FACIAL TRAUMA ASSOCIATION

The human face conveys emotions, facilitates verbal and nonverbal communication, defines physical identity, and changes over time.  Abrupt physical alterations in the face has profound psychological, functional, and societal implications.  Knowledge about options for treatment after an injury empowers affected individuals to move beyond the injury and continue on with living.  This page provides essential information to those directly or indirectly affected by injuries to the face.  Injuries include broken bones (fractures, lacerations (cuts), mouth and teeth injuries, vascular injury (damage to blood vessels), airway compromise, sensory nerve injury, and damage to the major senses (sight, smell, taste, hearing, vision). 

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Surgeon members of the Facial Trauma Association have demonstrated competence and excellence in treating facial trauma patients through three main measures:  training based competence, experience based competence, and outcomes based competence. Requesting a surgeon member of the Facial Trauma Association will help to insure you receive the highest quality of care available. 

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FACIAL INJURY INFORMATION 

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I.  FRACTURES 

 

Forehead Fractures

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These fractures involve the frontal bone which makes up the forehead.  The frontal bone extends from the eyebrows to the hairline and possesses and underlying sinus (hollow cavity).  A fracture of the frontal bone may require intervention by a facial trauma surgeon, a neurosurgeon, or both.  Reconstruction of the anterior table of the frontal sinus or other portions of the frontal bone requires access through the scalp or brow region and usually involves the placement of titanium plates and screws to put the broken segments back into a normal anatomic position.  Long term follow up is required in patients who sustain these fractures as there are several known late complications.  Click here for more information about forehead fractures.

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Nasal Bone Fractures

 

The majority of the visible nose is cartilage with the exception of the upper most portion where the cartilage joins with the paired nasal bones that articulate (connect) with the frontal bone at the radix (the depression you can feel between the forehead and nose.)  This is a commonly fractured bone.  It is not uncommon for patients to experience epistaxis (bloody nose) when these injuries occur.  Resetting the nasal bone usually requires general anesthesia in the operating room and patients often have internal nasal and external nasal splints for a period of time after surgery.  Failure to correct these fractures could result in nasal and facial deformity and/or nasal obstruction.  Click here for more information about nasal bone fractures.

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Cheek Bone Fractures

 

A prominent bone of the face, the cheek bone is also a frequently fractured bone. It is connected to the upper jaw, the forehead bone, the eye socket bone and the skull base. As such, the three dimensional position of the cheek bone is important to determine and is important to restore to the correct contours to re-establish facial symmetry and contours.  Often times, these fractures require at least three incisions.  Two incisions on the face and one within the mouth.  In addition, titanium plates and screws facilitate advancement and fixation of the fractured segments. Click here for more information about cheek bone fractures.

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Eye Socket Fractures

 

The eyes live within a bony cave (orbit/eye socket) with a floor, roof, lateral and medial wall.  Trauma to the globe (eyeball) results in an increase in pressure within the orbit (cave).  This pressure is transmitted through the eye socket and, if strong enough, results in a breakage of the bone.  This is a protective mechanism to avoid rupturing the eyeball at the expense of the thin surrounding bone.  Untreated moderate to severe fractures can result in a permanent abnormal position of the eyeball which can cause changes in vision, eyelid lowering (ptosis), limited range of motion, facial numbness, and pain. There are many ways to reconstruct the orbit. Each way depends on the fracture pattern.  Orbital floor fractures are treated with a plastic (porous polyethylene), metal (titanium), metal and plastic, bone grafts, or resorbable materials (materials that disappear over time.)  In certain cases, the eye must be operated on emergently to avoid long term complications. Click here for more information about eye socket fractures.

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Upper Jaw Fractures

 

The upper jaw, including the teeth is known as the maxilla in scientific terms.  It connects with the cheek bone, the eye socket bone, the nasal bones, the forehead bone, the lacrimal bone, the palate bone and the nasal cavity bone known as the vomer.  You may hear these fractures classified as a "LeFort" fracture.  This name came about because a French surgeon named Rene LeFort developed a classification scheme for fractures of the midface in the early 1900s. He described three types of fractures (LeFort I, LeFort II, LeFort III) based on the level of the fracture.  Each type of fracture requires a different level of intervention to repair and generally speaking the overall level severity of injury increases with increasing LeFort classification. Click here for more information about upper jaw fractures. 

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Lower Jaw Fractures

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Commonly associated with the concept of a "broken jaw". The mandible is the movable bone that has two joints which articulate with the skull base.  It contains all the lower teeth and assists in eating, speaking, and breathing.  Fractures of the lower jaw also have patterns and are described based on the anatomy of the bone.  The jaw joint area may fracture which is called a condylar fracture.  Just beneath the condyle is the subcondylar region, thus a break in this area is known as a subcondylar fracture.  The part of the jaw that makes a turn from vertical to horizontal is known as the angle of the mandible.  A break here is known as a mandibular angle fracture. Moving further forward along the horizontal aspect of the jaw, the body of the mandible is a thick central portion that holds the lower molars and premolars.  Further still, we encounter the parasymphysis which is the area between the body and the symphysis (midline in the front).  Due to the structure of the lower jaw, patients commonly experience more than one fractured site and may expect to have more than one approach to treat a broken jaw. Click here for more information about lower jaw fractures. 

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LACERATIONS

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Facial Lacerations

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Like most things, lacerations may be simple or complex, they may involve only the skin or other structures including nerves, ducts, blood vessels, muscles, ear canals, cartilage, lip lines, and hair follicles.  A laceration in its most simple form is a vertical cut in the skin.  A deep cut in the cheek may involve the gland and duct that provides saliva to the mouth, it may involve the nerve that facilitates facial animation (smiling, pouting, puffing out cheeks), and it may involve nerves that provide sensation to the face.  Lacerations in the setting of crush injuries, abrasions, or avulsed (completely lost) tissue could require moving tissue from other places to cover the defect and close the wound. Cartilage injuries require a special suture and care to avoid complications and further loss of tissue.  Scar tissue forms any time tissue is violated.  Initial results of laceration repairs may require additional treatment to improve appearance. Click here for more information about facial lacerations. 

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DENTAL INJURIES

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The mouth and teeth sustain injuries during trauma frequently. Broken teeth, dislodged teeth, chipped teeth can result in significant pain and poor aesthetic appearance. Algorithms have been developed to manage damage to teeth from traumatic events and may be found here.  Click here to understand important information about managing dental injuries.

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VASCULAR INJURIES

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Injury to blood vessels in the head and neck is not uncommon.  Several large vessels emerge from the heart and ascend through the neck to supply the face, neck, and brain with oxygen and nutrients.  Two types of vessels exist: arteries and veins.  Veins bring blood to the heart then lungs and arteries carry oxygenated from the lungs through the heart to the body.  Vascular injuries may be addressed by your facial trauma surgeon, an interventional radiologist, or a vascular surgeon. The severity and accessibility of the injury dictates the provider type to address vascular injuries. Click here for more information about vascular injuries. 

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AIRWAY COMPROMISE

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The airway commands strict attention throughout the assessment process and must be secured as soon as possible. "Securing" the airway simply means that a reliable method of oxygenation and ventilation has been established.  To learn more about the airway click here. 

 

DAMAGE TO SENSORY ORGANS 

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Sight

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Injury to the eyes can manifest in a variety of ways.  Corneal abrasions or scratches of the outermost layer of the eye may feel like a piece of sand is in the eye.  Traumatic optic neuropathy occurs when an injury to the optic nerve results in vision loss. This may result from direct penetration from foreign objects or bone fragments or indirectly from compression through a hematoma or transmitted shock.  Choroidal rupture is a break in the choroid, Bruch membrane, and retinal pigment epithelium that may occur after a closed globe injury from blunt trauma.  For more information on traumatic eye injuries including traumatic iritis, retinal detachment, hyphema, iridocyclitis, sympathetic ophthalmia, and globe rupture click here. 

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Smell

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Craniofacial trauma not infrequently results in anosmia due to shearing of the filia olfactoria or fracture of the cribiform plate.  Radiographic imaging may not demonstrate significant damage to the olfactory apparatus despite a patients inability to smell.  Intracranial hemorrhage due to skull base fractures has been described as a risk factor for anosmia in patient who sustain craniofacial trauma.   Treatment for anosmia in trauma patients has been limited to local irrigation or injection of steroids immediately after injury. Click here for more information about changes in the ability to smell after facial trauma. 

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Taste

 

Taste is functionally linked to smell.  A loss of smell often reduces taste sensation. Lingual nerve damage through trauma may also result in a loss of taste and tactile sensation on one or both sides of the tongue.  Vagus nerve damage may also result in reduced ability to taste.  The tongue is innervated by sensory and motor nerves.  The lingual nerve and chorda tympani from the facial nerve provide taste and tactile sensation for the anterior 2/3 of the tongue.  The glossopharyngeal nerve provides taste sensation to the posterior 1/3 of the tongue. Motor innervation is provided by the hypoglossal nerve and vagus nerves.  Click here for more information about changes in taste or tongue movement after trauma. 

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Hearing

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Damage to the ears or internal structures responsible for hearing may occur after craniofacial trauma. Temporal bone fractures, hematomas, ear canal stenosis, ossicle damage or nerve damage can result in temporary or permanent impairment in hearing. Click here for more information about hearing loss and craniofacial trauma. 

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Facial Nerve Injury

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Cranial nerve seven (CN VII) is known as the facial nerve.  This nerve is begins at the brainstem and is responsible for movement of the face.  After leaving the stylomastoid foramen (skull base canal) it branches into two divisions: the cervical and temporofacial.  Movements like smiling, frowning, eyelid closure, and eyebrow raising are a result of activation of this nerve. There are several scoring systems in use to describe the degree of injury, likelihood of recovery, and potential for intervention. Click here for more information about injuries to the facial nerve. 

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Trigeminal Nerve Damage

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The trigeminal nerve receives sensory input for most regions of the face. Three divisions relay sensory input from the forehead, nose, eyelids, eyebrows, cheeks, mouth, teeth, and gums to the brain. Damage to one of these paired sensory divisions may result in facial numbness, dysesthesia, allodynia, or hypoesthesia.   In addition to sensory function, the trigeminal nerve also supplies motor innervation to many muscles of mastication (chewing). 

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FACIAL TRAUMA INSTRUCTIONS​

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After an injury that results in laceration of the skin or a surgical approach that involves cutting of the skin or mucosa, scarring is inevitable. Methods are employed to camouflage scars and proper surgical techniques improve the appearance of the scarring but they nonetheless will exist. Basic wound care is of utmost importance to improve the appearance and healing of a facial soft tissue injury.  

 

1. Cleaning the Wound

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A clean wound is extremely important for favorable wound healing.  Bacterial contamination may lead to infection which can increase scarring and pain. Scabs and crusting separates the wound edges and results in a depression at the center of the wound further widening scars. Gently clear away scabs with a Q-tip or gauze sponge with dilute hydrogen peroxide or warm soap and water at least 2-3 times per day. Mild bleeding around the site is to be expected and should cease in several minutes.  Always wash hands thoroughly prior to initiating wound care as dirty hands could serve as a source of contamination.  Once clean, the wound should be covered generously with an antibiotic ointment (bacitracin, triple antibiotic ointment) and should be left open to air unless working in a dirty environment in which case it should be covered. If skin irritation occurs with ointments, discontinue use and consider a simple petrolatum application.  Moisture loss from wounds contributes to poor healing and poor migration of cells to repair defects. 

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2. Avoiding Sun Exposure 

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Wounds and incision incision lines darken when exposed to direct sunlight during the healing process.  Once the wound has closed, it is important to limit the amount of sun exposure to the healing site. This may be accomplished through high SPF sunscreen lotion, heavy cosmetics, hats, and limiting time in the sun during the healing phase. 

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3.  Sutures (Stitches) 

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Many types of sutures are used in facial laceration repair. Non-resorbable sutures must be removed in a clinic.  Resorbable sutures will dissolve and do not require removal. As resorbable sutures dissolve, strands of material may be noticed and may fall out spontaneously. Do not forcefully remove an exfoliating resorbable suture as this may open the wound. 

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4.  Wound Appearance 

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Recently repaired lacerations will appear slightly raised and red.  This appearance may persist for several months and is part of the normal healing process.  It may also feel warm to the touch and tender during the early stages of healing. Some wound are not amenable to closure and must heal from the "inside out", this is known as healing by secondary intention or granulation.  Granulating wounds appear white to yellow and exude a thin discharge and may bleed slightly.  Do not be alarmed as this also a normal part of the healing process. Clean all areas gently with soap and water to prevent crusting and to facilitate healing.  If fever or new swelling develops greater than five days after surgery, contact your surgeon. 

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5.  Antibiotics 

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If you have been given a course of oral antibiotics, complete the entire course, even though your symptoms may have subsided. Avoid alcoholic beverages when taking antibiotics. 

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6.  Nutrition 

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Nutrition plays a central role in the healing process.  Insure a balanced diet, adequate protein and caloric intake. Dietary supplements such as multivitamins or protein dense drinks help facilitate healing. 

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7.  Topical Scar Gels and Vitamin E 

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Commercial products are available to reduce the appearance of scars and are usually in the wound care aisle in pharmacies.  Some studies have found these topical agents to the be effective. They may be instituted after the would has healed primarily, usually within three weeks of a repair or procedure. Vitamin E is available in a gel capsule form and may be gently massaged into the wound to assist with healing and scar reduction. 

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8.  What to Expect

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As wounds heal, nerves regenerate into the lacerated skin.  There may be tingling, itching, unusual temperature sensations like cold or hot.  These are normal signs of healing.  The healing process may take 6 months to 1 year. 

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9.  Keloids/Hypertrophic Scarring 

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Individuals with a personal or family history of hypertrophic scarring or keloids should be aware that exuberant scar tissue may form at the site of a laceration repair or surgical excision. Steroid injections may serve to lessen the effects in some cases.  

 

10. Scar Revision

 

At times the appearance of the scar is displeasing to the patient. After an adequate time of healing and tissue maturation, scar revision surgery can improve the appearance through camouflaging techniques.

 

11. Tobacco and Alcohol Use 

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It is recommended to completely avoid tobacco and alcohol use during the healing process. Smoking or smokeless tobacco may result in significant increases in pain, potential for infection, and opening of the wound. 

 

12.  Pain Control 

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Facial trauma patients receive pain medication to help alleviate post injury or post operative discomfort. Often, a small dose of narcotic is provided for severe breakthrough pain.  It is important to remember that many prescription narcotic formulations contain acetaminophen. Do not take additional acetominophen containing products if prescribed an opiate combination medication.  Ibuprofen may be used alternating with acetominophen doses in healthy patients.  Selective COX inhibitors may also be used. 

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