Gunshot Wound To The Face: Possible Facial Injuries, Treatment, Prognosis

While gunshot wounds have become a serious public concern, the damage caused by these wounds is a major contributor to the morbidity of the victims. There are several locations in the body that can get injured by gunshot wounds; some are more sensitive and can prove to be fatal or cause more damage.

Gunshot wounds to the face pose a serious threat to the face, head and neck structures and demands careful attention. There are several structures located in the face region, which are very closely arranged and injury to a small area can cause serious effects in a larger region. The extent and severity of the injury can be influenced by many factors related to the bullet, firearm, victim’s condition and the tissue affected. The arrangement of facial muscles and structures is such that it may be difficult to determine the bullet’s projectile path; especially in case where only entry wounds are present and significant damage can be caused.

The concern also increases as along with bones, muscles and soft tissues there are important blood vessels and nerves associated with important functions of the body. Additionally, the wounds causing facial trauma require special attention as, apart from survival, the face of a person has an aesthetic significance. Earlier, facial disfigurement and functional defects were more of a concern, but advancement in medical science and reconstructive surgeries have made it possible to manage such cases. However, it is challenging as gunshot facial trauma leads to multiple wounds and involves multiple specialties.

The face and the scalp has an extensive blood supply, hence any minor injury can cause extensive hemorrhage. Injury to every single part is important and must be carefully evaluated. Some of the important structures and functions related to the facial structures include, cranial nerves, maxillofacial bones and joints, blood vessels, glands, sensorial structures and functions like ocular, auditory, smell, oral, speech and sensation.

Gunshot wounds to the face can cause injuries to:

• Scalp – Profuse bleeding may occur due to injury; proper visualization of wound and careful examination is essential. Suspicion of intracranial injuries, skull fracture and other associated injuries is appropriately addressed.
• Eyes – Injury to eyebrows may cause fracture of the supra-orbital ridge, which is a bony prominence under the eyebrows or the region of frontal sinuses. Eyelid injuries can range from minor lacerations to complex injuries involving internal structures. It may cause damage to the nasolacrimal and ocular ducts. Nerves supplying eyelids and muscles controlling closure of eyelids can get damaged leading to ptosis. Injury to eyes can cause tears, muscle injury, fracture of orbital floor, nerve damage and even affect vision.
• Ear – Injury to ears can cause damage of soft tissues, nerves and affect the auditory function along with chances of disfigurement.
• Nose – There may be fracture of the nasal bones or cartilages, soft tissue injuries and this often presents with bleeding.
• Mouth – Soft tissue injuries to the lips, cheeks, tongue, fracture of oral bony structures, dental injuries may be seen. Injuries may also occur to the temporomandibular joint, parotid gland, parotid duct and cause significant damage.
• Cranial Nerves – Facial nerve can get damaged due to gunshot facial wounds causing varying degrees of damage to the movement and functioning of eyebrows, eyelids, lips and other functional defects.
• Gunshot Injury to nearby areas like neck, head and spine can lead to fractures, soft tissue and nerve damage.

Gunshot wounds to the face resulting in significant facial trauma are treated according to the given American Trauma Life Support (ATLS) protocol. Emergency care of gunshot wounds to the face involves focused attempt for resuscitation and assessment for preliminary data. Bleeding, swelling and other consequences of trauma can cause much damage and affect breathing. Hence, assessment of the status of airways should be immediately done to plan the necessary action.

The treatment plan for victims of gunshot wound to the face involves four major steps; namely, ensuring airway and breathing, controlling hemorrhage, detecting facial injuries or associated injuries to other parts and initiation of immediate steps for repair of facial injuries. Maxillofacial injuries involve many small structures and careful observation is required at every step.

Airway status and breathing control can be obtained by appropriate measures, tracheostomy is performed if required. Complete evaluation of the patient including blood pressure, pulse, respiratory rate and other parameters is performed. Obtaining meticulous history, physical examination and appropriate diagnostic procedures can help in identification of the problem and guide in the management. Impaction of bullet in internal structures needs to be identified and carefully managed. Investigations like X-rays, CT scan and MRI are useful.

Surgical intervention for gunshot injury to the face is considered and may include surgical debridement, closure of wounds and stabilizing fractures. Facial fractures due to gunshot may be managed by surgical methods like closed reduction, external fixation, internal fixation, open reduction and internal stable fixation (ORIF). This is followed by repairing of hard and soft tissues, rehabilitation and correction of deformities of small structures and dental repairs.

In case of fractures, careful examination and investigations help to reveal the exact nature and extent of injury. Surgical repair involving maxillofacial specialty may be required to restore the structure and function of the injured part. Assessment of sensory and motor functions of the injured or fractured parts is performed and appropriate treatment measures are taken.

Prognosis of gunshot to the face depends on the location and severity of injury, presence of life-threatening injuries, hemorrhage and availability of emergency medical care.

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