Case Challenge: A Power Saw Cuts Into a Man's Face

Ronald N. Bogdasarian, MD; Mark S. Granick, MD

Disclosures

January 09, 2017

In order to correct a scar contracture, the scar should be removed and the line of the contracture must be lengthened. This is accomplished by a Z-plasty, which introduces lateral skin into the scarred area, lengthens the scar, and breaks up the line of contracture. Rhomboid flaps move skin into an adjacent defect using a rather geometric-appearing template, and they do not blend well into the neck skin. V-Y flaps are meant to transpose adjacent skin into a defect while hiding the scars in natural skin creases. The V-Y pattern does not break up the line of the contracture. A pedicled flap is not a skin transposition flap because it has a discreet vascular supply. A bilobed flap is meant to transpose tissue into a defect when the available adjacent tissue is insufficient.

The wound required thorough cleansing to remove blood, hematoma, debris, and grossly devascularized tissues. This process usually requires local anesthetics or regional field blocks. All bleeding sites must be well visualized prior to clamping or ligation. Important nerves often run adjacent to blood vessels, and these need to be carefully protected. Once bleeding is controlled, the skin injuries and deep tissues are assessed. Abrasive injuries often have ground-in debris, which must be removed by irrigation and scrubbing to avoid permanent tattooing from micro-debris.[11]

Once the patient is stabilized and the acute processes of the wound are controlled, treatment proceeds with a basic plan: to approximate edges and use only the available tissues in the most straightforward repair possible. One should minimize excision of any tissue other than crushed wound edges. Skin transposition flaps should be reserved for a later time. All layers and edges are approximated and closed to bring the tissues into alignment. The sutures should not be too tight because the tissues will swell and cause localized ischemia and increased scarring. Buried subcuticular and deep tissue absorbable sutures are helpful to minimize tension at the skin closure. Deep sutures, however, must be used judiciously because they can act as a nidus for infection. In general, small monofilament sutures are preferred for skin, although other techniques are available. Each of the subunits has specific important anatomic considerations.

The location of the nerves, blood vessels, and underlying deeper tissues must be understood in order to avoid iatrogenic injuries.

In this case, the patient was anesthetized with a regional bock involving the infraorbital nerves and the mental nerve. Additional field blocks were added as needed. The wound was thoroughly irrigated and debris removed. There was no abrasive component. The angular artery runs directly below the laceration. The labial artery was transected in the upper and lower lip. Bleeding was easily controlled once the field was cleaned. Minimal tissue removal was performed.

The key to reconstructing a defect that crosses the subunits is to identify the boundaries and to meticulously and precisely repair them (Figure 2). The boundaries here are the nasolabial fold, the vermillion borders, and the mental crease above the chin. First, the deeper tissues were approximated with an absorbable suture. Initially, the vermilion borders were approximated with key stitches. The left cheek required approximating sutures and subcuticular sutures for muscle closure. On the lip, the buccal mucosa needed to be closed and then the orbicularis muscle aligned. In the chin, the mentalis muscle and subcuticular tissues were repaired.

Figure 2. Repair of facial lacerations.

In each of the subunit boundaries, the skin edges were then precisely approximated. The lip vermillion needed to be lined up at the cutaneous junction at the level of the white roll. On the red part of the lip, the dry and moist areas needed to be lined up as well.

The patient went on to heal uneventfully, with normal function and appearance (Figure 3). A small Z-plasty was performed 6 months later under the chin to release a band of scar crossing his submental crease. In general, it is best to wait at least 6 months prior to any revisions. Six months allows the scars to mature prior to recreating a new wound. [12]

Figure 3. Ten months after initial injury: repair well healed, vermilion border aligned, oral competence intact.

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