PST wounds II category

A deep tear, a dog bite, a dirty wound or one with tissue loss is no longer a simple cut. Here it is essential to preserve the facial muscles, nerves, salivary ducts and the shape of the face. At UKRMED Maxillofacial Surgery, surgeon Anna Kravchenko performs complex primary treatment of facial wounds.

What category II includes

• large lacerations and bruised tears with ragged edges;
• wounds penetrating muscle or the mouth;
• wounds contaminated with soil, glass or wood;
• bite wounds;
• wounds with tissue loss;
• wounds with possible injury to facial nerve branches or a salivary duct.

Small superficial wounds are category I.

What makes it complex

A deep wound needs exploration: the surgeon examines all tissue layers to check nerves and ducts and look for foreign bodies and fractures. Loss of facial movement or sensation is visible before anaesthesia, so the examination starts by testing function. CT is ordered to assess the bones; with a jaw fracture, wound treatment is combined with reduction and fixation of the fragments.

Contaminated wounds

Dirt and small particles are the main cause of infection and of "tattooing" of the scar with dark specks. The wound is therefore irrigated thoroughly, all particles are removed and non-viable edges are trimmed sparingly. On the face, the surgeon preserves as much tissue as possible — the blood supply is good and most tissue recovers.

Bite wounds of the face

Bite wounds used to be left open for fear of infection. A meta-analysis of randomised trials found that primary closure of dog bite wounds does not increase infection overall, and facial wounds become infected less often than limb wounds. So after thorough irrigation, facial bite wounds are usually closed straight away, giving a better cosmetic result. An antibiotic is added.

After an animal bite, the WHO advises deciding on rabies vaccination — see an emergency department or infectious disease doctor on the day of the bite. Tetanus protection is also checked.

The procedure

1. Anaesthesia: local, sedation or general anaesthesia supervised by an anaesthesiologist, depending on the extent.
2. Wound exploration and assessment of deep structures.
3. Thorough irrigation and removal of foreign bodies.
4. Sparing excision of non-viable tissue.
5. Layered closure: lining, muscle, subcutaneous layer, skin.
6. Closure of defects with local tissue.
7. A drain if needed.

Recovery

• Scheduled check-ups and dressings.
• Facial stitches are removed after 5–7 days, mucosal stitches after 7–10 days.
• Antibiotics, if prescribed, as a full course.
• Protect the scar from the sun for at least six months.

The scar matures over about a year. If it remains noticeable, scar revision can help.

What to do before reaching the surgeon

• Press the wound with clean gauze or cloth for 10–15 minutes without lifting it to check.
• Rinse the wound with plenty of clean water, especially after a bite. Do not pour alcohol or iodine into the wound.
• Wrap a detached piece of tissue — ear, lip or nose — in damp gauze, place it in a bag and put the bag on ice. Do not put tissue directly on ice.
• Do not tape a deep wound or stitch it at home.

Risks and complications

• Infection — higher for bite and contaminated wounds, so an antibiotic and check-ups are prescribed.
• Salivary fistula — if the parotid duct is injured, saliva leaks through the wound. The duct is repaired during treatment, so it is checked in every cheek wound.
• Facial weakness — if a facial nerve branch is injured; the nerve is repaired as early as possible.
• Scar deformities — with tissue loss and on the lips; further correction is sometimes needed.

Prices at UKRMED

The surgeon gives the cost after examination: it depends on the size and depth of the wound, the extent of exploration and the anaesthesia.

Sources

1. Cheng H. T., Hsu Y. C., Wu C. I. Does primary closure for dog bite wounds increase the incidence of wound infection? A meta-analysis of randomized controlled trials. J Plast Reconstr Aesthet Surg, 2014. https://doi.org/10.1016/j.bjps.2014.05.051
2. Ali S. S., Ali S. S. Dog bite injuries to the face: A narrative review of the literature. World J Otorhinolaryngol Head Neck Surg, 2022. https://doi.org/10.1016/j.wjorl.2020.11.001
3. World Health Organization. Rabies. Fact sheet. https://www.who.int/news-room/fact-sheets/detail/rabies