Free flap reconstruction of self-inflicted submental gunshot wounds

Abstract

In this study, we review outcomes for 15 patients with self-inflicted submental gunshot wounds requiring free flap reconstruction. Patients presented to two tertiary care centers over a 7-year period. Mean age was 46 years (range, 16 to 76 years), 67% (n = 10) had a psychiatric history, and four were known to abuse illicit substances. Patients with oromandibular involvement required on average a total of 2.8 procedures, and those with midface (3.7) or combined defects (6) required more total procedures (p = 0.21). Donor sites included osteocutaneous radial forearm (n = 8), fibula (n = 4), fasciocutaneous radial forearm (n = 5), and anterior lateral thigh (n = 1). Median length of hospitalization was 8 days. Overall complication rate was 33% (n = 5), and included hematoma (n = 1), fistula (n = 1), and mandibular malunion (n = 2). Most patients were able to tolerate a regular or soft diet (92%), maintain oral competency (58%), and demonstrate intelligible speech (92%) at a median time to follow-up of 12 months. Despite the devastating nature of this injury, free flap reconstruction of self-inflicted submental gunshot wounds results in acceptable functional results for the majority of patients.

Keywords: Gunshot wounds; definitive management; free tissue transfer; reconstruction; self-inflicted.

Figure 1

Oromandibular and midface bony defect classification. (A) Oromandibular defects: C, condyle; R, ramus; B, body; S, symphysis. (B) Midface defects: N, nasal bones; M, maxilla; O, orbital rim; Z, zygoma; HP, hard plate.

Figure 2

Combined anterior mandible and overlying soft tissue destruction (A, B). The patient underwent rigid internal fixation of a Le Fort level II fracture and osteocutaneous radial forearm free flap reconstruction of the mandible (C, D). Patient 3 months postoperatively (E).

Figure 3

Computed tomography scan with 3-D bone reconstruction demonstrating anterior mandibular avulsion with bony destruction and involvement of the anterior maxillary complex and orbit (A). The patient underwent primary repair with placement of a mandibular reconstruction bar (B) and soft tissue closure (C) prior to definitive mandibular reconstruction (D) with radial forearm free tissue transfer (E).

Figure 4

Status post-gunshot wound involving the anterior mandible, maxilla, and nasal bones requiring both osteocutaneous radial forearm and fibular free flap reconstruction (A). The patient developed cutaneous loss of her fibula flap requiring radial forearm free tissue transfer for soft tissue loss (B). A paramedian forehead flap was utilized for nasal reconstruction (C). Patient 1 year postoperatively (D).

Figure 5

Extensive anterior mandible, maxillary, and soft tissue destruction following a self-inflicted gunshot wound (A, B). Patient status post–open reduction and internal fixation of naso-orbital-ethmoidal and zygomaticomaxillary complex fractures with fibula free flap reconstruction of the mandible and fasciocutaneous radial forearm lower and upper lip reconstruction (C,D).