Face Value: Evaluating the FISS Scoring System for Operative Intervention in Pediatric Facial Trauma

Background: The Facial Injury Severity Scale (FISS) quantifies maxillofacial trauma and predicts operative need, although its applicability in pediatric populations remains unclear. This study evaluated the association between FISS and operative management in pediatric facial fractures. Methods: We reviewed patients younger than 18 years with facial fractures from May 2021 to February 2025. Demographics, injury characteristics, and operative data were collected. Patients with incomplete data or mortality were excluded. FISS scores were calculated and compared between nonoperative (NOP) and operative (OP) groups. Univariate and multivariate analyses were performed. Results: Of 347 patients, 312 were included; 102 (32.7%) were OP and 210 (67.3%) were NOP. Demographics were similar between groups. The OP group had higher rates of mandibular fractures (72% versus 14%, P <0.001) and LeFort I fractures (8.8% versus 1.9%, P =0.012), and lower rates of orbital (31% versus 58%, P <0.001), calvarium (15% versus 44%, P <0.001), nasal (23% versus 36%, P =0.019) fractures, and traumatic brain injury (34% versus 63%, P <0.001). Median FISS scores were higher in the OP group (5 [3–6] versus 2 [1–5], P <0.001). Assault (OR: 11.7, P <0.001), mandibular fractures (OR: 6.5, P <0.001), and increasing FISS score (OR: 1.4, P =0.006) independently predicted operative intervention. Conclusions: Higher FISS scores were associated with surgery, supporting its role in pediatric risk assessment and planning. However, operative decisions also depended on injury mechanism and fracture location. FISS may aid triage, coordination, and counseling when used within a patient-centered approach. Level of Evidence: Level III (retrospective cohort study).