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Epidemiology ofSoft-Tissue
Injuries oftheHead andNeck
2
One of the main causes of facial scarring is facial
soft-tissue injury. It can appear either in combination with fractures of the underlying facial
bones or merely as injury to the soft tissues of the
face.
Facial trauma (including blunt, penetrating
injuries, and facial fractures) is common. It was
seen in over one-third (34%) of all trauma
patients reported in the Major Trauma Outcome
Study (MTOS) from 1982 to 1987, which
included 87,174 trauma patients from 139 North
American hospitals (single largest trauma database in North America) (Sastry etal. 1995). The
leading specic trauma diagnoses were open
wound of nose, face, and mouth (42%), followed
by contusion to the face and neck (15.4%) and
supercial injury to the face and neck (13.4%).
Facial fractures were seen in 25% of the patients
(Sastry etal. 1995).
In another, more recent, study from the United
Kingdom, facial injuries represented 4% of all
admissions at 163 accident and emergency
(A&E) departments (England, Scotland, Wales,
and Northern Ireland). Over the study week from
09:00h on Friday 12 September 1997 to 08:59h
on Friday 19 September 1997, there were 6114
patients with facial injuries out of a total of
152,692 A&E attendances (Hutchison et al.
1998).
Age is an important variant in facial/neck softtissue injuries. Shinya et al. (1993) retrospectively analyzed 108 patients with facial injuries
from falling. The latter injuries were common in
little children. In those under 6years of age, they
comprised 45.4% of injuries. The authors
observed age-dependent characteristic injury
sites. In patients under 2years, the forehead was
mainly injured; in small children, the chin; in students, the lip; and in older persons, the cheek was
the main location of the injury. The authors attributed this disparity to the different mechanisms of
injury. They also observed that the injury pattern
depended on age, varying activities, and tissue
strength. In children <6years of age, small lacerations on the forehead or chin were most common (Shinya et al. 1993). O’Neil et al. (2008)
reviewed 39,850 escalator-related injuries. The
head was the second most common injured body
part (25%, 95% CI: 20.5–29.5%). The rate of
head injuries and the rate of hospitalizations
increased with age. Gassner et al. (2003) in a
review of a large member of patients with craniomaxillofacial trauma (9543 cases with 21,067
injuries) reported that older people were more
prone to soft-tissue injuries with a rising risk of
2% per year of age, although no statistically signicant differences were found between the sexes
for soft-tissue trauma.
Various causes cause facial soft-tissue injuries. There are differences in the reported incidence per cause, depending on age and country
of origin of the study. Li etal. (2006) in a retrospective analysis of 3958 patients with facial
injuries from China reported that the most
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
C. A. Ioannidis, Soft Tissue Injuries of the Head and Neck,
https://doi.org/10.1007/978-3-031-14915-3_2
5
6
2 Epidemiology ofSoft-Tissue Injuries oftheHead andNeck
common cause of injury was trafc accident
(30.6%), followed by falls (21.4%) and collision
(15.8%). Gassner etal. (2004) in a study of craniomaxillofacial trauma in children from Austria
(3385 cases with 6060 injuries) reported that the
most common cause of injury was play (58.2%),
followed by sports (31.8%), trafc accidents
(5%), acts of violence (3.9%), and other causes
(1.1%). The same authors in another study of
9543 cases with craniomaxillofacial trauma
including all ages reported that the main cause
was activity of daily life (38%), followed by
sports (31%), violence (12%), trafc accidents
(12%), work accidents (5%), and other causes
(2%) (Gassner et al. 2003). Hutchison et al.
(1998) in a study from the United Kingdom
reported that 40% of the facial injuries were
caused by falls. Twenty-four percent of the facial
injuries were caused by assault. The commonest
sites for assault were the street followed by public drinking establishments. More women than
men were assaulted at home. The 15–25 age
groups suffered the greatest number of facial
injuries caused by assault. Fifty-ve percent of
assaults were related to alcohol consumption.
Eight percent of assaults were with bottles or
glasses. Only 5% of the facial injuries occurred in
road trafc accidents (RTAs). Fifteen percent of
RTA victims had consumed alcohol. At least 27%
of all the facial injuries in all age groups were
related to alcohol consumption within 4h of the
injury. In the over-15 age groups, alcohol consumption was associated with 90% of facial injuries occurring in bars, 45% on the street, and 25%
in the home. Assault, RTA, and alcohol consumption conveyed an increased risk of serious facial
injury (Hutchison etal. 1998). The probability of
suffering soft-tissue injuries (p<0.05) was raised
in trafc accidents by 58%, in sports by 12%,
during assaults by 31%, and in activity of daily
life/play accidents by 16% (Gassner etal. 2003).
As cell phones become part of everyday life,
they tend to become more hazardous. Povolotskiy
et al. (2020) retrospectively reviewed 2501
patients who presented with injuries of the head
and neck related to cell phone use. The most
commonly reported subsites of injuries in the
head and neck area included the head (33.1%),
the face (eyelid, eye area, and nose) (32.7%), and
neck (12.5%). The most common injury diagnoses were laceration (26.3%), contusion/abrasion
(24.5%), and internal organ injury (18.4%). Age
group distributions showed that most injuries
associated with cell phone user distraction
occurred among individuals aged 13–29years. In
addition, those younger than 13years were signicantly more likely to sustain direct mechanical injury from a cell phone (82.1%) than to have
a cell phone use-associated injury (17.9%).
There are various types of soft-tissue injuries:
lacerations, abrasions (excoriations), contusions,
and burns. Lacerations seem to be the most frequently occurring injuries. In the study by
Gassner etal. (2003), they comprised 41.3% of
all soft-tissue injuries (3205/7769). Excoriations
comprised 23.9% and contusions 11.1% of all
soft-tissue injuries. The mean age is ca 26years
(Gassner etal. 2003); however, they can occur at
all ages. Males seem to be involved more frequently than females. There was a 2.1:1 (Gassner
et al. 2003) male-to-female ratio. According to
another study, the ratio of male to female was
4.27:1 (Li et al. 2006). Both age and gender,
however, vary greatly depending on the injury
mechanism (Gassner etal. 2003). In a study of
escalator-related injuries among older adults, the
mean age of the study population was 80.1years
and 73.3% of the patients were females (O’Neil
etal. 2008). Similar ndings were reported more
recently in a study of 426 individuals aged
60 years or older hospitalized due to fall. The
main victims were women aged 80 or over.
Occurrences were common in the daytime period
and due to falls from self-height. Soft-tissue injuries in head and face were common, whereas
facial fractures showed low frequency (Cavalcanti
et al. 2020). Ninety-seven percent of children
5–18years of age having sustained cheer leadingrelated injuries in the United States were females
(Shields and Smith 2006).
Facial soft-tissue injuries occur as solitary
injuries in a large number of cases. The majority
of facial injuries reported by Gassner (62.5%)
were merely injuries to the soft tissues of the
face. Other authors reported lower percentages.
In a series of 2798 cases, Subhashraj etal. (2007)
2 Epidemiology ofSoft-Tissue Injuries oftheHead andNeck
7
reported that 42% of patients had soft-tissue injuries, and Li etal. (2006) reported that a total of
794/3598 patients (20.1%) showed only softtissue injuries. In the remaining patients, there
were concomitant fractures of the underlying
facial bones present.
Burns requiring medical attention rank fourth
among all injuries (Peck 2011). Fortunately, the
vast majority of burns are not fatal. However, in
low-income and middle-income countries (e.g.,
East Mediterranean Region), burn injuries are
one of the leading causes of mortality (Othman
and Kendrick 2010). The global mortality rate is
reported to be 4.8 per 100,000 per year (Othman
and Kendrick 2010). Nonetheless, re-related
burns are also among the leading causes of
disability- adjusted life years lost in low- and
middle-income countries (Peck 2011).
The WHO estimates indicate that globally
there were more than 7.1 million re-related
unintentional burns (ICD-10: X01-X09) in 2004
giving an overall incidence rate of 110 per
100,000 per year. The reported incidence varies
between different countries. The incidence in the
East Mediterranean region was 187 per 100,000
per year compared to the lowest incidence in the
Americas which was 19 and the highest incidence in Southeast Asia which was 243 per
100,000 per year (WHO 2004).
Risk factors for burns include those related to
socioeconomic status, race and ethnicity, age,
and gender, as well as those factors pertaining to
the region of residence, intent of injury, and
comorbidity (Peck 2011). The etiology and
nature of burn injuries vary signicantly by country (Dissanaike and Rahimi 2009). Gender differences play a signicant role in the risk of burn
injuries, across a spectrum with a predominance
of women injured in res from cooking and heating fuels in the developing world and industrial
accidents primarily affecting men in developed
nations. Children are particularly vulnerable to
burn injuries, accounting for almost 50% of all
burn patients in some studies. A majority of pediatric burns are scald injuries usually affecting
very young children below the age of 5 years.
Finally, the elderly form a rapidly increasing proportion of the population in many countries and
are often burdened with comorbidities that are
likely to pose signicant challenges in burn care
(Dissanaike and Rahimi 2009).
The head and neck are often the most frequently affected body areas. In an adult
population- based study from the Calgary Health
Region, Canada, burns of the head and neck were
the most prevalent (22.2%) (Burton etal. 2009).
D’Souza et al. (2009) reviewed 2,054,563
patients < or = 20years of age who were treated
in US emergency departments for burn-related
injuries between 1990 and 2006. The body parts
injured most frequently were the hand/nger
(36.0%), followed by the head/face (21.1%).
Chemicals and cleaners, compared with other
products, were 5.6 times (95% CI: 5.3–5.9 times)
more likely to burn the head and face than other
body parts. A comparative study by Teo et al.
(2012) illustrates the differences encountered in
different countries. Pediatric burns presenting in
the Royal Aberdeen Children’s Hospital (RACH),
Scotland, and the Red Cross War Memorial
Children’s Hospital (RXH), Cape Town, South
Africa, in 2009 were reviewed. During 2009, the
RACH received 192 children with burns (1% of
total emergencies) and the RXH received 994
(11% of total emergencies). At the RACH, most
burns involved the hands and were single site
(79%), while at the RXH, most were multiple
sites (76%) and involved the face. Scalds
accounted for the majority of injuries in both hospitals (RACH 45%, RXH 77%). Several other
studies indicated the face as the most common or
the second most common (after the hands) burned
body area (Kauvar etal. 2006; Foster etal. 2011).
Fatusi et al. (2006) reviewed the outcome and
associated factors in burn injuries with and without facial involvement. Fuel-related ames constituted the leading cause in both facial (71.1%)
and non-facial involved burns (65.3%). There
was no signicant difference in the incidence of
inhalation injury between burns with facial
involvement and burns without facial involvement; however, cases of facial involvement had
signicantly lower incidences of wound infections. No signicant difference was seen in the
incidence of mortality between burns with facial
involvement (31.6%) and burns without facial
8
2 Epidemiology ofSoft-Tissue Injuries oftheHead andNeck
involvement (30.7%). A study from Lille, France,
showed that the total burn area was less than 10%
in 63% of the cases. The average facial burned
area was 4%. The cheek, the forehead, and the
chin were most frequently involved (CaponDegardin etal. 2001). On the other hand, according to a study on 222 consecutive patients with
major burns, facial injury was one of the predictors of risk of death, as shown by the multivariate
logistic regression analysis of factors predicting
survival in patients with burn injury (Ganesamoni
etal. 2010).
Like burns, the majority of abrasions and contusions are injuries of minor to moderate severity.
A few patients suffer injuries of such severity that
endanger the individual’s life. The different types
of injuries and the special problems related to
each location (facial units) will be analyzed in the
following chapters.
References
Burton KR, Sharma VK, Harrop R, etal. A population-
based study of the epidemiology of acute adult burn
injuries in the Calgary Health Region and factors asso-
ciated with mortality and hospital length of stay from
1995 to 2004. Burns. 2009;35:572–9.
Capon-Degardin N, Martinot-Duquennoy V, Lesage-
Maillard V, et al. [Facial burns in children. 197
patients]. Ann Chir Plast Esthet. 2001;46:190–5.
Cavalcanti AF, Formiga S, de Arruda T, et al. Head and
face injuries in elderly patients victims of fall. A single
trauma center analysis. Stomatologija. 2020;22:39–43.
D’Souza, Nelson NG, McKenzie LB.Pediatric burn inju-
ries treated in US emergency departments between
1990 and 2006. Pediatrics. 2009;124:1424–30.
Dissanaike S, Rahimi M.Epidemiology of burn injuries:
highlighting cultural and socio-demographic aspects.
Int Rev Psychiatry. 2009;21:505–11.
Fatusi OA, Fatusi AO, Olabanji, etal. Management out-
come and associated factors in burn injuries with and
without facial involvement in a Nigerian population. J
Burn Care Res. 2006;27:869–76.
Foster MA, Moledina J, Jeffrey SL.Epidemiology of U.K.
military burns. J Burn Care Res. 2011;32:415–20.
Ganesamoni S, Kate V, Sadasivan J. Epidemiology of
hospitalized burn patients in a tertiary care hospital in
South India. Burns. 2010;36:422–9.
Gassner R, Tuli T, Hächl O, et al. Craniomaxillofacial
trauma: a 10-year review of 9,543 cases with 21,067
injuries. J Craniomaxillofac Surg. 2003;31:51–61.
Gassner R, Tuli T, Hächl O, et al. Craniomaxillofacial
trauma in children: a review of 3,385 cases with
6,060 injuries in 10 years. J Oral Maxillofac Surg.
2004;62:399–407.
Hutchison IL, Magennis P, Shepherd JP, etal. The BAOMS
United Kingdom survey of facial injuries part 1: aetiology and the association with alcohol consumption. British Association of Oral and Maxillofacial
Surgeons. Br J Oral Maxillofac Surg. 1998;36:3–13.
Kauvar DS, Cancio LC, Wolf SE, et al. Comparison of
combat and non-combat burns from ongoing U.S. military operations. J Surg Res. 2006;132:195–200.
Li YS, Tian WD, Li SW, etal. [Retrospective analysis of
3,958 patients with facial injuries]. Zhonghua Kou
Qiang Yi Xue Za Zhi. 2006;41:385–7.
O’Neil J, Steele GK, Huisingh C, etal. Escalator-related
injuries among older adults in the United States,
1991–2005. Accid Anal Prev. 2008;40:527–33.
Othman N, Kendrick D.Epidemiology of burn injuries in
the East Mediterranean Region: a systematic review.
BMC Public Health. 2010;10:83.
Peck MD. Epidemiology of burns throughout the
world. Part I: Distribution and risk factors. Burns.
2011;37:1087–100.
Povolotskiy R, Gupta N, Leverant AB, et al. Head and
neck injuries associated with cell phone use. JAMA
Otolaryngol Head Neck Surg. 2020;146:122–7.
Sastry SM, Sastry CM, Paul BK, etal. Leading causes of
facial trauma in the major trauma outcome study. Plast
Reconstr Surg. 1995;95:196–7.
Shields BJ, Smith GA.Cheer leading-related injuries to
children 5 to 18 years of age: United States, 1990-
2002. Pediatrics. 2006;117:122–9.
Shinya K, Taira T, Sawada M, etal. Facial injuries from
falling: age-dependent characteristics. Ann Plast Surg.
1993;30:417–23.
Subhashraj K, Nandockumar N, Revimbran C. Review
of maxillofacial injuries in Chennai, India: a study of
2,748 cases. Br J Oral Maxillofac Surg. 2007;45:637–9.
Teo AI, Van As AB, Cooper J.A comparison of the epi-
demiology of pediatric burns in Scotland and South
Africa. Burns. 2012;38:802–6.
WHO. Annual incidence (000s) for selected causes, in
WHO Regions (a), estimates for 2004. Geneva: WHO;
2004. http://www.who.int/healthinfo/global burden
disease/estimatesregional/en/index.htm.
General Principles ofWound
Management
3.1 Principles ofPatient
Management
The principles of facial soft-tissue injuries are
similar for all age groups:
1. Restoration and preservation of function
2. Achievement of optimal cosmetic results with
a minimum of scar formation by placing all of
the anatomic landmarks in their proper
location
3
Soft-tissue injuries encompass a spectrum that
includes ecchymoses, lacerations, contusions,
abrasions, degloving injuries, avulsions, and
burns (Figs.3.1, 3.2, 3.3, and 3.4). Minor softtissue injuries are the most common facial injuries. Most injuries may be repaired on an
outpatient basis using local anesthesia. In children, however, sedation is often required. If the
injuries are extensive or if there are underlying
fractures, it is advisable to use general anesthesia
for better control of the repair environment and in
order to optimize the outcome. Facial wounds
without additional injuries are repaired as soon as
possible. In major trauma, while instituting the
resuscitative measures, the wound may be dealt
with after 4–6h.
Patients with facial injuries often suffer from
associated trauma to other parts of the body
(Fig. 3.5) that may require more urgent attention. The prevalence of head and neck injuries in
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
C. A. Ioannidis, Soft Tissue Injuries of the Head and Neck,
https://doi.org/10.1007/978-3-031-14915-3_3
Fig. 3.1 Male victim of a road trafc accident (RTA)
with facial ecchymoses, lacerations, contusions, and
abrasions
major trauma patients is poorly documented in
the literature (Mohamed etal. 2021). In a retrospective review of 5364 patients from 26 hospitals in Ireland, the authors documented
soft-tissue injuries in ca 23% of the patients
(Mohamed et al. 2021). Head/facial injuries
9
10
Fig. 3.2 Female patient with facial ecchymoses, lacerations, and abrasions as a result of an RTA
Fig. 3.3 Male patient with traumatic ecchymosis and lacerations of the left side of the face
(HF) were more lethal and presented with severe
morbidity compared to other bodily injuries. Of
the HF injured patients, 2817/4799 (59%) died
during their presentation to the ED vs. 365/3048
(12%) of the other bodily injuries (Quenzer
etal. 2021).
The priorities of emergency trauma care must
always be airway maintenance (A), control of
3 General Principles ofWound Management
Fig. 3.4 Male patient with burns of the facial region
breathing (B), and circulation (C). Evaluation of
cranial and maxillofacial soft-tissue injuries
should begin while the patient is being
stabilized.
Photographic documentation should be a part
of the initial evaluation, especially if the patient
is to be treated on an outpatient basis.
Photographic documentation helps patients with
future insurance claims and physicians to address
medicolegal matters and serves as a safeguard
against possible litigation involving the causative
parties.
Through a comprehensive and accurate history, insight may be gained into the nature of
the soft-tissue injury and whether associated
fractures are also present. If the presence of foreign bodies (Fig.3.6) or associated maxillofacial fractures is suspected, imaging studies are
indicated. Plain radiographs often provide suboptimal results, and computer scans are then
indicated (Fig.3.7). Severe craniomaxillofacial
injuries warrant a CT scan of the brain, thus
providing the opportunity to obtain a concurrent maxillofacial CT scan for clear denition
of bone injuries (Fig.3.8). After the history and
physical examination are completed, thorough
wound examination is vital. Optimal treatment
of facial injuries depends on a thorough initial
evaluation (what tissue constituents are lost and
3.1 Principles ofPatient Management
11
ab
cd
Fig. 3.5
(a–e) Concomitant injuries and burns of the torso and limbs in patients with H&N injuries
12
3 General Principles ofWound Management
e
Fig. 3.5 (continued)
a
b
Fig. 3.6 Piece of glass (foreign body) which was
removed from the orbit of a patient with an orbital injury
c
de
Fig. 3.7 (a) Patient with bilateral eyelid ecchymoses and
limited lacerations to the right eyebrow and upper eyelid.
(b, c) CT scans of the same patient showing extensive
what tissues are exposed) and detailed description of the injury in the medical records.
Complications following acute facial injuries
will be predictably minimized if the treatment
is meticulously planned and executed. After
injury (fractures) to the fronto-orbito-basal skeleton. (d, e)
Peroperative pictures showing the fractured area. Note the
open frontal sinus
irrigation, initial assessment can be facilitated
if the wound is inltrated with 2% xylocaine
with epinephrine, 1:100,000. The edges can
then be easier retracted, to explore the depth of
the wound, which may contain embedded for-
3.2 Wound Preparation
13
Fig. 3.8 (a) Victim of
an RTA with a
depression of the
nasofrontal area. (b, c)
CT scans of the brain.
(d) Clinical picture
showing the nasofrontal
fracture. (From
Ioannides etal. 1993,
with permission)
a
cd
eign bodies, hematomas, or bone fragments in
cases of underlying fractures (Juncar et al.
2020). To prevent future deformities or an
unsightly scar, copious irrigation and meticulous removal of all foreign material are of an
utmost importance. Loupe magnication is
sometimes necessary to successfully complete
the debridement.
Thorough examination of the wound provides
information such as the condition of the surrounding tissue, the location of the injury, the
angle of the defect in relation to relaxed skin tension lines, and the involvement of signicant anatomical structures. Nerves, parotid ducts, lacrimal
ducts, and other critical facial structures may be
involved. These will be further analyzed in the
following chapters.
Whenever there is a composite full-thickness
loss of tissue, the requirement is lining, support,
and cover (eyelids, nose, ear, cheek, etc.).
Occasionally, consultation of other medical
specialists is necessary, e.g., ophthalmologists, in
cases of severe eyelid trauma. The type of the
injury, its location and extent, and the involvement of vital facial structures will aid the surgeon
to decide on the type of anesthesia (local, local
with sedation, general) and set up the treatment
plan.
b
3.2 Wound Preparation
The lines of tension in the skin were rst noted by
Dupuytren in 1832 (Place et al. 1997). (Langer
1861) also described the normal tension lines of
the skin, called “Langer’s lines” (Place et al.
1997).
Borges has written extensively on the subject
and lists 36 descriptive terms for skin lines
(Borges 1973). He refers to the skin lines as
“relaxed skin tension lines.” Wrinkle lines are
generally the same as the relaxed tension lines
and lie perpendicular to the long axis of the
underlying muscles. Maximal contraction occurs
when a scar crosses the lines of minimal tension
at a right angle.
When a wound is already present as a result of
trauma, it is important to consider how and to
what extent it transgresses the normal tension
lines of the face and whether it can be modied to
a more “favorable” orientation. It often proves
impossible or undesirable to make if conforming
as a primary maneuver, because of potential
infection, poor blood supply of wound margins,
skin damage, etc. (McGregor 1989). The aim
should therefore be to prepare it for the time
when, at a later date, it can be modied to conform to the principles of placing a facial scar, if
14
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3 General Principles ofWound Management
the result of wound repair is not satisfactory.
Langer’s lines do not seem to be a static feature
but are dynamic with rotation of up to 90° with
facial movement. It is possible that this rotation
in the axis of mechanical tension will affect the
appearance of the resulting scar (Bush et al.
2007).
It is axiomatic that a thorough debridement of
all dirt and foreign material should be the rst
step the surgeon must take. The presence or
absence of damaged tissue determines whether or
not parts of a wound should be excised. In the
face, the problem of excisional policy is more
difcult than elsewhere in the body. Excision of
damaged tissue converts a wound to an “atraumatic” one, in an attempt to get a satisfactory
nal result primarily. In more extensive wounds,
however, tissue excision may result in closure
under tension and a stretched or hypertrophic
scar or even a deformity. A more conservative
approach with removal of only necrotic tissue is
advocated. In this way, the salvage of tissue is
permitted, which might otherwise be excised,
and which later may prove valuable. One, however, is prepared for eventual secondary correction of the resulting scar.
The secret in suturing an irregular wound is to
look for landmarks on either side to match. Time
spent tting a “jigsaw” of tissue accurately at the
time of original suture is never wasted (McGregor
1989).
An added difculty arises when there has been
actual loss of tissue. The governing principle is to
replace surviving tissues in their correct anatomical position, so that the defect can be properly
displayed and assessed in terms of tissue lost. In
some cases of extensive tissue loss, tissue replacement with regional or free tissue transfer is necessary. This can also be the case when there is a
full-thickness defect with opening into the mouth,
which cannot be closed without undue
distortion.
In deciding on the extent of surgical debride-
ment, one must often know when a part of traumatized tissue is viable or not. In other words, the
surgeon has to check on the vascularity. Blanching
on pressure and the presence of dermal bleeding
are both evidences of an active circulation. In the
face and scalp, tissue vascularization is the richest of the whole body; therefore, tissue excision
should not be carried out lightly. In case of doubt,
it is advisable to be conservative and keep tissue
instead of removing it, as there is a good chance
that it will “pick up.” The state of tissue vascularity is assessed through the color of the overlying
skin. For this reason, the antiseptic chosen for
skin sterilization should be the one which does
not stain the skin or tissues. Betadine® (povidoneiodine 10% in an alcoholic solution), suitable
otherwise, should not be used; satisfactory agents
are cetrimide and chlorhexidine.
The wound edges to be sutured ought to be
vertical if the best scar result is to be achieved.
When preparing the wound for suture, the surgeon, with little tissue sacrice, should aim at
rendering the wound edges vertical. In cases of
an extensive, oblique wound or a degloving
injury, the method of suturing is altered. Accurate
suturing is also easier when the opposing surfaces are equally thick. A slight undermining of
both edges (for a few millimeters) allows slight
wound eversion. Wider undermining is occasionally required, in order to achieve a wound closure
without tension. When doing that, the surgeon
should be careful not to endanger the vascularity
of the aps. In the face, the appropriate level is
deep to the dermis, so that the subdermal vascular
plexus is kept unharmed, while leaving the
branches of the facial nerve undisturbed. In the
scalp, the plane is between the galea aponeurotica and the pericranium. The vascular anatomy
of the scalp is such that extensive undermining
can be carried out safely (McGregor 1989).
Surgeons vary in the extent to which they make
use of undermining in this way. It is important to
recognize its limitations and dangers of using it
in the presence of damaged tissue, particularly
involving degloving. Undermining should be
done by experienced surgeons, because otherwise the harm will be bigger than the benet.
When more than minimal advancement is
required to allow a wound to be closed, some
authors advocate the use of skin grafts (McGregor
1989). The latter, however, may produce a poor
cosmetic result.
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