J Oral Maxillofac Surg

59:277-282, 2001

Facial Gunshot Wounds:

A 4-Year Experience
Larry Hollier, MD,* Elena P. Grantcharova, MD
and Maan Kattash, MD
Purpose:

Facial gunshot wounds can result in devastating functional and aesthetic consequences for
patients. In an attempt to evaluate the management and outcome in these patients, a 4-year retrospective
review was undertaken of all patients presenting with facial gunshot wounds at a level I trauma center.
Patients and Methods: A total of 121 patients were identified. Medical documentation could be
obtained on 84 of those patients. The patients maxillofacial injuries were treated by the 3 participating
services: plastic surgery, oral and maxillofacial surgery, and otorhinolaryngology. The patients ranged in
age from 6 to 64 years, with a mean age of 27 years.
Results: The gunshot wounds were single in 64% of the cases and multiple in 36% of the cases. Overall
mortality in the series was 11%. Sixty-seven percent (56/84) of the patients suffered an injury to the
underlying craniofacial skeleton. Seventy-five percent of these patients required surgical intervention.
Twenty-one percent of the patients (16/75) required tracheostomy emergently for management of the
airway. Eighteen percent (15/84) of these patients had an intracranial injury, with 50% of these patients
requiring surgery. Fourteen percent of the patients in the series (12/84) had great vessel injuries
diagnosed at the time of angiography, with 50% of these patients requiring surgery for treatment.
Conclusion: Contrary to much of the published literature, most patients in this series required surgical
intervention for treatment of their facial gunshot wounds. Reconstructive procedures were performed
early in the patients course and, when possible, addressed both the soft tissue and underlying bony
injury in a minimum number of stages.
2001 American Association of Oral and Maxillofacial Surgeons
be considered early. Following this, hemodynamic
resuscitation should be performed, if necessary, followed by thorough patient evaluation to rule out
concomitant injuries.
Subsequent management of these patients becomes
more controversial in terms of surgical reconstruction. Numerous series in the literature advocate early
aggressive intervention for 1-stage reconstruction of
all involved structures.1-5 However, several series published in the literature favor a more conservative approach, advocating nonoperative management of
these injuries.6-11 This is extended to include angiographic management of bleeding problems and
closed treatment of skeletal injuries.12-19 Other series
advocate a more aggressive approach, particularly
with respect to facial reconstruction.1,5,6,20,21
This article reports a 4-year experience with facial
gunshot wounds at a level I trauma center. The demographics of the patient population and the injury
profile and subsequent management are evaluated.

The severity of injury resulting from facial gunshot

wounds varies according to the caliber of the weapon
used and to the distance from which the patient is
shot. Close range, high-velocity gunshot wounds and
shotgun wounds can result in devastating functional
and aesthetic consequences for the patient. Early
management of these patients must focus on the basics of resuscitation, with paramount attention given
to the status of the airway. Bleeding from the injury
and the subsequent swelling associated with it can
significantly compromise the airway. Control with
either an endotracheal tube or tracheostomy should

Received from the Division of Plastic and Reconstructive Surgery,

Baylor College of Medicine, Houston, TX.
*Assistant Professor.
Resident, General Surgery.
Resident, Plastic Surgery.
Address correspondence and reprint requests to Dr Hollier:
Division of Plastic and Reconstructive Surgery, Baylor College of
Medicine, Scurlock Tower, Suite 800, 6560 Fannin, Houston, TX,
77030; e-mail: Lhollier@aol.com

Patients and Methods

The medical records of all patients admitted to Ben
Taub General Hospital from September 1994 to December 1998 with a diagnosis of a facial gunshot

2001 American Association of Oral and Maxillofacial Surgeons

0278-2391/01/5903-0005$35.00/0
doi:10.1053/joms.2001.20989

277

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FACIAL GUNSHOT WOUNDS: MANAGEMENT AND OUTCOME

Table 1. PATIENT DEMOGRAPHICS

Sex, No. (%)

Age (yr)

Race, No. (%)

Type of GSW, No. (%)

Male, 69 (82%)
Female, 15 (18%)

Youngest (6)
Oldest (64)
Mean (27)

Asian, 4 (5%)
Black, 26 (31%)
Hispanic, 44 (52%)
White, 10 (12%)

Single, 54 (64%)
Multiple, 30 (36%)
Self-inflicted, 5 (6%)

wound were retrospectively reviewed. The admitting

services included plastic surgery, oral and maxillofacial surgery, otorhinolaryngology, and the trauma
service. Information gathered was divided into the
following categories: patient demographics, injury
pattern, initial management, reconstructive procedures, and outcome/complications.

Results
A total of 121 patients were identified (Table 1). Of
these, medical documentation could be obtained on
84. Patient age ranged from 6 to 64 years. Eighty-two
percent (69/84) were male and 18% (15/84) were
female. Sixty-four percent of patients (54/84) suffered
a single gunshot wound and 36% (30/84) suffered
multiple gunshot wounds. There were only 5 selfinflicted gunshot wounds in this series. Overall mortality was 11%, with 9 patient deaths at or shortly after
admission to the hospital.
The structures injured in the gunshot wound are
listed in Table 2. The most commonly injured facial
structure was the eye, with 31% of patients suffering
injury unilaterally or bilaterally. The second most
commonly injured structure was the brain. Eighteen
percent of patients had an intracranial injury, with
half requiring surgical intervention. Only 2 of the 15
patients with brain injury from a facial gunshot
wound died.
The underlying bones injured are listed in Table 3.
The most commonly injured bone was the zygomatic

complex, with 34% of patients affected. However,

injuries to this region required surgery in only 34% of
cases. On the other hand, the mandible was injured in
30% of patients and required surgery in 76% of cases.
Of the surviving patients, 21% (16/75) required
tracheostomy at or shortly after presentation. All of
these patients suffered gunshot wounds to the lower
third of the face. Of the 25 patients suffering gunshot
wounds to the mandible, 56% (14 patients) required
tracheostomy.
Twelve patients (14%) suffered injuries to the great
vessels of the neck or their branches. Of these, 50%
required intervention (6/12), with 5 of them taken to
the operating room for management. Only 1 of the 6
patients was embolized in the radiology suite.
The complications resulting from the facial gunshot
wounds are listed in Table 4. The most common and
perhaps troubling complications involved the eye and
the central nervous system. Almost 20% of patients
developed early or late ocular complications as the
result of their injury. Seventeen percent of patients
remained blind in one or both eyes. Twelve percent
of the patients had a residual hemiparesis or significant upper motor neuron weakness. Nineteen percent had residual cranial nerve palsies involving cranial nerves III, VII, VIII, and XII.
Mean hospital stay was 8.3 days, with a mean follow-up of 22 weeks. However, 40% of patients did not
return for follow-up. The shortest follow-up was one
week and the longest was 29 months.

Conclusions
Table 2. INJURED STRUCTURES

Injured Structures

No.

Percentage

Eye
Brain
Great vessels (neck)
Tongue
Cheek
Pharynx/larynx/subglottis
Ear
Palate
Tympanic membrane
Lip
Remote organ injury

26
15
12
11
7
7
6
4
4
2
7

30.95%
17.86%
14.29%
13.10%
8.33%
8.33%
7.14%
4.76%
4.76%
2.38%
8.33%

The initial care of facial gunshot wounds strictly

adheres to the basics of trauma resuscitation. Great
care has to be given to management of the airway in
patients with these injuries, as was demonstrated in
this series. A tracheostomy was performed in 21% of
these patients. All of the patients requiring tracheostomy had gunshot wounds to the lower third of the
face. In these injuries, the most frequent indication
for tracheostomy is difficulty in obtaining an endotracheal route because of bleeding and distortion of
facial structures or because of a concern about subsequent swelling. However, these patients will frequently be undergoing subsequent surgical proce-

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HOLLIER, GRANTCHAROVA, AND KATTASH

Table 3. FACIAL BONES INJURED AND NUMBER REQUIRING SURGERY

Facial Bones Injured

Zygoma
Mandible
Orbit
Skull
Nasoethmoid

No. Injured

Percentage of Total
Patients (%)

No. Requiring
Surgery

Percentage of Injuries
Requiring Surgery (%)

29
25
22
18
10

34.52%
29.76%
26.19%
21.43%
11.90%

10
19
7
7
5

34.48%
76.00%
31.82%
38.89%
50.00%

dures and a tracheostomy, in addition to securing an

immediate airway, simplifies management of the airway during the hospital course. Even in the event that
an endotracheal airway has been inserted in the shock
room, early subsequent tracheostomy in the operating room may be indicated for this reason.
Once the airway has been controlled, standard resuscitation protocols should be followed. The patient
must undergo a thorough examination directed toward recognition and treatment of additional injuries.
This is made clear by this series in which 36% (30/84)
of the patients had suffered multiple gunshot wounds,
including wounds to the abdomen. Attention may be
directed away from these gunshot wounds by the
obvious head and neck injury. However, failure to
detect these injuries may be lethal.
Another interesting finding of this study was the
high incidence of associated injuries to the eye. In this
series, 31% of patients suffered ocular injuries, with
54% of them having residual visual problems. This
finding underscores the importance of a careful ophthalmologic examination in the case of facial gunshot
wounds. Failure to document ocular injuries at the
time of presentation may result in these problems
being attributed to surgery for subsequent facial repair. It is particularly important to document visual
abnormalities in the case of traumatic optic neuropathy. Visual perception may be progressively compromised by swelling of the optic nerve caused by the

gunshot wound. Early in the course, the only finding

may be a very subtle decrease in visual acuity, particularly with respect to the perception of the color
red.22-25 Such a finding should mandate the postponement of all nonemergent operative procedures to
minimize the progression of this swelling.
Another interesting finding in this series was the
high frequency of surgical intervention required for
repair of the injuries from the gunshot wound. With
respect to bony injuries, surgical repair was required
from 32% to 76% of the time, depending on the injury
(Table 3). The injury most frequently requiring surgery was mandible fractures, with 76% of the patients
undergoing either open reduction and internal fixation, placement of an external fixator, or the application of maxillomandibular fixation.
It has been argued that gunshot wounds and the
bony injuries resulting from them can frequently be
managed nonoperatively.16-19,26 However, this argument is in direct contradiction to most of the published experiences with facial fractures.20,21,27-29 It has
been advocated that early operative repair of facial
fractures resulting from blunt trauma and reconstitution of the soft tissue position is critical in obtaining
an optimal result. Failure to do so may result in displacement of the bone and/or scarring of the soft
tissue into the bone defect. Once this has happened,
subsequent repair is exceedingly difficult. Bone injuries resulting from facial gunshot wounds are no dif-

Table 4. COMPLICATIONS AND RESIDUAL PROBLEMS

Early Complications

No.

Percentage

Residual Problems

No.

Percentage

Visual disturbances
Wound dehiscence
Generalized sepsis
Stroke
Speech difficulty
Cerebrospinal fluid leak
Facial nerve palsy
Seroma
Acute renal failure
DIC

10
4
2
1
1
1
1
1
1
1

11.90%
4.70%
2.38%
1.19%
1.19%
1.19%
1.19%
1.19%
1.19%
1.19%

Cranial nerve palsy

Blindness
Hemiparesis
Mental/psychiatric
Mandible
Epiphora
Ptosis

16
14
10
4
4
2
1

19.04%
16.67%
11.90%
4.76%
4.76%
2.38%
1.19%

Abbreviations: DIC, disseminated intravascular coagulation.

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FACIAL GUNSHOT WOUNDS: MANAGEMENT AND OUTCOME

FIGURE 1. Surgical repair of close range shotgun wound of the right side of the face with massive soft tissue loss associated and loss of the zygoma
and inferolateral orbit. A, Preoperative view. B, Rib graft reconstruction of malar eminence and orbit. C, Microvascular radial forearm ap used for
skin coverage and a de-epithelialized portion used for nasal lining. D, Six-month follow-up view.

281

HOLLIER, GRANTCHAROVA, AND KATTASH

ferent. Indeed, the need for early surgery and bone

grafting is greater, mainly because bone loss and soft
tissue injury is usually more severe in these injuries
than it is in blunt facial trauma. The soft tissue injury
may even mandate coverage with distant tissue, including microvascular tissue transfer. This should be
performed at the time of bone repair to obtain an
optimal result (Fig 1).
Operative intervention was also common in the
case of intracranial injuries. Although only 15 patients
in the series suffered an injury to the brain from the
gunshot wound, half of them required a craniotomy.
One patient required a cranial exclusion procedure
because of a large communication between the brain
and the mouth from 2 intraoral gunshot wounds (Fig
2). This was accomplished by elevating a galeafrontalis flap and securing it to the cranial base to
form a barrier between the oropharynx and the brain
(Fig 3).
It would be beneficial in a series such as this to
classify the injuries according to the type of gunshot
wound experienced. This would include clarification

FIGURE 3. Galeafrontalis ap elevated for inset into the oor of the

anterior cranial fossa.

of the type of weapon used and the distance from

which the patient was shot. These factors clearly have
an impact on the injury produced and patient outcome. However, this information is difficult to obtain,
given the circumstances surrounding many of these
injuries, and is notoriously unreliable when it is offered by the victim or witnesses. Nonetheless, from
the available information provided in this series, it
would seem that facial gunshot wounds are associated
with a very high incidence of injuries requiring surgical intervention. It is our belief that these injuries
should be addressed early, with procedures designed
to repair both bone and soft tissue injuries simultaneously. Despite this aggressive management, these
injuries are associated with a significant number of
residual problems.

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FIGURE 2. Three-dimensional reconstruction of the CT scan reveals a

communication between the oral cavity and the anterior cranial fossa.

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