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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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Ghosh /Vol.6/No.3/September 2017
Primary One Stage Reconstruction in Complex
Facial Avulsion Injury
Abhishek Ghosh*
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.
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.
Poona Hospital, Noble Hospital, Pune, I ndia
*Corresponding Author:
Abhishek Ghosh,
Poona Hospital, Noble Hospital,
B4, 201, Silver Oak, Pune 14, India
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.
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,
384 Reconstruction of facial avulsion injury /Vol.6/No.3/September 2017
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
Fig. 3: Orbit reformed with pieces of zygomatic
bone brought into position and xed with titanium
Ghosh /Vol.6/No.3/September 2017
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.
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.
The authors declare no conict of interest.
Denny AD, Bonawitz SC. Clostridial infection
following severe facial trauma. Ann Plast
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Fig. 4: Postoperative results. Fig. 5: Postoperative results after 1 month.
386 Reconstruction of facial avulsion injury /Vol.6/No.3/September 2017
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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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Abstract Gross maxillofacial injuries are challenging to manage because they can be complicated by airway obstruction, injuries to the cervical spine, and cranial structures. Deformities from such injuries have lasting psychological effects which if not addressed can be devastating. We present a 21-year-old male motorcyclist who was involved in a motor traffic collision and sustained avulsion and degloving of the forehead skin, left eyebrow, left upper and lower eyelids, the nose, the left cheek and part of the right cheek, upper and lower lips, and the skin overlying the chin. His airway was compromised; hence rapid sequence intubation was done to secure it. Thereafter single-stage primary reconstruction and repair were done. A multidisciplinary team approach involving different specialties yielded good outcomes for this patient's condition.
... 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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Abrasions and laceration of face are very common injury in a road traffic accident. Complex Hemi-facial Degloving injury of face is very rare injury in road traffic accident. Reconstruction of face and rehabilitation of patient poses a great challenge to treating surgeon. Here a case of hemifacial Degloving injury of face in A 45-year-old female patient from India is reported.
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There have been sparse reports in literature of avulsion and degloving injuries of individual areas of face like the nose, eyelids, ear and even mandible. Hemi-facial degloving is extremely rare. We present a case of post-assault degloving of the nose, part of forehead with anterior wall of frontal sinus, entire upper and lower eyelids and the cheek. Proper planning and staging of the surgical procedures and use of local flaps, meticulous and proper alignment of tissues gave us good aesthetic and functional outcome with a satisfied patient.
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COMPLEX, OPEN MAXILLOFACIAL FRACTURES ARE OFTEN ACCOMPANIED BY EXTENSIVE CONTAMINATION, CRUSH, OR AVULSION OF THE OVERLYING SOFT TISSUE, THERE HAVE BEEN TWO ALTERNATIVES TO TREATMENT: either radical debridement of all contaminated tissue, fixation of the underlying fractures, and soft tissue closure by pedicle flap or graft is done; or more conservative debridement is repeated multiple times until the contaminated tissue is removed and fracture fixation is deemed safe. Debridement is usually accomplished by sharp debridement or with high-pressure intermittent irrigation or some combination of both modalities. The problems with this standard treatment in the face are that facial features may be distorted, superficial branches of the facial and/or trigeminal nerve can be inadvertently sacrificed (even with the use of nerve stimulators), and scarring can distort contours and radically change facial appearance. A serious facial degloving injury with necrotic malodorous tissue and no clear anatomical delineations demanded special attention. The purpose of this report is to demonstrate the management of a soft tissue avulsive contaminated injury of the face with underlying maxillofacial fractures.
Sports are a common cause of facial injury. A wide variety of facial injuries occurs during sports. Severity of these injuries varies greatly. Understanding the diagnosis and treatment of these injuries is important to those participating in the health care of the athlete. Injuries that may threaten the airway or vision or cause bleeding are particularly crucial to understand. Dental injuries such as tooth fracture and tooth avulsion may need to be treated urgently in many cases. Facial lacerations may damage underlying structures, including the lacrimal system, facial nerve, or parotid duct. Closure of facial lacerations involves several considerations, such as cosmesis, method of wound closure, and complexity of the wound. Facial fractures occur commonly in sports, and familiarity with the various types and levels of severity is of key importance. Return-to-play guidelines after facial injury have yet to be established. Use of protective equipment can prevent facial injuries and protect athletes when returning to play after facial injury has occurred.
Facial injuries are often accompanied by soft tissue injuries. The complexity of these injuries is represented by the potential for loss of relationships between the functional and the aesthetic subunits of the head. Most reviews of craniofacial trauma have concentrated on fractures. With this article, we want to emphasize the importance of early aesthetic reconstruction of the face in polytrauma patients. We present 13 patients with soft tissue injuries of the face, treated in our emergency department in the 'day one surgery", without "second look"procedures. The final result always restored a sense of normalcy to the face. The face is the first most visible part of the human anatomy, so, in emergency, surgeons must pay special attention also to the reconstruction of the face, in polytrauma patients.
The traditional surgical management of complex craniofacial injuries is performed in three stages: immediate craniotomy, orbitofacial repair in 7 to 10 days, and cranioplasty delayed 6 to 12 months because of the perceived risks of infection and prolonged anesthesia in the head-injured patient. Cosmetic considerations have always played a secondary role; however, there are reports that suggest that bone fragments and grafts can be safely placed even in contaminated wounds. In addition, advances in neuroanesthetic technique allow for prolonged administration of anesthesia without untoward effects on the patient. The purpose of this prospective study was to determine if early single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality. In this study, 13 patients (9 men, 4 women) ranging in age from 3 to 53 years, with Glascow Coma Scale scores of 10 to 15, all had a combined single-stage repair of their complex craniofacial injuries within 24 hours of their trauma. After initial assessment and resuscitation, all patients were evaluated with computerized tomography of the face and head before surgery. Bicoronal skin flaps were used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, and calvarial reconstruction. Dural grafts were necessary in 12 of 13 patients (92%), and supplementary bone grafting was required in 9 of 13 patients (69%), of which 3 of the 9 (33%) had iliac bone grafts, where split calvarial grafts were used in the other 6 of 9 (67%). No artificial cranioplasty material was used.(ABSTRACT TRUNCATED AT 250 WORDS)
Severe posttraumatic wound infections are uncommon occurrences in the craniofacial region. Although most reported cases have occurred following an odontogenic infection or minor soft-tissue trauma, the potential for the development of this type of infection exists following complex facial fractures. We report a case with clostridial infection in the temporalis fascia complicating a complex facial fracture. The implications regarding antibiotic usage and delay of surgical treatment are discussed.