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Primary One Stage Reconstruction in Complex Facial Avulsion Injury

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Complex facial injuries with soft tissue degloving and bony avulsion are very devastating to the patient. Partial degloving injuries are described but hemifacial degloving with zygoma avulsion are rare. The author presents a case of post-traumatic degloving of the left upper lip, nose, part of forehead, upper and lower eyelids and cheek with avulsion of the left zygoma. The management included immediate resuscitation and early surgery to reposition the skeletal as well as soft tissue avulsion. The wound was thoroughly washed and primary repositioning and fixation were done. Early one stage surgery with meticulous debridement and alignment of the anatomical landmarks results in very good aesthetic and functional outcome.
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383
Ghosh
www.wjps.ir /Vol.6/No.3/September 2017
Primary One Stage Reconstruction in Complex
Facial Avulsion Injury
Abhishek Ghosh*
ABSTR AC T
Complex facial injuries with soft tissue degloving and bony
avulsion are very devastating to the patient. Partial degloving
injuries are described but hemifacial degloving with zygoma
avulsion are rare. The author presents a case of post-traumatic
degloving of the left upper lip, nose, part of forehead, upper
and lower eyelids and cheek with avulsion of the left zygoma.
The management included immediate resuscitation and early
surgery to reposition the skeletal as well as soft tissue avulsion.
The wound was thoroughly washed and primary repositioning
and xation were done. Early one stage surgery with meticulous
debridement and alignment of the anatomical landmarks results
in very good aesthetic and functional outcome.
KEY WORDS
Hemiface; Orbit; Zygoma; Avulsion; Degloving
Please cite this paper as:
Ghosh A. Primary One Stage Reconstruction in Complex Facial
Avulsion Injury. World J Plast Surg 2017;6(3):383-386.
INTRODUCTION
Poona Hospital, Noble Hospital, Pune, I ndia
*Corresponding Author:
Abhishek Ghosh,
Poona Hospital, Noble Hospital,
B4, 201, Silver Oak, Pune 14, India
Email: drabhishekghosh@gmail.com
Received: January 12, 2017
Revised: July 21, 2017
Accepted: August 1, 2017
Case Report
The face is a very important part of the human body giving
identity and sense of condence to a person. Any post traumatic
facial deformity not only causes functional problems but also
psychosocial dysfunction. This article reports a case of post-
traumatic degloving of majority of left side of the face with
avulsion of the zygomatic bone. There are various reports
suggesting better outcomes with early primary reconstruction
with less risk of infection1-3 and also better aesthetic outcome.4,5
An early single staged surgical correction was done for this case
which gave very good functional and aesthetic outcome.
CASE R EPORT
A 56 years old female presented with history of road trafc
accident with resultant avulsion of her left side of face. There was
degloving and avulsion of the left hemi-face including the upper
lip nose, forehead skin and eyebrow, upper and lower eyelids and
the entire left cheek. The zygomatic bone was also avulsed and
displaced laterally. The globe was displaced inferiorly towards
the maxillary sinus (Figure 1).
The patient was immed iately resuscitated ai rway management,
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control of bleeding and maintainence of
circulation. Other injuries were quickly ruled
out and CT scan with 3D CT of the face was
done. CT scan showed avulsion of the zygoma
with lateral blowout fracture of the orbit. There
was no brain injury. The vision was tested for
nger counting which was present at 2 to 3 feet.
Decision was taken for an immediate single
stage reconstruction of the bony as well as soft
tissue avulsion.
The patient was taken for surgery and
under anesthesia the wound was thoroughly
washed with normal saline and diluted betadine
solution. All contaminants and foreign bodies
were removed. Careful debridement was done
and crushed nonviable tissues were excised.
The orbital cavity was then reconstructed. The
globe was seen to be displaced towards the
maxillary sinus. The avulsed zygoma still had
soft tissue attachments. There was a piece of
lateral orbital rim with the soft tissue ap which
was repositioned and the lateral orbital wall was
reformed. The fractures were xed with titanium
miniplates. The eyeball was thus repositioned to
its original position and the volume of the orbital
cavity was restored (Figure 2 and 3).
Once the bony xation was done the soft tissue
reconstruction was started. The degloved ap
was repositioned. Tacking sutures were taken
to the periosteum wherever possible to keep
the ap in place. The upper lip was repaired in
layers after marking the anatomical landmarks.
The mucosa and muscle were repaired with
absorbable sutures and skin with nylon. The
nose was reconstructed with repair of the
mucosal lining followed by repair of the cartilage
framework. The nasal ala was repositioned and
the skin was repaired. The eyelids and forehead
were repaired in layers (Figure 4). The post-
Fig. 1: Preoperative picture showing complete
hemifacial and zygomatic avulsion.
Fig. 2: Preoperative picture after debridement and
wash.
Fig. 3: Orbit reformed with pieces of zygomatic
bone brought into position and xed with titanium
implants.
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Ghosh
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operative course was uneventful. The patient had
no problems in visual acuity. The patient was on
higher antibiotics for ve days and discharged.
The sutures were removed on 7th postoperative
day. All wounds healed well without any ap
necrosis (Figure 5). The patient had normal
vision and full facial functions at six months
follow up.
DISCUSSION
Complex hemifacial avulsion injuries are
challenging and difcult to treat. The most
common causes are high velocity trauma and
assault. There is not only a soft tissue degloving
but also a bony avulsion in such cases. The
problem is compounded by the presence of
foreign bodies and contaminations including
dirt and stone particles. Early single stage
reconstruction provides excellent functional
and aesthetic outcomes. Thorough washing
and removal of foreign bodies and precise
debridement help to prevent infection and ap
loss.6-8 Meticulous matching of the anatomical
landmarks and repair in anatomical layers
gives very good nal results. Immediate soft
tissue reconstruction results in less scarring
and infection. Delayed repair results in oedema
developing which obscures the anatomical
landmarks and give inferior aesthetic results.
There is higher risk of infection too in case
of delayed repair. The complete avulsion
with lateral displacement of the zygoma is a
rare occurrence and it causes displacement
of the globe inferiorly and outwards. Early
repositioning of the bony fragments and rigid
orbit reconstruction repositions the globe and
helps maintain visual acuity.9-11
Surgical management of unusual complex
problems is highly challenging as they do not
follow any set protocols. Sticking to the basic
tenets of reconstruction with matching of the
anatomical landmarks and reconstructing in
layers gives very satisfying outcomes even in
the most ghastly injuries. Immediate single stage
procedure with meticulous reconstruction is the
key to excellent functional and aesthetic results.
CONFLICT OF INTEREST
The authors declare no conict of interest.
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Denny AD, Bonawitz SC. Clostridial infection
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Fig. 4: Postoperative results. Fig. 5: Postoperative results after 1 month.
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... This team approach ensured timely subspecialty planning of primary repair, decision making and thus achieved favorable reconstructive results for the patient [6]. Early single-stage primary reconstruction provides good functional and cosmetic outcomes [7,8]. Wounds with contamination or embedded material are cleaned, debrided, and repaired without wasting time. ...
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... 9 Ghosh reported another case of hemi-facial degloving with an intact globe. 10 An extensive hemi-facial degloving avulsion injury with rupture of the eyeball, like the one encountered by us, is extremely rare. To the best of our knowledge, this is the first such reported case in literature. ...
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