Management of High-energy Avulsive Ballistic Facial Injury
Elbert E. Vaca, MD,*Justin L. Bellamy, MD,†Sammy Sinno, MD,‡ and Eduardo D. Rodriguez, MD, DDS†
Case 1
Delayed Reconstruction
A 36-year-old male was referred for consideration for facial transplant 7 months after a self-inflicted ballistic injury resulting in composite tissue defects of the midface and lower face (Fig. 6A). Note the contracted soft-tissue envelope with midface widening and loss of vertical facial height. CSP was used for mandibular reconstruction using a FOSC flap with intra- and extra-oral skin paddles (Fig. (Fig.6 B, C). A second FOSC flap to the maxilla—with skin paddles used to resurface the palate and nasal floor—was used during a subsequent procedure (Fig. 6D). Multistage nasal reconstruction was commenced with an ulnar forearm flap for nasal lining and costochondral rib grafting for structural support.
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A tissue expander was placed in the left forehead in preparation of a paramedian forehead flap (Fig. (Fig.6E). A rotation-advancement upper lip repair was performed to correct the “whistle” deformity, and the external mandibular FOSC flap skin flap was deepithelialized, and hair-bearing chin skin was advanced (Fig. (Fig.6). Dentoalveolar osseointegrated implants were subsequently placed. Finally, the expanded paramedian forehead flap—with additional costochondral grafting for nasal dorsum, sidewall, and tip/columella support—was used for external nasal resurfacing. Figure 6G demonstrates 7-month follow-up after forehead flap inset. Further planned procedures include laser resurfacing and minor tissue rearrangements to optimize cosmesis.
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Fig. 6.
Case 1. Delayed reconstruction (Fig. 6A reprinted with permission from Sinno S, Rodriguez ED. Nuances and pearls of the free fibula osteoseptocutaneous flap for reconstruction of a high-energy ballistic injury mandible defect. Plast Reconstr Surg. 2016;137:280–284. Figs. 6B–G printed with permission and copyright retained by Eduardo D. Rodriguez, MD, DDS).
References
REFERENCES
- Tessier P. The classic reprint. Experimental study of fractures of the upper jaw. I and II. René Le Fort, M.D. Plast Reconstr Surg. 1972;50:497–506 contd.. [PubMed] [Google Scholar]
- Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg. 2008;60:398–403.. [PubMed] [Google Scholar]
- Mithani SK, St-Hilaire H, Brooke BS, et al. Predictable patterns of intracranial and cervical spine injury in craniomaxillofacial trauma: analysis of 4786 patients. Plast Reconstr Surg. 2009;123:1293–1301.. [PubMed] [Google Scholar]
- Hollier L, Grantcharova EP, Kattash M. Facial gunshot wounds: a 4-year experience. J Oral Maxillofac Surg. 2001;59:277–282.. [PubMed] [Google Scholar]
- Clark N, Birely B, Manson PN, et al. High-energy ballistic and avulsive facial injuries: classification, patterns, and an algorithm for primary reconstruction. Plast Reconstr Surg. 1996;98:583–601.. [PubMed] [Google Scholar]
- Vayvada H, Menderes A, Yilmaz M, et al. Management of close-range, high-energy shotgun and rifle wounds to the face. J Craniofac Surg. 2005;16:794–804.. [PubMed] [Google Scholar]
- Gruss JS, Antonyshyn O, Phillips JH. Early definitive bone and soft-tissue reconstruction of major gunshot wounds of the face. Plast Reconstr Surg. 1991;87:436–450.. [PubMed] [Google Scholar]
- Futran ND, Farwell DG, Smith RB, et al. Definitive management of severe facial trauma utilizing free tissue transfer. Otolaryngol Head Neck Surg. 2005;132:75–85.. [PubMed] [Google Scholar]
- Lew TA, Walker JA, Wenke JC, et al. Characterization of craniomaxillofacial battle injuries sustained by United States service members in the current conflicts of Iraq and Afghanistan. J Oral Maxillofac Surg. 2010;68:3–7.. [PubMed] [Google Scholar]
- Vásconez HC, Shockley ME, Luce EA. High-energy gunshot wounds to the face. Ann Plast Surg. 1996;36:18–25.. [PubMed] [Google Scholar]
- Christensen J, Sawatari Y, Peleg M. High-energy traumatic maxillofacial injury. J Craniofac Surg. 2015;26:1487–1491.. [PubMed] [Google Scholar]
- Peled M, Leiser Y, Emodi O, et al. Treatment protocol for high velocity/high energy gunshot injuries to the face. Craniomaxillofac Trauma Reconstr. 2012;5:31–40.. [PMC free article] [PubMed] [Google Scholar]
- Stefanopoulos PK, Filippakis K, Soupiou OT, et al. Wound ballistics of firearm-related injuries—part 1: missile characteristics and mechanisms of soft tissue wounding. Int J Oral Maxillofac Surg. 2014;43:1445–1458.. [PubMed] [Google Scholar]
- Zhang DC, Qian CW, Liu YG, et al. Morphopathologic observations on high-velocity steel bullet wounds at various intervals after wounding. J Trauma. 1988;28:S98–S104.. [PubMed] [Google Scholar]
- Wang ZG, Feng JX, Liu YQ. Pathomorphological observations of gunshot wounds. Acta Chir Scand Suppl. 1982;508:185–195.. [PubMed] [Google Scholar]
- Wang ZG, Tang CG, Chen XY, et al. Early pathomorphologic characteristics of the wound track caused by fragments. J Trauma. 1988;28:S89–S95.. [PubMed] [Google Scholar]
- Sullivan D, Chung KC, Eaves FF, 3rd, et al. The level of evidence pyramid: indicating levels of evidence in Plastic and Reconstructive Surgery articles. Plast Reconstr Surg. 2011;128:311–314.. [PubMed] [Google Scholar]
- Dolin J, Scalea T, Mannor L, et al. The management of gunshot wounds to the face. J Trauma. 1992;33:508–514.; discussion 14–5. [PubMed] [Google Scholar]
- Kihtir T, Ivatury RR, Simon RJ, et al. Early management of civilian gunshot wounds to the face. J Trauma. 1993;35:569–575.; discussion 75–7. [PubMed] [Google Scholar]
- Taher AA. Reconstruction of gunshot wounds of the mandible. 128 cases treated by autogenous iliac crest bone grafts. J Craniomaxillofac Surg. 1990;18:310–314.. [PubMed] [Google Scholar]
- Alper M, Totan S, Cankayali R, et al. Gunshot wounds of the face in attempted suicide patients. J Oral Maxillofac Surg. 1998;56:930–933.; discussion 33–4. [PubMed] [Google Scholar]
- Shuck LW, Orgel MG, Vogel AV. Self-inflicted gunshot wounds to the face: a review of 18 cases. J Trauma. 1980;20:370–377.. [PubMed] [Google Scholar]
- Motamedi MH, Behnia H. Experience with regional flaps in the comprehensive treatment of maxillofacial soft-tissue injuries in war victims. J Craniomaxillofac Surg. 1999;27:256–265.. [PubMed] [Google Scholar]
- Yuksel F, Celikoz B, Ergun O, et al. Management of maxillofacial problems in self-inflicted rifle wounds. Ann Plast Surg. 2004;53:111–117.. [PubMed] [Google Scholar]
- Firat C, Geyik Y. Surgical modalities in gunshot wounds of the face. J Craniofac Surg. 2013;24:1322–1326.. [PubMed] [Google Scholar]
- Sun GH, Patil YJ, Harmych BM, et al. Inpatients with gunshot wounds to the face. J Craniofac Surg. 2012;23:e62–e65.. [PubMed] [Google Scholar]
- Glapa M, Kourie JF, Doll D, et al. Early management of gunshot injuries to the face in civilian practice. World J Surg. 2007;31:2104–2110.. [PubMed] [Google Scholar]
- Eser C, Gencel E, Kesiktaş E, et al. Outcomes of anatomic reconstruction of gunshot-inflicted lower face defects by free osteoseptocutaneous fibula flap and expanded or nonexpanded temporal scalp flap combination in males. J Craniofac Surg. 2016;27:1139–1142.. [PubMed] [Google Scholar]
- Manson PN, Clark N, Robertson B, et al. Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures. Plast Reconstr Surg. 1999;103:1287–1306.; quiz 307. [PubMed] [Google Scholar]
- Manson PN, Hoopes JE, Su CT. Structural pillars of the facial skeleton: an approach to the management of Le Fort fractures. Plast Reconstr Surg. 1980;66:54–62.. [PubMed] [Google Scholar]
- Borsuk DE, Christensen J, Dorafshar AH, et al. Aesthetic microvascular periorbital subunit reconstruction: beyond primary repair. Plast Reconstr Surg. 2013;131:337–347.. [PubMed] [Google Scholar]
- Fisher M, Dorafshar A, Bojovic B, et al. The evolution of critical concepts in aesthetic craniofacial microsurgical reconstruction. Plast Reconstr Surg. 2012;130:389–9ss8.. [PubMed] [Google Scholar]
- Schultz BD, Sosin M, Nam A, et al. Classification of mandible defects and algorithm for microvascular reconstruction. Plast Reconstr Surg. 2015;135:743e–754e.. [PubMed] [Google Scholar]
- Green JM, 3rd, Sabino J, Fleming M, et al. Intraoperative fluorescence angiography: a review of applications and outcomes in war-related trauma. Mil Med. 2015;180:37–43.. [PubMed] [Google Scholar]
- Kamolz LP, Andel H, Auer T, et al. Evaluation of skin perfusion by use of indocyanine green video angiography: rational design and planning of trauma surgery. J Trauma. 2006;61:635–641.. [PubMed] [Google Scholar]
- Manson PN, Crawley WA, Yaremchuk MJ, et al. Midface fractures: advantages of immediate extended open reduction and bone grafting. Plast Reconstr Surg. 1985;76:1–12.. [PubMed] [Google Scholar]
- Rodriguez ED, Martin M, Bluebond-Langner R, et al. Microsurgical reconstruction of posttraumatic high-energy maxillary defects: establishing the effectiveness of early reconstruction. Plast Reconstr Surg. 2007;120:103S–117S.. [PubMed] [Google Scholar]
- Bellamy JL, Molendijk J, Reddy SK, et al. Severe infectious complications following frontal sinus fracture: the impact of operative delay and perioperative antibiotic use. Plast Reconstr Surg. 2013;132:154–162.. [PubMed] [Google Scholar]
- Broyles JM, Abt NB, Shridharani SM, et al. The fusion of craniofacial reconstruction and microsurgery: a functional and aesthetic approach. Plast Reconstr Surg. 2014;134:760–769.. [PubMed] [Google Scholar]
- Gonzalez-Ulloa M. Restoration of the face covering by means of selected skin in regional aesthetic units. Br J Plast Surg. 1956;9:212–221.. [PubMed] [Google Scholar]
- Gonzalez-Ulloa M, Stevens E. Reconstruction of the nose and forehead by means of regional aesthetic units. Br J Plast Surg. 1961;13:305–309.. [PubMed] [Google Scholar]
- González-Ulloa M. Regional aesthetic units of the face. Plast Reconstr Surg. 1987;79:489–490.. [PubMed] [Google Scholar]
- Muresan C, Hui-Chou HG, Dorafshar AH, et al. Forehead reconstruction with microvascular flaps: utility of aesthetic subunits. J Reconstr Microsurg. 2012;28:319–326.. [PubMed] [Google Scholar]
- Wang YY, Zhang HQ, Fan S, et al. Mandibular reconstruction with the vascularized fibula flap: comparison of virtual planning surgery and conventional surgery. Int J Oral Maxillofac Surg. 2016;45:1400–1405.. [PubMed] [Google Scholar]
- Saad A, Winters R, Wise MW, et al. Virtual surgical planning in complex composite maxillofacial reconstruction. Plast Reconstr Surg. 2013;132:626–633.. [PubMed] [Google Scholar]
- Gruss JS, Mackinnon SE, Kassel EE, et al. The role of primary bone grafting in complex craniomaxillofacial trauma. Plast Reconstr Surg. 1985;75:17–24.. [PubMed] [Google Scholar]
- Avraham T, Franco P, Brecht LE, et al. Functional outcomes of virtually planned free fibula flap reconstruction of the mandible. Plast Reconstr Surg. 2014;134:628e–634e.. [PubMed] [Google Scholar]
- Shen YF, Rodriguez ED, Wei FC, et al. Aesthetic and functional mandibular reconstruction with immediate dental implants in a free fibular flap and a low-profile reconstruction plate: five-year follow-up. Ann Plast Surg. 2015;74:442–446.. [PubMed] [Google Scholar]
- De Santis G, Nocini PF, Chiarini L, et al. Functional rehabilitation of the atrophic mandible and maxilla with fibula flaps and implant-supported prosthesis. Plast Reconstr Surg. 2004;113:88–98.; discussion 99–100. [PubMed] [Google Scholar]
- Codner MA, McCord CD, Mejia JD, et al. Upper and lower eyelid reconstruction. Plast Reconstr Surg. 2010;126:231e–245e.. [PubMed] [Google Scholar]
- Nemli SK, Aydin C, Yilmaz H, et al. Quality of life of patients with implant-retained maxillofacial prostheses: a prospective and retrospective study. J Prosthet Dent. 2013;109:44–52.. [PubMed] [Google Scholar]
- Rodriguez ED, Bluebond-Langner R, Park JE, et al. Preservation of contour in periorbital and midfacial craniofacial microsurgery: reconstruction of the soft-tissue elements and skeletal buttresses. Plast Reconstr Surg. 2008;121:1738–1747.; discussion 48–9. [PubMed] [Google Scholar]
- Phillips JH, Rahn BA. Fixation effects on membranous and endochondral onlay bone-graft resorption. Plast Reconstr Surg. 1988;82:872–877.. [PubMed] [Google Scholar]
- Yim KK, Wei FC. Fibula osteoseptocutaneous free flap in maxillary reconstruction. Microsurgery. 1994;15:353–357.. [PubMed] [Google Scholar]
- Muzaffar AR, Adams WP, Jr., Hartog JM, Rohrich RJ, Byrd HS. Maxillary reconstruction: functional and aesthetic considerations. Plast Reconstr Surg 1999: 104: 2172–83.; quiz 84. [PubMed] [Google Scholar]
- Barrera A. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp. Plast Reconstr Surg. 2003;112:883–890.. [PubMed] [Google Scholar]
- Rodriguez ED, Martin M, Bluebond-Langner R, Manson PN. Multiplanar distraction osteogenesis of fibula free flaps used for secondary reconstruction of traumatic maxillary defects. J Craniofac Surg 2006: 17: 883–8.. [PubMed] [Google Scholar]
- Dorafshar AH, Bojovic B, Christy MR, et al. Total face, double jaw, and tongue transplantation: an evolutionary concept. Plast Reconstr Surg. 2013;131:241–251.. [PubMed] [Google Scholar]
- Mohan R, Borsuk DE, Dorafshar AH, et al. Aesthetic and functional facial transplantation: a classification system and treatment algorithm. Plast Reconstr Surg. 2014;133:386–397.. [PubMed] [Google Scholar]
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