GMKA
Support

Soft Tissue Injuries Of The Face

Surgery

Introduction

Soft tissue injuries to the face are increasingly common in combat settings due to use of explosive materiel in theatre and a lack of protective equipment available to soldiers. Civilians are at a much greater risk for the same reasons. The spectrum of injuries is broad ranging from simple lacerations to complex injuries associated with craniofacial insult requiring multidisciplinary care.
Repair of facial injuries lends itself to a thorough knowledge of the regional anatomy and approaches to complex injuries are poorly defined. For example, the US Military lacks a Clinical Practice Guideline (CPG) for facial trauma. As a result, facial injuries often require a methodical approach to reconstruction in order to restore form and function. Reconstruction of facial injuries is of particular importance to plastic surgeons as the importance of the human face to social interaction and sense of self cannot be underscored.
For the most part, facial injuries can be appropriately addressed with careful cleaning, irrigation, debridement, and closure under minimal tension. Some injuries may require more sophisticated techniques such as local or regional flaps, tissue expansion, or free tissue transfer. This article will serve to provide a framework for the evaluation and repair of soft tissue injuries to the face.

Initial Evaluation And Diagnostic Workup

Primary and secondary surveys
Initial approach to any injuries to the face should follow Advanced Trauma Life Support (ATLS) guidelines in order to stabilize life threats. The face can be a major source of hemorrhage and proximity to airway structures requires a thorough exploration and management during primary and secondary surveys. The possibility of hidden injuries requires a careful assessment of all soft tissue injuries, cranial nerve function (motor and sensory – prior to administration of any anesthesia), and bony structures (initially through palpation).
Imaging
The preferred image modality is computed tomography (CT) which allows for identification of bony injuries. Though CT has largely supplanted plain films in developed settings, the utility of this modality exists in resource limited areas to help identify foreign bodies and underlying fractures as well. CT angiography should be performed on any patients suspected of having blunt cerebrovascular injury.

General Treatment Considerations

 Anesthesia
Adequate anesthesia is important to patient comfort and cooperation to aid in repair of injuries. Most injuries to the face can be addressed with local anesthetics, though more complex cases may still require general anesthesia. The use of epinephrine in local anesthetics counteracts vasodilation and aids in hemorrhage control. Dermal infiltration provides the most appropriate solution for most soft tissue injuries to the face, providing fast and effective pain control. Importantly, infiltration can make anatomic landmarks more difficult to identify and as such these should be identified and marked prior to administration. Larger injuries may benefit from regional blocks as they require less numbers of injections but are typically more technically challenging and require longer to take effect.
  • Forehead: trigeminal nerve (V1). Insert needle lateral to the mid-pupillary line at the supraorbital notch and advance needle in direction of the medial canthus.
  • Midface: infraorbital nerve. Insert needle just medial to the mid-pupillary line approximately 1 cm below the orbital rim to locate the infraorbital foramen.
  • Lower face: mental nerve (V3). Insert needle at the mid-pupillary line halfway between the oral commissure and the mandibular border to locate the mental foramen.
  • Ears: anterior surface — auriculotemporal nerve, posterior surface — lesser occipital nerve, lower third of ear — greater auricular. These nerves can be anesthetized by infusing local in a diamond pattern around the ear. The concha and external auditory canal are innervated by Arnold’s nerve and require direct infiltration to that area.
Irrigation and decontamination
Irrigation and decontamination is essential to proper wound care. Large pieces of foreign material should be manually removed from the wound first. The aim of irrigation is to remove foreign material and reduce bacterial load. It is performed with normal saline with syringe or pulse lavage. In cases of extreme gross contamination, a dilute solution of soap and water suffices. In austere environments, tap water is a reasonable alternative to other solutions as it has not been found to contribute to infection [1]. Antiseptic solutions such as povidone iodine are typically avoided due to cellular injury [2].
Debridement
After wound decontamination, hemostasis should be achieved in order to provide better visualization of the wound bed. Electrocautery should be used sparingly as to reduce further injury and iatrogenic trauma to nerves. Debridement of clearly nonviable tissue should be performed sharply though surgeons should be very conservative in preserving soft tissue due to  the robust vascularity of the face.
Abrasions and Traumatic Tattoos
Abrasions can affect the epidermis, or be partial thickness, intruding into the dermis. Careful irrigation and use of surgical scrub brush to remove all foreign material should be undertaken in order to prevent the formation of traumatic tattoos. Management of abrasions should consist of dressing with petrolatum gauze or xeroform.
Avulsions
Treatment of avulsions should begin with a careful evaluation of the viability of the tissue. Capillary refill, intact skin bridge, and bleeding from the edges of the wound are indicators of good perfusion. Tissue should be attached under minimal tension, with the understanding that edema and retraction may increase tension of avulsed pedicles placed back in anatomic position. Venous congestion can be treated with medicinal leach therapy.
Lacerations
Lacerations should be repaired in layers under minimal tension. Tissue should be minimally undermined and placed in as close to anatomic position as possible. Scar revision and repositioning with z-plasties should be performed in secondary operations. Deep dermis should be closed with 5-0 interrupted, buried, absorbable sutures (vicryl/monocryl). Skin should be closed with 5-0 or 6-0 interrupted or permanent suture (prolene/nylon). To avoid epithelization of suture tracts and resultant “railroad track marks”, skin sutures should be removed within 5-7 days. In children, closure can be performed with 6-0 fast absorbing gut suture to avoid the need for subsequent removal.

Treatment Considerations Of Specific Areas

Scalp
The scalp is richly vascular. Hemostasis is key in scalp wounds and electrocautery should be performed carefully as to preserve hair follicles in hair bearing skin. Hair also complicates appropriate visualization of injuries and a careful examination should be performed. Shaving of scalp has not only been shown to not reduce infection rates but can even be associated an increased risk though is sometimes necessary for proper repair [3–6].
In those cases, care should be taken to prevent hair intrusion into the wound bed. Closure should have a layered approach and performed with running locking absorbable suture staples. Minimal tension is optimal and the galea can be undermined to achieve this [7]. Complete scalp avulsions are very amenable to microvascular replantation and the scalp can tolerate up to 18 hours of cold ischemia.
Eyebrows
Eyebrow repairs should take care to preserve as much tissue as possible to preserve the cosmetic aspect of this structure. Notably, eyebrow hair bulbs are located deeper in the dermis and are prone to injury when undermining tissue in the region. Electrocautery should be avoided due to risk of alopecia. Additionally, hair grows in a superior lateral direction and as a result incisions made should take care to not insult follicles. Common injuries here are to the temporal branch of the facial nerve which should be tested prior to administration of any anesthetics. Contrary to popular belief, there is no evidence that supports that brow hair will not grow back when shaved, though this may make alignment and repair more difficult [8].
Complete loss of the brows can be treated with various local advancement flaps. Smaller wounds that cannot be closed primarily should be allowed to heal via secondary intention with subsequent scar revision. The lateral brow is preferred for advancement as the medial brow is more important aesthetically. 
Eyelids
Eyelid injuries raise the index of suspicion for contaminant globe injury and as such a careful assessment should be performed with referral to ophthalmology. Ptosis on exam can indicate injury to the levator injury while rounding and mobility of the canthus is suggestive of nasoorboethmoid (NOE) fracture. The normal intercanthal distance is approximately 31-32 mm. If epiphora is present, there is likely injury to the lacrimal canaliculi. The canaliculus passes 2 mm perpendicular to the margin of the eyelid and courses medially to the nasolacrimal sac.
Medial eyelid injuries should raise suspicion as well for injury to the duct and a thorough inspection should be performed with a lacrimal probe. Repair of the conjunctiva should only be performed with large defects and with 5-0 chromic gut or other fast resorbable suture. Defects of <25% of the eyelid can be repaired primarily while those with >25% defect will need more extensive reconstruction. The eyelid should be performed in a layered fashion starting with tarsus with 5-0 vicryl. The lid margin should be repaired using a vertical mattress stitch as the gray line using a 6-0 permanent suture while everting to prevent notching of the lid margin. Monofilament is preferred to prevent abrasion to the cornea. Tails should be tied away from the globe and removed within 5-7 days. Canalicular repair involves placement of a silastic lacrimal stent secured with 8-0 sutures and left for 2-3 months.
Cheek
Injuries to the cheek are most concerning for possible injuries to the facial nerve and parotid duct. The zygomatic branch of the facial nerve exits from the parotid gland and runs inferior to the zygomatic arch. The buccal branch also exits the parotid gland and runs over the masseter along the parotid duct. The parotid duct generally runs along a line drawn from the tragus to the middle of the upper lip.
If buccal paralysis is noted on exam, parotid duct injury should be suspected as well. Injury to the duct can also be confirmed by injecting saline into Stensen’s duct opposite to the second molar and looking for fluid egress from the wound. Approach to closure should also be performed in a layered fashion. Approximation of mucosa, muscle, and skin should be performed and is typically amenable to primary closure due to skin laxity. Parotid duct injury can be repaired or a drain placed. Sialocele may develop which can be treated with serial aspirations and pressure dressings [9].
To repair the facial nerve, magnification should be used to locate distal nerve ends. If unable to locate, a nerve stimulator can be used up to 48-72 hours after injury to locate [10]. Nerves should be repaired with 9-0 nylon.
Nose
Being the most common type of facial fracture, examination of the bony and support structures of the nose should be performed with any facial injury. Internal examination should lookout for septal hematoma, lacerations of the mucosa, or injuries to the septal cartilage. Nasal hemorrhage should be controlled due to large volume blood loss and threat to the airway [11].
Hemostasis can be achieved with nasal packing with a variety of vasoconstrictors (phenylephrine/oxymetazoline/cocaine) and hemostatic agents (tranexamic acid/fibrin glue/cellulose polymer). If hemostasis cannot be achieved directed electrocautery, foley catheter insertion with balloon inflation and traction, or referral to IR for embolization if refractory to all other treatments.
Septal hematomas appear as a bluish boggy swelling of the septum and must be evacuated with a fine needle to prevent cartilage necrosis and septal perforation and subsequently closed with running quilted 4-0 gut suture. Nasal abrasions usually heal very well owing to the rich vascular supply in the nose. Trauma tattooing is possible however and care should be taken to clean the wound thoroughly. Repair of deeper wounds should be done in layers from inside out. The mucosa should be repaired with 4-0 chromic, cartilage with 5-0 clear nylon or monocryl, and finally the skin with 6-0 nylon. Avulsions should be treated by attempted replantation, or with composite grafts (retroauricular). Amputations have a high rate of failure after replantation and should only be performed if wound edges are clean and viable tissue is within 5 mm of the edge [12].
Ears
The ears are especially vulnerable to blunt and thermal injuries due to their thickness and exposure on both sides. The most common complication of blunt trauma is an auricular hematoma, which if left untreated can result in cartilage necrosis and obliteration of the topography of the ear. Aspiration (with a fine liposuction canula) and subsequent pressure dressing using through and through 3-0 mattress sutures and xeroform to prevent reaccumulation [13,14]. Lacerations should be repaired with eversion and mattress sutures in order to prevent permanent grooves [15].
Repair of the cartilage is controversial and most authors advocate for closure of soft tissue alone [15,16]. The use of antibiotics after large repairs is also controversial [17,18]. Soft tissue injuries to the outside of the auditory canal can lead to stenosis. These injuries should be stented [19]. Partial amputations are general amenable to suture repair with very small pedicles while complete amputations can be replanted with microsurgery. Congestion can be reduced with medical leach therapy [20].  
Mouth
Proper repair of injuries to the mouth are especially important to limit cosmetic defects. Proper alignment of structures such as the white roll and vermilion border are imperative during repair. The white roll should be marked with methylene blue prior to administration of anesthesia. The first stich in a superficial lip laceration should be placed at the vermillion border in order to achieve alignment for the rest of the repair.
6-0 nonabsorbable sutures should be used or 5-0 gut sutures if located on the moist part of the lip. Full thickness injuries should be repaired in layered fashion starting with a 5-0 gut to close the mucosa. The orbicularis is typically closed with 4-0 resorbable. Care should be taken to repair the muscle completely as failure to do so can result in a “whistle deformity”. Skin can then be closed as above. Avulsive injuries require suturing of the soft tissue to the alveolus, typically by passing suture around a tooth.

Special Cases

Animal Bites
Animal bites carry a wide spectrum of morbidity and severity and require a few special considerations. These wounds are also complex due to their potential for infection and subsequent psychological trauma. Wound repair principles of extensive irrigation, conservative debridement, and primary closure should be followed as above. Prophylactic antibiotics are controversial and studies have found no benefit to reducing risk of infection in bites without any signs of infection [21].
However, considering the limitations to this study, certain authors advocate for use of penicillin or Augmentin [22].  Dog bite injuries are considered crush injuries and may require repair of the microvasculature.
Ballistic Injuries
Gunshot wounds to the face cause extensive soft tissue damage in addition to injuries to the bony structures, great vessels of the neck, and CNS structures. Bullet injuries result in cavitation of soft tissue interior to the entry point and shock wave damages microvasculature [23].
Some munition types are also designed to fragment on impact causing extensive area of damage. Acute management of these injuries should follow ATLS guidelines to stabilize and mitigate life threats. Subsequent surgical management frequently involves craniofacial surgery in which bony structures are repaired. With respect to the soft tissue, wounds should be thoroughly irrigated and debridement should remain conservative though serial debridement q48 hours should be performed. All bullet fragments should be carefully removed. Reconstruction is often preferred early with either primary closure or 1-stage reconstruction if feasible [23]. Blast injuries to the face are similarly treated. Careful removal of all foreign material should be performed.

Conclusion

The face is a very important region for its both its form and function. Careful adherence to the above described principles of soft tissue repair and multidisciplinary care will facilitate the best possible cosmetic and functional outcomes.


References

  1. Sepehripour S, Dheansa BS. Wound irrigation and the lack of evidence-based practice. J Plast Reconstr Aesthet Surg. 2018 Jun;71(6):940–1.
  2. Heckmann N, Simcox T, Kelley D, Marecek GS. Wound irrigation for open fractures. JBJS Reviews. 2020 Jan;8(1):e0061.
  3. Horgan MA, Piatt JH. Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Pediatr Neurosurg. 1997 Apr;26(4):180–4.
  4. Kumar K, Thomas J, Chan C. Cosmesis in neurosurgery: is the bald head necessary to avoid postoperative infection? Ann Acad Med Singap. 2002 Mar;31(2):150–4.
  5. Siddique MS, Matai V, Sutcliffe JC. The preoperative skin shave in neurosurgery: is it justified? Br J Neurosurg. 1998 Apr;12(2):131–5.
  6. Sabatino F, Moskovitz JB. Facial wound management. Emerg Med Clin North Am. 2013 May;31(2):529–38.
  7. Hicks DL, Watson D. Soft tissue reconstruction of the forehead and temple. Facial Plast Surg Clin North Am. 2005 May;13(2):243–51, vi.
  8. Fezza JP, Klippenstein KA, Wesley RE. Cilia regrowth of shaven eyebrows. Arch Facial Plast Surg. 1999 Sep;1(3):223–4.
  9. Steinberg MJ, Herréra AF. Management of parotid duct injuries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Feb;99(2):136–41.
  10. Gosain AK, Matloub HS. Surgical management of the facial nerve in craniofacial trauma and long-standing facial paralysis: cadaver study and clinical presentations. J Craniomaxillofac Trauma. 1999;5(1):29–37.
  11. Dar PMUD, Gupta P, Kaul RP, Kumar A, Gamangatti S, Kumar S, et al. Haemorrhage control beyond Advanced Trauma Life Support (ATLS) protocol in life threatening maxillofacial trauma – experience from a level Ⅰ trauma centre. Br J Oral Maxillofac Surg. 2021 Jul;59(6):700–4.
  12. Clark K. Maxillofacial injuries volume I & II. Edited by N. L. Rowe and J. L. Williams, Churchill Livingstone Inc., New york. Head Neck. 1986 May;8(5):393–393.
  13. Cochran JH. “How I do it”–otology and neurotology. A specific issue and its solution. Treatment of acute auricular hematoma. Laryngoscope. 1980 Jun;90(6 Pt 1):1063–4.
  14. Krugman ME. Management of auricular hematomas with suction assisted lipectomy apparatus. Otolaryngol Head Neck Surg. 1989 Oct;101(4):504–5.
  15. Holmes RE. Management of traumatic auricular injuries in children. Pediatr Ann. 1999 Jun;28(6):391–5.
  16. Kirsch JP, Amedee RG. Management of external ear trauma. J La State Med Soc. 1991 Oct;143(10):13–6.
  17. Murphy J, Qaisi M. Management of human and animal bites. Oral Maxillofac Surg Clin North Am. 2021 Aug;33(3):373–80.
  18. Stierman KL, Lloyd KM, De Luca-Pytell DM, Phillips LG, Calhoun KH. Treatment and outcome of human bites in the head and neck. Otolaryngol Head Neck Surg. 2003 Jun;128(6):795–801.
  19. Templer J, Renner GJ. Injuries of the external ear. Otolaryngol Clin North Am. 1990 Oct;23(5):1003–18.
  20. Sullivan SR, Taylor HO. Images in clinical medicine. Ear replantation. N Engl J Med. 2014 Apr 17;370(16):1541.
  21. Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database Syst Rev. 2001;(2):CD001738.
  22. García-Gubern CF, Colon-Rolon L, Bond MC. Essential concepts of wound management. Emerg Med Clin North Am. 2010 Nov;28(4):951–67.
  23. Kaufman Y, Cole P, Hollier L. Contemporary issues in facial gunshot wound management. J Craniofac Surg. 2008 Mar;19(2):421–7.