Atlas_chap2_FINAL.pdf

Chapter II

faCe, NeCK,

aNd eye trauma

II.1

Complex facial

Wounds

CASE PRESENTATION

a male soldier in his mid-thirties was injured by an improvised

explosive device (Ied) detonated close to him while he stood

near a concrete barrier. He sustained multiple injuries to the

face (figs. 1 and 2), scalp (fig. 3), and extremities. the patient was

orally intubated in the ield. a thorough examination that included

radiographs revealed macerated facial and scalp wounds impregnated

with rocks and dirt, and a partially degloved mandible (fig. 2). although

exposed, there was no damage to the bony facial skeleton. His vision

was intact. during surgery, massive irrigation and debridement of his

wounds were performed. devitalized tissue was debrided, the penetrated

tissue was explored, and rocks and dirt were removed with meticulous

care. the intraoral mucosa was sutured to cover the exposed mandible

and to separate the oral cavity from the face. moist wet-to-dry sterile

dressings were placed on the patient’s scalp and face. He was taken

to the intensive care unit (ICu) for continued care. the patient was

evacuated by air to a level IV medical facility for further treatment.

TEACHING POINTS

1. Note that immediate recognition and appropriate management of

airway compromise are critical to survival. a survey for associated

eye (proptosis, pupil size), ear (ruptured tympanum), and head trauma

is imperative. Patients exposed to blasts may experience iridoplegia

(paralysis of the pupil), which does not indicate secondary effect of a

central nervous system mass lesion or herniation.

Perform wound debridement to thoroughly evaluate the extent of the

injury.

Perform complete intraoral and extraoral examinations to rule out

facial fractures.

Cleanse wounds thoroughly with scrub solutions and saline. use a scrub

brush to remove all dirt particles from the dermis. Copious irrigation,

forceps (curette and no. 11 blade tip, among other instruments), and

strong suction are keys to effective cleansing.

remove foreign bodies with meticulous care in order not to provoke

injury to underlying structures. the more time taken initially will

improve the cosmetic outcome for the patient.

treat vascular injuries using methods from direct pressure to dissection

and ligation of the offending vessel. Blind clamping of bleeding areas

should be avoided because critical structures, such as the facial nerve

faCe, NeCK, aNd eye trauma | 55

F i g u r e 1. Multiple facial wounds impregnated with

sand, rocks, and debris.

F i g u r e 2. Degloved mandible and extent of wounds.

and parotid duct, are susceptible to injury. use sharp

debridement of wound edges that are devitalized.

use antibiotics with gram-positive coverage for

penetrating injuries to decrease the incidence of

infection and to help promote optimal wound

healing. Consider tetanus toxoid.

Ingeneral,incontrasttoextremitywounds,primary

closure is an important aspect of managing facial

lacerations. When primary closure is possible, the

wound should be reapproximated in proper layers

to optimize an esthetic outcome for the patient

(figs. 4 and 5). In this case, the wounds were so

contaminated that primary closure was delayed,

and additional irrigation and debridement were

required.

CLINICAL IMPLICATIONS

In contrast to similar wounds of other body regions,

primary closure of small facial wounds is recommended

following thorough cleansing. Closure of deep wounds

involving many layers or hasty closure before adequate

irrigation and debridement, however, can lead to the

following adverse outcomes:

F i g u r e 3. Scalp injuries.

56 | War SurGery IN afGHaNIStaN aNd Iraq: a SerIeS Of CaSeS, 2003–2007

F i g u r e 4. Scalp healing 1-year post-op.

F i g u r e 5. Facial wound healing 1-year post-op.

Infected wounds.

it is not recommended that deeply contaminated wounds

be primarily closed during initial surgery. In heavily

contaminated wounds, multiple rounds of irrigation and

debridement are recommended with delayed primary

closure, if possible. rotational laps and skin grafts may

be necessary to obtain optimal results.

devitalized tissues being inadvertently incorporated

into the wounds.

Inadequate debridement of wounds with retention

of foreign bodies.

tattooing as a result of inadequate dirt removal.

SUGGESTED READING

Chapter 13: face and neck injuries. In: Emergency War

Surgery, Third United States Revision . Washington, dC:

department of the army, Ofice of the Surgeon General,

Borden Institute; 2004.

DAMAGE CONTROL

for mild bleeding, use compression. for signiicant

bleeding, perform ligation of the vessel. direct visual

location of the vessel is necessary before vessel ligation

to prevent damaging the parotid duct or facial nerve.

meticulous irrigation and debridement of grossly

contaminated wounds are vital to prevent infection.

Chapter 22: Soft-tissue injuries. In: Emergency War

Surgery, Third United States Revision . Washington, dC:

department of the army, Ofice of the Surgeon General,

Borden Institute; 2004.

SUMMARY

attempt to remove all obvious debris from wounds

during the irst operation to facilitate a more favorable

outcome for the patient. If the tissue margin looks dead or

macerated beyond repair, it should be removed up to 1 to

2 mm to facilitate a more esthetic wound closure. Because

of the highly vascular tissue in the face, small pedicles of

tissue can survive. Native tissue will always look better

than laps and grafts. although the face is very vascular,

fonseca r, Walker r. Oral and Maxillofacial Trauma .

2nd ed. Philadelphia, Pa: W. B. Saunders; 1997.

rowe N, Williams J. Maxillofacial Injuries . 2nd ed. New

york, Ny: Churchill Livingstone; 1994.

faCe, NeCK, aNd eye trauma | 57

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