Maxillofacial ballistic injuries: A 13-year single-institution experience

Abstract

Introduction

Maxillofacial ballistic and pyrotechnic injuries represent complex reconstructive challenges due to severe bone and soft tissue loss, infection risk, and high demands for both function and aesthetics. Recent trends favour early, definitive reconstruction with vascularized tissue, but optimal timing and outcomes remain controversial.

Materials and Methods

Patients with ballistic or pyrotechnic facial injuries treated between 2010 and 2023 were retrospectively analysed. Data included mechanism of injury, anatomical and soft tissue regions involved, reconstructive approaches, complications, and long-term functional and aesthetic outcomes. Major reconstruction was performed with free or regional pectoralis major flaps, classified as early (first hospitalization) or delayed (secondary hospitalization). Complications were defined as events requiring surgical intervention. Functional status was additionally reported by a modified Head and Neck Functional Integrity Scale (HNC-FIT), and aesthetic satisfaction by Visual Analog Scale (VAS).

Results

All seventeen patients suffered combined bone and soft tissue injuries; 71% were suicide attempts. The majority had midfacial and mandibular fractures, often requiring complex reconstruction. Free flaps were frequently used, with the osteofasciocutaneous radial forearm free flap (ORFFF) and fibula free flap (FFF) being most common. Significant complications occurred in 58.8% of patients, mainly infections and osteosynthetic material exposure. Early major reconstruction was associated with fewer and later-occurring complications compared to delayed reconstruction. Patients with lateral defects achieved better HNC-FIT scores and higher VAS satisfaction than those with central defects.

Conclusion

Early, definitive reconstruction is associated with fewer complications and superior long-term outcomes. Bone defects were reconstructed with bony free flaps. For complex central facial regions local flaps are essential to preserve anatomical integrity and achieve satisfactory functional and aesthetic results. Other subunits frequently require tailored combinations of techniques along the reconstructive ladder to address complex defects effectively.