FACIAL TRAUMA

Author: Dr Cheong Ee Cherk
Road traffic accidents and falls are the most common causes of traumatic facial injuries in Singapore. These could result in swelling, bruising or open wounds of the face and can also cause facial bone fractures.

Depending on the severity of the injuries and the extent of soft tissue (ie. skin) wounds, the resultant scarring and facial deformities from facial bone fractures vary greatly. 

Facial deformities affect the patients psychosocially. These injuries can also affect the various functions of the eye, nose and mouth. Patients may complain of seeing double images when eye movements are affected when there are injuries to the eye socket called orbit. They can experience obstructed nose breathing if there are nasal bone fractures. When there is fracture of the jaw bones, they may have difficulty with mouth-opening, or have severe pain in moving the jaws. Malocclusion results when the upper and lower rows of teeth are not biting together or in same way as before the injury.

TREATMENT

All facial wounds should be properly evaluated, cleansed and dressed. If the wounds are deeper, they should be meticulously debrided(cleansed of dirty or non-viable tissues) and stitched precisely for optimal healing and scar outcome. Specialized treatment is needed if the wound is communicating with underlying bone, especially if the bone is fractured. 

Management of facial fractures takes into consideration two aspects of the facial skeleton that fractures will affect, that of function and form. Fractures which have no separation or only mild separation of the bone fragments may be managed conservatively and allowed to heal as they are without surgery. This will generally take about 6-8 weeks. If any of the functions are affected or if the bony fragments' displacement is severe, surgery will be indicated so that patients do not have compromised functions affecting daily life or have permanent facial deformities. They will need surgery to reposition the bone fragments into good positions relative to each other and held in that position by plates and screws for bone healing to occur in a surgery called open reduction and internal fixation (ORIF) of the fractures. Displaced fractures that are not reduced will heal in their displaced configuration and result in permanent deformities which will require complex surgery to correct.

  • Preparing for Surgery

    Other than simple wounds, most surgeries for facial trauma will usually require a minimum of 6 hours of fasting time before the general anesthesia.


    With the exception of those with open wounds on the face or when eye movements are affected, most of the operations for ORIF can be performed in an elective manner rather than as an emergency. These are usually performed within 2-3 weeks from the time of injury so that the fracture healing would not have progressed to a stage so advanced as to render fracture reduction difficult.


  • Surgery

    This would involve exposing the bony fracture via well-placed skin incisions to manipulate the bone fragments into its original positions and then stabilizing these bone fragments by titanium plates and screws for bone healing to occur.


    If more than one fracture is present, your surgeon will manage them in a sequential manner according to an operative plan. 


    Fractures can involve the teeth-bearing bone of the upper jaw(maxilla) or the lower jaw(mandible) called alveolus, and the bite of the teeth at the lower and upper jaw called occlusion may be affected. When this condition of malocclusion occurs,  dental arch bars or braces may have to be inserted during surgery to help regain the patient's preinjury occlusion. Sometimes the upper and lower jaw may have to be 'locked' together with the use of dental arch bars for bony healing to occur in what is known as maxillo-mandibular fixation (MMF) or an older term of intermaxillary fixation (IMF).  Your surgeon will discuss with you the various aspects of the operation in detail prior to the surgery.


  • Post-Surgery Care

    When ORIF is performed, swelling, bruising and some pain are expected and these should subside within 2-3 weeks. Residual mild swelling after injury and surgery can last up to 3 months, however, and sometimes even beyond that. 


    If MMF is indicated, it will usually have to be maintained over a duration of 4-6 weeks. The patient's oral intake will be severely affected and will have to be on a liquid diet. A nutritionist is often called upon for advice to increase the nutritional value of the intake of the patients to prevent drastic caloric and nutritional deficits which will have a negative impact on health and may also result in delayed wound and bone healing.


    Postoperative CT scans will usually be performed after an ORIF where fracture reduction and appropriate implant placement can be verified radiologically. The surgeon will use these images to explain the operation carried out to the patients, and show them the location of their implants. This goes towards allaying their anxiety about the outcome of the surgery. 


COMPLICATIONS AND MANAGEMENT

Bruising and swelling can be expected and will abate gradually over the subsequent weeks. Ice packs and sleeping with head elevation of at least 30 degrees can be helpful in the initial few days to help reduce the swelling.

If surgery were to involve the bony eye socket called orbit, seeing double images after orbital surgery is common. This usually resolves over a few days to weeks but can become permanent in some rare cases.Blindness is an extremely rare complication and its likelihood depends on the nature and extent of the surgery.

Infection after ORIF is fortunately also uncommon. If infection occurs, it can lead to loosening of implants from the bone. This may necessitate the removal of these implants before the infection can be treated. This remains the main indication for the uncommon practice of removing these inert biocompatible titanium implants which are otherwise left in situ in the facial skeleton permanently. 

Residual facial asymmetry can sometimes persist despite good bony reconstruction. One effective option is to camouflage these with autologous fat grafts to achieve better overall symmetry.