Management of Close-Range, High-Energy Shotgun and Rifle Wounds to the Face

Abstract

Close-range, high-energy shotgun wounds of the face are life-threatening and devastating traumas of the face. Suicidal attempts are the main reason in the great majority of the patients in civilian life. There is no consensus on the timing of reconstruction for bone and soft tissue defects resulting from high-energy shotgun wounds. The conventional method is primary repair as soon as possible and serial debridements and definitive reconstruction in the delayed stage. An alternative to this approach is the immediate definitive surgical reconstruction of the patient during the first operation for acute management of trauma. We had 15 patients with close-range, high-energy shotgun wounds in 10 years. Six of 15 patients referred to our center for definitive reconstruction after the acute management of the patients were performed in another center and the rest were all admitted in the acute period. Either conventional approach with delayed reconstruction for 10 patients or immediate definitive surgical reconstruction for 5 patients was used. Immediate reconstruction eliminated disadvantages of the conventional method such as high infection and scarring rate and deformities resulting from contraction of tissues. The emotional conditions of the patients were evaluated and major depression signs were determined. Functional evaluation showed that there was great correlation between facial appearance after reconstruction and social activity level.

Maxillofacial Reconstruction of Ballistic Injuries

“…The conventional approach with delayed reconstruction was done for 10 patients and immediate definitive surgical reconstruction for 5 patients. They stated that immediate reconstruction eliminated the disadvantages of the conventional method such as high infection rate, high scarring rate and deformities resulting from contraction of tissues (similar to our findings) [13]. In our series, 22% of our patients required tracheotomies.…”

“…The conventional method is primary closure, serial debridements and definitive reconstruction at a later stage. An alternative to this approach is immediate definitive surgical intervention and reconstruction at the first operation [11][12][13][14][15][16][17]. The presence of concomitant injuries of the body, fear of postoperative infection, unavailability of surgical hardware and lack of surgical experience in the treatment of penetrating ballistic injuries are among the factors that had created supporters for delayed treatment [2].…”

“…Local undermining and the use of regional soft-tissue advancement rotation flaps for primary closure of maxillofacial soft tissue defects during the first operation has proved beneficial from both an esthetic and functional point of view [2,11,13,19]. Leaving defects open results in extensive scarring of the facial tissues and complicates subsequent surgical procedures, and should be avoided even in contaminated penetrating wounds [2,11,13,16,19].…”

“…Leaving defects open results in extensive scarring of the facial tissues and complicates subsequent surgical procedures, and should be avoided even in contaminated penetrating wounds [2,11,13,16,19]. In such situations, debridement and loose closure of the tissues transferred locally followed by administration of antibiotics may be a better alternative [2,11,13,14].…”

“…Antibiotic therapy plays a major role in the prevention of infection of both hard and softtissues; early and appropriate surgical debridement, copious irrigation, fixation and immobilization of injured tissues, detailed wound closure, drainage, maintenance of clean dressings, nutrition, tetanus prophylaxis, and restoration of circulating fluid volume are equally important in ballistic injuries [2,11,13,16,19]. Soft tissue healing is usually favorable in patients with penetrating facial injuries; however, postoperative discharge from the suture sites may be seen.…”