08 beauty is not skin deep

Soft tissue injuries & Soft tissue injuries & Composite defects of the Composite defects of the

faceface

Mamoon Rashid SE FCPS (Pak), FRCS (Eng)

Professor of Plastic SurgeryShifa College of Medicine

Consultant Plastic SurgeonShifa InternationalHospital Islamabad

An Advanced Dressing Station in France  1918  Henry Tonks

Modern Plastic Surgery:A specialty forged in the fire of battle

Part-ISoft Tissue Injuries Of The Face

Facial injuries Should alert the examiner to the possibility of

Airway compromise Cervical spine injuries Central nervous system

injuries.

Use of the AMPLE acronym facilitates acomplete trauma history. AAllergiesllergies MMedicationsedications PPast historyast history LLast mealast meal EEvents (surrounding the accident)vents (surrounding the accident)

Evaluation Thorough H&N examination starting pointThorough H&N examination starting point Do not be distracted by more impressive injuriesDo not be distracted by more impressive injuries Carefully assess the face for neurologic deficitsCarefully assess the face for neurologic deficits A complete ocular examinationA complete ocular examination Examination of the oral cavityExamination of the oral cavity Assess for facial bone fracturesAssess for facial bone fractures Records…. Photographs, sketchesRecords…. Photographs, sketches

Imaging

Facial trauma series is a useful screening tool Plain radiographs (anteroposterior [AP], lateral, Caldwell, and Water views).

Also useful for foreign bodies, glass Plain radiographs inadequate to assess severity and

displacement of fractures. In most patients with significant facial impact, CT is

essential ( Preferably with 3-D reconstruction)

Initial care & assessment

Clear airway Control hemorrhage Treat shock Evaluate associated injuries

Types of Soft tissue injuries

Contusion with or without haematoma Abrasion + - Accidental tattoos Retained foreign bodies Puncture Laceration Avulsion Injuries Crush injuries Soft tissue and Composite tissue loss

Preparation for treatment of soft tissue injuries

Good light Anesthesia Proper instruments and

sutures Shaving the area….

Never the eyebrow Consent and Counseling

Simple Lacerations:Technique of repair

Anaesthesia local or general Irrigation and Debridement Conservative Debridement of

ragged / tangential/ contused edges Secure haemostasis Repair in layers

Wind shield injuries

Avulsion flaps

Injury to Parotid Duct

Medial eye and Lacrimal apparatus

Eyelid injuries

Medial canthal Ligament Disruptions

Injury to Facial Nerve Branches

Part- IIComplex facial injury with composite loss of tissue

Composite Osteocutaneous defects

Management Protocol

Clinical Assessment General Defect

Investigations OPG 3D – CT Recon

Recreation of primary defect

Doppler USG (Fibula)

Template-based flap designing

Reconstruction Bone fixation Flap Inset

Follow-up

Lower face and Jaw defects

RE

Combined mid-face and Combined mid-face and mandibular defectsmandibular defects

The key to a successful reconstruction of composite facial injuries lies in;

Adequate defect assessment (including re-creation of original

defect) Meticulous flap planning A lot of imagination.

Osteo-cutaneous flaps should be considered as first choice for these complex situations.

Achieving a “normal” appearance remains elusive

Lessons Lessons LearntLearnt

Humbling Humbling ExperienceExperience

“If it is not normal it is not enough".

Dr. Paul Tessier (1917-2008)(1917-2008)

Thank you"Beauty, as defined by society at large, seemed to be only about who was best at looking like everyone else." — Lucy Grealy (Autobiography of a Face)