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36
4 Injuries oftheScalp, Forehead, andEyebrow
Furlanetti et al. 2010). Multiple burr holes are
drilled in the calvarium in order to expose the
diploe. Granulation tissue from the holes begins
to cover the defect after 4weeks. When the bed is
suitable, skin grafting can be performed. This
method has been successfully used as an alternative to scalp replantation in selected cases
(Terzioğlu etal. 1999; Furlanetti etal. 2010).
4.3 Forehead andEyebrow
Injuries
Forehead lacerations occur frequently. In children, they seem to take the brunt of most frequent
injuries. In a recent review of 3783 patients
(<15years of age), they accounted for 26.4% of
all facial lacerations (Hwang etal. 2013). In the
general population, forehead and eyebrow lacerations also seem to be the most frequently occurring, as was reported in a recent study from Korea
(Lee etal. 2015), where forehead injuries represented 22.6% and eyebrow injuries 16.6% of the
total (n=3683). An explanation could be the fact
that the underlying frontal bone resists more to
external forces compared for example with the
malar bone and the maxilla, as it possesses a
greater “fracture threshold” and thus resists to
deformation. Considering that the composition of
soft tissues is homogenous across the face, one
accepts that skin resistance of the forehead is the
same as skin resistance of the malar bone and
maxilla. When an external force acts on the forehead, the skin is disrupted with greater violence,
because there is greater absorption of energy in
that area, as the underlying bone resists to fracture and deformation and thus reduces the stopping distance of the acting force. Severity and
extent as well as depth of soft-tissue injuries are
directly related to the varying resistance and the
“fracture threshold” of facial bones. It has been
shown that the direction of soft-tissue injury
resulting after excision of a blunt force is such
that the injury to the underlying microcirculation
is minimized.
The severity of lacerations of the forehead and
eyebrow varies from simple linear cuts not bigger
than a few centimeters (Figs.4.4 and 4.5) to com-
plex wounds or avulsions associated with injury
to underlying and/or associated organs (Figs.
3.22 and 4.6). The physician ought to rule out an
underlying depressed fracture of the frontal bone,
frontal sinus, and/or dural leak and possible brain
injury (Fig. 4.7). The above would change,
namely, the management priorities of the patient.
A careful examination and, if necessary, a CT
scan of the area must be done prior to repair.
An anatomic layered repair is undertaken
beginning with closure of the periosteum followed by fascia, dermal, and skin repair to prevent
spreading and depression of the scar (Fig. 4.8).
During debridement, care is taken not to bevel the
wound edges, if possible, so that U-shaped, avulsion-type, trapdoor deformities can be prevented
(Rohrich 1991). In cases of bleeding due to a
sports injury and if the player has to continue,
Fig. 4.4 Laceration of the forehead <5cm in length
Fig. 4.5 Laceration of the eyebrow <5cm in length
4.3 Forehead and Eyebrow Injuries
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37
Fig. 4.6 (a) Complex
wound of forehead and
eyebrows, degloving of
the skin, and injury to
the underlying bony
skeleton and brain. (b)
Postoperative picture.
(From: Ioannides etal.
1984, with permission)
Fig. 4.7 (a) Forehead
injury with extensive
damage to the
underlying bony
skeleton. Frontal sinus
and brain injury. (b) The
same patient 1year
postoperatively. (From:
Ioannides etal. 1984,
with permission)
ab
ab
Fig. 4.8 (a–c)
Post-traumatic forehead
scars. An anatomic
layered repair was
undertaken, which
prevented stretching and
depression of the scar
a
b
c
38
4 Injuries oftheScalp, Forehead, andEyebrow
Fig. 4.9 (a) Eyebrow
laceration. (b) The
frontal branch of the
facial nerve was not
severed allowing for
normal wrinkling of the
forehead. (c) The
wound. (d) The same
patient 5days
postoperatively
a
b
cd
Fig. 4.10 (a) Eyebrow
laceration in a 10-yearold boy. Meticulous
alignment resulted in a
non-visible scar, as it is
shown in (b) 1year after
repair
a b
temporary stapling arrests bleeding and allows the
player to quickly return to play. The staplers are
removed after the match, and the wound can be
denitely sutured (Orchard 2004).
Every attempt should be made to preserve the
eyebrow, which provides an invaluable landmark.
If the eyebrow is malaligned, it is difcult to
repair (Rohrich 1991). Careful and meticulous
alignment of the wound edges is therefore necessary before denitive eyebrow repair (Figs. 4.9
and 4.10). Traumatic eyebrow defects can be
repaired using composite postauricular grafts in
combination with a microfollicular hair transplant technique (Vachiramon et al. 2004) or a
scalp island ap based on the supercial temporal artery (Piccagliani etal. 2009).
Occasionally, debridement of multiple contusions and lacerations of a large area of the forehead are necessary resulting in a large defect. The
defect can be reconstructed with bilateral temporal artery fasciocutaneous advancement aps
(Gruber etal. 1999).
Injuries to the frontal branch of the facial nerve
(neurotmesis) should be recognized and treated
References
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39
immediately, before skin closure (Fig.4.9b). The
anatomy of the frontal branch has been studied
(Gossain 1995; Lettieri 2008), and the surgeon
should know where to look for the nerve stumps.
After identication of both the proximal and the
distal nerve stumps, microsurgical nerve repair
should follow. Regaining of motor function can
last as long as 38months (Aydan-Köse etal. 2002).
Post-traumatic supraorbital neuralgia following
soft-tissue injuries to the frontal region seems to be
a frequent condition, although it is probably underdiagnosed (Penas-Prado et al. 2007).
Epidemiological data are lacking; however, a prevalence of 0.5% has been reported (Sjaastad etal.
2005). In approximately half of the cases, a mod-
erate ipsilateral sensory loss is noted (Sjaastad
etal. 2005). Hyperalgesia or allodynia and a positive Tinel’s sign have also been reported (PenasPrado etal. 2007). An increased tenderness upon
pressure over the exit site of the supraorbital nerve
(incisura frontalis) on the affected side is noted in
patients who are in an active phase. Medical treatment with gabapentin and amitriptyline has
improved or even cured patients’ pain. Supraorbital
nerve blockade with a local anesthetic has offered
temporary relief (Penas-Prado et al. 2007).
Sensory alterations, however, persist in all cases.
References
Anson BJ, McVay CB. In: McVay CB, editor. Scalp,
cranium, meninges and brain. In: Surgical anatomy
Anson BT.Philadelphia, PA: Saunders; 1971. p.1.
Arashiro K, Ohtsuka H, Ohtani K, et al. Entire scalp
replantation: case-report and review of the literature.
J Reconstr Microsurg. 1995;11:45–50.
Aydan-Köse A, Sezgin M, Karabaq-Li Y, et al.
Neurotization of the frontal muscle after scalp
replantation: a case report. J Reconstr Microsurg.
2002;18:677–80.
Basyuni S, Panayi A, Sharma V, etal. A missed scalp lac-
eration causing avoidable sequelae. Int J Surg Case
Rep. 2016;23:61–4.
Cheng K, Zhou S, Jiang K, et al. Microsurgical replan-
tation of the avulsed scalp: report of 20 cases. Plast
Reconstr Surg. 1996;97:1099–108.
Furlanetti LL, de Oliveira RS, Santos MV, etal. Multiple
cranial burr holes as an alternative treatment for total
scalp avulsion. Childs Nerv Syst. 2010;26:745–9.
Gossain AK.Surgical anatomy of the facial nerve. Clin
Plast Surg. 1995;22:241–51.
Gruber S, Papp C, Maurer H.Case report. Reconstruction
of damaged forehead with bilateral fasciocutaneous
temporal V-Y advancement island aps. Br J Plast
Surg. 1999;52:74–5.
Hock MO, Ooi SB, Saw SM, et al. A randomized
controlled trial comparing the hair apposition
technique with tissue glue to standard suturing in
scalp lacerations (HAT study). Ann Emerg Med.
2002;40:19–26.
Hollander JE, Richman PB, Werblud M, etal. Irrigation
in facial and scalp lacerations: does it alter outcome?
Ann Emerg Med. 1998;31:73–7.
Howell JM, Morgan JA. Scalp laceration repair without
prior hair removal. Ann J Emerg Med. 1988;6:7–10.
Howell JM, Dhindsa HS, Stair TO, etal. Effect of scrub-
bing and irrigation on staphylococcal and streptococcal counts in contaminated lacerations. Antimicrob
Agents Chemother. 1993;37:2754–5.
Hwang K, Huan F, Hwang PJ, etal. Facial lacerations in
children. J Craniofac Surg. 2013;24:671–5.
Ioannides C, Freihofer HP, Bruaset I. Trauma of the
upper third of the face. Management and follow-up. J
Maxillofac Surg. 1984;12:255–61.
Juri J, Irigaray A, Zeaiter C.Reimplantation of the scalp.
Ann Plast Surg. 1990;24:354–61.
Kanegaye JT, Vance CW, Chan L, etal. Comparison of
skin stapling devices and standard sutures for pediatric
scalp lacerations: a randomized study of cost and time
benets. J Pediatr. 1997;130:808–13.
Khan AN, Dayan PS, Miller S, etal. Cosmetic outcome
of scalp wound closure with staples in the pediatric
emergency department: a prospective, randomized
trial. Pediatr Emerg Care. 2002;18:171–3.
Lee JH, Jeon MS, Lee DL, etal. Analysis of patients with
facial lacerations repaired in the emergency room of
a provincial hospital. Arch Plast Surg. 2015;42:34–9.
Lemos MJ, Clark DE.Scalp lacerations resulting in hem-
orrhagic shock: case reports and recommended management. J Emerg Med. 1988;6:377–9.
Lettieri S.Frontal branch of the facial nerve: galeal tem-
poral relationship. Aesthet Surg J. 2008;28:143–6.
Miller GDH, Anstee EJ, Snell JA.Successful replantation
of an avulsed scalp by microvascular anastomoses.
Plast Reconstr Surg. 1976;58:133–6.
Mitchell RB, Nañez G, Wagner JD, et al. Dog bites of
the scalp, face and neck in children. Laryngoscope.
2003;113:492–5.
Morris SF, MacGill KA. Scalp replantation by arteri-
alised venous net-work ow-through. Br J Plast Surg.
1992;45:187–92.
Murakami M, Ogawa R, Nishikawa M, etal. A rare case
of hypertrophic scar of the scalp. Plast Reconstr Surg.
2006;117:321–2.
Ong ME, Chan YH, Teo J, etal. Hair apposition technique
for scalp laceration repair: a randomized controlled
trial comparing physicians and nurses (HAT2 study).
Am J Emerg Med. 2008;26:433–8.
Orchard JW. Video illustration of staple gun use to rap-
idly repair on-eld head laceration. Br J Sports Med.
2004;38:E7.
40
4 Injuries oftheScalp, Forehead, andEyebrow
Owens BD, Wenke JC.Early wound irrigation improves
the ability to remove bacteria. J Bone Joint Surg Am.
2007;89:1723–6.
Patil SB, Mody NB, Kale SM, et al. A review of 48
patients after bear attacks in central India: demograph-
ics, management and outcomes. Indian J Plast Surg.
2015;48:60–5.
Penas-Prado M, Martinez-Salio A, Porta-Etessaim J, etal.
[Post-traumatic supraorbital neuralgia: a benign con-
dition]. Rev Neurol. 2007;44:89–91.
Piccagliani L, Ferrara F, Palmieri B, et al. [Eyebrow
reconstruction with a scalp island ap based on super-
cial temporal artery. G Chir Ital. 2009;61:647–51.
Plant MA, Fialkov J. Total scalp avulsion with micro-
vascular re-anastomosis: a case report and literature
review. Can J Plast Surg. 2010;18:112–5.
Rohrich RJ.Complex injuries of the forehead/brow, cheek
and ear. In: Facial injury management, state of the art.
An international symposium. Program syllabus ASPS
and PSEF, Chicago; 1991, p.11.
Shokunbi MT, Komolafe EO, Malomo AO, et al. Scalp
closure without fracture elevation does not reduce the
risk of infection in patients with compound depressed
skull fractures. Afr J Med Sci. 2000;29:293–6.
Sinclair DC.Muscles and fasciae. In: Romanes GJ, editor.
Cunningham’s textbook of anatomy. Oxford: Oxford
University Press; 1972. p.280.
Sirimaharaj W, Boonpadhanapong T.Scalp replantation: a
case report of long ischemic time. J Med Assoc Thail.
2001;84:1629–34.
Sjaastad O, Petersen HC, Bokketeig LS. Supraorbital
neuralgia. Vågå study of headache epidemiology.
Cephalgia. 2005;25:296–304.
Sykes LN Jr, Cowgill F.Management of hemorrhage from
severe scalp lacerations with Raney clips. Ann Emerg
Med. 1989;18:995–6.
Terzioğlu A, Aslan G, Saydam M. Trephination in the
treatment of scalp avulsion: successful application of a historical method. J Oral Maxillofac Surg.
1999;57:204–6.
Turnage B, Maull KL.Scalp laceration: an obvious occult
cause of shock. South Med J. 2000;93:265–6.
Vachiramon A, Aqhabeigi B, Gean SJ. Eyebrow
reconstruction using composite graft and microsurgical transplant. Int J Oral Maxillofac Surg.
2004;33:504–8.
Yin JW, Matsuo JMS, Hsieh CH, et al. Replantation of
total avulsed scalp with microsurgery. Experience
with eight cases and literature review. J Trauma.
2008;64:796–802.
Zargar HR, Mohsin M, Shah RA, etal. Successful man-
agement of complex scalp wounds with exposed
calvarial bones by customized Negative pressure
wound therapy (NPWT): case series and review
of the literature. Trop Dr. 2022;52:258. https://doi.
org/10.1177/00494755211043377.
Zhang H, Wang S, Lei C, et al. Experimental study of
negative pressure wound therapy combined with
platelet- rich brin for bone-exposed wounds. Regen
Med. 2022;17:23–35.
Injuries oftheEyelids, Canaliculi,
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andCanthi
5
5.1 Anatomy oftheEyelids,
Lacrimal System, andCanthi
The eyelids, or palpebrae, are two (an upper and
a lower) thin surface folds (Fig.5.1) which are
strengthened by the presence in each of a rm
plate of condensed brous tissue, the tarsus
(Fig. 5.2). Each is covered by thin skin on its
external surface and by conjunctiva on its deep
surface. In the fat-free subcutaneous tissue, both
eyelids contain the palpebral bers of the orbicularis oculi muscle, which approximates their at,
free margins (limbi) (Romanes 1972). The eyelids meet at the lateral and medial angles of the
eye (commissures of the eyelids). There is a small
elevation at the free margin of each lid (medial
angle), the lacrimal papilla, on the apex of which
opens the lacrimal canaliculus through which
lacrimal uid is transported to the lacrimal sac.
The tarsus is a thin, elongated plate of dense
brous tissue which gives each lid its rmness. It
is connected to the lateral wall of the orbit by the
external tarsal ligament (lateral or external canthus), with the medial wall by the internal dorsal
ligament (medial or internal canthus), and with
the upper and lower orbital margins by an aponeurotic layer of brous tissue known as the
orbital septum (orbital ligament) (Fig.5.2). The
lateral canthus is attached to the orbital surface of
the zygomatic bone, and the medial canthus is
attached to the frontal process of the maxilla
anterior to the lacrimal fossa. The orbital septum
is attached peripherally to the periosteum of the
orbital margin. It prevents orbital extravasations
from entering the lids (Anson and McVay 1971).
In the upper eyelid, the orbital septum fuses with
the supercial layer of levator palpebrae superioris, anterior to the tarsus.
The conjunctiva is a highly sensitive membrane covering the deep surfaces of the eyelids
and is reected from them onto the anterior surface of the eyeball at the superior and inferior
conjunctival fornices, loose folds forming a culde- sac (Fig.5.3). The bulbar conjunctiva is very
thin and completely covers the eyeball in front,
whereas the tarsal conjunctiva is thicker and
highly vascular.
The eyelids protect the eyeball. Furthermore,
they protect the retina and brain from light, which
otherwise would create cortical images and maintain cerebral activity. Through the winking reex,
they serve to protect the cornea from injury and
assist in keeping it from undue drying (Anson
and McVay 1971).
The chief arteries of the eyelid are the superior
and inferior palpebral branches of the ophthalmic
artery. They run in loose tissue between the orbicularis muscle and the orbital septum. They anastomose with the lacrimal, supercial temporal
and transverse facial arteries forming an arch in
each lid (Anson and McVay 1971). The rich vascular anastomoses are of practical importance in
the rapid healing of wounds in this region.
Conjunctival veins drain into the muscular
© 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_5
41
42
(lo
Medial canthal
Fig. 5.1 Schematic
representation of the
eyelids
5 Injuries oftheEyelids, Canaliculi, andCanthi
Upper eyelid
Ant. surface of
lower eyelid
Tarsal plate
(upp. eyelid)
Tarsal plate
wer eyelid)
Fig. 5.2 Schematic representation of the tarsal plates and palpebral ligaments
tributaries of the ophthalmic veins, and pretarsal,
palpebral veins enter the facial and supercial
temporal veins. The lymphatics form pretarsal
and retrotarsal networks, which, for the most
part, drain into the preauricular and parotid
lymph nodes. The chief motor nerve of the region
is the facial nerve to the orbicularis oculi muscle.
It must be preserved, since the muscle plays the
important sphincter role of closing the lids. In the
event of nerve injury, special measures must be
taken to prevent desiccation and ulceration of the
cornea from non-closure of the eyelids. The levator palpebrae muscle is supplied by the oculomotor nerve, the paralysis of which results in ptosis
or inability to lift the lid.
The lacrimal apparatus consists of the lacrimal gland, the lacrimal canaliculi, the lacrimal
sac, and the nasolacrimal duct (Fig.5.4). The lacrimal gland lies for its greatest part in the lacrimal fossa on the medial surface of the zygomatic
process of the frontal bone. Three to nine excretory ductules open into the superolateral part of
ligament
Nasolacr
5.1 Anatomy oftheEyelids, Lacrimal System, andCanthi
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43
Sclera with
ocular
conjunctiva
Fig. 5.3 Schematic representation of the conjunctiva and conjunctival fornices
Fig. 5.4 Schematic
representation of the
lacrimal apparatus
Lacrimal sac
Inf. conjunctival
fornix
imal
duct
44
the superior conjunctival fornix. It is a serous
gland which moistens the conjunctival sac with a
watery uid containing lysozyme, which destroys
bacteria. The lacrimal uid helps to remove
particulate material and ows towards the medial
angle of the eye, assisted by contraction of the
orbicularis oculi. Just lateral to the lacrimal caruncle, the uid enters the puncta lacrimalis to
reach the lacrimal canaliculi. Each one of them
passes upwards or downwards into the corresponding eyelid and, then turning medially, is
distended to form an ampulla before coursing
respectively superior or inferior to the medial
palpebral ligament, to open into the lacrimal sac
a little above its midpoint, close to its fellow
(Romanes 1972). If the lower eyelid droops away
from the eyeball because of scarring contracture,
the lacrimal uid collects in the dependent eyelid
and spills over its free margin without even reaching the level of the inferior punctum.
The lacrimal sac is the blind, upper part of the
nasolacrimal duct through which lacrimal uid is
conveyed to the nasal cavity (Fig.5.4). The nasolacrimal duct passes downwards through a canal
formed by the maxilla, lacrimal bone, and inferior concha, to open into the anterior part of the
inferior meatus of the nose, approximately 3cm
behind the nostril. A lesion in any segment of the
lacrimal paths may produce excessive ow of
tears (epiphora).
5 Injuries oftheEyelids, Canaliculi, andCanthi
Fig. 5.5 Patient with an injury to the left eye; the extensive hyposphagma (subconjunctival hemorrhage) is
clearly noticeable
5.2 Eyelid andCanalicular
Lacerations
Lacerations of the eyelids are special wounds and
are therefore best managed, in the majority of
cases, by a specialized plastic or ophthalmic surgeon. Patients with eye injuries (Figs. 5.5 and
5.6) require an initial ophthalmologic examina-
tion (visual acuity, external examination, pupil
evaluation, motility), which is followed by a specialized ophthalmologic examination done by an
ophthalmologist if the former reveals pathological signs. The examiner should also check for
possible cornea lacerations (use of uorescein
blue light) and on the integrity of the lacrimal
apparatus (Jones dye test I and if negative Jones
dye test II) (Fig. 5.7). If the latter has been
Fig. 5.6 Patient with a left-eye injury; eyelid ecchymosis
and hyposphagma are clearly visible
injured, an obstruction may ensue resulting in
tear stagnation and, eventually, infection.
Therefore, prompt and accurate assessment is of
great importance. In children, clinical assessment
is usually done under sedation in the operating
theatre.
Eyelid lacerations are either partial thickness
(injury of skin and m. orbicularis oculi) (Fig.5.8)
or full thickness (injury of all three layers).
Furthermore, they are distinguished into mar-
Jones Dye Test1 (Primary)-Negative Jones Dye Test 2 (Secondary) Negative
5.2 Eyelid andCanalicular Lacerations
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Jones Dye Test1 (Primary)-Positive Jones Dye Test2 (Secondary)-Positive
45
Fig. 5.7 Schematic representation of Jones dye tests I
and II. The primary test: a drop of 2% uorescein is
instilled into the conjunctival sac. After 5min, a cottontipped bud moistened inlocal anesthetic is inserted under
the inferior turbinate at the nasolacrimal duct opening
• Positive: Fluorescein recovered from the nose indicates
patency of the drainage system
• Negative: No dye recovered from the nose indicates a
partial obstruction (site unknown) or failure of the lacrimal pump mechanism. In this situation, the Jones II
test is performed
The secondary test: Local anesthetic is instilled and any
residual uorescein washed out. The drainage system is
ginal (involvement of the free margin) and
non- marginal (free margin intact). Partialthickness and non-marginal lacerations are easier
to repair than full-thickness and marginal ones.
An important issue during repair of eyelid
defects (in cases of tissue loss or necrosis) is
then irrigated with saline with a cotton bud under the inferior turbinate
• Positive: Fluorescein-stained saliva recovered from the
nose indicates that uorescein entered the lacrimal sac,
thus conrming functional patency of the upper lacrimal
passages. Partial obstruction of the nasolacrimal duct is
inferred
• Negative: Unstained saliva recovered from the nose indicates that uorescein did not enter the lacrimal sac. This
implies partial obstruction of the upper lacrimal passages (puncta, canaliculi, or common canaliculus) or a
defective lacrimal pump
the direction of incisions, which if possible
should be placed parallel to skin tension lines.
However, it should be noted that with meticulous surgical technique even vertical to tension
lines lacerations can heal with an unsightly
scar. Another important factor is the direction
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