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functional deficits specific to the site of injury, unacceptable cosmetic
appearance, and the need for additional revision or adjunctive
procedures.
It is particularly important to keep parents informed of every step in the
treatment process of their child.
V. Operative Management by Location
Comprehensive reconstruction techniques for the facial subsites listed
below are beyond the scope of this Resident Manual. In some cases, the
principles discussed may serve as temporizing maneuvers until defini-
tive reconstruction is undertaken at a later time.
A. Scalp
Scalp tissue is thicker than one might expect and unforgiving in
extensibility.
y
y Assess for underlying bony fractures.
y
y Attempt to cover all exposed bone. If periosteum is missing, and
closure not possible, healing by second intent is greatly impaired and
may lead to desiccated calvarial bone exposure.
y
y If closure is unable to cover bone, cover with a nonadherent dressing
using an antibiotic ointment for moisture interface.
y
y Close wounds in layered fashion, with particular attention to closure
of the galea aponeurosis. The galea has a robust vascular supply, and
closure will reduce tension on the overlying cutaneous tissues.
y
y Close small wounds with chromic or fast-absorbing polyglactin 910
(Vicryl Rapide™) suture.
y
y Close larger wounds with surgical staples, which facilitate both the
speed of closure and the ease of removal in the hair-bearing scalp.
y
y Place a passive (Penrose) drain under large, undermined scalp flaps
to aid in the egress of serosanguinous fluid, prevent hematoma
formation, and eliminate dead space.
y
y Place compressive head wraps at least for 24–48 hours, until underly-
ing tissues reanneal.
B. Forehead
y
y Assess wounds for possible underlying frontal sinus fracture.
y
y Supratrochlear and supraorbital blocks facilitate wide-field
anesthesia.
y
y Close wounds in standard fashion, with attention to alignment of
rhytids, the trichion, and brow margins.