Cooperation of the maxillofacial and plastic surgeon in reconstructive surgical procedures in gunshot injury – a case report

Facial gunshot injuries can result in de­vastating functional and aesthetic consequences for the patients. Surgical management of facial gunshot injuries is challenging and requires a multidisciplinary approach. The timing and sequence of the surgical procedures used in reconstruction and rehabilitation of maxillofacial gunshot wounds are crucial to a successful outcome and aesthetic result. This article is focused on the cooperation of oral and maxillofacial surgeons and plastic surgeons in surgical management of a self-inflicted maxillofacial gunshot trauma in a 25-year--old man. The suicide attempt resulted in the devastation of the central part of the face with a loss of the nose and anterior sections of the jaws. An important point of the primary surgery was to reconstruct the preserved parts of the face and to create a stable base for the reconstruction of the missing parts of the face. The reconstruction of the nose took place 1 year after the primary surgery. This case presents a 7-year stable, functionally and aesthetically satisfactory result of nasal reconstruction after a gunshot wound.

Description of the case

A 25-year-old Slovak male was referred to the Trauma Centre of the University Hospital in Martin on 17 September 2014, directly after a suicidal attempt with long-barrelled weapon. He fired the gun with the barrel placed under his chin. The bullet left the face in the cent­ral midfacial area, not causing the damage of the neurocranium. He suffered a deva­stating injury of the central lower face and midfacial area with penetration to the orbital spaces without damage of the eyes. On admission, the patient was sedated, the airway was secured by oro­tracheal intubation and the injured face was covered with dressing, without signs of severe bleeding. He underwent tracheostomy, superficial debridement and an adaptive suture of a soft tissue injury to ensure local haemostasis (Fig. 1). After his stabilization, the check of airways and bleeding as well as the radiological and laboratory investigations were performed. The patient received a tetanus prophylaxis and was commenced on broad-spectrum antibiotics. Blood loss was substituted. The tomographic examination confirmed a devastating and comminutive injury of the frontal part of the mandible and midfacial area involving maxilla, palatal and nasal bones, zygomatic and orbital bones (Fig. 2). Because the injury was partially avulsive and involved the hard and soft tissue of the face, ma­xillofacial surgeons were consulted with the indication for a surgical revision, ­debridement, fracture ­stabilisation and primary closure. Next day, surgery was performed under general anaesthesia.

The first operation began with careful debridement of the facial injury. During the exploration, the removal of nonviable bone fragments, foreign particles and contaminated soft tissue parts were performed with continuous haemostasis. For the open reduction and internal fixation of both zygomatic, nasoorbital and lateral maxillary fractures, the multiple plate osteosynthesis and wire osteosutures were used. After the reconstruction and stabilisation of lateral midfacial fragments, the real extent of central upper jaw defect with an avulsion of external nose was obvious. This central defect was supported with a long osteo­synthetic titanium plate connecting both lateral maxillary segments. Subsequently the avulsive defect of the frontal part of the mandible was temporarily reconstructed with a prefabricated mandibular reconstruction plate. Satisfactory occlusion of the remaining distal teeth was achieved. The facial soft tissue wounds were than closed in layers. Local flaps were used for soft tissue reconstruction of skin and muconasal defects. Large plastic tubes were inserted to maintain the continuity of the inferior nasal meatus (Fig. 3). Postoperative computed tomography showed a good position of bony structures and reconstruction plates (Fig. 4, 5). For the enteral nutrition support, a gastrostomy tube was placed the next day. Nasal tubes were removed two weeks postoperatively. Tracheostomy tube was removed 3 weeks postoperatively and broad-spectrum antibiotic therapy was cancelled 28 days after the surgery. The wound healing was uneventful except of the area of soft tissue covering the reconstruction plate bridging the central mandibular defect (Fig. 6, 7). In this area the healing was complicated with a partial external exposure of the reconstruction plate with a subsequent chronic infection. Two months after the first operation the prefabricated mandibular reconstruction plate had to be removed. Afterwards, the skin defect in the chin area healed normally. The decision was made to prepare a patient-specific titanium implant for the secondary reconstruction of the central mandibular defect. A postoperative CT examination was used for this purpose. The gastric tube was removed 4 months after the surgery. Subsequent oral feeding of the patient was complicated with a persistent oronasal communication. This was successfully closed under local anaesthesia 8 months after the primary surgery by a maxillofacial surgeon. After complete healing of the facial wounds, a plastic surgeon was consulted for the reconstruction of the missing nose.

One year after the injury incident, the plastic surgery team started to recreate the nose. After measurements, the delayed Indian flap was created under general anaesthesia. The segment of the left ear cartilage was used to support the new columella, and a split thickness skin graft from the upper left arm was used for reconstruction of the nasal lining and covering the defect on the forehead (Fig. 8). The nostrils were supported by plastic tubing. After 2 weeks, delayed flap was lifted from its base and transposed to the defect to reconstruct the new nose. The donor site was covered with a split thickness skin graft from the left arm to avoid the deformation of the left eyebrow. During each stage the patient was given broad-spectrum antibiotics to prevent infection. After 24 days from the last operation, when the flap at the recipient site was well healed, the pedicle of the flap was divided and the whole flap was tailored to achieve a better aesthetic result.

Two years after the injury, the patient underwent another operation under general anaesthesia. The patient-specific titanium implant for the reconstruction of the missing frontal part of the man­dible was implanted from an extraoral approach by maxillofacial surgeons in cooperation with plastic surgeons. The next step of the reconstruction process was a medial canthoplasty of the right eye to correct epicanthal fold. The patient was placed on antibiotics and the postoperative course and wound healing was uneventful (Fig. 9).

Eight months after the reconstruction of the mandible with a patient-specific implant, the patient reported mandi­bular discomfort. The radiological exami­nation revealed a fracture of the implant on the left side. Therefore, the re-operation with explantation of the broken implant and implantation of a new patient-specific implant was scheduled a month later. The second individual mandibular implant was than inserted through the same extraoral approach under general anaesthesia. Unfortunately, the healing was complicated with exposure of the implant through the skin 2 months later. Finally, this second implant was removed 3 years after the injury and the defect of the mandible is planned for the secondary bone grafting with fibular flap to facilitate the reconstruction of missing teeth (Fig. 10, 11).

Discussion

The treatment of gunshot wounds in the maxillofacial region is a complex subject, with respect to treatment time [1]. This type of wounds represents a challenge in maxillofacial treatment for their heterogeneity and complexity [1]. Primary patient care of this case was provided in accordance with the recommendations of other authors for devastating gunshot wounds in the oromaxillofacial region [2]. In the literature, a disagreement exists regarding the proper timing of the treatment. The selection of therapeutic course depends on many factors such as experience, availability of means, lesion extent and general health circumstances of the patient [1]. The current literature supports immediate treatment [1]. These lesions are treated in two or three steps. The first one – debridement and primary closure; the ­second one – graft placement (bone, skin or myovascularized grafts), and the third one – correction of residual deformities and implant rehabilitation [3]. Stefanopoulos and Motamendi suggest immediate treatment of all lesions in order to optimize functional and aesthetic results [4,5]. They agreed with Holmes and Alper in leaving secondary treatments only for complex cases which involved the reconstruction with bone grafts, myocutaneous rotation or a microvascularized flap [6,7]. There is also a radical trend to conduct complex cases in primary phase, which includes harvesting of free grafts [8]. The presented case was an example of a complex facial injury, therefore the treatment of the missing external nose and the avulsive injury of frontal segment of the mandible was performed as delayed reconstruction in cooperation of maxillofacial and plastic surgeons. According to the literature, the secondary or delayed facial reconstruction in a patient after suicidal attempt should be considered carefully, because of low compliance or motivation of such patients for the secondary treatment. A part of the relatives of these patients believes that the repair of such deformities, even if it is a functional deformity, is not necessary [9]. Therefore, in such cases, one should do as much reconstruction as possible during the primary surgical intervention [9]. However, in the presented case, the patient resolved his psychological problems and was motivated for multiple secondary surgical reconstructive procedures.

The nose has a three-dimensional contour and represents a main aesthetic focus of the face. There are various options for nose reconstruction ­[10–12]. A forehead flap is the gold standard for nasal soft tissue reconstruction because of its size, good vascularity, texture, thickness and skin colour, which is very similar and matches the skin colour of the nose [13]. It has a strong pedicle, enough tissue and the forehead defect can be easily camouflaged. It possesses the capacity to result in the most natural appearance. That is why it was chosen for the reconstruction in this case. These types of wounds can be reconstructed both primarily and secondarily. In the present case, the nose reconstruction was started 1 year after the injury, once fractures of the middle part of the face were healed.

The most common complications are flap necrosis, infection and risk of eyebrow malposition. To avoid eyebrow deformity in this case, the forehead defect after forehead flap transposition was covered with a skin graft from the shoulder. Sometimes patients have breathing difficulties; dry mucosa and snoring can occur. However, these problems are not as serious as a noseless face, because it can also cause serious mental-health problems. The main goal of nasal reconstruction is to regain the maximum possible normal look and to restore the lost self-confidence, which was achieved in the presented case.

Different methods are used in the treatment of complex facial injuries associated with a partial avulsion of the mandible, e.g. distraction osteogenesis, patient-specific titanium implants, composite free flaps, etc. Autografts are the gold standard of the treatment of mandibular defects [14]. The reconstruction of mandibular defects is a challenge for the unique anatomy, the presence of vital structures, and the variety of defects [15]. These have, however, several disadvantages and contraindications, which led to research of alloplastic materials [15]. The choice of mandibular reconstruction should be carefully discussed with the patient, considering the patient factors, comorbidity, prognosis, and expectations regarding dental rehabilitation [16].

Free flap techniques are indicated in mandibular defects, especially in its anterior portion [17]. The soft tissue and bone are transplanted in composite free flaps, and dental implants can be inserted into the neo-mandible to facilitate occlusal rehabilitation. However, the use of composite free flaps has also some disadvantages. The surgery is time-consuming, two surgical teams have to work simultaneously to harvest the free flap; the volume and height of transplanted bone may be insufficient to achieve occlusal rehabilitation with an implant supported prosthesis; the shape of transplanted bone may not match the original contour of the mandible; there may be too much soft tissue and the restoration of sensation is usually unsatisfactory; and the harvest of composite free flaps is associated with variable donor-site morbidity [18,19].

Another way to restore the continuity of the mandible is to use the reconstruction plates or patient-specific implants. The use of a reconstruction plate has several advantages. The technique is safe and simple. One surgical team is sufficient for the procedure and donor-site morbidity is avoided. There is no need for special preparation. There are also potential complications of the technique: loosening of the screws, fracture of the reconstruction plate, plate exposure, infection, and fistula formation [20]. The aforementioned complications were also observed in the described case. A common argument to use composite free flaps instead of a reconstruction plate is the intention to insert dental implants into the transplanted bone to facilitate occlusal rehabilitation [16]. However, in practice, only a minority of patients reach the stage of dental rehabilitation following the reconstruction of the mandible with a composite free flap [21].

In the presented case, the first treatment for the frontal defect of injured mandible was the use of a prefabricated mandibular reconstruction plate. This is a simple and most available way to provisionally treat such a defect in urgent conditions. An external exposure of the plate and infection, a common complication of such procedure, occurred 2 months later and was the reason for removal of the reconstruction plate. The low quality and a scar nature of the soft tissue in chin area was probably the reason of the skin dehiscence over the plate. Subsequently, the decision was made for a secondary reconstruction of the mandible with a patient-specific titanium implant without a bone graft. Although it is not an optimal choice for the reconstruction of frontal defects of the mandible, this alternative treatment was chosen to prevent a donor-site morbidity and with respect to patient´s option. Unfortunately, both attempts to use the patient-specific titanium implant without a bone graft for mandibular reconstruction failed in this case because of implant-break in the first implant and the external exposure of the second implant. At the time, the patient consented to the use of bone graft and is planned for the reconstruction using a vascularized fibular flap to facilitate the reconstruction of missing teeth. The definitive reconstruction of the mandible is delayed because of an actual pandemic situation with COVID-19.

Conclusion

Multidisciplinary care is required for successful management of patients with facial gunshot injuries. Complex and perfected treatment of facial hard and soft-tissue gunshot injuries depends ultimately on the abilities and skills of the maxillofacial surgeons in cooperation with plastic surgeons. Complications in the treatment of facial gunshot wounds can be expressed as functional and aesthetic limitations in the patient’s life, causing reduction in mastication ability with weight loss, reduction in the sense of taste, partial or total loss of visual acuity, speech difficulty and other daily-life restrictions. These complications can also produce aesthetic changes of the face with social and emotional consequences for the patient. The minimizing of secondary revisions and prevention of revisional operations for complications is of utmost importance in this respect. In the described case report, we achieved a stable, functionally and aesthetically satisfactory result of nasal reconstruction using only partial skeletal reconstruction.

Role of authors: Daniel Hvizdoš – manuscript writing, Igor Homola – plastic surgery, Dagmar Statelová – maxillofacial surgery, Mária Janíčková – manuscript reviews and formal and English language edits, Igor Malachovský – critical revision of the article, Katarína Mikušková – manuscript writing and selection of photographic documentation.

Conflict of interests: There are no conflicts of interest to disclose. We declare that this study has received no financial support.

Disclosure: All procedures performed in this case were in accordance with ethical standards of the institutional and/ or national research committee and with the Helsinki declaration and its later amendments or comparable ethical standards.

Mikušková Katarína

Department of Stomatology

and Maxillofacial Surgery

University Hospital in Martin

Kollárova 2

036 01 Martin

Slovak Republic

e-mail: katarina.mikuskova@gmail.com

Submitted: 24.5.2021

Accepted: 4.9.2021