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.

Sensitive image, click to unblur and zoom.
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).

Auto closing in 2 seconds
Auto closing in 2 seconds