J OralMaxillofac
Surg
49:1007-1014.1991
The Management of Traumatic Scalp Injuries: Report of Cases TIMOTHY
B. WELCH, DDS,’ AND PHILIP J. BOYNE, DMDt
Oral and maxillofacial surgeons frequently are called upon to treat maxillofacial trauma (MFT) involving the scalp. Injuries involving the scalp often do not allow one the luxury of time to deliberate multiple treatment options. Because the first attempt at treating traumatic injuries often provides the best chance at obtaining the desired result, the surgeon must be thoroughly familiar with the anatomy and peculiarities of the scalp. The purpose of this article is to review the regional anatomy, describe the bicoronal flap, and discuss pertinent areas of concern in relation to traumatic scalp injuries. Four selected cases will illustrate the use of an axial pattern flap to treat an avulsion defect, the repair of a classic scalping injury, the use of a coronal flap in MFT, and the relationship between facial animation and a traumatic scalp injury.
bital and supratrochlear branches of the ophthalmic nerve also provide sensory innervation. They exit their bony foramina and run for a short time in the loose connective tissue before piercing the frontalis muscle to enter the dense connective tissue (Fig 2). The motor innervation of the scalp comes from the frontal branch of the facial nerve.‘.’ It leaves the parotid gland immediately caudad to the zygomatic arch and is contained within the superficial temporal (temporoparietal) fascia as it crosses the arch. The nerve travels anteriorly along the undersurface of this fascial layer across the temporal region, and enters the frontalis muscle above the level of the superior orbital rim. The arterial supply to the anterior scalp comes from the superficial temporal artery, a direct branch of the external carotid, and the supraorbital and the supratrochlear arteries, indirect branches of the internal carotid. The posterior auricular and occipital arteries, direct branches of the external carotid, supply the remainder of the scalp. The arterial adventitia or outer covering of the blood vessel blends intimately with the dense connective tissue layer so that the ends of the vessels tend to stay patent when cut.’ This causes spurting of blood from the area. The widespread anastomoses ensure excellent perfusion within the scalp. The venous drainage comes from veins that accompany the arteries as well as from parietal and mastoid emissary veins. These emissary veins are unique in that they pierce the skull and connect scalp veins to cranial venous sinuses. The two bony canals that allow passage of the parietal emissary veins are just anterior to lambda, the junction of the sagittal and lambdoidal sutures.
Regional Anatomy The layers of the scalp, from superficial to deep, are the skin, dense connective tissue, galea aponeurotica (aponeurosis between the occipitalis and frontalis muscles), loose connective tissue, and pericranium or periosteum of the calvarium (Fig l).’ The sensory innervation of the scalp comes partially from the auriculotemporal branch of the mandibular nerve and the zygomaticotemporal branch of the maxillary nerve. These are found entirely in the layer of dense connective tissue. The supraor-
Received from the Oral and Maxillofacial Surgery Service. Loma Linda University Medical Center, Loma Linda. CA. * Acting Program Director. t Professor and Chief. Address correspondence and reprint requests to Dr Welch: Oral and Maxillofacial Surgery Service, Loma Linda University Medical Center. Loma Linda, CA 92350. 0 1991 American geons
Association
of Oral and Maxillofacial
Technique for the Bicoronal Flap A 2-cm strip of hair is shaved off the scalp at the site of the proposed incision, usually 3 to 4 cm posterior to the hairline and above the ear on both
Sur-
0278-2391/91/4909-0014$3.00/0
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TRAUMATIC SCALP INJURIES
1008
connective tissue
Galea aponeurotica connective tissue
FIGURE 1. Layers of the scalp from superficial to deep. The loose layer is the plane of dissection in the scalping injury and the plane for initial elevation of the coronal flap. It is also the level at which edema spreads to the forehead and upper eyelids.
sides. This leaves a tuft of hair anterior to the incision that can be clipped shorter if it is excessively long. Sterile preparation is done using a povidoneiodine solution. The posterior aspect of the surgical field is well defined with cloth drapes stapled to the scalp. Liberal subcutaneous injection of 0.5% lidocaine hydrochloride with 1:200,000 epinephrine is made beneath the proposed incision to aid in hemostasis. A no. 10 blade is used to make an above-the-ear incision, going over the vertex to the opposite ear and carried deep through the level of the galea aponeurotica (Fig 3A). Incision of the temporalis fascia should be avoided as the facial nerve courses just beneath this layer. Raney clips are immediately applied in an adjacent fashion on the posterior and anterior aspects of the incision. Quick digital flap elevation may be necessary to allow the clips to attach properly. The scalp flap is developed anteriorly over the face through blunt dissection below the level of the galea in the loose connective tissue layer (Fig 3B). Digital dissection also can be very helpful at this time. Approximately 3 cm before reaching the supraorbital rims, the periosteum is incised and bluntly elevated to expose the supraorbital region. The supraorbital vessels and nerves should be identified bilaterally. Using an osteotome, a small portion of the supraorbital rim is removed inferiorly to allow egress of the supraorbital bundles from their bony foramina (Fig 3C). Defining the bone of the zygomatic arch is accomplished by incising the superficial temporal fascia 3 cm behind and parallel
to the lateral orbital rim, carrying the dissection inferiorly toward the body of the zygoma and the zygomatic arch. Care is taken to stay beneath the superficial temporal fascia as this is the layer where the frontal branches of the facial nerve travel. The nasal bridge and medial canthi can be exposed by elevating the periosteum inferior to the nasofrontal suture. Fractures can then be reduced under direct visualization. On completion of surgery, hemostasis is meticulously achieved through use of electrocautery. The periosteum is closed with 4-O resorbable sutures such as those made of polyglycolic acid. The galea aponeurotica is closed with 3-O polyglycolic acid or polydioxanone suture. The skin is closed with either staples or running 4-O nylon suture. The preauricular areas may require 6-O nylon sutures. A small silicone suction drain may be brought out through a separate stab incision posterior to the scalp incision, if necessary. A pressure dressing consisting of xeroform gauze strips on the incision, fluffed gauze, and a circumcephalic wrap is applied. The head dressing is removed in 48 hours and the head may be washed with a dilute solution of hydrogen peroxide. The skin sutures are removed in 10 days. Care must be taken to avoid the supraorbital, supratrochlear, and facial nerves when raising the coronal flap. While some frontal dysesthesia may occur, the supraorbital neurovascular bundles should move freely in their foramina when the flap is retracted.4 Also, when dissecting in the temporal region to gain access to the zygomatic arch, the safe plane of dissection is beneath the temporalis fascia, which will protect the facial nerve.5 An experimental study in primates has documented a disruption of blood flow to the remainder of the face when the bicoronal flap is used.6 However, in trauma, reconstruction, or resection of neoARTERIES
NERVES Third ocap~tal Greater ocap~tai
Superfaal
temporal
Aurtculotemporal Zygomatlcotemporal
Supraorbltal Supratrochleat
Supraorbltal Supratrochlear
FIGURE 2. Approximate location of the arteries and sensory nerves that course through the dense connective tissue layer of the scalp.
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WELCH AND BOYNE
/-ROICG HALOLD W4~ENRhut4
FIGURE 3. A, Outline of incision for coronal flap extending from the preauricular area over the vertex to the opposite ear. B. Elevation of the coronal flap at the level of the loose connective tissue layer after Raney clip application. C. Exposure of the zygomaticofrontal, nasofrontal, and zygomatic arch areas through a coronal flap. Note periosteum excised 3 cm above the supraorbital rims.
plastic disease, this has not appeared to be a clinical problem.4V7.8 The placement of suction drains will help prevent hematoma formation in the loose connective tissue layer of the scalp. The drain should be placed in the loose connective tissue layer and be maintained until it produces less than 5 mL per &hour shift. The drain should be placed dependently, taking into consideration that the extent of many patient’s injuries may require them to be completely supine in the postoperative period.
Report of Cases Case 1 A 26-year-old truck driver was admitted through the emergency department after being ejected through the window of his vehicle. He sustained a 5 x g-cm avulsion defect of the frontal scalp, as well as multiple lacerations (Fig 4A). He had deeply abraded his calvarium on the cement. He had also suffered a fractured clavicle, but had a negative C-spine series radiographically. There was no loss of consciousness.
TRAUMATIC SCALP INJURIES
FIGURE 4. Avulsion defect of the scalp. A, Loss of tissue and abraded calvarium apparent. E, Elevation of an axial pattern scalp flap to rotate over the avulsive defect. C, Axial flap rotated over defect and closed primarily. D, Four months postoperatively. Alteration of the hairline is acceptable to the patient.
He was taken to the operating room where his scalp was shaved, irrigated, and debrided with copious amounts of normal saline. An attempt was made to close the wound primarily by undermining of the local tissues. This resulted in excessive strain on the wound margins so the decision was made to rotate an axial pattern flap laterally over the defect (Fig 4B). The flap was based upon the superficial temporal and posterior auricular arteries and had a 2:l length-width ratio. It was elevated to the level of the loose connective tissue layer. The galea was closed with 4-O polydioxanone suture (PDS II monofilament, Ethicon, Somerville, NJ) and the skin was closed with 4-O nylon. The adjacent scalp was undermined lib-
erally and closed primarily (Fig 4C). A silicone drain (Miniflap Drain System, McGhan Medical Corporation, Santa Barbara, CA) was placed in the loose connective tissue layer. The procedure resulted in a wellvascularized flap over the defect, but moved the hairline on the left forehead into a more inferior position. The sutures were removed in 10 days and the wound became infected 4 cm posterior to the original defect at 21 days postoperatively. This was treated with needle aspiration, heat, and oral antibiotics, and the wound subsequently healed without complication. The alteration in the hairline on the left side was acceptable to the patient (Fig 4D).
WELCH AND BOYNE
Case 2 A 23-year-old nightclub dancer was admitted through the emergency department after her long hair became caught in the car door from which she had just exited. She was pulled on the pavement for 35 ft before her hair became free from the vehicle. She presented with a classic “scalping injury” where the integrity of the scalp was interrupted and had become separated from the skull at the area of least resistance (ie. loose connective tissue
FIGURE 5. A. Classic scalping injury occurring along the loose connective tissue layer. B, Appearance immediately postoperatively after two-layer closure.
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layer) (Fig 5A). She also sustained a fractured mandible in the symphysis region. She had no loss of consciousness and head computed tomography scan (CT) was negative. She was taken to the operating room where her head was shaved, copiously irrigated, and debrided. The galea was closed with 3-O Vicryl (Ethicon, Somerville, NJ) and the skin with 4-O nylon (Fig 5B). Sutures were removed in 7 days and the scalp healed uneventfully. The mandible was treated by an open reduction and maxillomandibular fixation (MMF) 3 days later and healed without complication.
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Case 3 A 16-year-old boy was transferred to our institution for evaluation of his maxillofacial trauma. He had lost control of the all-terrain vehicle he was riding on the desert sands. After full clinical and radiographic examination he was found to have a Le Fort III fracture, a naso-orbitalethmoidal (NOE) fracture with a 37-mm intercanthal distance, right angle and left parasymphysis fractures of the mandible with 3-cm lateral displacement, an avulsive defect of his right lip involving the base of the nose, degloving of the anterior maxilla, and multiple facial lacerations. He also sustained a compression fracture from T8-10. He had a negative C-spine series. The head CT could not be performed due to a malfunction in the machine. He was taken to the operating room where under general anesthesia he had debridement of the desert sand from his wounds and initial soft tissue closure, upper and lower dental impressions, and closed reduction of his grossly displaced mandible fracture. Immediate postoperative CT scans showed findings suggestive of diffuse cerebral edema, but physical examination showed no deficits in the extremities. Nine days later a tracheostomy was performed under local anesthesia by the general surgery service and his facial reconstruction was performed under general anesthesia. A lingual splint was placed, followed by Erich arch bar placement, MMF with elastics, and extraction of teeth nos. 1 and 32. Open reduction and internal fixation of the right angle and left parasymphysis fractures were accomplished percutaneously using a titanium bone plate (Ti-Mesh, Inc, Calabasas, CA) on the angle fracture and 22-gauge stainless steel wire in the parasymphysis. The patient was found to be in a pseudo class III malocclusion, so Rowe disimpaction forceps were used to bring the maxilla forward and 24-gauge wire was placed for MMF. The scalp was then prepared for a bicoronal flap. The flap was elevated at the level of the loose connective tissue layer and the periosteum was incised 3 cm above the supraciliary ridges. Titanium mesh bone plates and screws were used at the frontozygomatic junction bilaterally and a combination of no. 25 and no. 26 gauge wires were used at the nasofrontal suture and to reattach the medial canthal ligaments (Fig 6A). The galea was closed with 3-O polydioxanone sutures and the skin with 4-O and 6-O nylon sutures. The patient had Harrington rods placed 6 days later for stabilization of his T8-10 fracture and was discharged from the hospital 25 days after his admission (Fig 6B).
FIGURE 6. A, Nasofrontal separation of 8 mm seen prior to reduction of the Le Fort III fracture through a bicoronal incision. B, Lateral view 25 days postoperatively showing good anterioposterior position of the maxilla and healing of the bicoronal and
Case 4 A 30-year-old man was admitted through the emergency department after driving his truck underneath another truck on the freeway. Clinical and radiographic examination showed fractured ribs and a right pneumothorax, and soft tissue laceration on the right face and scalp with an avulsion defect of the right temporalis muscle from its bony origin (Fig 7A). The patient had a motor deficit of the right frontal branch of the facial nerve. He also had a right humerous fracture. The C-spine series was negative. A chest tube was placed in the emergency department and the patient was taken to the operating room where, under general anesthesia, his right facial wound was debrided. The temporalis was replaced in its
original position and attached to the galea aponeurotica superiorly with 4-O polydioxanone suture. The temporalis fascia was identified, but the frontal branch of the facial nerve appeared to be completely avulsed. The temporalis fascia was closed using 4-O polydioxanone suture and a round silicone suction drain was placed. The skin was closed with 6-O nylon suture. The wound healed without complications, but the cranial nerve deficit persisted (Fig 7B). The patient refused any microneurosurgical treatment options. The patient had an open reduction of his right humerous at a later date. He developed pneumonia, which was treated with antibiotics, and he was discharged 18 days after his admission.
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Discussion One of the most important aspects in treating scalp injuries or using the scalp to gain access to facial fractures is the manner in which the laceration or incision is closed. A two-layered closure should always be used, closing the galea and then the skin. The importance of this is highlighted by the comment of Dr Harvey Cushing, who, when asked what he wished to be remembered for in his career as the pioneer in neurosurgery, said, “Tell them I closed the galea.“’ This not only helps limit subgaleal bleeding, but also reestablishes the barrier protecting the skull and brain from infection. The development of a coronal flap in MFT patients may be indicated in Le Fort III fractures with NOE involvement .‘*I0 It provides good access to the frontozygomatic, frontonasal and medial canthal ligament areas and eliminates multiple facial scars. Alopecia may occur along the incision when using the bicoronal flap or following scalp lacerations. This can be minimized by not using excessive electrocautery near the incision or wound edges. Alterations in the hairline should also be kept in mind when moving scalp tissue from one area to another. Most scalp lacerations will result in some softtissue edema postoperatively. A good pressure dressing for 48 hours, and the prudent use of drains, will help minimize this problem. The bicoronal flap can produce significant facial edema, with both eyelids being swollen shut. This should resolve naturally in approximately 48 hours. The presence of scalp veins that may connect with a dural sinus via an emissary vein must be recognized. Because these veins traverse the loose connective tissue layer, they can become a source of blood that collects beneath the galea if torn. Due to a lack of valves, these veins also represent a direct pathway of infection to the brain. The proximity of the superior sagittal sinus must also be kept in mind. This may be a potential area of acute and life threatening hemorrhage if damaged inadvertently .‘I Acknowledgment The authors gratefully acknowledge Drs John Jensen, Lonnie Norris. Frank Rogers, Lonnie Smith, and Mark Womack for their care of these patients.
References FIGURE 7. A. Scalp injury involving the right temporal scalp region deep to the level of the calvarium. B. Evidence of injury to the temporal branch of the facial nerve postoperatively on animation of the forehead musculature.
1. Paff GH: Anatomy of the Head and Neck. Philadelphia, PA. Saunders, 1973 2. Stuzin JM. Wagstrom J, Kawamoto HK. et al: Anatomy of
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3.
4.
5.
6.
CHERUBISM
the frontal branch of the facial nerve: The significance of the temporal fat pad. Plast Reconstr Surg 83:265. 1989 Abul-Hussan HS, Ascher G, Acland RD: Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 77: 17, 1986 Shepherd DE, Ward-Booth RP, Moos KF: The morbidity of bicoronal flaps in maxillofacial surgery. Br J Oral Maxillofac Surg 23: 1, 1985 Al-Kayat A, Bramley P: A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 17:91, 1979 Wittenberg GJ, Meyer MW: Flap design and the Le Fort III osteotomy: Blood flow investigation. J Oral Maxillofac Surg 41:314, 1983
J Oral Maxillofac
IN A PATIENT WITH NOONAN SYNDROME
7. Abubaker AO, Sotereanos H, Patterson GT: Use of the coronal incision for reconstruction of severe craniomaxillofacial injuries. J Oral Maxillof Surg 48:579, 1990 8. Schwartz HC, Liebel DP: Use of a hemicoronal scalp flap to approach an osteochondroma of the coronoid process. J Oral Maxillofac Surg 45:545, 1987 9. Horrax G: Some of Harvey Cushing’s contributions to neurological surgery. J Neurosurg 1:3, 1944 10. Marschall MA. Cohen M. Garcia J. et al: Craniofacial aopreach for the reconstruction of severe facial injuries-J Oral Maxillofac Surg 46:305. 1988 11. Cannella DM, Hopkins LN: Superior sagittal sinus laceration complicating an autogenous calvarial bone graft harvest. J Oral Maxillofac Surg 48:741, 1990
Surg
49:1014-1018.1991
Cherubism in a Patient With Noonan Syndrome: Report BERNARD
LEVINE, DDS,* LEONARD SKOPE, DDS,t AND ROBERT PARKER, DMDS
Cherubism is a rare disease of the jaws.’ Noonan (Bonnevie-Ullrich) syndrome is a genetic phenotype whose frequency has been estimated as 1 in 1,000 to 1 in 2,500.2 The purpose of this article is to report a case of cherubism in a patient with Noonan syndrome and to discuss management. Report of a Case An 8-year-old white male was referred for evaluation of bilateral radiolucencies of the maxilla and mandible. The patient was asymptomatic and unaware of any problems with the jaws. Medical history and review of systems revealed a previous diagnosis of Noonan syndrome. Surgical history was significant for bilateral inguinal hernia repair and cardiac catheterization. A previous echocardiogram demonstrated a dysplastic pulmonic valve with a
Received from the Section of Oral and Maxillofacial Surgery, Hospital of St Raphael, New Haven, CT. * Chief; Associate Clinical Professor. Yale University School of Medicine. t Co-Director of Education; Assistant Clinical Professor, Yale University School of Medicine. $ Former Chief Resident; currently, in private practice, Guilford, CT. Address correspondence and reprint requests to Dr Levine: Oral and Maxillofacial Surgery, Hospital of St Raphael, 1450 Chapel St, New Haven, CT 06511.
0 1991 American geons
of a Case
Association
0278-2391/9114909-0015$3.00/O
of Oral and Maxillofacial
Sur-
minimal degree of obstruction. The patient was of short stature and slight build. Cardiac examination revealed a grade II/VI systolic ejection murmur at the left sternal border, with a widely split S-2 and split S-l. Vital signs were normal. Head, eye, ear, nose, and throat examination revealed abnormal auricles with a posterior inclination, slight webbing of the neck, and micrognathia (Fig lA, B). Oral examination revealed a class II malocclusion with the dentition in good repair, normal appearing mucosa, and bilateral expansions of the posterior maxilla and mandible which were asymptomatic. Extraorally no obvious facial deformity was present, although he seemed to have “full cheeks.” The radiographic evaluation, consisting of a panoramic view (Fig 2), Dentascan, and three-dimensional reconstruction (Fig 3A. B), demonstrated expansile, multilocular radiolucencies involving the mandible from the first molar area to the sigmoid notch bilaterally. Expansile, multilocular radiolucencies were also present in the right and left posterior maxilla from the first molar area to the tuberosities. All four lesions included multiple, unerupted teeth. Laboratory studies were within normal limits except for elevated serum alkaline phosphatase level (112 IU/L, normal 25 to 80 IU/L), and an electrocardiogram consistent with right ventricular hypertrophy. With a preoperative diagnosis of cherubism, the patient was taken to the operating room for exploration of the lesions. Following induction of general anesthesia via nasoendotracheal intubation, attention was directed to the right posterior mandible, where aspiration was attempted and was negative. A full-thickness mucoperiosteal flap was reflected and areas of bony perforation and soft tissue involvement by the tumor were noted. After removal of some of the overlying bone, multiple locules containing a gelatinous, brownish-yellow material were encoun-
Surg
49:1007-1014.1991
The Management of Traumatic Scalp Injuries: Report of Cases TIMOTHY
B. WELCH, DDS,’ AND PHILIP J. BOYNE, DMDt
Oral and maxillofacial surgeons frequently are called upon to treat maxillofacial trauma (MFT) involving the scalp. Injuries involving the scalp often do not allow one the luxury of time to deliberate multiple treatment options. Because the first attempt at treating traumatic injuries often provides the best chance at obtaining the desired result, the surgeon must be thoroughly familiar with the anatomy and peculiarities of the scalp. The purpose of this article is to review the regional anatomy, describe the bicoronal flap, and discuss pertinent areas of concern in relation to traumatic scalp injuries. Four selected cases will illustrate the use of an axial pattern flap to treat an avulsion defect, the repair of a classic scalping injury, the use of a coronal flap in MFT, and the relationship between facial animation and a traumatic scalp injury.
bital and supratrochlear branches of the ophthalmic nerve also provide sensory innervation. They exit their bony foramina and run for a short time in the loose connective tissue before piercing the frontalis muscle to enter the dense connective tissue (Fig 2). The motor innervation of the scalp comes from the frontal branch of the facial nerve.‘.’ It leaves the parotid gland immediately caudad to the zygomatic arch and is contained within the superficial temporal (temporoparietal) fascia as it crosses the arch. The nerve travels anteriorly along the undersurface of this fascial layer across the temporal region, and enters the frontalis muscle above the level of the superior orbital rim. The arterial supply to the anterior scalp comes from the superficial temporal artery, a direct branch of the external carotid, and the supraorbital and the supratrochlear arteries, indirect branches of the internal carotid. The posterior auricular and occipital arteries, direct branches of the external carotid, supply the remainder of the scalp. The arterial adventitia or outer covering of the blood vessel blends intimately with the dense connective tissue layer so that the ends of the vessels tend to stay patent when cut.’ This causes spurting of blood from the area. The widespread anastomoses ensure excellent perfusion within the scalp. The venous drainage comes from veins that accompany the arteries as well as from parietal and mastoid emissary veins. These emissary veins are unique in that they pierce the skull and connect scalp veins to cranial venous sinuses. The two bony canals that allow passage of the parietal emissary veins are just anterior to lambda, the junction of the sagittal and lambdoidal sutures.
Regional Anatomy The layers of the scalp, from superficial to deep, are the skin, dense connective tissue, galea aponeurotica (aponeurosis between the occipitalis and frontalis muscles), loose connective tissue, and pericranium or periosteum of the calvarium (Fig l).’ The sensory innervation of the scalp comes partially from the auriculotemporal branch of the mandibular nerve and the zygomaticotemporal branch of the maxillary nerve. These are found entirely in the layer of dense connective tissue. The supraor-
Received from the Oral and Maxillofacial Surgery Service. Loma Linda University Medical Center, Loma Linda. CA. * Acting Program Director. t Professor and Chief. Address correspondence and reprint requests to Dr Welch: Oral and Maxillofacial Surgery Service, Loma Linda University Medical Center. Loma Linda, CA 92350. 0 1991 American geons
Association
of Oral and Maxillofacial
Technique for the Bicoronal Flap A 2-cm strip of hair is shaved off the scalp at the site of the proposed incision, usually 3 to 4 cm posterior to the hairline and above the ear on both
Sur-
0278-2391/91/4909-0014$3.00/0
1007
TRAUMATIC SCALP INJURIES
1008
connective tissue
Galea aponeurotica connective tissue
FIGURE 1. Layers of the scalp from superficial to deep. The loose layer is the plane of dissection in the scalping injury and the plane for initial elevation of the coronal flap. It is also the level at which edema spreads to the forehead and upper eyelids.
sides. This leaves a tuft of hair anterior to the incision that can be clipped shorter if it is excessively long. Sterile preparation is done using a povidoneiodine solution. The posterior aspect of the surgical field is well defined with cloth drapes stapled to the scalp. Liberal subcutaneous injection of 0.5% lidocaine hydrochloride with 1:200,000 epinephrine is made beneath the proposed incision to aid in hemostasis. A no. 10 blade is used to make an above-the-ear incision, going over the vertex to the opposite ear and carried deep through the level of the galea aponeurotica (Fig 3A). Incision of the temporalis fascia should be avoided as the facial nerve courses just beneath this layer. Raney clips are immediately applied in an adjacent fashion on the posterior and anterior aspects of the incision. Quick digital flap elevation may be necessary to allow the clips to attach properly. The scalp flap is developed anteriorly over the face through blunt dissection below the level of the galea in the loose connective tissue layer (Fig 3B). Digital dissection also can be very helpful at this time. Approximately 3 cm before reaching the supraorbital rims, the periosteum is incised and bluntly elevated to expose the supraorbital region. The supraorbital vessels and nerves should be identified bilaterally. Using an osteotome, a small portion of the supraorbital rim is removed inferiorly to allow egress of the supraorbital bundles from their bony foramina (Fig 3C). Defining the bone of the zygomatic arch is accomplished by incising the superficial temporal fascia 3 cm behind and parallel
to the lateral orbital rim, carrying the dissection inferiorly toward the body of the zygoma and the zygomatic arch. Care is taken to stay beneath the superficial temporal fascia as this is the layer where the frontal branches of the facial nerve travel. The nasal bridge and medial canthi can be exposed by elevating the periosteum inferior to the nasofrontal suture. Fractures can then be reduced under direct visualization. On completion of surgery, hemostasis is meticulously achieved through use of electrocautery. The periosteum is closed with 4-O resorbable sutures such as those made of polyglycolic acid. The galea aponeurotica is closed with 3-O polyglycolic acid or polydioxanone suture. The skin is closed with either staples or running 4-O nylon suture. The preauricular areas may require 6-O nylon sutures. A small silicone suction drain may be brought out through a separate stab incision posterior to the scalp incision, if necessary. A pressure dressing consisting of xeroform gauze strips on the incision, fluffed gauze, and a circumcephalic wrap is applied. The head dressing is removed in 48 hours and the head may be washed with a dilute solution of hydrogen peroxide. The skin sutures are removed in 10 days. Care must be taken to avoid the supraorbital, supratrochlear, and facial nerves when raising the coronal flap. While some frontal dysesthesia may occur, the supraorbital neurovascular bundles should move freely in their foramina when the flap is retracted.4 Also, when dissecting in the temporal region to gain access to the zygomatic arch, the safe plane of dissection is beneath the temporalis fascia, which will protect the facial nerve.5 An experimental study in primates has documented a disruption of blood flow to the remainder of the face when the bicoronal flap is used.6 However, in trauma, reconstruction, or resection of neoARTERIES
NERVES Third ocap~tal Greater ocap~tai
Superfaal
temporal
Aurtculotemporal Zygomatlcotemporal
Supraorbltal Supratrochleat
Supraorbltal Supratrochlear
FIGURE 2. Approximate location of the arteries and sensory nerves that course through the dense connective tissue layer of the scalp.
1009
WELCH AND BOYNE
/-ROICG HALOLD W4~ENRhut4
FIGURE 3. A, Outline of incision for coronal flap extending from the preauricular area over the vertex to the opposite ear. B. Elevation of the coronal flap at the level of the loose connective tissue layer after Raney clip application. C. Exposure of the zygomaticofrontal, nasofrontal, and zygomatic arch areas through a coronal flap. Note periosteum excised 3 cm above the supraorbital rims.
plastic disease, this has not appeared to be a clinical problem.4V7.8 The placement of suction drains will help prevent hematoma formation in the loose connective tissue layer of the scalp. The drain should be placed in the loose connective tissue layer and be maintained until it produces less than 5 mL per &hour shift. The drain should be placed dependently, taking into consideration that the extent of many patient’s injuries may require them to be completely supine in the postoperative period.
Report of Cases Case 1 A 26-year-old truck driver was admitted through the emergency department after being ejected through the window of his vehicle. He sustained a 5 x g-cm avulsion defect of the frontal scalp, as well as multiple lacerations (Fig 4A). He had deeply abraded his calvarium on the cement. He had also suffered a fractured clavicle, but had a negative C-spine series radiographically. There was no loss of consciousness.
TRAUMATIC SCALP INJURIES
FIGURE 4. Avulsion defect of the scalp. A, Loss of tissue and abraded calvarium apparent. E, Elevation of an axial pattern scalp flap to rotate over the avulsive defect. C, Axial flap rotated over defect and closed primarily. D, Four months postoperatively. Alteration of the hairline is acceptable to the patient.
He was taken to the operating room where his scalp was shaved, irrigated, and debrided with copious amounts of normal saline. An attempt was made to close the wound primarily by undermining of the local tissues. This resulted in excessive strain on the wound margins so the decision was made to rotate an axial pattern flap laterally over the defect (Fig 4B). The flap was based upon the superficial temporal and posterior auricular arteries and had a 2:l length-width ratio. It was elevated to the level of the loose connective tissue layer. The galea was closed with 4-O polydioxanone suture (PDS II monofilament, Ethicon, Somerville, NJ) and the skin was closed with 4-O nylon. The adjacent scalp was undermined lib-
erally and closed primarily (Fig 4C). A silicone drain (Miniflap Drain System, McGhan Medical Corporation, Santa Barbara, CA) was placed in the loose connective tissue layer. The procedure resulted in a wellvascularized flap over the defect, but moved the hairline on the left forehead into a more inferior position. The sutures were removed in 10 days and the wound became infected 4 cm posterior to the original defect at 21 days postoperatively. This was treated with needle aspiration, heat, and oral antibiotics, and the wound subsequently healed without complication. The alteration in the hairline on the left side was acceptable to the patient (Fig 4D).
WELCH AND BOYNE
Case 2 A 23-year-old nightclub dancer was admitted through the emergency department after her long hair became caught in the car door from which she had just exited. She was pulled on the pavement for 35 ft before her hair became free from the vehicle. She presented with a classic “scalping injury” where the integrity of the scalp was interrupted and had become separated from the skull at the area of least resistance (ie. loose connective tissue
FIGURE 5. A. Classic scalping injury occurring along the loose connective tissue layer. B, Appearance immediately postoperatively after two-layer closure.
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layer) (Fig 5A). She also sustained a fractured mandible in the symphysis region. She had no loss of consciousness and head computed tomography scan (CT) was negative. She was taken to the operating room where her head was shaved, copiously irrigated, and debrided. The galea was closed with 3-O Vicryl (Ethicon, Somerville, NJ) and the skin with 4-O nylon (Fig 5B). Sutures were removed in 7 days and the scalp healed uneventfully. The mandible was treated by an open reduction and maxillomandibular fixation (MMF) 3 days later and healed without complication.
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Case 3 A 16-year-old boy was transferred to our institution for evaluation of his maxillofacial trauma. He had lost control of the all-terrain vehicle he was riding on the desert sands. After full clinical and radiographic examination he was found to have a Le Fort III fracture, a naso-orbitalethmoidal (NOE) fracture with a 37-mm intercanthal distance, right angle and left parasymphysis fractures of the mandible with 3-cm lateral displacement, an avulsive defect of his right lip involving the base of the nose, degloving of the anterior maxilla, and multiple facial lacerations. He also sustained a compression fracture from T8-10. He had a negative C-spine series. The head CT could not be performed due to a malfunction in the machine. He was taken to the operating room where under general anesthesia he had debridement of the desert sand from his wounds and initial soft tissue closure, upper and lower dental impressions, and closed reduction of his grossly displaced mandible fracture. Immediate postoperative CT scans showed findings suggestive of diffuse cerebral edema, but physical examination showed no deficits in the extremities. Nine days later a tracheostomy was performed under local anesthesia by the general surgery service and his facial reconstruction was performed under general anesthesia. A lingual splint was placed, followed by Erich arch bar placement, MMF with elastics, and extraction of teeth nos. 1 and 32. Open reduction and internal fixation of the right angle and left parasymphysis fractures were accomplished percutaneously using a titanium bone plate (Ti-Mesh, Inc, Calabasas, CA) on the angle fracture and 22-gauge stainless steel wire in the parasymphysis. The patient was found to be in a pseudo class III malocclusion, so Rowe disimpaction forceps were used to bring the maxilla forward and 24-gauge wire was placed for MMF. The scalp was then prepared for a bicoronal flap. The flap was elevated at the level of the loose connective tissue layer and the periosteum was incised 3 cm above the supraciliary ridges. Titanium mesh bone plates and screws were used at the frontozygomatic junction bilaterally and a combination of no. 25 and no. 26 gauge wires were used at the nasofrontal suture and to reattach the medial canthal ligaments (Fig 6A). The galea was closed with 3-O polydioxanone sutures and the skin with 4-O and 6-O nylon sutures. The patient had Harrington rods placed 6 days later for stabilization of his T8-10 fracture and was discharged from the hospital 25 days after his admission (Fig 6B).
FIGURE 6. A, Nasofrontal separation of 8 mm seen prior to reduction of the Le Fort III fracture through a bicoronal incision. B, Lateral view 25 days postoperatively showing good anterioposterior position of the maxilla and healing of the bicoronal and
Case 4 A 30-year-old man was admitted through the emergency department after driving his truck underneath another truck on the freeway. Clinical and radiographic examination showed fractured ribs and a right pneumothorax, and soft tissue laceration on the right face and scalp with an avulsion defect of the right temporalis muscle from its bony origin (Fig 7A). The patient had a motor deficit of the right frontal branch of the facial nerve. He also had a right humerous fracture. The C-spine series was negative. A chest tube was placed in the emergency department and the patient was taken to the operating room where, under general anesthesia, his right facial wound was debrided. The temporalis was replaced in its
original position and attached to the galea aponeurotica superiorly with 4-O polydioxanone suture. The temporalis fascia was identified, but the frontal branch of the facial nerve appeared to be completely avulsed. The temporalis fascia was closed using 4-O polydioxanone suture and a round silicone suction drain was placed. The skin was closed with 6-O nylon suture. The wound healed without complications, but the cranial nerve deficit persisted (Fig 7B). The patient refused any microneurosurgical treatment options. The patient had an open reduction of his right humerous at a later date. He developed pneumonia, which was treated with antibiotics, and he was discharged 18 days after his admission.
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Discussion One of the most important aspects in treating scalp injuries or using the scalp to gain access to facial fractures is the manner in which the laceration or incision is closed. A two-layered closure should always be used, closing the galea and then the skin. The importance of this is highlighted by the comment of Dr Harvey Cushing, who, when asked what he wished to be remembered for in his career as the pioneer in neurosurgery, said, “Tell them I closed the galea.“’ This not only helps limit subgaleal bleeding, but also reestablishes the barrier protecting the skull and brain from infection. The development of a coronal flap in MFT patients may be indicated in Le Fort III fractures with NOE involvement .‘*I0 It provides good access to the frontozygomatic, frontonasal and medial canthal ligament areas and eliminates multiple facial scars. Alopecia may occur along the incision when using the bicoronal flap or following scalp lacerations. This can be minimized by not using excessive electrocautery near the incision or wound edges. Alterations in the hairline should also be kept in mind when moving scalp tissue from one area to another. Most scalp lacerations will result in some softtissue edema postoperatively. A good pressure dressing for 48 hours, and the prudent use of drains, will help minimize this problem. The bicoronal flap can produce significant facial edema, with both eyelids being swollen shut. This should resolve naturally in approximately 48 hours. The presence of scalp veins that may connect with a dural sinus via an emissary vein must be recognized. Because these veins traverse the loose connective tissue layer, they can become a source of blood that collects beneath the galea if torn. Due to a lack of valves, these veins also represent a direct pathway of infection to the brain. The proximity of the superior sagittal sinus must also be kept in mind. This may be a potential area of acute and life threatening hemorrhage if damaged inadvertently .‘I Acknowledgment The authors gratefully acknowledge Drs John Jensen, Lonnie Norris. Frank Rogers, Lonnie Smith, and Mark Womack for their care of these patients.
References FIGURE 7. A. Scalp injury involving the right temporal scalp region deep to the level of the calvarium. B. Evidence of injury to the temporal branch of the facial nerve postoperatively on animation of the forehead musculature.
1. Paff GH: Anatomy of the Head and Neck. Philadelphia, PA. Saunders, 1973 2. Stuzin JM. Wagstrom J, Kawamoto HK. et al: Anatomy of
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3.
4.
5.
6.
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the frontal branch of the facial nerve: The significance of the temporal fat pad. Plast Reconstr Surg 83:265. 1989 Abul-Hussan HS, Ascher G, Acland RD: Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 77: 17, 1986 Shepherd DE, Ward-Booth RP, Moos KF: The morbidity of bicoronal flaps in maxillofacial surgery. Br J Oral Maxillofac Surg 23: 1, 1985 Al-Kayat A, Bramley P: A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 17:91, 1979 Wittenberg GJ, Meyer MW: Flap design and the Le Fort III osteotomy: Blood flow investigation. J Oral Maxillofac Surg 41:314, 1983
J Oral Maxillofac
IN A PATIENT WITH NOONAN SYNDROME
7. Abubaker AO, Sotereanos H, Patterson GT: Use of the coronal incision for reconstruction of severe craniomaxillofacial injuries. J Oral Maxillof Surg 48:579, 1990 8. Schwartz HC, Liebel DP: Use of a hemicoronal scalp flap to approach an osteochondroma of the coronoid process. J Oral Maxillofac Surg 45:545, 1987 9. Horrax G: Some of Harvey Cushing’s contributions to neurological surgery. J Neurosurg 1:3, 1944 10. Marschall MA. Cohen M. Garcia J. et al: Craniofacial aopreach for the reconstruction of severe facial injuries-J Oral Maxillofac Surg 46:305. 1988 11. Cannella DM, Hopkins LN: Superior sagittal sinus laceration complicating an autogenous calvarial bone graft harvest. J Oral Maxillofac Surg 48:741, 1990
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49:1014-1018.1991
Cherubism in a Patient With Noonan Syndrome: Report BERNARD
LEVINE, DDS,* LEONARD SKOPE, DDS,t AND ROBERT PARKER, DMDS
Cherubism is a rare disease of the jaws.’ Noonan (Bonnevie-Ullrich) syndrome is a genetic phenotype whose frequency has been estimated as 1 in 1,000 to 1 in 2,500.2 The purpose of this article is to report a case of cherubism in a patient with Noonan syndrome and to discuss management. Report of a Case An 8-year-old white male was referred for evaluation of bilateral radiolucencies of the maxilla and mandible. The patient was asymptomatic and unaware of any problems with the jaws. Medical history and review of systems revealed a previous diagnosis of Noonan syndrome. Surgical history was significant for bilateral inguinal hernia repair and cardiac catheterization. A previous echocardiogram demonstrated a dysplastic pulmonic valve with a
Received from the Section of Oral and Maxillofacial Surgery, Hospital of St Raphael, New Haven, CT. * Chief; Associate Clinical Professor. Yale University School of Medicine. t Co-Director of Education; Assistant Clinical Professor, Yale University School of Medicine. $ Former Chief Resident; currently, in private practice, Guilford, CT. Address correspondence and reprint requests to Dr Levine: Oral and Maxillofacial Surgery, Hospital of St Raphael, 1450 Chapel St, New Haven, CT 06511.
0 1991 American geons
of a Case
Association
0278-2391/9114909-0015$3.00/O
of Oral and Maxillofacial
Sur-
minimal degree of obstruction. The patient was of short stature and slight build. Cardiac examination revealed a grade II/VI systolic ejection murmur at the left sternal border, with a widely split S-2 and split S-l. Vital signs were normal. Head, eye, ear, nose, and throat examination revealed abnormal auricles with a posterior inclination, slight webbing of the neck, and micrognathia (Fig lA, B). Oral examination revealed a class II malocclusion with the dentition in good repair, normal appearing mucosa, and bilateral expansions of the posterior maxilla and mandible which were asymptomatic. Extraorally no obvious facial deformity was present, although he seemed to have “full cheeks.” The radiographic evaluation, consisting of a panoramic view (Fig 2), Dentascan, and three-dimensional reconstruction (Fig 3A. B), demonstrated expansile, multilocular radiolucencies involving the mandible from the first molar area to the sigmoid notch bilaterally. Expansile, multilocular radiolucencies were also present in the right and left posterior maxilla from the first molar area to the tuberosities. All four lesions included multiple, unerupted teeth. Laboratory studies were within normal limits except for elevated serum alkaline phosphatase level (112 IU/L, normal 25 to 80 IU/L), and an electrocardiogram consistent with right ventricular hypertrophy. With a preoperative diagnosis of cherubism, the patient was taken to the operating room for exploration of the lesions. Following induction of general anesthesia via nasoendotracheal intubation, attention was directed to the right posterior mandible, where aspiration was attempted and was negative. A full-thickness mucoperiosteal flap was reflected and areas of bony perforation and soft tissue involvement by the tumor were noted. After removal of some of the overlying bone, multiple locules containing a gelatinous, brownish-yellow material were encoun-
