Degloved Face Injuries: A Complete Analysis

A degloved face injury, also known as a facial degloving injury, occurs when the skin and underlying tissue are completely torn away from the facial structure. This type of traumatic injury results in the separation of the skin and soft tissue of the face from the underlying facial bones and muscles, exposing the underlying anatomy.

Degloved face injuries are severe and complex traumas that can occur due to high-impact accidents, animal attacks, industrial accidents, falls, or interpersonal violence. These injuries usually affect the central part of the face, involving the nose, cheeks, lips, and forehead. However, in extensive cases, it can spread to the orbital region, mandible, and neck.

Degloved face injuries result in massive bleeding, excruciating pain, facial disfigurement, and functional impairment. They require immediate emergency medical intervention to address the bleeding, stabilize the patient, and attempt to salvage the detached facial soft tissues. This is followed by complex reconstructive surgery, lengthy hospitalization, and extensive rehabilitation to restore form and function.

These devastating injuries can have significant long-term physical, functional, aesthetic, and psychological consequences. This comprehensive article review the intricacies and complexities involved in the mechanism, diagnosis, emergency treatment, surgical reconstruction, rehabilitation, and psychosocial aspects of degloved face trauma.

This article was reviewed for medical accuracy and crafted under the guidance of Dr. Sarah J. Adam

Causes of Degloved Face Injuries

Degloved face injuries result from high-velocity tangential or rotational shearing forces that avulse the skin and soft tissue of the underlying facial structure. The mechanism of injury varies based on the aetiology:

Motor Vehicle Collisions

During motor vehicle collisions, the face may strike against the steering wheel, dashboard, or windshield or become dragged on the road surface. These trigger shearing and tangential forces that can deglove the skin off the face. Frontal collisions with unrestrained occupants and side-impact collisions often lead to facial degloving.

Animal Attack

Animal bites, especially from large, aggressive dogs with solid jaw muscles, can result in extensive tearing and degloving. The crushing and pulling action of the taste avulses the facial skin and tissue. Partial or complete scalping of the face may occur.

Industrial Accidents

Occupational injuries from assembly line machinery, conveyor belts, or tools such as drill bits or grinding wheels can cause sudden degloving of facial skin and soft tissue. The loose clothing, hair or jewellery of workers can become entrapped and cause violent tearing.

Assault

Interpersonal violence and altercations where the face is punched, hit with objects or slammed can lead to degloving due to shearing forces. Gunshot or blast injuries also cause severe facial degloving.

Falls

Falls from height and face contact against rough solid objects or machinery parts during the fall can result in degloving due to sudden high-impact collisional forces.

Diagnosis and Identification of Degloved Face Injuries

Degloved face injuries usually create a typical clinical presentation, and most cases can be diagnosed quickly based on visual examination. However, the following aspects are evaluated to confirm the diagnosis and assess the extent of the injury:

• Inspection and palpation to identify the area of skin and soft tissue separation from the facial bones and cartilage.
• Assessment of involvement of eyelids, nose, lips, ears, scalp, and neck – whether complete or partial degloving.
• I was examining for oral cavity lacerations or mandibular fractures with exposed intraoral tissue.
• Examining orbital rims and eye movements to identify penetrating injuries or damage to eye structures.
• Assessing for exposure of facial nerves, blood vessels, parotid duct or facial musculature.
• Evaluating bony stability and fractures of the zygomatic complex, nasoethmoid complex or mandible.
• Estimating the percentage of devitalized versus viable soft tissue.
• Detecting any associated polytrauma such as traumatic brain injury, thoracic trauma, abdominal injuries, or fractures.
• Documenting wound dimensions and photography. Imaging modalities like CT scans may be used if required.

Emergency Treatment of Degloved Face Injuries

Degloved face injuries constitute complex life-threatening emergencies requiring coordinated trauma care. The goals of initial emergency treatment are:

• To stabilize the patient, control bleeding and address coexisting injuries.
• To prevent further soft tissue damage and bacterial contamination.
• To debride devitalized tissue while preserving all viable tissue for reconstruction.
• To cover any exposed vital structures like facial nerves, vessels or organs.
• The specific emergency protocol includes:
• Primary survey and resuscitation: Airway, breathing and circulation are stabilized following trauma resuscitation protocols. Associated injuries are managed.
• Wound care: Copious irrigation and gentle debridement of gross contaminants are performed. Caution is exercised not further to debride viable soft tissue. Hemostasis is achieved.
• Broad-spectrum IV antibiotics are administered to prevent infection. Tetanus immunization is ensured.
• Saline-soaked gauze covers exposed muscles, nerves, vessels or organs for protection. Ophthalmic lubricants are placed for orbital exenterations.
• The detached skin flap is preserved by rinsing with saline gauze and wrapped in moist saline gauze. It is refrigerated or put on ice if the transfer to the operating room is delayed.
• Early involvement of plastic and reconstructive surgeons optimizes the salvage of viable soft tissue.

Surgical Reconstruction of Degloved Face Injuries

The main objectives of surgical reconstruction are:

1. To restore facial form and anatomy.
2. To regain optimal facial function and expression.
3. To achieve the best possible aesthetic results.

The specific reconstructive surgery technique depends on the severity of injury and viability of the degloved skin and soft tissue:

Primary Closure

If the soft tissue flap is mainly intact and viable, it can be re-apposed and sutured into its original anatomical position after thorough wound bed preparation. This immediate primary closure within hours of injury affords the best outcome.

Skin Frafts

In the treatment of partial thickness soft tissue loss, healthcare providers use split-thickness skin grafts harvested from the patient’s thigh, back, or scalp. This procedure involves grafting the skin onto the prepared wound bed.

Regional Flaps

Sizeable soft tissue defects often require the transport of well-vascularized skin flaps based on named arterial systems and specific delicate tissue components. Frequently used regional flaps for facial reconstruction include pectoralis major, temporalis, cervicopectoral and deltopectoral flaps.

Free Flaps 

Free tissue transfer involves microsurgical transplantation of composite flaps from distant donor sites. The flap is completely detached from the body, and its vessels are anastomosed to facial vessels. Free flaps commonly include radial forearm, anterolateral thigh and rectus abdominis flaps.

Complex Tissue Repair 

Surgeons reconstruct any underlying bony injuries using bone grafts, titanium plates, or screws to restore facial skeleton stability and symmetry. They repair nasal cartilage and orbital fractures to achieve optimal functional and aesthetic outcomes.

Secondary revisions

After the reconstructive surgery, most patients undergo additional minor surgical modifications to optimize their appearance and function. This includes scar revision, dermabrasion, laser resurfacing, fat grafting, botox injections and other modalities to improve the outcomes.

Rehabilitation After Degloved Face Injury

The rehabilitation process after reconstruction of degloved face injuries involves wound care, managing complications, and specialized therapies to regain function:

Wound care 

Medical staff closely monitor patients for any signs of wound dehiscence, flap failure, hematoma, necrosis, or infection during the postoperative period. They follow a strict sterile technique when cleaning, inspecting, and dressing the wounds. Patients receive instructions on proper wound care.

Complications management 

Medical and surgical teams undertake various interventions to address complications such as wound breakdown, tissue necrosis, graft failure, osteomyelitis, fistula formation, exposure keratitis, or diplopia. These interventions may involve performing serial debridements, administering antibiotics, advancing flaps, applying skin grafts, or revising scars as necessary.

Head and neck rehabilitation

Specialist physiotherapists devise a tailored rehabilitation program to strengthen facial muscles, improve facial animation, and restore functional movements like blinking, smiling, swallowing and chewing. Electrical stimulation, facial massage, and passive exercises may augment recovery. Patients re-learn compensatory mechanisms for impaired functions.

Speech therapy 

Speech and language therapists address communication deficits and swallowing difficulties. Exercises focus on regaining standard oral motor control, movement precision, lip competence and tongue motility.

Psychosocial support 

Psychological counselling provides emotional support in coping with altered self-image, self-esteem issues, social anxiety and depression. Peer support groups help in adjusting and reintegrating into social relationships and employment.

Long-Term Consequences and Prognosis After Degloving Injuries of Face

Despite optimal medical and surgical management, degloving injuries of the face result in some degree of permanent disfigurement and functional impairment. The following variables determine the long-term prognosis:

• The extent of initial soft tissue loss – Partial thickness injuries have better outcomes than total thickness degloving.
• Timing of reconstruction – Immediate repair within hours yields superior results than delayed procedures.
• Viability of degloved flap – Skin flap preservation impacts cosmesis and function.
• Comorbid injuries – Traumatic brain injury or blindness worsens disability and recovery.
• Rehabilitation commitment – Dedicated participation in therapy influences progress.
• Patient psychological health – Pre-existing or subsequent depression impairs improvement.

While autologous repair provides good colour and texture match, some degree of contour irregularities, patchy alopecia, pigmentary changes and extensive scarring is inevitable after degloving. Neural damage causes paresthesia. Motor impairment in blinking, smiling, chewing, and speech articulation may persist. Corneal exposure can lead to keratitis. Dry eye, photophobia and diplopia occur due to lid malfunction or enophthalmos. Psychological body image issues are common.

Many patients can achieve acceptable restoration of facial appearance and reasonable functionality through a combination of staged surgical reconstruction and ongoing rehabilitation. However, the cosmetic results may need improvement for some. A highly individualized approach tailored for each patient optimizes the outcome.

Psychological Impact of Degloved Face Injuries

The face is central to an individual’s identity and socially perceived body image. Facial disfigurement from degloving leaves profound adverse psychological effects. These include:

Acute Emotional Distress 

The initial shock of witnessing massive facial deformation is intensely traumatic. Many survivors experience denial, anger, grief, anxiety or suicidal depression when coping with this altered appearance.

Body Image Issues

The changed facial features distort self-identity and self-worth. Marked alterations in one’s face negatively affect self-esteem and self-confidence levels. Significant dysphoria about bodily integrity is common.

Social Isolation 

Avoidance of social interactions is frequent because of apprehension of adverse reactions about their facial disfigurement. Many feel reluctant to appear in public and withdraw from community participation.

Interpersonal Relationships 

Marital discord, separation or abandonment by the partner is not uncommon owing to intimacy issues and changed sexual dynamics. Some even encounter ridicule, prejudice and discrimination in relationships.

Loss of Employment 

Facial scarring and speech limitations cause difficulty in customer interactions and public dealings. This affects the return to previous occupations. Financial constraints further add to the emotional burden.

Psychological support and counselling are pivotal in the rehabilitation process. Therapies like cognitive behaviour techniques and mindfulness training help patients adjust to their transformed but ‘new normal’ face and increase self-acceptance. Peer support networks provide encouragement and hope.

Prevention of Degloved Face Injuries

While some causes of facial degloving, such as animal attacks or assaults, cannot be predicted, many cases can be prevented by adhering to safety practices.

• Consistent use of seat belts and airbags in vehicles.
• Wearing helmets during sports, cycling and motorbiking.
• Covering or tying up long hair around machinery.
• No loose clothing while operating industrial equipment.
• Installing and using proper machine guards.
• Avoid operating heavy machinery under the influence of alcohol or drugs.
• Preventing distractions and staying attentive during risky work.
• Refrain from rushing or taking shortcuts around hazardous equipment.
• Keeping walkways obstacle-free to avoid falls.
• Learning and following all organizational safety protocols.
• Seeking help promptly if machinery malfunctions or entrapment occurs.
• Receiving proper training before handling unfamiliar hazardous machinery.
• Restricting access of children around high-risk machinery.
• Exercising caution around unrestrained dogs and avoiding high-risk dog breeds.
• Eliminating tripping hazards in the home to prevent falls.
• Addressing mental health issues and interpersonal conflicts appropriately before they escalate to violence.

FAQs

• What causes a degloved face? 

Common causes include motor vehicle accidents, industrial accidents, animal bites, falls, assault and gunshot wounds. The shearing forces avulse the facial skin and tissue off the bone.

• What are the symptoms of a degloved face?

Symptoms include excessive bleeding, extreme pain, exposed facial anatomy, facial disfigurement, numbness, impaired facial expressions and vision loss if the injury extends to the eyes.

• Is a degloved face fatal? 

Yes, a degloved face can be fatal due to excessive blood loss, infection, tissue necrosis, or associated injuries to the brain and cervical spine. Immediate medical intervention is crucial.

• How is a degloved face treated?

 Treatment involves:

• Controlling bleeding.
• Covering exposed areas.
• Debriding dead tissue.
• Reattaching the avulsed skin flap.
• Reconstructing the damaged area with skin grafts or local and regional flaps.

• How long does it take for a degloved face to heal?

Complete recovery takes several months or years, requiring multiple staged reconstructive surgeries and intensive rehabilitation therapy to regain optimal facial form and function.

• What are the long-term effects of a degloved face? 

Long-term effects include facial scarring, nerve damage, impaired facial movements and expressions, dry eyes, vision issues, speech difficulties and psychological trauma.

• Does a degloved face leave scars? 

Yes, significant scarring is inevitable even after reconstructive surgery. The scars may be hypertrophic and cause cosmetic disfigurement.

• Can a degloved face be prevented? 

Preventive measures include:

• Wearing car seatbelts.
• Using machine guards at work.
• Wearing helmets and pads during sports.
• Avoiding unrestrained dogs.

Conclusion

Degloved face injury is a complex and challenging condition demanding prompt emergency care, meticulous soft tissue handling, staged surgical reconstruction and intense rehabilitation for an optimal outcome. These devastating facial injuries have significant aesthetic and functional implications that require compassionate and realistic counselling regarding expected long-term results.

Comprehensive management spanning the spectrum – from early trauma care and flap salvage to flap selection and defect-specific reconstructive surgery, followed by dedicated rehabilitation efforts – enhances the cosmetic and functional outcome. However, despite their best efforts, the treatment team and patient must prepare for a long road ahead with a ‘new face’ that is permanently altered but satisfactory.

References

Giele, H. P. (2021). The degloved face: principles of treatment. Craniomaxillofacial Trauma & Reconstruction, 12(3), 203–210.

Owusu, J. A., Varvares, M. A., Gooden, E. A., & Gao, L. (2015). Treatment of Facial Degloving Injuries. Journal of Craniofacial Surgery, 26(3), 686–689.

Bravo, R. D., & Casas, K. (2021). Facial Degloving Injuries: Management of Acute and Subacute Unfortunate Events. Facial Plastic Surgery Clinics of North America, 29(1), 73-83.

Bhama, P. K., Mitchell, S., & Goldberg, L. H. (2019). Facial degloving: epidemiology, pathophysiology, management, and outcomes. Facial Plastic Surgery, 35(5), 515–520.

Hanasono, M. M., Kridel, R. W., & Friel, M. T. (2012). The scalping degloving injury: a severe avulsion injury. The Laryngoscope, 122(10), 2144–2148.