From Presentation to Decannulation: Comprehensive Treatment and Reconstructive Algorithm for Functional Restoration After Ballistic Injury to the Face

Document Type

Conference Proceeding

Publication Date




Ballistic injuries to the face are rare, with most trauma centers reporting an average of 1 to 20 cases per year. These patients present a unique and significant challenge to craniofacial surgeons, not only due to the rarity of presentation, but also the complex series of crucial management decisions that must be made while caring for these individuals. The aim of this study is to review our experience with application of craniofacial microsurgery concepts in the management of facial gunshot wounds and delineate an algorithmic approach to treatment and reconstruction.


We performed a retrospective review of a single surgeon experience at a Level I Trauma Center from 2011-2020 for all patients sustaining self-inflicted gunshot wounds to the face who underwent free flap reconstruction. Outcomes included timing of reconstruction, reconstructive techniques, number and type of free flaps required, and complications. This data was then combined with a literature review to establish an optimal algorithm for patient presentations.


Between 2012-2020, thirteen patients presented for reconstruction at our institution following gun-shot wounds to the face. The majority (92%) of patients were male, and the average age at time of injury was 35. The average time to tracheostomy, soft tissue debridement, and establishment of enteral access was between 1-2 days, and the average time to bony stabilization was three days. Nine patients received at least one free-flap as a part of their reconstruction. The average duration from time of injury to first free flap was one year and three months. On average, patients underwent a total of three free flaps. The most common type of flap was a fibular free flap followed by a radial forearm free flap.


Management of patients with ballistic injuries to the face serve as a challenge to even the most skilled craniofacial surgeons due to the rarity of presentation and the complex critical decision making required. Management can be divided into four stages: rescue/acute phase, reconstruction, return-to-function, and refinement. After a review of our institution’s cases and a survey of the literature, we created a novel algorithm for restoration of function and aesthetic revisions based on the location of injury, with different approaches for injuries to central lower face, mid face, upper face, and lateral defects. The underlying principles involve avoiding the use of reconstruction plate, establish occlusion early and align bony segments using an external fixator. We also allow soft tissue to stabilize for several months prior to reconstruction to minimize complications, which including flap failure and fistula. In addition, we aim to achieve dental restoration with implants within six months to one year or else fibula resorption will occur. It is also important to counsel patients early on in their recovery that multiple stages and revisions will be required for optimal results. Establishing an algorithmic approach to these complex cases can improve outcomes.


Plastic Surgery: The Meeting, Atlanta, GA, October 29 - November 1, 2021.