Basic Principles in the Basic Principles in the Management of Soft Management of Soft Tissue Injuries of the Tissue Injuries of the

FaceFace

IntroductionIntroduction

Facial trauma is common Facial trauma is common Susceptibility to injury comes with Susceptibility to injury comes with

the position and anatomy of the face the position and anatomy of the face Proper care and correct Proper care and correct

management ensure management ensure maintenance of functionmaintenance of function good wound cosmesisgood wound cosmesis low infection rate. low infection rate.

Frequency: Frequency: exact incidence is unknown but very exact incidence is unknown but very

commoncommon > 50% of facial traumas are secondary > 50% of facial traumas are secondary

to motor vehicle accidents, others are to motor vehicle accidents, others are from athletic and other recreational from athletic and other recreational activitiesactivities

AssaultAssault

IntroductionIntroduction

BiomechanicsBiomechanics Facial soft tissue injuries are usually due to Facial soft tissue injuries are usually due to

trauma from an external source rather than trauma from an external source rather than internal biomechanicsinternal biomechanics

External forces leading to soft tissue injuries External forces leading to soft tissue injuries may include may include frictionfriction ShearShear CompressionCompression Traction Traction

(Repeated blows or pressure against (Repeated blows or pressure against the ear, as in boxing, wrestling, or rugby, can the ear, as in boxing, wrestling, or rugby, can cause bleeding and result in cauliflower ear if left cause bleeding and result in cauliflower ear if left untreated) untreated)

Initial Approach and Initial Approach and AssessmentAssessment

History: History: The physician should obtain a thorough The physician should obtain a thorough

history from the patient or a family history from the patient or a family member, including any significant past member, including any significant past medical history, whenever possible. medical history, whenever possible.

A thorough history and physical exam is A thorough history and physical exam is essential for optimum management.essential for optimum management.

Knowing the onset and precise mechanism Knowing the onset and precise mechanism of injury is beneficial to the physician for of injury is beneficial to the physician for providing optimum treatment. providing optimum treatment.

Physical: Physical: airway, breathing, and circulationairway, breathing, and circulation A careful examination starts with a A careful examination starts with a

symmetry survey, looking for any symmetry survey, looking for any obvious deformities or deficits. obvious deformities or deficits.

When approaching a patient with a When approaching a patient with a laceration, the initial attention is laceration, the initial attention is focused on hemorrhage control. focused on hemorrhage control. Most bleeding due to simple lacerations can Most bleeding due to simple lacerations can

be easily controlled with direct pressurebe easily controlled with direct pressure

Initial Approach and Initial Approach and AssessmentAssessment

Occasionally, when relatively large Occasionally, when relatively large vessels are involved, special techniques vessels are involved, special techniques are requiredare required Temporary placement of a tourniquet Temporary placement of a tourniquet Small-vessel ligationSmall-vessel ligation placement of “figure of 8” suturesplacement of “figure of 8” sutures

repair of larger, named arteries and repair of larger, named arteries and veins may require consultation with, and veins may require consultation with, and operative repair by, another specialist. operative repair by, another specialist.

Initial Approach and Initial Approach and AssessmentAssessment

Once the patient is stabilized, attention can be Once the patient is stabilized, attention can be focused on the management of the soft tissue focused on the management of the soft tissue injury/laceration injury/laceration

A complete examination of the laceration is A complete examination of the laceration is necessary, making note ofnecessary, making note of Location and depthLocation and depth Gross contaminationGross contamination Obvious foreign bodies Obvious foreign bodies Associated injuriesAssociated injuries Orientation of the laceration with regard to skin tension Orientation of the laceration with regard to skin tension

lineslines Lacerations that are perpendicular to these lines are subject to Lacerations that are perpendicular to these lines are subject to

more static and dynamic tension and, therefore, develop more more static and dynamic tension and, therefore, develop more scarringscarring

Roentgenograms of the injured site may be necessary to rule Roentgenograms of the injured site may be necessary to rule out an associated fracture or a retained radiopaque foreign out an associated fracture or a retained radiopaque foreign bodybody

Any open fracture or laceration associated with injury to Any open fracture or laceration associated with injury to specialized ducts or glands, or vessels or nerves requiring specialized ducts or glands, or vessels or nerves requiring repair should be referred to the appropriate specialistrepair should be referred to the appropriate specialist

Initial Approach and Initial Approach and AssessmentAssessment

DIFFERENTIALSDIFFERENTIALS

Facial fracturesFacial fractures Facial soft tissue injuresFacial soft tissue injures Nasal fracturesNasal fractures

Work upWork up

Imaging Studies: Imaging Studies: Any deformity or significant bony Any deformity or significant bony

tenderness following a traumatic facial tenderness following a traumatic facial injury warrants the use of radiographic injury warrants the use of radiographic imaging to rule out facial fractures. imaging to rule out facial fractures.

X-ray films can also be obtained to look X-ray films can also be obtained to look for radiopaque foreign bodies. for radiopaque foreign bodies.

If further evaluation is indicated, a CT If further evaluation is indicated, a CT scan or MRI is needed.scan or MRI is needed.

TREATMENT TREATMENT

Acute Phase:Acute Phase: Possible Complications: Possible Complications:

InfectionInfection HematomaHematoma Flap necrosisFlap necrosis Nasal septum necrosisNasal septum necrosis Retained foreign bodiesRetained foreign bodies Cauliflower ear Cauliflower ear Poor cosmesis Poor cosmesis Loss of functionLoss of function

Surgical Intervention: Surgical Intervention: Anesthesia Anesthesia Adequate anesthesia must be Adequate anesthesia must be

administered for proper wound administered for proper wound examination and exploration. examination and exploration. Lidocaine 1% with and without epinephrine Lidocaine 1% with and without epinephrine

is used commonlyis used commonly Toxic doses are 7 mg/kg and 5 mg/kg, Toxic doses are 7 mg/kg and 5 mg/kg,

respectivelyrespectively

TREATMENT TREATMENT

For a complicated wound or if For a complicated wound or if prolonged anesthesia is needed:prolonged anesthesia is needed: bupivacaine 0.25-0.5% provides bupivacaine 0.25-0.5% provides

approximately 6 hours of pain control. approximately 6 hours of pain control. Toxic doses of bupivacaine are 2 mg/kg Toxic doses of bupivacaine are 2 mg/kg

without epinephrine and 3 mg/kg with without epinephrine and 3 mg/kg with epinephrine. epinephrine.

TREATMENT TREATMENT

Overadministration of anestheticOveradministration of anesthetic more likely to occur in the presence of a large more likely to occur in the presence of a large

laceration in a childlaceration in a child Mild lidocaine toxicity is expressed as an acute Mild lidocaine toxicity is expressed as an acute

change that may include slurred speech, change that may include slurred speech, drowsiness, confusion, nausea, vomiting, ataxia, drowsiness, confusion, nausea, vomiting, ataxia, twitching, tinnitus, and vertigo. Complications of twitching, tinnitus, and vertigo. Complications of higher levels of toxicity include psychosis, higher levels of toxicity include psychosis, seizures, respiratory depression, and death. seizures, respiratory depression, and death.

Topical anesthetic combinations such as Topical anesthetic combinations such as lidocaine, epinephrine, and tetracaine are an lidocaine, epinephrine, and tetracaine are an appealing approach in injuries of the face. appealing approach in injuries of the face. Application on the mucosal barrier must be Application on the mucosal barrier must be avoided to prevent systemic toxicity. avoided to prevent systemic toxicity.

TREATMENT TREATMENT

Regional nerve blocks Regional nerve blocks Four types of regional nerve blocks Four types of regional nerve blocks

SupratrochlearSupratrochlear Supraorbital Supraorbital InfraorbitalInfraorbital Mental Mental

associated with injuries on the face. associated with injuries on the face. save timesave time decrease the risk of systemic toxicitydecrease the risk of systemic toxicity involve less volume-related tissue involve less volume-related tissue

distortiondistortion

TREATMENT TREATMENT

Wound decontamination Wound decontamination Removing pyogenic bacteria and devitalized Removing pyogenic bacteria and devitalized

tissue is paramount to creating a clean wound. tissue is paramount to creating a clean wound. Irrigation is the mainstay procedure for Irrigation is the mainstay procedure for

accomplishing this goal. accomplishing this goal. 18- or 19-gauge catheter with a 60-mL syringe 18- or 19-gauge catheter with a 60-mL syringe

provides the needed pressure for adequate wound provides the needed pressure for adequate wound cleaning. cleaning.

A standard guideline for volume of irrigation is 60 A standard guideline for volume of irrigation is 60 mL/cm of wound length. Low-pressure irrigation mL/cm of wound length. Low-pressure irrigation with a bulb syringe or plastic bottle is inadequate. with a bulb syringe or plastic bottle is inadequate.

Normal saline Normal saline tap water tap water

Avoid chlorhexidine, hydrogen peroxide, Avoid chlorhexidine, hydrogen peroxide, benzalkonium chloride, and products containing benzalkonium chloride, and products containing detergent because of tissue toxicity. detergent because of tissue toxicity.

TREATMENT TREATMENT

Wound decontaminationWound decontamination Wounds may be scrubbed to remove gross Wounds may be scrubbed to remove gross

contamination. contamination. Take care in scrubbing wounds; activity that is too vigorous Take care in scrubbing wounds; activity that is too vigorous

increases tissue damage and infection rates. increases tissue damage and infection rates. Devitalized tissue is extremely pyogenic and can be Devitalized tissue is extremely pyogenic and can be

removed easily with a No. 15 blade or iris scissors. removed easily with a No. 15 blade or iris scissors. Preserve healthy tissue, if possible. Preserve healthy tissue, if possible. After adequate cleansing, drape the wound in sterile After adequate cleansing, drape the wound in sterile

fashion. Also, prepare the skin around the wound in fashion. Also, prepare the skin around the wound in sterile fashion. sterile fashion.

Povidone-iodine solution may be used for thisPovidone-iodine solution may be used for this toxic to tissue at its standard strengthtoxic to tissue at its standard strength 1% solution of povidone and iodine1% solution of povidone and iodine

TREATMENT TREATMENT

Wound exploration Wound exploration After adequate anesthesia and wound After adequate anesthesia and wound

cleansing, explore the wound. cleansing, explore the wound. Adequate lighting, hemostasis, and a cooperative Adequate lighting, hemostasis, and a cooperative

patient are of paramount importancepatient are of paramount importance Plain films can identify radiopaque foreign Plain films can identify radiopaque foreign

bodies (eg, glass, metal, gravel). Studies have bodies (eg, glass, metal, gravel). Studies have shown that on a 2-view radiograph, glass of at shown that on a 2-view radiograph, glass of at least 2 mm and gravel of at least 1 mm can be least 2 mm and gravel of at least 1 mm can be visualized. visualized.

Exploration with forceps can help identify Exploration with forceps can help identify some foreign bodies through a characteristic some foreign bodies through a characteristic "clink" sound generated when contact is made. "clink" sound generated when contact is made.

TREATMENT TREATMENT

Wound explorationWound exploration The advisability of removal of objects depends The advisability of removal of objects depends

on the on the expertise of the provider expertise of the provider proximity to vital structures. proximity to vital structures.

Hemostasis may be aided by the use of Hemostasis may be aided by the use of anesthetics containing epinephrine. The risk of anesthetics containing epinephrine. The risk of ischemia of wound edges on the face is low. ischemia of wound edges on the face is low.

A figure-eight stitch is also valuable for A figure-eight stitch is also valuable for controlling deep bleeding, but the clinician controlling deep bleeding, but the clinician must take care to not ligate a nerve.must take care to not ligate a nerve.

TREATMENT TREATMENT

Wound closure Wound closure The need to create an aesthetic wound The need to create an aesthetic wound Most lacerations are approximated with Most lacerations are approximated with

excellent cosmetic results using simple sutures excellent cosmetic results using simple sutures Observe lines of expression Observe lines of expression Wounds on the face may be closed up to 24 Wounds on the face may be closed up to 24

hours after injury in nonimmunocompromised hours after injury in nonimmunocompromised patientspatients

The wound edge (1-2 mm) may be removed The wound edge (1-2 mm) may be removed safely to rid the wound of devitalized tissue. safely to rid the wound of devitalized tissue.

A perpendicular wound edge creates a much A perpendicular wound edge creates a much smoother and less noticeable scarsmoother and less noticeable scar

TREATMENT TREATMENT

Wound closureWound closure skin sutures are placed under minimal to no tension. skin sutures are placed under minimal to no tension. If tension exists, the wound margins can be If tension exists, the wound margins can be

approximated by undermining the surrounding approximated by undermining the surrounding wound edges or by placing subcutaneous stitches. wound edges or by placing subcutaneous stitches.

use the least amount of subcutaneous sutures use the least amount of subcutaneous sutures necessary because subcutaneous materials increase necessary because subcutaneous materials increase the risk of wound infection. the risk of wound infection.

For deep wounds under tension, For deep wounds under tension, approximate with a 5-0 intradermal absorbable approximate with a 5-0 intradermal absorbable

monofilament suture. Then, close the overlying skin with a monofilament suture. Then, close the overlying skin with a 6-0 suture. 6-0 suture.

Simple interrupted sutures work well for facial Simple interrupted sutures work well for facial repair.repair.

TREATMENT TREATMENT

Delayed primary closure Delayed primary closure 1.1. may be used for lacerations that cannot be may be used for lacerations that cannot be

closed initially closed initially

2.2. gross contaminationgross contamination

3.3. violation of jointsviolation of joints

4.4. retained foreign bodiesretained foreign bodies

5.5. host immune statushost immune status

6.6. inability to adequately cleanse the woundinability to adequately cleanse the wound

7.7. delayed presentation. delayed presentation.

TREATMENT TREATMENT

Delayed primary closureDelayed primary closure The wound is irrigated and debrided as The wound is irrigated and debrided as

usual, then moist gauze is applied and usual, then moist gauze is applied and covered by a protective dressing. covered by a protective dressing. Antibiotics Antibiotics

On day 4, the dressing is removed and On day 4, the dressing is removed and the wound is irrigated and sutured. the wound is irrigated and sutured.

The cosmesis achieved with delayed The cosmesis achieved with delayed primary closure is equivalent to that of primary closure is equivalent to that of primary closure. primary closure.

TREATMENT TREATMENT

Wound edge eversion Wound edge eversion Improved cosmesis Improved cosmesis After the initial repair, the edges flatten and become After the initial repair, the edges flatten and become

flush with the surrounding skinflush with the surrounding skin If the edges were not everted initially, then the wound If the edges were not everted initially, then the wound

appears concave and has poor cosmesis. appears concave and has poor cosmesis. Shaving Shaving

increases the risk of infection increases the risk of infection do not shave around wounds to be closed do not shave around wounds to be closed hair can be clipped or parted with bacitracin or hair can be clipped or parted with bacitracin or

petroleum jelly to provide a clear viewpetroleum jelly to provide a clear view Surrounding hair can also be prepared with povidone-Surrounding hair can also be prepared with povidone-

iodine solution.iodine solution.

TREATMENT TREATMENT

Skin-closure tapeSkin-closure tape works well in nonmobile areas that have good works well in nonmobile areas that have good

wound edge approximation without tension. wound edge approximation without tension. Forceps are used to attach the tape to one side Forceps are used to attach the tape to one side

of the wound and then to pull the wound edges of the wound and then to pull the wound edges together for a good fit. The remaining part of together for a good fit. The remaining part of the tape is then attached to the opposite side the tape is then attached to the opposite side of the wound. of the wound.

advantage of skin tape is the lack of need for advantage of skin tape is the lack of need for anesthesia and removal of sutures. anesthesia and removal of sutures.

Staple closure is not suited for the face.Staple closure is not suited for the face.

TREATMENT TREATMENT

Abrasions or avulsions Abrasions or avulsions These types of wounds are commonly dirty and These types of wounds are commonly dirty and

require careful debridement and irrigation to require careful debridement and irrigation to prevent traumatic tattooing. prevent traumatic tattooing.

Radiographs are valuable in determining the Radiographs are valuable in determining the presence of deeply embedded glass and gravel. presence of deeply embedded glass and gravel.

Full-thickness avulsions are closed primarily with Full-thickness avulsions are closed primarily with 6-0 nonabsorbable sutures. 6-0 nonabsorbable sutures.

Gauze impregnated with petroleum jelly is then Gauze impregnated with petroleum jelly is then applied for protection during epithelialization. applied for protection during epithelialization.

In 7-8 days, the gauze may be removed and the In 7-8 days, the gauze may be removed and the patient should be evaluated for further repair by a patient should be evaluated for further repair by a plastic surgeon plastic surgeon

TREATMENT TREATMENT

  MEDICATION MEDICATION goals of pharmacotherapy goals of pharmacotherapy

1.1. eradicate the infection when presenteradicate the infection when present

2.2. to reduce morbidityto reduce morbidity

3.3. to prevent complicationsto prevent complications

TREATMENT TREATMENT

Tetanus toxoid Tetanus toxoid Immunizing agents of choice for most Immunizing agents of choice for most

adults and children >7 y are tetanus adults and children >7 y are tetanus and diphtheria toxoids. and diphtheria toxoids.

Pregnant patients should receive only Pregnant patients should receive only tetanus toxoid, not a diphtheria tetanus toxoid, not a diphtheria antigen–containing product.antigen–containing product.Administer dT 0.5 mL IM to patients >7 Administer dT 0.5 mL IM to patients >7 y who have not been immunized within y who have not been immunized within 5 y. 5 y.

TREATMENT TREATMENT

Tetanus toxoidTetanus toxoid Adult Dose Adult Dose Primary immunization: 0.5 mL IM; Primary immunization: 0.5 mL IM;

give 2 injections 4-8 wk apart and a third dose give 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection6-12 mo after second injectionBooster dose: 0.5 mL q10y Booster dose: 0.5 mL q10y

Pediatric Dose Pediatric Dose Administer as in adults Administer as in adults Contraindications Contraindications

Documented hypersensitivity; history of any type of Documented hypersensitivity; history of any type of neurological symptoms or signs following neurological symptoms or signs following administrationadministration

elective tetanus immunization be deferred during any elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative injections are an important cause of provocative poliomyelitispoliomyelitis

TREATMENT TREATMENT

Immunoglobulins Immunoglobulins Used for passive immunizationUsed for passive immunization Consists of administration of Consists of administration of

immunoglobulin pooled from serum of immunoglobulin pooled from serum of immunized subjects. immunized subjects.

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

TREATMENT TREATMENT

ImmunoglobulinsImmunoglobulins Adult Dose Adult Dose Prophylaxis: 250-500 U IM in Prophylaxis: 250-500 U IM in

opposite extremity to tetanus toxoid lesion opposite extremity to tetanus toxoid lesion Pediatric Dose Pediatric Dose Prophylaxis: 250 U IM in Prophylaxis: 250 U IM in

opposite extremity to tetanus toxoid opposite extremity to tetanus toxoid Contraindications Contraindications

do not administer within 3 mo of live virus do not administer within 3 mo of live virus immune globulin administration; may be immune globulin administration; may be necessary to revaccinate persons who received necessary to revaccinate persons who received immune globulin shortly after live virus immune globulin shortly after live virus vaccination vaccination

TREATMENT TREATMENT

AntibioticsAntibiotics Not recommended as part of routine, Not recommended as part of routine,

uncomplicated wound careuncomplicated wound care Indications Indications

large intraoral wounds large intraoral wounds Human bites or abrasions caused by human Human bites or abrasions caused by human

teeth teeth Puncture wounds (eg, nails, cat bites)Puncture wounds (eg, nails, cat bites) wounds with signs of infectionwounds with signs of infection grossly contaminated woundsgrossly contaminated wounds wounds with retained foreign bodieswounds with retained foreign bodies

TREATMENT TREATMENT

AntibioticsAntibiotics Penicillin G benzathine Penicillin G benzathine Dicloxacillin Dicloxacillin Amoxicillin and clavulanate Amoxicillin and clavulanate

(Augmentin) (Augmentin) CephalexinCephalexin Penicillin VK Penicillin VK Clindamycin Clindamycin

TREATMENT TREATMENT

Aftercare and follow-up procedures are Aftercare and follow-up procedures are as follows: as follows: The wound should be rechecked after 2-3 The wound should be rechecked after 2-3

days for signs of infection. days for signs of infection. An antibacterial ointment should be applied An antibacterial ointment should be applied

for the first 2 days after repair. for the first 2 days after repair. A dressing may be applied for up to 3 days A dressing may be applied for up to 3 days

after repair. after repair. Showering can begin 12-24 hours after Showering can begin 12-24 hours after

repair. repair. Facial sutures are usually removed after 3-5 Facial sutures are usually removed after 3-5

days.days.

TREATMENT TREATMENT

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