Physiological principles of therapy in head and neck cutaneous wounds

It is essential that surgeons treating soft tissue wounds about the head and neck have a basic understanding of skin anatomy and physiology. The quality as well as the rate of healing is usually dependent on the type and extent of the original injury. Having a practical working knowledge of the pathophysiology of the various types of head and neck soft tissue injuries allows an intelligent choice of the most appropriate approach to a particular wound. The best functional and cosmetic results routinely are achieved by the wound's undergoing primary healing. Skin tapes and various sutures each exhibit certain benefits and disadvantages in primary closure of wounds. Skin tapes cause less inflammatory reaction but fail to close the subepithelial wound spaces. The inflammatory reaction and subsequent scarring caused by the various sutures depends upon the size of the suture needle, the diameter of the suture material and whether it is a monofilament or a woven suture. The essential nutrition of the wound must be maintained with the body providing adequate amounts of carbohydrates, proteins, trace elements and vitamins. The lack of adequate wound tissue perfusion by a normal or reversed oxygen gradient will lead to tissue necrosis and infection. The size of the inoculum of micro-organisms, the virulence of the organisms and host antimicrobial defense mechanisms determine if an infection will develop. The pharmacological action of each antibiotic must be understood in order to choose the proper antibiotic, its route of administration and to avoid unwanted side effects. Crushing tissue injuries, high velocity projectile tissue injuries and major burns of tissue may require several days to exhibit the true scope of the original injury. Most of these injuries must be treated by the open delayed method of wound treatment until the proper tissue conditions exist for healing. The proper timing and correct choice of autografts and tissue flaps from the surgeon's personal experience, study and conferring with other qualified surgeons. Upon gaining insight into the cellular and humoral antimicrobial defense system, the surgeon is able to provide the best conditions to allow these systems to function properly. Studies in the ultrastructures of skin along with the recently developed microbioassay techniques will allow a closer monitoring during the process of wound healing that will provide the basis for future techniques in the beneficial manipulation of wound healing.