Primary care of wounds of the face
When you are treating facial wounds, whether minor or serious, your priority is to keep the patient’s airway clear at all times. Remember too that a severe facial injury may be associated with other injuries, which may also require your attention.
The choice of anaesthetic for the patient will normally depend on the nature of the injuries, but general anaesthesia is preferable in children. Use good lighting and fine instruments when examining and treating wounds of the face; ophthalmic instruments are ideal for this. Unless the wound is near the eyes, clean it with soap and water, while protecting the patient’s eyes, and then irrigate it with saline. Make every attempt to preserve tissue, especially skin, but remove all foreign material and all obviously devitalized tissue. A small, soft brush will facilitate this process.
Always administer tetanus toxoid. Cellulitis, a potentially serious complication, can be prevented by meticulous surgery and by prophylactic benzylpenicillin 600 mg (106 units) given twice a day intramuscularly.
Lip injuries are common. It is safe not to suture small lacerations of the buccal mucosa, but advise the patient to rinse the mouth frequently with salt water, particularly after every meal.
For an isolated laceration of the lip that requires suturing, local anaesthesia is usually adequate. Proper anatomical alignment is essential for wounds that cross the vermilion border. Achieve this by planning the first stitch to join the border accurately. This region may be distorted by swelling caused by local anaesthetic, so to ensure accuracy, premark the border with gentian violet.
After this key suture has been inserted, repair the rest of the wound in layers, starting with the mucosa and progressing to the muscles and finally the skin
Most wounds of the tongue require no suturing and heal rapidly, but you may need to suture lacerations with a raised flap in either the lateral border or the dorsum of the tongue. Local anaesthesia is usually sufficient. Instruct the patient to rinse the mouth regularly with salt water, until healing is complete.
Ear and nose
The three-dimensional curves of the pinna and the presence of cartilage can present difficulties in the repair of ear injuries. The wounds are commonly irregular, with cartilage exposed by loss of skin. Use the folds of the ear as landmarks to restore anatomical alignment.
After the patient has been anesthetized, as appropriate, close the wound in layers with fine sutures, using catgut for the cartilage. Dressing is important: the pinna should be supported on both sides by moist cotton pads and firmly bandaged to reduce haematoma formation.
Make every attempt to cover exposed cartilage either by wound suture or by split-skin graft.
The principles of repair of ear lacerations also apply to wounds of the nose.
Wounds of the ear and nose may result in deformities or necrosis of the cartilage.
Cellulitis of the face
Cellulitis of the face, which can be a complication of facial wounds, carries the serious risk of cavernous-sinus thrombosis, so the patient’s initial response to treatment with antibiotics is best observed in hospital. The organisms responsible are likely to be penicillin-sensitive. The patient must resist squeezing or otherwise manipulating any infected foci on the face, even if such foci are small.