While traumatic facial wounds are treated in a similar fashion to wounds in other areas of the body, some aspects of facial wound management deserve special attention. Maxillofacial wounds sustained in combat typically involve both soft tissue and other structures including bone, teeth, cartilage, mucosa-lined structures (sinuses, mouth, etc.), eyes and the cranial vault. As such, maxillofacial wound management may be more complicated than soft tissue wounds in other parts of the body, and may warrant multidisciplinary care. Facial wounds and their management can significantly impact the patient’s airway, vision, and ability to speak and eat. Severe injuries to the midface or mandible may necessitate immediate airway control.

The robust, redundant blood supply of the facial region promotes healing and reduces the incidence of wound infection compared to the trunk and extremities. As with other wounds, the first step in facial wound management involves excellent hemostasis, profuse irrigation, and meticulous debridement. All clearly non-viable tissue must be sharply excised. Threatened but potentially viable tissue should be maintained – especially around the eyes. Given the rich vascular supply of this region, it is better to conserve as much tissue as possible during the initial debridement as opposed to aggressive, wide debridement. Primary closure, while contraindicated in wounds in other areas of the body, is acceptable for many wounds of the face. Consider use of fast-absorbing sutures in any patient with unreliable follow up. Large areas of missing tissue may be covered temporarily with dressings, taking care to keep the tissues moist. Consider local or regional flaps in the acute phase when there is exposed bone or cartilage. In high velocity injuries, the surgeon should conserve as much tissue as possible during the first surgery and allow the wound to demarcate. After several days of wound care, the resulting defect can be repaired using a musculocutaneous flap.20 Most importantly, the surgeon must cover all exposed bone and cartilage with vascularized tissue and an appropriate antibiotic ointment to prevent infections in these structures.

The use of NPWT/ROCF has not been well documented in the treatment of facial wounds but may be appropriate in some situations where there is extensive tissue loss. If a cerebrospinal fluid leak is suspected, this should be avoided. Foreign bodies, along with damaged bone and cartilage lacking periosteum and perichondrium, should be removed while carefully preserving the remaining viable tissues to the greatest extent possible. Antibiotics should be used for all facial wounds associated with sinus, nasopharyngeal or oropharyngeal injuries. Injuries to cartilaginous structures (i.e. ears, nose) are especially susceptible to Pseudomonas aeruginosa and Staphylococcus aureus infections. (Refer to the Infection Prevention in Combat-Related Injuries CPG.)