Key points

Introduction

Complications are common in the facial trauma setting, and there are several causes. All facial trauma surgeons should be knowledgable about potential associated intracranial and ocular injuries and how to prevent further morbidity. A multidisciplinary approach is often required, and early consultation with appropriate specialists is recommended. An understanding of common posttraumatic complications will guide surgical management. The most common complications of facial trauma are summarized in Tables 1 and 2 .

Introduction

Complications are common in the facial trauma setting, and there are several causes. All facial trauma surgeons should be knowledgable about potential associated intracranial and ocular injuries and how to prevent further morbidity. A multidisciplinary approach is often required, and early consultation with appropriate specialists is recommended. An understanding of common posttraumatic complications will guide surgical management. The most common complications of facial trauma are summarized in Tables 1 and 2 .

Surgical complications of soft tissue and viscera

Important overall tenets of facial trauma are to minimize scarring and prevent further injury to adjacent structures. The bony skeleton of the face protects multiple organs that are important to the functions of daily life. It is imperative that these organs are thoroughly evaluated at the initial presentation and the findings accurately documented. Scarring may be unavoidable, depending on the damage to soft tissue from the primary injury and/or location of the fractures and the access required for their repair. Lacerations should be copiously irrigated, minimally debrided, and closed primarily in a layered fashion. Local skin flaps may be used to cover defects, if necessary. Hypertrophic or cosmetically unfavorable scars can be treated with dermabrasion, serial excision, or scar revision.

Brain injuries occur in up to 89% of patients with complex facial trauma. All patients should be evaluated for potential involvement of the brain or cervical spine ( Table 3 ), and an urgent neurosurgical consultation should be obtained for any positive findings. Traumatic brain injuries can be classified as closed, penetrating, and explosive blast injuries, with the severity based on the Glasgow Coma Scale. Cerebrospinal fluid (CSF) leaks carry a 10% to 30% risk of developing meningitis, and can present acutely at the time of initial injury or in a delayed fashion. Symptoms include persistent clear rhinorrhea or otorrhea, description of a salty taste in the mouth by the patient, headaches, or recurrent meningitis, and can be confirmed with a positive β2-transferrin test of collected fluid. Most CSF leaks resulting from accidental and surgical trauma heal with conservative measures over the course of 7 to 10 days, although waiting for the leak to close spontaneously can increase the risk of meningitis, and close assessment to assure that complete resolution has occurred is necessary. Surgical management includes exposure of the leak with primary repair or patch placement. Meningitis is treated aggressively with parenteral broad-spectrum antibiotics. To prevent irreversible neurologic injury, spinal-cord injury should be suspected in all trauma patients until it is ruled out. Repair of facial fractures may initially be delayed while the patient is hemodynamically stabilized. If repair is performed before clearance of the cervical spine, it is imperative that the cervical spine remains in a neutral position. Closed reduction or external fixation techniques may be necessary to avoid injury to the spinal cord if access is inadequate.

Table 3

Intracranial complications

Traumatic brain injury (TBI)	Closed head TBI	Typically a result of blunt impact. May result in a focal lesion in the brain (hematoma) or diffuse axonal injury (from shearing of axons against the skull base)	Neurosurgical consultation necessary
	Penetrating TBI	Occurs with foreign body violation of the skull and dura, entering the brain parenchyma. The size, speed, and track of the projectile determine the extent of neurologic damage	Neurosurgical consultation necessary
	Explosive blast TBI	More common in military combat and causes diffuse injury secondary to a pressure wave. Often results in rapidly developing cerebral edema, subarachnoid hemorrhage, and burst-pattern skull fractures	Neurosurgical consultation necessary
Cerebrospinal fluid (CSF) leak	Symptoms: persistent clear rhinorrhea or otorrhea, description of salty taste in mouth, headaches or recurrent meningitis	Neurosurgical or otolaryngology consultation may be necessary. Conservative management: bed rest, head elevation, avoidance of nose blowing or straining, and stool softeners. Antibiotic prophylaxis and lumbar drain placement is controversial and often surgeon dependent. Current studies have found no benefit from prophylactic antibiotics, though remains controversial Surgical management: transcranial, subcranial, or endoscopic approach with the placement of a mucosal, fascial, or bone graft. The endoscopic approach has become more prevalent and is shown to be safe and effective, with a 90% initial success rate that improves further with subsequent attempts, with lower morbidities than open procedures
Meningitis	Symptoms: headache, nausea, photophobia, altered level of consciousness, fever, nuchal rigidity and pain with flexion of the neck	Empiric first-line treatment in patients with postneurosurgical meningitis is intravenous vancomycin plus cefepime or ceftazidime

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