Facial injuries that involve the soft tissue can result from either blunt or penetrating trauma, and may occur in isolation or with associated facial skeletal fractures. Soft tissue injuries can range from simple lacerations to avulsion injuries with significant tissue loss. Animal bites can also be a cause of soft tissue injuries of the face in children. Interpersonal violence resulting in stabbing or human bites are additional causative factors in adolescents. Several specific subsites have unique presentations that must be recognized and managed appropriately.
Penetrating injury to the cheek can result in transsection of the parotid or Stensen’s duct that runs horizontally, just inferior to the zygomatic arch, and parallel to the buccal branch of the facial nerve, explaining the concurrence of facial nerve injuries in a significant number of duct injuries. Wound exploration may reveal pooling of saliva, especially on parotid massage, suggesting injury. Confirm the diagnosis by cannulating the duct from its intraoral opening with a lacrimal probe. The tip of the probe will be visualized within the wound.
Injuries of the lateral cheek/preauricular region, especially near the tragus of the ear, can result in the main trunk of the facial nerve being severed. The temporal branch of the facial nerve, which is responsible for forehead movement, is vulnerable along a path from the tragus to the lateral brow. The marginal mandibular branch may be transected when the injury occurs in the region of the lower border of the mandible. Paralysis of this branch results in elevation of the corner of the mouth. The zygomatic and buccal branches are vulnerable in the midcheek region. Inability to close the eye and drooping of the upper lip are the sequelae, respectively. It is imperative that all facial nerve branches are evaluated prior to any manipulation of the wound. Penetrating injuries of the lateral cheek may also result in trauma to the external carotid artery with acute hemorrhage.
Injury to the ear is complicated by the involvement of cartilage or soft tissue loss. Composite tissues losses (skin and cartilage for example) require special attention if successful reimplantation or partial salvage of the tissue is to be achieved.
Eyelid lacerations, periocular trauma, and injury to the nasal lacrimal system constitute several possible soft tissue injuries. Excessive tearing (epiphora) is one cardinal sign that the nasal lacrimal ductal system is not functioning.
Scalp trauma includes simple lacerations to complex avulsions with exposed calvarial bone. Scalp avulsions often occur between the galea aponeurosis layer and the periosteum of the skull; however, the entire scalp layer may be missing, leaving exposed bare bone. Scalp injuries can be associated with massive hemorrhage (5 arterial branches that provide blood supply to the scalp emanate from both internal and external carotid arteries).
Emergency Department Treatment and Disposition
First stabilize airway, breathing, and circulation following Advanced Trauma Life Support (ATLS) protocols. Next begin evaluation of the facial trauma and provide tetanus and antibiotic prophylaxis with coverage of gram-positive organisms and anaerobes if the injury involves the nasal, pharyngeal, or oral cavities. Use simple pressure, gauze packing, hemostatic agents, or vessel ligation for hemostasis at the wound site. If there is massive hemorrhage from a significant arterial bleed, perform vessel exploration and ligation in the operating room. In some severe instances, obtain interventional radiology consultation for embolization.
Figure 20.36 ▪ Cheek Laceration.
This deep laceration of the cheek was made by a boxcutter. With injuries in this region, examining physician must look for injuries to the parotid gland, duct, and facial nerve. (Photo contributor: Mark Silverberg, MD.)
Explore all wounds under sterile conditions after copious irrigation with sterile normal saline and close all wounds that can be safely repaired in the emergency department, optimally in a separate treatment area for privacy, minimization of patient/caregiver anxiety, and proper lighting and instrumentation. Facial wounds heal very well given their excellent blood supply; primary closure up to 24 hours after the injury is acceptable. Consider the use of conscious sedation to facilitate the repair. Otherwise, a low threshold for intraoperative repair should be adopted in the pediatric population.
If parotid duct injury is suspected, consult otolaryngology or plastic surgery. If a duct injury is confirmed, send the patient to the operating room for repair.
Diagnosis of a facial nerve injury is easiest when the patient is conscious and can follow commands. Consult the facial trauma team if there is a mechanism that may have resulted in facial nerve injury in an unconscious or unresponsive patient to coordinate the timing of wound exploration. It is possible for a seemingly minor penetrating trauma to be underestimated in the light of more serious injuries. Intraoperative exploration and repair of nerve transections should occur within 3 days of the injury.
Repair lacerations of the ear that extend through the skin to the cartilage without tissues loss by reapproximating the cartilage followed by soft tissue repair. If skin is absent and cartilage is exposed, use soft tissue advancement to avoid the need for daily wound care with antibiotic ointment and sterile dressing. If ear tissue is avulsed, reattach it primarily noting that avulsed ear tissue longer than 1.5 cm is not likely to survive. Other options include delayed reconstruction or banking the cartilage (removing the outer layer of skin) underneath the temporal scalp so that it can be used in the future secondary repair as a structural graft. For large, near total ear avulsion injuries, consult otolaryngology or surgery for microvascular techniques of reattachment.
Similar tenets of repair apply to the nose as to the ear, particularly if there is a composite injury. Use layered closure of wounds (nasal lining, cartilage, deep soft tissue, and skin).
Consult ophthalmology for all periocular trauma for a comprehensive examination of the globe. If possible, consult oculoplastic surgery for evaluation and management of patients with these delicate injuries to avoid secondary complications.
Repair extensive scalp injuries in the operating room and consult neurosurgery for concomitant skull or intracranial injury. Even seemingly minor degrees of tissue loss are challenging wounds to close as scalp tissue is quite inelastic. If repair can be accomplished in the ED, use layered closure with attention to repair of the galea aponeurosis and then the skin to prevent soft tissue depressions. Use pressure dressings or passive drains as needed.