Surgical Management of Gunshot Wounds to the Face

Abstract

PURPOSE: Gunshot wounds (GSW) to the face are high-velocity injuries often resulting in significant destruction of tissues and substantial displacement and comminution of fracture fragments. As a result, operative intervention is commonly an integral part of their care and frequently requires multiple staged procedures. This study was designed to evaluate the surgical management of these injuries. METHODS: A retrospective chart review of GSW injuries to the face from January 2009 to December 2017 was performed using the database of a major metropolitan level 1 trauma center. Inclusion criteria were patients who had a GSW to the face, survived more than 48 hours and received care at the admitting institution. Data collected included demographics, type of firearm, structures injured, bones fractured, antibiotic administration, and surgical details. Complex reconstruction was defined as autologous soft-tissue flap, bone flap, or bone graft. Univariate and multivariate statistical analyses were performed to examine the relationships between injury specifics and surgical treatment. RESULTS: A total of 270 patients met the inclusion criteria for the study. The cohort was predominantly male (82.6%) with an average age of 31.7 ± 15.5 years. The ethnicity breakdown of the group was 40.4% Black, 31.9% White, 19.6% Hispanic, 3.0% Asian, and 5.4% other. The majority of patients (207%–76.7%) had at least 1 facial surgical procedure. The average day of the first surgical procedure was 3.03 ± 4.00 days (range, 1–43). However, 62% of patients went to the operating room within 24 hours of their injury. Of those that had surgery, the average number of procedures was 1.6 ± 1.8. Intermaxillary fixation was used in 40.6% of all patients, and it was highest when the mandible was involved (79.2%). Open reduction internal fixation was necessary in 45.4% of patients and occurred on day 9.9 ± 9.97. An external fixation device was used in 12.6% patients. Complex reconstruction had the following breakdown: soft-tissue flaps were required in 11.1% of patients, bone grafts in 7.2%, and bone flaps in 5.3%. Factors that resulted in a higher likelihood for surgery were teeth involvement (89%), oral cavity involvement (86%), mandibular fracture (86%), and comminuted fracture (86%). All patients who had a shotgun or rifle injury required operative management. On multivariate analysis, patient age (P = 0.019), injured teeth (P = 0.018), and oral cavity involvement (P = 0.009) were associated with higher number of surgeries. CONCLUSIONS: Surgical intervention is often an integral part to the management of GSWs to the face. An aggressive, early initiation of care is the rule with injuries resulting from a gunshot or rifle, those involving the teeth and oral cavity and comminuted injuries, more likely to require operative management. Multiple procedures are often required with a delayed approach to definitive management of the comminuted facial skeleton.