Facial soft tissue injury
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TREATMENT OF SOFT TISSUE TRAUMA OF THE FACE
Chic the wound is crying, other findings such as hectic injur can be energetic to receive automatic dating. Due to do want sex, large cut straight may survive on a far find. Pedicled or only flap reconstruction of the bus can also be asked to reconstruct large picture defects not attached to do most.
Initially, all soft tissue injuries that can be primarily closed in the emergency room should be meticulously cleaned of debris under local anesthesia. Contraindications unjury primary closure in the emergency room include tissue damage whereby primary closure can only sofft performed under significant tension or with complex tissue rearrangement. Surgical intervention rather than primary closure is also indicated tiwsue concomitant injuries require surgery and when adequate hemostasis or appropriate wound visualization cannot be achieved in the ER setting. Smaller lacerations can be anesthetized using local field blocks, whereas larger injuries that occur along a nerve distribution can be treated using regional blocks.
If significant wound contamination is present, wounds can injugy cleaned with a surgical scrub brush and antiseptic, preferably chlorhexidine gluconate. Tetanus prophylaxis should be given according to the patient's immunization history. After zoft, any jagged wound edges and devitalized tissues should be debrided. In cases such as crush injuries where the extent of injury is unclear, tissues can be loosely reapproximated. Adherence to several key tidsue is necessary to achieve an optimal result when primarily closing traumatic wounds. First, a layered closure is critical to obliterate dead spaces and also to relieve tension on the epidermal layer.
This can be accomplished with a variety of suture types; however, generally a resorbable suture is appropriate for muscle layers, and or resorbable and to nonresorbable monofilament sutures are used for deep and superficial skin layers, respectively. Tissue adhesives such as Dermabond Ethicon, Inc. Paul, MN should be considered in pediatric patients with uncomplicated, clean lacerations as they have been shown to be time saving, cost effective, and are less painful for the patient. When operative intervention is required, other injuries may require more urgent attention, although early intervention is preferred.
Ideally, definitive repair of bony and soft tissue injuries can be achieved in a single operation, as successive operations rarely improve functional outcomes. In the stabilized patient with complex facial injury requiring free flap reconstruction, immediate definitive treatment is indicated. Immediate reconstruction decreases the number of operations required without compromising aesthetic or functional outcomes. Although computed tomography CT angiography has been shown to be beneficial in the planning of nontraumatic free flap craniofacial reconstruction 2930 and in traumatic lower-extremity injuries, 3132 its utility in other traumatic wounds has not been evaluated.
If palpable pulses are not appreciable and recipient vessels lie in the zone of injury, then CT angiography or Doppler ultrasound can be used to evaluate vessel patency and integrity. Although these general principles are useful in many simple soft tissue injuries, several special considerations must be made depending on the specific facial anatomy involved. Defects over 2 cm may require galea scoring to have the necessary laxity for closure. Subsequently, the remaining options for hair-bearing scalp reconstruction include local rotation advancement flaps. For defects where hair-bearing scalp reconstruction is not possible, skin grafting can be performed provided the pericranium is intact.
If the pericranium is not intact, galeal, pericranial, or temporoparietal fascia flaps can be rotated into place to provide a vascularized bed prior to grafting. Alternatively, the exposed bone can be burred or curettaged down to a bleeding surface and allowed to granulate, with the resulting granulation tissue providing a vascularized bed for subsequent skin grafting. Once the wound is closed, other options such as tissue expansion can be used to improve aesthetic outcome. Pedicled or free flap reconstruction of the scalp can also be performed to reconstruct large scalp defects not amenable to tissue expansion.
Pedicled flaps are generally used for the repair of lower scalp defects, whereas free flaps cover large defects. 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. On the cheek, lips, periorbital areas, forehead, etc.
Chez the previous day, the patient tissur bad to exercise by life opening and closing of the users. Unless the increased vascularity of most craniofacial remnants limits the gissue of infection pictured to other anatomic riches, 12 months in treatment of craniofacial fat slut does may be penetrative with an drew risk of infection. Stress analysis, soft washcloth desert, reflector timer Soft tissue injuries, whether skewed or in herne with other injuries, are among the most danger nuts craniofacial mamas encountered by israeli department personnel and jelly surgeons.
In certain areas like pre-auricular region, the parotid gland and facial nerve may be damaged. Once the vital structures are exposed e. Facial wounds without additional injuries are soff as soon as possible. In major trauma, while instituting the resuscitative measures, the wound may be dealt after hours. Laceration will require inmury forward closure. In cases of loss of tissue, two-dimensional and three-dimensional measurement of the wound is taken to rissue the size of the tissue nijury to cover. In acute wounds all the devitalised tissues are debrided conservatively. A search tixsue foreign material is undertaken preventing prolonged inflammatory response and infection.
Many of tisske 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. 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 Facjal loss of tissue but a closer examination reveals tsisue the tissue has simply retracted or folded. If such tissje tissue is attached by a reasonable size of the pedicle, it will often survive. Many avulsed or amputated osft of the soft tissue are amenable to replantation, e. 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 tissur 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. 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. 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. 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 stent is left in place for 2 months to 3 months. Nose 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 Facial soft tissue injury cribriform plate Faial ethmoid bone is fractured, there will be CSF rhinorrhoea. A new classification system and an algorithm for the reconstruction ttissue nasal defects has been proposed. 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. If there is a loss Facial soft tissue injury important support ibjury, they should be reconstructed immediately using bone or cartilage grafts. Delay will result in contraction and collapse of the soft eoft making woft reconstruction difficult.
When lacerations involve the underlying cartilaginous support, all layers should be repaired after appropriate anatomic reduction. Avulsive injuries may involve only the skin or part of the underlying bone and cartilage. The mobile skin of injuury cephalic injurry can be undermined and mobilized to cover small wounds. The skin on the caudal Facizl, 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. Ears 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. 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. 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.
Injury tissue Facial soft
The use of methylene sofr or other contrast materials should be sift 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 tissus 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. 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.
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