The operative surgery
of the head and neck
Structures of the scalp
The operative surgery of cerebral part of the head
The superficial fascia binds the skin to the subjacent
aponeurosis, and provides the proper medium for passage of vessels and
nerves to the skin. Wounds of the scalp bleed profusely because the
vessels are prevented from retracting by the fibrous fascia. Bleeding can
be arrested by applying pressure at the site of injury by a tight cotton
bandage against the bone.
The fifth layer of the scalp, called the pericranium, is loosely
attached to the surface of the bones, but is firmly adherent to their
sutures. The collections of fluid deep to the pericranitun known as
cephalhaematoma take the shape of the bone concerned when there is
fracture of particular bone.
Collection of blood in the layer of loose connective tissue causes
generalised swelling of the scalp.
The loose connective tissue layer (4th layer) of the scalp is
the danger area of the scalp because pus or blood spreads
easily in it. Infection in this layer can also pass into the cranial
cavity through small emissary veins, which pass through
parietal foramina in the calvaria, and reach intracranial
structures such as the meninges. An infection cannot pass into
neck because the occipital bellies of the occipitofrontalis
muscle attached to the occipital bone and mastoid part of the
temporal bone. Neither can a scalp infection spread laterally
beyond the zygomatic arches because the epicranial
aponeurosis is attaches to these arches. An infection can enter
the eyelids and root of the nose because the occipitofrontalis
muscle inserts into skin and does not attach to the bone.
To prevent the bleeding from the blood vessels it is necessary to know the
projection of those blood vessels. The supraorbital vessels are projected to the
supraorbital margin on point between the internal one-third and external two-third.
The supratrochlear vessels are projected to the inner part of supraorbital margin.
The superficial temporal artery is projected in front from tragus. The posterior
auricular artery is projected behind auricle. The occipital artery is projected in the
middle part of the line between mastoid process and external occipital protuberans.
SCALP SURGERY
Operative incisions should be made vertically, in line with the
main vessels. Bleeding is reduced if the incision is made with
diathermy, but larger vessels will still bleed and are difficult to
pick up in forceps. In minor excisional surgery, digital pressure on
the scalp lateral to the wound while surgery is completed,
followed by deep sutures and pressure to the sutured wound, is
often sufficient to control bleeding. In the more major scalp
incisions for neurosurgical access, bleeding from the scalp edges
must be controlled during surgery. Initial control by finger
pressure on the adjacent scalp can be followed by pressure with
Raney clips. Alternatively, a series of artery forceps is applied to
the galea aponeurotica at 1-cm intervals and then pulled back so
that the galea is drawn over the cut surface, stretching and
occluding the bleeding vessels.
The scalp is thick and the cut edges are often still bleeding when the
surgeon is ready to close an incision. Therefore, deep full-thickness
simple or mattress sutures, which compress the skin and
subcutaneous fibrous connective tissue layer, are ideal. If the scar
will later be covered by hair, any additional scarring attributable to
the sutures will not be visible. Separate absorbable deep sutures in
the galea are recommended in long wounds. Scalp apposition, after
either traumatic tissue loss or after the excision of a skin lesion, can
be surprisingly difficult considering the apparent mobility of the
scalp. Some tension on the suture line is permissible, as the scalp
has an excellent blood supply. However, if tension is unacceptable,
a rotational flap may be used. A skin graft will give a bald patch,
which is often cosmetically unacceptable, but occasionally this may
be the only immediate solution. A bald patch from the healing of a
scalp defect or burn can be excised later and hair-bearing scalp
mobilised and rotated; a large defect may be covered by adjacent
hair-bearing skin if the available tissue has been increased by an
implantable tissue expand.
Scalp Laceration
A laceration is a pattern of injury in which blunt forces result in a tear in the skin and
underlying tissues. Lacerations in the scalp are different from lacerations in other parts of the
face and body due to differences in the anatomy and blood supply. In lacerations, separation most
commonly occurs at the loose areolar tissue layer. The musculoaponeurotic layer contains the
superficial temporal artery as the muscles require copious blood supply for function.
Understanding the layers of the scalp and the blood supply is essential to successfully stopping
bleeding from lacerations, which can be substantial in many cases. The wound should undergo
proper assessment for length, depth, shape, contamination or foreign bodies, and skin loss.
Proper evaluation requires the removal of foreign bodies and achieving hemostasis. Sometimes,
the removal of scalp hair is necessary. Careful examination of the head and looking for signs of
associated injuries such as skull fractures and intracranial injury is essential as they may require
immediate intervention to prevent significant morbidity. The bleeding can usually be stopped by
applying direct pressure with or without the use of local lidocaine with epinephrine. Options for
closure include surgical staples, hair apposition, and suturing. Staples are generally the
preferred closure method in lacerations through the dermis in which bleeding is under control as
they are fast, cheap, and have few to complications. They also achieve similar cosmetic results
when compared to sutures. Straight, small wounds (under 10cm) can be repaired using modified
hair apposition, if there is adequate bleeding controlled and the patient has hair that is at least
1cm in length. Simple interrupted sutures may be used for closure if the wound was profusely
bleeding and could not attain adequate hemorrhage control without suturing. It is also a valid
option if staples are unavailable and hair apposition isn't applicable (e.g., large wound, short-
haired patient).
Hair apposition
1. Twist together 3-7 strands of hair on one side of the
wound.
2. Interlock these two hair bundles in a 360-degree
revolution. Do not tie a knot.
3. Secure the intertwined hair bundles by applying a few
drops of a tissue adhesive.
4. Repeat as needed to close the length of the laceration.
The patient no longer needs to return for staple removal
in 7-10 days. The hair will unravel on its own after a
week.
Craniotomy
A craniotomy is a surgical procedure in which a part of the skull is temporarily
removed to expose the brain and perform an intracranial procedure. The most common
conditions that can be treated via this approach include brain tumors, aneurysms,
arterio-venous malformations, subdural empyemas, subdural hematomas, and
intracerebral hematomas. Specialized tools and equipment are utilized to remove the
section of bone, which is called the bone flap. If the bone flap is discarded or not
placed back into the skull during the same operation, the procedure is called a
craniectomy. The surgical procedure to reconstruct and place the bone flap back into
the skull during a second intervention is known as cranioplasty.
Technique of craniotomy
Once the patient is under anesthesia, the correct position of the head is fixed
depending on the approach to be utilized. It is of utmost importance to avoid any
pressure points on vulnerable body areas by adequately padding throughout. The
location of the incision for the craniotomy depends on the part of the brain to be
operated. For surgery in the supratentorial area, the incision is usually made over the
frontal, temporal, parietal, or occipital bones, or over a combination of bones. For
surgery in the infratentorial area, the incision is usually made over the back portion of
the skull below the transverse sinus. After the desired location of the incision is chosen
on the skin, the hair in the area may be shaved off. Once the incision is confirmed, the
surgical area is cleaned with the preferred antiseptic agent followed by routine sterile
draping techniques. A local anesthetic with epinephrine is usually injected on the
After the skin incision is made, the muscles below the scalp are dissected to expose
the skull. Retractors can be placed on the edges of the incision to have adequate
exposure to the surgical area to be focused on. Alternatively, fish hook retractors or
sutures can be used to hold the scalp flap. The pericranium can be separated to be used
as a dural substitute if necessary during the closure. Several burr holes are made into
the skull utilizing the craniotome or cranial drill. The caution has to be employed to
avoid plunging the craniotome into the brain tissue. The holes are cleaned from any
bone fragment, and the dura is separated with a Freer elevator or Penfield dissector.
The burr holes are connected with a craniotome saw, and a bone flap is elevated after
carefully separating it from the dura matter below. The bone flap is held in the surgical
instrument table until the closure portion of the surgery. For the intradural procedure,
the dura is cut and retracted, exposing the brain. Once the surgery on the brain
concludes, the bone is reattached in position with plates and screws. Adequate
hemostasis should be obtained before closing the scalp. The overlying tissues are
reattached, and the scalp is then sutured in anatomical layers. Depending on the
surgeon’s preference, a subdural or subgaleal drain can be left in place to drain the
accumulated blood products.
The operative surgery of face
The skin of the face is very vascular. The superficial fascia contains: (1) The
facial muscles, all of which are inserted into the skin, (2) the vessels and nerves, to the
muscles and to the skin, and (3) a variable amount of fat. Fat is absent from the eyelids,
but is well developed in the cheeks, forming the buccal pads that are very prominent in
infants in whom they help in sucking. The deep fascia is absent from the face, except
over the parotid gland where it forms the parotid fascia, and over the buccinator where
it forms the buccopharyngeal fascia.
Arterial and Nerve Supply of Face:
From maxillary artery – infraorbital (below infraorbital margin in 0.5 cm) and
mental arteries (below angle of mouth in 0.5 cm); from external carotid artery – facial
artery (the projection line – from anterior margin of masseter muscle to the internal
angle of the eye).
The sensory branches: from trigeminal nerve – infraorbital, mental and
auriculotemporal nerves.
The motor branches – from facial nerve – temporal to the forehead, zygomatic
to the lateral angle of the eye, buccal to the upper lip, mandibular to the lower lip,
cervical branches to the platysma.
The facial vein communicates with the cavernous sinus via the angular
vein. This is a fact of great clinical significance, because any infection of
the region of the face drained by the facial vein can spread to the
cavernous sinus, resulting in a serious condition called thrombosis of the
cavernous sinus. Consequently, the triangular area from the upper lip to
the bridge of the nose is considered the danger triangle of the face.
The incisions in purulent process on the face
The radial incisions are made on under the projection lines
of the facial nerve to avoid injury to the facial nerve and its
branches. In purulent process in the infratemporal fossa the
incision is made near the angle of mandible. The cervical
branch of the facial nerve may be damaged, but it does not
cause any serious complication. The incision from the
zygomatic process of the frontal bone to lobule of the auricle
is performed in purulent process of the temporal region.
Plastic surgery of the face
Plastic surgery of the face has two main objectives: it
should correct dysfunctions and restore or improve the
aesthetics of the face. Apart from addressing malformations,
plastic reconstructive procedures are required to revise scars,
resurface skin and soft-tissue defects, or correct deformities
after trauma or tumor surgery.
Relaxed Skin Tension Lines (RSTL)
Whereas the RSTL correspond to the spontaneous course of wrinkles
after relaxation of the skin, the wrinkle lines are oriented perpendicular
to the direction of the fibers of the facial muscles. RSTL and wrinkles
lines are more or less identical, although they run directly in some
regions (glabella, lateral epicanthus, lateral nasal wall). Incisions on the
face should correspond to the direction of the RSTL (less wound tension,
rapid wound healing, minimal scar formation). Only atraumatic
needle/suture combinations are suitable for plastic surgery of the face.
Absorbable braided suture materials based on polyglycolic and
polylactic acid are used for subcutaneous sutures.
Skin sutures are placed using monofilament, nonabsorbable synthetic
strands made out of polyamide or polypropylene. These sutures have a
high tensile strength, skin irritation is minimal, and they have no “wick
effect”. Primary wound closure usually involves a subcutaneous suture
and a skin suture. The subcutaneous suture is placed in such a way that
the knot is buried in the depths of the tissue. The skin margins are then
re-approximated with an interrupted suture.
Vertical Mattress Suture
The advantage of the mattress suture is its safer re-approximation of wound edges
with different depths, e. g., at the alar base or the nasolabial region. This suture everts
the wound edges and helps avoid “furrowlike” scar formation. It also gives the suture
additional stability.
Continuous (Running) Suture
The area of usage of this suture corresponds to that of the interrupted suture, but it can be
sewn faster with longer wounds. Good results can be expected above all in areas of thin and
readily mobile skin with few sebaceous glands. The eyelids in particular, and the skin of older
people in general, have these properties.
W-plasty
Converting a linear scar into a zigzag shape distributes the tensile forces in the region of
the scar so that the scar line is optically “broken up.” With scars running perpendicular to the
RSTL (e. g., scars in the region of the cheek), part of the newly formed scar is redirected in a
parallel fashion. At the same time retracted scars are corrected by resection and undermining.
The operative surgery of neck
Superficial fascia of the neck contains areolar tissue with platysma. Lying deep to
platysma are cutaneous nerves, which arise from posterior border of
sternocleidomastoid muscle – lesser occipital, great auricular, transverse cutaneus,
supraclavicular nerves (from cervical plexus), superficial veins – external and anterior
jugular, lymph vessels, lymph nodes and small arteries.
Deep fascia of the neck is condensed to form the following layers: (1) investing
layer –forms the capsule for parotid and submandibular glands and also surround the
sternocleidomastoid and trapezoid muscles; (2) pretracheal fascia – forms the capsule
for thyroid gland and surround the infrahyoid muscles, it is continous posteriorly with
the buccopharyngeal fascia; (3) prevertebral fascia – it surround the longus colli,
longus capitis, scalenus muscle, also subclavian vessels, brachial plexus and
sympathetic trunk; (4) carotid sheath – contents are the carotid arteries, internal jugular
vein and the vagus nerve. In the upper part of sheath there are IX, XI, XIl nerves also.
The point on which we can compress the common carotid artery to the transverse
process of six cervical vertebrae is situated on the anterior border of the
sternocleidomastoid muscle at level of the cricoid cartilage of the larynx.
The compression of the subclavian artery. In severe traumatic accidents to the upper
limb involving laceration of the brachial or axillary arteries, it is important to remember that the
hemorrhage can be stopped by exerting strong pressure downward and backward on the third
part of the subclavian artery against the upper surface of the 1st rib.
The purulent process of the neck.
There are several spaces on the neck, which can involve in purulent process.
The pus in this process can spread to the anterior and posterior mediastinum,
compressing the trachea or larynx, and large blood vessels of the neck. Thus, the main
principle of getting rid of the abscess is to open and drain it. After dissection of the
skin, the fascia is separated with probe to avoid damage to the blood vessels. Besides
bleeding from the vessels, damage to the veins may also cause air emboli. After
opening, the tampon is applied to the wound or a drainage tube is fixed at the lower
margin of the wound.
The incisions in purulent process of the neck.
•In abscess of submandibular region - the incision is made parallel mardin of the
mandible.
•The abscess of the floor of the oral cavity - the incision is made from the mental
protuberance to the hyoid bone.
•In abscess around main vessels of the neck - the incision is made on anterior or
posterior margin of the sternocleidomastoid muscle. If the pus spread to the lateral
triangle the incision is made from posterior margin of the sternocleidomastoid muscle
parallel to anterior margin of trapezius muscle.
•In abscess of the previsceral space - the transverse incision is made through the skin
and 2nd and 3rd fascias of the neck.
Internal Jugular Vein Catheterization.
The internal jugular vein descends through the neck from a point halfway
between the tip of the mastoid process and the angle of the jaw to the sternoclavicular
joint. Above, it is overlapped by the anterior border of the sternocleidomastoid muscle,
and below, it is covered laterally by this muscle. In the posterior approach, the tip of the
needle and the catheter are introduced into the vein about two fingers above the
clavicle at the posterior border of the sternocleidomastoid muscle.
Cricothyroidotomy
In cricothyroidotomy, a tube is inserted in the interval between the
cricoid cartilage and the thyroid cartilage. The trachea and larynx are
steadied by extending the neck over a sandbag. A vertical or transverse
incision is made in the skin in the interval between the cartilages. The
incision is made through the following structures: the skin, the
superficial fascia (beware of the anterior jugular veins, which lie close
together on either side of the midline), the investing layer of deep
cervical fascia, the pretracheal fascia (separate the sternohyoid muscles
and incise the fascia), and the larynx. The larynx is incised through a
horizontal incision through the cricothyroid ligament and the tube
inserted.
Tracheostomy
Tracheostomy is rarely performed and is limited to patients with extensive
laryngeal damage and infants with severe airway obstruction. The thyroid and cricoid
cartilages are identified and the neck is extended to bring the trachea forward. A
vertical midline skin incision is made from the region of the cricothyroid membrane
inferiorly toward the suprasternal notch. The anterior jugular veins in the superficial
fascia are avoided by maintaining a midline position. The investing layer of deep
cervical fascia is incised. The pretracheal muscles embedded in the pretracheal fascia
are split in the midline two fingers superior to the sternal notch. The tracheal rings are
then palpable in the midline or the isthmus of the thyroid gland is visible. If a hook is
placed under the lower border of the cricoid cartilage and traction is applied upward,
the slack is taken out of the elastic trachea; this stops it from slipping from side to side.
A decision is then made as to whether to enter the trachea through the second ring
above the isthmus of the thyroid gland; through the third, fourth, or fifth ring by first
dividing the vascular isthmus of the thyroid gland; or through the lower tracheal rings
below the thyroid isthmus. At the latter site, the trachea is receding from the surface of
the neck, and the pretracheal fascia contains the inferior thyroid veins and possibly the
thyroidea ima artery. The preferred site is through the second ring of the trachea in the
midline, with the thyroid isthmus retracted inferiorly. A vertical tracheal incision is
made, and the tracheostomy tube is inserted.
Thyroidectomy
Excision of a malignant tumor of the thyroid gland, or other surgical procedure, sometimes
necessitates removal of part or all of the gland (hemithyroidectomy or thyroidectomy). In the
surgical treatment of hyperthyroidism, the posterior part of each lobe of the enlarge thyroid id
usually preserved, a procedure called near-total thyroidectomy, to protect the recurrent and
superior laryngeal nerve and to spare the parathyroid gland. The risk of injury to the recurrent
laryngeal nerves is ever present during neck surgery. Near the inferior pole of the thyroid gland,
the right nerve is intimately related to the inferior thyroid artery and its branches. Because of this
close relationship, the inferior thyroid artery is ligated some distance lateral to the thyroid gland.
Although the danger of injuring the left reccurens laryngeal nerve during surgery is not as great,
owing to its more vertical ascent from the superior mediastinum, the artery and nerve are also
closely associated near the inferior pole of the thyroid gland. Damage to the external laryngeal
nerve causes some weakness of phonation. When both recurrent laryngeal nerve are interrupted,
the vocal cord lie in position between abduction and adduction and phonation is completely lost.
When only one recurrent laryngeal nerve is interrupted, the opposite vocal cord compensate for it
and phonation possible but voice becomes hoarseness. The variable position of the parathyroid
glands puts them in danger of being damages or removed during surgical procedures in the neck.
Atrophy or inadvertent surgical removal off all the parathyroid glands results in tetany, a severe
neurologic syndrome characterized by muscle twitches and cramps. The generalized spasms are
caused by decreased serum calcium levels. To safeguarded these glands during thyroidectomy,
surgeons usually prevent the posterior part of lobes and fibrous capsule of the thyroid gland.
Parathyroid gland may also be transplanted, usually to the arm, so it will not be damaged by
subsequent surgery or radiation therapy.
