue, and reapproximation of the wounds. The tattooing of the cheek has significantly improved and will decrease the degree of permanent tattooing as well as the risk of posttrauma infection. (Color version of figure is available online.)
alcohol or tobacco abuse, or past radiation therapy may negatively affect wound healing.1 Under circumstances of deep penetrating injuries, patients should be questioned regarding their tetanus immunization status and updated if
Figure 4 A Standard instrument set used for soft-tissue plastic surgery including fine-tipped forceps, skin hooks, and fine-tipped scissors. (Color version of figure is available online.) Table 2
Local anesthetic maximal dosing concentrations
Anesthetic Figure 2 An intraoperative photograph of the patient from Figure 1 demonstrating the use of high-pressure pulsatile irrigation to clean and debride the contaminated facial wounds. (Color version of figure is available online.)
Lidocaine 1% Lidocaine 1% with epinephrine 1:100,000 Bupivacaine 0.25%
Dose (mg/kg)
Onset (min)
Duration (hr)
3 to 4 5 to 7
⬍2 ⬍2
1.5 to 2 2 to 6
2.5
5
2 to 4
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Figure 5 An illustration depicting the use of deep sutures to reapproximate the wound edges (A) to allow for an even and everted skin edge (B). Use of a layered closure relieves the tension on the epidermal sutures and minimizes scar widening during wound healing. (Reprinted with permission.9)
necessary. Current tetanus prophylaxis is based on the recommendations by the Center for Disease Control and Prevention in Table 1.6
Physical examination After obtaining the patient’s information, a thorough physical evaluation is imperative. This evaluation includes close examination of the head and face for any signs of skeletal instability, bony step-offs, or dental malocclusion. In the event that there is suspicion of more than soft-tissue injury, appropriate radiographic imaging should be obtained, such as a computed tomography scan of the head or face or radiographs of the facial skeleton. Injuries that involve the eye should include ophthalmology consultation.4 A thorough examination of the skin, eyes, ears, nose, oral cavity, oral pharynx, and cranial nerves should be performed. Early recognition of any injury to the facial nerve, lacrimal ducts, or Stensen’s ducts is important.
Initial wound management Before any repair, the wound must be thoroughly cleansed. Obtaining important facts regarding the mechanism of injury can help determine if there are significant foreign bodies within the wound (Figure 1). If computed tomography scans had been obtained previously, these can reveal radiopaque foreign bodies such as glass and can be helpful in localizing deep foreign bodies. The best means for cleansing the wound and removing foreign body material is high-pressure irrigation (Figure 2). Multiple methods can be used, such as high-pressure pulsatile irrigation or bulb syringe irrigation. This author prefers the use of high-pressure pulsatile irrigation (Figure 3).7,8 Both methods should use copious amounts of irrigant to remove contaminants and bacteria. Irrigants commonly used include saline or antibiotic-infused saline (such as, 50,000 units of bacitracin to 1 liter of saline). Once the wound has been irrigated, the areas of tissue revealing frank necrosis should be débrided. If left, the necrotic tissue can serve as a nidus for infection. However, any tissue that appears partially viable should be
Figure 6 Illustration depicting the management of wounds when there is an uneven thickness of the dermal edges being reapproximated (A). The use of a layered closure first involves placement of deep sutures to even realign the deep tissues (B). After closure of the deep tissues, if the dermal edges are uneven (C), placing the dermal suture such that the suture is placed more deeply through the thinner dermal edge and more superficially through the thicker dermal edge (D) will bring the epidermal edges together in an even manner (E). (Reprinted with permission.9)
Patel and Sykes Table 3
Management of Soft-Tissue Trauma to the Face
93
Suture caliber guidelines for facial subunits
Region
Cutaneous suture
Subcutaneous/fascia suture
Comments
Eyelid and periorbital
#6-0, #7-0
#4-0, #5-0
Nose and pinna
#5-0, #6-0
#4-0, #5-0
Lip and vermilion
#6-0
#3-0, #4-0
General facial and anterior neck
#4-0, #5-0 #6-0
#3-0, #4-0
Nasal and oral mucosa
#3-0, #4-0
#3-0, #4-0
Scalp and posterior neck
#3-0, #4-0
#2-0, #3-0
Minimal tensile strength requirements; aesthetic concerns at a premium Small tensile strength requirements; aesthetic concerns at a premium Moderate tensile strength requirements because of highly active region; aesthetic concerns at a premium Moderate-to-high tensile strength requirements because of regional mobility; significant aesthetic concerns Moderate tensile strength needed due to tissue mobility; may select suture based on ease or no need for removal; no aesthetic concern Tensile strength needed for moderately heavy tissue and very mobile region; minimal aesthetic concern
Reprinted with permission from Baker S, Swanson N, Skyes J, et al: Suture needles and techniques for wound closure, in Local Flaps in Facial Reconstruction. New York, Mosby, 1995.
preserved to allow for the opportunity to revascularize and to lessen the degree of tissue loss sustained. If the patient is awake, the wound may need to be anesthetized before irrigation to thoroughly cleanse the wound without inflicting too much pain.
Surgical repair
decision should depend on the severity of the injury and the patient’s medical condition. The operating suite provides a more controlled environment in terms of the patient’s airway and pain management. Additionally, operating rooms have superior lighting and usually have access to better instruments (Figure 4). If there is concern for nerve or ductal injury, the operating suite should be used to allow for the use of microscopic techniques. However, waiting for an operating room may delay the closure of open wounds,
The setting for surgical repair of the injury may occur in either the operating suite or in the emergency room. This
Figure 7 A photograph displaying a complex laceration involving the full-thickness of the skin and cartilage of the right ear. Closure of this wound required a layered closure of the cartilage and skin, as well as attempts to regain the original shape and contour of the ear. Lacerations of the ear also require close evaluation of the external auditory canal and tympanic membrane. If significant soft tissue edema is present within the external auditory canal, a wick should be placed temporarily to prevent canal stenosis. Note the ischemic discoloration of the ear lobule, which was later sutured to its original position. (Color version of figure is available online.)
Figure 8 A photograph of the patient from Figure 7 at 1-month follow-up revealing complete viability of the tissues repaired and good contouring of the concha, antihelix and ear lobule. Mild notching is noticed along the helical rim. (Color version of figure is available online.)
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Figure 9 A photograph of a patient who sustained a full-thickness laceration through the left upper lip. To restore muscle function and improve esthetic outcome, a layered closure reapproximating the orbicularis oris muscle as well as a meticulous realignment of the vermilion– cutaneous border was performed. (Color version of figure is available online.)
which can allow for increased edema of the soft tissues. Additionally, the severity of injury often does not warrant use of the operating room facilities. Typically, 1% lidocaine with 1:100,000 epinephrine provides anesthesia that is effective in the awake or intubated patient. The longevity of the anesthetic can be increased by using a 1:1 mixture of 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine (Table 2). The injection of the anesthesia can be painful for the awake patient; this pain can be alleviated by buffering the anesthetic with a ratio of 9:1 lidocaine to bicarbonate. Additionally, waiting 10 to 15 minutes to allow for the vasoconstrictive effects of the epinephrine in the patient greatly aides one in visualization within the wound. Techniques for wound closure depend on the location, depth, and characteristics of the injury. Abrasions should be kept clean and moist with application of a thin layer of antibiotic ointment, such as bacitracin. If the wound is
Figure 10 A photograph of the patient from Figure 9 several months postoperatively revealing excellent realignment of the vermilion– cutaneous border. (Color version of figure is available online.)
Figure 11 subunits.
An illustration demonstrating the facial esthetic
significantly contaminated or inflicted by a human or animal bite, loose closure helps prevent deep tissue abscess formation. Hematomas involving the ear and nasal septum should be evacuated to prevent cartilage loss and subsequent future deformities, such as a cauliflower ear or nasal dorsal collapse, respectively. After relieving the hematoma, the ear should be bolstered or the septum bilaterally splinted to prevent re-accumulation of blood with subsequent cartilage loss. The method of wound closure should be designed to minimize wound tension and maximize eversion of the skin edges (Figure 5).9 Any tension on the skin layer increases risk of a widened scar or wound dehiscence. Employment of a multi-layered closure most ably creates a tension-free wound.10 In addition to eversion, placement of the sutures to ensure the wound edges are even provides the best outcome for wound healing (Figure 6).9 Table 3 provides a guideline for the recommended suture selection for wound closure (Table 3).9 Additional key elements include covering any exposed cartilage or bone with soft tissue. If the cartilage has been disrupted, such as the upper or lower lateral cartilages of the nose, or the helical cartilage of the ear, reapproximation of the cartilage edges with absorbable suture helps regain structural support (Figures 7 and 8). If there is interruption of muscle, such as the orbicularis oculi or orbicularis oris muscles, these muscle edges should be realigned to maximize posttraumatic recovery of muscle function (Figures 9 and 10). Placement of horizontal mattress sutures with absorbable suture helps to efface the muscle
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95
Figure 12 A photograph of the left forehead and eyebrow of a patient involved in a motor vehicle accident. The complex laceration crossed the hair-bearing eyebrow subunit and exposed skull on the forehead. (Color version of figure is available online.) Figure 14 A postoperative photograph of the left forehead and eyebrow from the patient in Figure 12 during a 6-month follow-up visit. The patient’s subunits are well aligned but the soft tissue trauma resulted in hair loss within the eyebrow subunit. (Color version of figure is available online.)
edges in a tension-free manner. Failure to realign muscle layers can lead to both esthetic and functional deficit that is often later nonrepairable. Meticulous realignment of skin edges is important, especially along the borders of esthetic subunits (Figure 11). In closing the skin edges, a size 6.0 or smaller caliber suture should be used. Special attention should be paid to realign the vermilion-cutaneous border, eyelid margin, nasal rim, brow or any hair-bearing borders (Figures 12-15). Using vertical mattress suture technique is excellent for the realignment of esthetic borders such as the eyelid margin and vermilion-cutaneous border of the lip. If the edges are not well everted, notching will occur as the wound contracts, which is particularly noticeable at esthetic subunit borders. The traditional teachings for eyelid margin lacerations describe a three-layer closure realigning the lash line, gray
line, and meibomian glands with 7.0 silk vertical mattress sutures that leave the tags long enough to secure more peripherally to prevent corneal abrasions (Figure 16).8,11 However, more recent literature advocates the use of absorbable suture for the eyelid margin closure.12 In either situation, the tarsal plate should be reapproximated with absorbable suture to relieve tension from the skin closure. With injuries near the medial canthus, secondary healing is often preferred to prevent webbed scarring.10 In general, concave surfaces heal well by secondary intention (Figures
Figure 13 An immediate postoperative photograph of the left forehead and eyebrow from the patient in Figure 12. A layered closure was performed, a drain was placed in the forehead to prevent hematoma formation, and meticulous attention was paid in realigning the eyebrow. (Color version of figure is available online.)
Figure 15 A postoperative photograph of the left forehead and eyebrow from the patient in Figure 14 after undergoing a revision w-plasty of the scarred tissue. Restoration of the natural contour of the eyebrow camouflages the scar significantly. (Color version of figure is available online.)
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Figure 16 An illustration depicting the repair of a full-thickness eyelid laceration. First, deep sutures are placed to reapproximate the tarsal plate. At the eyelid margin, three vertical mattress sutures are placed at the lash line, gray line and meibomian glands with 7.0 silk (A). The mattress suture tags are left long enough to secure more peripherally to prevent corneal abrasions (B). (Reprinted with permission.18)
17 and 18). These concave surfaces include the lateral forehead subunits, glabella, medial canthal subunit, depressed areas of the ear, supra-alar crease, soft tissue triangles, philtral subunit, and the perinasal melolabial crease (Figure 19).13 Wound edges that are uneven in depth are both difficult to realign and often create a pin-cushioning effect during the healing period. Superiorly based wound flaps are particularly susceptible to pin-cushion defects.8 Sharply creating a ninety-degree angle with the skin edge can help prevent this
Figure 17 A photograph of a patient who has a full-thickness tissue defect exposing bone near the left medial canthus. (Color version of figure is available online.)
Figure 18 A photograph of the patient from Figure 17, who healed the full-thickness defect via secondary intention. Note the significant wound contraction after 1 month of healing. (Color version of figure is available online.)
complication; however, one must be careful not to remove too much skin that would prevent closure of the wound (Figure 20). If tissue loss is significant and inhibits wound closure, as much of the wound as possible should be reapproximated. For the remaining open wound, wet-to-dry dressings help débride the wound and allow it to heal with plans for later reconstruction.14 Immediate reconstruction using soft tissue flaps is possible but discouraged given the wound is not sterile. Thus, delayed reconstruction of gaping wounds allows the edema and risk of infection to resolve.15 If there is suspicion that the facial nerve has been injured and the penetrating injury lies lateral to a vertical line drawn from the lateral canthus, the wound should be immediately explored for transection of facial nerve branches. Identified transected nerves should be repaired under microscopic
Figure 19 An illustration of the face. The shaded areas represent concave regions of the face that heal well through secondary intention. These concave surfaces include the lateral forehead subunits, glabella, medial canthal subunit, depressed areas of the ear, supra-alar crease, soft tissue triangles, philtral subunit, and the perinasal melolabial crease. (Reprinted with permission.13) (Color version of figure is available online.)
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biotic ointments, petroleum jelly is equally effective. Approximately 3 to 4 weeks after wound closure, massaging of the wound can help soften scars and decrease hypertrophy of the scar edges. If scarring becomes raised or uneven, dermabrasion may be initiated as early as 4 weeks after wound closure.
Summary
Figure 20 An illustration of an oblique skin laceration that results in uneven dermal edges (A). These wounds are difficult to reapproximate and often cause a pin-cushioning skin defect. Skin edge eversion can be improved by sharply creating new edges with 90-degree angles (B); however, one must be careful not to remove too much skin that would prevent closure of the wound. After creating the new skin edges (C), reapproximation of the wound in a layered closure helps to relieve tension off the skin edges (D).
In summary, soft tissue trauma is often complex and requires thorough evaluation. The key for good wound healing includes repair of any injured functional structures, copious irrigation, debridement of necrotic tissue, with meticulous tension-free closure. During the wound closure, utmost attention should be paid to realigning all esthetic subunit borders.
References technique, usually with a 7.0 or smaller permanent monofilament suture to realign the epineurium. Using a nerve stimulator can also be helpful in identifying the severed nerve branches. Nerve injuries medial to a vertical line drawn from the lateral canthus are thought to have enough cross-innervation from surrounding branches to regain function. For this reason, nerve repair is usually not attempted for medial injuries to the facial nerve. Injuries over the buccal region should be carefully explored to rule out injury to Stenson’s duct. Using lacrimal probes or silastic tubing cannulated through the buccal orifice aides in identifying the injured duct. Again, microscopic repair is warranted and stenting the duct for 3 to 4 weeks with silastic tubing can help prevent postoperative ductal stenosis.8,14 Key adjunctive treatments include providing antibiotic prophylaxis to prevent wound infection. Often cefazolin or cephalxin is appropriate, however, if the injury was from an animal or human bite, broader spectrum antibiotic coverage is advisable such as amoxicillin-clavulanate.14 If stents, bolsters or nasal packing is used, the patient should be kept on antibiotic prophylaxis as long as the packing is in place. Tetanus immunization is important for all deep penetrating wounds. For bites, infectious disease status of the offender such as rabies, HIV, or hepatitis should be investigated and the patient treated when question of exposure exists.14
Postoperative care Diligent postoperative wound care is essential for good healing of soft tissue wounds. Keeping the reapproximated skin edges free of dried blood improves wound healing. Open wounds or abrasions should be kept moist with a thin layer of antibiotic ointment, such as bacitracin, to prevent wound desiccation. Moist wounds have been shown to reepithelialize 50% faster compared with desiccated wound beds.16,17 If the patient develops sensitivity to topical anti-
1. Hochberg J, Ardenghy M, Toledo S, et al: Soft tissue injuries to face and neck: Early assessment and repair. World J Surg 25:1023-1027, 2001 2. MacBean CE, Taylor DM, Ashby K: Animal and human bite injuries in Victoria, 1998-2004. Med J Aust 186:38-40, 2007 3. American College of Surgeons. Advanced Trauma Life Support. 2003. Available at: http://www.facs.org/trauma/atls/index.html. Accessed May 20, 2008 4. Perry M, Dancey A, Mireskandari K, et al: Emergency care in facial trauma—a maxillofacial and ophthalmic perspective. Injury 36:875896, 2005 5. Motamedi MH: Primary treatment of penetrating injuries to the face. J Oral Maxillofac Surg 65:1215-1218, 2007 6. Halaas GW: Management of foreign bodies in the skin. Am Family Physician 76:683-688, 2007 7. Svoboda SJ, Bice TG, Gooden HA, et al: Comparison of bulb syringe and pulsed lavage irrigation with use of a bioluminescent musculoskeletal wound model. J Bone Joint Surg Am 88:2167-2174, 2006 8. Park S, Frodel J: Maxillofacial and soft tissue trauma, in Park SS (ed): Facial Plastic Surgery, The Essential Guide. New York, Thieme, 2005, pp 161-222 9. Sykes J, Byorth P: Suture needles and techniques for wound closure, in: Baker SR, Swanson NA (eds): Local Flaps in Facial Reconstruction. New York, Mosby, 1995, pp 39-62 10. Key SJ, Thomas DW, Shepherd JP: The management of soft tissue facial wounds. Br J Oral Maxillofac Surg 33:76-85, 1995 11. Mustarde J: Primary and secondary repair, in: Repair and Reconstruction in the Orbital Region. Baltimore, Williams & Wilkins, 1966 12. Perry JD, Aguilar CL, Kuchtey R: Modified vertical mattress technique for eyelid margin repair. Dermatol Surg 30:1580-1582, 2004 13. Larabee WF, Sherris DA: Principles of Facial Reconstruction (ed 1): Philadelphia, Lippincott-Raven, 1995 14. Hogg NJ, Horswell BB: Soft tissue pediatric facial trauma: A review. J Can Dent Assoc 72:549-552, 2006 15. Ueeck BA: Penetrating injuries to the face: Delayed versus primary treatment— considerations for delayed treatment. J Oral Maxillofac Surg 65:1209-1214, 2007 16. Goslen JB: Wound healing for the dermatologic surgeon. J Dermatol Surg Oncol 14:959-972, 1988 17. Hinman CD, Maibach H: Effect of air exposure and occlusion on experimental human skin wounds. Nature 200:377-8, 1963 18. Lisman R, Spinelli H: Orbital adenexal injuries, in Sherman JE (ed): Surgery with Facial Bone Fractures. New York, Churchill Livingstone, 1987, p 108
Management of soft-tissue trauma to the face Krishna G. Patel, MD, PhD, Jonathan M. Sykes, MD From the Department of Otolaryngology–Head and Neck Surgery, University of California, Davis Medical Center, Sacramento, California. KEYWORDS Soft tissue trauma; Facial trauma; Facial injury
The management of acute soft-tissue trauma can be very challenging for the facial plastic surgeon. The goals of management of facial trauma are the preservation of form and function. These goals are particularly important in facial soft-tissue trauma, where injuries can cause not only esthetic deformities but also can affect neural function, normal mastication, visual fields, and salivary outflow. This article outlines the evaluation and treatment of acute soft-tissue facial trauma. The key components include allowing for the stabilization of the patient, complete examination of the injury and face, thorough wound irrigation and debridement of necrotic tissue, preservation of all viable tissue, tension-free closure, and realignment of important facial esthetic structures. Special consideration must be given to injuries of functional structures such as the facial nerve, ductal systems or organs, and ensuring appropriated management of these structures. © 2008 Elsevier Inc. All rights reserved.
In the United States, more than 146,000 patients per year are treated for soft-tissue trauma in emergency centers.1 The most common cause for soft-tissue trauma is motor vehicle accidents. Other common etiologies of trauma include falls, assault/altercations, sports, industrial accidents, self-inflicted trauma, and bites (both human and animal).1,2 The appropriate initial management of soft-tissue trauma during the acute phase can be invaluable for the long-term esthetic and functional outcomes. Given that many patients with soft-tissue trauma present with multiple injuries, the patient must first undergo a thorough evaluation under the standard guidelines of the Advance Trauma Life Support (ATLS) system.3,4 This evaluation allows the trauma patient to be stabilized if there are life-threatening injuries. However, soft-tissue trauma of the face can contribute to airway compromise if there is significant edema or oral bleeding.4 Mandible fractures that avulse the tongue’s attachment to the lingual mandible or mobilize the central mandible, such as bilateral parasymphyseal fractures, can reposition the tongue base posteriorly causing airway compromise. In addition to the airway, facial trauma can also play a role in circulatory compromise if
Address reprint requests and correspondence: Krishna G. Patel, Department of Otolaryngology–Head and Neck Surgery, University of California, Davis Medical Center, 2521 Stockton Blvd, Suite 7200, Sacramento, CA 95817. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2008.05.004
significant hemorrhage occurs. In the setting of hemorrhage, initially packing and applying pressure allows for the temporary tamponade of the vascular injury until the lacerated vessel can be identified and ligated, repaired, or embolized. If epistaxis is present, temporary nasal packing often sufficiently manages the bleeding.
Evaluation Once the initial assessment has been performed and the patient stabilized, the soft-tissue facial trauma can be carefully evaluated. Obtaining the patient’s history, such as the time and mechanism of the injury, aides in the management
Table 1
Tetanus prophylaxis in wound management
History of tetanus immunization (doses)
Clean, minor wounds, Td TIG
All other wounds, Td TIG
Unknown or ⬍3 doses 3 or more doses
Yes, No No,* No
Yes, Yes No,† No
Recommendations are based upon the CDC, Department of Health and Human Services Center for Disease Control and Prevention (www. cdc.gov/vaccines/). Td, diphtheria-tetanus toxoid; TIG, tetanus immune globulin. *Yes, if ⬎10 years since last dose. † Yes, if ⬎5 years since last dose.
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91
Figure 1 A photograph displaying a lateral view of an intubated patient involved in a motor vehicle accident. Note the extensive asphalt tattooing over the cheek and multiple contaminated lacerations and abrasions. (Color version of figure is available online.)
of care. If the mechanism of injury involved armory often there is deep tissue destruction and burn injury.5 Injuries involving motor vehicles or gunshots often require exploration and removal of foreign body material. Human and animal bites and contaminated wounds require extensive irrigation to prevent wound infection. Obtaining past medical history and social history can help identify factors that may affect wound healing. Comorbidities such as diabetes,
Figure 3 A postoperative photograph displaying a lateral view of the patient from Figure 1 after high-pressure pulsatile irrigation, debridement of necrotic tissue, and reapproximation of the wounds. The tattooing of the cheek has significantly improved and will decrease the degree of permanent tattooing as well as the risk of posttrauma infection. (Color version of figure is available online.)
alcohol or tobacco abuse, or past radiation therapy may negatively affect wound healing.1 Under circumstances of deep penetrating injuries, patients should be questioned regarding their tetanus immunization status and updated if
Figure 4 A Standard instrument set used for soft-tissue plastic surgery including fine-tipped forceps, skin hooks, and fine-tipped scissors. (Color version of figure is available online.) Table 2
Local anesthetic maximal dosing concentrations
Anesthetic Figure 2 An intraoperative photograph of the patient from Figure 1 demonstrating the use of high-pressure pulsatile irrigation to clean and debride the contaminated facial wounds. (Color version of figure is available online.)
Lidocaine 1% Lidocaine 1% with epinephrine 1:100,000 Bupivacaine 0.25%
Dose (mg/kg)
Onset (min)
Duration (hr)
3 to 4 5 to 7
⬍2 ⬍2
1.5 to 2 2 to 6
2.5
5
2 to 4
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Figure 5 An illustration depicting the use of deep sutures to reapproximate the wound edges (A) to allow for an even and everted skin edge (B). Use of a layered closure relieves the tension on the epidermal sutures and minimizes scar widening during wound healing. (Reprinted with permission.9)
necessary. Current tetanus prophylaxis is based on the recommendations by the Center for Disease Control and Prevention in Table 1.6
Physical examination After obtaining the patient’s information, a thorough physical evaluation is imperative. This evaluation includes close examination of the head and face for any signs of skeletal instability, bony step-offs, or dental malocclusion. In the event that there is suspicion of more than soft-tissue injury, appropriate radiographic imaging should be obtained, such as a computed tomography scan of the head or face or radiographs of the facial skeleton. Injuries that involve the eye should include ophthalmology consultation.4 A thorough examination of the skin, eyes, ears, nose, oral cavity, oral pharynx, and cranial nerves should be performed. Early recognition of any injury to the facial nerve, lacrimal ducts, or Stensen’s ducts is important.
Initial wound management Before any repair, the wound must be thoroughly cleansed. Obtaining important facts regarding the mechanism of injury can help determine if there are significant foreign bodies within the wound (Figure 1). If computed tomography scans had been obtained previously, these can reveal radiopaque foreign bodies such as glass and can be helpful in localizing deep foreign bodies. The best means for cleansing the wound and removing foreign body material is high-pressure irrigation (Figure 2). Multiple methods can be used, such as high-pressure pulsatile irrigation or bulb syringe irrigation. This author prefers the use of high-pressure pulsatile irrigation (Figure 3).7,8 Both methods should use copious amounts of irrigant to remove contaminants and bacteria. Irrigants commonly used include saline or antibiotic-infused saline (such as, 50,000 units of bacitracin to 1 liter of saline). Once the wound has been irrigated, the areas of tissue revealing frank necrosis should be débrided. If left, the necrotic tissue can serve as a nidus for infection. However, any tissue that appears partially viable should be
Figure 6 Illustration depicting the management of wounds when there is an uneven thickness of the dermal edges being reapproximated (A). The use of a layered closure first involves placement of deep sutures to even realign the deep tissues (B). After closure of the deep tissues, if the dermal edges are uneven (C), placing the dermal suture such that the suture is placed more deeply through the thinner dermal edge and more superficially through the thicker dermal edge (D) will bring the epidermal edges together in an even manner (E). (Reprinted with permission.9)
Patel and Sykes Table 3
Management of Soft-Tissue Trauma to the Face
93
Suture caliber guidelines for facial subunits
Region
Cutaneous suture
Subcutaneous/fascia suture
Comments
Eyelid and periorbital
#6-0, #7-0
#4-0, #5-0
Nose and pinna
#5-0, #6-0
#4-0, #5-0
Lip and vermilion
#6-0
#3-0, #4-0
General facial and anterior neck
#4-0, #5-0 #6-0
#3-0, #4-0
Nasal and oral mucosa
#3-0, #4-0
#3-0, #4-0
Scalp and posterior neck
#3-0, #4-0
#2-0, #3-0
Minimal tensile strength requirements; aesthetic concerns at a premium Small tensile strength requirements; aesthetic concerns at a premium Moderate tensile strength requirements because of highly active region; aesthetic concerns at a premium Moderate-to-high tensile strength requirements because of regional mobility; significant aesthetic concerns Moderate tensile strength needed due to tissue mobility; may select suture based on ease or no need for removal; no aesthetic concern Tensile strength needed for moderately heavy tissue and very mobile region; minimal aesthetic concern
Reprinted with permission from Baker S, Swanson N, Skyes J, et al: Suture needles and techniques for wound closure, in Local Flaps in Facial Reconstruction. New York, Mosby, 1995.
preserved to allow for the opportunity to revascularize and to lessen the degree of tissue loss sustained. If the patient is awake, the wound may need to be anesthetized before irrigation to thoroughly cleanse the wound without inflicting too much pain.
Surgical repair
decision should depend on the severity of the injury and the patient’s medical condition. The operating suite provides a more controlled environment in terms of the patient’s airway and pain management. Additionally, operating rooms have superior lighting and usually have access to better instruments (Figure 4). If there is concern for nerve or ductal injury, the operating suite should be used to allow for the use of microscopic techniques. However, waiting for an operating room may delay the closure of open wounds,
The setting for surgical repair of the injury may occur in either the operating suite or in the emergency room. This
Figure 7 A photograph displaying a complex laceration involving the full-thickness of the skin and cartilage of the right ear. Closure of this wound required a layered closure of the cartilage and skin, as well as attempts to regain the original shape and contour of the ear. Lacerations of the ear also require close evaluation of the external auditory canal and tympanic membrane. If significant soft tissue edema is present within the external auditory canal, a wick should be placed temporarily to prevent canal stenosis. Note the ischemic discoloration of the ear lobule, which was later sutured to its original position. (Color version of figure is available online.)
Figure 8 A photograph of the patient from Figure 7 at 1-month follow-up revealing complete viability of the tissues repaired and good contouring of the concha, antihelix and ear lobule. Mild notching is noticed along the helical rim. (Color version of figure is available online.)
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Figure 9 A photograph of a patient who sustained a full-thickness laceration through the left upper lip. To restore muscle function and improve esthetic outcome, a layered closure reapproximating the orbicularis oris muscle as well as a meticulous realignment of the vermilion– cutaneous border was performed. (Color version of figure is available online.)
which can allow for increased edema of the soft tissues. Additionally, the severity of injury often does not warrant use of the operating room facilities. Typically, 1% lidocaine with 1:100,000 epinephrine provides anesthesia that is effective in the awake or intubated patient. The longevity of the anesthetic can be increased by using a 1:1 mixture of 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine (Table 2). The injection of the anesthesia can be painful for the awake patient; this pain can be alleviated by buffering the anesthetic with a ratio of 9:1 lidocaine to bicarbonate. Additionally, waiting 10 to 15 minutes to allow for the vasoconstrictive effects of the epinephrine in the patient greatly aides one in visualization within the wound. Techniques for wound closure depend on the location, depth, and characteristics of the injury. Abrasions should be kept clean and moist with application of a thin layer of antibiotic ointment, such as bacitracin. If the wound is
Figure 10 A photograph of the patient from Figure 9 several months postoperatively revealing excellent realignment of the vermilion– cutaneous border. (Color version of figure is available online.)
Figure 11 subunits.
An illustration demonstrating the facial esthetic
significantly contaminated or inflicted by a human or animal bite, loose closure helps prevent deep tissue abscess formation. Hematomas involving the ear and nasal septum should be evacuated to prevent cartilage loss and subsequent future deformities, such as a cauliflower ear or nasal dorsal collapse, respectively. After relieving the hematoma, the ear should be bolstered or the septum bilaterally splinted to prevent re-accumulation of blood with subsequent cartilage loss. The method of wound closure should be designed to minimize wound tension and maximize eversion of the skin edges (Figure 5).9 Any tension on the skin layer increases risk of a widened scar or wound dehiscence. Employment of a multi-layered closure most ably creates a tension-free wound.10 In addition to eversion, placement of the sutures to ensure the wound edges are even provides the best outcome for wound healing (Figure 6).9 Table 3 provides a guideline for the recommended suture selection for wound closure (Table 3).9 Additional key elements include covering any exposed cartilage or bone with soft tissue. If the cartilage has been disrupted, such as the upper or lower lateral cartilages of the nose, or the helical cartilage of the ear, reapproximation of the cartilage edges with absorbable suture helps regain structural support (Figures 7 and 8). If there is interruption of muscle, such as the orbicularis oculi or orbicularis oris muscles, these muscle edges should be realigned to maximize posttraumatic recovery of muscle function (Figures 9 and 10). Placement of horizontal mattress sutures with absorbable suture helps to efface the muscle
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Figure 12 A photograph of the left forehead and eyebrow of a patient involved in a motor vehicle accident. The complex laceration crossed the hair-bearing eyebrow subunit and exposed skull on the forehead. (Color version of figure is available online.) Figure 14 A postoperative photograph of the left forehead and eyebrow from the patient in Figure 12 during a 6-month follow-up visit. The patient’s subunits are well aligned but the soft tissue trauma resulted in hair loss within the eyebrow subunit. (Color version of figure is available online.)
edges in a tension-free manner. Failure to realign muscle layers can lead to both esthetic and functional deficit that is often later nonrepairable. Meticulous realignment of skin edges is important, especially along the borders of esthetic subunits (Figure 11). In closing the skin edges, a size 6.0 or smaller caliber suture should be used. Special attention should be paid to realign the vermilion-cutaneous border, eyelid margin, nasal rim, brow or any hair-bearing borders (Figures 12-15). Using vertical mattress suture technique is excellent for the realignment of esthetic borders such as the eyelid margin and vermilion-cutaneous border of the lip. If the edges are not well everted, notching will occur as the wound contracts, which is particularly noticeable at esthetic subunit borders. The traditional teachings for eyelid margin lacerations describe a three-layer closure realigning the lash line, gray
line, and meibomian glands with 7.0 silk vertical mattress sutures that leave the tags long enough to secure more peripherally to prevent corneal abrasions (Figure 16).8,11 However, more recent literature advocates the use of absorbable suture for the eyelid margin closure.12 In either situation, the tarsal plate should be reapproximated with absorbable suture to relieve tension from the skin closure. With injuries near the medial canthus, secondary healing is often preferred to prevent webbed scarring.10 In general, concave surfaces heal well by secondary intention (Figures
Figure 13 An immediate postoperative photograph of the left forehead and eyebrow from the patient in Figure 12. A layered closure was performed, a drain was placed in the forehead to prevent hematoma formation, and meticulous attention was paid in realigning the eyebrow. (Color version of figure is available online.)
Figure 15 A postoperative photograph of the left forehead and eyebrow from the patient in Figure 14 after undergoing a revision w-plasty of the scarred tissue. Restoration of the natural contour of the eyebrow camouflages the scar significantly. (Color version of figure is available online.)
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Figure 16 An illustration depicting the repair of a full-thickness eyelid laceration. First, deep sutures are placed to reapproximate the tarsal plate. At the eyelid margin, three vertical mattress sutures are placed at the lash line, gray line and meibomian glands with 7.0 silk (A). The mattress suture tags are left long enough to secure more peripherally to prevent corneal abrasions (B). (Reprinted with permission.18)
17 and 18). These concave surfaces include the lateral forehead subunits, glabella, medial canthal subunit, depressed areas of the ear, supra-alar crease, soft tissue triangles, philtral subunit, and the perinasal melolabial crease (Figure 19).13 Wound edges that are uneven in depth are both difficult to realign and often create a pin-cushioning effect during the healing period. Superiorly based wound flaps are particularly susceptible to pin-cushion defects.8 Sharply creating a ninety-degree angle with the skin edge can help prevent this
Figure 17 A photograph of a patient who has a full-thickness tissue defect exposing bone near the left medial canthus. (Color version of figure is available online.)
Figure 18 A photograph of the patient from Figure 17, who healed the full-thickness defect via secondary intention. Note the significant wound contraction after 1 month of healing. (Color version of figure is available online.)
complication; however, one must be careful not to remove too much skin that would prevent closure of the wound (Figure 20). If tissue loss is significant and inhibits wound closure, as much of the wound as possible should be reapproximated. For the remaining open wound, wet-to-dry dressings help débride the wound and allow it to heal with plans for later reconstruction.14 Immediate reconstruction using soft tissue flaps is possible but discouraged given the wound is not sterile. Thus, delayed reconstruction of gaping wounds allows the edema and risk of infection to resolve.15 If there is suspicion that the facial nerve has been injured and the penetrating injury lies lateral to a vertical line drawn from the lateral canthus, the wound should be immediately explored for transection of facial nerve branches. Identified transected nerves should be repaired under microscopic
Figure 19 An illustration of the face. The shaded areas represent concave regions of the face that heal well through secondary intention. These concave surfaces include the lateral forehead subunits, glabella, medial canthal subunit, depressed areas of the ear, supra-alar crease, soft tissue triangles, philtral subunit, and the perinasal melolabial crease. (Reprinted with permission.13) (Color version of figure is available online.)
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biotic ointments, petroleum jelly is equally effective. Approximately 3 to 4 weeks after wound closure, massaging of the wound can help soften scars and decrease hypertrophy of the scar edges. If scarring becomes raised or uneven, dermabrasion may be initiated as early as 4 weeks after wound closure.
Summary
Figure 20 An illustration of an oblique skin laceration that results in uneven dermal edges (A). These wounds are difficult to reapproximate and often cause a pin-cushioning skin defect. Skin edge eversion can be improved by sharply creating new edges with 90-degree angles (B); however, one must be careful not to remove too much skin that would prevent closure of the wound. After creating the new skin edges (C), reapproximation of the wound in a layered closure helps to relieve tension off the skin edges (D).
In summary, soft tissue trauma is often complex and requires thorough evaluation. The key for good wound healing includes repair of any injured functional structures, copious irrigation, debridement of necrotic tissue, with meticulous tension-free closure. During the wound closure, utmost attention should be paid to realigning all esthetic subunit borders.
References technique, usually with a 7.0 or smaller permanent monofilament suture to realign the epineurium. Using a nerve stimulator can also be helpful in identifying the severed nerve branches. Nerve injuries medial to a vertical line drawn from the lateral canthus are thought to have enough cross-innervation from surrounding branches to regain function. For this reason, nerve repair is usually not attempted for medial injuries to the facial nerve. Injuries over the buccal region should be carefully explored to rule out injury to Stenson’s duct. Using lacrimal probes or silastic tubing cannulated through the buccal orifice aides in identifying the injured duct. Again, microscopic repair is warranted and stenting the duct for 3 to 4 weeks with silastic tubing can help prevent postoperative ductal stenosis.8,14 Key adjunctive treatments include providing antibiotic prophylaxis to prevent wound infection. Often cefazolin or cephalxin is appropriate, however, if the injury was from an animal or human bite, broader spectrum antibiotic coverage is advisable such as amoxicillin-clavulanate.14 If stents, bolsters or nasal packing is used, the patient should be kept on antibiotic prophylaxis as long as the packing is in place. Tetanus immunization is important for all deep penetrating wounds. For bites, infectious disease status of the offender such as rabies, HIV, or hepatitis should be investigated and the patient treated when question of exposure exists.14
Postoperative care Diligent postoperative wound care is essential for good healing of soft tissue wounds. Keeping the reapproximated skin edges free of dried blood improves wound healing. Open wounds or abrasions should be kept moist with a thin layer of antibiotic ointment, such as bacitracin, to prevent wound desiccation. Moist wounds have been shown to reepithelialize 50% faster compared with desiccated wound beds.16,17 If the patient develops sensitivity to topical anti-
1. Hochberg J, Ardenghy M, Toledo S, et al: Soft tissue injuries to face and neck: Early assessment and repair. World J Surg 25:1023-1027, 2001 2. MacBean CE, Taylor DM, Ashby K: Animal and human bite injuries in Victoria, 1998-2004. Med J Aust 186:38-40, 2007 3. American College of Surgeons. Advanced Trauma Life Support. 2003. Available at: http://www.facs.org/trauma/atls/index.html. Accessed May 20, 2008 4. Perry M, Dancey A, Mireskandari K, et al: Emergency care in facial trauma—a maxillofacial and ophthalmic perspective. Injury 36:875896, 2005 5. Motamedi MH: Primary treatment of penetrating injuries to the face. J Oral Maxillofac Surg 65:1215-1218, 2007 6. Halaas GW: Management of foreign bodies in the skin. Am Family Physician 76:683-688, 2007 7. Svoboda SJ, Bice TG, Gooden HA, et al: Comparison of bulb syringe and pulsed lavage irrigation with use of a bioluminescent musculoskeletal wound model. J Bone Joint Surg Am 88:2167-2174, 2006 8. Park S, Frodel J: Maxillofacial and soft tissue trauma, in Park SS (ed): Facial Plastic Surgery, The Essential Guide. New York, Thieme, 2005, pp 161-222 9. Sykes J, Byorth P: Suture needles and techniques for wound closure, in: Baker SR, Swanson NA (eds): Local Flaps in Facial Reconstruction. New York, Mosby, 1995, pp 39-62 10. Key SJ, Thomas DW, Shepherd JP: The management of soft tissue facial wounds. Br J Oral Maxillofac Surg 33:76-85, 1995 11. Mustarde J: Primary and secondary repair, in: Repair and Reconstruction in the Orbital Region. Baltimore, Williams & Wilkins, 1966 12. Perry JD, Aguilar CL, Kuchtey R: Modified vertical mattress technique for eyelid margin repair. Dermatol Surg 30:1580-1582, 2004 13. Larabee WF, Sherris DA: Principles of Facial Reconstruction (ed 1): Philadelphia, Lippincott-Raven, 1995 14. Hogg NJ, Horswell BB: Soft tissue pediatric facial trauma: A review. J Can Dent Assoc 72:549-552, 2006 15. Ueeck BA: Penetrating injuries to the face: Delayed versus primary treatment— considerations for delayed treatment. J Oral Maxillofac Surg 65:1209-1214, 2007 16. Goslen JB: Wound healing for the dermatologic surgeon. J Dermatol Surg Oncol 14:959-972, 1988 17. Hinman CD, Maibach H: Effect of air exposure and occlusion on experimental human skin wounds. Nature 200:377-8, 1963 18. Lisman R, Spinelli H: Orbital adenexal injuries, in Sherman JE (ed): Surgery with Facial Bone Fractures. New York, Churchill Livingstone, 1987, p 108