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3.7 Penetrating Injuries
Fig. 3.24 Penetrating injury to the eye (globe)
Fig. 3.25 Penetrating injury to the neck
fencing, or tree branches), as well as a variety of
non-projectile high-velocity projectiles, fragmentations from improvised explosive devices
(IGD), and shrapnel (Meer et al. 2010; Maier
etal. 2011; Aremu etal. 2012). The approach to
treatment should be multidisciplinary, beginning
with the trauma unit to provide airway maintenance and hemodynamic stabilization. An interventional radiologist may be consulted for
angiography. Penetrating facial trauma warrants
radiological assessment of key adjacent anatomical structures. In-driven fragments of native bone
potentiate tissue damage in projectile penetrating
facial trauma. Multi-detector computed tomography angiography (MDCTA) is the rst-line imaging modality in penetrating trauma of the neck
25
and often of the face (Ofah and Hall 2012).
MDCTA can provide accurate assessment of visceral injury of the neck, as well as vascular injury.
The imaging modality of choice in facial penetrating injuries remains non-contrast CT of the
facial bones and brain (Ofah and Hall 2012).
Organic material such as impaled wood fragments can be somewhat elusive on CT assessment unless appropriate window settings are
employed, depending on the amount of air and
uid within the interstices of the wood (Peterson
etal. 2002). Impaled wood fragments may appear
as “air” on CT and MRI assessment, but the radiologist should be alert on the possibility of an
embedded fragment of wood if this “air” exhibits
a geometrical margin (Ofah and Hall 2012).
Penetrating injuries of the neck and face represent a signicant source of acute admission of
civilians to accident and emergency departments
and trauma units in the United Kingdom. This
trend is reected across the rest of Europe (Ofah
and Hall 2012). It seems, however, that in South
Africa these injuries are even more common than
the rest of the world (Meer etal. 2010). In the
United Kingdom, the number of actual and grievous bodily harm offences involving a knife or
sharp instrument has remained more or less constant between 2009 and 2010, accounting for 4%
of violent and sexual offences recorded by the
police (Ofah and Hall 2012).
The ability of penetrating objects to cause
local supercial soft-tissue damage such as
parotid parenchymal or parotid duct injury should
be considered. Emergency parotidectomy for
vascular exposure in a case of penetrating trauma
to the face and upper zone III of the neck has
been reported. Facial nerve repair was also necessary, underscoring the importance of this
approach not only for successful vascular control
but also for preservation of nearby vital structures (Morris et al. 2007). Damaged external
carotid artery branches can be a source of catastrophic hemorrhage, which may warrant emergency endovascular treatment. MDCTA may be
of signicant value in such circumstances. Injury
to venous structures should not be ignored;
venous injuries occur in nearly 20% of patients
with penetrating trauma of the neck and are fre-
26
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3 General Principles ofWound Management
quently missed at physical examination
(Gonzalez etal. 2003).
Globe laceration, globe perforation, globe
rupture, or open globe injuries are forms of ocular trauma that require urgent diagnosis and treatment. The integrity of the globe can be disrupted
by two primary mechanisms: penetration/perforation/laceration and rupture due to blunt force
(Blair et al. 2022). Primarily blunt injuries are
more common (83%), whereas primarily sharp/
penetrating injuries are less common (17%)
(Kruse et al. 2021). In penetrating injuries, the
object does not traverse the entire eye, whereas in
perforating injuries, there is an entrance and an
exit. Diagnosis of globe rupture is based on the
history and clinical ophthalmologic examination
typically consisting of the slit lamp and funduscopic evaluation (Blair etal. 2022). In cases of
penetrating eye injuries, ultrasound of the eye is a
quick, reliable, accurate, and easy-to-learn
method, which offers valuable information
regarding the anterior as well as the posterior
compartments of the eye (Gay et al. 2013).
Penetrating eye injuries were the second most
common in a series of 147 patients with assaultrelated open globe injuries. Eyes that sustained
penetrating injuries were less likely to have nal
visual acuity of no light perception or require
enucleation (Banza et al. 2013). A recent study
from 13 hospitals (seven countries) using the
International Globe and Adnexal Trauma
Epidemiology Study platform showed that
female gender, older age, zone III injury, eyelid
injury, and intraocular foreign body were associated with higher risk of severe vision loss (Hoskin
etal. 2021). In another study, the authors observed
that the presence of relative afferent pupillary
defect (RAPD), injury at zone III, and rupture as
the mechanism of injury were signicant risk factors of no vision in cases of an open globe injury
(Ji etal. 2017). Roughly one-third (34.5%) of all
cases (51/148) ended up by enucleation (14 primary and 37 secondary enucleations). All the
enucleated eyes presented no light perception
before operation (Ji etal. 2017). Indications for
secondary enucleation were obvious eye atrophy,
ocular pain, and prophylaxis of sympathetic ophthalmia (Ji etal. 2017). Nearly 40% of cases with
ruptured globe were anatomically restored
through vitreoretinal surgery. The closed-funnel
retinal detachment or extensive retinal loss, proliferative vitreoretinopathy, intraocular foreign
body, eyelid injury, and choroidal damage were
correlated with poor outcomes (Feng etal. 2015;
Hoskin etal. 2021). In children, presenting visual
acuity and retinal detachment were independent
predictors of outcome. When visual acuity was
unknown, age at injury, lens involvement, and
retinal detachment were independently associated with nal visual acuity (Jacobson et al.
2020).
Meer et al. (2010) in a retrospective, cross-
sectional, and record-based study analyzed all
penetrating knife injuries reported at various
South African hospitals for a period of 11years.
Twenty-four cases of such injuries with the knife
in situ were analyzed. Twenty-one patients
(87.5%) were male and three (12.5%) were
female. Thirteen (54.2%) were colored and 11
(45.8%) were black. There were no denite signs
of vascular injury. Postsurgical recovery of all
patients was rapid and uneventful, and there were
no fatalities. The authors suggested that an angiogram is mandatory, if the patient presents with
excessive bleeding or an expanding hematoma or
if the knife blade is in the region of any large vessels (Meer etal. 2010). More details, as well as
more recent views on this subject, are presented
in Chap. 10.
3.8 Gunshot Injuries
Head and neck gunshot injuries pose a unique
challenge to the extent of injury and resulting
soft-tissue and osseous loss (Volk et al. 2019).
Important differences between military (commonly induced by high-velocity weapons) and
civilian gunshot wounds (GSW) in the maxillofacial region were established in a cross-sectional
study from the University of Florida. A signicant difference was measured between study
groups regarding the region of the face involved,
gender, and race. No signicant relationship was
measured regarding deaths during admission
(p = 0.6510) for either study group (Guevara
References
27
etal. 2016). GSW represent a major public health
dilemma in the United States (Volk etal. 2019);
however, even in countries like Sweden, an
increase of patients with GSW has been reported
in the largest nationwide epidemiological study
(92 for the time interval 2013–2015, 141 for
2016–2018) (Günther etal. 2021). The mortality
rate is much higher (ca 50%) compared to the
mortality rate for stab wounds (9–21%) (Günther
etal. 2021; Magyar etal. 2022).
Initial management should use advanced
trauma life support principles with the goal of
patient stabilization (Volk et al. 2019). Injuries
with a Glasgow Coma Scale (GCS) 14–15 were
likely to have little or no associated brain injury,
and the wounds were localized to the face.
However, in cases of brain trauma, the mortality
was signicantly higher (Quenzer et al. 2021).
Acute operative management of these lowvelocity injuries should focus on wound decontamination, debridement, and temporary wound
closure (Kassan et al. 2000; Volk et al. 2019).
Historically, denitive surgical management
focused on delayed reconstruction secondary to
high rates of wound infections, necrosis, and ischemia (Volk etal. 2019). Contemporary methods,
however, have shifted towards earlier more denitive reconstruction due to improved imaging,
advent of virtual surgical planning, and popularization of microvascular free aps. Early primary
reconstruction can be successful for patients with
facial gunshot wounds, particularly when the
entry point of the bullet is in the upper and midface area. Delayed primary reconstruction is more
common when the bullet enters the lower face
(Murphy et al. 2018). Unintentionally, delayed
treatment was observed to result in improved
healing and decreased postoperative complications and morbidity of high-velocity maxillofacial
injuries possibly due to a critical revascularization
period (Oren etal. 2021). Postoperative complications were signicantly higher in patients with
self-inicted injuries compared to patients with
non-self-inicted injuries in a series of 73 free
ap reconstructions of signicant facial defects
from ballistic missiles (Sokoya etal. 2019). The
result of this study is likely to be helpful in surgical planning and patient counseling.
Face transplantation has the potential to offer
an alternative solution to the shortcomings of
conventional reconstruction. However, the critical nature of the psychosocial component in
cases of facial self-inicted gunshot wounds
should be stressed given the history of mental illness and suicidal behavior in this subset of
patients (Kiwanuka etal. 2016).
Penetrating gunshot injuries to supra-aortic
arteries that cause life-threatening blood loss or
major neurologic decits are increasingly managed using modern endovascular treatment
(EVT). Yevich etal. (2014) reviewed ten patients
(seven men, age 17–50 years) who underwent
emergency EVT for acute gunshot injuries to
supra-aortic arteries requiring acute management. Eight penetrated external carotid artery
branches were occluded with liquid embolic
agents (acrylic glue or Onyx) or particles. All
except one patient survived with minor or no
residual decits. Understanding endovascular
techniques and being able to make rapid and
appropriate treatment decisions in the setting of
acute gunshot injuries to the face and neck can be
a lifesaving measure and greatly benets the
patient’s outcome (Yevich etal. 2014).
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Injuries oftheScalp, Forehead,
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andEyebrow
4
4.1 Anatomy oftheScalp,
Forehead, andEyebrow
The scalp is of particular surgical interest because
it covers the skull, it presents numerous skin
lesions, and its lacerations are the most common
type of head injury requiring surgical care (Anson
and McVay 1971).
The soft parts over the skull consist of ve
layers: the skin, the subcutaneous tissue, the
occipitofrontalis muscle and its galeal aponeurosis, a lax layer of connective tissue, and the outer
periosteum of the skull bone (Fig.4.1).
The skin of the scalp is thick, and it is attached
by tough brous septa to the underlying frontalis
muscle. It has an abundant arterial and lymphatic
supply; the arteries are derived from the vessels
in the subcutaneous tissue. Because of this abundant arterial supply, scalp and forehead lacerations heal well.
The subcutaneous tissue is dense and tough
because of the presence of numerous short brous
septa, which also enclose small fat lobules and
form an inelastic layer carrying the blood vessels
(Anson and McVay 1971). The latter are numerous
and amply anastomotic. The abundant blood supply leads to, occasional, considerable hemorrhage.
Simple compression of the skin adjacent to a
wound between the ngertips and the underlying
skull will, however, control even an alarming hemorrhage. The occipitofrontalis muscle is attached
posteriorly to the occipital protuberance and to the
superior nuchal line (occipital bone). The frontal
bellies of the epicranius (occipitofrontalis) muscle
extend forward from the galea to the region of the
eyebrow, where they become attached to the skin,
interlacing with the orbicularis oculi. The frontal
bellies blend with each other in the midline, and
some bers pass down over the nose to become
continuous with the procerus muscle (Sinclair
1972), which arises from the lower part of the
nasal bones; another small muscle, the corrugator
supercilii, arises from the medial end of the superciliary arch blending with the orbicularis oculi and
passes upwards and laterally to be inserted into the
skin of the eyebrow (Sinclair 1972).
The lateral arterial supply of the scalp is derived
from the supercial temporal artery, posterior
auricular artery, and occipital branches of the
external carotid artery (Anson and McVay 1971)
(Fig. 4.2). Furthermore, frontal and supraorbital/
supraciliary branches of the ophthalmic artery
contribute to the vascularization of the forehead
(Fig.4.2). All the vessels run in the subcutaneous
fat from the periphery towards the vertex and anastomose across the midline with one another
(Anson and McVay 1971). The frontal, parietal,
and occipital veins empty into the external jugular
vein. The frontal and supraorbital veins unite at the
median angle of the eye and communicate there
with the angular vein (the beginning of the facial
vein). The supraorbital veins drain into the ophthalmic vein and thence into the cavernous sinus
(Anson and McVay 1971).
© 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_4
31
32
e
Gale
auric. artery
temp. artery
4 Injuries oftheScalp, Forehead, andEyebrow
1 Skin
2 Subcutaneous
tissue
a
4 Subaponeurotic
connective tissu
Bone
Fig. 4.1 Schematic representation of the scalp layers (skin=1; subcutaneous tissue =2; subaponeurotic connective
tissue=4)
Fig. 4.2 Schematic
representation of the
vascularization of the
scalp
Pericranium
Dura Matter
The nerves of the scalp, with the exception of
the facial supply to the frontalis muscle, are
purely sensory.
The frontal bellies of the frontalis muscle are
supplied by the frontal branch of the facial nerve.
The sensory innervation is provided by the frontal nerve, branch of the ophthalmic nerve (rst
branch of the trigeminal nerve). The frontal nerve
divides into a larger supraorbital and a smaller
Post.
Sup.
supratrochlear branch. The supraorbital nerve
passes through the supraorbital groove or foramen and, turning upwards, supplies the forehead
and scalp as far as the vertex. The supratrochlear
nerve supplies the medial parts of the upper
eyelid and forehead (Sinclair 1972). The great
auricular and the major and lesser occipital
nerves are of spinal origin. They innervate the
side and back of the scalp.
4.2 Scalp Injuries
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33
4.2 Scalp Injuries
Scalp lacerations are the most common type of
head injury requiring surgical care (Anson and
McVay 1971). Studies on animal bite injuries of
the head and neck also showed that scalp lacerations were the most common injuries (>50%)
(Mitchell etal. 2003; Patil etal. 2015).
The abundant blood supply of the scalp may
lead to alarming hemorrhage in patients with
scalp lacerations (Fig. 4.3). Such patients often
have associated injuries that redirect the clinician’s attention to other injury sites. Some scalp
lacerations are severe enough to cause hypovolemic shock and acute anemia (Lemos and Clark
1988; Turnage and Maull 2000). If the patient
arrives in shock, the perfusion pressure may be
low; therefore, the active scalp bleeding may be
minimal. Under such circumstances, the scalp
wound may be initially neglected and attention
turned to assuring an adequate airway, establishing intravenous lines, initiating volume resuscitation, and searching for more occult sources of
blood loss (Turnage and Maull 2000). However,
as the blood pressure returns towards normal values, bleeding from the scalp wound becomes
more profuse and may present a hemostatic challenge to the clinician. Hemostatic forceps
(Fig.4.3) and vessel ligature or Raney clips to the
Fig. 4.3 Scalp laceration; the hemorrhage was controlled
using a mosquito artery forceps on a scalp vein
edges of the scalp lacerations when readily available can control scalp hemorrhage (Lemos and
Clark 1988; Turnage and Maull 2000). Following
stabilization and radiologic studies, the scalp
wounds can be managed denitely (Sykes and
Cowgill 1989).
Continued reduction in hemoglobin levels
calls for a more thorough examination of the
scalp. Adequate examination of lacerations
requires thorough cleaning, as coagulated blood
and other material may obscure ndings. This is
particularly important in scalp lacerations where
the overlying hair can form a barrier which hides
the wound edges (Basyuni etal. 2016).
Animal and human studies suggest that irrigation lowers the infection rate in contaminated
wounds (Howell etal. 1993; Owens and Wenke
2007). Irrigation of “clean” lacerations, however,
did not seem to signicantly alter the rate of
infection or the cosmetic appearance of clean,
non-contaminated scalp lacerations (Hollander
et al. 1998). The authors compared two similar
groups (irrigation–non-irrigation) and found that
the incidence of wound infection was not signicantly different between the two groups (0.9%
vs. 1.4%, respectively; p=0.28), and the percentage of patients with an optimal cosmetic appearance was similar in the two groups (75.9% vs.
81.7%, respectively; p= 0.07) (Hollander etal.
1998).
Concern exists among various surgeons that
not removing skin hair prior to scalp laceration
repair may lead to an increased incidence of
wound infections. Howell and Morgan (1988)
studied a group of 68 patients with scalp lacerations, which were repaired without hair removal.
The mean patient age was 21.8±19.8years, and
the mean laceration length was 2.5 ± 2.0 cm.
Sixty-three lacerations were repaired within 3h
of injury. The authors examined the patients prospectively for infection. No infections were noted
at 5-day follow-up. Because hair removal neither
contributes benets to the surgical outcome nor
decreases the risk of wound infection, but has
considerable cosmetic value for the patient, most
surgeons recommend that scalp lacerations
should be repaired without hair shaving, whenever this is technically feasible.
34
4 Injuries oftheScalp, Forehead, andEyebrow
The necessity of temporary suturing of scalp
lacerations in patients with compound depressed
skull fractures who need further denitive treatment has been an issue. Shokunbi et al. (2000)
reported that scalp closure without elevation of
the depressed fracture does not reduce the risk of
infection in patients with compound depressed
skull fractures. The authors based their conclusion on the results of a retrospective observational study of 79 patients who were treated
surgically at their unit. The rate of infection in
patients who presented with open wounds
(n=52) and those whose scalps had been sutured
prior to presentation (n=27) was similar without
signicant difference (X2 = 1.92, p > 0.05).
Suturing the scalp laceration alone prior to referral for denitive surgery did not reduce the rate of
infection of the cranial wound; therefore, the
authors recommended hemostasis, thorough irrigation of the scalp wound, and application of
sterile dressings prior to transfer for denitive
management in patients who do not have immediate access to neurosurgical care (Shokunbi
etal. 2000).
If there are no underlying fractures, denitive
management of the laceration should be conducted. Suturing of the scalp wound with nonabsorbable sutures under local anesthesia is the
simplest method. The sutures should equally
involve all layers of the scalp, in order to achieve
a better coaptation of the wound edges. A pressure head dressing, or occasionally a vacuum
drain in cases of wide undermining, should be
applied for 24 h for prevention of hematomas.
The sutures are left in place for 10–12 days.
Stapling is an alternative to suturing for simple
lacerations and has a number of advantages with
no additional complications. Kanegaye et al.
(1997) compared the total costs and the physician
time requirements for suture and staple repair of
pediatric scalp lacerations. Stapling resulted in
shorter wound closure times and was less expensive in terms of equipment and total cost (equipment+physician time). There were no cosmetic
or infectious complications in either group. A
more recent prospective, randomized trial by
Khan et al. (2002) from the Babies Hospital,
Columbia University, of 42 children (aged
1–16years) with simple scalp lacerations reached
the same conclusion that stapling is a fast and
cosmetically acceptable alternative to suturing
for simple scalp lacerations.
Another technique for treating scalp lacerations is the hair apposition technique (HAT). After
standard cleaning procedures, hair on both sides
of a laceration is apposed with a single twist. This
is then held with tissue adhesives. In a comparative (randomized controlled) study of HAT vs.
suturing, wound healing trended towards being
judged more satisfactory in the HAT group (Hock
et al. 2002). Patients who underwent HAT had
less scarring (6.3% vs. 20.4%; p= 0.005), fewer
overall complications, signicantly lower pain
scores (median 2 vs. 4; p < 0.001), and shorter
procedure times (median 5 min vs. 15 min;
p<0.001). There was a trend towards less wound
breakdown in the HAT group. Severely contaminated wounds, actively bleeding wounds, patients
with hair stand length less than 3cm, and hemodynamically unstable patients were excluded
from the study. Because of the advantages, the
authors stated that HAT has become their technique of choice for suitable scalp lacerations
(Hock etal. 2002). In a further randomized, prospective trial, the same group from Singapore
General Hospital showed that the HAT can be
safely performed by trained nurses with equivalent outcomes as doctors (Ong etal. 2008).
Scalp wounds with exposed calvarial bones
continue to be a challenge especially when no
local ap options are available and no microvascular surgery can be performed. Clinical and
experimental evidence has shown that such
wounds can effectively be treated with negativepressure wound therapy. In a recent review of 19
patients (scalp wounds 6×4cm to 17 ×11cm,
exposed bone 1×2cm to 10×10cm), Zargar
etal. (2022) observed healthy seven granulation
tissue covers after treatment with customized
negative-pressure wound treatment. All wounds
were then skin grafted. No major complications
were seen, and all wounds healed rapidly.
Combination of negative-pressure wound therapy
and platelet-rich brin was shown to be even
more effective than negative pressure alone
(Zhang etal. 2022).
4.2 Scalp Injuries
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35
Hypertrophic scarring after scalp laceration
repair is a very rare phenomenon. It is possible
that the rich subcutaneous blood ow in the scalp,
which is connected to bushy hair, prevents hypertrophic scar and keloid formation. Anecdotal
cases have been reported in hairless parts of the
scalp, which were successfully treated with reexcision of the hypertrophic scar, irradiation by a
linear accelerator, and pressure treatment for
6months (Murakami etal. 2006).
Total avulsion of the scalp is a rare but potentially devastating injury. It commonly results
from the entrapment of long hair in high-speed
rotary parts of industrial machinery, or less frequently from animal bites and assaults (Yin etal.
2008; Patil etal. 2015). The avulsed scalp may
include the eyebrows as well as all or part of the
ears, whereas the plain of cleavage is generally
through the loose connective tissue between the
galea aponeurotica and the periosteum.
Microsurgical scalp replantation has been the
method of choice for treating these injuries for
the past four decades (since 1976 when Miller
etal. described the rst case). Once the scalp has
been cleaned of hair, the next step is identication and preparation of the vessels for reanastomosis. Available branches of the temporal artery
and temporal veins are dissected proximally in
the patient and distally in the ap and mobilized
to gain as much length as possible for the reanastomosis. Under microscopic magnication, the
arteries and veins are reanastomosed using 9.0 or
10.0 nylon microsutures. The avulsed temporal
branch of the facial nerve should also be identied and reanastomosed. This is not always feasible due to the local edema and trauma (Plant
and Fialkov 2010). The scalp is then aligned into
its anatomical position, and the frontalis muscle,
if torn, is sutured with 4.0 Vicryl absorbable
sutures. The skin closure is then completed circumferentially. Because there is often severe
trauma to the vessels within the zone of injury,
many authors have recommended the use of
interposed vein grafts. Doubling the number of
anastomoses that can leak, clot, or fail during the
postoperative period; creating a donor site; and
increasing ischemia time are the disadvantages of
using vein grafts. Adequate length, however, is
thus provided to ensure a tension-free anastomosis. If two surgical teams are available, the operative time can be minimized. Because failure in
these replants is mainly due to venous congestion, it is recommended to use a minimum of two
veins. It should be noted, however, that singlevein anastomosis with excellent survival has also
been reported (Plant and Fialkov 2010).
In cases in which the scalp is so traumatized
that no viable arteries are available, the use of an
arteriovenous anastomosis has been described
(Morris and MacGill 1992).
Postoperative monitoring is required, because
congestion and/or necrosis of portions of the
scalp are not uncommon. The occiput is a common location for postoperative necrosis (Arashiro
etal. 1995; Plant and Fialkov 2010). This is prob-
ably due to the small caliber of the occipital vessels and the difculty in nding them and using
them in the anastomosis, and the gravitational
dependence of the area (Plant and Fialkov 2010).
If at least one occipital vein can be identied and
reanastomosed, the aforementioned complication
can be mitigated.
There is a wide variation in the literature
regarding ischemia time. The time margins
within which a scalp can survive have not been
dened. Ischemia times of up to 17h (warm) and
up to 24 h (cold) (Juri et al. 1990; Sirimaharaj
and Boonpadhanapong 2001) have been reported
with survival of the anastomosed scalp. However,
the shorter the ischemia time, the bigger the
chances of the scalp surviving. Cheng et al.
(1996) have suggested that if warm ischemia
time of the scalp is over 10h, the arteries should
be anastomosed rst in order to establish blood
supply to the avulsed scalp. Subsequently, when
the venous anastomoses are performed, one
should block blood ow in arteries intermittently
in order to decrease the considerable blood loss.
Overall success rate reaches 95%. One hundred percent survival was reported in 80% of
cases, partial survival in 15%, and total failures in
5% in a series of 20 patients from China (Cheng
etal. 1996). In cases of failure after scalp replantation, multiple trephination of the calvarium has
been suggested as an alternative treatment for
scalp reconstruction (Terzioğlu et al. 1999;
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