The importance of serial debridement and “second-look” procedures in high-energy ballistic and avulsive facial injuries

Abstract

Facial gunshot and high-velocity avulsive injuries are a tremendous challenge to the reconstructive surgeon. The complexity of these injuries is represented by the potential for loss of mucosal lining, bone, and cutaneous covering, as well as the jeopardized relationships between the functional and aesthetic subunit of the head and neck region. Traditionally, wounds of this nature have been managed conservatively with initial débridement, external skeletal fixation, and delayed secondary reconstruction of the missing skeletal and soft-tissue components. In this review, a protocol designed to optimize the functional and aesthetic outcomes of the management of facial gunshot and avulsive wounds is presented. Treatment is divided into three distinct but overlapping phases. At the time of patient admission, a sequential and direct clinical and radiographic assessment is made to define the injury zones of the bone and soft tissue, as well as the zones of bone and soft-tissue loss. This is immediately followed by, wound stabilization in preparation for component tissue reconstruction within the first 7 to 10 days of admission. The goal is to anatomically reconstruct the skeletal buttresses and surround them with a stable vascularized lining and cutaneous envelop within the primary phase of wound healing, thereby avoiding reconstruction after secondary contraction has taken place.