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Login Executive Editor: Edward Ellis III, Kazuo Shimozato General Editor: Daniel Buchbinder Authors: Carl-Peter Cornelius, Nils

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Executive Editor:

Edward Ellis III, Kazuo

Shimozato General Editor: Daniel Buchbinder Authors: Carl-Peter Cornelius, Nils Gellrich, Søren Hillerup, Kenji Kusumoto, Warren Schubert, Stefano Fusetti, Coauthors: Enno- Ludwig Barth, Harald Essig

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All Reductions & Fixations

Use of existing lacerations Principles General
Use of existing lacerations
Principles
General

considerations

Facial fractures are often associated with

lacerations. These existing soft-tissue injuries can be used to access directly the facial bones for management of the

fractures. The surgeon may elect to extend the laceration to attain enough access to the fractured area, placing additional incisions starting from the wound margins along the relaxed skin tension lines (RSTL). Bacterial contamination is not a contraindication for the use of existing lacerations for surgical approach. Access to infraorbital rim and orbital floor through a horizontal lower lid laceration is shown.

Clinical photograph of the same case showing
Clinical
photograph of
the same
case showing

osteosynthesis and orbital mesh plate applied through the existing laceration.

osteosynthesis and orbital mesh plate applied through the existing laceration. This photograph shows an acceptable outcome

This

photograph

shows an

acceptable

outcome after

using the

laceration for

surgical approach.

osteosynthesis and orbital mesh plate applied through the existing laceration. This photograph shows an acceptable outcome

Peripheral

nerve and

parotid duct

injuries

Depending on the location

of the laceration, structures such as nerves, the parotid gland, or the parotid duct may be affected by the injury. In the illustration, a peripheral facial nerve branch is directly involved. Respecting their functional importance the facial nerve branches can either be repaired primarily or tagged for ease of location during a secondary repair. Aggressive exploration and primary repair under microscopic magnification is advantageous at least for the branches responsible for lid closure.

Parotid duct

injury and

repair

Injuries of the parotid duct may cause an

acute leakage of saliva into the wound or surgical field resulting in salivary fistula. The parotid

acute leakage of saliva into the wound or surgical field resulting in salivary

fistula. The parotid duct ends can be explored through the laceration in such cases.

acute leakage of saliva into the wound or surgical field resulting in salivary fistula. The parotid
acute leakage of saliva into the wound or surgical field resulting in salivary fistula. The parotid

Repair of the parotid duct

The distal portion of the duct is entered from

the intraoral orifice and stented with silastic tubing until continuity is reached with the lumen of the proximal duct.

acute leakage of saliva into the wound or surgical field resulting in salivary fistula. The parotid

The edges of the duct are

reapproximated and closed over the stent using microsurgical instrumentation. The

silastic tubing is left in position for a period of up to 3 weeks. Unrepaired parotid duct injuries result in a persistent fistula or sialocele.

silastic tubing is left in position for a period of up to 3 weeks. Unrepaired parotid

This clinical

photograph

shows a

repaired

parotid duct.

silastic tubing is left in position for a period of up to 3 weeks. Unrepaired parotid

Wound

closure

Proper cleansing, debridement, and

hemostasis should be accomplished prior to the repair of the underlying bony injury, cranial peripheral nerve injuries, or an injured Stensen’s duct (parotid duct). Facial wounds can be closed primarily up to 24 hours after the injury due the high vascularization of this region. The laceration is closed in layers with short- term resorbable interrupted sutures, realigning the anatomic structures and eliminating dead space:

• Periosteum • Mimetic muscles • Platysma/SMAS • Subcutaneous tissues • Epidermis Particular attention is given to completing the repair of free eyelid margins, nasal alae,

the vermilion lip borders and the helical margins of the ear. A variety of skin closure techniques are available based on surgical preference. A drain may be placed if necessary. Usually the wound is not covered with dressings A pressure dressing, however, serves to flatten large soft tissue avulsions and avoid contour deformities by scar contraction.

Example of a facial laceration with underlying fracture
Example of
a facial
laceration
with
underlying
fracture

This image shows an example of soft-tissue laceration after a horse-shoe injury.

Elevating the soft- tissues reveals an underlying multifragmentary zygoma fracture.
Elevating
the soft-
tissues
reveals an
underlying
multifragmentary zygoma fracture.
the vermilion lip borders and the helical margins of the ear. A variety of skin closure

This image shows an example of soft-tissue laceration after a chain

saw injury.

Elevating the soft- tissues reveals an underlying
Elevating
the soft-
tissues
reveals an
underlying

multifragmentary fracture of the infraorbital rim and the orbital floor.

Postoperative care and follow-up

Close monitoring of the early wound healing phase is necessary in order to detect infection early enough to prevent wound slough and abscess formation. Remove sutures in an appropriate time frame. Instruct the patient to avoid sun exposure and use protection such as hats, shields and sunscreen. Further interventions may help to minimize scar contractures and hypertrophy. Remind the patient that facial scars need months to mature, lose their redness and become less conspicuous.

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v1.0 2009-12-03