Which specialist should a patient with facial fractures be referred to?

Specialist Referral for Facial Fractures

Patients with facial fractures should be referred to oral and maxillofacial surgery (OMFS) or plastic surgery with maxillofacial expertise, depending on institutional availability and the specific fracture pattern. 1

Primary Specialist Selection

Oral and maxillofacial surgeons or plastic surgeons with craniofacial training are the appropriate specialists for definitive management of facial fractures. 1 The choice between these specialists often depends on:

• Institutional practice patterns - Some trauma centers utilize OMFS as primary consultants, while others employ plastic surgery 2
• Fracture location and complexity - Both specialties are trained to manage the full spectrum of facial fractures 1
• Associated injuries - Multidisciplinary coordination is essential when concomitant injuries exist 3

Multidisciplinary Consultation Requirements

Neurosurgery Consultation

• Required when intracranial injury is present, which occurs in 68% of patients with facial fractures 4
• Specifically indicated for orbital wall fractures, as 9% have concomitant intracranial injury 4
• Subdural hematoma is the most frequent cerebral injury associated with facial fractures 3

Ophthalmology Consultation

• Mandatory for orbital fractures to assess visual acuity, extraocular movements, and globe integrity 4
• Up to 37% of patients with orbital fractures develop diplopia postoperatively 5
• Infraorbital nerve involvement requires documentation 6

Trauma Surgery/Orthopedics

• Essential for polytrauma patients, as 50.3% develop hospital complications including pulmonary injury (31.1% of cases) 3
• Cervical spine injury occurs in 7-11% of patients with significant maxillofacial trauma 4

Otolaryngology (ENT)

• Consider for frontal sinus fractures and complex nasoethmoidal-orbital injuries 4
• May assist with airway management in severe midface trauma 4

Timing of Consultation

Maxillofacial surgery consultation should occur during the initial trauma evaluation after primary survey stabilization, even if definitive repair is delayed 7, 2. Emergency surgical intervention by maxillofacial specialists is rarely required (only 10% of cases), but early consultation prevents delayed diagnosis and optimizes treatment planning 2.

Common Pitfalls to Avoid

• Do not delay consultation for "minor" fractures - Seemingly simple fractures may have complex displacement patterns visible only on CT 8
• Do not assume isolated facial injury - 43.7% have cerebral hematomas and 31.1% have pulmonary injuries 3
• Do not overlook cervical spine clearance - 11% of mandibular fracture patients have concomitant cervical spine injury 4
• Do not rely on clinical examination alone - CT maxillofacial without contrast is essential for surgical planning, as plain radiography misses 12% of fractures 6

Specific Fracture Patterns and Specialist Needs

Mandibular Fractures

• Primary: OMFS (traditional primary specialty for mandibular trauma) 1
• Dental occlusion assessment is critical 5

Midface Fractures (Le Fort, ZMC, NOE)

• Primary: OMFS or plastic surgery 1
• Requires CT maxillofacial imaging to evaluate zygomaticosphenoid suture status and orbital volume changes 6

Frontal Bone/Sinus Fractures

• Primary: Plastic surgery or OMFS 1
• Secondary: ENT for sinus management 4
• Neurosurgery if posterior table involvement 4

Orbital Fractures

• Primary: OMFS, plastic surgery, or oculoplastic surgery 1
• Mandatory ophthalmology co-management 4