Management of High-energy Avulsive Ballistic Facial Injury: A Review of the Literature and Algorithmic Approach

Background: High-energy avulsive ballistic facial injuries pose one of the most significant reconstructive challenges. We conducted a systematic review of the literature to evaluate management trends and outcomes for the treatment of devastating ballistic facial trauma. Furthermore, we describe the senior author's early and definitive staged reconstructive approach to these challenging patients. Methods: A Medline search was conducted to include studies that described timing of treatment, interventions, complications, and/or aesthetic outcomes. Results: Initial query revealed 41 articles, of which 17 articles met inclusion criteria. A single comparative study revealed that early versus delayed management resulted in a decreased incidence of soft-tissue contracture, required fewer total procedures, and resulted in shorter hospitalizations (level 3 evidence). Seven of the 9 studies (78%) that advocated delayed reconstruction were from the Middle East, whereas 5 of the 6 studies (83%) advocating immediate or early definitive reconstruction were from the United States. No study compared debridement timing directly in a head-to-head fashion, nor described flap selection based on defect characteristics. Conclusions: Existing literature suggests that early and aggressive intervention improves outcomes following avulsive ballistic injuries. Further comparative studies are needed; however, although evidence is limited, the senior author presents a 3-stage reconstructive algorithm advocating early and definitive reconstruction with aesthetic free tissue transfer in an attempt to optimize reconstructive outcomes of these complex injuries. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Published online 19 March 2018. Received for publication December 21, 2017; accepted January 12, 2018. Presented at the International Society of Craniofacial Surgery, October 28, 2017, Cancun, Mexico. Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. Eduardo D. Rodriguez, MD, DDS, Wyss Department of Plastic Surgery, New York University Langone Medical Center, 305 East 33rd Street, New York, NY 10016, E-mail: eduardo.rodriguez@nyumc.org Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.

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