Abstract
Facial traumatic events are commonly encountered in plastic and reconstructive surgery. Primary reconstruction is a reliable procedure with function and aesthetic considerations. We conduct a retrospective study of the experience of reconstructing facial traumatic defects in the first stage. One hundred and thirty‐two cases (aged 18–65) with facial traumatic events were recruited in the study from 2008 to 2014. Facial traumatic events included injured soft tissue, maxillofacial fractures and facial nerve rupture, which were repaired primarily. After primary reconstruction, encouraging functional and aesthetic outcomes were attained. Ten cases were re‐operated to reconstruct partial nasal defect. Four patients who had trouble with disabled occluding relations sought help from dentists. Inconspicuous scar and function restoration were presented. Facial wounds should be reconstructed in the first stage as far as possible. Then, satisfactory functional and aesthetic results can be achieved. However, combined injury should be carefully considered in those traumatic cases before we carry out the reconstructive surgery on the face.
Keywords: Facial traumatic events, Primary reconstruction
Level of evidence: VI
Facial trauma is a common injury, especially in urban centres 1, 2. As a centre for traumatic events, many acute cases were admitted to our hospital. Facial injury, including soft tissue defect, maxillofacial fractures and nerve rupture, which requires a high demand for reconstruction, accounts for a large part of the accidental events. Those traumatic sites involve comprehensive multi‐disciplinary treatment. Plastic and reconstructive surgery is usually consulted to further treat those patients who have facial injuries. Primary intervention in facial injury is essential to guarantee encouraging results, including functional and aesthetic restoration. In this study, we want to share our experience in reconstructing facial traumatic deformity in the Department of Plastic and Reconstructive Surgery.
Patients and methods
One hundred and thirty‐two cases (aged 18–65) were classified into the following types from 2008 to 2014: single injured soft tissue (n = 78), single maxillofacial fractures(n = 15), composite injured soft tissue and maxillofacial fractures(n = 30), composite facial nerve rupture and injured soft tissue(n = 9). Causes were car accident, burns, sharp instrument injury and so on. Soft tissue was directly closed and repaired by skin grafts or regional flaps; maxillofacial fractures were immobilised by titanium plates. Facial nerve rupture was sutured using thee end‐to‐end style. Patients' data is summarised in Table 1. Combined injury occurred in 48 cases, including bone fractures, cerebral contusion and laceration, chest and abdomen injury and so on. Related departments completed the surgery respectively. The other 84 cases were transferred to our department after consultation with our plastic surgeons in emergency department.
Table 1.
Patients data
| Type | Causes | Reconstruction | Reoperation |
|---|---|---|---|
| Injured Soft tissue | Car accident | Regional flaps | Partial Nasal repair |
| Fight | Closing the wound directly | Upper lid repair | |
| Burns | Skin graft | ||
| Others | |||
| Maxillofacial Fracture | Car accident | Template transplantation | None |
| Nerve rupture | Car accident | End‐to‐end suturing | None |
| Knife cut |
Results
All patients were reconstructed in the first stage. No infection and death were encountered. According to the severity of injured regions, those acute cases were transferred to different departments after the operation. Fifteen severe cases (ten cases with combined injury and five cases with single maxillofacial trauma) were transferred to the intensive care unit to monitor vital signs after the operation. After a mean of 13 months' follow‐up, ten cases were re‐operated to reconstruct partial nasal defects; four patients who had trouble with disabled occluding relations sought help from dentists (Figures 1, 2, 3, 4, 5, 6).
Figure 1.
A 32‐year‐old woman suffered from a contusion on the forehead and bilateral upper eyelids. After debridement and direct closure, an inconspicuous scar can be seen, and function was not affected when opening and closing eyes nearly 8 months postoperatively.
Figure 2.
An 18‐year‐old woman was hurt on the upper lip by accidentally falling down to the ground when she rode a horse. After debridement and closing the wound primarily, aesthetic results were achieved 6 years post‐surgery.
Figure 3.
A 21‐year‐old soldier was ordered to extinguish the forest fire. His face was burned unfortunately. After thorough debridement, a skin graft was harvested to repair the wound. Functional and aesthetic results were attained 9 years after the operation. He is now our People's Literative Army commander and on military commission.
Figure 4.
A 61‐year‐old peasant suffered from a maxillofacial fracture by a tractor turnover. Fractures of many sites can be observed by a three‐dimensional CT scan. After debridement, application of titanium and titanium screw to the fractures and soft tissue returned to its original site, inconspicuous scar and satisfactory facial appearance can be found 1 year after the operation. Function of the facial nerve was generally normal.
Figure 5.
A 33‐year‐old woman suffered from a cut on the right side of her face. She was admitted to our hospital 6 hours after the injury. After end‐to‐end suturing, function of facial nerve was restored to its original state. Static and dynamic sates were generally normal 8 months post‐surgery.
Figure 6.
A 23‐year‐old worker was hurt by a machine while he was working. Defects of right partial nasal and upper lip were cut off. After debridement and utility of a regional flap to cover the wound, tight nose‐wing was deficient, and an asymmetrical upper lip was presented 4 months after the operation (the first row). Then, the forehead flap was designed to repair the right nose‐wing defect, and Abbe's flap was transferred to correct the deformity of upper lip. Appearance was improved on the nose and upper lip 1 year after the operation (the second row).
Case series
Case 1: Soft tissue defect on the bilateral upper eyelids
Case 2: Soft tissue defect on the upper lip
Case 3: Facial burns
Case 4: Maxillofacial fracture and soft tissue defect
Case 5: Soft tissue defect and facial nerve rupture
Case 6: Critical tissue defect
Discussion
Facial traumatic events are common in the Department of Plastic and Reconstructive Surgery, which undertakes function and aesthetic restoration. However, it is noticeable that facial injuries predominantly affect young, economically active adults, mainly caused by interpersonal violence and traffic accidents 3. Several studies have been published regarding the epidemiology of facial trauma in all continents 4, 5, 6.A high demand for reconstructing facial deformity is proposed, especially in young patients.
As traffic accidents occur regularly because of more and more cars in China, an increasing number of acute cases are admitted to the emergency department. Aesthetic demand is another factor because patients want to restore their original appearance. Moreover, China is becoming richer, and people have money to consider their spiritual needs besides their material needs. Plastic surgery is also developing at a high speed in China. More and more people believe that plastic surgery can make their wounds heal better and result in an inconspicuous scar. Hence, plastic surgeons are required to complete the surgery that is assigned to other surgeons originally. However, these cases must pay a high fee of the surgery, and the majority of them can afford it. In our hospital, we set up an independent Emergency Plastic Surgery unit to treat these patients. Local anaesthesia surgery can be accomplished in the outpatient department for minor wound defects, while general anaesthesia surgery is performed for severe trauma in a regular operating room. However, plastic surgery cannot be popularised in remote areas. These acute cases cannot receive plastic surgery for their facial trauma because of a variety of reasons, allowing for unsatisfactory results and malformation at worst. Every week, some patients from remote areas are transferred to our hospital to request plastic surgery for facial traumatic events.
From the perspective of a plastic surgeon, when we treat an acute case, more consideration must be borne in mind. Functional and aesthetic problems are equally important. The primary goal in the management of traumatic events is to achieve rapid healing with optimal functional and aesthetic results, especially when a facial injury is encountered. Hence, primary reconstruction or repair must be completed as far as possible. Another important principle is restoring the injured tissue to its original region and allowing for anatomic recovery. Suturing must also performed without tension to reduce scars. If the wound cannot be sutured directly, we should use tissue transfer to cover the wound, such as local flaps. However, secondary deformity in the donor site must be avoided, and scar in the donor site should, at best, be hidden from view. As the face has been divided into different regions, we must adhere to regional reconstruction, especially in the skin graft technique. Facial nerves are a critical portion that can dominate the function of expressional muscle. While facial nerve injury is definite, it is indispensable that nerve anastomosis must be executed as far as possible. Neurotrophic drugs can be also an assistant treatment to facilitate nerve recovery. Then, the mandibular fracture is stiffly restored to its original site; the lower mandible fracture must be especially carefully fixed internally as it is responsible for the chewing motion. Patients must also perform chew motion exercises after recovery from the mandibular fracture. Problems with teeth may be solved by dentists.
Experience can be concluded as follows: combined injury, such as brain, chest, abdomen or other fatal injuries, is regularly encountered in those acute cases with instable vital signs, which cannot be admitted to plastic surgery immediately. Traumatic events involving facial sites are often non‐fatal. So, consults from a multi‐disciplinary team should be prepared. System appraisal of the acute case must be implemented. Surgery of many sites can be executed simultaneously to guarantee not only the survival of the acute cases but also function and aesthetic results. Critical complex structures on the face are usually challenges for plastic surgeons to reconstruct in the first stage, for instance, the nose and ear. It is advised that soft tissue defects must be covered by direct suturing or tissue transfer in the first stage. Cartilage can be carved to form three‐dimensional structures to be placed in the critical sites in the second stage. Hence, not all aesthetic results can be achieved in the first stage in those patients. Preoperative conversation with them about reconstruction with two stages is essential before the surgery. Regional flaps with the same character can be used to close the wound with priority if regional tissue is integral so as to allow for optimum results. However, the adjacent area is usually wounded. So, skin grafts or remote free flaps should be considered. From our perspective, complex procedures and high risk are included in remote free flaps, which are not suitable for traumatic cases. However, if skin grafts and regional flaps are not reliable tools to be used, we have to choose remote free flaps. We must bear in mind that a severe case, such as cerebral haemorrhage, is not suitable for immediate facial reconstructive surgery. Facial surgery is secondary to cerebral haemorrhage. Patients who suffer from combined injuries must be transferred to an intensive unit to be treated firstly, allowing for the stable vital signs. Then we can treat the injuries related to plastic surgery. Symmetry is also an essential consideration. Otherwise, an asymmetrical appearance is apparent. However, some severe traumas may hinder us from resetting the wounded tissue. Then, we should inform the patients of the postoperative asymmetry presentation before the surgery. Correction can be carried out in the second stage. A flow chart is disclosed (Figure 7)
Figure 7.
A flow chart of how to deal with a acute case in the opinion of a plastic surgeon.
Conclusions
Treatment of a patient with facial trauma should include a thorough history and physical examination to determine the location and extent of all injuries. The goal of treatment for patients with craniomaxillofacial injuries should be the reconstitution of all injured regions. Both injuries should be assessed, and a treatment plan should be established. The goals of treatment should be the restoration of function and appearance.
Acknowledgements
HS and JC contributed a large amount of clinical work. MX and QG assisted me in sorting the data and writing the article. There is no conflict of interests in this article.
References
References
- 1. Chrcanovic BR, Freire‐Maia B, Souza LN, Araújo VO, Abreu MH. Facial fractures: a 1‐year retrospective study in a hospital in Belo Horizonte. Braz Oral Res 2004;18:322–8. [DOI] [PubMed] [Google Scholar]
- 2. Gomes PP, Passeri LA, Barbosa JR. A 5‐year retrospective study of zygomatico‐orbital complex and zygomatic arch fractures in Sao Paulo State. J Oral Maxillofac Surg 2006;64:63–7. [DOI] [PubMed] [Google Scholar]
- 3. Van Beek GJ, Merkx CA. Changes in the pattern of fractures of the maxillofacial skeleton. Int J Oral Maxillofac Surg 1999;28:424–8. [DOI] [PubMed] [Google Scholar]
- 4. Hogg NJ, Stewart TC, Armstrong JE, Girotti MJ. Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997. J Trauma 2000;49:425–32. [DOI] [PubMed] [Google Scholar]
- 5. Olubayo FA, Nyako EA, Obiechina AE, Arotiba JT. Trends in the characteristics of maxillo‐facial fractures in Nigeria. J Oral Maxillofac Surg 2003;61:1140–3. [DOI] [PubMed] [Google Scholar]
- 6. Subhashraj K, Nandakumar N. Review of maxillofacial injuries in Chennai, India: a study of 2748 cases. Br J Oral Maxillofac Surg 2007;45:637–9. [DOI] [PubMed] [Google Scholar]