Early definitive bone and soft-tissue reconstruction of major gunshot wounds of the face

The use of craniofacial surgical techniques, extended open reduction, rigid fixation with plates and screws, and the replacement of severely damaged or missing bone with immediate bone grafting in the treatment of complex facial fractures has been applied to the management of severe gunshot wounds of the face. Early definitive bone and soft-tissue reconstruction has been performed in 37 patients. One-hundred and seventy-seven primary bone grafts were utilized in 33 patients for orbital, nasal, zygomatic, and maxillary reconstruction. Twenty-six patients required mandibular repair with compression or reconstruction plates. Soft-tissue reconstruction was provided by a combination of flaps. Four patients had extensive soft-tissue loss replaced by free vascularized omental flaps. The omentum provided circumferential coverage of the mandibular reconstruction and reconstruction of the floor of the mouth and was then tunneled in a circle through both cheeks into the middle and upper face. The omentum reconstructed deficits in the hard palate and upper buccal sulcus and was then wrapped around all zygomatic, orbital, and midfacial bone grafts and used to fill in dead space in the maxillary, ethmoid, and frontal sinuses. The omentum is not used to provide contour and bulk, but to cover bone grafts and plates and fill in dead space. Carefully shaped bone grafts provide the correct craniofacial scaffold. Early restoration of a midfacial bony scaffold and the prevention of soft-tissue contraction facilitate secondary reconstruction. Four late total nasal reconstructions with tissue-expanded forehead skin wrapped around bone grafts were performed.