SOFT TISSUE INJURIES OF MAXILLOFACIAL REGION

SOFT TISSUE INJURIES OF ORAL AND
MAXILLOFACIAL REGION
1/15/2020 SPHMMC, OMFS 1
Presenter: Dr. Maryie A.( OMFS-RII)
Moderator: Dr. Yordanos (OMFS-Consultant)
Dec , 2012 E.C

OUTLINE
• Objective
• Introduction
• Etiology and mechanism of injury
• Initial evaluation
• Types of soft tissue injuries
• Management of Special Anatomic Units
• Postoperative wound care
• References

OBJECTIVES
• Discuss the evaluation and management of soft tissue injury

INTRODUCTION
• Soft Tissue Injuries
• i.e. skin, sub-cutaneous tissues, fat, muscles, nerves, blood vessels,
ligaments, tendons, cartilage, hair and mucous membrane in any part
of the body.
• In the United States, over 11 million traumatic wounds are treated in
emergency departments each year.
• Facial lacerations account for approximately 50% of these wounds,
with motor vehicle collisions being the most prevalent cause of soft
tissue damage to the face.

• Goals of treatment are to achieve a repair without infection and to
minimize scarring.
• Because of the rich vascularity of the face there is no “golden period”
for suture repair of facial wounds.
• Ideally, closure of facial soft tissue injuries should occur within the
first 8 hours after injury.

ETIOLOGY AND MECHANISM OF INJURY
• Blunt injuries (MVA, falling)
• Penetrating injuries (Missile, gunshot, stab)
• Bite injuries (human & animal)
• Burn

INITIAL EVALUATION
 ATLS principles
 Hx: mechanism of injury, duration
 P/E
• All wounds should be evaluated
– depth, size, status of the wound for contusions, abrasions, crush
injury, viability of the wound edges, and contamination.
– should be kept moist with gauze soaked in an antibiotic solution
until final management

• Evaluate vital structures
– VII, XII, and sensory branch of the V
– Parotid gland and duct injuries
• Vessels
– Completely transected facial vessels
• bleeding stops spontaneously
– vessels become occluded with thrombi and compressed by
the enveloping hematoma.
– With an incomplete laceration of an artery
• a propensity for continued hemorrhage …..
possibly producing compression of vital structures
and potential airway compromise

• Assess for concomitant intracranial, craniofacial, ophthalmologic,
and cervical spine injuries.
– must be excluded by careful clinical and radiographic
examination

 WOUND CONTAMINATION
• Wounds can be divided into two groups, clean and contaminated
• Clean: fresh lacerations of the skin .. No Prophylactic antibiotics
• Contamination
– usually via Streptococcus and Staphylococcus spp. on the skin of
the face
– multiple types of bacteria if the mucosal layers are violated
– increases rapidly and is directly related to the length of time

• Contaminated Wounds
– through and through lacerations from the skin through the
mucosal layers (oral cavity and pharynx)
– Crushing of tissue, the embedding of foreign bodies or soil
– infectious inoculum must exceed 105 organisms/g of tissue for
G+ve & G-ve aerobic bacteria.
• critical number for anaerobes has not yet been determined

 Risk factors for wound infection
 Mechnism of injuries
impact injuries = 100x shear forces
 location of the injury
oral cavity = 2x maxillofacial region

 WOUND DÉBRIDEMENT
• A conservative approach should be the rule in débridement of facial
wounds.
– should be limited to devitalized tissue and tissue that is stained by
road tar or contains dirt or other particles

• Indications for Removal of Foreign Bodies from Soft Tissue

• Copious Irrigation
– irrigants should be delivered with a fluid jet impacting on the
wound with 7 lb/psi (< 15 Ib/psi)
– by forcefully expressing saline from a 35-mL syringe through an
18-gauge needle
– 50 to 100 mL per cm of laceration length
• pulsatile type of irrigating device
• Scrubbing with a scrub brush or no. 15 blade ….. increase wound
inflammation??

• A good rule is to avoid irrigating the wound with any solution that
would not be suitable for irrigating the eye.
• Toxic materials, such as alcohol, hydrogen peroxide, and
benzalkonium chloride, and strong soaps, such as those containing
hexachlorophene or povidone iodine
– should not have direct contact with the open wound cellular
damage and necrosis

• 1% Povidone-iodine OR 3% H2O2 diluted 1:1 should not be used
routinely to cleanse a wound
– actually impedes wound healing and has poor bactericidal activity
– does not appear to harm wounds protected by mature
granulation tissue but is toxic to fibroblasts
• unless diluted more than 1 : 100, at which point it has
minimal, if any, bactericidal activity

• In otherwise healthy patients, Dire and Welsh found no statistical
difference in infection rates when wounds were irrigated with normal
saline, 1% povidone-iodine solution, or a nonionic detergent (Shur-
Clens).

• Photographic records be obtained for insurance and legal purposes.
– before final treatment of the wounds and after cleansing of the
skin
– Follow-up
• assess healing and scar maturation and the necessity for future scar revision
• Repair of soft tissue wounds may be done with the patient under LA
or GA, depending on circumstances.
– If injuries are extensive, GA is indicated

 Tetanus prophylaxis
• Assess

 Antibiotics prophylaxis
• American College of Surgeons recommend for Trauma Patients

• Guidelines for Administration of Antibiotics to Trauma Patients
– Administer immediately on arrival at the emergency room
– Administer the antibiotics IV
– Dose at twice the t 1/2 of the antibiotic
– Discontinue the antibiotic at the end of surgery unless persistent
contamination is anticipated (e.g., salivary leakage)

TYPES OF SOFT TISSUE INJURIES
 CONTUSIONS
• usually by blunt trauma
• results in edema and hematoma formation in the subcutaneous
tissue
• Antibiotic cover & ice pack
• Hematoma
– usually resolve without necessity of treatment
unless it is large or becomes infected

 ABRASIONS
• Shear forces that remove a superficial layer of skin
• Painful expose reticular layer of dermis
• Gently cleansed and irrigated with NS
• thin layer of topical antibiotic ointment
– minimize desiccation and secondary crusting of
the wound
• Reepithelialization
– complete in 7 to 10 days

• Prevent traumatic tattoo
• clean small particles, dirt, grease, carbon, and other
pigments from the dermal layer
• Exposure of abraded skin wounds to excessive
sunlight during the first 6 months after injury may
cause permanent hyperpigmentation.

 LACERATIONS
– sharp injuries to the soft tissue
 Simple Lacerations
 Stellate Lacerations/Ragged lacerations
• blunt crushing trauma
• usually have a contused portion
 Flaplike Lacerations
• involve significant undermining of the soft
tissue, usually at the subcutaneous tissue
or supraperiosteal level, without loss of
tissue.

 Rx
 Anesthesia
 Cleaning of wound
 Removal of foreign bodies
 Debridement
 Hemostasis
 Closure in layers
 Dressing
 Prevention of infection
 Pain control
 Follow-up

• DELAYED PRIMARY WOUND CLOSURE
• May be indicated
– if a patient is seen late with extensive facial edema or
subcutaneous hematoma
– a crushing type of injury
– wound edges that are badly contused or devitalized
– increased risk of infection
• Limited débridement to remove devitalized tissue, moist dressings,
and antibiotic therapy ……. until definitive treatment

• Fig. Delayed primary closure of facial wounds following car-versus-pedestrian
injury.
• Wound is cleaned and debrided as required. Abrasions have been cleaned.
• Following deep sutures, the wound is now ready for skin.
• Following skin closure the wound is protected with an antibiotic cream
(chloromycetin). The routine use of this is controversial

 AVULSION INJURIES
• Actual loss of tissue in facial wounds
is fairly rare.
• If small areas of tissue are missing,
simple local undermining of the skin
may provide for primary closure
without tension on the wound
margins

• If there has been a notable loss of tissue and
the wound cannot be closed free from tension
with local undermining
– the raw surface should be covered with a
skin graft, local flaps, or apposition of the
skin margin to the mucous membrane.
• Under no circumstances should a wound on
the face be allowed to heal by secondary
granulation tissue because of excessive scar
formation

• FIGURE 21-16
 An avulsive injury involving the upper eyelid, eyebrow, and scalp with loss of soft
tissue so that primary closure was not possible.
 A split-thickness graft was obtained from the anterolateral area of the neck (skin
is similar in color and texture)
 The thinner the graft used, the quicker the graft will vascularize and survive. The
graft is secured with interrupted 6-0 sutures and a pressure dressing is applied.

Animal and Human Bites
• Dog bites are most common in children and the midface is frequently
involved.
• Cat bite twofold higher risk of infection than the more common dog
bite wounds.
– usually cause puncture wounds, they are difficult to clean.
• Human bites
• Incidence of infections ranges from 4% of facial injuries to 50% of
bites to the hand.

• Evaluation
• time of the bite (wild or
domestic)
• whether the attack was
provoked or unprovoked
• number of bites and/or injuries
• Radiographs
– if there is considerable edema
about the wound or if bony
penetration or foreign bodies are
suspected.

• Microbiology: polymicrobial
• Dog bite: Pasturella multocida, Pasturella canis, Streptococcus
species; Staphylococcus species and Capnocytophagia canimorus
most common
• Cat bite wounds: P. multocida, Bartonella henselae, Streptococcus,
and Staphylococcus species
• Human bites: Streptococcus and Staphylococcus species as well as
anaerobic bacteria Eikenella, Fusobacterium, Peptostreptococcus, and
Prevotella.

• Classification of Facial Bite Injuries

• Treatment
Protocol For
Common Facial
Bite Wounds

• Antibiotic prophylaxis
• Amoxicillin clavulanate is the current drug of choice for bite wounds.
• Allergic to penicillin: fluoroquinolones or clindamycin in combination with
second- or third-generation cephalosporins.
• Azithromycin is probably the most appropriate choice for penicillin-allergic
pregnant women or children
• For wounds that present after 24 hours of injury, Streptococcus and
Staphylococcus species
– penicillinase-resistant antibiotic should be chosen

• Rabies is a serious consideration with any animal bite
• Rx
– Postexposure rabies prophylaxis
• must begin immediately 20 IU/kg (0.133 mL/kg) of rabies
immune globin (RIG), in and around the site of the wound
• Rabies vaccine in five doses IM on the day of the attack and
on days 3, 7, 14, and 28 after the attack

FACIAL BURNS
• Burn injuries can be categorized into thermal,
chemical, radiation, and electrical types.
• Evaluation
• Airway evaluation
– Fiberoptic
• Initial ABGs and CXRs
– carbon monoxide poisoning
• Oropharyngeal exam
• Ophthalmology examination
• extent and depth of burn
FIGURE 28-6 Burn assessment—the rule of
nines.

• Burn injury
• First-degree burns (e.g., sunburn)
– the most superficial and involve the outer
epithelium, sparing the dermis.
– usually cause no permanent injury and
resolve in 3 to 6 days.
• Second-degree or partial-thickness burns
– frequently form bullae, and are
exquisitely painful.
– epidermis and outer dermis are
affected

• 3rd degree or full-thickness burns
– epidermis and entire dermis are damaged
– wounds are dry and appear pearly white or charred, or resemble
parchment.
– Resurfacing and grafting are necessary for wound closure

• Rx
• Any patient with 20% to 25% of TBSA
– support with IV fluids
– Foley catheter to monitor urine output
– placement of a NG tube because of the risk of intestinal ileus
• Analgesia
• Small burns (2% to 3% of the body surface area)
– use of cold water soaks
• if instituted within 10 to 15 minutes of injury, may reduce the
extent of tissue damage and pain
• tetanus prophylaxis is mandatory in all burn patients.

• Larger burns
– Direct tissue cooling is contraindicated … hypothermia & cardiac
arrhythmias
– topical antimicrobials are the mainstays of treatment
• the most serious offenders are G-ve bacteria, with Pseudomonas aeruginosa
being the most frequent
• 0.5% silver sulfadiazine (choice), 0.5% silver nitrate, and
mafenide acetate
– wet to dry dressings
– frequent débridement

• SCALP & FOREHEAD
• Five layers
• Scalp lacerations frequently
bleed profusely
• evaluated for possible
accompanying skull fractures
and intracranial trauma.
MANAGEMENT OF SPECIAL ANATOMIC UNITS

• Simple laceration
• Débridement, hemostasis and primary closure
• Scalp lacerations with defects 3 cm can be
closed primarily in most cases.
• It is unnecessary to shave the hair from the
region, but scissors should be used to trim the
hair in the area around the laceration.
• Larger defects may require galea scoring to
allow laxity for closure

• Larger defects
– local rotational or advancement flaps
– skin grafts provided pericranium is intact
– burring the outer table when pericranium absence exposes
bleeding bone to allow granulation tissue to form a vascular bed
for skin grafting
– rotation of adjacent intact pericranium, galea, or temporoparietal
fascia for a vascular base for skin graft coverage

• Hair Apposition Technique (HAT)
• Small superficial scalp lacerations
• Cleaning, débridement, hair on both sides of a laceration is apposed
with a single twist.
• It is then held into position with tissue adhesives
• may not be suitable for
– Severely contaminated wounds
– actively bleeding wounds
– patients with hair strands shorter than 3 cm

• EYELID
• evaluation for possible injury to the orbit, globe, and punctal and
canalicular systems
 Skin
 Orbicularis oculi muscle
 Tarsus
 septum orbitale
 tarsal (meibomian) glands
 conjunctiva

• Two categories of Lacerations of the eyelids
• Simple lacerations
• lower lid lacerations
– anatomic approximation- prevent ectropion
• upper lid lacerations
– levator aponeurosis integrity- prevent postoperative
ptosis
• Medial lid lacerations
– evaluation of the lacrimal ducts and
canaliculi and appropriate ophthalmologic
consultation for repair

• Marginal through and through lacerations
– Landmarks: lash line, meibomian gland
orifices, and gray line
– débridement with minimum tissue removal
– Layerd closure
• 5-0 and 6-0 plain gut for conjunctiva and
orbicularis
• 5-0 or 6-0 fast-absorbable plain gut or 6-0
nonabsorbable sutures for skin closure
• Suture remove in 48 to 72 hours to prevent suture
tracks of epithelium

• Avulsive injuries to the eyelids
– can be repaired primarily if the horizontal
length is 25% of the upper lid or one half of
the lower lid
– Complete or near complete avulsion of upper
and/or lower eyelid defects require switch
flaps, composite flaps, cheek flaps, or forehead
flaps.

• NOSE
• Septal hematoma
– small mucosal incisions or by needle
aspiration
– Nasal packing or Silastic nasal splints
– A running 4-0 chromic suture is placed
through and through the septum to
prevent recurrence.
– If untreated, septic necrosis of the
cartilage ….. destruction and collapse of
the septum ….. Saddle nose

• Lacerations of the skin of the nose
– inspection
– débridement
– Suture with 6-0 nylon or other nonabsorbable sutures
– remove in 3 to 5 days and adhesive tape should be used to
maximize the cosmetic result
• Partial avulsions and through and through lacerations
– mucosal layer with fine absorbable sutures
– skin with 6-0 nylon sutures
• Avulsive wounds of the nose may require skin grafts.

• LIP
• Identification and marking of key landmarks such
as the vermillion border, Cupid’s bow, and
commissure prior to injection of LA
– thorough irrigation and wound debridement,
closure of skin (4-0)
• lip mucosa only
– Irrigation and debridement closure with 3-0 or
4-0 chromic gut
• Through and through lip lacerations
– should be closed from inside out

• In avulsive injuries to the lips: Quantity
• 25% of the upper lip and up to 25% of the lower
lip can be lost without resultant functional or
aesthetic defects.
– tissue margins should be straightened, with removal of
a full-thickness wedge of lip tissue to facilitate closure
• lip switch procedures
• Bilateral and unilateral Karapanzic flaps
– defects greater than one half the lip length
• Significant loss of upper and/or lower lip
– create lip tissue from distant free tissue transfer (radial
forearm and anterolateral thigh (ALT))

• EAR
• otoscopic examination
• Hematomas
• aspirate with a fine needle or small
incisions
• Fibrosed hematoma … a thickened ear,
known as a cauliflower ear. Placement
of compression sutures eliminates dead
space and prevents recurrence.

• Lacerations of the ear typically involve both skin and
cartilage
• Debridement of cartilage should be kept to a
minimum
• require skin closure only
– Permanent nonabsorbable sutures except in
young children and infants

• Complex lacerations that lack support from
cartilaginous injury require cartilage sutures.
– Absorbable monofilament 5-0 sutures
– apply a contouring bandage for 5 to 7 days
• support and prevent hematoma or serosa
formation under the skin

• In avulsive injuries involving segmented
portions of the external ear that are
missing or attached only with a small
pedicle flap, the tissue should be
returned to proper anatomic position
and secured with sutures to the skin.
• Partial loss of ear skin can be repaired
with split-thickness skin grafts taken
from the contralateral ear postauricular
skin

FIGURE 15-16. A, Conversion of a defect to a wedge. B, The use of
Burrow’s triangles. C, Conversion of a defect to a star.
If the avulsed segment is 1 cm or less
it can be reattached and allowed to
revascularize

• Total amputation of the external ear is a difficult repair and
reconstruction problem
– implant-retained auricular prosthesis
– use the “pocket principle” described by Mladick and coworkers
• The detached ear is dermabraded to remove the superficial
dermis and reattached to the stump
• buried underneath a skin flap elevated in the posterior
auricular region to provide vascular supply to the
reattached ear.
• 2 to 3 weeks later, the revascularized ear is uncovered and
allowed to reepithelialize.

• PAROTID DUCT
• The parotid duct exits the gland anteriorly, runs along the superficial
portion of the masseter muscle, and penetrates the buccinator to
enter the oral cavity opposite the upper second molar.
FIGURE 21-43 The parotid duct is typically found
along the plane from the tragus of the ear to the
middle of the upper lip.

• Rx of parotid duct injury depends on the site of the
injury
– If the injury is anterior to the masseter and the distal
portion of the duct cannot be located, the duct may be
drained directly into the mouth.
– If the injury is over the masseter muscle, the distal and
proximal portions may be connected using a stent.
– If the injury is within the parotid gland, treatment should
include closure of the parotid capsule and application of a
pressure dressing.

• Lacrimal probes are useful in cannulating the duct and identifying injuries.
• A Silastic catheter is placed to bridge the defect.
• The severed ends are then sutured (6-0 nylon) over the catheter, which is
left in place for 10 to 14 days
• sialagogues, such as lemon drops, to prevent scar formation at the
anastomosis site
• prophylactic antibiotics, such as penicillin or cephalothin, should be used

• If the parotid duct cannot be repaired after traumatic laceration,
several treatment choices are available.
– Ligation of the duct …. temporary swelling and may develop as a
chronic source of infection.
– If possible, the proximal duct stump should be mobilized and
diverted into the mouth in the oropharynx.
– Irradiation of the gland to destroy its function is a last resort.

• Facial nerve
• loop magnification or operating microscope
• A nerve stimulator- nonparalyzed patient under GA
(48 to 72 hours)
• Proximal facial nerve injuries posterior to a
vertical line drawn from the lateral canthus
should be repaired using microsurgical
techniques.
• Because of the significant peripheral
anastomoses, repair of facial nerve injuries
involving distal branches anterior to the
canthal plane is unnecessary
FIGURE 15-3. Zone of arborization of the facial nerve.

POSTOPERATIVE WOUND CARE
• Cleanse wound twice daily using half strength hydrogen peroxide to
prevent crusting
• A topical antibiotic ointment should be applied after each cleaning
until sutures are removed or resorbed
• Antibacterial mouthwash (eg. chlorhexidine gluconate 0.12% ) 3X
daily after meals for 1 week for intraoral lacerations
• Saline nasal rinses for nasal mucosal injuries
721/15/2020 SPHMMC, OMFS

• The timing for nonabsorbable suture removal depends upon the
location
– Forehead, cheek, and chin - 5 days
– Eyebrow and nose – 3 to 5 days
– Eyelid - 3 days
• Patients should avoid sun exposure for the first 6 months after the
injury to avoid hyperpigmentation of the areas.

REFERENCES

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SOFT TISSUE INJURIES OF MAXILLOFACIAL REGION

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