1. Combat Related
Maxillofacial Injuries
Lt Col Darryl Tong RNZAMC
Oral and Maxillofacial Surgeon

2. Disclaimer and OPSEC

6. Role 3 MMU KAF
• Only designated Role 3 medical
facility in Southern Afghanistan
• Role 3 NATO asset designation
• Also Level III medical facility
• Highest level of care available within the
combat zone
• ICU and ward beds
• General, orthopaedic, neurosurgery,
maxillofacial
• Blood bank, laboratory, x-ray and CT,
mortuary

7. Role 3 MMU KAF
• Nations represented include:
• Canada (lead Nation)
• Denmark
• Netherlands
• United States
• United Kingdom
• Australia
• New Zealand

8. MMU
COMKAF
HQ
Primary
care

9. Role 3 MMU KAF
• 2 Surgical teams each consisting of:
• Anaesthetist
• Nurse anaesthetist
• General Surgeon
• Orthopaedic Surgeon
• Theatre staff
• 24 hour shifts with call-back option on
off days as required
• Canadian – Danish rotation

10. Role 3 MMU KAF
• Neurosurgery and Maxillofacial
surgery stand alone specialties
• R3 MMU is the referral centre for all
neurosurgical and maxillofacial trauma
for Southern Afghanistan
• 24 hour on call, 7 days a week
• Neurosurgery: United Kingdom
• Maxillofacial Surgery: UK, Canada, NZ

12. Role 3 MMU KAF
• 8 wards beds with surge capability of
extra 4 beds = 12 total
• 5 ICU beds with ventilators with one
extra bed often used for recovery
• 4 extra beds for ward or ICU capability
• One isolation room for infectious
disease or detainees

15. Role 3 MMU KAF
• Extra 8 beds in primary care and
surge capabilities in respective Role 1
facilities (UK, Dutch, Danish etc)
• 6 trauma bays with surge capability of
8 extra bays = total 14 trauma bays
with overflow to Role 1 facilities

16. Role 3 MMU KAF
• 2 operating theatres
• X-ray department
• Laboratory and blood bank
• Dental section ( 2 dentists + DAs)
• Psych med section (psychiatrist and 2
MH RNs)
• Prev med section
• Pharmacy

18. Patients
• Coalition personnel
• Civilian contractors
• ANA and militia
• ANP
• Local population
• Significant paediatric patient flow
• Minimal women’s health involvement

19. Surgeries by specialty
50 115
273
648
893
Other 4%
Neuro 7%
Maxfax 16%
General 39%
Ortho 53%
Period: 01 Sep 2007 – 01 Mar 2009
N = 1675

20. Patient category
642 635
303
48 47
0
100
200
300
400
500
600
700
Period: 01 Sep 2007 – 01 Mar 2009

21. Trauma sequence
• 9- liner called through
• Trauma teams notified
• Specialist staff notified
• Operating theatre on standby
• Triaged
• Primary survey: MARCHH
• Secondary survey

34. Maxillofacial injuries in combat
• Incidence of HFN wounds from Iraq
and Afghanistan currently ranges from
21-29% (US and UK data)
• Israeli data ranges from 26-54%
(Lebanon, Gaza and West Bank)
• Dobson et al. 1988:
 13 major conflicts from 1914-1986
 Overall incidence HFN wounds 16%
including WW1, WW2, Vietnam and

35. Maxillofacial injuries in combat
• Second most common injuries
sustained among combat personnel
• Fragment injuries >> GSW
• Blunt trauma still occurs
• Concomitant injuries:
 Cervical spine
 Traumatic head injury
 Ocular/Otologic

36. Maxillofacial injuries in combat
• Proportional increase in HFN injuries
due to survivability from the use of
CBA
• Exposed areas of extremities, face
and neck are issues for CBA design
• Mobility and ability to fight versus
protection

38. Surgical considerations
• Damage control surgery vs. definitive
care
• Primary versus secondary
reconstruction
• Choice of hardware
• General condition of patient
• Patient disposition
• Antibiotics

39. Surgical considerations
• Life, limb, eyesight
• Damage control surgery is typically
not necessary apart from airway or
haemorrhage control
• UK favours early evacuation for
definitive maxillofacial repair
• US study: definitive feasible in-country
but following strict criteria

40. Surgical considerations
• Potential need for secondary surgery
depends on:
 Patient condition
 Availability of tissue
 Surgeon skill set
 Demands on operating theatre
 Timings for STRATEVAC

41. Surgical considerations
• Local nationals tended to receive as
much definitive surgery as possible
 Local expertise issues
 Rehab and post op care issues
• Often time delay in presentation
 General condition of patient
 Availability of medevac
 Tactical situation at the time

42. Multiple roles in trauma
• Maxillofacial trauma
 Soft tissue
 Hard tissue
• Teeth
• Bones
• Ocular injuries
• Advanced airway management
including surgical airway
• Neck exploration

43. Multiple roles in trauma
• First assistant
 Orthopaedic surgery
 General surgery
 Neurosurgery
• Trauma team leader
• Post operative care complications

65. Points to consider
• Combat body armour saves lives but
not necessarily limbs or faces
• Head, face and neck wounds second
most common injuries in combat
personnel
• Surgeons with expertise in
maxillofacial trauma are an integral
part of the current military surgical
team

66. Points to consider
• Maxillofacial surgeons are force multipliers
• Essential that the lessons learnt in combat
trauma are passed on to other military
surgeons
• Maxfax surgeons need to be familiar with
other surgical specialties:
 Eyes / ENT
 Neurosurgery
 Orthopaedic surgery

67. Points to consider
• Adaptability essential (not civilian
tertiary hospital-centric mentality)
• Basic maxillofacial trauma skills as
part of a training module for other
specialists
• Regular opportunities to share
information

68. Acknowledgements
• AMMA/Joint Health Command
• NZ Defence Force
• University of Otago
• Role 3 MMU KAF
““The Best Care AnywhereThe Best Care Anywhere””