Discussion

Abstract

The management of maxillofacial gunshot wounds is a familiar experience at every level I trauma center in a major metropolitan area, but such injuries can also occur in more remote settings. This article focuses on the management of 121 gunshot patients over a 4-year period. The type of injuries, their mortality, and management is similar to that at our center. Our experience has been that surgical intervention is more frequently than not required to address both the skeletal and soft tissue injuries. Early management soon after the patient has been stabilized from other associated life-threatening concerns is the best way of addressing the maxillofacial trauma. Application of the principles of stabilization of the skeletal components with some type of rigid internal fixation or external fixator is indicated to obtain the very best skeletal reconstruction. Bone grafting to replace absent or severely damaged skeletal parts, where indicated, should also be considered in the reconstruction. Avulsed hard and soft tissues must be replaced, and microvascular composite grafts are frequently needed because of the severe tissue loss. Primary closures that are done under tension will usually fail, as the blast effect of the injury cannot be determined early. The damaged soft tissues, with compromised blood supply, will frequently necrose in the first 5 to 7 days. It is actually better in many cases to delay some soft tissue treatment until demarcation has taken place and debridement can be completed to well-vascularized margins. Then, definitive soft tissue management can occur.