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.

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).

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