Surgical Decision Making in Complex Facial Gunshot Wound Reconstruction

Introduction: With a rise in gun violence across the United States, facial gunshot wounds (GSWs) present a challenging reconstructive problem that was once seldom encountered in civilian populations. Reconstruction of facial GSW injuries requires a combination of both microvascular and craniofacial surgical techniques. The aim of this study is to explore our experience with facial GSW injuries through an anatomic classification scheme and investigate the surgical techniques necessary to complete such reconstructions. Methods: A retrospective review was conducted at a tertiary academic center. All subjects who suffered facial GSWs and underwent definitive reconstruction at our institution were included. Facial GSWs were classified into 4 distinct anatomical zones of injury: lower (mandible), middle (maxilla and orbit), upper (above the orbit), and multi-zone injury. Microvascular reconstruction was further investigated based on the types of flaps used and the location of flap inset. Surgical outcomes, numbers of procedures, and complications were assessed, and statistical comparisons were made. Results: Thirty-six subjects underwent a total of 322 surgeries. Twenty subjects had multi-zone injury; 16 had single zone injury. Eighteen of the 36 subjects (50%) required microvascular reconstruction. These 18 subjects underwent a significantly increased number of reconstructive procedures (P = .023). Twenty-six flaps were used, as multiple subjects required >1 flap. Fourteen of the 26 flaps were used in the middle third (54%), 7 in the lower third (27%), and 5 in the upper third (19%). Six flap complications required further surgical revision. On average, multi-zone injuries required more surgical procedures to complete reconstruction (P = .018). Conclusion: Composite multi-zone facial GSW injuries present a higher degree of reconstructive complexity, and thus often require more surgical procedures, especially when the midface is involved. In our experience, microvascular reconstruction is more often used in multizone injury, and in our series was associated with an increased number of reconstructive procedures.