ORIGINAL ARTICLE
Analysis of Traffic Accident-Related Facial Trauma
Su Hyun Choi, MD, Ja Hea Gu, MD, PhD, and Dong Hee Kang, MD, PhD
Abstract: The consequences of facial trauma remain of great
significance both functionally and esthetically. Traffic accident-
related facial trauma is a frequent and significant cause of max-
illofacial injury. The purpose of this study was to determine the
natural history of traffic accident-related facial injuries in 846
patients over a 10-year period at a regional emergency center.
The authors report a retrospective study of 846 patients with facial
trauma from traffic accidents. The medical records of these patients
were reviewed and analyzed to determine clinical characteristics,
treatments, and outcomes of traffic accident-related facial trauma.
In total, 687 of the 846 patients (81.2%) had fractures of the face,
and nasal bone fractures were the most common followed by
zygomatic complex fractures, blow-out fractures, and maxilla
fractures. About 51.2% patients had open wounds on the face,
such as lacerations, abrasions, skin or soft tissue defects, and
friction burns. Only 7.4% of patients were treated conservatively
and the others underwent repair or closed and open reduction. The
complication rate was 46.3%, and scars were the most common
followed by nose-related complication, hypoesthesia, and eyelid
deformities. In addition, 47.6% of complication patients underwent
secondary operations. Almost 15% of drivers were drunk, and about
8.7% were confessed drowsy during drive. Almost 30% of ped-
estrians were hit when they jaywalked across the street. Epidemio-
logical data regarding traffic accident-related facial trauma are
important and useful not only for decisions about patient care
and developing optimal treatment regimens but to develop new
methods to prevent injuries.
Key Words: Abbreviated injury scale (AIS), facial bone fracture,
facial trauma, injury severity score (ISS), traffic accident
(J Craniofac Surg 2016;27: 1682–1685)
T raffic accidents are a main detriment to health worldwide.
Therefore, traffic accident-related injury patterns have been
reported extensively, but studies considering facial trauma exclu-
sively are rare. Although enforcement of legislative measures, such
as mandatory seat belt use, speed limits, and drunk driving penal-
ties, has reduced their incidence, traffic accidents remain the most
frequent etiology of facial truma.1 Although the incidence of traffic
accident-related facial trauma has decreased in developed countries,
From the Department of Plastic Surgery, Dankook University Hospital,
Cheonan, Chungnam, Republic of Korea.
Received January 3, 2016; final revision received March 10, 2016.
Accepted for publication April 19, 2016.
Address correspondence and reprint requests to Ja Hea Gu, MD, PhD,
Department of Plastic Surgery, Dankook University Hospital, 201
Manghyangro, Dongnam-gu, Cheonan-si, Chungcheongnam-do 31116,
Republic of Korea; E-mail: jaheagu@gmail.com
The authors report no conflicts of interest.
Copyright # 2016 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000002916
1682 The Journal of Craniofacial Surgery  Volume 27, Number 7, October 2016
Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
it remains a frequent and significant cause of maxillofacial injury.2
The consequences of facial trauma remain of great significance both
functionally and esthetically. Facial trauma caused by a traffic
accident is a frequent and significant cause of maxillofacial injury,
and evaluating the cause, frequency, and severity of facial trauma is
important to establish effective treatment and prevention measures.
Few reports have examined the relationship between use of restraint
systems and injury severity score and the abbreviated injury scale of
the face. Several articles on facial trauma are available; however, no
association between the incidence of facial trauma and use of safety
equipment has been made. Alcoholism, speeding, legislation, and
fatigue are the most important factors associated with road traffic
accidents internationally.3 The purpose of this study was to deter-
mine the natural history of traffic accident-related facial injury and
to clarify the relationship between severity of facial injury or injury
severity score and use of restraint systems. Epidemiological data
regarding traffic accident-related facial trauma are important and
useful for decisions about patient care and developing optimal
treatment regimens and new injury prevention methods.
METHODS
The study was conducted in accordance with the Declaration of
Helsinki and was approved by the Dankook University Institutional
Review Board. A 12-year retrospective review of data was per-
formed among 846 patients with facial trauma from traffic accidents
treated in the plastic surgery department of a regional trauma center
in Korea. The medical records of these patients were reviewed and
analyzed to determine the clinical characteristics, treatments, and
outcomes of the traffic accident-related facial trauma. The
parameters assessed were age, sex, etiology, injury types, associated
injuries, treatments, and complications. Objective measures of
injury severity, the injury severity score (ISS), and the abbreviated
injury scale (AIS) were determined.2 The AIS is an anatomically
based consensus-derived global severity scoring system that clas-
sifies each injury in every body region according to its relative
severity on a 6-point ordinal scale of 1 (minor) to 6 (currently
untreatable). The body is divided into 6 regions, including head or
neck (including cervical spine), face, chest, abdomen or pelvis,
extremities or pelvic girdle and external. The ISS, which is useful
for assessing the severity of multiple injuries, is the sum of the
squares of the highest AIS score in each of the 3 most severely
injured body regions. Use of safety systems by vehicle occupants,
alcohol level, and drowsy driving were investigated. Differences
between restrained and unrestrained groups of drivers and front-seat
versus rear-seat passengers were examined by the ISS and ASI of
the face using unpaired t tests. Differences in ISS and ASI scores for
the face were compared by alcohol level and drowsiness during
driving. P values <0.05 were considered significant.
RESULTS
This retrospective study of 846 patients included 540 men and 306
women (age, 1–87 years). The age distribution is described in
Figure 1. The highest frequency of traffic accident-related facial
trauma was found in 21 to 30-year age group (n ¼ 213) followed by
the 31 to 40-year age group (n ¼ 167). A total of 503 of the 846
patients (59.5%) were 21 to 50 years of age (Fig. 1). The patients
The Journal of Craniofacial Surgery  Volume 27, Number 7, October 2016 Traffic Accident-Related Facial Trauma

TABLE 1. Fracture Sites of Traffic Accident-Related Facial Trauma

Fracture Site No. of Patients (%)

Nasal bone 369 (43.6%)

Zygoma 180 (21.3%)
Orbit 174 (20.6%)
Maxilla 38 (4.5%)
Mandible 32 (3.8%)
Zygoma arch 27 (3.2%)
Frontal 24 (2.8%)
Lefort II 20 (2.4%)
Naso-orbit-ethmoid 18 (2.1%)
Lefort I 14 (1.7%)
Alveolus 14 (1.7%)
FIGURE 1. Age distribution: number of patients in each age group. Panfacial 3 (0.4%)
etc 18 (2.1%)
None 159 (18.8%)
were most frequently the drivers (254 patients, 30.0%), followed by
pedestrians, front-seat passengers, motorcyclists, and rear-seat
passengers (Fig. 2). severely injured other region. Of the 254 automobile drivers, 106
The traffic accident-related facial injury areas are shown in were wearing a seat belt, and 56 were not. Of the 142 front-seat
Table 1. A total of 687 of the 846 patients (81.2%) had facial bone passengers, 70 were restrained, and 44 were not. Of the 105 rear-seat
fractures, and nasal bone fractures were the most common followed passengers, 10 were wearing a seat belt. Seat belt use could not be
by zygomatic complex, blow-out, and maxilla fractures. About determined in 92 drivers, 28 front-seat passengers, and 25 rear-seat
51.2% patients had open facial wounds, such as lacerations, passengers. The ISS scores were similar between restrained drivers
abrasions, skin or soft tissue defects, and friction burns. Only (6.19  0.5) and unrestrained drivers (5.03  0.51). The AIS score for
7.4% of patients were treated conservatively and the others under- the face was significantly higher in restrained drivers (1.91  0.05)
went repair or closed and open reduction. The complication rate was than that in unrestrained drivers (1.68  0.06). No difference in the
46.3%, and scars were the most common complication followed by ISS scores was observed between unrestrained (6.13  0.73) and
nose-related complications, hypoesthesia, and eyelid deformities restrained front-seat passengers (6.14  0.76). The AIS score for the
(Table 2). In addition, 47.6% of the complication patients underwent face of unrestrained front-seat passengers (2.00  0.07) was slightly
secondary operations, and scar revision was the most common higher than that of restrained front-seat passengers (1.82  0.06)
(58.7%). Most traffic accident-related facial injuries occurred in (P ¼ 0.057). No differences in the ISS or AIS scores for the face
the absence of any other injury. However, 325 patients (38.4%) were detected for rear-seat passengers who were and were not
had other injuries (Table 3). The mean ISS was 15.28 (range, 1–34). wearing a seat belt (6.00  1.38, 4.94  0.39, 1.8  0.13, and
About 70% of patients had an ISS <5, and 2.7% had an ISS >20. Six 2.0  0.05, respectively) (Figs. 3 and 4). Thirty-eight drivers had
percent had a severely injured face (AIS 3) and 11.6% had 1 been drinking alcohol before they got into an accident. Mean ISS and
AIS scores were significantly higher in drivers who did not consume
alcohol than those who did. Twenty-two drivers confessed that they
were drowsy during driving. Mean ISS scores and AIS scores for the
face of drowsy drivers were 6.04  1.12 and 1.94  0.06 and were not
different from those of alert drivers.

TABLE 2. Complications Associated With Traffic Accident-Related Facial Trauma

No. of Secondary Procedure

Complication Patients (%) No. of Patients (%)

Nasal hump 6 (0.7%) 2 (0.2%)

Nasal deviation 17 (2.0%) 0 (0.0%)
Saddle nose 11 (1.3%) 5 (0.6%)
Nasal obstruction 14 (1.7%) 5 (0.6%)
Scar 206 (24.3%) 81 (9.6%)
Hypoesthesia 32 (3.8%) 0 (0.0%)
Persistent pain 4 (0.5%) 0 (0.0%)
Infection 21 (2.5%) 11 (1.3%)
Enophthalmos 18 (2.1%) 2 (0.2%)
Diplopia 9 (1.1%) 1 (0.1%)
Limited eyeball movement 5 (0.6%) 2 (0.2%)
Blindness 1 (0.1%) 1 (0.1%)
Eyelid deformity 23 (2.7%) 12 (1.4%)
Facial asymmetry 9 (1.1%) 6 (0.7%)
Etc. 17 (2.0%) 6 (0.7%)
FIGURE 2. Distribution of patient car seating position and pedestrians.

# 2016 Mutaz B. Habal, MD 1683

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Choi et al The Journal of Craniofacial Surgery  Volume 27, Number 7, October 2016

TABLE 3. Associated Injuries

Associated Injuries No. of Patients (%)

Cerebral hemorrhage 66 (7.8%)

Basal skull fracture 30 (3.6%)
Lower extremity 95 (11.2%)
Upper extremity 71 (8.4%)
Chest 35 (4.1%)
Abdomen 12 (1.4%)
Spine 24 (2.8%)
Tooth 27 (3.2%)
Eyeball 12 (1.4%)

FIGURE 4. Comparison of abbreviated injury scale scores between seat belt use

or not for each car seat position ( P <0.05).

DISCUSSION
We observed that traffic accidents are most common in patients
aged 21 to 40 years, which may be due to the larger number of
young drivers who commonly exceed the speed limits, are less
inclined to observe the traffic patterns, and may abuse alcohol and
drive more frequently than those in the other age groups. Facial
fractures caused by traffic accidents were observed less frequently
in children and adults 60 years. Other authors have reported a
similar age and traffic accident relationship.1,4,5
The forces acting on the body during a collision can cause
multiple and complex fractures. According to Gassner et al,6 traffic
accidents may cause more severe trauma than that caused by other
etiologies. The severity of a facial fracture can be estimated by their
association with other trauma involving the skull, neck, upper limbs
and extremities (shoulder, arms, and hands), lower limbs (legs and
feet), thorax, and abdomen.1
Automobile-related injuries have decreased since the seat belt
was introduced and drunk-driving legislation has been enacted.
However, seat belt regulations in some countries are limited only to
the driver. Seat belt legislation for rear-seat passengers has been
enforced in Korea since 2015.
Lower extremities were the most common site of concomitant
injuries at a rate similar to the sum of cerebral hemorrhage and basal
skull fractures. Upper extremities were the second-most common
site, which contrasted with other reports.7,8 A total of 1.4% of our
patients suffered permanent blindness caused by a direct eyeball
injury or traumatic optic neuropathy and another patient suffered
blindness after surgery. Patients who had a concomitant injury that
especially needed an emergency operation tended to delay treating
facial trauma (average 6 days versus 15 days), and this resulted in
poor results such as nasal deviation, malunion of fractures, and scar
formation. The authors think that if concomitant injuries are not
FIGURE 3. Comparison of injury severity scores between seat belt use or not for

each car seat position ( P <0.05).
related to patients’ vital signs, emergent simultaneous operation or
early consultation is a better option.
Road traffic accidents have been steadily falling in developed
countries but they continue to rise dramatically in low- and middle-
income countries of Africa and Asia and are the major cause of
death in India. The majority of traffic accidents are the result of
speeding, and alcoholic use and fatigue are associated with road
traffic accidents internationally.3 In our study, alcohol use and
drowsy driving did not affect facial injury severity or the severity of
other injuries. However, patients who were dead or too severely
injured to refer to the plastic surgery department were excluded
from this study, which is a limitation of this study. Further study is
required including these patients or a multicenter analysis is needed
to interpret the data accurately.
In 2007, the World Health Organization9 reported that use of
seat belts reduced deaths of front-seat passengers from 65% to 40%
and from 75% to 25% in back-seat passengers. Some reports have
indicated that the advent of safety equipment, such as helmets, seat
belts, air bags, and lateral protection bars, has significantly reduced
the rate and complexity of facial fractures, as well as the number of
deaths from traffic accidents.1,10–12 Other studies have found no
associations between the incidence of facial trauma and use of
safety equipment (helmets and seat belts). We found no difference
in the ISS score between the restrained and unrestrained groups. In
addition, the AIS score for face was higher in restrained than that in
unrestrained drivers, which may be due to the steering wheel. We
suggest that although wearing a seat belt is effective for preventing
fatalities and generally decreases the severity of head, neck, and
trunk injuries, it cannot prevent all oral and maxillofacial injuries in
motor vehicle occupants. Therefore, although automobile-related
injuries have decreased since the seat belt use technology was
introduced, facial bone injuries have not decreased. Mendes et al1
reported that 42.86% of victims who were not wearing a seat belt
had nasal-orbital-ethmoidal fractures and skull injuries. The thorax
and abdomen showed a lower prevalence compared with that of
specific facial trauma, such as mandible, Le Fort, or frontal
fractures. The type and location of the trauma, patient systemic
condition, and the surgeon’s expertise may determine whether the
treatment for facial is surgical or conservative. Others have reported
77% conservative treatment and surgery for victims.1,13,14
Facial injuries are seldom fatal and are often considered minor
injuries with little weight assigned to them in measures of injury
severity.2,15,16 The AIS classifies most facial injuries as 1 or 2.2,15,16
We found a mean AIS of 1.95 (range, 1–5) for facial injuries. The
most common injury patterns were simple lacerations and simple
fractures, such as nasal bone or blow-out fractures. However, at this
point, patients needed additional surgery, especially aesthetic
surgery, after they had recovered.

1684 # 2016 Mutaz B. Habal, MD

Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 27, Number 7, October 2016
Soft tissue lesions and bony fractures occurred frequently in
traffic accident victims, leading to functional, aesthetic, and
psychological problems. Only 7.4% of our patients were treated
conservatively and the others underwent repair, closed reduction,
and open reduction. Lacerations can result from bursting glass and
contusions can occur after harsh impacts against some parts of the
car, such as the steering wheel.1 In addition, nowadays especially
young drivers prefer to decorate the interior of the car and install
some materials such as wheel handle discipline, large-sized rear
view back mirror, and various decorative materials. These materials
can cause injury to the driver’s eyes, nose, and other parts of face. In
addition, occasionally they inhibit airbag activation. Small decora-
tive materials like air freshner, frame, or hard dolls can cause injury
to a person’s face because some of them are sharp and could have
sharp edges after breakage. We recommend that people should not
use a handle discipline and should not decorate the frontal deck with
hard types of decorative materials. Navigations and other monitors
that are installed in the interior of the car itself could prevent victims
injured their faces by protruding equipment, then increase the
safety. In the present study, 51.2% patients had open facial wounds,
such as lacerations, abrasions, skin or soft tissue defects, and
friction burns. Scars were the most common complication, and
scar revision was the most common secondary operation (58.7%).
Laceration wounds are dirty and irregular, which leads to the
formation of a hypertrophic scar and occasionally laceration-related
skin defect. Abrasion wounds and laceration margins are dirty due
to asphalt, dirt, and small pieces of broken glass. Plastic surgeons
and emergency physicians should check the wound thoroughly to
achieve a good result. Occasionally, immediate skin grafting and
dermabrasion for removal of foreign body materials are good
options to prevent scar formation.
CONCLUSION
Epidemiological data regarding traffic accident-related facial
trauma are important and useful for decisions about patient care
and development of optimal treatment regimens and new injury
prevention methods. Our results show that seat belt use, alcohol
abuse, and fatigue may not be major factors affecting facial trauma
injury severity. Development of additional protective equipment is
expected and frontal deck decoration should be avoided. Patients
who have concomitant injuries should be treated early by simul-
taneous operation or rapid consultation. However, patients who
# 2016 Mutaz B. Habal, MD
Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Traffic Accident-Related Facial Trauma
were dead or too severely injured to refer to the plastic surgery
department were excluded from our study. Therefore, further study
is required including these patients or a multicenter analysis is
needed to accurately interpret these results.
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