Soft Tissue Injuries of the Head and Neck [1st ed. 2023] 3031149149, 9783031149146

This book provides a vividly illustrated description of a wide range of soft tissue injuries of the head and neck and th

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Table of contents :
Foreword
Preface
Acknowledgments
Introduction
Contents
About the Author
1: Importance of Normal and Scarred Facial Appearance
References
2: Epidemiology of Soft-Tissue Injuries of the Head and Neck
References
3: General Principles of Wound Management
3.1 Principles of Patient Management
3.2 Wound Preparation
3.3 Suturing Technique
3.4 Hematomas
3.5 Abrasions
3.6 Avulsions
3.7 Penetrating Injuries
3.8 Gunshot Injuries
References
4: Injuries of the Scalp, Forehead, and Eyebrow
4.1 Anatomy of the Scalp, Forehead, and Eyebrow
4.2 Scalp Injuries
4.3 Forehead and Eyebrow Injuries
References
5: Injuries of the Eyelids, Canaliculi, and Canthi
5.1 Anatomy of the Eyelids, Lacrimal System, and Canthi
5.2 Eyelid and Canalicular Lacerations
5.3 Medial and Lateral Canthus Lacerations
References
6: Injuries of the Nose
6.1 Anatomy of the Nose
6.2 Diagnosis of Nasal Trauma
6.3 Septal Hematoma
6.4 Nasal Lacerations
6.5 Bite Injuries
References
7: Injuries of the Cheek
7.1 Anatomy
7.2 Parotid Injury
7.3 Parotid Duct Injury
7.4 Facial Nerve Injury
7.5 Cheek Defects
References
8: Injuries of the Lips
8.1 Anatomy
8.2 Lacerations
8.3 Avulsions
8.4 Reconstruction
References
9: Injuries of the Ears
9.1 Anatomy
9.2 Auricular Hematoma, “Cauliflower Ear”
9.3 Lacerations
9.4 Avulsions
9.5 Reconstruction
References
10: Injuries of the Neck
10.1 Anatomy
10.2 Blunt and Penetrating Injuries to the Neck
10.3 Injuries to the Air Passages
10.4 Vascular Injuries
10.4.1 Blunt Extracranial Carotid Injuries
10.4.2 Penetrating Extracranial Carotid Injuries
10.5 Injuries of the Pharynx and the Esophagus
10.6 Neurologic Injuries
10.7 Thyroid and Submandibular Gland Injuries
References
11: Burns of the Scalp, Face, and Neck
11.1 Overview
11.2 Minor Burns: Ambulatory Treatment
11.3 Moderate and Severe Burns
11.4 Surgical Wound Care
11.5 Perioral Burns
11.6 Eyelids
11.7 Eyebrows
11.8 Neck
11.9 Scalp
11.10 Nose
11.11 Ears
11.12 Long-Term Sequelae of Burns
References
12: Wound Healing Disturbances: The Unfavorable Result
12.1 Phases of Wound Healing
12.1.1 Hemostasis
12.1.2 Inflammation
12.1.3 Proliferation
12.1.4 Remodeling
12.2 Mechanisms of Wound Healing
12.3 Pathologic Responses to Wound Healing
12.3.1 Hypo- and Hyperpigmentation
12.3.2 Hypertrophic Scars, Keloids, and Contractures
12.3.3 Other Scar Problems
The Stretched Scar
Suture Marks
Concavities and Convexities
Depressed Scars
Malaligned Scars
Trapdoor Scars
Anatomical Mismatch
Unstable Scars
Collagen Defects
12.4 Complications of Specific Anatomical Areas
12.4.1 Scalp
12.4.2 Eyebrow
12.4.3 Eyelids
12.4.4 Canthus
12.4.5 The Lacrimal System
12.4.6 Nose
12.4.7 Lips
12.4.8 Neck
References
Index
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Citation preview

Matthew P. Lungren Michael R.B. Evans Editors

Soft Tissue Injuries Clinical Medicine of the Head and Covertemplate Neck Subtitle for Charilaos A. Ioannidis Clinical Medicine Covers T3_HB Second Edition

1123 3 2

Soft Tissue Injuries of the Head and Neck

Charilaos A. Ioannidis

Soft Tissue Injuries of the Head and Neck

Charilaos A. Ioannidis Plastic Surgery IASO HOSPITAL GROUP, Consultant P/R Surgeon Athens, Greece

ISBN 978-3-031-14914-6    ISBN 978-3-031-14915-3 (eBook) https://doi.org/10.1007/978-3-031-14915-3 © Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

This work is the effort of one author to convey what he has learned in a long career treating injuries of the face, head, and neck in world-class training programs. His career interests and the experience in renowned centers in which he trained and staffed as an attending and responsible physician/surgeon permitted him to gain unique amounts of exposure and experience which were concentrated on the urgent/emergency management of injuries of the head, face, and neck. The author successfully takes materials from a number of disciplines: Plastic and Reconstructive Surgery, Oral Maxillofacial Surgery, Ophthalmology and Oculoplastic, Otolaryngology and Facial Plastics, Head and Neck Surgery, and General Surgery and completes a text with a broad overview of a subject which is individually mentioned in textbooks of those disciplines. Previously, I cannot recall anyone taking on the task of producing a more comprehensive multispecialty overview text, nor one that has been as well organized to present a multispecialty approach to the challenges seen in the urgent care area. This text introduces a comprehensive, broad overview meant to educate clinicians of all disciplines in the emergency room consultation for the various and specialty-specific injuries of the face, head, and neck. But besides offering a manual for these separate disciplines, perhaps the groups most likely to benefit from this collated information are those who spend much of their time in emergency management and treatment: emergency room specialists, nurses, NPs, PAs, and others who are unable to find a “single source” location for the multidisciplinary evaluation and management of separate and critically important injuries, which form a significant share of daily practice in emergency center locations. The book begins with a description of the unique importance of the face in appearance and human interaction, and in communication, perception, and information transfer. Indeed, there is nothing like it in the rest of the animal kingdom and thus its importance to the performance of human tasks and interaction. The long-term effects on health, survival, success, and performance are summarized in works mentioned in the introductory chapter. A chapter on epidemiology gives a broad perspective on demographics. A chapter on how wounds react to injury and healing gives a basic physiological perspective, and its corollary, Chap. 12 on disorders of healing—both provide basic scientific physiology explaining normal and disordered metabolic and physiological processes, and how we might improve results acutely and after

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initial healing, especially if problematic. In the wound management chapter are sections on the various patterns and mechanisms of injury, and where differences in management in the various types of mechanisms permit better results to be achieved. The sectional and specialty-specific sections then take us through, from top down, the forehead, scalp and eyebrow, then the eyelids, globe, and supporting structures, each with its specialized tissues and varied requirements for specialized evaluation and treatment. Ocular glands, ligaments, tear systems, and lubrication require specialized evaluation and management. Their special evaluation and the special particulars complete these descriptions. The nasal chapter emphasizes the evaluation of structures dealing with appearance and function—breathing and airway. Again, varied mechanisms of injury dictate special treatment evaluations, techniques, and management. The cheeks, with their complex separate sensory and motor nerve structures, and the glands including complex parotid injury, both duct and gland management and the facial mimetic muscles—all of these are again unique and specialized considerations. And nothing could exceed in complexity the lips, their structure and function—what a specialized functional unit where motor function and sensory perception allow a unique combined superior functional outcome. The neck is again a specialized region, and the importance of analyzing and restoring this most important functional conduit for airway, swallowing, circulation, and nerves—motor and sensory—what could be more important or specialized? Chapter 11 deals with the special problems of burninduced mechanisms, and of course whole textbooks could be written about these injuries. Chapter 12 deals with how to solve problems following the initial management—functional mechanisms, evaluation, and treatment discussions here set the stage and pathways for further evaluation, treatment, and analysis. So, all in all we have a text which combines a multidisciplinary perspective on initial evaluation and early treatment of injuries of the face, scalp, and neck. It sets the stage for further study, and for those interested, in-depth information on each of the specifics mentioned in each chapter and section is provided in the references which provide specific location and direction for that specific study. I am confident that the disciplines and specialists mentioned will benefit from the information contained in this text, and I thank the author very much indeed for providing all of us his studied perspectives and advice. Plastic and Reconstructive Surgery Johns Hopkins School of Medicine Baltimore, MD, USA Surgery, The University of Maryland Shock Trauma Unit and the University of Maryland School of Medicine Baltimore, MD, USA

Paul N. Manson

Preface

Trauma of the head and neck forms an integral part of basically two surgical disciplines: Plastic and Reconstructive Surgery and Cranio-Maxillofacial Surgery. Soft tissue injuries are, usually, treated by plastic surgeons, whereas skeletal injuries are managed by maxillofacial surgeons. However, accident and emergency physicians as well as colleagues from other surgical disciplines (ENT—surgeons, orthopedic surgeons, general surgeons, etc.) are often actively involved in soft tissue trauma of the head and neck either as treating physicians or in a multidisciplinary setting. Fortunately, most of the soft tissue injuries of the scalp, face, and neck are quite simple and can be treated on an ambulatory basis. A number of them, however, are serious or are associated with concomitant skeletal injuries of the head and/or the trunk and the extremities, requiring a multidisciplinary approach. The contribution of ophthalmologists, neurosurgeons, and other specialists is extremely important for a successful final outcome. This book is intended for interns, residents, and fellows of Plastic Surgery, Maxillofacial Surgery, ENT Surgery and Emergency Medicine, as well as attending surgeons and physicians of other disciplines dealing with soft tissue trauma of the head and neck. It may also prove useful to theater and A & E nurses, and medical students who have interest in this subject. Writing a book is time and energy consuming. Private and family life “gets the brunt of it.” So why then do it? The best answer is probably the one given by Dr. Ian T. Jackson: “It is an educational opportunity and a chance to convey lessons learned from many years of experience.” My hope is that this book will provide a source of stimulation to those new to facial and neck trauma and a source of continued inspiration to more experienced physicians. For the layperson who will read this text, I hope that it too will be a source of comfort that patients with disfiguring facial trauma may still have a potential for a harmonious, normal life ahead. Athens, Greece May 2022

Charilaos A. Ioannidis

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Acknowledgments

I am fortunate to have completed part of my surgical training at the Department of CMF Surgery, Radboud University Hospital (Level 1 trauma center), Nijmegen, the Netherlands (former Katholieke Universiteit NijmegenLeuven), Head of which was a surgeon with an outstanding reputation, Professor Hans-­Peter Freihofer†. He was one of the surgeons, internationally, with the knowledge and the experience to treat the full spectrum of head and neck injuries. I am deeply grateful to him for encouraging my interest in trauma surgery. He set high standards in judgment, philosophy, and technical skills, which guided me throughout my surgical career. I am also indebted to Professor Kostas Lekkas, University of Leiden, for stimulating my interest in Cranio-­Maxillofacial Surgery and especially surgery of the head and neck. Many thanks to my colleagues in Nijmegen, in Leuven, and in London and especially to my dear friend Prof. D.A. McGrouther for having contributed to the management of some of the cases illustrated in this book. Their enthusiasm has been a continuous source of inspiration to me. Particular thanks to my wife Olga and to my sons Alexandros and Konstantinos for their endurance and continuous support. My deepest gratitude and respect to all those patients who trusted their health into our hands and without whose photographs the completion of this book would not have been possible. Special thanks to Mrs. Olga Giagiakou for the preparation of the manuscript, to Mrs. Sofika Eleftheroudaki for her valuable advice, and to Dr. Irini Tsilomeleti for drawing some of the anatomical sketches (the others were drawn by the author). Last but not least, I wish to thank the highly skilled professionals at Springer Nature who helped make this book possible, especially Mrs. Daniela Heller and Ms. Madona Samuel. Charilaos A. Ioannidis Athens, May 2022

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Introduction

Facial appearance is extremely important to everyone regardless of age, sex, and race, as is highlighted in the first chapter of this book. It is understandable that facial injuries and the resulting facial scarring/disfigurement, being conspicuous, are more of a concern than injuries to the trunk and the extremities. Patients are more embarrassed with facial scars than with scars at other body parts. The effect on the victim’s personality and future can be detrimental. Aesthetics, however, is not the only cause of negative impact which facial scars have on patients. The soft tissues of the scalp and forehead give protection to the cranium. Furthermore, the region of the H&N is associated with important functions (sight, smell, breathing, eating, talking), which can be impaired in cases of extensive soft-tissue injury, thus affecting the patient’s quality of life. Soft-tissue injuries occur on the scalp, all parts of the face (forehead, eyebrows, eyelids, nose, cheeks, lips, chin), and the neck. In a study from the United Kingdom, almost half of the 458 open wounds which required treatment were in the upper third of the face (Ong and Dudley 1999). Injury patterns vary greatly depending on the patient population. Falls, trips, and slips are most common in children and the elderly, causing isolated soft-tissue injuries (lacerations, contusions). Violence and road traffic accidents (RTA) are the predominant causes of injury in the 15–50-year age group (Kretlow et al. 2010). More results on the epidemiology of facial and neck soft-tissue injuries are reported in the second chapter of this book. Facial soft-tissue injuries are rarely life threatening; however, they are indicators of the energy of injury. Most of them are treated by experienced accident and emergency physicians (90% in the study by Ong and Dudley 1999). A 1-year wound closure training provided to emergency physicians seems to reduce the incidence of early complications following facial laceration repair (Yamamoto et  al. 2018). The final outcome depends on initial wound care and primary repair. Suturing is still the mainstay of treatment; however, topical skin adhesives seem to be gaining in popularity in children as well as in adults, as their use is associated with a shorter emergency department length of stay than sutures (Otterness et al. 2020) and the risk of dehiscence is not statistically different between the two methods (Ste-Marie-Lestage et  al. 2019). The more complex cases are most appropriately managed by plastic surgeons that, besides thorough knowledge of applied anatomy and surgical skill, have an aesthetic sense and meticulous atraumatic tissue han-

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dling expertise (Bhattacharya 2012). In all cases, however, the treating physician/surgeon ought to be fully aware of the “dos and the don’ts.” Almost all injuries result from some form of trauma (physical force resulting in injury). Injuries may also result from chemical, thermal, or electrical trauma, though far less commonly than physical trauma. The severity of the injury depends, besides the applied force, on the anatomic region of impact, the surface of impact, the resistance of tissues, and the angulation of the strike (Hill et al. 2010). Assaults, falls, road traffic accidents (RTAs), sports injuries, animal bites, and burns are the commonest causes. Industrial injuries and war injuries are less common. The injury pattern differs among the different parts of the world. In some countries of the developed world, interpersonal violence seems to be the commonest, whereas in other developed countries (Japan, the Netherlands), as well as in the developing world, RTAs are the commonest cause of facial injuries. Soft-tissue lacerations are the most common maxillofacial injuries sustained (Hill et al. 2010). Almost 40% of all assault victims and 95% of victims of domestic violence have facial lacerations (Hill et al. 2010). However, despite their frequency, soft-tissue injuries are often overlooked in trauma epidemiology. Strategies (road/work legislation, speed limits, alcohol consumption and driving) and devices (seat belts, airbags and laminated safety glass windshields for drivers, helmets for motorcyclists, protection worn during sports and at work) to protect individuals have been designed and developed during the past decades. Due to them, a dramatic decrease of injuries associated, e.g., with RTAs has been observed (20.9 to 5.9% in 2 years; Perkins and Layton 1988). Bernstein et al. (1989) found that abrasions, contusions, and lacerations to face, neck, and head were considerably reduced (22.2% of 379 injuries vs. 13.8% of 356 injuries) after implementation of the safety belt law in New Mexico, USA.  Furthermore, significant cost and severity differences were observed after the law between belted and non-belted occupants: + 2569 compared with +662 and Injury Severity Score (ISS) of 3.6 compared with 2.0 (por= 65 years) for all countries, due to the combined effect of high incidence and high costs per patient. Mo et al. (2021) recently reviewed the data of 3,634,229 people from Korea regarding facial lacerations. The authors’ findings showed that their treatment costs increased substantially, more than inflation rate, over a 3-year period (2014–2018) and indicate that a greater economic burden is being imposed on patients and caregivers due to usage of nonpayment dressing material and topical ointments. Facial injuries requiring plastic surgery are costly. It is interesting to note that for minor injuries, the quality-of-life costs generally exceed the monetary costs (Miller et al. 1995). A lower incidence will probably reduce the high cost of treatment of these injuries. Therefore, new strategies to reduce the incidence of facial injuries need to be developed. At all times, however, thorough knowledge of the anatomy and physiology of the facial structures, the biomechanics of tissue injury, the molecular biology and biochemistry of wound healing, the art of soft-tissue repair using meticulous techniques, and a conscientious follow-up are of great importance regardless of whether A&E doctors or surgeons treat such injuries. Furthermore, a successful triage of the difficult and complex cases and their referral to a specialized facial surgeon (plastic surgeon, specialized oral and maxillofacial surgeon, specialized ENT surgeon) will warrant the best possible treatment and a good end result. Failure seems to arise more often than not from the inability to recognize the extent of an injury, rather than from the inability to treat the recognized injury (Bhattacharya 2012). References Bernstein E, Pathak D, Rutledge L, et al. New Mexico safety restraint law: changing patterns of motor vehicles injury, severity and cost. Am J Emerg Med. 1989;7:271–7. Bhattacharya V. Management of soft tissue wounds of the face. Indian J Plast Surg. 2012;45:436–43. Corso P, Finkelstein E, Miller T, et al. Incidence and lifetime costs of injuries in the United States. Inj Prev. 2006;12:212–8. Hill CM, Eppley BL, Thomas DW, et al. Etiology and prevention of maxillofacial trauma. In: Ward Booth P, Eppley B, Schmelzeisen R, editors. Maxillofacial trauma and esthetic facial reconstruction. Elsevier; 2010. Kraft A, Abermann E, Stigler R, et al. Craniomaxillofacial trauma: synopsis of 14,654 cases with 35,129 injuries in 15 years. Craniomaxillofac Trauma Reconstr. 2012;5:41–50. Kretlow JD, McKnight AJ, Izaddoost SA. Facial soft tissue trauma. Semin Plast Surg. 2010;24:348–56. Meerding WJ, Mulder S, van Beeck EF. Incidence and costs of injuries in the Netherlands. Eur J Public Health. 2006;16:272–8.

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Miller TR, Pindus NM, Douglas JB, et al. Databook of non-fatal injury: incidence, costs and consequences. Washington DC: The Urban Institute Press; 1995. Mo YW, Cho GY, Mo YT, et al. National level data analysis of facial lacerations in Korea using the National Health Insurance Service (NHIS) database. Medicine (Baltimore). 2021;100:e24163. Ong TK, Dudley M. Craniofacial trauma presenting at an adult accident and emergency department with an emphasis on soft tissue injury. Injury. 1999;30:357–63. Otterness K, Thode HC Jr, Singer AJ. Methods of laceration closure in the ED: a national perspective. Am J Emerg Med. 2020;38:1058–61. Perkins CS, Layton SA. The aetiology of maxillofacial injuries and the seat belt law. Br J Oral Maxillofac Surg. 1988;26:353–63. Polinder S, Meerding WJ, van Baar ME, et  al. Cost estimation of injury-­ related hospital admissions in 10 European countries. J Trauma. 2005;59:1283–90. Ste-Marie-Lestage C, Adler S, St-Jean G, et al. Complications following chin laceration reparation using tissue adhesive compared to sutures in children. Injury. 2019;50:903–7. Yamamoto R, Homma K, Masuzawa Y, et al. Early complications following facial laceration repair performed by emergency physicians after one year of wound closure training. AEM Educ Train. 2018; 2:259–68.

Introduction

Contents

1 Importance  of Normal and Scarred Facial Appearance��������������   1 References������������������������������������������������������������������������������������������   3 2 Epidemiology  of Soft-Tissue Injuries of the Head and Neck ������   5 References������������������������������������������������������������������������������������������   8 3 General  Principles of Wound Management����������������������������������   9 3.1 Principles of Patient Management��������������������������������������������   9 3.2 Wound Preparation��������������������������������������������������������������������  13 3.3 Suturing Technique ������������������������������������������������������������������  15 3.4 Hematomas ������������������������������������������������������������������������������  19 3.5 Abrasions����������������������������������������������������������������������������������  21 3.6 Avulsions����������������������������������������������������������������������������������  22 3.7 Penetrating Injuries ������������������������������������������������������������������  24 3.8 Gunshot Injuries������������������������������������������������������������������������  26 References������������������������������������������������������������������������������������������  27 4 Injuries  of the Scalp, Forehead, and Eyebrow������������������������������  31 4.1 Anatomy of the Scalp, Forehead, and Eyebrow������������������������  31 4.2 Scalp Injuries����������������������������������������������������������������������������  33 4.3 Forehead and Eyebrow Injuries������������������������������������������������  36 References������������������������������������������������������������������������������������������  39 5 Injuries  of the Eyelids, Canaliculi, and Canthi ����������������������������  41 5.1 Anatomy of the Eyelids, Lacrimal System, and Canthi������������  41 5.2 Eyelid and Canalicular Lacerations������������������������������������������  44 5.3 Medial and Lateral Canthus Lacerations����������������������������������  50 References������������������������������������������������������������������������������������������  52 6 Injuries  of the Nose��������������������������������������������������������������������������  53 6.1 Anatomy of the Nose����������������������������������������������������������������  53 6.2 Diagnosis of Nasal Trauma������������������������������������������������������  54 6.3 Septal Hematoma����������������������������������������������������������������������  55 6.4 Nasal Lacerations����������������������������������������������������������������������  56 6.5 Bite Injuries������������������������������������������������������������������������������  58 References������������������������������������������������������������������������������������������  62 7 Injuries  of the Cheek ����������������������������������������������������������������������  65 7.1 Anatomy������������������������������������������������������������������������������������  65 7.2 Parotid Injury����������������������������������������������������������������������������  66 xv

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7.3 Parotid Duct Injury ������������������������������������������������������������������  68 7.4 Facial Nerve Injury ������������������������������������������������������������������  69 7.5 Cheek Defects ��������������������������������������������������������������������������  73 References������������������������������������������������������������������������������������������  75 8 Injuries  of the Lips��������������������������������������������������������������������������  77 8.1 Anatomy������������������������������������������������������������������������������������  77 8.2 Lacerations��������������������������������������������������������������������������������  79 8.3 Avulsions����������������������������������������������������������������������������������  81 8.4 Reconstruction��������������������������������������������������������������������������  82 References������������������������������������������������������������������������������������������  83 9 Injuries  of the Ears��������������������������������������������������������������������������  85 9.1 Anatomy������������������������������������������������������������������������������������  85 9.2 Auricular Hematoma, “Cauliflower Ear”����������������������������������  86 9.3 Lacerations��������������������������������������������������������������������������������  88 9.4 Avulsions����������������������������������������������������������������������������������  89 9.5 Reconstruction��������������������������������������������������������������������������  91 References������������������������������������������������������������������������������������������  92 10 Injuries  of the Neck��������������������������������������������������������������������������  95 10.1 Anatomy����������������������������������������������������������������������������������  95 10.2 Blunt and Penetrating Injuries to the Neck ����������������������������  98 10.3 Injuries to the Air Passages ����������������������������������������������������  99 10.4 Vascular Injuries���������������������������������������������������������������������� 102 10.4.1 Blunt Extracranial Carotid Injuries�������������������������� 105 10.4.2 Penetrating Extracranial Carotid Injuries����������������� 107 10.5 Injuries of the Pharynx and the Esophagus���������������������������� 109 10.6 Neurologic Injuries ���������������������������������������������������������������� 111 10.7 Thyroid and Submandibular Gland Injuries��������������������������� 112 References������������������������������������������������������������������������������������������ 113 11 Burns  of the Scalp, Face, and Neck������������������������������������������������ 119 11.1 Overview�������������������������������������������������������������������������������� 119 11.2 Minor Burns: Ambulatory Treatment�������������������������������������� 124 11.3 Moderate and Severe Burns���������������������������������������������������� 131 11.4 Surgical Wound Care�������������������������������������������������������������� 134 11.5 Perioral Burns ������������������������������������������������������������������������ 136 11.6 Eyelids������������������������������������������������������������������������������������ 137 11.7 Eyebrows�������������������������������������������������������������������������������� 139 11.8 Neck���������������������������������������������������������������������������������������� 139 11.9 Scalp���������������������������������������������������������������������������������������� 143 11.10 Nose���������������������������������������������������������������������������������������� 145 11.11 Ears ���������������������������������������������������������������������������������������� 146 11.12 Long-Term Sequelae of Burns������������������������������������������������ 149 References������������������������������������������������������������������������������������������ 149 12 Wound  Healing Disturbances: The Unfavorable Result�������������� 155 12.1 Phases of Wound Healing ������������������������������������������������������ 155 12.1.1 Hemostasis���������������������������������������������������������������� 155

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12.1.2 Inflammation ������������������������������������������������������������ 155 12.1.3 Proliferation�������������������������������������������������������������� 156 12.1.4 Remodeling �������������������������������������������������������������� 156 12.2 Mechanisms of Wound Healing���������������������������������������������� 157 12.3 Pathologic Responses to Wound Healing ������������������������������ 158 12.3.1 Hypo- and Hyperpigmentation �������������������������������� 158 12.3.2 Hypertrophic Scars, Keloids, and Contractures�������� 159 12.3.3 Other Scar Problems ������������������������������������������������ 165 12.4 Complications of Specific Anatomical Areas ������������������������ 170 12.4.1 Scalp�������������������������������������������������������������������������� 170 12.4.2 Eyebrow�������������������������������������������������������������������� 170 12.4.3 Eyelids���������������������������������������������������������������������� 171 12.4.4 Canthus �������������������������������������������������������������������� 174 12.4.5 The Lacrimal System������������������������������������������������ 174 12.4.6 Nose�������������������������������������������������������������������������� 175 12.4.7 Lips �������������������������������������������������������������������������� 177 12.4.8 Neck�������������������������������������������������������������������������� 178 References������������������������������������������������������������������������������������������ 179 Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

About the Author

Charilaos  A.  Ioannidis  is a former Assist. Professor at the Radboud University of Nijmegen (former Katholieke Universiteit Nijmegen), the Netherlands. He was appointed Assoc. Professor of Surgery (Head & Neck Surgery) at the University of Leuven (Katholieke Univesiteit Leuven), Belgium (1991), and later Consultant at the Department of Plastic and Reconstructive Surgery, the Middlesex Hospital, University College London Hospitals NHS Trust, and honorary consultant, the Whittington Hospital (1996), London, Great Britain. Since 2002 he has been practicing plastic and reconstructive surgery as a consultant plastic surgeon in Athens, Greece. Besides trauma (head and neck, hand, soft tissues), his special fields of interest include head and neck surgery, skin cancer (melanoma and nonmelanoma), soft tissue tumors, breast surgery (congenital deformities, oncology), reconstructive surgery (microsurgery), necrotic soft tissue infections, and aesthetic surgery.He is, or has been, a member of numerous international scientific societies and associations, as well as numerous non-profit organizations. He is a fellow of the European Board of Cranio-­Maxillofacial Surgery (FEBCMFS). He was awarded the Leibinger Prize of the European Association of Cranio-Maxillofacial Surgery for his experimental work on cartilage transplants (1988) and numerous medals and decorations for his scientific and clinical work.Dr. Ioannidis has published over seventy-five scientific papers in peer-reviewed national and international journals, as well as four books. He has also published numerous articles in newspapers and magazines on plastic surgery, skin cancer, breast pathology, facial traumatology, and other topics. He is a member of the editorial board of the Journal of Cranio-Maxillofacial Surgery (he has also served as section editor for the same journal). In addition, he has served as a reviewer for various other international surgical journals.

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Importance of Normal and Scarred Facial Appearance

Vultus est index animi (The face is the index of the soul—Latin proverb). A good face is a letter of recommendation (Joseph Addison, 1672– 1719). Truth exists for the wise, beauty for the feeling heart (Friedrich Schiller, 1759–1805, Don Carlos). These are some ways to describe how important aspect of our phenotype our face is. So important that facial recognition is one of many innate, reflexive, cognitive competencies. The face is the “organ of emotion.” One constantly reads other people’s facial expressions to understand what they feel. Our faces are a dynamic canvas, one in which emotions are drawn vividly and then suddenly craved, only to be redrawn in a new expression an instant later. The face contains other powerful clues as well. Our identity is captured in our facial features. Our eyes reveal, often, important truths about us. Our face also plays a role in physical attractiveness (Langlois et al. 2000). The face is an important channel of identity. Our face develops as we do, from infancy into adulthood, crossing into middle age, and finally into the senior years, always retaining features already prominent in childhood. We constantly monitor the face, because it provides vital clues to an impressive variety of possibilities: attraction, whether another person likes or dislikes us, complexity of emotions, identity, age, humor, and a person’s

regional and even national background. Facial attractiveness and body weight seem to be the best predictors of overall physical attractiveness (Swami et al. 2007). Evolutionary and socialization theory suggests that human facial appearance and attractiveness in particular influence the perception of others in social interactions, as well as development of certain behaviors (e.g., social skills, dating) and traits (e.g., mental and physical health) (Langlois et al. 2000; Hoss et al. 2005). Studies have shown that people assign more positive qualities to attractive children and adults than to unattractive ones (Langlois et  al. 2000; Mobius and Rosenblat 2006). In addition, facial attractiveness correlates positively with mating success and, thus, supports the hypothesis that the attractiveness of the face is important in human mate selection (Rhodes et  al. 2005). Moreover, people’s view of facial attractiveness seems to be remarkably consistent, regardless of race, nationality, or age (Langlois et al. 2000). It is, therefore, hardly surprising that humans attach great importance to a beautiful, healthy, and youthful-­looking skin cover and an intact face. The significance of the appearance of facial skin is also evident in dermatologic disorders and scarring, which can have a major impact on patients’ daily activities, self-esteem, mental well-being, and social relationships because of their conspicuous visibility

© 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_1

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(Barankin and De Koven 2002; Beattie and Lewis-Jones 2006). Interestingly, a study of patients from different social and ethnic groups in South Africa revealed that women were more likely than men to report the effects of skin disease on self-esteem, clothing choice, treatment problems, and anxiety (Jobanputra and Bachmann 2000). Social class and language group influenced the impact of skin disease on the overall quality of life (QoL). Glynn et al. (2009) observed that socioeconomically disadvantaged adults manifest negative psychological outcomes even 1 year after an orofacial injury. Poor social support and unmet social service needs immediately after the injury, as well as high post-traumatic stress disorder symptoms at 1 month post-injury, are strongly associated with the risk of developing chronic post-traumatic stress disorder. Gender does not seem to have a significant impact on QoL and psychology in patients with facial scars. A recent study on 32 patients with facial burn scars showed no statistically significant difference in QoL between males and females suffering from anxiety and depression (Kundu et  al. 2021). There was, however, a significant relationship between early depressive symptoms and both patient-rated facial scar severity and subsequent self-esteem in patients with facial burns, as was observed in another study from the Netherlands (Hoogewerf et al. 2014). There is substantive evidence that an attractive and normal facial appearance is central to the development of normal peer relationships, healthy personal adjustment, and success in school and in an adult career (Speltz and Richman 1997; Pope and Ward 1997). As the face is of particular importance in human social communication (Haxby et al. 2002) and body image (Coterill and Cunliffe 1997), even minor imperfections can have an often disproportionately major impact on mental health and quality of life. A study by Abdullah et al. (1994) on children (6–18 years old) having suffered facial, neck, and hand burns showed that as the number of scars increased in those areas, the patient’s scores for “physical appearance” and “happiness and satis-

1  Importance of Normal and Scarred Facial Appearance

faction” decreased (p