eMedicine Specialties > Sports Medicine > Face and Head
Facial Soft Tissue Injuries: Treatment & Medication
Updated: Jul 10, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Medical Issues/Complications
Facial soft-tissue injury complications include, but are not limited to, infection, hematoma, poor cosmesis, flap/wound edge necrosis, nasal septum necrosis, retained foreign body, cauliflower ear, and loss of function.
Surgical Intervention
Lacerations
As with the physical examination, a systematic approach to facial laceration repair ensures the best chance at an optimum outcome. A summary of one methodological approach follows.Wound assessment
Familiarity with the pertinent anatomic aspects of the face is important. Clear anatomic boundaries are present that must be respected and carefully realigned to avoid obvious deformity. Cosmetic results are better when minimal tension is placed on the wound edges at the time of repair. Therefore, wounds with the long axis parallel to the natural skin tension lines have much better cosmetic outcomes. The degree of tension on the wound edges can be estimated by measuring the distance the wound edges retract away from the center of the lesion. Marked retraction (>5 mm) indicates strong skin tension. With such wounds, placement of dermal sutures in a 2-layer closure should be considered.
Anesthesia
Anesthesia can be provided by topical, local, or regional block. An advantage of using regional block in the face is that the wound edges are not distorted from the local anesthetic. The areas for regional block injection are shown in Image 2. Amide anesthetics (eg, lidocaine, bupivacaine, mepivacaine) are used most commonly. Allergic reactions are uncommon. When using anesthetics containing epinephrine, care should be used to avoid areas with end arteries (ie, the nose).
The regional block and the area of anesthesia are as follows:
- Supraorbital and supratrochlear blocks – Forehead, anterior one third of the scalp
- Infraorbital block – Lower lid, upper lip, and lateral aspect of the nose
- Mental nerve block – Lower lip and chin
All areas should be thoroughly explored, copiously irrigated, cleaned, and debrided of devitalized tissue before closure. Irrigation lessens the risk of infection. Interestingly, regardless of irrigation, noncontaminated wounds repaired within 6 hours of injury rarely develop infection, and the overall rate of infection of repaired scalp and facial wounds is 1%. After irrigation, gentle cleansing of the wound should be performed with a dilute povidone-iodine solution (Betadine; Purdue Pharma, LP, Stamford, Conn) or iodine solution. The wound edge (1-2 mm) can be safely removed to rid the area of devitalized tissue. Attempts should be made to make the wound edges perpendicular with the skin surface because this results in a smoother, less noticeable scar (see Image 4, bottom).
Repair
Deep wounds should be repaired in layers. Unrepaired muscle layers are much more likely to produce noticeable scarring. When performing a 2-layer closure, the deep layers should be closed with absorbable suture. Importantly, use the minimum amount of subcutaneous suture necessary because the risk of infection is related to the amount of suture used. Nonabsorbable monofilament suture should be used for skin closure. Monofilament suture is associated with a lower risk of infection compared with a polyfilament suture.
The suture technique should be selected based on the site of the wound and the amount of tension on the wound edges. A simple interrupted technique can be used in areas of low tension or in wounds in which the tension has been reduced with a layer of subcutaneous sutures. This technique is also useful for realigning wounds with irregular wound edges. Areas of high tension are best closed using a vertical mattress technique. All facial wounds should be repaired in less then 24 hours to decrease the risk of infection and achieve the best cosmetic result. If a delay in closure is necessary, wounds should be covered with saline-moistened gauze until the repair can be made.
Dermal adhesives, such as 2-octyl cyanoacrylate, have been shown to be equivalent to sutures for the repair of simple, clean wounds in areas of low tension.8 The adhesives are applied topically to the wound edges. Advantages of adhesives include shorter repair time, fewer supplies, less pain during repair, and elimination of the need to remove sutures or staples at a follow-up visit. Note: Dermal adhesives should not be used on the lips or mucous membranes. Avoid use in patients with poor circulation or who have a propensity to form keloids.
Staples are good alternatives to sutures in the repair of scalp lesions. Stapling involves shorter repair time and less cost compared with suture repairs. Rates of infection and inflammatory response are not higher than those associated with suture repair. During the staple application, an assistant helps evert and approximate the wound edges, while the primary operator uses the stapler. Disadvantages include the inability to accurately align the wound edges in irregular wounds and an increased likelihood of visible scarring, thus limiting the use of stapling to the scalp.
Follow-up
The athlete should be given instructions for proper wound care, including the normal healing process and signs that might indicate the presence of complications. Anticipate any complication (eg, infection, swelling, bleeding, dehiscence) and give precise instructions for early return. The following is a list of laceration sites and recommendations on suture size and typical time to removal:
- Scalp – 4-0 suture or staple, with removal in 7-14 days
- Forehead – 5-0/6-0 sutures, with removal in 5 days
- Eyebrow – 5-0/6-0 sutures, with removal in 3-5 days
- Face – 6-0 suture, with removal in 5 days
- Eyelid – 6-0/7-0 sutures, with removal in 3 days
- Nose – 5-0 sutures, with removal in 3-5 days
- Ears – 6-0 sutures, with removal in 10-14 days
- Lips – 6-0 sutures, with removal in 3-5 days
Septal Hematoma
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 by decompression, whether it is from needle aspiration with a large-gauge (>18-gauge) needle or by incision and drainage using a no. 11 scalpel. Following decompression, bilateral nasal packing should be placed to avoid reaccumulation of fluid. The use of prophylactic antibiotics in patients with a septal hematoma is controversial. Referral to otolaryngologist is warranted for close follow-up.
Hematoma of the External Ear (Cauliflower Ear)
Similar to the septal hematoma, hematoma can develop at the level of the perichondrium following 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 using a large-gauge (>18-gauge) needle. Following aspiration, an external compression dressing should be placed to avoid reaccumulation of fluid. Silicone ear splints can be molded to the front and back of the earlobe and are held in place using a head wrap, sutures, or both. When splints are not available, compression can be achieved by suturing a button or piece of nasal packing to the front and back of the auricle. Compressive dressing should be worn for 3-5 days.
Related eMedicine topics:
Nasal Pack, Anterior Epistaxis
Nasal Pack, Posterior Epistaxis
Consultations
Severe injuries to the structures of the face often require consultation with a specialist. Evaluation by an ophthalmologist is needed for any penetrating globe injuries, enucleation, eyelid lacerations involving the lid margins or lacrimal apparatus, and injury that compromises visual acuity. In the event of a major deforming injury (eg, ear or nose avulsion) or when epistaxis cannot be controlled, consultation with an otolaryngologist 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 that may or may not include concomitant nerve injury.
Other Treatment
Contusion
Contusions are the most common facial soft-tissue injury seen by a sports medicine team. They are usually the result of blunt trauma to the face. Ice should be applied for 10-20 minutes to minimize the immediate inflammatory response. This treatment should continue for the next 48-72 hours. Over-the-counter (OTC) nonsteroidal anti-inflammatory medications (NSAIDs) are good for symptom relief. Complications are uncommon.
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.
Corneal abrasion
Corneal abrasions result from loss of the surface epithelium. Disruption near the central visual axis interferes with visual acuity. Such abrasions should be treated with a course of ophthalmic topical antibiotics. Topical analgesics may be used initially, but avoid prescribing them to the athlete for home use because this may delay reepithelialization and suppress the normal blink reflex. Note: Emergent consultation with an ophthalmologist is warranted for suspected retained intraocular foreign bodies. Urgent consultation is needed for suspected corneal ulcerations (microbial keratitis). These injuries require close follow-up, and referral to an ophthalmologist should also be made for any athlete with continued pain after 48 hours or inadequate healing by 72 hours.
Epistaxis
Epistaxis typically does not require invasive treatment. Most often, bleeding can be controlled by maintaining continuous pressure for 10 minutes. This is achieved by asking the athlete to grasp and pinch his or her nose. While this task is performed, have the athlete tilt the head forward to avoid bleeding into the pharynx, which can lead to aspiration. Pressure should be maintained for at least 5 minutes and up to 20 minutes. If this is unsuccessful, a second attempt should be made.
Packing the affected nostril with gauze soaked in topical decongestant may be necessary to achieve hemostasis. If the bleeding site is clearly observed, chemical cautery can be attempted using silver nitrate directly at the site. If bleeding is not controlled despite these measures, the nasal cavity should be packed from posterior to anterior with ribbon gauze impregnated with petroleum jelly. Nasal tampons may also be helpful. For particularly resistant cases, referral to an otolaryngologist may be required.
Medication
Not all facial soft-tissue injuries require pharmacotherapy. When used, the goal is to decrease the potential morbidity and mortality and/or reduce the chance for complications.
Toxoids
Toxoids are used to induce active immunity.
Related Medscape topic:
Resource Center Vaccines
Tetanus toxoid
Induce active immunity against tetanus in selected patients. The immunizing agents of choice for most adults and childrenaged >7 y are the tetanus and diphtheria toxoids. It is necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen–containing product.
In children and adults, tetanus toxoid may be administered into the deltoid or midlateral thigh muscles. In infants, the preferred site is the mid thigh laterally.
Administer dT 0.5 mL IM to patients aged >7 y who have not been immunized within 5 y. Administer tetanus IgG (250 U) at a different site for patients with an incomplete immunization history.
Adult
Primary immunization: 0.5 mL IM; give 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y
Pediatric
Administer as in adults
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization because of poor immune responses; cimetidine may enhance or augment delayed hypersensitivity responses to skin-test antigens; avoid concurrent use of medications with systemic chloramphenicol because it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (this interaction is nevertheless clinically insignificant and does not preclude its concurrent use).
Documented hypersensitivity; history of any type of neurologic symptoms or signs following administration; the FDA recommends deferral of elective tetanus immunization during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat actual tetanus infections or for immediate prophylaxis of unimmunized individuals (instead, use tetanus antitoxin, preferably human tetanus immune globulin); diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; it is better to defer primary diphtheria immunization until immunosuppressive therapy is discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended.
Immunoglobulins
Immunoglobulins are used for passive immunization, consisting of the administration of immunoglobulin that is pooled from the serum of immunized subjects.
Related eMedicine topic:
Intravenous Immunoglobulin
Related Medscape topic:
Resource Center Allergy & Clinical Immunology
Tetanus immune globulin (Hyper-Tet)
Induces passive immunization in any person with a wound that might be contaminated with tetanus spores.
Adult
Prophylaxis: 250-500 U IM in opposite extremity to the tetanus toxoid lesion
Pediatric
Prophylaxis: 250 U IM in opposite extremity to the tetanus toxoid
None reported
Because antibodies in the globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live virus immune globulin administration; it may be necessary to revaccinate persons who received immune globulin shortly after live virus vaccination.
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Persons with isolated IgA deficiency have the potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing because intradermal injection of concentrated gamma globulin may cause localized inflammation and can be misinterpreted, causing the medication to be withheld from a patient who is not allergic to this material; true allergic responses to human gamma globulin given in the prescribed IM manner are extremely rare; do not admix with other medications because this is usually incompatible.
Antibiotics
Antibiotics are not recommended as part of routine wound care, particularly with the increasing number of multidrug-resistant bacteria. Empiric treatment is still recommended for wounds that are at high risk of infection. Large intraoral wounds may require treatment with penicillin. Bite injuries from a cat, dog, or human should be covered with amoxicillin/clavulanate or doxycycline and/or cefuroxime.
Because of a change in resistance patterns, cephalexin and dicloxacillin are no longer recommended for empiric treatment in many areas of the country. Methicillin-resistant Staphylococcus aureus (MRSA) is becoming increasingly problematic in community-acquired infections, and treatment should be based on the community resistance pattern (usually available from local hospitals or infectious disease specialists). When organism sensitivities are unknown, vancomycin should be considered until culture and sensitivity testing can be performed.
Related eMedicine topic:
MRSA Skin Infection in Athletes
Related Medscape topics:
Resource Center Emerging and Reemerging Infectious Diseases
Resource Center Sepsis
Specialty Site Infectious Diseases
Penicillin G benzathine (Bicillin L-A, Permapen)
Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Adult
1.2 million U IM (single dose)
Pediatric
25,000-50,000 U/kg IM; not to exceed 1.2 million U/dose
Probenecid can increase the effects; coadministration of tetracyclines can decrease the effects.
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in the presence of impaired renal function
Penicillin VK (Beepen-VK, Betapen-VK, Veetids, Robicillin VK)
Inhibits biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are achieved and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects.
Adult
500 mg PO q6h for 5-7d
Pediatric
<12 years: 25-50 mg/kg/d PO divided tid/qid up to 3 g/d
>12 years: Administer as in adults
Probenecid may increase the effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of penicillins when administered concurrently.
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in the presence of renal impairment
Amoxicillin and clavulanate (Augmentin)
Drug combination treats bacteria that are resistant to beta-lactam antibiotics. For children aged >3 mo, base the dosing protocol on the amoxicillin content. Because of different ratios of amoxicillin to clavulanic acid in the 250-mg tab (250/125) vs the 250-mg chewable tab (250/62.5), do not use the 250-mg tab until child weighs >40 kg
Adult
500-875 mg PO q12h or 250-500 mg PO q8h
Pediatric
<40 kg: 20-40 mg/kg/d PO divided bid
>40 kg: Administer as in adults
Coadministration with warfarin or heparin increases the risk of bleeding.
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Administer for a minimum of 10 d to eliminate the organism and prevent sequelae (eg, endocarditis, rheumatic fever); following treatment, perform cultures to confirm eradication of streptococci.
Doxycycline (Doryx)
Broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. Almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.
Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly the 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
100 mg PO bid
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d
The bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase the hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease the effects of oral contraceptives, causing breakthrough bleeding and an increased risk of pregnancy.
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce the dose in the presence of renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines.
Cefuroxime (Zinacef)
Second-generation cephalosporin that maintains gram-positive activity of first-generation cephalosporins; adds activity against Proteus mirabilis, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis.
Binds to penicillin-binding proteins and inhibits final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death. The condition of the patient, severity of the infection, and susceptibility of the microorganism determine the proper dose and route of administration. Resists degradation by beta-lactamase.
Adult
500 mg PO bid
Pediatric
15-30 mg/kg/d PO divided bid; not to exceed 500 mg/dose
Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase the hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics (eg, loop diuretics); coadministration with aminoglycosides increases the nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce the dosage by half if CrCl is 10-30 mL/min and by three quarters if it is <10 mL/min (high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy.
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who are unable to receive or whose infections have not responded to penicillins and cephalosporins or for infections with resistant staphylococci. Use CrCl to adjust the dose in patients diagnosed with renal impairment.
Adult
0.5 g IV q6h or 1 g IV q24h
Pediatric
Neonates:
<7 days and >2000 g: 30 mg/kg/d IV divided q12h
>7 days and >2000 g: 45 mg/kg/d IV divided q8h
<1 month and <1200 g: 15 mg/kg/d IV q24h
<1 month and 1200-2000 g: 20-30 mg/kg/d IV divided q12-18h
Infants >1 month and children: 40 mg/kg/d IV divided q8h
Seriously ill cancer patients and patients with suspected infection of the CNS: 60 mg/kg/d IV divided q6h
The necessity of monitoring the drug levels is debated; in order to achieve adequate therapeutic level in severe infections, the upper range of the peak (40 mcg/mL) should be reached.
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, the risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants.
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in the presence of renal failure or neutropenia; "red man" syndrome is caused by IV infusion that is too rapid (dose given over a few minutes) but rarely happens when the dose given IV is over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction
More on Facial Soft Tissue Injuries |
| Overview: Facial Soft Tissue Injuries |
| Differential Diagnoses & Workup: Facial Soft Tissue Injuries |
 Treatment & Medication: Facial Soft Tissue Injuries |
| Follow-up: Facial Soft Tissue Injuries |
| Multimedia: Facial Soft Tissue Injuries |
| References |
| « Previous Page | Next Page » |
References
Papakosta V, Koumoura F, Mourouzis C. Maxillofacial injuries sustained during soccer: incidence, severity and risk factors. Dent Traumatol. Apr 2008;24(2):193-6. [Medline].
Roccia F, Diaspro A, Nasi A, Berrone S. Management of sport-related maxillofacial injuries. J Craniofac Surg. Mar 2008;19(2):377-82. [Medline].
ADA Council on Access, Prevention, and Interprofessional Relations; ADA Council on Scientific Affairs. Using mouthguards to reduce the incidence and severity of sports-related oral injuries. J Am Dent Assoc. Dec 2006;137(12):1712-20; quiz 1731. [Medline]. [Full Text].
Echlin PS, Upshur RE, Peck DM, Skopelja EN. Craniomaxillofacial injury in sport: a review of prevention research. Br J Sports Med. May 2005;39(5):254-63. [Medline]. [Full Text].
Romeo SJ, Hawley CJ, Romeo MW, Romeo JP. Facial injuries in sports. A team physician's guide to diagnosis and treatment. Phys Sportsmed. Apr 2005;33(4):[Full Text].
Stackhouse T. On-site management of nasal injuries. Phys Sportsmed. Aug 1998;26(8):[Full Text].
Kaufman BR, Heckler FR. Sports-related facial injuries. Clin Sports Med. Jul 1997;16(3):543-62. [Medline].
Beam JW. Tissue adhesives for simple traumatic lacerations. J Athl Train. Apr-Jun 2008;43(2):222-4. [Medline].
Barr A, Baines PS, Desai P, MacEwen CJ. Ocular sports injuries: the current picture. Br J Sports Med. Dec 2000;34(6):456-8. [Medline]. [Full Text].
Bodor RM, Breithaupt AD, Buncke GM, Bailey JR, Buncke HJ. Swimmer's nose deformity. Ann Plast Surg. Jun 2008;60(6):658-60. [Medline].
Capão Filipe JA, Rocha-Sousa A, Falcão-Reis F, Castro-Correia J. Modern sports eye injuries. Br J Ophthalmol. Nov 2003;87(11):1336-9. [Medline]. [Full Text].
Curtin JW. Basic plastic surgical techniques in repair of facial lacerations. Surg Clin North Am. Feb 1973;53(1):33-46. [Medline].
Further Reading
Keywords
facial soft-tissue injuries, facial trauma, facial injury, facial fracture, face injury, cauliflower ear, subperichondrial hematoma, sports-related soft-tissue injury, facial laceration, facial abrasion, broken nose, epistaxis, facemask, face mask, maxillofacial trauma, maxillofacial injury, lip laceration, lip injury, eyelid injury, scalp injury, tongue injury, tongue laceration, corneal abrasion
