Facial Soft Tissue Injuries Treatment & Management
- Author: Kyle D Parish, MD; Chief Editor: Craig C Young, MD more...
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.
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.
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 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 the image below. 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
Wound cleaning and irrigation
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 below, bottom).
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. 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.
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
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.
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.
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.
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 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 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.
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