Baber Khatib1, Karl Cuddy2, Allen Cheng3, Ashish Patel4, Felix Sim5, Melissa Amundson6, Savannah Gelesko7, Tuan Bui8, Eric J Dierks9, R Bryan Bell10. 1. Fellow, Advanced Craniomaxillofacial and Trauma Surgery/Head and Neck Oncologic and Microvascular Reconstructive Surgery, Department of Surgery, Legacy Emanuel Hospital, Portland, OR; Head and Neck Surgical Associates, Portland, OR. Electronic address: baber.khatib@gmail.com. 2. Fellow, Advanced Craniomaxillofacial Surgery and Trauma, Legacy Emanuel Medical Center, The Head and Neck Institute, Portland, OR. 3. Attending OMS, Trauma Service, Legacy Emanuel Medical Center, Portland OR; Consultant, Head and Neck Institute, Portland, OR; Director, Head and Neck Cancer Program, Legacy Good Samaritan Medical Center, Portland, OR. 4. Attending OMS, Trauma Service, Legacy Emanuel Medical Center, Portland OR; Consultant Head and Neck Institute, Attending Head and Neck/Microvascular Surgeon, Portland, OR; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, Portland, OR. 5. Fellow, Head and Neck Oncologic and Microvascular Reconstructive Surgery, Providence Cancer Center, The Head and Neck Institute, Portland, OR. 6. Attending Oral and Maxillofacial Surgeon, Trauma Service, Legacy Emanuel Medical Center, The Head and Neck Institute, Portland, OR. 7. Former Resident, Head and Neck Surgical Associates, Portland, OR. 8. Director, Oral and Maxillofacial Pathology, Fargo, ND. 9. Director of Maxillofacial Trauma, Trauma Service, Legacy Emanuel Medical Center, Portland OR; Consultant, Head and Neck Institute, Portland, OR. 10. Attending OMS, Department of Surgery Trauma Service, Legacy Emanuel Medical Center, Portland OR; Consultant, Head and Neck Institute, Portland, OR; Medical Director, Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, Portland, OR; Investigator, Robert W. Franz Cancer Research Center in the Earle A. Chiles Research Institute at Providence Cancer Center, Portland, OR.
Abstract
PURPOSE: Virtual surgical planning (VSP) is an indispensable aid in craniomaxillofacial reconstruction, yet no protocol is established in facial gunshot wounds. We review our experience with computer-aided reconstruction of self-inflicted facial gunshot wounds (SIGSW'S) and propose a protocol for the staged repair. METHODS: A retrospective case series enrolling patients with SIGSW's managed with the Functional Anatomic Computer Engineered Surgical protocol (FACES) was implemented. Subjects were evaluated at least one month postoperatively. Outcome variables were jaw position, facial projection, oro-nasal communication, lip competence, feeding tube and tracheostomy dependence, descriptive statistics were computed. The FACES protocol implemented during the initial hospitalization is as follows 1) damage control; 2) selective debridement; 3) VSP reconstruction back converted into navigation software 4) navigation assisted midfacial skeletal reconstruction; 5) computer aided oro-mandibular reconstruction with or without microvascular free flaps using custom cutting guides/hardware; 6) navigation assisted, computer aided palatomaxillary reconstruction with or without microvascular free flaps using cutting guides/hardware; 7) navigation assisted reconstruction of the internal orbit; 8) and confirmation of accurate reconstruction using intraoperative CT. RESULTS: The sample was composed of 10 patients, mean age of 43 years (range, 28 - 62 years, 70% M), 100% with SIGSW's to the submental/submandibular region. All had satisfactory facial projection (n=10), nine had satisfactory jaw position, were decannulated by one month's follow up and were feeding tube independent (90%). All traumatic oro-antral communications were closed (n=8, 7 surgical, 1 obturator), seven had adequate lip competence (70%). Complications included fibula malunion (n=1), plate exposure (n=2) infection (n=2), intracranial abscess (n=1) and microstomia (n=2). CONCLUSION: Computer-aided surgery is an indispensable tool in the reconstruction of SIGSW's. Successfully implemented, it proved to be a useful adjunct for: the restoration of orbital volume, facial projection and symmetry; the inset of composite tissue, and the facilitation of dental implant supported prosthetic rehabilitation.
PURPOSE: Virtual surgical planning (VSP) is an indispensable aid in craniomaxillofacial reconstruction, yet no protocol is established in facial gunshot wounds. We review our experience with computer-aided reconstruction of self-inflicted facial gunshot wounds (SIGSW'S) and propose a protocol for the staged repair. METHODS: A retrospective case series enrolling patients with SIGSW's managed with the Functional Anatomic Computer Engineered Surgical protocol (FACES) was implemented. Subjects were evaluated at least one month postoperatively. Outcome variables were jaw position, facial projection, oro-nasal communication, lip competence, feeding tube and tracheostomy dependence, descriptive statistics were computed. The FACES protocol implemented during the initial hospitalization is as follows 1) damage control; 2) selective debridement; 3) VSP reconstruction back converted into navigation software 4) navigation assisted midfacial skeletal reconstruction; 5) computer aided oro-mandibular reconstruction with or without microvascular free flaps using custom cutting guides/hardware; 6) navigation assisted, computer aided palatomaxillary reconstruction with or without microvascular free flaps using cutting guides/hardware; 7) navigation assisted reconstruction of the internal orbit; 8) and confirmation of accurate reconstruction using intraoperative CT. RESULTS: The sample was composed of 10 patients, mean age of 43 years (range, 28 - 62 years, 70% M), 100% with SIGSW's to the submental/submandibular region. All had satisfactory facial projection (n=10), nine had satisfactory jaw position, were decannulated by one month's follow up and were feeding tube independent (90%). All traumatic oro-antral communications were closed (n=8, 7 surgical, 1 obturator), seven had adequate lip competence (70%). Complications included fibula malunion (n=1), plate exposure (n=2) infection (n=2), intracranial abscess (n=1) and microstomia (n=2). CONCLUSION: Computer-aided surgery is an indispensable tool in the reconstruction of SIGSW's. Successfully implemented, it proved to be a useful adjunct for: the restoration of orbital volume, facial projection and symmetry; the inset of composite tissue, and the facilitation of dental implant supported prosthetic rehabilitation.
Authors: Sean A Knudson; Kristopher M Day; Patrick Kelley; Pablo Padilla; Ian X Collier; Steven Henry; Raymond Harshbarger; Patrick Combs Journal: Craniomaxillofac Trauma Reconstr Date: 2021-06-21