Introduction
Facial gunshot injuries are among the most challenging conditions in reconstructive surgery. They typically involve extensive soft tissue and skeletal destruction, high contamination risk, and significant functional and aesthetic implications. Mortality and complication rates can be substantial, underscoring the need for a multidisciplinary, resource-conscious approach. This case report describes a rare self-inflicted facial gunshot wound in a young man of South Asian origin, managed through a carefully planned, staged reconstruction that prioritized airway stability, tissue preservation, and sequential restoration of form and function.
Case Presentation
A 19-year-old male of Pakistani origin presented with a three-day-old gunshot wound to the floor of the mouth, producing extensive defects of the maxilla and mandible, soft-tissue loss, and comminuted fractures of both maxillary and ethmoid sinuses. Initial management emphasized airway protection, debridement, and nutritional support, with a gastrostomy tube placed to ensure adequate nutrition during recovery. The patient’s history included a self-inflicted injury, necessitating a highly cautious, staged reconstructive plan.
Stage 1: Stabilization and Mandibular Reconstruction
One week after debridement, the mandible was reconstructed with an osseocutaneous free fibular flap (12 cm × 8 cm bone with a 6 cm × 4 cm skin paddle). The fibula was osteotomized to match mandibular contour. Microvascular anastomosis connected the peroneal vessels to the right superior thyroid artery and external jugular vein (ischemia time: 65 minutes). The patient recovered uneventfully and was discharged after five days.
Stage 2: Midface Soft Tissue and Alveolar Reconstruction
One month later, the upper lip was reconstructed with a free radial forearm flap (8 cm × 6 cm), in concert with an iliac crest bone graft (4 cm × 2 cm) to restore the maxillary alveolus. Vascular reconstruction involved the left superior thyroid artery and common facial vein, with the external jugular vein as an additional outflow path. The iliac crest graft was secured with titanium miniplates. Weekly follow-ups tracked healing and function.
Stage 3: Nasal Reconstruction and Soft Tissue Coverage
In November 2018, nasal deformity correction began with a 100 mL tissue expander placed beneath the forehead to expand local skin coverage, with a port placed in the left temporal region. Six weeks of serial expansion provided adequate tissue redundancy. Subsequently, the nasal framework was rebuilt using a costochondral rib graft, while a pre-expanded forehead flap furnished external coverage for durable soft tissue. Cartilage shaping recreated the dorsum, tip, and alar support.
Stage 4: Final Lip Release and Functional Refinement
After all major facial structures were reconstructed, a late lip-release procedure addressed reduced mouth opening and impaired oral intake. A second radial forearm free flap, configured as a staged Abbe flap, used vessels from the left neck. The flap was divided after four weeks, yielding marked improvements in oral competence and symmetry. Psychological support accompanied the surgical journey and helped the patient maintain adherence to follow-up care.
Discussion
This case exemplifies the intricacies of managing severe facial trauma with a long, staged reconstructive pathway. Key principles included early airway management, thorough debridement to minimize infection and fibrosis, and a skeletal-first strategy followed by soft tissue reconstruction. The chosen techniques—osseocutaneous fibular flap for mandible, radial forearm flap for lip, iliac crest graft for maxillary alveolus, costochondral rib graft for nasal framework, and forebrain/brow tissue expansion for nasal coverage—reflect well-established options whose combination yielded favorable functional and aesthetic outcomes. In resource-limited settings, such as Pakistan, meticulous planning and multidisciplinary collaboration can optimize results despite logistical challenges.
Outcomes
Following the final Abbe flap division, the patient achieved improved mouth opening, reliable oral intake, and acceptable facial symmetry. Tracheostomy and gastrostomy tubes were removed, and the patient returned to work and social life with ongoing psychological support. While this report emphasizes positive milestones, it also acknowledges potential late-stage refinements, such as additional minor adjustments to lip mobility or nasal contour, depending on patient needs and tissue behavior over time.
Conclusion
Staged, multidisciplinary reconstruction can transform severe facial gunshot injuries into functional and aesthetically acceptable outcomes, even in resource-constrained environments. This case demonstrates how a structured sequence of skeletal restoration, soft tissue coverage, and definitive refinements can restore airway safety, mastication, speech, and appearance. Sharing such detailed experiences contributes to the body of knowledge guiding surgeons facing similar complex maxillofacial trauma.
