Date of Award

2023

Degree Name

Doctor of Medical Science (Trauma Science)

Schools and Centres

Medicine

First Supervisor

George L. Mendz

Second Supervisor

Professor Zsolt Balogh

Abstract

ABSTRACT Introduction Injury can be defined as an act or event that causes harm, hurt or damage. It occurs as a result of the transfer of energy to living tissue. The biological response to such an insult is inflammation and is based on the activation of immune competent cells in tandem with alterations in vascular permeability. The process is orchestrated at a subcellular level by the release of immunomodulatory molecular mediators. T

he bones of the skull and face are the key determinant of human appearance. They form the framework to which other tissues are attached. The variability of facial proportions contributes to the individuality of the human face.

Facial injury, also called maxillofacial injury, is any physical trauma that results in damage to the hard and or soft tissue elements of the viscerocranium. Fractures of the facial skeleton result from mechanical overload following a high-energy impact. Soft tissue damage, sustained in either isolation or combination, can result from either a blunt, sharp or crush injury to the skin and supporting osseous structures. Treatment delay tends to result in a double insult both from the surgical access and tissue manipulation being imposed on the already contused and injured soft tissues. The totality of these events and the inevitability of postoperative contracture and subcutaneous fibrosis conspire to compromise facial aesthetics.

Hippocrates (460 – 370 BC) is widely considered to be the father of medicine. He stated that, “war is the only proper school for a surgeon”. A cursory glance at the history of trauma management suggests that a significant number of skills and techniques that have evolved over many millennia have been extrapolated into civilian practice from the treatment of battlefield casualties. The historical and contemporaneous treatment of facial trauma has been largely driven by the overt manifestations of the physical injury. Over the last 100 years the management of the physical aspects of facial injury has remained within the purview of surgical specialties that operate regionally within the Head and Neck.
To date, research into facial trauma has almost exclusively focused on either the aetiology, assessment, management or outcome of the physical injury. v However, there has been an emerging literature on the influence that a range of personnel and population determinants can have on the epidemiology of facial injury.

It has been reported that there are a number of victims of trauma who may co-incidentally suffer from a range of pre-existing psychiatric co-morbidities and who may sustain a facial injury.
Many of the traits of disordered thought, mood, and personality may predispose the patient to harmful behaviours, which in turn may expose them to injury through aggression, self-harm and risk taking.

In addition to this, there has been a growing body of research that has proposed that episodes of intentional injury, in particular assault, can incidentally result in the development of either immediate or delayed psycho-social distress in some patients. The constellation of symptoms suffered by a selection of such patients may be so intrusive or pervasive as to meet the criteria for diagnosis of a post-traumatic stress disorder. This may in turn result in impaired social and occupational functioning for extended periods of time.

Such pre- or post-trauma psychopathology might predispose to an increased risk of sustaining either an intentional or unintentional injury or to episodes of injury recidivism; which in turn may compromise the victim’s ability to withstand the stresses of both the injury and the subsequent recovery and, over their lifetime, make such patients more reliant on outpatient mental health care and community social support services.

Seasonal influenza epidemics are known to make a substantial contribution to national and international morbidity and mortality rates. They generally have no effect on the epidemiology of facial injury. However, the social distancing and lockdown measures that were primarily instituted to reduce the spread and infectivity of the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) pandemic throughout 2020 and beyond was seen to have had a secondary, serendipitous, effect on altering the epidemiology of facial injury in population groups.

Substance abuse has become a serious global and complex public health concern. The use of alcohol and illicit drugs can impose a significant burden on the delivery of government health and social services, infrastructure and funding. The sale and consumption of alcohol at pubs, bars, restaurants, registered clubs and nightclubs promotes a high-risk environment for the occurrence of non-accidental episodes of interpersonal violence and assault occasioning injury. It is accepted that up to 40% of patients who attend trauma centres have a positive blood alcohol concentration on presentation and that this figure might rise to as much as 60% when polydrug presentation is elicited from the patient’s history. As with alcohol use, there are substantive linkages between substance abuse and the occurrence of facial injury.

Contact and non-contact sporting and leisure activities, the workplace environment and motor vehicle use are generally considered as being responsible for the occurrence of a wide variety of accidental injuries. They play a major role in the presentation of facial injury, either in isolation or combination with polytrauma. In addition, there are several other situational misadventures that can sporadically predispose to the occurrence of facial injury. All the above important observations that have been identified within both individuals and population groups are well recognized co-morbidities that can influence the frequency and characteristics of facial injury that present to my tertiary referral hospital service.

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