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Type: Editorial
Published: 24-09-2018

 

The multidisciplinary management of complex facial trauma at Royal Adelaide Hospital

Broughton Snell MBBS (Hons) FRACS (Plast),1,2 Ben Grave FRACDS (OMS) MA Surg (Craniofac)3,4

1

Plastic and Reconstructive Surgery
Division of Surgery
Bendigo Health
Bendigo, Victoria
AUSTRALIA

 

2

Monash University
School of Rural Health
Bendigo, Victoria
AUSTRALIA

3

Australian Craniofacial Unit
North Adelaide, South Australia
AUSTRALIA

 

4

University of Adelaide
Adelaide, South Australia
AUSTRALIA

OPEN ACCESS

Correspondence

Name: Broughton Snell

Address: Clinical Director—Plastic Surgery
Bendigo Health
100 Barnard Street
Bendigo, Victoria, 2550
AUSTRALIA

Email: bsnell@bendigohealth.org.au

Phone: +61 3 5443 0294

Citation: Snell B, Grave B. The multidisciplinary management of complex facial trauma. Aust J Plast Surg. 2018;1(2):31–32.

Accepted for publication: 3 March 2018

Copyright © 2018. Authors retain their copyright in the article. This is an open access article distributed under the Creative Commons Attribution Licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.


Interpersonal violence, motor vehicle accidents and sporting activities are the most common causes of injuries in patients presenting with complex facial trauma in Australia.1 The severity and pattern of injury can be directly related to the level of energy involved in the impact. As with trauma in other anatomical regions, such as the lower limb, greater energy leads to more severe injury both in terms of complexity and variability of outcome.2 In the case of high-energy injuries to the lower limb, a well-resourced and organised ‘lower limb service’ that draws on expertise from orthopaedic surgeons, vascular surgeons and plastic surgeons has been shown to lead to better patient outcomes.3 The rationale behind multidisciplinary involvement is simple—each of the subspecialties has a necessary skill set to address the skeletal, vascular or soft tissue injury, and so predictably leads to a better outcome for the patient. It is on this principle that the combined facial fracture service at the Royal Adelaide Hospital, South Australia, is based.

Historically, in Australia, oral and maxillofacial surgery training has focused on the management of injuries to the facial skeleton and secondary correction of malocclusion. Plastic and reconstructive surgeons possess skills in both skeletal and soft tissue injuries—in addition to managing primary injuries of the facial skeleton, plastic surgeons are trained to manage difficult injuries to more complex soft tissue structures, such as eyelids, ears, nose and lips and can draw on their microsurgical training to reconstruct skeletal or soft tissue defects. Craniofacial surgeons (with backgrounds in either plastic and reconstructive surgery or oral and maxillofacial surgery) have additional experience and skills for transcranial approaches to the upper and mid-facial skeleton, as well as drawing on the armamentarium of skills from their primary area of specialist training.

The Royal Adelaide Hospital (RAH) has three surgical units—plastic surgery, oral and maxillofacial surgery and craniofacial surgery—that take calls for patients presenting with facial injuries. The combined facial fracture service treats around 600 patients per year, with each unit seeing about 200 patients (Table 1). A solid model of clinical governance has been built around regular audits of surgical outcomes and education programs, both pre-vocational for surgical trainees and continuing professional development of consultant surgeons. Educational opportunities for trainees are optimised by spending time working with surgeons from the other disciplines. This structure and governance not only fosters broader clinical perspectives, it further strengthens collegiality in the facial trauma subspecialty.

Table 1: Number of patients presenting and types of facial injuries—combined facial fracture service
  2009     2016    
Fracture location OMFS PRS ACFU OMFS PRS ACFU
Mandible 75 35 42 60 42 45
Maxilla 29 15 35 30 25 31
ZMC 35 47 33 31 38 32
Orbit 45 47 37 47 45 47
NOE 8 14 20 8 17 21
Nasal 7 35 12 15 35 20
Frontal 8 8 18 7 8 15
Subtotal 207 201 197 198 210 212
Annual 605     620    
OMFS=Oral and maxillofacial surgery PRS=Plastic and Reconstructive Surgery
ACFU=Australian Craniofacial Unit
ZMC=zygomaticomaxillary complex NOE=naso-orbito-ethmoid

The current medicolegal environment mandates having a strong audit process in place. This not only protects the professional integrity of surgeons, it enables a peer review process and feedback mechanisms that promote and maintain clinical standards. This, in turn, leads to excellence in the quality of care delivered. The combined facial fracture service at the RAH holds fortnightly combined audit meetings to allow each unit to present data and discuss complications and difficulties relating to cases. Decision-making is aided by shared experience in, and understanding of, other specialties’ domains, which also paves the way for multi-disciplinary clinical research.

With the ever-increasing focus on healthcare quality, the cross-section of available subspecialists available at a clinical service must meet the requirements of patients’ injuries or disabilities, which is based on the pathology of facial trauma and not necessarily on anatomical boundaries traditionally defined by any given subspecialty group.

Disclosure

The authors have no financial or commercial conflicts of interest to disclose.

References

  1. Lee H, Qiu M. Characteristics of alcohol-related facial fractures. J Oral Maxillofac Surg. 2017; 75(4):786.e1–786.e7.
  2. Lim LH, Lam LK, Moore MH, Trott JA, David DJ. Associated injuries in facial fractures: a review of 839 patients. Br J Plast Surg. 1993;46(8):635–638.
  3. Franz RW, Shah KJ, Halaharvi D, Franz ET, Hartman J, Wright ML. A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center. J Vasc Surg. 2011;53:160–1610.