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Management of Facial Soft Tissue Injuries in Children

Henry C. Vasconez, MD, FAAP, FACS,* Jason L. Buseman, MD,*and Larry L. Cunningham, MD, DDS, FACS

Abstract: Pediatric facial trauma can present a challenge to even

the more experienced plastic surgeon. Injuries to the head and neck

may involve bone and soft tissues with an assortment of specialized

organs and tissue elements involved. Because of the active nature

of children, facial soft tissue injuries can be diverse and extensive

as well as some of the more common injuries a plastic surgeon is

asked to treat. In 2007, approximately 800,000 patients younger than

15 years presented to emergency departments around the country

with significant open wounds of the head that required treatment.

In this review, we present the different types and regions of

pediatric soft tissue facial trauma, as well as treatment options and

goals of plastic surgery wound management. Special aspects, such

as bite wounds, burns, pediatric analgesia, and antibiotic therapy,

are also discussed.

Key Words: Soft tissue, trauma, wound management,

facial soft tissue injuries

(J Craniofac Surg 2011;22: 1320Y1326)

T he face is the central most recognizable feature of a person.Small subtle changes in the relatively few parts of the face makeit very easy to distinguish all people in the world. A child has arelatively large face and head, primarily due to the rapid growth of

the brain. Injuries to the soft tissue and skeletal parts of the face andskull are therefore extremely common and of great importance tothe patient and the parents.

The active and often carefree or careless attitude of childrenand adolescents leads to a disproportionate increase in injuriesto the head and neck. Pediatric soft tissue injuries to the faceand scalp continue to be a common injury that the plastic surgeonis frequently asked to consult on because of the location and itsobvious cosmetic implications. Usually, these patients presentthrough the emergency department. In 2007, the number of emer-gency room (ER) visits for open wounds of the head in patientsyounger than 15 years was 370,000 and 434,000 for girls and boys,respectively. This represented 1.7% and 1.9% of all ER visits in thiscountry.1 At our level I trauma institution, our ER evaluated 212

patients from August 1, 2009, to July 31, 2010, younger than17 years with lacerations to the face and scalp that required closure.

Depending on the severity and type of injury, both skeletaland soft tissues can be affected. We concentrate on the soft tissueinjuries of the face in this article as skeletal injuries are addressedin other areas of this series. The mechanisms of injury are also ratherparticular to this age group and include the full spectrum of sport-ing events, falls, motor vehicle collisions, interpersonal assaults, andeven intentional injuries.

The face, more than any other part of the body, plays a majorrole in establishing identity and self-esteem. An unfavorable result

from an injury or an attempted treatment can lead to devastatingresults in both aesthetic and functional outcomes. They can result infrequent office visits and the utilization of various measures, at firstconservative and then increasingly more aggressive to obtain func-tional and structural improvement. A great deal of psychologiccounseling is also necessary to the child as well as to the parents. Notinfrequently, litigation can also be present, usually directed to thecause of the injury but also at times its treatment.

The principal goals for the management of facial injuries andwounds are similar to those in other parts of the body. One wantsto obtain rapid and uninterrupted wound healing and also achieveoptimal functional as well as aesthetic results. Normal anatomicalignment of the various injured and disrupted soft tissues, as well asbone segments, and a gentle handling of these tissues are key ele-ments to good results. The fourth dimension of time and future facial

growth also needs to be taken into account. Often, this will befavorable for the injury, but at times, because of scarring and loca-tion, it can interfere with certain anatomic structures. The concept ofaesthetic units is very important in the treatment of facial injuries.Little can be done to the lacerations already present, but any addi-tional extensions or incisions can be placed within proper aestheticunits to obtain a more cosmetic result.

A classification of the soft tissue injuries of the face shouldinclude the etiology, location, size, and depth of the wound as wellas any associated structures such as bone, teeth, muscle, nerves,vessels, and glands. The types of injuries sustained can range froma simple laceration that may require only approximation to morecomplex contusions and avulsions with significant soft tissue defi-cits. Other types of injuries are abrasions, punctures, burns, blastinjuries, and other forms of blunt trauma.

A complete recognition of all tissues injured, of course, willlead to better management and overall better results.2 The timingof repair depends on the extent of injury and the overall conditionof the patient. Better results are obtained the earlier the repair isperformed. This is especially true in major contaminated injuries andanimal bites. The face has a very rich blood supply, so it is very rarethat delayed primary closure will be necessary. Most of the time, anadequate cleansing and debridement will be sufficient to allow pri-mary closure. Some wounds with tissue deficits may require local orregional flaps and in very few cases will require free-tissue transferor subsequent tissue expansion to obtain a satisfactory result.

Management of most lacerations in children can be per-formed in the ER setting. More extensive and complex situationsrequire the operating room where proper anesthesia, lighting, and

CLINICAL STUDY

1320 The Journal of Craniofacial Surgery&

Volume 22, Number 4, July 2011

From the *Division of Plastic Surgery, Department of Surgery, University ofKentucky College of Medicine; andDivision of Oral and MaxillofacialSurgery, University of Kentucky College of Dentistry Lexington,Kentucky.

Received November 4, 2010.Accepted for publication January 29, 2011.Address correspondence and reprint requests to Henry C. Vasconez, MD,

FAAP, FACS, Division of Plastic Surgery, Department of Surgery,University of Kentucky College of Medicine, 740 South Limestone,KY Clinic K446, Lexington, KY 40536-0284; E-mail: [email protected]

The authors report no conflicts of interest.Copyright* 2011 by Mutaz B. Habal, MDISSN: 1049-2275DOI: 10.1097/SCS.0b013e31821c9377

Copyright 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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instrumentation are available. Even the more common and superfi-cial injuries to a child may represent technical and emotional chal-lenges to the health care team. The patient and the family are usuallyvery distraught and frightened in these situations. Calm and con-siderate explanation and preparation of the patient and the parentwill reap many benefits in the long run.

PRINCIPLES OF ASSESSMENT ANDMANAGEMENT OF FACIAL INJURIES

Proper treatment of facial injuries depends on a correct diag-nosis and a thorough assessment of the patient.3,4 For more severeinjuries, appropriate emergency trauma workup is indicated where theABCs of airway, breathing, and circulation are adequately controlled.After life-threatening injuries have been resolved or stabilized, a de-tailed survey of the specific regions of the body and, in particular thehead and neck, is performed. At this point, evaluations of skeletal andsoft tissue injuries are assessed clinically and with various forms ofimaging. Also, a basic history of the patient is established, if possible.

Infants are usually best examined and treated in the presenceof the parent or guardian. In the case of toddlers or preschoolers, anonthreatening environment must be established in the presence of

the parent, although children of this age may ultimately respondbetter to a brief separation during the actual treatment. Older chil-dren and adolescents may require some element of control of thesituation in which their autonomy is respected, and they are able tomake certain choices. Kindness and patience may prove to be morerewarding than roughness and expediency and ultimately provide fora more favorable result.

Pictures of the wound can be valuable for documenting fu-ture progress of the injury. In cases of child abuse or potential legalmatters, photographs can be crucial. If there is a suspicion of thenature, location, or circumstances of the injuries, social services orhospital administration should be enlisted to investigate the casefurther. Any discussions of these matters or issuing judgmentalcomments are inappropriate and counterproductive during the periodof initial treatment. A brief and understandable description of the

proposed treatment of the wound or injury is given to the patient andparent. Realistic expectations of the results are established at theoutset so that no confusion is generated on future follow-up.

The patient and the parent should especially understand thatscars are permanent but that they will improve with time and can berevised at a future date. They should also be properly instructed inthe postoperative care of wounds and know what to look for toidentify problems in the immediate postoperative period. Writteninstructions and phone numbers to call are very important as thisinformation is often forgotten in the mid of the excitement.

CLINICAL EVALUATIONOnce the initial trauma evaluation and assessment have been

completed, the more superficial injuries can be properly examined. Itwill become quickly apparent where definitive treatment of the facialinjuries will need to be performed. This will depend in large measureon the other associated injuries of the patient, the extent of the facialand craniofacial injuries, the age of the child, and the facilitiesavailable in the ER, as well as other factors.

In most situations, a good examination can be performed in theER. Inspection and palpation of the injuries are imperative. We try touse a systematic approach to lessen the chance of missing injuredstructures. We move from top to bottom of the head and neck, fromoutside in, and from superficial to deep. We usually address the ob-viously injured sites last so that we can try to obtain the confidence ofthe already traumatized patient. Inspection will reveal lacerations,either simple, linear, or stellate; abrasions or burns; presence of for-eign material or traumatic tattoos; and contusions and avulsions with

or without loss of tissue. Further inspection and palpation will revealthe presence of bone involvement or crepitus, which can be from thesinuses or from the outside.

Innervation is assessed by testing for symmetry of sensationand motor function. The mouth is inspected for presence of loose ormissing dentition. These may be deciduous or permanent in nature.

They may have been lost in the wound or even aspirated. If this issuspected, a radiograph would be necessary. Mucosal lacerations,problems with occlusion, and tongue injuries should be evaluated.Brief examinations of special structures, such as the eyes, are im-portant. A simple check of vision and extraocular muscle movementcan suggest a more serious injury. The condition and position of theglobes may also warrant further inspection of the orbit and sur-rounding skeletal structures. An ophthalmology consult is manda-tory if globe injury is suspected. Because of its position andprojection, the nose is a commonly injured structure. Children fre-quently have greenstick fractures of the proper nasal bones, but theycan lead to significant deviation, septal hematoma, or bone andcartilage exposure. Nasal ethmoid orbital fractures may be present;the inspection for medial canthal injury, including lacrimal duct tearsor contusion, should be evaluated.

IMAGING STUDIESSeveral diagnostic studies may already have been done before

examination of the patients facial injuries. A computed tomographicscan of the craniofacial skeleton, if indicated, will provide cleardefinition and extent of the fractures and also alignment of thevarious structures such as the globe, nasal septum, the sinuses, andmuscle layers. A magnetic resonance imaging is valuable to assessintracranial structures and can be useful to evaluate the soft tissuelayers and structures of the face.

CONSULTATION TO OTHER SERVICESUsually, a proper evaluation of all systems will be done with

the multiply injured patient by the trauma service. However, theexamination of the craniofacial structures may warrant further

consultation with ophthalmology, neurosurgery, dentistry, and otherservices after evaluation from a plastic surgeon.

SEDATION AND ANESTHESIAA calm, cooperative child during the repair of a facial lacer-

ation is a key element to a satisfactory result. At times, the age of thepatient, location, and extent of the injury may dictate the use ofgeneral anesthesia in an operating room setting. Most simplelacerations can be addressed in the ER or treatment room under localanesthesia. An attentive parent holding the childs hand or the use ofjudicious sedation and analgesia may be necessary.

Sedation and analgesia are becoming much more commonoutside the operating room, mainly because of health care trends ofmore cost-effective measures.5 The surgeon, therefore, should bewell versed in the various forms of sedation and analgesia in chil-dren, including indications, specific types of sedation, techniquesand dosage, risks and treatment of complications, and rescue. TheSociety of Anesthesiology and the American Academy of Pediatricshave provided guidelines for the monitoring and management ofpediatric patients during and after sedation for various proceduresconducted outside the operating room.6 The goals of sedation are toprovide a relatively pain-free environment so that precise surgicalcare can be delivered by controlling the behavior of the child andproviding the potential for amnesia. The foremost goal, however, isto do this while optimizing the patients safety and well-being.Therefore, there should always be proper monitoring, facilities andequipment, adequate personnel, dietary precautions, and properdocumentation. A responsible parent or legal guardian should also

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be available, especially in the postsedation period. Proper instruc-tions need to be given so that the parents can watch for any problemsthat may arise during the transport home and in the subsequentfollow-up period.

The level of sedation and amount of pain medication requiredwill depend on the extent of injury, medical and psychologic con-

dition of the patient, and the family situation. The route of admin-istration is also important. Intravenous administration is faster andmakes it easy to titrate doses. However, intravenous access is re-quired, and overdosage and adverse effects can occur more quickly.Oral, intranasal, rectal, and intramuscular routes are other possibil-ities. The surgeon should be familiar with the dosage and adminis-tration based on the weight and age of the patient along with thepotential adverse effects of the drugs given.

Once proper sedation has been given and has been allowed totake effect, local anesthesia, at the site, provides the necessary anal-gesia while reducing the requirements of systemic sedation and nar-cotics. Local anesthetics are usually injected into the wounds;however, topical anesthetics such as EMLA Cream7 (eutectic mixtureof local anesthetics, lidocaine 2.5% plus prilocaine 2.5%) or TAC(tetracaine 0.9%, adrenaline 1:200,000, and cocaine 4%Y7%) have

been used to prepare the wound or skin for needle insertion orto repair simple skin lacerations. Mucosal administration must beavoided to prevent systemic absorption, which can cause complica-tions such as methemoglobinemia or cardiovascular dysrhythmias.8

Lidocaine is the most commonly administered local anestheticbecause of its long history of safety, rapid onset of action, and gooddiffusion. It is commonly combined with epinephrine to counteract itsvasodilatory effects and produce vasoconstriction at the site of in-jection. Its onset of action is almost immediate; however, epinephrinewill take 5 to 7 minutes for full vasoconstriction to occur. Bupivacaineis another amide local anesthetic which has a longer onset of action;however, its duration of action is also much longer than lidocaine,making it desirable in certain cases. The combination of lidocaine andbupivacaine should be used with caution because of the additive toxicadverse effects.

Local anesthetics are stored in an acidic medium (approxi-mately pH 4.5) to ensure stability and to lengthen the shelf life.When injected, they cause pain, and the childs reaction will be towithdraw violently. It is therefore recommended that the anestheticbe neutralized with sodium bicarbonate solution usually in a 1:10ratio (1 mL equivalent of sodium bicarbonate per milliliter with9 mL of 1% lidocaine with epinephrine). It is also very useful to useas small a needle as possible, such as a 27- or 30-gauge needle, toslow the injection and thereby lessen the pain and improve the ac-curacy of local injection. Injecting perpendicular to the skin initiallyalso aids in decreasing the pain.

Regional nerve blockade is another option that can be veryuseful for face injuries. First, the blockade can usually be madeoutside the direct area of injury. It can also provide a more extensiveanesthetic blockade of the area and therefore lessen the amountof infiltration needed. Most importantly, it can provide anesthesiawithout direct distortion of the tissues involved. A solid under-standing of the anatomy and distribution of the trigeminal nerve andother sensory nerves of the head and neck is essential. Often, furtherinfiltration of the wound will also be necessary, but it will be less inquantity and hurt less because the regional blockade is on board.

Ketamine is an excellent analgesic and anesthetic in childrenfor more invasive and painful procedures. It is a dissociative anes-thetic that produces profound analgesia yet little effect on respiratorydrive. It can be given intravenously (0.25Y0.5 mg/kg), orally orrectally (6Y10 mg/kg), or intramuscularly (2 mg/kg). It increasesheart rate, blood pressure, and intracranial pressure and can causecopious secretions; pharyngospasm and an incompetent gag reflexare seen in larger doses. To avoid or minimize these and other com-

plications, lesser doses are recommended and limited to 0.25- to0.5-mg/kg boluses intravenously with a maximum of 2 mg per kiloover 20 minutes.

Propofol is another popular sedative and hypnotic with veryfast onset and extremely short duration that is used most often in theoperating room. It is more commonly used for nonpainful pediatric

procedures; for example, magnetic resonance imaging, which is bestadministered by an anesthesiologist or certified anesthetist.5 Theseparenteral sedatives, of course, require proper monitoring and ade-quate personnel present.

GENERAL WOUND MANAGEMENTAND CLOSURE

Once good anesthesia in a stable patient has been obtained,direct attention to the wound can be made. A better inspection of thedegree of injury can now be made, including surrounding structures.The presence of foreign material can be noted and cleaned fromthe wound. Devitalized tissue can now be properly debrided, and thewound can be irrigated with copious amounts of normal saline so-lution. Judicious debridement needs to be used to maximally pre-serve precious facial structures. Nonetheless, jagged irregular edges

should be converted into sharper and better aligned margins.Adequate irrigation should allow for proper closure of the

wound. Notable exceptions are in cases of significant tissue lossor significant contamination. In both situations, a form of delayedclosure will usually give time for the surgeon, patient, and family toproperly decide on the ultimate closure technique. Avulsive injuries,in general, should be modestly debrided because of the fact that muchof the tissue will go on to survive even, although a small pedicle ornourishing segment may be present (Fig. 2A). Some notable excep-tions to this are, of course, avulsions of large facial segments that arebest repaired by replantation. These include, but are not limited to, thescalp, nose, lip, ear, and cheek. The literature has documented thereplantation of these facial segments. Vein grafts may be needed, andsystemic anticoagulation and medical leeches are often used. Thepatient and family need to be fully informed of the potential risks,

benefits, and complications. A skilled and complete replantation teamis necessary along with optimal conditions for a successful outcome.

CLOSURE OF THE WOUNDProper instrumentation and suture materials are important to

obtain optimal healing of all wounds and, in particular, of the face.Staples are quick and effective methods of closure on the scalp andcan be easily removed. They have, however, no place in the closure ofmost wounds on the face. Absorbable sutures are used to close deeperstructures such as muscle, fascia, and subcutaneous tissue. Preferably,monofilament sutures are used to help prevent infection. Skin closureshould be performed in such a manner as to obtain the best possibleoutcome. In children, all attempts should be made so that no sutureremoval is necessary. The child has already undergone sufficienttrauma and will be very scared and reluctant to endure further traumain trying to remove sutures. Therefore, carefully placed, fine, absorb-able sutures such as catgut can be used. Steri-Strips (3M, St Paul, MN)are also valuable aids in the closure of well-aligned lacerations. Tis-sue adhesives have recently found a popular place, especially in thepediatric population in the area of skin closure. The Food and DrugAdministration has now approved the use of cyanoacrylate tissueadhesives. Octyl-2-cyanoacrylates form a stronger and more flexiblebond with a breaking strength 4 times that of N-butyl varieties andhave, therefore obtained greater popularity (Dermabond, Ethicon,Somerville, NJ). Their use in children is obvious and has proven verypopular. There are even weaker, less concentrated varieties in over-the-counter products. The other advantage of using cyanoacrylateadhesives for skin closure is that they provide a waterproof dressing

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and can aid in bacteriostatic protection of the incision. There are otheradvantages of use in the ER setting: faster application and reducedpain. There is an increase in cost and a slight increased risk of su-perficial wound dehiscence. We recommend using cyanoacrylateadhesives along with some form of subcuticular closure.9 Petrolatumointment, such as antibiotic ointment, should not be used on the site

closed with cyanoacrylate adhesives because this will go on to de-grade the product and increase the chance of dehiscence.

POSTOPERATIVE CAREIf sutures are utilized, they should be removed as soon

as possible to avoid the presence of external marks or tracks. Other-wise, the Steri-strips or adhesives should remain until they fall off bythemselves or until the surgeon indicates that they can be removedwith soap, water, or ointment. Advice regarding treatment of thescar includes gentle massage, usually with a lotion of the patient orparents choice. The use of pressure therapy or silicone gel sheetingmay have some proven efficacy.10 Treatment of a reddened scar withpulsed dye vascular laser has been shown to be effective. Any signsof increased redness, pain, or drainage should be evaluated right away.Many times, the administration of antibiotics is sufficient to quell

a developing infection. However, if redness and drainage persist, thewound should be opened, drained, and properly packed and dressed.In these situations, frequent follow-up visits are important to obtainan optimal result as well as to assure the patient and the family.

ANTIMICROBIAL THERAPYA simple wound on the face that has been thoroughly cleaned,

irrigated, and closed appropriately does not routinely require pro-phylactic systemic antibiotics.11 Topical antimicrobial agents, in turn,have been shown to decrease the rate of infections of traumatic lac-eration. We commonly prescribe these topical agents to providea moist environment that will promote healing and decrease thechance of infection.12 An exception is when tissue adhesives such asthe cyanoacrylates are used because a petrolatum-based ointment will

tend to dissolve the adhesive. Certain wounds, such as animal bites,deep contaminated wounds, delayed wounds, or wounds that forsome reason cannot be adequately debrided on initial evaluation(ie, due to other more serious and life-threatening injuries), willbenefit from prophylactic antibiotics. The risk of the emergence ofresistant organisms must be weighed against the potential benefitsof prophylactic agents. A narrow spectrum of activity for as briefa period as possible should also be used. Recently, the incidenceof community-acquired methicillin-resistant Staphylococcus aureusstrains (MRSA) has greatly increased, especially in the pediatricpopulation. Empiric and prophylactic antibiotic coverage needs totake this into account.13

Although there are no specific studies in the pediatric popu-lation on prophylactic antibiotics, the American Academy of Pedi-atrics and the Centers for Disease Control and Prevention haveoffered some guidelines.14 Even fewer studies have been doneon patients seen in the ER. The indications are based on the statusof the wound, ranging from clean to contaminated and franklyinfected. In addition, the benefits of systemic antibiotics needto outweigh the potential risks associated with their use, includingadverse reactions or emergence of resistant strains. The durationof administration also needs to be taken into consideration. Again,the status of the wound plays an important role in prescribing 1or 2 doses after the repair versus a full week of therapy. For mostcases of traumatic wounds of the face, a first-generation cephalo-sporin for a few doses will be sufficient. In animal bites, especiallydog bites, and human bites, as well as deeply contaminated wounds,we prescribe a A-lactam antibiotic with an appropriate A-lactamaseinhibitor such as amoxicillin-clavulanate. Because in our area and

institution we have seen a dramatic rise in both hospital- andcommunity-acquired MRSA infection, we will commonly associ-ate in indicated cases, or where the organism is present on cul-ture, prophylaxis with a sensitive drug such as clindamycin ortrimethoprim-sulfamethoxazole. As further specific studies are con-ducted in children, we will need to modify our choice of antimi-

crobial agents as well as empiric antimicrobial therapy.13,14

BITE WOUNDSAn estimated 4.7 million people are bitten by dogs annually

in this country. There are about 400,000 cat bites and approximately250,000 human bites annually in the United States. Children are byfar the most common victims of dog bites, amounting to more than400,000 patients receiving medical attention in the ER on an annualbasis. The rate of infection after cat bites can be as high as 50% andbetween 10% and 15% for dog and human bites.15 A large of numberof the dog bites in children occur in the head and neck region. This iscommon because of the size of the child and a definite propensity ofthe dog to attack the face. The most common sites of dog bites to thehead and neck in children are the cheeks, the lips, the nose, and the

ears.16,17

The types of injuries are mostly complex irregular woundswith significant avulsion components. Severe lacerations and injuriesin the face can lead to infection and scarring if not treated appropri-ately. A concern for the transmission of rabies should be increasedwhen a bite is from a wild animal, especially a bat or a carnivore orfrom a domestic animal such as a dog, which cannot be observed for10 days after the bite. In such situations, proof of rabies vaccination inthe animal should be obtained. If this information is not attainable, thelocal health department should be contacted to determine whether toproceed with rabies immunization. All wounds should be cleanedwith soap and water or an antimicrobial solution such as Betadine(povidone-iodine). After careful cleansing of injuries of the face,suture closure can usually be performed because of its excellent bloodsupply. A careful inspection of the wound should take into accountthat the animal has an upper and lower jaw that may both penetrate the

facial soft tissues. Therefore, a bite should be thoroughly examinedwith this in mind. Judicious debridement should be performed offrankly devitalized tissue only. The edges of the wound should becarefully trimmed for better approximation; closure should then beperformed in layers, with as few sutures as necessary in the deep layerfollowed by absorbable sutures in the subcutaneous and subdermalregions. Deeply contaminated wounds that are more than 12 hours oldmay require leaving the wound open and performing a delayed pri-mary closure. In more rare situations, bony involvement may bepresent in which case the patient should be taken to the operatingroom for a more complete treatment of his/her injuries. Antimicrobialprophylaxis is usually indicated with animal bites, especially in thosechildren at high risk, including immunocompromised patients, and inmore contaminated and delayed wounds. Pasteurella multocida andS. aureus are 2 common organisms in dog and cat bitesthat can lead toinfection. These usually respond to antibiotics within the penicillinfamily such as Augmentin (amoxicillin and clavulanic acid) orally orUnasyn (ampicillin and sulbactam) intravenously. The increasingprevalence of community-acquired MRSA in several areas of theUnited States requires a change in antibiotic therapy to address thesepathogens. Oral floras in human bites that can cause infection includeStreptococcus, S. aureus and Eikenella corrodens. Penicillin or otherA-lactam agents can also be successful against these bacteria. A 2- or3-day course of therapy may be all that is required in mild to moderatecontaminated wounds. More severe wounds may require 7- to 10-daycourses of antibiotics.

Prevention is a hallmark in the topic of dog and animal bitesin children. There are a number of things that can be done to avoidthese injuries, especially dog bites, which are so prevalent. Proper




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training and socialization of the pet, as well as practical educationof the child when coming in contact with a pet, are of great value.Cautionshould be used around new and strange dogs. A baby or smallchild should never be left alone with a dog. Proper instructions onhow to treat a strange dog, or even a dog of thefamily, are important.18

REGIONAL INJURIESScalp

Scalp injuries have the potential for substantial blood loss. Anappreciation of the anatomic layers of the scalp is important for properwound management. The 5 layers are skin, connective tissue, galeaaponeurosis, loose areola tissue, and periosteum. When injuries tothese layers occur, tension of the specific layers can pull on the sep-arated skin edges and produce profound bleeding. Hemostasis canusually be obtained with pressure dressings and head wraps untilready for closure.

Attempts should be made to close the scalp injury in layers. Inparticular, the strong and well vascularized layer of the galea apo-neurosis should be closed with an absorbable suture. This will betterapproximate the skin edges as well as help prevent any hematoma

development in the future.19

Skin should be closed with an absorbablesuture to prevent traumatizing the patient with suture removal. Incases of profuse blood loss or severe trauma, attempts should be madeto ligate any arterial bleeders. If time is short, the skin can quickly beclosed with a running, locking suture or metal staples. In these typesof situations, the cosmetic long-term results are not of top priority.

EyebrowsIn most injuries involving the eyebrow, the most critical aspect

of repair is proper alignment of the margins. Shaving of the eyebrowregion is not indicated because of its unpredictable ability and speedto grow back. Irrigation of the wound is performed with minimumdebridement of tissue. Closure is then done in layers with attempts toapproximate any muscle layers. The final layer closed includes theeyebrow itself, and it is crucial to have an accurate alignment. Ap-

proximation is started at the superior border of the eyebrows; this isthe most obvious discrepancy that can continue to be seen afterhealing is complete.

Eyelid and Lacrimal Duct InjuriesInjuries and lacerations to the upper eyelid require closure in a

layered technique. Closure is done from the deepest layer first, withmore superficial layers closed subsequently. The conjunctiva is ap-proximated with a fine, absorbable suture, with the knots facingaway from the cornea to prevent any irritation or further injury. Next,the tarsal plate is repaired with a fine resorbable suture. If injury hasoccurred to any of the upper lid elevators, such as Mullers muscleor levator palpebrae aponeurosis, this is the time to reattach it tothe tarsal plate to prevent any ptosis or long-term sequela from theinjury. Finally, a fine, absorbable suture is used to approximatethe final skin layer. At times, a pull-out polypropylene suture can beused to lessen inflammation. It is crucial to align the gray line toensure proper curvature of the upper eyelid.

Injuries to the lower eyelid can be closed in a similar fashion.There is always an increased risk of ectropion and increased scleralshow with lower eyelid work. But in the case of acute injuries, therisk of these adverse events is minimal with proper alignment andrepair at the time of injury.

The lacrimal duct apparatus is a complex mechanism thatmerits a high degree of suspicion of injury whenever there is atrauma involving the medial canthal region. If injury is suspected,the severed ends need to be identified and realigned. Repair is thendone over a silastic catheter or Crawford tube.20 The catheter is leftin place until healing is restored. These structures require an atten-

tion to detail and meticulous dissection to prevent any further injuryto surrounding structures.

Nasal InjuriesAny injury to the nasal region can result in a substantial

functional as well as cosmetic defect that the plastic surgeon needs to

be aware of when attempting repair. Full-thickness injuries should berepaired in a layered technique, starting deep and working superfi-cial. The nasal mucosa should be repaired with a fine, absorbablesuture. Any cartilage injuries should be repaired using permanent orresorbable suture to allow proper support of the soft tissue. Finally,any skin defects should be closed with a fine, nonresorbable orreabsorbable suture or tissue adhesive, depending on the age ofthe patient.

Of all structures on the face, the nose has multiple angles,points, and curves that need to be addressed at the time of injury togain an acceptable long-term result. The concept of aesthetic unitsplays an important role in all facial reconstruction but an especiallykey one in the nose. For example, the alar rim needs to be alignedaccurately to prevent any minor defect or notching. The nasal foldregions and the tip need to be aligned properly to minimize any

tethering effect from the suture. Overall, the nose is a complexanatomic structure that can make any acute repair difficult.

CheekThe tissue that is defined as the cheek is usually thick and

muscular and can include numerous other anatomic structures(Fig. 1). It is bordered by the infraorbital region superiorly, the lateralnose and nasolabial fold medially, and the preauricular region later-ally. A thorough head and neck examination is mandatory before anytype of repair. If the oral cavity is penetrated as a full-thickness defect,the laceration should be closed in a layered fashion. Absorbable suturecan be used for the oral mucosa and deep muscle layer. The skinshould be closed with a fine, nonabsorbable or resorbable suture,depending on the age of the child.

The orifice of Stensen duct that communicates from the parotidduct to the oral cavity lies adjacent to the second molar. If injury issuspected, the duct should be probed. Frequently, an angiocatheter

FIGURE 1. Cheek laceration. A, Severe cheek and lip softtissue injury seen in the ER. B, Area of cheek to be debridedis outlined. C, Laceration immediately after closure.D, Laceration 3 months after trauma.




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is used to access the duct and inject saline. If either saliva or saline isvisualized in the wound, an injury of the duct is likely that will requirerepair. This can be done with identification of the cut ends and pri-mary closure over a stent catheter.21

Before any closure of a cheek wound, an accurate assessmentof the motor and sensory nerves is mandatory. Unidentified facial

nerve injuries can result in long-term functional and aesthetic defects.Injury to a sensory nerve usually has less long-term effects, withtemporary or mild hypesthesia being the main complaint. If there isinjury to the facial nerve, posterior to the lateral canthus, injury to themain nerve or major trunk is likely. These wounds should be exploredwith nerve stumps identified and approximated with microsurgicaltechnique. If tissue deficit precludes primary anastomosis of thenerve, nerve grafting will be required. If this needs to be delayed, thenerve ends should be tagged for identification purposes to allow futuresurgical repair. We use 72 hours from the time of injury as the windowto allow for proper nerve repair or nerve ending identification. Afterthis period, because of Wallerian degeneration, neurotransmission isinadequate in the distal nerve portion to allow proper identification viastimulation.

Injuries anterior to the lateral canthus usually do not require

surgical repair. The amount of redundancy in the facial nerve networkallows for compensation to permit adequate facial animation withoutdirect repair. Skin closure still needs to be accomplished in a layeredfashion for acceptable cosmetic results.

Lip InjuriesInjuries to the lip require attention to proper alignment to

prevent easily identifiable defects after repair. For full-thickness in-juries, absorbable suture is used to reapproximate the orbicularis orismuscle. This is critical to ensure proper function and prevent lateralmuscle bulging after recovery.22 Any intraoral mucosal defect is thenclosed using a fast-absorbing suture. Attention needs to be directed toalignment of the red line or border from wet to dry vermilion toprevent chafing and discomfort. Finally, the white roll or vermilion-cutaneous border is approximated with a fine, nonresorbable suture.

Failure to align this part of the lip will result in a noticeable defect thatwill be apparent at a conversational distance.Injuries that involve significant avulsion of lip tissue and in

which the avulsed segment is available should be considered for re-plantation. If this is not possible, careful debridement is preferred, andthe tissue loosely approximated. Plans are discussed for future re-construction of the lip or to aesthetically improve its appearance onceedema and the need for further debridement are resolved.

Ear InjuriesThe excellent vascularity of the ear allows it to sustain severe

trauma and if closed properly can result in little residual injuries ornoticeable effects even when it is hanging on a very thin pedicle(Fig. 2). Suture fixation with either nonabsorbable or absorbablesuture, depending on the situation, can be used for repair of the skinand cartilage. Usually, a 3-layer closure of posterior skin, cartilage,and anterior skin is preferred. Any large segments of cartilage that arenot able to be covered with skin due to tissue loss can be banked in asubcutaneous pocket near the ear region for future surgical recon-struction. A total or subtotal avulsion of the ear should be consideredfor replantation if the circumstances permit. If this is not possible, astaged ear reconstruction with costal cartilage may be required.

Hematomas are a well-known consequence of ear trauma andif not addressed can result in long-term deformity of the cartilage.Once identified, hematomas need to be evacuated immediately withan incision and some type of bolster dressing placed that can beanchored with a nonabsorbable suture. These dressings can usuallybe made to contour to the natural area of the ear affected and allowfor excellent healing.

BurnsThermal burns to the face in the pediatric patient are often a

difficult and drawn-out process that requires multiple procedures andreconstruction attempts to gain the most acceptable results in terms offunction and aesthetics. An average of 120,856 patients younger than20 years present to the ER annually with burn injuries. Of these,approximately 21% of the patients have burns that involve the scalp or

facial soft tissue.23

Although superficial and partial-thickness burnsusually do not require surgical intervention, the full-thickness burncan be problematic. After resuscitation and allowing time for theburn to demarcate, excision can be performed, and permanent ortemporary coverage provided with either autograft or allograft skin orsome type of dermal substitute material.

Further scar contracture is nearly a guarantee, and after 6 to12 months from the time of burn injury, the wounds should be readyfor reconstruction. A stepwise approach should be taken with thechild using function and protection of vital parts as a guidingprinciple. In order of priority, eyelids, perioral tissues, neck, cheek,and then any remaining tissues should be addressed.24 Needless tosay, the reconstructive process for these patients can be drawn outover an extended period, requiring multiple surgical procedures forrevision.

CONCLUSIONSSoft tissue injuries of the face are very common. In children,

not only are they common, but they also present heightened anxietyand concern on the part of the child and the family. It also willpotentially present a lasting mark of a most unpleasant event, es-pecially if inadequate or delayed treatment is performed. Carefuland early assessment of the wound and use of appropriate surgicaltechnique should be key elements to a successful outcome. Pre-vention of complications, including scars, infection, and long-termdisfigurement, is of utmost importance. Analysis of the injury, in-cluding location, size, and depth of penetration and presence ofassociated injuries, will aid in the formulation of a proper surgicalplan. As in all cases of plastic surgical planning, a keen appreciation

FIGURE 2. Ear avulsion. A, Near-complete avulsion of right

ear. B, Immediately after reattachment with leech therapy dueto venous congestion. C, Fourteen days after reattachmentwith necrotic helical skin. D, Six months after injury andskin debridement; viable anterior helical cartilage buried inpreauricular pocket. E, Frontal view at 6 months; patientwas content with results; further revision of helical rimremains an option.




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of the aesthetic units of the face and the skin tension lines is im-portant, especially when bringing together a complex, irregularlaceration. If absence of soft tissue is present, a decision needs tobe made whether pliable neighboring soft tissue can be broughttogether or if flaps or grafts may be necessary to bridge the gap.It should be kept in mind that a more conservative approach in

the acute stage may provide for adequate healing with a minimumof distortion in later stages. Revisions can always be performed ata later date. The treatment of scars is always a concern for the patientand the parents. Children, in general, produce exuberant hypertro-phic scars that will flatten and fade over time. It may take at leasta year before sufficient redness and softening of the scar will occur.If erythema is persistent, pulsed dye laser can be helpful. Derm-abrasion can also provide some smoothing of the scar. Ultimately,revisional surgery may be necessary. Adequate follow-up should beprovided for as long as necessary, and the surgeon should remainsensitive to the concerns of the patient and family. A good andsatisfactory result can usually be obtained if the surgeon maintainsproper management of the sequelae of injury as the child growsand develops.

REFERENCES1. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical

Care Survey: 2007 emergency department summary. Natl Health StatReport 2010;26:1Y31

2. Lee RH, Gamble WB, Robertson B, et al. The MCFONTZLclassification system for soft-tissue injuries to the face. Plast ReconstrSurg 1999;103:1150Y1157

3. Vasconez HC. Soft tissue injuries. In: Goldwyn RH, Green HH, eds.Plastic Surgery, Third Edition. Philadelphia, PA: Lippincott Williams &Wilkins, 2001;453Y468

4. Mueller RV. Facial trauma: soft tissue injuries. In: Mathes SJ,Weinberger SE, Hentz VR, eds. Plastic Surgery, Volume 3. 2nd ed.Philadelphia, PA: Saunders-Elsevier, 2005;1Y43

5. Kaplan RF, Yang CI. Sedation and analgesia in pediatric patientsfor procedures outside the operating room. Anesthesiol Clin

North Am 2002;20:181Y194

6. Cote CJ, Wilson S. Guidelines for monitoring and management ofpediatric patients during and after sedation for diagnostic andtherapeutic procedures: an update. Pediatrics 2006;118:2587Y2602

7. Bjerring P, Arendt-Neilsen L. Depth and duration of skin analgesiato needle insertion after topical application EMLA cream. Br

J Anaesth 1990;64:173Y177

8. Dailey RH. Fatality secondary to misuse of TAC solution.Ann Emerg Med 1998;17:159Y160

9. Chow A, Marshall H, Zacharakis E, et al. Use of tissue glue forsurgical incision closure: a systematic review and meta-analysis ofrandomized controlled trials. Am Coll Surg 2010;211:114Y125

10. Mustoe TA, Cooter RD, Gold MH, et al. International clinicalrecommendations on scar management. Plast ReconstrSurg 2002;110:560Y571

11. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of

simple wounds: a meta-analysis of randomized studies. Am JEmerg Med 1995;13:396Y400

12. Singer AJ, Dagum AB. Current management of acute cutaneouswounds. N Engl J Med 2008;359:1037Y1046

13. Elliott DJ, Zaoutis TE, Troxel AB, et al. Empiric antimicrobialtherapy for pediatric skin and soft-tissue infections in the era ofmethicillin-resistant Staphylococcus aureus. Pediatrics2010;123:e959Ye966

14. American Academy of Pediatrics, Committee on Infections Diseases.Antimicrobial prophylaxis in pediatric surgical patients. In: PickeringLK, Baker CJ, Long SS, et al, eds. Red Book: 2006 Report of theCommittee on Infectious Disease. 27th ed. Elk Grove, IL:American Academy of Pediatrics, 2006;824Y828

15. Talan Da, Citron DM, Abrahamian FM, et al. Bacteriologic analysisof infected dog and cat bites. N Engl J Med 1999;340:85Y92

16. Monroy A, Behar P, Nagy M, et al. Head and neck dog bites in children.

Otolaryngol Head Neck Surg 2009;140:354Y35717. Cole P, Hammoudeh JA, Habal MB, et al. Pediatric soft tissue injuries

to the head and neck. In: Bentz ML, Bauer BS, Zuker RM, eds.Principles and Practice of Pediatric Plastic Surgery. St Louis, MO:Quality Medical Publishing, 2008:213Y227

18. ASPS Media Press Release. National Dog Bite Prevention Week.Prevention Is Best Cure for Dog Bites. May 17Y23, 2009.Available at: http://www.plasticsurgery.org/Media/Press_Releases/

National_Dog_Bite_Prevention_Week_-_Prevention_is_Best_Cure_for_Dog_Bites.html. Accessed October 18, 2010

19. Gruss JS, Pollock RA, Phillips JH, et al. Combined injuries ofthe cranium and face. Br J Plast Surg 1989;42:385Y398

20. Pashby RC, Rathbun JE. Silicone tube intubation of the lacrimaldrainage system. Arch Ophthalmol 1979;97:1318Y1322

21. Steinberg MJ, Herrera AF. Management of parotid duct injuries.Oral Surg Oral Med Oral Pathol Oral Radiol Endod

2005;99:136Y

14122. Farrior RT, Jarchow RC, Rojas B. Primary and late plastic repair of

soft tissue injuries. Otolaryngol Clin North Am 1983;16:697Y708

23. DSouza AL, Nelson NG, McKenzie LB. Pediatric burn injuriestreated in US emergency departments between 1990 and 2006.

Pediatrics 2009;124:1424Y1430

24. Parks DH. Timing of burn therapy in the pediatric patient. ClinPlast Surg1990;17:65Y70



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