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Click photo to enlarge Cranio-Maxillo-Facial
Soft tissue injuries AN
INJURED FACE - A CHALLENGING PROBLEM
! Few
injuries are as challenging as the injuries of the face. Surgeons have a
dual responsibility : repair of the aesthetic defect and restoration of
facial functions. Not only is the regaining of the pre-injury appearance
important for the sagging self esteem of the injured patient but all
those functions of the various parts of the face which one takes for
granted in life like smiling, seeing, tasting, chewing, swallowing and
talking are effected and retrieving their pre-injury status is of
paramount importance. A
face is home to all the five sensory organs of the body as well as our
means of identity in the society. The most important part of the body
needs the attention of the most qualified persons in the health pyramid
as a prompt and definitive reconstructive programme, started as early as
possible, is the only deciding factor between a good result - which
should go unnoticed in the society, and an average result - which will
attract unwanted attention. Economic, sociologic and psychological
factors operating in a competitive society makes it imperative that an
aggressive, expedient, well planned and multi-deciplinary programme be
outlined, executed and maintained in order to return the victim to
active and productive life as soon as possible. A patient with facial injury often sustains other injuries as well, some of which may be life threatening, viz. Head injury, Chest injury, Spinal injury etc. and definitive care of facial injury must wait until these have been properly attended and treated. While motor vehicle accidents are the commonest cause of major facial injuries minor injuries can follow domestic accidents, trivial altercations and outdoor sports. At
the site of injury an injured victim if unconscious, should have his
airways cleared and head turned to one side. Bleeding should be
controlled by gentle pressure and an ambulance called for early
transportation to a hospital or a trauma centre. A conscious
patient should be reassured and made to sit up, if he can do so
comfortably, as they tend to bleed more while lying down. They should be
given nothing by mouth as they may require an emergency surgery which
may in turn require general anaesthesia. Every
management programme should start after ensuring that the victim has a
clear airway, is breathing properly and has a stable circulation.
Accompanying persons should be reassured and advised about voluntary
donation of blood for the victim if required.
Every injured patient should have a tetanus prophylaxis and an antibiotic
coverage and he or she should be made pain free as soon as possible.
A proper photographic documentation of the injury and a radiological assessment
of the facial skeleton is next on the agenda. With the advent of
CT Scans and more recently a new software which can produce a 3D CT image
of the facial skeleton, facial fractures can be best diagnosed by
this method whenever suspected. Now
is the time to gather the required multi-deciplinary team and to reassess
the patient and arrive at a diagnosis. Facial injuries can be injuries
to the soft tissues alone or a combination of soft tissue injuries and
facial fractures, or facial fractures alone. With a Plastic Surgeon as
the main anvil of the team, help can be sought from an ENT surgeon, a
Neurosurgeon or an Ophthalmologist depending upon the nature
of injury. Subsequently once the wounds have healed and the swelling
subsided the help of a prosthodontist for some missing teeth or an orthodontist
for minor problems in occlusion may be sought. Last but not the least,
the psyche of the injured person should never be forgotten and a friendly
Psychiatrist can do wonders by boosting his self esteem. Injuries in the face can be contusions, abrasions, lacerations, deep lacerations with underlying facial nerve or salivary gland / duct injury, avulsion of a part of the face, burn injury or ballistic injury with a through and through hole in the mouth. A simple black eye could be hiding a serious underlying fracture of the orbital floor or zygoma. A small puncture wound may be leading into the eye or even the brain. A small area of numbness or inability to chew with previous ease may actually be because of a jaw fracture. Because of such complexities in presentation this is not the domain of amateur interventionists. Every
part of the avulsed face or cut nose or amputated ear should be put in
a polybag, which in turn should be put in an ice box or a flask containing
ice and rushed to the hospital. If arteries and veins can be identified
under an operating microscope these pieces can be replanted, if they are
well preserved, and if the injury is fresh. Parents should realize that what they perceive as a small cut is, if nothing else, a cosmetic blemish. Yelling children should not be pinned down by overpowering relatives while an equally irritated doctor tries to put a few stitches in it in his own clinic in local or vocal anaesthesia. We need better preparation, better sterilization, better anaesthesia, better environment, better magnification and better suture materials for better results. Parents should also realize that, no matter what they read in magazines or hear in soap operas, no surgery has yet been invented in this world that does not leave any scars. Scar-less surgery is a myth, the fact is that we start scarring from the third month of our existence in our mother’s womb. We inherit the scarring qualities from our parents and none of us scar the same way. As a cosmetic surgeon our job is to camouflage the would be scars in the lines of facial expression so that they do not stand out in an animated face. Some suture-less surgeries are now available where skin sutures are being replaced by either strips of adhesive dressing materials or by a fibrin glue. These also leave behind scars and have in no way proved to be superior to a good suture technique. The decision to use them should certainly rest with the surgeon in charge. No
management programme is complete without a word about prophylaxis. Automobile
designers have come up with seat belts, padded dashboards, multi-laminated
windshield and improvement in the design of rearview mirrors and steering
wheels. Helmets for two wheelers is a must as is keeping a cool head on
the roads. In the end I can not stop myself from emphasizing that
- ‘ If you drink and drive, you are an idiot‘.
FACIAL
TRAUMA - TYPES
SOFT TISSUE INJURIES can be
With an overlying contusion, abrasion, ecchymosis, oedema, sub conjunstival haemorrhage an underlying fracture must be suspected. EXAMINATION
IN A SEQUENCE The following must be examined in sequence to avoid missing out on injuries which may leave behind serious cosmetic or functional handicaps:
TIMING
OF WOUND CLOSURE If
patient is seen in the Golden period, which is within 6 hours of trauma
then immediate repair is preferred. This is called Primary repair. In
the event of the following: ·
PATIENT SEEN LATE ·
EXTENSIVE SOFT TISSUE OEDEMA ·
SUBCUTANEOUS HAEMATOMA ·
CRUSHING
a delayed primary repair is chosen. In such a programme the unsatisfactory wound is subjected to: ·
LIMITED DEBRIDEMENT ·
WET DRESSING ·
ANTIBIOTICS ·
TRYPSIN / CHYMOTRYPSIN
before a delayed primary repair. PROPHYLAXIS
The
golden rule of debridement in the face is 'Err on the side of retaining
tissues that may not survive, rather than debride or destroy any that
might FACIAL
NERVE Theoretically
nerve repair need not be done anterior ·
IDENTIFY NAMED BRANCHES OF FACIAL N. ·
CAREFUL DISSECTION ·
FARADIC STIMULATION ·
MAGNIFICATION ·
MICRONEURAL REPAIR TRIGEMINAL
NERVE ·
SENSORY BRANCHES SMALL ·
APPROXIMATION IMPRACTICAL & UNNECESSARY ·
HYPOASTHESIA USUALLY REVERTS ·
INFRA ORBITAL ANAESTHESIA - CONTUSED NERVE PAROTID
DUCT The
duct lies somewhere in the straight line drawn from the tragus to the
philtrum. An injury at this level, paralysis of buccal branch of Facial
Nerve are two important criterion for suspecting Parotid Duct injury.For
repairing the duct: 1.
DISTAL END - CANULATE & IRRIGATE 2.
PROXIMAL END - EXPRESS SALIVA 3.
REPAIR UNDER MAGNIFICATION OVER STENT 4.
WOUND DRAINAGE LACRYMAL
SYSTEM
EYE The
eyes are perhaps the most important sense organs and need immediate
attention of the surgeon before a proper Ophthalmologic consultation.
Things not to be missed are: ·
VISION ·
RANGE OF EXTRA OCULAR MOTION ·
DIPLOPIA ·
PUPILS - SIZE & REFLEX ·
FUNDUS ·
INTRA OCULAR PRESSURE NOSE Being
the most prominent part of the face the nose is often tne site of injury
or bears the brunt. Bleeding from nose requires special attention to
rule out a concomitant Cerebro Spinal fluid leak. Once that is ruled out
nasal bleeding is addressed by anterior and posterior nasal packing. Lacerations and avulsions of
should
be addressed by ·
ALIGNING BONY /CARTILAGINOUS FRAMEWORK ·
ACCURATE APPROXIMATION OF LINING & COVER ·
USE SMALL AVULSED PIECES AS COMPOSITE GRAFTS ·
INTRANASAL PACKING ·
EARLY SUTURE REMOVAL AVULSED
WOUNDS Avulsed wounds of face can be with or without soft tissue loss. Those without soft tissue loss only require accurate approximation in three diamensions. Those with soft tissue loss can be best treated by replanting the avulsed part if a good vascular pedicle is available. Failing which a temporary solution can be offered by a skin graft and a permanent solution by a colour matching Wolfe graft for small defects and a microvascular free flap for larger defects. LIPS 1.
MINIMAL DEBRIDEMENT 2.
ESTABLISH CONTINUITY OF ORBICULARIS ORIS 3.
ACCURATE ALIGNMENT OF
NON
SUTURE TECHNIQUE ·
FOR SHARP LINEAR LACERATIONS ·
USUALLY IN CHILDREN ·
FOR WOUND STRENGTH - 2 WEEKS Two types of products adhesive strips and adhesive liquids are available for this purpose. EAR
COMPLICATIONS ·
UNSIGHTLY SCARS - HYPERTROPHIC ·
HYPERPIGMENTED PATCHES ·
TRAP DOOR SCARRING ·
ORAL INCONTINENCE ·
EPIPHORA ·
EXPOSURE KERATITIS ·
FACIAL ASYMMETRY · LOSS OF SELF ESTEEM |
