Management of self-inflicted gunshot wounds to the face: retrospective review from a single tertiary care trauma centre

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Abstract

There are limited published data about the surgical management of self-inflicted facial gunshot wounds. The aim of this retrospective study was to review our management of subjects who initially survive such a wound and were admitted to a tertiary care trauma centre between 2002 and 2012. Only subjects with definitive evidence of a self-inflicted facial gunshot wound and who were admitted alive were included. Data collected included personal and clinical details, characteristics of the gunshot wound, and medical and surgical management. Types of operations and their duration were recorded, and primary reconstruction was divided into early (within the first 48 hours after presentation) or delayed (longer than 48 hours). Determinants of infection were assessed with univariate analysis.

Seventy-six subjects (65 male and 11 female, mean (range) age 44 (18–83) years) were included in the study. Twenty-five patients needed an early surgical airway and five needed emergency intervention to control haemorrhage. Forty-five patients had primary reconstructions (28 early and 17 delayed) and 12 who were treated by delayed repair had a submental entry site to the wound. There were no significant differences in infection rates between those who had early, compared with those who had late, reconstructions.

Early primary reconstruction can be successful for patients with self-inflicted facial gunshot wounds, particularly when the entry point of the bullet is in the upper and midface area. Delayed primary reconstruction was more common when the bullet entered the lower face.

Introduction

Self-inflicted facial gunshot wounds can result in devastating injuries to the facial structures and have a high mortality.1 They are particularly distressing injuries, and not just for the patient. The psychological milieu of the injury means that the mindset of the surgeon must be considered as well as that of the patient, because of the strong emotion evoked by the nature of the injury.

Early primary reconstruction has been advocated for the management of facial gunshot wounds that result from civilian interpersonal violence,2 but its merits and feasibility have not been investigated in isolated, self-inflicted, facial gunshot wounds. In contrast to most facial gunshot wounds that result from interpersonal violence, the weapon is held in close proximity to the face in self-inflicted wounds, which could potentially affect the outcomes of early primary reconstruction. The potential impact of the surgeon’s misgivings must be acknowledged because of the self-inflicted nature of the injury and the complexity of the reconstructive surgery,3 but this should not be a reason for delaying primary reconstruction.

The purpose of this study was to analyse retrospectively the management of subjects who were seen with self-inflicted facial gunshot wounds at a tertiary care centre. The investigators hypothesised that the principles of early primary reconstruction could be successfully used in their management.

Section snippets

Methods

The institutional ethics review board approved this retrospective study. The group studied comprised all subjects who presented to a tertiary care trauma centre with a self-inflicted facial gunshot wound between January 2002 and December 2012.

To be included subjects had to be alive on arrival with definitive evidence of a self-inflicted facial gunshot wound (history, eye witness’s account, opinion of law enforcement officer, necropsy report, or strong medical opinion). The necropsy report (if

Results

A total of 76 subjects, 65 men and 11 women (mean (range) age 44 (18–83) years) met the inclusion criteria, 29 of whom died, 13 within 24 hours of presentation. None of those who died within 24 hours was operated on. Significantly more subjects with submental and intraoral entry sites survived the first 24 hours (p = 0.001). Table 1 gives a summary of interventions and outcomes. Emergency control of haemorrhage was by interventional radiology (n = 3) or in the operating theatre (n = 2). Packing was used

Discussion

Self-inflicted facial gunshot wounds are a major challenge to the oral and maxillofacial surgeon, and we sought to analyse the management of such subjects who were seen at a tertiary care centre to evaluate the hypothesis that the principles of early primary reconstruction can be successfully used in their management.

Previous publications have supported the use of early primary reconstruction for civilian, self-inflicted, facial gunshot wounds.4, 5, 6 This results from experience of the

Conclusion

Most self-inflicted facial gunshot wounds of the upper and midface can be managed with early primary reconstruction. Submental wounds were more likely to be managed with delayed primary reconstruction, although the reason for this was not clear. The possibility of increasing the use of early primary reconstruction in those with submental self-inflicted facial gunshot wounds should be investigated.

Conflict of interest

We have no conflicts of interest.

Ethics statement/confirmation of patients’ permission

The hospital Institutional Review Board granted permission for the study. Patients’ permission was not required as no identifying data are presented.

Acknowledgements

The authors thank Betsy Crammer for her help.

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