HIGH-ENERGY BALLISTIC AND AVULSIVE FACIAL INJURIES - CLASSIFICATION, PATTERNS, AND AN ALGORITHM FOR PRIMARY RECONSTRUCTION

A 17-year experience from 1977 to 1993 with gunshot, shotgun, and high -energy avulsive facial injuries emphasizes the superiority and safety of ''ballistic wound'' surgical management: (1) immediate stabilizati on in anatomic position of existing bone, (2) primary closure of exist ing soft tissue, (3) periodic ''second look'' serial debridement proce dures, and (4) definitive early reconstruction of soft-tissue and bony defects. The series contains 250 gunshot wounds, 53 close-range shotg un wounds, and 15 high-energy avulsive facial injuries. Four general p atterns of involvement are noted for both gunshot and shotgun wounds a nd three for avulsive facial injuries. The treatment algorithm begins with identifying zones of injury and loss for both soft and hard tissu e. Gunshot wounds are best classified by the location of the exit woun d; shotgun and avulsive facial wounds are classified according to the zone of soft-tissue and bone loss. Treatment, prognosis, and complicat ions vary according to four patterns of gunshot wounds and four patter ns of shotgun wounds. Avulsive wounds have not been recommended previo usly for ballistic wound surgical management. The appropriate manageme nt of high-energy avulsive and ballistic facial injuries is best appro ached by an aggressive treatment program emphasizing initial primary r epair of existing tissue, serial conservative debridement, and early d efinitive reconstruction. There is an entire category of fractures whi ch I will eliminate from this study; this is the group of fractures re sulting from gunshot wounds. These, usually resulting from suicide att empts, are often veritable explosions of the face without any surgical interest.