Airway management in the field setting may be deemed necessary if there is severe displacement of the mandibular symphysis and loss of anterior tongue support. Facial burns with intraoral or nasal involvement also pose a threat to airway patency and should be addressed aggressively. If the patient needs intubation in the field, orotracheal intubation is strongly preferred over blind nasotracheal intubation [7, 8]. An emergent tracheostomy is lifesaving in situations where the upper airway could not be accessed [9].

Facial bleeding is usually controlled by compression, and further managed by urgent suturing of the laceration or ligation of the relevant bleeding vessel. Facial arteries are rich in anastomoses and ligation of a single vessel is unlikely to result in tissue ischemia. Nevertheless, haphazard clamping or bulk tying may cause injury to adjacent nerves or ducts. Therefore identification of the bleeding vessel should be done in a controlled setting. If a massive uncontrollable bleed takes place, emergent external carotid ligation can be done through a lateral neck incision at the level of the hyoid bone [10]. An alternative choice would be selective embolization if personnel and equipment were available [11].

After addressing all life-threatening conditions, the secondary survey is performed by careful history and physical exam. The latter includes observation of facial and globe symmetries, lacerations, jaw opening, nasal septal hematomas, rhinorrhea, otorrhea, tympanic membrane integrity, and cranial nerve functions. Palpation of specific facial parts, nose, orbit, zygoma, eyes, maxilla, mandible, and forehead, for step-offs or significant tenderness should be done to rule out facial fractures [6, 12–15]. A computed tomography (CT) should be done, both coronal and sagittal views with three-dimensional reconstruction [16]. It has been shown that combining two-dimensional and three-dimensional CT reconstructions improves diagnosis and preoperative planning of complex facial fractures. CT angiography, on the other hand, is also useful in preoperative planning of an expanding facial hematoma or in ruling out aneurysms of the facial vessels in case free tissue transfer is indicated [17–23].

Empiric antibiotic treatment should be initiated as soon as possible, taking into account the prevalence of Acinetobacter and other contaminants in moist soil. Antibiotic coverage should also account for multidrug-resistant organisms when dealing with patients transferred from other hospitals or previously treated with antibiotics [24]. Preoperative antibiotic use is a must in facial war injuries associated with mucosal involvement, tissue devitalization or contamination, and exposed cartilage or open fractures. Infections in such wounds may lead to serious debilitating consequences such as Ludwig angina, cervicofacial necrotizing fasciitis, descending necrotizing mediastinitis, cavernous thrombosis, and brain abscesses [25]. Oronasal cavities and cervicofacial skin flora are staphylococcus, streptococcus, and enteric and anaerobic bacteria; hence penicillin derivatives with betalactamase inhibitors like amoxicillin-clavulanate and ampicillin-sulbactam are of choice; second- and third-generation cephalosporin may also be used like cefazolin, cefoxitin, ceftriaxone, as well as quinolones or clindamycin [26, 27].

Early initial debridement and empiric antibiotic treatment should be implemented as soon as possible. Thorough serial debridement is necessary to remove foreign bodies, decrease bacterial load, eliminate necrotic tissue, and prevent dirt tattooing [6, 28, 29]. It is important to be aware that healthy-appearing tissues following debridement may have suboptimal blood supply and undergo further necrosis [28, 30]. Therefore, revisit sessions are essential, and should be performed within 24–72 h to assess tissue viability. This is especially important in the maxillary region, which is more prone to infections and failure [31]. After adequate debridement, if cleanliness and vascularity of the injury site are still questionable, it is always recommended to observe the wound for more time than less [32]. Attaining a clean and well-vascularized injury site before definitive reconstruction helps avoid infectious complications, allows faster recovery time, and prevents the need of additional operative interventions [33]. A clean wound alone is not sufficient to ensure an adequate reconstruction. It is as important to maintain underlying skeletal support in order to avoid tissue shrinkage and distortion of normal anatomy. In the past, facial trauma used to be managed by soft-tissue closure despite underlying bone loss [33]. However, the healing process and resultant facial scar contraction render it impossible to perform optimal bony and soft-tissue reconstruction [33]. It is therefore critical to restore or stabilize the underlying bony skeleton in the initial phases of reconstruction. This can be achieved in various methods depending on the degree of soft-tissue loss and contamination. With satisfactory soft-tissue coverage, immediate bone grafting or temporary rigid plate and screw fixation of bone gaps awaiting future reconstruction are both viable options. With unsatisfactory soft-tissue coverage or bone loss with severe tissue contamination, vascularized composite tissue transfer is ideal [33–35]. The introduction of well-vascularized bone and soft tissues into a hostile wound environment maintains excellent survival of the free flaps and permits an early definitive reconstruction and shorter recovery period [36]. Although bone grafting may be used with high success rates, vascularized bone transfer has superior short- and long-term results and should be the first option when time and personnel are available [36–43].

Mandibular fractures are managed by reestablishing adequate occlusion using intermaxillary fixation prior to definitive fixation. This prevents jaw malocclusion, which can cause temporomandibular joint ankylosis in the long term. Simple mandibular fractures can be managed using external fixation in the form of intermaxillary fixation alone. When severe comminution is present, external fixation devises are advised in conjunction with intermaxillary fixation. This decreases the risk of infection by limiting instrumentation and maintaining good tissue viability [44]. Internal fixation with plates and screws on the other hand requires periosteal striping and devascularization of bony fragments that increase the risk of hardware infection and osteomyelitis.

Plate and screw fixation should be used with caution when fixating upper and middle third facial fractures because of a higher risk of infection in this area of the face [45]. In frontal sinus stripping care should be taken to burr the bony crypts that harbor mucosal cells. Incomplete mucosal striping may lead to mucocele formation up to 10 years from injury. Treatment of crushed maxillary sinus walls should start by irrigation through the same wound opening or using a Caldwell-Luc approach. Any free fragments of bone should be washed with water and removed, and then by gentle manipulation, fragments can be pushed back into position. Iodoform paste on ribbon gauze or Whitehead’s varnish should be laid down uniformly in the maxillary sinus. This pack preserves the bone fragments and anatomic features of the maxillary sinus in the correct position. The sinus packs should be removed after 2 weeks (Fig. 3.1).

Injuries of the facial nerve and its branches are frequently multilevel injuries with varying degrees of severity, involving most commonly the facial nerve branches exiting the parotid gland. Devitalized segments of nerve are often present and are considered nonsalvageable. Primary repair is thus not advised and nerve tagging should be performed using nonabsorbable sutures for future identification. At a later stage the surgeon should opt for a definitive primary repair if possible or using nerve grafts as well as temporalis and master muscle transfer.

The main concern when treating this region is maintaining medial canthal support and intercanthal distance. The canthal ligament can be fixated using a trans-nasal wire through the posterior lacrimal crest. If the soft tissues are not pulverized, and the ligament still attached to its bone fragment, the intercanthal space with its small bone fragments can be shaped back to their original anatomy by a two-finger squeezing technique. The intercanthal tissue can then be stabilized using two Portex tube-tailored wings or special buttons to contain the intercanthal space. These are fixed by nylon or silk sutures passed through the intercanthal tissue. The buttons or tubes can be removed after 2–4 weeks.

Severe blast injuries to the nasal region present with bone and cartilage matted in soft-tissue strands where no anatomic landmarks would be evident. Numerous methods have been devised to splint the fractured nose resulting from civilian trauma. However, none of these procedures are feasible for a severely avulsed or pulverized shredded nose. Shuker introduced a new technique in 1988 with intranasal stabilization that was accomplished with a plain Portex tracheostomy tube (No. 7 or 8 tube). The tube is modified by heating over a flame, squeezed with straight artery forceps, and immediately immersed in cold water to harden. A cross section of this segment will approximate a pyramid shape. A Portex tube should be inserted into each nostril and the fractured lacerated septum sandwiched in the middle between the two tubes. Those are left in position for 1 month. Intranasal lacerated tissues tolerate the Portex tube well, with no complications (Fig. 3.2) [46, 47].