Uncompromising removal (brush) of foreign bodies embedded in the skin is of the utmost urgency as otherwise permanent traumatic tattooing results. This is followed by cleansing and disinfection of wound surfaces. Oozing hemorrhage is treated by administration of an astringent or hemostatic.

External agents with antibiotics are now obsolete. Bleeding abrasions are covered with an ointment compress or a sterile gauze compress. Wound dressings should not adhere to the wound and must ensure that the wound surface remains moist.

Fixation of the dressing is with a tubular dressing or cohesive gauze padding. Elastic bandage wraps, which are applied with slight pressure, are an alternative, as the compression effect supports re-epithelization.

Primary care of mild abrasions includes application of a spray dressing or a ready-made dressing and then open treatment. Attention should be paid to sufficient tetanus prophylaxis.

Objects firmly positioned in the wound must always be left in place until definitive treatment, in order to avoid heavy bleeding. It may be necessary to place padding around the object. A sterile bandage should be applied until definitive treatment.

Radiographs should be taken to determine the position of any radiopaque object firmly lodged in the wound. If damage to large vessels or nerve trunks is suspected, the penetrating object should only be removed with surgical standby. Following removal thorough clinical evaluation of the wound tract is necessary to determine extent and depth of the wound as well as to rule out injury to deeper organs, vessels, tendons, and nerves.

The wound may be closed after being cleaned, assuming there is no suspicion of contamination. Attention must be paid to ensuring good drainage. Perioperative antibiotic treatment is required in injuries of the pharynx or paranasal sinuses. Additional administration of antibiotics depends on the type of injury, tissue damage, and type of operation.

Careful documentation of position and direction of the wound tract is important if there is third party involvement. It is absolutely crucial that the penetrating object (e. g., knife) be secured. Attention should be paid to adequate tetanus prophylaxis.

Bleeding must be controlled with application of a light compression bandage. Attention should be paid to good coaptation of wound edges. If needed, wound edges can be coapted with wound closure strips.

The full extent of injury should be determined at the beginning of treatment. If neural injury is suspected (e. g., facial nerve), functional diagnosis is absolutely essential for identifying the extent of damage and to be able to perform primary reconstruction.

Cleansing of the wound follows with hydrogen peroxide and sterile sodium chloride solution.

Small, superficial wounds can be coapted with wound closure strips.

Superficial, clean, wounds with smooth margins are treated with layered wound closure and, if needed, drained for 24 hours.

The skin is closed using interrupted or intracutaneous continuous suturing and covered with a sterile dressing (dry protective dressing). Sutures are removed after between 5 days (lids) and 10 days (scalp). Deeper, older wounds must be explored and cleansed, followed by prudent excision of wound margins and drainage placement. For facial injuries, unlike wounds involving other body parts, primary wound closure can be attempted, even for older wounds. Attention should be paid to adequate tetanus prophylaxis.

A sterile protective bandage should be applied, or, in the case of hemorrhage, a sterile compression bandage.

Fig. 15.1 Bite wound to the nose with loss of skin and cartilage.

a Situation at the beginning of treatment: extensive loss of skin and cartilage.

b Closure of the skin defect, reconstruction of the bony/cartilaginous nasal skeleton with costal cartilage.

c Healed forehead flap, which was used for reconstruction of the external nose.

d View of the lateral aspect of the nose after separating the flap pedicle.

A compression bandage is used to achieve hemostasis. For extensive injury in the oral cavity, immediate intubation, tracheotomy, or, in an emergency, cricothyrotomy, is necessary.

Graze wound: Treatment is with mechanical cleansing of the wound to remove embedded foreign bodies. After ruling out associated injuries (e. g., nerves), primary wound closure, with grafting techniques if needed, should be attempted.

Through-and-through wounds and retained missiles: In retained missile wounds, the embedded foreign bodies must be removed (image amplifier). Endoscopic techniques are useful. For through-and-through injuries, the wound should be cleaned, drained, and any defect injuries managed. If there are extensive defect wounds, definitive treatment should be after a period of several days as secondary necrosis can occur with this pattern of injury.

Paintball injury: The penetration of foreign bodies into tissues requires ample, possibly repeated, wound cleansing, with the goal of complete removal of foreign material. Attention should be paid to adequate drainage of the wound area after closure.