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An Algorithmic Approach to the Management of Ballistic Facial Trauma in the Civilian Population

Chattha, Anmol, BA; Lee, Johnson C., MD; Johnson, Philip K., BS; Patel, Ashit, MBChB

doi: 10.1097/SCS.0000000000004741
Original Articles

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.

Division of Plastic and Reconstructive Surgery, Albany Medical Center, Albany, NY.

Address correspondence and reprint requests to Ashit Patel, MBChB, FACS, Division of Plastic and Reconstructive Surgery, Albany Medical Center, 50 New Scotland Avenue, MC-190, Albany, NY 12208; E-mail:

Received 27 April, 2017

Accepted 3 May, 2018

The authors report no conflicts of interest.

The number of annual nonfatal ballistic civilian injuries in the United States has been on the rise for the last decade. In 2012, there were 81,396 injuries compared to just 58,841 injuries in 2002.1 Firearm-related injuries are a major economic burden to both the American health care system and society. Between 2006 and 2010, 386,769 firearm-related ED visits resulted in 141,914 hospital admissions, costing more than $88 billion in health care expenditure.2 With an increase in nonfatal injuries and associated costs, it is important for the surgical team to be able to formulate a reconstructive plan that efficiently and effectively restores facial form and function. However, despite thorough planning, there is not always a “one-size fits all” approach given the extreme variations in ballistic injuries. Previous literature has noted the importance of proper triage to a trauma center, the need for an organized approach and the development of effective guidelines.3

Currently the literature discussing the management of civilian ballistic facial injuries is sparse, with the majority of data being comprised of case studies and case series. Clark et al initially proposed one of the most comprehensive algorithms on ballistic trauma in 1996.4 Given the variable, clinical presentation of such injuries in combination with technologic and technical advancements of the last 20 years, a modern algorithmic approach to facial ballistic trauma management would better guide surgical decision-making tailored to each patient. In this study, we aim to clarify the best next steps in management of ballistic injury patients by undertaking a systemic review of the literature and devising an evidence-based algorithm.

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Literature Search Strategy

A systematic literature review was performed according to the PRISMA search strategy guidelines across 3 databases (MEDLINE, Embase, and PubMed) from 2016 to December 7, 2016 using the following search algorithm: (ballistic OR gun shot OR gunshot OR shotgun OR gun OR firearm) AND (facial OR craniomaxillofacial) AND (soft tissue OR fracture OR trauma OR wounds) AND (reconstruction OR management OR surgery OR experience OR outcomes).

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Selection Criteria

Titles and abstracts of the 873 articles were screened for the following exclusion criteria: publications about a topic other than reconstruction or management of ballistic facial trauma, publications that discussed military trauma, reviews, case reports (<2 patients), and publications in a foreign language or letters. Additional articles were extrapolated from references of identified manuscripts that met the original search criteria (Fig. 1).



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Data Extraction and Analysis

Articles were analyzed independently by 2 reviewers (ASC and PKJ). Data collected and reviewed from qualifying articles include the following variables: epidemiology, clinical presentation (type and site, reconstructive modality, complications, and outcomes). Pre-, intra-, and postoperative management data were refined, graded according to level of evidence5 and compiled into a single management algorithm (Fig. 2). A meta-analysis was included only for the subgroup of interest, if the outcome was clinically similar and data were available.



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A total of 873 articles were identified in the initial search. Out of these, 349 were excluded due to foreign language or incomplete text. Through analysis of titles and abstracts, an additional 394 were excluded due to lack of discussion on the outcomes and management of ballistic trauma. About 102 articles were excluded for either lack of discussion of the civilian population or were case reports. An additional 2 were added from references of these articles yielding a total of 30 articles reviewed. Table 1 included the details of our systematic review and summarizes all the major points of our systematic review.





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Epidemiology and Comorbidities

Shackford et al noted that mental disorders were present in 10% of the patients in their large case series.3 They also noted that 16% were positive on a toxicity screen and 31% had alcohol in their system. It is not uncommon for alcohol, drugs, and/or smoking to be present in this population.6,7 Rana et al had a 43% smoking rate in their cohort.7 About 50% of reviewed articles make some mention of having suicidal patients with rates between 27.3% and 100%. Four articles addressed the importance of getting a proper psychiatric evaluation and providing counseling services during the patient's stay8–11 (level of evidence 4, 4, 2b, 4, respectively). Two important observations in the study by Vayvada et al include: improving facial appearance and functions provided a beneficial effect on the patient's psychiatric condition, therefore obviating the potential costs and additional reconstructive burdens associated with re-attempted suicide, and that all patients (nonsuicide and suicide) were treated on 3 months to 1 year of antidepressant therapy10 (level of evidence 2b).

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Initial Presentation and Consultation

Twenty-six articles, including 1863 patients, discuss the location of ballistic facial trauma injury. After performing a meta-analysis, the most common sites of ballistic facial injury in patients included: 869 patients (46.6%) with mandibular injury and 577 patients (31.0%) with maxilla/midface injuries. Multiple zones of injury are reported in 12% to 22% of patients3,12 (level of evidence 2b, 2b respectively). Shackford et al found that following initial evaluation and resuscitation by the trauma service, definitive care was provided by plastic surgeons in 11% of cases. Plastic surgery was the third most consulted service after trauma surgery (14%) and oral and maxillofacial surgery (13%)3 (level of evidence 2b).

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Eleven articles with 443 patients discuss preoperative imaging with 383 patients (86.5%) receiving computed tomography (CT) scans as their standard imaging modality. A single study discussed angiography, which was used in 28.3% of cases13 (level of evidence 2b).

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Three articles delineate their antibiotic protocol. Rana et al determined that 600 mg clindamycin IV TID was considered to be ideal7 (level of evidence 1b). Shackford et al found that antibiotics (broad or narrow spectrum) given to 93% of patients within 24 hours of admission made no significant difference in infection rate when compared to delayed antibiotics3 (level of evidence 2b). Motamedi placed all patients on cephalosporin + aminoglycoside or ciprofloxacin upon admission14 (level of evidence 4).

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Surgical Timing

Twenty articles with 585 patients discuss timing of ballistic facial trauma. About 93.0% underwent immediate reconstruction and 7.0% underwent delayed reconstruction. More recent high-level evidence supported definitive early reconstruction of soft tissue and bony defects and early operative repair of facial fractures resulting from blunt trauma and reconstitution of the soft tissue4 (level of evidence 2b). Failure to do so may result in displacement of the bone and/or scarring of the soft tissue into the bone defect15 (level of evidence 2b).

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Timing of initial debridement is discussed in 2 articles, both within 24 hours16,17 (level of evidence 4, 4, respectively). Reasons for debridement included decreased infection rates, obliteration of dead space, and optimizing wound edges18 (level of evidence 4). Aggressive debridement was reported in 2 articles10,19 (level of evidence 2b, 2b, respectively). Serial debridement every 24 to 48 hours was performed until delayed reconstruction4 (level of evidence 2b). Debridement as the definitive reconstructive treatment was performed in 6.8% to 33.5% of patients13,20 (level of evidence 2b, 4, respectively).

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Reconstruction: Bony Fixation

Due to the heterogeneity of articles concerning reconstruction after ballistic facial trauma, we were unable to access the rates of different surgical modalities for ballistic facial trauma. Three articles discuss the importance of open reduction internal fixation as a first-line bony treatment of the mandible.7,15,16,21 Hollier et al reported the highest incidence of zygomatic complex fractures (34%) of which 34% required open reduction and internal fixation15 (level of evidence 2b).

Maxillomandibular fixation (MMF) is also a secondary option for bony fixation. Four studies discuss the use of MMF.7,16,21,22 In pediatric patients, 64% were managed conservatively with MMF and no flaps were used as there was less soft-tissue injury22 (level of evidence 4). The importance of early bony stabilization is due to future preservation of facial volume9 (level of evidence 4). Only one randomized study compared the 2 modalities of bony fixation found that patients undergoing open reduction techniques had less complications than closed reduction techniques7 (level of evidence 1b).

In terms of rates of each bony fixation modality, Orthopoulos et al reported 37.4% of patients with gunshot wounds requiring fracture fixation: 17% had external fixation done while the remaining 83% underwent internal fixation12 (level of evidence 2b). Pereira et al more commonly performed open reduction and internal fixation versus MMF at a rate of 50% to 70%21 (level of evidence 4).

Gurunluoglu et al was the only study in our systematic review which discussed dental rehabilitation and mentioned that timing of dental rehabilitation is best performed 3 months after the initial major surgeries which they denote as primary bony and soft-tissue coverage.16

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Reconstruction: Soft-Tissue Flap Reconstruction

Flaps were delineated into groups by soft-tissue reconstruction: static versus functional, and by region: local, regional, and free. No static local or regional flaps were described in the literature, nor were local functional and regional functional flaps; however, static free flaps were discussed heavily. The most common soft-tissue flap for reconstruction of facial deformity following facial trauma was the latissimus dorsi flap9,17,23 (level of evidence 4, 2b, 4, respectively). The anterolateral thigh (ALT) or LCFAP flap was performed for 3-dimensional (3D) defects of both the intraoral mucosal region, as well as external skin and soft-tissue defects, including some on the upper and lower lips12 (level of evidence 2b). Transverse rectus abdominis myocutaneous (TRAM), pectoralis myocutaneous, rectus abdominis, and omentum were also reported for additional soft-tissue bulk or coverage17,19,21 (level of evidence 2b, 2b, 4, respectively).

Distant functional free flaps were discussed in the literature. Gracilis muscle was used for functional reconstruction of the lower lip.16 For defects requiring a thin lining, the radial forearm flap was favored17 (level of evidence 2b).

One study discussed facial allotransplantation for ballistic trauma; however, it did not recommend any specific soft-tissue flap coverage.11

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Reconstruction: Bony-Tissue Flap Reconstruction

Studies with good level of evidence support use of the fibula flap for successful reconstruction of ballistic facial trauma12,17,21 (level of evidence 2b, 2b, 4, respectively). The vascularized bony radial forearm flap was also commonly described for maxillary reconstruction8,12,17 (level of evidence 2b, 4, 4). The scapular flap was reported in 1 article particularly used for midface defects17 (level of evidence 4). Free iliac crest osteocutaneous flap was described specifically for the symphysis region of the mandible8,10 (level of evidence 4, 2b, respectively). Firat and Geyik reported that the free fibular osteocutaneous flap is a good choice for primary mandibular reconstruction offering a long straight bone, good axial blood circulation, suitability for multiple osteotomies, and its long pedicle8 (level of evidence 4).

Bone grafting sources included calvarial for the midface, nasal orbital, and zygomatic structures and costal bone grafting for a bony mandibular angle and body defect8 (level of evidence 4).

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About 23 articles including 1583 patients discuss complication rates after ballistic facial trauma reconstruction. All-cause complication rates after reconstruction occurred in 491 patients (31.0%). In the meta-analysis of patients where infection was discussed, 153 patients of 1148 (13.3%) developed a postoperative infection. In the 2 articles including 308 patients, flap failure occurred in 20 patients (6.5%). Clark et al noted that gunshot wounds had overall lower complication rates as compared with shotgun wounds at 9.0% and 17.0%, respectively4 (level of evidence 2b). The highest complication rate by region for gunshot wounds was mandible (35.0%) then maxilla (34.0%)3,4 (level of evidence 2b, 2b, respectively). Highest complication rate by region for shotgun wounds was midface (27.0%) with central face (21.0%) close behind4 (level of evidence 2b). Motamedi noted that 64% of patients were managed in a single operation whereas 36% required 2 major operations14 (level of evidence 4).

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Ballistic facial injuries are both common and devastating. The relationship of mass-energy equivalence E = M/2*V 2, where E represents energy, M is mass, and V is velocity, shows us that velocity substantially increases energy transfer of a small-mass projectile. Substantial damage to the patient is created via multiple mechanisms including the primary trauma of the missile passing through tissue, a secondary shock wave, and lastly cavitation. The more the elastic capacity of the surrounding tissue has been exceeded, the greater the size of this permanent cavity.24 Shotguns in particular have the ability to leave microfragments of shrapnel within the body thus adding another layer of complexity to the reconstruction). In addition to the deleterious physical and psychiatric effects of ballistic facial injuries, there is significant economic burden to the patient and health care system.

There are numerous clinical reports and retrospective studies that examine the treatment and management of ballistic facial trauma. However, available management algorithms are outdated and created prior to the invention of more modern technologies and reconstructive techniques. In 1996, Clark et al created an algorithm for gunshots wounds based on their experiences and case series of 178 patients.4 This is the most recent comprehensive algorithm for gunshot wounds which includes flap coverage and plastic surgery involvement. Vayvada et al additionally proposed an algorithm dividing treatment strategy into 3 main phases, but did not include flap reconstruction options in the treatment plan.10 Peled et al created an algorithm taking into account high velocity and energy injuries mostly relevant to battle combat.25 In 2007, Doctor and Farwell wrote the most recent algorithm for gunshot wounds specific only to the head and neck in which only general recommendations were given.26 In reviewing the literature, we have created an updated civilian ballistic facial trauma algorithm including preoperative management, intraoperative management, and treatment options based on location and type of defect. Our algorithm is outlined based on the highest level of evidence for each step in management of ballistic facial trauma (Fig. 2).

Although the results of psychiatric management consist of low levels of evidence, and few studies previously recommend proper psychiatric care, we recommend a psychiatric evaluation after initial patient stabilization and before secondary revisions. In patients who attempt suicide, there is a high incidence of repeat attempts following initial self-harm and thus the plastic surgery team should only proceed with secondary reconstruction after a thorough psychiatric evaluation. Some literature note rates as high as 66 times the annual risk of suicide in the general population or a 15% repetition attempt after 1 year of follow-up.27–29 It is therefore imperative that patients are psychologically stable before undergoing these secondary/nonessential procedures, so as to reduce the number of unnecessary surgeries and burden on our health care system.

Our analysis revealed a high number of patients receiving a CT scan (86.5%). The importance and value in this finding stems from the ability of CT scans to help objectify the trajectory of the bullet with multi-plane reconstructions and assess the intraparenchyma lesions, fractures, and splinters, thereby determining prognosis.30 Both coronal and sagittal views are necessary as well as 1-mm axial views, from the top of the cranium through the bottom of the mandible.31–33 There was limited literature on the use of CT angiography (CTA) in civilian ballistic trauma. This could potentially be due to the low velocity of the penetrating trauma and the ability of a CT to gather enough preoperative data points. Peled et al indicated that a CTA should be ordered for all military maxillofacial ballistic injury patients, and selective angiography in midface injuries.25 However, our cohort of patients is civilian; therefore, CTA should be only used when the trajectory of the bullet is suggestive.34 We recommend the use of CTA for assessment of vascular injury to help allow for favorable surgical results in patients with ballistic trauma. At our institution, we implement volume-rendered 3D-CT reconstruction for proper preoperative planning and postoperative assessment.

Our literature review on antibiotic choice in ballistic facial trauma suggests the use of antibiotics although Shackford et al found no specific differences in infection rates.3 Despite mixed reviews on antibiotic choice, and given the high infection rate in this population due to the contaminated surgical field, an antibiotic with anaerobic or board spectrum coverage may be warranted.

A key issue that remains controversial in the management of ballistic facial trauma is the timing of surgical intervention. The pooled timing rate suggested that 93% of patients underwent early surgical timing. The evidence points toward aggressive and early timing of reconstruction; however, we stress the importance of a thorough psychiatric evaluation in patients attempting suicide and if needed a delayed secondary reconstruction only after the patient has been cleared and treated by psychiatry. If secondary surgery is done prematurely in a patient of this nature, it could lead to extensive mortality and morbidity of the reconstruction.

Initial debridement measures in the context of ballistic facial trauma are not well established but they are part of the recommended steps in management of ballistic facial trauma. Optimal debridement ensures proper removal of devitalized tissue without necrotic tissue remaining, thus reducing peri- and postoperative complications. There are few case series and cohort studies that tackle this issue with mixed recommendations. Variation in debridement choice is most likely due to surgeon specific choices in whether the surgeon prefers a definite or delayed reconstruction. If delayed for whatever reason, serial debridement every 24 to 48 hours should be performed. We believe that concurrent with what higher level evidence may suggest, with the increase use of free flaps in the maxillofacial region over the last decade and use of other loco-regional options for reconstruction, aggressive tissue debridement is the preferred and recommended option when dealing with ballistic facial trauma.

Although the principle of replacing “like with like” holds true, in the head and neck region, there are limited options and sometimes replacing “like with unlike” is necessary. This can be a challenging step in the reconstructive planning of ballistic facial trauma. Defect location, size, extent of soft tissue and bony involvement, and ballistic characteristics should be considered when selecting the surgical approach.

Clark et al discussed how the central face region is most challenging region to reconstruct due to the extensive loss of critical tissue.4 This region requires extensive reconstruction with preference toward regional cutaneous flap transfers and free flaps for midface defects.4 Firat and Geyik notes that if a free flap will be used for large soft-tissue defects, the recipient veins should be selected as far away from the laceration site as possible, and flaps with longer pedicles should be preferred.8 In the early period after injury, microvascular free flaps are preferred because of their excellent vascularity, good filling capacity, and the ability to transfer composite tissues specific to the defect.18

Reconstruction of the bony skeleton in ballistic facial trauma tends to pose a greater challenge, especially considering that most gunshot wounds produce larger size defects: ≥5 mm. Midface and mandibular bone defects larger than 5 mm that result from military ballistic facial trauma have been supported by grafting.31,32 Consideration for using vascularized bony replacement should be given for defects beyond 2 to 4 cm.26 For defects >5 cm, the fibula flap should be considered the gold standard for vascularized bone in both the midface and mandible due to its overwhelming superiority in the current literature.12,17

Literature suggests that delaying bone grafting 6 to 12 months does not change patient outcomes or effects patient's standard of living.19 We concur with this and recommend that bone grafting if need be, can certainly be delayed.

After analyzing our results of the meta-analysis of the complication profile, we hypothesize that complication and specifically infection rates following ballistic facial trauma were higher than most other plastic surgery procedures due to the physical forces that ballistic trauma causes and the fact that this kind of trauma results in wounds of higher contamination grade. However, these findings also highlight the need for further investigation into complications after reconstruction of ballistic facial trauma injuries.

This systematic review was limited by the low methodologic quality of the included studies. The majority of data were extracted from retrospective case series without standardized treatment protocols and control groups. In most studies, only a small number of patients were enrolled. Also sub-group meta-analysis was only performed including the studies that had the outcome of interest and thus there may be a discrepancy in patient populations, surgical technique, and methodology across studies. Surprisingly, there was also a paucity of literature on dental rehabilitation or facial nerve reanimation and thus our systematic review may not address the extent of possible options for patients in the later stages of ballistic maxillomandibular trauma in which dental reconstruction or facial nerve reanimation is performed. Despite these limitations, we systematically reviewed the current literature together with good clinical practice to critically reexamine the best possible surgical algorithm for patients with ballistic trauma.

Ballistic facial trauma and specifically gunshot wounds have become a national platform of interest with the increasing number of incidents of civilian gunshot violence in years, which have been extensively reported/covered by the media. These gunshot wounds place a tremendous burden on public health care and psychosocial outcomes. In the last few years, improvement in surgical technique, preoperative testing and reconstructive options have helped surgeons produce superior outcomes. Despite this, surgical treatment of ballistic facial trauma is a complex task that requires thorough preparation and precise planning. Although each ballistic facial trauma case represents a unique soft- and hard-tissue defect that may require individualized surgical planning, we herein present an algorithm that summarizes our approach as a possible loose framework to the main decision points of surgical management and reconstruction after ballistic facial trauma.

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Algorithm; ballistic facial trauma; gunshot; reconstruction; shotgun

© 2018 by Mutaz B. Habal, MD.