Management of soft tissue injuries in facial trauma Dr. Ahmed M. Adawy. Professor Emeritus, Dept. Oral & Maxillofacial Surg. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Soft-tissue injuries are the most common presentation following maxillofacial trauma. In general, injuries can initially be classified as open or closed wounds. A closed wound is one that damages underlying tissue and/or structures without breaking the skin. Examples of closed wounds include hematomas, contusions, and crush injuries. In contrast, open wounds involve a break in the skin, which exposes the underlying structures to the external environment. Open wounds include simple and complex lacerations, avulsions, punctures, abrasions, accidental tattooing, and retained foreign body. Detailed description of management is presented. The principles of repair is discussed.

2. Dr. Ahmed M. Adawy
Professor Emeritus, Dept. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University

3. Soft-tissue injuries with or without facial bone
involvement are the most common presentation following
maxillofacial trauma. The damage can be limited to
superficial tissues or involve deeper structures. Males are
more likely to sustain injury compared to females.
Although rarely life-threatening, the treatment of these
injuries can be complex and may have significant impact
on the patients' facial aesthetics and function. The
common causes of soft tissue facial trauma are falls,
activities of daily living, sports, violence, motor vehicle
accidents, animal attacks, and self-inflicted injuries (1,2).

4. Once the initial assessment has been performed and the
patient stabilized, the soft-tissue facial trauma can be
carefully evaluated. Obtaining past medical and social
history can help identify factors that may affect wound
healing. Compromised status such as diabetes, alcohol or
tobacco abuse, or past radiation therapy may negatively
affect wound healing. The time and mechanism of the
injury should be recognized. An immunization history will
help determine the need for rabies or tetanus prophylaxis
(3,4). Visual inspection and palpation should be used to
systematically examine the face for symmetry.
Examination should start superiorly, with the scalp and
frontal bones, and proceed inferiorly and laterally.

5. Thorough physical examination should be performed.
Clinical evaluation should be carried out under adequate
light source. The quality of the wound is examined, along
with an assessment of the lacrimal apparatus, the external
auditory meatus, the facial nerve, parotid duct, and the
underlying bone. The location, size, shape, and depth of
any wound should be noted, and exploration of the
wounds should be done for foreign bodies. In particular,
the presence of nonviable tissue and/or the presence of
gross contamination are important to discern. 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.

6. The wound is irrigated with normal saline and any debris
and small foreign bodies are removed to prevent infection
or traumatic tattooing. Digital agitation can help facilitate
irrigation, or normal saline can be placed in a large syringe
with an 18-gauge needle to increase the pressure of
irrigation. Devitalized tissue is then removed
conservatively with sharp debridement while preserving
as much soft tissue as possible. Bleeding is controlled
initially to arrest gross hemorrhage; then hemostasis is
achieved again during and after irrigation and debridement.
Direct pressure is the primary method to stop bleeding,
along with the identification and tying of visible vessels.

7. Facial soft tissue injuries vary in severity based on the
impact force and type of injury into minor superficial
wounds to massive avulsions. In general, injuries can
initially be classified as open or closed wounds. A closed
wound is one that damages underlying tissue and/or
structures without breaking the skin. Examples of closed
wounds include hematomas, contusions, and crush
injuries. In contrast, open wounds involve a break in the
skin, which exposes the underlying structures to the
external environment. Open wounds include simple and
complex lacerations, avulsions, punctures, abrasions,
accidental tattooing, and retained foreign body.

8. Wounds can be classified according to their general
condition, size, location, the manner in which the skin or
tissue is broken, and the agent that caused the wound (5).
1. Contusion:
Typically caused by blunt trauma. There is extravasation
of blood within the tissue that may or may not be
accompanied by a hematoma. Most frequently, contusions
are treated with conservative therapy even if a hematoma
is present. In some instances, a hematoma may require
evacuation and if neglected may lead to the accumulation
of scar tissue.

9. Contusions

10. 2. Abrasion: Abrasions are partial-thickness disruptions of
the epidermis without disruption of the deeper dermal
layer as a result of sudden, forcible friction. These wounds
require cleansing with mild non irritating soap and left
uncovered. Only when contaminated, topical application
of antibiotic ointment, is indicated. Ointment keeps the
wound moist and prevents scab formation, which aids in
the re-epithelialization process. Antibiotic ointment is
recommended in the first 2 to 7 days, followed by
ointment without antibiotics, such as petroleum jelly (6).
Systemic antibiotics are generally not recommended in
clean, simple wounds of the face and neck that are
adequately irrigated and debrided.

11. Abrasions

12. 3. Laceration: A laceration is a disruption of both the
epidermis and dermis. The resultant wound may have
clean edges that can be repaired with little manipulation or
nonviable tissue that requires extensive debridement
before closure. Simple lacerations are the most common
type. Skin repair should be undertaken when underlying
tissues are put in order. Muscles involved in a deep
lacerated wound should be accurately approximated with
fine sutures. The wound is then closed in layers from the
inside out. Ragged wound edges should be considerably
excised to provide perpendicular edges that will heal
primarily with a minimum of scar. Lacerations of the
parotid duct and/or facial nerve may require microsurgical
techniques for re-anastomosed.

13. Lacerations

14. 4. Avulsion:
An avulsion is the forcible tearing away or separation and
subsequent loss of a bodily structure or part, either as the
result of injury or as an intentional surgical procedure.
Avulsion injuries are the most challenging to repair and
should not be allowed to heal spontaneously by the scar
tissue. Completely detached tissue pieces and some small
avulsions can be sutured back into position as grafts. If the
wounds cannot be closed because of avulsion and loss of
soft tissue, dressing of the area with a split-thickness skin
graft provides immediate closure and avoids infection.
Larger defects may require local or regional flaps. In
extensive avulsion injuries, free tissue transfer may be
required.

15. Avulsions

16. The face can be divided into specific areas, designated as
“aesthetic units”, within which the skin has similar
characteristics, such as colour, thickness, amount of
subcutaneous fat, texture and presence of hair. These
“units” are separated from each other by relatively well-
defined ridges and creases, designated as “aesthetic
borders”. The borders include easily discernable
landmarks such as the hairline, eyebrows, nasolabial fold,
philtrum, vermillion border and labiomental fold (7).The
original 14 aesthetic units as classified by Gonzales-Ulloa
(8) included: forehead, right and left cheeks, nose, right and
left upper lids, right and left lower lids, right and left ears,
upper lip, lower lip, mental region, and the neck.

17. Burget and Menick (9), revitalized interest in the field of
aesthetic facial units by introducing the concept of the
“subunit theory.” They observed facial surfaces and
described ridges and valleys, which formed convex and
concave regions allowing different light reflection. They
further surmised that if a graft or a suture line is matched
to the shape of a particular subunit, the natural appearance
of lights and shadows is restored, thereby allowing the
reconstruction to remain imperceptible because the scars
are perceived as normal facial topography. Application of
this principle led to the establishment of nasal subunits by
nasal reconstructive surgeons. Additional minor
modifications of the aesthetic subunits have been
proposed.

18. Modified facial aesthetic units/subunits.

19. Regardless of whether the injury is an abrasion, avulsion,
or laceration, the initial management is the same. Keeping
the wound moist with sterile saline-soaked gauze is
recommended. All dirt, debris, and foreign material must
be carefully and thoroughly removed to avoid the risk of
infection or traumatic tattoos. If irrigation techniques are
not sufficient, then a scrub brush may be used to remove
all material, paying careful attention as to not further
damage the delicate tissues or devitalize any partially
avulsed flaps. Tissue manipulation can be performed under
local infiltration of anesthetic for most wounds, although
regional nerve blocks may also be appropriate in some
settings. In severe, multiple injuries general anesthesia is
required.

20. The timing of repair has been a topic of debate over the
course of the past 20 years. Currently, however, the
paradigm has shifted to immediate definitive repair after
irrigation and initial debridement of devitalized tissue.
Hochberg et al. (10), argue that the best period for primary
repair is within 8 hours of the injury. Tissues are less
vulnerable to infection, and wound healing is at its
optimum during that time. Further, early closure seals off
the pathways of infection and promotes rapid healing
which keeps scar contracture a minimum. Delayed closure
is reserved for grossly contaminated wounds, selected
animal bites, infected wounds, and wounds greater than 24
hours old. This is thought to reduce the chances of
becoming infected. Primary closure of contaminated
wounds may lead to an increased chance of infection.

21. Classifying traumatic wounds as either clean or dirty helps
to determine need for prophylactic antibiotics and tetanus
treatment. Clean traumatic wounds or lacerations without
evidence of contamination or signs of infection and do not
require prophylactic antibiotic treatment. Prophylactic
antibiotics should be used in contaminated wounds, with
devitalized tissue, patients with prosthetic devices, and
patients with compromised host defenses. Other factors
that must be considered include the mechanism of injury
and the time of presentation. Wounds associated with
compound fractures deserve prophylactic antibiotic
treatment as well. In general 5 to 7 days is sufficient.
Grossly infected wounds are given therapeutic treatment
with 48 hours of intravenous antibiotics, followed by a
total 10 to 14 days of the oral equivalent.

22. Techniques for wound closure depend on the location,
depth, and characteristics of the injury. Suturing is the
commonest method of wound closure, especially with full-
thickness or deep lacerations. These are usually closed
“in layers.” The underlying tissues are precisely aligned to
eliminate any “dead space” beneath the surface. Closing
the skin only and leaving a potential space or cavity can
predispose to abscess formation, and compromise wound
healing. When closing the skin the aim is to produce a
neatly opposed and everted wound edge. A small amount
of eversion is reported to compensate for depression of the
scar during wound contraction. Inversion of the wound
edges produces an inferior result and should be avoided.

23. There are many well-known suturing techniques; however,
regardless of the type of repair performed, 3 important
principles should be met: precise approximation and
eversion of the skin edges, avoidance of excessive tension,
and a layered closure to prevent dead space and fluid
accumulation (11). A small amount of eversion is reported
to compensate for depression of the scar during wound
contraction. Inversion of the wound edges produces an
inferior result and should be avoided. Any tension on the
skin layer increases risk of a widened scar or wound
dehiscence. Employment of a multi-layered closure most
ably creates a tension-free wound (12). Additional key
elements include covering any exposed cartilage or bone
with soft tissue.

24. When applicable, closure along the relaxed skin tension
lines, also referred to as “RSTL”, and abiding by the facial
aesthetic units, can aid in making a scar more
inconspicuous. Relaxed skin tension lines (RSTLs),
described by Borges and Alexander (13), result from the
orientation of the collagen fibers in the skin. These tend to
heal well and mature into acceptable scars that mimic or are
disguised by natural wrinkles. Unfortunately, this luxury is
not always available when managing traumatic wounds,
where as some lacerations may be sited unfavorably and
typically presented perpendicular to the RSTL. These are
more likely to heal poorly and stretch.

25. Relaxed skin tension lines

26. There are two fundamental suture types: absorbable and
permanent (14). Suture selection is based on several factors
including the depth of the injury, the extent of skin loss,
and the anatomic structures involved. In general, muscle
edges are realigned with a 4-0 absorbable suture. For deep
dermal sutures, a 4-0 or 5-0 resorbable mono- filament is
appropriate. For superficial skin layers, a 5-0 to 7-0 fast-
absorbing or nonresorbable monofilament, such as
propylene or nylon, is used. Meticulous realignment of
skin edges is important, especially along the borders of
esthetic subunits. The amount of undermining necessary
prior to closure varies with the degree of tension
anticipated with the closure. Special attention should be
paid to realign the vermilion-cutaneous border, eyelid
margin, nasal rim, brow or any hair-bearing borders.

27. A
B
C
Commonly used suture techniques for laceration repair;
(A) Single interrupted closure.
(B) Running continuous closure.
(C) Subcuticular running closure.

28. The use of drains in acute facial trauma is not routine but
may be advisable in wounds with extensive dead space or
following closure after evacuation of a hematoma. A
simple latex (e.g., Penrose) drain may be used to facilitate
drainage and inhibit re-accumulation. In areas with a large
dead space closed suction drains may be more appropriate.
Sutures placed in the face are usually removed around 5
days after surgery, or even earlier in delicate tissues such
as the eyelids. With neck lacerations, sutures are often
retained for longer (7-10 days). Scalp sutures are similarly
left for 7-10 days. It should be mentioned that the most
common reasons for suture scar or suture mark are closing
the wounds under tension and delayed sutures removal.

29. Alternatives to sutures include metal clips, adhesive paper
tapes and skin adhesives (e.g., cyanoacrylate glue). Staples
can be used in hair-bearing areas, and tape with or without
adhesive can be used alone in sub-centimeter wounds or in
conjunction with sutures. These can be applied quickly,
but accurate alignment of skin edges can be difficult.
Metal clips tend to be reserved for lacerations involving
the scalp. Adhesive paper tapes and skin glues are
especially useful in children and those who will not
cooperate. The final cosmetic results are less predictable
with these techniques compared to carefully placed
sutures.

30. Delayed primary closure may be necessary when doubt
exists about the viability of a wound, or if it becomes
infected. This is most likely to be the case following blast
or high-impact injuries. Crushed tissues are especially
difficult to manage. These may initially appear viable, but
may later become necrotic. Multiple surgical procedures
may be required. Split-thickness skin grafts may be used
as a temporary measure if there is tissue loss, with revision
surgery delayed until the patient has recovered or there are
minimal risks of infection. Frequently, extensive injuries
with massive tissues loss or avulsions may be
encountered. In these situations, proper planning, staging
of the surgical procedures, and use of local or regional
flaps may provide the patient with acceptable aesthetic and
functional outcome.

31. There are many methods available to import tissue to the
head and neck region; the management plan is
individualized to the case at hand. Local tissue flaps have
limited amounts of tissue and a modest vascular supply,
and thus are often saved for the final stages of
reconstruction for minor contouring. Pedicled
myocutaneous flaps offer large amounts of tissue with
reliable vascularity for soft tissue coverage, but are often
bulky and are limited by the length of the vascular pedicle.
Free tissue transfer allows the early reconstruction of
damaged bones and provides soft tissue coverage soon
after injury (15). Additional reconstructive techniques and
tools include implants, tissue expanders, and epidermal
skin grafting, although these are not frequently used in the
acute setting (16).

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