INTRODUCTION
Traumas caused by external causes had a significant increase in the hospitalization
rate in the Unified Health System (SUS) in the last decade1. In this context, facial
fractures have presented an increasing frequency. Due to their anterior body projection,
the facial skin and bones are extremely exposed in motor vehicle accidents and victims
of urban violence. The etiology of facial trauma, as well as its epidemiological profile,
is quite varied2.
According to the World Health Organization (WHO), approximately 1.2 million people
die in traffic every year. Annually, the number of seriously injured varies from 20
to 50 million people. Traffic accidents are the leading cause of death in the 15-29
age group. Most of these deaths (90%) are concentrated in low- and middleincome countries.
In Brazil, in 2013, approximately 40 thousand people died in traffic accidents. This
number has grown in recent years3.
From 2000 to 2015, there was a 33% increase in fatalities in land transport accidents
in Brazil. Of the 38,651 deaths, 31.4% were motorcyclists. The social and economic
impact is great. In 2013 alone, the Unified Health System (SUS) recorded 170,000 hospitalizations
due to land accidents, with a final cost of approximately BRL 231.5 million. Furthermore,
in underdeveloped countries, high rates of urban and domestic violence contribute
to increasing the social and economic impact of trauma4.
Since the face is the true region of expression of the soul, in which all feelings
are represented, knowledge of the particularities of facial trauma is important, as
it definitively compromises the life of the human being and, when poorly addressed,
leaves sequelae, marginalizing the individual from the social interaction, generating
work incapacity, condemning him to economic segregation5.
Facial fractures commonly result in injuries to soft tissues, teeth, mandible, maxilla,
zygoma, nasal bones, naso-orbito-ethmoidal complex and supraorbital structures6. Proper treatment reduces the possibility of permanent deformities, which bring aesthetic,
emotional and functional sequelae. Thus, detailed anatomical knowledge of facial structures
is essential to obtain an accurate diagnosis and the best form of intervention. Advances
in facial imaging and the improvement of evidence-based surgical indications have
led to a reassessment of time-honored techniques and guidelines.
Epidemiological data on facial fractures are also essential to warn about diagnoses
and draw attention to the management of these injuries and the need to carry out preventive
campaigns aimed at the population. Furthermore, they contribute to the planning and
assessment of collective health7. Given the relative frequency of this type of trauma in trauma centers and the socio-cultural
changes, this study aims to trace the epidemiological profile of patients treated
by the Plastic Surgery service of a teaching hospital in a city in the interior of
the state of São Paulo between April 2015 and April 2020.
OBJECTIVE
To carry out an epidemiological survey of facial trauma with a diagnosis of facial
fracture that were surgically treated among patients treated at the Plastic Surgery
Service of the Universidade Estadual de Campinas (UNICAMP), in Campinas-SP.
METHODS
A retrospective epidemiological study was carried out at the Hospital de Clínicas
da UNICAMP (HCUNICAMP), located in Campinas-SP, a university hospital.
The initial selection of patients was obtained through the registry of surgeries extracted
from the HCUNICAMP Information System. After identifying all facial fracture surgeries
performed between April 2015 and April 2020, there was an individual consultation
of the medical records of each of the patients selected for the study.
Two examiners performed data collection, both resident physicians in the Plastic Surgery
discipline, previously calibrated for standardized data collection.
Only patients who had a complete record in medical records related to facial fractures
were included in the study, including trauma etiology, gender and age of the patient,
the topography of facial fractures, comorbidities, treatment instituted, need for
admission to the Intensive Care Unit (ICU) ) at some point during hospitalization
and surgical complications. Participants who did not include the data proposed by
the protocol and patients who only had dentoalveolar fractures were excluded from
the study. This series did not include reductions in nasal bone fractures performed
in an outpatient setting or an emergency room.
The data were submitted for descriptive analysis and quantitative, represented by
mean, median, and percentages using Microsoft ExcelTM software.
Patients who are still undergoing outpatient followup or who have been contacted by
telephone signed the Free and Informed Consent Term (FICT). Patients who no longer
undergo outpatient follow-up and those not located (via telephone, contact with the
social service, among other ways) were exempted from signing the informed consent.
The Ethics Committee approved this work of the Universidade Estadual de Campinas under
the Certificate of Presentation of Ethical Appreciation: 33327220.2.0000.5404.
RESULTS
One hundred forty-seven patients who underwent surgery to correct a facial fracture
in the period mentioned above were selected. Six patients were excluded from the study,
as four had incomplete medical records, and two refused to sign the informed consent.
A total of 141 patients were included, 120 (85%) male and 21 female (15%) (Figure 1). The gender ratio was approximately 6:1. The mean age was 34.3 years (ranging from
5 to 77 years), with a median of 32 years and 26 years (Figure 2). Ninety-nine (70%) patients declared themselves white, 37 (26%) brown, 4 (3%) black
and 1 (1%) yellow.
Figure 1 - Distribution between sex (left) and ethnicity (right).
Figure 1 - Distribution between sex (left) and ethnicity (right).
Figure 2 - Age distribution of patients operated on for facial fractures.
Figure 2 - Age distribution of patients operated on for facial fractures.
As for the etiology of the trauma, 60 (42%) suffered accidents with motor vehicles,
38 (27%) were victims of physical aggression, 18 (13%) suffered falls, 10 (7%) bicycle
accidents, 7 (5%) being run over, 4 (3%) firearm injuries and 4 (3%) other mechanisms
(Figure 3).
Figure 3 - Etiology of facial trauma.
Figure 3 - Etiology of facial trauma.
In the analysis of CT scans of facial bones performed after the trauma, we obtained
the following results: 17 (12.0%) patients fractured the frontal bone, 95 (67%) the
orbit - 30 exclusively in the right orbit, 38 the left and 27 bilaterally; 46 (32%)
fractured the zygoma - 17 exclusively on the right, 24 exclusively on the left and
5 bilaterally; 38 (28%) fractured the nasal bone; 79 (56%) fractured the maxilla -
22 exclusively on the right, 34 exclusively on the left and 23 bilaterally; 58 (41%)
fractured the mandible; 2 (1%) fractured the sphenoid bone; 2 (1%) fractured the temporal
bone (both on the right) (Figure 4).
Figure 4 - Topography of facial fractures.
Figure 4 - Topography of facial fractures.
The mean time between trauma and surgery was 40.4 days (median: 18 days), with the
shortest time being 0 days and the longest being 910 days. Thirty-one (22%) patients
had some comorbidity, the most common being: hypertension (12) and smoking (9). Twenty
(14%) patients had some complications from the surgery, the most frequent being: surgical
wound dehiscence and titanium plate extrusion (5 patients with each complication).
Other complications included: visual changes, surgical wound infection (FO), granuloma,
palate fistula, lipodystrophy, periorbital cellulitis, and conjunctival hematoma.
Thirty-one (22%) patients had some sequel, predominantly ectropion and visual alteration.
Thirty (21%) patients required the ICU after the trauma, with a mean hospital stay
of 10 days. Sixty (43%) patients had injuries associated with facial fractures, the
most common being orthopedic and neurological injuries. Thirty-six (26%) patients
underwent surgery by other specialties during therapy. Fifteen (11%) patients had
reports of alcohol ingestion in their records prior to the traumatic event.
DISCUSSION
The face is prone to different types of aggression. Thus, facial trauma assumes a
prominent role in emergency care worldwide. The manifestations of facial fractures
may vary according to gender, ethnicity, age and socioeconomic status5.
In this study, a significant difference was found between the male and female patients
undergoing surgery to reduce and fix facial fractures. Approximately 85% of patients
were male. The male-female ratio was approximately 6:1. These data are consistent
with those found in the literature. Studies show ratios of 16.9:1, 14:1, 5.5:1, 8.2:1,
5.3:1 8-12. Several reasons can explain the higher incidence of facial fractures in men: men
are more frequent drivers, especially on highways, a higher rate of drug abuse, and
a greater tendency to get involved in accidents/fights2.
Although the male-female ratio remains high, we have seen a decrease in this ratio
in recent years. In the last three decades, there has been a significant increase
in the incidence of trauma in women, especially younger ones. This is due to the change
in female behavior in society, including an increase in the number of female drivers,
greater inclusion of women in the labor market, an association between alcohol and
driving, and the practice of sports that involve physical contact2,6. Despite the increasing number of traumas among women, there are few cases with most
female victims13.
The most prevalent ethnicity was white, followed by brown, black and yellow. Few epidemiological
articles analyzed addressed this topic. A study carried out in Salvador-BA in 2008
showed a higher incidence of facial trauma in browns and blacks13. This difference can be explained by the fact that our study was carried out in Campinas-SP,
whose ethnic composition is mostly white, while the other study was carried out in
Salvador-BA, whose population is mostly mixed race14.
Regarding the etiology of the trauma, the most common mechanism was that related to
motor vehicles, followed by physical aggression. In Brazil, traffic accidents and
aggressions predominate as the main mechanisms related to facial trauma2,5-7. In Europe, the main trauma mechanisms include sports accidents, especially cycling
accidents15,16. Another important factor that can influence the increase of a certain mechanism,
to the detriment of others, is the hospital where the study is being carried out.
This is what the study carried out by Motta in 200917 suggests, which presented the fall as the main mechanism of trauma. According to
the author, the fact that the study was carried out in a secondary hospital contributed
to this result since serious traumas, such as car accidents, are rare.
The results of this research are consistent with what is found in the Brazilian literature
on the etiology of trauma. In Brazil, accidents with motor vehicles and physical aggression
correspond to the main causes of facial trauma5-7,13,18,19. This can be explained by the fact that Brazil has high and growing socioeconomic
inequality, with a high rate of unemployment, low education and abuse of licit substances,
such as alcohol or illicit substances13.
The most fractured structure was the orbit, followed by the maxilla, mandible, zygoma,
nasal bone, frontal bone, sphenoid, and temporal. The literature is quite varied in
this regard. A study carried out in Austria with 14,654 patients also found the orbit
to be the most fractured structure15. Other studies point to the nasal bone as the most fractured6,17. The nasal bone is the most prominent structure on the face. This characteristic,
associated with the fragility of the nasal bone, makes this segment prone to fracture
in trauma17. Therefore, many authors consider it the most fractured facial bone in trauma.
In our study, the low incidence of nasal fractures can be explained by two reasons:
only patients who underwent surgery to correct a facial fracture under general anesthesia.
Not all patients who present a nasal fracture have indications for surgical intervention
for its correction. In addition, in our service, many cases of nasal bone fractures
are treated with a reduction in an outpatient setting, with local anesthesia and sedation
when necessary. These patients treated on an outpatient basis were not included in
this series.
The mean time between the trauma and the surgical procedure was 40.4 days. This data
is above that found in the literature17,20,21. This occurred because, in some cases, conservative treatment was initially chosen;
however, surgical intervention proved necessary during follow-up. In some cases, patients
had prolonged hospitalization due to the severity of the condition, requiring ICU
and surgical intervention by other specialties, causing facial fracture surgery to
be postponed until stabilization of the patient’s clinical condition or treated as
a sequel in varied time, but usually for more than one month after the trauma. For
comparative purposes, we can use the median found in our work, 18 days, which more
faithfully represents the mean time between trauma and surgical intervention. This
time is slightly higher than the average found in the literature, but it is within
an acceptable time interval for treating fractures17,20.
Approximately 14% of patients had some complications. This rate is higher than the
5.8% and 7.4% presented in other works by Brazilian authors17,22. We believe that one of the factors contributing to this high rate is the fact that
the study was carried out in a university hospital, a regional reference, where highly
complex cases are often referred to. The high rates of ICU admission (21%), associated
injuries (43%) and surgical procedures performed by other specialties (26%) demonstrate
the challenging scenario of traumas treated in our service.
Only 11% of patients reported drinking alcohol before the trauma. In the literature,
the relationship between alcohol use and facial fractures is well described17,22. This information is collected in trauma care with the patient, who may omit or lie
about this data. In addition, there is no routine test that evaluates the amount of
alcohol in the body. Furthermore, possibly in the high-demand emergency room scenario,
medical records are often not detailed, making it difficult to tabulate these data.
Therefore, we believe that this information is underestimated in our work.
When analyzing the age distribution of our patients, we observed that most of them
are between 20 and 40 years old. Traditionally, it represents the age group with the
highest risk of trauma, as young people, especially men, tend to have higher risk
behavior than children, adolescents and the elderly7. In no age group analyzed, there was a predominance of females. This study did not
explain the distribution between fracture etiology and age group. However, a greater
number of victims of accidents with motor vehicles and victims of aggression are expected
in young people and a greater number of falls in the elderly5.
CONCLUSION
Traffic accidents predominantly caused surgical facial fractures, followed by physical
aggression and falls. The victims were male in 85% of the cases, and the mean age
of the patients was 34.2 years. Orbit fractures were the ones that most required surgical
treatment. The epidemiological data are important for the Institution that seeks an
improvement in the measures of prevention, education, and systematization of care.
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1. Universidade Estadual de Campinas, Hospital de Clínicas, Departamento de Cirurgia,
Campinas, SP, Brazil
2. Universidade Cidade de São Paulo, São Paulo, SP, Brazil
Corresponding author: Luiz Henrique Zanata Pinheiro Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, Brazil, Zip Code:
13083-970, E-mail: henriquez_pinheiro@hotmail.com
Article received: May 12, 2021.
Article accepted: July 14, 2021.
Conflicts of interest: none.
