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Unintended Consequences: Combat-related injuries lead to advances in facial plastic and reconstructive surgery

by Jennifer Decker Arevalo, MA •

In a 2007 report, Dr. Lopez described how, prior to 2005, most military personnel with facial fractures were air evacuated from AFTH (Arch Facial Plast Surg. 2007;9(6):400-405). These patients received definitive treatment of their wounds with open reduction and internal fixation (ORIF), because of concerns about sterility, infection from Acinetobacter baumannii, and delayed evacuation out of theater.

Dr. Lopez, however, reported that definitive treatment of facial fractures with ORIF might be feasible and safe in theater if certain criteria were met:

  • The fracture site was exposed through either a soft tissue wound or because of an associated approach (e.g., a frontal sinus fracture exposed by a bicoronal flap during a decompression craniectomy)
  • Definitive treatment of the fracture would not delay evacuation from the theater
  • Treatment of the facial fracture would allow the patient to remain in theater

Delaying fracture fixation can increase infections, as well as technical difficulties, as surrounding facial muscles contract. Delayed treatment of jaw fractures may increase the odds of marginal nerve weakness and malocclusion. According to Dr. Lopez, primary closure of soft tissue defects by ORIF of facial fractures on initial presentation to a well-equipped in-theater hospital decreases the need for further facial surgery for patients when they return to the U.S.

Drs. Lopez and Holt agree that long-term reconstruction of badly traumatized faces will be advanced in the civilian community because of the experience gained by military surgeons and reported in specialty journals.

“Additionally, in Iraq and Afghanistan, local wound contaminants, such as Acinetobacter baumannii, can be an issue,” Dr. Holt said. “For U.S. civilians, it is methacillin-resistant staphylococcus aureus (MRSA). From Dr. Lopez’s work in closing wounds in Iraq using high-dose antibiotics and excellent attention to wound debridement and handling, more confidence is gained in the treatment of MSRA-contaminated wounds of the face, scalp and neck, and we can apply the same principles of care to this group of patients in the U.S.”

Certainly the evidence base from caring for these military wounds will enhance civilian care of traumatized patients, including those with head and neck and maxillofacial trauma.
—Richard Holt, MD

Neck Exploration

Data from the US Navy-Marine Corp Combat Trauma Registry reveals that almost 61 percent of all patients wounded during Operation Iraqi Freedom (OIF) have a head and neck wound and 65 percent of all HFNIs are to the face. The registry lists improvised explosive devices (IEDs) as the most frequent cause of HFNIs. IED shrapnel sprays upwards, causing complex facial lacerations, specifically small holes in the head and neck—areas not well protected by body armor. Although these high-velocity projectiles appear to just “nick” the skin, in reality they create serious pathology in the vascular structures of soft and hard tissues that can be difficult to detect.