Pearls and Pitfalls for the Reconstruction of Gunshot Injuries to the Face

Gunshot wounds to the faceGunshot wounds to face frequently present complex challenges to the reconstructive surgeon as they can cause significant bone and soft tissue defects and have high rates of tissue necrosis, ischemia, and infection. High-velocity (>1200 ft. per second, e.g., rifles) ballistic injuries produce debilitating soft tissue avulsions, hard tissue defects, sequential necrosis, and tissue loss over several days. Patients who have attempted suicide or been shot at close range with a shotgun can have similar injuries. Low-velocity bullets can result in the comminution of bone but do not typically cause such avulsive defects and rarely result in significant sequential necrosis and tissue loss. Initial management of gunshot injuries to the face is in accordance with Advanced Trauma Life Support (ATLS)Advanced Trauma Life Support (ATLS). After patients are stabilized, they are taken for debridement and damage control, often on the same day as arrival. This involves wound washout, examination under anesthesia, surgical hemostasis, conservative debridement of clearly nonviable tissues, wound closure, and/or packing. Occasionally, some bony fixation may be applied if it can be done easily and quickly. When tissue viability is questionable, it should be left to heal with ensuing necrotic areas debrided every 48 h with short trips to the operating room (OR). Immediately after injury, while patients are marginally stable and in a profound inflammatory state, extended and lengthy procedures should be avoided. Once the patient is stable and the injuries are no longer evolving, one can plan and approach the reconstruction. The purpose of this chapter is to review pearls and pitfalls for the reconstruction of gunshot injuries to the face.