ORIGINAL ARTICLE

Management of Facial Gunshot Wounds

Syed Gulzar Ali Bukhari, Idrees Khan, Babar Pasha and Waseem Ahmad

ABSTRACT
Objective: To determine pattern and presentation in terms of site of injury, airway, associated injuries; and management
of facial gunshot wounds.
Study Design: Case series.
Place and Duration of Study: Oral Surgery Department, Armed Forces Institute of Dentistry, Rawalpindi, between
January 2001 and December 2008.
Methodology: All patients with gunshot wounds of the face managed at the Oral Surgery Department during the study
period were included by convenient sampling method. Patients were treated by a multidisciplinary team of maxillofacial
surgeon, otorhinolaryngologist and plastic surgeon. Descriptive statistics were used to determine frequencies and mean
+SD for qualitative and quantitative variables respectively.
Results: A total of 38 patients with gunshot wounds to the face were identified. Age ranged from 15 to 42 years with mean
of 28+4.98 years. There were 32 (84%) males and 06 (16%) females. Twenty two (57%) patients required airway
management. The most frequent site involved was mandible in 25 (65%) patients while midface was involved in 13 (35%)
patients. Open reduction and internal fixation (ORIF) was performed in 17 (44%) patients, while 21 (56%) patients were
managed conservatively. Out of 38 patients, 15 (39%) patients had some complications; trismus, sinusitis and infection
being the most frequent (10.5% each).
Conclusion: Facial gunshot wounds frequently involve mandible with more likely requirement of establishment of
emergency airway and open reduction and internal fixation (ORIF). Early management of gunshot wounds results in better
psychosocial profile, aesthetics, reduced hospital stay and early return to function.

Key words: Facial gunshot wound. Facial reconstruction. Microvascular free flaps.

INTRODUCTION Recently Futran and colleagues have proposed a

Management of facial gunshot wounds poses a phased approach for management of avulsive wounds.6
challenge not only for the oral and maxillofacial The first phase involves evaluation of the ABC, life and
surgeons but also for the reconstructive surgeons. Facial limb threatening injuries, intracranial, ocular, facial
gunshot wounds bear a lot of morbidity for the affected nerve, vascular and other major injuries, excision of all
patients.1,2 Inordinate attention has been given in the necrotic tissue and maintenance of tissue of question-
past to wound classification based merely on the able prognosis, maintenance of occlusal relationships,
projectile’s velocity.1 These wounds can appropriately be maintaining mandibular segments with reconstructive
classified as penetrating, perforating and avulsive plates and maxillary defects and soft tissue envelope
wounds. Management of facial gunshot wounds has with temporary bone grafts to avoid later tissue
been evolving through ages from conservative delayed contracture. Pre-operative planning should also be done
operative repair to early aggressive single stage for anticipated definitive reconstruction with 3-D CT scan
approach.1 Penetrating and perforating wounds, mainly and stereolithography. Second phase involves definitive
resulting from low velocity projectiles, are managed in reconstruction which should be as early as possible.
the same way as blunt facial trauma, ranging from The third phase focuses on aesthetic and functional
closed reduction to open reduction and internal fixation refinements which may occur over weeks to years in
with minimal debridment and primary closure.2,3 While which free flap debulking and contouring is required.
management of avulsive wounds resulting from high Dental rehabilitation with tissue borne or implant borne
velocity projectiles has been evolving through ages with prosthesis, additional cosmesis, facial prosthesis and
controversies involving early and delayed reconstruction tissue tattooing may be done.6
as it suffers an evolving type of tissue necrosis.2,4,5
The timing and sequence of different stages in the
Department of Oral Surgery, Armed Forces Institute of management of facial gunshot wounds with reconstruction
Dentistry, Rawalpindi. and rehabilitation is of prime importance for successful
Correspondence: Dr. Syed Gulzar Ali Bukhari, Classified aesthetic and functional outcomes, if inadequate may
Maxillofacial Surgeon, Armed Forces Institute of Dentistry, lead to graft rejection and frequent infection and as such
Rawalpindi. multiple revisional operations.7-9
E-mail: [email protected] With the development of microsurgical techniques
Received April 02, 2009; accepted April 10, 2010. and local tissue advancement to distant free flaps re-

382 Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (6): 382-385
Facial gunshot wounds

construction, cosmetic and functional outcomes have of 38 gunshot wounds, 25 (65%) involved the mandible
markedly improved. Delayed definitive surgical manage- and 13 (35%) involved the midface. Out of 25 (65%)
ment of the avulsive gunshot wounds in the past has patients with mandibular entry sites, 16 (42%) patients
given way to the early definitive management.10-12 The required emergency airway, whereas out of 13 (35%)
objective of the study was to determine the pattern and patients of midface entry sites, 06 (18%) patients
presentation (site of injury, airway and associated required emergency airway. Types of emergency airway
injuries), implications for evaluation and management of establishment according to entry site are given in (Table I).
patients with facial gunshot wounds. Table I: Emergency airway establishment according to entry site.
Type of emergency airway Mandible (n=25) Midface (n=13)
METHODOLOGY Cricothyroidotomy 2 (8%) 1 (7%)

This was an observational study carried out at Oral Tracheostomy 13 (52%) 2 (15%)
Emergency airway 1 (4%) 3 (23%)
Surgery Department, Armed Forces Institute of
Dentistry, Rawalpindi, from January 2001 to December Out of 38 patients, 17 (44%) patients required open
2008. All patients with gunshot wounds of the face were reduction and internal fixation (ORIF) in the form of
included by convenient sampling method. Patients were plating and trans-osseous wiring. The frequency of
treated by three participating services; maxillofacial patients managed with open reduction and internal
surgeons, otorhinolaryngologists and plastic surgeons. fixation (ORIF) and those managed conservatively
Most of those patients suffered gunshot wounds in the according to entry site is given in (Table II).
field and were managed initially there with normalization
Table II: Type of treatment according to entry site.
of vital signs and then referred to the study centre for
Type of treatment Mandible (n=25) Midface (n=13)
definitive management.
ORIF 12 (48%) 05 (38%)
The face was identified to be from supraorbital margin to Conservative 13 (52%) 08 (62%)
the chin inferiorly and the area anterior to the external Total 25 (100%) 13 (100%)
auditory meatus. The entry site of projectile was further ORIF=Open reduction internal fixation.

subdivided into two anatomic subsites i.e. mandible-

There were a total of 06 (15.8%) patients with injury of
(lower face) and midface. Gunshot wounds of the upper
the facial nerve; 02 (5.2%) had complete transection of
third of the face were excluded from the study due to
the nerve and 04 (10.5%) had neuropraxia. There were
neurological deficit. Patients with projectile entry site
04 (10.5%) patients with parotid injuries. Intracranial
away from face like neck, chest etc. and secondarily
penetration was found in 08 (21%) patients. Globe was
involving face were excluded from the study.
affected in 05 (13%) patients. There were 02 (5.2%)
Data was analyzed by using SPSS version 10. vascular injuries involving the facial artery.
Descriptive statistics were used to calculate the data.
Out of 38 patients, 03 (7.9%) underwent reconstruction.
Mean and standard deviation were calculated for all
One patient referred from Afghanistan with avulsion of
quantitative variables like age. Frequency and percen-
complete midface and anterior mandible, reported with
tages were presented for qualitative variables like
the complaints of ill fitting dentures and poor aesthetics.
gender, entry site of projectile, emergency airway
Delayed reconstruction was done with rib on-lay grafts
establishment by entry site, types of emergency airway,
and later on patient acquired good retention of his
wounds with underlying bone fractures managed with
dentures. Out of those 3 patients, 02 (5.2%) patients
open reduction and internal fixation (ORIF), wounds
underwent early reconstruction with fibular free grafts.
managed conservatively, injury to associated structures
(facial nerve, parotid, cranium, globe and vessel), Out of 38 patients, 15 (39%) patients suffered compli-
wounds with bony reconstruction and complications cations while 23 (60.5%) of the patients did not have any
following the management of those cases. complications following management. The complication
included trismus, infection and sinusitis in 10 patients
RESULTS each; facial nerve palsy occurred in two and vision loss
occurred in one patient.
There were a total of 38 patients with gunshot wounds
to the face during the 7 years study period. Their age
ranged from 15 to 42 years with mean age of 28 + 4.98
DISCUSSION
years. There were 32 (84%) males and 06 (16%) Facial gunshot wounds and their management are very
females. There were 02 (5.3%) cases in 2001, 04 complex. Its management has to be refined with
(10.5%) in 2002, 03 (7.9%) in 2003, 02 (5.3%) in 2004, evolving projectiles and increasing incidence of new
08 (21.1%) in 2005, 05 (13.2%) in 2006, 04 (10.5%) in victims in South Asia, especially in Pakistan to reduce
2007 and 10 (26.3%) patients in 2008. The specific type morbidity. In this study the pattern of gunshot injury with
of weapon used was unidentified. Projectile entry site respect to site, injury to associated structures, their
was divided into midface and mandible (lower face). Out management and complications following management

Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (6): 382-385 383
Syed Gulzar Ali Bukhari, Idrees Khan, Babar Pasha and Waseem Ahmad

is discussed. There are many classification systems for patients with neuropraxic injuries and were managed
penetrating facial injuries but in this study entry site of conservatively. If there is need for frequent debridement
facial gunshot wounds was divided into midface wounds than severed facial nerve branches should be tagged
and lower third or mandible wounds as in other and repaired later on.
studies.7,13 Many patients did not require open reduction and
In all trauma patients securing the airway is very internal fixation (ORIF) of midface or mandible fracture
important. The airway of all patients with facial gunshot which is in accordance with other studies.14,18 The aim
wounds is at the risk of collapse later on due to was to fix the unstable, grossly comminuted fractures
extensive necrosis associated with these wounds. with transosseus wires and with plates and screws in
Studies reveal that gunshot wounds of lower face and case reconstruction is later required. Maximum effort
especially with floor of the mouth entry sites are at was done to remove the bullets and its secondary
increased risk of collapse and require emergency airway fragments because of early and delayed sequelae.16,19,20
intervention.10,14,15 There are other studies which Intraoperative C-arm fluoroscopy is recommended to
indicate that these patients may initially appear to have check the final position of the bullet, because a bullet
a stable airway but may decompensate rapidly due to may move spontaneously even in paranasal
extensive inflammatory edema associated with these sinuses.15,21,22 Latest radiographic techniques may be
wounds. They suggest airway intervention in both upper used to avoid excessive radiation exposure associated
and lower jaw.10,16,17 with fluoroscopy.8,22,23
A frequency of 57% for emergency airway establishment On the basis of patterns of injury, the importance of
was found in this study which is greater as compared to elective airway establishment is suggested in all facial
other studies with frequency of 25% and 35%.10 The gunshot patients especially with mandibular entry sites
reason for increased frequency of emergency airway or if there is anticipated edema of airway. There must be
management was that the most frequent entry site was multidisciplinary approach with active involvement of
mandible. The airway of most of those patients was anesthetists, neurosurgeons, ophthalmic surgeons,
managed in the field by general surgeons before vascular surgeons and otolaryngologists in addition to
referral. The need for emergency airway management the oral and maxillofacial surgeons in the acute phase.
differed according to entry site. Most of the patients with Path of projectile must be assessed by latest
mandibular entry site required tracheostomy and it was radiographic techniques for its potential damage to
also needed for later reconstructive surgeries. The adjacent vital structures cranium, globe, parotid gland
airway of patients with facial gunshot wounds and etc. Avulsive wounds should be managed in minimum
especially those involving lower third of face must be number of stages and as early as possible if general
managed immediately before either extensive edema or condition of the patient precludes this to avoid the
bleeding may cause life threatening emergency. potential consequences of scar tissue on aesthetic and
Facial gunshot wounds may result in injury of adjacent functional outcomes.
vital structures like facial nerve, globe, cranium, parotid Complications encountered in these patients were
gland and vascular structures. The kinetic energy of predominantly facial nerve palsy, sinusitis, trismus and
projectiles is very important. Greater the velocity of infection requiring revisional operations.
projectile greater will be the necrosis around its track
and as such increased risk of damage to adjacent CONCLUSION
structures.18 The type of bullet and density and resilience
Facial gunshot wounds frequently involve mandible with
of the tissue influence the degree of damage.3,14
more likely requirement of establishment of emergency
In this study, all patients with globe injury were referred airway and open reduction and internal fixation.
to the concerned specialist. All of these globe injuries Management of facial gunshot wounds is highly
occurred in patients with midface entry site. So patients individualized depending upon patient presentation,
with midface entry sites and possible involvement of general condition of the patient, available resources and
globe should be referred to the ophthalmologist. experience of operating team in the management of
In this study, gunshot wounds were having almost equal such patients. Better pre-operative planning and early
frequency for cranial entry irrespective of entry site. aggressive management approach towards facial
Plain face and lateral skull views should be immediately gunshot wounds result in good functional and esthetic
obtained in all patients to identify the path of projectile results with reduced morbidity.
with no exit wound, to rule out potential intra-cranial
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