1
|
Zeidan T, Kassouf E, Ahmadieh N, Nassar A, Jabbour G, Sleilati F. The Different Surgical Approaches to Maxillofacial Reconstruction after Ballistic Trauma. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6066. [PMID: 39139837 PMCID: PMC11321747 DOI: 10.1097/gox.0000000000006066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 06/21/2024] [Indexed: 08/15/2024]
Abstract
Background Ballistic trauma to the face is a challenge, combining complex bone injury with severe soft tissue loss. The various surgical methods available are influenced by the extent of injuries. This study compares different operative modalities and their outcomes with different variables, aiming to define the ideal therapeutic approach. Methods We retrospectively compared reconstructive modalities used to treat facial ballistic trauma cases at Hôtel-Dieu de France Hospital, Beirut, Lebanon, for a 12-year span. Statistical analysis was used to determine correlation between several factors and satisfactory results. Results Eighteen patients were included, with varying degrees of bone and soft tissue loss. After conservative debridement, fractures were treated by different modalities: open reduction and internal fixation, maxillomandibular fixation, and osteosynthesis with a reconstruction plate. Although primary closure was sufficient in 10 cases, severe loss of tissues was reconstructed with a fibular free flap in five cases, radial free forearm flap in two cases, and free parascapular flap in one case. Two others received an iliac bone graft as secondary reconstruction. The average follow-up was 2.45 years. Most cases achieved good aesthetic and functional results after several secondary operations, with few late complications. Early reconstruction and younger patients were associated with better outcomes. Conclusions We favor early debridement and reconstruction. Free flaps were ideal for extensive tissue loss. Bone grafting was needed secondarily. A single surgical procedure seldom led to satisfactory functional and aesthetic outcomes, and secondary operations were inevitable.
Collapse
Affiliation(s)
- Toufic Zeidan
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Elia Kassouf
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Nizar Ahmadieh
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Aref Nassar
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Georges Jabbour
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Fadi Sleilati
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| |
Collapse
|
2
|
Rehman U, Shemie M, Sarwar MS, Adebayo O, Brennan PA. The Reconstruction of Mandible Defects in War Injuries: Systematic Review and Meta-Analysis. Craniomaxillofac Trauma Reconstr 2024; 17:160-168. [PMID: 38779399 PMCID: PMC11107824 DOI: 10.1177/19433875231198947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
Study Design Systematic Review and Meta-Analysis. Objective There has been an increasing trend in maxillofacial injuries associated with combat trauma. Within the maxillofacial complex, the mandible is the most likely structure to be damaged during combat. The structural deficits as a result can be reconstructed with many options. These include vascularised bone grafts (VBGs), non-vascularised bone grafts (NVBGs), alloplastic implants, reconstruction bars and distraction osteogenesis. This study aimed to determine the common modality and efficacy of mandibular reconstruction in combat trauma-related defects. Methods A literature search was conducted on Pubmed, Prospero, Dynamed, DARE, EMBASE, COCHRANE and BMJ databases. Results A total of six articles met the inclusion criteria identifying 165 patients requiring mandibular reconstruction. Non-vascularised iliac bone graft (n = 137) was the most common method followed by ileac crest bone chips harvest using Dacron urethran osteomesh tray (n = 24) and frontoparietal grafts (n = 4). Meta-analysis of five out of six trials demonstrated an overall success rate of 85% (95% CI 79-90; I2 = 59%). A total of 13% (n = 22) of reconstructions failed either completely or partially and 21% (n = 34) of patients suffered postoperative complications. Conclusions NVBGs are a practical, cost-effective and favourable method of war zone management of mandibular defects with success rates comparable to those reported in the civilian literature. However, general trauma principles take precedence to rule out life-threatening injuries. Due consideration of patient factors, surgical factors, and available resources are required in the first-line management of combat-related mandibular defects.
Collapse
Affiliation(s)
- Umar Rehman
- Department of Plastic Surgery, Chelsea and Westminster Hospital, London, UK
| | - Melissa Shemie
- Department of Oral and Maxillofacial Surgery, Northwick Park Hospital, London, UK
| | - Mohammad Sohaib Sarwar
- Department of Oral and Maxillofacial Surgery, The Queen Victoria Hospital, East Grinstead, UK
| | | | - Peter A. Brennan
- Department of Oral and Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, UK
| |
Collapse
|
3
|
Tomassini L, Ascani G, Mancini P, Cacaci C, Scendoni R. A case of emergency reconstructive surgery following facial destructive gunshot wounds: clinical and medico-legal assessments. Int J Emerg Med 2023; 16:90. [PMID: 38114930 PMCID: PMC10731849 DOI: 10.1186/s12245-023-00572-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/11/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Facial gunshot wounds present a complex challenge to both medical professionals and victims with significant physical, psychological, and economic implications for those who suffer these types of injuries. Reconstructive surgery offers satisfactory aesthetic and functional outcomes, improving a patient's quality of life. In these cases, the surgical procedure may encompass additional phases beyond those initially identified based on the type of wound and the extent of tissue destruction. As a result, each case necessitates thorough evaluation to determine an appropriate strategy. Nonetheless, it is worth noting that the outcomes achieved in terms of both aesthetics and functionality in this domain have the potential to be excellent. CASE PRESENTATION A 66-year-old man attempted suicide with a shotgun, causing severe facial injuries and fractures. He had a history of depression and was taken to the emergency department promptly. CT scans revealed brain and facial bone injuries, and he underwent surgery to control bleeding and tracheostomy. Postoperative recovery was successful. The patient's condition stabilized, and he was discharged after 10 days. Follow-up visits showed gradual healing. Despite an offer for further facial reconstruction, he declined, satisfied with the achieved results. CONCLUSIONS The present case report is intended to support the argument that effective facial reconstruction should be considered in the medico-legal assessment. It could be beneficial to introduce a new classification system and personalized evaluation methods with careful consideration given to treatment costs (which can be very high) and expected results. Since reconstructive surgery modifies damage and impacts the long-term costs of permanent impairments, its inclusion in the decision-making process would promote improved personalized care.
Collapse
Affiliation(s)
- Luca Tomassini
- International School of Advanced Studies, University of Camerino, Camerino, Italy.
| | - Giuliano Ascani
- Department of Maxillofacial Surgery, Spirito Santo Hospital, Pescara, Italy
| | - Paolo Mancini
- Department of Maxillofacial Surgery, Spirito Santo Hospital, Pescara, Italy
| | - Claudio Cacaci
- Department of Law, Institute of Legal Medicine, University of Macerata, Macerata, Italy
| | - Roberto Scendoni
- Department of Law, Institute of Legal Medicine, University of Macerata, Macerata, Italy
| |
Collapse
|
4
|
Lee CJ, Calvo R, Rosales R, Akhter M, Sise MJ, Krzyzaniak A, Lance S. Ballistic Facial Trauma Reconstruction: Incidence and Practice Patterns in the Civilian Population. Ann Plast Surg 2023; 90:S315-S319. [PMID: 36752402 DOI: 10.1097/sap.0000000000003413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Management of nonfatal ballistic facial trauma is well described in the literature for wounds secondary to military combat. However, there is little literature describing such management in civilian practice. We aimed to describe nonmilitary patients with recent nonfatal facial injuries from ballistic trauma using the California Office of Statewide Health Planning and Development patient database. METHODS A retrospective study was performed using the California Office of Statewide Health Planning and Development Ambulatory Surgery and Inpatient datasets. All adults with the International Classification of Diseases, 10th Revision codes of severe nonfatal facial trauma from firearms requiring emergent surgery during 2016-2018 were included. Outcomes assessed include number and type of facial procedures performed, hospital length of stay, number of admissions, timing of definitive management, and lifetime hospitalization costs. RESULTS A total of 331 traceable patients were identified over this 3-year period. The average age was 35.4 years (SD, 15.2), and 87% were male. The median index admission length of stay was 8 days (interquartile range, 3-15 days). Subsequent readmission was required for 123 (37.2%) patients with 10% mortality in the index admission. Total median charges per patient for all admissions were $257,804 (interquartile range, $105,601-$531,916). A total of 215 patients (65%) had at least 1 facial repair performed. Of all 331 patients, 64.3% underwent musculoskeletal repair (n = 213), 31.4% underwent digestive system repair (n = 104), and 29.6% underwent respiratory system repair (n = 98). The average number of repairs per patient was 2.52 (SD, 3.38), with 35% not having any of the specified International Classification of Diseases, 10th Revision repair codes. A total of 27% of patients had 1 procedure performed, whereas 38% received 2 or more, for an average of 3.87 (SD, 3.5) repairs over the study duration. DISCUSSION To our knowledge, this is the first assessment of civilian characteristics of nonfatal ballistic facial trauma in California. Nonfatal facial ballistic trauma results in complex injuries to multiple body systems, requiring long admissions, costly hospital stays, and coordination of care across several surgical specialties. Many patients require a variety of procedures over multiple admissions, highlighting the overall morbidity of these injuries. Future studies will look at how care for these patients differs between various hospitals and geographic regions and whether current civilian management aligns with well-defined military reconstructive protocols for facial ballistic injuries.
Collapse
Affiliation(s)
- Clara J Lee
- From the Division of Plastic Surgery, University of California San Diego, La Jolla
| | - Richard Calvo
- Department of Trauma Surgery, Scripps Mercy Hospital, San Diego
| | - Ricardo Rosales
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Maheen Akhter
- Central Michigan University College of Medicine, Saginaw, MI
| | - Michael J Sise
- Department of Trauma Surgery, Scripps Mercy Hospital, San Diego
| | | | - Samuel Lance
- From the Division of Plastic Surgery, University of California San Diego, La Jolla
| |
Collapse
|
5
|
Jelmini J, Patel A. Utilizing a Nasal Speculum in Maxillofacial Trauma and Deep Space Neck Infections: A Technical Note. J Oral Maxillofac Surg 2022; 80:1518-1521. [PMID: 35853488 DOI: 10.1016/j.joms.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 11/15/2022]
Abstract
Maxillofacial trauma and odontogenic infections demand surgical access to sites often distant from wounds or incisions. We describe a simple, cost-effective, safe, and easy-to-implement technique of using a nasal speculum to facilitate surgical access in deep wounds of the head and neck region. This manuscript will describe 2 common indications and the technique for employing the nasal speculum as an adjunctive tool in oral and maxillofacial surgery.
Collapse
Affiliation(s)
- Jonathan Jelmini
- Resident, Department of Oral and Maxillofacial Surgery, Oregon Health and Science University, Portland, Oregon
| | - Ashish Patel
- Fellowship Director, Head and Neck Oncologic and Microvascular Surgery, Providence Cancer Institute, Medical Director, Craniomaxillofacial and Neck Trauma, Legacy Emanuel Medical Center, Head and Neck Surgical Associates, Portland, Oregon.
| |
Collapse
|
6
|
Knudson SA, Day KM, Kelley P, Padilla P, Collier IX, Henry S, Harshbarger R, Combs P. Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review. Craniomaxillofac Trauma Reconstr 2022; 15:206-218. [PMID: 36081679 PMCID: PMC9446274 DOI: 10.1177/19433875211026432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023] Open
Abstract
Study Design Retrospective case series; systematic review. Objective It is unknown whether the use of virtual surgical planning (VSP) to facilitate same-admission microsurgical reconstruction of the mandible following acute maxillofacial ballistic trauma (MBT) is sufficient to achieve definitive reconstruction and functional occlusion. Methods A single-center retrospective analysis was conducted for patients who underwent microsurgical reconstruction of the mandible using VSP after acute MBT. The PubMed/MEDLINE, Embase, ScienceDirect, and Scopus databases were systematically reviewed using blinded screening. Studies were evaluated via thematic analysis. Results Five patients were treated by same-admission and microsurgical reconstruction of the mandible using VSP. We observed an average of 16.4 ± 9.1 days between initial presentation and reconstruction, an average length of stay of 51.6 ± 17.9 days, 6.2 ± 2.8 operations, and 1.6 ± 0.9 free flaps per patient. Four types and 8 total flaps were employed, most commonly the anterior lateral thigh flap (37.5%). Care yielded complete flap survival. Each patient experienced at least 1 minor complication. All patients achieved centric occlusion, oral nutrition, and an approximation of their baseline facial aesthetic. Follow up was 191.0 ± 183.9 weeks. Systematic review produced 8 articles that adhered to inclusion criteria. Consensus themes in the literature were found for clinical goal and function of VSP when practicing MBT reconstruction, yet disagreement was found surrounding optimal treatment timeline. Conclusions Same-admission microsurgical reconstruction after MBT is safe and effective to re-establish mandibular form and function. VSP did not delay reconstruction, given the need for preparation prior to definitive reconstruction.
Collapse
Affiliation(s)
- Sean A. Knudson
- Division of Craniofacial and Pediatric
Plastic Surgery, Dell Children’s Medical Center, The University of Texas at Austin,
Austin, TX, USA
| | - Kristopher M. Day
- Division of Craniofacial and Pediatric
Plastic Surgery, Dell Children’s Medical Center, The University of Texas at Austin,
Austin, TX, USA
- Department of Plastic Surgery, Dell
Seton Medical Center, The University of Texas at Austin, Austin, TX, USA
- Dell Medical School, The University of
Texas at Austin, Austin, TX, USA
| | - Patrick Kelley
- Division of Craniofacial and Pediatric
Plastic Surgery, Dell Children’s Medical Center, The University of Texas at Austin,
Austin, TX, USA
- Department of Plastic Surgery, Dell
Seton Medical Center, The University of Texas at Austin, Austin, TX, USA
- Dell Medical School, The University of
Texas at Austin, Austin, TX, USA
| | - Pablo Padilla
- Department of Plastic Surgery,
University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Ian X. Collier
- Dell Medical School, The University of
Texas at Austin, Austin, TX, USA
| | - Steven Henry
- Department of Plastic Surgery, Dell
Seton Medical Center, The University of Texas at Austin, Austin, TX, USA
- Dell Medical School, The University of
Texas at Austin, Austin, TX, USA
| | - Raymond Harshbarger
- Division of Craniofacial and Pediatric
Plastic Surgery, Dell Children’s Medical Center, The University of Texas at Austin,
Austin, TX, USA
- Department of Plastic Surgery, Dell
Seton Medical Center, The University of Texas at Austin, Austin, TX, USA
- Dell Medical School, The University of
Texas at Austin, Austin, TX, USA
| | - Patrick Combs
- Division of Craniofacial and Pediatric
Plastic Surgery, Dell Children’s Medical Center, The University of Texas at Austin,
Austin, TX, USA
- Department of Plastic Surgery, Dell
Seton Medical Center, The University of Texas at Austin, Austin, TX, USA
- Dell Medical School, The University of
Texas at Austin, Austin, TX, USA
| |
Collapse
|
7
|
Facial Reconstruction Following Self-Inflicted Gunshot Wounds: Predictors, Complications, and Acceptable Outcomes. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2020018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Self-inflicted gunshot wounds (SIGSWs) produce devastating facial defects that are challenging to reconstruct, but are rarely reported in large cohorts in the literature. This study sought to characterize these injuries, and identify parameters influencing complications and outcomes among survivors following facial reconstruction. Methods: A retrospective cohort study was performed identifying 22 patients with SIGSWs to the face reconstructed at our center from 2009 to 2019. Charts were reviewed for patient, injury, and reconstructive details and course. Outcomes were statistically compared to various parameters. Results: The most common firearm, orientation, and injured structure were the handgun (40.9%), submental (59.1%), and mandible (68.2%), respectively. Patients averaged a 21.7-day length of stay (LOS), 17.4 h to debridement, 2.6 days to bony fixation, 5.4 reconstructive surgeries, and 7 (31.8%) patients received at least one free flap. Fifteen (68.2%) patients had at least one major complication, although functional outcomes were ultimately relatively good overall. Notable outcome associations included submental orientation with a longer LOS (p = 0.027), external fixation with a longer LOS (p = 0.014), financial stressors with a shorter LOS (p = 0.031), and severe soft tissue injury with an increased total number of reconstructive surgeries (p = 0.039) and incomplete reconstruction (p = 0.031). There were no cases of suicidal recidivism. Conclusions: Reconstruction following facial SIGSW is challenging for both patient and surgeon, and carries a high rate of complications. However, patients can regain substantial function following reconstruction and the achievement of satisfactory outcomes.
Collapse
|
8
|
Survival Following Self-Inflicted Gunshot Injuries to the Face Using the National Trauma Data Bank. J Craniofac Surg 2021; 32:2064-2067. [PMID: 33770041 DOI: 10.1097/scs.0000000000007634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Self-inflicted gunshot wounds to the face frequently result in devastating injuries; however, there is a paucity of large experiences describing determinants of mortality and outcomes. METHODS Using the National Trauma Databank from 2007 to 2015, patients suffering self-inflicted firearm facial injuries were included. RESULTS Over 9 years 7869 patients were included: 87.7% were male, 46.4% suffered traumatic brain injury (TBI) and overall in-hospital mortality was 44.7%. The majority (67.8%) of in-hospital mortality occurred within the first 24 hours. Using multiple regression, advanced age (>65 years), presence of TBI, admission hypotension, and decreased Glasgow coma score were each independently associated with increased odds of mortality (all P < 0.001). Mandible or combined mandible/midface fracture injury patterns were most likely to survive (P < 0.001). Of those surviving to hospital discharge, the median [interquartile range] length of stay was 13 [6, 23] days, 86.6% required an intensive care unit stay with 67% requiring intubation and 42.5% tracheostomy. Among survivors, the combined mandible and midface fracture pattern resulted in the highest rates of tracheostomy (70.5%), gastrostomy tube placement (50.5%), and facial operations (87.0%) with a median [interquartile range] of 5 [3, 7] operative trips (all P < 0.001). CONCLUSIONS Self-inflicted facial firearm injuries are highly morbid injuries with the majority of in-hospital deaths occurring the first hospital day. Differences including concomitant TBI, facial injury pattern, neurologic status, and presence of hypotension on admission were independently associated with survival/death. More extensive facial injuries (combined mandible and midface fracture patterns) were more likely to survive and required more intensive interventions.
Collapse
|
9
|
Endoscopic management gunshot wound at the face: Fact or fiction? Trauma Case Rep 2021; 35:100497. [PMID: 34435086 PMCID: PMC8374721 DOI: 10.1016/j.tcr.2021.100497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 11/21/2022] Open
Abstract
Shrapnel or gunshot injuries in Maxillofacial Region are highly considered to be challenging which leads to death in most cases, and even in the case of no mortality, they will cause morbidity and appearance impairment due to complex injuries to bone and soft tissue. Herein, in a particular case, the patient was a person injured by a gunshot of a Kalashnikovs҆ bullet in his face; the bullet was located at the end of the medial wall of the maxillary sinus and was removed through the functional endoscopy of the nose and sinuses. The bullet was removed without causing any additional incisions on the face and further damage through endoscopic ligation of severe bleeding from the sphenopalatine artery. The clinical approach to patients with penetrating trauma from a bullet to head and face demands prompt action. Functional endoscopic nasal and sinus surgery can maintain the patient's face cosmetic appearance.
Collapse
|
10
|
Current opinion in the assessment and management of ballistic trauma to the craniomaxillofacial region. Curr Opin Otolaryngol Head Neck Surg 2021; 28:251-257. [PMID: 32520756 DOI: 10.1097/moo.0000000000000634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Ballistic trauma represents a small proportion of injuries to the craniomaxillofacial (CMF) region, even in societies where the availability of firearms is more prevalent. The aim of this article is to review current opinion in the assessment and management of ballistic injuries sequentially from primary survey to definitive reconstruction. RECENT FINDINGS For mandibular fractures because of ballistic trauma, load-bearing fixation remains the mainstay in the treatment. The use of load sharing fixation is rarely advised, even if the fracture pattern radiologically appears to fulfil the traditional indications for its use. Clinicians must be aware of specific situations in early internal fixation is contraindicated, particularly in those unstable patients requiring short damage control surgical procedures, avulsive soft and hard tissue defects and those injuries at increased risk of infection. SUMMARY Staged surgery for complex injuries is increasingly becoming accepted, by which injuries are temporarily stabilized by means of maxillary--mandibular fixation (MMF) or an external fixation. Patients are subsequently repeat CT-scanned, and definitive internal fixation performed a few days later. Increased access to virtual surgical planning (VSP) and three-dimensional plates has revolutionized fracture reconstruction.
Collapse
|
11
|
The impact of delayed surgical intervention following high velocity maxillofacial injuries. Sci Rep 2021; 11:1379. [PMID: 33446855 PMCID: PMC7809344 DOI: 10.1038/s41598-021-80973-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 01/01/2021] [Indexed: 11/09/2022] Open
Abstract
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.
Collapse
|
12
|
Patterson B, Sangar S, Gnanadev R, Makkar G, Neeki M. An Interesting Civilian Case of Complex Maxillofacial Trauma Due to Target Fragmentation Following Bullet Impact and Review of the Branches of the Maxillary Artery. Cureus 2020; 12:e10484. [PMID: 32953366 PMCID: PMC7497285 DOI: 10.7759/cureus.10484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Serious morbidity and mortality for the operator and bystanders are associated with a lack of knowledge and failure to utilize appropriately manufactured targets. The management of firearm-related facial trauma is challenging and requires rapid intervention from a multidisciplinary team. We present a case of penetrating facial trauma secondary to the fragmentation of a homemade target. We highlight how firearm operators can optimize safety by matching ballistics with target selection and review pertinent vascular structures, including the terminal branches of the external carotid artery and branches of the maxillary artery. This case demonstrates that trauma physicians must be well-versed with complex maxillofacial anatomy and multimodal approaches to hemostasis.
Collapse
Affiliation(s)
| | - Sophia Sangar
- Head and Neck Surgery, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, USA
| | - Raja Gnanadev
- Surgery, Arrowhead Regional Medical Center, Colton, USA
| | - George Makkar
- Vascular Surgery, Arrowhead Regional Medical Center, Colton, USA
| | - Michael Neeki
- Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA
| |
Collapse
|
13
|
da Rocha SS, Sales PHDH, Carvalho PHR, Maia RN, Gondim RF, de Menezes Junior JMS, Mello MDJR. Mandibular traumas by gunshot. A systematic review with meta-analysis and algorithm of treatment. Br J Oral Maxillofac Surg 2020; 59:e99-e108. [PMID: 33678448 DOI: 10.1016/j.bjoms.2020.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
The treatment of mandibular fractures by gunshot ranges from late conservative repair to more aggressive early repair in a single stage. Treatments that preserve bony architecture as much as possible should be used, minimising patient morbidity and the complexity of future surgeries. The purpose of this study was to use a systematic review to determine which method of treatment was most effective for mandibular fractures by gunshot. Searches were conducted on Medline via PubMed, Scopus, Central Cochrane, and Sigle via Open Grey up to August 2019. Four studies were eligible to this systematic review, considering the previously establish inclusion and exclusion criteria. A total of 211 patients were evaluated. The mandibular body was the region more fractured followed by the symphyseal/parasymphyseal region. The closed treatment with intermaxillary fixation (IMF) was the most used followed by open surgery with internal rigid fixation (IRF) and external fixator. Considering the total adverse effects, the meta-analysis showed no statistically significant difference between the IMF and IRF groups (p=0.840), but IMF showed five times less infection and IRF six times less malunion. The algorithm was delineated from the types of injuries by gunshot, proposing forms of treatment from initial stabilisation to functional rehabilitation with implant-supported prostheses. The treatment of mandibular fractures by gunshot remains a challenge for surgeons. There was a statistically significant prevalence of success in the IRF group, however this group was also associated with a higher index of infection than the IMF group. New studies with high methodological quality and larger numbers of participants are needed to offer more safety for surgeons who treat patients with mandibular fractures by gunshot.
Collapse
|
14
|
Dutheil F, Baker JS, Navel V. To fight SARS-CoV-2: putting your guns down. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2020; 111:411-412. [PMID: 32542509 PMCID: PMC7295145 DOI: 10.17269/s41997-020-00339-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/07/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Frédéric Dutheil
- Université Clermont Auvergne, CNRS, LaPSCo, Physiological and Psychosocial Stress, CHU Clermont-Ferrand, University Hospital of Clermont-Ferrand, Preventive and Occupational Medicine, Witty Fit, F-63000, Clermont-Ferrand, France.
| | - Julien S Baker
- Centre for Health and Exercise Science Research, Department of Sport, Physical Education and Health, Hong Kong Baptist University, Kowloon Tong, Hong Kong
| | - Valentin Navel
- Université Clermont Auvergne, CNRS, INSERM, GReD, Translational Approach to Epithelial Injury and Repair, CHU Clermont-Ferrand, University Hospital of Clermont-Ferrand, Ophthalmology, F-63000, Clermont-Ferrand, France
| |
Collapse
|
15
|
De Paolo MH, Arzi B, Pollard RE, Kass PH, Verstraete FJM. Craniomaxillofacial Trauma in Dogs-Part II: Association Between Fracture Location, Morphology and Etiology. Front Vet Sci 2020; 7:242. [PMID: 32478108 PMCID: PMC7242568 DOI: 10.3389/fvets.2020.00242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/08/2020] [Indexed: 12/03/2022] Open
Abstract
Treatment of craniomaxillofacial (CMF) trauma in dogs requires a thorough understanding of the CMF skeletal structures involved. The human medical literature has several examples of CMF trauma and fracture classification, including the classically described Le Fort fractures. The recent classification schemes require large studies using computed tomography (CT). In the veterinary medical literature, such studies are lacking. The aims of part II of this retrospective study were to use a large number of CT studies of dogs evaluated for CMF trauma to determine whether specific fracture locations in the CMF region occur concurrently, and whether trauma etiology influences fracture morphology. This information may then be used to form a fracture classification scheme in the future. The medical records and CT studies of 165 dogs over a 10-year period were evaluated. The skeletal location of CMF fractures as well as the severity of displacement and fragmentation of each fracture was recorded. Dogs' demographic data and trauma etiology were also recorded. Fractured portions of the mandible tended to occur with fractures of adjacent bones, with the major exception of symphyseal separation, which occurred simultaneously with fractures of the cribriform plate. Fractures of the maxillary bone were accompanied by many concurrent fractures affecting the majority of the midface, skull base, and cranial vault. When the zygomatic bone was fractured, the other bones comprising the orbit also tended to fracture. Fractures of the relatively superficially located frontal and nasal bones were often accompanied by fractures of the skull base. Fracture etiology influenced fracture morphology such that vehicular trauma resulted in a relatively higher number of severely displaced and comminuted fractures than did other trauma etiologies. This study provides examples of fractures that, when found, should prompt veterinarians to look for additional injuries in specific locations. In addition, it further highlights the need for thorough CT evaluation of the entire CMF region, even when clinically apparent fractures appear relatively superficial.
Collapse
Affiliation(s)
- Mercedes H De Paolo
- School of Veterinary Medicine, William R. Pritchard Veterinary Medical Teaching Hospital, University of California, Davis, Davis, CA, United States
| | - Boaz Arzi
- Department of Surgical and Radiological Sciences, University of California, Davis, Davis, CA, United States
| | - Rachel E Pollard
- Department of Surgical and Radiological Sciences, University of California, Davis, Davis, CA, United States
| | - Philip H Kass
- Department of Population Health and Reproduction, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Frank J M Verstraete
- Department of Surgical and Radiological Sciences, University of California, Davis, Davis, CA, United States
| |
Collapse
|
16
|
Carvalho PHR, da Hora Sales PH, da Rocha SS, Cavalcanti AMM, de Jesus Rodrigues Mello M, Junior JMSM. Treatment of comminutive fractures by firearm projectiles with adapted wrist external fixator. Oral Maxillofac Surg 2019; 23:501-505. [PMID: 31643009 DOI: 10.1007/s10006-019-00804-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/11/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Facial and mandibular aggression with gunshot wound (GSW) is highly complex and represents a challenge for the assistant surgical team because in addition to the inherent lethal potential, they have the capacity for destruction and mutilation caused by the high kinetic energy conferred to the firearm projectile. Among these lesions, comminutive mandibular fractures are difficult to treat because the anatomical planes are distorted, soft tissues are in severe disarrangement, and bone fragments are without periosteum, which, if opted for an open treatment, with internal fixation, favor the development of soft tissue infections, osteomyelitis, and suture dehiscence. The treatment of comminuted mandibular fractures with external fixator, widely used during the Second World War, represents a modality of treatment that minimizes the risks of failure, since it allows stabilization of the fractured mandible with minimal aggression to the soft tissues. OBJECTIVES The objective of this study is to report three cases where surgical procedures were performed to treat comminuted mandible fractures with the adaptation of specific external orthopedic fixator for wrist.
Collapse
Affiliation(s)
| | - Pedro Henrique da Hora Sales
- Federal University of Pernambuco, Recife, Pernambuco, Brazil.
- Federal University of Pernambuco, School of Dentistry, Recife, Pernambuco, Brazil.
| | | | | | | | | |
Collapse
|
17
|
Breeze J, Bowley DM, Combes JG, Baden J, Rickard RF, DuBose J, Powers DB. Facial injury management undertaken at US and UK medical treatment facilities during the Iraq and Afghanistan conflicts: a retrospective cohort study. BMJ Open 2019; 9:e033557. [PMID: 31772107 PMCID: PMC6887033 DOI: 10.1136/bmjopen-2019-033557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To perform the first direct comparison of the facial injuries sustained and treatment performed at USA and UK deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan. SETTING The US and UK Joint Theatre Trauma Registries were scrutinised for all patients with facial injuries presenting alive to a UK or US deployed MTF between 1 March 2003 and 31 October 2011. PARTICIPANTS US and UK military personnel, local police, local military and civilians. PRIMARY AND SECONDARY OUTCOME MEASURES An adjusted multiple logistic regression model was performed using tracheostomy as the primary dependent outcome variable and treatment in a US MTF, US or UK military, mandible fracture and treatment of mandible fracture as independent secondary variables. RESULTS Facial injuries were identified in 16 944 casualties, with the most common being those to skin/muscle (64%), bone fractures (36%), inner/middle ear (28%) and intraoral damage (11%). Facial injuries were equally likely to undergo surgery in US MTF as UK MTF (OR: 1.06, 95% CI 0.4603 to 1.142, p=0.6656); however, variations were seen in injury type treated. In US MTF, 692/1452 (48%) of mandible fractures were treated by either open or closed reduction compared with 0/167 (0%) in UK MTF (χ2: 113.6; p≤0.0001). US military casualties who had treatment of their mandible fracture (open reduction and internal fixation or mandibulo-maxillary fixation) were less likely to have had a tracheostomy than those who did not undergo stabilisation of the fractured mandible (OR: 0.61, 95% CI 0.44 to 0.86; p=0.0066). CONCLUSIONS The capability to surgically treat mandible fractures by open or closed reduction should be considered as an integral component of deployed coalition surgical care in the future.
Collapse
Affiliation(s)
- John Breeze
- Royal Centre for Defence Medicine, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Douglas M Bowley
- Royal Centre for Defence Medicine, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James G Combes
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - James Baden
- Royal Centre for Defence Medicine, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Joseph DuBose
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - David B Powers
- Duke University Medical Center, Durham, North Carolina, USA
| |
Collapse
|
18
|
Abstract
Injury to the orbital region represents a significant proportion of emergency department attendances and it is a common injury in patients with multisystem trauma. To date, trauma remains a leading cause of monocular blindness.Traumatic optic neuropathy may be caused by direct trauma to the optic nerve and from compression caused by foreign bodies and bone fragments. Indirect trauma can lead to visual loss from transmitted force to the optic canal by blunt facial trauma without associated fractures. Occasionally traumatic optic neuropathy is due to reversible changes, such as edema or contusion.High-dose intravenous steroids and surgical decompression of the optic canal have been advocated for the management of acute traumatic optic neuropathy, but the efficacy and safety of these treatments have been questioned.The authors present 3 patients with traumatic optic nerve injury, 1 due to a gunshot wound to the face and 2 caused by blunt facial trauma, where fragments of bone intrude into the orbit leading to compression of its content. These injuries where successfully treated with both preoperative intravenous steroids followed by acute surgical decompression of the orbit with return of visual function.
Collapse
|
19
|
|
20
|
Rifkin WJ, Bellamy JL, Kantar RS, Farber SJ, Diaz-Siso JR, Brecht LE, Rodriguez ED. Autologous Reconstruction of a Face Transplant Candidate. Craniomaxillofac Trauma Reconstr 2018; 12:150-155. [PMID: 31073366 DOI: 10.1055/s-0038-1675844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/28/2018] [Indexed: 01/05/2023] Open
Abstract
Since 2005, facial transplantation has emerged as a viable reconstructive option for the most severe defects not amenable to conventional reconstructive techniques, with promising aesthetic and functional outcomes to date. Key facial subunits and midface structures such as the eyelids, lips, and nose are now able to be successfully replaced rather than reconstructed, enabling adequate functional outcomes in even the most extensive defects. However, even in cases of severe facial disfigurement, the decision to proceed with transplantation versus autologous reconstruction remains a source of debate, with no current consensus regarding precise indications and inclusion/exclusion criteria. This report details the case of a candidate referred for face transplantation who ultimately underwent autologous facial reconstruction. Through this representative case, our objective is to clarify the criteria that make a patient a suitable face transplant candidate, as well as to demonstrate the outcomes achievable with a conventional autologous reconstruction, using a methodically planned, multistaged approach.
Collapse
Affiliation(s)
- William J Rifkin
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Justin L Bellamy
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Scott J Farber
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - J Rodrigo Diaz-Siso
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Lawrence E Brecht
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York.,Jonathan and Maxine Ferencz Advanced Education Program in Prosthodontics, New York University College of Dentistry, New York, New York
| | - Eduardo D Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| |
Collapse
|
21
|
Sokoya M, Vincent AG, Joshi R, Kadakia S, Kohlert S, Lee TS, Saman M, Ducic Y. Higher Complication Rates in Self-Inflicted Gunshot Wounds After Microvascular Free Tissue Transfer. Laryngoscope 2018; 129:837-840. [PMID: 30247763 DOI: 10.1002/lary.27391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/19/2018] [Accepted: 05/29/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS Microvascular free tissue transfer is often employed to reconstruct significant facial defects from ballistic injuries. Herein, we present our comparison of complications between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer. STUDY DESIGN Retrospective case review. METHODS Approval was obtained from the JPS institutional review board. We performed a retrospective review of cases of ballistic facial injuries between October 1997 and September 2017 that underwent vascularized free tissue transfer for reconstruction. Comparisons were made between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer. The χ2 test was used for all comparisons. P value and 95% confidence interval (CI) were reported. RESULTS There were 73 patients requiring free flap reconstruction after gunshot wounds to the face during the study period. There was a statistically significant difference in the rates of nonunion between self-inflicted and non-self-inflicted wounds (P = .02, 95% CI: 0.9 to 35.8) There were also no significant differences in flap failure (P = .10, 95% CI: -2.8 to 24.2), plate exposure (P = .28, 95% CI: -6.7 to 33.0), wound infection (P = .40, 95% CI: -8.9 to 31.2), scar contracture (P = .60, 95% CI: -8.1 to 25.1), and fistula formation (P = .13, 95% CI: -2.8 to 28.8) between patients with self-inflicted and those with non-self-inflicted wounds. Overall, complication rates were significantly higher in the self-inflicted group compared to the non-self-inflicted group (P < .0001, 95% CI: 32.6 to 68.6). CONCLUSIONS Patients with self-inflicted injuries had more complications postoperatively than those with non-self-inflicted injuries. This is likely helpful in surgical planning and patient counseling. LEVEL OF EVIDENCE 4 Laryngoscope, 129:837-840, 2019.
Collapse
Affiliation(s)
- Mofiyinfolu Sokoya
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Aurora G Vincent
- Department of Otolaryngology-Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington, U.S.A
| | - Rohan Joshi
- Department of Otolaryngology-Head and Neck Surgery, New York-Presbyterian Hospital of Columbia and Cornell, New York, New York, U.S.A
| | - Sameep Kadakia
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Scott Kohlert
- Department of Facial Plastic and Reconstructive Surgery, Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas S Lee
- Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University, Richmond, Virginia, U.S.A
| | | | - Yadranko Ducic
- Department of Facial Plastic and Reconstructive Surgery, Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas, U.S.A
| |
Collapse
|
22
|
Al-Anee AM, Al-Quisi AF, Al-Jumaily HA. Mandibular war injuries caused by bullets and shell fragments: a comparative study. Oral Maxillofac Surg 2018; 22:303-307. [PMID: 30088109 DOI: 10.1007/s10006-018-0710-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/02/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE Is to compare the patterns, severity, and management of the high- and low-velocity mandibular war injuries managed at Al Shaheed Gazi Al-Hariri Hospital in Baghdad Medical City, Iraq, during a 2-year period. METHODS Forty-one patients with a history of mandibular war injuries treated by our maxillofacial team were reviewed during a period of 2 years (2015-2017). All patients were treated in the Maxillofacial Unit of the Hospital of Specialized Surgeries in Baghdad Medical City. RESULTS A 2-year retrospective study evaluated 41 patients with mandibular war injuries with a total of 94 fractures (comminution represents 79.06% of the bullet injuries, while it is only 62.74% with IED injuries). Management of these injuries was varied according to the severity of the injuries and resources available. Close reduction was used in 72.72% of the linear fracture cases, whereas open technique was used in 56.6% of the comminuted fractures. CONCLUSIONS Bullet injuries were associated with a higher number of mandibular comminuted fractures, in addition to more extensive bone loss. While shell injuries of IED (improvised explosive devices), on the other hand, were associated with higher infection rate and more postoperative complication.
Collapse
Affiliation(s)
- Auday M Al-Anee
- Department of Oral and Maxillofacial Surgery, College of Dentistry, University of Baghdad, Baghdad, Iraq
- Oral and Maxillofacial Surgeon at Al-Shaheed Gazi AL-Hariri Teaching Hospital, Medical City, Baghdad, Iraq
| | - Ahmed Fadhel Al-Quisi
- Department of Oral and Maxillofacial Surgery, College of Dentistry, University of Baghdad, Baghdad, Iraq.
- Oral and Maxillofacial Surgeon at Al-Kindi Teaching Hospital, Baghdad, Iraq.
| | - Hassanien A Al-Jumaily
- Department of Oral and Maxillofacial Surgery, College of Dentistry, University of Baghdad, Baghdad, Iraq
- Oral and Maxillofacial Surgeon at Al-Shaheed Gazi AL-Hariri Teaching Hospital, Medical City, Baghdad, Iraq
| |
Collapse
|
23
|
An Algorithmic Approach to the Management of Ballistic Facial Trauma in the Civilian Population. J Craniofac Surg 2018; 29:2010-2016. [PMID: 30028401 DOI: 10.1097/scs.0000000000004741] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Annual incidence of non-fatal ballistic civilian has been increasing for the last decade. The aim of the present study was to clarify the optimal reconstructive management of civilian ballistic facial injuries. A systematic review of PubMed was performed. Articles were evaluated for defect type and site, reconstructive modality, complications, and outcomes. A total of 30 articles were included. Most common region of injury was mandibular with a 46.6% incidence rate. All-cause complication rate after reconstruction was 31.0%. About 13.3% of patients developed a postoperative infection. Gunshot wounds had overall lower complication rates as compared with shotgun wounds at 9.0% and 17.0%. By region, complications for gunshot wounds were 35% and 34% for mandible and maxilla, respectively. Immediate surgical intervention with conservative serial debridement is recommended. However, for patients with pre-existing psychiatric disorders, secondary revisions should be delayed until proper psychiatric stabilization. When there is extensive loss of soft tissue in the midface, aesthetic outcomes are achieved with a latissimus dorsi or anterolateral thigh free flap. Radial forearm flap is favored for thin lining defects. Open reduction is suggested for bony-tissue stabilization. The fibula flap is recommended for bony defects >5 cm in both midface and mandible. For bony defects, <5 cm bone grafting was preferred. Delaying bone grafting does not worsen patient outcomes. Surgical treatment of ballistic facial trauma requires thorough preparation and precise planning. An algorithm that summarizes the approach to the main decision points of surgical management and reconstruction after ballistic facial trauma has been presented in this study.
Collapse
|
24
|
Management of High-energy Avulsive Ballistic Facial Injury: A Review of the Literature and Algorithmic Approach. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1693. [PMID: 29707453 PMCID: PMC5908512 DOI: 10.1097/gox.0000000000001693] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 01/12/2018] [Indexed: 01/13/2023]
Abstract
Background: High-energy avulsive ballistic facial injuries pose one of the most significant reconstructive challenges. We conducted a systematic review of the literature to evaluate management trends and outcomes for the treatment of devastating ballistic facial trauma. Furthermore, we describe the senior author’s early and definitive staged reconstructive approach to these challenging patients. Methods: A Medline search was conducted to include studies that described timing of treatment, interventions, complications, and/or aesthetic outcomes. Results: Initial query revealed 41 articles, of which 17 articles met inclusion criteria. A single comparative study revealed that early versus delayed management resulted in a decreased incidence of soft-tissue contracture, required fewer total procedures, and resulted in shorter hospitalizations (level 3 evidence). Seven of the 9 studies (78%) that advocated delayed reconstruction were from the Middle East, whereas 5 of the 6 studies (83%) advocating immediate or early definitive reconstruction were from the United States. No study compared debridement timing directly in a head-to-head fashion, nor described flap selection based on defect characteristics. Conclusions: Existing literature suggests that early and aggressive intervention improves outcomes following avulsive ballistic injuries. Further comparative studies are needed; however, although evidence is limited, the senior author presents a 3-stage reconstructive algorithm advocating early and definitive reconstruction with aesthetic free tissue transfer in an attempt to optimize reconstructive outcomes of these complex injuries.
Collapse
|
25
|
Ahmed FT, Aljeuary MT. The Strategy of Delayed Reconstruction of the Mandible in War Injuries. J Craniofac Surg 2018; 28:826-830. [PMID: 28468174 DOI: 10.1097/scs.0000000000003447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The most common causes of mandibular defects are ablative surgery of benign or malignant tumors, severe trauma, inflammatory diseases, and osteoradionecrosis. War injuries are another cause for mandibular defect. Reconstruction of the mandible is considered a challenge to the maxillofacial surgeon due to the accompanying functional and cosmetic importance. The object of this article was to show the role of nonvascularized bone graft in the reconstruction of segmental defect of the mandible resulted from projectiles and its snags. Seventeen patients underwent reconstruction of defect in the body of the mandible using non-vascularized iliac bone graft,in sixteen patients the grafts were fixed by reconstruction plate and in one by stainless-steel wire. In the emergency phase in which life-saving measures were done, in the immediate phase, treatments of associated facial and systemic injuries were carried out. The delayed phase includes the reconstruction of the residual defects and rehabilitation. A total of 17 male patients with a mean age of 34.5 years underwent reconstructive surgery, the time lapse between the injury and the delayed phase of treatment ranged from 20 days to 3 months. The size of the defects ranged from 4 to 7 cm. Treatment was considered successful in 15 patients (88.2%) in whom the grafts were incorporated to mandible with improvement of facial contour and symmetry and satisfactory occlusion of the remaining teeth. Nonvascularized bone graft is considered a feasible option for the reconstruction of a relatively small mandibular defect, especially in ascetic conditions for its role in improving facial appearance and to less extent functional benefit and more advanced method for the reconstruction needed to be introduced especially in war injuries.
Collapse
Affiliation(s)
- Firas Taha Ahmed
- Ghazi Al-Hariri Specialized Surgeries Hospital, Medical City, Baghdad, Iraq
| | | |
Collapse
|
26
|
Lawless MH, Lytle EJ, McGlynn AF, Engler JA. Surgical management of penetrating spinal cord injury primarily due to shrapnel and its effect on neurological outcome: a literature review and meta-analysis. J Neurosurg Spine 2018; 28:63-71. [DOI: 10.3171/2017.5.spine161037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThis study was performed to determine whether decompression of penetrating spinal cord injury (SCI) due to explosive shrapnel leads to greater neurological recovery than conservative management.METHODSIn accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive literature search using PubMed/MEDLINE, Web of Science, Google Scholar, and the Defense Technical Information Center public site was conducted on May 2, 2016. Studies that described penetrating SCI with shrapnel as an etiology, included surgical and/or conservative management, and demonstrated admission and follow-up neurological status were eligible for inclusion in this study. Odds ratios were calculated for the overall effect of surgical treatment on neurological recovery. Funnel plots were used to evaluate publication bias.RESULTSFive case series (Level IV evidence) met the study criteria, and 2 of them had estimable odds ratios for use in the Forest plot analysis. Among the patients from all 5 studies, 65% were injured by shrapnel, 25% by high-velocity bullet, 8% by low-velocity bullet, and 2% by an unknown cause. A total of 288 patients were included in the overall odds ratio calculations. Patients were stratified by complete and incomplete SCI. The meta-analysis showed no significant difference in outcomes between surgical and conservative management in the complete SCI cohort or the incomplete SCI cohort. Overall rates of improvement for complete SCI were 25% with surgery and 27% with conservative treatment (OR 1.07, 95% CI 0.44–2.61, p = 0.88); for incomplete SCI, 70% with surgery and 81% with conservative treatment (OR 1.67, 95% CI 0.68–4.05, p = 0.26).CONCLUSIONSThis study demonstrates no clear benefit to surgical decompression of penetrating SCI due predominantly to shrapnel. There is a considerable need for nonrandomized prospective cohort studies examining decompression and stabilization surgery for secondary and tertiary blast injuries.
Collapse
Affiliation(s)
| | - Evan J. Lytle
- 3Neurosurgery, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, Southfield, Michigan; and
| | | | - John A. Engler
- 4Department of Neurosurgery, Naval Medical Center, Portsmouth, Virginia
| |
Collapse
|
27
|
What Factors Necessitate Removal of Retained Ballistic Fragments in the Head and Neck? J Oral Maxillofac Surg 2017; 76:819-825. [PMID: 29288648 DOI: 10.1016/j.joms.2017.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 11/25/2017] [Accepted: 11/27/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE The purpose of this study was to estimate the frequency of retained ballistic fragment (RBF) removal and to identify factors associated with an increased risk for RBF removal. To date, there are no studies focused on identifying factors associated with removal of RBFs localized to the maxillofacial region. MATERIALS AND METHODS Using a retrospective cohort study design, the authors enrolled a sample composed of patients with RBFs localized to the maxillofacial region. The predictor variables included bullet size, location, involvement of bone, involvement of sinus, antibiotics, multiple antibiotics, and multiple locations. The primary outcome variable was RBF retrieval. The secondary outcome variables were timing of operative retrieval, fragment site infection, and migration of RBF. Appropriate uni- and bivariate statistics were computed and logistic regression modeling was used. RESULTS The sample was composed of 20 patients (mean age, 30 yr; 80% male) and 55% (11 patients) required or desired object removal overall. The number of projectiles ranged from 1 to 19 (total, 48) in the 20 patients. The logistic model identified larger size, final location of bone, final location of soft tissue, and final location of sinus as having a higher probability of removal that was statistically significant (P < .05); however, size was the only variable with a substantial odds ratio (OR; 1.96; P < .05). There was no evidence of migration and a low rate (2.3%) of infection was noted at subsequent follow-up radiography and clinical examination. CONCLUSION Size was the only statistically significant predictor variable with a substantial OR (1.96; 95% confidence interval, 1.31-3.40; P < .05). There was a low risk of infection even when considering oral pharyngeal contamination and low risk of migration. Further studies could focus on prudent antibiotic use and larger patient populations.
Collapse
|
28
|
Eser C, Gencel E, Kesiktaş E, Yavuz M. Outcomes of Anatomic Reconstruction of Gunshot-Inflicted Lower Face Defects by Free Osteoseptocutaneous Fibula Flap and Expanded or Nonexpanded Temporal Scalp Flap Combination in Males. J Craniofac Surg 2017; 27:1139-42. [PMID: 27258712 DOI: 10.1097/scs.0000000000002688] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Reconstruction of gunshot-inflicted composite lower face defects is a challenge for plastic surgeons. Functional and aesthetic repair of such defects mostly requires free or pedicled flap applications or combinations of both.In this study, the authors evaluated 7 males with gunshot-inflicted composite mandibular defects. All patients underwent reconstruction with a free osteoseptocutaneous fibula flap (FOCF) for the composite mandibular defect and a pre or nonexpanded temporal artery-based scalp flap for beardless facial skin. All patients were evaluated aesthetically and functionally with a postoperative evaluation scale. Average patient follow-up time was 3.5 years.All FOCFs survived completely. Expander exposition was observed in 2 preexpanded temporal scalp flaps. The problem was solved by rapid expansion and early flap application. All patients had acceptable functional and aesthetic results.In conclusion, the scalp flap should be considered in male beardless skin reconstruction due to its ease of application, reliability, and proximity to the defect. Preexpansion of this flap can decrease donor area morbidities. Moreover, the FOCF and scalp flap combination is a convenient procedure for gunshot-inflicted lower face defects, and such procedures produce good aesthetic and functional long-term outcomes.
Collapse
Affiliation(s)
- Cengiz Eser
- Department of Plastic Reconstructive and Aesthetic Surgery, Medical Faculty, Cukurova University, Saricam, Adana, Turkey
| | | | | | | |
Collapse
|
29
|
Kupfer P, Cheng A, Patel A, Amundson M, Dierks EJ, Bell RB. Virtual Surgical Planning and Intraoperative Imaging in Management of Ballistic Facial and Mandibular Condylar Injuries. Atlas Oral Maxillofac Surg Clin North Am 2016; 25:17-23. [PMID: 28153179 DOI: 10.1016/j.cxom.2016.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Philipp Kupfer
- Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Allen Cheng
- Head and Neck Institute, 1849 Northwest Kearney, Suite 300, Portland, OR 97209, USA; Trauma Service, Legacy Emanuel Medical Center, 2801 North Gantenbein, Portland, OR 97227, USA; Oral/Head and Neck Cancer Program, Legacy Good Samaritan Medical Center, 1015 Northwest 22nd Avenue, Portland, OR 97210, USA
| | - Ashish Patel
- Head and Neck Institute, 1849 Northwest Kearney, Suite 300, Portland, OR 97209, USA; Trauma Service, Legacy Emanuel Medical Center, 2801 North Gantenbein, Portland, OR 97227, USA; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, 4805 Northeast Glisan, Suite 2N35, Portland, OR 97213, USA
| | - Melissa Amundson
- Head and Neck Institute, 1849 Northwest Kearney, Suite 300, Portland, OR 97209, USA; Trauma Service, Legacy Emanuel Medical Center, 2801 North Gantenbein, Portland, OR 97227, USA
| | - Eric J Dierks
- Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA; Head and Neck Institute, 1849 Northwest Kearney, Suite 300, Portland, OR 97209, USA; Trauma Service, Legacy Emanuel Medical Center, 2801 North Gantenbein, Portland, OR 97227, USA
| | - R Bryan Bell
- Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA; Head and Neck Institute, 1849 Northwest Kearney, Suite 300, Portland, OR 97209, USA; Trauma Service, Legacy Emanuel Medical Center, 2801 North Gantenbein, Portland, OR 97227, USA; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, 4805 Northeast Glisan, Suite 2N35, Portland, OR 97213, USA.
| |
Collapse
|
30
|
Jorgensen JJ, Naess PA, Gaarder C. Injuries caused by fragmenting rifle ammunition. Injury 2016; 47:1951-4. [PMID: 27037026 DOI: 10.1016/j.injury.2016.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 02/16/2016] [Accepted: 03/17/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Although penetrating injuries are encountered on a regular basis in high volume trauma centres, most civilian trauma teams will be unfamiliar with the treatment of patients with injuries caused by fragmenting ammunition. The terrorist attacks in Norway on July 22, 2011 included a shooting spree causing 69 deaths and 60 injured. One of the weapons used was a semi-automatic rifle, calibre 5.56mm, with soft tip, short stop ammunition. The aim of the present study was to describe the characteristic injury patterns and lessons learned from the treatment of multiple patients admitted at the regional trauma centre with injuries from this type of ammunition. METHODS We undertook an observational study of patients admitted at Oslo University Hospital, Ulleval after the shooting spree at Utoya on July 22, 2011. Data on demographics, injuries, injury severity, surgical procedures and outcome were collected prospectively. RESULTS Of the 21 patients admitted after the shooting incident, 18 were identified with injuries caused by fragmenting ammunition and included in the study. Median age was 17 years (IQR 16, 19), median ISS 21 (IQR 12, 30) and 12 patients were female. They had been hit by a total of 38 projectiles, of which 32 were fragmenting bullets. Of the seven patients who sustained injuries to the head, neck and face, one patient required a craniotomy and one patient had a non-survivable head injury. Of the 11 patients with torso injuries, six of the eight patients with chest injuries had intra-thoracic injuries that could be treated with chest tubes only. One patient had cardiac tamponade, requiring thoracotomy. Six patients underwent laparotomy, four of them more than one. Of the 10 patients with extremity injuries, two had nerve injuries and six patients had fractures. Five amputations were performed within the first nine days. A total of 101 operations were required within the first four weeks. The majority of these were repeated soft tissue debridements due to progressive necrosis. CONCLUSION Knowledge about the specific challenges created by the progressive soft tissue necrosis caused by fragmenting ammunition should lead to planned, repeated debridements to reduce total tissue loss and complications.
Collapse
Affiliation(s)
- Jorgen Joakim Jorgensen
- Department of Traumatology, Oslo University Hospital, PO Box 4950, Nydalen, N-0424 Oslo, Norway; Department of Vascular Surgery, Oslo University Hospital, PO Box 4950, Nydalen, N-0424 Oslo, Norway.
| | - Paal Aksel Naess
- Department of Traumatology, Oslo University Hospital, PO Box 4950, Nydalen, N-0424 Oslo, Norway; Department of Paediatric Surgery, Oslo University Hospital, PO Box 4950, Nydalen, N-0424 Oslo, Norway
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital, PO Box 4950, Nydalen, N-0424 Oslo, Norway
| |
Collapse
|
31
|
Peonim V, Srisont S, Udnoon J, Wongwichai S, Thapon A, Worasuwannarak W. Entrance and exit wounds of high velocity bullet: An autopsy analysis in the event of dispersing the mass rally in Bangkok Thailand, May 2010. Leg Med (Tokyo) 2016; 23:10-16. [PMID: 27890096 DOI: 10.1016/j.legalmed.2016.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 08/07/2016] [Accepted: 08/25/2016] [Indexed: 11/24/2022]
Abstract
Fatal mass casualties by high velocity bullets (HVBs) are rare events in peaceful countries. This study presents 27 forensic autopsy cases with 32 shots fired by 5.56×45mm. HVB (M-16 rifle bullets) during the dispersing the mass rally in Bangkok Thailand, May 2010. It was found that twenty-three (71.88%) typical entrance HVB wounds had round sizes less than the bullet diameters. Most entrance wounds had microtears but no collar abrasion since a HVB has a small streamlined spitzer tip and full metal jacket. For exit wounds, there were various sizes and shapes depending on which section of wound ballistics presented when the bullet exited the body. If a bullet exited in the section of temporally cavity formation, there would be a large size exit wound in accordance with the degree of bullet yaw. This is different from civilian bullets whereby the shape looks like a cylindrical round nose and at low velocity that causes entrance wounds with a similar size to the bullet diameter and is usually round or oval shape with collar abrasion. The temporary cavity is not as large as in a HVB so exit wounds are not quite as large and present a ragged border compared to a HVB. We also reported 9 out of 32 shots (28.13%) of atypical entrance wounds that had various characteristics depending on site of injury and destabilization of bullets. These findings may be helpful to forensic pathologists and to give physicians, who need to diagnose HVB wounds, more confidence.
Collapse
Affiliation(s)
- Vichan Peonim
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Smith Srisont
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jitta Udnoon
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sompong Wongwichai
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Arisa Thapon
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wisarn Worasuwannarak
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
32
|
Interrami intraoral fixation technique for severe mandibular rifle fragmented bullet injury management. J Craniofac Surg 2015; 24:1168-74. [PMID: 23851763 DOI: 10.1097/scs.0b013e31829538c8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Interrami intraoral Kirschner wire fixation technique is presented for the reduction, stabilization, and immobilization of a pulverized and avulsed lower jaw caused by rifle fragmented bullet injuries. This indirect mandibular war injury fixation technique was tolerated by the patients and tissue more than any indirect external fixation. In addition, it is easier than open reduction using large bone plates for disrupted ballistics mandibular injury defects. An interrami intraoral fixation is appropriate for severely disrupted mandibular hard and soft tissues, and has been adapted in cases of mass casualties and limited resources. Benefits of use include limited hospital beds and fewer follow-up visits. Rifle fragmented bullet injuries need more attention for several reasons: not only because of the higher mortality and devastating nature of the injuries, but also because these injuries are responsible for an unreported type of bullet biomechanism wounding in the craniofacial region. In turn, this necessitates specialized victim management. The survival rates depend on immediate proper execution of airway, breathing, and circulation, which become more complicated as it relates to airway compromise and oropharyngeal hemorrhage resuscitation. Survival is predicated on the implementation of feasible, sensible, life-saving techniques that are applied at the appropriate time.
Collapse
|
33
|
|
34
|
Xing L, Duan Y, Zhu F, Shen M, Jia T, Liu L, Tao J, Chen Y, Gao Z, Zhang H. Computed tomography navigation combined with endoscope guidance for the removal of projectiles in the maxillofacial area: a study of 24 patients. Int J Oral Maxillofac Surg 2015; 44:322-8. [DOI: 10.1016/j.ijom.2014.12.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 11/20/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
|
35
|
Stefanopoulos P, Soupiou O, Pazarakiotis V, Filippakis K. Wound ballistics of firearm-related injuries—Part 2: Mechanisms of skeletal injury and characteristics of maxillofacial ballistic trauma. Int J Oral Maxillofac Surg 2015; 44:67-78. [DOI: 10.1016/j.ijom.2014.07.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 04/25/2014] [Accepted: 07/21/2014] [Indexed: 11/26/2022]
|
36
|
Wounds of war in the civilian sector: principles of treatment and pitfalls to avoid. Eur J Trauma Emerg Surg 2014; 40:461-8. [DOI: 10.1007/s00068-014-0395-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 03/10/2014] [Indexed: 10/25/2022]
|