Sir:
The use of commercial explosives such as fireworks is a typical cause of explosion injuries, located mostly on the hands and face. Only a few cases have been described in the medicolegal literature regarding oral explosions, in cases of suicide.1–3 The case we report is very peculiar because of the rarity of the trauma and because of the modality.
A 25-year-old man was referred to our department on December 31, 2005, because of a mouth injury caused by an explosion. He was playing a type of Russian roulette with some friends, who had been passing each other an explosive among the teeth in succession, until the firework blasted into his mouth.
The patient presented multiple lesions of the middle and lower thirds of the face, with laceration of the gums and dislocation of the inferior incisive tooth. There were multiple lacerations around the entire mouth, which involved the lips and adjacent skin for a 12 × 9-cm area. Blast-induced abrasion and contusion of the skin covered an 18 × 15-cm area (Fig. 1).
;)
Fig. 1.:
Preoperative frontal view showing the results of a blast injury to the face, including the mouth, nose, and surrounding tissues.
The nasal septum and wing cartilages were torn also. Gunpowder tattooing caused by the explosion was present on the entire face. An accurate exploration of the facial nerve showed its bilateral interruption close to the mouth.
After accurate débridement and removal of burned tissues, a superior and inferior vestibuloplasty was performed. The inferior incisive tooth was extracted and an implant was put successively in its place.
The right facial nerve was exposed. Because it was transected without a significant tissue loss and evident contusion, it was coapted by four to five 10-0 epineurial interrupted sutures. In contrast, the left facial nerve showed a 2-cm-long bruised tract, so it was microsurgically transected for a 2.8-cm length and a graft was taken from the anterior branch of the right medial antebrachial cutaneous nerve and interposed between the proximal and distal stumps to bridge the nerve gap.
We then performed face reconstruction with rotation-advancement local flaps. Muscle and skin layers were closed primarily by means of 5-0 Vicryl (Ethicon, Inc., Somerville, N.J.) and nylon interrupted stitches, respectively. A reconstructive rhinoplasty, with special attention paid to the tip, was then performed.
The patient was discharged from our department on the eighth postoperative day. Follow-up at 6, 12, and 24 months showed good results regarding functional and aesthetic appearance (Fig. 2).
Fig. 2.:
Postoperative frontal view obtained at 24-month follow-up.
Because these wounds exhibit a spectrum of complexity that includes extensive soft-tissue trauma complicated by burns, foreign bodies, and multiple fractures, the first acute surgical step is a wide débridement followed by immediate reconstructive procedures4,5 using local flaps. In selected cases, acute nerve and, more rarely, vessel reconstruction has to be performed.
In our experience, only in cases with extensive tissue loss is the use of distant flaps (e.g., pectoralis major or supraclavicular island flap) or free flaps (e.g., latissimus dorsi or anterolateral thigh flap) suggested.
Giovanni M. Di Benedetto, M.D., Ph.D.
Luca Grassetti, M.D.
William Forlini, M.D.
Aldo Bertani, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
Marche Polytechnic University Medical School
Ancona, Italy
REFERENCES
1. Blanco-Pampìn JM. Suicidal deaths using fireworks.
J Forensic Sci. 2001;46:402–405.
2. Ladham S, Koehler SA, Woods P, et al. A case of a death by explosives: The keys to a proper investigation.
J Clin Forensic Med. 2005;12:85–92.
3. Niemcunowicz-Janica A, Ptaszyńska-Sarosiek I, Janica J. Suicide by detonation of an explosive placed in the oral cavity.
Arch Med Sadowej Kryminol. 2005;55:171–173.
4. Cvetinović M. Reconstruction of a face destroyed by an explosion.
Vojnosanit Pregl. 1997;54(4 Suppl):73–76.
5. Köhnlein HE, Seitz HD. Management of an explosion injury of the face.
Langenbecks Arch Chir. 1987;372:713–714.
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