Soft Tissue Trauma

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Soft Tissue Trauma

Trauma
Author Credentials 

Erynne A. Faucett, MD
Pediatric Otolaryngologist
Department of Surgery, Division of Otolaryngology- Head and Neck Surgery, Phoenix Children’s Hospital
Assistant Professor of Otolaryngology, Mayo Clinic College of Medicine and Science
Assistant Professor, Department of Child Health, University of Arizona, College of Medicine 
1920 E Cambridge Ave. 
Phoenix, AZ 85016

 

Module Summary

The appropriate management of facial soft tissue injuries involves a host of issues and technical considerations. An understanding of the mechanisms involved with wound healing is of greatest importance. Tetanus prophylaxis, wound care of clean and contaminated wounds, proper use and indications for antibiotics, as well as the risks and complications associated with these injuries are all important concerns when dealing with soft tissue injuries. 

In addition, there are many specialized features and structures that require special attention. These include the pinna, lips, nose, eyelids, eyebrows, parotid gland, facial neve, lacrimal drainage system, and skin. Thoughtful assessment and decision making come into play when managing these injuries. Careful assessment of soft tissue injuries, wound preparation, and meticulous technique are all keys to success in the repair of these injuries. Bite wounds and electrical burns are fraught with hazards and require additional care and expertise. Potential complications can be managed effectively in most circumstances.

Module Learning Objectives 
  1. Review the different types of soft tissue injuries.
  2. Describe the stages of wound healing. 
  3. Describe primary and secondary healing of the wound healing process. 
  4. Discuss the appropriate care for abrasions, hematomas, lacerations, and avulsion injuries.
  5. Describe the effects of animal and human bites.
  6. Be able to evaluate and treat electrical burns involving the lips and oral commissure.
  7. Explain the types and indications for the most common suture materials used for repair of facial lacerations.
  8. Discuss the options available for secondary reconstruction of deformities resulting from facial soft tissue injuries.

 

Anatomy

Learning Objectives 
  1. Describe the layers of the skin.
  2. Define the superficial musculoaponeurotic system (SMAS) layer and its anatomic extensions. 
  3. Discuss the relationship of the facial nerve and the SMAS layer for different regions of the face.

 

References 
  1. Khan HA, Bagheri S. Surgical anatomy of the superficial musculo-aponeurotic system (SMAS). Atlas Oral Maxillofac Surg Clin North Am. 2014 Mar;22(1):9-15
  2. Whitney ZB, Zito PM. Anatomy, Skin, Superficial Musculoaponeurotic System (SMAS) Fascia. Treasure Island (FL): StatPearls Publishing; 2019 Jan
  3. Kochhar A, Larian B, Azizzadeh B, Facial Nerve and Parotid Gland Anatomy. Otolaryngol Clin North Am. 2016 Apr;49(2):273-84 

 

Pathogenesis

Learning Objectives 
  1. Describe different mechanisms of injury for abrasions, hematomas, lacerations, and avulsion injuries.
  2. Discuss risks and complications associated with electrical burns involving the lips and oral commissure.

 

References 
  1. Canady JW, Thompson SA, Bardach J. Oral commissure burns in children. Plast Reconstr Surg. 1996 Apr;97(4):738-44; discussion 745; 746-55 
  2. Hashem FK, Al Khayal Z.  Oral burn contractures in children.  Ann Plast Surg. 2003 Nov;51(5):468-71 

 

Basic Science

Learning Objectives 
  1. Describe the various growth factors associated with wound healing.
  2. Discuss the types of collagen involved with the wound-healing process.
  3. Discuss wound strength as it is measured over time.

 

References 
  1. Broughton G 2nd, Janis JE, Attinger CE.  The basic science of wound healing.  Plast Reconstr Surg. 2006 Jun;117(7 Suppl):12S-34S
  2. Peled ZM, Chin GS, Liu W, et al. Response to tissue injury. Clin Plast Surg. 2000 Oct;27(4):489-500

 

Patient Evaluation

Learning Objectives 
  1. Following a proper trauma protocol assessment, describe the evaluation of a patient with facial soft tissue injuries.
  2. Discuss the “specialized structures” that should be identified during the course of such an evaluation.
  3. Evaluate injuries involving the parotid duct, facial nerve branch(es), and lacrimal drainage system.

 

References 
  1. Braun TL, Maricevich RS. Soft Tissue Management in Facial Trauma. Semin Plast Surg. 2017;31(2):73–79
  2. Marks M, Polecritti D, Bergman R, Koch CA. Emergent Soft Tissue Repair in Facial Trauma. Facial Plast Surg Clin North Am. 2017 Nov;25(4):593-604

 

Imaging

Learning Objectives 
  1. Describe imaging modalities for patients following facial soft tissue injuries. 
References 
  1. Das D, Salazar L, Zaurova M. Maxillofacial trauma: managing potentially dangerous and disfiguring complex injuries [digest]. Emerg Med Pract. 2017 Apr 22;19(4 Suppl Points & Pearls):S1-S2 

Treatment

Learning Objectives 
  1. Discuss the options for management for open and contaminated wounds.  
References 
  1. Leach J. Proper handling of soft tissue in the acute phase. Facial Plast Surg. 2001 Nov;17(4):227-38 
  2. Mankowitz SL. Laceration Management. J Emerg Med. 2017 Sep;53(3):369-382
  3. Singer AJ, Hollander JE, Quinn JV.  Evaluation and management of traumatic lacerations. N Engl J Med. 1997 Oct 16;337(16):1142-8
  4. Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. Am Fam Physician. 2017 May 15;95(10):628-636

 

Medical Therapies

Learning Objectives 
  1. Discuss the guidelines regarding tetanus prophylaxis following soft tissue injuries.
  2. Describe the appropriate treatment of the patient suspected of having tetanus.
  3. Discuss the role of wound irrigation, antibiotic wound irrigation, and parenteral antibiotics following soft tissue injuries.

 

References 
  1. Moran GJ, House HR. Antibiotics in wound management. In: Singer AJ, Hollander JE, editors. Lacerations and Acute Wounds: An Evidence-Based Guide. Philadelphia: F.A. Davis; 2003. p. 194–204
  2. Rhee P, Nunley MK, Demetriades D, Velmahos G, Doucet JJ.  Tetanus and trauma: a review and recommendations. J Trauma. 2005 May;58(5):1082-8
  3. Yoshino Y, Ohtsuka M, Kawaguchi M, et al. Wound/Burn Guidelines Committee. J Dermatol. 2016 Sep;43(9):989-1010

 

Pharmacology

Learning Objectives 
  1. Discuss common organisms involved in wound infections following trauma, animal bites, human bites, and burns.
  2. Describe the use of antibiotics for both prophylaxis and treatment of wound infections following the above-mentioned injuries.

 

References 
  1. Moran GJ, Talan DA, Abrahamian FM. Antimicrobial prophylaxis for wounds and procedures in the emergency department. Infect Dis Clin North Am. 2008 Mar;22(1):117-43, vii 
  2. Aziz H, Rhee P, Pandit V, Tang A, Gries L, Joseph B. The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg. 2015 Mar;78(3):641-8. 

 

Surgical Therapies

Learning Objectives 
  1. Describe the proper technique for facial lacerations and avulsion injuries repair. 
  2. Discuss the treatment of hematomas involving the facial soft tissues, nasal septum, and external ear.
  3. Describe the specific techniques available for repair of:
  • a lacerated parotid duct.
  • a lacerated facial nerve branch(es).
  • a torn inferior canaliculus.
  1. Explain the optimal technique for repair of the following:
  • a full-thickness eyelid laceration (involving the lid margin).
  • a through-and-through laceration of the lower lip involving the vermilion.
  • a laceration through skin and cartilage involving the helix/antihelix of the ear.

 

References 
  1. Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. Am Fam Physician. 2017 May 15;95(10):628-636
  2. Della Rocca DA, Ahmad SM, Della Rocca RC.  Direct repair of canalicular lacerations. Facial Plast Surg. 2007 Aug;23(3):149-55 
  3. Medeiros Paz ALL, Caetano RDS, Borges AH, Ricci Volpato LE. Reconstruction of the Parotid Duct. Ann Maxillofac Surg. 2018;8(1):140–142 
  4. Condie D, Tolkachjov SN. Facial Nerve Injury and Repair: A Practical Review for Cutaneous Surgery. Dermatol Surg. 2019 Mar;45(3):340-357 
  5. Sabatino F, Moskovitz JB. Facial wound management. Emerg Med Clin North Am. 2013 May;31(2):529-38 
  6. Marks M, Polecritti D, Bergman R, Koch CA. Emergent Soft Tissue Repair in Facial Trauma. Facial Plast Surg Clin North Am. 2017 Nov;25(4):593-604 
  7. Costan VV, Dabija MG, Ciofu ML, Sulea D, Popescu E, Boisteanu O. A Functional Approach to Posttraumatic Salivary Fistula Treatment: The Use of Botulinum Toxin. J Craniofac Surg. 2019 May/Jun;30(3):871-875 
  8. Ko AC, Satterfield KR, Korn BS, Kikkawa DO. Eyelid and Periorbital Soft Tissue Trauma. Facial Plast Surg Clin North Am. 2017 Nov;25(4):605-616
  9. Matin MB, Dillon J. Lip reconstruction. Oral Maxillofac Surg Clin North Am. 2014 Aug;26(3):335-57 
  10. Steffen A, Frenzel H. Trauma Management of the Auricle. Facial Plast Surg. 2015 Aug;31(4):382-5

 

Rehabilitation

Learning Objectives 
  1. Discuss the role of prosthodontics in the treatment of electrical burns involving the lip and oral commissure.
  2. Discuss the role of various therapy modalities for severe burn injuries to the neck.

 

References 
  1. Al-Qattan MM, Rasool M, Al-Kattan W.  Fabrication of silicone oral splints for severe burn microstomia in children. Burns 2005 Mar;31(2):217-9
  2. Hashem FK, Al Khayal Z. Oral burn contractures in children. Ann Plast Surg. 2003 Nov;51(5):468-71 
  3. Sharp PA, Dougherty ME, Kagan RJ. The effect of positioning devices and pressure therapy on outcome after full-thickness burns of the neck. J Burn Care Res. 2007 May-Jun;28(3):451-9 
  4. Jennes S, Hanchart B, Keersebilck E, et al. Management of burn wounds of the head and neck region. B-ENT. 2016;Suppl 26(1):107-126
  5. Hamilton TJ, Patterson J, Williams RY, Ingram WL, Hodge JS, Abramowicz S. Management of Head and Neck Burns-A 15-Year Review. J Oral Maxillofac Surg. 2018 Feb;76(2):375-379
  6. Linebaugh ML, Koka S. Oral electrical burns: etiology, histopathology, and prosthodontic treatment. J Prosthodont. 1993 Jun;2(2):136-41

 

Case Studies

  1. A 25-year-old white female presents with a facial laceration following a knife injury. Examination shows a 3-cm vertical laceration involving the left cheek. There appears to be no communication with the oral cavity. Facial examination shows weakness in the region of the buccal branch of the facial nerve.
  • In this scenario, it must be assumed that the buccal branch has been transected. It is very likely that there is a concomitant injury to Stenson’s (parotid) duct, since this lies in close proximity to the buccal branch. For this reason, the patient’s facial injury needs to be explored in the operating room. The parotid duct should be cannulated and if found to be injured, re-anastomosis can be accomplished, leaving a stent in place. Once the duct has been identified within the wound, exploration should be accomplished in order to identify the buccal branch. If it is transected, a neurorrhaphy should be accomplished with 9-0 or 10-0 nylon.
  1. A 30-year-old male is involved in a motor vehicle accident. He has extensive abrasions throughout the right side of the face. In addition, there is missing soft tissue and skin (2.0cm x 3.0cm) involving the right lateral forehead and the right lateral one-third of the eyebrow. The patient has no other facial or systemic injuries.
  • Treatment of this patient involves extensive cleaning of all of the abrasions, being certain to ensure removal of all foreign material. Any lacerations should be closed using plastic surgery principles. The extensive avulsion injury described involving the forehead and eyebrow should be treated with wound care. It is recommended that reconstruction not be attempted primarily, allowing the wound to heal by secondary intention. A few months following the injury, secondary reconstruction can be considered. Reconstructive procedures might include serial excision, z-plasty techniques, or composite grafts (hair transplants) obtained from the scalp for eyebrow reconstruction.

 

Complications

Learning Objectives 
  1. List the complications (early and late) that may occur following soft tissue injuries of the face.
  2. Describe some of the treatment options available for the management of keloids, hypertrophic scars, and poorly oriented scars.
  3. Discuss the treatment of wound infections following soft tissue repair.
  4. Be able to offer treatment options for the following sequelae:
  • the vertically shortened lower eyelid.
  • the notched nasal alar margin.
  • a step-off deformity involving the vermilion of the upper lip.
  • a patch of alopecia involving the mid-eyebrow region.
  • scarring of the oral commissure in a child who has suffered an electrical burn.

 

References 
  1. Sabatino F, Moskovitz JB. Facial wound management. Emerg Med Clin North Am. 2013 May;31(2):529-38 
  2. Peled ZM, Chin GS, Liu W, et al. Response to tissue injury. Clin Plast Surg 2000;27:489-500
  3. Rohrich RJ, Watumull D. Primary and secondary reconstruction of facial soft tissue injuries. In: Cohen M, editor. Mastery of Plastic and Reconstructive Surgery. Boston: Little, Brown and Co.; 1994. p. 1083-100.
  4. Berman B, Maderal A, Raphael B. Keloids and Hypertrophic Scars: Pathophysiology, Classification, and Treatment. Dermatol Surg. 2017 Jan;43 Suppl 1:S3-S18 
  5. Goldman GD. Reconstruction of the nasal infratip, columella, and soft triangle. Dermatol Surg. 2014 Sep;40 Suppl 9:S53-61 
  6. Hom DB. Facial Scar Management. Facial Plast Surg Clin North Am. 2017 Feb;25(1):ix-x.
  7. Crecelius C. Soft tissue trauma. Atlas Oral Maxillofac Surg Clin North Am. 2013 Mar;21(1):49-60

 

Review

Review Questions 
  1. Name the different types of soft tissue injuries that may occur.
  2. Describe the stages of wound healing and the time period during which each stage occurs.
  3. What are the most common complications of electrical burns to the oral commissure?
  4. What is the optimal treatment for a forehead laceration without soft tissue loss that results from a dog bite in a 5-year-old child?
  5. Describe the treatment plan for a 2-x-3-cm defect in the left cheek following a human bite in a 20-year-old male.
  6. Describe the relationship of the facial nerve to the facial muscles and the SMAS layer.
  7. What are the latest treatment guidelines regarding tetanus prophylaxis following soft tissue injuries?
  8. Describe the techniques used to repair a left cheek laceration involving both the parotid duct and the buccal branch of the facial nerve.
  9. Describe the repair of a full thickness laceration which involves the helix and antihelix of the left auricle.
  10. What landmarks are useful in the repair of eyelid injuries involving the lid margin?