Facial, Eye, Nasal, and Dental Injuries

Timing of Repair

It is not necessary to repair facial wounds immediately. However, when possible, most wounds should be closed within 4 to 6 hours. The rate of infection in facial lacerations does rise significantly until after 24 hours, but the progressive tissue edema makes meticulous closure more difficult and therefore should be performed sooner rather than later. In the case of significantly contaminated wounds, it is appropriate to perform “delayed primary” closure after extensive débridement and a period of packing/cleansing over 24 to 72 hours to lessen the chance of infection. This procedure is usually only undertaken for extensive contaminated wounds that require closure in the operating room.

Healing by secondary intention is less than ideal for soft tissue injuries on the face unless significant tissue loss has occurred; the scar from primary closure of a laceration is significantly better than that of a similar wound left to heal on its own.

Anesthesia

Simple lacerations that are not full thickness through the epidermis will, at a minimum, require cleaning prior to treatment; thus a topical anesthetic cream can be considered. Topical anesthetic creams include a eutectic mixture of local anesthetics (EMLA): tetracaine, liposome-encapsulated tetracaine, and liposome-encapsulated lidocaine. However, most patients will require injection of a local anesthetic prior to definitive treatment of their wounds, and prior application of a topical anesthetic can deaden the pain of needle insertion to a small degree. This factor is probably most important in pediatric patients who have very little tolerance for pain before they become frightened, with a resultant need for sedation.

In most adults, local anesthetic injections are well tolerated without prior application of topical anesthetic cream and allow the wound to be treated in the most expeditious manner. The pain from local anesthetic injection evolves from both the acidity in the commercially prepared anesthetic (to prolong shelf life) and the dermal distension from the volume of the anesthetic. The buffering of local anesthetic with sodium bicarbonate in a 10% volume to volume can significantly reduce the perception of pain. However, even if buffered anesthetic is used, poor injection technique will result in significant pain. Local anesthetic solution should be injected with a 27-gauge or smaller needle. Experienced practitioners often do not let patients see the needle to be used, and recent studies have shown that visualizing the needle increases the perception of pain. The plane of injection should be in the subcutaneous tissue immediately beneath the dermis. The most common mistake is to inject anesthetic intradermally, which will be exquisitely painful as the pain receptors in the dermis distend. Whenever possible, the subcutaneous plane should be entered through an existing laceration, because pain is experienced when the needle enters through intact skin.

The use of an anesthetic combined with epinephrine is helpful both for increasing the duration of the anesthesia and for decreasing bleeding during wound repair. Epinephrine as dilute as 1:200,000 g/mL is as efficacious as more concentrated solutions in providing vasoconstriction. The onset of anesthesia after infiltration is rather rapid (<1 minute), but the vasoconstrictive effect is maximal after 20 minutes. Use of an anesthetic that contains epinephrine is safe in all areas of the face, including the ear and nose. The practitioner should not be concerned about ischemia of the tissue because the blood supply in the face is very robust.

Cleaning

All traumatic soft tissue wounds should be considered contaminated and require some degree of cleansing prior to treatment, the degree of which is determined by the extent of the wound. In partial-thickness wounds, copious irrigation is not required and a simple cleaning with moist gauze will suffice prior to bandaging or applying superficial sutures in a sterile fashion. In full-thickness skin lacerations, tap water has shown to be as effective as sterile solutions. Because the irrigation of wounds can be painful, an anesthetic should be infiltrated beforehand, which also provides time (a maximum of 20 minutes) for the vasoconstrictive effect of epinephrine. In extensive soft tissue injuries, pulsed irrigation provides the best treatment. The content of the irrigant is not as important as the pulsed method of delivery. In fact, the use of more concentrated antiseptics, such as hydrogen peroxide, can inhibit early fibroblasts, which are important in wound healing.

Choice of Closure

Wounds closed “primarily” result in better scars than those allowed to heal by secondary intention, because the opposed wound edges allow for direct healing. Although individual variations exist in the way a wound heals, there are clear distinctions between well-approximated wounds and those that are closed poorly. To obtain the finest scar, wound edges must be closed with minimal tension, edge eversion, and edge height match.

Partial-thickness lacerations (i.e., lacerations with at least a portion of the dermis still intact) have already met the criteria for primary wound healing; that is, the dermis is already opposed, has matched height, and will heal under no tension. Therefore sutures are not required and an occlusive dressing can be applied with excellent results. For full-thickness lacerations, a physical force is required to hold the wound edges in opposition. Because the dermis is the strength layer of the skin, classically it was thought that it needed to be held together with sutures. However, tissue glues, such as Dermabond, which only hold the more superficial epidermis together, have similar wound outcomes when compared with suture closure of simple lacerations.

As mentioned, simple lacerations can be closed with tissue glues. However, many practitioners are hesitant to use tissue glues for any wounds other than simple lacerations, because it provides a limited amount of control in managing the wound edges. When tissue glue is used, care must be taken not to apply pressure with the applicator (to prevent spread of the wound edges), which could allow glue to enter the space between the wound edges, resulting in delayed healing and a wider scar. Suturing of simple linear lacerations can be achieved with a single layer of sutures, as long as the sutures include both epidermal and dermal portions of the skin. However, a single layer of sutures means that the tension-bearing strength layer (the dermis) is included in the same suture throw as the edge height match and eversion layer (epidermis). If concern exists about proper wound approximation, it is easier to use two separate layers of suture: a deeper dermal layer to bear the strength of the closure and a more superficial layer to match the height and provide eversion of the epidermis.

Complex lacerations should be closed with two layers of sutures for the aforementioned reasons. The suture choice varies widely. For single-layer closure, permanent sutures should be used and removed at the appropriate time (discussed in the Postclosure Wound Care section). The use of 6-0 suture is preferred on the face, and no larger than 5-0 suture should be used. If a two-layer suture technique is to be used, a 4-0 or 5-0 absorbable suture such as Vicryl or PDS should be used for the deep layer.

Antibiotics

Traumatic lacerations anywhere on the body have an infection rate of 3.5%. Those on the head and neck have a significantly lower risk (1%), which is thought to be due to the robust blood supply in these areas. Factors that increase the rate of infection include the presence of diabetes mellitus, a wide laceration, and the presence of a foreign body. Given the low risk of infection, prophylactic antibiotics are not required for most small lacerations. However, after repair of soft tissue injuries, most plastic surgeons will prescribe a short course (5 to 7 days) of antibiotics that cover skin flora (e.g., cephalexin or clindamycin). However, there is a likely selection bias because plastic surgeons typically are consulted to treat larger wounds.

Postclosure Wound Care

If tissue glue has been used to close a wound, nothing should be applied to the hardened glue, because water or petroleum will cause the glue to fall off the wound sooner than the expected (7 to 10 days). If sutures have been used to close the wound, a significant improvement in the scar outcome can be achieved by the constant application of petroleum-based ointments for the first 2 weeks. If preferred, an emollient that contains an antibiotic, such as Bacitracin, can be used for the first week after closure but no longer, because a small percentage of patients will experience a reactive dermatitis. If permanent sutures were used to close the wound, they can be removed as early as postclosure day 5 in areas under minimal tension. They should stay no longer than 7 days because “railroad” tracks tend to form with longer duration. However, sutures or staples used in the hair-bearing scalp should stay for 10 to 14 days because more time is needed in this thicker skinned area for healing, and “railroad” tracks will not be as visible (unless patient has the potential for future hair loss in the region).

After suture removal followed by a week of petroleum emollient application (for a total of 2 weeks), some further improvement in the ultimate outcome can be obtained with 2 months of silicone treatment ( Fig. 23.1 ). Silicone therapy can be applied either as sheeting (at night) or as a gel (during the day). To some patients, the added burden of silicone therapy may not be worth the small return. However, for most patients the ability to affect even a slight change in the appearance of their scar gives them a sense of control over something that has otherwise been out of their control. More recently, the application of paper tape over a scar has been shown to result in equal improvement in scar healing as in silicone therapy. However, silicone therapy remains the standard of care for managing scars.

In addition to silicone therapy, patients should be counseled regarding exposing newly formed scars to the sun. Beginning 2 weeks after repair or after full epithelialization of the wound, patients should apply sunscreen daily to prevent darkening of the scar. After this time, makeup also can be applied if desired. Sun protection is especially important on facial scars because they receive regular sunlight during routine activities.

A scar takes 6 months to fully mature, and patients should be counseled that the scar will evolve through a red, raised, indurated phase with telangiectatic vessel ingrowth that will progress to a softer, paler, less noticeable scar. In the case of hypertrophic or keloid scar formation, the patient should be referred to a specialist for possible early intervention.

Simple Lacerations

Simple lacerations can be closed by using one of many suture methods. The use of deep dermal sutures should be considered for simple lacerations with any diastasis of the dermis. Dermal sutures will minimize wound tension, reduce dead space, and, if placed properly, help with edge eversion. When placing deep dermal sutures, every effort should be made to start and end at a point farthest from the surface of the skin. Care must be taken to match the entry and exit points of the suture on both sides of the wound ( Fig. 23.2 ).

Cutaneous closure can be performed with the use of tissue glue or various methods of cutaneous suture techniques. When using a cutaneous (epidermal) suture technique, the practitioner must take care to properly place the suture with equal distribution of wound edge tension and create everted wound edges ( Fig. 23.3 ). In time, an everted wound edge will deflate, leaving a flat scar. If a wound is closed with no eversion, contractile forces will result in a depressed or widened scar ( Fig. 23.4 ). A common mistake is the placement of cutaneous sutures too far from the wound edge, which results in telltale suture marks (train tracks) from pressure necrosis.

Complex Lacerations

Any laceration that is more complicated than a simple linear cut is considered complex. The practitioner must maintain the same goals of minimizing tension, everting wound edges, and matching the edge height. These goals can be more difficult when the edges converge, akin to pieces of a puzzle, instead of being two parallel lines. In these cases, using the “known to unknown” principle can work well. Often a jagged edge can be matched to its sister portion of the wound. Once a few “known” areas are worked together, the final result can be enhanced to a degree better than expected ( Fig. 23.5 ). The practitioner must resist the urge and tendency to prune any edges of the laceration that may not seem viable. Most skin attached to the patient will survive, and if it loses its viability, it can always be trimmed later.

Many traumatic lacerations can occur at oblique angles to the skin surface, causing a skive-type laceration. These lacerations can be difficult to repair well because differing amounts of dermis and epidermis are present on the opposing edges of the laceration. In this type of laceration, the use of a single cutaneous layer of suture may be best to ensure that the edges match appropriately. Placing deep dermal sutures will often result in superficial edge mismatch, which is difficult to correct with the superficial layer.

Lip Lacerations

Repairing a lip laceration can be a challenging task. The lip is vital in speech, food intake, and appearance. A detailed discussion on the aesthetics of the lips is beyond the scope of this chapter, but it is important to understand the fundamentals. The lips are separated into the white lip and the red lip. The red lip is further divided into the dry and wet portions, with the separation being where the lips make contact. The junction of the white and dry red lip is referred to as the anterior vermilion border, and the junction of the dry and wet red lip is referred to as the posterior vermilion border ( Fig. 23.6 ). The anterior vermilion border is the most important landmark to reestablish during closure because a 1-mm discrepancy in edge match will be noticeable at a normal talking distance. Edge eversion is also important in lip closure because the mobile lips tend to form depressed scars if they are closed without eversion. If muscle is involved, referral to a plastic surgeon is recommended.

Intraoral/Tongue

Tongue lacerations are common in sports and can cause a significant amount of bleeding as a result of the tongue's abundant vascularity. Immediate first aid includes controlling bleeding through the application of compression with moist gauze inside the mouth. Vicryl sutures are preferred for the tongue. Simple suture repair will often tear through the tissue because the tongue is predominantly muscle, and hence the use of either vertical mattress or horizontal mattress sutures is preferred. If the laceration is deep, referral to a specialist is often warranted.

Lacerations of the intraoral mucosa, such as the inner lip or cheek, are treated identically as external facial lacerations with regard to anesthetization, cleansing, and closure. A soft absorbable suture is preferred for patient comfort and obviously will not require removal.

Lateral Face Lacerations

A physician treating any deep laceration lateral to the lateral canthus needs to ensure function of the facial nerve. Any injury to the facial nerve in this area is possibly treatable with early surgery (within 3 days) to reanastomose the nerve ( Fig. 23.7 ).

Soft Tissue Ear Injuries

Most injuries to the ear are simple lacerations that do not involve the underlying cartilage and can be sutured in a single layer. If the underlying cartilage is involved, it is important to reapproximate the cut edges. A nonbraided absorbable suture such as PDS or Monocryl is the most effective suture to use for the ear.

An auricular hematoma is another common injury of the ear. Untreated, it can lead to formation of a “cauliflower ear,” which is commonly seen in wrestlers. This complication occurs because the blood supply to the cartilage is dependent upon the overlying perichondrium. A hematoma develops as a result of a shearing injury that separates the perichondrium from the cartilage, with the cartilage subsequently resorbing over time. To prevent this phenomenon, the hematoma needs to be drained and the perichondrium needs to be held fast to the cartilage for a week with use of a pressure bolster. These injuries are best treated by a specialist because of the risk of recurrence.

Periorbital Lacerations

Any wound deeper than a superficial eyelid laceration is best treated by either a plastic surgeon (a face specialist) or an ophthalmologist. The many lamellae and muscles of the eyelids require precise, layered closure of the lid structures.