Soft Tissue Injuries of the Face

Hema Thakar, MD, and Jennifer Blumetti, MD

I. ANATOMY

A. Surface anatomy of the face (Fig. 16-1)

B. Surface anatomy of the nose (Fig. 16-2)
C. Surface anatomy of the ear (Fig. 16-3)
D. Superficial musculoaponeurotic system (SMAS): Multilayer
fibromuscular and adipose network located deep to the dermis and

16
superficial to the facial motor nerves
16
1. It extends from the temporoparietal (TP) fascia to the platysma.

SOFT TISSUE INJURIES OF THE FACE

2. It is an important landmark for protection of the facial nerve branches.
E. Facial nerve distribution (Fig. 16-4): All facial muscles are innervated
from the underside.
1. The temporal branch innervates the frontalis, corrugator, procerus, and
orbicularis oculi (upper lid).
a. The nerve is most superficial as it crosses the zygomatic arch, where
it lies beneath the SMAS/TP fascia.
b. Injury to this nerve results in paralysis of the forehead and brow.
2. The zygomatic branch innervates the orbicularis oculi (lower lid),
buccinator, and upper lip muscles (orbicularis oris, levator labii
muscles, zygomaticus muscles) and the ala muscles.
a. Injury to this nerve results in paralysis of the upper lip and cheek.
3. The buccal branch innervates the buccinator and the upper and lower
lip muscles (orbicularis oris, risorius, depressor anguli oris).
a. Injury to this nerve results in paralysis of the upper lip and cheek.
4. The marginal mandibular branch innervates the lower lip muscles.
a. Injury results in paralysis to lower lip.

II. PHYSICAL EXAMINATION

A. Inspect the face and scalp for soft tissue injuries.

B. Assess soft touch sensation to the face and neck prior to administration
of local anesthesia.
1. Trigeminal nerve distributions (Fig. 16-5):
a. Ophthalmic (V1): supraorbital, supratrochlear, infratrochlear,
external nasal, and lacrimal nerves
b. Maxillary (V2): infraorbital, zygomaticofacial, zygomaticotemporal nerves
c. Mandibular (V3) divisions: mental, buccal, auriculotemporal nerves
2. Terminal cutaneous branches of C2-3 (see Fig. 16-5)
a. Greater auricular and transverse cervical nerves
3. Locally explore wounds if a sensory deficit is appreciated.
a. Repair a severed nerve trunk with microsurgical technique if
proximal and distal ends can be found.

109
 110 II. Physical Examination

Frontal

Pa
r
iet
al
Supraorbital

Glabella Forehead
Temporal
Eyebrow
Lateral
canthal

e
pl

tal
Orbital

m
region

ipi
ar c Te

c
Oc
Medial

ol ati
Auricular

(m om
)
canthal
Preauricular

g
Nasal

Zy
region
Mastoid
Infraorbital Labial Buccal
process
Maxillary

r
Trapezius

la
bu
di
Posterolateral

an
belly of

M
Mental

id
r sternocleido-
Posterio

sto
Submental
cervical mastoid

ma
triangle Anterior
triangle

ido
cervical
Laryngeal

cle
triangle
vicular
prominence Supracla
r no fossa
Ste
Greater
Lesser
Clavicle

FIGURE 16-1
Surface anatomy of the face and neck.

b. New nerve endings will grow and renew sensation typically within 6
months if the nerve trunk is intact.
C. Assess function of the facial nerve distributions prior to administration of
local anesthesia.
1. Ask the patient to raise the eyebrows, close both eyes, smile, pucker the
lips, and show the lower teeth.
2. Injuries to the facial nerve anterior to the level of the lateral canthus will
likely regenerate.
3. Injuries to the facial nerve posterior to the level of the lateral canthus
require exploration and microsurgical repair within 2 to 3 days of injury.
 III. Wound Classification and Basic Management 111

Root

Bridge

Nasofacial

m
rsu
ral angle
ate

Do
L
Alar crease
Anterior 16
Tip nasal
Ala
vestibule

SOFT TISSUE INJURIES OF THE FACE

Nasolabial
Columella crease

FIGURE 16-2
Surface anatomy of the nose.

4. Obtain an electromyogram if the physical examination is uncertain.

a. Findings of muscle amplitude in the weak muscles indicate nerve
stretch or contusion.
b. The lack of electrical signal suggests transection of a branch of the
facial nerve.

III. WOUND CLASSIFICATION AND BASIC MANAGEMENT

A. Wound types
1. Contusion
a. Produced by blunt trauma that ruptures subcutaneous vessels
without disruption of the overlying skin, resulting in edema,
ecchymosis, and hematoma
b. Drain hematoma if present in eyelid, nasal septum, or ear.
 112 III. Wound Classification and Basic Management

(Superior)
helix
Scaphoid Auriculotemporal
fossa (scapha) sulcus

Crura of Darwinian
antihelix tubercle
Triangular Posterior
fossa (retro) auricular
Crus of
Concha surface
helix
(Mid) Postauricular
helix scalp
Tragus
Antihelix Postauricular
sulcus
Antitragus

Incisura
Mastoid
intertragica Lobule process

FIGURE 16-3
Surface anatomy of the ear.

2. Abrasion
a. Avulsion of the epithelium and papillary dermis resulting from shear
forces that expose the reticular layer as a raw, bleeding surface
b. Will re-epithelialize within 7 to 10 days
c. Irrigate the wound and apply topical antibiotic ointment twice a day
for 4 days.
d. Significant scar may result if the wound depth extends deep into the
dermal layer. Debride the wound if it is deep. Closure options
include primary closure or full-thickness skin graft.
3. Laceration
a. May be simple, linear, jagged, or stellate. The margins may be
abraded, contused, or crushed.
b. Irrigate and debride the wound. Close in layers. Use 4-0 monocryl
for buried deep dermal stitches. Place 6-0 prolene or nylon sutures
in skin. Remove skin sutures in 3 to 5 days.
c. To avoid the need for suture removal, 6-0 fast-absorbing gut can
also be used in the skin (appropriate in children or unreliable
patients who may not follow up for suture removal).
d. Apply topical antibiotic ointment twice a day for 4 days.
4. Avulsion
a. In cases of full-thickness loss of skin, apparent tissue loss is usually
found in the form of rolled borders and/or retracted edges.
 IV. Anesthesia 113

Buccal branch
Temporal branch

Zygomatic branch
16

SOFT TISSUE INJURIES OF THE FACE

Cervical branch

Mandibular branch

FIGURE 16-4
The branches of the facial nerve.

b. Small avulsion defects can usually be closed by undermining and

local adjacent tissue advancement.
c. Large avulsion defects can be closed using local flaps or a full-
thickness skin graft.
d. Dermabrasion or scar revision may be performed in the future for
poor cosmesis.

IV. ANESTHESIA

Most soft tissue facial injuries can be repaired in the emergency

department using local and IV sedation.
A. Sedation may be indicated depending on the extent of injury and length
of repair. IV sedation requires supplemental oxygen and monitoring with
pulse oximetry, blood pressure, and electrocardiography.
1. Midazolam (Versed) for its amnestic properties
a. Antagonist: Flumazenil IV bolus at 0.2 mg every 5 minutes up to a
total of 1 mg
2. Morphine or fentanyl for analgesia
 114 IV. Anesthesia

Ophthalmic division V

C2

C2-3 Maxillary division V

C3

C4 Mandibular
C2-3 division V

C5
C3-4 Greater auricular
C6

FIGURE 16-5
Sensory anatomy within the face and neck.

a. Antagonist: Naloxone IV bolus at 0.04 mg every 2 to 3 minutes until

desired effect
B. Local anesthesia
1. Lidocaine, 1% to 2%, with 1:100,000 epinephrine is appropriate in
any location in the head and neck.
a. It decreases blood flow to the area of injection.
b. It provides 3 to 4 hours of soft tissue anesthesia.
2. Local nerve blocks are preferable to infiltration in wound margins.
a. Local nerve blocks reduce the total dose of anesthetic required.
b. Avoid distortion of the wound margins from infiltration of local
anesthetic.
c. Decrease edema at the wound edges to promote better healing.
3. Local blocks in the face
a. Infraorbital block (transcutaneous nasolabial approach): Blocks the
lateral nose, cheek, lip, and lower eylid. Technique: Enter the skin
lateral to the alar groove. Advance the needle toward the infraorbital
 V. Wound Closure Techniques 115

foramen, which is 4 to 7 mm below the infraorbital rim. Inject 1 to

2 mL of anesthetic.
b. Mental block: Blocks the lower lip and chin. Technique: Pull the
lower lip out. Enter the mucosa in the sulcus at the base of the
second lower bicuspid. Inject 1 mL of anesthetic.
c. Supraorbital/supratrochlear/infratrochlear block: Blocks the forehead,
frontoparietal scalp, and medial upper eyelid. Technique: Stretch the
eyebrow laterally. Enter the skin at the middle third of the eyebrow.
Advance the needle toward the supraorbital notch and inject 1 to 2 mL
of anesthetic at the notch under the muscle to get the supraorbital
nerve. Then advance the needle along the rim in the medial direction
16
and inject with another 1 mL of anesthetic to get the supratrochlear

SOFT TISSUE INJURIES OF THE FACE

nerve. Continue to advance the needle to the nasal bone and inject
another 1 mL of anesthetic to get the infratrochlear nerve.
d. Dorsal nasal block: Blocks the cartilaginous dorsum of the nose and
nasal tip. Technique: Palpate the junction of the nasal bone and
upper lateral cartilages. Insert the needle at the junction along the
midline. Inject 1 to 2 mL on each side of the midline.
e. Zygomaticotemporal block: Blocks the side of the face from the
lateral orbital wall to the hairline. Technique: Insert needle about
1 cm behind the lateral orbital rim. Advance along the bony wall to
about 1 cm below the lateral canthus. Inject 1 mL while pulling the
needle back.
f. Zygomaticofacial block: Blocks the middle and posterior cheek.
Technique: Insert the needle just lateral to the confluence of the
infraorbital and lateral orbital rims. Inject 1 mL of anesthetic.
g. Great auricular block: Blocks the lower third of the ear and the
postauricular skin. Technique: Measure 6.5 cm from the lower
border of the external acoustic meatus to the middle of the
sternocleidomastoid. Inject 1 mL of anesthetic at this location onto
the sternocleidomastoid muscle fascia.
h. Mandibular (V3) block: Blocks the lower cheek, preauricular and
auriculotemporal hair regions. Technique: Insert a 22-gauge spinal
needle at the sigmoid notch of the mandible (between the condyle
and coronoid). Advance the needle straight to the pterygoid plate.
Mark the needle depth at the skin. Then retract the needle and
direct it about 1 cm posterior. Advance it only as far as your mark
on the needle. Inject 4 to 5 mL of anesthetic.

V. WOUND CLOSURE TECHNIQUES

A. Primary closure
1. Relaxed skin tension lines (RSTL)
a. The RSTL or Langer lines follow the furrows formed when the skin is
relaxed.
b. They are based on the orientation of the fibers in the reticular layer
of the skin.
 116 VI. Repair of Facial Structures

c. They run parallel to the principal muscle fibers below the skin.
Therefore, there is less tension on wound margins when skin
closures lie parallel to the RSLT.
d. Lacerations and incisions that fall parallel to these lines produce
the most inconspicuous scars. Attempt to place all incisions in
the RSTL.
B. Local skin flaps
1. Local skin flaps provide one-stage repair of avulsion defects. They are
appropriate to use when unable to close wounds primarily.
2. Local flaps include advancement flaps, rotational flaps, V-Y
advancement flap, Z-plasty, and rhomboid flaps.
3. Flap incisions can be hidden in RSTL.
4. Jagged scars are less noticeable on the face relative to single long linear
scars.
C. Skin grafts
1. Avoid split-thickness grafts because these lead to poor cosmesis.
2. Split-thickness grafts create color and texture mismatch and therefore
are not ideal for repair of facial injuries.
3. Harvest full-thickness grafts from supraclavicular donor sites for best
color and texture match.

VI. REPAIR OF FACIAL STRUCTURES

A. Scalp
1. The layers of the scalp (Fig. 16-6):
a. Skin
b. Subcutaneous tissue
c. Galea aponeurosis
d. Loose areolar tissue
e. Periosteum
2. Scalp lacerations may bleed significantly due to the high vascularity and
inelasticity of the subcutaneous layer that prevents blood vessel retraction
when lacerated.
3. Management
a. Hemostasis
b. Debridement and irrigation
c. Close the galea with 2-0 Vicryl interrupted stitches.
d. Close the skin with staples, which are less traumatic to hair follicles
relative to suture.
e. Place horizontal mattress 3-0/4-0 prolene suture if hemostasis is
inadequate.
4. Large avulsions usually require immediate flap rotation or future skin
grafting.
B. Eyebrow
1. Do not shave the eyebrow, as this will distort the anatomy and hinder
proper alignment during closure.
 VI. Repair of Facial Structures 117

Skin and
subcutaneous Retinacula
tissue Vessels
Galea and nerves
aponeurotica Galea
Loose Outer table aponeurotica
subaponeurotic Periosteum 16
tissue Inner table Bone

SOFT TISSUE INJURIES OF THE FACE

Diploë Dura

FIGURE 16-6
Anatomic layers of the scalp.

2. Debride only nonvital tissue. Incise or cut parallel to the hair follicles to
prevent damage to the follicles.
3. Perform 2-layer closure for full-thickness lacerations. Align the superior
and inferior aspects of the eyebrow first.
a. 4-0 monocryl interrupted sutures for the dermis
b. 6-0 prolene/nylon/fast-absorbing gut for the skin
4. Avulsion defects may require revision with hair transplantation as a
secondary procedure.
C. Eyelids
1. Anatomy of the upper and lower eyelids (Fig. 16-7A and B).
2. Any injury of the eyelid should prompt an ophthalmologic examination
for associated globe injury.
3. Explore lacerations to the upper lid to rule out damage to the levator
aponeurosis.
a. Ptosis of the eyelid indicates transection of the levator muscle.
b. Repair the levator muscle with 6-0 monocryl to re-establish the lid
fold and function of the eyelid.
4. Simple lacerations to the eyelid can be closed in a single layer.
a. Use 6-0 prolene/nylon/fast-absorbing gut to approximate the skin.
b. Avoid placing skin sutures through the septum, which will result in
cicatricial ectropion.
5. Marginal lacerations involve the lid margin.
a. Use 6-0 prolene/nylon to first approximate the lash line, meibomian
glands, and gray line (junction of the skin and mucosa). The
marginal sutures are left long and taped to the skin surface to
prevent corneal abrasion.
b. Use 6-0 monocryl to approximate the fascia.
 118 VI. Repair of Facial Structures

6. Avulsion injuries to the eyelids

a. Repair avulsion injuries with full-thickness skin graft from the
postauricular area or contralateral eyelid.
b. Avulsion injuries to the lid margins can be primarily closed if they
constitute < 25% of the lid length. A lateral canthotomy may be
required to achieve tension-free closure. Larger defects may require
grafts or rotation flaps.
D. Lacrimal apparatus
1. The lacrimal system is composed of the superior and inferior puncta,
canaliculi, lacrimal sac, and duct. More than half of tear drainage is
through the inferior canaliculus.
2. Lacerations or fractures to the medial orbital area may result in
transection of the canaliculi or lacrimal sac. Damage to this system is
usually apparent as epiphora (excessive tearing of the eye).
3. Laceration through the canaliculus
a. Place Silastic canalicular tubing into severed canaliculi. Repair with
microsurgical techniques.

Skin
Frontal sinus
Frontalis muscle

Brow fat pad

Levator muscle

Septum

Preaponeurotic fat

Levator aponeurosis

Orbicularis
Superior
rectus muscle
Müller’s muscle
Tarsal plate

Meibomian glands
A
FIGURE 16-7
Anatomic layers of the eyelids. A. Upper eyelid.
 VI. Repair of Facial Structures 119

Tarsus

Inferior
oblique muscle Inferior tarsal muscle
Inferior suspensory
Inferior
ligament of fornix 16
rectus muscle
Septum

SOFT TISSUE INJURIES OF THE FACE

Lockwood’s
suspensory ligament
Preaponeurotic fat

Capsulopalpebral
fascia

FIGURE 16-7—cont’d
B. Lower eyelid.

E. Nose
1. Inspect the septum for septal hematoma or presence of
mucoperichondrial laceration.
a. Incise and drain hematoma if present.
2. Through-and-through lacerations
a. Repair the mucosa with 4-0 chromic interrupted stitches.
b. Reapproximate cartilage with 4-0 monocryl interrupted sutures.
c. Close skin with 6-0 prolene/nylon/fast-absorbing gut. Align known
landmarks (i.e., alar rim, tip) for proper orientation.
3. Options for avulsion defects
a. Tack down skin flap if present and viable.
b. Perform immediate reconstruction with a composite graft if injured
skin is available or full-thickness skin graft.
c. Treat with local wound care and allow healing by secondary
intention. Secondary reconstructive flap may be needed for scar
revision once the area is completely healed.
F. Lips
1. Lacerations across vermilion border (Fig. 16-8):
a. Align the vermilion border first with a single 6-0 suture.
 120 VI. Repair of Facial Structures

First suture at
vermilion border

FIGURE 16-8
Repair of laceration involving the lip across the vermilion border.

b. Approximate orbicularis oris fibers with 4-0 Vicryl.

c. Close skin with 6-0 prolene/nylon/fast-absorbing gut.
2. Through-and-through lacerations
a. Close inside-out starting with the mucosa. Repair the mucosa with
3-0 chromic gut.
b. Irrigate the subcutaneous tissue.
c. Close remaining layers as above.
3. Avulsion defects
a. Close avulsion defects primarily if less than 25% of lip tissue is lost.
b. More extensive tissue loss will require regional advancement flap.
G. Parotid duct
1. Anatomy
a. The parotid duct (Stensen’s duct) exits the anterior aspect of the
parotid gland.
b. It courses across the middle third of the cheek along a line from the
tragus of the ear to the middle of the upper lip.
 VI. Repair of Facial Structures 121

c. The duct crosses superficial to the masseter, then pierces the buccinator
to enter the oral cavity at the level of the maxillary second molar.
2. Identification of a duct injury
a. Direct inspection of the wound may be insufficient.
b. Dry the buccal mucosa and then massage the parotid gland and duct.
Smooth flow of secretions into the oral cavity indicates a patent duct.
c. Cannulate the duct orifice with No. 22 angiocath and irrigate. Saline
flush in the wound indicates an injury.
d. Cannulate the duct orifice with a probe. Then inspect the wound for
visibility of the probe and laceration.
e. Obtain sialography if the results of the examination are indeterminate.
16
3. Repair of duct injury

SOFT TISSUE INJURIES OF THE FACE

a. Place Silastic tubing through the intraoral orifice across the laceration.
b. Repair the duct primarily over the tubing with 6-0 monocryl or PDS.
c. Maintain the Silastic tubing in place for 5 to 7 days.
H. Ear
1. The ear has an excellent blood supply and can maintain large areas of
skin on relatively small pedicles. Therefore, perform minimal
debridement.
2. Skin lacerations with exposed cartilage
a. Close the skin over exposed cartilage. Do not leave the cartilage
uncovered.
b. Trim cartilage to skin edges if skin loss is present.
c. Antibiotics: Give a fluoroquinolone for 7 days for cartilage protection.
d. Close skin with 6-0 prolene/nylon/fast-absorbing gut.
3. Lacerations through cartilage
a. Repair cartilage with 4-0 monocryl interrupted suture.
b. Close skin as described above.
c. Give antibiotics as above for cartilage protection.
4. Place a light pressure dressing on ear repairs to prevent edema, seroma,
and sub-perichondrial hematoma. These complications may lead to
fibrosis and formation of a “cauliflower ear.”
a. Aspirate a hematoma or seroma under sterile conditions with an
18-gauge needle.
b. May require daily drainage until the fluid collection stops
5. Avulsion defects
a. Small avulsion defects may be replaced as a composite graft if
injured skin is available.
b. Utilize postauricular skin with advancement flap to cover posterior
ear defects.
c. Provide local wound care for areas without cartilage exposure to heal
by secondary intention.
d. Secondary reconstruction may be done in the future once the wound
has healed.
I. Oral mucosa and tongue
1. Mucosal lacerations
 122 VIII. Suggested Readings

a. Close the wound with 3-0 chromic suture in interrupted, running, or

running locking fashion.
b. The running locking method will give the tightest, water-sealed
closure.
2. Tongue lacerations
a. Perform lingual nerve block to prevent tissue distortion around
wound edges.
b. Close with 3-0 chromic suture.
3. Submandibular ducts (Wharton’s ducts)
a. Located in the anterior floor of the mouth
b. Cannulate to evaluate for injury similar to parotid duct evaluation.
c. Perform sialography if examination results are indeterminate.
d. Repair the duct over silastic tubing similarly to the technique described
for the parotid duct, above. Keep the tubing in place for 5 to 7 days.
e. Perform proximal duct diversion if unable to repair injury primarily.

VII. ANIMAL BITES

A. Irrigate and debride to convert wound from contaminated to clean.

B. Close wounds primarily if possible.
C. Close large defects with local advancement flap or allow healing by
secondary intention with future scar revision.
D. Prophylactic antibiotics with ampicillin-sulbactam for 7 days are indicated
to cover dog and cat flora (gram-positive cocci and Pasteurella multocida).
E. Administer tetanus prophylactic.

VIII. SUGGESTED READINGS

Bennett RG: Fundamentals of Cutaneous Surgery. St. Louis, CV Mosby, 1988.
LaTrenta GS: Atlas of Aesthetic Face and Neck Surgery. Philadelphia, Saunders, 2004.
McCarthy JG: Plastic Surgery, Vol 2. Philadelphia, Saunders, 1990.
Nerad JA: Oculoplastic Surgery: The Requisites in Ophthalmology. St. Louis, Mosby,
2001.
Rohrich RJ, Robinson JB: Wound Healing. Selected Readings in Plastic Surgery,
Vol 9, No. 3. Dallas, University of Texas Southwestern Medical Center and Baylor
University Medical Center; 1999.
Seckel BR: Facial Danger Zones, Avoiding Nerve Injury in Facial Plastic Surgery.
St. Louis, Quality Medical Publishing, 1994.
Thal ER., Weigelt JA, Carrico CJ: Operative Trauma Management: An Atlas, 2nd ed.
New York, McGraw-Hill, 2002.
Zide BM, Swift R: How to block and tackle the face. Plast Reconstr Surg 101:840-851,
1998.