|PROF. MIRA SEN (BANERJEE) C.M.E. ARTICLE
|Year : 2012 | Volume
| Issue : 3 | Page : 436-443
Management of soft tissue wounds of the face
Department of Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttra Pradesh, India
|Date of Web Publication||12-Jan-2013|
B33/14 - 16, Gandhi Nagar, Naria, Varanasi - 221 005, Uttra Pradesh
Source of Support: None, Conflict of Interest: None
Since time, immemorial soft-tissue injuries to the face have been documented in literature and even depicted in sculptures, reflecting the image of society. In a polytrauma the face may be involved or there may be isolated injury to the face. The face consists of several organs and aesthetic units. The final outcome depends on initial wound care and primary repair. So one should know the "do's and don'ts". Disfigurement following trauma, becomes a social stigma and has the gross detrimental effect on the personality and future of the victim. Therefore, such cases are most appropriately managed by Plastic Surgeons who have a thorough knowledge of applied anatomy, an aesthetic sense and meticulous atraumatic tissue handling expertise, coupled with surgical skill to repair all the composite structures simultaneously.
Keywords: Facial injury and management; facial soft tissue trauma; facial trauma; soft tissue trauma of face
|How to cite this article:|
Bhattacharya V. Management of soft tissue wounds of the face. Indian J Plast Surg 2012;45:436-43
| » Introduction|| |
Soft-tissue injuries may or may not have associated fractures. The aim of management is functional and aesthetic recovery in the shortest period. Many such cases come to the casualty after having incorrect, randomly single layer deep stitches with misaligned tissue. Variety of foreign bodies and unnoticed hematoma complicates the situation. Due to the complexity of face, it is essential to anticipate the injuries in various structures underneath the wound. The first chance is the best chance for repair as it decides the outcome. The surgeon needs to understand the biomechanics of tissue wounding, biochemistry, molecular biology of wound healing and the art of soft-tissue repair. It is important to appreciate that many facial malformations in adults can be attributed to trauma in early childhood because trauma has the deleterious effect on the growth and development of facial bones.
| » Clinical Evaluation|| |
Facial injuries themselves are rarely life-threatening, but are indicators of the energy of injury. The types of soft-tissue injuries encountered include abrasions, tattoos, simple or complex contused lacerations with loss of tissue, avulsions, bites and burns. Common etiologies are road traffic accidents, gunshot injuries, blast injuries, foreign bodies, homicidal trauma, thermal, chemical and electrical burn, suicidal injuries, human bites, animal bites or caused by different animals  etc., [Figure 1]a-d. There may be echymosis, oedema, sub-conjunctival haemorrhage, crepitus, hyperaesthesia, evidence of facial nerve palsy, inadequate excursion of the muscles of expression and mastication, wound with or without exposed vital structures and fractures. One should realize that usually a horizontal injury across the face is likely to damage more vital structures than a vertical injury as it passes through more number of zones. The aesthetic units on the face are frontal, temporal, supraorbital, orbital, infraorbital, nasal, zygomatic, buccal, labial, mental, parotid-masseteric and auricular. In deep injury, it is necessary to evaluate communication with oral cavity, nasal cavity, and maxillary or frontoethmoid sinuses.
|Figure 1: (a) Homicidal deep penetrating bullet injury of left cheek. (b) Suicidal blast injury causing extensive damage to the soft tissue and bones of lower and upper jaws including oral cavity. (c) Human bite of subtotal lower lip sparing the commissures. (d) Dog bite causing full thickness loss of lower lip|
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| » Emergency Management|| |
The person should be resuscitated first with stability of vital signs. A quick history of the pre-existing diseases should be taken. If airway abnormality is found, one should not proceed until the airway is secured. The result of airway compromise is either direct laryngeal injury, presence of foreign bodies, including aspirated teeth and bone fragments, or excessive bleeding from the upper airway. Foreign bodies can be mechanically removed by the finger-sweep technique. Airway compromise can also occur when the floor of the mouth and tongue lose support from a comminuted mandible fracture. However, It can be alleviated by simple anterior traction on the mandibular symphysis. , Sometimes if the tongue is falling back, one should pull it out with an atraumatic forcep. Edema at the base of the tongue or laryngotracheal air way can contribute to sudden respiratory obstruction. However, one should not hesitate to perform a tracheostomy if need be.
Similarly, control of bleeding and volume resuscitation takes an upper hand. Bleeding may be massive which if imprudently managed, may lead to shock and death. Blood transfusion may be required in case of excessive blood loss. The first line of defence in nasal bleeding is packing, whereas oral bleeding is controlled by direct pressure and suture ligation of the bleeding sites.  In case of external haemorrhage, there is no indication for clamping without direct observation of the site of bleeding. Indiscriminate clamping may cause damage to the branches of the facial nerve. Surgical ligation of the external carotid artery will not control bleeding from its injured branches because of the robust collateralization present and should not be attempted. However, a major vessel, like carotid, needs to be repaired.
| » Diagnostic Studies|| |
Soft-tissue injuries do not need any special diagnostic study. However, they may be helpful in identifying foreign material in cases of gun shot or blast injuries. Nevertheless, concomitant facial fractures require radiographic evaluation.
Evaluation of wound
The examination should be done in the operation theatre under proper light, magnification, copious irrigation and homeostasis. Electrocautery should be used in its lowest setting, conducive to coagulation. It needs to be remembered that nerves are often in proximity to the vessels. Electrocautery may cause iatrogenic injury. It is important to evaluate what tissue constituents are lost and what tissues are exposed. Sometimes the wound apparently may look small but might have wide undermining with overlying devascularisation. Such an undermined tissue should be primarily excised until the bleeding margins are reached. Then the actual measurement of the wound should be made, failing which the evidence of necrosis followed by infection will set in.
Principles of management
The face consists of several prominent zones and organs e.g., Ear, eyes, nose, lips, chin, cheek, forehead etc., It is important to realise that whenever there is a composite full thickness loss of tissue, the requirement is lining, cover and support, for eyelids, nose, ear, cheek, etc., If the upper eyelid is damaged, it should be reconstructed to avoid exposure keratitis. On the cheek, lips, periorbital areas, forehead, etc., there are underlying muscles, which are likely to be damaged depending upon the magnitude of injury. In certain areas like pre-auricular region, the parotid gland and facial nerve may be damaged. Once the vital structures are exposed e.g., Bone, cartilage, etc., suitable vascularised resurfacing procedure should be advocated.
Facial wounds without additional injuries are repaired as soon as possible. In major trauma, while instituting the resuscitative measures, the wound may be dealt after 4-6 hours. Laceration will require straight forward closure. In cases of loss of tissue, two-dimensional and three-dimensional measurement of the wound is taken to assess the size of the tissue required to cover. In acute wounds all the devitalised tissues are debrided conservatively. A search for foreign material is undertaken preventing prolonged inflammatory response and infection. Many of the procedures can be performed under local anesthesia. However, a substantial number of cases may need general anesthesia. The choice of reconstruction depends upon the location of the defect, dimension, and tissue constituents. The final selection is decided by considering the tissue requirement and donor site morbidity. The surgeon has many geometrical local or regional flaps in his armamentarium, but that does not mean they have to be applied randomly. One may reconstruct a defect nicely but the donor site morbidity is likely to discredit the craftsmanship. A well-chosen reconstruction performed in an acute situation, may deteriorate because of contamination of the traumatic field or contused soft tissue included in the reconstructive design. Few may need free tissue transfer. Associated fractures are stabilised first, followed by soft-tissue repair.
Lacerations repaired properly achieve less conspicuous scar. 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.
Many wounds suggest significant tissue loss, on first impression. However, by a careful replacement of tissue, it becomes apparent that most of the tissue is present. Similarly, in cases of avulsion, initial inspection may indicate loss of tissue but a closer examination reveals that the tissue has simply retracted or folded. If such a tissue is attached by a reasonable size of the pedicle, it will often survive. Many avulsed or amputated portions of the soft tissue are amenable to replantation, e.g., Scalp, lip, nose, ear and cheek. If there is no loss of tissue, the irregular margins are neatly freshened; key stitches are applied followed by completion of the repair. In deep wounds, the muscle is repaired first followed by subcutaneous tissue and skin. This provides anatomical alignment of tissue, obliterates the dead space and prevents complications like hematoma, infection, wound dehiscence, tension on the suture line and hypertrophic scarring.
Periorbital and frontal injury
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.  Any injury near the eye should prompt a check of visual aquity, diplopia and evidence of globe injury.  Palpation of the orbital rims discloses step deformity of the bone. The condition of the eyelids and integrity of medial and lateral canthi should be tested. Similarly, the supraorbital and supratrochlear nerves that emerge to provide sensory innervation to the forehead and scalp, may get damaged in association with the eyebrow. In major trauma, the eye globes along with surrounded periorbital structures are destroyed. The bone may get exposed or even partly avulsed exposing the dura. At the root of the nose, the frontoethmoid sinus may get exposed [Figure 2]a-d.
|Figure 2: (a) Major orbito fronto nasal injury. (b) Frontal injury with exposed dura. (c) Fronto-ethmoido-orbital injury with avulsed part of frontal bone. (d) Compound nasal injury with fracture of nasal bones and septum resulting in deformed nose|
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Lacerations that involve the lid margin require careful closure to avoid lid notching and misalignment. Several "key" stiches of 6/0 proline are put in the lid margin to align the grey line and lash line. They are kept untied until the conjunctiva and tarsal plate are repaired. Then the skin sutures are placed. Avulsive injuries to the lids are treated by post auricular full-thickness skin graft. Injuries that involve full-thickness loss up to 25% of the lid are closed primarily. Loss of more than 25% of the lid will require reconstruction by different flaps. A laceration at the medial third of the eyelid may involve canalicular injury. It can be identified using 3X loupe magnification. If the proximal end of the canaliculus is not found, a lacrimal probe may be inserted into the punctum and passed distally out of the cut end of the canaliculus. The distal end of the canaliculus may be located by introducing a pool of saline in the eye and by instilling air into the other intact canaliculus. Bubbles will reveal the location of the distal canalicular stump. The canaliculus is repaired over a silastic or polyethylene lacrimal stent with 8/0 absorbable sutures. The stent is left in place for 2 months to 3 months.
The nose is at a high risk to trauma due to its prominent position. The external covering, frame and lining should be considered. The external soft tissue is assessed for lacerations or loss of soft tissue. The frame can be assessed by asymmetry or deviation of the nasal dorsum. Nasal fractures are usually evident through clinical examination and radiograph. The cartilaginous injuries are easily seen through the open wound. A speculum examination of the internal nose is done for mucosal lacerations, exposed cartilage or bone, or septal hematoma [Figure 3]a-d. If the cribriform plate of ethmoid bone is fractured, there will be CSF rhinorrhoea. A new classification system and an algorithm for the reconstruction of nasal defects has been proposed. 
|Figure 3: (a) Composite defect of caudal part of nose. (b) Divided right ear with exposed cartilages at the margins with wide pedicle. (c) Damaged upper third of left ear with narrow pedicle and congested tissue. (d) Horizontal sharp injury across the parotid, cheek, maxillary antrum, nose and upper lip|
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Lining should be repaired with 5/0 catgut or vicryl. In septal fracture, if lining is present on one side, it does not pose a significant problem. If lining is missing on both sides, a mucosal flap should be used to cover at least one side. Lacerations of the cartilages are repaired with non-absorbable 5/0 sutures. If there is a loss of important support structures, they should be reconstructed immediately using bone or cartilage grafts. Delay will result in contraction and collapse of the soft tissue making later reconstruction difficult. When lacerations involve the underlying cartilaginous support, all layers should be repaired after appropriate anatomic reduction.  The skin around the nose is repaired by placing key sutures at the rim of the nose, using 6/0 poliethylene, before the residue of the closure. Avulsive injuries may involve only the skin or part of the underlying bone and cartilage. The mobile skin of the cephalic portion can be undermined and mobilized to cover small wounds. The skin on the caudal dorsum, tip and ala is adherent and less mobile and often defies primary closure. Post-auricular full thickness skin graft provides good colour match. Larger defects need local flaps, which should be done primarily if the bone or cartilage is exposed.
Injury to ears is common as it is also a prominent organ. The pinna should be examined whether there is only laceration or loss of tissue. The injury to the cartilage may be in the form of crushing, laceration or sharp incised injury. Once the cartilage is injured one should notice the condition of the soft-tissue covering. It is important to find out whether the skin cover is totally bare or intact on at least one surface of the cartilage. One should inspect for injury in the external auditory canal to prevent future stenosis. The periauricular area should be assessed as most of the time this tissue is utilized for reconstruction.
The two most prominent concerns in ear injuries are hematoma and 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.  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.  Microsurgical replantation should be considered whenever it is feasible.
Cheek and oral cavity
In laceration of the cheek, one should specifically look for injury to the branches of facial nerve and parotid duct. In deep wounds, there is a possibility of damage to multiple muscles. The oral cavity is inspected for loose or missing teeth, evidence of injury to the mucosa with submucosal or sublingual hematoma. In severe horizontal compound wounds, all the possible soft tissue and bony elements from skin to bone may be damaged, including maxillary sinus.
In intraoral injury, the muscle and overlying mucosa can be approximated as a single layer or individually. Lip lacerations can result in important cosmetic defects if not sutured in a precise manner. Even minor misalignments of the white roll or vermilion border are conspicuous from a distance. Local or regional nerve blocks are useful. In superficial laceration, the first suture should be placed at the vermilion border and then the remainder should be closed. Great care must be taken to separately reapproximate the underlying orbicularis oris muscle. Failure to do so will result in bunching of the muscle on either side of the laceration. Full thickness injuries are repaired in three layers from inside out [Figure 4]a-c. Avulsive injuries with even small pedicle should be approximated due to the possibility of survival. If there is a substantial loss of tissue, reconstruction by a local flap is necessary. Wound crossing a line from the tragus to the oral commissure should be viewed as potential injury to the parotid duct. In suspected case, a 22 gauge catheter is inserted intraorally to cannulate the Stensen duct and a small quantity of saline is injected. Egress of fluid from the wound confirms parotid duct injury. The use of methylene blue or other contrast materials should be avoided because staining of the area only complicates localization of the proximal end of the duct. If the parotid duct is divided, two ends should be identified and repaired over a fine stent. Laceration to the parotid gland without duct injury may result in sialocele. It gets sealed by repeated aspirations. If only the gland is injured, overlying soft tissue is repaired with a drain. Many of the gunshot injuries of the parotid gland have associated facial nerve palsy, which is difficult to identify initially. 
|Figure 4: (a) Deep lacerated wound with gross displacement of tissue without loss of structures. (b) Successfully repaired with proper placement of tissues by key stitches. (c) Full thickness defect of upper lip and adjoining areas|
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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 with loupe magnification or 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. One should specially test the elevation of the brow, forced closure of the eyes, voluntary smile and eversion of the lower lip. 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. Thus, 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. Facial nerve injuries should be primarily repaired. 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. 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 by 9/0 or 10/0 non-absorbable stitches. The result of direct approximation is better than nerve grafting. Nerve regeneration typically occurs at a rate of 1 mm per day after a month lag  .
Grafts and flaps
The reconstructive options for soft tissue vary from skin grafts to different types of flaps. When there is only skin loss, which cannot be approximated, post-auricular full thickness skin graft is the choice followed by the supraclavicular and medial arm. When the underlying tissue of varied constituents is lost, a flap is indicated. Common local flaps are suitable for majority of the defects. An abraded skin area can be safely included in the flap [Figure 5]a-d. One should avoid using fancy flaps with multiple limbs as ultimately it may result in an extra scar. If the wound is larger requiring a wider flap, it may cause secondary deformity as the donor site is unnecessarily undermined for suturing, leading to distortion of adjacent facial features such as: Eyebrow, eyelids, ala of the nose, perioral areas and commissure, etc., In such situations one needs to design more than one flap with easy primary closure of the donor site. After the wound is demarcated, the planned flap is sketched slightly larger and wider than the defect to compensate for tissue retraction. The choice of tissue transfer also depends upon the easy reach of the flap to the defect. For perioral and perinasal defects, facial artery perforator flaps are useful.  Similarly temporoparietal fascia flap is very versatile for ear and fronto orbital reconstruction.  Some of these locoregional flaps require a second minor procedure to detach the pedicle after 2 to 3 weeks. Sometimes thicker flaps require secondary debulking and scar revision after 4 to 6 months to achieve better aesthetic result. Topical adjuvant therapy further improves the suture marks.
|Figure 5: (a) Full thickness defect of the right upper eyelid with adjoining periorbital trauma. (b) Interpolation Fricke's flap from supra orbital area used for reconstruction. (c) Pedicle detached after 3 weeks. (d) Functional and esthetic result after 4 weeks|
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Burns of the face
The causative agents in order of frequency are flame, scalds, electrical, chemical and industrial burns [Figure 6]a-c. Respiratory tract damage is secondary to chemical injury from the inhalation of products of incomplete combustion. Management of burns of the face is particularly difficult as many important functional organs are involved. Most electrical burns occur in the perioral region, nose and ears, as they are prominent organs, coming into frequent contact with live wires. Usually they are third-degree burns with extensive coagulation necrosis extending for a considerable distance. Reconstructive surgery is delayed for electrical burn and chemical burn. They require repeated debridement till healthy tissue appears and infection is controlled.
|Figure 6: (a) Right hemifacial multiple deformities following thermal burn. (b) Electrical injury destroying the whole nose. (c) Chemical injury of right ear with loss of lobule and evidence of chondritis|
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There are successive stages (a) : Pre-grafting and skin grafting phase in acute period (b) Early and final reconstructive phase in chronic period.  Early treatment includes cleansing with saline, removal of debris and loose epithelium and evacuation of blisters. The exposure method or loose dressing may be employed. Silver sulfadiazine is the most popular topical antimicrobial agent. Superficial second-degree burns heal uneventfully without scarring. Intermediate burns are treated with twice hydrotherapy, debridement and topical antibacterials.  After 7 to 10 days the wounds are evaluated to determine which areas will not heal within 3 weeks of injury. In cases where the wound does not heal, excision and grafting is required. This will greatly reduce the amount of subsequent hypertrophic scar. In applying skin grafts, the surgeon should keep in mind the aesthetic units of the face.  Bioengineered skin substitute has also been used. 
The thin skin of the eyelids and its intimate relation with the pre-tarsal portion of the orbicularis oculi muscle, explains the high frequency of corneal damage and ectropion. During the early phase of eyelid burn, local conservative measures with frequent application of ophthalmic ointment and taping of eyelids suffice. Early split skin grafting should be performed to prevent ectropion of the upper eyelid with possible corneal exposure. During the waiting phase, the patient is encouraged to exercise by frequent opening and closing of the eyes. Occasionally thinner free flaps have been used. Free ALT flap could resurface upper and lower eyelids simultaneously. 
The most important consideration is prevention of cellulitis and suppurative chondritis.  The management is aimed at preventing a partial thickness burn from becoming a full thickness injury. Regular cleaning and application of topical antibiotics are effective. Incision and drainage with resection of involved cartilage has been recommended for suppurative chondritis. If the overlying skin is destroyed, early split skin grafting prevents further complications. A full thickness burn of the ear invariably damages and exposes the cartilage, which must be covered with vascularised tissue. The frame-work is either buried under a post auricular skin flap, a local cervical flap or a temporoparietal facial flap with skin graft.
Nose and mouth
The skin is adherent to the underlying cartilage at the caudal portion of the nose. Thus chondritis followed by deformity is not uncommon. In thermal burns most of the time the mucosa may remain unaffected providing adequate circulation to the cartilaginous frame. However, in electrical burns, devitalisation is more extensive. Such full thickness defects often require several operative procedures to achieve reasonable results. Vestibular stents are worn continuously to prevent the nostril from either being obliterated or severely narrowed. Burn around the mouth often leads to contracture. An useful elastic appliance, fitting into the corners of the mouth, along with intermittent physiotherapy of mouth opening and closing prevents such complication.
| » Conclusion|| |
It is an important and arduous task to repair and restore the function and aesthetics of the face because the face is an important physical feature, for complex social interactions in every-day life. Acute wounds of different etiologies offer a significant challenge to the reconstructive surgeons. Critical assessment of the nature and magnitude of the wound is of enormous importance, in relation to the ultimate surgical outcome. Adequate understanding of vascularity and meticulous execution is the key to success. Locoregional flaps of different constituents and combinations are popular and of enormous value in managing moderate size defects. Larger defects require free tissue transfer. Failure arises more often than not from the inability to recognize the extent of an injury, rather than from the inability to treat the recognized injury.
| » Acknowledgment|| |
The author thanks Dr. Shipra Bhattacharya, PhD (English), for editing and correcting the manuscript.
| » References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]