Resident Manual of Trauma to the Face, Head and Neck

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.

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