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An Algorithmic Approach To Ballistic Facial Trauma Reconstruction In The Civilian Population: A Systematic Review Of The Literature And Evidence Based Guidelines
Anmol Chattha, BA1, Johnson C. Lee, MD2, Ashit Patel, MBChB2.
1Albany Medical College, Albany, NY, USA, 2Albany Medical Center, Albany, NY, USA.

PURPOSE: The annual incidence of non-fatal ballistic civilian injuries in the United States has been increasing for the last decade. Given the extreme variations in ballistic injury, defects are extensive and commonly involve multiple zones of injury. We aim to clarify the best reconstructive management of civilian ballistic injuries by undertaking a systemic review of the literature.
METHODS: A systematic review of Pubmed was performed. Articles were evaluated for defect type and site, reconstructive modality, complications, and outcomes.
RESULTS: Fourty-seven articles containing 1459 patients were included. The highest complication rate by anatomic region was mandible (35 to 36 percent). The most common complication was wound infection followed by trismus, malunion, fistula formation & flap dehiscence.
CONCLUSION: Immediate surgical intervention with conservative serial debridement is recommended. However, for patients with pre-existing psychiatric disorders, secondary revisions should be delayed until proper psychiatric stabilization. When there is extensive loss of soft tissue in the midface, aesthetic outcomes are achieved with an LD or ALT free flap. Radial forearm flap is favored for thin lining defects. Open reduction is suggested for bony tissue stabilization. The fibula flap is recommended for bony defects >5cm in both midface and mandible. For bony defects <5cm bone grafting was preferred. Delaying bone grafting does not worsen patient outcomes. We present an evidence based algorithm to guide management after ballistic facial trauma (Figure 1).


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