Midface - Approach - Use of existing lacerations - AO Surgery Reference Page 1 of 6

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Executive Editor:
Edward Ellis III, Kazuo
Shimozato General
Use of existing lacerations
Editor: Daniel Principles
Buchbinder
General
Authors: Carl-Peter
Cornelius, Nils Gellrich,
Søren Hillerup, Kenji
Kusumoto, Warren
Schubert, Stefano
Fusetti, Coauthors: Enno-
Ludwig Barth, Harald
Essig
considerations
Facial fractures are often associated with
Midface
lacerations. These existing soft-tissue
back to CMF overview injuries can be used to access directly the
Search facial bones for management of the
fractures.
Shortcuts The surgeon may elect to extend the
All Preparations laceration to attain enough access to the
All Approaches fractured area, placing additional incisions
All Reductions & Fixations starting from the wound margins along the
relaxed skin tension lines (RSTL).
Bacterial contamination is not a
contraindication for the use of existing
lacerations for surgical approach.
Access to infraorbital rim and orbital floor
through a horizontal lower lid laceration is
shown.

Clinical
photograph of
the same
case showing

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osteosynthesis and orbital mesh plate

applied through the existing laceration.

This
photograph
shows an
acceptable
outcome after
using the
laceration for
surgical approach.

Peripheral
nerve and
parotid duct
injuries
Depending on
the location
of the
laceration, structures such as nerves, the
parotid gland, or the parotid duct may be
affected by the injury.
In the illustration, a peripheral facial nerve
branch is directly involved. Respecting their
functional importance the facial nerve
branches can either be repaired primarily or
tagged for ease of location during a
secondary repair. Aggressive exploration and
primary repair under microscopic
magnification is advantageous at least for
the branches responsible for lid closure.

Parotid duct
injury and
repair
Injuries of the
parotid duct
may cause an

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acute leakage
of saliva into
the wound or
surgical field
resulting in
salivary
fistula.
The parotid duct ends can be explored
through the laceration in such cases.

Repair of the
parotid duct
The distal
portion of the
duct is
entered from
the intraoral
orifice and stented with silastic tubing until
continuity is reached with the lumen of the
proximal duct.

The edges of
the duct are

reapproximated and closed over the stent

using microsurgical instrumentation. The

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silastic tubing is left in position for a period

of up to 3 weeks.
Unrepaired parotid duct injuries result in a
persistent fistula or sialocele.

This clinical
photograph
shows a
repaired
parotid duct.

Wound
closure
Proper
cleansing,
debridement,
and
hemostasis
should be accomplished prior to the repair of
the underlying bony injury, cranial peripheral
nerve injuries, or an injured Stensen’s duct
(parotid duct).
Facial wounds can be closed primarily up to
24 hours after the injury due the high
vascularization of this region.
The laceration is closed in layers with short-
term resorbable interrupted sutures,
realigning the anatomic structures and
eliminating dead space:
• Periosteum
• Mimetic muscles
• Platysma/SMAS
• Subcutaneous tissues
• Epidermis
Particular attention is given to completing
the repair of free eyelid margins, nasal alae,

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the vermilion lip borders and the helical

margins of the ear.
A variety of skin closure techniques are
available based on surgical preference. A
drain may be placed if necessary.
Usually the wound is not covered with
dressings
A pressure dressing, however, serves to
flatten large soft tissue avulsions and avoid
contour deformities by scar contraction.

Example of
a facial
laceration
with
underlying
fracture
This image
shows an example of soft-tissue laceration
after a horse-shoe injury.

Elevating
the soft-
tissues
reveals an
underlying

multifragmentary zygoma fracture.

This image
shows an
example
of soft-tissue
laceration
after a chain
saw injury.

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Elevating
the soft-
tissues
reveals an
underlying

multifragmentary fracture of the infraorbital

rim and the orbital floor.

Postoperative care and follow-up

Close monitoring of the early wound healing
phase is necessary in order to detect
infection early enough to prevent wound
slough and abscess formation.
Remove sutures in an appropriate time
frame.
Instruct the patient to avoid sun exposure
and use protection such as hats, shields and
sunscreen.
Further interventions may help to minimize
scar contractures and hypertrophy.
Remind the patient that facial scars need
months to mature, lose their redness and
become less conspicuous.

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v1.0 2009-12-03

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