new jishant cosmetic outcome of maxillofacial lacerations and … · 2017. 5. 25. · journal of...

Journal of the International Society of Head and Neck Trauma (ISHANT)

Research

Cosmetic outcome of maxillofacial lacerations and fracture management; a comparison of two

treatment regimens Gulraiz Zulfiqar1, Riaz Ahmed Warraich 2 , Khurshid Alam1, M. Asim Naqash 1, Fatima Tuz Zahra1,

Ali Abubakar1 , Anam Abid1

1 Department of Oral and Maxillofacial Surgery, Allama Iqbal Medical College, Lahore, Pakistan

2 Department of Oral and Maxillofacial Surgery, King Edward Medical University, Lahore, Pakistan

Corresponding Author:

Gulraiz Zulfiqar. Assistant Professor, Department of Oral and Maxillofacial Surgery, Allama Iqbal Medical College / Jinnah Hospital, Lahore

[email protected]

Received August 2016. Accepted following peer review October 2016. Published October 2016

JISHANT 2016:9

Keywords: lacerations, emergency, elective, cosmesis

AbstractOne of the most important goals in managing facial lacerations is to achieve an

optimal cosmetic outcome. This is because the primary concern of the patient is mainly the appearance of the scar. The aim of this study was to compare the cosmetic outcome of through and through lacerations combined with fracture management in emergency versus elective settings. A total of 128 cases were randomly selected to be treated in an emergency setting (Group A, 64) or elective setting (Group B, 64). The wounds were evaluated after 6 months by a blinded observer, using Visual Analogue and Wound Evaluation Scales. In group B, 56.3% wounds were contaminated and 43.8% were clean contaminated, while in group A, 75% patients had contaminated wounds. Visual Analogue Scale showed that 54.7% cases had excellent outcome in Group A as compared to 18.8% in group B. Wound Evaluation Scales demonstrated

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that group A possessed a better cosmetic outcome of 48.4%, whereas 14.1% was observed in group B. Patients treated in an emergency setting had better cosmetic outcomes compared to those who were treated under elective conditions. Therefore it is recommended that through and through lacerations and fractures should be managed together and immediately.

Introduction

A significant percentage of emergency room and hospital admissions are due to facial injuries in isolation or in combination with other injuries (1).The average length of facial laceration with which a patient usually presents is about 2.67 cm (2). Most wounds are located on the head or neck (3,4). The most common mechanism of injury is the application of a blunt force, such as striking one’s head against a hard object. This type of contact crushes the skin against the underlying bone, causing it to split. Other causes of lacerations include sharp instruments, glass, wooden objects and animal bites (4).

Wounds are usually classified into clean, clean-contaminated, contaminated and dirty (5). A clean wound is an aseptic wound. Clean contaminated wounds involve colonised tissue, whereas contaminated wounds contain foreign or infected material. Old traumatic wounds with retained devitalised tissue are referred to as dirty wounds (6).

Facial lacerations warrant a meticulous approach due to their cosmetic importance. Patients are often concerned and disconcerted about the potential for scarring from facial lacerations (7-9). Most lacerations are managed by primary closure as this leads to rapid wound healing and less discomfort, compared to secondary healing. Suturing is the most commonly used method for laceration closure (10). Other techniques include staples, adhesive tapes, tissue adhesives etc(11).

The time from injury is an important factor in determining if a laceration should be closed primarily. However, controversy exists over when or if to close wounds that present late to the Emergency department. It has been argued that “old” lacerations should be considered contaminated and left open because of high levels of bacteria found 6 to 8 h after occurrence (12). Other researchers believe that lacerations that have not been grossly contaminated can be repaired without a significant increase in wound infection up to 12 h after the


injury (14,15). Dirty and high energy wounds such as gunshot wounds, human bites and wounds with deeply embedded dirt should not be closed immediately because of concerns about wound infection (15).

Most lacerations can be managed with local anaesthesia, but patients with fractures and extensive soft tissue injuries are better managed with general anaesthesia. Copious wound irrigation with normal saline or tap water washes away foreign matter and dilutes the bacterial concentration to decrease infection. Warmed irrigation solution is more comfortable for the patient. It has been argued that povidone-iodine solution, hydrogen peroxide and detergents should not be used because their toxicity to fibroblasts impedes healing (15).

Suturing is the preferred technique for laceration repair. Absorbable sutures are used deep. Optimal cosmetic results can be achieved by using the finest suture possible, depending upon skin thickness and wound tension. In general, 4–0 or 5–0 on the extremities and scalp, and 5–0 or 6–0 on the face are used (16).

Materials and MethodsThe calculated sample size was 128

cases with 95 % confidence level and 0.5 % margin of error. Approval from Local Ethics Committee (Institutional

Ethics Board) of Allama Iqbal Medical College / Jinnah Hospital Lahore (AIMC/JHL) was obtained prior to conduction of this study. All patients presenting to the Emergency room of Jinnah Hospital Lahore and fulfilling the inclusion criteria were included in this study from Jun 01 until Dec 31, 2015. Patient’s demographic data was recorded on a questionnaire after taking informed consent.

Inclusion / exclusion criteria are listed in Table 1. Patients were divided into two equal groups, A and B, and were randomly selected to be treated under an emergency or elective setting respectively. In the emergency setting (Group A), through and through lacerations and facial fractures were managed simultaneously under general anaesthesia in the emergency room, whereas in elective setting (Group B), only the through and through lacerations were managed at the time of presentation in the emergency room under local anaesthesia. The facial fractures were treated electively at a week's interval under general anaesthesia. Mandibular fractures were temporarily stabilised with dental wiring (bridal wires, arch bar splinting, eyelet wiring and IMF/ MMF) under local anaesthesia before open reduction and internal fixation was undertaken on an elective operation. In our unit, the average waiting time for repair of all


fractures (including mandibles) can be up to 12 - 15 days and so this delay (although not ideal) fell within current accepted practice.

Tetanus toxoid was administered to the patient on presentation, if the immunisation history was unknown or they had received less than three doses in the last 10 years. Empirical antibiotic cover was also given for five days (Gram positive cover, 1 gram I/V Ceftriaxone, Gram negative cover, 80 mg I/V Gentamycin and anaerobic cover 500 mg I/V Metronidazole, injected after a test dose). The wound was irrigated with 1000cc of normal saline, followed by 5ml Hydrogen Peroxide diluted in 100ml normal saline. The wound was subsequently irrigated and washed by another 3000cc of normal saline and gently brushed.

Facial fractures were managed with mini plates and mini screws (2mm system). After repair the lacerations were closed in layers (muscle, then skin, then mucosa) using 4-0 vicryl for subcutaneous and muscle layers, 5-0 proline for skin and 3-0 vicryl for mucosa.

Patients were given the following post-operative instructions:

1 Gently wipe the suture lines three times daily with 0.9%Normal Saline

soaked gauze. After this, apply a liberal amount of Bacitracin ointment.

2 You may shower the second day following your repair. Use a gentle shampoo.

3 At 6 weeks after suture removal massage the wound, preferably with a non- irritant oil.

4 Report immediately any signs of bleeding that persist for more than ten minutes, redness, fever, unusual drainage, or pain.

5 The non-absorbable sutures from face should be removed on 5th day followed by adhesive strips (steri-strips) application for 3 days, whereas, from scalp, sutures will be removed on 7th day. Please contact our office to schedule this appointment.

6 Eat a well balanced diet.

ResultsThe collected information was

transferred to SPSS (Statistical Package for the Social Sciences) version 20.0. The results were presented in the form of frequencies and percentages. All the 128 patients were included in the study with age ranging between 18 & 69. In group A, mean age was 40±13.06 and in group B mean age was 42.03±11.32. In both group A&B, 76.6% patients were males and 23.4% were females. Most common


aetiology of trauma was RTA in both groups. (Table 3)

In group B, 56.3% wounds were contaminated and 43.8% were clean contaminated, while in group A, 75% patients had contaminated wounds. In both groups the average length of lacerations ranged from 4-6cm. Cheek was the most common location of laceration in both groups (Table 4).

Cosmetic outcome, as evaluated by an independent observer, by using VAS showed that 35 patients of group A had very good outcome followed by 22 patients with good outcome. In group B, 27 patents were marked as good followed by 16 patients of average category. A significant association between group A and cosmetic outcome ( Chi sq value: 24.11, P-value:0.0001) as compared to group B was noted by the observer (Table: 5).

The overall score of WES showed that 31 patients of group A had high outcome followed by 25 patients with median outcome. In group B, 37 patients had median outcome and only 9 patients had high outcome (Table 6). These results showed a statistically significant correlation between group A and WES as compared to group B (Chi sq value:18.269, p-value:0.0001) (Table 7).

DiscussionThe most important consideration for

the patient presenting with facial lacerations and fractures is the cosmetic appearance. This is often considered as a primary concern (17). MVC was found as the most common cause of injury. The second and third most common aetiologies in our study were assaults and falls which are comparable with other reports from regional countries such as India (18). Facial laceration is typically considered a problem affecting primarily in young urban males. But in our study we found that age 21-50 was most affected, with a mean age of 41.01±12.22. The absolute increase in trauma victims in elderly population relates to more active life style, increased life expectancy, a more inclined percentage of geriatric persons in the general population and poor compliance to the road traffic laws in under developed and developing countries. The present study showed 76.6% of patients were males, an almost universal finding in many countries like Canada, Poland, Nigeria and UAE (19,20). This is attributed to the fact that men are more involved outdoor activities and more frequently involved in violent interactions and alcohol abuse. Furthermore, male vehicle drivers outnumber female drivers.


Subjective and objective assessment of the wound cosmetically can be done by using different methods such as WES or VAS (21, 22) or questionnaire methods. We used VAS in our study because of its easy of reproducibility, simplicity and sensitivity. Despite the benefits of VAS its results can be difficult to interpret. There is no criterion standard with which to measure and test validity. Thus VAS must be combined with descriptive measures and outcomes that can help to define the numerical values of scale and improve the validity. We therefore combined VAS with WES which assesses these various clinical variables. Our results found a significant difference in cosmetic outcomes between the two groups. Group A found to have better cosmetic outcomes compare to group B on the basis of VAS. Observer bias was controlled by blinding pre and post operatively.

Group A was found to be superior in cosmetic outcome compared to group B by an independent observer on WES. This statistical significant difference was found on the basis of overall cosmetic outcome total score of 6 different components as shown by p value and chi sq value. In group A most patients achieved a high WES score 5-6, followed by medium outcome 3-4. However in group B, medium outcome was predominantly common, which is presumably due to the re-opening of

stitched lacerations in order to access and treat the fractures. This in turn leads to less fine wound margins and sub-optimal scar.

Cosmetic outcome in Group A patients was better i.e. when lacerations and fractures were managed together in the emergency room. This may have been due to restricted invasion of bacteria to the wound site and less swelling, making surgical access to the fracture area easier (with less stripping of the periosteum and overlying soft tissues). Moreover, the importance of a stable bony base cannot be understated for an optimal soft tissue healing. Underlying fractures should be stabilised to maintain vascular integrity and prevent ischaemia. If these considerations are not met early in management, poorer results with extensive soft tissue scarring and compromised osseous healing may occur. Furthermore, suboptimal healing events in the tissues can make future attempts at restoration very difficult.

The limitation of our study was that an independent observer observed the scales and his opinion might differ with that of patient. But allowing the patients to assess their wound has methodological problems. It is impossible to blind the patients to the treatment of their wound and thus difficult to control observer bias.


Moreover in our study there was only one observer.

The final cosmetic and functional result of closure of a facial wound is many times determined by the promptness and appropriateness of initial care. To prevent infection and promote healing, an antibiotic or white petrolatum ointment can be applied daily to wounds not repaired with tissue adhesives (23,24). Facial sutures are removed more quickly in order to prevent “railroad tracks” from forming. These generally occur when sutures are left in place greater than 8 days after wound repair. After removing sutures from the face, applying skin tape to decrease the likelihood of dehiscence, as wound tensile strength is extremely low this early in healing (25).

The results of our study suggest that patients treated in the emergency setting had a higher cosmetic outcome in comparison to those who were treated under elective setting according to Visual Analogue and Wound Evaluation scales. Thus, it is best for the patients

that their through and through facial lacerations and fractures be managed together at the time of presentation in emergency room with copious irrigation, fracture reduction, fixation and layered closure of the wound.

Learning points1 Obtain a detailed history and assess for risk factors associated with poor wound healing.

2 Optimise the procedure by ensuring adequate resources.

3 Determine the most appropriate method of anaesthesia.

4 Thoroughly explore, irrigate, and debride all wounds.

5 Manage facial lacerations and fractures in a single setting as soon as possible.

6 Educate the patient on proper aftercare, and on the unavoidable nature of scar formation.

Conflict of interest

The authors declare that they have no competing interests.

Consent statement

Written informed consent was obtained from the patients for publication of this study and accompanying images.


Table 1: Inclusion and Exclusion Criteria

Table 2: Wound Evaluation Scale

Table 3: Distribution of Mode of injury in Group A and B

Inclusion Criteria Exclusion Criteria

Age 11 to 70 years Below 11 or above 70 years

Patients from both genders

Systemically compromised patients e.g patients with diabetes , chronic renal fa i lure , malnutrition, immunosuppressive medication, and inherited or acquired connective tissue disorder.

Patients with through and through facial lacerations and Maxillofacial fractures

Patients without through and through lacerations or not having maxillofacial fractures along with lacerations.

Patients with informed consent Patients without informed consent

Dirty wounds

1-Step off borders 0 for yes, 1 for no

2-Contour irregularity-puckering 0 for yes, 1 for no

3-Scar width greater than 2mm 0 for yes, 1 for no

4-Edge inversion-sinking, curling 0 for yes, 1 for no

5-Inflammation-redness,discharge 0 for yes, 1 for no

6-Overall cosmesis 0=poor, 1=acceptable

Mode of injury Group A Group B

Road traffic accident (RTA) 33 21

Interpersonal Violence (IPV) 10 15

Fall 3 8


Table 4: Distribution of location of lacerations in group A and B

Table 5: Visual Analogue Scale results in Group A and B

Industrial Accident 3 7

Blast Injury 5 4

Gun Shot 3 4

Axe Injury 4 1

Crush Injury 1 2

Mechanical Injury 1 1

Stab Injury 1 1

Location Group A Group B

Cheek 25 17

Chin 14 8

Lips 7 8

Nose 11 16

Orbit 1 3

Forehead 6 12

Visual Analogue Scale Therapeutic Intervention

Group A Group B

0-20 0 8

21-40 6 16

41-60 22 27

61-80 35 12

81-100 1 1

Total 64 64


Table 6: Results of WES components in group A and B

Table 7: WES Cosmetic outcome in Group A and B

Name of the component Group A Group B Chi-sq Value P - Value

Step off border 37 21 8.07 0.004

Contour Irregularity 44 29 7.17 0.007

Scar Width 33 16 9.15 0.002

Edge Inversion 42 22 12.50 0.0001

Inflammation 11 10 0.057 0.811

Overall cosmesis 16 14 0.114 0.676

Wound Evaluation Scale

Therapeutic Intervention

Group A Group B

1-2 (low outcome) 8 18

3-4 (medium outcome) 25 37

5-6 (high outcome) 31 9

Total 64 64


Figure 1a) Pre-operative, b) Six months follow up




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Accepted October 2016

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