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KEY POINTS

KEY POINTS

  • A thorough understanding of head and neck anatomy is critical in identifying the true extent of injuries to soft tissue and underlying viscera.

  • Early documentation of facial nerve function is critical in guiding management of facial nerve injuries, particularly in critically ill patients in whom sedation may confound later examination.

  • The goal of bony reconstruction in maxillofacial trauma is to restore function, structure, and symmetry.

  • Long-term follow-up and postoperative imaging are often required to confirm correct skeletal repair and to watch for skeletal or soft tissue complications that would benefit from revision surgery.

INTRODUCTION

The face is the centerpiece of human interaction and expression. Facial structures are also integral in essential functions such as breathing, vision, eating, and communication. Patients with facial deformity pay a significant social penalty1 and suffer functional impairment. Therefore, restoring facial form and function can greatly improve a patient’s quality of life.

The evaluation of any trauma patient should begin with a primary survey that is focused on airway, breathing, circulation, disability, and exposure, or the “ABCDEs.” After the appropriate Advanced Trauma Life Support (ATLS) algorithms are instituted and the patient is acutely stabilized, secondary survey begins, including a thorough evaluation of facial injuries (Fig. 24-1). The anatomy, evaluation, and management of soft tissue and bony trauma of the face are reviewed.

FIGURE 24-1

An approach to maxillofacial trauma. C-spine, cervical spine; CT, computed tomography; O2 sats, oxygen saturation.

MANAGEMENT OF FACIAL SOFT TISSUE TRAUMA

Scalp and Forehead

ANATOMY

The scalp is a multilayered soft tissue structure that envelopes the calvarium, extending from the external occipital protuberance to the supraorbital rim. The forehead aesthetic subunit of the scalp includes the arc from the supraorbital rims to the hairline, or trichion. The soft tissue of the scalp and forehead consists of five layers and can be remembered using the mnemonic SCALP: skin, subcutaneous tissue, aponeurosis galea, loose areolar tissue, and periosteum (Fig. 24-2).

FIGURE 24-2

Anatomic layers of the scalp. (Reproduced with permission from AO Surgery Reference. www.aosurgery.org. Copyright by AO Foundation, Switzerland.)

The arterial supply to the scalp comes from five named vessels off of the internal and external carotid arteries.2 The external carotid branches include the occipital artery, superficial temporal artery, and the posterior auricular artery. Internal carotid artery branches include the supraorbital and supratrochlear arteries. These ultimately form extensive anastomoses in the subcutaneous tissue layer of the scalp, providing a robust blood supply and vascular redundancy that limits watershed areas of compromised blood supply. Injury to vessels in this layer can ...

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