High-velocity trauma

a police chief was struck in the face by an AK-47 and sustained extensive facial injuries that included the loss of most of the left zygomaticomaxillary complex, a shattered left zygomatic arch, orbital rim and floor, loss of most of his nose, and a gaping wound of the left midface (Fig. 1).

Fig. 1. Click to unblur
Extensive facial injuries after the patient was injured by an AK47 round.

A “home run” surgery was undertaken through a planned, bicoronal flap. This gave sufficient access for an open reduction internal fixation (ORIF) of the zygomatic arch, orbital floor implant, and cranial bone grafts to reconstruct the orbital rim and maxilla. A large cervicofacial advancement/rotation flap was used to cover the left cheek and nasal base defect. Septal flaps lined the nasal cavity. Conchal cartilage was harvested to replace the missing upper and lower lateral nasal cartilages and a paramedian forehead flap was used to cover the nasal skin defect (Figs. 2, 3).

Fig. 2. Click to unblur
Multiple procedures were performed to reconstruct and close
the wound, to include ORIF, cervicofacial advancement flap, paramedian forehead flap, and septal flap.
Fig. 3. Click to unblur
Completed midface reconstruction.

Within a few weeks of this surgery, the medial portion of the cervicofacial flap died and the patient exposed midface plates and craniofacial grafts (Fig. 4).

Fig. 4. Click to unblur
Exposure of midface plates and wound breakdown after failure
of cervicofacial advancement flap.

This case demonstrated that the full extent of soft tissue injury from high kinetic energy wounds is difficult to appreciate early, and a staged reconstruction can often be a more prudent choice. In situations with extensive soft tissue and bony injuries, initial surgery should be limited to irrigation, debridement, and conservative wound closure.
The primary goal of soft tissue reconstruction for high velocity trauma should be primary closure of the wound with coverage of the bone and plates. Because of the temporary cavity trauma, extensive tissue undermining and flap rotation will almost always result in dead tissue.