INTRODUCTION

Facial trauma represents a substantial source of trauma-related morbidity, most often resulting from road traffic accidents (RTAs), interpersonal violence, falls, and sports injuries [1]. The face is particularly vulnerable because of its exposed anatomical position and its complex bony and soft tissue structures, making management both functionally and aesthetically challenging [2]. Although facial injuries are rarely life-threatening, they are frequently associated with airway compromise, severe hemorrhage, and traumatic brain injury, necessitating a systematic approach to evaluation and intervention [1]. The Advanced Trauma Life Support (ATLS) protocol provides the foundation for managing facial trauma, ensuring airway stabilization, hemorrhage control, and recognition of associated injuries before addressing reconstructive needs [2]. Pediatric facial trauma presents unique considerations due to skeletal immaturity and the greater elasticity of bones, often warranting conservative management strategies. Airway control remains a critical challenge in cases of severe trauma [3]. This case series describes the clinical presentation, management challenges, and treatment strategies employed in facial trauma.

CASE REPORTS

The patient information, including clinical findings and outcomes are summarized in Table 1 and shown in Figs. 1–8.

Case 1

A 21-year-old man presented to our trauma center after an RTA. He was initially treated at a local health center and subsequently referred to our hospital for further management. Evaluation followed ATLS protocol. The primary survey was unremarkable. Secondary survey revealed a ruptured right eye globe with a sutured wound over the right eyebrow and upper eyelid (Fig. 1A). Noncontrast computed tomography (NCCT) of the head showed a comminuted right frontal fracture with underlying frontal contusion and pneumocephalus (Fig. 1B, C). NCCT of the face demonstrated a displaced right zygomaticomaxillary complex (ZMC) fracture (Fig. 1D). Ophthalmology consultation for ocular trauma recommended evisceration of the right eye. The head injury was managed conservatively. Open reduction and internal fixation (ORIF) of the ZMC fracture was performed, along with evisceration of the ruptured globe by the ophthalmology team. The postoperative course was uneventful. The patient was discharged on postoperative day (POD) 8 and continues to do well on follow-up.

Case 2

A 56-year-old man presented to our trauma center following an RTA involving a two-wheeler. He was a non-helmeted rider. Evaluation followed ATLS protocol. He had experienced loss of consciousness, right ear and nasal bleeding, and vomiting, but no seizures. On primary survey, the airway was patent, and cervical spine motion was restricted using a hard cervical collar. Breathing was labored, with decreased air entry on the left side and a respiratory rate of 22 breaths per minute. A positive chest compression test was also noted on the left side. The patient was tachycardic but fluid responsive at the time of assessment. Neurological examination revealed a Glasgow Coma Scale (GCS) score of 15. Chest x-ray demonstrated left third to sixth lateral rib fractures with hemothorax. Left tube thoracostomy drained 100 mL of hemorrhagic content. Secondary survey identified a 10×3×1.5-cm lacerated wound extending from the superior part of the right nasal ala to the right angle of the mandible (Fig. 2A). Radiological imaging of the head and face revealed no abnormalities. He was taken to the operating room for wound irrigation and primary suturing. Layered facial closure was performed, and sutures were removed on POD 5. The postoperative course was uneventful, and the patient was discharged on POD 10 following suture removal. He remains well on follow-up with an aesthetically favorable outcome (Fig. 2B).

Case 3

A 22-year-old man presented to our trauma center after a motor vehicle crash. He was a non-helmeted bike rider who sustained a high-speed skid and fall, followed by a collision with a pole. He reported a brief loss of consciousness (1–2 minutes). Evaluation followed ATLS protocol. The primary survey was within normal limits. Secondary survey revealed a 10×4×1.5-cm laceration on the left side of the face and forehead (Fig. 3A). The wound extended across the left forehead and cheek, passing 2 mm lateral to the lateral canthus of the left eye, with exposed muscle and bone. Radiological investigations were performed after stabilization. NCCT of the head was normal, while NCCT of the face demonstrated a left zygoma fracture and fracture of the inferior wall of the left orbit (Fig. 3B). He underwent operative wound management and reconstruction. After thorough wound irrigation with povidone iodine (Betadine), miniplates and screws were applied for zygoma fixation (Fig. 3C). Layered closure was performed. The postoperative course was uneventful, and sutures were removed on POD 5. He was discharged on POD 10 and remains well on follow-up.

Case 4

A 32-year-old woman presented to our trauma center following a motor vehicle crash in which she was a pillion rider on a two-wheeler that rear-ended a tractor. She was not wearing a helmet at the time. The primary survey was within normal limits. Secondary survey revealed a degloving injury extending from the right temporal scalp to the right angle of the mouth in a craniocaudal direction and across to the left side of the forehead in a horizontal direction (Fig. 4A). NCCT of the head and face revealed no abnormalities. With a diagnosis of degloving injury, she underwent operative wound management. The wound was thoroughly irrigated and closed in layers (Fig. 4B, C). She was subsequently shifted to the ward. Sutures were removed on POD 5. She was discharged on POD 10 and continues to show favorable aesthetic outcomes on follow-up (Fig. 4D).

Case 5

A 60-year-old man was brought to our trauma center after a rail track injury that resulted in extensive maxillofacial trauma. Evaluation in the emergency department followed ATLS protocol. Primary survey revealed severe facial trauma with a high risk of airway obstruction, necessitating immediate airway management (Fig. 5A). Attempts at conventional airway management, including endotracheal intubation, were unsuccessful due to the extent of injury. A cricothyroidotomy was therefore performed to secure the airway. Once stabilized, the patient was transferred to the operating room for further evaluation. Detailed assessment of maxillofacial injuries was undertaken, and layered repair of soft tissue injuries was performed. An open tracheostomy was also completed. The wound was irrigated thoroughly before closure (Fig. 5B). The patient was shifted to the intensive care unit (ICU). Subsequent radiological evaluation, including NCCT of the face, revealed nasal bone and left ZMC fractures (Fig. 5C). ORIF was performed for fracture stabilization. He was gradually weaned off the ventilator and shifted to the ward. Tracheostomy was removed on POD 12, and the patient was discharged. He remains well on follow-up with favorable aesthetic outcomes (Fig. 5D).

Case 6

An 8-year-old boy presented to our trauma center following a motor vehicle crash involving a lateral collision between a two-wheeler and an autorickshaw, which subsequently toppled. He experienced a brief loss of consciousness and presented with nasal and right ear bleeding. The primary survey was within normal limits. Secondary survey revealed a degloving injury on the right side of the face, measuring approximately 15×8×0.5 cm, involving the right ear with avulsion of the right pinna. Additionally, a degloving injury of the left parieto-occipital scalp measuring 6×5×0.5 cm was noted (Fig. 6A). NCCT of the head and face showed no abnormalities. The patient was taken to the operating room, where layered wound repair was performed (Fig. 6B). He was shifted to the ward and discharged on POD 3, with instructions for suture removal at follow-up after one week. Sutures were removed as planned, and the patient continues to do well on follow-up.

Case 7

A 47-year-old man presented to our trauma center with a gunshot injury to the face. Primary survey was within normal limits. Secondary survey revealed an entry wound over the left cheek, crepitus, and abnormal mobility over the left mandible. Intraoral examination demonstrated a buccal mucosal tear on the left side. Skull x-ray showed a bullet lodged posterior to the left ramus of the mandible near the vertebra (Fig. 7A, B). NCCT of the face revealed a comminuted fracture of the left mandibular angle with segmental bone loss (Fig. 7C). After stabilization, the patient underwent surgery for bullet retrieval and mandibular fixation. The bullet was successfully extracted, and reconstruction of the mandible was performed using two angular plates secured with screws to stabilize the fractured segments (Fig. 7D). Intraoral repair was performed by suturing the mucosa with layered closure, including muscle and fascia. The extraoral incision was also meticulously closed (Fig. 7E). An orthopantomogram confirmed fixation with angular plates and screws (Fig. 7F). The patient was admitted to the ICU, sutures were removed on POD 5, and he was discharged. Postoperative follow-up has demonstrated encouraging outcomes (Fig. 7G).

Case 8

A 23-year-old man was brought to the emergency department after a high-speed head-on collision between two-wheelers. He was not wearing a helmet. On arrival, the primary survey revealed a threatened airway due to severe maxillofacial trauma and active oral bleeding. Immediate endotracheal intubation was performed using a 7.5-mm tube, and the patient was placed on ventilator support. Breathing and circulation were stable. Neurological evaluation showed a GCS score of 7 (E1VTM5). Secondary survey identified a 10×4-cm lacerated wound in the left submandibular region communicating with the oral cavity, along with a 5×2-cm laceration at the left oral commissure also communicating with the oral cavity (Fig. 8A). Additionally, a laceration of the posterior pharyngeal wall on the left side with active bleeding was noted. NCCT of the face revealed a left parasymphysis mandibular fracture with substantial bone loss (Fig. 8B). After optimization, operative intervention was undertaken. Following thorough irrigation, a 5-cm segmental bone loss was confirmed in the left mandibular body. A rib graft was harvested from the left seventh rib and used for reconstruction with a titanium reconstruction plate, secured by locking screws (Fig. 8C). Soft tissue injuries, including lacerations in the submandibular region and oral commissure, were meticulously debrided and repaired in layers with tension-free closure. Intraoral mucosal lacerations were sutured with absorbable sutures. Postoperative three-dimensional NCCT of the face confirmed successful reconstruction with rib graft and titanium plate (Fig. 8D). The patient was weaned off the ventilator on POD 1 and resumed oral feeding on POD 2. Recovery was uneventful. Tracheostomy was removed, and he was discharged on POD 10. He remains well on follow-up with ongoing rehabilitation.

Ethics statement

Informed consent for publication of the research details and clinical images was obtained from all patients (or their guardians).

DISCUSSION

Facial trauma is a major component of traumatic injuries, most often caused by RTAs, interpersonal violence, and sports-related activities, with alcohol implicated in nearly 50% of cases. Advances in imaging modalities, surgical fixation techniques, and multidisciplinary management have markedly improved outcomes, underscoring the importance of restoring both function and aesthetics [2].

Epidemiological studies indicate that facial trauma is predominantly associated with RTAs (66.7%), followed by falls (14.7%), assaults (8.7%), sports injuries (6.7%), and alcohol-related incidents (3.3%), making it a significant public health concern [1]. The incidence is higher in men (67.3%), particularly in the age 26–45 years, which may reflect greater exposure to high-risk activities such as driving and outdoor labor. In our case series, 75% of facial trauma cases resulted from RTAs, with 83.3% involving non-helmeted riders. Soft tissue injuries, including degloving injuries, accounted for 37.5% of cases. These injuries demand meticulous surgical repair to restore function and cosmesis. In this series, thorough irrigation, layered closure, and surgical precision produced favorable outcomes, with 87.5% of patients experiencing uneventful recovery.

Fractures of the ZMC and mandible each represented 25% of cases. In the literature, ZMC fractures are the most common facial fractures (66.0%), whereas mandibular fractures frequently involve the parasymphysis (30.0%) and condylar regions (28.7%), typically requiring operative intervention. Concomitant head injuries are reported in up to 64% of severe facial trauma, further complicating management. While 67.3% of cases in prior studies healed uneventfully, complications such as infection (18.0%) and malocclusion (11.3%) highlight persistent challenges in recovery. Given the strong association between RTAs and maxillofacial trauma, stricter enforcement of helmet laws, improved road safety measures, and development of specialized trauma centers remain critical for reducing incidence and enhancing patient outcomes [1].

The initial management of facial soft tissue injuries follows a structured ATLS-guided approach, with priorities including airway stabilization, hemorrhage control, and secondary survey to identify fractures or neurovascular compromise. Definitive treatment consists of wound irrigation, hemostasis, debridement, and layered closure to ensure functional and aesthetic restoration. In complex cases involving high-energy trauma or avulsion injuries, staged reconstruction with rotational flaps, skin grafts, or microvascular techniques may be necessary to achieve optimal long-term outcomes [4].

Emergency airway management was required in 37.5% of cases in this series, including endotracheal intubation in two cases and cricothyroidotomy in one case. Establishing a secure airway is a critical priority in maxillofacial trauma, as obstruction may result from swelling, bleeding, bony displacement, or tongue prolapse. Endotracheal intubation with video-assisted laryngoscopy or fiberoptic guidance is the preferred method. However, in severe midfacial trauma, submental intubation or tracheostomy may be necessary to maintain airway patency while preserving surgical access. In cases where conventional intubation is unsuccessful, surgical airway procedures such as cricothyroidotomy or tracheostomy must be performed promptly to prevent hypoxia and further complications, in line with ATLS protocols [3].

The incidence of facial fractures in children is considerably lower than in adults, owing to the elasticity of pediatric bones, the relative prominence of the cranium, and the protective effect of the buccal fat pad. Falls (58.4%) are the leading cause of pediatric facial trauma, followed by RTAs (24.7%). Mandibular fractures are most common in this population (63.6%), particularly in the parasymphysis and condylar regions. Management options range from conservative measures such as closed reduction and splinting to ORIF in severe cases [5].

This case series highlights the complexities of managing severe maxillofacial trauma and underscores the pivotal role of a multidisciplinary approach in achieving favorable outcomes. RTAs, particularly those involving non-helmeted riders, were the leading cause of injuries, emphasizing the urgent need for stricter road safety regulations and mandatory helmet use. Meticulous adherence to ATLS principles ensured effective airway stabilization, hemorrhage control, and definitive management of fractures and soft tissue injuries. Surgical interventions, including ORIF and layered wound closure, yielded excellent functional and aesthetic results, with 87.5% of patients achieving uneventful recovery. Nevertheless, challenges such as airway compromise, infection risk, and complex fracture patterns persist, underscoring the need for continued innovation and refinement in trauma care strategies. This series reinforces the critical importance of early intervention, precise surgical technique, and comprehensive follow-up in optimizing recovery and improving the quality of life for patients with maxillofacial trauma.

ARTICLE INFORMATION

Author contributions

Conceptualization: HK; Investigation: all authors; Methodology: RS; Resources: DK; Visualization: AH, MA; Writing–original draft: HK, AH; Writing–review & editing: AVK, RS, DK, MA. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Case 1. (A) Clinical photograph showing a sutured wound over the right eyebrow and upper eyelid with associated periorbital swelling and ocular trauma. (B, C) Axial noncontrast computed tomography (NCCT) of the head demonstrating a right frontal comminuted fracture with underlying frontal contusion and pneumocephalus. (D) Three-dimensional NCCT reconstruction of the face revealing a displaced right zygomaticomaxillary complex fracture.

Fig. 2.

Case 2. (A) Clinical photograph showing a lacerated wound over the right cheek, extending from the superior part of the right nasal ala to the right mandibular angle. (B) Postoperative clinical photograph demonstrating a well-healed wound with a well-approximated scar.

Fig. 3.

Case 3. (A) Clinical photograph showing a laceration involving the left forehead and cheek. (B) Three-dimensional noncontrast computed tomography (NCCT) image of the face revealing a left zygoma fracture with an associated fracture of the inferior orbital wall. (C) Postoperative 3D NCCT image demonstrating open reduction and internal fixation of the left zygoma fracture. (D) Postoperative follow-up clinical photograph showing well-healed surgical scars.

Fig. 4.

Case 4. (A) Clinical photograph showing an extensive degloving injury of the face. (B) Intraoperative photograph demonstrating wound debridement and flap elevation for primary suturing. (C) Intraoperative photograph showing layered closure to restore soft tissue integrity. (D) Postoperative follow-up photograph demonstrating well-healed surgical scars with good tissue approximation. The patient provided informed consent for publication of the clinical images.

Fig. 5.

Case 5. (A) Clinical photograph showing extensive maxillofacial trauma with significant soft tissue damage and potential airway compromise. (B) Intraoperative photograph demonstrating thorough irrigation and layered repair of facial soft tissue injuries. (C) Three-dimensional noncontrast computed tomography reconstruction of the face revealing a nasal bone fracture and a left zygomaticomaxillary complex fracture. (D) Postoperative follow-up photograph showing well-healed facial wounds. The patient provided informed consent for publication of the clinical images.

Fig. 6.

Case 6. (A) Clinical photograph showing an extensive degloving injury on the right side of the face. (B) Intraoperative photograph demonstrating meticulous irrigation, hemostasis, and layered closure of facial and scalp injuries. The patient's guardian provided informed consent for publication of the clinical images.

Fig. 7.

Case 7. (A, B) X-ray image showing a bullet lodged posterior to the left mandibular ramus near the vertebra. (C) Three-dimensional noncontrast computed tomography reconstruction of the face revealing a comminuted fracture of the left mandibular angle with segmental bone loss. (D) Intraoperative image demonstrating mandibular reconstruction using two angular plates secured with screws. (E) Intraoperative image showing meticulous suturing of the extraoral incision wound. (F) Orthopantomogram demonstrating angular plates and screws. (G) Postoperative follow-up image showing good wound healing. The patient provided informed consent for publication of the clinical images.

Fig. 8.

Case 8. (A) Clinical photograph showing extensive maxillofacial trauma with multiple lacerations, including a submandibular wound and a laceration at the left oral commissure. (B) Three-dimensional noncontrast computed tomography (NCCT) image of the face revealing a left parasymphysis mandibular fracture with bone loss. (C) Intraoperative image showing harvesting of the left seventh rib for grafting and reconstruction of the mandibular defect, followed by fixation with a titanium reconstruction plate secured with locking screws. (D) Postoperative 3D NCCT image of the face demonstrating successful reconstruction of the left mandibular body with a rib graft and titanium reconstruction plate.

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