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Revista Española de Cirugía Oral y Maxilofacial

On-line version ISSN 2173-9161Print version ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.28 n.5 Madrid Sep./Oct. 2006




Initial therapeutic management of firearm wounds in the maxillofacial area

Manejo terapéutico inicial de las heridas por arma de fuego en el territorio maxilofacial



L. Ruiz Laza1, J. Herrera Cobos2, J.M. Díaz Fernández3, J.D. González Padilla4,
R. Belmonte Caro4, A. García-Perla García4, J.L. Gutiérrez Pérez4

1 F.E.A Cirugía Oral y Maxilofacial. Hospital Infanta Cristina. Badajoz.
2 Especialista en Cirugía Plástica, Reparadora y Estética. Médico Residente de Cirugía Oral y Maxilofacial.
Hospital Gregorio Marañón. Madrid.
3 F.E.A
4 Cirugía Oral y Maxilofacial. Hospital General Universitario de Valencia.
Servicio de cirugía oral y maxilofacial. Hospitales Universitarios Virgen del Rocío. Sevilla. Madrid

Dirección para correspondencia




Introduction. The firearm injuries are not very common in our country, and the experience in its management is limited. In this review we show the experience of our Service in this wounds and review the literature to systematize the initial management of the firearm injuries in maxillofacial region.
Material and Method. We present six patients treated in our Service in 2002. We study the demographics characteristic, aetiology, lesions patterns and treatment.
Results. Five male and a female were treated of firearm lesions during this period, with a mean age of 38 years (range 13-74). Most frequent aetiology was the aggression. Only one patient required emergency airway control with tracheotomy. No complications were noted after primary surgical treatment and only one patient needed secondary surgical intervention.
Discussion. There are controversy in definitive surgical treatment in patients with high-energy lesions in maxillofacial region , because the literature describe two forms of management. The first way is the primary reconstruction with microvascular techniques, or secondary reconstruction after desbridement, stabilization of existing bone and primary closure of soft tissue. We think that the choice of treatment must be individualized, and we choose the secondary reconstruction as early as possible after primary stabilization of wounds.

Key words: Firearm; Maxillofacial injuries; Reconstruction.


Introducción. Las heridas por armas de fuego son poco frecuentes en nuestro medio, de ahí que la experiencia en el manejo de las mismas sea limitada. En este artículo mostramos la experiencia de nuestro Servicio en el tratamiento de estas lesiones y realizamos una revisión del tema para intentar protocolizar la actuación inicial ante este tipo de pacientes.
Material y Método. Presentamos seis casos tratados en nuestro Servicio durante el año 2002. Estudiamos las características demográficas, etiología, patrón de lesiones y tratamiento recibido.
Resultados. Cinco hombres y una mujer presentaron heridas por arma de fuego durante este período, con una edad media de 38 años (Rango 13-74). La etiología más frecuente fue la agresión, seguido del intento de autolisis. Sólo un paciente requirió estabilización urgente de vía aérea mediante traqueotomía. No existieron complicaciones postoperatorias y sólo un enfermo requirió intervenciones secundarias por secuelas.
Discusión. El aspecto más controvertido en el tratamiento de estas lesiones es el manejo quirúrgico de pacientes con lesiones extensas de la cara que involucran partes blandas y hueso, ya que pueden tratarse con técnicas reconstructivas complejas en el primer acto operatorio o, por el contrario, esta reconstrucción se puede realizar de forma diferida tras una primera fase de tratamiento quirúrgico de desbridamiento, estabilización de fracturas y cierre de partes blandas con técnicas simples. Pensamos que la elección del tipo de tratamiento debe ser individualizada en cada caso, aunque solemos optar por una reconstrucción diferida de los defectos tan pronto como sea posible.

Palabras clave: Armas de fuego; Traumatismos faciales; Reconstrucción.




Facial trauma produced through firearms is rare in our country, probably due to current legislation on firearm possession. This lack of experience together with the particular characteristics of these injuries, which on many occasions require the use of microsurgical reconstruction techniques for their definitive treatment, make this type of patient a challenge for the oral and maxillofacial surgeon.

The severity of firearm injuries depends fundamentally on two variables. The first variable depends on the caliber of the projectile and the speed at which it is fired, and this depends on the firearm employed. The second related variable is the distance at which it is fired. This was classified by Sherman and Parrish into three types: Type I, those carried out at a distance of more than 6.6 meters; Type II between 6.6 and 2.74 meters; and Type III from less than 2.74 meters.1 As we shall see later, these lesions can be classified in a basic form into two large groups: high energy and low energy.2 In addition, one has to take into account where these are produced, as injuries in the maxillofacial region can have important aesthetic and functional sequelae, or what is more serious, lead to the death of the patient.

Initial management of the injured

The patient with firearm injuries should be evaluated initially according to the rules of basic reanimation for any polytraumatized patient (ABC Rule).3 The first step consists in stabilizing the airways. There are many parameters that have to be evaluated in order to determine the need or not for stabilizing the airways, as according to various publications only 25 to 35% of these patients require emergency airway stabilization.4 The most important factor in this sense is the seriousness and extension of the injuries produced, and urgent stabilization of the injuries affecting the lower third of the face and floor of the mouth are clearly indicated.5 However, those patients with injuries that are less important should be monitored continuously for the first few hours after being admitted because of the possibility of hematoma formation in the airways. With regard to airway stabilization, this should be carried out according to the pattern and location of the injuries encountered. Nasothracheal intubation is preferable when there are no contraindications such as involvement of the middle third of the face.4 Once the airways have been stabilized we should maintain the correct ventilation of the patient with the appropriate measures (Step B).

Step C of basic reanimation is hemodynamic stabilization. In these patients we may find active bleeding because of the injuries, or what is more serious, vascular injury of considerable importance. In the first case, the bleeding tends to revert with the use of compression in the area, such as anterior and posterior nasal packing, oropharyngeal packing, etc. In the second case, carrying out a diagnostic arteriography and selective embolization of the injured vessel is indicated,6 or if not urgent surgical examination and hemostasia of the affected vessel.

Once the more important aspects of the patient have been controlled we can then proceed with their assessment as a whole, concentrating especially on the intracranial and ocular lesions that are quite common in these types of patients, with around 15% relating to the brain, 30% to the eye, which should be managed by the respective specialists.7 In addition, wide spectrum antitetanus and antibiotic prophylaxis should be carried out in all patients.1

Specific injury assessment

Once the patient has been stabilized, a thorough evaluation should be carried out of the injuries produced by the firearm in the maxillofacial area. For this we proceed to clean the lesion using a generous amount of sterile saline and any strange bodies that are found are removed. In this examination we should concentrate firstly on soft tissues. The area of the lesion is examined, and the tissues that have been lost are noted together with the degree of viability of those that have been damaged. At this point it is important to observe if there are any injuries as a result of the exit of the projectile, as if there is no injury of this type we should assume that the missile is lodged in a different part of the maxillofacial area. We will then examine the skeleton following the same system, that is, lost bone will be noted together with the viability of damaged bone.2

All this should be carried out together with specific radiologic tests. This should include plain film radiography of two vi ews of the face which is of great use, an orthopantomography and a Water’s view. In addition, when the midthird of the face is affected, or an ocular or neurological lesion is suspected, carrying out a Computerized Tomography is indicated, with different views being necessary in order to evaluate all facial structures.5 Reconstructions in 3D in order to plan treatment are particularly useful.8 Other diagnostic tests can be useful, such as an arteriography. This is particularly indicated when there is active bleeding that does not cease with the normal steps mentioned previously, and one should be carried out if a strange body is suspected near the main vascular bundle, and in general when there are penetrating injuries in the area of the neck and skull base.5 When there are penetrating injuries or perforating neck injuries, carrying out an endoscopy may be indicated in order to evaluate the esophagus, and any possible injury to this area should be searched for.3

Surgical treatment

Once we have carried out the previous steps, we should be able to classify the injuries produced by the firearms. This will serve as a guide for the definitive management of these traumas. There are many classifications, although we follow two of these: the first distinguishes three types according to the pattern of entry and exit of the projectile. There are penetrating injuries (with only an entry orifice); perforating injuries (entry and exit orifices) that tend to be produced by small caliber weapons from a long distance; and avulsive injuries produced by arms at a short distance from the patient with great loss of matter.3 Other authors simplify this classification into lesions with a low or high-energy grade in relation to the loss of substance and injuries produced in the face.2

Low-energy wounds are the most frequent. These wounds are produced by small caliber weapons a short distance away from the patient. This group of wounds have a similar pattern to that of facial trauma with open wounds; soft tissue has a minimum loss of substance and there is little perilesional necrosis; associated bone injuries are very variable depending on the area affected. Bone avulsion is not appreciated, but comminuted fractures that are difficult to treat may occur. In principle, this type of injury should be treated in a similar fashion to that of any other patient with facial trauma, bearing in mind that the patient can have the projectile within him and its extraction should be assessed. The prognosis for injuries with this pattern is good, due to there being good existing soft tissue coverage. However, complications have been described in patients with wounds in the lower third of the face leading to comminuted mandibular fractures and damage to the oral mucosa that compromises the vascularization of these fragments. In these cases bone fragments should be replaced and soft tissue repaired. The presence of localized infection should monitored during the post-operative period together with any fistulas resistant to adequate treatment. If there is a delay in fracture consolidation we should consider early debridement of the area and the posterior reconstruction of the defect. This should be carried out eight weeks later, once the integrity and health of the soft tissue in the area has been confirmed.2,9

High energy injuries from firearms are those from large projectiles or high energy firearms at a short distance. These injuries are quite complex; large areas of soft tissue and surrounding tissue is lost, and there is a tendency for ischemia to develop and for later necrosis, accompanied in addition by variable bone injuries with bone loss and complex fractures.2 When treating this type of injury, priority is given to soft tissue replacement in order for there to be good coverage of bone injuries and possible reconstruction with grafts and microvascular flaps. It is assumed that the surgical management of these lesions is divided into three phases: the first is debridement, stabilization of fractures and primary closure with simple techniques; the second, bone reconstruction with adequate soft tissue cover by means of grafts or preferably microvascular flaps; and the third and last, when there is a correction of residual deformities and the patient is prepared for oral rehabilitation that is as complete as possible.10 The controversy lies in if these phases should be carried out in a single surgical act in a primary fashion, or as various interventions. While most authors recommend immediate reconstruction of all lesions in order to improve aesthetic and functional results by means of complex reconstruction techniques with microvascularized flaps,1,7,10 others recommend a more conservative attitude and that treatment be carried out in various stages for those complex cases where soft tissue and bone is seriously affected, and where primary reconstruction may fail.2,3 Choosing a therapeutic approach depends on various aspects such as experience, availability of resources, wound extension and the general health of the patient.10 In any event, all authors agree that secondary reconstruction should be carried out as quickly as possible once the soft tissue is in good condition.


Material and Methods

We present six cases of patients with firearm wounds that were treated in our department of Oral and Maxillofacial Surgery in the Hospitales Universitarios Virgen del Rocío (Sevilla, España) during 2002. The demographic characteristics, etiology, pattern of injuries, treatment received and aesthetic and functional results are examined.



The results obtained are summed up in table 1. Five men and one woman were treated by our department. Mean age was 38 (range 13-74). Two of the patients were suicide attempts with hunting rifles placed to the chin that produced high energy injuries. The four remaining cases were small caliber injuries from a distance of over 2.74 meters that caused low energy injuries, three of these were because of aggression, and the other was accidental. Only one patient required urgent stabilization of the airways by means of a tracheostomy (Patient 1) due to the severity of the injuries to the center of the face from the weapon and that affected the lower third of the face. None of the patients required hemodynamic stabilization due to active bleeding from injuries. Only one patient (Patient 3) required an arteriography as injury to the large vessels in the neck was suspected, as a result of the entry orifice and direction of the projectile. There was interdepartmental consultation with Ophthalmology only with Patient 1 as there was a possibility of ocular injury.

Treatment in stages was opted for with the patients with high energy injuries due to the age of these patients and the complexity of the injuries (Patient 1); or because primary treatment had satisfactory results (Patient 2). With regard to the remaining patients with low-energy injuries, these were treated as any other trauma of another etiology. There were no intraoperative complications worth mentioning, and the results were satisfactory.



The postoperative stay was 14 days (range 4-36 days). There were no cases of postoperative infection, and only Patient 1 required reintervention because of microstomia. A commissuroplasty was carried out so that the patient could use a removable total prosthesis. This patient is awaiting nasal reconstruction, and an implant supported epithesis has been decided on that has still to be made.




The demographic characteristics in our country basically follow two patterns: the first is made up of elderly patients from rural areas who, following a suicide attempt, have high energy injuries because of placing the weapon to the chin; the second pattern is made up of younger urban patients that suffer low energy injuries from lower caliber weapons that are produced following an aggression. These cases are increasing slowly in our cities. These patterns are not comparable with other studies that have been published due to the social and cultural differences in our country.

In our experience only one patient required urgent stabilization of the airways (16.6%) coinciding with other series, due to the complexity of the facial injuries presented.4,5 None of these cases had active bleeding as a result of injuries from the weapons, probably due to the thermal effect produced by the weapon on soft tissue, and there were no associated ocular or neurological injuries in the pattern of injuries suffered by our patients.


The treatment carried out for all these patients consisted in the stabilization of fractures and repair of the associated soft tissue by means of simple techniques. In this sense, we believe that it is the treatment of choice for most patients, and that complex microsurgery techniques should be left for a second stage once the defects and reconstruction needs of each patient have been properly outlined. Like other authors, we believe that secondary reconstruction should be carried out as swiftly as possible in order to achieve the best aesthetic and functional results.2,3




Firearm injuries are rare in our country and experience in this kind of treatment is limited. It is important that the initial management of these patients is comprehensive, as with any other polytraumatized patient, and definitive therapy of the injuries should be rationalized according to the characteristics of the patient and the experience of the team carrying out the treatment.



Luis Ruiz Laza
Av. de Elvas s/n - 06080 Badajoz. España

Recibido: 19.04.2004
Aceptado: 06.10.2006




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