Elsevier

Injury

Volume 48, Issue 1, January 2017, Pages 70-74
Injury

The surgical management of facial trauma in British soldiers during combat operations in Afghanistan

https://doi.org/10.1016/j.injury.2016.08.009Get rights and content

Abstract

Introduction

The recent Afghanistan conflict caused a higher proportion of casualties with facial injuries due to both the increasing effectiveness of combat body armour and the insurgent use of the improvised explosive device (IED). The aim of this study was to describe all injuries to the face sustained by UK service personnel from blast or gunshot wounds during the highest intensity period of combat operations in Afghanistan.

Methods

Hospital records and Joint Theatre Trauma Registry data were collected for all UK service personnel killed or wounded by blast and gunshot wounds in Afghanistan between 01 April 2006 and 01 March 2013.

Results

566 casualties were identified, 504 from blast and 52 from gunshot injuries. 75% of blast injury casualties survived and the IED was the most common mechanism of injury with the mid-face the most commonly affected facial region. In blast injuries a facial fracture was a significant marker for increased total injury severity score. A facial gunshot wound was fatal in 53% of cases. The majority of survivors required a single surgical procedure for the facial injury but further reconstruction was required in 156 of the 375 of survivors aero medically evacuated to the UK.

Conclusions

The presence and pattern of facial fractures was significantly different in survivors and fatalities, which may reflect the power of the blast that these cohorts were exposed to. The Anatomical Injury Scoring of the Injury Severity Scale was inadequate for determining the extent of soft tissue facial injuries and did not predict morbidity of the injury.

Section snippets

Background

As the weapons of war change so do the patterns of injury. In World War One the troops in the trenches sustained horrific facial injuries from shrapnel that required surgeons to try new combinations of techniques forming the basis of modern plastic surgery [1]. United Kingdom service personnel were operating in Afghanistan as part of International Security Assistance Forces (ISAF) from 2001 on Operation HERRICK. The Improvised Explosive Device (IED) was the defining weapon used against ISAF in

Patients and methods

The UK Joint Theatre Trauma Registry (JTTR) is a restricted database of all injuries sustained by British service personnel admitted to a Field Hospital on operations [12]. The JTTR uses the Abbreviated Injury Scale (AIS) as an anatomical scoring system to code every injury, the military version of AIS 2005 was used [13].

The face in the JTTR includes facial skin and soft tissues, the maxillofacial skeleton, eyes and ears. Injuries to the scalp, head and neck are separately coded. For the

Results

A total of 633 UK service personnel with facial injury were identified. Blast injury accounted for 563 of the facial injuries and gunshot wounds (GSWs) for 70. 59 blast injury casualties were excluded after suffering isolated tympanic membrane perforation and no other facial injury. 8 facial GSWs were excluded as the facial injury itself was not related to the GSW or miscoded. Therefore a total of 504 blast injuries and 62 GSWs were further studied. There were 405 survivors (wounded in action)

Mechanism of injury

The predominant mechanism of injury in both survivors and fatalities was the IED. The type of gunshot injury was not specified. All mechanisms are listed in Table 2.

UK hospital care

In the blast cohort 136 soldiers required facial and/or ophthalmic surgery at the Royal Centre for Defence Medicine. There were a total of 230 operations for these patients, a mean of 1.7, range of 1–8. Multiple staged reconstructive facial surgeries were required in 21 (16%) of these patients. This was predominantly eyelid (n = 7) and nasal (n = 9) reconstructions. There were 3 free flaps and 7 local flaps used in facial reconstructions in this group.

In the GSW cohort 20 soldiers required further

Discussion

Complex injuries from improvised explosive devices were the hallmark of the conflict in Afghanistan [14]. Typically the blast wave is from underneath the soldier, whether on foot or mounted in a vehicle [15], which would explain why lower limb injuries were most commonly associated with facial injuries in blast victims and why the pattern of injury was predominantly affecting the mid and lower face.

From this data it appears that in this conflict the pattern of blast injury to the face is

Conflict of interest statement

There are no other potential conflicts of interests.

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