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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

The surgical management of facial trauma in British soldiers during

combat operations in Afghanistan
Matthew Wordsworth, MRCSa,b , Rachael Thomas, MRCSa,c,
John Breeze, PhD, MRCS, MFDSa,c , Demetrius Evriviades, FRCS (Plast)c ,
James Baden, FRCS (Plast)a,c,* , Shehan Hettiaratchy, DM FRCS (Plast)a,b
a
Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, United Kingdom
b
Imperial College Healthcare NHS Trust, United Kingdom
c
University Hospitals Birmingham NHS Foundation Trust, United Kingdom

A R T I C L E I N F O A B S T R A C T

Introduction: The recent Afghanistan conflict caused a higher proportion of casualties with facial injuries
Keywords: due to both the increasing effectiveness of combat body armour and the insurgent use of the improvised
Blast
explosive device (IED). The aim of this study was to describe all injuries to the face sustained by UK
Facial trauma
Afghanistan
service personnel from blast or gunshot wounds during the highest intensity period of combat operations
War 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.
ã 2016 Published by Elsevier Ltd.

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 this
conflict; this caused higher rates of multiple amputations than
* Corresponding author at: Department of Plastic and Reconstructive Surgery,
Queen Elizabeth Hospital, Birmingham, B15 2TH, United Kingdom.
E-mail address: James.baden@uhb.nhs.uk (J. Baden).
previous conflicts [2,3,4]. Whilst much has been published on the
blast injury patterns and outcomes to the limbs, it that has been
shown that the Afghanistan conflict also generated a higher
proportion of casualties with facial injuries [5–8].
Wade et al. [9] in their study of head, face and neck injuries in
the last Iraq conflict postulated that the higher rates of these
injuries was due to an increased proportion of blast injuries
secondary to insurgent use of the improvised explosive device
(IED). Tong and Beirne [10] in a systematic review of the Iraq and
Afghanistan conflicts suggested that increased survivability of all
injuries (due in part to combat body armour) and the lack of
protection to the face were two further reasons for the increased
incidence of facial trauma. Combat body armour needs to balance
protection with mobility and capability, in the face it is particularly
important but challenging to preserve auditory and spatial
awareness. Breeze et al. identified the lower face as being

http://dx.doi.org/10.1016/j.injury.2016.08.009
0020-1383/ã 2016 Published by Elsevier Ltd.

Please cite this article in press as: M. Wordsworth, et al., The surgical management of facial trauma in British soldiers during combat operations
in Afghanistan, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.08.009
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2 M. Wordsworth et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
particularly poorly protected and the potential for visors or
mandibular guards to enhance protection [8,11].
Combat operations in Afghanistan finished in 2014. The aim of
this study was to describe and compare all injuries to the face
sustained by UK service personnel from blast or gunshot wounds
during the highest intensity period of UK combat operations in
Afghanistan. This would quantify the impact on the medical chain
from point of injury, during evacuation, at the field hospital and the
definitive surgical care. By examining the medical records of
patients transferred back the UK for ongoing care it also aimed to
determine injury patterns and the surgical reconstructive needs of
survivors.
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 purpose of this study, the face
was defined as the area anterior to the external auditory meatuses
from the top of the forehead to the chin, the soft tissue injuries
were further categorized into three zones, lower, middle and upper
thirds: the chin to the base of the nose, the base of the nose to the
eyebrows, above the brows respectively. The inclusion criteria
were all casualties who sustained any facial injury by blast or
gunshot wound mechanism in UK service personnel in the
Afghanistan conflict, during the highest intensity of combat
operations between 01 April 2006 until 01 March 2013.
The Clinical Information & Exploitation Team maintains the
JTTR and all injuries are entered retrospectively by AIS certified
nurses. Along with the injuries sustained, all airway and surgical
procedures in Afghanistan were recorded. Data on the demo-
graphics, incident, pre-hospital emergency care, Injury Severity
Score (ISS), hospital care in Afghanistan and subsequent care at the
UK hospital was included.
All soldiers who required further treatment were aero-
medically evacuated to the Royal Centre for Defence Medicine at
the Queen Elizabeth’s Hospital, Birmingham. The medical records,
operative notes and clinic letters of this cohort were retrospec-
tively studied.
The Medical Director of the Royal Centre for Defence Medicine
and the University Hospitals Birmingham NHS trust gave permis-
sion for this study. Statistical analysis was performed using a
statistical software package (Graphpad, CA, USA). Results were
analysed for significance using Fisher’s exact test and probabilities
with p < 0.05 were considered statistically significant.
Table 1
Demographics of facial injury patients.
Demographic Blast n
Mean age 26 yrs
Service
Army 431
Royal Marines & Royal Navy 59
Royal Air Force 14
Outcome
Killed in Action 112
Died of Wounds 16
Wounded in Action 376
Mean Injury Severity Score (ISS)
All casualties 26.7
Fatalities 64.4
Survivors 13.8
Please cite this article in press as: M. Wordsworth, et al., The surgical management of facial trauma in British soldiers during combat operations
in Afghanistan, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.08.009
Table 2
Mechanism of injury.
n
Improvised Explosive Device 378
Mine 40
Gunshot wound 62
Rocket Propelled Grenade 53
Grenade 14
Mortar 14
Other 5
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) with 375 returned to the
UK for further medical treatment. Detailed information on groups
of five or less casualties is not discussed to prevent identification of
individuals in accordance with UK Ministry of Defence guidelines.
The demographics of these patients are listed in Table 1.
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.
Pattern of injuries
Isolated injury to the face with no injuries to any other body
region was uncommon in both blast (7% n = 36) and GSWs (16%
n = 11) casualties. In blast injuries the most commonly associated
body region injured with the face was the lower extremity, injured
in 336/505 cases (66%). In casualties from blast the median number
of total injuries across the body was 8 (range 1–57); the median
affecting the face was 2 (range 1–9). In casualties from GSWs the
median number of total injuries across the body was 7 (range 1–27)
and the median number of facial injuries was 2 (range 1–8).
A facial fracture was a significant marker for more severe total
body injury severity score in blast injury. In blast injuries the mean
survivor ISS was 22.6 ( SD 2.1) with a fracture compared with a
mean ISS of 11 (0.7) without a fracture (p < 0.001). The mean
fatality ISS was 68.13 (1.5) with a fracture, the mean ISS was 58.5
(2.2) without a fracture (p < 0.001). This pattern was not seen in
the GSW cohort, there was no correlation between facial fracture
and overall injury severity score
The mandible was the most frequently fractured bone in 118 of
the 556 facial injuries studied. In blast survivors, the orbit was the
most frequently fractured bony complex in 34 cases (these
GSW n
fractures were not sufficiently coded via AIS to differentiate the
25 yrs different bone components of the orbit). In GSWs the mandible
54
was the most commonly fractured bone of the face.
6 Fig. 1 below demonstrates the number of fractures by bones or
2 bony complexes for blast injuries and gunshot wounds.
The fractures were grouped into the upper, middle and lower
30
thirds of the face. Blast injuries survivors had predominantly mid-
3
29 facial injuries compared with fatalities that were predominantly
lower third facial injuries. Fatalities were more likely to be injured
40.7 in multiple facial zones and have associated head injuries
66 (concurrent head injury in 86% fatalities v 28% in survivors).
12
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Fig. 1. Facial bone injuries.

Fig. 2 demonstrates the facial fractures by third of the face.
Multiple fractures in a single zone are scored once.
GSW’s survivors had predominantly lower facial injuries
compared with fatalities that were predominantly middle or
multiple (graph 4). However due to low numbers this did not reach
statistical significance (Fig. 3).
In blast injury survivors the soft tissue injuries were grouped
into the upper middle and lower zones of the face when they could
be accurately determined from JTTR and hospital notes. Soft tissue
injuries showed a mid-facial predominance with 193 injuries
(53%), upper face 39 (10%) and lower third of the face in 142 (38%).
Flash or flame burns occurred in 14 survivors (4%). There were 4
facial nerve injuries.
Surgical workload
Three quarters of all injured soldiers with facial blast injuries
survived (75%, n = 376) and were treated in the British Field
Hospital. The average ISS of survivors was 13.8 (Range 1–75, SD 15)
with eight ‘unexpected survivors’ (ISS > 60) [6]. In fatalities the
average ISS was 64.4 (Range 30–75 SD14.9). In the GSW cohort
there were proportionally fewer survivors with a 47% survival rate
(n29). The average Injury Severity Score (ISS) was 12 (Range 1–75
SD 15) with one unexpected survivor. The average ISS score of the
fatalities was 66 (Range 29–75, SD 17). A facial blast injury was
present in 29% and a facial GSW in 7% of the 439 total UK military
deaths in Afghanistan in this period [4].

Fig. 2. Number of fractures in facial third for blast injuries.

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Fig. 3. Number of fractures in facial thirds for GSW’s.

352 of the 376 blast injury survivors were treated at the British maxillary defect and a total of 9 local flaps used in facial
Field Hospital at Camp Bastion; four were initially treated at a reconstructions in this group.
United States Field Hospital at Kandahar or Bagram. Three
survivors were transferred from Bastion to Kandahar for a
Discussion
specialist ophthalmic or neurosurgical procedure. All 29 of the
GSW survivors were seen at the British hospital at Camp Bastion in
Complex injuries from improvised explosive devices were the
Afghanistan. Three survivors were transferred to a United States
hallmark of the conflict in Afghanistan [14]. Typically the blast
Field Hospital for ophthalmic review.
wave is from underneath the soldier, whether on foot or mounted
Facial surgery was required in 70% (n = 283) of the 405 facial
in a vehicle [15], which would explain why lower limb injuries
injuries treated at the British Field Hospital in Camp Bastion. The
were most commonly associated with facial injuries in blast
122 injured service personnel whose facial injuries did not require
victims and why the pattern of injury was predominantly affecting
surgery were predominantly small lacerations or abrasions
the mid and lower face.
managed in the emergency department or were simple closed
From this data it appears that in this conflict the pattern of blast
maxillofacial fractures managed non-operatively (e.g. a nasal
injury to the face is different in survivors and fatalities. This study
fracture). Of the 283 who required facial surgery approximately
adds further evidence to the UK experience that the mandible is
half (n = 145) required only a single procedure. Debridement and
the most commonly fractured bone in fatalities but the mid-face is
primary closure of facial wounds was the most common operation
most commonly fractured area in survivors. Chan et al. [7] in their
in 134 cases. No facial infections were reported in this cohort who
10yr study of 4020 US injured survivors evacuated from Iraq and
underwent primary closure and were subsequently evacuated to
Afghanistan and Feldt et al. [16] in their study of over 11,000 facial
the UK. 375 casualties were evacuated to the UK for further
fractures also found that the maxilla sustained the most injuries.
treatment, 30 soldiers (8% of survivors- all from minor blast
The reasons for this were not studied in this paper but it may be
injuries) were discharged from the hospital and returned to
that this is a reflection of the power of the blast wave. The mandible
military duty in Afghanistan.
necessitates a higher force to fracture than the maxillary sinus [17]
and therefore may be associated with other unsurvivable injuries,
UK hospital care
such as massive disruption of the pelvis in dismounted soldiers.
Postmortem determinant of cause of death was not known in this
In the blast cohort 136 soldiers required facial and/or
study, therefore concomitant neck injures associated with
ophthalmic surgery at the Royal Centre for Defence Medicine.
mandibular fracture or subsequent airway obstruction are other
There were a total of 230 operations for these patients, a mean of
plausible explanations of the increased mortality rate with
1.7, range of 1–8. Multiple staged reconstructive facial surgeries
mandibular fracture and worthy of closer investigation. This paper
were required in 21 (16%) of these patients. This was predomi-
has demonstrated that any facial fracture is significantly associated
nantly eyelid (n = 7) and nasal (n = 9) reconstructions. There were 3
with a higher total body injury severity score that reflects the force
free flaps and 7 local flaps used in facial reconstructions in this
of the blast wave.
group.
Half of the injuries sustained to the face from blast were
In the GSW cohort 20 soldiers required further facial or
relatively minor and managed by a single procedure in the Field
ophthalmic surgery at the Royal Centre for Defence Medicine. A
Hospital. The absence of reported facial infections supports the
total of 52 facial surgeries were required with a range of
practice of primary debridement and wound closure. Complex
procedures from 1 to 11 per patient, a mean of 2.6. The majority
facial soft tissue reconstruction that required multiple procedures
of procedures in this cohort were on the mandible (n = 23) or
occurred in the mid-face but was relatively uncommon (16%).
maxilla (n = 12). There was one composite free fibular flap for a

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Accurate scoring of soft tissue facial injuries is difficult from
current AIS coding of facial injuries in the JTTR database.
Furthermore the severity of the facial injury from an AIS score
may have little use in predicting a final functional or cosmetic
outcome in the face. An isolated injury to a key aesthetic structure
may cause substantial morbidity with a minor AIS score – for
example the 10 survivors in our cohort requiring staged
reconstructive surgery to the nose all scored only 1 or 2 on the
facial AIS component. The difficulty in scoring facial injuries is not
solely a military problem; a number of scoring systems for
craniofacial fractures in civilian trauma have been proposed in
recent years [18–22]. Lawnick et al. [13] in their 2013 review of
combat injury scoring found that the AIS could not adequately
score penetrating injuries to the face and recommended the
Military Combat Injury Scale (MCIS). A scoring system for the face
in trauma should include both skeletal and soft tissue elements,
which relates to severity, functional deficits and aesthetic
considerations. This has previously been suggested by Breeze
et al. who proposed an Occulo-Facial Functional and Aesthetic
outcome score and is the focus of ongoing work [4].
In conclusion the face is a commonly injured region in modern
conflict blast injury, most commonly due to the Improvised
Explosive Device. A facial gunshot wound is a fatal a mechanism of
injury in 53% of cases. Maxillofacial fractures were a marker of
injury severity in both survivors and fatalities. This overview of UK
casualties may direct further work into a more precise scoring
system for military facial trauma, as current AIS scoring of facial
injury cannot predict the extent of reconstructive surgery that may
be required or the functional and aesthetic morbidity of combat
injury to the face.
Conflict of interest statement
There are no other potential conflicts of interests.
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