Facial Soft Tissue Injuries 

Updated: Aug 22, 2018
Author: Kyle D Parish, MD; Chief Editor: Craig C Young, MD 



Facial soft-tissue injuries are not uncommon in athletics.[1, 2, 3, 4, 5, 6, 7, 8, 9, 10] The position and anatomy of the face make it particularly vulnerable to trauma. In addition, few sports mandate the use of protective equipment, leaving the face susceptible to injury. Although most such injuries are minor in nature, they should be evaluated promptly with a focused history and thorough examination (see image below). In addition, facial injuries should be treated early to reduce the likelihood of possible adverse outcomes (ie, infection, loss of function, poor cosmesis). In this article, common sports-related soft-tissue facial injuries are discussed, with an emphasis on the initial evaluation, diagnosis, and treatment.[11, 12]

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

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center and Eye and Vision Center. Also, see eMedicineHealth's patient education articles Facial Fracture, Black Eye, Nosebleeds, Bicycle and Motorcycle Helmets, and Bicycle Safety.



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.[5] 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 have fewer soft-tissue injuries compared with sports that do not mandate the use of such equipment.

Sport-Specific Biomechanics

The mechanism of facial soft-tissue injuries is often a direct impact from an external source (eg, sporting equipment, another participant, environment/playing surface). The forces exerted by the impact can lead to friction, shear, compression, and/or traction of the soft tissue and underlying structures. Injury patterns vary widely by sport, based on various factors (eg, rules, equipment).[13, 14, 15]




A focused and thorough history should be obtained from the injured athlete, including his or her pertinent medical history, the mechanism of injury (if not witnessed by the medical staff), and the source of pain. If the patient is unable to report history information, family members can provide such information. The presence of symptoms such as visual changes or altered sensorium should also be ascertained at this time.


As with any head and neck injury, examination of an individual with trauma to the face must start with an evaluation of the patient's airway, breathing, and circulation (ABCs). Cervical spine injury should also be considered based on the mechanism of injury, and appropriate precautions should be taken. The physical examination should be focused on the specific injury site.

The face is extremely vascular, and even minor injuries may result in profuse bleeding. Copious irrigation should be used to clean and accurately assess the injury. Visual inspection and palpation should be used to systematically examine the face for symmetry. Start superiorly, with the scalp and frontal bones, and proceed inferiorly and laterally. Examine the oral cavity for any disrupted dentition or lacerations. During inspection, pay particular attention to any areas of swelling because this may indicate a more significant underlying injury.

Note the location, size, shape, and depth of any lacerations, and explore wounds for foreign bodies. Palpate for areas of crepitus or bony step-off. Gross asymmetry may signify underlying nerve damage. Assess neurologic function by evaluating sensation and motor function.


Due to rich vascularity, the amount of bleeding present may not be proportionate to the size of a soft-tissue injury. This is particularly true of the scalp. After cleaning the wound, hemostasis should be attempted with direct pressure. The areas around any lacerations should be examined for bony step-off that would indicate a possible underlying skull fracture. Try to avoid removing hair at the border of any wound because this helps serve as a landmark for accurate repair and may have important cosmetic implications.

Orbital rim/Eyebrow

Inspect the orbital rim carefully because injury in the area of the eyebrow may indicate the presence of an underlying fracture. The rim should be palpated 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. 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 is at significant risk of not growing back or growing back with an abnormal pattern or color.


Simple lacerations of the eyelid, without involvement of the margins, can be treated without concern for further eye injury. If the protective function of the lid is compromised in any way, serious ophthalmologic injury may result. Exploration for foreign bodies must be performed. Flip the eyelids over and examine the tarsal plate. Damage to either side of the tarsal plate 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 an ophthalmologist. Additional injuries that warrant an evaluation by an ophthalmologist are any injuries that involve the canthi, lacrimal system, or lid margin.[16]


Look for any gross injury or asymmetry in the globes.[17, 18] Check the papillary responses to light directly and indirectly. Using an ophthalmoscope, the anterior chamber should be visualized 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 other topical ocular anesthetic) should be used to ensure an adequate examination.

Extraocular movements should be evaluated. 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 controls globe movement (cranial nerves [CNs] III, IV, and VI). Evaluate for conjugate gaze and smooth pursuit.

Visual acuity should also be assessed. On the sideline or in the locker room, a hand-held 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 on the sideline, and the patient should be sent to the appropriate facility for definitive care.


A direct blow or shearing force to the ear may result in tearing of the blood vessels at the level of the perichondrium. The result is a subperichondrial hematoma. These injuries can result in significant cosmetic deformity if missed or if not treated immediately. Fibrosis develops within 2 weeks of the injury, and the athlete can be left with abnormally shaped pinnae (a condition also known as cauliflower ear). Blunt trauma or barotrauma (in specific sports) 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 athletes are asymptomatic, but vertigo and otalgia may be present.


When the nose is fractured, it usually appears deformed.[19] Nevertheless, epistaxis without obvious nasal deformity may be the only clinical finding in some nasal fractures. Performing an adequate and thorough nasal examination is difficult without epistaxis control. The origin of most nosebleeds is the extremely vascular area on the anterior septum (Kiesselbach area).

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.[20]

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


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 image below, top). A step-off of the vermilion border as small as 1 mm is apparent at conversational distance.

Top: Improper repair of an angled laceration. Bot Top: Improper repair of an angled laceration. Bottom: Proper repair of an angled laceration, with creation of perpendicular edges for a flush repair.

Inspect the inside of the lip for through-and-through wounds. An intraoral examination is a necessary part of the facial evaluation. The inside of the lips and cheeks should be examined thoroughly for any through-and-through wounds. Special attention should be given to the area around the parotid duct, as depicted below. With any injury involving the mid cheek, 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. Any suspected injury should be referred for possible stenting and repair. Also, look for disrupted teeth and hematoma.

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


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


The bones of the face should be inspected for any asymmetry. Palpate all of the bones; be sure to include the temporomandibular joint. The movements of facial expression should be assessed by observing the patient as he or she raises the eyebrows, closes the eyes, smiles, and frowns. Any deficit is suggestive of injury to one of the branches of the facial nerve (CN VII). Examine sensation for each of the 3 branches of the trigeminal nerve (CN V) (see image below). Deficits in any area warrant further evaluation. Injuries along a topographic line extending from the tragus to the base of the nose, and lateral to the lateral canthus, should raise the suspicion of a parotid duct injury, and the evaluation should proceed as described above under Mouth/Lips.

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


Most facial soft-tissue injuries are the result of direct trauma. The trauma can be a result of contact with another participant, sport-specific equipment, and/or the environment/playing surface.



Differential Diagnoses



Approach Considerations

With any significant facial and head trauma, providers must consider the possibility of an associated concussion.[21]



Imaging Studies

Facial injuries in which there is significant bony tenderness or obvious deformity warrant imaging to evaluate for fractures. Start with plain films of the face, including Water, Caldwell, and lateral views. Panoramic x-ray images may also be of benefit. These images may also be helpful in the evaluation of a possible foreign body presence. If the clinical suspicion is high or plain films are inconclusive, computed tomography (CT) scans can be useful. If necessary, 3-dimensional (3-D) reconstructions can be made for a more detailed analysis.



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.


As with the physical examination, a systematic approach to facial laceration repair ensures the best chance at an optimum outcome.[23] 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 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).

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

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).

Top: Improper repair of an angled laceration. Bot Top: Improper repair of an angled laceration. Bottom: Proper repair of an angled laceration, with creation of perpendicular edges for a flush repair.


Deep wounds should be repaired in layers. Unrepaired muscle layers are much more likely to produce noticeable scarring.[24] 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.[25] 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

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.


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


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 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 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 Summary

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.


Class Summary

Toxoids are used to induce active immunity.

Tetanus toxoid adsorbed or fluid

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.


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 (TIG)

Induces passive immunization in any person with a wound that might be contaminated with tetanus spores.


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, Permapen)

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

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.

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

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.

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.

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.



Return to Play

Return to play should be based on the location and severity of the injury, sport and position requirements, and risk of the injury causing a concomitant injury. Most athletes are able to return to play immediately after treatment on the sideline or in the training room. When making return-to-play decisions, attention should be given to whether the area in question can be protected from further injury.


See Medical Issues/Complications for a list of potential complications.


The use of protective equipment, such as helmets and headgear, face masks, eye protection (shields or goggles), and mouthpieces are useful in preventing some types of facial soft-tissue injuries. Importantly, make sure the rules of the sport allow for the use of such protective equipment before recommending or providing the protective equipment.


The prognosis for most facial soft-tissue injuries is good; the injuries usually heal rapidly, allowing the athlete to return to play. Knowing the expectations of the athlete and the athlete's family is important to ensure the treatment result is optimal.


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