An impressive case of complete traumatic maxillofacial degloving

Abstract

By definition, degloving is skin and subcutaneous tissue detachment, most often affecting the limbs and extremities and occasionally the scalp. Degloving generally stems from high-energy trauma, but can also be intentional, such as in the case of planned surgical access in the anterior region of the mandible in oral-maxillofacial surgery. This paper describes an extreme case of complete traumatic maxillofacial degloving that caused partial avulsion of the soft tissues and maxilla. This is an extremely rare condition that has not previously been described in the literature, as the patient survived despite the risk of imminent death. This case report addresses the decisions made regarding the prevention of necrosis and infection that guided the emergency care and subsequent elective steps.

Globally, the incidence of facial fractures stemming from automobile accidents has decreased . Head and facial trauma account for a significant number of trauma cases and may cause irreparable, life-threatening damage.

Degloving normally results from traffic or industrial accidents. This type of injury involves the separation of the skin and subcutaneous tissue from the bones, compromising the adjacent fascia, muscles, blood vessels and nerves . Such injuries are more common in the hands, but may occur in other parts of the body, such as the craniofacial region .

Owing to the rarity of patients who experience facial degloving of this magnitude, there is no pre-established treatment protocol. The aims of initial treatment include ensuring the permeability of the airways and controlling bleeding. A shorter operation time reduces the risk of infection and necrosis and allows favourable conditions for the subsequent reestablishment of bone structures, providing the patient with adequate function and aesthetics.

The authors describe a unique, extreme case of complete maxillofacial degloving associated with multiple fractures of facial bones that required emergency measures for the stabilization and maintenance of the patient’s life.

Case Report

A 30-year-old white woman was the victim of severe facial trauma stemming from a rollover automobile accident after the driver had lost control of the vehicle. It was a small automobile not equipped with airbags and was transporting five passengers. The patient was on the back seat and was not wearing a seatbelt. One of the individuals involved in the accident reported that no passenger had been ejected from the vehicle, but this did not appear to be true, considering the degree of exogenous contamination of the wounds and the precise characteristics of the borders of the injury, which suggested high impact with a hard object on the street, such as a guard rail. The other passengers suffered minor injuries. The patient was initially taken to a low-complexity hospital for primary care, which included a tracheostomy. 9 h after the accident, she was admitted to the trauma unit of a high-complexity hospital.

On initial evaluation, the patient was conscious, oriented, pale, tachypneic, tachycardic and tracheostomized and had a cranial tomogram revealing no neurosurgical lesions. Physical examination revealed severe facial trauma with a broad laceration–contusion injury with a high degree of contamination (sticks, grass, sand and food scraps). The injury extended from the right parotid-masseter region, contoured below the chin and terminated in the left temporal region, forming a large flap with the entire area of the face. Several tissue layers were involved, along with nearly the entire maxilla, which was attached by its vestibular mucosa alone. The intensity of the trauma caused the avulsion and destruction of anatomic structures, resulting in complex fractures in the upper and middle thirds of the face. The fronto-naso-ethmoidal regions suffered substantial bone loss. The zygomatic-orbital complex suffered bilateral damage to the medial walls and orbital floors. A transverse fracture extended through the palatine process, with the breakage of the greater palatine arteries, resulting in the partial interruption of the blood supply to the maxilla, which was maintained by a vestibular vascular pedicle and separated from the rest of the facial skeleton ( Fig. 1 ). No damage to had occurred to the patient’s vision, subsequently confirmed by routine ophthalmological examination.

Fig. 1
(A) Frontal view of the patient with facial flap down showing communication between the nasal and oral cavities after severe trauma; (B, C) right and left profiles of the patient. Note that the whole mouth and a large fragment of jaw were kept in place only by the soft tissue of the buccal vestibule.

The patient was taken to the surgery room for emergency care. Under general anaesthesia through the tracheostomy, exploration and rigorous surgical cleaning of the extensive facial wound and hemostasis of the injured vessels were performed, with the blood volume reestablished with 2000 ml of lactated Ringer’s solution and two red blood cell concentrates. The aims of the primary surgery were to reconstruct the nasal structures to allow permeability of the upper airways, to reposition the extrinsic musculature of the orbits and to reposition the maxilla through maxillomandibular fixation with Erich arch bars for the maintenance of the dental arches ( Fig. 2 ). The only bone fractures treated in this first surgery were those that were exposed by the trauma: anterior wall of the frontal sinus, left zygomatic arch and nasal bones. All other fractures were left for a subsequent routine elective procedure as discussed below.

Fig. 2
(A, B) The patient after copious washing of the wound with saline, removal of devitalized tissue and fixation of fractures of the frontal bones and nasal and left zygomatic arches with titanium miniplates; (C) repositioning of the maxilla; (D) the immediate postoperative period.

The initial surgical procedure lasted 6 h, after which the patient was sent to the post-anaesthesia care unit. At that point, she was conscious and hemodynamically stable, did not require mechanical ventilation and was taking venous antibiotics and pain killers, in addition to enoxaparin prophylaxis for venous thrombosis.

12 h after admission to the post-anaesthesia recovery room, the patient was sent to the infirmary of the oral-maxillofacial surgery and traumatology sector to await clinical improvement and the planning of subsequent surgery. In the first 72 h, small perforations with an insulin needle were made daily to assess the perfusion and colouration of the vestibular and palatine mucosae in order to establish an early diagnosis of any sign of bone necrosis, but none occurred. There was no need for coadjuvant therapy, such as hyperbaric oxygenation. 10 days later, new imaging examinations were performed, including an angiogram, which revealed adequate vascularization of the face and areas suggesting vascular neoformation ( Fig. 3 A, B). Despite the injury to her left facial nerve and aesthetic impairments, characterized by traumatic telechantus and a drooping right eyelid, her progress was deemed quite satisfactory, as her masticatory function had been preserved and there were no signs of tissue necrosis or infection ( Fig. 4 ).

Jan 26, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on An impressive case of complete traumatic maxillofacial degloving
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