Most people equate oral & maxillofacial surgeons as your wisdom tooth, dental implant, and broken jaw expert, but we are also one of the key experts in managing acute soft tissue trauma. With up to two years of general surgery training during residency, close work with plastic and reconstructive surgery, and our hard tissue expertise, we are often the first to be called for all aspects of facial trauma. On a personal level, I find that treatment of the acutely injuried person is one of the most rewarding aspects of our field. I hope that you find this lecture useful.

1. George P. Hatzigiannis DMD, MD
Management of Soft Tissue
Trauma in Maxillofacial Surgery
George P. Hatzigiannis DMD, MD
Diplomate, American Board of Oral & Maxillofacial
Surgery
Dr. George PC

2. George P. Hatzigiannis DMD, MD
Introduction
Most important
presenting part of
human body
Goal is to achieve
optimal cosmesis while
preserving & restoring
function
Facial soft tissue
injury common with a
variety of mechanisms

3. George P. Hatzigiannis DMD, MD
Outline
Anatomy & physiology of skin
Physiology of wound healing
Initial management
Principles of repair
Suture materials
Technique
Adjunctive treatments

4. George P. Hatzigiannis DMD, MD
Skin Anatomy
Thickness (neck >
eyebrows > upper eyelid)
Epidermis
Stratum corneum
Stratum granulosum
Stratum spinosum
Stratum germinativum
Dermis
Superficial papillary
Deep reticular
Subcutaneous tissues

5. George P. Hatzigiannis DMD, MD
Vascular Anatomy
Superficial vascular plexus
Nutrient supply to skin
Superior aspect of reticular dermis
Deep vascular plexus (Subdermal
Plexus)
Musculocutaneous vs. direct
cutaneous arteries

6. George P. Hatzigiannis DMD, MD
Wound Healing
Inflammator
y Phase
Proliferative
Phase
Remodeling
Phase

7. George P. Hatzigiannis DMD, MD
Wound Healing

8. George P. Hatzigiannis DMD, MD
Inflammatory Phase
Platelet plug
Hemostasis, then
chemotaxis
Cytokine & growth
factor infiltration
PMNs first cells,
followed by
macrophages
Beginning of
angiogenesis

9. George P. Hatzigiannis DMD, MD
Proliferative Phase
5 days post-injury
Increased collagen
Wound contraction
(myofibroblasts)

10. George P. Hatzigiannis DMD, MD
Remodeling Phase
Beginning about 3
weeks
Vascularity
decreases
Scar paler
Final collagen
amount dependent
on initial volume

11. George P. Hatzigiannis DMD, MD
Initial Management
ABCDE of ATLS
Complete secondary exam
Hemorrhage control
Foreign bodies
Wound management

12. George P. Hatzigiannis DMD, MD
Hemorrhage
Airway risk
Common in midfacial injuries
Primary management is compression;
ligate visible vessels; selective cautery
Embolization vs carotid control

13. George P. Hatzigiannis DMD, MD
Foreign Bodies
Always assume foreign bodies
present!
Glass, bullets, road rash, etc.
Scrub with stiff nylon handbrush
Deep foreign bodies removed with
blade, snaps

14. George P. Hatzigiannis DMD, MD
Classification of Wound Cleanliness
Clean
May be closed primarily up to 48 hours out
No antibiotics
Clean contaminated
Oral cavity exposure
Contaminated
Crush injury, foreign body
Antibiotics advised

15. George P. Hatzigiannis DMD, MD
Soft Tissue Trauma
Hematoma
Abrasions
Traumatic
Tattoos
Puncture
Wounds
Bite Wounds
Laceration
Simple
Complex
Avulsions
Burns

16. George P. Hatzigiannis DMD, MD
Hematoma
Often the result of blunt trauma
SQ extravasation of blood
Expect spontaneous resolution
Exceptions: septal and auricular

17. George P. Hatzigiannis DMD, MD
Abrasions
Frictional injury
Skin surface loss is variable
Rx with thorough irrigation/cleansing,
topical antibiotic or antimicrobial ointment
until reepithelialization
Wound dessication may retard re-
epithelialization

18. George P. Hatzigiannis DMD, MD
Traumatic Tattoo
Foreign bodies embedded within
lacerations
Scrub wounds aggressively, copious
irrigation ? high pressure lavage
? Role of Dermabrasion to basal layer or
to superficial papillary dermis
May need to physically remove debris
from wounds; risk vs. benefit when vital
structures involved

19. George P. Hatzigiannis DMD, MD
Puncture Wound
Mechanism may preclude primary closure
Careful exam for retained FB
Radiographs useful to ID radioopaque FB
Copious irrigation
Healing by secondary intention

20. George P. Hatzigiannis DMD, MD
Bite Wounds
Heavily contaminated
Immediate irrigation, scrubbing and
debridement of devitalized tissue
Vast vascular supply to the face allows
primary closure of these injuries in many
cases
Most recommend antibiotics
Be cognizant of rabies infection potential

21. George P. Hatzigiannis DMD, MD
Laceration
Result from shear, compressive and tensile
forces
Closed in layers restoring structural integrity
Bury deep sutures to limit interference of epidermal
healing, which could lead to scar formation
Limit number of deep sutures because as FB can
potentiate infection
Deep sutures reduce dead space and limit hematoma
formation
Debridement of wound should be conservative
and reserved for nonviable/necrotic tissues

22. George P. Hatzigiannis DMD, MD
Soft Tissue Trauma
Avulsions
At first glance, facial injury often appears
avulsive (i.e. lip lacerations)
True avulsion not common in facial
region
Repair difficult on face because of
distinct anatomy and lack of excess tissue
Small superficial areas can be managed
with undermining & then primary closure

23. George P. Hatzigiannis DMD, MD
Principles of Repair
Timing
Prophylaxis
Tetanus, rabies, antibiotics
Materials
Technique

24. George P. Hatzigiannis DMD, MD
Timing
Primary
Majority of cases
Secondary
Rarely in face
Tertiary
Delayed primary
For contused/infected
areas

25. George P. Hatzigiannis DMD, MD
Tetanus Prophylaxis

26. George P. Hatzigiannis DMD, MD
Rabies Considerations

27. George P. Hatzigiannis DMD, MD
Rabies Considerations

28. George P. Hatzigiannis DMD, MD
The Reconstructive Ladder

29. George P. Hatzigiannis DMD, MD
General Principles of Wound Repair
Meticulous cleansing and preparation
is most important factor to avoid
infection
Remove all foreign bodies
“Square” wound margins to facilitate
closure
Surgically debride devital tissue
“Approximate, don’t strangulate”

30. George P. Hatzigiannis DMD, MD
Relaxed Skin Tension Lines

31. George P. Hatzigiannis DMD, MD
Wound Management
Direct scrubbing with a sterile surgical
sponge remove both bacteria and particulate
matter
Scrubbing contributes to tissue damage and
may reduce the ability of the wound to resist
infection
Consider high-pressure irrigation
Nonviable tissue may impair the ability to
resist infection; judicious debridement

32. George P. Hatzigiannis DMD, MD
Wound Cleansing Agents

33. George P. Hatzigiannis DMD, MD
Wound Management
Irrigation solutions
Normal saline solution remains the most cost-
effective and readily available choice
Detergents, hydrogen peroxide, and
concentrated forms of povidone-iodine
should not be used to irrigate wounds b/c of
tissue toxicity in open wounds
Never shave the eyebrow
Anatomic boundaries aligned first

34. George P. Hatzigiannis DMD, MD
Local Anesthetics

35. George P. Hatzigiannis DMD, MD
Wound Tension
Excessive tension may cause ischemia of the
wound edges leading to necrosis and scar
formation
Deep sutures placed properly can reduce
wound tension
Undermining of dermis and superficial fascia
will release these layers from deeper structures
Placing more sutures, closer together will
decrease tension exerted by each individual
suture

36. George P. Hatzigiannis DMD, MD
Undermining

37. George P. Hatzigiannis DMD, MD
Suturing
Approximate, not
strangulate
Avoid leaving dead
space

38. George P. Hatzigiannis DMD, MD
Suture Materials
Absorbable
Gut: significant tissue rxn with
minimal tensile strength used
mainly with mucosal surfaces,
Resorbs in 5-7 days
Chromic: significant tissue rxn
with better tensile strength,
tends to be stiff and can be
irritating to patient, resorbs in
10-14 days, perhaps less in
the mouth
Dexon (polyglycolic acid)
braided; less tissue reactivity
with increased tensile
strength, duration in tissues
approx 3-4wks

39. George P. Hatzigiannis DMD, MD
Suture Materials
Absorbable
Vicryl (polyglactin 910) braided; less tissue
reactivity with increased tensile strength, tends
to spit through wound during healing, do not
use dyed suture on face, lasts approx 4 weeks
in tissue
Maxon (polyglyconate) monofilament; minimal
tissue reaction with superior tensile strength,
found in tissues up to 4-5 or weeks or more
PDS (polydioxanone) monofilament; minimal
tissue reaction with significant tensile strength,
used where desire high degree of security,
duration in tissue up to 5-8 weeks

40. George P. Hatzigiannis DMD, MD
Suture Materials
Non-Absorbable
Nylon- (monofilament)
tend to unravel b/c
greater inherent
memory
Prolene- (monofilament)
significant memory, little
tissue reactivity may
allow it to slide out of
tissues easier (i.e. pull
out dermal closure)
Silk- (braided) greater
tendency for infection,
good knot security

41. George P. Hatzigiannis DMD, MD

42. George P. Hatzigiannis DMD, MD
Staples

43. George P. Hatzigiannis DMD, MD
Surgical Tape
Require the use of adhesive adjuncts
(eg, tincture of benzoin) that increase
local induration and wound infection
Tapes alone cannot maintain wound
integrity in areas subject to tension
Typically used after sutures removed
for 3-5 days to minimize wound tension
and allowed to fall off on their own

44. George P. Hatzigiannis DMD, MD
Tissue Adhesives
2-Octylcyanoacrylates (eg, Dermabond; Ethicon)
approved for use in the United States in August of
1998
Time required for laceration closure and the pain
associated significantly less for tissue adhesives
Should not be placed within wound, only on top of
epithelium
Apply at least 3 or 4 coats of 2-octylcyanoacrylate to
provide adequate strength; exothermic rxn so
excessive amounts can damage surface epithelium
Usually sloughs off in 7-10 days, Do not use with
topical Abx ointment because weakens the adhesive

45. George P. Hatzigiannis DMD, MD
Laceration Repair

46. George P. Hatzigiannis DMD, MD
Laceration Repair

47. George P. Hatzigiannis DMD, MD
Laceration Repair

48. George P. Hatzigiannis DMD, MD
Laceration Repair

49. George P. Hatzigiannis DMD, MD
Wound Closure
Knots tied on side of wound b/c
these are sites of debris
accumumlation which will contribute to
inflammation and scar formation of the
wound

50. George P. Hatzigiannis DMD, MD
Dog Ear Deformity

51. George P. Hatzigiannis DMD, MD
Suture Removal

52. George P. Hatzigiannis DMD, MD
Scalp Lacerations
Tend to bleed
profusely
Often associated
with large hematomas
which must be
managed
Hair removal not
necessary unless
interferes with closure
Can be closed with
sutures (6-8 days) or
staples (10 days)
■Head wrap used to prevent
post-traumatic hematoma

53. George P. Hatzigiannis DMD, MD
Scalp Injury
Control
hemorrhage
Evaluate for skull
fracture
Meticulous
cleansing of wound,
consider pressurized
irrigation
Layered wound
closure
Consider suction
drain George P. Hatzigiannis DMD, MD

54. George P. Hatzigiannis DMD, MD
Avulsive Scalp Lacerations
Control
hemorrhage
Status of
pericranium
Evaluate for
skull fractures
Skin graft with
intact pericranium
Flap procedure
if pericranium lost

55. George P. Hatzigiannis DMD, MD
Eyelid Lacerations

56. George P. Hatzigiannis DMD, MD
Wound Care

57. George P. Hatzigiannis DMD, MD
Scarring
Collagen fiber contracture responsible for
the degree of retraction of a wounds margins
Cicatrization is this process during wound
healing
Tissue tension will predispose the wound to
scar formation in addition to other factors
Lacerations perpendicular to RSTL heal with
wider scars than those parallel b/c of
dynamic forces on the wound

58. George P. Hatzigiannis DMD, MD
Techniques of Scar Revision

59. George P. Hatzigiannis DMD, MD
Thank You!