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Disa JD, Robertson BC, Metzinger SE, et al.: Transverse glabellar flap for obliteration/isolation of the nasofrontal duct from
the anterior cranial base, Ann Plast Surg 36:453–457, 1996.
Guy WM, Brissett AE: Contemporary management of traumatic fractures of the frontal sinus, Otolaryngol Clin North Am
46(5):733–748, 2013.
Ioannides C, Freihofer HP, Friens J: Fractures of the frontal sinus: a rationale of treatment, Br J Plast Surg 46:208–214,
1993.
Koento T: Current advances in sinus preservation for the management of frontal sinus fractures, Curr Opin Otolaryngol
Head 20(4):274–279, 2012.
Minniti JG, Harshbarger M: Fractures of the frontal sinus. In Weinzweig J, editor: Plastic surgery secrets, Philadelphia,
1999, Hanley & Belfus.
Rodriguez ED, Stanwix MG, Nam AJ, et al.: Twenty-six-year experience treating frontal sinus fractures: a novel algorithm based
on anatomical fracture pattern and failure of conventional techniques, Plastic Reconstr Surg, 122: 1850-1866, 2008.
Rohrich RJ, Hollier LH: Management of frontal sinus fractures: changing concepts, Clin Plast Surg 19:219–232, 1992.
Rohrich RJ, Mickel TJ: Frontal sinus obliteration: in search of the ideal autogenous material, Plast Reconstr Surg
95:580–585, 1995.
Smith TL, Han JK, Loehrl TA, Rhee JS: Endoscopic management of the frontal recess in frontal sinus fractures: a shift in the
paradigm? Laryngoscope 112(5):784–790, 2002.
Torre DD, Burtscher D, Kloss-Brandstätter A, Rasse M, Kloss F: Management of frontal sinus fractures–treatment decision
based on metric dislocation extent, Journal of Cranio-Maxillo-Facial Surgery 42:1515–1519, 2014.
Weathers WM, Wolfswinkel EM, Hatef DA, Lee EI, Brown RH, Hollier Jr LH: Frontal sinus fractures: a conservative shift,
Craniomaxillofac Trauma Reconstr 6(3):155–156, 2013.
Wolfe SA, Johnson P: Frontal sinus injuries: primary care and management of late complications, Plast Reconstr Surg
82:781–789, 1988.
MANAGEMENTOFSOFTTISSUE
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FACIALINJURIES
Sapna Lohiya, Jasjit Dillon, Bashar Rajab
1. What are the three important mechanisms involved in protecting the human body
against microbiologic invasion?
• Mechanical barrier: Skin and mucous membranes act as physical barriers against invading
microorganisms.
• Chemical barrier: Lipids on the skin surface are hydrophobic and prevent entry of water-soluble
substances. Mucosal surfaces provide protection via immunoglobulin (IgA) that neutralizes foreign
antigens.
• Biological barrier: Microorganisms activate the kallikrein-kinin system with release of vasoactive
amines that increase vascular permeability. This allows for an influx of humoral and cellular immunologic elements, which recognize and phagocytose the microorganisms. Normal flora on skin
and oral mucosal surfaces also compete with potential microbial pathogens.
2. What are the classifications of soft tissue injuries?
• Contusions
• Flap-likelacerations
• Abrasions
• Avulsioninjuries
• Lacerations
3. What are the different types of soft tissue repair?
• Primaryclosure
• Distanceap
• Healingbysecondaryintention
• Freeap
• Localap
• Specializedap
4. What are the types of wound closures?
• Primaryclosureandhealingbyprimaryintention
• Leavingthewoundopen,treatingitwithfrequentdressingchanges,andallowingittohealby
secondary intention and wound contracture
• Delayedprimaryclosure,inwhichthewoundissplintedinapositionofrestwithanocclusive
dressing and is closed in 3 to 5 days when it is free of infection and necrotic tissue
The timing of wound closure directly correlates with the risk of infection. Wounds with a high
risk of infection should be closed as soon as possible (within the first 6 to 8 hours), whereas wounds
with low risk of infection, such as those in the head and neck area, can be closed primarily within
therst18to24hoursafterinjury.After24hours,formostwounds,considerationshouldbegivento
packing them open and performing a secondary repair 4 to 8 days later. An absolute contraindication
to primary wound closure is any evidence of wound infection such as erythema, warmth, swelling,
and/or pus drainage.
5. What factors predispose a wound to infection?
Wound factors:(1)size,conguration,anddepthofthewound;(2)locationoftheinjury;(3)mecha-
nismofinjury;(4)typeandamountofcontamination,includingpresenceofforeignbody;(5)
timebetweeninjuryandwoundclosure;and(6)careofthewoundbetweeninjuryanddenitive
care.
Technical risk factors:(1)inadequatedebridementofforeignbodies,bacterialcontamination,and
presence of devitalized tissues; (2) inadvertent introduction of foreign material into the wound
duringcleansing;(3)inadequatehemostasisandfailuretoeliminatedeadspace,whichprovides
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an environment for bacterial colonization; (4) using an excessive number of sutures to close the
wound; and (5) placing excessive tension on the sutures used to approximate the tissue edges
and compromising local tissue perfusion.
Host factors: age and systemic condition of the patient including predisposition to diabetes mellitus,
peripheral artery disease, malnutrition, chronic renal failure, and use of immunosuppressive agents.
6. What are the five steps for treating posttraumatic soft tissue wound infection in
the head and neck region?
1. Early recognition of infection
2. Rapidresuscitationandinitiationofempiricantibiotics
3. Immediate surgical debridement
4. Hemodynamicandnutritionalsupport
5. Early wound closure
7. How should bleeding from facial injuries be managed?
Bleeding is managed initially with compression by direct pressure for up to 15 minutes. If bleed-
ingpersists,thenlocalanesthesiawithepinephrinecaneitherbeinjectedordirectlyappliedtothe
wound. Bleeding from arterial vessels may not respond to these measures so hemostasis should be
attempted by suturing the laceration or ligating the relevant vessel. Tissue ischemia is unlikely due to
the extensive anastomoses among facial arteries. Massive uncontrollable bleeding can be treated with
arterial embolization via interventional radiology or ligation of the external carotid artery.
8. What are anesthetic options available for the repair of facial lacerations?
Anesthesiacanbeachievedusingtopicalgels,localanesthesia,orregionalblocks.Regionalblocks
provideaspecicadvantage,aswoundedgesdonotbecomedistorted.Regionalblockscommonly
usedforfacialsofttissueinjuriesandtheirassociatedareasofanesthesiaareasfollows:
• Supraorbitalandsupratrochlearblocks:forehead,anteriorone-thirdofthescalp
• Infraorbitalblock:lowerlid,upperlip,andlateralaspectofthenose
• Mentalnerveblock:lowerlipandchin
9. In which areas of soft tissue injury should we avoid local anesthesia with
vasoconstrictor?
In areas of skin or tissue flaps of doubtful viability, where the use of vasoconstrictors might further
impair circulation.
10. What is the role of irrigation with wound preparation?
Irrigation is essential in preventing infection as it removes debris, dirt, micro, and devitalized tissue
fromthewound.High-pressureirrigationwithnormalsalinehasbeenshowntodecreasethebacterial
count of wounded tissues and decrease the rate of infection. The use of concentrated povidone-iodine,
hydrogen peroxide, and detergents may cause significant tissue damage and should be avoided. When
available, warmed saline may be more comfortable for the patient than room-temperature saline.
11. What are the different types of organisms isolated from a bite wound, and what is
the optimal therapeutic agent for these injuries?
• Dog bites: Pasteurella canis
• Cat bites: Pasteurella multocida and Pasteurella septica
• Human bites: S. aureus, Eikenella corrodens, Haemophilus influenzae, and beta-lactamase–
producing oral anaerobic bacteria
The optimal therapeutic agents include a combination of beta-lactam antibiotic and beta-lactamase
inhibitors.Oralamoxicillin-clavulanicacidwillprovideadequatecoverageofthesuspectedpathogens
particularlyinpatientspresenting9to24hoursaftertheinitialinjury.Ertapenemalsohasanexcellent
potency against the full range of animal and human bite pathogens.
Fordeeporseverewoundinfections,patientsshouldreceiveintravenousantibioticsratherthan
oralantibioticsimmediatelyafterinjury.Onceclinicalimprovementisseen,theantibioticregimencan
be transitioned to outpatient oral therapy.
12. In order, what are the layers of the skin? What is the relation of the muscles of
facial expression to the layers of the skin?
1. Theepidermis(stratiedsquamousepithelium)
• Stratum corneum
• Stratum spinosum
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• Stratum lucidum
• Stratum germinativum
• Stratum granulosum
2. The dermis
• Papillarylayer
• Reticularlayer
A thin subcutaneous layer supports the facial dermis. The muscles of facial expression are within the
subcutaneous layer and insert into the reticular layer of the dermis.
13. In order, what are the layers of the scalp? What is the appropriate management of
scalp lacerations?
• S:Skin
• C:Connectivetissue
• A:(Galea)Aponeurosis
• l:Looseareolarconnectivetissue
• P:Periosteum
Bleeding can be a serious issue with scalp lacerations, often resulting in significant amounts of blood
loss.Directpressuretothewoundandlocalanesthesiawithepinephrineoftencanprovideadequate
hemostasis. If not, then the edges of the laceration should be everted and the wound should be closed
rapidlywithcircumferentialsutureplacement.Primaryclosureupto48hoursafterinjuryisthetreatment
ofchoiceforscalplacerationsthatextendintoorthroughthedermis.Delayedprimaryclosuremaybe
indicatedinwoundsthatareatahigherriskforinfectionandpresentafter24hours.Hairtrimmingmay
be necessary but hair shaving should be avoided. If hemostasis is easily achieved, then the wound should
be closed using staples, with staples placed approximately .5 to 1 cm apart. Staples should be removed
in7to14days.Penrosedrainscanbeplacedtopreventhematomaformationandeliminateddeadspace.
14. What is the interaction of the suture material and tissue healing process?
Woundhealingisaprocessthatcanbedividedintothreephases:
1. Initiallagphase(0to5days):Thereisnogaininwoundstrength.Thewoundandtheentireburden
of tissue approximation are entirely dependent on the suture and epidermal cellular adhesion.
2. Fibroblasticphase(5to15days):Characterizedbyarapidincreaseinwoundstrength.
3. Maturationphase(14daysandonward):Thereisfurtherconnectivetissueremodellingduringthis
phase.
As the tissue reduces the suture strength with time, the relative rates at which the suture material
loses strength and the wound gains strength are important in wound healing.
15. What are the indications of a skin graft for traumatic wounds? Which areas can
accept a skin graft?
Indications:
• Tolimittheamountofcontractionsandtissuedeformityfollowingalargeskinloss
• Temporarycoveragebeforedenitivetreatment
Tissues that support a skin graft are muscle, fat, fascia, dura, and periosteum. Tissues that cannot
support a skin graft are cortical bone denuded of its periosteum, tendons, nerves, or cartilage.
16. What are the classification types of free skin grafts?
1. Split-thicknessgrafts,whichconsistoftheepidermisandaportionofthedermis:
• Thin (0.008 to 0.012 inch)
• Medium (0.012 to 0.018 inch)
• Thick (0.018 to 0.030 inch)
2. Full-thicknessskingrafts,whichincludeboththeepidermisandthedermis
17. What are the properties of split-thickness and full-thickness skin grafts?
1. Split-thicknessskingraft:
• Thinner graft, which rapidly vascularizes and survives under less optimal conditions. It can be
• Thicker split-thickness skin graft closely resembles the color, texture, and limited contractions of
2. Full-thicknessskingraft:Providesagoodcolorandtexturematch,requiresoptimalwoundcondi-
expanded and can be taken from multiple donor sites that will heal with minimal scarring.
a full-thickness graft. This type of graft is usually harvested with a dermatome.
tions, and is less prone to tissue contraction. The graft is usually harvested by dissection and the
donor site must be closed primarily.
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18. What are the most common causes of graft failure?
• Hematomaformation
• Failureofimmobilization
19. What are the types of eyelid injury, and how are they managed?
• Simple lacerations: These should be closed in layers, restoring the orientation of the skin, muscle,
tarsal,andconjunctivallayers.Carefulattentionshouldbegiventoapproximatingthelidmarginsto
avoid functional or cosmetic defects.
• Upper lid lacerations: These may involve detachment of the levator muscle and Muller’s muscle
from the tarsal plate. The muscles should be identified and reattached to the tarsal plate to prevent
ptosis and to restore levator function.
• Laceration of the medial third of the lid: These may involve the lacrimal canaliculus. The
laceration should be explored using a probe and irrigation to rule out involvement of the canaliculi.
Lacerationsinvolvingtheteardrainagesystemrequireplacementofsiliconetubestomaintain
patency of the ducts during healing.
• Avulsive injuries:Full-thicknessavulsionof<25%ofthelidlengthcanberepairedprimarilyas
asimplelacerationorbysecondaryintention.Otherwise,avulsiveinjuresaretreatedwithafull-
thickness skin graft from the postauricular region or the contralateral upper eyelid.
20. What is the treatment of an eyelid injury that involves the lacrimal drainage
system?
Thelowercanaliculusismorecommonlyinjuredthantheuppercanaliculus.Thetreatmentbegins
with identifying the two segments of the canaliculus. A silicon tube is passed through the punctum
and lateral portion of the canaliculus and through the remaining medial canaliculus into the lacrimal
sac, nasolacrimal duct, and nasal cavity beneath the inferior turbinate. The other end of the tube
is passed into the uninvolved punctum, traveling through the nasolacrimal duct to exit beneath the
inferior turbinate. The free ends are then tied and secured in the nose. The tube is left in place for 2 to
3 months or longer if epiphora persists.
21. What are the causes of traumatic transection of the lacrimal system? How is it
diagnosed, and how is it treated?
Traumatic transection of the lacrimal system is usually caused by a laceration in the vicinity of the
medialcanthusoraccompaniesLeFortornasoethmoidalfractures.Thelacrimalpunctummaybe
dilated,andsalinemaybeinjectedthroughthepunctumintothesystem.Appearanceofsalineinthe
wound is diagnostic of a canalicular laceration.
These transections are treated by the placement of tubes into the nose, through the lacerated
canaliculus to splint the repair. Both upper and lower canalicular lacerations should be explored
andrepairedifneeded.Repairandrepositioningofthefracturefragmentsoftenpermitadequate
functionofthesystem.Repairofachronicallyobstructednasallacrimalductisaccomplishedwitha
dacryocystorhinostomy.
22. What craniofacial injuries are accompanied by facial nerve palsy?
Fracturesofthetemporalboneasapartofskull-basefracturesmaycausefacialnervepalsy.In
absenceoffaciallaceration,acomputedtomography(CT)scanofthetemporalbonemayshowsuch
injury.High-dosesteroidsanddecompressionareconsideredforcertaininjuries.Theprognosisvaries
with the site of the fracture.
23. What is the course of the parotid duct?
The duct exits from the anterior portion of the gland and passes inferiorly superficial to the masseter
muscle parallel with a plane drawn from the tragus of the ear to the midpoint of the upper lip. One
cm anterior to the anterior border of the masseter muscle, the duct turns medially and penetrates the
buccinator muscle, opening into the mouth at the level of the second maxillary molar.
24. What are the ways to diagnose a parotid duct injury?
• Identicationofthelocationofclearuidinthewoundaftercompressingtheglandtoexpresssaliva
• Directinspectionwithlacrimalprobecannulationofthedistalaspectoftheductandobservationif
the probe is visible in the wound
• Injectionofmethyleneblue,saline,ormilkintotheductinaretrogradefashion.Ofnote,methylene
bluediscolorstissuesandmaymakesubsequentvisualizationofstructuresmorechallenging
• Radiographicexamination(sialogramorCTimaging)
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25. How is a parotid duct injury managed?
• PlaceanIntracathstentthroughthedistalportionoftheductfromtheoralorice.
• Identifytheproximalportionoftheduct,whichcanbefacilitatedbymassagingtheglandto
express saliva. The proximal end is then cannulated.
• ClosetheendsoftheductovertheIntracathwithsmallnylonorProlenesutures.
• SecuretheIntracathtothebuccalmucosa.
• Layertheclosureofthewoundandplaceanexternalpressuredressingfor24to48hours.
• Leavethecatheterinplacefor10to14days.
Sialocele and salivary fistulas can often be managed with antibiotics, pressure dressings, anticho-
linergics,andserialaspirations.Iftherepairoftheductalinjuryisdeterminedtobeimpossible,the
proximal portion of the duct should be ligated. This will initially result in marked swelling of the gland
followed by its secondary physiologic death.
26. What is the treatment process of parotid duct injury in relation to the location of
the injury?
• Posteriortothemassetermuscleorwithintheparotidgland:Closureoftheparotidcapsuleand
application of pressure dressing.
• Overthemassetermuscle:Primaryanastomosisorligation.Ifenoughlengthremains,anastomosis
should be performed over a silastic stent or an epidural catheter.
• Anteriortothemassetermuscle:Ifprimaryanastomosisisimpossible,theproximalportionofthe
duct can be drained directly into the mouth by creating a new opening. If this cannot be achieved
without undue tension, then the proximal duct segment should be ligated.
27. What anatomic structures need to be evaluated in a patient with a large throughand-through laceration of the cheek?
Cheeklacerationsmayinvolveseveralunderlyingvitalstructures,includingtheparotidglandand
duct,facialnervebranches,facialarteryanditsbranches,andthebuccalfatpad.Carefulexamination
ofthewoundtoidentifythesestructuresiswarranted.Parotidductlacerationrequirestheplacement
of a stent and careful suturing of the cut ends with 6.0 nylon suture under magnification to prevent
formationofacutaneousstula.Overlyingtissuesarethenclosedinlayers.Glandinjurieswithout
duct involvement should be closed routinely and followed for sialocele or parotid fistula formation,
whichmaybetreatedusingpressuredressingsorantisialagogues.Facialnervelacerationsproximal
to a vertical perpendicular line through the lateral canthus are amenable to surgical repair. The
transversefacialarteryrunsadjacenttotheparotidductand,ifinjured,doesnotneedtoberepaired.
The buccal fat should be preserved and replaced, if possible, to prevent cosmetic deformity or cheek
hollowing.
28. What is the etiology and treatment of septal hematomas?
Septalhematomasaremostfrequentlyassociatedwithtraumatotheanteriornasalseptumandwill
present as dark purple or bluish masses against the septum. If left untreated, they can be associated
with infection and necrosis.
Treatment: Incision and expression of the clot should be performed as soon as possible. The
nares should then be packed for approximately 2 to 3 days.
29. What is the etiology and treatment of ear hematomas?
Themostcommonetiologyofauricularhematomaisblunttrauma.Unevacuated,theextravasated
blood is replaced by fibrous tissue or new cartilage, resulting in the cauliflower ear. The hematoma
also caries the risk of secondary infection.
Treatment:Evacuationofthehematomabyneedleaspirationsoonaftertheinjury,orincision
and drainage in late treatment of the hematoma. Application of an external pressure dressing (bolster
dressing) after hematoma evacuation will prevent reformation of the hematoma.
30. What are the ear injury classifications? What are their most common treatments?
Simple lacerations: Simple lacerations are classified as those that spare cartilage. These wounds
should be closed primarily using simple interrupted stitches with a 6-0 absorbable or nonabsorbable suture. It is important to preserve and maintain all attached tissue due to the rich blood
supply to the auricle.
Split earlobe: Split earlobes most often occur by the pulling through of earrings or by an allergic
responsetoearringmetalalloys.Theseinjuriesshouldbeclosedwithsubcutaneousplacementof
4-0 or 5-0 resorbable sutures and then skin closure with 6-0 absorbable or nonabsorbable sutures.
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Complex lacerations:Unlikesimplelacerations,thesetypesofinjuriesexposeorextendthrough
cartilage. Sutures should not be passed through the cartilage layer. The deepest layer of closure
should be the perichondrium. Often due to the thin overlying skin, stitches will incorporate both
the perichondrium and skin layer, which is an accepted method for closure.
Avulsive injuries:
• Partial avulsion with a wide pedicle:Useprimaryclosureduetoadequatebloodsupply.
• Partial avulsions with a narrow pedicle: In the setting of marginal blood supply, local
• Complete avulsions:
• Simple reattachment as a composite graft. The ear is cleansed and sutured directly into
• The pocket principle. The ear is thoroughly dermabraded, a posterior auricular incision is
31. What management considerations are required in repairing an ear laceration?
A complete physical exam evaluating the pinna, external auditory canal, tympanic membrane,
32. What is the appropriate management of tongue lacerations?
The tongue has a very rich blood supply that can lead to significant bleeding. Simultaneously, the
33. What is the treatment process of a through-and-through lip laceration?
• Regionalanesthesiaviainfraorbitaland/ormentalnerveblocks
• Initialirrigationofthewoundandclosureoftheintraoralmucosallayer
• Copiousirrigationoftheexternalwound
• Re-approximationofthemuscular(orbicularisoris)layer
• Closureofthedermisandsubcutaneouslayer
• Skinclosurewithcarefulalignmentofthevermilionborder
advancement flaps or other surgical interventions become necessary to preserve the segment.
the vascular bed. Small incisions are made in the skin to decrease venous congestion.
Administration of dextran or heparin to decrease blood viscosity might be helpful. Success
ofreattachmentisgreatestwithin4hoursoftheinjurybutstudieshaveshownadequate
reimplantation results up to 33 hours post-avulsion.
made, and a pocket is created into which the auricle is tucked. After 10 to 14 days, the auricle
is retrieved and allowed to reepithelialize or is raised with the postauricular skin as coverage.
The donor site can be closed primarily or by a harvested full-thickness graft from elsewhere.
andhearingisessentialbeforetreatmentofexternalearinjuries.Thepinnaisthemostfrequently
lacerated component of the ear, consisting of a relatively avascular cartilage layer covered by a thin,
but richly vascular, skin layer. Anesthesia should be achieved without the use of vasoconstrictors to
prevent disruption of the vascular supply to the ear cartilage. Management then includes irrigation and
conservativedebridement.Conservativedebridementiskeyasexcisionofcartilagecanleadtonotching of the auricular contours and debridement of skin can lead to difficulty in achieving total closure
over exposed cartilage. 6-0 nylon skin sutures can then be placed to align known landmarks and to
re-approximate the soft tissue envelope. The patient’s contralateral ear can be used as a model to
reestablish ear anatomy when normal landmarks are otherwise obscured. Suturing the cartilaginous
frameworkisseldomrequired;however,ne,permanenttackingsuturesmaybeused.Hematoma
formationrequiresdrainage,eitherthroughne-needleaspirationorasmallincision.Sometypeof
pressuredressingisrequiredincomplexlacerationstopreventre-accumulationofblood;thiscanbe
most easily accomplished using a transcartilaginous horizontal mattress suture and bolster dressing.
The patient should be re-evaluated 24 to 48 hours after repair to assess for hematoma formation or
infection. If perichondritis develops, then Pseudomonas aeruginosa is the likely offending pathogen,
andtheinfectionshouldbetreatedwithdrainageifnecessaryandoraluoroquinolones.
tonguehasaremarkableabilitytohealfairlyquickly.Therefore,smalltonguelacerations,especiallyin
children,oftendonotwarrantprimaryrepair.Indicationsforrepairinclude:largelacerations(>1cm)
that extend into the muscular layers, lacerations with significant bleeding, and lacerations that may
cause dysfunction if healing occurs without repair (anterior split tongue). After local anesthesia
is administered via direct local infiltration and inferior alveolar nerve block, the wound should be
irrigated and debrided. The laceration should then be closed in layers with interrupted resorbable
sutures.Duetotheconstantmotionandmuscularityofthetongue,eachsutureshouldbetiedwith
atleastfoursquareknots.Largelacerationsmeritathoroughevaluationoftheairwaybecauseof
the possibility of significant swelling and posterior displacement of the tongue. Wounds should be
explored and radiographs taken to rule out the presence of foreign bodies, such as dental fragments.
Lacerations over 24 hours old should be left to heal by secondary intention.
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34. What percentage of tissue can be lost without a significant cosmetic defect after
primary closure in an avulsive injury of the upper and lower lips?
Avulsiveinjuriesinvolvingupto25%oftheupperlipand35%ofthelowerlipstructurecanbeclosed
primarily without significant functional or cosmetic deformity. In these situations, tissue margins
should be straightened, with the removal of a tissue wedge for primary closure. Attention must be
giventoproperalignmentofthevermilionborderandorbicularisorismuscles.Largeravulsiveinjuries
may be amenable to repair via Abbe or local rotational flaps.
35. Do facial lacerations require debridement before their repair?
Debridementreferstotheremovalofpermanentlydevitalizedtissuewithinawoundinaneffortto
prevent future wound infection. Therefore, the zone of contusion should be excised, if permitted by the
exibilityandavailabilityofsofttissue.Contraindicationstodebridementincludefunctionandcosmetics. Excision should not be performed in the upper and lower eyelid areas as the eyelids then may not
be able to close completely over the globe. In general, excision also should not be performed in nostril
rim, ear, or lip margin lacerations because distortion may be noticeable even with minimal tissue
deficiency at the suture line. Excisions should be performed in parallel to the relaxed skin tension
lines to minimize facial scarring. Once debridement is indicated, then resection of the contused skin
allows conversion to a primary surgically created wound with more predictable healing and generally
improvedappearance.Followingthisprocedure,alayeredrepairofthefacialsofttissueshouldbe
performed.
36. How do animal and human bites differ from other traumatic injuries?
Animalandhumanbitesdifferfromothertraumaticinjuriesbecausetheyarecontaminatedbythe
oral flora. Thorough cleansing and debridement of the wound with the use of copious normal saline
irrigationisessentialbeforeclosure.Facialwoundscanthenbeclosedinroutinelayeredfashion.
WoundinfectionsfromhumanbitesarefrequentlycausedbyStreptococcus and Staphylococcus
organisms. Serious infections may also be associated with Eikenella.Unlikehumanbites,50%to75%
of infections in animal bites are caused by P. multocida. Amoxicillin-clavulanic acid is recommended
forprophylaxisinbothhumanandanimalbites.Tetanusimmunizationisrequiredforallbites,and
rabiesprophylaxismayberequiredwhenanimalsexhibitsuspiciousbehavior.
37. What are the zones of the neck, and how are they assessed in penetrating neck
injuries?
Penetratingtraumatotheneckcarriessignicantriskofvascularinjury.Tostandardizemanagement,
three zones of the neck have been defined. Zone 1 extends from the clavicle to the cricoid cartilage,
zone 2 from the cricoid cartilage to the mandibular angle, and zone 3 from the mandibular angle to
thebaseoftheskull.Diagnosisofvascularinjurybyphysicalexaminationorexploratorysurgeryis
mosteasilyaccomplishedinzone2,whereaszone1and3injuriesoftenremainobscure.Similarly,
surgicalrepairofzone2injuriesisfrequentlysuccessful,whereasrepairofzones1and3isoften
fraughtwithdanger.Arteriographyisusefultolocatethesiteofarterialinjuryinthesezones.Bleeding
can then be controlled by intraluminal blockage of the severed artery by embolization.
38. What distinguishes facial lacerations from other lacerations?*
Cosmeticappearanceisclearlyofprimaryimportance.Qualityofthenalresultdependsonstrict
adherencetobasicprinciplesofwoundmanagementandmeticuloussurgicaltechnique.Copious
irrigation,judiciousdebridement,gentletissuehandling,adequatehemostasis,minimizationofthe
numberofsuturesused,andearlystitchremovalarecriticalforoptimalresults.Useofnesutures,
sharp instruments, eversion of the wound margins, layered closure, obliteration of dead space, and
tension-free repair are mandatory. As we age, facial skin will develop predictable creases, known as
Langer’s lines. Lacerations that run parallel to Langer’s lines will have less prominent scarring than
those that run perpendicular to them.
39. How are clean lacerations repaired?*
TheyshouldbeirrigatedwithnormalsalineorRinger’slactate.Onlythesurroundingskinshouldbe
prepared,andnoantisepticshouldbeintroducedintothewound.Regionalanesthesiaispreferred
becauseofthepotentialforspreadofcontaminationwithdirectinjectionofthewoundmargin.Epi-
nephrine should be avoided because it devitalizes tissue and may potentiate infection. Wounds should
be repaired in layers with absorbable suture in deep tissue. The fewest number of sutures necessary
to overcome the natural resting wound tension should be used. Sutures should be removed within 3 to
5days,andthewoundmarginshouldbesubsequentlysupportedwithSteri-Strips.
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40. How are dirty lacerations repaired?*
Heavilycontaminatedwoundsshouldremainopenafterirrigationanddebridementforsubsequent
delayed closure. Because of cosmetic considerations, however, this approach is unacceptable in the
face. Therefore, meticulous debridement of devitalized tissue and removal of all foreign material are
essential. The wound should be cultured before copious irrigation, and a broad-spectrum antibiotic
should be instituted prophylactically. The patient must be informed of the potential of a post-repair
infection.
41. What factors influence suture selection?*
Wounds should be closed with sutures when excessive scarring will result if the wound edges are
not properly approximated. Suture types are classified by their absorption rates, physical configuration, tensile strength, elasticity, and memory. Absorbable sutures are defined as those that will lose
theirtensilestrengthwithin60days.Fast-absorbinggutisrecommendedforpercutaneousclosure
of facial lacerations while Vicryl and Monocryl sutures are recommended for the dermal closure of
deeplacerations.ChromicgutorVicrylcanbeusedfortongueororalmucosalwounds.Nonabsorbablesuturesincludesilk,nylon,andProlenesutures.Sinceanymethodofsuturingprovokestissue
damage, impairs host defense, increases scar proliferation, and invites infection, it is recommended to
use as few sutures as possible to close a deep wound. Braided sutures in particular can often harbor
bacteria between strands and can result in higher rates of infection.
42. Can absorbable sutures be used in repair of facial lacerations?
Yes.Inchildren,theuseofplaincatgutabsorbablesuturesintherepairoftraumaticlacerationsin
general and in facial lacerations in particular is an acceptable alternative to nonabsorbable sutures.
Long-term cosmetic outcome seems to be at least as good with no difference in the rate of dehiscence or infection. In a randomized study on repair of facial lacerations in the emergency department, using fast-absorbing catgut or nylon sutures showed no significant differences in the rates of
infection, wound dehiscence, keloid formation, and parental satisfaction. In addition, the lack of need
to remove the sutures compared to nonabsorbable sutures is less traumatic to the child.
43. Which wounds are suitable for closure with tissue adhesives?*
N-butyl-2-cyanoacrylatemaysufceforcutaneousclosureof<4-cmlow-tensionlacerationswith
good wound approximation in children (preferred method) and adults. This adhesive effectively closes
low-tensionlacerations.Thismethodisfast,relativelypainless,anddoesnotrequiretheuseof
injectedlocalanesthesia.Ithasalowcomplicationrateandproducesexcellentcosmeticoutcomes.In
many instances, if initial wound orientation is against Langer’s lines, it may, in fact, offer an advantage
over conventional manual suturing. Once applied, maximum bonding strength is obtained within
2.5 minutes; the adhesive will then slough off approximately 5 to 10 days later.
44. Should eyebrows be shaved when facial lacerations are repaired?*
No. They provide a landmark for realignment of disrupted tissue edges and do not always grow back.
In addition, shaving hair to skin level can deposit particles in the wound bed, increasing the risk of
infection. This practice should, therefore, be avoided in all lacerations if possible.
45. Should skin grafts or flaps be used for primary closure of a wound?*
Complicatedtissuetransfertechniqueshavenoplaceintheacutetreatmentoffacialwounds.Closure
should be achieved in the simplest way possible, and complex reconstructive efforts should be
deferred until the scar has matured (months). When tissue loss prevents closure, it may be necessary
to use a thin split-thickness skin graft for coverage.
46. When are antibiotics indicated in the treatment of facial lacerations?*
Copiousirrigation,debridement,andgentletissuehandlingaremorepertinenttothepreventionofinfec-
tion than the use of antibiotics in facial wounds, especially skin wounds. Antibiotic coverage is indicated,
however,incrushavulsioninjuries,bites,andheavilycontaminatedinjuries.Antibioticprophylaxis
should also be considered in through-and-through lip laceration, avalusive and degloving scalp laceration, and when the wound involves exposed cartilage of the ear or nose or evidence of devascularization.
Ifprophylacticantibiotictherapyisrequired,thentheantibioticshouldbeselectedonthebasis
of the normal bacterial flora associated with the wound site.
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47. When should scars be revised?*
A scar usually has its worst appearance at 2 weeks to 2 months after suturing. Scar revision should
await complete maturation, which may take 4 to 24 months. A good rule of thumb is to undertake no
revisions for at least 6 to 12 months after initial repair. The maturation of the wound may be assessed
by its degree of discomfort, erythema, and induration.
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