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Septal injuries are more frequently missed in
children (Olsen et al. 1980). If untreated, septal
injury may progress to localized septal necrosis and/
or disruption of growth centers, which may eventually lead to a more substantial deformity (Rohrich
and Adams 2000). Such a sequence of events may
explain much of the nasal deformities seen in adults.
Twenty children were reviewed by Canty and
Berkowitz (1996) for a hematoma (n = 8) and
abscess (n=12) of the nasal septum. The diagnosis was made 1–14days (mean 5.9days) after the
episode of trauma. Nasal obstruction was the most
common symptom found. Pain, rhinorrhea, and
fever were present in 50%, 35%, and 25% of
patients, respectively. Hematoma was associated
with cartilage destruction in 2/8 (25%) and
abscess in 12/12 (100%) patients. Corrective surgery was necessary in 1/8 hematoma patient
(12.5%) and 4/12 abscess patients (33%) (Canty
and Berkowitz 1996).
The importance of recognizing and promptly
treating septal hematomas cannot be overemphasized. An unrecognized septal deformity is one of
the major reasons for unfavorable outcomes.
Repairing soft-tissue nasal trauma while neglecting septal injury is futile.
6 Injuries oftheNose
6.4 Nasal Lacerations
Nasal lacerations can vary from simple lacerations (Fig.6.5) or abrasions (Figs.6.6 and 6.7) of
the skin to more complex injuries involving cartilage and inner mucosal lining (Fig. 6.8). They
Fig. 6.6 Nasal
abrasions in a female
patient
Fig. 6.5 Nasal injury in a male teenager. A laceration at
the nasal root as well as abrasions at the nasal tip and forehead are clearly visible
6.4 Nasal Lacerations
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57
Fig. 6.7 (a) Nasal
abrasion in a female
patient. (b, c) The same
patient 3weeks after
conservative
management
Fig. 6.8 (a, b) Complex
nasal injury (nasal
separation) involving all
nasal structures. (c)
Frontal and (d) Lateral
view of the same patient
3months after surgical
repair. (From Ioannides
etal. 1984, with
permission)
a
b
c
a
b
cd
58
6 Injuries oftheNose
can be horizontal, vertical, or oblique. The nasal
cartilage, just like the ear cartilage, depends on
the surrounding perichondrium and supporting
tissue for its metabolic needs. This applies in particular to the septal cartilage and its surrounding
perichondrium (see section on “Septal hematoma”). Meticulous reapproximation of injured
mucosa, especially if the injury is bilateral,
secures vascular supply to the septal cartilage.
Repair of nasal lacerations involves accurate
reapproximation of each injured tissue layer.
Simple lacerations of the overlying skin may be
closed with 5.0 or 6.0 monolament nonabsorbable sutures (usually polypropylene, Prolene®).
An alternative to sutures for simple, short, supercial skin lacerations in children is either sterile,
adhesive tapes (steristrips) or tissue adhesives.
In full-thickness lacerations which involve cartilage, debridement of ischemic tissue and cartilage should be kept to a minimum. Removal of
even a small amount of nasal cartilage can produce
a signicant defect and resultant asymmetry of the
healed wound (Brown etal. 2007). Likewise, the
nasal skin should be minimally debrided because
it is inexible, tears easily, and has minimal redundancy (Brown etal. 2007). Furthermore, the rich
vascular supply to the nasal soft tissues ensures
satisfactory recovery of most ischemic tissues. The
cartilage is reapproximated using 4.0 PDS or 4.0
Vicryl, and the nasal mucosa is usually repaired
with 5.0 Vicryl rapide. The three-layered approach
to the full-thickness nasal laceration begins with
the intranasal mucosa followed by cartilage and
nally the external skin (Fig.6.9).
Fig. 6.9 Full-thickness nasal laceration after threelayered repair; the external skin was the last repaired layer
Signicant cosmetic landmarks such as epidermal–mucosal junctions, nasal fold junctions,
or critical angles in jagged lacerations should be
aligned rst to decrease the incidence of deformity. Precise alignment of the free rim of the nostril is the most cosmetically important aspect of
the repair (Fig.6.7). Misalignment of the free rim
can produce unsightly notching of the alar edge.
6.5 Bite Injuries
It is estimated that half of all Americans will be
bitten by an animal or another human being during
their lifetimes. Dogs cause a majority of these bite
injuries (Mendoza and Chi 2019). It is interesting
to note that pediatric patients with dog bite injuries
are more frequently admitted with facial injuries,
whereas adult patients are more frequently admitted with upper extremity injuries and upper
extremity vascular injuries (Tam etal. 2021). The
vast majority of the estimated two million animal
and mammalian bite wounds are minor, and the
victims never seek medical attention. Avulsions
with tissue present or avulsions with loss of tissue
are more serious injuries which require medical
treatment (hospitalization) (Mendoza and Chi
2019). Bite wounds account for approximately 1%
of all emergency department visits and more than
30 million dollars in annual healthcare costs
(Griego etal. 1995; Piccart et al. 2019). Human
bite wounds have long had a bad reputation for
severe infection and frequent complications.
Recent data demonstrate that human bites occurring anywhere other than the hand present no more
of a risk for infection than any other type of mammalian bite (Griego etal. 1995). However, development of cellulitis and transmission of
communicable diseases still remain challenging
problems. Jenkins etal. (2018) conducted a survey
among leading clinicians in England and Wales
regarding the management of human head and
neck bite injuries. In roughly 78% of units,
“needlestick protocols” are followed, when stratifying risk for blood-borne viruses.
The nose being quite prominent is often
involved in bite injuries (Fig. 6.10). Domestic
animal (dog, cat) and human bites are frequent;
6.5 Bite Injuries
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Fig. 6.10 8-year-old child with a bite injury to the tip of
the nose
however, wild animal bites can also occur
(Bahram etal. 2004).
The spectrum of pathogenic bacteria and
viruses that cause bite infections is broader than
is generally appreciated. Both aerobic and anaerobic bacteria and a number of viruses (rabies,
hepatitis B and C, HIV) must be taken into
account (Goldstein 1989; Wilhelm etal. 2004).
The bacteriology of bite wounds inicted by
exotic animals reects the animal’s oral ora
(Goldstein 1992), which often reects the microbiome of its diet. Whenever possible, samples
should be taken from all suspected wound infections for aerobic and anaerobic bacterial culture,
to guide antibiotic therapy (Cheng etal. 2016).
Treatment consists of copious saline pressure
irrigation, meticulous wound and wound edge
debridement, repeated copious saline pressure irrigation, antibiotic coverage, wound closure or
defect restoration, and close postoperative monitoring. In addition to chemoprophylaxis, consideration must be given to administering tetanus toxoid
and rabies prophylaxis (Patil etal. 2009). In general, tetanus toxoid should be administered for any
bite wound that breaks the skin if the patient has
not received previous doses of tetanus toxoid, if
the vaccination history is unknown, if the most
recent dose was administered more than 10years
ago, or if the most recent dose was administered
more than 5 years ago and the wound is severe
(Cheng etal. 2016; Kim and Hunter 2019). Human
tetanus immune globulin should be added for
59
severe wounds (wounds contaminated with dirt,
feces, soil, or saliva; avulsions; wounds resulting
from missiles, crushing, burns, or frostbite) in
patients who have not received three prior doses of
the tetanus vaccine or in whom the number of previous doses is unknown and in those who have a
humoral immunodeciency (Cheng et al. 2016;
Hibberd 2021). The rabies virus is transmitted
only by mammals. Unless previously immunized,
patients should receive a combination of rabies
immune globulin administered subcutaneously
around the site of the wound, as soon as possible
after exposure (but it can be administered within
7days of exposure), as well as the rabies vaccine
intramuscularly. The vaccine must be given at a
different body site from the immune globulin
(Cheng et al. 2016; WHO 2021). The schedules
for postexposure prophylactic vaccination vary in
accordance with the product used, prior exposure
to rabies vaccine, and immunocompetence (Cheng
et al. 2016). When used according to current
guidelines, postexposure prophylaxis is highly
efcacious. However, failure to inltrate wounds
with rabies immune globulin and primary closure
of wounds before inltration of the immune globulin have been associated with the development of
rabies despite otherwise adequate postexposure
prophylaxis (Wilde etal. 1996).
A wound infection rate of 0.53–10.7% has
been reported (Guy and Zook 1986; Monroy
etal. 2009). When no antibiotics were administered, the infection rate did not increase signicantly. Guy and Zook (1986) reported a change
from 0.53% to 1.4% wound infection rate and
1.8–4% patient infection rate, when they changed
their protocol and stopped using antibiotics.
Studies investigating risk factors for infection
showed that wounds requiring surgical debridement and older patients (>50years) had a higher
infection rate (Dire etal. 1994). Factors associated with wound infections were longer time
interval until emergency department treatment,
attempting wound care at home, and having a
more severe or deeper wound (Dire 1991). Fullthickness wounds (OR = 6.23), female gender
(OR=2.88), and wound debridement (OR=5.01)
were found to be the best predictors for wound
infections (Dire etal. 1994).
60
6 Injuries oftheNose
Culture results of wound swabs taken from
deep within the wound before initiating treatment
will determine denitive antimicrobial therapy, if
and when the latter is needed. Culture for anaerobic organisms should be included as anaerobes
have been isolated from more than two-thirds of
human and animal bite wound infections, especially those with abscess formation (Brook
2003). There are no clear guidelines for the initia-
tion of antibiotic prophylaxis. Antibiotics should
cover common pathogens such as Streptococcus
and Staphylococcus and provide broad anaerobic
cover (Brook 2003; Patil et al. 2009). In vitro
studies demonstrated that amoxicillin- clavulanate
and moxioxacin showed excellent activity
against these isolates (Patil etal. 2009). Addition
of metronidazole may occasionally be helpful
against anaerobes. If patients are to receive antimicrobial prophylaxis, the rst dose ideally may
be given parenterally to obtain effective tissue
levels as quickly as possible, although there is not
sufcient evidence to support or refute that this is
a better practice than oral antibiotics alone (Patil
etal. 2009). Appropriate oral antibiotics should
be given and continued for 3–5 days for uninfected and 7–14days for infected wounds (Patil
etal. 2009; Mendoza and Chi 2019).
In case of a human bite, and if possible, the
assailant should be tested for HB surface antigen
and HB envelope antigen. If positive, the patient
should be given a single dose of HB immunoglobulin and an accelerated course of HB vaccine
(doses at 0, 1, and 2months), unless the patient is
known to be immune (Kelly et al. 1996).
However, the rate of transmission of HB virus is
not high enough to warrant routine prophylaxis in
bites from an unknown source (Patil etal. 2009).
HIV PEP is not routinely indicated after a
human bite. PEP is to be started only in rare circumstances where there has been an exposure to
a known HIV-infected source with a high viral
load and the exposure involves signicant blood
transfer, a deep wound, etc. (Patil etal. 2009).
Primary wound closure of the bite wounds
has been controversial and a matter of debate. De
Melker and de Melker (1996) conducted a literature search on dog bites (1975–1994) and found
no evidence that the infection rate after primary
closure of wounds is higher. Chen etal. (2000)
reviewed 145 mammalian bite patients (133 animal bites, 12 human bites). Patients had a mean
age of 21 ± 20years and presented a mean of
1.8 ± 1.2h after injury. Fifty-seven percent of
wounds occurred in the head and neck. Wounds
had a mean length of 2.5cm and a mean width of
0.48 cm. Twelve percent involved structures
deep to subcutaneous tissue. After primary
wound closure, wound infections occurred in
5.5% of the patients. The authors’ data suggest
that carefully selected mammalian bite wounds
can be sutured with a ca. 6% rate of infection,
which may be acceptable in lacerations where
cosmesis is a primary concern. In a more recent
publication, Piccart et al. (2019) observed secondary infection in only 2.24% of cases after primary closure of dog bite-related wounds. One
death of a 6-year- old girl was reported by the
authors over the course of 20 years (0.45%)
(Piccart etal. 2019).
Usually, human bites are contaminated
wounds and are thus closed by delayed primary
or secondary suturing. Because bites on the face
are associated with better vascularization, they
are at a lower risk of infection following primary
closure. Thus, primary closure of all uninfected
wounds of the face is indicated, whereas debridement and delayed closure may be performed in
certain high-risk or already infected wounds
(Stefanopoulos and Tarantzopoulou 2005).
Donkor and Bankas (1997) studied 30 patients
who presented with human bites of the face and
noted that a thorough debridement followed by
primary closure, direct suturing, a local ap, or
skin grafting on the day of presentation resulted
in 90% complete wound healing.
In cases of partially avulsed tissue, immediate
replantation has been reported to have partial
success (Grabb and Dingman 1972; Miller etal.
1998; Cantarella et al. 2005). The amputated
piece should be cleansed in povidone-iodine and
chilled in an antibiotic solution. Intravenous antibiotic therapy should be started immediately and
continued for at least 10days. The replantation
should be performed in the operating room. After
debridement and irrigation, the amputate is
replanted with mucosal and skin sutures only.
6.5 Bite Injuries
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61
The nasal cavity is packed (control of bleeding
and support). Postoperatively, the graft is cooled
with iced saline gauze and allowed to drain, with
multiple stab incisions, heparinization, and leeching as needed. Postoperatively, the graft may take
on a dark blue crashed appearance, raising the
suspicion of full-thickness necrosis. Restraint is
the preferred treatment. Often, the color indicates
only partial necrosis, whereas the majority of the
age. The most direct method is successful venous
anastomosis. Locating suitable veins, however, is
difcult or even impossible. There have been
very few reports of an amputated nose, where
both an artery and vein were successfully repaired
(Yao etal. 1998; Hammond etal. 2000). The use
of an arteriovenous stula as a source of venous
return has also been documented (Jeng et al.
1991).
amputate survives (Miller et al. 1998). In the
worst-case scenario, the graft serves as a biological dressing that facilitates healing and prevents
would contracture. Other authors have criticized
lished, venous stasis was overcome by means of
stab-wound wiping (Akyürek et al. 2000) or
medicinal leeching (Stillaert etal. 2012).
the replantation of amputated tissue when the
injury is sustained from animal and human bite
wounds (Stucker etal. 1990). In such cases, they
claim, the resulting defect is worse than the original deformity. Would primary reconstruction be
the treatment of choice?
Replantation serves many therapeutic functions. Forehead aps and conchal grafts are more
willingly accepted following a “failed” replantation than as primary reconstructions. As the ultimate defect after replantation is smaller than the
original deformity and the need for vestibular
reconstruction far less, nal nasal reconstruction
is facilitated (Miller etal. 1998; Cantarella etal.
2005). At a second stage (4–12weeks postopera-
tively), the nasal framework is reinforced by conchal and septal cartilage grafts. Cover is replaced
with a forehead ap, and the outcome is functionally and aesthetically satisfactory. In cases of
children, secondary scar revisions or even an
open septorhinoplasty at an older age may be
required to maintain the patency of the microsurgical repair or to ensure continued oozing from
the amputated part until new venous channels are
formed. This can lead to signicant blood loss
requiring multiple transfusions. Oozing from the
skin edges continued till the fourth postoperative
day, when reendothelialization of the arterial
repairs and/or revascularization of the amputated
segment from the nasal bed occurred, resulting in
stable arterial inow and venous outow to the
nose once the anticoagulation was stopped
(Hammond etal. 2000). Other authors prefer to
chemically leech congested aps and replantations by locally injecting 2000–3000 U of concentrated heparin solution (10,000 U/mL) into
either an abraded or a multiply pinpricked area.
The subcutaneously injected heparin ensures
continuous oozing. Heparin is readministered
when the oozing stops, but typically one injection
lasts 12h or more (Pribaz 2000).
necessary to achieve an acceptable nal result
(Miller etal. 1998).
The uncertainty of composite graft survival
led to attempts at revascularization once microsurgical techniques were developed.
Microsurgical replantation of partial (Jeng etal.
1991; Akyürek et al. 2000) as well as near-total
avulsion (Hammond et al. 2000) has been
reported. Arterial, and occasionally venous,
revascularization was successful resulting in
complete survival of the revascularized segment.
The most signicant technical difculty in
achieving success with nasal replantation has
been the establishment of adequate venous drain-
to replant difcult. Replantation on the other
hand offers the best functional and aesthetic
result. Therefore, in cases of nasal amputation or
amputation of other specialized facial structures
(ear, lip, scalp), replantation should be considered when the amputated segment has not been
severely injured, when appropriate vessels can be
isolated and repaired, and when the replanting
surgeon considers the result of a successful
replantation to be superior, both functionally and
aesthetically, to the result obtained with standard
methods of reconstruction (Hammond et al.
2000; Pribaz 2000).
In cases that venous drainage was not reestab-
In any case, systemic anticoagulation may be
This facet of replantation makes the decision
62
6 Injuries oftheNose
When replantation is not feasible or has failed,
traditional methods of reconstruction are used to
restore the resulting nasal defect in all cases of
nasal avulsion. Allografts (Integra® grafts) have
been used to nally cover traumatic defects after
mucoperichondrial septal aps, and cartilage
grafts were used for inner layer and skeletal
reconstruction (Raphaël etal. 2010; Tiengo etal.
2012). A secondary full-thickness skin graft
replaced the Integra a few weeks after the rst
operation. The aesthetic outcome has been
reported satisfactory; therefore, allografts are
considered a useful option especially when, due
to scar or consent problems, it is not possible to
use other techniques. Skin grafts have also been
used for temporary cover of nasal tip defects (Di
Benedetto etal. 1999).
Early secondary reconstruction with an
expanded forehead ap restores the normal nasal
appearance (Di Benedetto etal. 1999). In selected
cases, immediate reconstruction of the resulting
defect with a forehead ap is a reliable method.
Second- and third-stage operations are necessary
to thin and divide the ap (Huang and Wong
2013; Cerne etal. 2019). Some authors are hesi-
tant to use acute cartilage grafts due to concern of
wound contamination. If collapse of the nasal
vestibule occurs, it is addressed at a later stage
with secondary cartilage grafting (Huang and
Wong 2013). Tissue engineering of cartilage has
recently been described (Lee et al. 2021). This
engineered 3D construct might serve as a promising future candidate for cartilage tissue engineering in nasal reconstruction.
Forehead aps have been used in the acute setting mostly in adults. However, scarce case
reports in infants have also been published.
Kadlub etal. (2008) performed a microsurgical
replantation of a large nasal segment in a
15-month-old child, which proved unsuccessful.
The wound healed with debridement and local
care. At age 2, the authors performed nasal reconstruction with autogenous ear cartilage and a
forehead ap. The reconstructed nose appeared
to be of good color and texture match and seemed
to function normally a few years postoperatively.
Long-term results regarding nasal function and
growth, however, remain to be seen (Kadlub etal.
2008). Exner etal. (2010) more recently reported
on a 4-month-old girl requiring subtotal nose
reconstruction due to necrosis, caused by a congenital malformation. An immediate forehead
ap and later renements were performed. The
functional and aesthetic result 20years later, presented in this report, was satisfactory with no
growth impairment. More long-term results will
document the utility of the forehead ap in the
acute setting in children.
Age, general medical condition, complexity
of surgical procedures, and patients’ refusal to
undergo surgery may be contraindications for
surgical reconstruction. If surgery is not an
option, prosthetic rehabilitation offers a plausible alternative in selected cases (Nagaraj etal.
2011).
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Injuries oftheCheek
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7.1 Anatomy
The cheek is the lateral region of the face. It
extends from the lower eyelid above to the lower
border of the mandible below and from the nasolabial sulcus and corner of the mouth anteriorly
to the preauricular area.
Several important structures lie in this region.
Their injury should be diagnosed early so that a
proper surgical repair can be carried out.
The bulk of the parotid gland lies on the side
of the face posterior to the angle of the mandible; however, its anterior facial prolongation
(the accessory parotid) and duct are supercial
structures lying within this region (Fig.7.1a).
The parotid duct emerges through the masseter
fascia, winds around the anterior border of the
masseter muscle, and enters the buccinator
muscle coursing anteriorly on the buccal
mucous membrane. Its course is represented by
the middle third of a line drawn from the inferior edge of the external acoustic meatus to a
point midway between the ala of the nose and
the commissure of the lip. It penetrates the buccal mucosa and opens into the vestibule of the
mouth by a slit-like orice on a variably developed papilla opposite the second upper molar
tooth; through this orice, the duct may be
catheterized.
The fat pad of the cheek is a collection of the
subcutaneous fatty tissue in the space between
the masseter and buccinator muscles.
The supercial muscle layer is made up of
many small muscles adjacent to the mouth. For
the most part, they converge to the labial commissures. The buccinator muscle is placed more
deeply and extends from the alveolar arch of the
maxilla to that of the mandible forming the lateral wall of the mouth.
The only important artery to the cheek is the
facial artery, which enters at the anteroinferior
angle of the masseter muscle, courses forward on
the buccinator muscle, and becomes the angular
artery at the corner of the mouth. It is accompanied by the facial vein.
The most important structures of the cheek are
the branches of the fourth part of the facial nerve,
which extends from the stylomastoid foramen to
the muscles of facial expression. The facial nerve
enters the parotid gland immediately upon leaving the stylomastoid foramen. It branches off
within the parotid parenchyma; it usually bifurcates into a temporofacial and a cervicofacial
division. The two divisions divide into peripheral
branches (upper nerves to the forehead muscles
and the upper and lower eyelids—lower buccal
branch nerves to the upper and lower lip and platysma), which exit from the anterior part of the
parotid and course anteriorly to the facial muscles (Fig.7.1b). The more anterior they run, the
more supercial they lie. The course of the facial
nerve branches is more or less horizontal; therefore, it is more likely that they get injured during
vertical traumas of the cheek.
© 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_7
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