Management of firearm injuries to the facial skeleton: Outcomes from early primary intervention

AIM: Treatment of maxillofacial firearm injuries is still controversial with regard to timing of management. We postulate that not all maxillofacial firearm injuries need be delayed and that many may be treated early. To this end, a 19-year retrospective study was undertaken seeking to evaluate patients treated for firearm injuries to the facial skeleton at our center. The criteria which dictated when to operate are presented as are the results, benefits, and outcomes of the patients treated acutely. PATIENTS AND METHODS: From 1991 to 2010, 51 patients with maxillofacial firearm injuries were treated; 30/51 patients received early primary repair and simultaneous open reduction for facial fractures. These underwent primary debridement and arch bar placement followed by open reduction of fractures (with or without osteosynthesis) and primary wound closure. Patient age ranged from 8 to 50 years, with a mean age of 24.4±7.8 years. Primary early intervention was done when there was no gross infection, no bone comminution or extensive soft tissue avulsion (precluding wound coverage), and when general health, concomitant injuries requiring more urgent attention or those requiring major grafts did not preclude this. Primary intervention included extensive oral and extraoral irrigation (dilute hydrogen peroxide + povidone iodide), debridement of the facial wound, removal of floating fragments (teeth particles, debris, and shell fragments) precluding viable bone within the wound, access to the bone, finding the scattered bone segments and putting them back into place to restore bone continuity. Projectiles beyond the wound were not searched for. Tooth roots within the alveolus were not extracted at this stage. In addition to arch bars, titanium miniplates or wire osteosynthesis was done when necessary. All wounds were closed primarily (using local advancement flaps when necessary) and all patients were placed on antibiotics (cephalosporin + aminoglycoside or ciprofloxacin) upon admission. RESULTS: Of 51 patients, 30 were treated acutely and 21 warranted delayed intervention. In the acute-treated group, 6/30 patients had minor complications such as scarring and wound discharge. Early intervention for firearm wounds to the face was effective for facial firearm injuries in selected cases. This resulted in restoration of occlusion and continuity of the jaw, fixation of luxated teeth, early return of function, prevention of segment displacement and tissue contracture, less scarring, and decreased the need for major bone graft reconstruction later on. Those treated secondarily were only debrided and had arch bars placed. Definitive treatment of hard and soft tissue management was rendered in another subsequent operation. Bone reduction was more difficult because of scarring, and displacement of remaining segments. No significant differences were noted in terms of infection or other major complications. CONCLUSIONS: Firearm wounds were associated with a high incidence of maxillofacial injuries requiring surgical intervention. Many may be treated definitively and acutely with procedures designed to repair both bone and soft tissue injuries simultaneously aiming to restore bony continuity, esthetics and function using the tissues at hand (especially in the mandible). Early treatment is advocated because the course of healing is not disrupted with another subsequent operation (in the same wound) and because it may decrease hospital stay without increasing patient morbidity in selected patients. Patients with residual defects can be treated later as out-patients.