Conservative Management of Lip Avulsion with Hydrocolloid Dressings in Three Cases

Summary

The protocol evaluates the efficacy of hydrocolloid dressing application in treating traumatic partial-thickness lip avulsion.

Abstract

Lip avulsion is a common orofacial trauma that poses challenges due to its aesthetic and functional implications. This retrospective case series evaluated the outcomes of three patients with partial-thickness traumatic lip avulsion managed using different wound healing approaches. Two patients underwent conservative treatment (secondary intention healing), including daily wound cleansing and application of hydrocolloid dressings. The hydrocolloid dressings could maintain a moist wound environment that promoted granulation formation and epithelialization while reducing infection risk. Both conservatively managed patients achieved favorable cosmetic and functional outcomes. The third patient initially underwent immediate wound suturing (primary intention healing), followed by wound dehiscence, necessitating subsequent conservative management. This patient developed noticeable scar contracture and distortion of the vermilion border. Our findings suggest that clinicians should carefully evaluate wound characteristics, contamination risks, and patient-specific factors when determining the initial management approach. Besides, conservative management with hydrocolloid dressings represents an effective, convenient, and practical therapeutic option for treating traumatic partial-thickness lip avulsion injuries.

Introduction

Lip vermilion injuries involving perioral regions are frequently encountered in clinical practice, often resulting in aesthetic deformities and functional impairments, underscoring the importance of appropriate clinical management. Anatomically, the lips consist of three layers from internal to external: mucosa, orbicularis oris muscle, and skin. The ideal management for lip injury includes restoration of both aesthetic appearance and functional integrity^1,2.

Lip avulsion injuries, characterized by partial or complete detachment of lip tissue, pose particularly complex clinical challenges. The wound management of avulsed lips generally involves immediate primary closure with layered sutures (primary intention healing) and subsequent surgical repair employing local flaps or tissue transfers to restore anatomical continuity³. However, those procedures commonly necessitate extensive mobilization of regional soft tissue, potentially resulting in increased scarring and further distortion of local anatomy. Additionally, due to the unique histological structure of vermilion, lip reconstruction with skin grafts, mucosal grafts, or local tissue advancements might result in inadequate tissue match, leading to suboptimal cosmetic outcomes⁴. Considering these inherent limitations of surgical reconstruction, secondary intention healing has been increasingly recognized as a viable alternative strategy⁵. Conservative wound management strategy, including frequent wound irrigation and dressing application, has demonstrated promising results, particularly when immediate surgical intervention is contraindicated or impractical⁶.

In this report, we present three cases illustrating conservative management of partial-thickness traumatic lip injuries. The injuries occurred under different clinical settings: one was caused by a dog bite, another was caused by an accidental fall, and the third was caused by failed primary closure. Given clinical constraints that precluded immediate surgical interventions, two patients received initial conservative treatment, while the third underwent immediate wound suturing followed by secondary management due to wound dehiscence. This case series aimed to present the efficacy and limitations of conservative management strategies, hypothesizing that such approaches could yield acceptable cosmetic and functional outcomes while minimizing complications associated with conventional surgical reconstruction.

Case presentation:

Clinical presentation 1

A 33-year-old male presented to our department 8 h after sustaining a dog bite. Clinical examination revealed an upper lip avulsion measuring approximately 3 cm x 2 cm, representing about 30% of the total lip width. The defect extended laterally toward the right oral commissure, accompanied by a linear laceration at the middle of the lower lip. The upper lip tissue defect involved lip vermilion, superficial muscle layer, and perioral skin, while mucosa and other intraoral tissue remained intact (Figure 1). The avulsed tissue was not retrieved.

Clinical presentation 2

A 25-year-old woman presented to our department due to an accidental fall 3 days earlier. Examination revealed a 2.5 cm x 1.5 cm avulsion of the lower lip (about 20% of the lower lip width) involving the vermilion border and superficial orbicularis oris fibres, with the mucosa remaining intact (Figure 2). The wound edges were uneven and contaminated.

Clinical presentation 3

A 34-year-old man presented to our department with a lower lip avulsion resulting from a car crash. Initial treatment included wound debridement and layered suturing. After 3 days, the patient returned due to wound dehiscence. Upon clinical examination, a 1.5 cm x 2 cm avulsion on the lower lip was observed, with blood oozing and mild infection (Figure 3).

Diagnosis, assessment, and plan:

Patients included in this study presented with clear consciousness, were ambulatory upon arrival, and showed no signs of life-threatening conditions such as airway obstruction or significant blood loss. An initial clinical assessment was performed systematically to evaluate the extent and severity of facial trauma, specifically the lip avulsion injuries. Clinical examination confirmed partial-thickness lip avulsions, characterized by varying degrees of vermilion, muscle, and perioral skin involvement, while intraoral mucosal integrity remained intact. Prior to local anesthesia administration, facial sensation was tested using a gentle cotton swab touch around the injured region and the symmetric, unaffected areas.

Cone-beam computed tomography (CBCT) scans were performed for patients who suffered from trauma or animal bites to rule out associated maxillofacial bone fractures. The absence of underlying bone involvement was confirmed in all cases.

Considering the risk of contamination and wound tension due to significant tissue loss, a conservative management strategy with daily wound cleansing and application of hydrocolloid dressings was planned. Tetanus and rabies vaccinations were administered following institutional guidelines for traumatic wounds and animal bites. Patients were instructed to self-administer oral cephalosporin antibiotics after careful consideration of their personal medical history and known drug allergies. Potential complications, including delayed healing, wound infection, hypertrophic scarring, and possible aesthetic or functional deficits, were discussed.

Protocol

All 3 patients were managed at the Department of Cleft Lip and Palate, West China Hospital of Stomatology. All patients provided informed consent for the disclosure and publication of their treatment procedures and photographs. The protocol was reviewed and approved by the Institutional Review Board of West China Hospital of Stomatology, Sichuan University (No. WCHSIRB-D-2016-084R1).

1. Initial evaluation of lip injuries ⁷

NOTE: Conservative treatment strategies were employed, consisting primarily of meticulous wound irrigation and daily application of hydrocolloid dressings.

1. Inclusion and exclusion criteria
   1. Conservative management of lip injuries was indicated in patients presenting with superficial wounds, partial-thickness soft tissue trauma with high tension at wound margins, and wounds with localized contamination or infection. Additionally, secondary intention healing is considered appropriate in cases where surgical repair was contraindicated or impractical due to patient instability.
   2. For wounds with minimal tissue loss and absence of contamination, primary closure was preferred rather than secondary intention healing. Conservative management was not suitable for patients with full-thickness avulsion injuries or extensive tissue loss exceeding one-third of the total lip width. Furthermore, patients with compromised immunity or systemic conditions (e.g., diabetes mellitus, immunosuppression) required individualized assessment to ensure suitability for conservative management.
2. The patient was instructed to sit in the examination room. The patient's consciousness, breathing status, and general stability were confirmed through verbal communication and visual inspection.
3. Precise wound characteristics were recorded by clinical inspection, including size, depth, location, and anatomical involvement. Facial sensation was assessed around the injured region prior to anesthesia injection by gently touching the perioral skin with a sterile cotton swab, comparing responses from injured versus non-injured areas.
4. CBCT imaging of the maxillofacial region was performed to rule out underlying bone fractures. Rabies vaccinations were administered within 24 h of the injury.

2. Wound cleaning and disinfection

1. A disposable oral kit was prepared. The wound was thoroughly irrigated with sterile saline solution (0.9% sodium chloride). Foreign materials and devitalized tissue were gently removed. The surrounding skin was disinfected with iodophor, avoiding direct instillation into deep tissues.
2. Hydrocolloid dressings were removed from their sterile packaging and trimmed to match the wound size with sterile surgical scissors. The prepared dressing was then placed over the wound bed using sterile forceps. A sterile dry gauze was placed over the dressing and secured with hypoallergenic surgical tape to maintain dressing stability. The patient was instructed to minimize facial movements and avoid moisture exposure to preserve dressing adherence and wound protection.
3. For contaminated wounds and animal-bite wounds, patients were prescribed oral amoxicillin and clavulanate potassium tablets at a dose of 400 mg, 2x daily for 5-7 consecutive days. Prior to initiation, patients were screened for a history of antibiotic hypersensitivity to ensure safe administration.

3. Daily wound care and dressing changes

1. Dressing changes were scheduled 1x daily. The existing hydrocolloid dressing was gently removed after pre-moistening with approximately 20-30 mL of sterile saline solution, minimizing trauma to new granulation tissue.
2. The wound was inspected daily for formation of healthy red granulation tissue (typically evident by day 7 post injury), progressive reduction in wound size, and absence of infection signs (e.g., purulence, persistent redness or swelling).
3. After cleaning the wound with sterile saline (0.9% sodium chloride), a new hydrocolloid dressing was reapplied as previously described. Dressing application was discontinued after complete epithelialization and wound closure, typically around 14 days post-injury.

4. Follow-up and monitoring

1. After complete wound healing, a clinical evaluation of lip sensation and movement was performed.
2. The patient was instructed to maintain regular online communication with the clinician, providing images and brief self-assessments regarding aesthetic outcomes and satisfaction. For functional assessment, the patient was guided to perform specific facial movements, such as smiling, puckering, and depressing the lower lip, to evaluate lip mobility and dynamic symmetry. Sensory function was assessed by light touch using a sterile cotton swab along the vermilion and perioral skin to identify sensory abnormalities. Persistent concerns, including hypertrophic scarring, functional deficits, or sensory impairment, were documented and addressed during follow-up assessments.
3. At the 1-year review, patients with symmetric lip movement, intact oral continence, normal sensation, and minimal scarring were discharged from follow-up. Those not meeting these benchmarks were counselled on appropriate secondary interventions.

Results

Clinical presentation 1

After a 7-day course of daily wound cleansing, dressing changes, and antibiotic application, no signs of infection were observed (Figure 1). Therefore, wound management continued with saline irrigation followed by application of hydrocolloid dressing. At 17 days post-injury, the wound exhibited a marked reduction in size (Figure 1

Discussion

Lip wounds are among the most prevalent orofacial injuries, frequently leading to significant cosmetic disfigurement and functional impairment. Unlike tissue defects resulting from congenital conditions (e.g., cleft lip) or surgical resections, traumatic defects are typically irregular and contaminated⁸. The macerated, uneven edges predispose wounds to infection and pose considerable challenges for primary surgical realignment⁹. In particular, large lip avulsion injuries in...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
500 mL bag 0.9% NaCl solution	Kelun Pharmaceutical Co., Ltd.		Wound irrigation
Cotton swab	Chengdu Mingsen Medical Device Co., Ltd
Diposable dressing tray	Xinxiang Huaxi Sanitary Materials Co., Ltd.	PAC015
Hydrocolloid dressing	Shanghai NewValue Medical Products Co., Ltd	6921	Provide moist wound healing
Medical absorbent gause swab	Xinxiang Huaxi Sanitary Materials Co., Ltd.	GAU001
Surgical tape	Zibo Qichuang Medical Products Co., Ltd.	W125