Facial Gunshot Wound: Mandibular Fracture With Internal Fixation and a Pectoralis Myocutaneous Flap Coverage

Facial penetrating gunshot wounds (GSWs) are seen in an assault, suicide, and accidental injury. They often carry high mortality given the important anatomical structures located within the neck. The foundations of maxillofacial GSWs are rooted in data from military combat, specifically the last world war. This type of injury is complex for reconstructive surgery due to significant soft tissue and bone loss. Management of maxillofacial GSWs is often challenging and has trended from serial debridement, immediate reconstruction, local tissue flaps, and distant free flap transfers depending on bullet trajectory and wound intricacy. We present a case of a 51-year-old male with a 22-caliber GSW to the left side of his face. Hemodynamics were stable on arrival and history included alcohol use. A left mandibular wound measured approximately 8 cm in diameter with exposed bone. A small 0.5-1 cm wound was also present inferiorly. A maxillofacial CT scan was utilized, showing a left mandibular body fracture. The patient underwent exploration and debridement on the same day of injury. Open reduction with internal fixation of the left mandible fracture and Synthes 2.5 mm locking plate was done. Additionally, a left pectoralis major myocutaneous muscle flap was performed two days later. Regional pectoralis flap reconstruction of facial firearm injury is scarcely acknowledged in the literature. Due to the location of the wound, the functionality of the jaw can be maintained in addition to ample blood supply by performing mandibular fixation and pectoralis major myocutaneous flap.