Facial gunshot wounds: trends in management

Abstract

Facial gunshot wounds, often comprising significant soft and bone tissue defects, pose a significant challenge for reconstructive surgeons. Whether resulting from assault, accident, or suicide attempt, a thorough assessment of the defects is essential for devising an appropriate tissue repair and replacement with a likely secondary revision. Immediately after injury, management is centered on advanced trauma life support with patient stabilization as the primary goal. Thorough examination along with appropriate imaging is critical for identifying any existing defects. Whereas past surgical management advocated delayed definitive treatment using serial debridement, today's management favors use of more immediate reconstruction. Recent advances in microsurgical technique have shifted favor from local tissue advancement to distant free flap transfers, which improve cosmesis and function. This has resulted in a lower number of surgeries required to achieve reconstruction. Because of the diversity of injury and the complexity of facial gunshot injuries, a systematic algorithm is essential to help manage the different stages of healing and to ensure that the best outcome is achieved.

Keywords: Facial gunshot wounds; management; reconstruction.

Figure 1

On initial evaluation, missile injury may be misleading and cover the severe underlying skeletal injury (arrowhead, entrance wound; arrow, exit wound).

Figure 2

Some bullets are designed to fragment within the body. This produces multiple individual tracks, which extend the injury well beyond the site of penetration.

Figure 3

Scalp flaps can provide temporary coverage of facial defects. Backgrafting of the resulting defect can be achieved using xenograft or allografts, deferring definitive coverage to a later date.

Figure 4

With delayed reconstruction, severe swelling is allowed to dissipate, revealing the extent of irreversible injury.

Figure 5

For extensive bone comminution with minimal soft tissue damage, external fixation stabilizes the fragments, providing scaffolding for osteogenic regeneration.

Figure 6

Reapproximation in the operating room may be achieved even when on initial evaluation the injuries appear too severe for primary closure.

Figure 7

A combination of both microvascular and local flap techniques may be necessary for the repair of severe defects.