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Penetrating Injuries to the Face: Delayed Versus Primary Treatment—Considerations for Delayed Treatment
CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART ONE J Oral Maxillofac Surg 65:1209-1214, 2007
Penetrating Injuries to the Face: Delayed Versus Primary Treatment— Considerations for Delayed Treatment Brett A. Ueeck, DMD, MD* As with any debate in the practice of surgery, there must be no absolutes. Each patient deserves the attention of directed thought and treatment his or her individual problem demands. Adhering blindly to algorithms and approaching treatment options closedminded produces only average results the majority of the time and poor results too frequently. Creative thinking based on sound surgical principles coupled with good clinical judgment drives excellent patient care outcomes and the discovery and advancement of new techniques. A penetrating injury is defined as an injury that occurs as a result of an object, such as a knife, bullet, or shrapnel, which violates cutaneous or mucosal barriers and enters the body. This definition encompasses a large number of injuries with a wide spectrum of severity. Certain body regions provide a stricter definition of what classifies as penetrating. For example, a neck wound is classified as penetrating if it violates the platysma muscle and a penetrating head wound if it violates the dura mater.1,2 Injuries of the penetrating type lend themselves to further classification. Classification is not standardized, however. Wounds are often distinguished as high velocity versus low velocity or missile versus nonmissile. Injuries are described commonly as avulsive when soft or hard tissue is lost. A composite defect is one where both soft and hard tissue is lost. It is this category of wounds that has the greatest potential for severity and complex reconstructive challenges.2,3 In contrast, blunt injuries do not violate the cutaneous or mucosal coverings. These injuries can range from simple contusions to severe panfacial fractures. *Assistant Professor of Surgery, Division of Oral and Maxillofacial Surgery, Oregon Health and Sciences University, Portland, OR. Address correspondence and reprint requests to Dr Ueeck: OHSU, Dept OMS, 611 SW Campus Drive, Portland, OR 97239; e-mail: [email protected] © 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6506-0022$32.00/0 doi:10.1016/j.joms.2006.10.078
There are several subclassifications of these injuries. In general it is unwise to correlate severity with either a blunt or penetrating injury type. The terms primary and delayed treatment are somewhat ambiguous and can be defined differently depending on the context. For our purpose primary treatment will be defined as initial treatment of a wound within 48 hours with the intent to definitively manage all aspects of the injury. The goal of primary treatment is to repair the wound in such a way that both hard and soft tissue is restored and all wounds primarily closed. Delayed treatment will include all other forms of treatment, which are numerous. Classically, surgeons selecting delayed treatment have advocated debriding soft tissue injuries and stabilizing bony injuries. After edema has resolved and the soft tissues have healed to cover the wounds, the final reconstruction is attempted. Staged repair of wounds also will be classified as a form of delayed treatment.
Historical Background Historically penetrating wounds were treated open with frequent bandage changes and various medicaments applied. In the time of Ambrose Pare, the mindset of burning and cauterizing wounds underwent a paradigm shift to one of a more biologically sound method of cleaning and caring for vital tissue without inflicting further insult. Eventually, methods of primary wound treatment evolved to the current level of sophistication, whereby the majority of wounds can be cleaned and closed. The advent of anesthesia and antibiotics combined with knowledge of wound treatment and healing was crucial in this evolution. Today, the increasing sophistication of technology and surgical critical care continues to advance our reconstruction options.4 Without a doubt, the majority of penetrating wounds to the maxillofacial area are lacerations that are generally cleaned easily and closed primarily. Little controversy exists regarding this current standard of practice. For more complex penetrating wounds, however, the debate continues regarding which
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wounds should be treated primarily versus delayed. Proponents that favor primary treatment claim superior esthetic and functional outcomes, whereas those of the delayed approach claim fewer complications due to infection. Interestingly, there are more issues to the debate that are seldom discussed and will be presented in regard to circumstances when more substantial penetrating wounds should be considered for delayed repair.
Treatment Considerations There are situations today that demand delay in treatment for several valid reasons. This clinical vignette presents some of the issues. A 17-year-old male was riding a motorized scooter when he was run over by a large truck at a high rate of speed. The trauma system was activated and he was rushed to a nearby level 1 trauma center for care. His resuscitation and stabilization was successful, although he remained in the ICU on cardiac and ventilator support. Injuries to his head, thorax, abdomen, pelvis, and long bones were severe. He sustained complex penetrating injuries to his face consisting of several long complex lacerations with open comminuted panfacial fractures. Planning for early operative intervention was begun and then aborted when it was learned that he was a Jehovah’s Witness. Family refused consent for any blood products despite a hemoglobin of 4 gm/dL. Issues that prevent early intervention include patient medical status, family/patient autonomy, and inability to conduct an informed consent discussion with the patient.
Patient Status An obvious reason for delayed treatment is the inability for the patient to tolerate an operative intervention. Common injuries that preclude operative intervention are neurologic, cervical spine, and severe thoracic or abdominal injuries. The polytrauma patient with a considerable overall physiologic wound burden is prohibitive as well. Generally, one thinks in terms of the patient being medically stable, and once cleared by the trauma critical care team, operative intervention for the facial injuries can commence. However, both the risk of adverse outcome to the patient, as well as the medical-legal aspect must be considered. Uncertain neurologic or cervical spine statuses are examples. Even though the patient may be stable for surgery, unexpected or adverse outcomes of these injuries may result in questioning the decision for early facial surgery. The argument is easily made the patient’s outcome would have been different (better) if your facial surgery was delayed.
FIGURE 1. The state of severe facial wounds 1 month after admission in a patient with a hematocrit averaging 15. (Same patient presented in the opening case of this study.) Brett A. Ueeck. Penetrating Injury Treatment. J Oral Maxillofac Surg 2007.
A patient was treated recently by our service with a large facial laceration and orbital fractures. She had just undergone an emergent nephrectomy to control abdominal bleeding and while still on the operating room table was deemed stable for our team to repair her facial lacerations. Shortly after commencing the cleaning of her periorbital lacerations she developed asystole. Even though she regained a perfusing sinus rhythm she never recovered.5 Tissue perfusion and oxygenation is another problem encountered frequently in the critical trauma patient. This can be the result of acute blood loss, as well as other underlying disease states such as cardiac, pulmonary, and peripheral vascular disease. It is well documented that wound healing is less than ideal in these situations. Reduction in hematocrit, even with appropriate volume resuscitation, causes a decrease in white blood cell infiltration, blood vessel ingrowth, and collagen content and strength within the wounded tissue. Impaired wound healing is seen with a hematocrit below 30 and less than 20 is generally considered too low especially in the setting of other comorbidities such as cardiovascular disease (Fig 1).6,7 Often there is a need for blood transfusions in the trauma setting for treatment of anemia and shock. It is well understood that blood transfusions are detrimental to immune function. Both proliferation and function of immune cells are impaired. Furthermore, the inflammatory response is induced and exacerbated by transfusions. Combine this with the already hypercoagulable state of the trauma patient and the risk of microvascular free flap failure probably increases. Overall, transfusions are independent risk factors for
BRETT A. UEECK
perioperative infection, multi-organ failure, and death.8-13 Glycemic control in the critically ill patient is essential for wound healing as well as overall outcome. Maintaining blood glucose within normal ranges has been shown to be superior to treating fluctuating levels. This type of control can be difficult for many reasons in the trauma patient as a result of pre-existing diabetes, obesity, stress response, steroid use, nutritional support, and several other reasons.14 Finally, the premorbid state of the patient is an important consideration. Pre-existing cardiovascular and pulmonary disease affecting tissue perfusion and oxygenation has already been discussed. However, obesity, metabolic derangements, endocrine disease, immune dysfunction, and renal and hepatic failure also impair normal wound healing profoundly.15-18 Bose and Tejwani19 reviewed recently the evolving trends in the care of the critically ill polytrauma patient and outlined clear indications for damage control surgery and staging delayed repair. Often surgery for facial trauma can and should wait. A patient not optimized properly for surgery runs the risk of not only poor overall outcome, but poor results of the reconstruction efforts. Not infrequently breakdown of wounds leads to “revisions” and more insult to tissues. Free flaps are lost in the effort to reconstruct too hastily. After several flaps have been “burned” the option for flaps dwindles as does hope for optimal outcome. A compromised patient portends a compromised reconstructive outcome.
Wound Considerations Although the majority of lacerations can be repaired by primary definitive closure, there are circumstances when delayed treatment of complex soft tissue injuries may be best accomplished by delayed techniques. It should be said that aggressive excision of tissue is not advocated in either primary or delayed treatment. The blood supply is adequate to nearly all tissue no matter how contused or small a pedicle. A common technique used for contaminated or infected lacerations is delayed primary closure. This involves a period of dressing changes when the wound is cleaned and conditioned to promote a healthy bed of granulation tissue to form while decreasing the bacterial burden. The wound can then be closed with less chance of infection and the associated sequela. In the past, this technique was used frequently, whereas today this technique is most useful for infected or contaminated wounds that have failed attempt at primary closure. In situations where defects are large enough to require grafts or flaps, there are benefits to delaying these to gain superior results. In the case of a ques-
1211 tionable or poor recipient bed, wound conditioning is used to ensure better chance for the graft or flap to heal. There also may be instances when the exact size and configuration of the defect is not clear due to continued necrosis. As stated earlier, the unnecessary loss of flaps is undesirable. Color and texture matching is best done with local flaps. Providing enough tissue may require the use of a tissue expander. In the case where tissue expansion is desired, the wound should be maintained by dressing changes or wound vacuum-assisted therapy or covered with temporary skin graft until tissue expansion is complete. This approach accomplishes both wound conditioning and providing adequate amount of local tissue needed for transfer without adversely affecting the donor site. A common reason for delaying treatment is to allow for resolution of edema. In cases of open fractures, the overlying soft tissue wounds can be closed in an interval fashion. Once the edema has resolved in 7 to 10 days bony defects can be repaired more easily. Orbital fractures are common scenarios. This technique not only allows for subtle deformities to be appreciated, but also prevents the undo retraction of the soft tissue that can produce poor outcomes in the periorbital region. Furthermore, properly identifying all deformities allows a single intervention rather than multiple insults to the soft tissue that produces fibrosis and decreased vascularity ultimately leading to thick and stiff tissue. In treating complex composite injuries circumstances necessitate thoughtful planning. Simply “closing the hole” with microvascular transfer does not always provide the most desired outcome. Midface composite defects oftentimes involve a great deal of subtle anatomic detail. This detail lies both in the skeleton as well as the soft tissue drape. For the skeleton, fabrication of stereolithic models can be very helpful in planning. Templates can be designed and information discovered that would alter choices of flaps. It also may be decided that custom implants or other prosthetic types of reconstruction would prove superior.20 Many facial composite defects can be restored with osteocutaneous free flaps such as maxillary or mandibular composite defects that can be restored with fibula free flaps. Gunshot wounds are common scenarios. There exists a dogma between low velocity and high velocity ballistic wounds. Although low velocity wounds often permit early successful treatment, high velocity ballistic wounds present certain clinical differences that must be appreciated. The amount of tissue loss and devitalization is often much greater. As a result, there exists a phenomenon of an enlarging area of necrosis over several days. This requires observation of the wound and serial debride-
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FIGURE 3. Patient presenting after nasal reconstruction and before maxillary and dental reconstruction. (Courtesy of Eric J. Dierks, DMD, MD.) Brett A. Ueeck. Penetrating Injury Treatment. J Oral Maxillofac Surg 2007.
FIGURE 2. Initial injury to midface from a .357 handgun at close range. (Courtesy of Eric J. Dierks, DMD, MD.) Brett A. Ueeck. Penetrating Injury Treatment. J Oral Maxillofac Surg 2007.
ments until surviving tissue is identified. Although early reduction of bone and closure of soft tissue is carried out, this does not classify as primary definitive reconstruction as the actual definitive reconstruction at times is delayed for several weeks. Often several revisions are required, thereby voiding the term “definitive.”21 In cases that require multiple stages of reconstruction, the free flap option is often best delayed until the exact nature of the defect is diagnosed and the patient is best prepared for this intervention. In the case illustrated, the patient suffered a close-range hand gun injury to the midface resulting in loss of nose and maxillary tissue. His reconstruction was staged in a way allowing for initial stabilization and staged repair beginning with his nose and ending with his dentition. Using this approach was crucial in determining the exact amount of facial projection and midface height. He ultimately gained a favorable appearance and function based on proper tooth position, lip to tooth ratio, and vertical dimension of occlusion (Figs 2-4). For complex composite defects in the partially dentate patient, there exists at times a better option than osteocutaneous free flaps. Distraction osteogenesis is a promising technique that has been very useful for
the reconstruction of these defects. To facilitate distraction, soft tissue reconstruction and healing should be complete to ensure integrity of the wound. By using distraction, the overall shape and amount of regenerate provides superior bone and soft tissue relationship and contour. Another well-observed benefit of distraction is the increase in native soft tissue. Patients and prosthodontists prefer the benefits of normal oral mucosa to large, bulky, and hairy skin paddles. Once the distraction has healed, restoration of the dentition is undertaken with implant support prostheses.22 Finally, there are times when a multidisciplinary approach is best due to complexity. Temporizing wounds allows time for the team to be assembled,
FIGURE 4. The use of a fibula free flap to repair maxillary bone and oral soft tissue defects. (Courtesy of Eric J. Dierks, DMD, MD.) Brett A. Ueeck. Penetrating Injury Treatment. J Oral Maxillofac Surg 2007.
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diagnostic imaging and models can be attained, and input from the various providers discussed. Patient/ family input can be sought and informed consent secured. Once the patient is stable and optimally tuned for surgery, the best intervention can be delivered with the hopes for the ideal outcome.
Patient Autonomy/Informed Consent Beginning down the path of major reconstructive surgery in today’s environment requires proper informed consent. Patient autonomy has taken the place of provider paternalism. Major surgical decisions must include direct patient or family input. There are times when the patient’s desires will preclude or eliminate such intervention as with the scenario presented above. The patient’s spiritual beliefs prevented intervention although there are often other reasons as well.23 A part of the informed consent discussion is educating the patient about the expenses that will be incurred. This is not only proper for the patient, but is socially conscious as well. Some authors have suggested doing as much surgery as possible at the first operation because patients will often not return for further reconstruction. This may be because the patients do not feel further surgery is necessary; that again is an expression of autonomy. It may also be due to issues of expense.24 A majority (⬎50%) of the patients treated by our service do not have insurance or the resources to cover their treatment. This results in cost shifting and ultimately higher costs, not only for those paying, but for those not paying as well. Although this is not the venue to discuss the social aspects of who gets what care, these are issues that must be considered. Patients without means to cover extensive reconstruction should be informed of all their options with discussion of the associated expenses and the devastating consequences of not paying for these services. There exists a continuum of repair and reconstruction for all wounds. This ranges from simple primary repair of lacerations to staged reconstructive efforts for complex composite defects. Although we are making ongoing advances in the treatment of all types of wounds, we are unable presently to provide definitive primary repair in severe cases of penetrating facial trauma. Critical appraisal of what is termed “definitive primary care” is in reality staged repair. Actual primary repair is not always possible or favorable for a variety of reasons. These include not only the patient’s medical status, certain wound considerations and lack of technology, and capability, but also reasons of culture, religion and, unfortunately, finances as the ability to pay for future advanced treatment is further challenged.
Reflecting back to the introductory case where early and definitive operative treatment would have been desirable, a different treatment course was dictated ultimately by patient autonomy. In circumstances such as this, knowledge and skill with alternative treatment methods provided a way for acceptable treatment. By staging the closure of his wounds and the application of several methods of closed reduction, we were able to steadily and safely restore his form and function with delayed treatment. Technology is available currently that allows for rigid internal fixation, safe and reliable closure of soft tissue, as well as importing both soft and hard tissue into the area from local or distant sites. There are cases when we possess the ability to provide early primary treatment using one or all these options. However, clearly it is not always the best treatment to use a technology simply because it exists. The known soft tissue effects of multiple surgical procedures—fibroses, stiffening, contraction, and color changes—are difficult at best to remedy. A poorly planned or executed primary repair may not prevent multiple operations and ultimately result in a less desirable outcome than if treatment was delayed initially. In the future, technology will provide us the ability to primarily repair all wounds nearly completely in a single early operation without the use of autogenous flaps or grafts. Matrices with the appropriate constituents for the regrowth of whatever tissue is required in the desired form and amount will become standard. However, the ability to continually provide thoughtful individualized patient care will always be required.
References 1. Medline Plus. US National Library of Medicine and National Institutes of Health. Available at http://www.nlm.nih.gov/medlineplus/head andbraininjuries.html, and http://www.biausa.org/Pages/types_of_ brain_injury.html. Accessed April 5, 2007 2. Gussack GS: Penetrating Face and Neck Trauma. Baileys Head and Neck Surgery–Otolaryngology (vol 1). Philadelphia, Lippincott, 1993, pp 1008-1017 3. Osborne TE, Bays RA: Pathophysiology and management of gunshot wounds to the face, in Fonseca RJ, Walker RVOral and Maxillofacial Trauma (vol 2). Philadelphia, WB Saunders, 1991, pp 672-701 4. Rowe NL, Killey HC: The evolution of the treatment of maxillofacial injuries, in Rowe NL, Killey HC: Fractures of the Facial Skeleton. London: E&S Livingston, 1970, pp 825-856 5. Osborn TM, Ueeck BA, Ham B, et al. A case of asystole from periorbital laceration manipulation and oculocardiac reflex in an acute trauma setting. J Trauma 2007 (in press) 6. Buchmiller-Crair TL, Kim CS, Won NH, et al: Effect of acute anemia on the healing of intestinal anastomoses in the rabbit. J Trauma 51:363, 2001 7. Jonsson K, Jensen JA, Goodson WH 3rd, et al: Tissue oxygenation, anemia, and perfusion in relation to wound healing in surgical patients. Ann Surg 214:605, 1991
1214 8. Shapiro MJ, Gettinger A, Corwin HL, et al: Anemia and blood transfusion in trauma patients admitted to the intensive care unit. J Trauma 55:269, 2003 9. Dzik S, Blajchman MA, Blumberg N, et al: Current research on the immunomodulatory effects of allogeneic blood transfusion. Vox Sang 70:187, 1996 10. Malone DL, Dunne J, Tracy JK, et al: Blood transfusion, independent of shock severity, is associated with worse outcome in trauma. J Trauma 54:898, 2003 11. Avall A, Hyllner M, Bengtson JP, et al: Postoperative inflammatory response after autologous and allogeneic blood transfusion. Anesthesiology 87:511, 1997 12. Claridge JA, Sawyer RG, Schulman AM, et al: Blood transfusion correlates with infections in trauma patients in a dose-dependent manner. Am Surg 68:566, 2002 13. Moore FA, Moore EE, Sauaia A: Blood transfusion. An independent risk factor for postinjury multiple organ failure. Arch Surg 1997 132:620, 1997 14. Roberts SR, Hamedani B: Benefits and methods of achieving strict glycemic control in the ICU. Crit Care Nurs Clin North Am 16:537, 2004 15. Williams DT, Harding K: Healing process of the skin and muscle tissue in critical illness. Crit Care Med 31:S547, 2003
PENETRATING INJURY TREATMENT 16. Riou JP, Cohen JR, Johnson H Jr: Factors influencing wound dehiscence. Am J Surg 163:324, 1992 17. Lin KY, Johns FR, Gibson J, et al: An outcome study of breast reconstruction: Presurgical identification of risk factors for complications. Ann Surg Oncol 8:586, 2001 18. Rico RM, Ripamonti R, Burn AL, et al. The effects of sepsis on wound healing. J Surg Res 102:193, 2002 19. Bose D, Tejwani NC. Evolving trends in the care of polytrauma patients. Injury 37:20, 2006 20. Yuksel F, Celikoz B, Ergun O, et al: Management of maxillofacial problems in self-inflicted rifle wounds. Ann Plast Surg 53:111, 2004 21. Clark N, Birely B, Manson PN, et al: High-energy ballistic and avulsive facial injuries: classification, patterns, and an algorithm for primary reconstruction. Plast Reconstr Surg 98:583, 1996 22. Labbe D, Nicolas J, Kaluzinski E, et al: Gunshot wounds: Reconstruction of the lower face by osteogenic distraction. Plast Reconstr Surg 116:1596, 2005 23. Phipps E, Shelton W: Forgoing medical treatment in severe facial trauma. J Trauma 43:970, 1997 24. Alper M, Totan S, Cankayali R, et al: Gunshot wounds of the face in attempted suicide patients. J Oral Maxillofac Surg 56: 930, 1998
Penetrating Injuries to the Face: Delayed Versus Primary Treatment— Considerations for Delayed Treatment Brett A. Ueeck, DMD, MD* As with any debate in the practice of surgery, there must be no absolutes. Each patient deserves the attention of directed thought and treatment his or her individual problem demands. Adhering blindly to algorithms and approaching treatment options closedminded produces only average results the majority of the time and poor results too frequently. Creative thinking based on sound surgical principles coupled with good clinical judgment drives excellent patient care outcomes and the discovery and advancement of new techniques. A penetrating injury is defined as an injury that occurs as a result of an object, such as a knife, bullet, or shrapnel, which violates cutaneous or mucosal barriers and enters the body. This definition encompasses a large number of injuries with a wide spectrum of severity. Certain body regions provide a stricter definition of what classifies as penetrating. For example, a neck wound is classified as penetrating if it violates the platysma muscle and a penetrating head wound if it violates the dura mater.1,2 Injuries of the penetrating type lend themselves to further classification. Classification is not standardized, however. Wounds are often distinguished as high velocity versus low velocity or missile versus nonmissile. Injuries are described commonly as avulsive when soft or hard tissue is lost. A composite defect is one where both soft and hard tissue is lost. It is this category of wounds that has the greatest potential for severity and complex reconstructive challenges.2,3 In contrast, blunt injuries do not violate the cutaneous or mucosal coverings. These injuries can range from simple contusions to severe panfacial fractures. *Assistant Professor of Surgery, Division of Oral and Maxillofacial Surgery, Oregon Health and Sciences University, Portland, OR. Address correspondence and reprint requests to Dr Ueeck: OHSU, Dept OMS, 611 SW Campus Drive, Portland, OR 97239; e-mail: [email protected] © 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6506-0022$32.00/0 doi:10.1016/j.joms.2006.10.078
There are several subclassifications of these injuries. In general it is unwise to correlate severity with either a blunt or penetrating injury type. The terms primary and delayed treatment are somewhat ambiguous and can be defined differently depending on the context. For our purpose primary treatment will be defined as initial treatment of a wound within 48 hours with the intent to definitively manage all aspects of the injury. The goal of primary treatment is to repair the wound in such a way that both hard and soft tissue is restored and all wounds primarily closed. Delayed treatment will include all other forms of treatment, which are numerous. Classically, surgeons selecting delayed treatment have advocated debriding soft tissue injuries and stabilizing bony injuries. After edema has resolved and the soft tissues have healed to cover the wounds, the final reconstruction is attempted. Staged repair of wounds also will be classified as a form of delayed treatment.
Historical Background Historically penetrating wounds were treated open with frequent bandage changes and various medicaments applied. In the time of Ambrose Pare, the mindset of burning and cauterizing wounds underwent a paradigm shift to one of a more biologically sound method of cleaning and caring for vital tissue without inflicting further insult. Eventually, methods of primary wound treatment evolved to the current level of sophistication, whereby the majority of wounds can be cleaned and closed. The advent of anesthesia and antibiotics combined with knowledge of wound treatment and healing was crucial in this evolution. Today, the increasing sophistication of technology and surgical critical care continues to advance our reconstruction options.4 Without a doubt, the majority of penetrating wounds to the maxillofacial area are lacerations that are generally cleaned easily and closed primarily. Little controversy exists regarding this current standard of practice. For more complex penetrating wounds, however, the debate continues regarding which
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wounds should be treated primarily versus delayed. Proponents that favor primary treatment claim superior esthetic and functional outcomes, whereas those of the delayed approach claim fewer complications due to infection. Interestingly, there are more issues to the debate that are seldom discussed and will be presented in regard to circumstances when more substantial penetrating wounds should be considered for delayed repair.
Treatment Considerations There are situations today that demand delay in treatment for several valid reasons. This clinical vignette presents some of the issues. A 17-year-old male was riding a motorized scooter when he was run over by a large truck at a high rate of speed. The trauma system was activated and he was rushed to a nearby level 1 trauma center for care. His resuscitation and stabilization was successful, although he remained in the ICU on cardiac and ventilator support. Injuries to his head, thorax, abdomen, pelvis, and long bones were severe. He sustained complex penetrating injuries to his face consisting of several long complex lacerations with open comminuted panfacial fractures. Planning for early operative intervention was begun and then aborted when it was learned that he was a Jehovah’s Witness. Family refused consent for any blood products despite a hemoglobin of 4 gm/dL. Issues that prevent early intervention include patient medical status, family/patient autonomy, and inability to conduct an informed consent discussion with the patient.
Patient Status An obvious reason for delayed treatment is the inability for the patient to tolerate an operative intervention. Common injuries that preclude operative intervention are neurologic, cervical spine, and severe thoracic or abdominal injuries. The polytrauma patient with a considerable overall physiologic wound burden is prohibitive as well. Generally, one thinks in terms of the patient being medically stable, and once cleared by the trauma critical care team, operative intervention for the facial injuries can commence. However, both the risk of adverse outcome to the patient, as well as the medical-legal aspect must be considered. Uncertain neurologic or cervical spine statuses are examples. Even though the patient may be stable for surgery, unexpected or adverse outcomes of these injuries may result in questioning the decision for early facial surgery. The argument is easily made the patient’s outcome would have been different (better) if your facial surgery was delayed.
FIGURE 1. The state of severe facial wounds 1 month after admission in a patient with a hematocrit averaging 15. (Same patient presented in the opening case of this study.) Brett A. Ueeck. Penetrating Injury Treatment. J Oral Maxillofac Surg 2007.
A patient was treated recently by our service with a large facial laceration and orbital fractures. She had just undergone an emergent nephrectomy to control abdominal bleeding and while still on the operating room table was deemed stable for our team to repair her facial lacerations. Shortly after commencing the cleaning of her periorbital lacerations she developed asystole. Even though she regained a perfusing sinus rhythm she never recovered.5 Tissue perfusion and oxygenation is another problem encountered frequently in the critical trauma patient. This can be the result of acute blood loss, as well as other underlying disease states such as cardiac, pulmonary, and peripheral vascular disease. It is well documented that wound healing is less than ideal in these situations. Reduction in hematocrit, even with appropriate volume resuscitation, causes a decrease in white blood cell infiltration, blood vessel ingrowth, and collagen content and strength within the wounded tissue. Impaired wound healing is seen with a hematocrit below 30 and less than 20 is generally considered too low especially in the setting of other comorbidities such as cardiovascular disease (Fig 1).6,7 Often there is a need for blood transfusions in the trauma setting for treatment of anemia and shock. It is well understood that blood transfusions are detrimental to immune function. Both proliferation and function of immune cells are impaired. Furthermore, the inflammatory response is induced and exacerbated by transfusions. Combine this with the already hypercoagulable state of the trauma patient and the risk of microvascular free flap failure probably increases. Overall, transfusions are independent risk factors for
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perioperative infection, multi-organ failure, and death.8-13 Glycemic control in the critically ill patient is essential for wound healing as well as overall outcome. Maintaining blood glucose within normal ranges has been shown to be superior to treating fluctuating levels. This type of control can be difficult for many reasons in the trauma patient as a result of pre-existing diabetes, obesity, stress response, steroid use, nutritional support, and several other reasons.14 Finally, the premorbid state of the patient is an important consideration. Pre-existing cardiovascular and pulmonary disease affecting tissue perfusion and oxygenation has already been discussed. However, obesity, metabolic derangements, endocrine disease, immune dysfunction, and renal and hepatic failure also impair normal wound healing profoundly.15-18 Bose and Tejwani19 reviewed recently the evolving trends in the care of the critically ill polytrauma patient and outlined clear indications for damage control surgery and staging delayed repair. Often surgery for facial trauma can and should wait. A patient not optimized properly for surgery runs the risk of not only poor overall outcome, but poor results of the reconstruction efforts. Not infrequently breakdown of wounds leads to “revisions” and more insult to tissues. Free flaps are lost in the effort to reconstruct too hastily. After several flaps have been “burned” the option for flaps dwindles as does hope for optimal outcome. A compromised patient portends a compromised reconstructive outcome.
Wound Considerations Although the majority of lacerations can be repaired by primary definitive closure, there are circumstances when delayed treatment of complex soft tissue injuries may be best accomplished by delayed techniques. It should be said that aggressive excision of tissue is not advocated in either primary or delayed treatment. The blood supply is adequate to nearly all tissue no matter how contused or small a pedicle. A common technique used for contaminated or infected lacerations is delayed primary closure. This involves a period of dressing changes when the wound is cleaned and conditioned to promote a healthy bed of granulation tissue to form while decreasing the bacterial burden. The wound can then be closed with less chance of infection and the associated sequela. In the past, this technique was used frequently, whereas today this technique is most useful for infected or contaminated wounds that have failed attempt at primary closure. In situations where defects are large enough to require grafts or flaps, there are benefits to delaying these to gain superior results. In the case of a ques-
1211 tionable or poor recipient bed, wound conditioning is used to ensure better chance for the graft or flap to heal. There also may be instances when the exact size and configuration of the defect is not clear due to continued necrosis. As stated earlier, the unnecessary loss of flaps is undesirable. Color and texture matching is best done with local flaps. Providing enough tissue may require the use of a tissue expander. In the case where tissue expansion is desired, the wound should be maintained by dressing changes or wound vacuum-assisted therapy or covered with temporary skin graft until tissue expansion is complete. This approach accomplishes both wound conditioning and providing adequate amount of local tissue needed for transfer without adversely affecting the donor site. A common reason for delaying treatment is to allow for resolution of edema. In cases of open fractures, the overlying soft tissue wounds can be closed in an interval fashion. Once the edema has resolved in 7 to 10 days bony defects can be repaired more easily. Orbital fractures are common scenarios. This technique not only allows for subtle deformities to be appreciated, but also prevents the undo retraction of the soft tissue that can produce poor outcomes in the periorbital region. Furthermore, properly identifying all deformities allows a single intervention rather than multiple insults to the soft tissue that produces fibrosis and decreased vascularity ultimately leading to thick and stiff tissue. In treating complex composite injuries circumstances necessitate thoughtful planning. Simply “closing the hole” with microvascular transfer does not always provide the most desired outcome. Midface composite defects oftentimes involve a great deal of subtle anatomic detail. This detail lies both in the skeleton as well as the soft tissue drape. For the skeleton, fabrication of stereolithic models can be very helpful in planning. Templates can be designed and information discovered that would alter choices of flaps. It also may be decided that custom implants or other prosthetic types of reconstruction would prove superior.20 Many facial composite defects can be restored with osteocutaneous free flaps such as maxillary or mandibular composite defects that can be restored with fibula free flaps. Gunshot wounds are common scenarios. There exists a dogma between low velocity and high velocity ballistic wounds. Although low velocity wounds often permit early successful treatment, high velocity ballistic wounds present certain clinical differences that must be appreciated. The amount of tissue loss and devitalization is often much greater. As a result, there exists a phenomenon of an enlarging area of necrosis over several days. This requires observation of the wound and serial debride-
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FIGURE 3. Patient presenting after nasal reconstruction and before maxillary and dental reconstruction. (Courtesy of Eric J. Dierks, DMD, MD.) Brett A. Ueeck. Penetrating Injury Treatment. J Oral Maxillofac Surg 2007.
FIGURE 2. Initial injury to midface from a .357 handgun at close range. (Courtesy of Eric J. Dierks, DMD, MD.) Brett A. Ueeck. Penetrating Injury Treatment. J Oral Maxillofac Surg 2007.
ments until surviving tissue is identified. Although early reduction of bone and closure of soft tissue is carried out, this does not classify as primary definitive reconstruction as the actual definitive reconstruction at times is delayed for several weeks. Often several revisions are required, thereby voiding the term “definitive.”21 In cases that require multiple stages of reconstruction, the free flap option is often best delayed until the exact nature of the defect is diagnosed and the patient is best prepared for this intervention. In the case illustrated, the patient suffered a close-range hand gun injury to the midface resulting in loss of nose and maxillary tissue. His reconstruction was staged in a way allowing for initial stabilization and staged repair beginning with his nose and ending with his dentition. Using this approach was crucial in determining the exact amount of facial projection and midface height. He ultimately gained a favorable appearance and function based on proper tooth position, lip to tooth ratio, and vertical dimension of occlusion (Figs 2-4). For complex composite defects in the partially dentate patient, there exists at times a better option than osteocutaneous free flaps. Distraction osteogenesis is a promising technique that has been very useful for
the reconstruction of these defects. To facilitate distraction, soft tissue reconstruction and healing should be complete to ensure integrity of the wound. By using distraction, the overall shape and amount of regenerate provides superior bone and soft tissue relationship and contour. Another well-observed benefit of distraction is the increase in native soft tissue. Patients and prosthodontists prefer the benefits of normal oral mucosa to large, bulky, and hairy skin paddles. Once the distraction has healed, restoration of the dentition is undertaken with implant support prostheses.22 Finally, there are times when a multidisciplinary approach is best due to complexity. Temporizing wounds allows time for the team to be assembled,
FIGURE 4. The use of a fibula free flap to repair maxillary bone and oral soft tissue defects. (Courtesy of Eric J. Dierks, DMD, MD.) Brett A. Ueeck. Penetrating Injury Treatment. J Oral Maxillofac Surg 2007.
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diagnostic imaging and models can be attained, and input from the various providers discussed. Patient/ family input can be sought and informed consent secured. Once the patient is stable and optimally tuned for surgery, the best intervention can be delivered with the hopes for the ideal outcome.
Patient Autonomy/Informed Consent Beginning down the path of major reconstructive surgery in today’s environment requires proper informed consent. Patient autonomy has taken the place of provider paternalism. Major surgical decisions must include direct patient or family input. There are times when the patient’s desires will preclude or eliminate such intervention as with the scenario presented above. The patient’s spiritual beliefs prevented intervention although there are often other reasons as well.23 A part of the informed consent discussion is educating the patient about the expenses that will be incurred. This is not only proper for the patient, but is socially conscious as well. Some authors have suggested doing as much surgery as possible at the first operation because patients will often not return for further reconstruction. This may be because the patients do not feel further surgery is necessary; that again is an expression of autonomy. It may also be due to issues of expense.24 A majority (⬎50%) of the patients treated by our service do not have insurance or the resources to cover their treatment. This results in cost shifting and ultimately higher costs, not only for those paying, but for those not paying as well. Although this is not the venue to discuss the social aspects of who gets what care, these are issues that must be considered. Patients without means to cover extensive reconstruction should be informed of all their options with discussion of the associated expenses and the devastating consequences of not paying for these services. There exists a continuum of repair and reconstruction for all wounds. This ranges from simple primary repair of lacerations to staged reconstructive efforts for complex composite defects. Although we are making ongoing advances in the treatment of all types of wounds, we are unable presently to provide definitive primary repair in severe cases of penetrating facial trauma. Critical appraisal of what is termed “definitive primary care” is in reality staged repair. Actual primary repair is not always possible or favorable for a variety of reasons. These include not only the patient’s medical status, certain wound considerations and lack of technology, and capability, but also reasons of culture, religion and, unfortunately, finances as the ability to pay for future advanced treatment is further challenged.
Reflecting back to the introductory case where early and definitive operative treatment would have been desirable, a different treatment course was dictated ultimately by patient autonomy. In circumstances such as this, knowledge and skill with alternative treatment methods provided a way for acceptable treatment. By staging the closure of his wounds and the application of several methods of closed reduction, we were able to steadily and safely restore his form and function with delayed treatment. Technology is available currently that allows for rigid internal fixation, safe and reliable closure of soft tissue, as well as importing both soft and hard tissue into the area from local or distant sites. There are cases when we possess the ability to provide early primary treatment using one or all these options. However, clearly it is not always the best treatment to use a technology simply because it exists. The known soft tissue effects of multiple surgical procedures—fibroses, stiffening, contraction, and color changes—are difficult at best to remedy. A poorly planned or executed primary repair may not prevent multiple operations and ultimately result in a less desirable outcome than if treatment was delayed initially. In the future, technology will provide us the ability to primarily repair all wounds nearly completely in a single early operation without the use of autogenous flaps or grafts. Matrices with the appropriate constituents for the regrowth of whatever tissue is required in the desired form and amount will become standard. However, the ability to continually provide thoughtful individualized patient care will always be required.
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