Management of Facial Fractures

Immediate Assessment

Before completing a detailed history and physical evaluation of the facial area, critical injuries that may be life threatening must be addressed. The first step in evaluating a trauma patient is to assess the patient’s cardiopulmonary stability by ensuring that the patient has a patent airway and that the lungs are adequately ventilated. Vital signs, including respiratory and pulse rates and blood pressure, should be taken and recorded. During this initial assessment (i.e., primary survey), other potentially life-threatening problems, such as excessive bleeding, should also be addressed. Immediate measures, such as pressure dressings, packing, and clamping of briskly bleeding vessels, should be accomplished as quickly as possible. An assessment of the patient’s neurologic status and an evaluation of the cervical spine should be completed next. Forces severe enough to cause fractures of the facial skeleton are often transmitted to the cervical spine. The neck should be temporarily immobilized until neck injuries have been ruled out. Careful palpation of the neck to assess possible areas of tenderness and a cervical spine radiographic series should be completed as soon as possible.

Treatment of head and neck injuries generally should be deferred until a thorough evaluation, assessment, and stabilization of the patient has been accomplished. However, some initial treatment is often necessary to stabilize the patient. Management of the patient’s airway is of vital importance. Frequently, fractures of the facial bones severely compromise the patient’s ability to maintain the airway, particularly when the patient is unconscious or completely supine. Severe mandible fractures, especially bilateral or comminuted fractures, can cause posterior displacement of the mandible and tongue, which results in obstruction of the upper airway (Fig. 24-1).

Simply grasping, repositioning, and stabilizing the mandible into a more anterior position may alleviate this obstruction. Placement of a nasopharyngeal or an oropharyngeal airway may also be sufficient to temporarily maintain a patent airway. In some cases, endotracheal intubation may be necessary. Any prosthetic devices, avulsed teeth, pieces of completely avulsed bone, or other debris may also contribute to airway occlusion and must be removed immediately. Any areas of bleeding should be quickly examined and managed with packing, pressure dressings, or clamping. All excess saliva and blood must be suctioned from the pharynx to avoid aspiration and laryngospasm.

Injuries to the facial region may involve not only bones of the face but also soft tissue, such as the tongue or upper neck areas, or they may be associated with injuries such as a fractured larynx.² In some cases an emergency tracheostomy may be necessary to provide an adequate airway. In trauma patients who have complete upper airway obstruction, a cricothyrotomy is the most rapid way to access the trachea (Fig. 24-2).

History and Physical Examination

After the patient has been initially stabilized, as complete a history as possible should be obtained. This history should be obtained from the patient; however, because of loss of consciousness or impaired neurologic status, information must often be obtained from witnesses or accompanying family members. Five important questions should be considered: (1) How did the accident occur? (2) When did the accident occur? (3) What are the specifics of the injury, including the type of object contacted, the direction from which contact was made, and similar logistic considerations? (4) Was there a loss of consciousness? (5) What symptoms are now being experienced by the patient, including pain, altered sensation, visual changes, and malocclusion? A complete review of systems, including information about allergies, medications, and previous tetanus immunization, medical conditions, and prior surgeries should be obtained.

Physical evaluation of the facial structures should be completed only after an overall physical assessment that addresses cardiopulmonary and neurologic functions and other areas of potential trauma, including the chest, abdomen, and pelvic areas. Because patients with multiple severe injuries frequently require evaluation and treatment by several specialists, trauma teams have become standard in the emergency departments of major hospitals. These teams usually include general surgeons and specialists in cardiothoracic surgery, vascular surgery, orthopedic surgery, neurosurgery, and anesthesiology; these specialists are on call to provide immediate attention to emergency department patients. Other trauma team specialists include oral and maxillofacial surgeons, ophthalmologists, otolaryngologists, plastic surgeons, and urologists. The combined efforts of these specialists are frequently required to assess and treat the patient’s injuries properly.

Evaluation of the facial area should be performed in an organized and sequential fashion. The face and cranium should be carefully inspected for evidence of trauma, including lacerations, abrasions, contusions, areas of edema or hematoma formation, and possible contour defects. Areas of ecchymosis should be carefully evaluated.

Periorbital ecchymosis, especially with subconjunctival hemorrhage, is often indicative of orbital rim or zygomatic complex fractures (Fig. 24-3). Bruises behind the ear, or Battle’s sign, suggest a basilar skull fracture. Ecchymosis in the floor of the mouth usually indicates an anterior mandibular fracture.

A neurologic examination of the face should include careful evaluation of all cranial nerves. Vision, extraocular movements, and pupillary reaction to light should be carefully evaluated. Visual acuity or pupillary changes may suggest intracranial (cranial nerve II or III dysfunction) or direct orbital trauma. Uneven pupils (anisocoria) in a lethargic patient suggest an intracranial bleed (subdural or epidural hematoma or intraparenchymal bleed) or injury. An asymmetric or irregular (not round) pupil is most likely caused by a globe (eyeball) perforation. Abnormalities of ocular movements may also indicate central neurologic problems (cranial nerves III, IV, or VI) or mechanical restriction of the movements of the eye muscles resulting from fractures of the orbital complex (Fig. 24-4). Motor function of the facial muscles (cranial nerve VII) and muscles of mastication (cranial nerve V) and sensation over the facial area (cranial nerve V) should be evaluated. Any lacerations should be carefully cleaned and evaluated for possible transection of major nerves or ducts, such as the facial nerve or Stensen’s duct.

The mandible should be carefully evaluated by extraorally palpating all areas of the inferior and lateral borders and the temporomandibular joint, paying particular attention to areas of point tenderness. The occlusion should be examined, and step deformities along the occlusal plane and lacerations of gingival areas should be assessed (Fig. 24-5). Bimanual palpation of the suspected fracture area should be performed by placing firm pressure over the mandible posterior and anterior to the fracture area in an attempt to manipulate and elicit mobility in this area. The occlusion should be reexamined after this maneuver. Mobility of the teeth in the area of a possible fracture should also be noted.

The evaluation of the midface begins with an assessment of the mobility of the maxilla as an isolated structure or in combination with the zygoma or nasal bones. To assess maxillary mobility, the patient’s head should be stabilized by using pressure over the forehead with one hand. With the thumb and forefinger of the other hand, one grasps the maxilla; firm pressure should be used to elicit maxillary mobility (Fig. 24-6).

The upper facial and midfacial regions should be palpated for step deformities in the forehead, orbital rim, or nasal or zygoma areas. Firm digital pressure over these areas is used to carefully evaluate the bony contours and may be difficult when these areas are grossly edematous. In checking for a zygomatic complex or arch fracture, an index finger can be inserted in the maxillary vestibule adjacent to the molars while palpating and applying pressure superolaterally. Bony crepitus (the ability to feel the vibration as fractured bone edges are rubbed against one another) or extreme tenderness warrants a further workup. An evaluation of the nose and paranasal structures includes measurement of the intercanthal distance between the innermost portions of the left and right medial canthus. Frequently, nasoorbital ethmoid injuries cause spreading of the nasal bones and displacement of the medial canthal ligaments, resulting in traumatic telecanthus (widening of the medial intercanthal distance; Fig. 24-7). Normally, the medial intercanthal distance should equal the alar base width. The nose should also be evaluated for symmetry. The bony anatomy of the nose should be evaluated by palpation. A nasal speculum is used to visualize internal aspects of the nose to locate excessive bleeding or hematoma formation, particularly in the area of the nasal septum.

Intraoral inspection should include an evaluation of areas of mucosal laceration or ecchymosis in the buccal vestibule or along the palate and an examination of the occlusion and areas of loose or missing teeth. These areas should be assessed before, during, and after manual manipulation of the mandible and midface. Unilateral occlusal prematurities with contralateral open bites are highly suspicious for some type of jaw fracture.

Radiographic Evaluation

After a careful clinical assessment of the facial area, radiographs should be taken to provide additional information about facial injuries.³ In cases of severe facial trauma, cervical spine injuries should be ruled out with a complete cervical spine series (i.e., cross-table, odontoid, and oblique views) before any manipulation of the neck. The facial radiographic examination should depend to some degree on the clinical findings and the suspected injury. Haphazard or excessive radiographic examination is generally not warranted. In the patient with facial trauma, the purpose of radiographs should be to confirm the suspected clinical diagnosis, obtain information that may not be clear from the clinical examination, and more accurately determine the extent of the injury. Radiographic examination should also document fractures from different angles or perspectives.

Radiographic evaluation of the mandible generally requires two or more of the following four radiographic views: (1) panoramic view, (2) open-mouth Towne’s view, (3) posteroanterior view, and (4) lateral oblique views (Fig. 24-8). Occasionally, even these radiographs do not provide adequate information; therefore, supplemental radiographs, including occlusal or periapical views, may be helpful.³ Computed tomography (CT) scans, axial views without intravenous contrast medium, may provide information not obtainable from plain radiographs or when cervical spine precautions or other injuries do not permit standard facial films. Because many patients with facial trauma often receive a CT scan to rule out neurologic injury, this scan can also be used to supplement the radiographic evaluation.

Evaluation of midface fractures was often supplemented with radiographic views, including Waters’ view, lateral skull view, posteroanterior skull view, and submental vertex view (Fig. 24-9). However, because of the difficulty of interpreting plain radiographs of the midface, more sophisticated techniques are generally used. These techniques often include CT scans done in several planes of space (e.g., axial and coronal) or, frequently with three-dimensional reconstruction (Fig. 24-10).⁴

Causes of Facial Fractures

The major causes of facial fractures include motor vehicle accidents and altercations. Other causes of injuries include falls, sports-related incidents, and work-related accidents.^5,6 Facial fractures resulting from motor vehicle accidents are far more frequent in persons who were not wearing restraints at the time of the accident.

Mandibular Fractures

Depending on the type of injury and the direction and force of the trauma, fractures of the mandible commonly occur in several locations. One classification of fractures describes mandibular fractures by anatomic location. Fractures are designated as occurring in the condylar, ramus, angle, body, symphyseal, alveolar, and, rarely, coronoid process areas. Figure 24-11 illustrates the location and frequency of different types of mandibular fractures.⁷

Another system of classification of mandibular fractures categorizes the type of fracture as greenstick, simple, comminuted, and compound fractures (Fig. 24-12). These categories describe the condition of the bone fragments at the fracture site and possible communication with the external environment. Greenstick fractures are those involving incomplete fractures with flexible bone. Greenstick fractures generally exhibit minimal mobility when palpated and the fracture is incomplete. A simple fracture is a complete transection of the bone with minimal fragmentation at the fracture site. In a comminuted fracture the fractured bone is left in multiple segments. Gunshot wounds, penetrating objects, and other high-impact injuries to the jaws frequently result in comminuted fractures. A compound fracture results in communication of the margin of the fractured bone with the external environment. In maxillofacial fractures, communication with the oral or external environment may result from mucosal tears, perforation through the gingival sulcus and periodontal ligament, communication with sinus linings, and lacerations in the overlying skin. By definition, any jaw fracture within a tooth-bearing segment is an open or compound fracture.

Fractures of the mandible are referred to as favorable or unfavorable, depending on the angulation of the fracture and the force of the muscle pull proximal and distal to the fracture. In a favorable fracture, the fracture line and the muscle pull resist displacement of the fracture (Fig. 24-13). In an unfavorable fracture, the muscle pull results in displacement of the fractured segments.

Midface Fractures

Midfacial fractures include fractures affecting the maxilla, the zygoma, and the nasoorbital-ethmoid (NOE) complex. Midfacial fractures can be classified as Le Fort I, II, or III fractures, zygomaticomaxillary complex fractures, zygomatic arch fractures, or NOE fractures. These injuries may be isolated or occur in combination.⁸

The Le Fort I fracture frequently results from the application of horizontal force to the maxilla, which fractures the maxilla through the maxillary sinus and along the floor of the nose. The fracture separates the maxilla from the pterygoid plates and nasal and zygomatic structures (Fig. 24-14, A). This type of trauma may separate the maxilla in one piece from other structures, split the palate, or fragment the maxilla. Forces that are applied in a more superior direction frequently result in Le Fort II fractures, which is the separation of the maxilla and the attached nasal complex from the orbital and zygomatic structures (Fig. 24-14, B). A Le Fort III fracture results when horizontal forces are applied at a level superior enough to separate the NOE complex, the zygomas, and the maxilla from the cranial base, which results in a so-called craniofacial separation (Fig. 24-14, C). Invariably, midfacial fractures are hybrids or combinations of the previously mentioned injuries.

The most common type of midfacial fracture treated in the operating room setting is the zygomatic complex fracture (Fig. 24-15, A). This type of fracture results when an object, such as a fist or a baseball, strikes the lateral aspect of the cheek. Similar trauma can also result in isolated fractures of the nasal bones, the orbital rim, or the orbital floor areas. Blunt trauma to the eye can result in compression of the globe and subsequent blow-out facture of the orbital floor (Fig. 24-16). The zygomatic arch may also be affected, alone or in combination with other injuries (Fig. 24-15, B and C).

Mandibular Fractures

The first and most important aspect of surgical correction is to reduce the fracture properly or place the individual segments of the fracture into the proper relationship with each other. In the proper reduction of fractures of tooth-bearing bones, it is most important to place the teeth into the preinjury occlusal relationship. Merely aligning and interdigitating the bony fragments at the fracture site without first establishing a proper occlusal relationship rarely results in satisfactory postoperative functional occlusion.

Establishing a proper occlusal relationship by wiring the teeth together is termed maxillomandibular fixation (MMF) or intermaxillary fixation (IMF). Several techniques have been advocated for IMF (Fig. 24-18). The most common technique includes the use of a prefabricated arch bar that is adapted and circumdentally wired to teeth or acid-etch bonded in each arch; the maxillary arch bar is wired to the mandibular arch bar, thereby placing the teeth in their proper relationship. Other wiring techniques, such as Ivy loops or continuous loop wiring, have also been used for the same purpose. When fractures have not been treated for several days or are grossly displaced, it may be difficult to place the fractured segments immediately into their proper position and into adequate IMF. Heavy elastic traction can be used to pull the bony segments into their proper positions gradually over several hours or a few days (Fig. 24-19). Treatment of fractures using only IMF is called closed reduction because it does not involve direct opening, exposure, and manipulation of the fractured area.

In the case of a fracture of an edentulous patient, the mandibular dentures can be wired to the mandible with circummandibular wiring, and the maxillary denture can be secured to the maxilla using wiring techniques or bone screws to hold the denture in place. The maxillary and mandibular dentures can then be wired together, which produces a type of IMF. In many instances, the totally edentulous fracture patient undergoes open reduction and internal fixation with anatomic alignment (Fig. 24-20). After an appropriate period of healing (minimum of 4 to 6 weeks), new dentures can be fabricated.

A splinting technique that can be used for dentate patients involves the use of a lingual or occlusal splint (Fig. 24-21). This technique is particularly useful in treatment of mandibular fractures in children in whom placement of arch bars and bone plates is difficult because of the configuration of the deciduous teeth, because of developing permanent teeth, and because patient understanding and cooperation is difficult to obtain. After a complete clinical and radiographic examination, all fractures and soft tissue injuries should be identified and categorized. Then, with input from the patient and the patient’s family, a treatment plan should be developed as to method and sequencing of surgery. Discussion regarding closed versus open reduction, any period of IMF, and anticipated morbidity should lead to a decision, and surgical consent should be obtained.

After completing a closed reduction of the mandible and placing the dental component or alveolar process into the proper relationship with the maxilla, the necessity for an open reduction (i.e., direct exposure and reduction of the fracture through a surgical incision) must be determined. If adequate bony reduction has occurred, IMF may provide adequate stabilization during the initial bony healing phase of approximately 6 weeks. Indications for open reduction include continued displacement of the bony segments or an unfavorable fracture, such as in an angle fracture (Fig. 24-13), in which the pull of the masseter and medial pterygoid muscles can cause distraction of the proximal segment of the mandible. With rigid fixation techniques, patients can be allowed to heal without undergoing IMF or at least a decreased time of IMF. This alone may be an important factor in the decision to perform an open reduction. In most instances, patients opt to undergo open reduction and internal fixation, which allows an earlier return to more normal function without IMF.

In some cases it is not be necessary to achieve an ideal anatomic reduction of the fracture area. This is especially true of the condylar fracture. In this fracture, minimal or moderate displacement of the condylar segment generally results in adequate postoperative function and occlusion (but only if a proper occlusal relationship was established during the period of healing of the fracture site). In these cases, IMF is used for a maximum of 2 to 3 weeks in adults and 10 to 14 days in children, after which there is a period of aggressive functional rehabilitation. Longer periods of IMF can lead to bony ankylosis or fibrosis and severe limited mouth opening. When there is significant anatomic displacement of the condylar segment, the outcome of treatment may be improved with open reduction and rigid fixation.¹¹

When open reduction is performed, direct surgical access to the area of the fracture must be obtained. This access can be accomplished through several surgical approaches, depending on the area of the mandible fractured. Intraoral and extraoral approaches are possible. Generally, the symphysis and anterior mandible areas can be easily approached through an intraoral incision (Fig. 24-22), whereas posterior angle or ramus and condylar fractures are more easily visualized and treated through an extraoral approach (Fig. 24-23). In some cases, posterior body and angle fractures can be treated through a combination approach using an intraoral incision combined with insertion of a small trocar and cannula through the skin to facilitate fracture reduction and fixation (Fig. 24-24). In either case a surgical approach should avoid vital structures such as nerves, ducts, and blood vessels and should result in as little scarring as possible.

The traditional and still acceptable method of bone fixation after open reductions has been the placement of direct intraosseous wiring combined with a period of MMF ranging from 3 to 8 weeks. This method of fixation can be accomplished through a variety of wiring techniques (e.g., wire osteosynthesis) and is often sufficient to maintain the bony segments in the proper position during the time of healing (Fig. 24-25). If wire osteosynthesis is used for fixation and stabilization of the fracture site, continued immobilization with IMF (generally 4 to 6 weeks) is required until adequate healing has occurred in the area of the fracture.

Currently, techniques for rigid internal fixation are widely used for treatment of fractures.¹² These methods use bone plates, bone screws, or both to fix the fracture more rigidly and stabilize the bony segments during healing (Figs. 24-26 and 24-27). Even with rigid fixation, a proper occlusal relationship must be established before reduction and fixation of the bony segments. Advantages of rigid fixation techniques for treatment of mandibular fractures include decreased discomfort and inconvenience to the patient because IMF is eliminated or reduced, improved postoperative nutrition, improved postoperative hygiene, greater safety for patients with seizures, and frequently, better postoperative management of patients with multiple injuries.

Midface Fractures

Treatment of fractures of the midface can be divided into those fractures that affect the occlusal relationship—such as Le Fort I, II, or III fractures—and those fractures that do not necessarily affect the occlusion, such as fractures of an isolated zygoma, zygomatic arch, or nasoorbital-ethmoid (NOE) complex.

In zygoma fractures, isolated zygomatic arch fractures, and NOE fractures, treatment is primarily aimed at the restoration of normal ocular, nasal, and masticatory function and facial esthetics. In an isolated zygoma fracture (the most common midfacial injury), an open reduction is generally performed through some combination of intraoral, lateral eyebrow or infraorbital approaches. An instrument is used to elevate and place the zygoma into the proper position. If adequate stabilization is not possible by simple manual reduction, bone plating of the zygomaticomaxillary buttress, zygomaticofrontal area, and the inferior orbital rim area may be necessary (Fig. 24-28).

In a zygomatic arch fracture, an extraoral or an intraoral approach can be used to elevate the zygomatic arch and return it to its proper configuration. In addition to restoring adequate facial contour, this approach eliminates the impingement on the coronoid process of the mandible and the subsequent limitation of mandibular opening. Elevation and reduction of the zygomatic arch should be performed within several days of the injury. Longer delays make maintaining the arch in a stable supported configuration difficult, and it tends to collapse or drift to its injured position.

The goal of treatment for NOE fractures is to reproduce normal nasolacrimal and ocular function while repositioning the nasal bones and medial canthal ligaments into an appropriate position to ensure normal postoperative esthetics. In these situations, open reduction of the NOE area is usually necessary. Wide exposure to the supraorbital rim and nasal, medial canthal, and infraorbital rim areas can be achieved through a variety of surgical approaches. The most popular approach currently in use is the coronal flap, which allows exposure of the entire upper facial and nasoethmoidal complex through a single incision that can be easily hidden in the hairline (Fig. 24-29).¹³ Small bone plates and direct transnasal wiring appear to be most effective in stabilizing and maintaining bony segments in these types of injuries.

In midfacial fractures involving a component of the occlusion, as in mandibular fractures, it is important to reestablish a proper occlusal relationship by placing the maxilla into the proper occlusion with the mandible. This step is accomplished by methods identical to the various types of IMF for mandibular fractures. However, as with mandibular fractures, reestablishing the occlusal relationship may not provide adequate reduction of the fractures in all areas. In addition to the need for anatomic reduction, additional stabilization of the fracture sites is often required.

When adequate bony reduction occurs after IMF but the fracture remains unstable, direct wiring, suspension wiring techniques, or bone plates may be used to stabilize the fracture. An example of such a case is a Le Fort I, II, or III midfacial fracture with an intact mandible. By placing the patient in IMF, any movement of the mandible tends to dislodge the midfacial bones. Direct wiring techniques (i.e., wire osteosynthesis) or bone plates (i.e., rigid fixation) attempt to fixate the individual fractures directly.

Suspension wiring is sometimes used in addition to direct wiring or bone plating. The purpose of suspension wiring is to provide stabilization of fractured bones by suspending them to a more stable bone superiorly.¹⁴ Suspension wiring techniques include those with wires attached to the piriform rim area, infraorbital rims, zygomatic arch, or frontal bone (Fig. 24-30). The suspension wires can be connected directly to the maxillary arch wire, or they can be connected with an intermediate wire to an interocclusal splint or to the mandible. These suspension wires prevent movement of the maxilla caused by the inferior pull of the mandible during attempted opening. The use of direct and suspension wire fixation does have significant limitations in many cases. The limited rigidity of wires may make it difficult to reconstruct and maintain the appropriate anatomic contours, particularly in concave and convex areas, such as orbital rims and the prominence of the zygoma. Wires may not provide adequate resistance to muscular forces during the entire healing period, eventually resulting in some fracture displacement. Rigid fixation using plating systems for the most part has eliminated the need for suspension wires.

The development and improvement in miniature and micro bone plate systems has greatly enhanced the treatment of midfacial fractures. These titanium alloy plates range in thickness from 0.6 to 1.5 mm and are secured by screws with 0.7- to 2.0-mm external thread diameters (Fig. 24-31). Each of the advantages listed for rigid fixation of mandibular fractures applies to midface fractures. In addition to these advantages, small bone plates have greatly improved the ability to obtain proper bony contours at the time of surgery. When limited to the use of direct-wiring or suspension-wiring techniques, reestablishing curve configurations of bony anatomy is nearly impossible, particularly in the areas of severely comminuted small bone fragments. Severely comminuted unstable midface fractures can now routinely be treated by wide exposure of all fractured segments combined with the use of bone plates to reestablish the facial pillars, develop adequate contours, and stabilize as many facial bone fragments as possible (Fig. 24-32). These titanium bone plates and screws are biocompatible and do not require removal at a second surgery unless they become palpable, infected, or interfere with secondary reconstructive surgery (e.g., bone grafting or implants).

Various polymers of polyglycolic acid and polylactic acid have been developed for resorbable plate and screw systems (Fig. 24-33).^15,16 Resorbable plating systems may be particularly desirable in pediatric and skull trauma, where growth and CT scan reimaging are considerations. However, because of the current designs, mechanical limitations, need for tapping, and cost, these systems are not routinely used. Use of bone plates and screws has also facilitated the use of immediate bone grafting to replace comminuted or missing bone segments at the time of surgery and to improve stabilization of comminuted segments.

Lacerations

The general guidelines for management of facial lacerations are outlined in Chapter 23. Frequently, fractures of the facial bones are associated with severe facial lacerations. The principles of laceration repair remain the same regardless of how small or large the injury.

Cleansing of the laceration and examination of the area for disruption of any vital structures is important. Possible injuries include lacerations of Stensen’s duct, the facial nerve, or major vessels. In these cases, attempts mus0t be made to reanastomose the duct, identify and perform a primary repair of the severed nerve, or manage all associated bleeding (Fig. 24-34). Examination for these injuries before injection of local anesthesia or induction of general anesthesia is important because structural integrity and function (i.e., facial motion and salivary flow) may not be assessable after anesthesia.

The lacerations should be closed from the inside out, that is, from the oral mucosa to the muscle to the subcutaneous tissue and skin. All closures should be completed in layers to orient tissues properly and to eliminate any dead space within the wound to prevent hematoma formation. Easily identifiable landmarks, such as the vermilion border of the lip, ala of the nose, or areas of the laceration that can be easily identified and properly repositioned, should be sutured first (Fig. 24-35), after which the surgeon should close areas where wound margins are not so clearly reapproximated. All wounds should be cleansed periodically with hydrogen peroxide. Some surgeons advocate including the use of antibiotic ointment in wound care. However, use of dry occlusive dressings, such as Steri-Strip coverings can be equally effective. Sutures from facial wounds are generally removed in 5 to 7 days, depending on the location of the wound and the amount of tension necessary to provide adequate wound closure.

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