Psychological Impact on Post-Traumatic Patients Following Maxillofacial Injuries

By Sana Farooq, Tauqir Ul Islam

Affiliations

1. Department of Oral and Maxillofacial Surgery, Liaquat National Hospital and Medical College, Karachi, Pakistan

doi: 10.29271/jcpsp.2025.07.44

ABSTRACT
Objective: To assess the frequency and extent of psychological impact, with a particular focus on post-traumatic stress disorder (PTSD), among patients who have sustained maxillofacial injuries.
Study Design: A descriptive, cross-sectional study.
Place and Duration of the Study: Department of Oral and Maxillofacial Surgery, Liaquat National Hospital, Karachi, Pakistan, from November 2024 to April 2025.
Methodology: A total of 195 patients were included in the study after obtaining ethical approval. Data collection involved a trauma screening questionnaire (TSQ) and a sociodemographic questionnaire. Data analysis was performed using the SPSS version 27. Frequencies and percentages were calculated for qualitative variables. Quantitative variables such as age and TSQ scores were presented as mean ± standard deviation (SD).
Results: One month after the traumatic event, 72 (37%) patients were diagnosed with PTSD, while the remaining 123 (63%) patients showed no signs of the disorder. Statistically significant associations with PTSD were found in younger patients (73.6%), singles (59.7%), those who had not returned to work (31.8%), those with cosmetic and functional injuries (54.2%), hospital stays over 4 days (52.8%), no family support (72.2%), those with substance abuse history (52.8%) (all with p-values <0.001), and below average earners (45.8%, p = 0.008). No significant associations were found with gender, literacy, employment status, or mechanism of injury.
Conclusion: While physical injuries are readily treated, psychological impacts often go unnoticed. The study highlights an increased frequency of PTSD among maxillofacial trauma patients, emphasising the need for routine psychological screening and timely mental health referrals to enhance patient recovery and quality of life.

Key Words: Maxillofacial injuries, Frequency, Psychological impact, Post-traumatic patients, Trauma screening questionnaire, Mental health, Post-traumatic stress disorder.

INTRODUCTION

According to statistics, approximately 60.7% of men and 51.2% of women experience a traumatic event at least once in their lifetime.¹ As per the findings of the Victorian State Trauma Registry, approximately 16% of patients with major trauma experienced injuries in the maxillofacial region.² The causes of maxillofacial trauma are diverse and can vary from one country to another due to cultural, socioeconomical, and environmental factors.³ Road traffic accidents (RTAs), violence, falls, and sports injuries were identified as the primary factors contributing to maxillofacial trauma.⁴ In developed countries, interpersonal violence is the primary cause of maxillofacial trauma, whereas in developing countries, RTAs are the leading contributor  to  such  injuries.⁵

Annually, over 1 million individuals lose their lives due to such RTAs, with an additional 25 million experiencing permanent injuries or disabilities as a consequence of it.⁶

According to the World Health Organization (WHO), around 450 million people are impacted by mental disorders, with around 11% of sufferers globally are due to all diseases and injuries.⁷ Since the face is a distinctive identity and is more prone to injuries, disfigurement to the facial region can result in physical impairment as well as psychological distress.⁸ The physical aspects are clinically evident and are treated appropriately, whereas the post-traumatic psychological impacts are less obvious and may go unnoticed. Many patients who experience maxillofacial trauma display symptoms of anxiety, depression, and post-traumatic stress disorder (PTSD).⁹ Since the initial publication on this topic, the trauma screening questionnaire (TSQ) has been the most commonly used tool for assessing the quality of life (QOL) in patients with craniofacial trauma. Although trauma-related symptoms often diminish over time, addressing any psychological disorders remains essential to ensure complete physical and emotional recovery in these patients. The optimal time to evaluate the patient is during the one-month follow-up phase, as many temporary stress reactions are likely to have subsided by then.¹⁰

Untreated psychological disorders following trauma can result in severe consequences, including self-harm, harm to others, impaired social relationships, diminished workplace functioning, increased risk of violent behaviour, and substance abuse. Early identification and timely referral are essential to mitigate these outcomes, underscoring the importance of structured follow-up and psychological evaluation in trauma care. In developing countries, such as Pakistan, there remains a significant gap in data and a lack of standardised protocols for addressing post-traumatic psychological stress in patients with maxillofacial injuries. Consequently, this important aspect of patient care is often overlooked in clinical practice.

The objective of this study was to determine the frequency of psychological stress in post-traumatic patients with maxillo- facial injuries.

METHODOLOGY

A cross-sectional, descriptive, and analytical study was conducted using a non-probability consecutive sampling technique. The sample size was calculated using the WHO software for sample size determination, based on a prevalence of psychological stress of 24%,¹¹ as reported in previous studies, with a margin of error of 6% and a 95% confidence level. The final calculated the sample size was 195 patients. Patients aged between 18 and 60 years, presenting with any type of maxillofacial injury and a Glasgow coma scale (GCS) score of 12 or higher, were included. Exclusion criteria included cognitive impairments (pre-existing or resulting from trauma), associated neurological, abdominal, thoracic, vascular, or orthopaedic injuries, a history of psychological disorders, previous use of antidepressants or anxiolytics, or unwillingness to participate in follow-up assessments. Participants were stratified into three age groups: 18-30 years, 31-45 years, and 46-60 years.

The study was approved by the Institutional Ethical Review Board of the Liaquat National Hospital and Medical College, Karachi, Pakistan, (Ref. Letter # 1110-2024-LNH-ERC), and was conducted at the Department of Oral and Maxillofacial Surgery, Liaquat National Hospital and Medical College, Karachi, Pakistan, from November 2024 to April 2025. Eligible patients were recruited from the Emergency Department and Outpatient Department (OPD) based on the predefined inclusion and exclusion criteria. Follow-up assessments were conducted one-month postoperatively in the maxillofacial OPD. During follow-up visits, patients were interviewed by the attending physician, who administered the study questionnaires. Informed written and verbal consent was obtained from all participants after providing a detailed explanation of the study objectives, methods, and ethical considerations, including confidentiality of the data. Data collection was carried out by using the two structured instruments i.e., the sociodemographic questionnaire and TSQ. The first one recorded patients’ age, gender, contact information, socio- economic status, literacy level, cause, and type of facial injury, employment status, return-to-work status, length of hospital stay, family support, and substance abuse, while the second one is a validated instrument for screening PTSD, consisting of 10 items based on DSM-IV criteria. The first five items assess re-experiencing symptoms, while the remaining five address hyperarousal symptoms. A TSQ score ≥6 was considered indicative of PTSD.

Data were analysed using the SPSS Software version 27. Categorical variables, such as gender, literacy level, socioeconomic status, employment status, return-to-work status, cause, and type of facial injury, family support, substance abuse, and presence of PTSD, were summarised as frequencies and percentages. Continuous variables, such as age and TSQ score, were presented as means ± standard deviations (SD). The Shapiro-Wilk test was used to assess the normality of data. Post-stratification Chi-square tests were performed to evaluate associations between the PTSD and potential effect modifiers, including age, gender, literacy level, socio- economic status, employment status, return-to-work status, cause, and type of facial injury, family support, and substance abuse. A two-tailed p-value ≤0.05 was considered statistically significant.

RESULTS

Table I outlines the descriptive characteristics of the study population. Of the 195 participants, majority were male (65.6%) and predominantly belonged to the younger age group (52.3%). Most individuals were married (52.3%) and came from an average socio-economic background (50.3%). A significant proportion of participants was literate (61%) and either employed (65.1%), or had resumed work following the trauma (66.9%). RTAs were identified as the leading cause of maxillofacial injuries, accounting for 51.3% of cases. Regarding the type of trauma, functional injuries were the most prevalent (40%), followed by a combination of cosmetic and functional injuries (32.8%), and cosmetic disfigurement alone (27.2%). Majority of patients had a hospital stay lasting up to two days (35.9%). Furthermore, 59% of participants reported having family support during their recovery, while 30.8% had a history of substance  use  at  the  time  of  the  traumatic  event.

 Figure  1:  Distribution  of  post-traumatic  stress  disorder.

Figure 2: Positive responses to each item on the trauma screening questionnaire (TSQ) for evaluation of post-traumatic stress disorder.
  Figure 3: Frequency of positive PTSD responses by patient characteristics, one-month post-trauma.

The TSQ was administered in a structured questionnaire format to aid in the provisional identification of PTSD among study participants. As illustrated in Figure 1, at the one- month follow-up following trauma or surgical intervention, 72 (37%) patients screened positive for PTSD, while the remaining 123 (63%) participants did not meet the criteria for PTSD. Positive responses to the TSQ, used to assess symptoms of PTSD, are detailed in Figure 2.

Table II presents the association between PTSD and various patient-related characteristics. Results demonstrated a significant association between PTSD at one-month post- trauma (as measured by TSQ scores) and several patient factors. These included: Younger age (73.6%, p <0.001), being single (59.7%, p <0.001), lower socioeconomic status (45.8%, p = 0.008), and patients who did not return to work (31.8%, p <0.001). Additionally, PTSD was significantly more frequent in individuals with both cosmetic and functional injuries (54.2%) or cosmetic deformity alone (36.1%) compared to those with only functional injuries (p <0.001). Other significantly associated variables included a hospital stay longer than 4 days (52.8%, p <0.001), lack of family support (72.2%, p <0.001), and a history of substance abuse at the time of injury (52.8%, p <0.001). Conversely, no statistically significant association was found between PTSD and variables such as gender (p = 0.243), educational status (p = 0.133), employment status (p = 0.368), or the mechanism of injury (p = 1.000).

Figure 3 represents the distribution of patients with positive PTSD symptoms (score >5) stratified by key demographic and clinical characteristics, one month after the traumatic event.

Table I: Descriptive statistics of study participants.

Variables	Frequencies (%)
Gender	-
Male	128 (65.6)
Female	67 (34.4)
Age group	-
18-30 years	102 (52.3)
31-45 years	63 (32.3)
46-60 years	30 (15.4)
Marital status	-
Single	79 (40.5)
Married	102 (52.3)
Widowed / divorced	14 (7.2)
Socioeconomic status	-
Below average	66 (33.8)
Average	98 (50.3)
Above average	31 (15.9)
Educational status	-
Uneducated	76 (39)
Educated	119 (61)
Employment status	-
Employed	127 (65.1)
Unemployed	68 (34.9)
Return to work (n = 127)	85 (66.9)
Cause of facial injury	-
RTA	100 (51.3)
Fall	54 (27.7)
Assault	31 (15.9)
Sports injury	10 (5.1)
Type of facial injury	-
Cosmetic	53 (27.2)
Functional	78 (40)
Both	64 (32.8)
Length of hospital stay	-
Up to 2 days	70 (35.9)
Up to 4 days	63 (32.3)
Above 4 days	62 (31.8)
Presence of family support	115 (59)
History of substance abuse at the time of the incident	60 (30.8)

Table II: Associations of post-traumatic stress disorder.

Variables	Post traumatic stress disorder n (%)		p-values
	Yes	No
Gender	-	-	-
Male	51 (70.8)	77 (62.6)	0.243
Female	21 (29.2)	46 (37.4)	-
Age group	-	-	-
18-30 years	53 (73.6)	49 (39.8)	<0.001*
31-45 years	13 (18.1)	50 (40.7)	-
46-60 years	6 (8.3)	24 (19.5)	-
Marital status	-	-	-
Single	43 (59.7)	36 (29.3)	<0.001*
Married	22 (30.6)	80 (65)	-
Widowed / divorced	7 (9.7)	7 (5.7)	-
Socioeconomic status	-	-	-
Below average	33 (45.8)	33 (26.8)	0.008*
Average	26 (36.1)	72 (58.5)	-
Above average	13 (18.1)	18 (14.6)	-
Educational status	-	-	-
Uneducated	33 (45.8)	43 (35)	0.133
Educated	39 (54.2)	80 (65)	-
Employment status	-	-	-
Employed	44 (61.1)	83 (67.5)	0.368
Unemployed	28 (38.9)	40 (32.5)	-
Return to work status (n = 127)	14 (31.8)	71 (85.5)	<0.001*
Cause of facial injury	-	-	-
RTA	37 (51.4)	63 (51.2)	1.000
Fall	20 (27.8)	34 (27.6)	-
Assault	11 (15.3)	20 (16.3)	-
Sports injury	4 (5.6)	6 (4.9)	-
Type of facial injury	-	-	-
Cosmetic	26 (36.1)	27 (22)	<0.001*
Functional	7 (9.7)	71 (57.7)	-
Both	39 (54.2)	25 (20.3)	-
Length of hospital stay	-	-	-
Up to 2 days	11 (15.3)	59 (48)	<0.001*
Up to 4 days	23 (31.9)	40 (32.5)	-
Above 4 days	38 (52.8)	24 (19.5)	-
Presence of family support	20 (27.8)	95 (77.2)	<0.001*
History of substance abuse at the time of the incident	38 (52.8)	22 (17.9)	<0.001*
Chi-square / Fisher’s exact test was applied. p ≤0.05 was considered significant. *Significant at 0.05 level.

DISCUSSION

The existing literature indicates that 10 to 70% of individuals experience symptoms of emotional and psychological distress following maxillofacial trauma.¹² Despite widespread recognition of the importance of integrated treatment models that address psychological sequelae post-injury, such frameworks are seldom incorporated into routine follow-up care within maxillofacial surgery settings.¹³ Approximately one-third of patients with facial trauma reported limitations in daily functioning, which can significantly impact both their physical health and psychological well-being.¹⁴ Therefore, assessing the patient QOL—particularly in relation to mental health and satisfaction—should be considered a critical component of trauma care.

The present study identified PTSD and emotional distress as the most prevalent long-term complications associated with maxillofacial trauma. Notably, 37% (n = 72) of participants screened positive for PTSD, one-month post-injury. This is consistent with previously reported PTSD prevalence ranging from 23 to 41% in similar populations,¹³ and is considerably higher than the 7% observed in the general population.¹⁵ Kishore et al. also reported a PTSD rate of 24% among patients evaluated one month following facial trauma.¹¹

Symptoms commonly associated with PTSD include persistent re-experiencing of the traumatic event, nightmares, avoidance behaviours, intrusive recollections, hyperarousal, sleep disturbances, and emotional numbing. Coexisting psychological injury may lead to notable systemic and localised physiological responses.¹⁶ A recent survey found that only 45% of surgeons believed that psychological concerns were adequately addressed in hospitals, while 95% supported the need for a dedicated psychosocial aftercare programme.¹⁷

Feranden et al. identified strong associations between facial trauma and adverse psychological outcomes such as unemployment, substance abuse, prolonged hospital stays, marital conflict, and dissatisfaction with body image.¹⁸ In line with these findings, the present study observed higher PTSD rates among patients with hospital stays exceeding four days (52.8%). Although no statistically significant association was found between employment status and PTSD, patients who were employed but had not returned to work post-injury exhibited a higher prevalence (68.2%).

Furthermore, in this study, patient-related factors such as younger age (73.6%) with a mean age of 31 years for men and 28 years for women,⁹ substance use before the injury (52.8%), and being from a socioeconomically disadvantaged background (45.8%) were significantly associated with the development of PTSD. These findings are consistent with previously published literature.^18,19

Additionally, the role of family support is crucial in mitigating the post-traumatic psychological distress. This finding reaffirms this, as individuals lacking family support had notably higher PTSD rates (72.2%).²⁰ Cosmetic deformities have also been identified as the significant contributors to psychological morbidity, with 36.1% of affected individuals in this study displaying elevated PTSD scores. This supports previous literature indicating a strong association between disfigurement and mental health deterioration,²¹ which was also reported in this study to be 36.1%. According to Maslow’s pyramid, unmet aesthetic needs can adversely affect psychological well-being.²² These data confirm this, highlighting cosmetic deformity as a significant risk factor for PTSD, aligning with the findings of Hirobe et al.²³ Facial disfigurement may undermine self-esteem and personal identity, thus exacerbating psychological vulnerability.

Consistent with prior studies, no significant correlation was found between PTSD and the mechanism of injury or literacy level in this study.²⁴ Importantly, numerous effective PTSD treatment protocols emphasise early recognition as the cornerstone of management. Psychological intervention should be regarded as equally critical as surgical or medical treatment. A multidisciplinary care model, incorporating mental health professionals, is recommended for comprehensive management. Psychotherapeutic interventions, alongside pharmacological therapy when indicated, have demonstrated efficacy in trauma care.²⁵ Therefore, structured psychological follow-up and support systems are essential for the holistic rehabilitation of maxillofacial trauma patients.

This study has several limitations. Firstly, it did not distinguish between surgical and non-surgical treatment approaches, which could potentially influence the development of PTSD. Future research should aim to evaluate the impact of several different treatment modalities on psychological outcomes. Secondly, the assessment of stress disorders relied solely on the TSQ; incorporating additional tools such as the hospital anxiety and depression scale (HADS) or the depression anxiety stress scales (DASS) could enhance the accuracy and depth of psychological evaluation.

CONCLUSION

Individuals sustaining maxillofacial injuries face a substantial risk of developing psychiatric disorders, not only as a consequence of the traumatic event itself, but also due to the resulting functional impairments and aesthetic disfigurement. The present study demonstrates an increased frequency of psychological distress among post-traumatic patients, emphasising the importance of recognising and addressing their mental health needs. Therefore, the primary goals of trauma management should extend beyond the physical restoration of maxillofacial structures to also include the psychological well being of the patient. Incorporating routine mental health screening into standard postoperative care can enable early detection of those at the risk for post-traumatic psychiatric conditions, such as PTSD. Timely and appropriate referrals to mental health professionals—within a multidisciplinary framework that includes psychosocial support, patient education, counselling, and, when necessary, pharmacotherapy—are crucial to improving patient outcomes. Adopting such holistic and integrated approach will not only enhance recovery but also significantly improve the long-term quality of life for individuals recovering from maxillofacial trauma.

ETHICAL  APPROVAL:
Ethical approval was obtained from the Institutional Ethical Review Board of the Liaquat National Hospital and Medical College, Karachi, Pakistan (Ref. Letter # 1110-2024-LNH-ERC). All the procedures performed in studies involving human participants were conducted by the ethical standards of the institutional and/or national research committee and in accordance with the Helsinki Declaration.

PATIENTS’  CONSENT:
Written informed consent was taken from the participants.

COMPETING  INTEREST:
The authors declared no conflict of interest.

AUTHORS’  CONTRIBUTION:
SF: Conceptualised the study design, performed the data collection, analysis, interpretation, and manuscript writing.
TUI: Supervised the study, reviewed the article critically, and proofread the article.
Both authors approved the final version of the manuscript to be published.
 

REFERENCES

1. Javidi H, Yadollahie M. Post-traumatic stress disorder. Int J Occup Environ Med 2012; 3(1):2-9.
2. Shahim F, Cameron P, McNeil JJ. Maxillofacial trauma in major trauma patients. Aust Dent J 2006; 51(3):225-30. doi: 10.1111/j.1834-7819.2006.tb00433.x.
3. Leles JLR, Santos EJd, Jorge FD, Silva ETd, Leles CR. Risk factors for maxillofacial injuries in a Brazilian emergency hospital sample. J Appl Oral Sci 2010; 18(1):23-9. doi: 10. 1590/s1678-77572010000100006.
4. Allareddy V, Allareddy V, Nalliah RP. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg 2011; 69(10): 2613-8. doi: 10.1016/j.joms.2011.02.057.
5. Adebayo ET, Ajike O, Adekeye E. Analysis of the pattern of maxillofacial fractures in Kaduna, Nigeria. Br J Oral Maxillofac Surg 2003; 41(6):396-400. doi: 10.1016/s0266- 4356(03)00165-7.
6. Sureshkumar L, Patil P, Iyer Y. Effect on quality of life and psychosocial issues of patients with maxillofacial fractures in rural setting. Indian J Dent Sci 2021; 13(3):187-91. doi: 10.4103/IJDS.IJDS_165_20.
7. Persaud A, Day G, Ventriglio A, Gupta S, Ramachandran P, Ruiz R, et al. Geopolitical factors, foreign aid and mental health II: Value for money. Int J Soc Psychiatry 2018; 64(8):786-98. doi: 10.1177/0020764018808552.
8. El Hawary H, Salimi A, Gilardino MS. Ethics of facial transplantation: The effect of psychological trauma associated with facial disfigurement on risk acceptance and decision making. Ann Surg 2022; 275(5):1013-7. doi: 10.1097/SLA. 0000000000004156.
9. Ranganathan V, Panneerselvam E, Chellappazham S, Balasubramaniam S, Raja VBK. Evaluation of depression associated with post-traumatic stress disorder after maxillofacial injuries—A prospective study. J Oral Maxillofac Surg 2018; 76(6):1282.e1-.9. doi: 10.1016/j.joms.2018.02.011.
10. Joshipura MK. Trauma care in India: Current scenario. World J Surg 2008; 32(8):1613-7. doi: 10.1007/s00268-008- 9634-5.
11. Kishore J, Vatsa R, Singh J, Kumari M, Kumar T, Bandgar S. Psychological impact on maxillofacial trauma patients–an observational study. J Med Life 2020; 13(4):458. doi: 10. 25122/jml-2020-0111.
12. Braimah RO, Ukpong DI, Ndukwe KC, Akinyoola AL. Comparative study of anxiety and depression following maxillofacial and orthopedic injuries. Study from a Nigerian University Teaching Hospital. Clin Exp Dent Res 2017; 3(6):215-9. doi: 10.1002/cre2.90.
13. Howson K, Yeung E, Rayner L, Fan K. Real-time screening tool for identifying post-traumatic stress disorder in facial trauma patients in a UK maxillofacial trauma clinic. Int J Oral Maxillofac Surg 2021; 50(11):1464-70. doi: 10.1016/j.ijom. 2021.01.022.
14. Herrera-Escobar JP, Seshadri AJ, Stanek E, Lu K, Han K, Sanchez S, et al. Mental health burden after injury: It's about more than just posttraumatic stress disorder. Ann Surg 2021; 274(6):e1162-9. doi: 10.1097/SLA.000000000000 3780.
15. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62(6):593-602. doi: 10.1001/archpsyc.62.6.593.
16. Burg MM, Soufer R. Post-traumatic stress disorder and cardiovascular disease. Curr Cardiol Rep 2016; 18(10):94. doi: 10.1007/s11886-016-0770-5.
     
17. Zazzali JL, Marshall GN, Shetty V, Yamashita D-DR, Sinha UK, Rayburn NR. Provider perceptions of patient psychosocial needs after orofacial injury. J Oral Maxillofac Surg 2007; 65(8):1584-9. doi: 10.1016/j.joms.2006.09.028.
18. Lupi-Ferandin S, Glumac S, Poljak N, Galic T, Ivkovic N, Brborovic O, et al. Health-related quality of life in patients after surgically treated midface fracture: A comparison with the croatian population norm. Ther Clin Risk Manag 2020; 16:261-7. doi: 10.2147/TCRM.S249116.
19. Gandjalikhan-Nassab SA, Samieirad S, Vakil-Zadeh M, Habib-Aghahi R, Alsadat-Hashemipour M. Depression and anxiety disorders in a sample of facial trauma: A study from Iran. Med Oral Patol Oral Cir Bucal 2016; 21(4):e477-82. doi: 10.4317/medoral.21068.
20. Fares J, Gebeily S, Saad M, Harati H, Nabha S, Said N, et al. Post-traumatic stress disorder in adult victims of cluster munitions in Lebanon: A 10-year longitudinal study. BMJ Open 2017; 7(8):e017214. doi: 10.1136/bmjopen-2017- 017214.
21. Hu W, Mehta D, Garg K, Patel S, Shukla S, Agrawal M, et al. Post traumatic stress disorder following facial and dental trauma: preliminary findings from a study conducted in India. Oral Maxillofac Surg 2023; 27(2):297-303. doi: 10. 1007/s10006-022-01068-9.
22. Armstrong DJ. The pragmatic application of attachment theory in medical decision making regarding emotionally unstable personality disorder presentations to healthcare settings. J Psychol Ther 2020; 5(2):135-47. doi: 10.33212/jpt.v5n2.2020.135.
23. Hirobe Y, Koshinuma S, Nakamura M, Baba M, Yamamoto G, Hitosugi M. Factors influencing the long‐term hospitalization of bicyclists and motorcyclists with oral and maxillofacial injuries. Dent Traumatol 2021; 37(2):234-9. doi: 10.1111/ edt.12622.
24. Braimah RO, Ukpong DI, Ndukwe KC, Akinyoola L. Self- esteem following maxillofacial and orthopedic injuries: Preliminary observations in sub-Saharan Africans. Oral Maxillofac Surg 2019; 23(1):71-6. doi: 10.1007/s10006-018- 0735-5.
25. Schrader C, Ross A. A review of PTSD and current treatment strategies. Mo Med 2021; 118(6):546-51.