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VII. Special Circumstances

A. Abrasions

Ensure that wounds are thoroughly cleansed and debrided.

Remove foreign material, especially dark particulate matter, while

wounds are open if possible, as it will lead to dermal tattooing.

Keep wounds moist with antibiotic ointments, and later petroleum

jelly, to promote epithelial migration and healing.

B. Avulsion Injuries

Avulsion injuries typically involve soft tissue appendages that are

focally anchored to the craniofacial skeleton. Tissue viability must be

assessed based on the mechanism of injury (i.e., blunt versus shearing

or laceration), ischemic time since injury, and method of preservation

and transport of the tissue. See the auricle discussion under section

V.C, above.

C. Facial Nerve Injuries

Physical examination must assess facial nerve status at the time of

presentation.

For blunt injuries that present with facial nerve paresis or paralysis,

see Chapter 6 for management of temporal bone trauma.

For penetrating soft tissue injuries with nerve paresis, close observa-

tion and the use of diagnostic testing, such as nerve excitability and

conduction tests, are warranted.

For penetrating injuries with facial nerve paralysis in the distribution

of the soft tissue trauma, nerve exploration is required.

Within 72 hours of injury, a nerve stimulator may assist in identifica-

tion of the distal segment prior to Wallerian degeneration.

Anastomosis of the proximal and distal segments is performed with

tension-free, epineurial repair using microscopic assistance.

If the segments are identified, but intervening tissue is lost, an

interposition nerve graft will be needed. Great auricular and sural

nerves are the donors of choice.

D. Bite Injuries

All bites should be considered contaminated wounds. Teeth from the

animal or human attacker are always a potential foreign body in any bite

wound. Bite injuries typically only involve soft tissue. However, the force

imparted in the bite may lead to bony trauma as well.

For small punctate penetrating wounds, it is preferable to excise the

puncture tract with a 2-, 3-, or 4-mm dermatologic punch, thereby

removing damaged and contaminated tissue. This clean, cylindrical