title: A critical review of the literature and an evidence-based approach for life-threatening hemorrhage in maxillofacial surgery.
abstract: BACKGROUND
  Life-threatening facial hemorrhage in Maxillofacial Surgery (MFS) has an approximate incidence of 1% in the trauma patient and in elective surgery. The treatment of acute life-threatening hemorrhage in MFS to prevent hypovolemic shock or airway obstruction forms the basis of emergency care and necessitates the need for further analysis given the multitude of options proposed for treatment. A systematic review of the literature was undertaken to formulate an evidence-based approach to the treatment of life-threatening hemorrhage in MFS.
  
  
  METHODS
  A comprehensive search of journal articles was performed using PubMed and Ovid databases. Keywords and phrases used were "life threatening facial hemorrhage," "life threatening facial bleeding," "external carotid artery ligation," and "external carotid artery embolization." Our search yielded 1441 articles. In an attempt to focus on hemorrhage exclusively from traumatic and operative events, articles that cited hematological disorders as the underlying cause of bleeding were excluded from the study. There were 40 articles which met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence. There was 1 Level II, 21 Level III, 12 Level IV, and 6 Level V papers.
  
  
  RESULTS
  Seven Level III evidence-based studies noted a high association between midface injuries, particularly Lefort III fractures and massive oronasal hemorrhage. One Level II study, 8 Level III studies, and 3 Level IV studies concluded that the internal maxillary artery was most frequently associated with intractable posttraumatic hemorrhage. One Level II, 16 Level III, 3 Level IV, and 3 Level V articles cited anterior and posterior nasal packing and conservative measures as the first attempt to manage traumatic hemorrhage. Subsequently, 8 Level III studies re-enforced the importance of temporary reduction of facial fractures as an effective means to control massive hemorrhage early in the algorithm. Seven Level III studies, 4 Level IV, and 2 Level V studies documented the importance of ligation of arteries as one of the absolute measures to manage facial hemorrhage, whereas 1 Level II, 14 Level III, 2 Level IV, and 3 Level V studies alluded to embolization as the most reliable technique for control of the hemorrhage. In orthognathic surgery, the internal maxillary artery was most frequently the source of massive hemorrhage according to 2 Level III, 4 Level IV, and 1 Level V studies. Two Level III, 5 Level IV, and 1 Level V study proposed packing as the first attempt to tamponade the hemorrhage. Two Level IV and 1 Level V study cited pseudoaneurysm as a potentially life-threatening vascular complication after elective surgery.
  
  
  CONCLUSIONS
  Management of facial hemorrhage should be performed in a sequential and consistent manner to optimize outcome. An evidence-based algorithm for posttraumatic and elective life-threatening hemorrhage in MFS based on this critical review of the literature is presented and discussed.
authors.affiliation: Division of Oral and Maxillofacial Surgery, Long Island Jewish Hospital, and Division of Plastic Surgery, SUNY, Stony Brook, NY 11794-8191, USA.
authors.forename: Shachika
authors.initials: S
authors.lastname: Khanna
authors.forename: Alexander B
authors.initials: AB
authors.lastname: Dagum
mesh_terms: D000465:Algorithms; D003661:Decision Support Techniques; D017558:Elective Surgical Procedures; D005151:Facial Injuries / Q000150:complications / Q000601:surgery; D006470:Hemorrhage / Q000209:etiology / Q000628:therapy*; D006489:Hemostatic Techniques; D006801:Humans; D019647:Oral Surgical Procedures; D019106:Postoperative Hemorrhage / Q000628:therapy