Facial Soft Tissue injuries

ByDr Saleem

Importance

• No other part of the body is as conspicuous, unique, or aesthetically significant as the face. Because an individual's self-image and self-esteem are often derived from his or her own facial appearance, any injury affecting these features requires particular attention.

Initial Examination

• examination of an individual with trauma to the face must start with an evaluation of the patient's airway, breathing, and circulation (ABCs). Cervical spine injury should also be considered based on the mechanism of injury, and appropriate precautions should be taken

1. identifying areas of bruising or active bleeding2. inspecting the nasal septum and external ear

for hematomas and nasal obstruction3. observing facial asymmetry or structural depressions4. looking for a sunken eye globe suggestive of a blow-out fracture5. observing lacerations or deep abrasions overlying suspected fractures

Classifications

• According to anatomy• Type of wound

Classification of Injury

• Contusion• Abrasion• Accidental Tattoo• Retained Foreign

Bodies

• Puncture Wounds• Simple Laceration• Avulsion (flap)• Avulsion (complete)

Contusions

• Bruising injury caused by blunt trauma (with or without hematoma)

• Cleansing and observation usually sufficient

• Some hematomas spontaneously resorb

• Other hematomas require surgical intervention

• Basis for “cauliflower ear” deformity

Abrasion

Abrasions are partial-thickness disruptions of the epidermis as a result of sudden, forcible friction. These wounds should be gently cleansed of all debris. Failure to remove all debris can lead to "tattooing" of the skin and a poor cosmetic result. Local or regional anesthetic may be required to keep the patient comfortable and achieve adequate cleaning. Lubrication of the wound using an antibiotic ointment and covering with a sterile bandage may encourage healing

• Accidental Tattoo • (dermal

imbedded particles)• Remove promptly

from abrasion to prevent tattoo

• Fixation occurs within 24-48 hours

• Scrub with stiff bristle brush

• Grease or oil removal with ether or acetone

Puncture wounds

• Not common on the face

• Possible injury to deeper structures

• Often swell due to hematomas

• Remove implanted foreign bodies

• Sometimes excised for best healing

Avulsion

• Avulsion - flap (undermining laceration)• One of the most

disfiguring injuries• Minimal debridement

(preserve tissue)• Remove beveled

wound margins• Pressure

dressings/drains to prevent hematomas

• Avulsion - complete (loss of tissue)• Direct primary closure

is preferable• Flap or skin graft may

be indicated• Don’t let it heal by

secondary granulation

Lacerations

• Repair should be undertaken after underlying structures have been assessed and foreign bodies removed.

• Time lapse between injury and repair is important relative to risk of infection and the choice of repair technique.

• With the exception of animal bites and traumatic tattoo, most soft tissue wounds of the face, properly cleansed and dressed, can await primary repair up to 24 hours, without serious risk of infection.

Contd• Tissue that is devitalized must be excised,

regardless of its location or of how important it was.

• Although debridement should be conservative, it must be adequate. Ragged, severely contused wound edges should be conservatively excised to provide perpendicular skin edges that will heal primarily with minimal scarring.

• Closely parallel lacerations can be converted to a single wound by excising the intervening skin bridge, facilitating repair and reducing scar formation.

• Displaced tissue should be returned to its original position.

• If contused marginal tissues are of anatomical importance ,it is best to avoid debridement and consider secondary reconstructive surgery.

• The muscles of facial expression are so closely associated with the skin that careful closure of the wound in layers gives adequate approximation of the muscle

• If possible, muscle layer should be identified and closed separately with fine absorbable sutures

Special regional considerationsScalp All injuries need to be copiously irrigated and

have all foreign bodies removed. Simple linear lacerations with good hemostasis can be closed with staples. Close more extensive lacerations, lacerations with profuse bleeding, or large avulsions of the scalp flap with continuous nonabsorbable sutures encompassing all layers of the scalp. This method usually achieves good hemostasis.

Eye brow

• Forehead and Brow• Preservation of

the eyebrow• Do not shave

eyebrow• Repair muscles to

prevent depression

• Rule out fractures

Eyelid

Simple lacerations of the eyelid, without involvement of the margins, can be treated without concern for further eye injury. If the protective function of the lid is compromised in any way, serious ophthalmologic injury may result. Exploration for foreign bodies must be performed. Flip the eyelids over and examine the tarsal plate. Damage to either side of the tarsal plate , ptosis is present, injury to the levator aponeurosis , any injuries that involve the canthi, lacrimal system, or lid margin

need opthalmologic consultation

Nose

• Soft tissue injuries usually simple

• Reduce fractures first• Align nasal structures

accurately• Use 6-0 non-

absorbable sutures (Nylon or Polypropylene)

• Rule out hematoma

EAR

• A direct blow or shearing force to the ear may result in tearing of the blood vessels at the level of the perichondrium. The result is a subperichondrial hematoma. These injuries can result in significant cosmetic deformity if missed or if not treated immediately. Fibrosis develops within 2 weeks of the injury, and the pt can be left with abnormally shaped pinnae (a condition also known as cauliflower ear).

• Carefully clean and debride ear injuries. If the wound is a linear laceration, it usually requires only primary closure with careful approximation of the cartilage perichondrium and skin and closure in 3 layers, using 5-0 nonabsorbable sutures for the skin layer.

Tragus

Antitragus

Antihelix

Hematoma

Lip

• Vermilion border• Single 5-0 Nylon or

Polypropylene suture to re-orient

• Close in layers• Muscle layer-use

Dexon or Vicryl• Skin - use 6-0 Nylon

or Polypropylene sutures

Tongue

Examine the tongue for lacerations; importantly, note the extent of the injury. Most lacerations, however, do not require repair. One exception is a complete anterior laceration, which can result in a bifid tongue if not properly repaired. Through-and-through and deep lacerations should be explored for the presence of foreign bodies and the potential need for repair

Facial nerve

• Any facial injury demands a complete functional evaluation of the main facial nerve trunk and its branches before any treatment. If transection has occurred, obvious signs of motor deficit will be present. Injuries to the temporal and eyebrow regions affect the temporal and zygomatic branches, causing inability to raise the eyebrows or close the eyelids. Injuries to the mandibular area margins affect the marginal mandibular, causing inability to frown. Buccal branch injuries cause inability to smile and loss of the nasolabial crease. Infraorbital nerve injury creates wrinkles in the cheek.

• Repair transection of the facial nerve as soon as possible after the injury, ideally within 72 hours. If repair is delayed, the distal severed ends will contract, rendering identification of the severed ends using a nerve stimulator difficult or impossible. Carry out nerve anastomosis under a microscope, using 8-0 nonabsorbable sutures in 3-4 positions circumferentially under minimal tension to prevent fibrosis. If the nerve ends cannot be delineated clearly (ie, if the ends are macerated or jagged), trim them off prior to anastomosis. If significant nerve loss makes direct anastomosis impossible, find and tag the nerve ends for future nerve grafting.

Parotid duct

• Lacerations of the parotid duct should be repaired at the time of wound closure to prevent fistula to the skin or to the mucous membrane of the mouth.

• To identify the course of the parotid duct, a line is drawn from the tragus of the ear to the midportion of the upper lip. The duct traverses the middle third of the line.

• The parotid duct travels adjacent to the buccal branch of the facial nerve. Buccal branch paralysis with an overlying laceration should suggest the possibility of a parotid duct injury.

• The parotid duct empties into the mouth opposite the maxillary second molar.

• A Silastic tube or silver probe can be inserted into the opening of the duct and the course of the duct followed. The duct can be irrigated with saline using a No. 22 Angiocath sleeve. The appearance of saline in the wound indicates that the duct is injured. The proximal end of the duct can be identified in the wound expressing secretion of saliva.

• A Silastic catheter is placed in the duct and the wound repaired with fine sutures. The tube is left in for a 2-week period, as tolerated

• Eyelid• Face• Oral cavity• Scalp• Lip• Trunk• Limbs• Hands/feet

6/0

5/0, 6/0

4/0

3/0, 4/0

4/0, 5/0

4/0

3/0, 4/0

4/0, 5/0

Slection of suture

Timing of Sutures Removal

• Eyelid• Face• Oral cavity• Scalp• Lip• Trunk• Limbs• Hands/feet

3-5 (days)

3-5

7-8…or dissolve

7-12

3-5

6-12

6-14

7-12

Distance between Sutures

• Eyelid• Face• Nose• Scalp• Forehead• Trunk• Limbs• Volar hand• Dorsal hand

1-2 (mm)

2-4

3-4

10-15

4-6

6-10

5-8

3-5

2-4