An Algorithmic Approach to the Management of Ballistic Facial Trauma in the Civilian Population

Annual incidence of non-fatal ballistic civilian has been increasing for the last decade. The aim of the present study was to clarify the optimal reconstructive management of civilian ballistic facial injuries. A systematic review of PubMed was performed. Articles were evaluated for defect type and site, reconstructive modality, complications, and outcomes. A total of 30 articles were included. Most common region of injury was mandibular with a 46.6% incidence rate. All-cause complication rate after reconstruction was 31.0%. About 13.3% of patients developed a postoperative infection. Gunshot wounds had overall lower complication rates as compared with shotgun wounds at 9.0% and 17.0%. By region, complications for gunshot wounds were 35% and 34% for mandible and maxilla, respectively. Immediate surgical intervention with conservative serial debridement is recommended. However, for patients with pre-existing psychiatric disorders, secondary revisions should be delayed until proper psychiatric stabilization. When there is extensive loss of soft tissue in the midface, aesthetic outcomes are achieved with a latissimus dorsi or anterolateral thigh free flap. Radial forearm flap is favored for thin lining defects. Open reduction is suggested for bony-tissue stabilization. The fibula flap is recommended for bony defects >5 cm in both midface and mandible. For bony defects,

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