[Facial trauma and multiple trauma]

The human face contains the sense organs and is responsible for essential functions: swallowing, chewing, speech, breathing and communication. It is also and most importantly the seat of a person's identity. Multiple trauma adds a life-threatening dimension to the physical and psychological impact of a facial trauma.

Characteristics of ballistic and blast injuries

Ballistic injury wounds are formed by variable interrelated factors, such as the nature of the tissue, the compositional makeup of the bullet, distance to the target, and the velocity, shape, and mass of the of the projectile. This complex arrangement, with the ultimate outcome dependent on each other, makes the prediction of wounding potential difficult to assess. As the facial features are the component of the body most involved in a patient's personality and interaction with society, preservation of form, cosmesis, and functional outcome should remain the primary goals in the management of ballistic injury. A logical, sequential analysis of the injury patterns to the facial complex is an absolutely necessary component for the treatment of craniomaxillofacial ballistic injuries. Fortunately, these skill sets should be well honed in all craniomaxillofacial surgeons through their exposure to generalized trauma, orthognathic, oncologic, and cosmetic surgery patients. Identification of injured tissues, understanding the functional limitations of these injuries, and preservation of both hard and soft tissues minimizing the need for tissue replacement are paramount.

Traumatic brain injury in intimate partner violence: a critical review of outcomes and mechanisms

The prevalence of intimate partner violence (IPV) is striking, as are its consequences to the lives of women. The IPV often includes physical assault, which can include injuries to the head and attempted strangulation injuries. Both types of injuries can result in traumatic brain injury (TBI). The TBI sustained during IPV often occurs over time, which can increase the risk for health declines and postconcussive syndrome (PCS). Current studies have identified sequelae of cognitive dysfunction, posttraumatic stress disorder, and depression in women experiencing IPV, yet, most fail to determine the role of TBI in the onset and propagation of these disorders. Although imaging studies indicate functional differences in neuronal activation in IPV, they also have not considered the possibility of TBI contributing to these outcomes. This review highlights the significant gaps in current findings related to neuropsychological complications and medical and psychosocial symptoms that likely result in greater morbidity, as well as the societal costs of failing to acknowledge the association of IPV and TBI in women.

A comparison of motorcycle and bicycle accidents in oral and maxillofacial trauma

PURPOSE

The aim of this study was to present a large series of motorcycle- and bicycle-related traumas to the face in an attempt to identify the injury pattern in motorcyclists and bicyclists.

PATIENTS AND METHODS

Data were collected from patients during a 10-year period (1999 through 2009), which included demographic data, diagnosis of facial fractures, use of protective devices, dentoalveolar trauma, and facial soft tissue injuries.

RESULTS

There were 556 patients with bicycle accidents and 367 with motorcycle accidents. Men were involved in 79% (436) of bicycles accidents and 82% (299) of motorcycle accidents. Young male patients were more frequent in bicycle and motorcycle accidents. Two hundred fifty bicyclists showed 311 maxillofacial fractures. Two hundred twenty-one motorcyclists showed 338 maxillofacial fractures. Motorcycle accidents caused multiple fractures in more patients. Seventy-six percent of motorcyclists were using helmets at the time of the accidents, whereas 6% of cyclists were using helmets. Motorcyclists showed a larger number of lacerations, whereas bicyclists showed a larger number of abrasions. Avulsion was the most common dentoalveolar injury for these accident types. Hospital stays were 3.8 days for motorcyclists and 1.3 days for bicyclists.

CONCLUSIONS

The high-impact collisions typically observed in motorcycle accidents is directly related to larger percentages of soft tissue lacerations and facial fractures. The low-impact trauma that is observed in bicycle accidents is more commonly associated with soft tissue abrasion, hematoma, and dentoalveolar fractures. This stresses the need for compulsory legislation for helmet use with face-guards for cyclists and motorcyclists. It is important to take measures to alert the public regarding the severity of injuries likely to occur in bicycle- and motorcycle-related accidents and ways to prevent them.

[Delayed pan-facial fractures-injury patterns associated with deficient treatment results and clinical classification]

OBJECTIVE

To analyze the injury patterns in pan-facial fractures (PFF) which potentially lead to deficient treatment outcomes and then to propose a clinical classification.

METHODS

Thirty-nine patients, 31 male and 8 female, with an average age of 33, treated from 1998 to 2007 in the Center of Maxillofacial Trauma, Peking University School and Hospital of Stomatology, were included. Zygomatic complex, maxilla and mandible were involved in the extensive fracture concomitant with nasal-orbital-ethmoid (NOE) fracture or not. All cases experienced a delay of over 4 weeks after injury. An analysis was made to display the relationship between facial architecture demolition and disfigurement and disability. Treatment results were assessed with facial appearance, opening range, occlusion and regional deformities. The associated injury patterns most frequently leading to deficient outcomes were summarized as references to scheme a clinical classification.

RESULTS

Facial deformities presented in 90% of the patients and mostly related to condylar fracture/dislocation and zygomatic complex fracture. Limited mouth opening occurred in 59% of patients and were caused most frequently by displacement of zygomatic complex and joint ankylosis. Malocclusion was found in 100% of cases and there were the associated optical signs in 46%. Thirty-nine cases were divided into two types. Zygomatic, maxillary and mandibular fractures all together constituted type I, which accounted for 46% of patients. Type I plus NOE fracture was type II, which accounted for 54% of patients. Furthermore, A, B and C sub-types were recognized in corresponding to involvement of condylar dislocation/fracture and zygomatic complex fracture. In treatment outcomes, a difference between type I and type II fractures remained with NOE fractures. The outcomes of term "moderate" and "worse" in subtype C group were attributed to severe soft tissue injuries and trauma-induced ankylosis.

CONCLUSIONS

NOE fracture, condylar fracture and dislocation, and zygomatic complex fracture were closely associated with deficient treatment outcomes. Correspondingly, an clinical classification was proposed for PFF.

Maxillofacial trauma with emphasis on soft-tissue injuries in Malaysia

Soft-tissue injuries with or without facial bone involvement are the most common presentation following maxillofacial trauma. The objective of this study was to look at the distribution, pattern and type of soft-tissue injury in relation to aetiology. Records of patients over a period of 5 years (1998-2002), who sustained maxillofacial injuries and were treated at Kajang Hospital, a secondary referral hospital, were reviewed. Out of 313 patients with maxillofacial injuries, 295 patients sustained soft-tissue injuries. Males (79%) between 21 and 30 years old (34%) were the majority of patients. Road-traffic accident was the main cause of soft-tissue injuries (75%) with motorcycle accident being the most frequent (40%). The upper lips (23%) and the lower lips (18%) were the most common extraoral site involved, while the labial mucosa and sulcular areas, both accounting for 21%, were the most common intraoral sites. Stringent road-traffic regulations should be practiced in developing countries, as morbidity arising from road-traffic accidents poses a national economic and social problem.

Acute injury patterns of intimate partner violence victims

Although millions of women receive injuries from intimate partner violence (IPV) each year in the United States alone, there has been only limited research of acute injury patterns and the types, locations, and mechanisms of IPV injuries. The mechanism of being punched to the face with a fist resulting in blunt trauma-related injuries is most commonly reported. Strangulation, especially manual strangulation, is a frequently cited mechanism of injury; however, less is known about the types of injuries that result from strangulation. In general, clinicians should assess all patients who present for treatment of head, neck, and face injuries for IPV. There is little consistency between and much inaccuracy with medical terms used to describe types of injuries. To increase the accuracy and generalizability of findings from studies of acute IPV injuries, researchers need to use more standardized medical forensic terminology.

Overlooked but critical: traumatic brain injury as a consequence of interpersonal violence

Despite evidence that more than 80% of female victims of intimate partner violence, seen for medical treatment of violence-related injuries, have sustained facial injuries, traumatic brain injury is often overlooked as a consequence of those injuries. This article reviews the scant literature available and examines research on equivalent injuries sustained by athletes. Practical domains of symptoms are described, as is a review of literature pertinent to culturally relevant rehabilitation for victims sustaining traumatic brain injuries.

[Permanent essential defacement--remarks on the possibilities of verification of the accepted criteria in medico-legal certification in criminal and civil law proceedings]

Despite the fact that some criteria of medico-legal certification in criminal and civil proceedings have been established, there are still some topics which are controversial and thus require modification. This is also true of the notion of "permanent essential defacement". In the opinion of the authors, changes in social conventions that are occurring nowadays, as well as a highly diversified, subjective perception of esthetic values indicate the need for discussing a possible modification of the presently obligatory criteria. Apart from the assessment of posttraumatic changes, an important problem is posed by defining the notion of "a part of the body customarily open to the view ". Additionally, the authors bring up for discussion the issue of experts taking into consideration the age and sex of the victims while assessing damages. A separate problem lies in difficulties in assessing the degree of detriment to health because of defacement due to the fact that official tables for evaluating permanent or long-term detriment to health do not include relevant information.

[Ocular injuries in mild facial trauma]

Ocular contusions are common and cause significant morbidity. The mechanism of ocular contusion is a decrease in the length of the anterioposterior axis whereas the transversal axis increases. Epidemiology data shows that young men are most injured in relation with sports, aggression, work, or car or work accidents. Injury to the ocular surface (conjunctiva and cornea) is minor. The iris is very frail, usually leading to hyphema which can progress to glaucoma. A cataract can appear after a contusion but usually years after the trauma. Final visual acuity can be compromised by retinal contusion or retinal detachment (due to a retinal dehiscence or post-traumatic dialysis). The worst outcome is optic neuropathy. The most difficult task is to predict visual acuity after the initial ocular lesion.

Nomenclature of Frontobasal Trauma: A New Clinicoradiographic Classification

BACKGROUND

High-velocity accidents cause significant injury to the cranial and facial skeleton. Frontobasal fractures include fractures of the upper third of the face and anterior skull base. The pattern and classifications of these fractures are poorly understood at present. The authors have attempted a new comprehensive classification based on detailed clinicoradiographic evaluation.

METHODS

A prospective study was undertaken in a tertiary care hospital in 1 calendar year (July of 2000 to June of 2001). All 63 patients with frontobasal fractures had detailed clinical and radiographic evaluation with plain radiographs and high-resolution computed tomographic scan. The fractures were classified as frontal, basal, and combined. Areas were separated as central (designated type 1) and lateral (designated type 2) to differentiate the pattern in the sagittal plane according to the site of impact. Combined fractures involving both central and lateral areas were designated type 3. These could be further classified into unilateral or bilateral or pure or impure, depending on the absence or presence of midfacial fractures.

RESULTS

The fractures were subdivided into nine types considering the whole lateral and anteroposterior extents of the frontobasal region. The most common was the combined frontobasal type (30.16 percent). We found the pure type in 38.1 percent (24 of 63) and the impure type in 61.9 percent (39 of 63) of patients. Cerebrospinal fluid leaks occurred more commonly in impure types of frontobasal fracture. Blunt trauma leading to closed frontobasal fracture was seen in 35 patients. Penetrating trauma with open fractures was found in 28 patients and cerebrospinal fluid leak through the wound was seen in six of them.

CONCLUSIONS

The new comprehensive classification clearly defines the anatomical areas within the frontobasal region, the nature of injury, and its association with midfacial injuries, and is helpful in planning the approach to their exposure in surgery.

Helmet use and bicycle-related trauma in patients presenting to an acute hospital in Singapore

INTRODUCTION

To describe the relationship between bicycle helmet use and injury pattern sustained by patients presenting to an emergency department (ED) in Singapore for bicycle-related trauma.

METHODS

Data was collected from all individuals treated for bicycle-related trauma between September 1, 2004 and May 31, 2005 using a closed-ended questionnaire.

RESULTS

160 bicyclists with mean age of 34.4 years (range 10 to 89 years) were surveyed. Among them, 80 percent were male and 30.6 percent were non-residents. Helmets were worn by 10.6 percent of the patients. Alcohol was clinically detected in 11.3 percent of bicyclists. There was no difference in bicycle helmet use between Singaporeans and non-residents (p-value is 0.275). However, compared to younger bicyclists, bicyclists aged 30 years or older (p-value is less than 0.05), and compared to recreational or sport bicyclists, those who commute by bicycle, tended not to wear helmets (p-value is less than 0.01). Compared to Singaporeans (p-value is less than 0.05), non-residents and bicyclists aged 30 years or older (p-value is 0.011) believed that helmets did not protect against head injury. Comparing the helmeted group with the non-helmeted group, injury patterns by body region were: head injury 5.9 percent versus 40.0 percent (p-value is less than 0.01); facial injury 5.9 percent versus 37.1 percent (p-value is less than 0.05). Not wearing a helmet, being hit by a motor vehicle and age were significantly associated with higher injury severity scores, after adjusting for several potential confounding factors.

CONCLUSION

Bicycle helmet use was low in our sample of injured patients. When worn, protection against injury was demonstrated. A campaign to promote use of bicycle helmets should be targeted at non-residents and older bicyclists. Authorities should consider compulsory helmet laws for bicyclists and expanding anti-drunk driving campaigns to target alcohol-intoxicated bicyclists.

[Epidemiology of facial trauma]

OBJECTIVES

This study aims to determine the incidence, etiology, severity of facial trauma and associated injuries enabling a greater understanding of its range and magnitude

METHODS

A hundred and sixty four patients were selected with some degree of facial trauma regardless of gender, age and skin color. Data were analyzed by the Pearson chi2 statistical method.

RESULTS

A male predominance was observed (78%) and its peak age was between 20 and 39 years. The major cause was interpersonal violence (48.1%), followed by fall (26.2%), run overs 6.4%), sports (5.4%), car accidents (4.2%), motorcycle accidents (3.1%), non-fall impacts (2.4%), occupational injuries (1.8%), gunshot wounds (1.2%), unspecific (1.2%). Contusion is the most common injury (23.8%), followed by fractures of the mandible (21.9%), Le Fort/pan facial/complex (17.8%), nasal bones (11.6%), zygoma (10.3%), tooth (9.1%), orbit (4.9%) and maxilla (0.6%). Associated injuries occurred mostly in run overs, but also because of car accident, fall and interpersonal violence.

CONCLUSIONS

The causes of facial trauma are directly related to the age and type of lesion. No evidence was found that the causes were related to gender or severity of the lesion.

Management of Close-Range, High-Energy Shotgun and Rifle Wounds to the Face

Close-range, high-energy shotgun wounds of the face are life-threatening and devastating traumas of the face. Suicidal attempts are the main reason in the great majority of the patients in civilian life. There is no consensus on the timing of reconstruction for bone and soft tissue defects resulting from high-energy shotgun wounds. The conventional method is primary repair as soon as possible and serial debridements and definitive reconstruction in the delayed stage. An alternative to this approach is the immediate definitive surgical reconstruction of the patient during the first operation for acute management of trauma. We had 15 patients with close-range, high-energy shotgun wounds in 10 years. Six of 15 patients referred to our center for definitive reconstruction after the acute management of the patients were performed in another center and the rest were all admitted in the acute period. Either conventional approach with delayed reconstruction for 10 patients or immediate definitive surgical reconstruction for 5 patients was used. Immediate reconstruction eliminated disadvantages of the conventional method such as high infection and scarring rate and deformities resulting from contraction of tissues. The emotional conditions of the patients were evaluated and major depression signs were determined. Functional evaluation showed that there was great correlation between facial appearance after reconstruction and social activity level.

The Effects of Depowered Airbags on Skin Injuries in Frontal Automobile Crashes

The purpose of this study was to determine the effects of depowered frontal airbags on the incidence of skin injuries. The National Automotive Sampling System database files from 1993 to 2000 were examined in a study including 2,246,524 occupants exposed to airbag deployment in the United States. There was no significant difference between full-powered and depowered airbags, with 60.2 percent of those exposed to a full-powered deployment sustaining a skin injury versus 59.5 percent of occupants exposed to a depowered airbag (p = 0.19). Whether occupants were exposed to a full-powered airbag (1,936,485 occupants) or a depowered airbay (310,039 occupants), the majority of skin injuries were to the upper extremity and the face. Regardless of airbag power, the overwhelming majority of the skin injuries were minor (99.8 percent). There was not a significantly greater risk of injury from any source for occupants exposed to a depowered airbag or a full-powered airbag (p = 0.87). The data suggest that the implementation of depowered airbags did not affect the number, seriousness, location, or source of skin injuries.

[The forensic-medical expertise in craniofacial trauma]

Archive materials of the recent 6 years, including 14720 death cases of victims, were analyzed for the purpose of detecting the general regularities of injuries within the craniofacial trauma (CFT). The diversity of CFT with injuries to skull bones and medullary substance was found not to interfere with establishing an actual type and mechanism of trauma provided all injuries are thoroughly and comprehensively examined. The trauma specificity must be evaluated with respect to a location and direction of traumatic force in order to define an actual impact that caused death. CFT is special variation of craniocerebral trauma, whose onset mechanism needs more research. The efficiency of forensic-medical examination of CFT cadavers directly depends on the coordination and logic of measure undertaken by expert as well as on his technical outfit and knowledge of such trauma. The diversity of variations of damage to anatomic head structures requires an interdisciplinary approach with the need to isolate a predominant chain that affects the course and outcome of trauma.

[Eyebrow injuries. Classification and therapy concept]

The aim of primary treatment for eyebrow injuries should be preservation of the original eyebrow under any circumstances. Debridement should be kept to a minimum even when the wound is severe. The treatment of total or partial loss of an eyebrow concerning the exact reconstruction of details and aesthetic aspects is a challenge for the surgeon. The therapy option depends on the type of eyebrow selected for reconstruction. We present a classification for eyebrow injuries, which considers type and size of defects. Based on this, different techniques and methods of reconstruction are recommended. Advantages and disadvantages are discussed and illustrated by several examples.

Effect of restraint systems on maxillofacial injury in frontal motor vehicle collisions

PURPOSE

Motor vehicle collisions (MVCs) are the leading cause of maxillofacial fractures. Additionally, maxillofacial injuries are the most common injury related to air bag deployment. We sought to characterize the occupant restraint system (seat belt and air bag) and collision characteristics associated with MVC-related maxillofacial injuries.

MATERIALS AND METHODS

The 1991-2000 National (United States) Automotive Sampling System Crashworthiness Data System (CDS) data files were used. The CDS is a national probability sample of passenger vehicles involved in police-reported tow-away MVCs. Analysis was limited to front seat occupants involved in frontal collisions of delta-V (estimated change in velocity) of greater than 15 km/hr. The risk of facial injury was calculated according to occupants' restraint use (unrestrained, seat belt only, air bag only, and seat belt and air bag combined) and compared using risk ratios (RRs) and associated 95% confidence intervals (CIs).

RESULTS

Occupants restrained with a seat belt only (RR, 0.48; 95% CI, 0.40 to 0.57) or a seat belt and an air bag (RR, 0.83; 95% CI, 0.73 to 0.94) had a significantly reduced risk of any facial injury compared with completely unrestrained occupants. There was no association for those restrained with an air bag only (RR, 1.19; 95% CI, 0.82 to 1.73). A similar pattern of results was observed for moderate to severe facial injuries and for facial fractures.

CONCLUSION

Seat belt use significantly reduces the risk of facial injury in frontal MVCs. Air bag use was not associated with the risk of facial injury.

Determinants of surgical decisions about mandible fractures

PURPOSE

The study goal was to explore contextual patient- and surgeon-related characteristics that influence the perception of injury severity and treatment strategy for mandible fractures.

METHODS

After reviewing plain radiographs of 22 patients with mandible fractures, 18 oral and maxillofacial surgeons were queried on summary severity ratings and treatment decisions for each injury. Subsequently, they were asked to indicate how various hypothetical fracture and patient-specific factors would alter their perception of injury severity and original treatment recommendations. The effect of the level of clinician trauma expertise on perception of injury severity and treatment choice was also assessed.

RESULTS

Each of the fracture-specific characteristics-number of constituent fractures, fracture complexity, degree of displacement, and summary injury severity-influenced the choice of treatment modality. Surgeon-specific characteristics were related to both perception of injury severity and treatment choice. Although clinicians with greater trauma loads tended to provide higher summary severity ratings for the same range of injuries (P <.001), they appeared to recommend maxillomandibular fixation for a much broader spectrum of injury severity (R = -0.42). Surgeons' perception of injury severity appeared to escalate with increasing damage to the soft tissue envelope; the influence of patient-related risk factors was less distinct. More than half of the surgeons suggesting maxillomandibular fixation for a particular case changed their treatment recommendation to rigid internal fixation on learning that the patient was noncompliant.

CONCLUSIONS

Clinical decision making for mandible fractures is not a precise and fully reliable activity. Contextual factors (fracture, patient, and surgeon related) appear to influence the clinical decision and may be responsible for the existing variations in practice patterns.

[Options of plastic surgery in burns. How the burn victim gets a "new skin"]

Plastic surgery following burns may be divided into primary and secondary reconstructive measures. Primary reconstruction covers all steps leading to the healing of the patient's wounds. Secondary reconstruction comprises all subsequent interventions required to improve the results of primary surgery. The treatment of burn victims is always a team effort. Reconstructive measures aim to achieve, as early as possible, anatomical primary reconstruction that takes account of the aspects of function and cosmesis. The primary surgical operation is all important--if successful, only few subsequent corrective interventions will be needed.

Soft tissue deformity after craniofacial fracture repair: analysis and treatment

BACKGROUND AND OBJECTIVES

The primary repair of facial fractures requires sufficient subperiosteal dissection and mobilization of soft tissues to permit accurate fracture reduction. Improper repositioning of soft tissues predisposes the site to deformities with subsequent adverse effects on the aesthetics of the final result. The purpose of this paper is to describe these deformities, the modification of surgical approaches to avoid them, and the various techniques for secondary soft tissue reconstruction.

METHODS AND MATERIALS

The paper reviews the assessment of soft tissue deformity and the principles of soft tissue reconstruction in addressing temporal contour deformity, cheek ptosis, eyelid deformities, and medial and lateral canthal dystopia.

RESULTS AND/OR CONCLUSIONS

The morbidity of remote incisions and soft tissue degloving used in primary facial fracture repair can be minimized by using a meticulous technique and precise soft tissue repositioning at closing.

Facial gunshot wounds: a 4-year experience

PURPOSE

Facial gunshot wounds can result in devastating functional and aesthetic consequences for patients. In an attempt to evaluate the management and outcome in these patients, a 4-year retrospective review was undertaken of all patients presenting with facial gunshot wounds at a level I trauma center.

PATIENTS AND METHODS

A total of 121 patients were identified. Medical documentation could be obtained on 84 of those patients. The patients' maxillofacial injuries were treated by the 3 participating services: plastic surgery, oral and maxillofacial surgery, and otorhinolaryngology. The patients ranged in age from 6 to 64 years, with a mean age of 27 years.

RESULTS

The gunshot wounds were single in 64% of the cases and multiple in 36% of the cases. Overall mortality in the series was 11%. Sixty-seven percent (56/84) of the patients suffered an injury to the underlying craniofacial skeleton. Seventy-five percent of these patients required surgical intervention. Twenty-one percent of the patients (16/75) required tracheostomy emergently for management of the airway. Eighteen percent (15/84) of these patients had an intracranial injury, with 50% of these patients requiring surgery. Fourteen percent of the patients in the series (12/84) had great vessel injuries diagnosed at the time of angiography, with 50% of these patients requiring surgery for treatment.

CONCLUSION

Contrary to much of the published literature, most patients in this series required surgical intervention for treatment of their facial gunshot wounds. Reconstructive procedures were performed early in the patient's course and, when possible, addressed both the soft tissue and underlying bony injury in a minimum number of stages.

Soft tissue injuries of the face: a 10 year review

A review of 1,173 soft tissue injuries seen and managed at the University College Hospital, Ibadan over a 10 year period was made. The age range was from 4 months to 85 years with a dominant age group range of 21-30 years. The commonest type of soft tissue injury was laceration while the commonest aetiology was road traffic accidents followed by falls. Males were generally more involved than females and the commonest complication was wound dehiscence.

Surgical management of sports-related traumatic injuries

The increasing popularity of all sporting events results in increased potential for injury. Despite helmet, facemask, and mouthguard use, the face often remains an exposed area at risk in many sports. Dentists rehabilitating patients after facial injuries should understand their patients' previous injuries and treatment.

Self-inflicted shotgun injuries to the face: a case report

Shotgun injuries to the face are difficult to care for due to the often massive tissue and bone destruction and the complications that can accompany these injuries. Psychological responses from the family, significant other, and nursing staff in dealing with disfiguring and sometimes fatal injuries are additional challenges that nurses will face.

The MCFONTZL classification system for soft-tissue injuries to the face

A review of the literature and case records reflected a need for the development of a clinically applicable assessment scheme and classification system for soft-tissue laceration injuries to the face. Herein, a systematic approach for assessing facial lacerations is proposed based on location, depth of penetration, branching, directionality, size, presence of soft-tissue defect, and translation of such injuries into the current procedural terminology (CPT) code. Moreover, a new classification system for facial laceration injuries is presented that may serve as the basis for simplification of current billing codes. Prospective clinical application of this classification system may lead to standardization of facial injury assessment and improvement in the incomplete and inconsistent patient record. This system will establish a reliable database that may identify factors in soft-tissue injuries that contribute to poor aesthetic results or secondary functional deformities. These data will lead to the modification of established treatment plans.

Plastic bullet injuries in Northern Ireland: experiences during a week of civil disturbance

BACKGROUND

Plastic bullets were introduced to Northern Ireland for riot-control purposes in 1973. Their use has been controversial, with a number of fatalities. In the week beginning July 7, 1996, some 8,000 plastic bullets were fired during widespread rioting.

METHODS

Details of injuries attributed to plastic bullets were obtained retrospectively from patient notes for the period July 8 to 14, 1996, in six hospitals. A total of 172 injuries in 155 patients were recorded.

RESULTS

Nineteen percent of injuries were to the face/head/neck, 20% were to the chest or abdomen, and 61% were to the limbs. Abbreviated Injury Scale scores ranged from I to 3. Forty-two patients were admitted for hospitalization, three to intensive care units. No fatalities occurred.

CONCLUSION

Plastic bullet impact to the abdomen or above may cause life-threatening injuries. Below this site, major trauma is unlikely.

Management of weapon injuries to the craniofacial skeleton

One thousand one hundred thirty-five patients suffering from different types of facial injuries caused by various weapons were treated in two university hospitals in Tehran, Iran from 1984 to 1990. The referred patients suffered from one of three types of facial injuries: soft-tissues injuries, 9.16% (N = 104); bone fractures, 18.15% (N = 206); and soft-tissue injuries and bone fractures (mixed injuries), 72.69% (N = 825). The number of male patients was greater than females (1,123 males and 12 females). Anatomically the facial injuries were classified into seven groups (lower third; middle third; upper third; lower and middle third; lower and upper third; middle and upper third; and lower, middle, and upper third). Lower-third facial injuries were the most common injuries, 72.60% (N = 824); followed by the middle-third injuries, 36.30% (N = 412); and the upper-third injuries, 20% (N = 227). The mandible was the most common site of injury in the lower-third injuries, zygomatico-orbital fractures were the most common site in the middle-third injuries, and the frontal bone was the most common site in the upper-third injuries. Of the total number of patients, 3.17% were children (N = 36) with different types of maxillofacial injuries. The majority of the injuries (52.42%; N = 595) were from bullets. The most common injuries not associated with maxillofacial injuries were head and ocular injuries. The least common were abdominal injuries. The head injuries were classified into five grades according to clinical and computed tomographic findings. Treatment of facial injuries ranged from minor repair and/or closed reduction to major soft-tissue and/or bone reconstruction. Postinjury complications were very high. The follow-up period ranged from 3 months to 3 years. The aim of this study is to add our experience in the management of facial injuries to the literature.

[Gunshot injuries of the face. Analysis of 165 cases and reevaluation of the primary treatment]

Our large experience of shotgun injuries to the face emphasizes the need for a reappraisal of primary treatment for this poorly documented topic. The medical records of 165 patients, treated at our institution between january 1st, 1982 and december, 31st 1996 for such an injury, were reviewed. Almost all cases were exclusively self-inflicted lesions. The guns were mainly twelve-gauge and occasionally 16 or 20-gauge. Close range wounds in an heterogeneous area--soft-tissue, mandible, muscles of the tongue and floor of the mouth, oral and nasal cavities, maxilla and paranasal sinuses--caused massive damage. A topographic classification based on the soft-tissue and bone loss is reported. After initial management (including securing the airway and control of bleeding), conservative debridement of all devitalized tissues and stabilization of the fractures were performed. As soon as possible, bone and soft tissue reconstruction was undertaken using local or distant flaps. However, immediate definitive reconstructive procedures were scarcely [corrected] used and only in particular cases. We believe that a carefully planned reconstruction schedule is required to achieve satisfactory appearance and function.

Irrigation in facial and scalp lacerations: does it alter outcome?

STUDY OBJECTIVE

Animal and human studies suggest that irrigation lowers the infection rate in contaminated wounds, but there is no evidence that this common practice is beneficial for "clean" lacerations. We tested the null hypothesis that there is no difference in the infection rate for noncontaminated lacerations to the face and scalp that are irrigated before primary closure compared with similar wounds that are closed primarily without irrigation.

METHODS

We performed a cross-sectional study of consecutive patients presenting to a suburban, academic emergency department between October 1992 and August 1996. Patients with nonbite, noncontaminated facial skin or scalp lacerations who presented less than 6 hours after injury were included. Structured, closed-question data collection instruments were completed at the time of laceration repair and at suture removal. The primary outcome parameters were the incidence of wound infection and the short-term cosmetic appearance of lacerations in patients who did or did not receive irrigation.

RESULTS

A total of 1,923 patients were included in the study group; 1,090 patients received saline irrigation, and 833 patients did not. The irrigation and nonirrigation groups were similar with regard to time from injury to presentation (1.56 versus 1.42 hours, respectively), frequency of linear wound morphology (82% versus 88%), frequency of smooth wound margins (72% versus 82%), number of layers of closure (1.14 versus 1.26), number of skin sutures applied (4.98 versus 4.65), number of deep sutures applied (.70 versus 1.05), and use of oral antibiotic prophylaxis (2.8% versus 4.0%). With respect to outcomes, the incidence of wound infection was not significantly different between the two treatment groups (.9% versus 1.4%, respectively; P = .28). Likewise, the percentage of patients who had an "optimal" cosmetic appearance was similar in the two groups (75.9% versus 81.7%, respectively; P = .07).

CONCLUSION

Irrigation before primary closure did not significantly alter the rate of infection or the cosmetic appearance in our study population with clean, noncontaminated facial and scalp lacerations.

Imaging of facial trauma

Severe facial fractures produce a variety of radiographic and CT abnormalities. Careful evaluation of plain films and any CT images should allow rapid and accurate diagnosis of the extent of injury. Table 3 summarizes the radiographic findings seen in the severe mid facial fractures.

Maxillofacial injuries in a group of South Africans under 18 years of age

OBJECTIVE

To find out the incidence of maxillofacial injuries in South African children aged 18 years or less.

DESIGN

Retrospective study of casenotes.

SETTING

Six teaching hospitals affiliated to the University of Witwatersrand, Johannesburg, serving a population of about 5 million people.

SUBJECTS

All 326 children treated for facial injuries in the maxillofacial and oral departments of the six hospitals between 1 January 1989 and 30 June 1992.

MAIN OUTCOME MEASURES

Classification of the types of injury, associated injuries, cause of the injury, and methods of diagnosis.

RESULTS

Of the total of 4192 patients of all ages treated for facial injuries, 326 (8%) were within the age range of the study. The female:male ratio was 1:2.3. Most of the injuries (227, 70%) occurred in the 13-18 age group, and assaults, fights and gunshot wounds accounted for 155 injuries (48%). Of the 326 children, 173 (53%) had single injuries and 153 (47%) had multiple injuries. Mandibular fractures were the most common (64%) followed by maxillomandibular fractures (25%). Violence was the most common cause of injury, as in the USA and Zimbabwe, but unlike the rest of the world in which it is motor vehicle accidents. Soft tissue injuries were the most common associated injuries, and conventional plain radiography was the usual investigation.

CONCLUSION

The incidence of 8% compares favourably with those in other countries, but far too many injuries are the result of violence.

Maxillofacial injuries in multiply injured patients

Experience in team management of multiply injured patients with maxillofacial injuries is reported. During 1992, out of 169 patients transferred to the Royal London Hospital, UK by the Helicopter Emergency medical Service 38 (22.4%) had injuries to the maxillofacial region, 17 of whom were scored on the Abbreviated Injury Scale (AIS) as having sustained facial AIS > 2. The median Injury Severity Score (ISS) was 22, while the ISS was 17.7 for survivors and 34.5 for those who died (chi 2 = 7.3, 0.05 < P > 0.02). Facial AIS (median 4) and facial AIS contribution to ISS were found to be poor indicators of severity of injury. Revised Trauma Score (RTS) and percentage probability of survival (Ps%) were found to be useful discriminators of severity of overall injuries. RTS compared between survivors and those who died was 0.05 < P > 0.02 (chi 2), while Ps% was 0.01 < P > 0.001 (chi 2). It was concluded that the severity of maxillofacial injuries, and hence their contribution to total injury assessments, tended to be underscored. We propose that refined facial injury assessment methods be tested.

Dog bites of the face with tissue loss

Children are most frequently the victims of dog bites; the face is often the favored target. Even in apparently extensive injuries, enough skin generally remains to allow a reasonably direct closure, which is the preferred treatment. Infrequently, when significant soft tissue loss occurs, more complex methods require the surgeon's ingenuity in order to restore function and cosmesis without risking widespread infection or disfigurement. This article discusses the use of local flaps, skin grafts, or regional flaps in the proper circumstances. These options must be chosen carefully following an appropriate hierarchy of priorities, in order to achieve wound closure, to simultaneously restore anatomic landmarks, and to lessen the need for subsequent surgical revisions and psychological trauma.

The management and repair of wounds of the face

A practical guide to the causes, types, and repair of injuries of the face

[Use of keratinocyte cultures in treatment of severe burns--experiences up to now, outlook for further subsequent developments]

There is a world-wide growing interest in cultured epithelium. It is commonly accepted that cultured epithelial auto- or allografts can stimulate wound healing and shorten re-epithelialization time. Sheets of cultured autologous epidermal cells have been used for more than 15 years as grafts to achieve permanent coverage of full-thickness burn wounds. Yet many surgeons who have used cultured epidermal grafts have reported a substantial variability in their outcome. The best results have been obtained by performing early excision, followed by temporary coverage with a cadaver homograft. Within 3 weeks the donor allodermis is incorporated and forms a neodermis. The epidermal parts of the donor skin are removed after about 3 weeks and cultured epidermal autografts are transplanted (composite graft technique). There is some hope that progress in the cultivation procedure and a modified transplantation technique will shorten the healing time. In our opinion, great progress was made when cryopreserved allogeneic epithelial grafts became available for the treatment of deep dermal burn wounds. We obtained a good re-epithelialization rate (56%) after 9.5 days in 56 cases. In the last 25 cases, the re-epithelialization time was 72% after 11.5 days. Especially burn wounds of the face have been treated successfully, avoiding over-grafting and achieving highly acceptable, aesthetic and functional results. Many laboratories are developing dermal equivalents, combining synthetic and biological materials in order to form a multilayer neodermis. Although it seems possible to cultivate adnexae of the skin, a neodermis with cultivated adnexae is not yet in sight.

[Surgical approaches in the treatment of burns]

The indication for operative treatment of third-degree burns, necrectomy and the possibilities for closing the defects are discussed. Special problems have to be considered in the operative therapy of third-degree hand injuries. In cases of extensive burns the donor areas are mostly limited and a biological dressing must be used. Different kinds of wound coverage are available for the final autologous skin reconstruction in these patients. Last but not least, the right postoperative immobilisation of both the patient and the transplanted areas is very important for successful skin grafting.

[Facial injuries caused by dog bite]

Dog bite injuries occur statistically in urban areas every three days. Thirty such injuries to the face were treated at the Ear-Nose-Throat University Hospital, Erlangen-Nuremberg, between 1973 and 1990. The average age of the patients was 15 years. The dogs most frequently involved were the Alsatian wolfhound (43%) and the badger dog (21%). The majority of the victims were family members (59%) or at least known to the owner of the dog (28%). Only in 14% of the cases was no correlation found. Dog bite injuries most frequently happened during playing with the dog (53%) or when the victim bowed to the dog (33%). Dog bites without cause were uncommonly found (7%). Of all facial injuries the nose was most frequently involved (50%) and severely afflicted. In our experience, replantation of the avulsed part always resulted in necrosis. In contrast, the most favorable results were achieved when defects were reconstructed immediately.

A comprehensive analysis of craniofacial trauma

A review of the literature identified a need for a prospective study of the complete range of craniofacial trauma. The aims of this study were to determine the incidence, etiology, and mechanisms of craniofacial and associated injuries, enabling a greater understanding of their range and magnitude. Nine hundred fifty consecutive patients seen at an urban university hospital with any degree of craniofacial trauma were prospectively investigated. Craniofacial trauma was found to be very common at all ages. The causes were directly related to age, sex, and alcohol consumption, and determine the type and severity of injury. The commonest cause of soft-tissue injury was falls, whereas that of fractures was interpersonal violence. Falls accounted for most of the injuries in children and the elderly, whereas interpersonal violence was mainly responsible for those occurring in patients aged 15 to 50 years. Interpersonal violence mostly involved young male adults: fights occurring mainly between strangers who had consumed excessive amounts of alcohol. Women were usually assaulted by assailants known to them, their partners. Pedestrians showed a propensity to sustain cranial fractures, whereas motor vehicle occupants tended to sustain midfacial fractures and bicyclists mandibular fractures. Pedestrians incurred the severest injuries of all road users, and a significant proportion of road user collisions involved bicyclists. Sports were responsible for a significant proportion of craniofacial injuries in youths and young adults. Craniofacial soft-tissue injuries overall occurred most frequently on the forehead, nose, lips, and chin, and a method for their classification is proposed. The commonest craniofacial fracture was that of the nasal bones (45%), followed by cranial bones (24%), mandible (13%), zygoma (13%), orbital blow-out (3%), and maxilla (2%). The incidence of craniofacial trauma can be greatly reduced by improvements in interior home design, school education in alcohol abuse and handling potentially hostile situations (especially for men), improvement in automotive safety devices and compliance by motor vehicle occupants, and utilization of full-face helmets by bicyclists and motorcyclists.

[Facial injuries. Classification]

The present paper was intended as an introduction to the symposium organized in Paris on 4 October 1990 by the Royal Belgian Society for Surgery under the heading "Eurosurgery 90". The anatomical and functional properties of the facial bones and soft tissues were recalled. The face is the support of the main social functions of Man. The classification makes a distinction between fractures of the middle third and of the mandible. Among the formers, classical fractures of Le Fort I, II and III, are now less frequent than asymmetrical or complex fractures with multiple soft tissue lacerations. The main types of mandibular fractures are described. Part of these may show important displacements, due to the insertion of strong muscles. The aims of treatment are defined and to-day technology briefly described. Tendency is to shorten the duration of intermaxillary fixation thanks to the more recent procedures of internal fixation.

[Facial injuries caused by dog bites in childhood. Clinical staging, therapy and prevention]

Dog bite injuries are a frequent cause of facial injuries in childhood. Between 1986 and 1990 we treated 16 children with facial dog bite injuries. Based on these experiences we suggest a clinical classification, corresponding therapeutic rules and prophylactic possibilities, summarized according to the literature. It is our aim to establish guidelines for the physician concerned with the therapy of these injuries, and advice to involved families.

Gunshot injuries of the soft and bony tissues of the face

A classification of wounds into penetrating, avulsive and perforating, applied to the face and neck region is given. The results of the management of 60 patients with gunshot injuries treated in Gondar College of Medical Sciences Hospital in 1987-1988 are evaluated. In all cases there was soft tissue damage associated with comminuted fractures of the facial bones. Primary wound healing was possible in 31 patients. Complicated wound repair was needed in 22 cases. Open wound management with secondary suturing was performed in 4; the other 3 casualties died of brain damage. Differences from the treatment of combat wounds in the extremities are pointed out. All salvageable soft tissue of the face and neck region should be preserved, and methods of intraosseous suturing of fractured facial bones, craniofacial suspension, and compression osteosynthesis can be applied.

Facial trauma and associated brain damage

CT continues to be the most important diagnostic study for detection and classification of maxillofacial injury. MR has a complementary role in specific situations because of its multiplanar imaging capabilities and exquisite soft tissue contrast resolution. MR is particularly useful for evaluation of orbital "blow-out" fractures, intraorbital and intraocular hemorrhage, traumatic vascular injuries, and associated intracranial damage.

Penetrating facial trauma: a management plan

Penetrating wounds of the face present a spectrum of injuries and multiple management dilemmas. The surgeon's first concern remains the establishment of a proper airway and control of life-threatening injuries. Selected ancillary diagnostic procedures should be used to confirm vascular, aerodigestive, or central nervous system injuries. Diagnosis of injuries may require arteriography, endoscopic examination, barium studies, computerized tomography, and detailed ophthalmologic examination. We review 16 cases of penetrating facial trauma treated at the University of South Alabama Trauma Center over a one-year period. The injuries resulted from 13 gunshot wounds and three stab wounds. Injuries of the central nervous system occurred in three patients, mandibular fractures in four, optic nerve or globe injury in three, and maxillary sinus fracture in seven. Our experience with these patients demonstrates the spectrum of injuries and serves as a basis for a management algorithm.