A 14-Year Review of Craniomaxillofacial Gunshot Wounds in a Resource-Limited Setting

Cranial Vault Defects and Deformities Resulting from Combat-Related Gunshot, Blast and Splinter Injuries: How Best to Deal with Them

Combat-related gunshot and blast injuries of the craniomaxillofacial region present a unique and challenging situation for the maxillofacial and reconstructive surgeon. The devastating cosmetic deformities and severe functional debility ensuing as a result of extensive hard and soft tissue disruption caused by these highly complex injuries, can have disastrous consequences, unless managed in a swift and efficient manner, by a multidisciplinary team approach. Large calvarial defects and deformities are frequent sequelae of these injuries and could result from shattering of the cranial vault by the force of an exploding shell, mine or improvised explosive device, or due to penetration of the skull by the projectile, such as a bullet, flying splinters or shrapnel. It could also result from the decompressive craniectomy carried out in these patients as a neurosurgical procedure to deal with the traumatic brain injury sustained. Management of such injuries is significantly different from that of other craniomaxillofacial injuries, owing to the quantum and severity of hard and soft tissue destruction encountered in the former and also the need to deal with aspects such as splinters from the projectile deeply embedded within vital structures such as the delicate brain tissue and meninges. Further, restoration of the lost structural and functional integrity of the cranial vault using the most suitable cranioplasty material, is imperative to provide protection to the vulnerable and vital cranial contents. Correction of the cranial deformity is also essential from an esthetic and psychosocial standpoint, to restore the morale of the patient. The present study elaborates the immediate/primary management as well as the secondary/definitive management of blast and ballistic head injury patients. Comprehensive treatment and rehabilitation of these patients, including reconstruction of extensive calvarial defects and deformities, resulting either directly or indirectly from combat injuries, have been described in detail. This study also aims to analyze, review and reassess the currently accepted management perspectives and treatment protocols of combat-related cranial injuries and proposes a useful algorithm to best manage them.

Treatment Strategies in the Management of Maxillofacial Ballistic Injuries in Low-Intensity Conflict Scenarios

Introduction

The facial disfigurement and functional debility resulting from craniomaxillofacial injuries in low-intensity conflict scenarios can physically and psychologically traumatize the afflicted personnel. Efficient and definitive management, with complete esthetic restoration and functional rehabilitation, is not only an organizational obligation, but also a tactical necessity to maintain a high state of morale among the troops. There exist two schools of thought on principles of management of such injuries. The older, three-phased approach consists of initial debridement and suturing, followed by conservative closed reduction in maxillofacial fractures using splints and ligatures, thereafter followed by delayed repair and late reconstruction of residual bone defects and deformities after the soft tissue healing is complete. The newer trend involves early and aggressive open surgical reduction and craniomaxillofacial fixation techniques along with reconstructive procedures carried out hand in hand with the soft tissue debridement and closure.

Aim

The aim was to compare the efficacy of the two management protocols, namely the contemporary approach of early aggressive surgical intervention, versus the conservative approach of initial debridement, closed reduction and delayed repair, as the definitive treatment modality of maxillofacial injuries sustained in low-intensity conflicts.

Methods

This retrospective analytical study included 40 patients with maxillofacial injuries sustained in combat scenarios treated over a period of 3 years. These patients who had been treated for ballistic maxillofacial injuries were divided into two groups: The first group of 20 patients (Group 1) included those who had undergone an early, aggressive, surgical intervention, and the second group of 20 patients (Group 2) included those who had undergone resuscitation and primary soft tissue closure followed by conservative, closed reduction techniques, delayed repair (including open reduction and internal fixation (ORIF) procedures), and late reconstruction of bone soft tissue defects (which included utilization of various grafts and flaps). Both groups were evaluated and compared for postoperative recovery and early and late complications such as impaired esthetic results and impaired functional recovery.

Results

Early, definitive, and aggressive maxillofacial surgical techniques proved superior to the conservative approach by bringing about primary bone healing and minimizing residual deformities and subsequent scar contractures, thus yielding improved functional as well as superior esthetic outcomes.

Conclusion

In today's low-intensity conflict scenario, the emphasis in management of maxillofacial injury victims should be on an early, definitive, and aggressive surgical repair and reconstruction of the facial skeleton, thus restoring quality of life to these soldiers, sparing them life-long indignity after a potentially severe esthetically and functionally debilitating injury.