Facial Soft Tissue Trauma 

Updated: Jun 07, 2019
Author: Daniel D Sutphin, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

This article focuses on facial soft tissue trauma. 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.

Patients with traumatic facial injuries often present with extremely disfigured appearances. Such injuries may distract receiving physicians from other potentially life-threatening injuries such as closed head trauma or cervical spine injuries that can be associated with severe facial trauma. Each patient who presents with significant traumatic facial injuries should be treated in accordance with American Trauma Life Support (ATLS) protocols.

Once immediately life-threatening issues such as airway compromise and uncontrolled bleeding have been addressed, other multisystem trauma is excluded. Attention can then be turned to defining and definitively treating the patient’s facial injuries.

Historically, severe facial trauma often resulted in cosmetic and functional defects; however, advances in the science of reconstructive surgery and in the management of trauma patients have significantly improved the morbidity associated with facial traumatic injuries. In the most extreme cases, facial transplantation has even been accomplished at a number of centers throughout the world.[1, 2]

Etiology

In the United States, motor vehicle accidents (MVAs) were the most frequent cause of facial injuries before 1970. Since then, with the institution of state seat belt laws, the number of deaths from MVAs has declined, and so has the incidence of facial injuries. (Indeed, a retrospective Korean study by Kim et al indicated that in relation to MVAs, wearing a seat belt reduces the likelihood of sustaining a severe soft tissue injury to the face.[3] )

 However, the prevalence of facial trauma has remained fairly constant. This steady prevalence is attributable to the growing population and to other human factors, such as on-the-job accidents, sports-related injuries, domestic interpersonal violence, self-inflicted wounds, and animal bites.[4, 5, 6, 7, 8]

The mechanism of injury for facial trauma varies widely from one locality to the next, depending significantly on the degree of urbanization, the socioeconomic status of the population, and the cultural background of each region. In rural areas, MVAs continue to be a primary contributor to significant facial injuries. In inner metropolitan areas, however, domestic violence is the leading cause of facial trauma despite a denser population, a difference that may be due to stricter enforcement of traffic laws.

Epidemiology

In the United States, approximately 3 million people present to emergency departments (EDs) for treatment of traumatic facial injuries each year. Most of these injuries are relatively minor soft tissue injuries that simply require first-aid care or primary closures.

The exact frequency of facial soft tissue injuries related to sports participation is unknown. This is, in part, due to the minor nature of many injuries, which can lead to underreporting; it may also be due to the wide variation that is seen between demographic groups and between specific sports.

Previous reports estimate sports participation to account for 3-29% of all facial injuries.[9] In terms of overall sports-related injury, facial trauma accounts for 11-40% of injuries attended to by medical professionals. Most injuries are reported in males, particularly those aged 10-29 years. Sports that mandate the use of helmets and face masks tend to be associated with fewer soft tissue injuries than sports that do not mandate the use of such equipment.

Using the National Electronic Injury Surveillance System, a study by Bobian et al determined that among 109,795 nursing home residents aged 60 years or older who, between January 1, 2011, and December 31, 2015, suffered facial trauma requiring emergency department care, lacerations (48,679 persons, or 44.3%) and other soft tissue trauma (45,911 persons, or 41.8%) were most common.[10]

Prognosis

The prognosis for most facial soft tissue injuries is good. Due to the robust vascularity of the facial region, such injuries usually heal rapidly, allowing the patient to return to usual activities, including sports. Knowing the expectations of the patient and his or her family is important in ensuring an optimal treatment result. Likewise, proper management of those expectations, depending on the nature and extent of the injury (eg, clean laceration as opposed to high-velocity avulsion injury with extensive soft tissue loss) is equally imperative. 

Facial soft tissue injury complications include, but are not limited to, infection, hematoma, flap or wound-edge necrosis, nasal septum necrosis, parotid duct laceration with associated siaolocele and/or fistula formation, retained foreign body, poor cosmesis and permanent deformity (eg, cauliflower ear), and loss of function related to facial motor nerve injury, mimetic muscle loss, or scarring. Periocular injuries with associated ectropion can lead to exposure keratitis and prove particularly devastating.

Patient Education

Proper home wound care should be clearly explained to the patient and his or her family.

For patient education resources, see the Eye and Vision Center, as well as Black Eye and Eye Injuries.

 

Presentation

Physical Examination

Systematically examine the face by means of visual inspection and palpation, starting superiorly with the scalp and the frontal bones and proceeding inferiorly and laterally. Inspect and note any obvious swellings, depressions, or ecchymosis. These indicate possible underlying bone fracture or hematoma. A formal evaluation of the cranial nerves with attention to ocular function, sensation, and facial mimetic motor function should be completed. Any gross soft tissue asymmetry may signify underlying nerve damage.

With palpation, determine the presence and location of any fractured bone fragments and dislodged or dislocated bony prominences; be sure to include the temporomandibular joint. Determining the presence of crepitus, tenderness, or stepoffs is essential. If possible, assess the sensorimotor functions of the face.

The following summarizes examination approaches and findings associated with injuries to specific areas of the face.

Scalp injuries

Because of the extensive blood supply of the scalp, the amount of bleeding present may not be proportionate to the size of the soft tissue injury. Hemorrhaging of the scalp often appears profuse and always heightens suspicion of intracranial damage. On the other hand, it is not uncommon for minor scalp injures to be missed as a result of an inadequate examination. To avoid missing any scalp injuries, examine patients thoroughly during the secondary survey.

After cleaning the wound, attempt hemostasis with direct pressure. Examine the areas around any lacerations for bony stepoff that would indicate a possible underlying skull fracture. Although shaving of hair is usually unnecessary, some shaving may be needed to avoid missing additional lacerations if obvious foreign body fragments are lodged in the hair or if the patient has long hair. However, adequate visualization of the wound is imperative, as is recognition that scalp wounds can be associated with large-volume blood loss that may even be fatal.[11]

Eyebrow injuries

Eyebrow injuries should direct the examiner’s attention toward the possibility of underlying fracture of the supraorbital ridge or frontal sinuses.

Inspect the orbital rim carefully, palpating it around its circumference. Subtle displacement of the rim may be identified by placing an index finger on each infraorbital rim and viewing from above or below with the patient’s head tilted back. If fractures of the underlying bony structures are present, plastic or maxillofacial surgical consultation should be sought and surgical repair of the overlying soft tissues completed depending upon specialist recommendation. Check carefully for any deficit in sensation in the area. Attempt to maintain the alignment of the brow borders during repair. Never shave the eyebrow, because this may result in significant cosmetic deformity; the brow may not grow back or may grow back with an abnormal pattern or color.

Eyelid injuries

Patients presenting with eyelid injuries must be examined thoroughly for any associated ocular and nasolacrimal duct injuries. Exploration for foreign bodies must be performed. Flip the eyelids over and examine the tarsal plate. Damage to either side of the tarsal plate should be referred to an ophthalmologist for repair. If ptosis is present, injury to the levator aponeurosis should be suspected, and this injury should also be referred to a plastic surgeon or ophthalmologist.

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, eye-threatening keratitis may result. Extensive or complex injuries of the eyelid, particularly those that involve the canthi, lacrimal system, or lid margin, should prompt immediate plastic surgical consultation.

Eye injuries

In patients who have sustained injury to the eye, look for any gross injury or asymmetry in the globes.[12, 13] Check the papillary responses to light directly and indirectly. Using an ophthalmoscope, inspect the anterior chamber to look for blood, rupture of the iris, or asymmetry. Examine the cornea, and look for foreign bodies, abrasions, tears, or lacerations. Fluorescein dye and tetracaine (or another topical ocular anesthetic) should be employed to ensure an adequate examination.

Assess extraocular movements. Deficits in movement may indicate entrapment or injury to one of the extraocular muscles. Deficits may also indicate injury to one of the nerves that control globe movement (cranial nerves [CNs] III, IV, and VI). Evaluate for conjugate gaze and smooth pursuit.

Assess visual acuity. Outside the clinical setting (eg, on the sideline or in the locker room at a sporting event), a handheld eye chart may be used for gross investigation. Significant loss of visual acuity may be due to injury of the globe, retina, or optic nerve or due to an injury that is more central. These injuries are an indication for more urgent ophthalmologic care than can be provided in such an environment, and the patient should be sent to the appropriate facility for definitive care.

In addition, evaluate the patient for enophthalmos or exophthalmos. These conditions indicate either an orbital floor fracture or a blow-in fracture, respectively. Such findings also warrant oculoplastic consultation.

Ear injuries

A direct blow or application of 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 patient may be left with abnormally shaped pinnae (a condition also known as cauliflower ear).

Auricular hematoma and myriad ear lacerations of varying complexity, including ear amputation, should prompt plastic surgical consultation.

Blunt trauma or barotrauma may cause perforation of the tympanic membrane. An otoscope should be used to visualize the defect and to look for any serous or bloody discharge. Most patients are asymptomatic, but vertigo and otalgia may be present.

Nose injuries

Visual inspection of the nose usually provides ample information as to the underlying injury. Fracture is usually associated with some degree of deformity.[14] Gross midline deviation of the nose typically indicates underlying fractured nasal bones or cartilages. Soft tissue swelling of the nose indicates hematoma, fractured nasal bones or cartilages, or both. Intranasal inspection with a nasal speculum may reveal a deviated septum.

Nevertheless, epistaxis without obvious nasal deformity may be the only clinical finding in some nasal fractures. The origin of most nosebleeds is the extremely vascular area on the anterior septum (Kiesselbach area). Performing an adequate and thorough nasal examination is difficult when epistaxis is not controlled.

Once the bleeding is controlled, intranasal inspection using a nasal speculum should be performed, and the position and integrity of the nasal septum should be noted. The turbinates and inferior meatus should be visualized bilaterally, and the septum should be inspected for the presence of a septal hematoma. Any mucosal lacerations should be noted because they may be a sign of underlying fracture.

The presence of rhinorrhea associated with significant trauma should suggest a possible cerebrospinal fluid (CSF) leak. The patient may report a very salty taste in the mouth. An easy way of objectively testing for a CSF leak is to look for the halo or ring sign. To perform this test, place a drop of the rhinorrhea in question on a piece of filter paper. A clear ring around a blood-tinged center indicates the presence of CSF. A positive test result may indicate a basilar skull fracture that warrants more urgent tertiary care.

Mouth and lip injuries

Inspect the lips carefully. Any disruption of the vermilion border should be noted; failure to do so can lead to inadequate repair, which can result in significant cosmetic deformity (see the image below). A stepoff of the vermilion border as small as 1 mm may be apparent at conversational distance. The presence of a commissural laceration also adds a level of complexity to the wound that may require plastic surgical consultation.

Top row of images depicts improper repair of angle Top row of images depicts improper repair of angled laceration. Bottom row of images depicts proper repair of angled laceration, with creation of perpendicular edges for flush repair.

Inspect the inside of the lips for through-and-through wounds. An intraoral examination is a necessary part of the facial evaluation. The inside of the cheeks should also be examined thoroughly for any through-and-through wounds. Special attention should be given to the area around the parotid duct (see below).

Parotid and lacrimal duct injuries

Because the parotid gland is situated superficially in the cheek, it is vulnerable to any trauma to the face (see the image below). Any injury along an imaginary line drawn from the tragus of the ear to the base of the nose, and lateral to the lateral canthus, should alert practitioners to the possibility of parotid injury. With any injury involving the midcheek, an attempt should be made to milk the parotid gland and observe the flow of saliva from the Stensen duct in order to ensure duct patency.

Location of parotid gland and duct system. Location of parotid gland and duct system.

Consider injury to the gland if there is clear discharge from the cheek wound. Similarly, a sagging upper lip indicates possible injury to the parotid duct, since the buccal branches of the facial nerve often run along with the parotid duct. Any suspected injury should be referred for possible stenting and repair. Also, look for disrupted teeth and hematoma.

Injuries to the medial canthal region must be inspected for lacrimal duct injury. Both upper and lower canaliculi must be examined thoroughly to determine the extent of injury.

Tongue injuries

When examining the injured tongue, note the depth and length of the injury as well as the absence of any tissue. Many minor lacerations do not require repair. Complex injuries such as through-and-through lacerations may be associated with foreign bodies and can result in a bifid tongue if not properly repaired.

Nerve injuries

The facial nerve (CN VII), because of its extracranial course and relatively superficial distribution, is susceptible to facial injuries (see the image below). Injury to the nerve may cause significant cosmetic and functional defects.

If a neurapraxic or axonometric injury 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. Buccal branch injuries may contribute to an inability to smile and loss of the nasolabial crease. Injuries to the mandibular area may affect the marginal mandibular branch, causing an asymmetric smile with elevation of the lower lip on the affected side.

Any wound with a corresponding facial nerve deficit warrants operative exploration.

Distribution of nerves for regional anesthesia of Distribution of nerves for regional anesthesia of face.

In addition, examine sensation for each of the 3 branches of the trigeminal nerve. Deficits in any distribution may correspond to underlying bony injuries.

 

DDx

Differential Diagnoses

  • Abrasions

  • Contusions

  • Lacerations

  • Soft tissue injury with facial fracture

 

Workup

Approach Considerations

Although most soft tissue facial trauma consists of contusions, abrasions, lacerations, or a combination of these that require only a careful physical examination, more complex wounds benefit from radiologic studies.

Order diagnostic studies only after determining that the patient is clinically stable. Defer studies if they may interfere with or delay clinical treatment.

Radiography

Head and neck films

Facial injuries in which there is significant bony tenderness or obvious deformity warrant imaging to evaluate for fractures. Plain films of the face, including Water, Caldwell, and lateral views, have been historically important. Panoramic radiographic images may also be of benefit if there is concern for mandibular fractures.

Computed tomography, however, has greater sensitivity in defining bony facial trauma. Any patient with a bony stepoff or instability, periorbital swelling or contusion, Glasgow Coma Scale score less than 14, malocclusion, or tooth absence is at high risk for an associated facial fracture, and computed tomography scanning is warranted.[15] Cervical spine imaging is also imperative depending on patient complaints and the mechanism of injury, particularly in unconscious or intoxicated patients.

Arteriography

In patients in whom extensive hemorrhage occurs with questionable source, arteriography serves as an excellent study to evaluate and isolate the source of hemorrhage or to exclude major vascular injuries, particularly those of the carotid and vertebrobasilar system.

Computed Tomography

Computed tomography is an excellent modality for diagnosing more complex facial traumatic injuries according to the criteria earlier listed.[15] It is invaluable in its ability to provide 3-dimensional relationships among the structures in question.

Obtain 2.5-mm axial and coronal cuts of the facial skeleton. In delicate and complex areas such as the eyes, obtain lateral oblique cuts through the globe to evaluate the bony architecture surrounding the orbit. If necessary, 3-dimensional reconstructions can be made for a more detailed analysis.

The main disadvantage of CT scanning is the higher dosage of radiation to which the patient is exposed.

Magnetic Resonance Imaging

Although it avoids the need to expose patients to radiation, MRI is generally not a practical or necessary study for the evaluation of acute soft tissue facial trauma.

 

Treatment

Approach Considerations

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

Airway management

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.[16, 17]

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.

Pharmacologic Therapy

Antibiotics

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.

Anesthetics

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

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.[18]

Another report, by McGuire et al, found that among 158 dog bite patients who presented to the emergency department of a tertiary care pediatric hospital, bites had been sustained most often to the face (42.9%).[19]

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.

Surgical Repair

General principles

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.[20]

The following summarizes approaches to the repair of injuries to specific areas of the face.

Scalp injuries

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.

Eyebrow injuries

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.

Eyelid injuries

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.

Ear injuries

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.

Nose injuries

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.[21]

Lip injuries

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.

Steps to repair lip laceration: 3-layered approach Steps to repair lip laceration: 3-layered approach.

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.

Nerve 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.

Consultations

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.

Long-Term Monitoring

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.[22]

 

Medication

Medication Summary

Not all facial soft-tissue injuries require pharmacotherapy. When drugs are employed, the goal is to decrease the potential morbidity and mortality and reduce the risk of complications.

Vaccines, Inactivated, Bacterial

Class Summary

Toxoids are used to induce active immunity.

Tetanus toxoid adsorbed or fluid

Tetanus toxoid induces active immunity against tetanus in selected patients. The immunizing agents of choice for most adults and children older than 7 years 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 the midlateral thigh muscles. In infants, the preferred site is the midthigh laterally.

Administer diphtheria and tetanus toxoids 0.5 mL intramuscularly (IM) to patients older than 7 years who have not been immunized within 5 years. Administer tetanus immunoglobulin G (IgG) 250 U at a different site for patients with an incomplete immunization history.

Immune Globulins

Class Summary

Immunoglobulins are used for passive immunization, consisting of the administration of immunoglobulin that is pooled from the serum of immunized subjects.

Tetanus immune globulin (HyperTET)

Tetanus immune globulin (TIG) induces passive immunization in any person with a wound that might be contaminated with tetanus spores.

Antibiotics

Class Summary

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.

Penicillin G benzathine (Bicillin L-A)

Penicillin G interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Penicillin VK

Penicillin VK inhibits biosynthesis of cell wall mucopeptide. It is bactericidal against sensitive organisms when adequate concentrations are achieved and is most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects.

Amoxicillin and clavulanate (Augmentin, Augmentin XR)

The combination of amoxicillin and clavulanate treats bacteria that are resistant to beta-lactam antibiotics. For children older than 3 months, base the dosing protocol on the amoxicillin content. Because of different ratios of amoxicillin to clavulanic acid in the 250-mg tab (250/125) and in the 250-mg chewable tab (250/62.5), do not use the 250-mg tab until the child weighs more than 40 kg.

Doxycycline (Doryx, Adoxa, Ocudox, Vibramycin, Oraxyl)

Doxycycline is a broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. It is almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.

Doxycycline inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly the 50S ribosomal subunits of susceptible bacteria. It may block dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Cefuroxime (Ceftin, Zinacef)

Cefuroxime is a second-generation cephalosporin that maintains the gram-positive activity of the first-generation cephalosporins and adds activity against Proteus mirabilis, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis.

Cefuroxime binds to penicillin-binding proteins and inhibits the final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death. The condition of the patient, the severity of the infection, and the susceptibility of the microorganism determine the proper dose and route of administration. Cefuroxime resists degradation by beta-lactamase.

Vancomycin (Vancocin)

Vancomycin is a potent antibiotic directed against gram-positive organisms and active against Enterococcus species. It is useful in the treatment of septicemia and skin structure infections. It is indicated for patients who are unable to receive penicillins and cephalosporins or whose infections have not responded to these agents, as well as for patients who have infections with resistant staphylococci. Use the creatinine clearance to adjust the dose in patients diagnosed with renal impairment.