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Critical Reappraisal of Pan-Facial Injury: Evolution of a 12 Year Experience-Based Treatment Algorithm
Branko Bojovic, M.D.1, Gerhard S. Mundinger, M.D.2, Joseph A. Kelamis, M.D.2, Amir H. Dorafshar, M.B.Ch.B.1, Suhail K. Mithani, M.D.1, Paul N. Manson, M.D.2, Eduardo D. Rodriguez, M.D.1.
1R Adams Cowley Shock Trauma Center, Baltimore, MD, USA, 2Johns Hopkins Hospital, Baltimore, MD, USA.
PURPOSE: Panfacial trauma remains the most challenging facial injury pattern. Past experience from our center has provided an algorithm for the treatment of these patients. Here, we present our updated experience and critically reevaluate management using a treatment-based algorithm.
METHODS: An IRB approved retrospective review was conducted of all patients admitted to the R Adams Cowley Shock Trauma Center from January 1998 to September 2010. Patients with fractures of the upper, middle and lower facial thirds were identified using ICD-9 fracture codes. All identified patient craniofacial CT scans were reviewed by the study team. Panfacial patterns were defined as having at least one fracture in each of the facial thirds. Only patients meeting this definition were included. Patient medical records were reviewed to assess outcomes and demographic information, including age, gender, mechanism of injury, associated injuries, Injury Severity Score (ISS) and Glasgow Coma Scale (GCS).
RESULTS: Of 77, 202admissions during the study period, 81 patients sustained pan-facial injuries (81.5% (n=66) male, 50.3% (n=48) Caucasian, 28.4% (n=23) black, 9.9% (n=8) other), mean age 34 years (range 14-87)). Mechanism of injury included: blunt 79% (n=64), penetrating 16% (n=13), explosives 3.7 % (n=3), and crush injuries 1.2 % (n=1). Blunt assault and penetrating assault were etiologies in 12.3% (n=10) and 7.4% (n=6) of cases. 51.9 % (n=42) cases resulted from motor vehicle collisions.10 patients (12.3%) attempted suicide, which involved firearms in 7 instances (8.6%). Average admission ISS was 29 (± 10.1, range 8-57) and average admission GCS was 9.2 (± 5.1, range 3-15). 28 patients (24.6%) were intubated in the field. Percentages of patients sustaining associated brain, neck, thoracic, upper extremity, lower extremity, abdominal, and spine injuries were as follows, respectively97.5% (n=79, 87.7% (n=71), 54.3% (n=44), 37.0% (n=30), 13.3% (n=27), 22.2% (n=18), 19.8% (n=16).: Average number of facial fractures was 9 (±4.9, range 3-22). 19.7% (n= 16) of patients sustained basilar skull fractures. Average length of hospitalization was 14.8 days (range 0-60), and average intensive care unit hospitalization was 7.3 days (range 0-31.8). 14.8% (n=12) of patients expired and 27.2% (n=22) of patients were discharged to home with no services.
CONCLUSION: Critical analysis of our data is used to illustrate an updated algorithm for the management of the patient with panfacial injury. Treatment continues to follow the basic principles previously described by our group: early surgical debridement, immediate anatomical stabilization of existing bone, and definitive reconstruction of soft tissue and bony defects. Building on these tenets, we now employ early microsurgical reconstruction of composite tissue defects to prevent soft-tissue contracture and improve patient and aesthetic outcomes.
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