AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Initial Survey and Evaluation
• Specific Anatomic Areas
• Animal Bites and Gunshot Wounds
• Workup
• Treatment
• Conclusion
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Initial Survey and Evaluation
• Specific Anatomic Areas
• Animal Bites and Gunshot Wounds
• Workup
• Treatment
• Conclusion
• References

No other part of the body is as conspicuous, unique, or aesthetically significant as the face. Because an individual's self-image and self-esteem are often derived from his or her own facial appearance, any injury affecting these features requires particular attention.

Historically, severe facial trauma often resulted in cosmetic and functional defects; however, recent advances in the science of reconstructive surgery and in the management of trauma patients have significantly improved the morbidity and mortality of patients with facial traumatic injuries. This article focuses on facial soft tissue trauma.

Frequency

In the United States, approximately 3 million people present to emergency departments for treatment of traumatic facial injuries each year. Most of these injuries are relatively minor soft tissue injuries that simply require first-aid care or primary closures. A small percentage of facial traumas (0.04-0.09%) require major repair with possible bony reconstruction.

Etiology

In the United States, motor vehicle accidents (MVAs) were the most frequent cause of facial injuries before 1970. In recent years, with the institution of state seat belt laws, the number of deaths from MVAs has declined along with the incidence of facial injuries, although the prevalence of facial trauma has remained fairly constant. This is due to the growing population and other human factors, such as on-the-job accidents, sports-related injuries, domestic interpersonal violence, self-inflicted wounds, and animal bites.

The mechanism of injury for facial trauma varies widely from one locality to the next, depending significantly upon the degree of urbanization, socioeconomic status of the population, and cultural background of each region. MVAs continue to be a primary contributor to significant facial injuries in rural areas. In contrast, in inner metropolitan areas, domestic violence is the leading cause of facial trauma despite a denser population, a difference that may be due to stricter enforcement of traffic laws.

INITIAL SURVEY AND EVALUATION

Section 3 of 9  

• Authors and Editors
• Introduction
• Initial Survey and Evaluation
• Specific Anatomic Areas
• Animal Bites and Gunshot Wounds
• Workup
• Treatment
• Conclusion
• References

Initial survey

Although patients with traumatic facial injuries often present with extremely disfigured appearances, their injuries are seldom life threatening. Treat each patient who presents with significant traumatic facial injuries as a patient with general trauma, and strictly adhere to American Trauma Life Support (ATLS) protocols.

After obtaining the patient's pertinent history and mechanism of injury on initial assessment, follow the ATLS ABCDE mnemonic (ie, airway, breathing, circulation, disability, exposure), and address the most life-threatening problems first. Evaluate the patient's facial injuries only after establishing a definitive airway, stabilizing hemodynamics, and assessing other associated life-threatening injuries.

Airway

The foremost priority in treating any trauma patient is establishing a definitive airway. In a conscious patient who is alert, awake, talking, and in no obvious respiratory distress, it can be assumed that the patient has a patent airway, and the physical assessment of other areas may be continued.

Consider airway obstruction in a conscious patient who demonstrates any degree of respiratory distress. Blood, vomitus, facial bone fragments, dentures, or other foreign bodies may cause either partial or complete airway obstruction. Perform a quick finger sweep of the oral cavity if any physical obstruction to the airway is suggested; this frequently suffices to dislodge any matter and to relieve any obstructions in the upper airway. Consider nasal intubation if respiratory distress continues; however, due to possible intracranial contamination, do not intubate if the patient presents with a considerably distorted nasal anatomy, extensive nasopharyngeal hemorrhaging, leakage of cerebrospinal fluid, or possible fracture of the cribriform plate. Sedate the patient and perform an orotracheal intubation.

If a conscious patient is uncooperative and combative (often seen in those with alcohol intoxication), insert an endotracheal or nasotracheal tube after administering sedation. In an unconscious patient with poor vital reflexes (ie, gag, cough, swallow) or in a patient with a Glasgow Coma Scale (GCS) score of 8 or less, perform orotracheal intubation to prevent aspiration and to protect the airway. Patients with massive soft tissue damage, such as that caused by shotgun injuries to the face, must be sedated and intubated at once. Aspiration from hemorrhaging becomes a primary concern.

If attempts at intubation are unsuccessful, emergency cricothyroidotomy or a formal tracheostomy may be performed. As these are invasive procedures with their own complications, use them only as a last resort to ensure an adequate airway.

Hemorrhage and shock

Hemorrhage resulting in systemic shock from facial trauma alone rarely occurs, except in cases of extensive penetrating injuries such as gunshot wounds to the face. Bleeding from the facial artery, the superficial temporal artery, the angular artery, or a combination of these is most commonly encountered and can usually be controlled, at least temporarily, by applying direct pressure to the wound.

Closely monitor the airway at all times as blood from facial hemorrhage may obstruct the upper airway or may result in emesis and aspiration that can further compromise the airway. If a patient with facial trauma presents with shock, promptly assess other associated injuries.

Definitive evaluation and physical examination

Systematically examine the face by visual inspection and by palpation, starting superiorly with the scalp and the frontal bones and proceeding inferiorly and laterally. Inspect and note any obvious swellings, depressions, or ecchymosis. These indicate possible underlying bone fracture or hematoma. Any gross soft tissue asymmetry may signify underlying nerve damage. With palpation, determine the presence and location of any fractured bone fragments and dislodged or dislocated bony prominences. Determining the presence of crepitus, tenderness, or step-offs is essential. If possible, assess sensorimotor functions of the face.

SPECIFIC ANATOMIC AREAS

Section 4 of 9  

• Authors and Editors
• Introduction
• Initial Survey and Evaluation
• Specific Anatomic Areas
• Animal Bites and Gunshot Wounds
• Workup
• Treatment
• Conclusion
• References

General anatomy

Scalp injuries

Due to the extensive blood supply of the scalp, hemorrhaging of the scalp often appears profuse and always heightens suspicion of intracranial damage. On the other hand, it is not uncommon for minor scalp injures to be missed due to an inadequate examination. To avoid missing any scalp injuries, examine patients thoroughly during the secondary survey. Search for any possible underlying skull fractures. Though shaving of hair is usually unnecessary, some shaving may be needed to avoid missing additional lacerations if obvious foreign body fragments are lodged in the hair or if the patient has long hair.

All injuries need to be copiously irrigated and have all foreign bodies removed. Simple linear lacerations with good hemostasis can be closed with staples. Close more extensive lacerations, lacerations with profuse bleeding, or large avulsions of the scalp flap with continuous nonabsorbable sutures encompassing all layers of the scalp. This method usually achieves good hemostasis. If lacerations are jagged or macerated, obtain clean edges by trimming the macerated areas, and bevel the incisions parallel to the hair follicles to avoid secondary alopecia.

Eyebrow injuries

Eyebrow injuries should focus attention toward any underlying fractures of the supraorbital ridge or frontal sinuses. These fractures are often not well depicted in radiographs. If present, consider their management prior to any surgical repair of the overlying soft tissues.

Eyebrows are never shaved. Superficial linear lacerations across the eyebrow are meticulously closed with nonabsorbable sutures and careful alignment of the margins. The resulting scar can be anticipated and concealed in the hairs of the eyebrow. Subcuticular sutures may also be placed, provided that the strength is adequate for the wound. Close deeper lacerations in layers. Approximate lacerations involving divided muscles to minimize surface contractures and functional defects. Neatly trim and debride jagged or macerated tissue, following the line of the eyebrows to avoid additional hair loss.

Eyelid injuries

Patients presenting with eyelid injuries must be examined thoroughly for any associated ocular and nasolacrimal duct injuries. Any evidence of lens displacement, hyphema, retinal detachment, visual impairment, global disruption, or foreign body presence warrants an ophthalmologic consultation. Presence of enophthalmos or exophthalmos must be established, as these conditions indicate either an orbital floor fracture or a blow-in fracture, respectively. Extraocular muscle functions must be assessed with voluntary eye movements. A visual acuity test must also be performed.

The eyelid is perhaps the most delicate structure of the face and consists of several layers of fine musculature. Improper repair may result in ptosis or a retracted eyelid. Lacerations of the eyelid are characterized as superficial or deep and horizontal (parallel to the lid margins) or vertical (perpendicular to the lid margins). Superficial horizontal lacerations require only simple sutures or Steri-Strips. Close superficial vertical lacerations in layers, as they often traverse normal skin tension lines and the underlying musculature. The key suture is placed at the ciliary margin. Close the subcutaneous tissue and muscles with absorbable sutures first and then the skin with 6-0 interrupted nonabsorbable sutures.

Deep and through-and-through lacerations of the eyelid warrant a careful search for retained foreign bodies. Wound margins must be aligned carefully, and key sutures must be placed first at the ciliary margin and at the tarsus. The remainder of the eyelid is then apposed and repaired. Conjunctival lacerations may be disregarded, as they generally heal well without any intervention. Skin sutures may be removed after 48 hours.

Ear injuries

Though deceptively simple, the ears consist of unique arches and contours that are symmetrical to each other, which makes their repair and reconstruction often difficult and challenging for the plastic surgeon. If the repaired ear is slightly uneven compared to the nonaffected ear, the aesthetic symmetry of the patient is grossly affected.

Carefully clean and debride ear injuries. If the wound is a linear laceration, it usually requires only primary closure with careful approximation of the cartilage perichondrium and skin and closure in 3 layers, using 5-0 nonabsorbable sutures for the skin layer. For lacerations involving the helix, key sutures are placed at the outer rim to preserve its contour and to prevent subsequent notching.

If the injury is an avulsion, the wound is thoroughly cleansed and debrided, and the margins are minimally trimmed and closed in layers. Small avulsed ear fragments can be reattached similarly. As the ear has a highly vascular pedicle, avulsions of the ear or even amputations, if properly treated, tend to heal quite well. Venous congestion can be troublesome.

If a small area of the ear is peripherally jagged or missing, a wedge resection may be performed and the skin closed primarily. In addition, if the defect requires skin grafts, they should be grafted only onto regions where underlying perichondrium is present. However, if the wound is a large and grossly noticeable defect, leave the wound open and plan reconstruction for a future date. Frequently clean the wound and change dressings to avoid desiccation.

Nasal injuries

Visual inspection of the nose usually provides ample information as to the underlying injury. Gross midline deviation of the nose usually indicates underlying fractured nasal bones or cartilages. Soft tissue swelling of the nose indicates hematoma, fractured nasal bones and/or cartilages, or both. Intranasal inspection with a nasal speculum may reveal a deviated septum, a septal hematoma, or cerebrospinal fluid leakage. If a septal hematoma is suspected, aspirate it using an 18- or 20-gauge needle; perform an incision and drainage procedure if the hematoma is confirmed. If the hematoma is missed and untreated, chondromalacia of the nasal cartilages may develop and become what is known as a saddle-nose deformity.

Superficial lacerations through the skin of the nose require only simple nonabsorbable skin sutures to close the wound. Deeper bites that include the cartilages may be used if the laceration extends down to the cartilages and if the cartilages are aligned easily with no significant deviation.

For full-thickness lacerations of the nose, perform wound closure in layers, ie, through the skin, cartilage, and mucous membrane. First, carefully align and close the divided mucous membranes with 4-0 to 6-0 absorbable sutures. Then, accurately align and close the skin and cartilage with nonabsorbable interrupted sutures.

For lacerations that involve distinct nasal landmarks, such as the nasal rim, nostril border, or the alar rim, first place key sutures at those regions to ensure smooth, continuous contours without notching.

Nasal packing after surgical closure of the wound is at the surgeon's discretion. In general, packing is unnecessary if the underlying supporting elements are intact and in good alignment. Petrolatum-impregnated gauze may be used to pack the nose to provide support if unstable underlying cartilaginous or bony fragments are suspected. Note that nasal packing, in addition to causing discomfort, obstructs air circulation and drainage and may cause additional bleeding when removed from the delicate mucous membrane.

Lip injuries

Laceration of the lip is always repaired with reference to the cutaneous-vermilion border or the white roll. Identify, carefully align, and mark distinct landmarks, such as the white roll or the philtral column, prior to local anesthesia injection. This is especially important if the injury extends through the mid line of the lip at the Cupid's bow or the philtral tubercle. If not properly treated as described, such regions may become distorted or obliterated when local edema occurs after injection, thus causing improper suture placement and necessitating a subsequent secondary repair.

After proper alignment and anesthetizing of the tissue, the first anchoring suture should approximate the 2 sides of the laceration at the white roll, forming a smooth and continuous line throughout the border. If the injury extends deep to or through the orbicularis oris muscle, the musculature is closed first with buried absorbable sutures. Proper alignment must be achieved for muscular continuity. The mucous membrane is then closed with absorbable sutures, again with attention to alignment. The skin layer is closed last with 5-0 or 6-0 nonabsorbable interrupted sutures. Instruct patients to minimize movement and strain on the mouth.

Special areas

Nerve injuries

The facial nerve, because of its predominant and superficial distribution, is most susceptible to facial injuries. Injury to the nerve causes significant cosmetic and functional defects. Any facial injury demands a complete functional evaluation of the main facial nerve trunk and its branches before any treatment. If transection has occurred, obvious signs of motor deficit will be present. Injuries to the temporal and eyebrow regions affect the temporal and zygomatic branches, causing inability to raise the eyebrows or close the eyelids. Injuries to the mandibular area margins affect the marginal mandibular, causing inability to frown. Buccal branch injuries cause inability to smile and loss of the nasolabial crease. Infraorbital nerve injury creates wrinkles in the cheek.

Repair transection of the facial nerve as soon as possible after the injury, ideally within 72 hours. If repair is delayed, the distal severed ends will contract, rendering identification of the severed ends using a nerve stimulator difficult or impossible. Carry out nerve anastomosis under a microscope, using 8-0 nonabsorbable sutures in 3-4 positions circumferentially under minimal tension to prevent fibrosis. If the nerve ends cannot be delineated clearly (ie, if the ends are macerated or jagged), trim them off prior to anastomosis. If significant nerve loss makes direct anastomosis impossible, find and tag the nerve ends for future nerve grafting.

Parotid duct injuries

As the parotid gland is situated superficially in the cheek, it is vulnerable to any trauma to the face. Any injury along an imaginary line drawn from the tragus of the ear to the mid portion of the upper lip should alert practitioners to the possibility of parotid injury.

Consider injury to the gland if there is clear discharge from the cheek wound. Similarly, a sagging upper lip indicates possible injury to the parotid duct, since the buccal branches of the facial nerve often run along with the parotid duct.

If parotid duct transection is suspected, probe and cannulate it in the operating room. A small catheter is inserted into the parotid duct orifice, which opens on the oral mucosa directly opposite the second maxillary molar tooth. If no transection is present, the catheter passes freely and meets resistance. If transection has occurred, either partial or complete, the catheter will pass through the distal open end of the transected duct and become visible. The proximal severed end of the duct can be identified by massaging the gland to express saliva. The catheter then should be cannulated through the proximal end of the duct until it meets resistance.

Under magnification, the duct can be anastomosed over the catheter using 7-0 or 8-0 monofilament sutures. After repair, the catheter can be removed if the duct is only partially transected and if there are minimal associated injuries. However, if the duct is completely transected or other significant associated damage to the area is present, leave the catheter in place 5-7 days to ensure duct patency and to minimize fistula formation.

If the parotid duct is damaged such that the distal end cannot be identified or if the duct orifice is obliterated, a new orifice can be constructed more proximally to maintain parotid gland function. An alternative is duct ligation, which causes the parotid gland to atrophy and cease functioning.

Lacrimal duct injuries

Injuries to the medial canthal region must be inspected for lacrimal duct injury. Both upper and lower canaliculi must be examined thoroughly to determine the extent of injury. With complete transection, if the severed ends of the duct can be identified easily, align the ends, cannulate with a fine catheter, and repair with fine sutures. In cases in which the duct is partially transected, the canaliculus can simply be approximated and observed.

With more severe injuries involving other excretory components of the lacrimal system, such as the lacrimal sac and nasolacrimal duct, repair of the lacrimal duct may be deferred until the main components have returned to function unless epiphora and obstructive dacryocystitis occurs.

ANIMAL BITES AND GUNSHOT WOUNDS

Section 5 of 9  

• Authors and Editors
• Introduction
• Initial Survey and Evaluation
• Specific Anatomic Areas
• Animal Bites and Gunshot Wounds
• Workup
• Treatment
• Conclusion
• References

Animal bites

Animal bites to the face are generally the results of dog attacks. The facial soft tissue injuries sustained are usually lacerations and tears of the scalp, cheek, or neck. As animal saliva harbors numerous virulent microorganisms, the main concern from such injury is wound infection. Human bites, though appearing to be more innocuous, are actually more destructive in terms of infection. The human oral florae are unique from those of animals and are more virulent. The treatment, however, is similar to that for animal bites.

Copiously irrigate facial wounds from animal bites with isotonic sodium chloride solution, and excise any macerated or destroyed tissue. If the wound is less than 6 hours old and if the margins can be clearly delineated, the wound may be approximated and closed with fine interrupted sutures. If the wound is more than 6 hours old, depending on the degree of penetration and size of bite, closure of the wound is at the surgeon's discretion. Animal bite wounds of this duration are extremely prone to infection and, if closed, have a higher rate of wound dehiscence.

Administer antibiotics in all cases of animal bites regardless of duration. Although antibiotics do not usually prevent local infection, they may avert fulminant sepsis.

The decision whether to administer rabies vaccine depends on the status of the animal. Whether the animal is a domesticated, immunized pet or a wild animal must be determined. Ideally, the animal should be caught, confined, and observed because the incubation period of the rabies virus is about 10-14 days in animals and 2-8 weeks in humans. If the animal shows signs of rabies, the patient can be treated within the incubation period. If the animal is found dead or is killed, a microscopic examination of the brain for Negri bodies or the fluorescein antibody test is mandatory to determine whether the animal was rabid. If the results are positive, the patient must undergo the rabies vaccination protocol.

Gunshot wounds to the face

The first priorities with any gunshot wound are to establish a definitive airway, control any hemorrhage, and stabilize the patient.

Civilian gunshot wounds to the face generally result from recreational accidents, domestic violence, or suicide attempts. Gunshot wounds to the face range from small-caliber recreational BB gun pellets to full-scale shotgun blasts in which the facial soft tissue is obliterated.

Although the entry wound may appear trivial for small-caliber, low-velocity missile injury, the blast effect produced along the path of the missile can be devastating. Patients with this type of injury must be observed closely. If the bullet is lodged within the soft tissue with no functional deficit or major aesthetic defect, it may be left in place. If the wound becomes grossly infected or begins to cause significant discomfort, initiate surgical intervention with removal of the bullet and incision and drainage of the wound.

Through-and-through gunshot injuries or close-range shotgun wounds often produce associated maxillofacial bony injuries. These must be evaluated fully prior to any soft tissue repair. If facial fractures are present, consider rigid fixation first. Carefully debride unsalvageable soft tissue, heavily damaged bony fragments, and foreign bodies, and preserve and replace displaced viable soft tissues in their corresponding anatomic locations.

If the patient survives the initial injury, complete facial reconstruction procedures can often encompass a period of many years, depending on the extent of injury, the degree of infection, and the health of the patient.

WORKUP

Section 6 of 9  

• Authors and Editors
• Introduction
• Initial Survey and Evaluation
• Specific Anatomic Areas
• Animal Bites and Gunshot Wounds
• Workup
• Treatment
• Conclusion
• References

Although most soft tissue facial trauma consists of contusions, abrasions, lacerations, or a combination of these that require only a careful physical examination, more complex wounds benefit from radiologic studies that may reveal any foreign body implanted within the soft tissue or any underlying fractures that may complicate management. Order diagnostic studies only after determining that the patient is clinically stable. Defer studies if they may interfere with or delay clinical treatment.

• Radiographs
  • As in any trauma patient, first obtain cervical spine radiographs to exclude neck injury. (Include patients who are unconscious or alcohol intoxicated.)
  • Skull radiographs may also help to assess the degree of suspected skull fractures, although current recommendations lean toward head CT scanning for a more localized diagnosis.
  • Facial radiographs, including anteroposterior, lateral, submentovertex, Panorex, mandibular, Towne, and Waters views, are required if significant facial fractures are suspected.
  • Though quick and relatively inexpensive, radiographs lack 3-dimensional representation. Physicians must extrapolate the information presented to form a diagnosis.
• CT scanning
  • CT scanning is an excellent modality in diagnosing the more complex facial traumatic injuries and is invaluable in its ability to provide 3-dimensional relationships among the structures in question. Obtain both axial and coronal cuts of the facial skeleton.
  • In delicate and complex areas such as the eyes, obtain lateral oblique cuts through the globe to evaluate the bony architecture surrounding the orbit.
  • If necessary, 3-dimensional reconstructions can be made for a more detailed analysis.
  • The main disadvantage of CT scanning is the higher dosage of radiation exposure to the patient.
• Magnetic resonance imaging
  • As MRI has become more widely accessible and established in medical centers, it has proven beneficial in assessing traumatic soft tissue injuries.
  • In addition to its main advantage of operation without radiation, MRI also provides 3-dimensional information similar to CT scanning.
  • Because the device uses very powerful magnets, its disadvantages are in its danger of operation for patients with metallic implants (eg, pacemakers, mechanical heart valves) and its cost.
• Arteriography: In patients in whom extensive hemorrhage occurs with questionable source, arteriography serves as an excellent study to evaluate and isolate the source of hemorrhage or to exclude major vascular injuries.

TREATMENT

Section 7 of 9  

• Authors and Editors
• Introduction
• Initial Survey and Evaluation
• Specific Anatomic Areas
• Animal Bites and Gunshot Wounds
• Workup
• Treatment
• Conclusion
• References

Medical therapy

Antibiotics

The use of antibiotics depends on the mechanism of the facial injury (eg, animal or human bite, assaults, MVA), the degree of injury (superficial or extensive), and the immune status of the patient. Because infection of the face secondary to trauma can become devastating and can cause significant cosmetic and functional deformities, 24-hour prophylactic coverage with a cephalosporin is usually necessary. Approximately 10% of patients who are allergic to penicillin have an adverse reaction to cephalosporins. If this occurs, an aminoglycoside may be used.

Anesthesia

For facial lacerations that can be closed primarily, local anesthetic agents such as lidocaine (Xylocaine) 1% or 2% with epinephrine (1:100,000) are used. The vasoconstrictive effects of epinephrine provide for hemostasis and prolong the effect of anesthesia. Avoid epinephrine in areas with end arteries, such as the tip of the nose or the ear lobe, as it may induce irreversible vasoconstriction leading to necrosis. For injuries involving the nares, topical anesthetic agents applied to the nasal mucous membranes may be used. Cocaine (5%) is the agent of choice in this case because it is fast acting, has an intermediate duration of action, and can be introduced easily via cotton-tipped applicators or cotton gauze.

Surgical therapy

Timing

If possible, repair facial injuries within the first 8 hours of the initial insult. Tissues are less vulnerable to infection and the wound healing process is at its optimum during that time. Repair may be postponed for up to 72 hours if the patient is unstable, provided that he or she receives antibiotic coverage and that the wound is cleansed and dressed. If it is still not possible to repair injuries after 3 days, then healing by secondary intention becomes necessary, and subsequent scar revision might be indicated after secondary wound closure.

Location

Unless the injury is superficial and toward the periphery of the face, repair extensive facial soft tissue injuries in the operating room and not in the emergency department. Frequently, adult patients sustaining significant facial trauma from assault are intoxicated and combative, which complicates the delicate procedures required on the face. Treat such patients under general anesthesia. Similarly, for younger children, who are usually uncooperative, conduct operative treatment under general anesthesia.

Wound preparation

All forms of facial injuries, such as abrasions, lacerations, and avulsions, should be well irrigated with isotonic sodium chloride solution prior to any handling of tissue. This serves to cleanse and to provide better visualization of the wound. Carefully remove any lodged foreign body fragments to minimize disturbance to surrounding tissue. If any macerated or friable tissue is present, meticulous debridement of the affected areas may be carried out, provided that subsequent possible cosmetic deformities are considered and minimized.

If the injury extends through hirsute regions, such as the scalp, mustache, or beard, the hair may be shaved around the wound to facilitate suturing. The eyebrow, however, is never shaved. (Once shaved, the eyebrow may not grow back.) In addition, the form and contour of the eyebrow also serve as crucial positions for aesthetic symmetry and as important landmarks for repair. Mishandling of the eyebrow may result in difficult to correct defects of improper alignment, disproportionate growth, or both.

Wound closure

Close most facial wounds with fine sutures. If the wound requires closure in layers, fine absorbable 4-0 or 5-0 sutures may be used on the mucosa or muscles. Close the skin with nonabsorbable monofilament sutures. Subcuticular sutures may be used on conspicuous areas. Trim macerated or jagged wound margins before any closure.

Suture removal

The face has a very rich vasculature that promotes quicker healing. In areas where the skin is thin, as in the eyelids, sutures are removed in 3-4 days; elsewhere on the face, they are left 4-6 days. Sutures in children can be removed earlier due to their ability to heal quickly. Sutures in the ears are often left in place 10-14 days, especially with underlying cartilage injury, as scars over divided ear cartilage tend to thicken and spread when sutures are removed too early.

CONCLUSION

Section 8 of 9  

• Authors and Editors
• Introduction
• Initial Survey and Evaluation
• Specific Anatomic Areas
• Animal Bites and Gunshot Wounds
• Workup
• Treatment
• Conclusion
• References

Treat each patient presenting with significant traumatic facial injuries as a patient with general trauma, and strictly adhere to ATLS protocols to ensure optimal outcome. Though patients with facial injuries may appear extremely disfigured, these injuries are seldom life threatening; therefore, address traumatic facial injuries only after the patient is stabilized. Postoperatively, patients must be closely monitored to ensure proper wound healing, to provide reassurance, and to realistically address any concern the patient may have about functional and cosmetic facial disfigurements. This ensures successful treatment of the patient with facial trauma.

For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education articles Black Eye and Eye Injuries.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Initial Survey and Evaluation
• Specific Anatomic Areas
• Animal Bites and Gunshot Wounds
• Workup
• Treatment
• Conclusion
• References

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• Capan LM, Miller SM, Olickman R. Management of facial injuries. In: Capan LM, Miller SM, Turndorf H, eds. Trauma: Anesthesia and Intensive Care. New York, NY:. JB Lippincott;1991:385-408.
• Chole RA, Yee J. Antibiotic prophylaxis for facial fractures. A prospective, randomizedclinical trial. Arch Otolaryngol Head Neck Surg. Oct 1987;113(10):1055-7. [Medline].
• Edgerton MT, Kenney JG. Emergency care of maxillofacial and otological injuries. In: Zuidema GD, Rutherford RB, Ballinger WF, eds. The Management of Trauma. 4th ed. Philadelphia, Pa:. WB Saunders Co;1985:275.
• Goodstein WA, Stryker A, Weiner LJ. Primary treatment of shotgun injuries to the face. J Trauma. Dec 1979;19(12):961-4. [Medline].
• Gussack GS, Jurkovich GJ. Penetrating facial trauma: a management plan. South Med J. Mar 1988;81(3):297-302. [Medline].
• Karlson TA. The incidence of hospital-treated facial injuries from vehicles. J Trauma. Apr 1982;22(4):303-10. [Medline].
• Kersten TE, McQuarrie DG. Surgical management of shotgun injuries of the face. Surg Gynecol Obstet. Apr 1975;140(4):517-22. [Medline].
• Lindqvist C, Sorsa S, Hyrkas T. Maxillofacial fractures sustained in bicycle accidents. Int J Oral Maxillofac Surg. Feb 1986;15(1):12-8. [Medline].
• Linn EW, Vrijhoef MM, de Wijn JR, et al. Facial injuries sustained during sports and games. J Maxillofac Surg. Apr 1986;14(2):83-8. [Medline].
• Manson PN. Maxillofacial injuries. In: Siegel JH, ed. Trauma: Emergency and Critical Care. New York, NY:. Churchill Livingstone;1987:983.
• Marks MW, Smith DJ. Complications of traumatic wounds of the face. In: Greenfield LJ, ed. Complications in Surgery and Trauma. Philadelphia, Pa:. JB Lippincott;1989.
• McDade AM, McNicol RD, Ward-Booth P, et al. The aetiology of maxillo-facial injuries, with special reference to the abuse of alcohol. Int J Oral Surg. Jun 1982;11(3):152-5. [Medline].
• Seyfer AE. Maxillofacial and mandibular injuries. In: Feliciano DV, Moore EE, Mattox KL, eds. Trauma. 3nd ed. Norwalk, Conn:. Appleton & Lange;1996:291-306.

Article Last Updated: Dec 1, 2006