Early Management, With a Minimal Initial Hospitalization Length, of Major Self-inflicted Rifle Wounds to the Face by a Single Latissimus Dorsi Free Musculocutaneous Flap: A 10-Year Experience

OBJECTIVE Severe ballistic injuries to the face create complex, composite defects of 2 facial subunits. These injuries have an extremely high economic impact for the Medicare system. The surgical goal with these patients is to restore basic functions of the face with a rapid morphological improvement. Our hypothesis is as follows: Early restoration of facial segments with a single free multiple island latissimus dorsi flap without primary bone reconstruction can significantly reduce hospitalization time and allow earlier psychiatric therapy with good morphological results. SURGICAL METHOD (1) Large debridement, bony stabilization with external fixation, and tracheotomy. (2) Definitive early reconstruction of soft tissue with composite free latissimus dorsi-scapular musculocutaneous flap. (3) Several refinements will optimize the results. STUDY DESIGN Retrospective case series of lower- and middle-face composite facial close-range high-energy gunshot wound patients were evaluated. Age, gender, mechanism of injury, anatomic subsites involved, surgical procedures, flaps utilized, complications, functional outcomes, time of tracheotomy closure, hospitalization duration, and beginning of psychiatric treatment were analyzed. RESULTS Twelve defects were gunshot wounds, 12 free latissimus dorsi flaps, and no flap losses. Patients received psychiatric treatment after 22 days (7-29); the tracheotomy was removed in 10 patients with normal alimentation in all cases. Mean hospitalization duration was 21 days. CONCLUSIONS Free tissue transfer techniques allow early reconstruction of the soft tissue framework of the face with a single multiple-island flap. Rapid restitution of facial compartments at a soft tissue level can dramatically reduce duration of hospitalization.