Dr. Sadaf Syed

M.D.S II Year

SCALP AND FACE

The soft tissues of the face can be described,from superficial to deep, in the followingorder:

1. Superficial fat compartments2. Superficial musculo aponeurotic system (SMAS)3. Retaining ligaments4. Mimetic muscles5. Deep plane, including the deep fat compartments

FACE

System or network of collagen fibers, elastic fibers, and fatcells connects the mimetic muscles to the overlying dermisand plays an important functional role in facial expression

The SMAS can be considered as a sheet of tissue that extends from

• The neck (platysma) into the face (SMAS proper),

• Temporal area (superficial temporal fascia), and

• Medially beyond the temporal crest into the forehead (galeaaponeurotica).

True retaining ligaments

• Easily identifiable structures that connect thedermis to the underlying periosteum.

False retaining ligaments

• More diffuse condensations of fibrous tissuethat connect superficial and deep facial fasciae

Retaining Ligaments

• The sub-orbicularis oculi fat and deep cheek fatrepresent deeper fat compartments.

• That provide volume and shape to the face.

• Act as gliding planes within which the muscles offacial expression can move freely

Deep Plane Including the Deep Fat Compartments

The types of soft-tissue injuries encounteredinclude:

Abrasions,Tattoos,Simple or complex contused lacerations

with loss of tissue,Avulsions,Bites andBurns.

The response is determined by

• The mechanism of injury

• Energy exerted on the tissues

• Mechanical arrangement of tissues

• Blood supply

These factors Help In Predicting tissue response to injury.

Trauma care by Peter Discoll and David skinner

Facial injuries themselves are rarely life-threatening, but are indicators of the energy of injury.

• Ligation• Compression• Cautery• Clamps• Electrocautery.

• Face is well supplied with blood vessels.

• On being transected these vessels contract and collapse.

• Also the Thrombi may form occluding the vessel as does theenveloping haematoma by compressing the vessel.

Classification of Wound

• Clean• Clean-contaminated• Contaminated• Dirty or infected

Majority ofsuperficialwoundsfall in thefirst twocategories

Severely traumatized tissue falls in the latter categories

• Increased probability of contamination increase

with time.

• Wounds of skin mainly involve staphylococcus and

streptococcus.

• The number of bacteria is of more concern than the

species of bacteria.

• Through and through lacerations are considered

contaminated.

• Crushing of tissue, embedding of foreign bodies,

soil or perforation into oral cavity markedly

increase the bacterial count

Wound Contamination

Previously immunized patient:• If active immunization was not done within 10 years

- 0.5ml of tetanus toxoid

Unimmunized patient -• Passive immunization with hyperimmune tetanus

globulin• Followed by two doses of active immunization at a

months interval

Profusely contaminated woundshould be considered for tetanusprophylaxis even if the booster dosehas been given in the past 5 years.

Tetanus prophylaxis

• Establish the airway• Control bleeding• Stabilize the injury

During this period or during thetreatment of other injuries cover thewound with a moist gauze soaked inantibiotic solution till final management

AIM / PRIMARY CONSIDERATION

o The main aim is to get all the soft tissue injuries fully

debrided, reconstructed and closed by the end of fifth

day .

o By the end of three days it is usually possible, but 5

days considered to be the window period in which

closure can be done safely and satisfactorily

o Soft tissue injuries don’t cause morbidity as such, but if

not properly managed can lead to long term morbidity.

o It is important to repair and reconstruct tendon or nerve

damage, within the five days, either immediately or

future planning of the same.Aisha J. McKnight, M.D., and Shayan A. Izaddoost, M.D., Ph.D

• History• The mechanism of injury along with clinical

examination

Documentation

• The finding should describe the anatomical site andmeasurement of surface wounds.

• Should also include diagrams and/or photography.

• CT Scan and MRI can provide visualization of soft tissuesand foreign bodies as well as bony abnormality

Diagnosis of the nature Examine facial lacerations under sterile conditions to

assess depth of penetration or intracranial violation.

Craniomaxillofacial Trauma; Ch - 15By David and Simpson,contributary author J.Tomich

.

Preferably as soon as possible, after more serious conditionshave been dealt with.

When delay is inevitable beyond 48 hours.Clean the woundand cover it with moist sterile dressing.

Foreign bodies removed.

Few tacking sutures might be placed to approximate the softtissue prior to definitive treatment.

Topical antibiotic and bacteriocidal solution used only ifthere’s gross contamination.

Intravenous antibiotics in severe contamination.

• Irrigation Preliminary step in the care of any injury.

Generates significant discomfort for the patient. Forthis reason, pre-treatment local anesthesia isrecommended whenever possible.

The unaffected skin should be prepared swabbing awayfrom the wound.

Irrigation with copious amounts of saline.

This doesn’t remove the devitalized tissue orparticulate matter

In areas of beard, moustache or those lacerationsextending to scalp shaving is done except eyebrowand hairline for guide for future reconstruction.

Cleansing with antiseptic solution after removingthe foreign bodies ,if present.

Any wound with foreign material should bethoroughly examined to prevent infections and allthe foreign materials to be removed carefully.

Special care to be taken for eyes.

Hydrogen peroxide.

Povidone – Iodine.

Iodophor.

Chlohexidine.

To be clinically effective

irrigants should be

delivered with fluid jet

of 7lb of psi.

This can be generated

by forcefully expressing

saline from 35 ml

syringe through an 18-

gauge needle

Commercial products are available for simultaneous,aggressive lavage and microdebridement of wounds.

Surgical scrub solutions may be used, but with precaution :

1. They may cause ocular chemical burns2. If in direct contact with the wound they

cause further cellular damage.“Rule Regarding Application of Antiseptic”

Never put anything in a wound that could not be comfortably tolerated in

the conjunctival sac.

Avoided unless there is overwhelming amount of foreign debris in the wound

The wound is scrubbed with swabs or nylon brush.

Along with betadine and solvents like ether for grease and other oily particles.

This is specially important for abrasion injuries where the dirt is in abraded dermis or deeper.

If not done properly can cause “tattooing”,that can be unesthetical

Brush Solutions

• Deeply embedded particles may require removal with finetipped scissors and/or scalpel.

• It should be limited to devitalized tissue, tissue containingdirt grease or other particles not removed by scrubbing.

• Radical excision in facial region avoided because of richblood supply, tissues will survive with a small pedicle.

• If the wound margin is extremely irregular and re-approximation is difficult ,edges are excise to produce cleanwound margin and minimize scar formation.

HALSTEDIAN PRINCIPLES

Facial Trauma : Aisha J. McKnight, M.D., and Shayan A. Izaddoost, M.D., Ph.D

1. Thoroughly explore the wound, cleaning and debridingeach layer specificly.

2. Possible repair of nerve and tendon damage, severednerve trunk should be identifiedand marked with tags forfuture reconstruction.

3. Salvage skin grafts from skin that is to be excised

• Layered closure to obliterate dead space and relieve tensionon the epidermal layer.

• Wounds covering nerves or ducts should not be closed untiloperative management of deeper injury is complete.

• Other injuries may require urgent attention.

• In case of surgical intervention definitive repair of allinjured tissues can be achieved in single operation.

Key principles of closure

• Definitive repair of bony and soft tissue injuries can beachieved in a single operation, as successive operationsrarely improve functional outcomes.

• In high-velocity or blast injuries, this is often not possibledue to the need for multiple debridements;

• However, early soft tissue reconstruction should beattempted to prevent significant soft tissue contractureand provide coverage for osseous reconstruction.

Periosteal closure and suspension:

• Re-establish periosteal continuity

• SMAS layer reinforced

• Mimetic soft tissue drape re-established

• In scalp - closure of galeal layer

• Suspension of cheek periosteum to deep temporal fascia

• Goal: prevent facial sag due to muscle diastasis

Contraindications to primary closure in the emergency room

Tissue damage whereby primary closure can only beperformed under significant tension or with complextissue rearrangement.

When concomitant injuries require surgery and whenadequate hemostasis or appropriate woundvisualization cannot be achieved in the ER setting

Eyelid or periocular injuries can be classifiedinto four classes based on the injured region

Upper eyelid, Lower eyelid, Medial canthus, and Lateral canthus

The medial canthus comprises two limbs and functions to maintain the shape of the eye and to assist in drainage of the lacrimal sac.

Inserts on the lacrimal bone :

– Anterior tendon inserts on the anterior lacrimal crest– Posterior tendon insertson the posterior lacrimal crest.

Lacrimal duct lies in between and is pumped with blinking (Jone spump)

Medial Canthal ligament

To evaluate the integrity of the medial canthaltendon

• A lax medial canthal tendon or medial orbital wall motionis consistent with a NOE complex fracture.

• Place the thumb and index finger over the nasal root andcarefully apply lateral tension to each lower lid.

• A periosteal elevator also can be inserted through the noseto palpate the stability of the medial canthal tendoncomplex.

• Normally, a defined endpoint to the maneuver is evidentwithout palpable motion at the medial canthus.

SYNONYMS

• Tarsal strip re-suspension.• Lateral canthal plication.• Lateral retinacular suspension.• Inferior retinacular suspension.

Canthoplasty" refers to a procedure designed to reinforcelower eyelid support by detaching the lateral canthaltendon from the orbital bone and constructing areplacement.

"Canthopexy," on the other hand, refers to a less invasiveprocedure designed to stabilize the existing tendon (as wellas surrounding structures) without removing it from itsnormal attachment.

Definition.

• Canthoplasty implies division of the canthus, inwhole or in part.

Requires division of either the inferior crus or common crusof the lateral canthal tendon and . These are then mobilizedand reinserted as a single unit as indicated by the degree oflower-lid laxity.

Canthopexy implies that lid support is achieved byplication or redirection without division of the canthus.

In performing the canthopexy, the lower lid or lateral is notshortened or divided but secured in a new position to a rigidstructure like the periorbita.

First, simple eyelid lacerations should be closed in three layers:

conjunctiva, tarsus, and skin.

For lacerations involving the lid margin, tarsal plate mustbe carefully re-approximated and the lid margin evertedwith a vertical mattress suture to prevent notching.

• For lower- lid lacerations, proper alignment minimizes therisk of ectropion.

• In upper-lid lacerations, the levator muscles should becarefully evaluated as the muscular insertions onto thetarsal plate may be damaged.

• Injuries to the lateral eyelid commonly involve thelateral canthus and can require either a canthopexyor canthoplasty to repair the injured canthus.

• Depending on the degree of injury, primary repairmay be possible, but frequently more significantinjury necessitates re-creation of the ligament.

• When treating soft tissue defects in this region, cheekadvancement flaps or full-thickness skin grafts can beused for coverage

• Injuries to the medial canthal region may involve themedial canthal tendon and/or lacrimal system.

• Medial canthus injuries without concomitant fracturesare uncommon due to the relative protection providedby the maxilla and nasal bone.

• Injuries to the lacrimal canaliculi can also occur in thisregion and should be addressed with anophthalmologic assessment and Jones dye test.

• A Jones I test is first performed by instillingfluorescein dye in the eye ipsilateral to the suspectedinjury.

• After 5 minutes, the patient is instructed to occludethe contralateral nare and blow his or her nose onto aclean, white tissue or towel.

• The presence of fluorescein on the tissue indicates apatent, functioning lacrimal system.

The eyelids are inspected for

Ptosis, suggesting levator apparatus injury.

Rounding or laxity of the canthi suggests canthal injury ornaso-orbital-ethmoidal fracture.

In case of periorbital injury, it is important to judge theintegrity of Levator palpebrae superioris, Orbicularis oculiand Frontalis muscles. [5]

Any injury near the eye should prompt a check of visualaquity, diplopia and evidence of globe injury.

• Loss of more than 25% of the lid will require reconstructionby different flaps.

Approaches to infra-orbital region

Based on the position of incision

• Bleph,

• Subciliary,

• Lower lid,

• Subtarsal infra orbital

Advantages:

• Natural skin crease

• Laxity of skin makes it immune to keloid

• Allows stretching

• Scar inconspicuous in time

The two most prominent concerns in ear injuries are:

• Haematoma.• Chondritis.

• Hematomas must be evacuated as quickly as possible toavoid cartilage resorption followed by deformity.

• A bolster dressing is advisable to prevent re-accumulation ofthe hematoma.

• Due to good blood supply, large cut portion may survive on asmall pedicle.

• If one surface of the cartilage has viable soft tissue, it shouldsurvive.

The cheeks are by surface area the largest subunit ofthe face thus

1. A high frequency of injury to the cheek andunderlying structures

2. A multitude of approaches that can be used forposttraumatic reconstruction.

Many cheek wounds can be repaired primarily due tothe laxity and availability of surrounding soft tissue.

Cheek Is Divided into three overlapping aestheticsubunits :

I. Infraorbital,

II. Preauricular, and

III. Buccomandibular.

• Very small wounds in inconspicuous areas may be allowed toheal secondarily though primary closure is preferred.

Resident Manual of Trauma to the Face, Head, and NeckPaul J. Donald, MD Professor and Vice Chair, Department of

Otolaryngology University of California-Davis Medical CenterSacramento, California

• If primary closure is not possible, local advancement,transposition, or regional flaps can be used to repair manydefects due to the skin excess and laxity in the cheek.

• In cases where this is not possible, full-thickness skingrafting can be performed with the cervical, preauricular,and postauricular skin being preferred donor sites for colormatching.

• Free flaps are also used for cheek reconstruction for morecomplex soft tissue defects.

Resident Manual of Trauma to the Face, Head, and NeckPaul J. Donald, MD Professor and Vice Chair, Department of

Otolaryngology University of California-Davis Medical CenterSacramento, California

• Aim of lip injury management are

1. Correct alignment of lip landmarks and

2. A layered, tension-free closure to ideally restore

• Markings should be made to identify the white roll,Cupid’s bow, and philtral columns prior to injectionof any local anesthetic to prevent obscuration.

Motor, Aesthetic, Sensory

Facial Soft Tissue TraumaJames D. Kretlow, Ph.D., Aisha J. McKnight, M.D., and

Shayan A. Izaddoost, M.D., Ph.D.

• Primary closure should be considered when less than30% of the lip is involved, and the layered primaryclosure should separately approximate the skin,orbicularis, and mucosal layers.

• For defects of the central upper lip, primary closuremay disrupt the normal anatomy of the philtralcolumns and dimple.

• For wounds that cannot be primarily closed, thebest method to achieve restoration is to useavailable lip tissue for the repair.

• Skin grafting can play an important role inmanagement, although color mismatches maybe an issue when grafting to vermillion defects.

• Corrected by using an Abbe ´ flap toreconstruct the central vermillion withoutmoving the commissure.

• Larger defects or those involving other areas ofthe lip can be repaired using similar lip-switchprocedures or a variety of local advancementflaps

• Injuries to the facial and/or trigeminal nerve canalso accompany soft tissue trauma.

• Sites of structural compression and/or injury needto be identified and addressed appropriately.

• If the facial nerve has been severed, initialmanagement requires primary repair of the injury,

• If a defect exists, the nerve ends should be tagged sothat formal nerve repair can be performed withinthe first 72 hours after injury.

Parotid Gland & Facial nerve

In an injury that has traversed through the parotid region, both the gland and the facial nerve should be assessed.

• If it is anterior to the parotid gland, the branches of the seventh nerve are examined under the operative microscope.

• The nerve stimulator is a useful tool for identification of the distal segment within 48 h of injury.

• After 48-72 h, the distal nerve segments will no longer conduct the impulse to the involved facial musculature.

• The use of local anesthesia should be delayed until the function of the facial nerve has been established.

• The trauma, extending anterior to the parotid gland iscrucial as far as the function of the muscles of expressionis concerned.

• If it is posterior to the gland, then the main trunk of thenerve may be involved.

• Test the Following ;

1. The elevation of the brow,2. Forced closure of the eyes,3. Voluntary smile and4. Eversion of the lower lip.

• Nerve regeneration typically occurs at a rate of 1 mm per dayafter a month lag

• If primary repair is not possible, the proximal and distalnerve ends should be tagged with non-absorbable suturefor easy identification during future repair.

• If the nerve trunk is damaged at the pre-parotid and intra-parotid course, it needs to be explored under magnificationand approximated with sutures.

Analysis of the wound depth is critical in these cases.

•

• The result of direct approximation is better than nerve grafting

•

• In a more superficial wound resulting in laceration ofonly the parotid glandular tissue, the gland can beoversewn and subsequently repaired independent of theparotid duct

• Parotid duct repair performed by suturing the duct over astent has been described, but conservative treatment isgenerally well tolerated and is not associated with long-term functional consequences.

• Patients with parotid duct injuries being managedconservatively should be warned to expect a significantdegree of temporary swelling after the injury.

•

SCAR REVISION

Various modalities in scar revision

• Simple excision and serial excision.

• Z-Plasty.

• W-Plasty and Geometric line closure.

• Subcision.

DCNA Nov 2013 :vol 25 : No.4 ;Correction of facial trauma related soft injuries:.

Simple excision and serial excision

• Small scars already oriented parallel to relaxed skin line

• Excised in elliptical fashion,• Peripherally undermined :

1. Aids in reducing wound tension • Suturing with eversion is obtained

2. Adequate eversion prevents formation of depressed scar following wound contracture and healing

• Wide scar oriented along skin tension line

1. Advantage of mechanical creep of tissues, viscoelastic properties of skin

• Partial scar excision followed by periods of healing reducing broad scar to a smaller one

Z- Plasty

3 Primary purpose :

• Reorient the direction of scar• Interrupt scar linearity to aid in scar camouflage.• Lengthen the scar which is beneficial when there is

undesirable contracture of surrounding tissues.

Advantages :

• Reorient scar to fall between anatomic subunits of face making them less conspicuous.

• It requires minimal excision of tissue.

• A prerequisite for other types of revision procedures

Disadvantage

• Increases the length of scar.

• Atleast one limb of scar lies outside of relaxed skin tension line

W-Plasty

• Wide linear scar running perpendicular to the skin tension lines

• Convex areas of face like eyebrow temporal and malar prominence.

• The concerned area should have sufficient tissue laxity to allow the necessary tissue advancement.

• 50% of the limbs should be parallel to the relaxed skin tension lines

Geometric broken line closure

Modified W- Plasty

• Linear scar parallel to skin tension lines, in the convex parts of the face

• Same principle that it is a geometric bilateral advancement flap

• In case of long scars W-Plasty becomes easily noticable, broken line circumvents this issue

• Management of depressed scar.• Easily performed • Minimal post op morbidity due to minimal invasive

nature

Disadvantage :

Pain SwellingBruisingHyperpigmentationHaematomaToo vigourous procedure or too deep needle penetration

Principle• Severeing subcutaneous

fibrotic attachments .• Subsequent induction of

neocollagenesis,thuselevating a depressed scar

DCNA Nov 2013 :vol 25 : No.4 ;Correction of facial trauma related soft injuries:.

1. Tissue Expanders.

2. Tissue adhesives.

3. Tissue Engineering.

Tissue Expanders

• Skin is stretched beyond its physiological limit,mechano transduction pathways are activated.

• This leads to cell growth as well as to the formationof new cells.

• One of the ways is , by the implantation of inflatableballoons under the skin.

• The growth of tissue is permanent, but will retract tosome degree when the expander is removed.

• It provides skin with a near-perfect match in color and texture,

• Minimal donor site morbidity and scarring occur.

• Provide tissue with specialized sensory function or adnexal characteristics

• Temporary cosmetic deformity during the expansion phase,

• Prolonged period of expansion,

• The need for multiple procedures, and

• Complications associated with the implant and placement.

TISSUE ENGINEERING

Bioengineered products,

Polymers (poly-N -acetyl-glucosamine) with bioactive properties, and,

Genetically modified tissue with various growth factors.

Materials for Wound ClosureAuthor: Margaret Terhune, MD; Chief Editor: Dirk M Elston, MD

COLLAGENMINERAL BASED eg. Calcium phosphate

TISSUE ADHESIVES

Quick and easy to apply, requiring only one-tenth to one-fourth of the time required for suture placement.

They provide an antimicrobial and waterproof coating, but repeated washing removes the adhesive in a few days.

The cosmetic outcome is good, and

No postoperative visit is required for removal.

Materials for Wound ClosureAuthor: Margaret Terhune, MD; Chief Editor: Dirk M Elston, MD

EXAMPLES

Cyanoacrylates

Octylcyanoacrylate (Dermabond; Ethicon) and

N -butyl-2-cyanoacrylate (Indermil; Syneture)

ACTIONExothermic reaction on contact with fluid to form a 3-dimensional, strong, flexible bond, with uses comparableto those of 5-0 monofilament nylon.

These are available in single-use vials/ampules.

Laser Welding

• Used on a limited basis as an alternative to traditional wound closure.

• Collateral thermal injury has prevented its regular clinical use.

• To minimize this injury, laser soldering was introduced.

• This process involves the application of a biologic "solder" eg, bovine serum albumin prior to temperature-controlled laser welding.

Closure by secondary intent is permissible, wherein both patient and surgeon participate in good wound care and allow for slow but steady closure of the defect.

Adjunctive therapies, such as the implementation of wound-healing factors or devices or the use of hyperbaric oxygen, may also be required.

Post-Healing After the wound is healed, the scar can be dealt with appropriately.

It should be considered in cases of1. Uncontrolled diabetes,2. Chronic hypoxia due to cardiopulmonary

disease, 3. Other significant wound-healing deficit.

Compared with other closure materials, laser welding is :

• Faster,

• Watertight, and

• Avoids a foreign-body reaction.

• Complete eyelid and orbital reconstruction can be achieved using :

a) Dorsalis pedis with septal cartilage.

b) Radial forearm f laps, and

c) Anterolateral thigh f laps.

• Massive exsanguiating bleeding from soft-tissuetrauma of face is not a common event.

• Putting patient in a sitting position candramatically reduce venous bleeding.

“The extensive facial blood supplypermits tissue survival, even in the settingof severe trauma. Therefore limited,rather than extensive, debridement oftissue deemed marginal should beattempted in most cases.”

Patient with head and neck injury going into hypovolemic shock :

1. Trauma is extensive and complex

2. Delayed treatment or repeated episodes of bleeding

3. Other injuries eg. Abdominal injuries

Plastic surgery of head and neck new york 1987

,Churchill,Livingstone

Ghassemi et al. describe two variations of SMASarchitecture.

Type I SMAS

Consists of a network of small fibrous septae that traverseperpendicularly between fat lobules to the dermis and deeply tothe facial muscles or periosteum.

This variation exists in the1. Forehead,2. Parotid,3. Zygomatic, and

4. Infrao rbital areas.

PROCEDURE

• Tarsal tuck canthopexy.

• The modified lateral tarsal strip procedure

(Canthoplasty).

• The common canthoplasty.

Type II SMAS

o Consists of a dense mesh of collagen, elastic,and muscle fibers

o Is found medial to the nasolabial fold, in theupper and lower lips.

o Although extremely thin, type II SMAS bindsthe facial muscles around the mouth to theoverlying skin

o It has an important role in transmittingcomplex movements during animation

Over The Parotid gland.

• The SMAS is relatively thick.• Further medially, it thins considerably making it difficult to dissect.• In the lower face, the SMAS covers the facial nerve branches as well

as the sensory nerves.Dissection superficial to the SMAS in this region protects facial nerve

branches.

Above The Zygomatic Arch. • The SMAS exists as the superficial temporal fascia, which splits to

enclose the temporal branch of the facial nerve and the intermediatetemporal fat pad.

Dissection in this area should proceed deep to the superficial temporal fascia, on the deep temporal fascia, to avoid nerve injury.

Wobig JL, Dailey RA (2004) Facial anatomy. In: Wobig JL, Dailey RA (eds) Oculofacial

plastic surgery. Thieme, New York, p 5

• The layer of fascia covering the parotid gland andmasseter, termed parotidomasseteric fascia, continuessuperiorly to insert into the inferior border of the zygo-matic arch.

• In the temporal area, the corresponding fascia in thesame plane is present as deep temporal fascia, whichinserts into the superior border of the zygomatic arch.

• In the lower face, branches of the facial nerve lieunderneath the deep fascia.

• Above the zygomatic arch and in the upper face, facialnerve branches lie superfi cial to the deep fascia and aresusceptible to injury during superfi cial dissections.

The Superficial

Fascia

In cases of large particulate matter (e.g.,glass or gravel) manual debridement isnecessary.

Pretreatment with local anesthesia isadvocated.

Prior to definitive closure, obviouslydevitalized soft tissue should be debrided.

Microdebridement

Accomplished with sterile saline, or tap water from aclean outlet should sterile saline be unavailable, todecrease the bacterial load in tissues.

2:1 solution of saline and povidone-iodine, usually in thevolume of 1.5 liters is preferable.

High pressure irrigation with 19-gauge plastic catheter attached to a 60 ml syringe using 250ml of 0.9% saline.

Some contaminants are retained by strong adhesive forces as they require higher hydraulic forces and direct contact

Skin incision down to muscle Full thickness eyelid cut atlateral canthus

A surgical scrub brush is helpful for abrasions. A small brush is used aggressively along with high pressure irrigation can clean the wound of particulate matter and bacteria, under GA.

This prevents Tattooing

For larger wounds, a bulb syringe or intravenoustubing irrigation will suffice.

For smaller penetrations or puncture wounds, aplastic intravenous catheter on a 20-cubic-centimeter syringe works well.

Face doesn’t have specific layers like scalp. Subcutaneous tissue is missing. Muscles are directly attached to the skin.

The superficial fat compartments of the face comprise the following:

• The nasolabial fat compartment.

• The medial, middle, and lateral temporal-cheek “malar” fat pads

• The central, middle, and lateral temporal-cheek pads in the forehead.

• The superior, inferior, and lateral orbital fat pads

The firm adherence of the skin to the underlying cartilage framework ensures that accurate skin approximation aligns the cartilage. If the cartilage must be sutured, absorbable 5/0 sutures are used. In partial amputation with relatively large pedicle, the prognosis is good following conservative debridement and meticulous repair. If the pedicle is narrow, the chance of venous congestion is much higher. In such a situation, soft tissue like lobule may survive but the cartilage may not. If the pedicle is narrow with inadequate or no perfusion, it should be treated like a complete amputation. In case of exposed cartilage, local or regional flaps should be considered to salvage the cartilage. In complete amputation, one may make an effort to salvage the cartilage frame by burying it in a subcutaneous pocket at the post auricular area or abdomen. [10] Microsurgical replantation should be considered whenever it is feasible.

Risks and complications:Canthoplasty: The anatomy of the canthus is delicate and complicated. If canthoplasty is not well performed (or sometimes even when it is expertly performed), the junction between the upper and lower eyelids may become rounded, retracted, or deformed either immediately or after several years. In the presence of a prominent eye, shallow eye socket, or inadequate bony cheek projection, canthoplasty may result in unintended downward retraction. If overdone in patients with normal or deep-set eyes, it may, on the other hand, result in an unnatural upward slant to the eyes.Canthopexy: By reinforcing and stabilizing the stretched supporting structures around the eye, more than just sagging skin and bulging fat are addressed. The procedure is much less invasive than canthoplasty and not associated with many of the risks noted above.

• Patient with complex facial injury requiring free flapreconstruction, immediate definitive treatment isindicated.

• Immediate reconstruction decreases the number ofoperations required without compromising aestheticor functional outcomes.

• The presence of contamination has not beenassociated with an increase in perioperative or long-term complications after early definitive repair offacial injuries with free Flaps

• If the orbicularis oculi and frontalis muscles arefunctioning, it means that the temporofacial division of thefacial nerve is intact.

• Similarly, the continuity of the buccal, mandibular andcervicofacial branches can be assessed by the function of thebuccinator, orbicularis oris and other muscles.

• If the proximal ends of the facial nerves cannot be located,the uninjured proximal nerve trunk can be located andfollowed distally to the cut end of the nerve.

• The branches anterior to the parotid, need to beapproximated by 9/0 or 10/0 proline/nylon.

Theideallowerlidpositionis1.5to2.0mmabovetheinferior corneoscleral junction. The nadir of the curvature should lie halfwaybetweenthemedialandlateralfissures,andthelateralcanthusshouldlieapproximately10to15degreesaboveahor- izontal line that bisects the medial fissure. In the normal state, the intrinsic and extrinsic forces acting on the lower lid main-tainafinebalancethatholdsitapproximatedtotheglobe(Fig. 39.13). Imbalances in these forces—as a result of the effects of age, trauma, or previous surgeries—results in malposition of the lower lid.

Tarsal Tuck Canthopexy

• The tarsal tuck provides support to the lower lid without divi-sion of the lateral canthal tendon,the inferiorcrus,or thetarsal plate.

• It is not a “lid-shortening” procedure; rather, it is a “lid-supporting” procedure.

• Transcutaneously or through a transconjunctival approach.

• The indication for the independent tarsal tuck procedure is apatient with mild lower-lid laxity and an intact lateral canthalcomplex.

• If the laxity is too great,the plicated tissue will tend tobuckle,causing the lower lid to lose its apposition with theglobe,resulting in an unsatisfactory appearance poorlyfunctional eyelid.

Advantages of the independent tarsal tuck procedure are its simplicity, minimally invasive na- ture, andability to concomitantly transpose or resect orbital fat to fill perioculardefects.

disadvantage is that it can only be used when there is minimal lid laxity

serve to restore the natural appearance and function of the lower lid regard-less of the manifestation of the lower-lid laxity, a new inferior canthal crus is created from the tarsus, which is independently supported.

Modified Lateral Tarsal Strip Procedure

Common Canthoplasty and Common Canthopexy The common canthoplasty is useful alone or in combination with other procedures. It is especially useful when the goal is to correct a shortened intercommissural distance and/or infe-riordisplacementoftheentirelateralcanthus.Itcanbeappliedinbothcosmeticandreconstructivescenarios.Inaddition,con- sideration should be given to this technique in any patient un- dergoing a procedure that can compromise the balance of in- trinsic and extrinsic forces providing lower-lid support (4). Accesstothelateralcanthaltendoncanbeachievedthrough an incision of either the upper or lower lid; however, incision of the upper lid is more favorable for achieving the appro- priate vector of suspension. Regardless of the access incision, the lateral canthal tendon must be identified and mobilized in its entirety with disinsertion of the common tendon from the Whitnall tubercle. Once the retinacular elements are lysed, the entirelateralcanthalcomplexcanbemovedcephalicallyand/or laterally.

• Absorbable 4/0 or 5/0 Vicryl or Polydioxanone sutures (PDS) is suitable for muscle and subcutaneous tissue.

• Proline/nylon 6/0 is the choice for skin approximation. Key stitches are given first to align the points followed by the rest of the repair.

• Vermillion cutaneous border of the lip, the free margin of the alar rim, the grey line of the eyelids, and the helical rim of the ear provides guidelines for the restoration of normal anatomic position.

Maxillary Vestibular Approach

• Entire anterior face of maxilla

• Zygomaticomaxillary buttress

• Infraorbital rim

• Zygomatic body, antero-caudal

part of zygomatic arch

• Piriform aperture

Maxillary Vestibular Approach

• Entire anterior face of maxilla

• Zygomaticomaxillary buttress

• Infraorbital rim

• Zygomatic body, antero-caudal

part of zygomatic arch

• Piriform aperture

Tetanus prone wounds :

• Wound of more than six hours

• Stellate wound

• More than 1 cm

• Mechanism of injury involves missiles, crush , burn

rather than sharp surface

• Signs of infection

• Devitalized tissue

• Presence of contaminants

• Denervated or ischemic tissue

Soft tissue loss

Local flaps :

Local rotational Advancement flaps

Skin grafts :

Full-thickness skin grafting Partial thickness skin grafting

Microvascular tissue transfer

Buccal Fat

Pad

Common etiologies are :

1. Road traffic accidents.2. Gunshot injuries.3. Blast injuries.4. Foreign bodies.5. Homicidal trauma.6. Thermal, chemical and electrical burn.7. Suicidal injuries.8. Human bites, animal bites or caused by different

animals.