Original Article

Craniomaxillofacial Trauma &

Reconstruction
1-7
Factors Associated With Violence ª The Author(s) 2020
Article reuse guidelines:
Against Women and Facial Trauma sagepub.com/journals-permissions
DOI: 10.1177/1943387520949339

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Brazilian Population: Results of

a Retrospective Study

Gabriela Mayrink, DDS, MsD, PhD1 , Stella Araújo, DDS1,

Laisa Kindely, DDS1, Renato Marano, DDS, MsD, PhD2,
Aguimar Bourguinon de Mattos Filho, DDS, MsD2,
Thassio Vidal de Assis, DDS2, Manoel Jadijisky Jr, DDS, MsD2,
and Natacha Kalline de Oliveira, DDS, MsD3

Abstract
Study Design: Violence against women is a challenge in public health. It involves women of all ages, socioeconomic
statuses, cultures, and religions.
Objective: The objective of this study was to perform an epidemiological survey of facial trauma among women who
experienced physical aggression by an intimate partner.
Methods: Electronic medical records from a public tertiary referral hospital for trauma in the Brazilian state of Espı́rito
Santo were analyzed between 2013 and 2018.
Results: Patients were most commonly between 20 and 29 years of age (33.9%), and 50% of the patients were of mixed
race. When separated by days of the week, facial trauma was most commonly inflicted on Sundays (24.2%) and on
Saturdays (22.6%). Of the 62 women included in the study, 47 had facial fractures, and 7 had more than 1 concomitant
fracture. Forty of the total fractures (72.7%) were on the middle and upper thirds of the face, while 15 fractures (27.3%)
were on the lower third of the face. The most commonly observed signs and symptoms of these injuries were edema
(56.5%), periorbital ecchymosis (35.5%), deviated nasal dorsum (22.6%), and hematoma (16.1%).
Conclusions: Facial trauma may be considered an important marker of attempted femicide. Health care professionals
must be aware of and attentive to this correlation, since many cases of attempted femicide go unnoticed or are attributed
to another etiology.

Keywords
violence against women, facial trauma, ethnic violence

Introduction
Violence against women is a challenge to public health; it
reflects gender inequality and is a violation of women’s
human rights.1 It generates emotional, psychological, and
physical consequences and can affects women of all ages,
socioeconomic classes, cultures, and religions.1 The most
common cause is the domestic violence, which is realized
by their intimate partner, more than violence in the streets.
A significant progress has been made in Brazil concerning
the establishment of the Women’s Protection Police
1
São Pedro Integrated Colleges, FAESA University, Vitória, Espı́rito Santo,
Brazil
2
Department of Oral and Maxillofacial Surgery, Jayme dos Santos Neves
Hospital, Serra, Espı́rito Santo, Brazil
3
Department of Oral and Maxillofacial Surgery, School of Dentistry,
University of Sao Paulo, Butanta, São Paulo, Brazil
Corresponding Author:
Gabriela Mayrink, São Pedro Integrated Colleges, FAESA University,
Vitalino dos Santos Valadares St, N 290, Santa Luiza, Vitória 29045-360,
Espı́rito Santo, Brazil.
Email: gabimayrink@gmail.com
2 Craniomaxillofacial Trauma & Reconstruction XX(X)
Station. But even with all public politics, there are an
expressive homicide data. Espı́rito Santo is considered one
of the most violent states with homicide tax, over than a
medium Brazil tax. Other very important aspect is the dif-
ferent races, where the black women have the homicide tax
significantly higher.
In 1993, the United Nations defined violence against
women as “any act of gender-based violence that results
in, or is likely to result in, physical, sexual or psychological
harm or suffering to women.” Male aggressors commonly
have personal or intimate relationships with the women
they abuse. Studies based on data from the World Health
Organization (WHO, 2002) report that between 10% and
69% of women worldwide have experienced physical vio-
lence from an intimate partner at some time in their lives.2
The WHO (2019) defines violence as “any act of
gender-based violence that results in, or is likely to result
in, physical, sexual or mental harm or suffering to women,
including threats of such acts, coercion or arbitrary depri-
vation of liberty, whether occurring in public or in private
life.”3 Violence is a social issue and is therefore not exclu-
sively associated with any specific field within health care.
In Brazil, there is no question that society has made
progress on combating violence against women in recent
years. In 2003, Brazil passed Law No. 10.778, which made
it mandatory for health care professionals in both public
and private care to report suspected or confirmed cases of
any kind of violence against women. Article 5 of the law
outlines the consequences for medical professionals who
do not comply.4 Health care professionals in the country
therefore need to be properly trained in treating trauma, as
well as in being receptive to victims, giving victims access
to support services or protection, counseling victims on the
importance of reporting the crime, and filing the mandatory
report.5 Giffin also emphasizes the importance of incidence
and prevalence data on violence against women, as well as
of training health care professionals on how to counsel and
support victims.6
However, in a ranking on femicide frequency world-
wide, Brazil came in fifth place out of 83 countries, behind
only El Salvador, Colombia, Guatemala, and Russia. The
survey found that a woman is killed in Brazil every 2 hours,
most frequently by a man who is or has been her intimate
partner. According to a national study from 2015, the Bra-
zilian state in which violence against women is most fre-
quent is Roraima, followed by Espı́rito Santo. The state
capital in which violence against women was found to be
most frequent was Vitória, the capital of Espı́rito Santo.
The city of Serra, where the current study took place, came
in 14th place out of all of the cities in Brazil.2
It is crucial to understand the details of facial trauma,
since these injuries negatively affect victims’ social lives
and emotional states, leave scars and other sequelae, and
often marginalize victims from society.7 Facial trauma
worsens workplace performance, increases absenteeism
from the workplace, and makes it more likely that victims
will lose their jobs.8 It is therefore clear that, in addition to
emotional damage, facial trauma creates a socioeconomic
problem and increases victims’ use of social services.7,8
Violence against women is not new; however, it is only
relatively recently in Brazil’s history that measures have
been taken in an attempt to reduce these crimes. In 1940,
the Brazilian penal code characterized physical aggression
against a woman as a punishable crime. In the 1980s, Bra-
zil’s first women’s police stations were implemented as a
safe space for women to report crimes and ensure legal
support.9 In August 2006, Brazilian Law No. 11.340 went
into effect. Known locally as the Maria da Penha law, it has
sought to increase the terms of punishments for crimes
against women.2 Article 5 of the law defines domestic and
family violence against women as any action that causes
death, injury, or physical, sexual, or psychological suffer-
ing.4 After the implementation of the Maria da Penha law,
crimes against women continued to increase in frequency,
but at a slower rate: the national increase in femicide
decreased to 2.6% annually. In 2015, Brazilian Law No.
13.104 went into effect in the country. Known as the Femi-
cide Law, it classifies violence against women as a heinous
crime and defines it as aggravated when the violence is
committed in cases of vulnerability, such as against minors,
during pregnancy, or in the presence of children.4
The face is the most evident, exposed, and unprotected
area of the body; an individual’s face and facial expressions
are closely tied to their identity.10 When an aggressor
leaves a victim’s face disfigured, the disfigurement affects
the victim’s self-esteem and creates both physical and emo-
tional scars.10 Trauma to the face may result in cosmetic
deformities and a loss of functional abilities such as chew-
ing and swallowing, changes to speech or breathing, pain,
changes in dental occlusion or a loss of teeth, as well as
damage to soft tissue, such as ecchymosis and abrasions.11
According to Halpern, injuries to the head, face, and neck
may represent a marker of intimate partner violence.12
The objective of this study was to investigate the num-
ber of facial fractures and the patterns between these frac-
tures and women who experienced physical aggression
from intimate partners between 2013 and 2018 and who
were treated at a public tertiary referral hospital for trauma
in the Brazilian state of Espı́rito Santo.
Methodology
This was a retrospective, observational, descriptive, and long-
itudinal epidemiological study of patients with maxillofacial
trauma treated by the Department of Oral and Maxillofacial
Surgery and Traumatology of Dr. Jayme Santos Neves State
Hospital in the city of Serra, Espı́rito Santo State, Brazil. In
this study, patient records over a 6-year period (February 1,
2013 to December 31, 2018) were analyzed.
This study was approved by the research ethics commit-
tee of São Pedro Integrated Colleges (FAESA) under ethics
evaluation submission certificate (CAAE) registry number
Mayrink et al. 3

Table 1. Frequency and of Age Range and Ethnicity of Abused

Women Included in this Study.

Variable N %
Age range
16 to 19 years 3 4.8
20 to 29 years 21 33.9
30 to 39 years 18 29.0
40 to 49 years 8 12.9
50 to 59 years 7 11.3
60 years or older 5 8.1
Ethnicity
Mixed race 31 50.0
Black 11 17.7
White 11 17.7
Figure 1. Etiology of facial trauma. *Eighty percent of the Of Asian ancestry 2 3.2
aggressions the women’s partner or the past partner was the Information not available 7 11.3
responsible.

73203017.0.0000.5059. The study was exempt from the use

of an informed consent form (ICF) due to its retrospective
nature; only relevant information was obtained from
patients’ medical records, and patient identity was kept
confidential.
Patients whose medical records were not properly com-
pleted were excluded from the study, as were patients with
facial trauma who had refused treatment and patients with
facial trauma who were not evaluated by the hospital’s oral
and maxillofacial surgery and traumatology team.
Data on patient age, as well as on the etiology, nature,
and type of injury were collected. The maxillofacial frac-
tures were organized by their etiological factors into motor
vehicle accidents, motorcycle accidents, falls, physical
aggression, and gunshot wounds. The fractures were also
divided into 2 groups based on the location of the fracture:
the mid and upper thirds of the face and the lower third of
the face. The fractures of the mid, upper and lower thirds of
the face were investigated.
Other data collected included the length of time between Figure 2. Frequency of trauma experienced by female victims of
the trauma and treatment, length of preoperative and post- physical aggression as organized by day of the week, month, and
operative hospitalization, prevalent signs and symptoms, and year.
the days, months, and years in which the injuries occurred.
The length of time between trauma and medical atten-
tion was up to 1 week in 66.1% of cases; 16.1% of patients
Results sought care immediately or within 24 hours. The period of
The study evaluated female facial trauma patient records preoperative hospitalization was up to 7 days in 35.5% of
from 2013 to 2018 of Dr. Jayme Santos Neves State Hospi- cases and the postoperative hospitalization was up to 7 days
tal. During this period, 216 female patients were treated, of in 54.8% of cases (Table 2).
these patients, 62 (21.2%) of the women reported that their The facial fractures were divided into 2 groups: fractures
trauma was the result of physical aggression (Figure 1). of the middle and upper thirds of the face, and those that
Among the self-reported victims of aggression, the most involved the mandible. Of the 62 women included in the
frequent age range was 20 to 29 years, and 50% of the study, 75.8% had facial fractures, and 7 (4.34%) had more
patients were of mixed race (Table 1). than 1 concomitant fracture. Forty of the total fractures
When separated by days of the week, facial trauma was (72.7%) were on the middle and upper thirds of the face, while
most commonly inflicted during the weekends (35.1%). 15 fractures (27.3%) were on the lower third of the face. On
Trauma caused by physical aggression was most frequent the middle and upper thirds of the face, the most common
in the year 2017 (24.2%), followed by the year 2015 fractures were nasal fractures (21 patients; 38.1%), zygoma-
(21.0%) (Figure 2). ticomaxillary complex fractures (10 patients; 18.2%), and
4 Craniomaxillofacial Trauma & Reconstruction XX(X)

Table 2. Time Between Traumatic Aggression and First Treatment, cause (27.6%), followed closely by physical aggression
and Length of Pre- and Postoperative and Hospitalization. (21.2%) and motor vehicle accidents (10.2%). Because
Variable N %
etiology was self-reported by the victims, there is the pos-
sibility that the victims were hiding the true causes of their
Time between aggression and first treatment injuries due to fear or shame. According to Silva et al, it is
Within the first 24 hours/immediately 10 16.1 not uncommon for the aggressor to accompany the victim
Up to 1 week 41 66.1
to the hospital in an attempt to intimidate her or prevent her
More than 1 week 3 4.8
Not applicablea 8 12.9 from reporting the true cause of the trauma.5 The aggres-
Time of preoperative hospitalization sors may aid in or insist upon hiding the signs of aggression
Up to 7 days 22 35.5 in order to avoid being punished through the Maria da
From 8 to 15 days 12 19.4 Penha law.
More than 15 days 1 1.6 When women are abused by men, some do not report it
Not applicablea 27 43.5 or answer health care professionals’ questions honestly,
Time of postoperative hospitalization
often because they are financially dependent upon or emo-
Up to 7 days 34 54.8
More than 15 days 1 1.6 tionally involved with the aggressor.13,14 For these reasons,
Not applicablea 27 43.5 it is difficult for medical professionals to identify victims
Total 62 100.0 and refer them to support services or protective care. Thus,
a
the number of violence victims may be smaller than the
Not applicable: Patients were not hospitalized.
reality. Another complicating issue is the victim’s emo-
tional fragility at the time of care.11 This information shows
Table 3. Most Frequent Types of Fractures and Their Signs and the importance of a multidisciplinary team to lead with the
Symptoms in Abused Women. patient in this specific situation, like social and psycholo-
gical assistance, in addition to medical and dental treat-
Variable ment, to provide more comfort and safety for the victim.
Type of fracture N % The most common age range of the victims in this study
was between 20 and 29 years (33.9%), findings which are
Nasal fracture 21 38.1 consistent with those reported by Silva.15 The prevalent
Mandible 15 27.3
Zygomaticomaxillary complex fracture 10 18.2
victim ethnicity in this study was mixed race (50.0%), fol-
Orbital fracture 4 7.2 lowed by black (17.7%); these data may vary depending on
Naso-orbito-ethmoidal fractures 2 3.6 where studies are performed.8 But, in general, the violence
Maxilla fracture 1 1.8 against women is a social issue that does not correlate with
Frontal bone fracture 1 1.8 any specific social class, race or ethnicity, religion, age, or
Maxillary alveolar fracture 1 1.8 education level.4
Total 55 100 In 2019, a study in Brazil showed a significative
Signs and symptoms N % increase (30.7%) in Brazil women’s homicides numbers
Edema 35 56.5 from 2007 to 2017.16 The same study shows that the
Periorbital ecchymosis 22 35.5 Espı́rito Santo State had the feminicide highest rates in the
Deviated nasal dorsum 14 22.6 country during 2012 and actually, the state is in the seventh
Hematoma 10 16.1 place between the other states, what means a reduction in
Malocclusion 9 14.5 lethal women violence in the state probably because of the
Abrasions 8 12.9
various public policy implemented by the government.
Penetrating injuries to the face 7 11.3
Bone crepitus 7 11.3 This article showed that more women were treated with
Restricted mouth opening 6 9.7 face trauma in 2017. These numbers contrast the data pre-
Epistaxis 5 8.1 sented in other study,17 what is probably related with the
Total 62 100.0 public policy that made the women more stimulated to
report the aggressor and search for treatment. As soon as
the patient have the hospital care, the professional must
orbital fractures (4 patients; 7.2%). The most commonly notify the aggression against the woman, this attitude is
observed signs and symptoms of these fractures were edema extremely important, because these notifications can gen-
(56.5%), periorbital ecchymosis (35.5%), a deviated nasal erate early penalties for the aggressor, preventing lethal
dorsum (22.6%), and hematoma (16.1%) (Table 3). traumas.
Another important finding was that, when organized by
the day of the week on which men carried out physical
Discussion aggression against the female victims included herein, the
This study evaluated the etiology of facial trauma in findings corroborate a study by Castro et al, in which phys-
women and found falls to be the most commonly reported ical aggression was most likely to occur on the weekend
Mayrink et al.
(20.82% on Sundays and 14.35% on Saturdays).11 The
higher incidence of physical aggression on the weekends
coincides with the days on which aggressors are more
likely to be intoxicated, as well as with the days on which
victims have fewer options for escape.5,18
The length of time between the trauma and the initial
treatment may be prolonged due to the victim’s fear,
shame, financial dependence on or emotional relationship
with the aggressor, or if the aggressor prohibits the victim
from seeking medical attention. These factors may explain
why 66.1% of the women treated in this study waited up to
1 week to seek medical attention for their trauma. Mala-
chias found that women tended to seek medical care a few
days after the incident in an attempt to hide the true cause
of the trauma; this delay often causes permanent physical
sequelae.4
Marano et al demonstrated an epidemiologic data from
the same hospital from 2013 to 2017.19 A total of 428
patients with facial trauma were included in this study,
among these patients, 82 were women. The main etiologies
were traffic accident, followed by fall and physical aggres-
sion. Considering the physical aggression, the author high-
lights that most of the women (80%) had suffered
aggression by men with the majority being their partners
or past partners.
In the current study, we maintained the same data, in
which 80% of the aggressions, the women’s partner or the
past partner was the responsible. For other cases (20%), we
were unable to identify who the aggressor was.
The high costs of health care treatments, legal fees,
victim absenteeism from the workplace, and extended pre-
operative and postoperative hospital stays are all a burden
on taxpayers.7 According to the United Nations, violence
against women costs 1.5 trillion dollars globally per year
through the expenses involved in caring for women, the
consequences of aggression, and the enforcement of related
laws. In Brazil, the country’s public health care system
(SUS) treats an estimated 147,691 female victims of sex-
ual, physical, or psychological violence per year and
spends an annual average of 5 million Brazilian reais
(1327 USD) on hospitalization alone.20
Extended hospitalization increases hospital expenses. In
the current study, 35.5% of the women required hospitali-
zation before their procedures and 54.8% required post-
operative hospitalization for a period of up to 7 days.
This extended preoperative hospitalization may be
explained by the fact that some of the victims waited to
seek treatment and were thus required to wait for their
edema to be treated before surgery could be performed.
Another factor is the presence of concomitant injuries that
may increase the risk of death, such as neurological dam-
age. According to data from the Brazilian Department of
National Public Health Care Data (DATASUS), the aver-
age cost of hospitalization per patient in the southeastern
region of the country is BRL$1402.01 (US$372), an
expense which could be reduced if funds were focused on
5
prevention and awareness campaigns (Ministério da Saúde
2019)
Facial trauma is often caused by an aggressor punching,
hitting, or kicking a victim. When aggressors cause cosmetic
or functional damage to the victim’s face during this trauma,
psychological consequences for the victim are common.18 A
study by Saddki et al21 found a predominance of injuries to
the maxillofacial region resulting from intimate partner vio-
lence, followed by injuries to the limbs (47.9%). The authors
report that the injuries to the limbs are likely the result of
victims’ natural tendency to defend themselves from aggres-
sors during an assault. Another study in Rio de Janeiro
researched men and women involved in intimate partner
violence using data from police reports. They found that
aggressors were most likely to punch victims in the face and
to damage victims’ eyes and teeth.8
A study performed by Leles et al22 found that the highest
incidence of facial injuries involves the nasal cavity, fol-
lowed by the zygomatic complex and the orbital region.
Arasarena et al23 also report that, in cases of physical
aggression against women, nasal fractures are the most
common injuries. The current findings corroborate this
study, since isolated nasal fracture was most prevalent
among the patients included herein (21 patients; 39.1%).
This major nasal fracture prevalence is a different pattern
when compared with the other types of etiologies, which
we have shown in this study, such as falls and traffic acci-
dent. In those cases, the zygomatic orbital complex fracture
was more frequent, with 68% and 65.7%, respectively;
however, all trauma cases can be associated with nasal
fracture. This frequency may be explained by the position
of the nose on the face and its greater exposure to trauma.
A study in 2011 reported that the high incidence of nasal
fractures is likely the result of the relatively low amount of
force required to fracture this relatively thin bone of the
face.24 Exactly, what was seen in this current study, physical
aggression, is generally considered to be a lower energy
trauma; thus, the possibility of zygomatic trauma is smaller
in this case (Figure 3). Low-energy trauma should rely on
meticulous clinical examination, affecting the extension of
imaging, type of intubation, and future surgical approaches.
High-energy trauma requires total body CT.25
These interconnection between trauma energy and the
fracture are important to help the surgeon to presuppose the
etiology and to identify aggression cases, even if there is an
omission from patient. The professional always must report
a suspect case of aggression against women.
The most commonly reported signs and symptoms of
physical aggression to the face are abrasions, ecchymosis,
penetrating injuries to the face, edema, and restricted
mouth opening.13,26 These cosmetic and functional dam-
ages were found in the patients in the current study; the
highest incidence was of edema (56.5%), periorbital ecchy-
mosis (35.5%), deviated septum (22.6%), and hematoma
(16.1%). Signs and symptoms that were observed at a lower
incidence were penetrating injuries to the face (11.3%),
6 Craniomaxillofacial Trauma & Reconstruction XX(X)

Figure 3. Pattern of facial fracture considering the energy: A and B, coronal and axial section—the etiology was fall: medium energy,
zygomatic and nasal fracture. C and D, coronal and axial section—the etiology was physical aggression, isolated nasal fracture.

abrasions (12.9%), and epistaxis (8.1%). However, these Conclusion

data may vary between studies due to the delay at which
Despite a variety of efforts to combat violence against
women seek treatment; the signs and symptoms recorded in
women, the data show that the number of women who
a patient record vary depending on the time between the
report experiencing daily physical aggression has increased
aggression and care.5 Some studies have found that the
in recent years. Many violent episodes are able to produce
teeth are also commonly damaged; the most common den-
facial fractures, and this type of injury may be a marker of
tal fracture is of the maxillary central incisor.11 In this
attempted femicide.
study, edema and periorbital ecchymosis were the most
More than half of the facial traumas treated in this study
common signs, which were present in 92% of the cases.
were produced by physical aggressors, and the midface was
The women population awareness looking for treat-
the region of the face most commonly affected. Some cases
ment, as soon as possible after the aggression is impor-
in which the patients reported a fall as the cause may have
tant because can avoid more serious lesions or even
actually been the result of violence; this self-reporting may
lethal lesions in the future. Facial trauma may involve
be a limitation of this study. It is crucial that health care
soft tissue, bone, paranasal sinuses, eyes, teeth, and in
professionals be able to identify potential victims and
cases in which the aggressor also injures the cranium,
notify them of their options.
neurological damage. It is therefore important that
trauma patients be initially treated by a multidisciplinary
team involving ophthalmology, plastic surgery, oral and Declaration of Conflicting Interests
maxillofacial surgery, and neurosurgery in order to bet- The author(s) declared no potential conflicts of interest with
ter ensure a correct diagnosis, as well as adequate and respect to the research, authorship, and/or publication of this
effective treatment.4,27,28 article.
Mayrink et al.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Gabriela Mayrink, DDS, MsD, PhD https://orcid.org/0000-
0003-2436-8216
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