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PRACTI CE


Soft Tissue Pediatric Facial Trauma: A Review
Nicholas J .V. Hogg, MD, DDS, MSc, FRCD(C); Bruce B. Horswell, MD, DDS, MS, FACS
Contact Author
Dr. Hogg
Email: n_hogg@yahoo.com




ABSTRACT

Facial soft tissue injuries are common in pediatric trauma patients. Early diagnosis and
definitive treatment as well as good postoperative wound care are important when
dealing with soft tissue injuries, such as facial nerve and parotid injuries, animal bites,
avulsive skin wounds and eyelid and ear lacerations. Children heal quickly, but they also
tend to develop hypertrophic scars. Proper wound management during the healing
period can help to minimize the risk of adverse scar formation. Dentists may be involved
in the initial assessment of these patients. Knowledge of the diagnosis and management
of soft tissue trauma is useful when dealing with pediatric patients and their parents post-
operatively.


MeSH Key Words: child; facial injuries/etiology; facial injuries/surgery; surgical flaps
J Can Dent Assoc 2006; 72(6):54952
This article has been peer reviewed.





entists may be involved in the primary
assessment of pediatric trauma patients.
Dentists acquire a keen eye for detail
through continued training and practice and
this, combined with their knowledge of facial
anatomy, makes them ideally suited to the
diagnosis and management of facial trauma.
Although dentists may not be involved in all
aspects of craniofacial soft tissue treatment,
they form an important part of the manage-
ment team. Dental professionals may be one of
the key health care providers who assess the
patient postoperatively and provide some
aspect of orofacial reconstruction. To be an
effective member of the trauma management
team, dentists require a thorough knowledge
of the diagnosis and treatment of soft tissue
craniofacial injuries.
There has been a gradual rise in the inci-
dence of trauma in children, probably due to
increased risk-taking and aggressive behaviour
in children, who are more commonly left to
their own devices without close supervision.
Injury is still the number one killer of children,
with a large proportion of the mortality related
to head injury.
1

In this paper, we review soft tissue injuries,
the role of prophylaxis and, antibiotic use, and
the prevention and control of scarring.

Soft Tissue Injuries
Soft tissue injuries are more common than
fractures in children who have sustained facial
trauma, particularly in younger children
whose facial skeletons are resistant to fracture.
2

During initial assessment of any facial injury, it
is important to review the mechanism and
time of injury and determine whether it was
witnessed. Knowing what caused the injury
will be valuable during later exploration and
debridement of wounds and the prediction of
subsequent wound healing. Every effort should
be made to cleanse the wound and remove all
foreign material; this may have to be done in
the operating room under anesthesia. If there
is an open wound, the tetanus status of the
child should be assessed and appropriate man-
agement commenced early.
3
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Hogg






check 3 days after closure in the pediatric trauma patient.
Blunt trauma may result in extensive and prolonged tissue
damage with subsequent deep scarring and poor esthetics.








Figure 1: Deep laceration to the cheek
from a dog bite. Evidence of deep subcu-
taneous fat implies possible underlying
injury to the facial nerve.












Figure 2: Pulse-vacuum irrigation of a
contaminated scalp avulsion injury is used
to dislodge foreign bodies and decrease
the bacterial load of the tissues.


Several key elements of wound care are important in
predicting the quality of healing in children:
eliminate foreign body contamination and the
resulting excessive inflammatory response
keep sutures below the skin surface, if possible
use supportive skin dressings, such as wound support
tapes, during the first 6 weeks of wound repair
protect wounds from subsequent injury, excessive
drying, wetting or temperature variations
engage parental participation in postoperative wound
care, such as cleansing the wound of debris and scabs,
applying dressings and massaging scars.
The wound healing response is generally more intense
and accelerated in children, as they do not usually have
compromising systemic disease or indulge in abusive
habits such as alcohol or tobacco use. However, although
children heal quickly and predictably, increased collagen
deposition in wounds tends to cause hypertrophic scars.
Soft tissue wounds that are clean or only mildly contami-
nated and with little tissue compromise can be cleansed
and closed. Antibiotics are not usually indicated unless
there is a question of host immune status. Wounds can be
closed up to 24 hours after injury. Older wounds should be
thoroughly cleansed and their margins freshened before
closure. Vigilance for wound breakdown necessitates a
Nerve and Duct Injuries
Generally, wounds distal to a line drawn from the lat-
eral canthal region to the mid-mandible will not require
facial nerve exploration or repair. Wounds proximal to this
line should be explored under magnification for possible
nerve injury and the need for repair (Fig. 1).
Preoperative clinical assessment may reveal nerve
injury and palsy. Injuries below the subcutaneous fat in
the parotid region should be explored for parotid duct
injury. A small catheter or a lacrimal probe inserted
through Stensens duct will reveal a proximal ductal injury
in the wound bed.
All nerve and ductal injuries require micro-repair
with permanent sutures. In addition, severed ducts
should be stented for at least 2 weeks or until epithelial
tissue continuity has been restored in the lumen.
4

When ducts are stented, the patient should be prescribed
antibiotics for 710 days, as the gland may become
somewhat static and prone to obstructive sialadenitis.
The use of chewing gum or sugar-free lozenges to stimu-
late saliva production may be considered.

Bites
Animal bites require confirmation of rabies status,
thorough wound exploration and irrigation and prompt
closure of the linear aspects of the wound. Puncture
wounds should be irrigated to their depths, kept open and
seen frequently to detect infection. All animal bites will
result in intense but temporary (23 days) inflammation,
which should subside.
Human bites are more problematic due to the presence
of virulent and resistant organisms.
3,5
Wounds should be
thoroughly cleansed, then approximated, but not com-
pletely closed, if there is any concern over tissue viability.
The infectious status (hepatitis, HIV, etc.) of the offending
person must be ascertained and documented and appro-
priate management must be commenced.
Antibiotic prophylaxis is advisable for both animal and
human bites. Amoxicillinclavulanate is widely regarded
as the gold standard in the treatment of animal and
human bites.
3
Antibiotic therapy in the penicillin-allergic
patient is more controversial. Clindamycin combined with
trimethoprimsulfamethoxazole is an appropriate choice
in children, and azithromycin may be an option in the
pediatric penicillin-allergic patient.
3


Avulsive Wounds
Avulsive wounds of the facial region result from high
velocity recreational activities, such as bicycling, skate-
boarding, etc., or from motor vehicle accidents including
those involving off-road vehicles. Under general anesthesia
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Soft Tissue Facial Trauma

in the operating room, wounds
require careful exploration under
magnification, debridement, pulse-
vacuum irrigation with an antibiotic-
containing solution (Fig. 2),
conservative trimming of nonviable
tissue margins and primary closure if
possible. Avulsed or widely under-
mined soft tissue flaps require proper
suction drainage to prevent
hematoma formation and pressure or
support dressings to allow both arte-
rial inflow and venous outflow.
Frequent checks of the wound to con-
firm tissue viability are important. If
there is concern over viability, steps
should be taken to optimize tissue
vascularity through suture removal,
improved tissue support or enhance-
ment of wound drainage. Adjunctive
measures such as hyperbaric oxygen
treatment have been shown to be
beneficial for marginally viable or
hypoxic wounds.
6

When loss of tissue is extensive, a
staged approach to reconstruction is
required. The initial effort is directed
at cleansing and debriding the wound
to prevent infection and further
tissue loss. Serial wound debride-
ments and numerous tissue dressing
changes may be required in the first 2
weeks after injury. Vacuum-assisted
drainage can be helpful to remove
debris, reduce the circumference of
wounds and stimulate the vascular


a b










c d










Figure 3: (a) A hair-bearing scalp avulsion defect addressed with a staged reconstruction
using (b) tissue expansion, followed several weeks later by (c and d) second-stage scalp
advancement.

a b










Figure 4: (a) Complex wound with avulsion of nasal cartilage. (b) Postoperative repair
using supportive stent and bolster dressings, which will remain 57 days.
bed in preparation for final repair. Large avulsive wounds,
e.g., in the scalp, may require staged tissue expansion and
local flap reconstruction (Fig. 3).

Special Wounds
Special wounds, such as those involving nasal and ear
cartilage, require thorough cleansing and removal of any
foreign bodies, then meticulous approximation of the car-
tilage and skin. Cartilage requires less oxygen than bone,
but it still needs complete soft tissue coverage and support
or bolster dressings (Fig. 4) to eliminate hematoma and
seroma formation. Bolster dressings can generally be
removed in 57 days. Cartilaginous disruption, particu-
larly of the nasoseptal cartilaginous skeleton, is susceptible
to growth disturbances.
Injuries to the eyelids require an initial ophthalmo-
logic assessment and possibly dilation and slit lamp exam-
ination to rule out globe injury. Fluorescein staining will
reveal corneal epithelial and lacrimal injuries. If the tear
ducts are injured, obstruction, stasis and infection may
follow, so prompt and thorough evaluation is necessary. If
a child will not tolerate lacrimal and canalicular evalua-
tion, then a detailed examination in the operating room is
indicated. Placement of silicone intubation tubes through
the severed tear ducts will preserve the canalicular and
lacrimal system. The eyelids are composed of anatomical
layers called lamellae (anterior, middle and posterior),
and each lamella must be repaired or supported to ensure
proper eyelid function.
Surgical treatment of eyelid injuries is completed in
the operating room under general anesthesia with the
patient paralyzed to prevent unexpected movement. The
tissue is irrigated thoroughly and loose flaps of skin are
debrided (Fig. 5). A corneal shield is routinely used to
prevent corneal abrasion, which can be a painful and
irritating postoperative sequela (Fig. 6). Just as the ver-
milion border and white roll are the important landmarks
Hogg
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Figure 5: Avulsive eyelid injury. Figure 6: Complex eyelid laceration with
corneal shield in place.
Figure 7: Silicone pressure dressings on
scars resulting from a dog bite. These
dressings are soft, cleansable and well
tolerated by children.


in lip repair, the gray line of the eyelid is the key to proper
lid alignment. The tarsal plate, which is the supportive
structure of the eyelids, must also be repaired. If the
orbital septum has been violated, yellowish orbital fat will
be seen protruding through the septum. Meticulous
hemostasis is mandatory before closure of the septum to
reduce the risk of retrobulbar hematoma, which may place
excessive pressure on the globe and optic nerve and could
potentially result in blindness. Some surgeons monitor the
orbit for 24 hours in hospital and, although the treatment
is controversial, place the patient on steroids to prevent
increased intraorbital edema and pressure.
7


Scar Management
Because children have a tendency to heal with scarring,
it is important to guide the wound during active healing.
8

All permanent sutures should be removed in 35 days and
wound support dressings applied for 1014 days to
remove tension from the wound bed, which would
increase collagen deposition. During this period, any irri-
tating influences and encrustations should be removed
from the wound and the area should be kept moist and
covered. Topical antibiotic ointment should be discon-
tinued after 7 days to prevent tissue reaction.
When the wound is well epithelialized, usually in
710 days, silicone sheeting or topical scar gels can be
applied for several weeks (Fig. 7). These agents keep ten-
sion off the wound, as well as maintain slight pressure on
it, to help reduce excessive collagen deposition into the
scar. During this period, it is important to avoid excessive
wetting, drying, heat or irritating agents that might exac-
erbate the inflammatory response. The patient should use
sunblock with a high sun protection factor while outside
and wear a wide-brimmed hat to cover the face, if possible,
for up to a year after injury to avoid ultraviolet stimulation
of melanocytes in the wound bed and subsequent
hyperpigmentation.
Children with darker skin pigmentation may be prone
to excessive scarring (keloids) and pigmentation changes.
If scarring appears to extend beyond the wound margins,
a keloid scar may be forming. Topical hydrocortisone,
injectable triamcinolone and even low-dose radiation may
be helpful in reducing keloid scars. Finally, scars that are
discoloured can be tattooed with permanent medical
grade pigment to match the surrounding skin. Revision of
scars should be deferred until final maturation is complete
approximately 612 months postinjury.

Conclusions
Pediatric facial injuries are common due to childrens
high level of physical activity, decreased supervision and
tendency toward risk-taking behaviour. Dentists may
be involved in the initial assessment of these patients and
can refer them appropriately for definitive treatment.
Repair of soft tissue wounds is a high priority identi-
fying and maintaining tissue viability is paramount, as
is early diagnosis and repair of nerve and ductal integrity.
Wound support and daily cleansing of wounds, as
well as measures to decrease tension, help decrease scar
formation. C

THE AUTHORS


Dr. Hogg is craniofacial surgery fellow in the department
of surgery, Charleston Area Medical Center, Charleston,
West Virginia.



Dr. Horswell is director of the First Appalachian Craniofacial
Deformity Specialists, at the Charleston Area Medical Centers
Women and Childrens Hospital, Charleston, West Virginia.

Correspondence to: Dr. Nicholas J.V. Hogg, Charleston Area Medical Center,
Facial Surgery Center, Suite #302, 830 Pennsylvania Ave, Charleston, WV,
25302, USA.
The authors have no declared financial interests.


References
To view the complete list of references, consult the electronic JCDA at www.cda-
adc.ca/jcda/vol-72/issue-6/549.html.
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