GENERAL METHOD FOR LESSER FACE WOUNDS

If a patient’s eyelids and eyebrows are injured, turn to the previous chapter(60.3). If he has a severe maxillofacial injury, turn to the next one. Read on for injuries of his lips, gums, and tongue (61.2), injuries to his facial nerve and parotid gland (61.3), and for injuries to his ears and nose (61.4). You will probably be able to treat him as an out-patient, but if repair is likely to take 2 hours or more, or you have to graft him, admit him.

Figure 61.1: SUTURING A SEVERE FACE WOUND. This patient was thrown against the windscreen of her car. The flap on her forehead has a bevelled edge, so B, and C, show the thin edge of this flap being excised before suture. D, the final result. E, if a patient’s face looks like this, make sure you suture his tissues back in their proper places. With the kind permission of James Smith.

EQUIPMENT A No. 5 scalpel handle, No.15 scalpel blades, Metzenbaum scissors, Glasgow pattern scissors, Adson’s dissecting forceps, Derf needle holder, 2 skin hooks, mosquito haemostats, skin graft knife and board, fine needles, and 4/0 chromic and monofilament sutures.

BLEEDING Try to control this by direct pressure, and avoid buried ligatures if you can.

EXAMINATION If a patient’s facial nerve might have been injured, test its function before you anaesthetize him. Ask him to smile, and see if his smile is symmetrical. Don’t forget to examine his eyes (23.1).

ANAESTHESIA (1) Ketamine. (2) General anaesthesia with intubation. (3) Local nerve blocks, which are better than local infiltration because they will not distort the tissues. Where possible, use a mental nerve block (A 6.3), or an infraorbital or supraorbital nerve block (A6.5). If you do use local infiltration, add hyaluronidase (1500 units in 10 ml) to help the solution spread through the tissues and minimize swelling.

If you sedate a patient with diazepam or chlorpromazine, he may fall asleep during the operation. A child will usually cooperate if you reassure him authoritatively and sedate him adequately. If you can, do the repair quickly. You may be able to do it while you restrain him. If necessary, wrap his arms and legs in a sheet as in Figure A 18-1.

TOILET If necessary, shave the patient’s scalp, moustache, and beard, but leave his eyebrows. A wound can be difficult to align without them. Do a social and, when necessary, a surgical toilet (54.1). Clean his wound adequately, irrigate it copiously, and explore it. You may find a fracture, or foreign bodies, such as glass from a broken windscreeen, or grit from the road.

Figure 61.2: METHODS FOR FACE WOUNDS. When you suture a patient’s nose, don’t leave a notch as in A; make sure there is no kink in the edge, as in B. If his wound is jagged, excise its edges and make them fit together, as in C, to F, and G, and H. Don’t make sutures too tight, or they will leave an ugly scar. If a suture has to be tight, a subcuticular suture (I and J) will leave a better scar. The scar will be neater if you take each subcuticular suture back a little (I), and don’t put sutures straight across a wound, as in K, and L. Partly after ’Techniques Elementaires pour Medecins Isolés’, with kind permission.

Where possible, plan the suture lines in or parallel to the skin lines as in Fig. 61-3. This will greatly improve the look of the scar.

If the wound edges are ragged or bruised, excise the minimum amount of skin, to give them a clean edge. Small tags of the skin which you would remove in other parts of the body will usually survive on the face, so replace them carefully.

CAUTION! If you remove too much tissue, you will make a plastic repair later more difficult.

If the patient’s wound is very extensive, be conservative and only remove dirt and obviously dead tissue. The scar will inevitably be ugly, but he may be able to have it revised later.

If his skin is grossly contaminated with dirt, only excise it if there is no other way of removing the dirt.

If the edge of the laceration is steeply bevelled, as in B, Fig. 61-1, and you leave it like this, the scar will be ugly. So cut off the thin edge of the flap to make it perpendicular. The best wound edges for suture are vertical.

If two lacerations are closely parallel, the final scar may be neater if you excise the bridge of tissue between them.

If a piece of the patient’s cheek is missing, as in B, Fig. 61-4, suture his skin to his mucous membrane, and refer him for a plastic repair later.

If his wound is ugly and you can excise it along the skin lines, do so.

If an extensive wound has distorted his anatomy, so that you do not know how to suture it, as in F, Fig. 61-1, look for a landmark at either side of his wound. Match these and the rest of the jig saw will fit together.

CAUTION! Time spent fitting the jig saw together is never wasted.

If his face has been extensively destroyed, fit the pieces that remain into their correct places. This will help you to see what has been lost.

IMMEDIATE PRIMARY SUTURE Don’t close the skin until you have done all that is necessary to the structures underneath it. If you have done an adequate toilet, you can close most wounds by immediate primary suture.

Close the wound accurately at all points and in all planes. There must be no dead spaces. So, if necessary, insert tissue sutures of fine catgut to prevent cavities. If the patient’s muscles of facial expression have been injured, try to bring them together to avoid dimples. Control bleeding, preferably by pressure, before you start to suture the wound.

Repair muscle, mucosa, and subcutaneous tissue with 4/0 chromic catgut, and skin with fine interrupted sutures of 4/0 monofilament. Place them 2 to 4 mm from the edge of the wound, but let them take an adequate bite of deeper tissue. Tie them only just tight enough to bring the skin edges together because the wound will probably swell and make them tighter. Tight sutures will leave the stitch marks.

If you cannot bring the skin edges together, cautiously undercut them and insert fat stitches.

CAUTION! The level at which you undercut the face is important. Cut just deep to the dermis, superficial to the branches of the facial nerve, as in A, Fig. 54-6.

If you have to suture a wound under moderate tension, you will have to leave sutures in for 2 or 3 weeks, or the wound will burst open. Leaving ordinary stitches in as long as this will cause ugly stitch marks. Instead, insert subcuticular sutures. If you are not suturing a wound under tension, ordinary sutures give a better result.

If you cannot bring the skin edges together, even by undermining them or by suturing under moderate tension, graft the bare area with split skin. This will provide the best conditions for plastic surgery later.

CAUTION! (1) Don’t allow the wound to close by spontaneous scarring. (2) Don’t try to rotate any flap as a primary procedure, or try to graft with full thickness skin. These are both secondary procedures after a wound has healed and its scar has been excised. (3) Don’t make ’relaxing incisions’.

If a small haematoma develops, evacuate it after removing a suture.

ANTIBIOTICS If a wound is more than 6 hours old give the patient a systemic antibiotic.

PARTICULAR FACE INJURIES

HAEMATOMAS If necessary, aspirate these with a wide bore needle.

Figure 61.3: THE SKIN LINES OF THE FACE. The scar on a patient’s face will be less obvious if you can make it in or parallel to one of his natural wrinkle lines. These are the lines of election for a scar. With the kind permission of James Smith.

ACCIDENTAL TATTOOS If grit or foreign bodies have been rubbed into the patient’s skin, remove them with a stiff sterile nail brush. Use small circular movements, and press hard. If oil or grease has been rubbed into his wound, remove it with a little ether. If you leave foreign material in place in his skin, it will leave a permanent ugly scar.

AVULSION FLAPS After repairing the wound, apply a pressure dressing for several weeks, if necessary. This will minimise haematoma formation under the flap and will improve the scat.

BITES of any kind, especially human bites, are very likely to become infected. Excise the wound margins, and give the patient an antibiotic (2.7).

POSTOPERATIVE CARE OF FACE INJURIES

To minimize stitch marks, remove alternate stitiches after 3 days and the remaining ones 4 to 8 days later (except on the ears).

Reassure the patient that the scars on his face will soften and improve with time. He will not know what he is finally going to look like until at least a year after the accident. Don’t refer him for revision of the scars for a year or more.