Primary Palate Reconstruction Combined With Cranio-Maxillo-Facial Fixation After Self-Inflicted Gunshot Wound Injury: Critical Incision Planning for Regional Flap Reconstruction.

Abstract

Self-inflicted gunshot wounds (GSW) to the palate result in complex bony and soft tissue trauma to the mid and upper face. Patients who survive these injuries are faced with significant speech and feeding difficulties. Upper and midface fractures open reduction and internal fixation (ORIF) is required for many of these patients, and consideration to incision planning is critical in order to preserve a primary option for oroantral fistula repair. The temporoparietal fascia (TPF) flap is an excellent option for primary palate repair as it is often exposed in the operative field during facial fracture ORIF and can be readily used for this purpose if its blood supply and width is not inadvertently compromised while making a temporal incision. This flap is easy to elevate, does not require any microvascular expertise, and using the TPF to reconstruct the palate injury primarily may save the patient years of wearing an obturator and/or subsequent trips to the OR for operative fistula management. In contrast to the temporalis muscle flap, this flap does not create temporal hollowing after elevation, which is a significant aesthetic complaint among patients. Proper incision planning is critical to preserve this flap as an option for palate fistula repair as the fascial layer is often incised when making coronal incisions. Primary repair of palate injuries using the TPF flap at the same time as upper facial ORIF has very little morbidity in this setting, and greatly augments patients' quality of life.