| Abstract|| |
Aim : Treatment of maxillofacial firearm injuries is still controversial with regard to timing of management. We postulate that not all maxillofacial firearm injuries need be delayed and that many may be treated early. To this end, a 19-year retrospective study was undertaken seeking to evaluate patients treated for firearm injuries to the facial skeleton at our center. The criteria which dictated when to operate are presented as are the results, benefits, and outcomes of the patients treated acutely. Patients and Methods : From 1991 to 2010, 51 patients with maxillofacial firearm injuries were treated; 30/51 patients received early primary repair and simultaneous open reduction for facial fractures. These underwent primary debridement and arch bar placement followed by open reduction of fractures (with or without osteosynthesis) and primary wound closure. Patient age ranged from 8 to 50 years, with a mean age of 24.47.8 years. Primary early intervention was done when there was no gross infection, no bone comminution or extensive soft tissue avulsion (precluding wound coverage), and when general health, concomitant injuries requiring more urgent attention or those requiring major grafts did not preclude this. Primary intervention included extensive oral and extraoral irrigation (dilute hydrogen peroxide + povidone iodide), debridement of the facial wound, removal of floating fragments (teeth particles, debris, and shell fragments) precluding viable bone within the wound, access to the bone, finding the scattered bone segments and putting them back into place to restore bone continuity. Projectiles beyond the wound were not searched for. Tooth roots within the alveolus were not extracted at this stage. In addition to arch bars, titanium miniplates or wire osteosynthesis was done when necessary. All wounds were closed primarily (using local advancement flaps when necessary) and all patients were placed on antibiotics (cephalosporin + aminoglycoside or ciprofloxacin) upon admission. Results : Of 51 patients, 30 were treated acutely and 21 warranted delayed intervention. In the acute-treated group, 6/30 patients had minor complications such as scarring and wound discharge. Early intervention for firearm wounds to the face was effective for facial firearm injuries in selected cases. This resulted in restoration of occlusion and continuity of the jaw, fixation of luxated teeth, early return of function, prevention of segment displacement and tissue contracture, less scarring, and decreased the need for major bone graft reconstruction later on. Those treated secondarily were only debrided and had arch bars placed. Definitive treatment of hard and soft tissue management was rendered in another subsequent operation. Bone reduction was more difficult because of scarring, and displacement of remaining segments. No significant differences were noted in terms of infection or other major complications. Conclusions : Firearm wounds were associated with a high incidence of maxillofacial injuries requiring surgical intervention. Many may be treated definitively and acutely with procedures designed to repair both bone and soft tissue injuries simultaneously aiming to restore bony continuity, esthetics and function using the tissues at hand (especially in the mandible). Early treatment is advocated because the course of healing is not disrupted with another subsequent operation (in the same wound) and because it may decrease hospital stay without increasing patient morbidity in selected patients. Patients with residual defects can be treated later as out-patients.
Keywords: Early intervention, facial skeleton, firearm injuries
|How to cite this article:|
Motamedi MK. Management of firearm injuries to the facial skeleton: Outcomes from early primary intervention. J Emerg Trauma Shock 2011;4:212-6
|How to cite this URL:|
Motamedi MK. Management of firearm injuries to the facial skeleton: Outcomes from early primary intervention. J Emerg Trauma Shock [serial online] 2011 [cited 2019 Dec 12];4:212-6. Available from: http://www.onlinejets.org/text.asp?2011/4/2/212/82208
| Introduction|| |
Injuries to the face due to firearms are either high-energy or low-energy. Penetrating injuries of the face resulting from projectiles also vary according to the caliber of the weapon used and the distance from which the patient is shot. High-velocity projectiles can result in devastating functional and esthetic consequences shattering the hard tissues. Sometimes the entry wound is inconspicuous while the exit wound is extensive. The timing of surgical intervention of patients sustaining firearm wounds remains controversial. Recognized treatment modalities include aggressive early primary reconstruction versus delayed staged reconstruction. ,, Some feel that high-energy transfer results in soft tissues that may initially appear viable, but may necrose within days.  On the other hand, delayed reconstruction involves the initial avoidance of mini-plates, use of small incisions, minimal exposure of bony fragments, external pin fixations, and avoidance of intraosseous wiring, fearing necrosis, or infection. Advocates state that late repair ensures a clean, segregated wound bed. However, it faces the irreversible effects of contracture scars and deformity and an additional operation to reopen the same wound and graft the bones.  Although firearm wounds are considered contaminated, not all maxillofacial firearm injuries need be delayed. Many may be treated early. Several authors have criticized this traditional strategy of delaying surgical intervention of bony facial firearm injuries and have suggested a comprehensive primary surgical treatment. , Proponents  have more recently reported good results after acute treatment of projectile wounds to the face during a 4-year period in the Afghan war. Early definitive and comprehensive treatment of the facial injury in the first stage with minimal debridement has been shown to result in lower morbidity, faster return of function, shorter hospital stay, and one less operation for the patient (when bone continuity is obtained). , Additional advantages of early single-stage repair include a fresh wound, ability to expose, and locate displaced fracture segments upon debridement, easier anatomic reduction (no fibrosis), facilitated arch bar placement bone reduction and osteosynthesis, and definitive soft-tissue management. It also allows for restoration of occlusion, salvaging loose teeth, a more expedient return of function (when bone continuity is obtained), and near pretraumatic appearance postoperatively. ,, We postulate that most firearm injuries to the face may be managed acutely and sought to report results of facial skeleton injuries from firearms at our center to assess the patient population, the injury profile, demographics, indications, complications, and outcomes of those rendered primary management.
| Patients and Methods|| |
A case series of patients rendered early primary intervention for firearm wounds (30/51) between 1991 and 2010 were studied retrospectively using hospital records. Ages ranged from 8 to 50 years (mean 24.4±7.8).
Primary early intervention was done when there was no gross infection, no bone comminution or extensive soft tissue avulsion (precluding wound coverage), and when general health, concomitant injuries requiring more urgent attention or, those requiring major grafts did not preclude this. In these cases, acute management was directed toward early treatment of both hard and soft tissue injuries in the first operation. All 30 patients underwent primary wound closure following extensive oral and extraoral irrigation (dilute hydrogen peroxide + povidone iodide), debridement of the facial wound, arch bar placement, removal of floating fragments (teeth particles, debris, and shell fragments) precluding viable bone, locating the scattered bone segments within the wound and restoring bone continuity with the bone at hand. Tooth roots within the alveolus were not extracted at this stage nor were loose or displaced teeth. In addition to arch bars, titanium miniplates or wire osteosynthesis were done as necessary. In all cases, arch bars were placed and intermaxillary fixation (IMF) was done, prior to bone reduction to re-establish occlusion. Following that, IMF was done and then the fractured and scattered bone segments were realigned and fixated using miniplates, lag screws, reconstruction plates, or titanium trays. Arch bars with IMF but without osteosynthesis were possible when the bone segments contained teeth. As high velocity gunshot wounds cause fracture and dispersion of teeth, bone, and foreign bodies into the lips, tongue, cheeks, and elsewhere, these sites were visualized and palpated prior to closure. Soft tissue injuries were treated by debridement and primary wound closure, tailoring standard regional flap techniques to fit the location of the injury, and compensate for tissue loss when necessary. All wounds were closed primarily. Patients were placed on antibiotics (cephalosporin + aminoglycoside or ciprofloxacin IV preoperative and up to 1 week postoperative then orally for 2-4 weeks). Closure was performed in layers loosely from the inside out. Minor surgery was performed later for scars, defects, and dental implant placement.
Cases that had to be treated with delay included those with concomitant more serious injuries of the body, patients with pulverized bone, extensive loss of soft-tissue requiring distant flaps, or requiring large bone grafts, those with gross infection or those requiring composite grafts or poor general health.
| Results|| |
Thirty of 51 patients were treated acutely. Patient ages ranged from 8 to 50 years (mean 24.4±7.8 years). All patients were male. The mandible was injured in 96% and the maxilla in 54%; 22% required tracheostomy; 91% had isolated facial injuries with no other body area injured; 64% were managed in a single definitive early operation and 36% required two major operations. In the acute group, 6/30 patients had minor complications such as scarring and wound discharge. Transient postoperative discharge from the flap suture site was noted in these patients; this resolved within several weeks following daily irrigation and cleansing of the wound site. Early intervention for firearm wounds to the face was effective for facial firearm injuries in selected cases. This resulted in restoration of occlusion and continuity of the jaw, fixation of luxated or extruded teeth, early return of function, prevention of segment displacement and tissue contracture, less scarring, and decreased need for major bone graft reconstruction later [Table 1] and [Table 2]. Flap healing was favorable in all patients. No patients had major complications (i.e., necrosis or osteomyelitis).
|Table 1: Open fracture with wire, plate, or screw osteosynthesis and wound closure versus open fracture reduction wound closure without wire, plate, or screw osteosynthesis |
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|Table 2: Comparison of possible benefits of acute management with delayed management of maxillofacial firearm injuries |
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| Discussion|| |
Timing of treatment
There is no consensus on the timing of treatment for bone and soft tissue defects resulting from high-energy firearm wounds. The conventional method is primary repair as soon as possible 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. ,,, The presence of concomitant body injuries, fear of postoperative infection, unavailability of surgical hardware and lack of surgical experience in the treatment of penetrating warfare injuries are among the factors that had created supporters for delayed treatment of high velocity gunshot wounds.  Recently, there has been a reported increase in the use of external fixators  but in our unit we find them to be bulky, uncomfortable, and add additional scars to the already damaged face. With the materials available to surgeons today, facial fractures can be reduced, immobilized, and fixed in occlusion at the time of primary closure with internal fixation provided that soft tissue coverage is present and IMF is used. 
Rationale for primary treatment
In our unit, we aimed to restore bone continuity primarily (especially in the mandible). If this is done late, fibrosis occurs around bone segments and makes locating and mobilizing them difficult or they may become necrotic. Restoration of pre-injury form and function in jaws without continuity is more difficult and often remaining segments become displaced due to muscle pull (i.e., medial and superior displacement of the mandibular ramus) making reduction extremely difficult following fibrosis in delayed cases. Projectiles not within the wound are left in situ as often exploration for these foreign bodies is unnecessary and may be injurious. In addition to arch bars, titanium miniplates or wire osteosynthesis were applied when necessary following open reduction [Table 1]. Often in high velocity facial injuries, the hard tissues are found to be scattered and displaced rather than avulsed. Locating and securing them in place is better than aggressive debridement to remove them in fear of sequestration and infection that devitalizes and strips the fragments from their vital attachments [Figure 1] and [Figure 2]. Often these fractures can be manipulated and wedged into their proper place after locating them during debridement of the wound by tracking the bullet or shrapnel path to the fracture. All fractures do not always require internal fixation thus arch bar placement and restoration of occlusion following open reduction and IMF may be adequate.  This is usually possible when fractured bone segments contain teeth. Sali Bukhari recently reported on facial gunshot wounds. He found facial gunshot wounds to frequently involve the mandible and reiterated that early management of gunshot wounds not only results in better, aesthetics, reduced hospital stay and early return to function, but also better psychosocial profile.  The latter is an important issue to consider.
|Figure 1: Posterior-anterior skull radiograph of a typical patient shot in the face revealing multiple fragments of the mandible displaced inferiorly into the neck (commonly due to suprahyoid muscle pull)|
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|Figure 2: Lateral view after location, reduction of segments, and screw fixation to a reconstruction plate restoring continuity and chin projection|
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Problems in cases which are delayed
Loss of loose teeth (which cannot be placed back into the alveolus later), problems in restoring occlusion and fracture reduction, excessive granulation tissue, problems in feeding, anxiety, scarring + less esthetic results, increased cost, and length of hospital stay are potential problems in cases which are delayed. Delayed intervention may also lead to a poor psychosocial profile or depression because the patient has to tolerate the mutilated face and defective jaw for several days or longer until definitive treatment. Vayvada et al. treated 15 patients with high-energy bullet wounds. The conventional approach with delayed reconstruction for 10 patients and immediate definitive surgical reconstruction for 5 patients was used. They stated that immediate reconstruction eliminated disadvantages of the conventional method such as high infection and scarring rate and deformities resulting from contraction of tissues. 
In this series, 22% of patients required tracheotomies. This compared well to that found by Hollier et al.,  with 21% of all facial fractures required a tracheostomy. In all cases, in our series arch bars were placed with IMF prior to bone reduction to ensure proper occlusion. IMF also prevents chronic osteomyelitis or nonunion via preventing movement of segments. Thus, the application of arch bars for gunshot injuries of the jaws has proved to be the mainstay of treatment to re-establish arch form, occlusion and stabilize dento-alveolar fragments.
Soft tissue management
Local undermining and the use of regional soft-tissue advancement rotation flaps for primary closure of maxillofacial soft tissue defects during the same operation has also proved beneficial from both an aesthetic and functional point of view. ,, Leaving defects open results in extensive scarring of the facial tissues complicates subsequent surgical procedures, and should be avoided even in contaminated penetrating wounds. ,, In such situations, debridement and loose closure of the tissues transferred locally followed by administration of antibiotics may be a better alternative. ,,
Antibiotic therapy plays a major role in the prevention of infection of both hard and soft-tissues; 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.  Soft tissue healing is usually favorable in patients with penetrating facial injuries; however, postoperative discharge from the suture sites may be seen. This usually resolves within several weeks after daily irrigation with dilute povidone iodine or hydrogen peroxide solutions. Form and function of the soft tissue reconstructed regions recover usually within a year postoperatively. The esthetic results that can be obtained are generally acceptable to patients. 
The general health and status of the patient are important. The hemodynamics of the patient must be addressed as the oxygen carrying capacity is influential in both wound healing and prevention of infection in multiply-injured victims who have suffered extensive blood loss. ,, This factor may warrant delayed intervention especially in the face of more serious concomitant injuries.
The emotional conditions of patients with facial firearm injuries have been evaluated and major depression signs have been reported. Functional evaluation showed that there is a significant correlation between facial appearance after reconstruction and social activity level.  Thus, it may be postulated that the earlier surgical treatment is rendered the sooner the recovery.
Revisions and secondary operations (in other areas) are often necessary and were performed in 36% of the patients in this case series. Revisions are usually needed to remove scars, etc. near the eyes, the alar base of the nose, and oral commissures and the vermilion border of the lips. Many of these and other operations including masticatory rehabilitation and restoration of occlusion with osseointegrated implants can be done later under local anesthesia and sedation on an out-patient basis. ,
| Conclusions|| |
Firearm wounds are associated with a high incidence of maxillofacial injuries requiring surgical intervention. We advocate that these injuries be treated early when possible, with procedures designed to repair both bone and soft tissue injuries simultaneously aiming to restore bony continuity and function using the tissues at hand (especially in the mandible). Early treatment ensures that the course of healing is not disrupted with another subsequent operation (in the same wound) and may decrease patient morbidity and hospital stay in selected patients [Table 2].
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Mohammad Hosein Kalantar Motamedi
Department of Oral and Maxillofacial Surgery, Trauma Research Center, Baqiyatallah Medical Sciences University, Tehran
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2]