Maxfacts

Damage

This page gives a general overview of procedures and approaches in repairing soft tissue damage in the head and neck area.

Initial steps

The initial treatment steps include a thorough exploration of the wound(s) and other structures, as well as stopping bleeding.

Gaping penetrating wounds of the neck (see Figure 1; deep to the platysma, the large but thin muscle covering the front middle and sides of the neck) need to be explored in an operating theatre environment.

Figure 1: The marginal mandibular branch of the facial nerve and the mandible were damaged in this meat cleaver injury.

Blood vessels need to be checked for bleeding (often blood vessels that were only partially transected, or blood vessels (often completely transected) in a spasm). Damaged blood vessels are repaired by ligating them (tied up) or by using diathermy (using heat to cause clotting). Vital blood vessels are repaired by using fine sutures (stitches) as required.

There is a range of methods of treating haemorrhage (stopping bleeding):

Similar to blood vessels, nerves that have been partially or completely divided may require microsurgical repair, either by directly connecting the proximal and distal ends, or by using a nerve graft.

Other structures and organs in the face that may be involved in a wound are the eyes (see Figure 2), ears or salivary glands.

Figure 2: Penetrating facial skin injury with underlying globe damage.

It is obviously important to identify and repair such underlying damage, failure to do so could result in long term morbidity (ongoing problems). A scalp laceration may overlie a skull fracture, a black eye may overlie an orbital / zygomatic (cheek bone) fracture, and a facial laceration may overlie a parotid (major salivary gland near / in front of ear) duct laceration, facial nerve laceration or underlying fracture.

Other investigations

Foreign bodies: if the mechanism of injury suggests a left behind foreign body (tooth, glass, dirt, projectile), then radiographs taken from two directions are used for localisation (see Figure 3). Some foreign bodies may be more obvious, see Figure 4. Some foreign bodies are not straightforward to detect by imaging methods: organic structures like wood can be confusing and thin hollow plastic objects may resemble air pockets on CT scans.

Figure 3: Fractured tooth fragment in the upper lip localised by radiographs. Such foreign bodies must be removed because they will always cause persisting severe infection. Foreign bodies, however, can be tricky to find.
Figure 4: In contrast to the fractured tooth fragment (Figure 3), this toothbrush injury was obvious to all concerned.

Depending on size, location, nature and toxicity, most foreign bodies will require removal. In certain circumstances, it may be acceptable to leave inaccessible or innocuous objects; shotgun pellets are such an example.

Infection: swabs for culture and sensitivity will provide baseline information but rarely actually influence treatment. Most traumatic soft tissue wounds should have the bacterial contamination treated by surface cleansing (see below) and a broad-spectrum antistaphylococcal antibiotic.

Large complicated or deeply contaminated wounds are best treated under general anaesthesia. Most wounds and all complex wounds in children (see Figure 5) are best treated using general anaesthesia.

Figure 5: Top: multiple lacerations from a dog bite in a child should be addressed under general anaesthesia in the operating theatre; bottom: after repair.

Frankly infected wounds, or wounds with a high likelihood of infection are sometimes best left dressed with an antiseptic dressing; antibiotics are given and the wounds are closed once clean.

Wound cleansing

Cleaning the wounds is the most important stage in reducing the risk of infection and preventing possible ‘tattooing’ of the tissues by debris such as gravel which may have become impacted in or around the wound. There are a variety of cleansing solutions available. It is not a good idea to compromise adequate cleaning of wounds just to avoid general anaesthesia.

General method of cleansing involves:

Wound closure

This should always be performed in a good light and preferably with assistance (closure of wounds often requires the hands of more than one operator). The patient should be positioned supine (lying on the back) even when local anaesthesia is used, to minimise the risk of a faint.

There is a considerable choice of materials for wound closure:

Suture material and its strength have to match the defect that needs closing. Tight immobile wounds require thicker sutures; delicate, lax areas require fine stitches (see Figure 6 for an example).

Figure 6: Typical monofilament nylon suture.

Resorbable sutures may occasionally be used to close skin wounds in children where removal at a later date would necessitate another anaesthetic. Resorbable sutures are used in deep layer closure (see below) routinely and in inaccessible sites. They can play a useful role in subcuticular (under the skin) closure techniques.

Staples can be used as an effective method of closure of the skin surface in simple larger wounds. They are removed using a staple remover which is often less uncomfortable than removing sutures.

Removal of sutures

All sutures, being foreign bodies, cause irritation to the tissues and hence have the potential to cause scarring. Skin sutures are removed as soon as tissue healing allows, preventing further irritation of the tissues and avoiding binding of the sutures to the tissues as they heal.

As a rough guide non-resorbable sutures are best removed from the face at a period of five or six days, when sufficient healing has usually taken place to allow function of the tissue without re-opening of the wound.

Wound closure with sutures (wounds without tissue loss)

Where there has been little or no tissue loss and the margins of the wound consist of viable (healthy and stable) tissue, primary closure with sutures can usually be achieved.

Commonly used techniques are

Interrupted sutures are the simplest type of suture but also tend to be the most time consuming. Individual interrupted sutures can be used to close points of apposition in wounds until the entire length of the wound is closed (see Figure 7).

Figure 7: Closure of a simple linear incision with interrupted sutures.

Interrupted sutures are most useful for closing wounds of irregular contour and have the advantage that the closure of the entire wound is not dependent on just one suture (see Figure 8).

Figure 8: Top: complex facial laceration caused by multiple slashes; bottom: after repair of the wounds.

Continuous sutures are useful for closing straight wounds where tissue apposition is easy to achieve with accuracy (see Figure 9).  

Figure 9: An example of continuous subcuticular (below top layer of skin) suture to close a simple linear wound.

There is no interruption to the course of the suture, giving this suture the advantage of being less time consuming and possibly creating a more evenly balanced force of closure on the tissues. However, continuous sutures have the disadvantage that the whole layer of wound closure is dependent on just one suture, and therefore failure may mean re-suturing of the entire wound. Continuous sutures also tend only to be useful for closure of straight wounds.

Layered closure is a suitable approach for deep wounds, where tissue should be closed in layers to remove dead space and confer strength to the wound.

The technique for layered closure involves closing the deeper tissues first, usually with a continuous suture or ‘buried’ (resorbable) interrupted sutures, and then closing the skin with interrupted sutures (or occasionally adhesive strips) as above.

Deep or extensive wounds may require the insertion of a drain, which lies along the length of the depth of the wound. The purpose of a drain is to remove excessive inflammatory exudate and ‘oozed’ blood from the wound to prevent it collecting as a focus for infection. A drain placed in a wound is usually exited via an area of intact skin and subcutaneous tissue and may cause a small scar at that exit point following removal. Drains are usually made from plastic tubing which is perforated along the section lying within the wound to allow inflow of fluid. The outer portion of tubing remains intact and can be attached to a container (usually vacuumed) to collect and monitor the out-flowing fluid.

Wounds with tissue loss

In cases with tissue loss, occasionally the surrounding tissues are sufficiently elastic to allow them to be advanced into the area of defect and achieve functional and aesthetic closure. Where a substantial amount of tissue loss has occurred such that closure of the defect without excessive tension on the tissues cannot be achieved or would cause disfigurement, there are several options available for treatment.

Undermining the skin: when tissue loss is not extensive and mainly involves skin, a small border of skin either side of the wound may be carefully separated from the underlying fat. This allows advancement of the released elastic skin across the wound. Specific areas of the face are suitable for this technique.

Partial closure / granulation: this involves suturing the wound such that it is partially closed and not under excessive tension. The resulting defect is then allowed to heal by granulation. This technique is suitable for smaller defects but tends to increase the level of scarring; therefore it is usually inappropriate for facial wounds.

Skin grafting: this is used when mainly large areas of skin have been lost. It is often possible to harvest skin from a donor site elsewhere in the body for placement over the wounded area. Skin can be taken in a partial or full thickness graft from a site such as the inner thigh or arm (split thickness) or supraclavicular (above the collarbone), pre- or post-auricular (near the ears) regions (full thickness). The donated skin may be meshed (multiply punctured to allow stretching of the skin over a wider area, the epithelium spreading into the small resulting defects as healing occurs). Skin colour varies across the body and therefore care must be taken to ensure that the donor site is a reasonable match to the recipient site (see Figure 10).  

Figure 10: Split-thickness grafting seldom produces a good aesthetic result in the face but does allow coverage and initial wound healing.

Local flap repair: it may be possible to utilise skin from an area local to the defect by means of raising a flap of skin and repositioning it to cover the defect. This requires some ‘give’ in the skin at the donor site and therefore may require wide undermining of the skin in areas where the skin and underlying tissues are under tension or tightly bound to underlying structures (for example, the scalp). Common designs of flap for repair of defects include rotation and advancement flaps.

Local tissue can be augmented by local tissue expansion (see Figure 11). This takes time but creates a large amount of surplus local tissue for wound repair which gives close to the ideal colour and texture match.

Figure 11: Left: tissue expansion in the patient in Figure 10 to use healthy local tissue for closure; right: after excision of skin graft and movement of local flaps.

Distant flap repair: this involves removing donor tissue, including vasculature (blood vessels) from a distant body site and anastomosing (connecting) the vessels to the vasculature of the recipient site prior to repair.

There is a small risk that the circulation in the ‘free flap’ will fail (usually due to thrombosis in the venous system) and this is generally a more time consuming and complex operation. This repair method should be reserved for areas where there is extensive tissue loss and local flap repair would not suffice.

After damage repair: wound healing, scarring and potential problems

Following tissue trauma, there is an initial acute inflammatory response until fibrous tissue in the wound eventually matures to form a ‘scar’.  A number of factors affect the wound healing process, including:

Almost every injury involving a breach of the skin will result in a degree of scarring. In many circumstances, scars are in areas where they will not readily be noticed by other people and therefore they are of little or no consequence. Indeed, even in clearly visible areas, scars are often so fine as to be barely noticeable, or may be disguised within the natural skin creases or relaxed skin tension lines. Elective incisions for surgery are designed such that they respect the relaxed skin tension lines and so produce as minimal scarring as possible. However, trauma has no respect of aesthetics and therefore the scar produced by a trauma wound may prove to be particularly unsightly. Linear wounds tend to develop more obvious scarring than do irregular wounds unless a linear repair eyebrow has been mismatched (see Figure 12. Good wound care, early suture removal, moisturisation and massage all help to reduce scarring.

Figure 12: Left: a typical hypertrophic (deposit of excessive amount of connective tissue (collagen)) scar; right: a mismatch of natural facial features (in this case the eyebrow) produces a poor aesthetic appearance.

Non-surgical techniques to improve scars include silicone based gels for self-application, silicon pressure dressings, application of intra-lesional steroids or steroid impregnated tape.

If a scar is particularly aesthetically disturbing, it may be possible to perform ‘scar revision’, that is to surgically modify the scar such that it is reduced or is aesthetically disguised. There are a variety of techniques for such purposes and it is essential that the timing for such corrective interventions is well chosen: it usually takes about 18 months for a scar to be fully matured. Ideally scar revision should not be undertaken any earlier than that.

The most common problems following soft tissue damage repair are various forms of wound infection. Common reasons for infection(s) include:

Pre-operatively:

Post-operatively:

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