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CHAPTER 103 • Skin Graft—Split Thickness and Full Thickness 1155

STEP 4: POSTOPERATIVE CARE

◆ Wounds that result from decompression should be kept moist and wrapped with the burn.

Elevation should be routine to help decrease edema whenever possible.

STEP 5: PEARLS AND PITFALLS

◆ Keep in mind that all circumferential burns do not need to have decompression.

◆ In a moderate burn with an awake patient, you can follow closely with a clinical

examination.

SELECTED REFERENCES

1. Herndon DN: Total Burn Care. London, Saunders, 2002.

2. Barret JP, Herndon DN: Color Atlas of Burn Care. London, Saunders, 2001.

3. Sood R, Achauer BM: Achauer and Sood’s Burn Surgery: Reconstruction and Rehabilitation. Philadelphia,

Elsevier, 2006.

4. Green DP, Hotchkiss RN, Pederson WC, Wolfe S: Green’s Operative Hand Surgery, 5th ed. Amsterdam,

Elsevier, 2005.

1158

STEP 1: SURGICAL ANATOMY

The following anatomic features must be observed:

◆ Mastoid muscle

◆ Sternocleidomastoid muscle

◆ Thyroid cartilage

◆ Trachea

◆ Esophagus

◆ Carotid sheath

◆ Carotid artery (common, internal, external) (Figure 104-1)

◆ Jugular vein (facial vein)

◆ Vagus nerve and ansa cervicalis

◆ Angle of mandible (see Figure 104-1)

◆ Platysma muscle

◆ Hypoglossal nerve

◆ Digastric muscle (see Figure 104-1)

◆ Zone I: Inferior to cricothyroid cartilage

◆ Zone II: Cricothyroid to angle of mandible

◆ Zone III: Superior to angle of mandible

CHAPTER

104

Neck Exploration for Trauma

William J. Mileski

CHAPTER 104 • Neck Exploration for Trauma 1159

Cricoid

cartilage

Angle of

mandible

Zone III

Zone II

Zone I

FIGURE 104 –1

1160 Section XVI • Operations—Elective and Trauma

◆ Omohyoid muscle

◆ Inferior thyroid artery

◆ Middle thyroid vein

◆ Thyroid gland

◆ Parotid gland

◆ Cross-sectional view (Figure 104-2)

◆ Investing layer of deep cervical fascia

◆ Carotid sheath

◆ Prevertebral fascia

◆ Retropharyngeal space

Retropharyngeal

space

Pretracheal

space

Carotid sheath

Investing fascia

Prevertebral fascia

Investing layer of

deep fascia

FIGURE 104 –2

CHAPTER 104 • Neck Exploration for Trauma 1161

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ The most common indication for neck exploration is penetrating trauma, although blunt

trauma may also present with vascular and aerodigestive tract injury requiring treatment,

identiﬁ ed by hard signs on examination (active hemorrhage, expanding hematoma) or by

diagnostic study, computed tomography (CT), or ultrasound.

STEP 3: OPERATIVE STEPS

1. POSITIONING AND PREPARATION

◆ The patient is placed supine with a 3-inch towel roll beneath the shoulder, and the head is

rotated to the contralateral side.

◆ The ﬁ eld is prepared from the base of the skull to include the entire chest, abdomen, and

both groins (for possible vein graft).

1162 Section XVI • Operations—Elective and Trauma

2. INCISION AND DISSECTION

◆ The skin incision is made along the anterior border of the sternocleidomastoid muscle from

the mastoid to the clavicle. The platysma muscle is incised (using electrocautery), the

sternocleidomastoid is retracted lateral, and the carotid sheath is opened from proximal to

distal. Transection of the omohyoid muscle proximally and digastric muscle distally may

improve exposure (Figure 104-3). Ligation of the facial vein, the inferior thyroid artery, and

the middle thyroid vein and transection of the ansa cervicalis allow exposure of the trachea

and esophagus by permitting easy lateral mobilization of the carotid sheath contents and

medial retraction of the thyroid gland (Figure 104-4, A).

◆ Tracheal injury may be primarily repaired with interrupted 3-0 polydioxanone (PDS)

sutures. Esophageal injuries are best repaired in two layers with an inner layer of 3-0 Vicryl

and an outer layer of 3-0 silk.

◆ When very distal exposure of the internal carotid is required, the mandible may be sub-

luxed anteriorly and medially using temporary wire ﬁ xation (26 gauge) between the lower

bicuspids and anterior incisors (Figure 104-4, B). As the dissection on the anterior aspect

of the internal carotid is carried distally, transection of the digastric muscle will be neces-

sary, and care must be taken to avoid injury to the hypoglossal nerve.

Middle thyroid

vein

Inferior thyroid

artery

Internal jugular vein

Carotid artery

Sternocleidomastoid

muscle

Ansa cervicalis

Facial vein

Carotid sheath

opened

Omohyoid muscle

FIGURE 104 –3

CHAPTER 104 • Neck Exploration for Trauma 1163

Posterior belly of

digastric muscle

Acessory nerve (XI)

Internal jugular vein

Vagus nerve

Internal carotid artery

External carotid artery

Cut edge of

carotid sheath

Submandibular

gland

Hypoglossal nerve

Masseter muscle

Glossopharyngeal nerve

Parotid gland

Sternocleidomastoid

muscle

Styloid process

Lower Upper

Anterior lateral

movement

FIGURE 104 –4

1164 Section XVI • Operations—Elective and Trauma

3. CLOSING

◆ A closed-suction drain is placed in the deep space between the investing fascia

(Figure 104-5) and closed with absorbable suture (3-0 Vicryl), and the skin is closed with

subcuticular 4-0 Monocryl.

Recurrent

laryngeal

nerve

Inferior thyroid

artery

Ansa cervicalis

(sternohyoid branch)

FIGURE 104 –5

CHAPTER 104 • Neck Exploration for Trauma 1165

STEP 4: POSTOPERATIVE CARE

◆ Elevate head, and maintain close observation for hematoma formation.

STEP 5: PEARLS AND PITFALLS

◆ Selective use of closed suction drainage may be indicated in aerodigestive injuries.

SELECTED REFERENCE

1. Thal ER, Weigelt JA, Carrico CJ: Operative Trauma Management: An Atlas, 2nd ed. New York,

McGraw Hill, 2002, pp 75-90.

1166

STEP 1: SURGICAL ANATOMY

The following structures must be observed (Figure 105-1):

◆ Clavicle

◆ Sternum

◆ Sternoclavicular junction

◆ Deltopectoral groove

◆ Right subclavian artery

◆ Right subclavian vein

◆ Innominate artery

◆ Innominate vein

◆ Aorta

◆ Left subclavian artery

◆ Left subclavian vein

◆ Thoracic duct (left)

CHAPTER

105

Subclavian Artery Stab

William J. Mileski