FACIAL WOUND MANAGEMENT: A REVIEW ARTICLE
Authors : Dr. Abdul Hameed Attar , Dr. Akshay Deshpande .
Most of these defects are repaired or rebuilt immediately for better restoration of form and function with early healing and repair.Surgeon should require understanding the biomechanics and molecular biology of wound rejuvenating and the art of soft tissue rehabilitation for better outcome. Management of involute soft tissue injuries is always a challenge to the surgeons.
Customarily people are apprehensive about the scars on their face. Thus, primary closure typically results in least flamboyantly blatant scar and is the preferred treatment for most facial cuts.
Fortuitously, because of the laxity of facial skin, most wounds can be rehabilitated primarily unless they have paramount tissue loss or tissue swelling. To ascertain good rejuvenating and an inconspicuous scar on the face, surgeons have to take into consideration the following characteristics of facial tissue.The facial structures have very good blood supplies, hence facial wounds usually heal well and fast.
CASE 2 (Assault): Two cases of assault reported to the emergency derpartment. A 25 year old male was assulted with glass bottle sustaining facial injury. On examination, wound was extending from right angle of mouth to tragus of the ear, with excessive bleeding from the damaged facial artery with suspected branches of facial nerve. Wound debrided under local anesthesia and glass particles has been removed from wound. Haemostasis was achieved by ligation and diathermy. Wound was closed in layers.
In the second case, a 17 year old girl was assaulted with sharp knife from back in the neck; multiple cuts were seen with excessive bleeding. Injury involved deep muscles of the neck. Under general anaesthesia, the wound was debrided, haemosatsis achieved and closed in layers.
CASE 3 (Accidental injury by Sharp stone cutter): A 32 year male (Sculptor) admitted with history of accidental injury by sharp stone cutter, which bounced while he was making statue, sustaining facial injury exteding from chin running through both lips and to the ala of nose with varying depth upto the bone. Wound was debrided and sutured in layers.
Diminutive and superficial wounds can be dealt under local anaesthesia while sizeably voluminous, extensive and perplexed injuries would best be treated under general anaesthesia. The facial wounds should be irrigated and cleaned with good antiseptic solution and the wound explored exhaustively to abstract any foreign bodies and to determine the extent of the injury. Debridement of skin edges should be kept to a minimum, unless the tissue is conspicuously dead. Because of the excellent blood supply of the face, tissue that seems ischemic often survives.
Bleeding vessels should be ligated and minute bleeders coagulated with diathermy. Sometimesbleeding may be massive if not managed meticulously, may lead to haemorrhage and shock. Once the emergency situation is managed the wound should be evaluatedfor the disoriented and exposed tissue constituents. The wound may look small but might have wide undermined devascularized margins which need surgical excision.The facial wounds should be rehabilitated anatomically in layers to procure anatomic alignment and to eschew dead space.
Every effort should be made to approximate the structures in the correct layers with absorbable sutures and surperficial skin layers would then be sutured with fine non-absorbable preferably with monofilament sutures. En-masse closure of a facial wound with thick sutures should be avoided to prevent a wide uneven scar with poor contour and marked stitch marks.In cases of tissue loss, three-dimensional quantification of the wound is taken to assess the size of the tissue to cover with local or regional flap.
Some time it gives a misleading impression of major tissue loss, but on repair it appears that tissue are present. Facial structure should be simulating the original tissue adjacent to it, in terms of colour, texture, contour, etc. Reconstructed area should participate in mundane facial function such as smile verbalization and mastication.
In areas with extensive superficial skin abrasions or skin loss, healing by secondary intention with regular dressing changes can be carried out. The resulting red and irregular wound can be improved later with scar revision or with other modalities.Pressure dressing should be avoided in devitalized tissues to prevent anaerobic infection.Topical antibiotic ointment for postoperative use should be discontinued after 7 days to prevent tissue reaction.
ABSTRACT
Facial soft tissue injury is more common since the incidence of road traffic accidents is very high. Facial soft tissue injury is given maximum attention because the management is based on both aesthetic and functional aspect. The final outcome depends on the initial wound care and primary repair. Disfigurement and scarring becomes a social stigma and has detrimental effect on individual’s personality and future. With this article we want to accentuate the consequentiality of early aesthetic rehabilitation of the facial subunits in poly-trauma cases. Here we present few cases with soft tissue injuries of the head neck and face, treated at our emergency department. The final result has been always restored with complete functional and aesthetic outcome. Surgeons who have complete knowledge of applied anatomy, aesthetic sense and surgical skill to repair the complex structure manage these cases.INTRODUCTION
Facial soft tissue injuries are one of the most conundrums faced by the facial aesthetic surgeon. The life and aplomb of patients with facial injuries may damage transitory or perpetually depending upon the outcome. Road traffic contingency makeup the major proportion (70%) of these injuries. Facial soft tissue injuries vary in astringency predicated on the impact force and type of injury into minor superficial wounds to massive avulsions. The aim of management is to restore function and aesthetics in short period. Because of intricacy of face it is essential to evaluate the injuries to sundry structures, depth of wound, and consequential anatomical structures such as nerves (facial), ocular perceivers, auditory perceivers, etc..
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| Case 1a: RTA with facial abrasion and laceration. Treated with suturing and kollegenR grafting |
Classification of soft tissue injuries:
Facial injuries themselves are infrequently life threatening, but are designators of the kind and impact of injury:- Abrasions
- Tattoos
- Simple or complex contused lacerations with loss of tissue
- Avulsed wound
- Bites
- Burns
Most of these defects are repaired or rebuilt immediately for better restoration of form and function with early healing and repair.Surgeon should require understanding the biomechanics and molecular biology of wound rejuvenating and the art of soft tissue rehabilitation for better outcome. Management of involute soft tissue injuries is always a challenge to the surgeons.
Customarily people are apprehensive about the scars on their face. Thus, primary closure typically results in least flamboyantly blatant scar and is the preferred treatment for most facial cuts.
Fortuitously, because of the laxity of facial skin, most wounds can be rehabilitated primarily unless they have paramount tissue loss or tissue swelling. To ascertain good rejuvenating and an inconspicuous scar on the face, surgeons have to take into consideration the following characteristics of facial tissue.The facial structures have very good blood supplies, hence facial wounds usually heal well and fast.
- Infection is not common unless the wound is contaminated and poorly prepared.
- The human face is complex and has various facial features. Special care has to be taken not to distort these features as well as to ensure symmetry of the face.
- The anatomy of the face is also complex with variations in the thickness, texture and tension of the skin in different areas. In planning for any facial wound repair, considerations have to be taken into account of the skin crease alignment and skin quality to produce an inconspicuous linear fine line scar.
CASE PRESENTATION:
CASE 1(RTA): Two cases with road traffic accident were reported to emergency department. On examination patient had abrasive wound and small laceration on the right side of face. Under local anaesthesia, the lacerated wound was debrided and sutured in layers. Deep layers were closed with vicryl 4-0 and superficial skin layer is closed with 5-0 monofilament suture. In the patient with abrasive wound dermabrasion and kollagenR grafting is done. In both cases sutures were removed after 7th day where as kollagenR graft shaded after getting dried. In both the cases healing was satisfactory with minimal or no scarring.
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| Case 1b: Lacerated wound closure with subcuticular suturing. |
CASE 2 (Assault): Two cases of assault reported to the emergency derpartment. A 25 year old male was assulted with glass bottle sustaining facial injury. On examination, wound was extending from right angle of mouth to tragus of the ear, with excessive bleeding from the damaged facial artery with suspected branches of facial nerve. Wound debrided under local anesthesia and glass particles has been removed from wound. Haemostasis was achieved by ligation and diathermy. Wound was closed in layers.
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| Case 2a: Assault on face with glass bottle |
In the second case, a 17 year old girl was assaulted with sharp knife from back in the neck; multiple cuts were seen with excessive bleeding. Injury involved deep muscles of the neck. Under general anaesthesia, the wound was debrided, haemosatsis achieved and closed in layers.
 |
| Case 2a: Assault on neck with sharp knife |
CASE 3 (Accidental injury by Sharp stone cutter): A 32 year male (Sculptor) admitted with history of accidental injury by sharp stone cutter, which bounced while he was making statue, sustaining facial injury exteding from chin running through both lips and to the ala of nose with varying depth upto the bone. Wound was debrided and sutured in layers.
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| Case 3: Accidental injury by sharp stone cutter. |
DISCUSSION
Facial soft tissue injuries are prevalent after road traffic accidents, accidental falls, sports injuries and assault incidents. The facial wounds should be managed at the earliest available time slot (golden period is first six hours). The timing, sequence, and felicitous surgical procedure technique depends on size, location and involution of deeper structures.Diminutive and superficial wounds can be dealt under local anaesthesia while sizeably voluminous, extensive and perplexed injuries would best be treated under general anaesthesia. The facial wounds should be irrigated and cleaned with good antiseptic solution and the wound explored exhaustively to abstract any foreign bodies and to determine the extent of the injury. Debridement of skin edges should be kept to a minimum, unless the tissue is conspicuously dead. Because of the excellent blood supply of the face, tissue that seems ischemic often survives.
Bleeding vessels should be ligated and minute bleeders coagulated with diathermy. Sometimesbleeding may be massive if not managed meticulously, may lead to haemorrhage and shock. Once the emergency situation is managed the wound should be evaluatedfor the disoriented and exposed tissue constituents. The wound may look small but might have wide undermined devascularized margins which need surgical excision.The facial wounds should be rehabilitated anatomically in layers to procure anatomic alignment and to eschew dead space.
Every effort should be made to approximate the structures in the correct layers with absorbable sutures and surperficial skin layers would then be sutured with fine non-absorbable preferably with monofilament sutures. En-masse closure of a facial wound with thick sutures should be avoided to prevent a wide uneven scar with poor contour and marked stitch marks.In cases of tissue loss, three-dimensional quantification of the wound is taken to assess the size of the tissue to cover with local or regional flap.
Some time it gives a misleading impression of major tissue loss, but on repair it appears that tissue are present. Facial structure should be simulating the original tissue adjacent to it, in terms of colour, texture, contour, etc. Reconstructed area should participate in mundane facial function such as smile verbalization and mastication.
In areas with extensive superficial skin abrasions or skin loss, healing by secondary intention with regular dressing changes can be carried out. The resulting red and irregular wound can be improved later with scar revision or with other modalities.Pressure dressing should be avoided in devitalized tissues to prevent anaerobic infection.Topical antibiotic ointment for postoperative use should be discontinued after 7 days to prevent tissue reaction.
CONCLUSION
It is a paramount and at the same times an arduous task to rehabilitate and restore the function and aesthetics of the face. Facial wound of different etiologies offers challenge to the aesthetic surgeon. Felicitous assessment of the nature of wound and understanding the rejuvenating biology of facial wounds is vital, in anticipation of the ultimate surgical outcome.|
Table : 1 Factors to Consider during Initial Assessment of facial tissue Laceration |
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1. What is the risk for embedded foreign objects? |
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Table : 2 Closure Considerations for Simple Lacerations |
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Wound Tape |
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Tissue Adhesives “Dermabond” |
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Sutures |
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Table 3. Laceration Characteristics That Require Sutures |
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Shape |
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Table : 4 Suture type |
Tissue type |
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Absorbable 3-0, 4-0, 5-0 vicryl or polydioxanone |
Muscles and Subcutaneous tissue |
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Non absorbable 5-0, 6-0 proline, nylon |
Skin |
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Table : 5 Following are the timings for removal of sutures based on different areas of head and neck. |
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Face/Ear |
4-6 Days |
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Scalp |
6-8 Days |
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Eyelid |
3-5 Days |
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Neck |
5-7days |