A description of facial layers and handling of various types of soft tissue injuries. General soft tissue management in trauma

1. Dr. Sadaf Syed
M.D.S II Year

2. SCALP AND FACE

4. The soft tissues of the face can be described,
from superficial to deep, in the following
order:
1. Superficial fat compartments
2. Superficial musculo aponeurotic system (SMAS)
3. Retaining ligaments
4. Mimetic muscles
5. Deep plane, including the deep fat compartments
FACE

6. System or network of collagen fibers, elastic fibers, and fat
cells connects the mimetic muscles to the overlying dermis
and plays an important functional role in facial expression
The SMAS can be considered as a sheet of tissue that
extends from
• The neck (platysma) into the face (SMAS proper),
• Temporal area (superficial temporal fascia), and
• Medially beyond the temporal crest into the forehead (galea
aponeurotica).

7. True retaining ligaments
• Easily identifiable structures that connect the
dermis to the underlying periosteum.
False retaining ligaments
• More diffuse condensations of fibrous tissue
that connect superficial and deep facial fasciae
Retaining Ligaments

9. • The sub-orbicularis oculi fat and deep cheek fat
represent deeper fat compartments.
• That provide volume and shape to the face.
• Act as gliding planes within which the muscles of
facial expression can move freely
Deep Plane Including the Deep Fat Compartments

10. The types of soft-tissue injuries encountered
include:
Abrasions,
Tattoos,
Simple or complex contused lacerations
with loss of tissue,
Avulsions,
Bites and
Burns.

11. The response is determined by
• The mechanism of injury
• Energy exerted on the tissues
• Mechanical arrangement of tissues
• Blood supply
These factors Help In Predicting tissue response to
injury.
Trauma care by Peter Discoll and David skinner
Facial injuries themselves are rarely life-threatening, but are
indicators of the energy of injury.

12. • Ligation
• Compression
• Cautery
• Clamps
• Electrocautery.
• Face is well supplied with blood vessels.
• On being transected these vessels contract and collapse.
• Also the Thrombi may form occluding the vessel as does the
enveloping haematoma by compressing the vessel.

13. Classification of Wound
• Clean
• Clean-contaminated
• Contaminated
• Dirty or infected
Majority of
superficial
wounds
fall in the
first two
categories
Severely traumatized tissue falls in the
latter categories

14. • Increased probability of contamination increase
with time.
• Wounds of skin mainly involve staphylococcus and
streptococcus.
• The number of bacteria is of more concern than the
species of bacteria.
• Through and through lacerations are considered
contaminated.
• Crushing of tissue, embedding of foreign bodies,
soil or perforation into oral cavity markedly
increase the bacterial count
Wound Contamination

15. Previously immunized patient:
• If active immunization was not done within 10 years
- 0.5ml of tetanus toxoid
Unimmunized patient -
• Passive immunization with hyperimmune tetanus
globulin
• Followed by two doses of active immunization at a
months interval
Profusely contaminated wound
should be considered for tetanus
prophylaxis even if the booster dose
has been given in the past 5 years.
Tetanus prophylaxis

16. • Establish the airway
• Control bleeding
• Stabilize the injury
During this period or during the
treatment of other injuries cover the
wound with a moist gauze soaked in
antibiotic solution till final management

17. AIM /PRIMARY CONSIDERATION
o The main aim is to get all the soft tissue injuries fully
debrided, reconstructed and closed by the end of fifth
day .
o By the end of three days it is usually possible, but 5
days considered to be the window period in which
closure can be done safely and satisfactorily
o Soft tissue injuries don’t cause morbidity as such, but if
not properly managed can lead to long term morbidity.
o It is important to repair and reconstruct tendon or nerve
damage, within the five days, either immediately or
future planning of the same.Aisha J. McKnight, M.D., and Shayan A. Izaddoost, M.D., Ph.D

18. • History
• The mechanism of injury along with clinical
examination
Documentation
• The finding should describe the anatomical site and
measurement of surface wounds.
• Should also include diagrams and/or photography.
• CT Scan and MRI can provide visualization of soft tissues
and foreign bodies as well as bony abnormality
 Diagnosis of the nature
 Examine facial lacerations under sterile conditions to
assess depth of penetration or intracranial violation.
Craniomaxillofacial Trauma; Ch - 15
By David and Simpson,contributary author J.Tomich
.

19.  Preferably as soon as possible, after more serious conditions
have been dealt with.
 When delay is inevitable beyond 48 hours.Clean the wound
and cover it with moist sterile dressing.
 Foreign bodies removed.
 Few tacking sutures might be placed to approximate the soft
tissue prior to definitive treatment.
 Topical antibiotic and bacteriocidal solution used only if
there’s gross contamination.
 Intravenous antibiotics in severe contamination.

20. • Irrigation
 Preliminary step in the care of any injury.
 Generates significant discomfort for the patient. For
this reason, pre-treatment local anesthesia is
recommended whenever possible.
 The unaffected skin should be prepared swabbing away
from the wound.
 Irrigation with copious amounts of saline.
 This doesn’t remove the devitalized tissue or
particulate matter

21.  In areas of beard, moustache or those lacerations
extending to scalp shaving is done except eyebrow
and hairline for guide for future reconstruction.
 Cleansing with antiseptic solution after removing
the foreign bodies ,if present.
 Any wound with foreign material should be
thoroughly examined to prevent infections and all
the foreign materials to be removed carefully.
 Special care to be taken for eyes.

23.  Hydrogen peroxide.
 Povidone – Iodine.
 Iodophor.
 Chlohexidine.
To be clinically effective
irrigants should be
delivered with fluid jet
of 7lb of psi.
This can be generated
by forcefully expressing
saline from 35 ml
syringe through an 18-
gauge needle

24.  Commercial products are available for simultaneous,
aggressive lavage and microdebridement of wounds.
 Surgical scrub solutions may be used, but with
precaution :
1. They may cause ocular chemical burns
2. If in direct contact with the wound they
cause further cellular damage.“Rule Regarding Application of Antiseptic”
Never put anything in a wound that
could not be comfortably tolerated in
the conjunctival sac.

25. Avoided unless there is overwhelming amount of
foreign debris in the wound
 The wound is scrubbed with swabs or nylon brush.
 Along with betadine and solvents like ether for
grease and other oily particles.
 This is specially important for abrasion injuries
where the dirt is in abraded dermis or deeper.
 If not done properly can cause “tattooing”,that can be
unesthetical

26. Brush Solutions

27. • Deeply embedded particles may require removal with fine
tipped scissors and/or scalpel.
• It should be limited to devitalized tissue, tissue containing
dirt grease or other particles not removed by scrubbing.
• Radical excision in facial region avoided because of rich
blood supply, tissues will survive with a small pedicle.
• If the wound margin is extremely irregular and re-
approximation is difficult ,edges are excise to produce clean
wound margin and minimize scar formation.

28. HALSTEDIAN
PRINCIPLES

29. Facial Trauma : Aisha J. McKnight, M.D., and Shayan A. Izaddoost, M.D., Ph.D
1. Thoroughly explore the wound, cleaning and debriding
each layer specificly.
2. Possible repair of nerve and tendon damage, severed
nerve trunk should be identifiedand marked with tags for
future reconstruction.
3. Salvage skin grafts from skin that is to be excised

30. • Layered closure to obliterate dead space and relieve tension
on the epidermal layer.
• Wounds covering nerves or ducts should not be closed until
operative management of deeper injury is complete.
• Other injuries may require urgent attention.
• In case of surgical intervention definitive repair of all
injured tissues can be achieved in single operation.
Key principles of closure

31. • Definitive repair of bony and soft tissue injuries can be
achieved in a single operation, as successive operations
rarely improve functional outcomes.
• In high-velocity or blast injuries, this is often not possible
due to the need for multiple debridements;
• However, early soft tissue reconstruction should be
attempted to prevent significant soft tissue contracture
and provide coverage for osseous reconstruction.

32. Periosteal closure and suspension:
• Re-establish periosteal continuity
• SMAS layer reinforced
• Mimetic soft tissue drape re-established
• In scalp - closure of galeal layer
• Suspension of cheek periosteum to deep temporal fascia
• Goal: prevent facial sag due to muscle diastasis

33. Contraindications to primary closure in the
emergency room
 Tissue damage whereby primary closure can only be
performed under significant tension or with complex
tissue rearrangement.
 When concomitant injuries require surgery and when
adequate hemostasis or appropriate wound
visualization cannot be achieved in the ER setting

35.  Eyelid or periocular injuries can be classified
into four classes based on the injured region
 Upper eyelid,
 Lower eyelid,
 Medial canthus, and
 Lateral canthus

37. The medial canthus comprises two limbs and functions to
maintain the shape of the eye and to assist in drainage of the
lacrimal sac.
Inserts on the lacrimal bone :
– Anterior tendon inserts on the anterior lacrimal crest
– Posterior tendon insertson the posterior lacrimal crest.
Lacrimal duct lies in between and is pumped with
blinking (Jone spump)
Medial Canthal ligament

39. To evaluate the integrity of the medial canthal
tendon
• A lax medial canthal tendon or medial orbital wall motion
is consistent with a NOE complex fracture.
• Place the thumb and index finger over the nasal root and
carefully apply lateral tension to each lower lid.
• A periosteal elevator also can be inserted through the nose
to palpate the stability of the medial canthal tendon
complex.
• Normally, a defined endpoint to the maneuver is evident
without palpable motion at the medial canthus.

41. SYNONYMS
• Tarsal strip re-suspension.
• Lateral canthal plication.
• Lateral retinacular suspension.
• Inferior retinacular suspension.

42. Canthoplasty" refers to a procedure designed to reinforce
lower eyelid support by detaching the lateral canthal
tendon from the orbital bone and constructing a
replacement.
"Canthopexy," on the other hand, refers to a less invasive
procedure designed to stabilize the existing tendon (as well
as surrounding structures) without removing it from its
normal attachment.
Definition.

43. • Canthoplasty implies division of the canthus, in
whole or in part.
Requires division of either the inferior crus or common crus
of the lateral canthal tendon and . These are then mobilized
and reinserted as a single unit as indicated by the degree of
lower-lid laxity.
Canthopexy implies that lid support is achieved by
plication or redirection without division of the canthus.
In performing the canthopexy, the lower lid or lateral is not
shortened or divided but secured in a new position to a rigid
structure like the periorbita.

44. First, simple eyelid lacerations should be closed in three
layers:
conjunctiva, tarsus, and skin.
 For lacerations involving the lid margin, tarsal plate must
be carefully re-approximated and the lid margin everted
with a vertical mattress suture to prevent notching.
• For lower- lid lacerations, proper alignment minimizes the
risk of ectropion.
• In upper-lid lacerations, the levator muscles should be
carefully evaluated as the muscular insertions onto the
tarsal plate may be damaged.

45. • Injuries to the lateral eyelid commonly involve the
lateral canthus and can require either a canthopexy
or canthoplasty to repair the injured canthus.
• Depending on the degree of injury, primary repair
may be possible, but frequently more significant
injury necessitates re-creation of the ligament.
• When treating soft tissue defects in this region, cheek
advancement flaps or full-thickness skin grafts can be
used for coverage

46. • Injuries to the medial canthal region may involve the
medial canthal tendon and/or lacrimal system.
• Medial canthus injuries without concomitant fractures
are uncommon due to the relative protection provided
by the maxilla and nasal bone.
• Injuries to the lacrimal canaliculi can also occur in this
region and should be addressed with an
ophthalmologic assessment and Jones dye test.

47. • A Jones I test is first performed by instilling
fluorescein dye in the eye ipsilateral to the suspected
injury.
• After 5 minutes, the patient is instructed to occlude
the contralateral nare and blow his or her nose onto a
clean, white tissue or towel.
• The presence of fluorescein on the tissue indicates a
patent, functioning lacrimal system.

49. The eyelids are inspected for
 Ptosis, suggesting levator apparatus injury.
 Rounding or laxity of the canthi suggests canthal injury or
naso-orbital-ethmoidal fracture.
 In case of periorbital injury, it is important to judge the
integrity of Levator palpebrae superioris, Orbicularis oculi
and Frontalis muscles. [5]
 Any injury near the eye should prompt a check of visual
aquity, diplopia and evidence of globe injury.
• Loss of more than 25% of the lid will require reconstruction
by different flaps.

50. Approaches to infra-orbital region
Based on the position of incision
• Bleph,
• Subciliary,
• Lower lid,
• Subtarsal infra orbital
Advantages:
• Natural skin crease
• Laxity of skin makes it immune to keloid
• Allows stretching
• Scar inconspicuous in time

52. The two most prominent concerns in ear injuries are:
• Haematoma.
• Chondritis.
• Hematomas must be evacuated as quickly as possible to
avoid cartilage resorption followed by deformity.
• A bolster dressing is advisable to prevent re-accumulation of
the hematoma.
• Due to good blood supply, large cut portion may survive on a
small pedicle.
• If one surface of the cartilage has viable soft tissue, it should
survive.

53.  The cheeks are by surface area the largest subunit of
the face thus
1. A high frequency of injury to the cheek and
underlying structures
2. A multitude of approaches that can be used for
posttraumatic reconstruction.
 Many cheek wounds can be repaired primarily due to
the laxity and availability of surrounding soft tissue.

54. Cheek Is Divided into three overlapping aesthetic
subunits :
I. Infraorbital,
II. Preauricular, and
III. Buccomandibular.
• Very small wounds in inconspicuous areas may be allowed to
heal secondarily though primary closure is preferred.
Resident Manual of Trauma to the Face, Head, and Neck
Paul J. Donald, MD Professor and Vice Chair, Department of
Otolaryngology University of California-Davis Medical Center
Sacramento, California

56. • If primary closure is not possible, local advancement,
transposition, or regional flaps can be used to repair many
defects due to the skin excess and laxity in the cheek.
• In cases where this is not possible, full-thickness skin
grafting can be performed with the cervical, preauricular,
and postauricular skin being preferred donor sites for color
matching.
• Free flaps are also used for cheek reconstruction for more
complex soft tissue defects.
Resident Manual of Trauma to the Face, Head, and Neck
Paul J. Donald, MD Professor and Vice Chair, Department of
Otolaryngology University of California-Davis Medical Center
Sacramento, California

57. • Aim of lip injury management are
1. Correct alignment of lip landmarks and
2. A layered, tension-free closure to ideally restore
• Markings should be made to identify the white roll,
Cupid’s bow, and philtral columns prior to injection
of any local anesthetic to prevent obscuration.
 Motor, Aesthetic, Sensory
Facial Soft Tissue Trauma
James D. Kretlow, Ph.D., Aisha J. McKnight, M.D., and
Shayan A. Izaddoost, M.D., Ph.D.

58. • Primary closure should be considered when less than
30% of the lip is involved, and the layered primary
closure should separately approximate the skin,
orbicularis, and mucosal layers.
• For defects of the central upper lip, primary closure
may disrupt the normal anatomy of the philtral
columns and dimple.
• For wounds that cannot be primarily closed, the
best method to achieve restoration is to use
available lip tissue for the repair.

59. • Skin grafting can play an important role in
management, although color mismatches may
be an issue when grafting to vermillion defects.
• Corrected by using an Abbe ´ flap to
reconstruct the central vermillion without
moving the commissure.
• Larger defects or those involving other areas of
the lip can be repaired using similar lip-switch
procedures or a variety of local advancement
flaps

60. • Injuries to the facial and/or trigeminal nerve can
also accompany soft tissue trauma.
• Sites of structural compression and/or injury need
to be identified and addressed appropriately.
• If the facial nerve has been severed, initial
management requires primary repair of the injury,
• If a defect exists, the nerve ends should be tagged so
that formal nerve repair can be performed within
the first 72 hours after injury.

61. Parotid Gland & Facial nerve
In an injury that has traversed through the parotid region, both
the gland and the facial nerve should be assessed.
• If it is anterior to the parotid gland, the branches of the
seventh nerve are examined under the operative microscope.
• The nerve stimulator is a useful tool for identification of the
distal segment within 48 h of injury.
• After 48-72 h, the distal nerve segments will no longer
conduct the impulse to the involved facial musculature.
• The use of local anesthesia should be delayed until the
function of the facial nerve has been established.

62. • The trauma, extending anterior to the parotid gland is
crucial as far as the function of the muscles of expression
is concerned.
• If it is posterior to the gland, then the main trunk of the
nerve may be involved.
• Test the Following ;
1. The elevation of the brow,
2. Forced closure of the eyes,
3. Voluntary smile and
4. Eversion of the lower lip.

63. • Nerve regeneration typically occurs at a rate of 1 mm per day
after a month lag
• If primary repair is not possible, the proximal and distal
nerve ends should be tagged with non-absorbable suture
for easy identification during future repair.
• If the nerve trunk is damaged at the pre-parotid and intra-
parotid course, it needs to be explored under magnification
and approximated with sutures.
Analysis of the wound depth is critical in these cases.
•

64. • The result of direct approximation is better than nerve grafting

65. •
• In a more superficial wound resulting in laceration of
only the parotid glandular tissue, the gland can be
oversewn and subsequently repaired independent of the
parotid duct
• Parotid duct repair performed by suturing the duct over a
stent has been described, but conservative treatment is
generally well tolerated and is not associated with long-
term functional consequences.
• Patients with parotid duct injuries being managed
conservatively should be warned to expect a significant
degree of temporary swelling after the injury.
•

67. SCAR REVISION

68. Various modalities in scar revision
• Simple excision and serial excision.
• Z-Plasty.
• W-Plasty and Geometric line closure.
• Subcision.
DCNA Nov 2013 :vol 25 : No.4 ;Correction of facial trauma related soft injuries:.

69. Simple excision and serial excision
• Small scars already oriented parallel to relaxed skin line
• Excised in elliptical fashion,
• Peripherally undermined :
1. Aids in reducing wound tension
• Suturing with eversion is obtained
2. Adequate eversion prevents formation of depressed
scar following wound contracture and healing
• Wide scar oriented along skin tension line
1. Advantage of mechanical creep of tissues, viscoelastic
properties of skin
• Partial scar excision followed by periods of healing reducing
broad scar to a smaller one

70. Z- Plasty
3 Primary purpose :
• Reorient the direction of scar
• Interrupt scar linearity to aid in scar camouflage.
• Lengthen the scar which is beneficial when there is
undesirable contracture of surrounding tissues.
Advantages :
• Reorient scar to fall between anatomic subunits of face
making them less conspicuous.
• It requires minimal excision of tissue.
• A prerequisite for other types of revision procedures
Disadvantage
• Increases the length of scar.
• Atleast one limb of scar lies
outside of relaxed skin
tension line

72. W-Plasty
• Wide linear scar running
perpendicular to the skin
tension lines
• Convex areas of face like
eyebrow temporal and
malar prominence.
• The concerned area should
have sufficient tissue laxity
to allow the necessary
tissue advancement.
• 50% of the limbs should be
parallel to the relaxed skin
tension lines
Geometric broken line
closure
Modified W- Plasty
• Linear scar parallel to skin
tension lines, in the convex
parts of the face
• Same principle that it is a
geometric bilateral
advancement flap
• In case of long scars W-
Plasty becomes easily
noticable, broken line
circumvents this issue

75. • Management of depressed scar.
• Easily performed
• Minimal post op morbidity due to minimal invasive
nature
Disadvantage :
Pain
Swelling
Bruising
Hyperpigmentation
Haematoma
Too vigourous procedure or too deep needle penetration
Principle
• Severeing subcutaneous
fibrotic attachments .
• Subsequent induction of
neocollagenesis,thus
elevating a depressed scar
DCNA Nov 2013 :vol 25 : No.4 ;Correction of facial trauma related soft injuries:.

77. 1. Tissue Expanders.
2. Tissue adhesives.
3. Tissue Engineering.

78. Tissue Expanders

79. • Skin is stretched beyond its physiological limit,
mechano transduction pathways are activated.
• This leads to cell growth as well as to the formation
of new cells.
• One of the ways is , by the implantation of inflatable
balloons under the skin.
• The growth of tissue is permanent, but will retract to
some degree when the expander is removed.

81. • It provides skin with a near-perfect match in
color and texture,
• Minimal donor site morbidity and scarring
occur.
• Provide tissue with specialized sensory function
or adnexal characteristics

82. • Temporary cosmetic deformity during the
expansion phase,
• Prolonged period of expansion,
• The need for multiple procedures, and
• Complications associated with the implant and
placement.

83. TISSUE ENGINEERING
 Bioengineered products,
 Polymers (poly-N -acetyl-glucosamine) with
bioactive properties, and,
 Genetically modified tissue with various growth
factors.
Materials for Wound Closure
Author: Margaret Terhune, MD; Chief Editor: Dirk M Elston, MD

84. COLLAGEN
MINERAL BASED eg.
Calcium phosphate

85. TISSUE ADHESIVES

86.  Quick and easy to apply, requiring only one-tenth
to one-fourth of the time required for suture
placement.
 They provide an antimicrobial and waterproof
coating, but repeated washing removes the
adhesive in a few days.
 The cosmetic outcome is good, and
 No postoperative visit is required for removal.
Materials for Wound Closure
Author: Margaret Terhune, MD; Chief Editor: Dirk M Elston, MD

87. EXAMPLES
Cyanoacrylates
 Octylcyanoacrylate (Dermabond; Ethicon) and
 N -butyl-2-cyanoacrylate (Indermil; Syneture)
ACTION
Exothermic reaction on contact with fluid to form a 3-
dimensional, strong, flexible bond, with uses comparable
to those of 5-0 monofilament nylon.
These are available in single-use vials/ampules.

90. Laser Welding
• Used on a limited basis as an alternative to traditional wound
closure.
• Collateral thermal injury has prevented its regular clinical
use.
• To minimize this injury, laser soldering was introduced.
• This process involves the application of a biologic "solder"
eg, bovine serum albumin prior to temperature-controlled
laser welding.

91.  Closure by secondary intent is permissible, wherein
both patient and surgeon participate in good wound
care and allow for slow but steady closure of the
defect.
 Adjunctive therapies, such as the implementation of
wound-healing factors or devices or the use of
hyperbaric oxygen, may also be required.
 Post-Healing After the wound is healed, the scar can
be dealt with appropriately.
It should be considered in cases of
1. Uncontrolled diabetes,
2. Chronic hypoxia due to cardiopulmonary
disease,
3. Other significant wound-healing deficit.

92. Compared with other closure materials, laser
welding is :
• Faster,
• Watertight, and
• Avoids a foreign-body reaction.

93. • Complete eyelid and orbital reconstruction can
be achieved using :
a) Dorsalis pedis with septal cartilage.
b) Radial forearm flaps, and
c) Anterolateral thigh flaps.

94. • Massive exsanguiating bleeding from soft-tissue
trauma of face is not a common event.
• Putting patient in a sitting position can
dramatically reduce venous bleeding.
“The extensive facial blood supply
permits tissue survival, even in the setting
of severe trauma. Therefore limited,
rather than extensive, debridement of
tissue deemed marginal should be
attempted in most cases.”

95. Patient with head and neck injury going into
hypovolemic shock :
1. Trauma is extensive and complex
2. Delayed treatment or repeated episodes of bleeding
3. Other injuries eg. Abdominal injuries
Plastic surgery of head and neck
new york 1987
,Churchill,Livingstone

96. Ghassemi et al. describe two variations of SMAS
architecture.
Type I SMAS
Consists of a network of small fibrous septae that traverse
perpendicularly between fat lobules to the dermis and deeply to
the facial muscles or periosteum.
This variation exists in the
1. Forehead,
2. Parotid,
3. Zygomatic, and
4. Infrao rbital areas.

97. PROCEDURE
• Tarsal tuck canthopexy.
• The modified lateral tarsal strip procedure
(Canthoplasty).
• The common canthoplasty.

98. Type II SMAS
o Consists of a dense mesh of collagen, elastic,
and muscle fibers
o Is found medial to the nasolabial fold, in the
upper and lower lips.
o Although extremely thin, type II SMAS binds
the facial muscles around the mouth to the
overlying skin
o It has an important role in transmitting
complex movements during animation

99. Over The Parotid gland.
• The SMAS is relatively thick.
• Further medially, it thins considerably making it difficult to dissect.
• In the lower face, the SMAS covers the facial nerve branches as well
as the sensory nerves.
Dissection superficial to the SMAS in this region protects facial nerve
branches.
Above The Zygomatic Arch.
• The SMAS exists as the superficial temporal fascia, which splits to
enclose the temporal branch of the facial nerve and the intermediate
temporal fat pad.
Dissection in this area should proceed deep to the superficial temporal
fascia, on the deep temporal fascia, to avoid nerve injury.
Wobig JL, Dailey RA (2004) Facial anatomy. In: Wobig JL, Dailey RA (eds) Oculofacial
plastic surgery. Thieme, New York, p 5

100. • The layer of fascia covering the parotid gland and
masseter, termed parotidomasseteric fascia, continues
superiorly to insert into the inferior border of the zygo-
matic arch.
• In the temporal area, the corresponding fascia in the
same plane is present as deep temporal fascia, which
inserts into the superior border of the zygomatic arch.
• In the lower face, branches of the facial nerve lie
underneath the deep fascia.
• Above the zygomatic arch and in the upper face, facial
nerve branches lie superfi cial to the deep fascia and are
susceptible to injury during superfi cial dissections.
The
Superficial
Fascia

102.  In cases of large particulate matter (e.g.,
glass or gravel) manual debridement is
necessary.
 Pretreatment with local anesthesia is
advocated.
 Prior to definitive closure, obviously
devitalized soft tissue should be debrided.

103. Microdebridement
 Accomplished with sterile saline, or tap water from a
clean outlet should sterile saline be unavailable, to
decrease the bacterial load in tissues.
 2:1 solution of saline and povidone-iodine, usually in the
volume of 1.5 liters is preferable.
 High pressure irrigation with 19-gauge plastic catheter
attached to a 60 ml syringe using 250ml of 0.9% saline.
 Some contaminants are retained by strong adhesive
forces as they require higher hydraulic forces and direct
contact

104. Skin incision down to muscle Full thickness eyelid cut at
lateral canthus

105.  A surgical scrub brush is helpful for abrasions. A
small brush is used aggressively along with high
pressure irrigation can clean the wound of
particulate matter and bacteria, under GA.
This prevents Tattooing
 For larger wounds, a bulb syringe or intravenous
tubing irrigation will suffice.
 For smaller penetrations or puncture wounds, a
plastic intravenous catheter on a 20-cubic-
centimeter syringe works well.

106.  Face doesn’t have specific layers like scalp.
 Subcutaneous tissue is missing.
 Muscles are directly attached to the skin.

107. The superficial fat compartments of the face
comprise the following:
• The nasolabial fat compartment.
• The medial, middle, and lateral temporal-cheek
“malar” fat pads
• The central, middle, and lateral temporal-cheek pads
in the forehead.
• The superior, inferior, and lateral orbital fat pads

108. The firm adherence of the skin to the underlying cartilage framework ensures that
accurate skin approximation aligns the cartilage.
If the cartilage must be sutured, absorbable 5/0 sutures are used. In partial
amputation with relatively large pedicle, the prognosis is good following conservative
debridement and meticulous repair. If the pedicle is narrow, the chance of venous
congestion is much higher. In such a situation, soft tissue like lobule may survive but
the cartilage may not. If the pedicle is narrow with inadequate or no perfusion, it
should be treated like a complete amputation. In case of exposed cartilage, local or
regional flaps should be considered to salvage the cartilage. In complete amputation,
one may make an effort to salvage the cartilage frame by burying it in a subcutaneous
pocket at the post auricular area or abdomen. [10] Microsurgical replantation should be
considered whenever it is feasible.

109. Risks and complications:
Canthoplasty: The anatomy of the canthus is
delicate and complicated. If canthoplasty is
not well performed (or sometimes even
when it is expertly performed), the junction
between the upper and lower eyelids may
become rounded, retracted, or deformed
either immediately or after several years. In
the presence of a prominent eye, shallow eye
socket, or inadequate bony cheek
projection, canthoplasty may result in
unintended downward retraction. If
overdone in patients with normal or deep-
set eyes, it may, on the other hand, result in
an unnatural upward slant to the eyes.
Canthopexy: By reinforcing and stabilizing
the stretched supporting structures around
the eye, more than just sagging skin and
bulging fat are addressed. The procedure is
much less invasive than canthoplasty and
not associated with many of the risks noted
above.

110. • Patient with complex facial injury requiring free flap
reconstruction, immediate definitive treatment is
indicated.
• Immediate reconstruction decreases the number of
operations required without compromising aesthetic
or functional outcomes.
• The presence of contamination has not been
associated with an increase in perioperative or long-
term complications after early definitive repair of
facial injuries with free Flaps

111. • If the orbicularis oculi and frontalis muscles are
functioning, it means that the temporofacial division of the
facial nerve is intact.
• Similarly, the continuity of the buccal, mandibular and
cervicofacial branches can be assessed by the function of the
buccinator, orbicularis oris and other muscles.
• If the proximal ends of the facial nerves cannot be located,
the uninjured proximal nerve trunk can be located and
followed distally to the cut end of the nerve.
• The branches anterior to the parotid, need to be
approximated by 9/0 or 10/0 proline/nylon.

112. Theideallowerlidpositionis1.5to2.0mmabovetheinferior corneoscleral junction.
The nadir of the curvature should lie
halfwaybetweenthemedialandlateralfissures,andthelateral
canthusshouldlieapproximately10to15degreesaboveahor- izontal line that
bisects the medial fissure. In the normal state, the intrinsic and extrinsic forces
acting on the lower lid main-
tainafinebalancethatholdsitapproximatedtotheglobe(Fig. 39.13). Imbalances in
these forces—as a result of the effects of age, trauma, or previous surgeries—
results in malposition of the lower lid.

113. Tarsal Tuck Canthopexy
• The tarsal tuck provides support to the lower lid without divi-
sion of the lateral canthal tendon,the inferiorcrus,or the
tarsal plate.
• It is not a “lid-shortening” procedure; rather, it is a “lid-
supporting” procedure.
• Transcutaneously or through a transconjunctival approach.
• The indication for the independent tarsal tuck procedure is a
patient with mild lower-lid laxity and an intact lateral canthal
complex.
• If the laxity is too great,the plicated tissue will tend to
buckle,causing the lower lid to lose its apposition with the
globe,resulting in an unsatisfactory appearance poorly
functional eyelid.

114. Advantages of the independent tarsal tuck procedure are
its simplicity,
minimally invasive na- ture, and
ability to concomitantly transpose or resect orbital fat to fill periocular
defects.
disadvantage is that it can only be used when there is minimal lid laxity

115. serve to restore the natural appearance and function of the lower lid regard-
less of the manifestation of the lower-lid laxity,
a new inferior canthal crus is created from the tarsus, which is independently
supported.
Modified Lateral Tarsal Strip Procedure

116. Common Canthoplasty and Common Canthopexy The common canthoplasty is
useful alone or in combination with other procedures. It is especially useful when
the goal is to correct a shortened intercommissural distance and/or infe-
riordisplacementoftheentirelateralcanthus.Itcanbeapplied
inbothcosmeticandreconstructivescenarios.Inaddition,con- sideration should be
given to this technique in any patient un- dergoing a procedure that can
compromise the balance of in- trinsic and extrinsic forces providing lower-lid
support (4). Accesstothelateralcanthaltendoncanbeachievedthrough an incision
of either the upper or lower lid; however, incision of the upper lid is more
favorable for achieving the appro- priate vector of suspension. Regardless of the
access incision, the lateral canthal tendon must be identified and mobilized in its
entirety with disinsertion of the common tendon from the Whitnall tubercle.
Once the retinacular elements are lysed, the
entirelateralcanthalcomplexcanbemovedcephalicallyand/or laterally.

117. • Absorbable 4/0 or 5/0 Vicryl or Polydioxanone sutures (PDS)
is suitable for muscle and subcutaneous tissue.
• Proline/nylon 6/0 is the choice for skin approximation. Key
stitches are given first to align the points followed by the rest
of the repair.
• Vermillion cutaneous border of the lip, the free margin of
the alar rim, the grey line of the eyelids, and the helical rim of
the ear provides guidelines for the restoration of normal
anatomic position.

118. Maxillary Vestibular Approach
• Entire anterior face of maxilla
• Zygomaticomaxillary buttress
• Infraorbital rim
• Zygomatic body, antero-caudal
part of zygomatic arch
• Piriform aperture

120. Maxillary Vestibular Approach
• Entire anterior face of maxilla
• Zygomaticomaxillary buttress
• Infraorbital rim
• Zygomatic body, antero-caudal
part of zygomatic arch
• Piriform aperture

121. Tetanus prone wounds :
• Wound of more than six hours
• Stellate wound
• More than 1 cm
• Mechanism of injury involves missiles, crush , burn
rather than sharp surface
• Signs of infection
• Devitalized tissue
• Presence of contaminants
• Denervated or ischemic tissue

122. Soft tissue loss
 Local flaps :
Local rotational Advancement flaps
 Skin grafts :
Full-thickness skin grafting Partial thickness skin grafting
 Microvascular tissue transfer

123. Buccal Fat
Pad

124. Common etiologies are :
1. Road traffic accidents.
2. Gunshot injuries.
3. Blast injuries.
4. Foreign bodies.
5. Homicidal trauma.
6. Thermal, chemical and electrical burn.
7. Suicidal injuries.
8. Human bites, animal bites or caused by different
animals.