Geoffrey 3 C. Gurtner, Peter C. Neligan, Daniel Z. Liu – Plastic Surgery-Craniofacial, Head and Neck Surgery-Pediatric Plastic Surgery. 3-Elsevier (2018)

18
CHAPTER 1 • Anatomy of the head and neck
surface of the ear is supplied by the latter through its perforat-
ing branches and over the helical rim. The branches of the
superficial temporal artery only supply the superior helical
rim and triangular fossa and scapha network. These vascula-
ture networks form an interconnecting system, which allows
either of the systems to support the ear.128–130
The sensory nerve supply of the ear is derived from a
combination of cranial and extracranial branches. The poste-
rior ear and lobule are innervated by the greater auricular
nerve (C2, C3) and the lesser occipital nerve (C2). The anterior
ear and tragus are supplied by the trigeminal nerve (auricu-
lotemporal branch of V3). The inferior ear and parts of the
preauricular area are innervated by the greater auricular
nerve (C2,3). The superior portion of the ear and mastoid
region are innervated by the lesser occipital nerve (C2).
Anatomy of the eyelids
There is no consensus on the “ideal” aesthetic eyelids, with
several factors such as age, ethnicity, and surrounding skeletal
structure causing wide variation in what are considered
normal eyelids. In general, the palpebral fissure measures
29–32 mm horizontally and 9–12 mm vertically, with the
lateral canthus 1–2 mm higher than the medial canthus. The
upper eyelid usually covers the upper 1–2 mm of the iris
(lying approximately halfway between the edge of the pupil
and the limbus), while the lower eyelid rests at roughly the
level of the inferior limbus. The highest point of the upper
eyelid lies just nasal to the center of the pupil. Ensuring the
eyelid lies in normal position is important after periorbital
surgery, especially if the canthal tendons are disrupted.
The eyelids can be separated into an anterior lamella,
formed of skin and orbicularis oculi muscle, and a posterior
lamella, formed by the tarsus and the conjunctiva (Fig. 1.14).
The skin of the eyelids is the thinnest skin of the body,
mainly due to its thin dermis, and is relatively more elastic.
As the skin crosses over the orbital rims, it abruptly thickens.
Incisions in the eyelids usually heal rapidly and with minimal
scarring.
The orbicularis oculi lies directly deep to the skin with
minimal subcutaneous fat in between, and is divided into
pretarsal, preseptal (both lying in the eyelid) and orbital
(around the eyelids) portions. The pretarsal muscle arises
medially by two heads that surround the lacrimal sac and
attach to the anterior and posterior lacrimal crests. The deep
head, also known as Horner’s muscle, also attaches to the
fascia over the lacrimal sac. This peculiar arrangement allows
the muscle to play an important role in the lacrimal pump
mechanism.131 The preseptal orbicularis originates from the
medial canthal ligament and inserts on the zygoma lateral to
the orbital rim. The orbital part of the orbicularis muscle
originates from the medial canthal ligament and the adjacent
maxillary and frontal bones, and inserts with the preseptal
portion into the lateral palpebral raphe (see below).
The tarsi provide support and rigidity to the eyelids. They
are formed of collagen, aggregens, and chondroitins. The
upper tarsus measures 10–12 mm, while the lower tarsus
measures 4–5 mm.132 The edges of the tarsi are firmly attached
to the eyelids margins, while the opposite edge is convex
giving the tarsus a semilunar shape. The Meibomian glands
are embedded within the tarsus, and their ducts orifices are
first premolar (or first molar in children). It soon divides into
2–3 branches to innervate the lower lip and the chin.
The auriculotemporal nerve passes around the neck of the
mandible and ascends over the posterior root of the zygomatic
arch, giving a branch to supply the temporomandibular joint.
As its names indicates, it supplies the auricle (and the external
acoustic meatus and the tympanic membrane) and the skin of
the temple. It also carries parasympathetic postganglionic
fibers to the parotid gland, explaining its role in the develop-
ment of Frey’s syndrome (gustatory sweating). The best place
for an auriculotemporal nerve block is 10–15 mm anterior to
the upper origin of the helix.118
The buccal nerve runs in deep plane on the surface of the
buccinators. It sends branches to the skin of the cheek before
piercing the buccinator to supply the mucous membrane of
the cheek.
Of all the cervical cutaneous nerves, the great auricular
nerve has the most significance to the plastic surgeon.126 It
supplies the lower two-thirds of the lateral surface of the ear,
the posterior and lower cheek, and the skin over the mastoid.
It appears around the midpoint of the posterior border of the
sternomastoid passing obliquely upwards towards the angle
of the jaw. However, along the mid-belly of the muscle, it
gently curves changing its direction towards the ear lobe. It
passes either superficial or deep to the sternomastoid fascia.127
It can be consistently found at a point on the mid-belly of the
sternomastoid muscle 6.5 cm caudal to the bony external
auditory meatus.126
Anatomy of the ear
The appearance of the external ear is unique. Its shape and
contour follows the cartilaginous framework that is enveloped
by a very thin skin and soft tissue. In general, there are
three parts of external ear: helix–antihelical complex, conchal
complex, and lobule. Each of these complexes has its own
convoluted structures forming the surface anatomy with
specific landmark nomenclature.128
These three divisions of ear are closely related to the
embryological development process. The ear arises from the
first and second branchial arches, also known as mandibular
and hyoid. These arches then continue to develop into hillocks
between the 3rd and 6th week of gestation. Located anteriorly,
the first branchial arch forms into three hillocks: root of helix,
tragus, and superior helix. The second branchial arch, which
is located posteriorly, gives rise to the other three hillocks:
antihelix, antitragus, and lobule. They become fully formed
structures by the 4th gestational month and continue to
develop around the external meatus, which will canalize by
week 28. The middle ear arises from the first pharyngeal arch
during the 4th week and forms into the incus and malleus.
The stapes, on the other hand, is formed from the second
arch.128,129
The component of soft tissue covering the cartilaginous
framework is comprised of vestigial intrinsic muscles of the
ear, such as helicis major and minor, tragicus and antitragus,
and the transverse and oblique muscles. Most of the extrinsic
muscle covering is comprised of auricularis muscles (anterior,
superior, and posterior). All of these structures are vascular-
ized by the arborization of vessels from superficial temporal
and posterior auricular arteries. The majority of the anterior

19
Anatomy of the eyelids
Fig. 1.14  Sagittal view through the eyelids. ROOF, retro-
orbicularis oculi fat; SOOF, suborbicularis oculi fat.
Müller’s muscle
Orbicularis oculi
Inferior tarsal muscle
Levator aponeurosis
Tarsus
Orbital septum
Orbital septum
Orbital fat
Malar crease
Arcus marginalis
Arcus marginalis
Whitnall’s ligament
Levator palpebrae superioris
Superior rectus
Inferior rectus
Lockwood’s ligament
Inferior oblique
ROOF
SOOF
Orbicularis retaining
ligaments
Orbicularis retaining
ligaments
the eyeball with its movement. The levator aponeurosis inserts
into the anterior surface of the tarsus, sending fibrous attach-
ments thought the orbital septum and the orbicularis muscle
to skin to form the upper eyelid crease. The deep part of the
levator muscle is Müller’s muscle, which is sympathetically
innervated.134 In hyperthyroidism, sensitization of Müller’s
muscle leads to upper eyelid retraction and pseudoproptosis.
On the other hand, in Horner’s syndrome loss of this muscle
action leads to ptosis. Müller’s muscle also sends a lateral
extension surrounding the lacrimal gland and playing a role
in tear excretion.135
The capsulopalpebral fascia assists in lower eyelid retrac-
tion and coordinates it with extraocular movement. It arises
as an extension of the inferior rectus muscle and inserts into
the lower edge of the lower tarsus and the adjacent orbital
septum.136
The medial and lateral canthal ligaments are of significant
importance due to their role in supporting and shaping the
eyelids. The anatomy of the lateral canthal ligament has been
controversial in terms of composition, and various terminol-
ogy has been used to describe this structure.23,137–141 Gross
anatomical and histological studies show that the lateral
canthal ligament is a bifurcated structure comprised of a
superficial tendinous and deep ligamentous component.23,141
located along the eyelid margin posterior to the eyelashes.
Between the dust orifices and the lashes is the “gray line”,
which can be seen as a faint gray line or groove. This line
corresponds to a terminal extension of the orbicularis muscle
known as Riolan’s muscle.133 The gray line serves as an impor-
tant landmark; the plane between the anterior and posterior
lamella of the eyelids.
The orbital septum extends from the edges of the tarsi to
the orbital rims, attaching to the edge of the rim except infe-
riorly, where it extends for 1–2 mm on the anterior surface of
the inferior orbital rim, sharing a common origin with the
orbicularis retaining ligament (see above). Directly deep to the
septum is the orbital fat and the retractors of the upper and
lower eyelids.
The levator palpebrae superioris is the important upper
eyelid retractor; injury or weakness to this muscle leads to
eyelid ptosis. Originating from the back of the orbit, its mus-
cular fibers pass forwards above the superior rectus muscle.
They then turn into the fibrous levator aponeurosis and curve
inferiorly into the upper eyelid. This transition is encircled by
the Whitnall’s ligament. The Whitnall’s ligament sends medial
and lateral horns to attach to the zygomatic bone laterally and
the medial canthal ligament and the posterior lacrimal crest
medially. These attachments maintain the eyelids opposed to

20
CHAPTER 1 • Anatomy of the head and neck
The deep stronger ligamentous component connects the
lateral ends of the upper and lower tarsus to Whitnall’s
tubercle, located on the deep surface of the lateral orbital wall,
3 mm behind the rim.138,141,142 The superficial tendinous com-
ponent receives contributions from the muscle of Riolan, the
pretarsal orbicularis oculi muscle, and the septum orbitale
which are fused to the underlying anterior surface of the tarsal
plates.138,141 The superficial portion attaches laterally to the
anterior surface of the orbital rim and is continuous with
the lateral orbital thickening and adjacent temporalis fascia.23
The orbicularis oculi muscles, superficial to the tarsi and the
ligaments, curve around the eyelids and interlace together
forming the lateral orbital raphe, which is superficial to the
superficial component of the lateral canthal ligament.139 Medi-
ally, the medial canthal ligaments arise from the medial edge
of the upper and lower tarsus, and are similarly formed of
anterior and posterior limbs that attach to the anterior and
posterior limbs of the lacrimal crest.
Anatomy of the nose
The nose is strategically located in the central portion of
the face with three-dimensional projection associated with
complex and intricate anatomy. Nose anatomy can be divided
into three parts: the outer skin and soft tissue envelope, bony
and cartilaginous framework, and inner lining. The intricate
relationship between first two components form contour
reflections, which forms a unique individual nasal appearance
varying from individual to individual.143–145
The skin and soft tissue covering of the nose is variable in
its thickness, texture, and components. It is relatively thin in
the cephalad two-thirds of the nose, especially at the osseo-
cartilaginous junction (rhinion). The lower third portion of the
nose covering has thicker skin and subcutaneous tissue with
varying presence of sebaceous glands, contributing to the
nasal tip morphology.146 The nerves and vasculatures reside
within this subcutaneous tissue. The nasalis muscle lies under
the subcutaneous tissue and partially covers the bone and
cartilages.
The skeletal framework of the nose is structured by nasal
bones and cartilages. They determine the individual nose
configuration and shape. Starting cephalad, the paired nasal
bones bridge the frontal process of the maxilla and frontal
bones at the nasofrontal suture. The overlapping region
between the inferior portion of the nasal bones with the
superior portion of the upper lateral cartilages is called the
keystone area. The most caudal portion of the framework
is supported by a uniquely shaped lower lateral (alar) car-
tilage. The inferior medial portion of this cartilage is called
the medial crus. As it ascends, it becomes the middle or
intermediate crus and continues curving laterally to become
the lateral crus. The junction between the middle and lateral
crus is called the dome, the most angulated portion of the
structure plays an important role in forming nasal tip defini-
tion. There are accessory cartilages, which are interspersed
in the aponeurosis connecting the lateral crus and piriform
aperture.147–149
The inner lining of the nose is mostly covered by thin
mucosa, providing passage of the airway. Destruction or inap-
propriate reconstruction of this thin mucosal lining can cause
a narrowing of the breathing passage.
The surface anatomy of the nose follows the underlying
structural anatomy of its framework in combination with the
skin and soft tissue envelope. The most cephalad portion of
the nose is called the root or radix of the nose. This continues
caudally in the midline as a sloping downward segment
called the dorsum of the nose. The tip of the nose has several
landmark anatomies. The region just above the tip of the
nose is called the supra-tip region or break. It is the surface
landmark above the dome (lateral genu) of the lower lateral
cartilages. The dome of each lower lateral cartilage marks
the tip defining point, and the region caudal to this point
forms the infra-tip lobule and columella. The lateral curvature
portion of the nose is called the alar lobule, which forms the
nostril opening. These surfaces form topographic subunits
of the nose that are often used in recognizing the boundar-
ies of light reflections bordering the anatomic landmarks:
dorsum, sidewalls, nostril sills, nasal tip, soft triangles,
and columella.150
The nose is vascularized by dual blood supply. Superiorly,
the branches of the ophthalmic, anterior ethmoid, dorsal
nasal, and external nasal arteries supply the proximal portion
of the nose. The inferior region and tip of the nose is primarily
supplied by branches of the facial artery, which include supe-
rior labial and angular vessels.145
2. Baker DC, Conley J. Avoiding facial nerve injuries in
rhytidectomy: Anatomical variations and pitfalls. Plast Reconstr
Surg. 1979;64:781–795.
5. Stuzin JM, Baker TJ, Gordon HL. The relationship of the
superficial and deep facial fascias: relevance to rhytidectomy and
aging. Plast Reconstr Surg. 1992;89:441. The authors performed
cadaveric dissections and made intraoperative observations to clarify the
relationships between the muscles of facial expression, the facial nerve,
and fascial planes. It is confirmed that the facial nerve branches in the
cheek lay deep to the deep facial fascia.
16. Gosain AK, Sewall SR, Yousif NJ. The temporal branch of the
facial nerve: how reliably can we predict its path? Plast Reconstr
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21. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the
ligamentous attachments in the temple and periorbital regions.
Plast Reconstr Surg. 2000;105:1475–1490. The authors report consistent
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regions. The clinical relevance of predictable relationships between
neurovascular structures and this connective tissue framework is
discussed.
47. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and
clinical applications of the buccal fat pad. Plast Reconstr Surg.
1990;85:29–37. The clinical importance of the buccal fat pad is
discussed. Anatomical dissection and clinical experience inform
recommendations for surgical modification of the structure to maximize
aesthetic outcomes.
64. Barton FE Jr, Hunt J. The high-superficial musculoaponeurotic
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21
Anatomy of the nose
branch of the facial nerve is addressed. In platysmal facelifts,
diminished modiolus retrusion may be secondary to an injury to
the cervical, rather than the marginal mandibular, branch of the
facial nerve.
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21.e1
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74. Davis RA, Anson BJ, Budinger JM, et al. Surgical anatomy of the
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75. Savary V, Robert R, Rogez JM, et al. The mandibular marginal
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76. Knize DM. Transpalpebral approach to the corrugator supercilii
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81. Woltman M, Fauri R, Sgrott EA. Anatomical study of the marginal
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82. Daane SP, Owsley JQ. Incidence of cervical branch injury with
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83. Ellenbogen R. Pseudo-paralysis of the mandibular branch of the
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84. Salinas NL, Jackson O, Dunham B, et al. Anatomical dissection
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87. McCord S, Codner M, Nahai F, et al. Analysis of the nerve
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1994:10.

SECTION I • Craniofacial Trauma
2 
Facial trauma: Soft tissue injuries
Reid V. Mueller
SYNOPSIS
■ Look for hidden injuries under the skin.
■ Thoroughly cleanse to prevent dirt tattoo.
■ Conservative debridement.
■ Careful anatomic alignment and suture technique.
Introduction
As humans, we live in a complex social structure that depends
not only on the words we use for communication, but the
emotive subtext of facial expression that imbues our words
with greater meaning. Our faces are able to express a won-
drous range of subtle emotions and silent messages. Because
the face is so important for negotiating the complex social
interactions that are part of our everyday lives, the careful
repair and restoration of function is an important task we
must not engage in lightly. The achievements of those who
have gone before us have given us the knowledge to repair
the majority of soft tissue injuries to the face, provided we
carefully consider the nature of the injury and craft a well
thought out reconstructive plan.
Soft tissue injuries are commonly encountered in the care
of traumatized patients. Many of these injuries are simple
superficial lacerations that require nothing more than a
straightforward closure. Other seemingly uncomplicated
wounds harbor injuries to other structures. Recognition of
the full nature of the injury and a logical treatment plan will
determine whether there will be future aesthetic or functional
deformities. All wounds will benefit from cleansing, irrigation,
conservative debridement, and minimal tension closure. Some
wounds will benefit from local or regional flaps for closure;
and a few wounds will need tissue expansion or free tissue
transfer for complete restoration of function and appearance.
Access the Historical Perspective section online at

Basic science
The etiology of facial soft tissue trauma varies considerably
depending upon age, sex, and geographic location. Many
facial soft tissue injuries are relatively minor and are treated
by the emergency department without a referral to a special-
ist. There are little data regarding the etiology of facial trauma
that is subsequently referred to a specialist, but it is weighted
towards more significant traumas such as road crashes and
assaults. The location of facial soft tissue trauma tends to
occur in certain areas of the head depending on the causative
mechanism. When taking all etiologies of facial trauma into
account, the distribution is concentrated in a “T-shaped” area
that includes the forehead, nose, lips, and chin. The lateral
brows and occiput also have localized frequency increases.4
These areas are more prone to injury because they primarily
overlie bony prominences that are at risk from any blow to
the face, whether that be an assault, fall, or accident (Fig. 2.1).
Global considerations
Almost all soft tissue injuries of the head involve the skin in
some manner. The skin of the head shows more variety than
any other area of the body in terms of thickness, elasticity,
mobility, and texture. Consider the profound differences
between the thick, inelastic, hair-bearing skin of the scalp
compared with the thin, elastic, mobile skin of the eyelids.
Consider also, the transitions from external skin of the face to
the orbital, nasal, and oral linings. Significant differences in the
structure of the facial skin in different areas require different
methods for the repair and reconstruction. In addition, many
facial structures are layered with an outer skin layer, central
cartilaginous support or muscular layer, and an inner mucosal
lining or second skin layer (e.g., eyelids, nose, lips, ears).
Anyone who has suffered a cut lip or scalp knows firsthand
that the face is well perfused. The dense interconnected
network of collateral vessels in the face means that injured
tissue with seemingly insufficient blood will in fact survive,
whereas the same injury would result in tissue necrosis in
another area of the body. The implication is that more (and

22.e1
Historical perspective
Historical perspective
Our understanding of the management of maxillofacial inju-
ries is the result of thousands of years of accumulated knowl-
edge and experience by those who came before us. The ancient
texts of the Sumerians (5000 BC) and the Egyptians (3500 BC)
offer specific advice for the management of a variety of maxil-
lofacial injuries. In particular, they discuss that soft tissue
injuries may harbor other deeper injuries to bone or brain and
that the surgeon should explore the wound with their finger
to feel for these injuries.1,2 The renaissance texts from Europe
and Mexico write about the importance of treating life-
threatening wounds and not ignoring the restoration of
cosmetic appearance: “the wounds of the face … have to be
cured with extreme care because the face is a man’s honor.”3
They also understood that infection was uncommon in facial
wounds but very common in extremity wounds. Because of
this, the usual recommendation for placement of a cotton wick
to drain the wounds was not a part of facial wound closure.
They also understood that sutures should be removed early
to prevent suture marks on the face.
Today we have a better understanding of the science behind
the empiric knowledge of the past, but the basic tenets
described hundreds and thousands of years ago still stand:
look for underlying injuries, cleanse the wound, minimal
debridement and careful anatomic alignment and suture
technique.

23
Diagnosis and patient presentation
alteration in appearance; however, we should not be distracted
from a methodical examination for other injuries. Seemingly
straightforward wounds often harbor injuries to the facial
skeleton, teeth, nerves, parotid duct, eyes, or brain.
Evaluation for immediate life-threatening
injuries
Evaluation of an injured patient should always start with
establishment of an airway, ventilation, volume resuscitation,
control of hemorrhage, and stabilization of other major
injuries – the ABCs of an initial trauma assessment. While
the plastic surgeon is rarely “on the front lines” of trauma
care, neither can the plastic surgeon be complacent and
assume that the emergency or trauma physician has com-
pleted a trauma assessment.
Once you are satisfied that there are no immediate life-
threatening injuries, you should begin your examination. The
assessment of facial injuries is guided by the nature of the
mechanism of injury. A thermal burn will be approached very
differently than a motor vehicle crash. The history of the
injury, if known, will often provide some clue as to what other
injuries one might expect to find. A child who falls against
a coffee table is unlikely to have any associated fractures
whereas a soccer player has a 17% chance of having an under-
lying fracture. Practitioners will have their own style of
examination, but one should stick to a routine to decrease the
likelihood of forgetting to check something. The author prefers
to move from outside to inside, and top to bottom.
Systematic evaluation of the head and neck
Initial observation, inspection and palpation will generally
provide most of the information a practitioner will need.
Ideally, the examination should be done with adequate anes-
thesia and sterile technique, as well as good lighting, irriga-
tion, and suction as needed.
Inspection of the skin will reveal abrasions, traumatic
tattoos, simple or “clean” lacerations, complex or contusion
type lacerations, bites, avulsions, or burns. A careful check for
facial symmetry may reveal underlying bone injury. One
should systematically palpate the skull, orbital rims, zygo-
matic arches, maxilla, and mandible feeling for asymmetry,
bony step-off, crepitus, or other evidence of underlying facial
fracture. Palpation within the wound may identify palpable
fractures or foreign bodies. Sensation of the face should be
tested with a light touch, and motor activity of the facial nerve
should be tested before the administration of local anesthetics.
If local anesthetics are administered it is important that the
time, location, and composition of the anesthetic is well docu-
mented in the chart so that subsequent examinations will not
be confounded.
Eye examination
Trauma to the periorbital area or malar prominence should
raise concern for associated orbital injury. Having the patient
read or count fingers can be used to test gross visual acuity.
The presence of a bony step-off, diplopia, restricted ocular
movements, enophthalmos, or vertical dystopia may suggest
an orbital blowout fracture. Traction on the eyelids can be
used to test the integrity of the medial and lateral canthi. The
canthi should have a snug and discernible endpoint when
traction is applied. Rounding or laxity of the canthi suggests
potentially invaluable) tissue can be salvaged. This is espe-
cially important for areas with little or no excess tissue to
sacrifice, or areas that are notoriously difficult to recreate later,
for example, the oral commissure. When repairing the face,
conservative debridement is usually preferable. If a segment
of tissue appears only marginally viable but is indispensable
from a reconstructive standpoint, it should be loosely approxi-
mated and re-examined in 24–48 h. At that time, a line of
demarcation will usually delineate what will survive and
what will die. Nonviable tissue may then be debrided during
a second look procedure.
Because the face is so well perfused its ability to resist
infection is better than other areas of the body. Human bites
to the hand treated without antibiotics have approximately a
47% risk of infection,5 whereas if we inadvertently bite our
cheeks, lips, or tongue we almost never develop an infection.
The lower risk of infection in the face has practical applica-
tions for management of facial soft tissue injuries. Many a
medical student has been told that any wound that has been
open for 6 hours cannot be closed primarily. This belief is
based on tradition rather that good science. While there is no
doubt that the longer a wound is open the more likely it is to
become contaminated, there is no magical time cut-off for
primary closure.6 Because the face carries such profound
cosmetic importance, the small increased risk of infection
associated with delayed closure of a wound will be trumped
by improved cosmesis associated with primary closure. This
author recommends closure of facial wounds at the earliest
time possible that will not interfere with the management of
other more serious injuries, but do not let time deter you from
obtaining primary closure.
Diagnosis and patient presentation
Our attention is often captured by the obvious external mani-
festations of craniofacial soft tissue injuries because of the
Fig. 2.1  A total of 700 facial soft tissue injuries segregated into the number of
injuries for different facial areas, indicated by color. Note the “T” distribution across
the forehead, nose, lips, and chin. Also note the concentration of injuries at the
lateral brow. (Data from Hussain K, Wijetunge DB, Grubnic S, et al. A
comprehensive analysis of craniofacial trauma. J Trauma. 1994;36:34.)
100
75
50
25
0

24
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
or aspirated. If you cannot account for a missing tooth an
X-ray of the head and chest should be done. The oral lining
should be inspected for lacerations, and the occlusion should
be checked. Palpation of the maxillary buttresses and man-
dible may reveal fractures. A sublingual hematoma suggests
a mandible fracture.
Neck examination
The first priority when evaluating a soft tissue injury to the
neck is evaluation of the airway. You should be concerned
about the patient’s airway if they have garbled speech, dys-
phonia, hoarseness, persistent oropharyngeal bleeding, or if
they appear agitated or struggling for air.7 Once the airway
is secured and the exam shows no compromise, the soft
tissue injury should be examined with adequate light and
suction to rule out penetration deep to the platysma. If the
soft tissue injury penetrates through the platysma then the
trauma surgeons must be consulted to evaluate a penetrat-
ing neck injury.
Diagnostic studies
Any diagnostic studies are directed towards defining injuries
to underlying structures. Most soft tissue injuries in and
of themselves do not need any special diagnostic studies,
however the search for foreign bodies, missing teeth, or con-
comitant facial fractures should be followed-up with a radio-
graphic evaluation.
Plain films
Plain films may be helpful in the evaluation of foreign bodies
or to elucidate underlying facial fractures. In most institu-
tions, imaging of facial trauma with plain films has largely
been supplanted with computed tomography (CT).
canthal injury or naso-orbital-ethmoidal (NOE) fracture. Any
laceration near the medial third of the eye should raise suspi-
cion of a canalicular injury. If there is any suspicion of globe
injury, an immediate ophthalmology consultation is needed.
Ear examination
The ears should be inspected for hematomas that will appear
as a diffuse swelling under the skin of the auricle (Fig. 2.2).
Any lacerations should be noted. Otoscopy should be done to
look for lacerations of the auditory canal, tympanic membrane
injuries, or hemotympanum.
Nose examination
Inspect the nose for any asymmetry, or deviation to one side
or the other. Palpate the nasal bones and cartilage for fracture
or crepitus. Examine the internal nose with a speculum and
good light to look for mucosal lacerations, exposed cartilage
or bone, a deviated or buckled septum, or septal hematoma
(a bluish boggy bulge of the septal mucosa).
Cheek examination
Any laceration of the cheek that is near any facial nerve branch
or along the course of the parotid duct will need to be inves-
tigated. Asking the patient to raise their eyebrows, close their
eyes tight, show their teeth or smile, and pucker while looking
for asymmetry or lack of movement will reveal any facial
nerve injury. An imaginary line connecting the tragus to the
central aspect of the philtrum defines the course of the parotid
duct (Fig. 2.3). The duct is at risk from any injury in the central
third of this line. If you are unsure about a duct injury,
Stensen’s duct should be cannulated and fluid instilled to see
if it leaks out of the wound.
Oral cavity and mouth
Inspect the oral cavity for loose or missing teeth. Any unac-
counted for teeth may be loose in the wound, lost at the scene,
Fig. 2.2  An auricular hematoma after a wrestling injury. The collection of blood
must be drained to prevent organization and calcification of the hematoma.
Untreated hematomas will result in a “cauliflower ear”.
Fig. 2.3  The middle third of a line between the tragus and the middle of the upper
lip defines the course of the parotid duct. Evidence of injury to the zygomatic or
buccal branches of the facial nerve or lacerations or the cheek near the area shaded
in green should raise suspicion for parotid duct injury.

25
Treatment and surgical techniques
of application for adequate anesthesia. The most common
mistake leading to failure is not allowing sufficient time for
diffusion and anesthesia. Some areas, such as the face, with a
thinner stratum corneum may have onset of anesthesia more
quickly.
Local infiltration
Local anesthetics are appropriate for the repair of most simple
facial soft tissue trauma. Subdermal infiltration will provide
rapid onset of anesthesia and control of bleeding if epineph-
rine has been added. However, injection may distort some
facial landmarks needed for alignment and accurate repair
(such as the vermilion border of the lip), and, therefore,
anatomic landmarks should be noted and marked prior to
injection.
Facial field block
Field block of the face can provide anesthesia of a larger area
with less discomfort and fewer needle sticks for the patient.
A field block may provide better patient tolerance of multiple
painful injections of local anesthetic when a local infiltration
of an epinephrine-containing solution is needed. Field blocks
are more challenging to perform and take time to take effect.
Impatient surgeons often fail to wait a sufficient amount of
time (at least 10–15 min) for most blocks to take effect.
Forehead, anterior scalp to vertex, upper eyelids, glabella
(supraorbital, supratrochlear, infratrochlear nerves)
Anatomy: The supraorbital nerve is located at the superior
medial orbital rim about a finger-breadth medial to the mid-
pupillary line. The supratrochlear nerve lies about 1.5 cm
farther medially near the medial margin of the eyebrow. The
infratrochlear nerve is located superior to the medial canthus.
Method: Identify the supraorbital foramen or notch along
the superior orbital rim and enter just lateral to that point.
Direct the needle medially and advance to just medial of the
medial canthus (about 2 cm). Inject 2 cc while withdrawing
the needle (Fig. 2.4).12
Lateral nose, upper lip, upper teeth, lower eyelid, most of
medial cheek (infraorbital nerve)
Anatomy: The infraorbital nerve exits the infraorbital foramen
at a point that is medial of the mid-pupillary line and 6–10 mm
below the inferior orbital rim.
Method: Identify the infraorbital foramen along the inferior
orbital rim by palpation. An intraoral approach is better toler-
ated and less painful (Fig. 2.5). Place the long finger of the
nondominant hand on the foramen and retract the upper lip
with thumb and index finger. Insert the needle in the superior
gingival buccal sulcus above the canine tooth root and direct
the needle towards your long finger while injecting 2 cc. You
may also inject percutaneously by identifying the infraorbital
foramen about 1 cm below the orbital rim just medial to the
mid-pupillary line. Enter perpendicular to the skin, advance
the needle to the maxilla, and inject about 2 cc (Fig. 2.6).12
Lower lip and chin (mental nerve)
Anatomy: The mental nerve exits the mental foramen about
2 cm inferior to the alveolar ridge below the second premolar.
CT
Maxillofacial CT is primarily used to evaluate brain injury
and underlying facial fractures, and it may have some utility
in identifying or locating foreign bodies within the soft tissues.
Consultation with other providers
Ophthalmology
Any patient with zygomaticomaxillary fractures, naso-orbital-
ethmoidal fractures, orbital blowout fracture, canalicular
injury, or suggestion of ocular injury should have an evalua-
tion by an ophthalmologist.
Dental/OMFS
Dental injuries are commonly associated with facial soft tissue
trauma and are rarely an emergency. A dentist should evalu-
ate dental injuries, such as fractured or missing teeth, once the
patient has recovered from their initial injury. If the patient
has an avulsed tooth, an urgent consult should be called to
replant the tooth if possible.
Treatment and surgical techniques
Anesthesia for treatment
Good anesthesia is often necessary for patient comfort and the
cooperation that is needed to complete a comprehensive
evaluation. Most soft tissue injuries of the head and neck can
be managed with simple infiltration or regional anesthesia
blocks. Patients who are uncooperative because of age, intoxi-
cation, or head injury may require general anesthesia. Patients
with extensive injuries requiring more involved reconstruc-
tion, or who would require potentially toxic doses of local
anesthetics, will likewise require general anesthesia.
With the exception of cocaine, all of the local anesthetics
cause some degree of vasodilatation. Epinephrine is com-
monly added to anesthetic solutions to counteract this effect,
to cause vasoconstriction, to decrease bleeding, and to slow
absorption and increase duration of action. Epinephrine
should not be used in patients with pheochromocytoma,
hyperthyroidism, severe hypertension, or severe peripheral
vascular disease or patients taking propranolol. Every medical
student has learned that epinephrine should never be injected
in the “finger, toes, penis, nose, or ears”. This admonition is
based on anecdotal reports or simple assumptions. There is
very little data to support the notion, and plastic surgeons
routinely use epinephrine in the face including the ears and
nose with very rare complications.
Topical
Topical anesthetics are well established for the treatment of
children with superficial facial wounds and to decrease the
pain of injection. The most widely used topical agent is a 5%
eutectic mixture of local anesthetics (EMLA) containing lido-
caine and prilocaine.8,9 EMLA has been shown to provide
adequate anesthesia for split-thickness skin grafting10 and
minor surgical procedures such as excisional biopsy and
electrosurgery.11 Successful use of EMLA requires 60–90 min

26
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
The nerve can often be seen under the inferior gingival buccal
mucosa when lower lip and cheek are retracted. It branches
superiorly and medially to supply the lower lip and chin.
Method: The lower lip is retracted with the thumb and
finger of the nondominant hand and the needle inserted at the
apex of the second premolar. The needle is advanced 5–8 mm,
and 2 cc are injected (Fig. 2.7). When using the percutaneous
approach, insert the needle at the mid-point of a line between
the oral commissure and inferior mandibular border. Advance
the needle to the mandible and inject 2 cc while slightly
withdrawing the needle (Fig. 2.8).12
Posterior auricle, angle of the jaw, anterior neck (cervical
plexus: great auricular, transverse cervical)
Anatomy: Both the great auricular nerve and transverse cervi-
cal nerves emerge from the midpoint of the posterior border
of the sternocleidomastoid muscle at Erb’s point. The great
auricular nerve parallels the external jugular vein as it passes
up towards the ear. The transverse cervical nerve is located
about 1 cm farther inferiorly and passes parallel to the clavicle
and then curves towards the chin. Both are in the superficial
fascia of the sternocleidomastoid muscle.
Method: Locate Erb’s point by having the patient flex
against resistance. Mark the posterior border of the sterno-
cleidomastoid muscle and locate the midpoint between clavicle
and mastoid. Insert the needle about 1 cm superior to Erb’s
point and inject transversely across the surface of the muscle
towards the anterior border. A second more vertically oriented
Fig. 2.4  The majority of the forehead, medial upper eyelid, and glabella can be
anesthetized with a block of the ophthalmic division of the trigeminal nerve (CN V1).
Identify the supraorbital notch by palpation and enter the skin just lateral to that
point near the pupillary midline. Aim for a point just medial to the medial canthus
(marked by an X) and advance the needle about 2 cm. Inject 2–3 cc while
withdrawing the needle.
Supraorbital
Supratrochlear
Infratrochlear
External nasal
Larimal
X
Supraorbital
Supratrochlear
Infratrochlear
External nasal
Larimal
Fig. 2.5  The lower eyelid, medial cheek, and lower nose can be anesthetized with
an infraorbital nerve block. The infraorbital foramen may be palpable about 1 cm
below the orbital rim just medial to the mid-pupillary line (X). The intraoral
approach is less painful and anxiety provoking for most patients. Place the long
finger of the nondominant hand on the orbital rim at the infraorbital foramen. Grasp
and retract the upper lip. Insert the needle in the superior gingival buccal sulcus
above the canine tooth root and direct the needle towards your long finger and the
foramen while injecting 2–3 cc.
Zygomaticotemporal
Infraorbital
Zygomaticofacial
X
a
b
c
Zygomaticotemporal
Infraorbital
Zygomaticofacial
Fig. 2.6  The lower eyelid, medial cheek, and lower nose can be anesthetized with an
infraorbital nerve block. The infraorbital foramen may be palpable about 1 cm below
the orbital rim just medial to the mid-pupillary line (X). Enter the skin directly over the
palpable or anticipated location of the infraorbital foramen and advance to the maxilla.
Inject about 2 cc of anesthetic. Anesthesia of the anterior temple area can be achieved
with a block of the zygomaticotemporal nerve. Enter just posterior to the lateral orbital
rim at a level above the lateral canthus (marked a) and advance towards the chin to a
point level with the lateral canthus (b). Inject 2–3 cc while withdrawing the needle.
The zygomaticofacial nerve supplies the lateral malar prominence. To block this nerve,
enter at a point one finger-breadth inferior and lateral to the intersection of the inferior
and lateral orbital rim. Advance the needle to the zygoma and inject 1–2 cc.
Zygomaticotemporal
Infraorbital
Zygomaticofacial
X
a
b
c
Zygomaticotemporal
Infraorbital
Zygomaticofacial

27
Treatment and surgical techniques
sulcus while injecting. It may be necessary to insert the needle
a third time along the posterior sulcus to complete a ring
block. Care should be taken to avoid the temporal artery
when directing the needle along the preauricular sulcus. If the
artery is inadvertently punctured, apply pressure for 10 min
to prevent formation of a hematoma.
If anesthesia of the concha or external auditory canal is
needed, local infiltration will be required to anesthetize the
auditory branch of the Vagus nerve (Arnold’s nerve).
General treatment considerations
The ultimate goal is to restore form and function with
minimum morbidity. Function generally takes precedence
over form, however the face plays a fundamental role in
emotional expression and social interaction, and therefore the
separation of facial appearance from function is impossible.
Irrigation and debridement
Once good anesthesia has been obtained, the wound should
be cleansed of foreign matter and clearly nonviable tissue
removed. This is the process of converting an untidy to a tidy
wound. Clean lacerations from a sharp object will result in
little collateral tissue damage or contamination, while a
wound created by an impact with the asphalt will have sig-
nificant foreign material and soft tissue damage. The process
starts by irrigating the wound with a bulb syringe or a 60 cc
syringe with an 18-gauge angiocatheter attached to forcibly
irrigate the wound. More contaminated wounds may benefit
from pulse lavage systems.
Fig. 2.7  The lower lip and chin can be anesthetized with a block of the mental
nerve (CN V3). Retract the lower lip with the thumb and index finger of the
nondominant hand. Many times the mental nerve is visible under the mandibular
gingival buccal sulcus near the apex of the second premolar. Insert the needle at
the apex of the second premolar and advance the needle 5–8 mm while injecting
2 cc.
X
Buccal
Buccal
Mental
Mental
Fig. 2.8  The lower lip and chin can be anesthetized with a block of the mental
nerve (CN V3). The mental foramen is located near the mid-point of a line from the
oral commissure and the mandibular border. Enter the skin at this point and
advance to the mandible. Inject 2–3 cc while slightly withdrawing the needle. The
auriculotemporal nerve emerges deep and posterior to the temporomandibular joint
and travels with the temporal vessels to supply the temporal scalp, lateral temple,
and anterior auricle. Palpate the temporomandibular joint and base of the zygomatic
arch. Enter the skin superior to the zygomatic arch just anterior to the auricle.
Aspirate to ensure you are not within the temporal vessels and inject 2–3 cc.
Auricuotemporal
Buccal
Mental
X
Auricuotemporal
Buccal
Mental
injection may be needed to block the transverse cervical
nerve.12
Ear (auriculotemporal nerve, great auricular nerve, lesser
occipital nerve, and auditory branch of the vagus
(Arnold’s) nerve)
Most ear injuries will not require a total ear block and can be
managed with local infiltration of anesthetic. While there is a
theoretical concern of tissue necrosis when using epinephrine
in any appendage (in medical school we learned “finger, toes,
penis, nose, and ears”), there is no good data to support this.
Most plastic surgeons routinely use 1 : 100 000 epinephrine
in the local anesthetics for ear infiltration. The advantages
are prolonged duration of anesthesia and less bleeding.
Complications attributed to the anesthetic infiltration are
extremely rare.
Anatomy: The anterior half of the ear is supplied by the
auriculotemporal nerve that branches from the mandibular
division of the trigeminal nerve (CN V3). The posterior half of
the ear is innervated by the great auricular and lesser occipital
nerves that are both branches from the cervical plexus (C2,
C3). The auditory branch (Arnold’s nerve) of the vagus nerve
(CN X) supplies a portion of the concha and external
auditory canal.
Method: Insert a 1.5 inch needle at the junction of the earlobe
and head and advance subcutaneously towards the tragus
while infiltrating 2–3 cc of anesthetic (Fig. 2.9). Pull back the
needle and redirect posteriorly along the posterior auricular
sulcus again injecting 2–3 cc. Reinsert the needle at the supe-
rior junction of the ear and the head. Direct the needle along
the preauricular sulcus towards the tragus and inject 2–3 cc.
Pull back and redirect the needle along the posterior auricular

28
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
of foreign matter are removed. Failure to do so may result in
later infection.
Abrasions
Abrasions result from tangential trauma that removes the
epithelium and a portion of the dermis leaving a partial-
thickness injury that is quite painful. This type of injury is
often the result of sliding across pavement or dirt and there-
fore embeds small particulate debris within the dermis. If dirt
and debris are not promptly removed the dermis and epithe-
lium will grow over the particulates and create a traumatic
tattoo that is very difficult to manage later. Topical anesthet-
ics, if properly applied and given sufficient time for onset, can
give good anesthesia for cleansing of simple abrasions. This
can be accomplished with generous irrigation and cleansing
with a surgical scrub brush (Fig. 2.10). If more involved
debridement is needed, general anesthesia is advisable.
Traumatic tattoo
There are two basic types of traumatic tattoo: those which
result from blast injuries and those which result from abrasive
injuries. In either case, various particles of dirt, asphalt, sand,
carbon, tar, explosives, or other particulate matter are embed-
ded into the dermis.
Abrasive traumatic tattoos are more common. Typically, a
person is ejected from a vehicle, or thrown from a bicycle and
subsequently grinds their face into the pavement. This causes
a simultaneous traumatic dermabrasion of the epidermis and
superficial dermis, and embedding of the pigment (dirt). If
left untreated, the dermis and epidermis heal over the pigment
resulting in a permanent tattoo (Fig. 2.11).
Blast type injuries seen in military casualties and civilian
powder burns, as well as firework and bomb mishaps, produce
numerous particles of dust, dirt, metal, combustion products,
un-ignited gunpowder, and other foreign materials that act
like hundreds of small missiles, each penetrating the wound
to various depths. The entry wounds collapse behind the
particle, trapping them within the dermis.
After irrigation, hemostasis should be secured to give the
surgeon a better opportunity to inspect the wound. The use
of epinephrine in the local anesthetic will cause some degree
of vasoconstriction and assist in this regard. Electrocautery
should be applied at the lowest setting conducive to coagula-
tion and applied to specific vessels. Wholesale indiscriminate
application of electrocautery causes unnecessary tissue necro-
sis. Use electrocautery cautiously when working in areas
where important nerves might be located to avoid iatrogenic
injury. Remember that nerves often are in proximity to vessels.
Limited sharp debridement should be used to remove
clearly nonviable tissue. In areas where there is minimal tissue
laxity or irreplaceable structures (e.g., tip of nose, oral com-
missure), debridement should be kept to a minimum and later
scar revision undertaken if needed. Areas such as the cheek
or lip have significant tissue mobility debridement and will
tolerate more aggressive debridement.
After the preliminary debridement and irrigation, a
methodical search for foreign material should be undertaken.
Small fragments of automobile glass become embedded
through surprisingly small external wounds. They are usually
evident on X-ray or CT scan or by careful palpation. Patients
thrown from vehicles will often have dirt, pebbles, or plant
material embedded in their wounds. Patients who have blast
injuries from firearms or fireworks may have paper, wadding,
or bullet fragments present. One should not undertake a
major dissection for the sake of retrieving a bullet fragment,
however one should make sure that other identifiable pieces
Fig. 2.9  The majority of the external ear can be anesthetized with a ring block.
Insert a 1.5-inch needle at the superior junction of the ear and the head at (a).
Direct the needle along the preauricular sulcus towards the tragus and inject
2–3 cc. Pull back and redirect the needle along the posterior auricular sulcus while
injecting. Reinsert the needle at the junction of the earlobe and head, at (b), and
advance subcutaneously towards the tragus while infiltrating 2–3 cc of anesthetic.
Pull back the needle, and redirect posteriorly along the posterior auricular sulcus
again injecting 2–3 cc. It may be necessary to insert the needle a third time at (c),
along the posterior sulcus to complete a ring block. If anesthesia of the concha or
external auditory canal is needed, local infiltration (marked with Xs) will be required
to anesthetize the auditory branch of the vagus nerve (Arnold’s nerve).
Auriculotemporal
Vagus (Arnold’s)
c
×
×
×
×
Lesser occipital
Greater auricular
b
a
Auriculotemporal
Vagus (Arnold’s)
Fig. 2.10  Facial abrasions should be cleansed of any dirt and debris with
generous irrigation and gentle scrubbing with a surgical scrub brush.

29
Treatment and surgical techniques
If initial laser treatment suggests the presence of un-ignited
gunpowder in the dermis, laser removal should be discontin-
ued in favor of other treatments such as dermabrasion or
surgical micro-excision of the larger particles.
Simple lacerations
Sharp objects cutting the tissue usually cause simple or
“clean” lacerations. Lacerations from window and automobile
glass or knife wounds are typical examples (Fig. 2.12). Simple
lacerations may be repaired primarily after irrigation and
minimal debridement, even if the patient’s condition has
delayed closure for several days. When immediate closure is
not feasible, the wound should be irrigated and kept moist
with a saline and gauze dressing. Prior to repair, foreign
bodies such as window glass should be removed. Wounds of
this type usually require little or no debridement. A few well
placed absorbable 4-0 or 5-0 sutures will help align the tissue
and relieve tension on the skin closure. The temptation to
place numerous dermal sutures should be avoided because
excess suture material in the wound will only serve to incite
inflammation and impair healing. The skin should be closed
with 5-0 or 6-0 nylon interrupted or running sutures; alterna-
tively, 5-0 nylon or monofilament absorbable running subcu-
ticular pullout sutures can be placed. Any suture that traverses
the epidermis should be removed from the face in 4–5 days.
If sutures are left in place longer than this, epithelization of
the suture tracts will lead to permanent suture marks known
as “railroad tracks”. Sutures of the scalp may be left in place
for 7–10 days. Pullout sutures should usually be removed
following the same guidelines, however there is less risk of
permanent suture marks. It should be noted that fast gut or
plain gut sutures may not fall out within a sufficiently brief
time period to avoid “railroad track” scars and should be
removed in a timely manner if needed.
Complex lacerations
When soft tissue is compressed between a bony prominence
and an object, it will burst or fracture resulting in a complex
laceration pattern and significant contusion of the tissue.
Typical examples of these types of lacerations are a brow
laceration sustained when a toddler falls onto a coffee table, or
when an occupant is ejected from a vehicle in a crash striking
an object (Fig. 2.13). Many wounds on first impression suggest
that there is significant tissue loss; however, after irrigation,
minimal debridement, and careful replacement of the tissue
fragments piece by piece it becomes apparent that most of the
tissue is present (Fig. 2.14). Contused and clearly nonviable
tissue should be debrided. Tissue that is contused but has
potential to survive should usually be returned to anatomic
position. Elaborate repositioning of tissue with Z-plasties and
the like should usually be reserved for secondary reconstruc-
tions after primary healing has finished. Limited undermin-
ing may be used to decrease tension and achieve closure;
however, wide undermining is rarely indicated. It is probably
better to accept a modest area of secondary intention healing
and plan for later scar revision rather than risk tissue necrosis
from overzealous undermining of already injured tissue.
Avulsions
Many wounds of the face suggest tissue loss upon initial
inspection, but closer examination reveals that the tissue has
Regardless of the mechanism of injury, prompt removal of
the particulate matter results in a far better outcome than later
removal. Once the skin has healed, the opportunity to remove
the particles with simple irrigation and scrubbing is lost. The
initial treatment is vigorous scrubbing with a surgical scrub
brush or gauze and copious irrigation.13–17 Wounds treated
within 24 hours show substantially better cosmetic outcome
than those treated later;15 however, some improvement has
been seen as late as 10 days.18 Larger particles should be
searched for and removed individually with fine forceps or
needles, loupe magnification, and generous irrigation.19 The
tedious and time-consuming nature of this procedure may
require serial procedures over several days to complete,
nonetheless meticulous debridement of the acute injury is the
best opportunity for optimal outcome.
The treatment of a traumatic tattoo remains an unresolved
problem in plastic surgery, and as such, there are multiplici-
ties of techniques, none of which are perfect. Some of the
treatment options include surgical excision and microsurgical
planning,20,21 dermabrasion,22–25 salabrasion,26 application of
various solvents such as, diethyl ether,16 cryosurgery, electro-
surgery, and laser treatment with carbon dioxide, argon
lasers,13,14,16,27 Q-switched Nd:YAG laser,28,29 erbium–YAG
laser,30 Q-switched alexandrite laser,31,32 and Q-switched ruby
laser.33,34 The mechanism for laser removal is not entirely
understood but is thought to involve the fragmentation of
pigment particles, rupture of pigment-containing cells, and
subsequent phagocytosis of the tattoo pigment.35,36 Laser
therapy for pigment tattoos will require slightly higher fluen-
cies than those used for removal of professional tattoos.34
A note of caution is in order when treating gunpowder
traumatic tattoos. Several authors have noted ignition of
retained gunpowder during laser tattoo removal,25,34 resulting
in spreading of the tattoo or creation of significant dermal pits.
Fig. 2.11  This man has an established traumatic tattoo. The best opportunity to
prevent such an outcome is meticulous debridement at the time of injury.
Secondary treatment of traumatic tattoo is very difficult and includes dermabrasion,
excision, and laser treatments.

30
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
A
B
Fig. 2.12  A clean forehead laceration sustained in a motor vehicle crash (A)
requires nothing more than irrigation and closure (B). Several months later, a good
result can be expected (C).
C
A
B
Fig. 2.13  Initial debridement of eyebrow lacerations should be minimal. Even badly contused tissue will survive and usually lead to a result better than any graft, flap, or
hair transplantation.

31
Treatment and surgical techniques
simply retracted or folded over itself. Avulsive injuries that
remain attached by a pedicle will often survive, and the
likelihood of survival depends on the relative size of the
pedicle to the segment of tissue it must nourish. Fortunately,
the remarkably good perfusion of the face allows for survival
of avulsed parts on surprisingly small pedicles. If there is
any possibility that the avulsed tissue may survive it should
be repaired and allowed to declare itself. If venous conges-
tion develops it should be treated with medicinal leeches
until the congestion resolves. Reconstruction of a failed reat-
tachment can always be undertaken later, but a discarded
part can never be replaced.
Many avulsed and amputated parts are amenable to
replantation provided that the patient does not have underly-
ing injuries or medical conditions that would preclude a
lengthy operation. Examples of facial parts that have been
successfully replanted include scalp, nose, lip, ear, and cheek.
Vein grafts are often needed to complete the replantation, and
venous congestion is a common complication that can be
successfully managed with leeches or bleeding the part.
If tissue is truly missing such that primary repair cannot be
accomplished then a more complex repair with an interpola-
tion flap or other reconstruction may be needed. These specific
techniques for specific areas are covered elsewhere.
Secondary intention healing
Some wounds with tissue loss may be best treated by second-
ary intention healing rather than a more complex reconstruc-
tion. The advantages of secondary intention treatment are that
it is simple, it does not require an operation, the wound
contraction can work to the patient’s advantage, and in certain
situations, the cosmetic result can rival other methods of
Fig. 2.14  Complex facial laceration after
motor vehicle crash (A) that gives the
impression of significant tissue loss. Irrigation,
minimal debridement, and careful
repositioning of the tissue fragments
– “solving the jigsaw puzzle” – reveals that
most of the tissue is present and usable (B).
A
B
closure. The best cosmetic results are obtained on concave
surfaces of the Nose, Eye, Ear, and Temple (NEET areas),
whereas those on the convex surfaces of the Nose, Oral lips,
Cheeks, and chin, and Helix of the ear (NOCH areas) often
heal with a poor-quality scar. Most wounds can be dressed
with a semi-occlusive dressing or petrolatum ointment to
prevent desiccation. Common complications include pigmen-
tation changes, unstable scar, excessive granulation, pain,
dysesthesias, and wound contracture.38,39
Treatment of specific areas
Scalp
Most scalp injuries are the result of blunt force injuries sus-
tained in road crashes, assaults, and falls. Motor vehicle
crashes cause most of the avulsive injuries, while complete
avulsion of the scalp happens in industrial or farm accidents
when the hair becomes entangled around a rotating piece of
machinery.
Scalp injuries can generally be evaluated with inspection
and palpation of the scalp. One should determine if there is
underlying unrecognized skull or frontal sinus fracture by
palpation of the wound or X-ray examination.
The thickness of the skin of the scalp ranges from 3 to 8 mm
making it some of the thickest on the body.40 The galea is a
strong relatively inelastic layer that is an important structure
in repair of scalp wounds. It plays a role in protecting the
skull and pericranium from superficial subcutaneous infec-
tions, provides a strength layer when suturing, and limits
elastic deformation of the scalp, often making closure more
difficult.

32
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
The wound should be thoroughly irrigated and hemostasis
of major vessels should be completed with electrocautery or
suture ligature. All foreign material such as dirt, glass, rocks,
hair, plant matter, grease, and small bone fragments should
be removed. The wound should be explored for any previ-
ously unrecognized skull fractures. There is seldom a need for
radical debridement of the scalp due to the rich blood supply.
Surprisingly large segments of scalp can survive on relatively
small vascular pedicles and therefore it is often preferable to
preserve any scalp tissue that has even a remote probability
of survival. Shaving of the scalp in nonemergent neurosurgery
has not been shown to be of any benefit in reducing wound
infections.47–50 It is reasonable to shave sufficient hair so that
clear visualization of the injury is had. There is probably no
benefit to shaving the scalp for simple clean lacerations.
In general, scalp closure involves closure of the galea and
subcutaneous tissue to control bleeding and provide strength,
followed by skin closure. Absorbable 3-0 sutures are used for
the galea and subcutaneous tissue in either a running or an
interrupted manner. The skin can be closed with staples, or
sutures. In children, a rapidly absorbable suture is often used
to avoid the need for later removal.
Repair of the scalp will depend on the nature of the
injury, whether there is tissue loss, and the condition of the
underlying pericranium and bone. Simple cuts from sharp
objects require nothing more than simple closure. Blows to the
head from assaults, falls, and road crashes often crush the soft
tissue against the skull resulting in a jagged bursting of the
tissue. In these injuries, the initial impression may be that
there has been tissue loss, but after careful inspection, and
systematic replacement of tissue (solving the jigsaw puzzle)
it becomes apparent that very little tissue is missing. The
pieces should be reassembled and any areas of dubious sur-
vival should be given time to declare themselves. They often
will survive.
Defects of 3 cm or less in diameter can usually be closed
with wide undermining of the scalp at the subgaleal level.51
The scalp is notoriously inelastic and will often require scoring
The subgaleal fascia is a thin loose areolar connective tissue
that lies between the galea and the pericranium and allows
scalp mobility. The emissary veins cross this space as they
drain the scalp into the intracranial venous sinuses. This is a
potential site of ingress for bacteria contained within a subga-
leal abscess leading to meningitis or septic venous sinus
thrombosis although the incidence is very low.41–44
The treatment of other life-threatening injuries will take
precedence over the scalp with the exception of bleeding. The
adventitia of scalp arteries is intimately attached to the sur-
rounding dense connective tissue so that the cut ends of
vessels do not collapse and tend to remain patent and bleed-
ing. This coupled with the rich blood supply can make the
scalp a source of significant and ongoing blood loss.45 A pres-
sure dressing or rapid mass closure will provide time for
treatment of other more urgent injuries with deferred treat-
ment of the scalp up to 24 h later.
Closed scalp injuries such as abrasions and contusions will
heal without surgical intervention. Small scalp hematomas
are common and do not need to be evacuated acutely. Large
hematomas may benefit from evacuation after bleeding has
stopped from tamponade and the patient is otherwise stabi-
lized. Large undrained hematomas have the potential to
organize into a fibrotic or calcified mass. This is of minimal
consequence in the hair-bearing scalp, but may be a cosmetic
deformity on the forehead.
Full-thickness scalp wounds with tissue loss may be treated
with nonsurgical management as a bridge to later reconstruc-
tion. The bone or periosteum must be kept moist at all times,
if there is to be any growth of granulation tissue over it or
secondary intention healing. If the bone becomes desiccated,
it will die. Once a bed of granulation tissue has formed, a skin
graft may be applied, or allowed to epithelize from the
margins of the wound. Often secondary intention healing will
contract the wound such that later excision of the scar and
associated alopecia will be easily achieved (Fig. 2.15). Some
have advocated a purse-string around the wound to expedite
closure of the scalp wound.46
Fig. 2.15  A dog bite scalp avulsion with intact pericranium in a child (A). After 1 month of secondary intention healing with bacitracin ointment and petrolatum gauze
dressings the wound has contracted and epithelized markedly (B). Several months later the wound was fully epithelized, and a simple scar excision and primary closure
achieved a good cosmetic result (C).
A
B
C

33
Treatment and surgical techniques
of the galea with multiple incisions perpendicular to the
desired direction of stretch. This is best done with electrocau-
tery on low power or a scalpel. Care should be taken to only
cut through the galea leaving the subcutaneous tissue and
vessels within unharmed (Fig. 2.16). Scalp defects too large
for primary closure may be dressed with a damp dressing and
closed with other standard scalp reconstruction techniques as
described elsewhere in this volume.
Total scalp avulsion is best treated with microsurgical
replantation whenever possible (Figs. 2.17, 2.18). Avulsion
injuries are most commonly caused when long hair becomes
entangled around a rotating piece of industrial or agricultural
machinery. The scalp detaches at the subgaleal plane with the
skin tearing at the supraorbital, temporal, and auricular areas.
Many authors have reported excellent results with scalp
replantation, even when only one vein and artery were avail-
able for revascularization.52–74 The scalp will tolerate up to
18 h of cold ischemia. Because the injuries are usually avulsive
in nature, the veins and arteries needed for replantation have
sustained significant intimal stretch injury. Because of this,
vein grafts are frequently needed to bridge the zone of injury.
Blood loss can be significant and blood transfusion is common.
If possible, the venous anastomoses should be completed
before the arteries to minimize unnecessary blood loss.61 The
scalp can survive on a single vessel, however other vessels
should be repaired if possible.
Eyebrows
The eyebrows are nimble structures that are an important cos-
metic part of the face and serve as nonverbal organs of com-
munication and facial expression.75–78 Several notable anatomic
considerations are important in the treatment of soft tissue
injuries in this area. The most conspicuous aspect of the
eyebrow is the pattern and direction of the associated hair fol-
licles. The hair bulbs of the eyebrows extend deeply into the
subcutaneous fat, placing them at risk if undermining is under-
taken too superficially. The hairs grow from an inferior medial
to superior lateral direction; therefore, incision placed along
the inferior aspect of the brow may inadvertently transect hair
bulbs lying inferior to the visual border of the brow. Any inci-
sion in the brow should be beveled along an axis parallel to the
hair shafts to avoid injury to the hair bulbs or shafts.
Lacerations of the lateral brow area are common and place
the temporal branch of the facial nerve at risk. The administra-
tion of local anesthetics will cause loss of temporal nerve
function and mimic a nerve injury, and therefore temporal
branch injury should be tested before the administration of
anesthetics. After adequate anesthesia and irrigation, the
underlying structures should be inspected and palpated. In
particular, the wound should be inspected for possible frontal
sinus fracture, orbital rim fractures, and foreign bodies.
Reconstruction of the brow is difficult because the short
thick hair of the brows and the unique orientation of the hair
shafts are nearly impossible to accurately reproduce. There-
fore, every effort should be made to preserve and repair the
existing brow tissue with as little distortion as possible. After
testing the integrity of the frontal branch of the facial nerve,
local infiltration with local anesthetic will provide good
anesthesia in most cases. Despite the fact that generations of
medical students have heard that the brow should never be
shaved for fear that it will not grow back, there is no scientific
evidence to support this belief.79 It is rarely necessary to shave
the brow, and in fact shaving the brow may make proper
alignment of the eyebrow repair more difficult. If the brow
prevents proper visualization, it may be lightly clipped.
After irrigation, the underlying structures should be
inspected and palpated. In particular, the wound should be
inspected for possible frontal sinus fracture, orbital rim frac-
tures, and foreign bodies. Debridement of the wound should
be very conservative. Any tissue that has a potential to survive
should be carefully sutured into position. If clearly nonvital
tissue must be removed then the incision should be created
parallel to the hair shafts to minimize damage to the underly-
ing hair follicles. The closure should not be excessively tight,
as constricting sutures may damage hair follicles and cause
brow alopecia (see Fig. 2.13).
Most brow wounds are simple lacerations, and as such may
be simply closed by approximating the underlying muscular
layer with fine resorbable suture and the skin with 5-0 or 6-0
nylon. Areas of full-thickness brow loss (up to 1 cm) with little
or no injury to the surrounding area can be repaired primarily
with a number of local advancement flaps including a Burow’s
wedge advancement flap,80 double-advancement flap,81 and
O-to-Z repair (Fig. 2.19).82 Primary closure of larger defects
may distort the remainder of the brow excessively. The medial
half of the brow is thicker and cosmetically more prominent,
and therefore the illusion of symmetry is easier to preserve if
the medial brow position is not disturbed. For this reason, it
is generally better to advance the lateral brow medially to
accommodate closure.80 Small areas of tissue loss not ame-
nable to primary closure should be allowed to heal by second-
ary intention. The resulting scar or deformity can be revised
6–12 months after the injury when the tissues have softened.
Wound contracture and the passage of time may allow for
local flap reconstruction that was impossible initially. Larger
defects may need to be reconstructed with a variety of scalp
pedicle flaps83–91 or individual hair follicle transplants.92,93
Local flap
A variety of local brow advancement flaps have been described
for brow reconstruction of smaller defects. The cosmetic focus
of the brow is in its medial half where the hair growth is
thickest. When possible, it is usually preferable to advance the
lateral brow medially, rather than advance the medial brow
laterally, to close a defect. This is most important for defects
of the medial brow. A Burow’s wedge advancement flap is
suitable for these defects (see Fig. 2.19). When elevating the
flap to be advanced, it is important that the dissection is of
sufficient depth that the vulnerable hair follicles are not
damaged. Defects of the lateral brow can be closed by advanc-
ing tissue from both directions with two advancement flaps
(the so-called A-to-T closure), so long as there is no undue
distortion of the medial brow.
The double advancement flap method that uses two rect-
angular flaps for closure affords similar capabilities as the
Burow’s wedge rotation flap but requires four incisions (see
Fig. 2.19). It is important that the margins of the hair-bearing
skin are accurately aligned in much the same way as the
vermilion border is aligned for lip lacerations. Inaccurate
repair will result in an unsightly step-off. Both the Burow’s
wedge rotation flap and the double advancement flap closures
make alignment of the hair-bearing margin relatively easy.

34
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
Fig. 2.16  Defects of the scalp of more than 2 cm (A) will often require creation of scalp flaps (B) for closure. Scoring the galea with electrocautery (C) or a scalpel will
allow advancement of the flaps (D) and wound closure (E). It is not necessary to shave any hair as a matter of routine when repairing scalp wounds unless visualization is
impaired. The scalp tends to heal well. Sutures are removed in about 14 days (F).
A
B
C
D
E
F

Fig. 2.17  A 15-year-old girl with a total scalp
avulsion after her hair became entangled in a
machine. (A) The avulsed scalp is shown at top.
(B,C) The entire scalp, eyelids, right ear, face, and
a portion of the neck were avulsed. Multiple vein
grafts were needed for vascular anastomosis to the
superficial temporal, supraorbital and facial vessels.
Immediately after replantation (D,E) using multiple
vein grafts. The right side of the face was congested
and required leech therapy for 6 days.
A
B
C
D
E
Fig. 2.18  At 2 months after replantation of scalp, eyelids, right face and ear. An area on the posterior neck needed skin grafting.
A
B
C

36
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
Epiphora may be a tip-off for canalicular injury. A search for
concomitant globe or facial fractures should be undertaken.
Any injury to the eyelids should raise suspicion to a globe
injury. If there is any doubt about ocular injury, an ophthal-
mology consultation is needed.
Local graft
More significant brow defects will require more involved
brow reconstruction with grafts and flaps. These techniques
are discussed elsewhere.
Eyelids
Treatment of eyelid injuries is important to preserve the vital
functions of the eyelids, namely protection of the globe, pre-
vention of drying, and appearance.
The eyelids are composed of very thin skin, alveolar tissue,
orbicularis oculi muscle, tarsus, septum orbitale, tarsal (mei-
bomian) glands, and conjunctiva (Fig. 2.20). At the lid margin,
the conjunctiva meets the skin at the gray line. Embedded
within the margins of the lids are the hair follicles of the
eyelashes. The tarsal plates are dense condensations of con-
nective tissue that support and give form to the eyelids and
assist in keeping the conjunctiva in apposition to the globe. It
is important to remember that the eyelids are lamellar struc-
tures and in general each layer should be individually
repaired. A detailed discussion of eyelid anatomy can be
found elsewhere.
The eyelids should be inspected for ptosis (suggesting
levator apparatus injury) and rounding of the canthi (suggest-
ing canthus injury or NOE fracture). It may be helpful to tug
on the lid with fingers or forceps to check the integrity of the
canthi. A firm endpoint should be felt (try it on yourself).
A
B
Fig. 2.19  A Burow’s wedge triangle closure (A) favors
movement of the lateral brow medially. It affords easy
alignment of the hair-bearing margin and a broad-based
flap design. Two opposing rectangular flaps can be
advanced with the aid of Burow’s wedge triangle excisions
(B). This flap also provides easy alignment of the brow
margins but has a greater scar burden. The O-to-Z excision
(C) and closure (D) results in some distortion of the
eyebrow hair orientation.
C
D
Fig. 2.20  Lower eyelid seen in cross-section shows the lamellar nature of the
eyelids. Repair of full-thickness eyelid lacerations should include repair of the
conjunctiva, tarsal plate, and skin. The lash line or gray line should be used as an
anatomic landmark to ensure proper alignment of the lid margin during repair.
Gray line
Tarsal plate
Orbicularis muscle
Orbital septum
Fat pad
Arcus marginale
Inferior
oblique muscle
Inferior
rectus muscle

37
Treatment and surgical techniques
larger lacerations should be repaired with 5-0 or 6-0 gut
suture. The tarsal plate should be repaired with a 5-0 absorb-
able suture and the skin with 6-0 nylon.
Lacerations that involve the lid margin require careful
closure to avoid lid notching and misalignment. The technique
involves placement of several “key sutures” of 6-0 nylon at
the lid margin to align the gray line and lash line. These
sutures are not initially tied but used as traction and align-
ment sutures. The conjunctiva and tarsal plate are repaired,
and then the “key sutures” may be tied. The sutures are left
long. Subsequent skin sutures are placed starting near the lid
margin and working away. As each subsequent suture is
placed and tied, long ends of the sutures nearer the lid margin
are tied under the subsequent sutures to prevent the loose
ends from migrating towards the eye and irritating the cornea
(Fig. 2.22). Avulsive injuries to the lids that involve only skin
may be treated with full-thickness skin grafts from the post-
auricular region or contralateral upper eyelid. Lid switch
pennant flaps are also an option. Injuries that involve full
thickness loss of 25% of the lid may be debrided and closed
primarily as any other full thickness laceration.95 Loss of more
than 25% of the lid will require more involved eyelid recon-
struction covered in other chapters.
Any laceration to the medial third of the eyelids should
raise suspicion for a canalicular injury (Fig. 2.23). The cana-
liculus is a white tubular structure that is more easily seen
with ×3 loop magnification. If the proximal end of the cana-
liculus cannot be found, a lacrimal probe may be inserted into
the puncta and passed distally out the cut end of the canalicu-
lus. It is important to remember that the canaliculus travels
perpendicular to the lid margin for 2 mm and then turns
medially to parallel the lid margin.
The distal end of the inferior canaliculus may be located by
placing a pool of saline in the eye while instilling air into the
other (intact) canaliculus. Bubbles will reveal the location of
the distal canalicular stump. Avoid instilling methylene blue
or other tissue dye as it will color all the tissue blue and limit
your ability to distinguish the canaliculus from the surround-
ing tissue. Once identified, the canaliculus is repaired over a
small double-ended silastic or polyethylene lacrimal stent
with 8-0 absorbable sutures. The stent is left in place for 2–3
months. Unless the physician has specific experience with this
procedure, a consultation with ophthalmology is indicated.
Most patients with one intact canaliculus will not experience
epiphora;96,97 however, if repair can be accomplished at the
time of injury without jeopardizing the intact canaliculus,
most authors would repair it. Good results are generally had
with repair over a stent.98,99
Ears
Traumatic ear injuries may result from mechanical trauma
such as motor vehicle crashes, boxing, wrestling, sports,
industrial accidents, ear piercing, and animal or human bites.
Thermal burns to the ear are seen in over 90% of patients with
other head and neck burns.100 The ears are at particular risk
because they are thin and are exposed on two sides.
Anatomy
The skin of the anterior ear is tightly adherent to the underly-
ing auricular fibrocartilage that gives shape to the external ear.
The posterior skin is somewhat thicker and more mobile. The
In general, nonsurgical treatment of eyelid injuries or
neighboring areas with tissue loss is not advisable because the
natural contraction of secondary intention healing may distort
the lid and result in lagophthalmos, ectropion, or distortion
of the lid architecture (Fig. 2.21). Nonetheless, some wounds
are amenable to nonsurgical treatment,38,39,94 in particular
wounds of the medial canthal area that do not involve the lid
margin nor lacrimal apparatus tend to do well especially in
the elderly, who have greater intrinsic laxity of the skin. In
most cases secondary intention nonsurgical treatment should
be reserved for those cases where primary closure is not pos-
sible due to tissue loss, or where secondary intention healing
is preferable to skin grafting or other reconstruction.
Simple lacerations of the eyelid that do not involve the lid
margin or deeper structures may be minimally debrided and
closed primarily. The eyelid is a layered structure and as such,
full-thickness injuries should be repaired in layers. Usually,
repair of the conjunctiva, tarsal plate, and skin is sufficient.
Small injuries to the conjunctiva do not require closure, but
Fig. 2.21  A superficial cheek avulsion injury (A) was allowed to heal by secondary
intention (B) resulting in a cicatricial ectropion. Any injury to the eyelids or on the
upper cheek has the potential to distort the eyelid from the normal contractile
forces of healing.
A
B

38
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
as a “cauliflower ear”. Ear cartilage is dependent upon the
adjacent soft tissue for blood supply, and therefore separation
of the cartilage from the perichondrium places the cartilage at
risk for necrosis and infection.
The treatment for an ear hematoma is evacuation of the
hematoma, control of the bleeding, and pressure to prevent
an accumulation of blood and to encourage adherence of the
soft tissues to the cartilage. Simple aspiration within a few
hours of the injury may evacuate the blood, but without any
other treatment hematoma or seroma will reaccumulate.101,102
Some have advocated using a small liposuction cannula to
more effectively evacuate the hematoma.103 Aspiration with
subsequent pressure dressing has been used effectively;104,105
most authors recommend a surgical approach for more reli-
able removal of adherent fibrinous material that may delay
healing of the soft tissue to the cartilage.101,104,106–115
Surgical drainage can be accomplished with an incision
placed parallel to the antihelix and just inside of it where the
scar can be hidden. The skin and perichondrial flap is gently
elevated and a small suction used to evacuate the hematoma.
If adherent fibrinous material remains, it should be removed
with forceps. After the wound is irrigated, it should be
inspected for bleeding that may require cautery for control.
There are many different methods of pressure dressing. Some
mold saline-soaked cotton behind the ear and then mold more
cotton into the anterior contours of the ear.107 A head wrap
dressing follows this. Others have used thermoplastic splints
molded to the ear.116 The author prefers to mold Xeroform
(petrolatum jelly, bismuth tribromophenate impregnated)
A
B
C
Fig. 2.22  A full-thickness eyelid injury involves skin, tarsal plate, and conjunctiva
(A). Repair starts with the conjunctiva and tarsal plate (B); a “key” suture is placed
at the lash line to align the eyelid margin and prevent an unsightly step-off (C). The
repair progresses from the lid margin outward. The ends of each suture are left
long, such that they are captured under the subsequent sutures (D and inset). This
prevents the loose suture ends from migrating up and irritating the eye.
D
anterior surface is rich in topography, while the posterior
surface is simple. As with most other areas of the face, the
blood supply is rich.
A clinical examination is generally all that is required to
diagnose and treat ear trauma. The pinna should be examined
to determine if there has been any tissue loss or injury to the
auricular cartilage. After blunt trauma or surgical procedure,
patients may develop an auricular hematoma, which is an
accumulation of blood under the perichondrium that can take
several hours to develop. This presents as a painful swelling
that obliterates the normal contours of the surface of the ear
(see Fig. 2.2).
The goal of treatment is to restore cosmetic appearance of
the ear, to maintain a superior auricular sulcus that can
accommodate eyeglasses, and to minimize later complications
from infection or fibrosis.
Hematoma
The most common complication of blunt trauma to the ear
is the development of an auricular hematoma. Blunt trauma
may cause a shearing force that separates the cartilage from
the overlying soft tissue and perichondrium. Inevitably there
is bleeding into the space that further separates the cartilage
and perichondrium. The clinical appearance is of a convex ear
with loss of the normal contours (see Fig. 2.2). If left untreated
the blood will clot and eventually develop into a fibrotic mass
that obliterates the normal ear topography. Over time (and
with repeated injury), the fibrotic mass may develop into a
calcified bumpy irregular mass leading to what is known

39
Treatment and surgical techniques
gauze into the ear contours and secure the bolsters with
several 3-0 nylon through-and-through mattress sutures (Fig.
2.24). A head wrap dressing is applied and the sutures and
bolsters are removed in 1 week.
Lacerations
Simple lacerations should be irrigated and minimally
debrided. Like other areas of the face, the blood supply of the
ear is robust and will support large portions of the ear on small
pedicles (Fig. 2.25). The cartilage is dependent on the peri-
chondrium and soft tissue for its blood supply; as long as one
surface of the cartilage is in contact with viable tissue, it should
survive. Known landmarks such as the helical rim or antihelix
should be approximated with a few “key” sutures. The
remainder of the repair is accomplished with 5-0 or 6-0 nylon
skin sutures.112 It is important that the closure be accurate with
slight eversion of the wound edges, using vertical mattress
sutures if needed. Any inversion will persist after healing and
result in unsightly grooves across the ear.117 It is usually not
necessary to place sutures in the cartilage, and most authors
prefer to rely on the soft tissue repair alone.107,114,118–122 There is
some concern that suturing the cartilage is detrimental,123
Fig. 2.23  A lower lid laceration involving the medial third of the lid (A). A lacrimal
probe is passed through the inferior puncta to identify the proximal end of the
canaliculus (B). The canaliculus was repaired over a silastic stent after locating the
distal canalicular duct, and the lid repaired in layers (C).
A
B
C
Fig. 2.24  After evacuation of an auricular hematoma, a through-and-through
tie-over bolster should be molded and secured to the ear to prevent reaccumulation
of the hematoma.

40
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
epithelize.114,123,136,140–142 These techniques are simple and
provide a period of nutritive support until the wound heals
and the ear becomes self-sustaining. It further maintains the
delicate relationship between cartilage and dermis, so impor-
tant in maintaining the subtle folds and architecture that give
an ear its shape.
Some authors have recommended similar techniques that
remove the entire dermis and then cover denuded cartilage
under retroauricular skin,143 under a cervical flap,144 or with a
tunnel procedure.145,146 Others have used a temporoparietal
fascial flap to cover the denuded cartilage and then cover
the temporoparietal fascial flap with a skin graft.147 Another
method involves removing the posterior skin from the avulsed
part and fenestrating the remaining cartilage in several areas
and then surfacing the posterior part with a mastoid skin
flap.148 The idea behind the cartilage fenestrations is to allow
vascular ingrowth from the posterior to the anterior surface
and increase the likelihood of survival. One criticism of all of
the methods that attempt to cover denuded cartilage is that
the subtle architecture of the ears is often lost, resulting in a
distorted thick formless disk.149
Complete amputation of all or part of the ear with the
amputated part available
Amputated ear parts are difficult to reconstruct, and the larger
the defect the more challenging and time consuming the
reconstruction. Reattaching amputated facial parts as com-
posite grafts has a long history dating back to at least 1551.150
Contemporary reports describe occasional successes and
many failures.125,136,148–152 A good outcome after simple reat-
tachment of a composite graft is probably the exception rather
than the rule. The final outcome is often marred by scar,
hyperpigmentation, partial loss, and deformity.114 Spira and
Hardy153 stated, “if the amputated portion consists of anything
more than the lobe or segment of helix, replacement is invari-
ably doomed”.
In an effort to salvage the cartilage, many authors have
advocated burying the cartilage in a subcutaneous pocket in
the abdomen153–156 or under a postauricular flap.143 Mladick
improved upon these techniques by dermabrading the skin,
rather than removing it, prior to placement in a subcutaneous
leading to necrosis and increased risk of infection. If cartilage
must be sutured, an absorbable 5-0 suture is best.124
There are no good data regarding the use of postoperative
antibiotics following repair of ear lacerations; however, many
authors recommend a period of prophylactic antibiotics to
prevent suppurative chondritis, especially for larger injuries
or those with degloved or poorly perfused cartilage.125–131
There is no role for postoperative antibiotics after repair of
simple lacerations of the ear.
Auditory canal stenosis
When an injury involves the external auditory canal, scarring
and contracture may result in stenosis or occlusion of the
canal. Canal injuries should be stented to prevent stenosis.114
If a portion of the canal skin is avulsed out of the bony canal
it may be repositioned and stented into place as a full-thickness
skin graft.
Partial amputation with a wide pedicle
Fig. 2.25 demonstrates a partial amputation with a wide
pedicle relative to the amputated part. Because the pedicle is
relatively large it should provide adequate perfusion and
venous drainage of the part. The prognosis is excellent after
conservative debridement and meticulous repair. Because
there is no way to quantitatively assess for the adequacy of
venous drainage the ear should be observed over the first
4–6 h for any signs of venous congestion if there is any sus-
picion that it may not be adequate. If venous congestion
develops, leech therapy should be instituted.
If the pedicle is very narrow with inadequate or no perfu-
sion, the avulsed part should be treated like a complete
amputation (see below) or the perfusion should be augmented
with local flaps.121,132–139 Many varieties of local or regional
flaps have been devised for ear salvage, and all rely on
opposing the flap to dermabraded dermis or denuded
cartilage. Some have advocated elevating a mastoid skin flap
and applying the flap to a dermabraded portion on the
lateral135 or medial121 surface of the avulsed ear, while others
have dermabraded the avulsed part and placed it into a
subcutaneous retroauricular pocket. In 2–4 weeks, the ear is
removed from the pocket and allowed to spontaneously
Fig. 2.25  An upper ear laceration from a motor vehicle crash (A) is attached by a posterior skin bridge (B,C). The upper auricle survived on this pedicle because of the
generous blood supply of the ear. The helical rim was sutured first for alignment and the remainder of the skin closed with 6-0 nylon (D).
A
B
C
D

41
Treatment and surgical techniques
incidence of orbital injuries following major midfacial frac-
tures has been reported to be as high as 59%.161
The goal is to restore normal nasal appearance without
subsequent nasal obstruction. Less complex nasal injuries can
be managed with local anesthesia, while major nasal injuries
are best managed with general anesthesia. Laceration of the
nose should be repaired primarily when possible. Smaller
avulsive injuries of the cephalic third of the nose may be
allowed to heal by secondary intention because of the mobil-
ity and laxity of the overlying skin in this area. Avulsive
injuries to the remainder of the nose, if allowed to heal by
secondary intention, will cause distortion of the nasal archi-
tecture due to contractile forces during healing.94
Abrasions
Nasal abrasions tend to heal rapidly and well due to the rich
vascular supply and abundance of skin appendages that allow
for rapid epithelization. The skin of the caudal half of the nose
is rich in skin appendages that allow for rapid epithelization.
Traumatic tattooing is not uncommon after nasal abrasions.
Meticulous cleaning of the wound with pulse lavage, loop
magnification to remove embedded particles, and very con-
servative debridement are needed. Occasionally, one is faced
with the difficult decision to debride further, thereby creating
a full-thickness wound, or leaving some embedded material
within the dermis. In general, when faced with such a decision
it is best to stop the debridement and proceed with excision
and reconstruction later, if needed, for cosmesis.
A septal hematoma should be evacuated to prevent subse-
quent infection and septic necrosis of the septum, or organi-
zation of the clot into a calcified subperichondrial fibrotic
mass. If a clot has yet to form within the hematoma, it is
possible to aspirate with a large bore needle. Evacuation that
is more reliable can be achieved with a small septal incision
in the mucosa of the hematoma. The blood and clot is
evacuated with a small suction, and a through-and-through
running 4-0 chromic gut quilting suture is placed across the
septum to close the dead space and prevent reaccumulation
of the blood.
Lacerations
In general, the repair of nasal trauma should begin with the
nasal lining and then proceed from the inside out, repairing
in turn lining, framework, and finally skin.
Lining
The lining of the nose should be repaired with thin absorbable
sutures such as 5-0 gut sutures. Because of the confined
working space, a needle with a small radius of curvature will
facilitate placement of the sutures. The knots should be placed
facing into the nasal cavity. Small areas of exposed septal car-
tilage associated with septal fractures or mucosal lacerations
will not pose a significant problem as long as intact mucosa is
present on the other side. If lining is missing from both sides a
mucosal flap should be created to cover at least one side.
Framework
Fractures of the septum should be reduced, and if the septum
has become subluxed off the maxillary ridge, it should be
reduced back towards the midline. Lacerations of the upper
or lower lateral cartilages should be repaired anatomically if
pocket.123,142,157,158 This has the advantage of preserving the
intimate and delicate relationship between the dermis and
cartilage that is so important for maintaining the subtle archi-
tecture of the ear.
Microsurgical replantation should be considered whenever
feasible for patients who do not have concomitant trauma or
medical conditions that would preclude a lengthy operation.
The ear has fairly low metabolic demands and, as such, will
tolerate prolonged periods of ischemia, with successful
replantation reported after 33 hours of cold ischemia time.159
After sharp injuries, the branches from the superficial tempo-
ral artery or posterior auricular artery may be identifiable and
repairable. In some cases, a leash of superficial temporal
artery may be brought down to the ear. In a similar manner,
veins may be repaired primarily or with vein grafts. Nerves
may be repaired if they can be identified; surprisingly,
however, a number of replanted ears without any nerve repair
are reported to have had good sensation.160 A protective dress-
ing is placed that will allow for clinical monitoring for arterial
or venous compromise.
Nose
The prominent position of the nose on the face places it at risk
for frequent trauma. Many injuries result in nasal fractures
without any soft tissue involvement. Failure to treat nasal
injuries appropriately at the time of injury may result in dis-
torted appearance or nasal obstruction, whether due to loss
of tissue, scarring, or misalignment of normal structures.
The nose is a layered structure that in simple terms can be
thought of as an outer soft tissue envelope composed of skin,
subcutaneous fat, and nasal muscles; a support structure
composed of cartilage and bone to give the envelope shape;
and an internal mucosal lining that filters particulates, and
exchanges heat and moisture.
When examining the nose, the three primary components
(external covering, support structures, and lining) should be
considered. The external soft tissue envelope can be quickly
assessed for lacerations or tissue loss. The support structures
of the nose can be assessed by observation for asymmetry or
deviation of the nasal dorsum. Fractures can usually be
ascertained with palpation for bony step-off or crepitus. Sig-
nificant nasal fractures are usually evident from clinical exam;
X-rays rarely add significant information. If the lacerations
are present, they will provide a window to the underlying
structures of the nose. After adequate anesthesia and irriga-
tion, any open wounds should be inspected for evidence of
lacerations or fractures of the upper lateral or lower lateral
cartilages.
Examination of the internal nose requires a nasal speculum,
good lighting, and suction if there is active bleeding. The
mucosa should be examined for any evidence of septal hema-
toma, mucosal laceration, or exposed or fractured septal carti-
lage. Septal hematoma will appear as a fusiform bluish boggy
swelling of the septal mucosa. After adequate anesthesia and
irrigation, the full nature of the injury to the support frame-
work of the nose and lining can be appreciated.
Nasal fractures are common and should be suspected after
blunt nasal trauma. Plain radiographs rarely add significant
information to a thorough clinical exam in most isolated nasal
injuries. If there is any suspicion of other facial fractures, or
paranasal structures, a facial CT scan should be acquired. The

42
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
skin, but may involve portions of the underlying cartilage.
One is frequently faced with the decision to proceed with
nasal reconstruction with a local flap or temporary coverage
with a skin graft. Smaller defects of the cephalic portion of
the dorsum and sidewalls will heal by secondary intention
without significant distortion of the anatomy. The skin of
the caudal dorsum, tip, and ala is adherent and less mobile
and will often defy primary closure. Secondary intention
healing will result in contraction and distortion of the nasal
anatomy and are best treated with a retroauricular skin graft
(Fig. 2.26). Retroauricular full-thickness skin grafts have excel-
lent color and texture match. The healed skin graft limits most
wound contraction. If secondary reconstruction is needed, the
skin graft can be excised and a local flap reconstruction can
be performed later.
Amputation
Small, amputated parts can be reattached as a composite
graft;163,164 however, some authors warn of the risk of poor
outcome and infection after reattachment of bite amputa-
tions.162,165 Davis and Shaheen166 have reported up to 50%
failure of composite grafts, even under ideal conditions. They
recommend that composite graft be attempted only when the
wound edges are cleanly cut; there is little risk of infection;
the repair is not delayed; no part of the graft is more than
0.5 cm from viable cut edge of the wound; and when all bleed-
ing is controlled. Others have advocated hyperbaric oxygen
they are structurally significant. Usually 5-0 absorbable or
clear nonabsorbable sutures should be used. Displaced bony
fragments within the wound should be repositioned anatomi-
cally or removed if not needed to maintain the structure or
shape of the nose. If loss of important support structures has
occurred, then reconstruction of the nasal support must be
undertaken within a few days. Delay will result in contraction
and collapse of the soft tissues of the nose. Later, reconstruc-
tion is almost impossible. Reconstruction of this type will
usually involve bone or cartilage grafts. If there is doubt about
the viability of lining or coverage over the area where grafted
cartilage or bone will be placed, then reconstruction should
be delayed for a few days until the survival of the soft tissue
coverage is no longer in doubt or secondary soft tissue recon-
struction can be accomplished.
Skin covering
After repair of the lining and framework, the skin of the nose
can be repaired. Key sutures should be placed at the nasal rim
to ensure proper alignment prior to the remainder of the
closure with 6-0 nylon sutures. The mobile skin of the cephalic
nose is forgiving and can be undermined and mobilized to
close small avulsive wounds.162
Avulsions
Avulsive injuries are frequently the result of automobile
crashes and animal or human bites. They usually involve only
Fig. 2.26  A full-thickness dog bite avulsion injury to the nose (A) was treated with a full-thickness retro-auricular skin graft (B). (C) At 6 weeks after grafting. (D) At 2
years later there is good contour and color match (D).
A
B
C
D

43
Treatment and surgical techniques
administration of local anesthetics. Some patients will exhibit
asymmetry in facial movement, simply due to pain and edema
not related to any underlying facial nerve injury.
If parotid duct injury is suspected, a 22-gauge catheter may
be inserted into Stensen’s duct and a small quantity of saline
solution can be injected. This can be facilitated with a lacrimal
probe; however, care must be taken not to injure the duct with
overzealous probing. If egress of the fluid from the wound is
noted, the diagnosis of parotid duct injury has been made.
Repair of parotid duct
Laceration to the parotid gland without duct injury may result
in a sialocele but will rarely cause any long-term problems. If
a gland injury is suspected, the overlying soft tissue should
be repaired and a drain left in place. If a sialocele develops,
serial aspirations and a pressure dressing should be sufficient
(Fig. 2.27).
Facial nerve injury
Facial nerve injuries should be primarily repaired. Surgical
exploration and ×3 magnification with good lighting and
hemostasis will assist in locating the cut ends of the nerve.
Wounds with contused, stellate lacerations will provide
greater challenges to finding the nerve ends. A nerve stimula-
tor can be used to locate the distal nerve segments if within
48 hours of injury. After 48 hours, the distal nerve segments
will no longer conduct an impulse to the involved facial
musculature rendering the simulator useless. If the proximal
ends of the facial nerves cannot be located, the uninjured
proximal nerve trunk can be located and followed distally to
the cut end of the nerve. The nerves should be repaired pri-
marily with 9-0 nylon. If primary repair is not possible, nerve
grafts should be placed, or the proximal and distal nerve ends
should be tagged with nonabsorbable suture for easy location
during later repair.
Mouth and oral cavity
The lips are the predominant feature of the lower third of the
face and are important for oral competence, articulation,
expression of emotion, kissing, sucking, playing of various
therapy163 or cooling167 to improve tissue survival. Microsurgi-
cal replantation may be possible with larger amputated nasal
segments168 or nose and lip composite replantation.169
Cheek
When repairing lacerations of the cheek, the primary concern
is for injury to the underlying structures, namely facial nerve,
facial muscles, parotid duct, and bone.
The blood supply of the cheek is derived primarily from
the transverse facial and superficial temporal arteries. Gener-
ous collaterals and robust dermal plexus provide reliable
perfusion after injury and reconstruction.
The facial nerve exits the stylomastoid foramen. It divides
into five main branches within the substance of the parotid
gland. The temporal and zygomatic branches run over the
zygomatic arch; the buccal branch travels over the masseter
along with the parotid duct. The mandibular branch usually
loops below the inferior border of the mandible, but rarely
more than 2 cm, and then rises above the mandibular border
anterior to the facial artery and vein.170–176 The zygomatic and
buccal branches are at particular risk from cheek lacerations.
The buccal branches usually have a number of interconnec-
tions and therefore a laceration of a single buccal branch may
not be clinically apparent.
The parotid gland is a single-lobed gland with superficial
and deep portions determined by their relation to the facial
nerve running between them. The superficial part of the gland
is lateral to the facial nerve and extends anteriorly to the
border of the masseter. The parotid duct exits the gland
anteriorly and passes over the superficial portion of the mas-
seter, penetrating the buccinator to enter the oral cavity
opposite the upper second molar. The course of the parotid
may be visualized on the external face by locating the middle-
third of a line drawn from the tragus to the middle of the
upper lip (see Fig. 2.3). The parotid duct travels adjacent to
the buccal branches of the facial nerve. If buccal branch
paralysis is noted in conjunction with a cheek laceration, then
parotid duct injury should be suspected.
Clinical examination is directed towards identifying
underlying injury to bone, facial nerve, or parotid duct. The
function of facial nerve branches should be tested prior to
Fig. 2.27  A laceration of the cheek may injure the substance of the parotid gland resulting in an accumulation of saliva under the skin or a sialocele (A,B). If recognized at
the time of injury, a drain may be left in place and a pressure dressing applied. When a sialocele presents after initial repair, serial aspirations (C) and a pressure dressing
will resolve the problem (D).
A
B
C
D

44
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
Repair of the tongue can be challenging for the patient and
physician alike. Gaining the patient’s confidence is important
if cooperation is to be had. Topical 4% lidocaine on gauze can
be applied to an area of the tongue for 5 min and will provide
some anesthesia that will allow for local infiltration of anes-
thetic or lingual nerve block. General anesthesia is frequently
needed when repairing such lacerations in children. The lac-
eration can be closed with an absorbable suture such as 4-0 or
5-0 chromic gut or polyglycolic acid.
Oral mucosa repair
The buccal mucosa can be approximated in a single layered
closure using interrupted 4-0 or 5-0 chromic gut or polygly-
colic acid sutures. Only the minimal sutures should be placed.
Occasionally, large flaps of degloved gingiva will need repair.
It can be difficult to suture these wounds because the gingiva
does not hold suture well. It can be helpful to attach these
flaps of tissue with a suture passed around a nearby tooth.178
The lips
Poorly repaired lip lacerations can cause prominent cosmetic
defects if not treated in a precise and proper manner. In par-
ticular, small misalignments of the white roll or vermilion
border are conspicuous to even the casual observer.
Anesthesia of lip wounds is best accomplished with
regional nerve blocks and minimal local infiltration. This will
prevent distension and distortion of anatomic landmarks
critical for accurate repair. An infraorbital nerve block is used
for the upper lip and a mental nerve block for the lower.
When repairing simple superficial lip lacerations involving
the vermilion border, the first suture should be placed at the
vermilion border for alignment. The remainder of the lacera-
tion is then closed with 6-0 nonabsorbable sutures. If the
laceration extends onto the moist portion of the lip, 5-0 or 6-0
gut sutures are preferred because they are softer when moist
and therefore less bothersome for the patient.
Full thickness lip lacerations are repaired in three layers
from the inside out. The oral mucosa is repaired first with
absorbable suture such as 5-0 chromic or plain gut. If the oral
mucosa and gingiva has been avulsed from the alveolus, the
soft tissue may be reattached by passing a suture from the soft
tissue around the base of a neighboring tooth. In general,
proceeding from buccal sulcus towards the lip makes the most
sense. The muscle layer is approximated with 4-0 or 5-0
absorbable suture. Failure to approximate the orbicularis oris
muscle or later dehiscence will result in an unsightly depres-
sion of the scar. It is best to include some of the fibrous tissue
surrounding the muscle for more strength when placing these
sutures. A key suture of 5-0 or 6-0 nylon is placed at the ver-
million border, and then the remainder of the external sutures
are placed.
Avulsive wounds of the lip will often survive on surpris-
ingly small pedicles. It is usually advisable to approximate
even marginally viable tissue because of the possibility of
survival (Figs. 2.28, 2.29).
Neck
The most important consideration in soft tissue injuries of the
neck is to exclude penetrating neck trauma deep to the pla-
tysma and compromise of the airway. Once those are excluded,
closure of neck wounds is generally straightforward. Because
musical instruments, and as a symbol of beauty. In addition,
the lips are important sensory organs that may provide plea-
sure and protect the oral cavity from ingestion of unacceptably
hot or cold materials. The primary function of the lips is
sphincteric, and this is accomplished by the action of the
orbicularis oris muscle. Other facial muscles are important for
facial expression and clearing the gingival sulci but are not
important in maintaining oral competence. The oral cavity
should be carefully examined for dental, dentoalveolar, oral
mucosal, tongue, and palate injuries.
Repair of the lip must provide for oral competence, adequate
mouth opening, sensation, complete skin cover, oral lining,
and the appearance of vermilion.177 The restoration of the
mental and nasolabial crease lines, philtral columns, and
precisely aligned vermilion border are important cosmetic
goals. The lip is a laminar structure composed of inner mucosal
lining and orbicularis oris muscle, and outer subcutaneous
tissue and skin. Closure of lip lacerations should consider
repair of each of these structures.
Smaller lacerations of the cheek mucosa or gingiva will
heal well without any repair. The exceptions are larger lacera-
tions (>2 cm) where food may become entrapped in the lac-
eration, and those that have a flap of tissue that falls between
the occlusal surfaces of the teeth. Small flaps of tissue that fall
between the teeth should be debrided.178
The majority of lip lacerations can be managed in the out-
patient setting after infiltration of local anesthetic with epi-
nephrine. If the laceration involves the white roll or vermilion
border, it may be useful to mark this important landmark with
a needle dipped in methylene blue prior to infiltration with
larger amounts of local anesthetic because subsequent vaso-
constriction may obscure the vermilion border.
A good rule of thumb is to work from the inside of the
mouth outwards. To this end, urgent dental or dentoalveolar
injuries should be treated first so that repaired soft tissue is
not disrupted by retraction during repair of deeper structures.
The wounds should be gently irrigated to remove any loose
particles and debris. In most cases, normal saline applied with
a 30 cc syringe and an 18-gauge angiocatheter will be suffi-
cient. If there is evidence of broken teeth, and the fragments
are not accounted for, a radiograph should be obtained to
make sure the tooth fragments are not embedded within the
soft tissues. Dead or clearly nonviable tissue should be
debrided: once again, it should be emphasized that tissue of
the face, and lips in particular, can survive on small pedicles
that would be inadequate on any other part of the body.
Fortunately, the lips have sufficient redundancy and elasticity
that loss of up to 25–30% of the lip can be closed primarily.
This also means that, unlike many other areas of the face,
more aggressive debridement may be undertaken.
The oral cavity
The tongue has a rich blood supply, and injuries to the tongue
may cause significant blood loss. In addition, subsequent
tongue swelling after larger injuries may cause oropharyngeal
obstruction. Most tongue lacerations such as those associated
with falls and seizures are small, linear, and superficial and
do not require any treatment. Larger lacerations or those that
gape open or continue to bleed should be repaired. The sub-
sequent edema of the tongue may be profound, and therefore
the sutures should be loosely approximated to allow for some
edema.

45
Treatment and surgical techniques
Fig. 2.28  An upper lip avulsion after a motor vehicle crash (A) is attached by a small lateral pedicle (B). (C) After conservative debridement the landmarks were
approximated and the wound closed. (D) An area of poor perfusion was present resulting in a small area of necrosis 4 days later. The necrotic area was allowed to heal by
secondary intention (E) and ultimately resulted in a healed wound (F).
A
B
C
D
E
F

46
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
prompt treatment of underlying injuries will minimize
complications for the patient. Meticulous cleansing of
particulate matter will spare the patient a lifetime of facial
discoloration from traumatic tattoo. Minimal debridement
will salvage irreplaceable soft tissue structures. Careful
approximation of important landmarks will minimize
unsightly visual step-offs. And careful suture technique and
timely suture removal will give your patient the best possible
cosmetic outcome.
the skin is mobile and has a fair amount of redundancy, neck
lacerations can usually be closed primarily. Remember the
course of the marginal mandibular branch deep to the platysma
just below the mandibular border during the repair.
Conclusion
The repair of facial soft tissue injuries can be very satisfy-
ing for the patient and physician alike. Recognition and
Fig. 2.29  At 3 months after repair of an avulsive lip wound (A) there is good orbicularis oris function and oral competence (B), and an acceptable cosmetic result (C,D).
A
B
C
D
4. Hussain K, Wijetunge DB, Grubnic S, Jackson IT. A comprehensive
analysis of craniofacial trauma. J Trauma. 1994;36:34–47. Craniofacial
soft tissue injuries occur most often on the forehead, nose, lips, and chin
in a “T”-shaped zone. There is significant variability in the common
causes of craniofacial trauma that can be stratified by sex and age. Falls
are the most common cause in children and the elderly. Interpersonal
violence and alcohol are associated with the majority of injuries in young
men. Sports are a common cause of injury among youth. This article is a
detailed review of craniofacial trauma patterns.
5. Zubowicz VN, Gravier M. Management of early human bites of the
hand: a prospective randomized study. Plast Reconstr Surg.
1991;88:111–114.
6. Leach J. Proper handling of soft tissue in the acute phase. Facial
Plast Surg. 2001;17:227–238. An excellent overview of basic techniques
for management of craniofacial soft tissue injuries, starting with initial
evaluation, wound preparation, and anesthetic techniques. The
management of wound contamination and steps to reduce the risk of
infection are discussed. Planning of difficult closures by respecting the
resting skin tension lines is discussed. Wound undermining and specific
suture techniques are discussed in detail.
7. Kesser BW, Chance E, Kleiner D, Young JS. Contemporary
management of penetrating neck trauma. Am Surg. 2009;75:1–10.
8. Friedman PM, Mafong EA, Friedman ES, Geronemus RG. Topical
anesthetics update: EMLA and beyond. Dermatol Surg.
2001;27:1019–1026.
9. Chen BK, Eichenfield LF. Pediatric anesthesia in dermatologic
surgery: when hand-holding is not enough. Dermatol Surg.
2001;27:1010–1018.
10. Ohlsen L, Englesson S, Evers H. An anaesthetic lidocaine/
prilocaine cream (EMLA) for epicutaneous application tested for
cutting split skin grafts. Scand J Plast Reconstr Surg. 1985;19:201–209.
11. Gupta AK, Sibbald RG. Eutectic lidocaine/prilocaine 5% cream and
patch may provide satisfactory analgesia for excisional biopsy or
curettage with electrosurgery of cutaneous lesions. A randomized,
controlled, parallel group study. J Am Acad Dermatol.
1996;35:419–423.
12. Eaton JS, Grekin RC. Regional anesthesia of the face. Dermatol Surg.
2001;27:1006–1009. Successful regional blocks for facial trauma repair can
often provide anesthesia for repair of larger facial wounds and provide
initial anesthesia for later widespread infiltration of vasoconstricting
agents. Successful regional anesthesia is based on a clear understanding of
the anatomy. This article provides a detailed guide for success.
39. Zitelli JA. Secondary intention healing: an alternative to surgical
repair. Clin Dermatol. 1984;2:92–106. This article reminds us that in
cases of tissue loss secondary intention healing may produce acceptable
outcomes in certain anatomic areas. The best cosmetic results are obtained
on concave surfaces of the nose, eye, ear, and temple (NEET areas), while
those on the convex surfaces of the nose, oral lips, cheeks and chin, and
helix of the ear (NOCH areas) often heal with a poor-quality scar. Most
wounds can be dressed with a semi-occlusive dressing or petrolatum
ointment to prevent desiccation. Common complications include
pigmentation changes, unstable scar, excessive granulation, pain,
dysesthesias, and wound contracture.
Access the complete reference list online at

46.e1
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in a “T”-shaped zone. There is significant variability in the common
causes of craniofacial trauma that can be stratified by sex and age. Falls
are the most common cause in children and the elderly. Interpersonal
violence and alcohol are associated with the majority of injuries in young
men. Sports are a common cause of injury among youth. This article is a
detailed review of craniofacial trauma patterns.
5. Zubowicz VN, Gravier M. Management of early human bites of the
hand: a prospective randomized study. Plast Reconstr Surg.
1991;88:111–114.
6. Leach J. Proper handling of soft tissue in the acute phase. Facial
Plast Surg. 2001;17:227–238. An excellent overview of basic techniques
for management of craniofacial soft tissue injuries, starting with initial
evaluation, wound preparation, and anesthetic techniques. The
management of wound contamination and steps to reduce the risk of
infection are discussed. Planning of difficult closures by respecting the
resting skin tension lines is discussed. Wound undermining and specific
suture techniques are discussed in detail.
7. Kesser BW, Chance E, Kleiner D, Young JS. Contemporary
management of penetrating neck trauma. Am Surg. 2009;75:1–10.
8. Friedman PM, Mafong EA, Friedman ES, Geronemus RG. Topical
anesthetics update: EMLA and beyond. Dermatol Surg.
2001;27:1019–1026.
9. Chen BK, Eichenfield LF. Pediatric anesthesia in dermatologic
surgery: when hand-holding is not enough. Dermatol Surg.
2001;27:1010–1018.
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prilocaine cream (EMLA) for epicutaneous application tested for
cutting split skin grafts. Scand J Plast Reconstr Surg. 1985;19:201–209.
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patch may provide satisfactory analgesia for excisional biopsy or
curettage with electrosurgery of cutaneous lesions. A randomized,
controlled, parallel group study. J Am Acad Dermatol.
1996;35:419–423.
12. Eaton JS, Grekin RC. Regional anesthesia of the face. Dermatol Surg.
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initial anesthesia for later widespread infiltration of vasoconstricting
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39. Zitelli JA. Secondary intention healing: an alternative to surgical
repair. Clin Dermatol. 1984;2:92–106. This article reminds us that in
cases of tissue loss secondary intention healing may produce acceptable
outcomes in certain anatomic areas. The best cosmetic results are obtained
on concave surfaces of the nose, eye, ear, and temple (NEET areas), while
those on the convex surfaces of the nose, oral lips, cheeks and chin, and
helix of the ear (NOCH areas) often heal with a poor-quality scar. Most
wounds can be dressed with a semi-occlusive dressing or petrolatum
ointment to prevent desiccation. Common complications include
pigmentation changes, unstable scar, excessive granulation, pain,
dysesthesias, and wound contracture.
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45. Paff G. Anatomy of the Head and Neck. Philadelphia: Saunders; 1973.

46.e2
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
46. Cruz AP, Campbell RM, Perlis CS, Dufresne RG Jr. Double
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59. Eren S, Hess J, Larkin GC. Total scalp replantation based on one
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80. Gormley DE. Use of Burow’s wedge principle for repair of wounds
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82. Hammond RE. Uses of the O-to-Z-plasty repair in dermatologic
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83. Brent B. Reconstruction of ear, eyebrow, and sideburn in the burned
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85. Juri J. Eyebrow reconstruction. Plast Reconstr Surg.
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87. Mantero R, Rossi F. Reconstruction of hemi-eyebrow with a
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88. McConnell CM, Neale HW. Eyebrow reconstruction in the burn
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89. Pensler JM, Dillon B, Parry SW. Reconstruction of the eyebrow
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90. Sloan DF, Huang TT, Larson DL, Lewis SR. Reconstruction of
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91. Sutterfield TC, Bingham HC. Reconstruction of the eyebrow and
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92. Goldman GD. Eyebrow transplantation. Dermatol Surg.
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93. Van Droogenbroeck JB. Eyebrow transplantation. Int J Lepr Other
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94. Goldwyn RM, Rueckert F. The value of healing by secondary
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1977;112:285–292.
95. Beadles KA, Lessner AM. Management of traumatic eyelid
lacerations. Semin Ophthalmol. 1994;9:145–151.
96. Canavan YM, Archer DB. Long-term review of injuries to the
lacrimal drainage apparatus. Trans Ophthalmol Soc UK.
1979;99:201–204.
97. Ortiz MA, Kraushar MF. Lacrimal drainage following repair of
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98. Dortzbach RK, Angrist RA. Silicone intubation for lacerated
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99. Shafer D, Bennett J. Associated soft tissue injuries. Atlas Oral
Maxillofac Surg Clin North Am. 1994;2:47–63.
100. Dowling JA, Foley FD, Moncrief JA. Chondritis in the burned ear.
Plast Reconstr Surg. 1968;42:115–122.
101. Butt WE. Auricular haematoma–treatment options. Aust N Z J
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102. Schuller DE, Dankle SD, Strauss RH. A technique to treat
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103. Krugman ME. Management of auricular hematomas with suction
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SECTION I • Craniofacial Trauma
3 
Facial injuries
Eduardo D. Rodriguez, Amir H. Dorafshar, and Paul N. Manson
SYNOPSIS
■ Facial injuries often involve bone and soft tissue, and each must be
managed precisely in a timely fashion.
■ Soft tissue injuries include contusions, lacerations, hematomas, and
avulsions.
■ Bone injuries are fractures, and they are classified by anatomic area
and are characterized by displacement and comminution.
■ Bone injuries are treated with open or closed reductions, and typically
rigid fixation is used for stabilization. The thick areas and edges where
bones articulate are called “buttresses”; these areas guide application
of fixation devices. Fracture stabilization is conducted through aesthetic
incisions, which provide access to buttress articulations. The
sequence of reduction and the need for exposure of a specific buttress
articulation depend upon the level of comminution, displacement, and
the presence of adjacent fractures.
■ Anatomic closure of incisions, reattaching the soft tissue to its proper
location on the bone, provides the soft tissue “reduction” necessary to
obtain aesthetic results.
■ Finally, a specific sequence of immediate injury management for both
the bone and soft tissue is necessary in ballistic or high-energy
injuries where bone and soft tissue are badly contused, avulsed and/or
missing.
Introduction
Over ten million people are injured in automobile accidents
in the US yearly.1 Statistics on the number of facial injuries
vary widely based on social, economic, and geographic dif-
ferences. The causes of facial injuries in the US include motor
vehicle collisions, assaults, altercations, bicycle and motorcycle
accidents, home and industrial accidents, domestic violence,
athletic injuries, and falls, particularly in the elderly.2 The
automobile is frequently responsible for some of the most
devastating facial injuries, and injuries to the head, face, and
cervical spine occur in over 50% of all victims.3,4 Seat belts and
airbags have reduced the severity and incidence of facial
injury, but primary and secondary enforcement of the laws
vary in effectiveness with ethnicity, education, and geographic
location.5–7
A unique aspect of facial injury treatment is that the aes-
thetic result may be the chief indication for treatment. In other
cases, injuries may require surgery to restore function, but
commonly, both goals are necessary. Although there are
few facial emergencies, the literature has underemphasized
the advantages of prompt definitive reconstruction and
early operative intervention in achieving superior aesthetic
and functional results. Economic, sociologic, and psychologic
factors in a competitive society make it imperative that an
expedient and well-planned surgical correction be executed
in order to return the patient to an active and productive life
while minimizing disability.
Access the Historical Perspective section, including
Fig. 3.1, online at

Initial assessment
Management begins with an initial physical examination and
is followed by a radiologic evaluation accomplished with
computerized tomographic (CT) scanning. CT scans visualize
soft tissue and bone.9 It is no longer feasible or economically
justifiable to obtain plain radiographs with certain exceptions,
such as the panorex mandible examination or dental films.
The availability of regional Level I and II trauma centers has
provided earlier, safer, and improved trauma care for poly-
trauma, severely injured patients.
Clinical examination of the face
A careful history and thorough clinical examination forms the
basis for the diagnosis of almost all facial injuries. Thorough

47.e1
Historical perspective
Historical perspective
In the 1980s, the application of craniofacial exposures
improved the ability to restore the pre-injury facial appear-
ance by providing access to the entire facial skeleton (Fig.
3.1). These techniques had their adverse sequela of soft tissue
and nerve damage and displacement of soft tissue position on
the facial skeleton. Current facial injury treatment minimizes
potentially morbid exposures. The techniques of extended
open reduction, immediate bone grafts, and microvascular
tissue transfer have made impossible injuries manageable.
The principle of immediate skeletal stabilization in anatomic
position has been enhanced by the use of rigid fixation. Soft
tissue position and volume over this expanded skeleton are
maintained, preventing soft tissue shrinkage, displacement,
and contracture. These techniques improve the functional
and aesthetic results of facial fracture treatment. In the last
thirty years, the improvements in automobile construction,
restraints, and traffic regulation have offered much protection
from facial injury. The use of restraints, airbags and padded
surfaces, the multi-laminated windshield, and the improved
design of rearview mirrors and steering wheels have all
reduced the frequency and severity of facial injuries.8 Over the
years, the popularity of the motorcycle still remains a factor
in the etiology of major facial trauma. At the University of
Maryland Shock Trauma Unit, the number of ballistic injuries
has increased in proportion to the increase in drug traffic. The
character of ballistic injuries has also changed over the years
from more destructive weapons to smaller caliber weapons.
Fig. 3.1  Cutaneous incisions (solid line) available for open reduction and internal
fixation of facial fractures. The conjunctival approach (dotted line) also gives access
to the orbital floor and anterior aspect of the maxilla, and exposure may be
extended by a lateral canthotomy. Intraoral incisions (dotted line) are also indicated
for the Le Fort I level of the maxilla and the anterior mandible. The lateral limb of an
upper blepharoplasty incision is preferred for isolated zygomaticofrontal suture
exposure if a coronal incision is not used. A horizontal incision directly across the
nasal radix or vertical incision along the glabellar fold is the one case in which a
local incision can be tolerated over the nose. In many instances, a coronal incision
is preferable unless the hair is short or the patient is balding.
Coronal incision
Upper
blepharoplasty
incisions
Transcon-
junctival
incisions
Intraoral
incisions
Extraoral
incisions
Peri-
auricular
incisions
Extraoral
incisions
Transcon-
junctival
incisions

48
SECTION I
CHAPTER 3 • Facial injuries
examination of the face is indicated even if the patient has
only minor wounds or abrasions.
The clinical examination should begin with the evaluation
for symmetry and deformity, inspecting the face and compar-
ing one side with the other. Palpation of all bony surfaces
follows in an orderly manner. The forehead, orbital rims, nose,
brows; zygomatic arches; malar eminence; and border of the
mandible should be evaluated (Fig. 3.2). Careful inspection of
the intra-nasal areas should be made using a nasal speculum
to detect lacerations or hematomas. A thorough inspection of
the intra-oral area should be made to detect lacerations, bleed-
ing, loose teeth, or abnormalities of the dentition (Fig. 3.3).
Palpation of the dental arches follows the inspection, noting
mobility of dental–alveolar arch segments. The maxillary and
mandibular dental arches are carefully visualized and pal-
pated to detect any irregularity of the bone, loose teeth, intra-
oral lacerations, bruising, hematoma, swelling, movement,
tenderness, or crepitus. Mobility of the midface and mandible
should be methodically assessed (Figs. 3.4 & 3.5).
A
Fig. 3.2  Palpation of the superior and inferior orbital rims. (A) The superior orbital
rims are palpated with the pads of the fingertips. (B) Palpation of the inferior orbital
rims. One should feel for discontinuity and level discrepancies in the bone of the
rim and evaluate both the anterior and vertical position of the inferior orbital rims,
comparing the prominence of the malar eminence of the two sides of the face.
B
Fig. 3.3  An intraoral examination demonstrates a fracture, a gingival laceration,
and a gap in the dentition. These alveolar and gingival lacerations sometimes
extend along the floor or roof of the mouth for a considerable distance.
Fig. 3.4  Condylar examination. The mandible is grasped with one hand, and the
condyle area is bimanually palpated with one finger in the ear canal and one finger
over the head of the condyle. Abnormal movement, or crepitation, indicates a
condylar fracture. In the absence of a condylar fracture, a noncrepitant movement of
the condylar head should occur synchronously with the anterior mandible.
Disruption of the ligaments of the condyle will permit dislocations of the condylar
head out of the fossa in the absence of fracture.
Fig. 3.5  With the head securely grasped, the midface is assessed for movement
by grasping the dentition. Loose teeth, dentures, or bridgework should not be
confused with mobility of the maxilla. Le Fort fractures demonstrate, as a rule, less
mobility if they exist as large fragments, and especially if they are a “single
fragment”, than do lower Le Fort fractures. More comminuted Le Fort fractures
demonstrate extreme mobility (“loose” maxillary fractures).

49
Upper facial fractures
Upper facial fractures
Frontal bone and sinus injury patterns
The frontal sinuses are paired structures that have only an
ethmoidal anlage at birth. They have no frontal bone compo-
nent initially. They begin to be detected at 3 years of age, but
significant pneumatic expansion does not begin to occur until
approximately age 7 years. The full development of the frontal
sinuses is complete by the age of 18 to 20. The frontal sinuses
are lined with respiratory epithelium, which consists of a cili-
ated membrane with mucus secreting glands. A blanket of
mucin is essential for normal function, and the cilia beat this
mucin in the direction of the nasofrontal outflow tracts
(NFOT). The exact function of the paranasal sinuses is still
unclear. When injured and obstructed, they serve as a focus
for infection, especially when NFOT function is impaired. The
nature of the open frontal sinuses and the multiple layers of
the skull protect the intracranial contents from injury by
absorbing energy.
The predominant form of frontal sinus injury is fracture.
Fracture involvement of the frontal sinus has been estimated
to occur in 2% to 12% of all cranial fractures, and severe
fractures occur in 0.7% to 2% of patients with cranial or
cerebral trauma.
Approximately one-third of fractures involve the anterior
table alone, and 60% involve the anterior table and posterior
table and/or ducts. The remainder (7%) involve the posterior
wall alone. Some 40% of frontal sinus fractures have an
accompanying dural laceration.
Clinical examination
Lacerations, bruises, hematomas, and contusions constitute
the most frequent signs of frontal bone or sinus fractures. The
“spectacle hematoma” is a sign of an anterior cranial base
fracture, and frontal sinus and skull fractures must be sus-
pected if any of these signs are present. Anesthesia of the
supraorbital nerve may be present. Cerebrospinal fluid rhi-
norrhea may occur. There may or may not be subconjunctival
or periorbital ecchymoses with or without air in the orbit or
intracranial cavity. In some cases, a depression may be
observed over the frontal sinus, but swelling is usually pre-
dominant in the first few days after the injury, which may
obscure the depression.
Small fractures of the frontal sinus may be difficult to
detect, especially if they are nondisplaced. Therefore, the first
presentation of a frontal sinus fracture may be an infection
or symptom of frontal sinus obstruction, such as mucocele
or abscess formation.17 Infection in the frontal sinus may
produce quite serious complications because of its location
near the brain and meninges. Infections include meningitis,
extradural or intradural abscess, intracranial abscess, osteo-
myelitis of the frontal bone, or osteitis in devitalized bone
fragments.18–22
Nasofrontal outflow tract
The development of a frontal sinus mucocele is linked to
obstruction of the NFOT, which is involved with fractures in
up to 50% of cases of frontal sinus injury. The NFOT passes
An evaluation of sensory and motor nerve function in the
facial area is performed. The presence of hypesthesia or
anesthesia in the distribution of the supraorbital, infraorbital,
or mental nerves suggests a fracture along the bony path of
these sensory nerves (cranial nerve V). Cutaneous branches
of these nerves may also have been interrupted by a facial
laceration.
Extraocular movements (cranial nerves III, IV, and VI)
and the muscles of facial expression (cranial nerve VII)
are examined in the conscious, cooperative patient. Pupil-
lary size and symmetry, speed of pupillary reaction, globe
turgor, globe excursion, eyelid excursion, double vision,
and visual acuity and visual loss are noted. A funduscopic
examination and measurements of globe pressure should be
performed. The presence of a hyphema, corneal abrasion,
visual field defect, visual loss, diplopia, decreased vision, or
absent vision should be noted and appropriate consultation
requested.
Computerized tomographic scans
The definitive radiographic evaluation is the craniofacial CT
scan with axial, coronal, and sagittal sections of bone and soft
tissue windows.10,11 CT evaluation of the face can define bone
fractures, whereas the soft tissue views allow for soft tissue
definition of the area of the fracture. 3D CT scans12 allow for
comparison of symmetry and volume of the facial bones
bilaterally. Specialized views, such as those of the orbital apex,
provide a special magnified visualization.
Timing of treatment
Timing is important in optimizing the management of facial
injuries. Bone and soft tissue injuries in the facial area should
be managed as soon as the patient’s general condition permits.
Time and time again it has been the authors’ impression that
early facial injury management decreases permanent facial
disfigurement and limits serious functional disturbances.13,14
This does not mean that one can be cavalier about deciding
who might tolerate early operative intervention. Indeed, the
facial surgeon must have a complete knowledge of the
patient’s ancillary injuries as well as those of the face. Classi-
cally, facial soft tissue and bone injuries are not acute surgical
emergencies, but both the ease of obtaining a good result and
the quality of the result are better with early or immediate
management. Less soft tissue stripping is required, bones are
more easily replaced into their anatomic position, and easier
fracture repairs are performed. There are some patients,
however, whose injuries cannot be definitively managed
early. Exceptions to acute treatment include patients with
ongoing or significant blood loss (i.e. pelvic fractures), elevated
intracranial pressures, coagulation problems, and abnormal
pulmonary ventilation pressures.15 Under local anesthesia,
however, lacerations are debrided and closed, interdental fixa-
tion applied, and grossly displaced fractures reduced. Many
patients with mild brain injuries or multi-system traumas do
not have criteria preventing operative management.16 These
patients may receive facial injury management at the time that
other injuries are being stabilized. It is not uncommon,
however, in the University of Maryland Shock Trauma Unit
for several teams to operate on a patient at the same time in
several anatomic areas.

50
SECTION I
CHAPTER 3 • Facial injuries
thoroughly stripped, even into the recesses of the sinus, and
the NFOT occluded with well-designed “formed-to-fit” cal-
varial bone plugs or calvarial bone particulate grafting mate-
rial (Fig. 3.6). If most of the posterior bony wall is intact, the
entire frontal sinus cavity may be filled with cancellous bone.
The iliac crest provides a generous source of rich cancellous
bone.32 Formerly, the cavity was left vacant to heal by a slow
process called “osteoneogenesis”, filling slowly with a combi-
nation of bone and fibrous tissue. However, the incidence of
infection is higher by comparison to filling the empty cavity
with cancellous bone graft.33
If the posterior table is missing, grafting may be performed
for localized defects, but it is always emphasized that the floor
of the anterior cranial fossa should be reconstructed with
bone. For large defects, a process called cranialization is
selected, where the posterior wall of the frontal sinus is
removed, effectively making the frontal sinus a part of the
intracranial cavity. The “dead space” may be filled with can-
cellous bone or left open. Any communication with the nose
by the NFOT or with the ethmoid sinuses should be sealed
with carefully designed bone grafts or bone graft particulate
material after debridement. The orbital roof should be recon-
structed primarily by thin bone grafts placed external to the
orbital cavity. An intracranial exposure is often preferred for
large defect orbital roof reconstruction.
The use of a galeal flap in the treatment of extensive frontal
bone defects designed with a pedicle of the supraorbital and
supratrochlear artery or with the superficial temporal artery
is recommended for vascularized soft tissue obliteration of
“dead space”.
Complications
Complications of frontal bone and sinus fractures include:
1. CSF fluid rhinorrhea
2. Pneumocephalus and orbital emphysema
3. Absence of orbital roof and pulsating exophthalmos
4. Carotid–cavernous sinus fistula
Orbital fractures
Orbital fractures may occur as isolated fractures of the
internal orbit (also called “pure”) or may involve both the
internal orbit and the orbital rim (also called “impure”)34,35
(Fig. 3.7).
Surgical anatomy of the orbit
The orbits are conceptualized in thirds progressing from
anterior to posterior. Anteriorly, the orbital rims consist of
thick bone. The middle third of the orbit consists of thin bone,
and the bone structure thickens again in the posterior portion
of the orbit. The orbital bone structure is thus analogous to a
“shock-absorbing” device in which the middle portion of the
orbit breaks first, followed by the rim, both absorbing energy
and protecting the poster third from displacement and the
globe from rupturing.
The optic foramen is situated at the junction of the lateral
and medial walls of the orbit posteriorly and is well above the
horizontal plane of the orbital floor. The foramen is located
40–45 mm behind the inferior orbital rim.
through the anterior ethmoidal air cells to exit adjacent to the
ethmoidal infundibulum. Blockage of the NFOT prevents
adequate drainage of the normal mucosal secretions and
predisposes to the development of obstructive epithelial lined
cysts or mucoceles. Mucoceles may also develop when islands
of mucosa are trapped by scar tissue within fracture lines and
attempt to grow after the injury, producing a mucus mem-
brane lined obstructed cystic structure.23
The sinus is completely obliterated only when it is deprived
of its lining and when the bone is burred, eliminating the
foramina of Breschet24 where mucosal ingrowth occurs along
veins in the walls of the sinuses. Regrowth of mucosa can also
occur from any portion of the frontal sinus, especially if
incompletely debrided. The reported average interval between
the primary injury and development of frontal sinus mucocele
is 7.5 years.
Radiography
Frontal bone and sinus fractures are best demonstrated using
CT Scans.25 Hematomas or air fluid levels in the frontal sinus
may be visualized as well as potential injuries to the NFOT.
Persisting air-fluid levels imply the absence of NFOT function
as do displaced fractures in the medial floor of the frontal
sinus.
Surgical treatment
The best technique of exposure in major fractures involving
the frontal bone is the coronal incision. This allows a combined
intracranial and extracranial approach to the anterior cranial
fossa which provides visualization of all areas, including
repair of dural tears, debridement of any necrotic sections of
frontal lobe, and repair of the bone structures.
Frontal sinus fractures should be characterized by describ-
ing both the anatomic location of the fractures and displace-
ment. The indications for surgical intervention in frontal sinus
fractures include depression of the anterior table, radiographic
demonstration of involvement of the NFOT with presumed
future non-function, obstruction of the NFOT with persistent
air-fluid levels, mucocele formation, and fractures of the
posterior table which may have lacerated the dura.26,27 Some
authors recommend exploration of any posterior table fracture
or any fracture in which an air-fluid level is visible. Others
have a more selective approach, exploring posterior wall
fractures only if their displacement exceeds the width of the
posterior table, a distance suggesting simultaneous dural
laceration.28,29 Simple linear fractures of the anterior and
posterior sinus walls which are undisplaced are safely
observed.
Any depressed frontal sinus fracture of the anterior wall
potentially requires exploration and wall replacement to
prevent contour deformity. Most of these patients have no
compromise of NFOT function; however, those that do will
have fractures of the medial floor of the sinus. If sinus drain-
age is compromised, the sinus should be defunctionalized.
The anterior wall of the sinus may be explored by an appro-
priate local laceration or a coronal incision, or more recently
endoscopic drainage and elevation have been recommended
for simpler fractures. Anterior wall fragments are elevated
and plated into position. If it is desired that the NFOT30,31 and
sinus be obliterated because of involvement, the mucosa is

51
Orbital fractures
A
B
C
Fig. 3.6  (A) Nasofrontal outflow tract (NFOT). (B) Bone plug for NFOT. (C) Bone obliteration of frontal sinus.
(D) “Back table” surgery for bone replacement. (E) Bone reconstruction and cranialization of the frontal sinus;
intracranial neurosurgery. (F) Postoperative result.
D
E
F
Orbital physical examination
The most important component of the physical examination
is to check the visual acuity in each eye: the patient’s ability
to read newsprint or an ophthalmic examination card such as
the Rosenbaum Pocket card. Visual field examinations should
be performed to detect edema, corneal abrasion, globe lacera-
tion, contusion, and hematoma. The simultaneous presence of
a subconjunctival hematoma and a periorbital hematoma
confined to the distribution of the orbital septum (so called
“spectacle hematoma”) is evidence of a facial fracture involv-
ing the orbit until proven by radiographs (Fig. 3.8). Extraocular
movements should identify double vision or restricted globe
movement. All patients with orbital injuries must be frequently
checked for light perception and pupillary afferent defects
post-injury, preoperatively and postoperatively. Globe pres-
sure may be assessed by tonometry and should be less than
15 mm. The results of a fundus examination should be
recorded. The presence of no light perception generally indi-
cates optic nerve damage or globe rupture.36 Light perception
without usable vision usually indicates optic nerve damage,
retinal detachment, hyphema, vitreous hemorrhage, or ante-
rior or posterior chamber injuries. Globe and eye injuries
require expert ophthalmologic consultation.
Radiographic evidence of fracture
CT scans performed in the axial, coronal, and sagittal planes,
using both bone and soft tissue windows, are essential to
define the anatomy of the orbital walls and soft tissue
contents, and the relation of the extraocular muscles to the
fracture.
Indications for surgical treatment
The indications for surgical treatment include:
1. Double vision caused by incarceration of muscle or the
fine ligament system, documented by forced duction
examination and suggested by CT scans.
2. Radiographic evidence of extensive fracture, such that
enophthalmos would occur.
3. Enophthalmos or exophthalmos (significant globe
positional change) produced by an orbital volume
change.
4. Visual acuity deficit, increasing and not responsive to
medical dose steroids, implying that optic canal
decompression may be indicated, although this has
become more controversial.36

52
SECTION I
CHAPTER 3 • Facial injuries
5. “Blow-in” orbital fractures that involve the medial or
lateral walls of the orbit and severely constrict orbital
volume, creating increased intraorbital and globe
pressure.
Blow-out fractures of the floor of the orbit
A blow-out fracture is caused by the application of a traumatic
force to the rim, globe, or soft tissues of the orbit. Blow-out
fractures are accompanied by a sudden increase in intraorbital
pressure.37
Medial orbital wall fractures
Medial orbital wall fractures may be isolated or combined
with fractures of the floor.38 With the loss of the infero-medial
orbital strut (connected to the middle turbinate) located
between the medial wall and floor, there is increased difficulty
achieving the proper shape and volume of the orbital contents.
This is an indication for repair with either anatomically con-
toured calvarial bone grafts or alloplastic implants to repro-
duce the normal inwardly contoured shape of the orbit. The
exposure for reduction of a medial orbital fracture include
trans- or retrocaruncular approaches, which can be used in
combination with a transconjunctival incision to provide wide
exposure to the floor and medial orbit for repair.39 A coronal
incision provides the broadest exposure of the medial orbital
wall.
Blow-out fractures in younger individuals
In children, the mechanism of entrapment is more frequently
trapdoor than the “blow-out or punched out” fracture seen in
adults. As opposed to incarceration of fat adjacent to the
A
Fig. 3.7  (A) Mechanism of blow-out fracture from displacement of the globe itself
into the orbital walls. The globe is displaced posteriorly, striking the orbital walls
and forcing them outward, causing a “punched out” fracture the size of the globe.
(B) “Force transmission” fracture of orbital floor.
B
Fig. 3.8  The combination of a palpebral and subconjunctival hematoma is
suggestive of a fracture somewhere within the orbit. There is frequently a zygomatic
or orbital floor fracture present when these signs are confirmed.

53
Orbital fractures
Operative technique for orbital fractures
Endoscopic approaches for orbital floor fractures
Recently, endoscopic approaches through the maxillary sinus
have permitted direct visualization of the orbital floor and
manipulation of the soft tissue and floor repair with this
approach, which avoids an eyelid incision.44–46
Cutaneous exposures
A number of incisions have been employed to approach the
orbital floor:
1. Inferior lower eyelid incision. These have the least
incidence of lower eyelid ectropion of any lid incision
location but tend to generate the most noticeable scar
and are prone to lymphedema.47–49
2. Subciliary skin muscle flap incision. This incision near
the upper margin of the lid leaves the least conspicuous
scar of any cutaneous incision.50,51 However, they are
prone to have the highest incidence of lid retraction
(scleral show and ectropion). The mid-lid variation has
less ectropion but more obvious scar if taken lateral to
the pupil, and more edema.
3. Transconjunctival incision. A preseptal or retroseptal
dissection plane can be established. There is no
cutaneous lid scar unless a lateral canthotomy is
utilized.
Surgical technique
Generally, a corneal protector is placed over the eye to protect
the globe and cornea from instruments, retractors, or rotating
drills. The inferior rectus muscle, the orbital fat, and any
orbital soft tissue structures should be carefully dissected free
from the areas of the blow-out fracture. Intact orbital floor
must be located around all the edges of the fracture, and any
displaced “blow-out” soft tissue gently released from the
fracture.
The fracture may be made larger permitting easier removal
of incarcerated soft tissue. The floor must be explored suffi-
ciently posteriorly that intact orbital floor beyond the defect
is confirmed. This “ledge” is frequently the orbital process of
the palatine bone, 35–38 mm posterior to the rim. Placing a
freer into the maxillary sinus, one may locate the back of the
sinus and move it superiorly to verify the position of the
“ledge” which will be felt as a projection from the back wall
of the sinus. The “ledge” may be verified on sagittal CT scan
images.52,53 The “ledges” in fracture treatment are landmarks
with which implant material should be aligned to re-establish
an anatomic orbital shape and volume.
The forced duction test
Limitation of forced rotation of the eyeball (the “forced
duction” test or the “eyeball traction” test) (Fig. 3.10) provides
a means of differentiating entrapment of the extraocular
muscles from muscle weakness, paralysis, or contusion. The
forced duction test should be performed for initial diagnosis,
and then 1) before dissection; 2) after dissection; 3) after the
insertion of each material used to reconstruct the orbital wall;
4) just prior to closure of the incisions. It is crucial that these
inferior rectus muscle, children more frequently “scissor” or
capture the muscle directly in the fracture site, as the springy
bone of children recoils faster than the entrapped soft tissue,
pinning the muscle. This may be suggested on physical
examination with near immobility of the eye when upgaze is
attempted on the affected side, pain with attempted eye
motion, as well as nausea, vomiting, and presence of an
oculocardiac reflex, which consists of nausea, bradycardia,
and hypotension (Fig. 3.9). Trapdoor fractures with actual
muscle incarceration is an urgent situation that demands
immediate release of the incarcerated muscle to preserve its
perfusion.40–42 Most practitioners emphasize that a better
prognosis occurs if the muscle is released early, although more
recently it has been suggested that appropriate surgical tech-
nique is more important than the timing of release per se.43
Surgical treatment
The surgical treatment of orbital fractures has three goals:
1. Disengage entrapped structures and restore ocular
rotatory function.
2. Replace orbital contents into the usual confines of the
normal bony orbital cavity, including restoration of both
orbital volume and shape.
3. Restore orbital cavity walls, which in effect replaces the
tissues into their proper position and dictates the shape
into which the soft tissue can scar.
The timing of surgical intervention
In isolated blow-out fractures, it is not necessary to operate
immediately unless true muscle incarceration is present. In
the presence of significant edema, retrobulbar hemorrhage,
optic nerve injury, retinal detachment, or other significant
globe injuries, such as hyphema, it is advisable to wait a
number of days until stability of ocular condition is
confirmed.
Significant orbital fractures are best treated by early surgi-
cal intervention. The authors firmly believe that the earlier
significant orbital volume change or functional muscle
derangement can be corrected, the better the final aesthetic
and functional result.
Fig. 3.9  Blow-out fracture in a child produced by a snowball. Note the nearly
complete immobility of the ocular globe and the enophthalmos. Such severe loss of
motion implies actual muscle incarceration, an injury that is more frequent in
children than in adults. This fracture deserves immediate operation with release of
the incarcerated extraocular muscle system. It is often accompanied by pain on
attempted rotation of the globe and sometimes nausea and vomiting. These
symptoms are unusual in orbital floor fractures without true muscle incarceration.

54
SECTION I
CHAPTER 3 • Facial injuries
preoperative results. Both double vision and blindness have
sometimes occurred after day 1 either in orbital fractures
or in postoperative treatment, but these conditions are
usually present at the time of injury or acutely following
the surgery.
Complications of orbital fractures
Diplopia
Extraocular muscle imbalance and subjective diplopia are
usually the result of muscle injury or contusion but can be the
result of incarceration of either the muscle or the soft tissue
adjacent to the muscles, or the result of nerve damage to the
third, fourth, and sixth cranial nerves.55–59 Traumatic surgical
dissection is also a mechanism as is forceful removal of
measurements all be compared to detect what is causing
interference. Reconstructive material must not interfere with
globe movement, and a full range of oculo-rotatory move-
ments must accompany restoration of proper eye position.
Restoration of continuity of the orbital floor
The purpose of the orbital floor replacement, whether a bone
graft or an inorganic implant, is to re-establish the size and
the shape of the orbital cavity. This replaces the orbital soft
tissue contents and allows scar tissue remodeling to occur in
an anatomic position and proper shape (Fig. 3.11).
Bone grafts for orbital floor reconstruction
Split calvarial, iliac, or split rib bone grafts provide the ideal
bone substitute for reconstruction of the internal orbital
fractures.54 It is not known whether bone grafts resist bacterial
colonization better than inorganic implants, but that is the
presumption. Bone grafts are presumed to survive at the
50–80% level.
Inorganic implants
The inorganic implant offers the reconstruction of the orbital
floor without an additional operation for bone graft harvest.
Titanium mesh alone or titanium mesh with polyethylene
may be easily utilized for larger defects.
The incidence of late infection with any technique is less
than two percent, and displacement should not occur if the
material has been properly anchored. Rarely, artificial or bone
graft materials exposed to the sinus may not re-mucosalize,
and may be responsible for recurrent cellulitis.
Postoperative care
Light perception must be confirmed preoperatively and fre-
quently postoperatively. Pupillary reactivity must be assessed
before and at least twice daily for the first several days after
surgery. Double vision should be noted and compared with
Fig. 3.10  The forced duction test. Forceps grasp the ocular globe at the insertion
of the inferior rectus muscle, which is approximately 7–10 mm from the limbus. A
drop of local anesthetic instilled into the conjunctival sac precedes the procedure.
A
Fig. 3.11  Medial orbital wall fracture. (A) Coronal CT scan image illustrating
medial orbital wall fracture. (B) Postoperative three-dimensional CT scan
demonstrating repair of medial orbital wall repair using titanium alloplastic mesh
implant.
B

55
Orbital fractures
the globe position has been stabilized by enophthalmos
correction.
Scleral show, ectropion, and entropion – vertical
shortening of the lower eyelid
Vertical shortening of the lower eyelid with exposure of the
sclera below the limbus of the iris in the primary position
(scleral show) may result from downward and backward
displacement of the fractured inferior orbital rim. The septum
and lower lid are “fixed length” structures and are therefore
dragged downward by their tendency to adhere to the abnor-
mally positioned inferior orbital rim. This can result in scleral
show or ectropion if occurring in the “anterior lid lamellae”
(skin or orbicularis) or entropion if occurring in the “posterior
lid lamellae” (septum, lower lid retractors, and conjunctiva).
Only in the actual performance of the operation can the
surgeon define the true nature of the problem, release the
adhesions, correct the lid shortening, and stabilize the lid
position with appropriate grafts into the proper location.66
Correction procedures generally do not elevate the lower lid
by more than 3 mm.
Infraorbital nerve anesthesia
Infraorbital nerve anesthesia is extremely disconcerting to
patients who experience it, especially initially. The area of
sensory loss usually extends from the lower lid to involve the
medial cheek; the lateral portion of the nose, including the ala;
and the ipsilateral upper lip. The anterior maxillary teeth may
be involved if the branch of the infraorbital nerve in the
anterior maxillary wall is involved. Decompression of the
infraorbital nerve from pressure of the bony fragments within
the infraorbital canal may be indicated either acutely or late
after fracture treatment especially if the zygoma demonstrates
medial displacement impinging the infraorbital canal with
impaction into the nerve.
The “superior orbital fissure” syndrome and
the “orbital apex” syndrome
Significant fractures of the orbit extend posteriorly to involve
the superior orbital fissure and optic foramen. Involvement
of the structures of the superior orbital fissure produces a
symptom complex known as the superior orbital fissure
syndrome. This consists of partial or complete involvement
of the following structures: the two divisions of the cranial
nerve III, superior and inferior, producing paralysis of the
levator, superior rectus, inferior rectus, and inferior oblique
muscles; cranial nerve IV causing paralysis of the superior
oblique muscle; cranial nerve VI producing paralysis of the
lateral rectus muscle; and the ophthalmic division of the
trigeminal nerve (V) causing anesthesia in the brow, medial
portion of the upper lid, medial upper nose, and ipsilateral
forehead. Symptoms of the superior orbital fissure syndrome
may be partial or complete in each of the nerves.67 When
accompanied by visual acuity change or blindness, the injury
implies concomitant involvement of the combined superior
orbital fissure (CN III, IV, V & VI) and optic foramen (CN II).
If involvement of both the optic nerve and superior orbital
fissure occur, this symptom complex is called the orbital
apex syndrome.
incarcerated orbital contents from a fracture, where tearing of
the muscle occurs.
Enophthalmos
Enophthalmos60,61 is the second major complication of a blow-
out fracture, and the major cause is enlargement of the bony
orbit with herniation of the orbital soft tissue structures into
a larger space with remodeling of the shape of the soft tissue
into a spherical configuration. Displacement of intramuscular
cone fat into the extramuscular compartment is another
mechanism, initiating a loss of globe position, as is retention
of the ocular globe in a backward position by scar tissue. A
popular theory was fat atrophy, but computerized volume
studies prove that fat atrophy makes a significant contribution
in only 10% of orbital fractures.
Retrobulbar hematoma
In severe trauma, retrobulbar hematoma may displace the
ocular globe. Retrobulbar hematoma is signaled by globe
proptosis and exophthalmos, congestion and prolapse of the
edematous conjunctiva. Diagnosis is confirmed by a CT scan
image with soft tissue windows. Drainage is not possible as
retrobulbar hematomas usually are diffuse. Orbital fracture
treatment in the setting of retrobulbar hematoma has increased
risk, as volume increase and vascular spasm may affect globe
circulation. The reconstruction is best performed when hem-
orrhage, swelling and congestion have subsided, and vision
is stabilized.
Ocular (globe) injuries and blindness
The incidence of ocular injuries following orbital fractures is
14–30%. The incidence depends on the scrutiny of the exami-
nation and the recognition of minor injuries, such as corneal
abrasion. Ocular globe injury may vary in severity from a
corneal abrasion to loss of vision to globe rupture, retinal
detachment, vitreous hemorrhage, or a fracture involving the
optic canal.62 Blindness, or loss of an eye, is remarkably infre-
quent despite the severity of some of the injuries sustained
because of the “shock absorber” type construction of the orbit.
The incidence of acute visual loss following facial fractures
is on average 1.7%,63 and blindness following facial fracture
repair has been estimated to be about 0.2%.64
Implant migration, late hemorrhage around
implants, and implant fixation
Migration of an implant anteriorly may occur with extrusion
if the implant is not secured to the orbital floor or to a plate
that attaches to the rim. Spontaneous late proptosis can be
caused by hemorrhage from longstanding low-grade infec-
tion around orbital implants or from chronic sinus or lacrimal
system infection.65
Ptosis of the upper lid
True ptosis of the upper lid should be differentiated from
“pseudoptosis” resulting from the downward displacement
of the eyeball in enophthalmos. True ptosis results from
loss of action of the levator palpebrae superioris. Ptosis in
the presence of enophthalmos should not be treated until

56
SECTION I
CHAPTER 3 • Facial injuries
Anteroposterior blows result in posterior displacement of
the nose into the nasal cavity and may occur with or without
lateral impact. They also occur in three degrees of severity:
plane I, where the distal portion of the nasal bones are
involved; plane II, where the entire nasal bones and dorsal
septum are involved; and Plane III, where the comminution
extends beyond the nose into the frontal processes of the
maxilla; again, the latter injuries are true nasoethmoidal–
orbital fractures. With any nasal fracture of significance, the
septum “telescopes”, losing height, and the nasal bridge
drops. Violent blows result in multiple fractures of the nasal
bones, frontal processes of the maxilla, lacrimal bones, septal
cartilages, and the ethmoidal areas (i.e. the true nasoethmoidal
orbital fracture).
Fractures and dislocations of the nasal septum
Fractures and dislocations of the septum may occur indepen-
dently or concomitantly with fractures of the distal nasal bone
framework. Most commonly, the two injuries occur together,
but frontal impact nasal fractures carry the worst prognosis
regarding preservation of nasal height with closed reduction
techniques (Fig. 3.13). Because of the intimate association of
the bones of the nose with the nasal cartilages and bony nasal
septum, it is unusual to observe fractures of either structure
without damage to the other. In particular, the caudal or
cartilaginous portion of the septum is almost always injured
in nasal fractures.
The caudal portion of the septum has a degree of flexibility
and bends to absorb moderate impact. The first stage of nasal
septal injury is fracturing and bending, and the next stage
involves overlap between fragments, which reduces nasal
height. In mid-level severity injuries, the septum fractures,
often initially with a C-shaped or double transverse compo-
nent in which the septum is fractured and dislocated out of
the vomerine groove with or without involvement of the
Midfacial fractures
Nasal fractures
Types and locations of nasal fractures
Lateral forces68 account for the majority of nasal fractures and
produce a wide variation of deformities, depending on the
age of the patient, intensity and vector of force. Younger
patients tend to have fracture dislocations of larger segments,
whereas older patients with more dense, brittle bone often
exhibit comminution. A direct force of moderate intensity
from the lateral side may fracture only one nasal bone with
displacement into the nasal cavity (plane I lateral impact).
When forces are of increased intensity, some displacement of
the contralateral nasal bone occurs and the fracture may be
incomplete or greensticked requiring completion of the
contralateral fracture to centralize the nasal processes (plane
II lateral impact). In more severe (plane III lateral impact)
frontal impact injuries, the frontal process of the maxilla may
begin to fracture and may be depressed posteriorly on one
side. This depression first arises at the pyriform aperture
inferiorly and then involves the entire structure of the frontal
process of the maxilla, and is in effect the first stage of a
hemi-nasoethmoidal fracture, displaced inferiorly and poste-
riorly (plane III “lateral impact” nasal fractures are identical
to “type I” hemi-nasoethmoidal fractures) (Fig. 3.12A–C).
These fractures are “greensticked” or almost undisplaced at
the internal angular process of the frontal bone. The sidewall
of the nose drops on one side, the septum telescopes and
displaces, and the nasal airway is effectively closed on the
ipsilateral side by the sidewall and turbinate impacting
toward the septum blocking the airway. In stronger blows, the
septum begins to collapse from an anteroposterior perspec-
tive as the comminution increases.
Fig. 3.12  Frontal impact nasal fractures are classified by degrees of displacement, as are lateral fractures. (A) Plane I frontal impact nasal fracture. Only the distal ends of
the nasal bones and the septum are injured. (B) Plane II frontal impact nasal fracture. The injury is more extensive, involving the entire distal portion of the nasal bones and
the frontal process of the maxilla at the piriform aperture. The septum is comminuted and begins to lose height. (C) Plane III frontal impact nasal fractures involve one or
both frontal processes of the maxilla, and the fracture extends to the frontal bone. These fractures are in reality nasoethmoidal orbital fractures because they involve the
lower two-thirds of the medial orbital rim (central fragment of the nasoethmoidal orbital fracture), as well as the bones of the nose.
A
B
C