[hermantheshocker]

A mid-30-year-old male contractor in Afghanistan suffered a self-inflicted low-velocity gunshot wound to the face. The projectile entered in the submental space and traversed the right parasymphyseal and symphyseal portions of his mandible, obliterating his anterior floor of the mouth and exiting via his lower lip with significant soft and bony tissue loss, including loss of a portion of his anterior maxillary alveolar ridge and nasal sill.


Fig.1 Left: Cavitary lesion caused by submental gunshot wound. Right: Two months status postdefinitive mandibular reconstruction.


Fig.2 Left: 3D reconstruction of maxillofacial CT showing significant bony injury. Right: Intraoperative image of mandible ORIF.

On arrival, he was tenuously protecting his airway due to the combination of soft tissue injury, loss of anterior tongue attachment to the mandible, and oral cavity hemorrhage. He was immediately taken to the operating room for airway management and initial repair of his injuries. Given the patient’s status as an American citizen, only life-saving and necessary stabilizing procedures were performed at the theater hospital, with the goal of early evacuation to the United States for definitive repair once the patient was stable for travel.


Fig.3 Left: Closure of soft tissue defects. Right: Postoperative 3D reconstruction of maxillofacial CT scan.


Fig.4 Reconstruction of parasymphyseal mandibular defect 2 months after injury. Titanium basket spanning defect filled with iliac bone. 3D reconstruction of maxillofacial CT scan.

After awake intubation, the in-theater surgeons performed washout, debridement, and closure of the wounds. The mandible wound was stabilized with a large reconstruction bar to provide internal fixation as a temporary measure, to include attachment of the genial tubercle to the lingual side of the bar for tongue stabilization which averted the need for tracheostomy tube placement.


Fig.5 Two months status postdefinitive mandibular reconstruction.

The soft tissue wounds of the lip, oral cavity, and nose were closed primarily in multiple layers using Vicryl for the muscular and mucosal layers and Chromic and Fast Ab-sorbing Gut sutures for the skin. As wounds are frequently contaminated, the clinical practice guidelines (CPGs) recommend irrigation with at least 6 L of saline for wounds in theater (austere environments). Contaminants can include a variety of different forms of debris including sand and shrapnel. He was discharged from the theater hospital on postoperative day 3 and evacuated to San Antonio Military Medical Center for further care.

Two weeks after his initial injury, he underwent a facial artery myomucosal flap to treat a persistent floor of mouth defect with communication into the submental space. Virtual surgical planning was performed with the Oral Surgery department to address the segmental mandibular defect. Two months after the orocutaneous fistula was closed, a transcervical approach was used to place a patient specific milled plate with a titanium cage (Synthes) to accommodate a free iliac bone graft with a good result.

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This post is for educational purposes only and is nonprofit. Under Section 107 of the US Copyright Act of 1976; Allowance is made for "Fair Use" for purposes such as criticism, comment, news reporting, teaching, scholarship, and research. OP is not a medical expert. No copyright infringement intended. This post does not encourage or glorify violence/harassment. Images might have been upscaled and enhanced. Text might have been shortened and simplified/reorganized for online view.

[ride]

I'd prefer the no velocity gunshot wound. To each, their own.

I hope he likes beards. Looks pretty normal as long as there is scruff. Kudos to the docs - and as usual, to you as well, Mr. Herm.

[Pyramid_Head]

Another case of a failed suicide attempt and then they go on living. Any suicide survivor I've listened to has always said they instantly regretted it.

[Faust]

I cannot imagine how horrible it must have been for the person to become suicidal. Looks like an excellent recovery. Hope they take care of him now, apparently a lot of army people develop depression and become suicidal