Facial Soft Tissue Trauma Treatment & Management
- Author: Daniel D Sutphin, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
Although patients with traumatic facial injuries often present with extremely disfigured appearances, their injuries are seldom life-threatening. Treat each patient who presents with significant traumatic facial injuries as a trauma patient in accordance with American Trauma Life Support (ATLS) protocol.
Address the most life-threatening problems first. Evaluate the patient’s facial injuries only after establishing a definitive airway, stabilizing hemodynamics, and assessing other associated life-threatening injuries.
Initial Supportive Measures
The foremost priority in treating any trauma patient is establishing a definitive airway. In a conscious patient who is alert, awake, talking, and in no obvious respiratory distress, the airway is patent and the physical assessment of other areas may be continued.
Consider airway obstruction in a conscious patient who demonstrates any degree of respiratory distress. Blood, vomitus, facial bone fragments, dentures, or other foreign bodies may cause either partial or complete airway obstruction. Perform a quick finger sweep of the oral cavity if any physical obstruction to the airway is suggested; this frequently suffices to dislodge any matter and to relieve any obstructions in the upper airway.
If respiratory distress continues, consider nasal intubation; however, in view of the possibility of intracranial contamination, do not intubate if the patient presents with a considerably distorted nasal anatomy, extensive nasopharyngeal hemorrhaging, leakage of cerebrospinal fluid (CSF), or possible fracture of the cribriform plate. Sedate the patient, and perform an orotracheal intubation.
If a conscious patient is uncooperative and combative (eg, from alcohol intoxication), insert an endotracheal or nasotracheal tube after administering sedation. In an unconscious patient with poor vital reflexes (ie, gag, cough, swallow) or with a Glasgow Coma Scale (GCS) score of 8 or less, perform orotracheal intubation to prevent aspiration and to protect the airway. Patients with massive soft tissue damage (eg, from shotgun injuries to the face) must be sedated and intubated at once. Aspiration from hemorrhage is a concern in these patients.[14, 15]
If attempts at intubation are unsuccessful, emergency cricothyroidotomy or a formal tracheostomy may be performed. Because these are invasive procedures with their own complications, they should be used only as a last resort to ensure an adequate airway.
Management of hemorrhage and shock
Hemorrhage resulting in systemic shock from facial trauma alone is rare, except in cases of extensive penetrating injuries such as gunshot wounds to the face. Bleeding from any branch of the external carotid system (facial artery, superficial temporal artery, angular artery) may be encountered. While many of these injuries can be controlled or temporized with direct pressure, the maxillary artery and its branches deep within the mid face may be particularly problematic. Persistent bleeding that is not readily definable may warrant interventional arteriography for diagnosis and treatment. Closely monitor the airway at all times as blood from facial hemorrhage may obstruct the upper airway or may result in emesis and aspiration that can further compromise the airway. If a patient with facial trauma presents with shock, promptly assess other associated injuries.
The use of antibiotics depends on the mechanism of injury (eg, animal or human bite, assault, or motor vehicle accident [MVA]), the degree of injury (superficial or extensive) and concern for devitalized tissue, and the patient’s immune status. No extensive prospective data exist regarding which antibiotic is best or necessary, but important factors guiding therapy in each case include whether the wound is related to a bite (animal or human), the degree of gross contamination, intraoral or sinusoidal mucosal violation, and the presence of associated fractures. Tetanus status of the patient should always be verified and anaerobic coverage provided under the above circumstances.
For facial lacerations that can be closed primarily, local anesthetic agents such as lidocaine 1% or 2% with epinephrine (1:100,000) are used. The vasoconstrictive effects of epinephrine provide hemostasis and prolong the effect of anesthesia. Avoid epinephrine in areas with end arteries, such as the tip of the nose or the ear lobe, because it may induce irreversible vasoconstriction leading to necrosis.
For injuries involving the nares, topical anesthetic agents applied to the nasal mucous membranes may be used. Cocaine (5%) is the agent of choice in this case because it is fast acting, has an intermediate duration of action, and can be introduced easily via cotton-tipped applicators or cotton gauze.
Considerations for Special Injury Types
Animal bites to the face are generally the results of dog attacks. A French study, by Touré et al, of dog bite injuries to the face, as analyzed from emergency admissions to the investigators’ service, found that such injuries made up 0.83% of such admissions, with the majority of patients (68.5%) being under age 16 years and 33.3% being between age 2 and 5 years. The prospective study, which included 108 patients, also reported that German shepherds were the dogs most frequently involved in bite injuries to the face and that most of the children who were bitten were in a single-parent environment at the time.
The facial soft tissue injuries sustained from animal bites are usually lacerations and tears of the scalp, cheek, or neck. Because animal saliva harbors numerous virulent microorganisms, the main concern from such injury is wound infection. Human bites, though appearing to be more innocuous, are actually more destructive in terms of infection. The human oral flora is different from those of animals and is more virulent. The treatment, however, is similar to that for animal bites.
Copiously irrigate facial wounds from animal bites with isotonic sodium chloride solution, and excise any macerated or destroyed tissue. If the wound is less than 6 hours old and if the margins can be clearly delineated, the wound may be approximated and closed with fine interrupted sutures.
If the wound is older than 6 hours, depending on the degree of penetration and the size of the bite, closure of the wound may require plastic surgical discretion. Animal bite wounds of this duration are extremely prone to infection and, if closed, have a higher rate of wound complications.
Administer antibiotics in all cases of animal bites, regardless of duration.
The decision whether to administer rabies vaccine depends on the status of the animal. Whether the animal is a domesticated, immunized pet or a wild animal must be determined. Ideally, the animal should be caught, confined, and observed because the incubation period of the rabies virus is about 10-14 days in animals and 2-8 weeks in humans.
If the animal shows signs of rabies, the patient can be treated within the incubation period. If the animal is found dead or is killed, a microscopic examination of the brain for Negri bodies or a fluorescein antibody test is mandatory to determine whether the animal was rabid. If the results are positive, the patient must undergo the rabies vaccination protocol.
Gunshot wounds to the face
The first priorities with any gunshot wound are to establish a definitive airway, control any hemorrhage, and stabilize the patient.
Civilian gunshot wounds to the face generally result from recreational accidents, domestic violence, or suicide attempts. Gunshot wounds to the face range from small-caliber recreational pellet gun wounds to full-scale shotgun blasts in which the facial soft tissue and underlying bony construct are destroyed.
With a small-caliber, low-velocity missile injury, the entry wound may appear trivial, but the blast effect produced along the path of the missile can be extensive. Patients with this type of injury must be observed closely. If the bullet is lodged within the soft tissue with no functional deficit or major aesthetic defect, it may be left in place depending on the morbidity associated with its removal. If the wound becomes grossly infected or causes pain or impairment in jaw function, initiate surgical intervention with removal of the bullet and incision and drainage of the wound.
Through-and-through gunshot injuries or close-range shotgun wounds often produce associated maxillofacial bony injuries. Wounds of this extensive nature require immediate plastic surgical consultation.
If the patient survives the initial injury, complete facial reconstruction procedures can often encompass a period of many years, depending on the extent of injury, the degree of infection, and the health of the patient.
If possible, repair facial injuries within the first 8 hours after the initial insult. If the patient is unstable, repair of extensive wounds may be loosely accomplished while critical procedures are being performed. Definitive revision can be provided later. If it is still not possible to repair injuries after 3 days, then healing by secondary intention becomes necessary, and subsequent scar revision might be indicated after secondary wound closure.
Unless the injury is superficial and toward the periphery of the face, extensive facial soft tissue injuries should be addressed in the operating room (OR) rather than the emergency department (ED). Additionally, adult patients with extensive facial trauma may often be intoxicated and combative. Such patients should be treated under general anesthesia as well, in order to effect optimal wound closure and necessary treatment. Similarly, younger children, who are usually uncooperative, should receive operative treatment under general anesthesia.
All forms of facial injuries (eg, abrasions, lacerations, and avulsions) should be well irrigated with isotonic sodium chloride solution before any tissue is handled. This serves both to cleanse the wound and to provide better visualization. Carefully remove any lodged foreign body fragments to minimize disturbance to surrounding tissue. If any macerated or friable tissue is present, meticulous debridement of the affected areas may be carried out, provided that subsequent possible cosmetic deformities are considered and minimized.
If the injury extends through hirsute regions (eg, scalp, mustache, or beard), the hair may be shaved around the wound to facilitate suturing. The eyebrow, however, is never shaved; once shaved, it may not grow back. In addition, the form and contour of the eyebrow also serve as crucial indicators of aesthetic symmetry and as important landmarks for repair. Mishandling of the eyebrow may result in difficult-to-correct defects of improper alignment, disproportionate growth, or both.
Close most facial wounds with fine sutures. If the wound requires closure in layers, fine absorbable 4-0 or 5-0 sutures may be used on the mucosa or muscles. Close the skin with nonabsorbable monofilament sutures. Subcuticular sutures may be used on conspicuous areas. Trim macerated or jagged wound margins before any closure. Tissue adhesives have been used for simple traumatic lacerations, although they may be associated with a higher rate of dehiscence.
The following summarizes approaches to the repair of injuries to specific areas of the face.
All scalp injuries must be copiously irrigated, and all foreign bodies must be 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. If lacerations are jagged or macerated, obtain clean edges by trimming the macerated areas, and bevel the incisions parallel to the hair follicles to avoid secondary alopecia.
Eyebrows are never shaved. Superficial linear lacerations across the eyebrow are meticulously closed with nonabsorbable sutures and careful alignment of the margins. The resulting scar can be anticipated and concealed in the hairs of the eyebrow. Subcuticular sutures may also be placed, provided that the strength is adequate for the wound.
Close deeper lacerations in layers. Approximate lacerations involving divided muscles to minimize surface contractures and functional defects. Neatly trim and débride jagged or macerated tissue, following the line of the eyebrows to avoid additional hair loss.
The eyelid is perhaps the most delicate structure of the face and consists of several layers of fine musculature. Improper repair may result in ptosis or an ectropion. Lacerations of the eyelid are characterized as partial- or full-thickness defects. They may also be described as superficial or deep and as horizontal (parallel to the lid margins) or vertical (perpendicular to the lid margins).
Superficial horizontal lacerations require only simple sutures for closure. Close superficial vertical lacerations in layers because they often traverse normal skin tension lines and the underlying musculature. The key suture is placed at the ciliary margin. First close the subcutaneous tissue and muscles with absorbable sutures, then close the skin with 6-0 interrupted nonabsorbable sutures.
Deep and through-and-through lacerations of the eyelid warrant a careful assessment of the globe and the integrity of the cornea. Retained foreign bodies are also sought. Wound margins must be aligned carefully, and key sutures must be placed first at the ciliary margin and at the tarsus. The remainder of the eyelid is then apposed and repaired. Skin sutures may be removed after 5 days.
The ears consist of unique arches and contours that are distinctly symmetrical. Repair and reconstruction of the ears may often be difficult and challenging, for even a plastic surgeon.
Injuries are classified in terms of upper, mid, and lower-third injuries. Carefully clean and débride ear injuries. If the wound is a linear laceration, careful trilayer reapproximation of the cartilage perichondrium and skin is usually adequate. Use 5-0 nonabsorbable sutures for the skin. For lacerations involving the helix, key sutures are placed at the outer rim to preserve its contour and to prevent subsequent notching.
If the injury is an avulsion, the wound is thoroughly cleansed and conservatively débrided, and the margins are minimally trimmed and closed in layers if possible. Because the ear is highly vascular, smaller injuries may heal quite well if properly treated. However, if the wound is a large and is a grossly noticeable defect, conservative management with Sulfamylon cream and Xeroform gauze helps prevent chondritis while avoiding desiccation and allowing the wound to heal. Reconstruction may still be required at a future date.
Venous congestion can be troublesome, as can auricular or helical hematomas. Somewhat analogous to septal hematoma, hematoma of the external ear (cauliflower ear) can develop at the level of the perichondrium after trauma to the auricle. Without timely treatment, the hematoma begins to fibrose over several weeks. Within 2-3 months, a fibrotic mass with new cartilage formation develops. Treatment is less difficult and more successful when completed immediately after the injury.
Aspiration should be performed with a large-bore (≥18-gauge) needle. After aspiration, an external compression dressing should be placed to prevent reaccumulation of fluid. Silicone ear splints can be molded to the front and back of the earlobe and held in place with a head wrap, sutures, or both. When splints are not available, compression can be achieved by suturing a piece of nasal packing to the front and back of the auricle. Compressive dressing should be worn for 3-5 days.
A septal hematoma is a blood-filled cavity between the cartilage and the supporting perichondrium. If unrecognized or untreated, the septal cartilage is subjected to continuous pressure. The pressure exerted by the hematoma eventually results in necrosis of the underlying cartilaginous support. The result is a saddle deformity of the septum that requires surgical repair. Occasionally, the hematoma becomes infected and a similar process of necrosis ensues.
Septal hematoma is managed through decompression, either by needle aspiration with a large-bore (≥ 18-gauge) needle or by incision and drainage with a No. 11 scalpel. After decompression, bilateral nasal packing is placed to prevent fluid reaccumulation. Antibiotic prophylaxis in patients with a septal hematoma is controversial. Referral to an otolaryngologist is warranted for close follow-up.
Superficial lacerations through the skin of the nose require only simple nonabsorbable skin sutures to close the wound. Deeper bites that include the cartilages may be used if the laceration extends down to the cartilages and if the cartilages can be aligned easily with no significant deviation.
For full-thickness lacerations of the nose, perform wound closure in layers—that is, through the skin, cartilage, and mucous membrane. First, carefully align and close the divided mucous membranes with 4-0 to 6-0 absorbable sutures. Next, accurately align and close the skin and cartilage with nonabsorbable interrupted sutures.
For lacerations that involve distinct nasal landmarks (eg, the nasal rim, the nostril border, or the alar rim), first place key sutures at those regions to ensure smooth, continuous contours without notching.
Nasal packing after surgical wound closure is done at the surgeon’s discretion. In general, packing is unnecessary if the underlying supporting elements are intact and in good alignment. Petrolatum-impregnated gauze may be used to pack the nose for support if unstable underlying cartilaginous or bony fragments are suspected. Note that nasal packing, in addition to causing discomfort, obstructs air circulation and drainage and may cause additional bleeding when removed from the delicate mucous membrane.
A retrospective study by Tan et al suggested that full-thickness skin grafts are an effective means of reconstructing partial-thickness defects of the nasal ala. The study, which involved 181 patients who underwent Mohs micrographic surgery for skin cancer of the ala, stated that all patients obtained good to excellent cosmetic results, with low incidence of graft failure and infection.
As previously noted, 1-mm discrepancies of the vermillion border are noticeable at conversational distance. Thus, the vermillion serves as the key reference point in repair of lip lacerations. Identify, carefully align, and mark distinct landmarks (eg, the white roll or the philtral column) before local anesthesia injection. This is especially important if the injury extends through the midline of the lip at the Cupid’s bow or the philtral tubercle. If not properly treated, such regions may become distorted or obliterated when local edema occurs after injection, causing improper suture placement and necessitating a subsequent secondary repair.
After proper alignment and anesthetizing of the tissue, the first anchoring suture should approximate the 2 sides of the laceration at the white roll, forming a smooth and continuous line throughout the border. If the injury extends deep to or through the orbicularis oris, the musculature is closed first with buried absorbable sutures. Proper alignment must be achieved for muscular continuity.
The same holds true for commissural lacerations, which may be more complex in nature given disruption of the central anchoring modiolus. The mucous membrane is then closed with absorbable sutures, again with attention to alignment. The skin layer is closed last with 5-0 or 6-0 nonabsorbable interrupted sutures. Instruct patients to minimize movement and strain on the mouth. As with previously described injuries, plastic surgical consultation is often appropriate to address many of these wounds.
Parotid and lacrimal duct injuries
If sialorrhea is present or a laceration over the check raises suspicion for a parotid duct injury, exploration and cannulation of the duct in the OR is warranted. A small catheter is inserted into the parotid duct orifice, which opens on the oral mucosa directly opposite the second maxillary molar tooth. If no transection is present, the catheter passes freely and meets resistance.
If transection has occurred, either partial or complete, the catheter will pass through the distal open end of the transected duct and become visible. The proximal severed end of the duct can be identified by massaging the gland to express saliva. The catheter is then advanced through the proximal end of the duct until it meets resistance.
Under magnification, the duct can be anastomosed over the catheter with 7-0 or 8-0 monofilament sutures. After repair, if the duct is only partially transected and if there are minimal associated injuries, the catheter can be removed. However, if the duct is completely transected or other significant associated damage to the area is present, the catheter should be left in place for at least 7 days to ensure duct patency and to minimize fistula formation.
If the parotid duct is damaged in such a way that the distal end cannot be identified or the duct orifice is obliterated, a new orifice can be constructed more proximally to maintain parotid gland function. An alternative is duct ligation, which causes the parotid gland to atrophy and cease functioning.
With complete transection of the lacrimal duct, proper realignment of the canalicular ends is crucial and dacryocystorhinostomy under magnification may be required. Epiphora and obstructive dacryocystitis may complicate these injuries.
Facial nerve transection is repaired as soon as possible after the injury, ideally within 72 hours. If repair is delayed, the severed ends of the nerve stump tend to contract, making it technically difficult to reapproximate the nerve ends primarily.
Epineural repair is performed under microscope magnification by plastic surgeons. If primary repair cannot be effected, nerve grafts become an option.
Severe injuries to the structures of the face often necessitate consultation with a specialist. Evaluation by an ophthalmologist is needed for any penetrating globe injury, enucleation, or injury that compromises visual acuity. In the event of a major deforming injury such as complex nasal or lid lacerations and or ear amputation, plastic and reconstructive expertise is needed. In the event of uncontrollable epistaxis, consultation with an otolaryngologist and possibly and interventional radiologist is warranted.
For any suspected or confirmed CSF leak, a neurosurgeon should be consulted. A plastic surgeon should evaluate any complex and potentially cosmetically disfiguring lacerations, whether they include concomitant nerve injury or not.
Postoperatively, patients must be closely monitored to ensure proper wound healing, to provide reassurance, and to realistically address any concern the patient may have about functional and cosmetic facial disfigurements. This ensures successful treatment of the patient with facial trauma.
The face has a very rich vasculature that promotes quicker healing. In areas where the skin is thin, as in the eyelids, sutures are removed in 3-4 days; elsewhere on the face, they are left 4-6 days. In children, who heal quickly, sutures can be removed earlier. Sutures in the ears are often left in place for 10-14 days. This is especially true with underlying cartilage injury; scars over divided ear cartilage tend to thicken and spread when sutures are removed too early. Ardeshirpour et al outline different techniques for improving facial scars resulting from posttraumatic soft-tissue facial injuries.
Gordon CR, Siemionow M, Papay F, et al. The world's experience with facial transplantation: what have we learned thus far?. Ann Plast Surg. 2009 Nov. 63(5):572-8. [Medline].
Alam DS, Chi JJ. Facial transplantation for massive traumatic injuries. Otolaryngol Clin North Am. 2013 Oct. 46(5):883-901. [Medline].
Massimiliano B, Nicola S, Sante B, Carmela F, Palmieri V, Paolo Z. Female boxing in Italy: 2002-2007 report. Br J Sports Med. 2011 Jun. 45(7):563-70. [Medline].
Lawson BR, Comstock RD, Smith GA. Baseball-related injuries to children treated in hospital emergency departments in the United States, 1994-2006. Pediatrics. 2009 Jun. 123(6):e1028-34. [Medline].
Day C, Stolz U, Mehan TJ, Smith GA, McKenzie LB. Diving-related injuries in children 11111111111Pediatrics</i>. 2008 Aug. 122(2):e388-94. [Medline].
Rajput D, Bariar LM. Study of maxillofacial trauma, its aetiology, distribution, specturm, and management. J Indian Med Assoc. 2013 Jan. 111(1):18-20. [Medline].
Romeo SJ, Hawley CJ, Romeo MW, Romeo JP. Facial Injuries in Sports: A Team Physician's Guide to Diagnosis and Treatment. Phys Sportsmed. 2005 Apr. 33(4):45-53. [Medline].
Hamilton J, Sunter J, Cooper P. Fatal hemorrhage from simple lacerations of the scalp. Forensic Science, Medicine, and Pathology. Humana Press; December, 2005. Vol 1, No 4: 267-71.
Bodor RM, Breithaupt AD, Buncke GM, Bailey JR, Buncke HJ. Swimmer's nose deformity. Ann Plast Surg. 2008 Jun. 60(6):658-60. [Medline].
Sitzman TJ, Hanson SE, Alsheik NH, Gentry LR, Doyle JF, Gutowski KA. Clinical criteria for obtaining maxillofacial computed tomographic scans in trauma patients. Plast Reconstr Surg. 2011 Mar. 127(3):1270-8. [Medline].
Goodstein WA, Stryker A, Weiner LJ. Primary treatment of shotgun injuries to the face. J Trauma. 1979 Dec. 19(12):961-4. [Medline].
Kersten TE, McQuarrie DG. Surgical management of shotgun injuries of the face. Surg Gynecol Obstet. 1975 Apr. 140(4):517-22. [Medline].
Toure G, Angoulangouli G, Meningaud JP. Epidemiology and classification of dog bite injuries to the face: a prospective study of 108 patients. J Plast Reconstr Aesthet Surg. 2015 May. 68 (5):654-8. [Medline].
Tan E, Mortimer N, Salmon P. Full-thickness skin grafts for surgical defects of the nasal ala - a comprehensive review, approach and outcomes of 186 cases over 9 years. Br J Dermatol. 2014 May. 170 (5):1106-13. [Medline].
Ardeshirpour F, Shaye DA, Hilger PA. Improving posttraumatic facial scars. Otolaryngol Clin North Am. 2013 Oct. 46(5):867-81. [Medline].