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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.
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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
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Predictors of Infection and Benefit of Antibiotics in Gunshot Wounds to the Face. Ann Plast Surg 2022; 89:517-522. [PMID: 36279576 DOI: 10.1097/sap.0000000000003284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gunshot wounds (GSWs) to the face are at high risk for infection due the extent of tissue injury and often-observed violation of oral and sinus cavities. Given the ambiguous data on antibiotic benefit in GSW to the face, the purpose of this study is to characterize antibiotic usage, infection details, and risk factors associated with higher infection rates in GSW to face. METHODS We conducted a retrospective review of patients presenting with GSW to the face from 2009 to 2017. The primary outcome was to identify risk factors associated with infections in patients with facial GSWs. A stepwise multivariate linear regression analysis was performed to determine the impact of specific injury details. RESULTS Two hundred sixty-nine patients qualified for the study. Demographic information and details of hospital stay are presented in tables. Most patients (88.8%) received admission antibiotics. Facial infections were observed in 36 patients (13.4%). The infected cohort required more antibiotic days (P < 0.001), higher percentage of invasive airway procedures (P = 0.01), longer length of stay (P < 0.001), greater number of surgeries (P < 0.022), and higher readmission rates (P < 0.001). Factors associated with head or neck infections included oral cavity (odds ratio, 1.23; P = 0.04) and sinus involvement (odds ratio, 1.10; P = 0.045). CONCLUSIONS Bullet trajectories that violated the oral or maxillary sinus cavities were associated with higher head and neck infection rates. Patients without oral cavity or sinus involvement had a lower chance (4.1%) of developing an infection and therefore may have marginal benefit from antibiotics.
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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.
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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
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Daniels JS, Albakry I, Braimah RO, Samara MI, Albalasi RA, Al-Rayshan SM. Management of Maxillofacial Gunshot Injuries With Emphasis on Damage Control Surgery During the Yemen Civil War. Review of 173 Victims From a Level 1 Trauma Hospital in Najran, Kingdom of Saudi Arabia. Craniomaxillofac Trauma Reconstr 2022; 15:58-65. [PMID: 35265279 PMCID: PMC8899348 DOI: 10.1177/19433875211012211] [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: 11/17/2022] Open
Abstract
Study Design Studies on the concept of Damage Control Surgery (DCS) in the management of firearm injuries to the oral and maxillofacial region are still scarce, hence the basis for the current study. Objectives The objectives of the current study is to share our experience in the management of maxillofacial gunshot injuries with emphasis on DCS and early definitive surgery. Methods This was a retrospective study of combatant Yemeni patients with maxillofacial injuries who were transferred across the border from Yemen to Najran, Kingdom of Saudi Arabia. Demographics and etiology of injuries were stored. Paths of entry and exit of the projectiles were also noted. Also recorded were types of gunshot injury and treatment protocols adopted. Data was stored and analyzed using IBM SPSS Statistics for Windows Version 25 (Armonk, NY: IBM Corp). Results A total of 408 victims, all males, were seen during the study period with 173 (42.4%) males sustaining gunshot injuries to the maxillofacial region. Their ages ranged from 21 to 56 years with mean ± SD (27.5 ± 7.6) years. One hundred and twenty-one (70.0%) victims had extraoral bullet entry, while 53 (30.0%) victims had intraoral entry route. Ocular injuries, consisting of 25 (14.5%) cases of ruptured globe and 6 (3.5%) cases of corneal injuries, were the most commonly associated injuries. A total of 78 (45.1%) hemodynamically unstable victims had DCS as the adopted treatment protocol while early definitive surgery was carried out in 47(27.2%) hemodynamically stable victims. ORIF was the treatment modality used for the fractures in 132 (76.3%) of the victims. Conclusions We observed that 42.4% of the war victims sustained gunshot injuries. DCS with ORIF was the main treatment protocol adopted in the management of the hemodynamically unstable patients.
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Affiliation(s)
- John S. Daniels
- Department of Oral and Maxillofacial Surgery, King Khalid Hospital, Najran, Kingdom of Saudi Arabia
| | - Ibrahim Albakry
- Department of Oral and Maxillofacial Surgery, King Khalid Hospital, Najran, Kingdom of Saudi Arabia
| | - Ramat O. Braimah
- Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran, Kingdom of Saudi Arabia,Ramat O. Braimah, FWACS, Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran, Kingdom of Saudi Arabia.
| | - Mohammed I. Samara
- Department of Oral and Maxillofacial Surgery, King Khalid Hospital, Najran, Kingdom of Saudi Arabia
| | - Rabea A. Albalasi
- Department Oral and Maxillofacial Surgery, Sharorah General Hospital, Kingdom of Saudi Arabia
| | - Saleh M.A. Al-Rayshan
- Department of Oral and Maxillofacial Surgery, Khobash General Hospital, Khobash, Saudi Arabia
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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.
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Naija S, Yacoub A, Barhoumi M, Akkeri K, Chebbi G. [Ballistic trauma of the face: A new scourge in Tunisia]. ANN CHIR PLAST ESTH 2021; 66:210-216. [PMID: 33838955 DOI: 10.1016/j.anplas.2021.03.004] [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: 02/09/2021] [Revised: 03/08/2021] [Accepted: 03/10/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Ballistic trauma of the face has aroused growing interest since the proliferation of conflicts in the world and particularly in the fight against terrorism. Their polymorphous and disfiguring character, their particular evolution and prognosis due to the ballistic aetiology, differentiate them from classic maxillofacial trauma. Tunisia did not escape this scourge after the revolution of 2011, and must therefore face the challenge of ballistic trauma in general and of the face in particular. MATERIALS AND METHODS We conducted a descriptive retrospective study on 30 patients who were victims of ballistic trauma of the face in the otolaryngology and maxillofacial surgery and ophthalmology departments of the Main Military Hospital of Tunis during the period from January 2011 to April 2018. Our objective was to assess the prevalence of these traumas in Tunisia after the revolution, and to assess their clinical and therapeutic aspects. RESULTS Our results showed a clear upward trend in these traumas, mainly caused by the opposition of our armed forces to the terrorist threat. The discussion of our results was therefore descriptive, comparing them to the literature. CONCLUSION Currently, it is imperative to develop a strategy for precise and effective management of ballistic trauma of the face due to the increase of armed conflicts, attacks and terrorist acts. Likewise, technological advances to develop soldier protection systems must be implemented.
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Affiliation(s)
- S Naija
- Services d'oto-rhino-laryngologie, de chirurgie maxillo-faciale et d'ophtalmologie de l'hôpital militaire principal d'instruction de Tunis, Tunis, Tunisie
| | - A Yacoub
- Services d'oto-rhino-laryngologie, de chirurgie maxillo-faciale et d'ophtalmologie de l'hôpital militaire principal d'instruction de Tunis, Tunis, Tunisie.
| | - M Barhoumi
- Services d'oto-rhino-laryngologie, de chirurgie maxillo-faciale et d'ophtalmologie de l'hôpital militaire principal d'instruction de Tunis, Tunis, Tunisie
| | - K Akkeri
- Services d'oto-rhino-laryngologie, de chirurgie maxillo-faciale et d'ophtalmologie de l'hôpital militaire principal d'instruction de Tunis, Tunis, Tunisie
| | - G Chebbi
- Services d'oto-rhino-laryngologie, de chirurgie maxillo-faciale et d'ophtalmologie de l'hôpital militaire principal d'instruction de Tunis, Tunis, Tunisie
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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.
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Neurological injuries and their medicolegal aspects as a result of criminal and non-criminal acts in a Pakistani sample. FORENSIC SCIENCE INTERNATIONAL: REPORTS 2020. [DOI: 10.1016/j.fsir.2020.100143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Niu XG, Du YB, Ji K. Clinical use of internal distraction osteogenesis in the rehabilitation of gunshot injuries of the mandible. Br J Oral Maxillofac Surg 2020; 58:324-328. [PMID: 31983482 DOI: 10.1016/j.bjoms.2019.12.012] [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: 05/01/2019] [Accepted: 12/27/2019] [Indexed: 11/28/2022]
Abstract
Rehabilitation of gunshot injuries that require combined reconstruction of bone and soft tissue poses a considerable challenge. We describe three cases of rehabilitation for mandibular defects and deformities caused by gunshot injuries. After debridement, three kinds of internal distractors were used. The bony transport discs were distracted about 10-22mm, and the new bone formed well in the distracted gaps. There was no evidence of infection during the consolidation period or follow up. Aesthetic appearance was also pleasing after treatment. Internal distraction osteogenesis after debridement might be a practical way of synchronously reconstructing bony and soft tissue after mandibular gunshot injuries.
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Affiliation(s)
- X-G Niu
- Department of Stomatology, First Outpatient Department, Logistics Support Department of Central Military Commission, Beijing 100842, PR China.
| | - Y-B Du
- Department of Stomatology, First Outpatient Department, Logistics Support Department of Central Military Commission, Beijing 100842, PR China.
| | - K Ji
- Department of Stomatology, First Outpatient Department, Logistics Support Department of Central Military Commission, Beijing 100842, PR China.
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Siddiqui SUD, Iqbal N, Baig MH, Mehdi H, Mahmood Haider S. Efficacy of open reduction and internal fixation in achieving bony union of comminuted mandibular fractures caused by civilian gunshot injuries. Surgeon 2019; 18:214-218. [PMID: 31806484 DOI: 10.1016/j.surge.2019.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 08/21/2019] [Accepted: 10/31/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Comminuted fractures of the mandible caused by gunshot injuries were traditionally treated with closed reduction using maxillo-mandibular fixation (MMF).2,3 Open reduction and internal fixation (ORIF) has become a valuable treatment modality in the management of comminuted mandibular fractures due to low rate of complications and predictable healing 4, 5. OBJECTIVE To compare the efficacy of ORIF compared with MMF in achieving bony union of comminuted mandibular fractures in gunshot injury patients. METHOD ology: Randomized controlled trial conducted at the department of Oral & Maxillofacial Surgery, Abbasi Shaheed Hospital for a period of 3 years; total of 40 patients divided equally into two groups. Group A were treated with ORIF and group B were treated with MMF. Callus formation radiographically was confirmed by 8th week post operatively. Data was collected using proforma, entered on a statistical software SPSS version 20. Frequency percentages were computed for age and gender. Chi square and Fisher's exact tests were applied. P value ≤ 0.05 considered significant. RESULT A total of 40 patients of gunshot injuries were included in this study. 37 (92.5%) were males and 3 (7.5%) were Females with mean age of 36.35 ± 12.9 years SD. 19 (47.5%) patients showed callus formation, whereas, 21 (52.5%) did not. Out of 19 patients, 14 (70%) belonged to group A, and 5 (25%) from group B. The final healing considered by 8th week was in 16 (80%) of ORIF group A, and 8 (40%) group B (MMF) after calculating the clinical and radiographic evidences. CONCLUSION Comparative clinical trials have proven that ORIF is superior to MMF in the management of comminuted mandibular fractures. Early primary repair and internal fixation provides predictable and cost effective results.
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Affiliation(s)
- Saad-Ud-Din Siddiqui
- Civil Hospital Karachi, Opposite Allawala Market, M.A. Jinnah Road, Baba-e-Urdu Road, Nanakwara, Karachi, Pakistan.
| | - Naveed Iqbal
- Fatima Jinnah Dental College & Hospital Trust, Building No. 1, Street No. 1, 100 Foot Road, Azam Town, Karachi, Pakistan.
| | - Mirza Hamid Baig
- Fatima Jinnah Dental College & Hospital Trust, Building No. 1, Street No. 1, 100 Foot Road, Azam Town, Karachi, Pakistan.
| | - Hassan Mehdi
- Fatima Jinnah Dental College & Hospital Trust, Building No. 1, Street No. 1, 100 Foot Road, Azam Town, Karachi, Pakistan.
| | - Syed Mahmood Haider
- Principal Karachi Medical & Dental College, Consultant OMS Abbasi Shaheed Hospital, Pakistan.
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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.
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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
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Cranial Vault Defects and Deformities Resulting from Combat-Related Gunshot, Blast and Splinter Injuries: How Best to Deal with Them. J Maxillofac Oral Surg 2019; 19:184-207. [PMID: 32346228 DOI: 10.1007/s12663-019-01258-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 07/04/2019] [Indexed: 10/26/2022] Open
Abstract
Combat-related gunshot and blast injuries of the craniomaxillofacial region present a unique and challenging situation for the maxillofacial and reconstructive surgeon. The devastating cosmetic deformities and severe functional debility ensuing as a result of extensive hard and soft tissue disruption caused by these highly complex injuries, can have disastrous consequences, unless managed in a swift and efficient manner, by a multidisciplinary team approach. Large calvarial defects and deformities are frequent sequelae of these injuries and could result from shattering of the cranial vault by the force of an exploding shell, mine or improvised explosive device, or due to penetration of the skull by the projectile, such as a bullet, flying splinters or shrapnel. It could also result from the decompressive craniectomy carried out in these patients as a neurosurgical procedure to deal with the traumatic brain injury sustained. Management of such injuries is significantly different from that of other craniomaxillofacial injuries, owing to the quantum and severity of hard and soft tissue destruction encountered in the former and also the need to deal with aspects such as splinters from the projectile deeply embedded within vital structures such as the delicate brain tissue and meninges. Further, restoration of the lost structural and functional integrity of the cranial vault using the most suitable cranioplasty material, is imperative to provide protection to the vulnerable and vital cranial contents. Correction of the cranial deformity is also essential from an esthetic and psychosocial standpoint, to restore the morale of the patient. The present study elaborates the immediate/primary management as well as the secondary/definitive management of blast and ballistic head injury patients. Comprehensive treatment and rehabilitation of these patients, including reconstruction of extensive calvarial defects and deformities, resulting either directly or indirectly from combat injuries, have been described in detail. This study also aims to analyze, review and reassess the currently accepted management perspectives and treatment protocols of combat-related cranial injuries and proposes a useful algorithm to best manage them.
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Fagin AP, Dierks EJ, Bell RB, Cheng AC, Patel AA, Amundson MS. Infection prevalence and patterns in self-inflicted gunshot wounds to the face. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 128:9-13. [PMID: 30987890 DOI: 10.1016/j.oooo.2019.02.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 02/03/2019] [Accepted: 02/25/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Self-inflicted gunshot wounds (SIGSWs) to the craniomaxillofacial region are uncommon injuries but are associated with a high mortality rate. Therefore, treating these patients is a rare occurrence even in the largest trauma centers. As with many rare conditions, data specifically addressing this injury pattern are scarce. Because of the proximity of the blast, even low-velocity injuries can be associated with significant avulsion of tissue, comminution of structures, and tissue die back. Previous case reports have recommended the use of prophylactic antibiotics, but no study has specifically investigated the postinjury infection rate or microbial patterns in this patient population. The purpose of this study was to answer the following clinical question: "Among patients with SIGW to the maxillofacial region, what is the prevalence of postinjury infection, and are there any microbial patterns that can guide empiric antibiotic selection?" STUDY DESIGN We designed retrospective cohort study at a level I trauma center in Portland, Oregon. Data on 17 patients who had sustained a SIGSW involving the maxilla or the mandible and survived their initial injury were collected from 2010 to 2017. RESULTS Patients who had a culture-positive infection within 30 days of their injury were defined to have a postinjury infection. Six of the 17 patients (35%) developed a postinjury infection, with an average time to infection of 11 days from initial injury (range 3-19 days). Of the 17 subjects, 15 (88%) received a course of prophylactic antibiotics, on average, for 14 days (range 3-24 days). Of the 6 cases of postinjury infection, culture grew gram-negative bacteria in 4 cases-anaerobic bacteria in 2 and polymicrobial organisms in 2. There was no clear pattern or prevalence of any specific bacterium, but cultures notably included Staphylococcus aureus, Enterobacter species, Bacteroides species, and Escherichia coli. CONCLUSIONS SIGSWs are associated with a high rate of postinjury infection (35%) despite prophylactic antibiotic usage in 88% of these cases. Given the antimicrobial patterns observed in this study, prophylactic antibiotics in this patient population should include empiric coverage for gram-negative and anaerobic bacteria.
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Affiliation(s)
- Adam P Fagin
- Oral and Maxillofacial Surgery Resident, Oregon Health and Science University, Portland, OR, USA.
| | - Eric J Dierks
- President and Medical Director of Head and Neck Surgical Associates; Senior Consultant of the Head and Neck Institute, Portland, OR, USA
| | - R Bryan Bell
- Medical Director, Providence Head and Neck Cancer Program, Head and Neck Institute, Portland, OR, USA
| | - Allen C Cheng
- Section Chair of Oral and Maxillofacial Surgery at Legacy Emanuel Hospital; Medical Director of the Legacy Good Samaritan Oral/Head and Neck Cancer Program; Head and Neck Institute, Portland, OR, USA
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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.
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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.
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Khatib B, Cuddy K, Cheng A, Patel A, Sim F, Amundson M, Gelesko S, Bui T, Dierks EJ, Bell RB. Functional Anatomic Computer Engineered Surgery Protocol for the Management of Self-Inflicted Gunshot Wounds to the Maxillofacial Skeleton. J Oral Maxillofac Surg 2018; 76:580-594. [DOI: 10.1016/j.joms.2017.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Treatment Strategies in the Management of Maxillofacial Ballistic Injuries in Low-Intensity Conflict Scenarios. J Maxillofac Oral Surg 2018; 17:466-481. [PMID: 30344389 DOI: 10.1007/s12663-018-1089-0] [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: 11/18/2017] [Accepted: 01/23/2018] [Indexed: 10/18/2022] Open
Abstract
Introduction The facial disfigurement and functional debility resulting from craniomaxillofacial injuries in low-intensity conflict scenarios can physically and psychologically traumatize the afflicted personnel. Efficient and definitive management, with complete esthetic restoration and functional rehabilitation, is not only an organizational obligation, but also a tactical necessity to maintain a high state of morale among the troops. There exist two schools of thought on principles of management of such injuries. The older, three-phased approach consists of initial debridement and suturing, followed by conservative closed reduction in maxillofacial fractures using splints and ligatures, thereafter followed by delayed repair and late reconstruction of residual bone defects and deformities after the soft tissue healing is complete. The newer trend involves early and aggressive open surgical reduction and craniomaxillofacial fixation techniques along with reconstructive procedures carried out hand in hand with the soft tissue debridement and closure. Aim The aim was to compare the efficacy of the two management protocols, namely the contemporary approach of early aggressive surgical intervention, versus the conservative approach of initial debridement, closed reduction and delayed repair, as the definitive treatment modality of maxillofacial injuries sustained in low-intensity conflicts. Methods This retrospective analytical study included 40 patients with maxillofacial injuries sustained in combat scenarios treated over a period of 3 years. These patients who had been treated for ballistic maxillofacial injuries were divided into two groups: The first group of 20 patients (Group 1) included those who had undergone an early, aggressive, surgical intervention, and the second group of 20 patients (Group 2) included those who had undergone resuscitation and primary soft tissue closure followed by conservative, closed reduction techniques, delayed repair (including open reduction and internal fixation (ORIF) procedures), and late reconstruction of bone soft tissue defects (which included utilization of various grafts and flaps). Both groups were evaluated and compared for postoperative recovery and early and late complications such as impaired esthetic results and impaired functional recovery. Results Early, definitive, and aggressive maxillofacial surgical techniques proved superior to the conservative approach by bringing about primary bone healing and minimizing residual deformities and subsequent scar contractures, thus yielding improved functional as well as superior esthetic outcomes. Conclusion In today's low-intensity conflict scenario, the emphasis in management of maxillofacial injury victims should be on an early, definitive, and aggressive surgical repair and reconstruction of the facial skeleton, thus restoring quality of life to these soldiers, sparing them life-long indignity after a potentially severe esthetically and functionally debilitating injury.
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Abstract
The management of soft tissue injury after facial trauma poses unique challenges to the plastic surgeon, given the specialized nature of facial tissue and the aesthetic importance of the face. The general principles of trauma management and wound care are applied in all cases. The management of severe injuries to the face is discussed in relation to the location and the mechanism of injury. Facial transplants have arisen in the past decade for the management of catastrophic soft tissue defects, although high morbidity and mortality after these non-life-saving operations must be considered in patient selection.
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Affiliation(s)
- Tara L Braun
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Renata S Maricevich
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Amole O, Osunde O, Akhiwu B, Efunkoya A, Omeje K, Amole T, Iliyasu Z. A 14-Year Review of Craniomaxillofacial Gunshot Wounds in a Resource-Limited Setting. Craniomaxillofac Trauma Reconstr 2017; 10:130-137. [PMID: 28523086 DOI: 10.1055/s-0037-1601341] [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: 02/05/2015] [Accepted: 08/18/2015] [Indexed: 10/20/2022] Open
Abstract
This study analyzed the prevalence, clinical characteristics, and management of civilian-type craniomaxillofacial gunshot wounds (CGSWs) seen over a 14-year period in a Northern Nigerian teaching hospital. A retrospective study of all hospital records relating to CGSWs from January 2000 to December 2013 was conducted to determine the prevalence of CGSWs. Information retrieved included site of injury, type of projectile, management protocol, as well as duration of hospitalization. A total of 46 admissions for CGSWs were recorded during the period under review from a total of 2,228 maxillofacial admissions. This gave a prevalence of 2.1% for CGSWs (95% confidence interval = 1.56-2.81). Sex distribution was 14.3:1 (M:F) with overall mean age of 32.9 ± 8.4 years. Average length of hospitalization was 17.7 (±15.56) days. Management of CGSWs consisted of emergency care, preliminary intervention, definitive reconstruction, revisions, and rehabilitation. Conclusively, analysis of the yearly incidence of CGSWs showed that the incidence and severity increased within the past 2 years under review (18 cases, 39.13%; χ2 trend = 7.7, p = 0.006). This period was noted to correspond with heightened violence within the region mostly due to the acts of unknown gunmen and insurgents.
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Affiliation(s)
- Olushola Amole
- Department of Oral and Maxillofacial Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Otasowie Osunde
- Maxillofacial Unit, Department of Dental Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria
| | - Benjamin Akhiwu
- Department of Oral and Maxillofacial Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Akinwale Efunkoya
- Department of Oral and Maxillofacial Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Kelvin Omeje
- Department of Oral and Maxillofacial Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Taiwo Amole
- Department of Community Medicine, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Zubairu Iliyasu
- Department of Community Medicine, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
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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.
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Vatsyayan A, Adhyapok AK, Debnath SC, Malik K. Reconstruction and rehabilitation of short-range gunshot injury to lower part of face: A systematic approach of three cases. Chin J Traumatol 2016; 19:239-43. [PMID: 27578384 PMCID: PMC4992133 DOI: 10.1016/j.cjtee.2016.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Gunshot injuries are always known to cause severe morbidity and mortality when head and neck are involved. They vary in morbidity, which can occur in civilian surroundings. The wound largely depends on the type of weapon, mass and velocity of the bullet, and the distance from where it has been shot. Close-range gunshot wounds in the head and neck region can result in devastating aesthetic and functional impairment. The complexity in facial skeletal anatomy cause multiple medical and surgical challenges to an operating surgeon, demanding elaborate soft and hard tissue reconstruction. Here we presented the successful management of three patients shot by short-range pistol with basic life support measures, wound management, reconstruction and rehabilitation.
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Abstract
The World Health Organization estimates that in the year 2000, approximately one million people died from suicide worldwide. Over the last 45 years, suicide rates have increased by 60%, with a particularly precipitous rise among young people. The underlying psychology of suicide is complex and individual. However, certain themes emerge from studying individuals who have attempted or completed suicides. This paper will provide an overview of suicide and suicidal behaviour as it relates to trauma practitioners, detailing risk factors, biologic and genetic interactions, and opportunities for prevention and treatment.
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Affiliation(s)
- Marie Crandall
- Department of Surgery, Northwestern University, Chicago, IL 60611, USA,
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24
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Late Oropharyngeal Functional Outcomes of Suicidal Maxillofacial Gunshot Wounds. J Craniofac Surg 2015; 26:691-5. [DOI: 10.1097/scs.0000000000001588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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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]
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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]
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Rehabilitation of a patient with gunshot injury through the iliac graft and implant-retained restorations with a 3-year follow-up: a brief clinical study. J Craniofac Surg 2014; 25:e207-10. [PMID: 24621772 DOI: 10.1097/scs.0b013e3182a2ecc4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Trauma is one of the most common causes of teeth loss. Assault with a gunshot and bullet shot is life threatening, and for patients who survive the injury, it results in hard and soft tissue loss in the tissues and organs crossed by the bullet. The tissue loss results in the loss of structure and function. Rehabilitation of these patients to function and aesthetics requires surgical and prosthodontic procedures over time. This report is of a 24-year-old male patient who had a bullet injury resulting in hard and soft tissue deficiency. The ridge deficiency was augmented with iliac bone graft, and 3 months later, implants were placed. Five months later, hybrid prosthesis was delivered. At 3-year follow-up visit, the hybrid prosthesis was replaced with porcelain fused to a metal bridge. The bone levels on all the implants were stable.
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Peled M, Leiser Y, Emodi O, Krausz A. Treatment protocol for high velocity/high energy gunshot injuries to the face. Craniomaxillofac Trauma Reconstr 2013; 5:31-40. [PMID: 23449809 DOI: 10.1055/s-0031-1293518] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 08/16/2011] [Indexed: 10/15/2022] Open
Abstract
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.
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Affiliation(s)
- Micha Peled
- Department of Oral and Maxillofacial Surgery, Rambam Medical Center, Technion-Israel Institute of Technology ; The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Gurunluoglu R, Glasgow M, Williams SA, Gurunluoglu A, Antrobus J, Eusterman V. Functional reconstruction of total lower lip defects using innervated gracilis flap in the setting of high-energy ballistic injury to the lower face: Preliminary report. J Plast Reconstr Aesthet Surg 2012; 65:1335-42. [DOI: 10.1016/j.bjps.2012.04.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Revised: 03/23/2012] [Accepted: 04/26/2012] [Indexed: 11/29/2022]
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Johnson J, Markiewicz M, Bell R, Potter B, Dierks E. Gun orientation in self-inflicted craniomaxillofacial gunshot wounds: risk factors associated with fatality. Int J Oral Maxillofac Surg 2012; 41:895-901. [DOI: 10.1016/j.ijom.2012.05.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Accepted: 05/14/2012] [Indexed: 11/16/2022]
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Kaufman Y, Cole P, Hollier LH. Facial gunshot wounds: trends in management. Craniomaxillofac Trauma Reconstr 2011; 2:85-90. [PMID: 22110801 DOI: 10.1055/s-0029-1202595] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Facial gunshot wounds, often comprising significant soft and bone tissue defects, pose a significant challenge for reconstructive surgeons. Whether resulting from assault, accident, or suicide attempt, a thorough assessment of the defects is essential for devising an appropriate tissue repair and replacement with a likely secondary revision. Immediately after injury, management is centered on advanced trauma life support with patient stabilization as the primary goal. Thorough examination along with appropriate imaging is critical for identifying any existing defects. Whereas past surgical management advocated delayed definitive treatment using serial debridement, today's management favors use of more immediate reconstruction. Recent advances in microsurgical technique have shifted favor from local tissue advancement to distant free flap transfers, which improve cosmesis and function. This has resulted in a lower number of surgeries required to achieve reconstruction. Because of the diversity of injury and the complexity of facial gunshot injuries, a systematic algorithm is essential to help manage the different stages of healing and to ensure that the best outcome is achieved.
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Affiliation(s)
- Yoav Kaufman
- Department of Plastic Surgery, Baylor College of Medicine, Houston, Texas
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Motamedi MHK. Management of firearm injuries to the facial skeleton: Outcomes from early primary intervention. J Emerg Trauma Shock 2011; 4:212-6. [PMID: 21769208 PMCID: PMC3132361 DOI: 10.4103/0974-2700.82208] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Accepted: 09/24/2010] [Indexed: 12/22/2022] Open
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 24.4±7.8 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.
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Bidra AS, Veeranki AN. Surgical and prosthodontic reconstruction of a gunshot injury of the mandible using dental implants and an acrylic resin fixed prosthesis: A clinical report. J Prosthet Dent 2010; 104:142-8. [PMID: 20813227 DOI: 10.1016/s0022-3913(10)00120-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Avinash S Bidra
- Department of Prosthodontics, University of Texas Health Science Center, San Antonio, TX 78229-3900, USA.
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von See C, Bormann KH, Schumann P, Goetz F, Gellrich NC, Rücker M. Forensic imaging of projectiles using cone-beam computed tomography. Forensic Sci Int 2009; 190:38-41. [DOI: 10.1016/j.forsciint.2009.05.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Revised: 05/08/2009] [Accepted: 05/12/2009] [Indexed: 11/28/2022]
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Intraoperative navigation assisted reconstruction of a maxillo-facial gunshot wound. Oral Maxillofac Surg 2009; 12:199-203. [PMID: 18654804 DOI: 10.1007/s10006-008-0125-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION This case report describes a suicidal gunshot wound to the head using a handgun (9 x 19 mm). During mandibular penetration, the solid hollow point projectile (Aktion4) was deformed but did not fragment. The mandible, mid-face, orbit, and nasal complex were severely damaged. Here, the authors present, for the first time, a new approach for bilateral mid-facial fractures. MATERIALS AND METHODS For virtual reconstruction, a naso-orbito-ethmoidal complex of an unaffected skull (same age, sex, and ethnic group) was merged into the computed tomography (CT) data set. Based on this data set, a navigation assisted operation was performed. CONCLUSION The favorable outcome leads us to recommend the technique of merging comparable CT data for reconstructive planning of bilateral mid-facial fractures.
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Stuehmer C, Blum KS, Kokemueller H, Tavassol F, Bormann KH, Gellrich NC, Rücker M. Influence of Different Types of Guns, Projectiles, and Propellants on Patterns of Injury to the Viscerocranium. J Oral Maxillofac Surg 2009; 67:775-81. [DOI: 10.1016/j.joms.2008.08.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 07/22/2008] [Accepted: 08/29/2008] [Indexed: 12/24/2022]
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Cone beam CT imaging of airgun injuries to the craniomaxillofacial region. Int J Oral Maxillofac Surg 2008; 37:903-6. [PMID: 18768294 DOI: 10.1016/j.ijom.2008.07.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Revised: 01/28/2008] [Accepted: 07/16/2008] [Indexed: 02/06/2023]
Abstract
In airgun injuries, the removal of the projectile is often recommended. The material properties of airgun projectiles make it difficult to determine their precise anatomical location using conventional radiological techniques. Conventional X-rays give only a two-dimensional representation of projectiles and do not allow a foreign object to be located precisely. Multi-slice computed tomography (CT) has become a standard tool in diagnosis. Metal objects can cause artefacts in CT scans and make it difficult to identify adjacent anatomical structures. By contrast, cone-beam CT (CBCT) provides three-dimensional images largely free from metal artefacts. The authors present three cases of airgun injuries and discuss the diagnostic and treatment approaches used. CBCT has proved to be a useful diagnostic tool in planning the treatment of craniofacial airgun injuries. It is superior to CT in detecting hard-tissue structural damage in the immediate vicinity of high-density metal projectiles.
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Poster 085: Comprehensive Management of Cranio-Maxillofacial Ballistic Injuries: A 5-Year Experience. J Oral Maxillofac Surg 2008. [DOI: 10.1016/j.joms.2008.05.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Facial gunshot wounds pose a significant challenge for reconstructive surgeons, particularly when composed of significant soft and bone tissue defects. Often the result of assault, accident, or suicide attempt, facial defects must be thoroughly evaluated to devise an appropriate tissue repair and replacement with the likely prospect of secondary revision. In the acute setting after injury, the primary concern is patient stabilization centered on advanced trauma life support. Thorough examination along with appropriate imaging is critical for identifying any existing defects. As opposed to past surgical management that advocated delayed definitive treatment using serial debridement, today's management favors the use of more immediate reconstruction. Recent improvements in microsurgical technique have shifted favor from local tissue advancement to distant free-flap transfers, which improve cosmesis and function. This has reduced the number of surgeries necessary to achieve reconstruction. Given the diversity and complexity of facial gunshot injuries, a systematic algorithm is essential to help manage the different stages of healing and to ensure that the best outcome is ultimately achieved.
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Abstract
PURPOSE OF REVIEW Gunshot wounds to the head and neck result in significant bone and soft tissue loss. These defects pose a challenge to the facial reconstructive surgeon. This paper reviews the current literature on the management of ballistic injuries to the head and neck and outlines a treatment algorithm. RECENT FINDINGS With recent advances in free tissue transfer, early definitive reconstruction of bone and soft tissue deficits with vascularized flaps has become the treatment of choice. Computed tomography angiography of the neck has been shown to be a sensitive, specific, and safe technique in screening for vascular injuries. SUMMARY Management of ballistic injuries to the head and neck begins with advanced trauma life support protocols. Computed tomography angiography is now widely available and provides an accurate and rapid evaluation of head and neck vasculature. The initial operation aims to establish occlusion, stabilize bone and close soft tissue defects. Serial debridement of wounds with delayed reconstruction has given way to early definitive repair with vascularized tissue. This has led to improved function, fewer operations, and shorter hospital stays.
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Affiliation(s)
- Vishal S Doctor
- Department of Otolaryngology-Head and Neck Surgery, UC Davis Medical Center, Sacramento, California, USA
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