Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXIII: Maxillofacial Wounds and Injuries

Initial Wound Surgery

United States Department of Defense

The surgical field is prepared as usual, ingrained dirt being removed by gentle scrubbing with a soft brush. The eyebrows are not shaved.

Debridement. Tissues should be handled very gently, with fine instruments. The blood supply of the facial tissues is so adequate and resistance to infection so high that only the most minimal excision of skin is necessary. From 1 - 2 mm of the wound edges are trimmed to be certain that noncontaminated, nonbeveled edges can be accurately approximated. The trimming is done with ophthalmic scissors or a sharp No. 15 blade. The remainder of the procedure is carried out with conservation of as much tissue as possible. No bone with retained periosteal or musculovascular attachment should be removed from the wound. Only that bone which washes freely away with copious irrigation should be removed.

Primary wound closure. Maxillofacial injuries furnish one of the very few exceptions to the general rule that softtissue wounds should not be closed at the time of initial wound surgery Whereas primary wound closure of facial injuries is preferred to delayed primary wound closure, this policy does not pertain to associated wounds of the neck.

Ideally, treatment of these multisystem wounds is carried out by multidisciplinary teams that include otolaryngologists, ophthalmologists, neurosurgeons, oral surgeons, dentists or plastic surgeons. This sort of coordinated team approach allows surgeons of several different specialties to make diagnostic, prognostic, or therapeutic contributions during a single general anesthetic.

Closure, which must be accomplished without tension, is begun intraorally and proceeds outwardly. When the parotid duct is found severed, primary repair should be considered. If primary repair is not deemed practical, both the distal and proximal portions of the duct should be cannulated with a plastic catheter which is securely sutured to the buccal mucosa and retained in place for 5 - 7 days. When the proximal portion of the duct cannot be located or is missing, the cannula should still be placed into the depth of the wound prior to closure and brought out through the distal segment of the duct intraorally. If the distal segment of the duct is missing, the catheter should be brought out into the mouth through the mucosal wound repair in order to prevent or reduce the incidence of cutaneous salvary fistulae. The foregoing guidance is more difficult to apply with injuries of the submandibular gland because of its dependent position in the floor of the mouth and the likelihood that an injured duct will become stenotic. Extensive injury to the submandibular gland duct is often best managed by removal of the gland.

The repair of severed branches of the facial nerve, identified during wound repair, should be accomplished utilizing fine suture material and magnification. All branches proximal to a vertical line extending downward from the lateral canthus should be repaired primarily. When there is bone destruction as well as extensive soft-tissue damage, it may be necessary to suture the buccal mucosa to the margins of the skin to cover the fracture site. Watertight closure over a fracture is always desirable. The oral mucosa is closed with fine chromic catgut; otherwise, the finest nylon or silk, mounted on swaged needles, should be used. Skin sutures are introduced close to the cut edge and are placed not more than 3 mm apart. Temporary application of a pressure dressing may help to prevent edema and hematoma formation.

In rare cases, when a defect is so large that closure is impossible without tension or distortion, a flap may be used. All skin flaps must be carefully approximated and held in position by suturing without tension.  

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Operational Medicine 2001

Health Care in Military Settings

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