Small-vessel pathology and anastomosis following maxillofacial firearm wounds: an experimental study

Evidence-Based Medicine for Ballistic Maxillofacial Trauma

Ballistic trauma is a serious health issue with significant costs to physical, psychosocial, economic, and societal well-being. It may be caused from firearms, explosive devices, or any other projectile forces, and is characterized by severe tissue loss and evolving tissue devitalization. This review covers mechanism, diagnosis, and management of ballistic maxillofacial trauma, specifically. Initial evaluation includes stabilization of airway, bleeding, and circulation, followed by assessment of other injuries. The overall degree of tissue damage is determined by intrinsic patient factors and extrinsic projectile factors. Management of ballistic injuries has shifted toward advocation for early operative repair with the advent of antibiotics and advanced techniques in maxillofacial reconstruction. Appropriate timing and method of reconstruction should be carefully selected on a case-by-case basis. While ballistic trauma research is limited to studies biased by institutional practices, areas for further study identified from current literature include guidelines directing timing of reconstructive surgery; thresholds for free tissue transfer; handling of retained projectiles; incidence of surgical complications; and clinical outcomes for computer-aided surgical repair of these highly destructive injuries.

Management of mole gun injuries: Review of 19 cases with proposed treatment algorithm

Injuries caused by mole guns are mostly localized in the hands and characterized by contaminated and necrotic tissues due to the blast effect and a large number of residual foreign bodies in the wound. This study analyzed the medical records of patients' who had hand injuries caused by mole guns and presents our approach through a reconstruction algorithm. Data from 19 consecutive patients who sustained mole gun injuries between March 2015 and May 2019 were reviewed in this retrospective study. Demographics, affected tissues at the injury site, surgical treatment, presence of foreign bodies, and postoperative complications were recorded. A treatment algorithm was created based on the results of this study. Six patients underwent one operation, while the remaining 13 underwent more than one operation. A bone defect was found in four patients, skin and soft tissue defects in six patients, and a neurovascular defect in six patients. Two or less foreign bodies were seen in seven patients. Foreign body removal and debridement procedures are important in the first surgical session. The repair of defectless structures during the same session is also essential. Preparation of the structures with defects that will be repaired 5-7 days later simplifies the secondary surgery.

The impact of delayed surgical intervention following high velocity maxillofacial injuries

Our study compares the number of postoperative complications of Syrian patients admitted to the Galilee Medical Center (GMC) over a 5-year period (May 2013-May 2018) for treatment after initial high-velocity maxillofacial injuries sustained during the Syrian civil war. Specifically, we evaluated complication rates of patients arriving "early," within 24 h, to the GMC versus those who arrived "late," or 14-28 days following high-velocity maxillofacial injuries. Both groups of patients received definitive surgical treatment within 48 h of admission to our hospital with a total of 60 patients included in this study. The mean age was 26 ± 8 years (range: 9-50) and all except one were male. Postoperative complications in the early group were found to be significantly higher compared to the delayed arrival group (p = 0.006). We found that unintentionally delayed treatment may have contributed to a critical revascularization period resulting in improved healing and decreased postoperative morbidity and complications. We discuss potential mechanisms for complication rate variations, including critical vascularization periods. Our study may add to a growing body of work demonstrating the potential benefit of delayed surgical treatment for high-velocity maxillofacial injuries.

Bullet removal from the infratemporal fossa

War injuries are the cornerstone of maxillofacial surgery, and it led to the initiation and development of this specialty, and each case represents a challenge to the surgeon who deals with it. In this article, we present a 30-year-old male patient who was referred to our emergency department complaining of gunshot wound, severe pain, and limitation in mouth opening. Preoperative imaging showed a bullet with a very long path lodged in the infratemporal fossa. Three different approaches with the aid of C-arm imaging system were used for the removal of this bullet; the last approach was the successful one.

Treatment protocol for high velocity/high energy gunshot injuries to the face

Major causes of facial combat injuries include blasts, high-velocity/high-energy missiles, and low-velocity missiles. High-velocity bullets fired from assault rifles encompass special ballistic properties, creating a transient cavitation space with a small entrance wound and a much larger exit wound. There is no dispute regarding the fact that primary emergency treatment of ballistic injuries to the face commences in accordance with the current advanced trauma life support (ATLS) recommendations; the main areas in which disputes do exist concern the question of the timing, sequence, and modes of surgical treatment. The aim of the present study is to present the treatment outcome of high-velocity/high-energy gunshot injuries to the face, using a protocol based on the experience of a single level I trauma center. A group of 23 injured combat soldiers who sustained bullet and shrapnel injuries to the maxillofacial region during a 3-week regional military conflict were evaluated in this study. Nine patients met the inclusion criteria (high-velocity/high-energy injuries) and were included in the study. According to our protocol, upon arrival patients underwent endotracheal intubation and were hemodynamically stabilized in the shock-trauma unit and underwent total-body computed tomography with 3-D reconstruction of the head and neck and computed tomography angiography. All patients underwent maxillofacial surgery upon the day of arrival according to the protocol we present. In view of our treatment outcomes, results, and low complication rates, we conclude that strict adherence to a well-founded and structured treatment protocol based on clinical experience is mandatory in providing efficient, appropriate, and successful treatment to a relatively large group of patients who sustain various degrees of maxillofacial injuries during a short period of time.

Characteristics of ballistic and blast injuries

Ballistic injury wounds are formed by variable interrelated factors, such as the nature of the tissue, the compositional makeup of the bullet, distance to the target, and the velocity, shape, and mass of the of the projectile. This complex arrangement, with the ultimate outcome dependent on each other, makes the prediction of wounding potential difficult to assess. As the facial features are the component of the body most involved in a patient's personality and interaction with society, preservation of form, cosmesis, and functional outcome should remain the primary goals in the management of ballistic injury. A logical, sequential analysis of the injury patterns to the facial complex is an absolutely necessary component for the treatment of craniomaxillofacial ballistic injuries. Fortunately, these skill sets should be well honed in all craniomaxillofacial surgeons through their exposure to generalized trauma, orthognathic, oncologic, and cosmetic surgery patients. Identification of injured tissues, understanding the functional limitations of these injuries, and preservation of both hard and soft tissues minimizing the need for tissue replacement are paramount.

The role of maxillofacial radiologists in gunshot injuries: a hypothesized missile trajectory in two case reports

Gunshot injuries are an emerging form of trauma that oral radiologists increasingly have to deal with. There are two main types of gunshot injuries: high-velocity and low-velocity bullet injuries. The outcome of high-velocity gunshot injury is usually fatal; however, a non-fatal low-velocity injury to the maxillofacial region is more likely to be encountered by the oral and maxillofacial radiologist. It is therefore important to up-to-date knowledge of ballistic science and its implications in the field of maxillofacial radiology. The ability of oral and maxillofacial radiologists to predict the missile trajectory will aid the assessment and localization of the damage caused by the bullet and its splinters. Predicting the missile trajectory may also be of help to law enforcement agencies and forensic scientists in determining the type of firearm used and direction of fire. This article, which examines two cases, attempts to highlight to the oral radiologist this emerging form of trauma and its implications.

Biomechanical changes in the head associated with penetrating injuries of the maxilla and mandible: an experimental investigation

PURPOSE

In this experiment, we studied the craniocerebral injury that occurs due to the transmission of forces when maxillofacial gunshot wounds are sustained by the facial bones and cranium.

MATERIALS AND METHODS

Forty fresh pigs' heads were wounded by one of the following methods: steel spheres weighing 1.03 g at an impact velocity of 1,400 m/s, steel spheres weighing 1.03 g at an impact velocity of 800 m/s, M193 military bullets, or M56 military bullets. Pressure waves in the brain, acceleration of the head, and stress changes in the facial bones and cranium at the moment of the impact were recorded by pressure and acceleration transducers and strain gauges and were statistically compared.

RESULTS

Some obvious differences between the mechanical values obtained from high-and low-velocity missile wounds were found. A negative relationship between the peak value of the pressure wave in the brain and the distance from the point of impact to the transducer was obtained. The acceleration of the head in the direction of the ballistic path was the strongest in absolute value. There were differences in the stress values between the mandible and the temporal bone.

CONCLUSIONS

Acceleration of the head, pressure wave changes in the brain, and injury from bony stress conduction all play important roles in associated craniocerebral damage after maxillofacial firearm wounds.

A gross and microscopic study of cerebral injuries accompanying maxillofacial high-velocity projectile wounding in dogs

PURPOSE

This study investigated the pathologic characteristics and some related factors of cerebral damage associated with maxillofacial high-velocity missile wounds.

MATERIALS AND METHODS

Sixty dogs, divided into two groups, were wounded randomly by steel spheres weighting 1.03 g at impact velocities of 1,400 m/s (46 dogs) and 800 m/s (14 dogs). Six dogs served as controls. The maxillofacial wounds and cerebral injuries were examined grossly. The distance between the center of wound and the base of skull and the largest diameter of the wound were measured, and the incidence of the brain injury in the two groups was compared. The cerebral specimens, dissected at 1 and 6 hours after trauma, were observed by light and electron microscopy.

RESULTS

Cerebral hyperemia, contusion, spotty hemorrhage, and intracerebral hematoma were found in some of the dogs. In the 1,400 m/s velocity missile wound group, the incidence of the brain injury was 71.7% (33 of 46), and in the 800 m/s group it was 7.1% (1 of 14) on macroscopic examination. Microscopic observation showed intracerebral microhemotomas and degeneration and necrosis of the nervous cells.

CONCLUSION

High-velocity projectile maxillofacial wounds can induce associated brain injury.