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Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 110-115

Multistage management of complex maxillofacial defects due to gunshot injury

Department of Plastic, Reconstructive and Aesthetic Surgery, Selcuk University Medical Faculty, Konya, Turkey

Date of Submission19-May-2020
Date of Acceptance08-Jun-2020
Date of Web Publication26-Mar-2021

Correspondence Address:
Dr. Osman Akdag
Department of Plastic Reconstructive and Aesthetic Surgery, Alaaddin Keykubat Campus, Selcuk University Medical Faculty Hospital, Selcuklu, Konya
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_54_20

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Background and Aim: The injuries due to gunshot can form extensive defects. The management of these defects is required in multistage procedures, and the treatment achievement should be evaluated in many aspects. In this study, a methodology was tried to be developed to reveal the path to be followed in the management of maxillofacial defects caused by high-energy close-range gunshot injury. In addition, similar cases were analyzed retrospectively, and the functional and social successes of the treatment were evaluated. Subjects and Methods: Five patients with high-energy gunshot injuries were retrospectively analyzed. The tissue requirements of the patients were identified. The technical and quantitative details of the treatment were recorded. The facial disability index was used to evaluate the patient's social and motor functions in the 1st year after the operations were completed. Results: The patients' mean age was 31 (17–45), and all of them were male. The mean follow-up time was 25 months (14–26), and the mean operation amount was 7.6 (3–11). Four mandibular, one maxillary, and five soft-tissue defects were detected. It was detected that these defects were managed in basic four steps. Satisfactory, functional, and social results were obtained in four patients in the postoperative 1 year. Conclusions: The management of this group of patients comprises complicated procedures. First, the patient should be stabilized vitally. Definitive reconstruction should be carried out after the wound is stabilized. To increase treatment success, the patient's mental status should be stabilized during the treatment period. Providing social function is important along with physical function.

Keywords: Firearm injury, gunshot injury, maxillofacial defect, reconstruction

How to cite this article:
Erkol EE, Isik C, Sutcu M, Akdag O. Multistage management of complex maxillofacial defects due to gunshot injury. Turk J Plast Surg 2021;29:110-5

How to cite this URL:
Erkol EE, Isik C, Sutcu M, Akdag O. Multistage management of complex maxillofacial defects due to gunshot injury. Turk J Plast Surg [serial online] 2021 [cited 2023 Jan 31];29:110-5. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/2/110/312186

  Introduction Top

Gunshot injuries to the face cause life-threatening pathologies in addition to complex maxillofacial defects. Maintaining life support and eliminating these pathologies should be the first step in these injuries. Extensive facial bone and soft-tissue defects should be managed after vital stabilization of patients is provided and additional pathologies are excluded.

These defects should be reconstructed with complex multistage procedures. Problems such as infection, surgical complication, and the patient's adaptation difficulty may occur during the treatment period.[1],[2] To achieve satisfactory results at the end of the long procedures to be performed requires great care and patience for the surgeon and the patient.

Preserving the social functions of the patients and eliminating the aesthetic problems that occur are important as well as repairing the tissue defects and preserving the motor functions of the face in the evaluation of treatment success. There are some studies on the repair techniques of tissue defects and evaluation of the motor functions of the face, but not enough study evaluating the treatment success socially was detected in the available English literature.

In this study, a methodology was tried to be developed to reveal the path to be followed in the management of maxillofacial defects caused by high-energy close-range gunshot injury, similar cases were analyzed retrospectively, and the functional and social successes of the treatment were evaluated. Furthermore, this methodology was discussed by reviewing the studies that include similar injuries.

  Subjects and Methods Top

Five patients with high-energy gunshot injuries were retrospectively analyzed between 2014 and 2019. The tissue requirements of the patient were identified according to facial anthropometric analysis and aesthetic subunits of the face. The techniques and numbers of the operation and the initial surgery times of the performed operations were recorded. Understandable speech, functional swallowing, evaluation of the patient's self-aesthetic appearance, and complications were recorded. The facial disability index (FDI) was used to evaluate the patient's social function and motor functions such as nutrition and speech in the 1st year after operations were completed.[3] The patients filled out a questionnaire consisting of five questions about physical and social functions in line with the FDI [Table 1].[3] The total score of the answers was added for each patient. The number of questions was subtracted from the total score and divided by the number of questions. The obtained number was multiplied by 25 for the physical score and 20 for the social score, and the final score was achieved.
Table 1: Facial disability index

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  Results Top

The mean age of the patients was 31 (17–45), and all of them were male. The injury etiology of four patients was recorded as suicide and one patient was recorded as an armed attack. The mean follow-up time was 25 months (14–26), and the mean operation amount was 7.6 (3–11). It was detected that patients were operated in the first 24 h after starting treatment in our clinic. Four mandibular, one maxillary, and five soft-tissue defects were detected. To reconstruct these defects, four free fibula osteoseptocutaneous flaps (FOSF), two free anterolateral thigh (ALT) flaps, one radial forearm flap (RFF), two paramedian forehead flaps, two costal cartilage graftings, one volar tongue flap, and one tissue expander were detected to have been carried out [Figure 1],[Figure 2],[Figure 3]. It was detected that tracheostomy was performed to all patients for airway safety and prophylactic ampicillin/sulbactam (6 g/day) and metronidazole (4 g/day) treatment were applied.
Figure 1: (a) A 46-year-old male who suffered from suicidal close-range gunshot injury. After serial debridement, wound stabilization and skeletal fixation were provided. (b) After deciding tissue requirements, free fibula osteoseptocutaneous flaps were carried out. (c) To reconstruct lower lip, volar tongue flap was carried out and lower vestibule was deepened in the same session. A satisfactory result was obtained

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Figure 2: (a) In order to decide bone requirement, the defect was analyzed with virtual surgical planning. (b) Required fibula length was measured. Osteotomy points and angles were planned. (c) According to the preoperative planning, the free fibula osteoseptocutaneous flaps were adapted in the mandible defect and fixated with 2.4 mm reconstruction plate

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Figure 3: (a) A 24-year-old male who suffered from close-range suicidal gunshot injury. There were mandibular, maxillary, skin, and mucosal defects. (b) Bone fragments were fixated whether there were bone defects or not. The wound was stabilized. (c and d) Combined microsurgical operation was carried out using free anterolateral thigh and fibula osteoseptocutaneous flaps to reconstruct these defects. (e and f) The facial skin was reconstructed with the neck skin with the aid of a tissue expander

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All the patients were found to have an early infection and were brought under control with local wound care and IV antibiotics. Plate and screw exposition in one patient, tissue expander exposition in one patient, and partially ALT flap necrosis in one patient were observed.

The mean physical function score was 98 (71–110), and the mean social function index was 107 (84–120) according to FDI calculations. It was determined that four patients maintained their social life without wearing a face mask and they were satisfied with the treatment. Three of four patients could also maintain their professional life, whereas one patient could not maintain his professional life due to nontraumatic reasons.

Management methodology

In the retrospective analysis, it was determined that the operations of the patients were completed in four basic steps. While the first step was completed by the emergency department, treatment was carried out by the plastic reconstructive and aesthetic surgery department in the absence of life-threatening pathology.

As the first step of management, it was detected that hemodynamic stabilization was provided, tracheostomy was carried out on all patients for airway safety in the early period, and additional medical problems due to injury were identified.

In the second step, all the patients were taken into operation within 24 h in order to carry out bone fixation with titanium plate and screw system whether there is bone defect or not, to carry out minimal debridement, and to identify tissue requirement after starting treatment by our clinic was detected.

In the third step, it was detected that the bone and soft-tissue defects which were identified previously were reconstructed. A bone flap should definitely be transferred, and if necessary, another fasciocutaneous flap can be added in this session for soft-tissue replacement.

In the fourth step, it was found out that operations were carried out to fix contour problems and to reconstruct facial aesthetic subunits. It was detected that paramedian forehead flap for nasal reconstruction, volar tongue flap for lower lip reconstruction, and tissue expander for facial skin reconstruction were carried out. It was determined that psychiatric support was provided to patients at every stage.

  Discussion Top

Gunshot-related face defects should be managed initially in accordance with advanced trauma life support protocol.[4] Additional medical problems such as airway obstruction, ocular injuries, hemorrhage, mental instability, and cervical injury may occur after injury.[5] These problems should be identified and managed in a short period.

Providing airway safety is one of the important situations in the first intervention. As a result of intraoral bleeding, airway edema, and broken bone fragments escaping into the airway and tooth fragments getting into the airway, the airway safety can be jeopardized. In these cases, alternatives such as cricothyrotomy, tracheostomy, and percutaneous needle tracheostomy can be used in order to maintain airway safety. An oral intubation was achieved in 83% and a surgical airway was required in 5% of the patients who had facial gunshot injuries. It was also stated that a surgical airway was required in 23% of the patients with lower face injury.[6-8] Considering that these patients will be operated many times and the airway can be jeopardized due to airway edema in the future too, tracheostomy was performed on all patients in the study group contrary to the literature.

After exposure of multiple bullets to the face, foreign body contamination and high rates of infection due to contamination with oral secretions require the use of broad-spectrum antibiotics.[9] Broad-spectrum IV antibiotics were used for all patients included in the study; however, wound infection could not be prevented. Thus, wound stabilization was provided with local wound care and agent-specific antibiotics before microsurgical reconstruction stage.

The debridement which was carried out in the first 24 h after injury was found advantageous in terms of reducing infection rates.[10],[11] There are studies that advocate for aggressive debridement in the literature.[12],[13] However, minimal debridement should be performed since the facial soft tissue is unique and has a very intensive vascular supply. Intraoperative fluorescent angiography should be kept in mind as a good alternative in terms of determining the debridement limits.[14],[15]

Reduction and fixation of bone tissues should be provided in the early period in order to determine the defect, stabilize the facial volume, and prevent scar contracture of the face without skeletal support.[16] It has been advocated that definitive reconstruction should be performed within the first 2 weeks due to reasons such as shortening the treatment period, lower cost, and redefining the defect due to scar tissue that will be made in the late period.[17],[18],[19],[20],[21] Major surgical interventions after their injury can be very challenging for the patient, and the patient's motivation is thought to affect the success of the surgery after the operation. Although early definitive reconstruction is seen to be advantageous in some ways, in this group of patients with severe facial injuries, late reconstruction will enable stabilizing the wound, as well as the psychiatric stabilization, thereby increasing the success of the final outcome of the long treatment period.[13],[22],[23],[24]

Skin and mucosal defects also accompany bone defects in gunshot-related maxillofacial injuries.[25] In order to reconstruct these defects, composite free bone flaps should be the first choice.[16],[26] Three-dimensional computed tomography images were analyzed and tissue requirements were specified for the patient group included in our study. Free FOSF was carried out in all patients for bone reconstruction.

Free osteoseptocutaneous flaps may be enough for soft-tissue reconstruction in the early period. However, using free FOSF skin for the face may be insufficient in terms of color harmony and pliability and may lead to unsatisfactory aesthetic results in the following period. In our study, soft-tissue defects were firstly reconstructed with osteoseptocutaneous free flaps. If necessary, the second free flap can be carried out to provide facial volume in the same session. In the following period, using volar tongue flap for lower lip vermillion reconstruction, free RFF for nasal reconstruction, and neck skin with the help of a tissue expander placed in the neck for buccal skin reconstruction, aesthetically satisfying results were obtained.

Providing swallowing function at the end of the treatment process is important.[19] In these patients, swallowing dysfunction is usually due to mechanical factors, and if needed, quantitative tests may be performed in case of swallowing dysfunction. The solid and liquid food swallowing functions of the patients were preserved, and no additional examination was needed at the end of the treatment process.

The patient's family and physicians who spend time with the patient after the trauma can understand the patient's speaking, regardless of the patient's speech quality. When evaluating the patient's understandable speech, it should be considered as a criterion of success that individuals who communicate with the patient for the first time can communicate without problems, rather than individuals who frequently interact with the patient. The fact that the patients who are included in the study had no difficulty in making any sounds and stated that they could be understood with their environment without difficulty showed that understandable speech function was provided.

Performing aesthetic reconstruction of the face has a great importance for the patients to feel in the same level with the society in terms of social and psychological aspects. Diaz-Siso et al. and Fischer et al. used FDI to evaluate the physical and social functions of the face in face transplant patients.[27],[28] The fact that FDI calculations made for our patients are similar to the measurements made for the patients who underwent facial transplantation suggests that satisfactory results can be obtained with multistage microsurgical interventions without the need for facial transplantation in the appropriate patient group.

Social and professional lives of people who experience facial deformity after trauma may be affected negatively.[29]

The face of every person is his/her social identity with which s/he exists. Regardless of what is performed during the treatment, the patients should be explained that they cannot have their faces as the way they used to be and it should be ensured that the patient's expectations are determined accordingly. We think that the aesthetic success of the treatment process is to be able to enable the person to continue his/her life socially and professionally without a face mask.

[TAG:2]Conclusion [/TAG:2]

Management of maxillofacial injuries due to gunshot is challenging procedures. Microsurgical procedures to be performed are challenging for the patient as well as the surgeon. It is thought that multistage microsurgical procedures, which are carried out over a long period after psychiatric stabilization is achieved, are required in this patient group in order to obtain better results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

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