A penetrating facial injury, inherently fraught with life-threatening implications, mandates immediate and decisive emergency intervention. Such injuries, induced by penetrating objects like knives or glass, have the potential to lead to the fragmentation of these objects, consequently entrapping foreign bodies within the soft tissue or in bone. ¹

The prominence of the face as the most conspicuously exposed region in the human body accounts for the prevalence of injuries in this area. The intricate process of deciding upon the removal of foreign bodies from the maxillofacial region is contingent upon considerations such as size, accessibility challenges, and the proximity to critical anatomical structures. ^{2, 3}

The initial management of a patient experiencing a penetrating facial injury poses formidable challenges due to its proximity to vital structure like orbit, and major blood vessels.⁴ Abundance in nerve supply and blood supply in the maxillofacial region demands a thorough and multidisciplinary approach. In the presence of a substantial foreign body within the maxillofacial region, vital and resuscitative interventions must be promptly initiated. ⁵ Immediate stabilization of the airway and respiratory functions is imperative. Proper planning of the case with the aid of CT can play pivotal role in foreign body retrieval.

Case 1

A 55-year-old male presented to the emergency department with a history of a stabbing incident involving a knife on the right temporal region of his head. Upon clinical examination, the patient exhibited a lacerated wound measuring 4x2x3 cm near the right lateral canthus of the eye, as well as another lacerated wound of size 3x1x2 cm on the right infraorbital margin. There was no visible evidence of the assault weapon during the examination, clinically. Active bleeding from the stab wound was successfully managed through suturing. Despite the traumatic incident, the patient remained alert and oriented to person, place, and time, with stable vital signs and laboratory results (Glasgow Coma Scale score of 15). Although there was no loss of consciousness, the patient did experience two episodes of vomiting.

Following the Advanced Trauma Life Support (ATLS) guidelines and adhering to the traditional trauma protocol, the patient was stabilized. A comprehensive assessment, including a computed tomography (CT) scan of the head and neck, was conducted to assess the extent of injury to the adjacent maxillofacial structures. The CT scan revealed a fracture of the right zygomatic bone and bilateral nasal bone fractures. Importantly, there was no indication of orbital or cranial penetration (Figure 1 a).

The CT scan also identified a linear hyperdense material in the right subcutaneous plane of the temporal region, measuring approximately 8.7 cm in length, suggestive of a knife fragment. Subsequently, surgical procedure was planned for the retrieval of the knife fragment.

Surgical Management                                 

The patient underwent a surgical procedure in the operating room for removal of foreign object, under general anaesthesia. The incision was meticulously performed along the existing margins of the lacerated wound on the right lateral aspect of the eye. Subsequently, the incision was laterally extended to enhance visual access. Dissection was carried out with utmost care to prevent any inadvertent damage to neighbouring structures. The Zygomatic bone was successfully identified, and the foreign body was visualized in all directions. While ensuring stability of the head and neck, the foreign object was manually retrieved as a single piece. Surgical site hemostasis was achieved. Closure done in layers. Skin approximation done with 5-0 prolene suture material. The patient’s postoperative course was uneventful, and the facial wound healed well without objectionable scarring or deformity. The patient was discharged on post op day 4 and had been seen in the follow-up period regularly without any complications (Figure 2).

Case 2

A 35-year-old patient presented to the outpatient department with complaints of diminished mouth opening and purulent discharge from a lacerated wound in the left frontal region. The patient had sustained a traumatic injury from a wooden log, resulting in restricted mouth opening. Upon clinical examination, the patient's overall condition was deemed fair, with a mouth opening of approximately 18mm observed. Notably, pus discharge was evident from the wound site. A CT scan revealed the presence of a foreign body in the left infratemporal region (Figure 1 b). Subsequently, appropriate wound management protocols were initiated, alongside intravenous medication administration, and a surgical intervention was planned under general anaesthesia for the retrieval of the foreign object.

Surgical Management

The surgical procedure was performed under general anaesthesia. An incision was made along the existing laceration, followed by meticulous dissection through various tissue layers. The foreign object was found deeply lodged within the infratemporal fossa, to facilitate enhanced visualization and complete removal of foreign body, a zygomatic osteotomy was performed, to gain access to infratemporal region, on further exploration a wooden log was found deeply embedded in the infratemporal region. Care was taken to minimize damage to surrounding vital structures as the wooden log was removed intact. Hemostasis was carefully ensured, and the osteotomized zygomatic bone was repositioned anatomically using miniplates. Layered closure of the surgical site was performed, with skin approximation achieved using 3-0 Silk suture material. The patient experienced an uncomplicated postoperative recovery, with an improved mouth opening measuring approximately 26mm on postoperative day 4, prompting the recommendation of active physiotherapy; subsequently discharged on postoperative day 7, and maintained regular follow-up visits without any complications (Figure 3).

Case 3

An 11-year-old male patient presented to the outpatient department with complaints of purulent discharge emanating from the intraoral region of the lower anterior teeth as well as the lower lip, subsequent to a traumatic event, history of fall from bicycle. The general condition of the patient was fair. Clinical examination revealed multiple avulsions within the maxillary and mandibular anterior regions. Notably, purulent exudate was observed between the mandibular teeth numbered 41 and 42 and additionally in the region of the lower lip. No further traumatic injuries were identified. In order to ascertain the presence of any foreign body, a mandibular occlusal radiograph was performed. The radiographic examination revealed a radio-opaque entity within the socket of tooth 41 regions (Figure 1 c). Based on these findings, it was determined that surgical intervention was necessary to remove the foreign body. The procedure was scheduled to be conducted under local anaesthesia.

Surgical Management

The surgical intervention was meticulously planned under local anaesthesia. Upon administration of the local anaesthetic to the mandibular area, a crestal incision was made, facilitating a trans-alveolar exploration aimed at locating the foreign body with minimal disruption to the surrounding tissues. The foreign body, identified as a stone particle, was located within the middle third of the tooth socket. Subsequent to its removal, the socket was extensively irrigated, and the surgical site was meticulously closed using 3-0 vicryl sutures. Concurrently, exploration of the lower lip region was conducted through an existing laceration. This examination led to the retrieval of a small stone fragment. Post-operative follow-up after one week revealed complete clinical healing of both the socket in the mandibular anterior region and the corresponding soft tissue in the lower lip region. Radiographic evaluation confirmed the absence of any residual foreign bodies and showed a clear socket, indicating a successful resolution of the initial traumatic complications (Figure 4)

Penetrating maxillofacial injuries pose life-threatening risks and potential disfigurement. Initial patient management involves an ATLS primary survey, followed by secondary and tertiary surveys after stabilization, crucial for systematically diagnosing and managing injuries to reduce morbidity and mortality. ^6-8          

The chief concern in managing the penetrating maxillofacial injuries is to prioritize securing the airway and controlling life-threatening bleeding. Rapid diagnosis of craniomaxillofacial structure injuries involves immediate CT imaging to determine the foreign body's position and depth, facilitating the exclusion of vascular injury or intracranial penetration.⁹ A systemic and multidisciplinary approach is essential for the comprehensive diagnosis and management of all facial injuries.     Every maxillofacial injury necessitates systematic management involving a thorough examination, a detailed history, and appropriate investigations. ¹⁰ Facial cut wounds should not be immediately addressed in primary care without prior thorough investigations. The practitioner must adhere to fundamental surgical principles when undertaking cut wound repairs. Optimal outcomes in penetrating maxillofacial injuries hinge on timely intervention, encompassing early exploration and debridement of wounds, anatomical fixation, repair of fractured bone fragments, prompt definitive management of soft tissue, and judicious antimicrobial coverage. ¹¹

A paramount concern in the management of these injuries is securing the airway, as obstructions can rapidly lead to hypoxia and subsequent complications. ¹² Control of life-threatening bleeding is equally critical, as the rich vascular supply of the maxillofacial region can result in significant hemorrhage. The use of immediate CT imaging is instrumental in the rapid diagnosis of injuries to craniomaxillofacial structures.⁹ CT scans provide detailed information on the position and depth of foreign bodies, allowing for the exclusion of vascular injuries or intracranial penetration.⁶ This imaging modality is invaluable in guiding the clinical team’s decisions, ensuring that interventions are precise and effective. ⁷ 

A multidisciplinary approach, involving maxillofacial surgeons, otolaryngologists, radiologists, and trauma specialists, is essential for the comprehensive management of facial injuries. ¹⁰ This collaborative strategy ensures that all aspects of the injury are addressed, from the initial stabilization and diagnosis to the definitive surgical management and post-operative care. ⁸ Each maxillofacial injury requires a systematic management plan, which includes a thorough examination, a detailed patient history, and appropriate investigations.¹¹ Facial cut wounds, in particular, should not be addressed in primary care without thorough prior investigations to avoid complications.¹² Adhering to fundamental surgical principles during wound repair is crucial for optimal outcomes. Early exploration and debridement of wounds, anatomical fixation, and repair of fractured bone fragments, along with prompt and definitive management of soft tissue injuries and judicious antimicrobial coverage, are key components of effective treatment for penetrating maxillofacial injuries.⁹

In addition to the immediate clinical management, long-term considerations play a crucial role in the comprehensive care of patients with penetrating maxillofacial injuries. Rehabilitation and reconstructive surgery are often necessary to address functional and aesthetic concerns, which can significantly impact the patient’s quality of life.⁶ Psychological support and counseling should also be integrated into the care plan, as the emotional and psychological effects of facial trauma can be profound.¹⁰ Ensuring access to these resources helps patients cope with the aftermath of their injuries and supports their overall recovery process. ⁸

Advancements in surgical techniques and imaging technologies continue to improve the outcomes of patients with penetrating maxillofacial injuries.⁷ The development of minimally invasive surgical approaches, along with the use of 3D imaging and printing, allows for more precise and less traumatic interventions.¹² These innovations enhance the ability of surgeons to repair complex injuries with greater accuracy, reducing recovery times and improving aesthetic and functional outcomes.¹¹ Ongoing research and clinical trials are essential to further refine these techniques and develop new strategies for managing such injuries.⁹

Finally, the importance of preventive measures cannot be overstated. Public health initiatives aimed at reducing the incidence of penetrating facial injuries, such as campaigns to prevent violence and accidents, play a vital role in mitigating these risks.⁹ Educating the public about the dangers of sharp objects and the importance of safety measures in high-risk environments can help reduce the occurrence of such injuries.⁹Additionally, training first responders and healthcare providers in the latest trauma management protocols ensures that patients receive the best possible care from the moment of injury through their recovery.^6,

Penetrating maxillofacial injuries pose life-threatening risks and potential disfigurement. Initial patient management involves an ATLS primary survey, followed by secondary and tertiary surveys after stabilization, crucial for systematically diagnosing and managing injuries to reduce morbidity and mortality. ^6-8          

The chief concern in managing the penetrating maxillofacial injuries is to prioritize securing the airway and controlling life-threatening bleeding. Rapid diagnosis of craniomaxillofacial structure injuries involves immediate CT imaging to determine the foreign body's position and depth, facilitating the exclusion of vascular injury or intracranial penetration.⁹ A systemic and multidisciplinary approach is essential for the comprehensive diagnosis and management of all facial injuries.     Every maxillofacial injury necessitates systematic management involving a thorough examination, a detailed history, and appropriate investigations. ¹⁰ Facial cut wounds should not be immediately addressed in primary care without prior thorough investigations. The practitioner must adhere to fundamental surgical principles when undertaking cut wound repairs. Optimal outcomes in penetrating maxillofacial injuries hinge on timely intervention, encompassing early exploration and debridement of wounds, anatomical fixation, repair of fractured bone fragments, prompt definitive management of soft tissue, and judicious antimicrobial coverage. ¹¹

A paramount concern in the management of these injuries is securing the airway, as obstructions can rapidly lead to hypoxia and subsequent complications. ¹² Control of life-threatening bleeding is equally critical, as the rich vascular supply of the maxillofacial region can result in significant hemorrhage. The use of immediate CT imaging is instrumental in the rapid diagnosis of injuries to craniomaxillofacial structures.⁹ CT scans provide detailed information on the position and depth of foreign bodies, allowing for the exclusion of vascular injuries or intracranial penetration.⁶ This imaging modality is invaluable in guiding the clinical team’s decisions, ensuring that interventions are precise and effective. ⁷ 

A multidisciplinary approach, involving maxillofacial surgeons, otolaryngologists, radiologists, and trauma specialists, is essential for the comprehensive management of facial injuries. ¹⁰ This collaborative strategy ensures that all aspects of the injury are addressed, from the initial stabilization and diagnosis to the definitive surgical management and post-operative care. ⁸ Each maxillofacial injury requires a systematic management plan, which includes a thorough examination, a detailed patient history, and appropriate investigations.¹¹ Facial cut wounds, in particular, should not be addressed in primary care without thorough prior investigations to avoid complications.¹² Adhering to fundamental surgical principles during wound repair is crucial for optimal outcomes. Early exploration and debridement of wounds, anatomical fixation, and repair of fractured bone fragments, along with prompt and definitive management of soft tissue injuries and judicious antimicrobial coverage, are key components of effective treatment for penetrating maxillofacial injuries.⁹

In addition to the immediate clinical management, long-term considerations play a crucial role in the comprehensive care of patients with penetrating maxillofacial injuries. Rehabilitation and reconstructive surgery are often necessary to address functional and aesthetic concerns, which can significantly impact the patient’s quality of life.⁶ Psychological support and counseling should also be integrated into the care plan, as the emotional and psychological effects of facial trauma can be profound.¹⁰ Ensuring access to these resources helps patients cope with the aftermath of their injuries and supports their overall recovery process. ⁸

Advancements in surgical techniques and imaging technologies continue to improve the outcomes of patients with penetrating maxillofacial injuries.⁷ The development of minimally invasive surgical approaches, along with the use of 3D imaging and printing, allows for more precise and less traumatic interventions.¹² These innovations enhance the ability of surgeons to repair complex injuries with greater accuracy, reducing recovery times and improving aesthetic and functional outcomes.¹¹ Ongoing research and clinical trials are essential to further refine these techniques and develop new strategies for managing such injuries.⁹

Finally, the importance of preventive measures cannot be overstated. Public health initiatives aimed at reducing the incidence of penetrating facial injuries, such as campaigns to prevent violence and accidents, play a vital role in mitigating these risks.⁹ Educating the public about the dangers of sharp objects and the importance of safety measures in high-risk environments can help reduce the occurrence of such injuries.⁹Additionally, training first responders and healthcare providers in the latest trauma management protocols ensures that patients receive the best possible care from the moment of injury through their recovery.^6,

Optimal outcomes in penetrating maxillofacial injuries hinge on timely intervention, encompassing early exploration and debridement of wounds, anatomical fixation, repair of fractured bone fragments, prompt definitive management of soft tissue, and judicious antimicrobial coverage.

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12. Oikarinen KS, Nieminen TM, Mäkäräinen H, Pyhtinen J: Visibility of foreign bodies in soft tissue in plain radiographs, computed tomography, magnetic resonance imaging, and ultrasound: an in vitro study. Int J Oral Maxillofac Surg. 1993; 22:119-124. 10.1016/S0901-5027(05)80232-4.