Author: Quentin Reuter, MD (EM Resident Physician, PGY-2, NUEM) // Edited by: Michael Macias, (EM Resident Physician, PGY-3, NUEM) // Expert Commentary: Matt Levine, MD
Citation: [Peer-Reviewed, Web Publication] Reuter Q, Macias M (2016, May 24). Quick Guide To Minor Facial Trauma: Part I. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from http://www.nuemblog.com/blog/minor-facial-trauma-1/
In the emergency department, we commonly encounter minor injuries to the face and mouth. In a two part series, we will provide a short overview of some helpful strategies for dealing with these cosmetically sensitive injuries in an effective manner.
Core facial laceration management principles
Cosmesis is very important to consider when deciding on closure of facial lacerations thus primary closure should be considered in all facial lacerations unless significant tissue loss or swelling is present.
Injury to important underlying structures of the face should always be ruled out and proper physical exam & consultation should be considered when appropriate.
The facial skin has an abundant blood supply and as a result lacerations can be repaired up to a day after the injury occurred without a high risk of subsequent infection.
Facial nerve blocks should be considered to obtain anesthesia for lacerations that cross important facial creases or borders to avoid distortion of anatomy.
Proper alignment of the vermillion border or facial crease affected by a laceration is critical to avoid obvious cosmetic defects.
Sutures on the face should be placed approximately 1-2 mm from the skin edge and 3 mm apart to achieve optimal tissue approximation.
Hair does not increase in the risk of wound infection and shaving (such as the scalp or eyebrow) should be avoided.
Goals: Obtain hemostasis and evaluate for galea injury, foreign body, and underlying skull fracture. Visually inspect and use instrument to palpate the inside of the laceration once hemostasis is obtained. If you see injury to the shiny, slippery galea or palpate a defect in this dense fibrous tissue covering of the skull, it needs to be repaired.
Importance: Scalp lacerations almost never get infected, unless you fail to repair a galeal injury, therefore identification of this injury is critical. Since the frontalis muscle also anchors to the galea, failure to identify a disruption in this scalp layer can result in significant cosmetic deformity. One caveat is that skull fractures and galeal injury can often be confused with one another, making both visual inspection and palpation necessary to avoid misinterpretation of wound severity.
- These wounds are prone to significant hemorrhage and immediate hemostasis is critical for both repair and evaluation for underlying galeal or skull injury. Direct pressure using a moistened sponge and an elastic bandage for 30-60 minutes can be effective. Direct injection of lidocaine with epinephrine should also be considered. A large figure-of-eight suture can be placed initially if both of these measures fail.
- Repair of the galea should be performed with 3-0 or 4-0 absorbable sutures. Common techniques include a single layer of simple interrupted or vertical mattress sutures.
- Staple gun repair of the overlying scalp tissue is appropriate however the hair apposition technique can also be considered. This involves using small bundles of hair from both sides of the wound and then twisting the hair bundles together with a hemostat. A dab of skin glue can then be applied to prevent the hair from unraveling.
Goals: Determine if laceration is partial thickness versus full thickness. A full thickness injury implies involvement of the cheek skin, underlying subcutaneous tissue/muscle, and intra-oral mucosa. Evaluation for injury to the parotid gland and the facial nerve should be performed.
Importance: If a full thickness injury is identified, these wounds must be repaired in layers to ensure appropriate cosmesis. You must identify parotid gland and facial nerve injuries as these need specialist repair.
- Uncomplicated partial thickness lacerations can be closed with 6-0 monofilament. Be sure to place first suture in alignment with any facial crease as this is as important as alignment of the vermillion border in lip lacerations.
- Assessing for parotid gland injury: Inspect the wound for evidence of salivary fluid. You should also look inside the mouth assess for bloody fluid coming from the opening of the parotid duct located on the buccal mucosa of the cheek at the level of the maxillary second molar.
- Assess for facial nerve injury: Test the 5 branches of the facial nerve.
- If laceration is medial to the lateral corner of the eye, it is typically safe to repair. If the laceration is lateral to the lateral corner of the eye, consider specialist consultation if worried about the facial nerve and/or parotid gland injury.
- If full thickness laceration is found and there is no concern for parotid gland or facial nerve injury, repair can proceed. Mucosal lacerations are first repaired with 5-0 chromic gut using simple interrupted technique. The external wound should then be irrigated to eliminate residual oral flora and closed with 6-0 monofilament.
Goals: Cover the cartilage, identify septal hematomas. Identify underlying fracture.
Importance: You must cover exposed cartilage to help prevent chronic chondritis, closing the skin and nasal mucosa over the cartilage helps to ensure adequate healing. You also must identify septal hematomas as they can lead to pressure necrosis and cosmetic deformities if not drained appropriately.
- Repair of skin can be performed with 6-0 monofilament. There is minimal redundancy of skin over the nose therefore avoid debridement and attempt to tact down as much tissue as possible. A consultant should handle any avulsion or mutilating injuries.
- The septum should be carefully visualized with high powered light and nasal speculum to assess for a septal hematoma. These can be recognized by their bluish, budging appearance inthe anterior septal area.
- To drain a septal hematoma, make a crescent or hockey stick shaped incision in the dependent portion of the hematoma. In order to prevent re-accumulation, apply anterior nasal packing with petroleum impregnated gauze and refer to ENT in 24-48 hours for follow up. Discharge home with amoxicillin or trimethoprim-sulfamethoxazole.
- Radiographs are often unnecessary for identifying fractures and relying on palpation and visual displacement is usually appropriate unless there is concern for other significant facial bone injury or complex nasal injuries.
Eyelid & Eyebrow Lacerations
Goals: Identify lacerations that mandate specialist repair. Evaluate the orbit for underlying injury. Approximate brow margins prior to repair of eyebrow laceration.
Importance: Damage to any important anatomic eye structure will require repair by a specialist. The danger area to suture around the eye is medial to the medial (nasal) border – that is where the lacrimal duct is and if not diagnosed and repaired the patient's eye will always tear. A laceration lateral to the lateral (temporal) aspect of the eye is safe to close if the patient has a normal exam and wound exploration is normal.
- Simple lid lacerations that do not involve the margin or underlying structures can be closed with a single layer of 6-0 monofilament.
- Eyebrow lacerations can be closed with a single layer of 5-0 or 6-0 monofilament and care should be taken to first approximate the brow margins to prevent cosmetic deformity. The eyebrow should never be shaved or trimmed.
- Suspect injury to the levator palpebrae superioris muscle if you have fat extrusion (retrobulbar fat), suggesting a laceration to the orbital septum. Evaluate for ptosis.
- Injury to the medial palpebral ligament will give you a cross-eyed appearance.
- Injury to the lacrimal canaliculus should be considered if the laceration is medial to the punctum. Profuse tearing down the cheek should also raise concern for injury to the lacrimal apparatus.
- Intramarginal lid lacerations require extreme precision to ensure alignment of structures and should be left to consultants for repair.
- Careful inspection of eye should be undertaken to rule out corneal abrasion, hyphema, globe rupture, blow-out fracture and foreign body.
Thank you for your review of something we deal with commonly and take pride in managing. While a lot of considerations regarding facial wounds are cosmetic, before we consider cosmesis, the emergency physician should always go through a few other critical factors.
Most lawsuits related to wound care are not related to cosmesis. The top three are failure to diagnose or treat an infected or infectious-prone wound, missed foreign body (FB), and missed nerve (which was nicely covered by Dr. Reuter) or tendon injury (which is mostly irrelevant for the face) . Think cosmesis after you have at least clinically ruled these out.
Wound FBs are rare in the face compared to the extremities. However, they should be suspected in certain scenarios: [12,13]
- Wounds around the mouth when teeth are broken (tooth fragments are about the worst missed FB)
- Wounds from an MVC (often are from broken glass)
- Wounds from being hit with a beer bottle
Plain films have poor sensitivity for facial FBs and CT is impractical unless also seeking fractures or brain injury, so wound exploration is key. Make sure your equipment, anesthesia, and lighting are optimal to give yourself the best chance .
Besides a missed FB, another scenario that increases risk for infection is a scalp hematoma. While stapling a bleeding scalp wound closed will tamponade the bleeding quickly, a leftover hematoma can be a setup for infection. Optimal care would be to obtain hemostasis first with infiltration with lidocaine with epinephrine and direct pressure prior to stapling.
Now, back to cosmesis.
Local infiltration can be deforming to the tissues, so consider nerve blocks when this is a concern. A great easy-to-remember landmark guide is that the three main nerve block injection sites of the face align with the pupil – the supraorbital, infraorbital, and mental nerves. The latter two can be reached intraorally as a preferred approach, avoiding skin puncture.
An ideal scenario for a nerve block would be for a vermillion border laceration, so the border won’t get deformed. To meticulously align the vermillion border, the first suture placed should be the one that aligns the vermillion border. The rest will fall into place after that.
A cosmetic consideration unique to the face is an animal (usually dog) bite. While dogma for dog bites is to leave them open to minimize infection risk, this would lead to a certain poor cosmetic outcome for the face. If these wounds are meticulously irrigated, closed, and then prescribed antibiotics, at least the patient will have a chance for a good cosmetic result. Of course a detailed conversation about the thought process and warning signs with the patient is key.
And speaking of patient conversations, they come in quite handy when dealing with possible nasal fracture patients. Patients are often anxious that their nose is broken and they will have deformity so they think that an x-ray is important. If their nose is midline and without a bump or deformity, tell them that even a tiny fracture on films would not affect management. Tell patients with swelling or deformity that they need to ice their nose for the next week to see what their nose really looks after the swelling is gone. Provide them with a specialist referral so that if they do not like the way it looks at that time, the specialist can fix it for them. This approach works even with the most anxious patients because they just want assurance that they won’t be left with a deformity. Using this approach, I have not ordered nasal x-rays in 15 years.
Matt Levine, MD
Director of Trauma Services, Department of Emergency Medicine
Northwestern Memorial Hospital
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