Case Of Avulsive Ballistic Facial Injury

Avulsive Ballistic Injury
Fig 6A: Defects of the lower face and midface; Fig 6B & C: FOSC flap with intra- and extra-oral skin paddles; Fig 6D: Skin paddles used to resurface the palate and nasal floor; Fig 6E: Paramedian forehead flap; Fig 6F: FOSC flap skin flap was deepithelialized, and hair-bearing chin skin was advanced; Fig G: 7-month follow-up after forehead flap insert.
  • Existing literature has shown that early and aggressive interventions of avulsive ballistic injuries improve outcomes.
  • A 3-stage reconstructive algorithm advocates definitive and early reconstruction and optimises reconstructive outcomes of complex injuries.
  • However, there is a need for further comparative studies.

A 36-year-old male patient was referred for facial transplant after an avulsive facial ballistic injury. The patient presented 7 months after the incident which caused composite tissue defects of the midface and lower face. Examination showed contracted soft-tissue envelope and a widening of the midface with loss of vertical facial tissue height.

Treatment plan

The treatment plan included use of CSP for mandibular reconstruction and a FOSC flap with intra- and extra-oral skin paddles. A second FOSC flap was used Moreover, during a subsequent procedure, skin paddles were used to resurface the nasal floor and palate. An ulnar forearm flap was used for grafting the nasal lining and costochondral rib for structural support.

Similarly, in preparation of a paramedian forehead flap, a tissue expander was placed in the left forehead. Additionally, the whistle deformity was corrected with a rotation-advancement upper lip repair. The external mandibular FOSC flap skin flap was deepithelialized and the skin of the chin bearing hair was advanced. Subsequently, dentoalveolar osseointegrated implants were also placed. For extra nasal surfacing, the paramedian forehead flap was used for tip/columella and sidewall support with additional costochondral grafting of the nasal dorsum.

Further planned procedures included minor tissue rearrangement and laser resurfacing to optimise cosmeisis.


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

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Dr. Aiman Shahab is a dentist with a bachelor’s degree from Dow University of Health Sciences. She is an experienced freelance writer with a demonstrated history of working in the health industry. Skilled in general dentistry, she is currently working as an associate dentist at a private dental clinic in Karachi, freelance content writer and as a part time science instructor with Little Medical School. She has also been an ambassador for PDC in the past from the year 2016 – 2018, and her responsibilities included acting as a representative and volunteer for PDC with an intention to make the dental community of Pakistan more connected and to work for benefiting the underprivileged. When she’s not working, you’ll either find her reading or aimlessly walking around for the sake of exploring. Her future plans include getting a master’s degree in maxillofacial and oral surgery, settled in a metropolitan city of North America.


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