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Matthew P. Lungren
Michael R.B. Evans
Editors
Soft Tissue Injuries
Clinical Medicine
oftheHead and
Covertemplate
Neck
Subtitle for
CharilaosA.Ioannidis
Clinical Medicine Covers T3_HB
Second Edition
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123
Soft Tissue Injuries of the Head and Neck
CharilaosA.Ioannidis
Soft Tissue Injuries of
the Head and Neck
CharilaosA.Ioannidis
Plastic Surgery
IASO HOSPITAL GROUP, Consultant P/R Surgeon
Athens, Greece
ISBN 978-3-031-14914-6 ISBN 978-3-031-14915-3 (eBook)
https://doi.org/10.1007/978-3-031-14915-3
© Springer Nature Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
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The publisher, the authors, and the editors are safe to assume that the advice and information in
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the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword
This work is the effort of one author to convey what he has learned in a long
career treating injuries of the face, head, and neck in world-class training
programs. His career interests and the experience in renowned centers in
which he trained and staffed as an attending and responsible physician/surgeon permitted him to gain unique amounts of exposure and experience
which were concentrated on the urgent/emergency management of injuries of
the head, face, and neck. The author successfully takes materials from a number of disciplines: Plastic and Reconstructive Surgery, Oral Maxillofacial
Surgery, Ophthalmology and Oculoplastic, Otolaryngology and Facial
Plastics, Head and Neck Surgery, and General Surgery and completes a text
with a broad overview of a subject which is individually mentioned in textbooks of those disciplines. Previously, I cannot recall anyone taking on the
task of producing a more comprehensive multispecialty overview text, nor
one that has been as well organized to present a multispecialty approach to
the challenges seen in the urgent care area. This text introduces a comprehensive, broad overview meant to educate clinicians of all disciplines in the
emergency room consultation for the various and specialty-specic injuries
of the face, head, and neck.
But besides offering a manual for these separate disciplines, perhaps the
groups most likely to benet from this collated information are those who
spend much of their time in emergency management and treatment: emergency room specialists, nurses, NPs, PAs, and others who are unable to nd a
“single source” location for the multidisciplinary evaluation and management
of separate and critically important injuries, which form a signicant share of
daily practice in emergency center locations.
The book begins with a description of the unique importance of the face in
appearance and human interaction, and in communication, perception, and
information transfer. Indeed, there is nothing like it in the rest of the animal
kingdom and thus its importance to the performance of human tasks and
interaction. The long-term effects on health, survival, success, and performance are summarized in works mentioned in the introductory chapter. A
chapter on epidemiology gives a broad perspective on demographics. A chapter on how wounds react to injury and healing gives a basic physiological
perspective, and its corollary, Chap. 12 on disorders of healing—both provide
basic scientic physiology explaining normal and disordered metabolic and
physiological processes, and how we might improve results acutely and after
v
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initial healing, especially if problematic. In the wound management chapter
are sections on the various patterns and mechanisms of injury, and where differences in management in the various types of mechanisms permit better
results to be achieved.
The sectional and specialty-specic sections then take us through, from
top down, the forehead, scalp and eyebrow, then the eyelids, globe, and supporting structures, each with its specialized tissues and varied requirements
for specialized evaluation and treatment. Ocular glands, ligaments, tear systems, and lubrication require specialized evaluation and management. Their
special evaluation and the special particulars complete these descriptions.
The nasal chapter emphasizes the evaluation of structures dealing with
appearance and function—breathing and airway. Again, varied mechanisms
of injury dictate special treatment evaluations, techniques, and management.
The cheeks, with their complex separate sensory and motor nerve structures,
and the glands including complex parotid injury, both duct and gland management and the facial mimetic muscles—all of these are again unique and
specialized considerations. And nothing could exceed in complexity the lips,
their structure and function—what a specialized functional unit where motor
function and sensory perception allow a unique combined superior functional
outcome. The neck is again a specialized region, and the importance of analyzing and restoring this most important functional conduit for airway, swallowing, circulation, and nerves—motor and sensory—what could be more
important or specialized? Chapter 11 deals with the special problems of burninduced mechanisms, and of course whole textbooks could be written about
these injuries. Chapter 12 deals with how to solve problems following the
initial management—functional mechanisms, evaluation, and treatment discussions here set the stage and pathways for further evaluation, treatment,
and analysis.
So, all in all we have a text which combines a multidisciplinary perspective on initial evaluation and early treatment of injuries of the face, scalp, and
neck. It sets the stage for further study, and for those interested, in-depth
information on each of the specics mentioned in each chapter and section is
provided in the references which provide specic location and direction for
that specic study. I am condent that the disciplines and specialists mentioned will benet from the information contained in this text, and I thank the
author very much indeed for providing all of us his studied perspectives and
advice.
Foreword
Plastic and Reconstructive Surgery
Johns Hopkins School of Medicine
Baltimore, MD, USA
Surgery, The University of Maryland Shock
Trauma Unit and the University of
Maryland School of Medicine
Baltimore, MD, USA
PaulN.Manson
Preface
Trauma of the head and neck forms an integral part of basically two surgical
disciplines: Plastic and Reconstructive Surgery and Cranio-Maxillofacial
Surgery. Soft tissue injuries are, usually, treated by plastic surgeons, whereas
skeletal injuries are managed by maxillofacial surgeons. However, accident
and emergency physicians as well as colleagues from other surgical disciplines (ENT—surgeons, orthopedic surgeons, general surgeons, etc.) are
often actively involved in soft tissue trauma of the head and neck either as
treating physicians or in a multidisciplinary setting. Fortunately, most of the
soft tissue injuries of the scalp, face, and neck are quite simple and can be
treated on an ambulatory basis. A number of them, however, are serious or are
associated with concomitant skeletal injuries of the head and/or the trunk and
the extremities, requiring a multidisciplinary approach. The contribution of
ophthalmologists, neurosurgeons, and other specialists is extremely important for a successful nal outcome.
This book is intended for interns, residents, and fellows of Plastic Surgery,
Maxillofacial Surgery, ENT Surgery and Emergency Medicine, as well as
attending surgeons and physicians of other disciplines dealing with soft tissue
trauma of the head and neck. It may also prove useful to theater and A & E
nurses, and medical students who have interest in this subject.
Writing a book is time and energy consuming. Private and family life “gets
the brunt of it.” So why then do it? The best answer is probably the one given
by Dr. Ian T.Jackson: “It is an educational opportunity and a chance to con-
vey lessons learned from many years of experience.” My hope is that this
book will provide a source of stimulation to those new to facial and neck
trauma and a source of continued inspiration to more experienced physicians.
For the layperson who will read this text, I hope that it too will be a source of
comfort that patients with disguring facial trauma may still have a potential
for a harmonious, normal life ahead.
Athens, Greece CharilaosA.Ioannidis
May 2022
vii
Acknowledgments
I am fortunate to have completed part of my surgical training at the Department
of CMF Surgery, Radboud University Hospital (Level 1 trauma center),
Nijmegen, the Netherlands (former Katholieke Universiteit NijmegenLeuven), Head of which was a surgeon with an outstanding reputation,
Professor Hans- Peter Freihofer†. He was one of the surgeons, internationally,
with the knowledge and the experience to treat the full spectrum of head and
neck injuries. I am deeply grateful to him for encouraging my interest in
trauma surgery. He set high standards in judgment, philosophy, and technical
skills, which guided me throughout my surgical career. I am also indebted to
Professor Kostas Lekkas, University of Leiden, for stimulating my interest in
Cranio- Maxillofacial Surgery and especially surgery of the head and neck.
Many thanks to my colleagues in Nijmegen, in Leuven, and in London and
especially to my dear friend Prof. D.A.McGrouther for having contributed to
the management of some of the cases illustrated in this book. Their enthusiasm has been a continuous source of inspiration to me.
Particular thanks to my wife Olga and to my sons Alexandros and
Konstantinos for their endurance and continuous support.
My deepest gratitude and respect to all those patients who trusted their
health into our hands and without whose photographs the completion of this
book would not have been possible.
Special thanks to Mrs. Olga Giagiakou for the preparation of the manuscript, to Mrs. Soka Eleftheroudaki for her valuable advice, and to Dr. Irini
Tsilomeleti for drawing some of the anatomical sketches (the others were
drawn by the author). Last but not least, I wish to thank the highly skilled
professionals at Springer Nature who helped make this book possible, especially Mrs. Daniela Heller and Ms. Madona Samuel.
Charilaos A.Ioannidis
Athens, May 2022
ix
Introduction
Facial appearance is extremely important to everyone regardless of age, sex,
and race, as is highlighted in the rst chapter of this book. It is understandable
that facial injuries and the resulting facial scarring/disgurement, being conspicuous, are more of a concern than injuries to the trunk and the extremities.
Patients are more embarrassed with facial scars than with scars at other body
parts. The effect on the victim’s personality and future can be detrimental.
Aesthetics, however, is not the only cause of negative impact which facial
scars have on patients. The soft tissues of the scalp and forehead give protection to the cranium. Furthermore, the region of the H&N is associated with
important functions (sight, smell, breathing, eating, talking), which can be
impaired in cases of extensive soft-tissue injury, thus affecting the patient’s
quality of life.
Soft-tissue injuries occur on the scalp, all parts of the face (forehead, eyebrows, eyelids, nose, cheeks, lips, chin), and the neck. In a study from the
United Kingdom, almost half of the 458 open wounds which required treatment were in the upper third of the face (Ong and Dudley 1999).
Injury patterns vary greatly depending on the patient population. Falls,
trips, and slips are most common in children and the elderly, causing isolated
soft-tissue injuries (lacerations, contusions). Violence and road trafc accidents (RTA) are the predominant causes of injury in the 15–50-year age group
(Kretlow etal. 2010). More results on the epidemiology of facial and neck
soft-tissue injuries are reported in the second chapter of this book.
Facial soft-tissue injuries are rarely life threatening; however, they are
indicators of the energy of injury. Most of them are treated by experienced
accident and emergency physicians (90% in the study by Ong and Dudley
1999). A 1-year wound closure training provided to emergency physicians
seems to reduce the incidence of early complications following facial laceration repair (Yamamoto et al. 2018). The nal outcome depends on initial
wound care and primary repair. Suturing is still the mainstay of treatment;
however, topical skin adhesives seem to be gaining in popularity in children
as well as in adults, as their use is associated with a shorter emergency department length of stay than sutures (Otterness etal. 2020) and the risk of dehiscence is not statistically different between the two methods (Ste-Marie-Lestage
et al. 2019). The more complex cases are most appropriately managed by
plastic surgeons that, besides thorough knowledge of applied anatomy and
surgical skill, have an aesthetic sense and meticulous atraumatic tissue han-
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xii
dling expertise (Bhattacharya 2012). In all cases, however, the treating physician/surgeon ought to be fully aware of the “dos and the don’ts.”
Almost all injuries result from some form of trauma (physical force resulting in injury). Injuries may also result from chemical, thermal, or electrical
trauma, though far less commonly than physical trauma. The severity of the
injury depends, besides the applied force, on the anatomic region of impact,
the surface of impact, the resistance of tissues, and the angulation of the strike
(Hill etal. 2010). Assaults, falls, road trafc accidents (RTAs), sports injuries,
animal bites, and burns are the commonest causes. Industrial injuries and war
injuries are less common.
The injury pattern differs among the different parts of the world. In some
countries of the developed world, interpersonal violence seems to be the
commonest, whereas in other developed countries (Japan, the Netherlands),
as well as in the developing world, RTAs are the commonest cause of facial
injuries.
Soft-tissue lacerations are the most common maxillofacial injuries sustained (Hill etal. 2010). Almost 40% of all assault victims and 95% of victims of domestic violence have facial lacerations (Hill etal. 2010). However,
despite their frequency, soft-tissue injuries are often overlooked in trauma
epidemiology.
Strategies (road/work legislation, speed limits, alcohol consumption and
driving) and devices (seat belts, airbags and laminated safety glass windshields for drivers, helmets for motorcyclists, protection worn during sports
and at work) to protect individuals have been designed and developed during
the past decades. Due to them, a dramatic decrease of injuries associated, e.g.,
with RTAs has been observed (20.9 to 5.9% in 2 years; Perkins and Layton
1988). Bernstein etal. (1989) found that abrasions, contusions, and lacerations to face, neck, and head were considerably reduced (22.2% of 379 injuries vs. 13.8% of 356 injuries) after implementation of the safety belt law in
New Mexico, USA.Furthermore, signicant cost and severity differences
were observed after the law between belted and non-belted occupants: + 2569
compared with +662 and Injury Severity Score (ISS) of 3.6 compared with
2.0 (p<0.005) (Bernstein etal. 1989). Helmets reduce the risk of lacerations
and fractures to the upper and middle face by 65% (Hill etal. 2010). The relatively low incidence of facial injuries in contact sports may reect the wearing of mouth guards and protective headgear (Hill etal. 2010).
In recent years, safety design has been improved, legislation has become
tougher, and there has been no generalized war. However, interpersonal
violence in the Western world seems to be rising and the age of the population
is increasing (Hill etal. 2010). Corso etal. (2006) observed a 20% decrease
of injuries for those aged 0–44 (1985–2000), whereas persons aged 75 and
older experienced a 20% increase. Furthermore, Kraft etal. (2012) observed
that older craniomaxillofacial trauma victims were more prone to soft-tissue
lesions with a rising risk of 2.1% per year older, showing no signicant difference between male and female patients. These two factors will probably
necessitate the increase of maxillofacial trauma services resulting in an
increase of costs, which are already high. In a study from the Netherlands,
Meerding etal. (2006) reported that supercial injuries had the second high-
Introduction
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