Aesthetic, functional and psychological outcomes of traumatic facial soft tissue injuries over three months—a prospective observational study

Introduction

Background

Facial soft tissue injuries have various esthetic, functional, and psychological outcomes. Nearly 10% of all emergency room visits are for facial soft tissue injuries (1). Soft tissue injuries are broadly categorized into contusions, abrasions, and lacerations which are usually managed by application of principles of trauma management and wound care (2).

Primary wound closure involves approximation of the wound edges, whereas wound closure by secondary intention suggests that healing occurs from the deepest to the most superficial part of the wound because the wound margins are not approximated (3). Primary wound closure is usually favored because it leaves the least amount of scarring. Scar tissue lacks the characteristics of normal uninjured skin (4). Scar assessment scales are utilized for systematic assessment of the characteristics of a scar, including its color, thickness, relief, pliability, and surface area. Both objective and subjective evaluation of scarring is essential (5). In addition to scar assessment by a practitioner, the opinions of patients on their scars must be considered to ensure that assessment is performed comprehensively (6).

The functional effects of an injury can be apparent depending on the location of the injury. Functional impairment is usually caused by loss of pliability. Asymmetry and altered or decreased facial expressions are usually caused by a lack of facial elasticity (7).

The psychological effects of facial trauma are more difficult to recognize than the functional effects (8). Acute stress reaction, post-traumatic stress disorder (PTSD), depression, generalized anxiety, and other affective disorders may occur after a facial injury. Thus, clinicians must be able to distinguish between the diagnostic traits of typical psychological presentations (9).

Rationale and knowledge gap

Facial soft tissue injuries are relatively common; however, few studies offer combined evaluation of their impact in three dimensions of aesthetics, function and psychology. Comparing patient’s perceptions of facial soft tissue injury with observer’s assessments through the healing period offers a dual perspective to inform comprehensive care approaches including mental health support. Many studies on sequelae of facial injuries include bony injuries but exclude soft tissue injuries (10).

Objective

The aim of this study was to compare the aesthetic outcomes of facial soft tissue injuries as assessed by doctor (observer) and patients, evaluate the functional sequelae of facial soft tissue injuries and their psychological effects in terms of the tendency to develop PTSD. We present this article in accordance with the STROBE reporting checklist (available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-27/rc).

Methods

Study design

This was a prospective observational study conducted from December 2020 to December 2022, with follow-up conducted at 1 week, 1 month, and 3 months post-trauma. Wound healing in facial soft tissues is mostly completed by 3 months and any long-term sequelae becomes evident by this time. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Ethics Board of Manipal College of Dental Sciences Mangalore (No. 20092) and informed consent was obtained from all individual participants. Patients with traumatic facial soft tissue injuries, including contusions, abrasions, or lacerations, who were aged 16 years or older and who understood the study protocol and were willing to come for follow-up were considered for inclusion. Exclusion criteria were surgical incisions, polytrauma, fracture displacement of underlying facial bones, traumatic brain injury [Glasgow Coma Scale (GCS) <13], subjects unable or unwilling to participate in the study.

Sample

To detect an improvement in Patient and Observer Scar Assessment Scale (POSAS) scores of 38.6% from baseline (1 week) to 3 months, assuming 95% confidence interval (CI), 10% allowable error with 10% patient attrition rate, sample size estimated was 105 facial soft tissue injuries based on study conducted by Shao et al. (11).

Sample size was estimated using the following formula: n = Z_(1-α/2)p(1 − p)/d², where Z is the standard normal variate corresponding to 95% CI, p=38.6%, d=10% allowable error.

Data collection

Patients who visited the Accident and Emergency Department with facial contusions, abrasions or lacerations were considered for inclusion in the study. Contusions were managed conservatively, abrasions by debridement and application of medicated dressings and lacerations by debridement followed by suture under local anesthesia. They were recalled to visit the outpatient department 1 week later. Each facial injury was considered separately. At this time, the study protocol was explained to them, and consent was obtained. Each injury was examined, and the extent of healing was assessed. Thereafter, the size of each injury was measured using Vernier calipers. The location of each injury was marked using the diagram of frontal and profile views of facial subunits. One-week follow-up photographs were taken under standardized lighting. However, follow-up assessments were in person assessments.

Variables

Aesthetic outcome

POSAS was used to evaluate the aesthetic outcomes of facial injuries in the present study (12). The POSAS includes Patient Scar Assessment Scale (PSAS) which records scar-related pain, itching, thickness, color, stiffness, and irregularity. Observer Scar Assessment Scale (OSAS) comprises vascularity, pigmentation, thickness, surface irregularity, pliability, and surface area. The scores for each item range from 1, which denotes “like normal skin”, to 10, which denotes “worst scar imaginable”. The overall score is the sum of the scores of the six items. Category boxes are added for each item. Additionally, the overall opinion of the observer is graded on a scale from 1 to 10. Ideally, these values should be compared with those of healthy skin at the same anatomical site as that of the assessed scar (12).

Functional outcome

Functional assessments were performed depending on the location of the injury. Marked frontal and profile views of facial subunits were used for systematic assessments (13). Functional damage, including nerve injuries, hair loss, scar contracture, and loss of facial expression, were assessed in each facial subunit. Functional damage in the facial subunits was assessed as follows:

• Sensory and motor nerve damage: the functions of all five branches of the facial nerve were tested. The temporal branch was tested by assessing the tightening of the forehead muscles when the eyebrow is raised. The zygomatic branch was tested by assessing the opening and closing of the eyes. The buccal branch was tested by assessing the patient’s ability to smile. The mandibular branch was tested by assessing the patient’s ability to frown. The cervical branch was tested by assessing the tightening of the platysma muscle (14). The trigeminal nerve is the principal sensory nerve of the facial region, and the functions of its three divisions—ophthalmic, maxillary, and mandibular—were evaluated using light touch, two-point discrimination, and a temperature test performed using a cold metal instrument.
• Scar contracture: ectropion, the outward turning of the eyelid margin, can be caused by infraorbital scar contracture. Thus, infraorbital scar contracture was investigated in cases of patients that presented with Ectropion.
• Hair loss: scarring of the hair-bearing areas, such as eyebrows, mustache, or beard, leads to hair loss (15). Hair loss in these areas was recorded.
• Abnormalities in facial expressions due to scarring were evaluated.

Follow-up at 1-month post-trauma

Patients were followed up at 1-month post-trauma. Scar evaluation was performed, follow-up images were obtained, the scars were measured. Esthetic evaluation was repeated using the POSAS. Functional deficits, if previously reported during the first visit, were reevaluated for any residual deficits.

Psychological outcome

Psychological evaluation was performed 1-month post-trauma using the Trauma Screening Questionnaire (TSQ). TSQ is a self-reported measure of responses to a traumatic event that consists of 10 questions on re-experiencing and arousal symptoms adapted from the PTSD symptom scale (16). Six or more positive responses indicate that the client is at risk of developing PTSD. The scale assesses current symptoms and was designed to use 1 month or more following traumatic events.

Follow-up at 3 months post-trauma

The final follow-up was performed 3 months after the trauma. At 3 months, healing is apparently complete, and all outcomes associated with facial soft injuries have manifested. Facial photographs and measurements were obtained. The POSAS scores, functional evaluation findings, and TSQ scores of the patients were recorded.

Assessments of POSAS, functional sequelae and TSQ were carried out, in person, by a single trained observer (R.B.) at all evaluation points. Sample assessment forms used for POSAS v 2.0/EN by Draaijers et al. (12), the Frontal and Profile Facial Subunits by Fattahi (13), and the TSQ by Brewin et al. (16) have been submitted as supplementary material (Appendix 1).

Statistical analyses

Continuous variables were expressed as mean ± standard deviation (SD). Categorical data was expressed as percentages. Normality of data was assessed using Kolmogorov-Smirnov test with P>0.05. Independent t-test was used to compare the difference between patient and observer rated scar assessment. Repeated measures analysis of variance (ANOVA) was used to investigate changes in mean rating scores over 3 time points. Chi-square test was used to test the association of TSQ score at 1 and 3 months with age, gender and type of injury. P<0.05 was considered as statistically significant.

Results

A total of 96 patients were included in this study (Figure 1). The mean age of the participants was 38±15 years (range, 17–87 years). Most of the patients were in the 20–29, 30–39, and 40–49 age groups. Collision in a road traffic accident was the most common cause of injury 53 (55.2%), followed by a fall at home 12 (12.5%), and a fall from a two-wheeler 12 (12.5%). The number of male patients was 54 (56.3%) and females 42 (43.8%). Laceration was the most common type of injury 54 (56.3%), followed by abrasion 30 (31.3%) and contusion 12 (12.5%) (Table 1). The most injured facial subunit was the forehead 25 (26%), followed by the eyelid 21 (21.9%), cheek 14 (14.6%), chin 12 (12.5%), upper lip 11 (11.5%), nose 7 (7.3%), and lower lip 6 (6.2%) (Table 2).

Figure 1 Flowchart of patient inclusion.

The mean observer rated scar assessment scores at the 1 week and 1-month follow-up were 6.63±0.72 and 4.72±0.59 respectively. The observer rated scar assessment score at 1 month was reduced compared to that at 1 week and this was statistically highly significant (P<0.001). The mean observer rated scar assessment scores at 1 week and 3 months were 6.63±0.72 and 2.95±0.66 respectively. The observer rated scar assessment score at 3 months was considerably reduced compared to that at 1 week and was statistically highly significant (P<0.001) (Figure 2).

Figure 2 Contusion, abrasion & laceration depicted at the time of injury, after 1 week, 1 month, and 3 months. These images are published with the patient/participant’s consent.

The mean observer and patient rated scar assessment scores at 1 week were 6.63±0.72 and 7.53±0.71 respectively. The patient rated scar assessment score was higher than the observer rated score. There was a statistically highly significant difference between the mean observer and patient rated scar assessment scores at 1 week (P<0.001).

The mean observer and patient rated scar assessment scores at 1 month were 4.72±0.59 and 5.09±0.67 respectively. There was a significant difference between the observer and patient rated scar assessment scores at 1 month and those recorded at 1 week. The difference between the mean observer and patient rated scar assessment scores at 1 month was statistically highly significant (P<0.001).

The mean observer and patient rated scar assessment scores at 3 months were 2.95±0.66 and 3.43±0.61 respectively. The observer and patient rated scar assessment scores at 3 months was reduced compared to those recorded at 1 month. The difference between the mean observer and patient rated scar assessment scores at 3 months was found to be statistically highly significant (P<0.001) (Tables 3,4).

A repeated measures ANOVA with Greenhouse-Geisser correction determined that mean observer rated scar assessment score differed significantly between the time points [F (1.627, 154.585) =1,076.254, P<0.001]. Post-hoc analysis with a Bonferroni adjustment revealed that observer rated scar assessment score was statistically highly significantly improved from 1 week to 1 month (1.91 with 95% CI: 1.76 to 2.10, P<0.001) and from 1 week to 3 months (3.67 with 95% CI: 3.44 to 3.89, P<0.001) and from 1 to 3 months (1.760 with 95% CI: 1.570 to 1.951, P<0.001).

Also, the mean patient rated scar assessment score differed significantly between the time points [F (1.855, 176.284) =1,457.871, P<0.001]. Post-hoc analysis with a Bonferroni adjustment revealed that patient rated scar assessment score was statistically highly significantly improved from 1 week to 1 month (2.438 with 95% CI: 2.254 to 2.621, P<0.001) and from 1 week to 3 months (4.104 with 95% CI: 3.895 to 4.313, P<0.001) and from 1 to 3 months (1.667 with 95% CI: 1.503 to 1.831, P<0.001).

At 3 months, parameters recorded on POSAS that persisted as sequelae of injury were hypopigmentation, hyperpigmentation, and scar thickening for lacerations, none for contusions, and hypopigmentation for abrasions. The observer and patient-rated scar assessment scores were highest for laceration followed by abrasion and contusion. (observer scale: laceration 3.14±0.52, abrasion 2.78±0.48, contusion 1.83±0.38; patient scale: laceration 3.50±0.56, abrasion 3.10±0.59 and contusion 2.67±0.66).

Regarding functional damage, three and seven patients showed scar contracture and hair loss (Figure 3), respectively, at 3 months. Scar contracture and hair loss were most observed in the eyelid and chin subunits. Scar contracture and hair loss were the residual functional disabilities that persisted after 3 months (Table 5).

Figure 3 Residual scar and cicatricial hair loss. These images are published with the patient/participant’s consent.

There was a statistically highly significant difference between the mean TSQ scores recorded at 1 and 3 months (P<0.001) (Table 6). This suggests that the number of patients at risk of developing PTSD at 3 months was smaller than that at 1 month. The results of a Chi-square test showed that there was no statistically significant difference in TSQ score between sexes, age or type of facial injury (P>0.05) (Tables 7-9).

Discussion

Key findings

Traumatic facial soft tissue injuries, either alone or in addition to facial skeletal trauma, are frequently observed in accident and emergency departments (17). Facial soft tissue injuries can result in poor cosmesis and loss of function (18). Scarring is a common sequela of facial soft tissue injuries, and we used POSAS to evaluate the aesthetic outcomes of traumatic facial soft tissue injuries. There was considerable improvement in the overall scar scores at 1 and 3 months, with a statistically highly significant difference between the scores recorded at the two timepoints. These findings can be used for patient education and motivation. In the present study, lacerations showed aesthetic sequelae, including hypopigmentation, hyperpigmentation, and scar thickening at the end of the 3-month follow-up. Hypopigmentation was the residual esthetic outcome of abrasions, whereas no residual esthetic sequela of contusions was observed. Scar contracture was most observed in the eyelid subunit, whereas hair loss was frequently observed in the chin subunit. Of 96 injuries, 10 resulted in residual functional sequelae even after 3 months.

TSQ was used to evaluate the psychological outcomes of traumatic facial soft tissue injuries at one and 3 months in the present study. At 1 month, 50 (52%) participants (24 males and 26 females) had a score of ≥6, which denotes a high risk of developing PTSD. At 3 months, the total number of participants with a score ≥6 reduced to 26 (27%) (15 males and 11 females). The Chi-square test revealed no statistically significant differences in TSQ score between sexes, age or type of injury (P>0.05). There was a statistically highly significant difference between the mean TSQ scores at 1 and 3 months (P<0.001). This suggests that the number of patients at risk of developing PTSD at 3 months was lower than that at 1 month.

Strengths and limitations

Previous studies have shown that patient-rated scar severity or disfigurement is related to psychosocial distress; however, a validated scar assessment tool developed for patients and observers was not used (10). Hence, in our study we have attempted to provide a holistic assessment of the impact of traumatic facial soft tissue injuries. Some of the limitations of the study is that we have evaluated PTSD through a survey which is one component in making a psychological diagnosis. A full psychological/psychiatric evaluation would provide better data. Also, we have not correlated PTSD to cause of injury. For instance, a dog bite or traumatic accident/fall would have a disproportionate PTSD-like response to degree of injury.

Comparison with similar research

The etiology and distribution of facial soft tissue injuries in the present study are like that reported in other studies. In a study by Khare and Galinde, the incidence of maxillofacial lacerations was highest in the 21–30 years age group. In that study, males were more commonly affected, and the etiology of lacerations was mostly road traffic accidents, followed by falls. For injuries sustained in a road traffic accident, the area of the face most involved was the eyebrow region, followed by the zygomatic complex region (19). In another study by Gaur et al., the incidence of facial injuries was highest in the 19–40 years age group (44, 55%), followed by the 41–60 years age group (17, 21.25%). The numbers of male and female patients included in that study were 68 (85%) and 12 (15%), respectively, with a male-to-female ratio of 5.6:1. Road traffic accident was the most common cause of facial trauma (58, 72.5%), followed by fall from a height (12, 15%), animal bite (5, 6.25%), assault (4, 5%), and sports (1, 1.25%) (1).

Scar quality is affected by the patient’s wound healing conditions, trauma type, and skin features, which differ according to ethnicity (20). A scar assessment scale is considered suitable for comparing clinical results if it has been confirmed to be reliable, feasible, consistent, and valid (21). The available subjective scar assessment scales include the Vancouver Scar Scale (VSS), Manchester Scar Scale, POSAS, Visual Analog Scale, and Stony Book Scar Evaluation Scale (22). Draaijers et al. formulated the POSAS and compared it to the existing VSS (12). van de Kar et al. (23) concluded that the POSAS is an appropriate subjective tool for the evaluation of linear scars.

In similar study by Shao et al., the POSAS was used to grade scars at two timepoints (1 week and 3 months postoperatively), and the results indicated that early scar appearance predicts later scar appearance, and that scars will improve by nearly 40% 3 months after surgery (11).

Fattahi provided an overview of facial aesthetic units, which is the currently accepted classification (13). This classification of subunits was used in the present study in the evaluation of functional outcomes of traumatic facial soft tissue injury. Scar contracture is the result of contractile wound healing processes occurring in scars that have already been re-epithelialized and adequately healed. Cicatricial alopecia or scarring alopecia is commonly seen in soft tissue injuries that involve hair-bearing areas, such as the eyebrows, beards, and mustache. Patients may view their scars differently from others based on their own perceptions (24).

Previous studies on the effects of facial trauma on a patient’s psychological state have conflicting results. Tebble et al. reported that even minor injuries may act as powerful triggers of psychological symptoms (25). Rahtz et al. suggested that facial injury does not carry a psychological burden; instead, psychological processes in individuals who are concerned about their appearance play stronger roles than physical changes (26). Several other previous studies have also indicated that patients with acquired facial trauma are more likely to report depression, anxiety, and hostility than matched normal control groups for up to one-year post-trauma (8). Howson et al. conducted a prospective cohort study in which adult patients (>16 years old) with maxillofacial trauma underwent screening for PTSD using TSQ. The results showed that the prevalence of PTSD following facial trauma ranged from 23% to 41% (27). The results of the study by Howson et al. are in accordance with those of the present study, which indicate that the risk of developing PTSD at 3 months after facial injury was 27%.

Explanations of findings

Patients’ perception of scaring was worse than that of the observers at all the follow-up time points; however, the overall patient-rated score improved over 3 months. This significant difference in observer- and patient-rated scores can be attributed to the pain and pruritus experienced by patients, which led to a higher overall patient-rated scar score. It is important to include patient-related outcomes in the analysis and management of facial soft tissue injuries. As the aesthetic and functional outcomes of traumatic facial soft tissue injuries improve over 3 months, the risk of developing PTSD, measured using the TSQ, decreases significantly.

Implications and actions needed

Considering the impact of traumatic facial soft tissue injuries, aesthetic sequelae were scored highest after lacerations, scar contracture and hair loss were functional sequelae persisting beyond 3 months. The inclusion of patient perception in the evaluation of facial soft tissue injuries leads to improved patient care and psychological outcomes. In addition, screening for psychological sequelae should be included as part of the routine clinical examinations for patients with traumatic facial soft tissue injuries.

Conclusions

In conclusion, there are aesthetic, functional and psychological outcomes of facial soft tissue injuries, different patient and observer perception, and their assessment provides a holistic view of their impact that can inform clinical practice.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-27/rc

Data Sharing Statement: Available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-27/dss

Peer Review File: Available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-27/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-27/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Ethics Board of Manipal College of Dental Sciences Mangalore (No. 20092) and informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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