Facial Gunshot
Transcript of Facial Gunshot
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 19
Facial gunshot wound debridement Debridement of facial soft tissue
gunshot wounds
Michael B Shvyrkov Oleg O Yanushevich 1
Moscow State Medico-Stomatologikal University Maxillo-facial Traumatology Department Moscow Russia
a r t i c l e i n f o
Article history
Paper received 29 March 2010
Accepted 10 April 2012
Keywords
Treatment of soft tissues
Gunshot wound
a b s t r a c t
Over the period 1981e
1985 the author treated 1486 patients with facial gunshot wounds sustained incombat in Afghanistan In the last quarter of 20th century more powerful and destructive weapons such
as M-16 ri1047298es AK-47 and Kalashnikov submachine guns became available and a new approach to
gunshot wound debridement is required Modern surgeons have little experience in treatment of such
wounds because of rare contact with similar pathology This article is intended to explore modern wound
debridement The management of 502 isolated soft tissue injuries is presented Existing principles
recommend the sparing of damaged tissues The authorrsquos experience was that tissue sparing lead to
a high rate of complications (476) Radical primary surgical debridement (RPSD) of wounds was then
adopted with radical excision of necrotic non-viable wound margins containing infection to the point of
active capillary bleeding and immediate primary wound closure After radical debridement wound
infection and breakdown decreased by a factor of 10 Plastic operations with local and remote soft tissue
were made on 14 7 of the wounded Only 07 patients required discharge from the army due to facial
muscle paralysis andor facial skin impregnation with particles of gunpowder from mine explosions
Gunshot face wound modern debridement
2012 European Association for Cranio-Maxillo-Facial Surgery Published by Elsevier Ltd All rights
reserved
1 Introduction
There are two types of damage with a wounding projectile
(bullet shell-splinter) direct and indirect (lateral) blows Modern
high velocity projectiles create temporary throb (pulse) cavities
inside tissue which deliver an indirect force producing serious
functional disorders and 3 morphological alteration such as hae-
morrhage thrombosis and necrosis Such damage was not
described previously (Fig 1) (Callender and Franch 1935 Rybeck
1974 Berkutov 1990 Holt and Kostohryz 1983 Rudakov 1984
Alexandrov 1985 Marshall 1986 Lukianenko 2010)
Therefore modern weapons require new approach to gunshotwound debridement There are many wound debridement concepts
described The shortest belongs to Pirogov (1941) ldquo to convert
a crushed wound into incised woundrdquo Based on my experience con-
tused crushed dead and dying wound edges must be excised to the
point of active capillary bleeding then the wound becomes an incised
wound Thewoundcan then be drained and suturedallowing wound
closure without suppuration rejection disintegration and suture
breakage Struchkov (1972) and Berkutov recommended excising
wound edges and depths with the removal of all damaged contami-
nated and blood saturated tissues After debridement wound edges
should be well perfused and resistant to bacterial invasion to ensure
rapidhealing In military maxillo-facial surgery the ldquobasicprinciples of
maxillo-facial gunshot wound debridementrdquo formulated in 1943 still
hold These principles require sparing of damaged tissues soft tissues
of wound sides which should be excised economically removing
obvious non-viable tissues only New weapons high velocity projec-
tiles and changes in wound characteristics with combined wound
quantity(woundand burn) arenot takeninto consideration(Callenderand Franch1935 Chartes and Charters1976 Berkutov1981 Holt and
Kostohryz1983 Alexandrov1985 Marshall1986) Combined wound
(wound thorn burn) quantity was increased (Fig 2)
The experience of military surgery is forgotten again and again
between wars This article aims to share my experience of facial
gunshot injury
2 Materials and methods
Working in the theatre of war in Afghanistan for 4 years I treated
1486 patients In the 2-nd World War 23 of facial injuries were soft
Corresponding author Tel thorn7 499 261 93 75 thorn8 905 537 77 28
E-mail addresses mbshvyrkovgmailcom mbshvyrkovramblerru
(MB Shvyrkov)1 Present address 7 495 Moscow 105005 Pleteshkovskii pereulok hous 8 korp 1
1047298at 17 Russia
Contents lists available at SciVerse ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery
j o u r n a l h o m e p a g e w w w j c m f s c om
1010-5182$ e see front matter 2012 European Association for Cranio-Maxillo-Facial Surgery Published by Elsevier Ltd All rights reserved
doihttpdxdoiorg101016jjcms201204001
Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 29
tissues wounds and 13 fractures of the facial skeleton In
Afghanistan these proportions were reversed In my 1047297rst manu-
script I would like to consider debridement of isolated gunshot
wounds of the face soft tissues of 502 (33 8) wounded In my 1047297rst
year in the central military hospital of Afghanistan I followed the
military-medical principles of cautious wound debridement
strictly It became clear to me that it was impossible to adhere to
these principles due to the use of new high velocity weaponry
Analysis of my results showed me that sparing soft tissue gunshot
wound debridement resulted in disability multiple surgical inter-
ventions and prolonged duration of treatment I performed radical
primary surgical debridement (RPSD) of gunshot wounds meaningexcision of soft tissuewound margins to the point of active capillary
bleeding This shows a normally functioning microcirculation
system in the remaining viable soft tissues which rapidly heal I
excised 3e5 mm and sometimes more of skin and mucous
membrane from wound walls Fat the most vulnerable tissue must
be excised more extensively I assessed muscle viability by the
strength of capillary bleeding and muscle jerk under the scalpel
Soft tissues have to be removed from the walls and depth of
a wound only then can successful drainage and closure be achieved
It is known that the critical concentration of microbes in
a wound is 105e106 microbes per gramme of tissue If the
concentration is increased acute purulent in1047298ammation develops
(Krizek and Robson 1975) Soft tissues excision together with
microbes decreases microbial load in a wound (Kousin et al 1981)
Microbiological examinations were performed in 235 wounds at
various times after injury from 1 h to 15 days Wound smears and
soft tissues samples from the wounds were placed into culture
medium (Shvyrkov and Demenkov 2003) Gunshot wounds were
not infected during the 1047297rst 12 h after injury Wounds were not
infected in 586e644 of the wounded within 3 days after injury
(Table 1)
Purulent in1047298ammation was found in 8 of 21 infected wounds on
the 1047297rst day only At 4e6 days after injury 707 of the wounded
were infected while suppuration happened in 561 of the wounds
Fig 1 There are three zones of tissues gunshot damages zone of primary necrosis
where cells of soft and bony tissues were perished in the wounding moment zone of
following (total) necrosis where cells metabolism stops and cells will perish the next
day zone of parabiosis where cells metabolism was braked to a great extent half of
these cells will be dead 2e3 days later line of demarcation arises here and 1047297nally zone
of healthy tissues Upper channel from old bullet down e from modern high velocity
bullet
Fig 2 Face gunshot wounds from mine explosion There are a few wound on left
forehead nose lip and cheek Several bubbles (blisters) because of burn 2 stage are
seen
Table 1
Bacterial 1047298ora availability in the face gunshot wound depending on period (term) of
wounding
Time after
injury
Patients quantity from total number in the line
Bacterial 1047298ora
is absent
Bacterial 1047298ora
is present
Altogether
patients
Quantity of
suppuration from
infected wounds
Up to 24 h 3864 4 2135 6 59 838 1
2e3 days 3458 6 2441 4 58 1562 5
4e6 days 1729 3 4170 7 58 2356 1
7e9 days 316 7 1583 3 18 746 7
10e12 days 321 4 1178 6 14 218 2
12e15 days 517 9 2382 1 28 14 3
Altogether 10042 6 13557 4 235 5623 8
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e9
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 39
At 12e15 days 821 of the wounds were infected but suppuration
occurred in only 43 At 15 days after injury bacterial 1047298ora was not
found in 426 of the wounds and suppurating infection occurred
in 415 It was assumed that microbial growth into a wound from
the skin requires a few days Skin around wounds was smeared
with a 2 iodine solution Microbial growth in the wound was not
found up to end of wound healing It is clear microbes need a few
days to grow from skin to wound
Smoliannikov (1960) measured the temperature of bullets shot
from a ri1047298e barrel It was 137e156 C As far as 600 m its temper-
ature decreased to 92e126 C Bullets travel at 600 m and in non-
penetrating unclothed facial wounds the wound is sterile
21 Primary debridement of the facial gunshot wound
A 1047298ying bullet presses air in front of itself forming a ldquofront
percussion waverdquo The bullet enters in soft tissue as a piston drives
forward the air tearing and separating the tissue A conical fountain
of ground and disintegrated tissue 1047298ies out in front of and behind
the bullet through the entrance and exit (Fig12) Thus microbes do
not remain in a wound Microbial cells on the skin surface and
tissue cells are killed by contact with bullet at high temperatures
Non-perforated and perforated soft tissues wounds which werenot in contact with a primary infected cavity (mouth nose and
accessory sinuses of nose) without bleeding and haematoma were
treated without incision of the canal These wounds were 1047297lled
with gauze saturated with proteolytic enzymes for 4e5 h with the
purpose of digesting of necrotic tissues and then 1047297lled with anti-
septic or antibiotic ointment Gauze with liniment balm Vishnevski
may be changed every 2e3 days with other medicines e once or
twice daily
In penetrating wounds there always are few non-perforated
canals created by foreign objects (splinters of bone teeth and
wounding projectiles) which are situated inside the canal These
canals must be cut and opened and the foreign object removed
Small wound infection (up to 106 microbes per gramme of tissue)
may be successfully liquidated with leucocytes but as was noted byMechnikov in 1883 (1955) a foreign body will divert part of
leucocytes toitselfIn areas of the face tissues where use of a scalpel
is contraindicated or it is impossible to incise canals without harm
for wounded (for example penetrating wound of neck lengthwise
or across of face etc) (Figs 3 and 4)
In the case enzymatic debridement is recommended Ribbon
gauze with proteoclastic enzymes in buffered solution (for diges-
tion of killed tissues) antibiotics or antiseptics must be inserted
into wound and canals in turns These medicines may be injected
around the wound For 4e5 following days it is necessary to
alternate gauze with enzymes for 3e5 h with gauze with liniment
balm Vishnevski or antiseptic liniment Usually the1047297rst granulation
tissue emerges on the 6th day and the wound may be closed with
delayed primary sutures If granulation tissues grow slowly lini-ment balm Vishnevski is poured into the wound without gauze
because it oppresses granulation tissues with its pressure After
2e3 days a canal is 1047297lled with granulation tissue and the wound is
ready for closure
Primary debridement of wound (PD) which is initially per-
formed by maxillofacial surgeon right after wounding should be
distinguished from a secondary (repeated) debridement (SD) per-
formed some time after PD was done if necessary Primary
debridement is subdivided into early PD which is performed up to
24 h after injury postponed PD e is carried out between 24 and
48 h and late PD performed 48 h or more after wounding Wound
closure was performed with continuous sutures on the tongue and
interruptedsutures in wounds in the sublingual region This may be
done through external wounds especially after splinting
Interrupted sutures were used for closure of oral cavity wound lips
ensuring continuity of the vermilion border muscles fat and skin
Wounds must be drained Local 1047298aps were utilised as necessary to
achieve primary closure (Fig 5ab Fig 6ae
c Fig 7ab Fig 8ab
Fig 3 Perforating missile wound of left cheek and mastoid process Wound entrance
is very small exit e about 4 cm diameter It should not to cut and open this canal
because crumbly tamponade with same medicines gives good result
Fig 4 Perforating missile wound from left maxilla to parotid notch (exit) with rupture
of soft palate How to cut and open this canal
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e10
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 49
Fig 9ab) Primary and secondary sutures are distinguished
depending on term wound stitching after PD Early primary suture
used in layers immediately after PD Late PD is an easier process
than early PD because 2e4 days later vital and non-vital tissue is
demarcated with a pink line on skin which can lead the surgeon toexcise non-vital tissue without damaging healing potential Post-
poned primary closure was performed 3e4 days after wound
debridement in the following cases (1) following debridement of
very contaminated wound (2) in suppurative in1047298ammation of
wound edges (3) in the absence of complete excision of necrotic
tissues These wounds were prepared with hypertonic solution
sodium chloride enzymes antiseptics antibiotics ointment lini-
ment balm Vishnevski and physical therapy (Fig 10)
Delayed primary suture was used every 6e7 days after PD in
slow cleaning wound and 1047297nally is covered with granulation
tissues Treatment of these wounds was the same
Early secondary closure after 8e16 days after PD was performed
if (1) the wound was covered with healthy granulation tissue
(2) pus debris and necrotic tissue were absent from the woundSoft unscarred tissue is mobile and easily manipulated Sometimes
only 1e2 mm of skin excision is required for good aesthetic scar
formation
Late secondaryclosurewas used rarelythat is17e31days afterPD
when (1) in1047298ammation is 1047297nished (2) granulation tissue has grown
(3) necrotic tissues separation has occurred very slowly (4) wound
borders start scarring and became tough with little mobility Soft
tissues must be mobilised with a scalpel before late closure Wound
size can be diminished with button sutures in (1) large defects of soft
tissues (2) large and heavy 1047298ap formation or (3) festering wound
edges These are either approximation (approaching) relaxation
(retention) or directive button suture used in accordance with wound
morphology Rubber stopper from antibiotics bottles lavsan thread is
used which is more comfortable than wire and buckshot In all cases
horizontal mattress sutures were used thrusting a needle into skin
2 cm away from wound border with stoppers on both sides of the
wound Approximation (approaching) button suture is used to bring
woundedgescloser gradually It is used in big wide wound or wounds
with in1047297ltrated borders when stitching is impossible (Fig 10) Afterstitching the surgeon brings wound edges together closure by hand
and the assistant knots the all threads ends together minimising the
woundbut it does remain open therefore it hasto be1047297lled with gauze
saturatedwith antisepticointmentor liniment balmVishnevski Every
2e4 days the surgeon brings wound edges closer and repositions the
suture knots Gauze with liniment balm Vishnevski may be changed
every the third day and with antiseptics or antibiotics e daily
Relaxation button sutures are applied to decrease skin tension
after wound stitching the thread ends are knotted together After
the procedure skin tension must be eliminated between button
sutures around of stitched up wound and skin tension may be
checked by 1047297nger
A directive suture is required after large 1047298ap repositioning
Intermittent wound lavage with solution antiseptic or antibioticthrough thin tubing gives good results Thirty-40 drops are infused
into wound hourly except for 6 h at night Two or three aspirating
needles are placed aroundthe wound for permanent drops infusion
of antibiotics solution or dioxidin solution
Radical primary surgical debridement of gunshot wounds is in
fact sparing debridement because dead tissue is removed and all
intact tissue is spared and retained free of purulent in1047298ammation
3 Results
In the 2-nd World War primary sutures were used in 130e150
of the wounded after sparing debridement The sutures destroyed
tissues and wound edges splayed in 500e770 patients (Zbarge
1951) Suppurative in1047298
ammation increases treatment time is
Fig 5 a e The old wound is bullet exit tangentional fracture of the mandible which was 1047297xed by device Rudko Tissuesrsquo 1047298aps were 1047297xed with two button sutures b e soft tissues
were cut off and defect was closed with bipolar scalp 1047298ap
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e11
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 59
accompanied with mental and physical trauma serious breach of
microcirculation system unsightly scarring and facial deformity
Radical PSD reduced wound infection by a factor of ten
compared to sapring debridement147 of the patients needed
local 1047298ap reconstruction during radical PSD (primarily operation) or
delayed plastic from remote area of patientrsquos body (bipolar scalp
1047298ap rope 1047298ap etc) 07 of the patients wounded were demobilised
from the army due to facial muscle paralysis ocular destruction and
impregnation of facial skin with gunpowder particles (Fig 11ab)
4 Discussion
Treatment of facial gunshot injuries especially wound debride-
ment is controversial There are two opposing approaches proposed
Some recommend economical cautious soft tissue excision with
planned secondary debridement (Alexandrov 1985 Berkutov 1975
Shaposhnikov and Rudakov 1986 Deriabin and Lytkin 1979 Owen-
Smith 1985 Rich 1968 Reis et al 1991) Others excise all necrotic
and soft tissue of dubious viability together with foreign bodies and
Fig 6 a e Wounded after mine explosion Apparatus Rudko 1047297xed the mandible fractured button sutures brought wound borders closer Neck skin was damaged too therefore it
could not be used for cheek restoration b e wounds are clean and 1047297lled with good succulent granulation c e monopolar pedicle 1047298ap from left humerus closes cheek wound d e
the same patient after 2 months
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e12
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 69
microbes to preventing in1047298ammation and toxaemia (OrsquoBrein 1973
Al-Shawi 1986 Shvyrkov et al2001) Only vital soft tissue should be
left in wound to withstand bacterial invasion Those in the1047297rst group
hold that it is impossible to distinguish dead from live tissue
However a microcirculation system supports tissue metabolism
This means that if there is active capillary bleeding after tissue
excision the tissue is alive Leaving necrotic tissue in wounds ignores
established surgical principles
However a certain relaxation in rigid attitude of military
doctorsrsquo 1047297
rst group sometimes is useful to meet Alexandrov (1985)
has written about delayed wound management ldquoRemoving
damaged tissues from the wound must be more extensive (does not
spare as require beforee MSh) those tissues which could be used
fordefect closure lose their vitality gradually and cannotbe used for
wound closurerdquo According to histopathological examination and
my experience these tissues lose their vitality at the time of injury
not 2e3 days later Histological alteration increases gradually and
necrosis becomes visible only after 2e3 days when a line of
demarcation appears The author disagrees with the position of
leading military doctors who excise tissue after necrosis has been
Fig 7 Z-plastic a e gunshot defect of lower lip b e defect liquidated with Z-plastic by Limberg
Fig 8 Wounded after perforating missile wound of the maxilla a e subtotal gunshot defect of nose b e bipolar tube 1047298ap sutured to a skin frontonasal notch c e after operation
1047297rst stage
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e13
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 79
Fig 9 a - Wounded with gunshot upper lip defect on right side due to gutter wounding b - local plastic of upper lip triangular musculocutaneous pedicle 1047298ap is cut out from lower
lip and moved to a defect of upper lip
Fig10 a e Old avulsive penetrating deep wound as a result of gutter wounding with in1047297ltrated borders b e after medical treatment wound become clean and closed with 1047297brin
ce wound borders were brought closer gradually by two approximation button sutures wound was 1047297lled with granulation tissue de thin narrow strip of skin (about 1 mm) was
cut off from wound borders (for borders refreshes) and wound closed with cooptation sutures
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e14
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 89
diagnosed The authorcontendsthat indirect lateral blow with high
velocity projectile inevitably causes tissue necrosis and considers
that cautious debridement leads to avoidable purulent in1047298amma-tion and unnecessary resource expenditure Reis et al (1991) rec-
ommended ldquo primary radical wound excision repeated every
48 h The wound is always left openrdquo This debridement cannot be
termed radical because this type of debridement requires multiple
surgical interventions
Differing from Berchenko et al (1985) and Shaposhnikov and
Rudakov 1986 the author has identi1047297ed three zones of gunshot
tissue damages a zone of primary necrosis where soft and bony
tissues are destroyed at the time of initial injury (4) a zone of
delayed necrosis where cell metabolism stops and cells perish the
day after initial injury (3) a zone of parabiosis where cells metab-
olism ceases to a great extent with cell death occurring 2e3 days
later the zone at which a line of demarcation arises (2) and 1047297nally
a zoneof healthy tissue(1) (Fig1) Dead anddyingtissues inevitably
remain in cautious debridement becoming an in1047298ammatory focus
suppuration starts These tissues became heterogeneous substance
for patientrsquos organism which tries to remove them by in1047298amma-
tion Leukocytes macrophages and tissues enzymes attack them A
bacterial 1047298ora develops lysing dead tissue and contributing to
wound cleaning Davydovski (1952) attached great importance to
microscopic1047298ora asa ldquobiological cleanerrdquo However acute purulent
in1047298ammation does not always happen Bleeding and local traumareduce tissue resistance creating favourable conditions for the
development of wound infection Kostuchonok and Karlov (1990)
stated ldquo purulent infection development is possibly only in
substrate availability for vital functions of microbes e tissues
necrosis haematoma etc Such situation happens more often in
inadequate wound debridementrdquo Acute in1047298ammation increases
tissue acidity collagen 1047297laments expand and weaken sutures start
to tear tissue wound edges diverge and the wound opens
The in1047298ammatory process is very expensive for a wounded
organism The mobilisation of leucocytes macrophages and oste-
oclasts expends much energy to demolish damaged tissue instead
of preserving this for healing The organism will reject the non-
viable tissues if they were not incised again expending energy
The appearance of a scar is also compromised by inadequatedebridement of the initial wound
The examination of the microbial growth con1047297rms the introduc-
tion of infection as a result of ingrowth of microbes from theskin not
as a result of their penetration with a bullet Most surgeons consider
all gunshot wounds to be infected This assumption is probably
correct if shreds of clothing have been incorporated in the wound
which less frequently occurs with facial wounds Shell-splinters are
hotter because explosion of the projectile occurs at higher temper-
atures In such penetrating wounds on the face ribbon gauze with
proteolytic enzymes is packed into the wound for 4e5 days the skin
is smeared with 2 iodine solution and covered with sterile gauze
Foreign object are thus encapsulated and healing occurs
Microbes take several days to grow from skin into a wound
When saliva 1047298ows into wound contamination occurs immediately
Fig 12 Conical fountain of ground and disintegrated tissues 1047298ies out in front and
behind of the bullet through entrance hole and outlet
Fig 11 a e Wounded after mine explosion with wounds burn and impregnation face and neck skin b e the same wounded there are a few granulated wounds on face and neck
and skin impregnation with burnt gunpowder both eyes were damaged
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e15
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 99
Damaged tissue cannot resist microbial invasion It is the author rsquos
practice to close intraoral wound with interrupted sutures and
isolate the wound from the oral cavity and saliva Skin grafts are
occasionally employed to allow closure of the mucosa Often
a surgeon adopts wait-and-see position and starts to use drugs
therapy on suppurating wounds or wounds covered with necrotic
tissue which is erroneous Surgical debridement of a wound must
always performed irrespective of clinical condition or the length of
time lapsed since the injury was sustained It is necessary to
remember that wound debridement ful1047297ls two functions (1)
prevention of wound infection and (2) management of established
infection Microbes and toxins are removed from the wound and
tissue regeneration is promoted by removal of suppurative and
necrotic tissues Wound debridement the 1047297rst step and conserva-
tive treatment is a second
5 Conclusion
The treatment of facial gunshot injuries is performed in accor-
dance with the following principles
1) Evaluation of the woundedrsquos general clinical condition
2) Detailed examination of the wound by means of inspection
palpation and probing probe Within the 1047297rst few hours it may
be done without of any anaesthesia because tissue loses
sensitivity to pain due to local shock
3) Radical excision of wound borders to the point of active
capillary bleeding
4) Prevention of infection
5) Flap preparation if necessary
6) Primary closure of wounds with sutures and drainage
7) Application of button sutures if necessary
8) Physiotherapy
9) Massage
10) Therapeutic physical training
Ethics statements
This work has been approved by the appropriate ethical
committees related to the military hospital of Afghanistan in
1981e1985 where it wasperformed Subjects gave informed consent
Funding source
None
Con1047298ict of interest
None
References
Alexandrov NM Surgical debridement of modern gunshot wounds In Clinicaloperative maxillo-facial surgery L 1985 431e433 1985
Al-Shawi A Experience in the treatment of missile injuries of the maxillofacialregion in Iraq Brit J Oral Surg 24 244e250 1986
Berchenko GN Shaposhnikov JG Rudakov BJ Morphological characteristics of experimental wound treatment with collagen sponge In Study reparativeprocess and method them corrections Moscow Collection of Scienti1047297c Works 1MMI 81e84 1985
Berkutov AN Progress and management of traumatic and gunshot wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection MoscowMedicina 628e662 1990
Berkutov AN Modern gunshot wound Bulletin of AMS USSR 1 40e47 1975Callender GK Franch RW Wound ballistics studies in mechanism of wound
production by ri1047298e bullets Mil Surgeon 77 177e201 1935ChartesZ AC Charters AC Wounding mechanism of very high velocity projectiles
J Trauma 16 464e470 1976Davydovski IV Gunshot wounds in men M AMS USSR 1 360e362 1952Deriabin II Lytkin MI Basic principles of gunshot wound treatment Bulletin of
AMS USSR 3 52e56 1979Holt GR Kostohryz G Gunshot injuries to the head and neck Arch Otolaringol 109
313e318 1983Kostuchonok BM Karlov VA Clinic of woundsrsquo process In Kusin MI
Kostuchonok BM (eds) Wound and wound infection Moscow Medicina264e324 1990
Kousin MI Kostuchonok BM Karlov VA Treatment of suppurating wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection Moscow
Medicina 324e
484 1981Krizek T Robson M Evaluation of quantitative bacteriology in wound management
Am J Surg 130 579e584 1975Lukianenko AV Handbook of facial gunshot wound treatment Perm CLR The
Printerrsquos ldquoAsterrdquo 160 2010Marshall WG An analysis of 1047297rearm injuries to the head and face in Belfast Brit J
Oral Surg 24 233e243 1986Mechnikov II Pages of memoris vol 4 Moscow Medicina 137e161 1955OrsquoBrein DD Missile wounds Belfast 1971 Proc Roy Soc Med 66 292e294 1973Owen-Smith M Wounds caused by the weapons of war In Westby S (ed) Wound
care London W Heinemann 110e120 1985Pirogov NI General sources of military medicine vol 1 M -L Medgis 156 1941Reis ND Zinman C Besser MIB Shifrin LZ Rosen H A philosophy of limb salvage in
war use of external 1047297xator Milit Med 156 505e520 1991Rich NM Vietnam missile wounds evaluated in 750 patients Milit Med 133 9e22
1968Rybeck B Missile wounding and hemodynamic effects of energy absorption Acta
Chir Scand 450(Suppl) 1e32 1974Rudakov BJ Wounding mechanism of injuring projectiles In Shaposhnikov JG
(ed) Wound diagnostics and treatment 1984 21e
59 1984Shaposhnikov JG Rudakov BJ Gunshot wound pathogenesis and principles of their
surgical treatment Surgery 6 7e13 1986Shvyrkov MB Burenkov GI Demenkov VR Gunshot wounds of the face ENT
organs and neck In Manual for physicians vol 400 Moscow MeditsinaPublishers 15 2001
Shvyrkov MB Demenkov VR Microbial contamination of facial and neck gunshotwound Milit Med J 1 54e60 2003
Smoliannikov AB Pathological anatomy of gunshot trauma M Voenisdat p340e345 1960
Struchkov VI Modern aspects of in1047298ammation In International congress of surgeons 24-th M 1972 40e50 1972
Zbarge JP Gunshot wound of the mandible In Entin DA (ed) ) Experience of Soviet medicine in Great Patriotic war 1941e1945 ye vol 6 M Medgis163e165 1951
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e16
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 29
tissues wounds and 13 fractures of the facial skeleton In
Afghanistan these proportions were reversed In my 1047297rst manu-
script I would like to consider debridement of isolated gunshot
wounds of the face soft tissues of 502 (33 8) wounded In my 1047297rst
year in the central military hospital of Afghanistan I followed the
military-medical principles of cautious wound debridement
strictly It became clear to me that it was impossible to adhere to
these principles due to the use of new high velocity weaponry
Analysis of my results showed me that sparing soft tissue gunshot
wound debridement resulted in disability multiple surgical inter-
ventions and prolonged duration of treatment I performed radical
primary surgical debridement (RPSD) of gunshot wounds meaningexcision of soft tissuewound margins to the point of active capillary
bleeding This shows a normally functioning microcirculation
system in the remaining viable soft tissues which rapidly heal I
excised 3e5 mm and sometimes more of skin and mucous
membrane from wound walls Fat the most vulnerable tissue must
be excised more extensively I assessed muscle viability by the
strength of capillary bleeding and muscle jerk under the scalpel
Soft tissues have to be removed from the walls and depth of
a wound only then can successful drainage and closure be achieved
It is known that the critical concentration of microbes in
a wound is 105e106 microbes per gramme of tissue If the
concentration is increased acute purulent in1047298ammation develops
(Krizek and Robson 1975) Soft tissues excision together with
microbes decreases microbial load in a wound (Kousin et al 1981)
Microbiological examinations were performed in 235 wounds at
various times after injury from 1 h to 15 days Wound smears and
soft tissues samples from the wounds were placed into culture
medium (Shvyrkov and Demenkov 2003) Gunshot wounds were
not infected during the 1047297rst 12 h after injury Wounds were not
infected in 586e644 of the wounded within 3 days after injury
(Table 1)
Purulent in1047298ammation was found in 8 of 21 infected wounds on
the 1047297rst day only At 4e6 days after injury 707 of the wounded
were infected while suppuration happened in 561 of the wounds
Fig 1 There are three zones of tissues gunshot damages zone of primary necrosis
where cells of soft and bony tissues were perished in the wounding moment zone of
following (total) necrosis where cells metabolism stops and cells will perish the next
day zone of parabiosis where cells metabolism was braked to a great extent half of
these cells will be dead 2e3 days later line of demarcation arises here and 1047297nally zone
of healthy tissues Upper channel from old bullet down e from modern high velocity
bullet
Fig 2 Face gunshot wounds from mine explosion There are a few wound on left
forehead nose lip and cheek Several bubbles (blisters) because of burn 2 stage are
seen
Table 1
Bacterial 1047298ora availability in the face gunshot wound depending on period (term) of
wounding
Time after
injury
Patients quantity from total number in the line
Bacterial 1047298ora
is absent
Bacterial 1047298ora
is present
Altogether
patients
Quantity of
suppuration from
infected wounds
Up to 24 h 3864 4 2135 6 59 838 1
2e3 days 3458 6 2441 4 58 1562 5
4e6 days 1729 3 4170 7 58 2356 1
7e9 days 316 7 1583 3 18 746 7
10e12 days 321 4 1178 6 14 218 2
12e15 days 517 9 2382 1 28 14 3
Altogether 10042 6 13557 4 235 5623 8
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e9
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 39
At 12e15 days 821 of the wounds were infected but suppuration
occurred in only 43 At 15 days after injury bacterial 1047298ora was not
found in 426 of the wounds and suppurating infection occurred
in 415 It was assumed that microbial growth into a wound from
the skin requires a few days Skin around wounds was smeared
with a 2 iodine solution Microbial growth in the wound was not
found up to end of wound healing It is clear microbes need a few
days to grow from skin to wound
Smoliannikov (1960) measured the temperature of bullets shot
from a ri1047298e barrel It was 137e156 C As far as 600 m its temper-
ature decreased to 92e126 C Bullets travel at 600 m and in non-
penetrating unclothed facial wounds the wound is sterile
21 Primary debridement of the facial gunshot wound
A 1047298ying bullet presses air in front of itself forming a ldquofront
percussion waverdquo The bullet enters in soft tissue as a piston drives
forward the air tearing and separating the tissue A conical fountain
of ground and disintegrated tissue 1047298ies out in front of and behind
the bullet through the entrance and exit (Fig12) Thus microbes do
not remain in a wound Microbial cells on the skin surface and
tissue cells are killed by contact with bullet at high temperatures
Non-perforated and perforated soft tissues wounds which werenot in contact with a primary infected cavity (mouth nose and
accessory sinuses of nose) without bleeding and haematoma were
treated without incision of the canal These wounds were 1047297lled
with gauze saturated with proteolytic enzymes for 4e5 h with the
purpose of digesting of necrotic tissues and then 1047297lled with anti-
septic or antibiotic ointment Gauze with liniment balm Vishnevski
may be changed every 2e3 days with other medicines e once or
twice daily
In penetrating wounds there always are few non-perforated
canals created by foreign objects (splinters of bone teeth and
wounding projectiles) which are situated inside the canal These
canals must be cut and opened and the foreign object removed
Small wound infection (up to 106 microbes per gramme of tissue)
may be successfully liquidated with leucocytes but as was noted byMechnikov in 1883 (1955) a foreign body will divert part of
leucocytes toitselfIn areas of the face tissues where use of a scalpel
is contraindicated or it is impossible to incise canals without harm
for wounded (for example penetrating wound of neck lengthwise
or across of face etc) (Figs 3 and 4)
In the case enzymatic debridement is recommended Ribbon
gauze with proteoclastic enzymes in buffered solution (for diges-
tion of killed tissues) antibiotics or antiseptics must be inserted
into wound and canals in turns These medicines may be injected
around the wound For 4e5 following days it is necessary to
alternate gauze with enzymes for 3e5 h with gauze with liniment
balm Vishnevski or antiseptic liniment Usually the1047297rst granulation
tissue emerges on the 6th day and the wound may be closed with
delayed primary sutures If granulation tissues grow slowly lini-ment balm Vishnevski is poured into the wound without gauze
because it oppresses granulation tissues with its pressure After
2e3 days a canal is 1047297lled with granulation tissue and the wound is
ready for closure
Primary debridement of wound (PD) which is initially per-
formed by maxillofacial surgeon right after wounding should be
distinguished from a secondary (repeated) debridement (SD) per-
formed some time after PD was done if necessary Primary
debridement is subdivided into early PD which is performed up to
24 h after injury postponed PD e is carried out between 24 and
48 h and late PD performed 48 h or more after wounding Wound
closure was performed with continuous sutures on the tongue and
interruptedsutures in wounds in the sublingual region This may be
done through external wounds especially after splinting
Interrupted sutures were used for closure of oral cavity wound lips
ensuring continuity of the vermilion border muscles fat and skin
Wounds must be drained Local 1047298aps were utilised as necessary to
achieve primary closure (Fig 5ab Fig 6ae
c Fig 7ab Fig 8ab
Fig 3 Perforating missile wound of left cheek and mastoid process Wound entrance
is very small exit e about 4 cm diameter It should not to cut and open this canal
because crumbly tamponade with same medicines gives good result
Fig 4 Perforating missile wound from left maxilla to parotid notch (exit) with rupture
of soft palate How to cut and open this canal
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e10
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 49
Fig 9ab) Primary and secondary sutures are distinguished
depending on term wound stitching after PD Early primary suture
used in layers immediately after PD Late PD is an easier process
than early PD because 2e4 days later vital and non-vital tissue is
demarcated with a pink line on skin which can lead the surgeon toexcise non-vital tissue without damaging healing potential Post-
poned primary closure was performed 3e4 days after wound
debridement in the following cases (1) following debridement of
very contaminated wound (2) in suppurative in1047298ammation of
wound edges (3) in the absence of complete excision of necrotic
tissues These wounds were prepared with hypertonic solution
sodium chloride enzymes antiseptics antibiotics ointment lini-
ment balm Vishnevski and physical therapy (Fig 10)
Delayed primary suture was used every 6e7 days after PD in
slow cleaning wound and 1047297nally is covered with granulation
tissues Treatment of these wounds was the same
Early secondary closure after 8e16 days after PD was performed
if (1) the wound was covered with healthy granulation tissue
(2) pus debris and necrotic tissue were absent from the woundSoft unscarred tissue is mobile and easily manipulated Sometimes
only 1e2 mm of skin excision is required for good aesthetic scar
formation
Late secondaryclosurewas used rarelythat is17e31days afterPD
when (1) in1047298ammation is 1047297nished (2) granulation tissue has grown
(3) necrotic tissues separation has occurred very slowly (4) wound
borders start scarring and became tough with little mobility Soft
tissues must be mobilised with a scalpel before late closure Wound
size can be diminished with button sutures in (1) large defects of soft
tissues (2) large and heavy 1047298ap formation or (3) festering wound
edges These are either approximation (approaching) relaxation
(retention) or directive button suture used in accordance with wound
morphology Rubber stopper from antibiotics bottles lavsan thread is
used which is more comfortable than wire and buckshot In all cases
horizontal mattress sutures were used thrusting a needle into skin
2 cm away from wound border with stoppers on both sides of the
wound Approximation (approaching) button suture is used to bring
woundedgescloser gradually It is used in big wide wound or wounds
with in1047297ltrated borders when stitching is impossible (Fig 10) Afterstitching the surgeon brings wound edges together closure by hand
and the assistant knots the all threads ends together minimising the
woundbut it does remain open therefore it hasto be1047297lled with gauze
saturatedwith antisepticointmentor liniment balmVishnevski Every
2e4 days the surgeon brings wound edges closer and repositions the
suture knots Gauze with liniment balm Vishnevski may be changed
every the third day and with antiseptics or antibiotics e daily
Relaxation button sutures are applied to decrease skin tension
after wound stitching the thread ends are knotted together After
the procedure skin tension must be eliminated between button
sutures around of stitched up wound and skin tension may be
checked by 1047297nger
A directive suture is required after large 1047298ap repositioning
Intermittent wound lavage with solution antiseptic or antibioticthrough thin tubing gives good results Thirty-40 drops are infused
into wound hourly except for 6 h at night Two or three aspirating
needles are placed aroundthe wound for permanent drops infusion
of antibiotics solution or dioxidin solution
Radical primary surgical debridement of gunshot wounds is in
fact sparing debridement because dead tissue is removed and all
intact tissue is spared and retained free of purulent in1047298ammation
3 Results
In the 2-nd World War primary sutures were used in 130e150
of the wounded after sparing debridement The sutures destroyed
tissues and wound edges splayed in 500e770 patients (Zbarge
1951) Suppurative in1047298
ammation increases treatment time is
Fig 5 a e The old wound is bullet exit tangentional fracture of the mandible which was 1047297xed by device Rudko Tissuesrsquo 1047298aps were 1047297xed with two button sutures b e soft tissues
were cut off and defect was closed with bipolar scalp 1047298ap
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e11
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 59
accompanied with mental and physical trauma serious breach of
microcirculation system unsightly scarring and facial deformity
Radical PSD reduced wound infection by a factor of ten
compared to sapring debridement147 of the patients needed
local 1047298ap reconstruction during radical PSD (primarily operation) or
delayed plastic from remote area of patientrsquos body (bipolar scalp
1047298ap rope 1047298ap etc) 07 of the patients wounded were demobilised
from the army due to facial muscle paralysis ocular destruction and
impregnation of facial skin with gunpowder particles (Fig 11ab)
4 Discussion
Treatment of facial gunshot injuries especially wound debride-
ment is controversial There are two opposing approaches proposed
Some recommend economical cautious soft tissue excision with
planned secondary debridement (Alexandrov 1985 Berkutov 1975
Shaposhnikov and Rudakov 1986 Deriabin and Lytkin 1979 Owen-
Smith 1985 Rich 1968 Reis et al 1991) Others excise all necrotic
and soft tissue of dubious viability together with foreign bodies and
Fig 6 a e Wounded after mine explosion Apparatus Rudko 1047297xed the mandible fractured button sutures brought wound borders closer Neck skin was damaged too therefore it
could not be used for cheek restoration b e wounds are clean and 1047297lled with good succulent granulation c e monopolar pedicle 1047298ap from left humerus closes cheek wound d e
the same patient after 2 months
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e12
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 69
microbes to preventing in1047298ammation and toxaemia (OrsquoBrein 1973
Al-Shawi 1986 Shvyrkov et al2001) Only vital soft tissue should be
left in wound to withstand bacterial invasion Those in the1047297rst group
hold that it is impossible to distinguish dead from live tissue
However a microcirculation system supports tissue metabolism
This means that if there is active capillary bleeding after tissue
excision the tissue is alive Leaving necrotic tissue in wounds ignores
established surgical principles
However a certain relaxation in rigid attitude of military
doctorsrsquo 1047297
rst group sometimes is useful to meet Alexandrov (1985)
has written about delayed wound management ldquoRemoving
damaged tissues from the wound must be more extensive (does not
spare as require beforee MSh) those tissues which could be used
fordefect closure lose their vitality gradually and cannotbe used for
wound closurerdquo According to histopathological examination and
my experience these tissues lose their vitality at the time of injury
not 2e3 days later Histological alteration increases gradually and
necrosis becomes visible only after 2e3 days when a line of
demarcation appears The author disagrees with the position of
leading military doctors who excise tissue after necrosis has been
Fig 7 Z-plastic a e gunshot defect of lower lip b e defect liquidated with Z-plastic by Limberg
Fig 8 Wounded after perforating missile wound of the maxilla a e subtotal gunshot defect of nose b e bipolar tube 1047298ap sutured to a skin frontonasal notch c e after operation
1047297rst stage
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e13
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 79
Fig 9 a - Wounded with gunshot upper lip defect on right side due to gutter wounding b - local plastic of upper lip triangular musculocutaneous pedicle 1047298ap is cut out from lower
lip and moved to a defect of upper lip
Fig10 a e Old avulsive penetrating deep wound as a result of gutter wounding with in1047297ltrated borders b e after medical treatment wound become clean and closed with 1047297brin
ce wound borders were brought closer gradually by two approximation button sutures wound was 1047297lled with granulation tissue de thin narrow strip of skin (about 1 mm) was
cut off from wound borders (for borders refreshes) and wound closed with cooptation sutures
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e14
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 89
diagnosed The authorcontendsthat indirect lateral blow with high
velocity projectile inevitably causes tissue necrosis and considers
that cautious debridement leads to avoidable purulent in1047298amma-tion and unnecessary resource expenditure Reis et al (1991) rec-
ommended ldquo primary radical wound excision repeated every
48 h The wound is always left openrdquo This debridement cannot be
termed radical because this type of debridement requires multiple
surgical interventions
Differing from Berchenko et al (1985) and Shaposhnikov and
Rudakov 1986 the author has identi1047297ed three zones of gunshot
tissue damages a zone of primary necrosis where soft and bony
tissues are destroyed at the time of initial injury (4) a zone of
delayed necrosis where cell metabolism stops and cells perish the
day after initial injury (3) a zone of parabiosis where cells metab-
olism ceases to a great extent with cell death occurring 2e3 days
later the zone at which a line of demarcation arises (2) and 1047297nally
a zoneof healthy tissue(1) (Fig1) Dead anddyingtissues inevitably
remain in cautious debridement becoming an in1047298ammatory focus
suppuration starts These tissues became heterogeneous substance
for patientrsquos organism which tries to remove them by in1047298amma-
tion Leukocytes macrophages and tissues enzymes attack them A
bacterial 1047298ora develops lysing dead tissue and contributing to
wound cleaning Davydovski (1952) attached great importance to
microscopic1047298ora asa ldquobiological cleanerrdquo However acute purulent
in1047298ammation does not always happen Bleeding and local traumareduce tissue resistance creating favourable conditions for the
development of wound infection Kostuchonok and Karlov (1990)
stated ldquo purulent infection development is possibly only in
substrate availability for vital functions of microbes e tissues
necrosis haematoma etc Such situation happens more often in
inadequate wound debridementrdquo Acute in1047298ammation increases
tissue acidity collagen 1047297laments expand and weaken sutures start
to tear tissue wound edges diverge and the wound opens
The in1047298ammatory process is very expensive for a wounded
organism The mobilisation of leucocytes macrophages and oste-
oclasts expends much energy to demolish damaged tissue instead
of preserving this for healing The organism will reject the non-
viable tissues if they were not incised again expending energy
The appearance of a scar is also compromised by inadequatedebridement of the initial wound
The examination of the microbial growth con1047297rms the introduc-
tion of infection as a result of ingrowth of microbes from theskin not
as a result of their penetration with a bullet Most surgeons consider
all gunshot wounds to be infected This assumption is probably
correct if shreds of clothing have been incorporated in the wound
which less frequently occurs with facial wounds Shell-splinters are
hotter because explosion of the projectile occurs at higher temper-
atures In such penetrating wounds on the face ribbon gauze with
proteolytic enzymes is packed into the wound for 4e5 days the skin
is smeared with 2 iodine solution and covered with sterile gauze
Foreign object are thus encapsulated and healing occurs
Microbes take several days to grow from skin into a wound
When saliva 1047298ows into wound contamination occurs immediately
Fig 12 Conical fountain of ground and disintegrated tissues 1047298ies out in front and
behind of the bullet through entrance hole and outlet
Fig 11 a e Wounded after mine explosion with wounds burn and impregnation face and neck skin b e the same wounded there are a few granulated wounds on face and neck
and skin impregnation with burnt gunpowder both eyes were damaged
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e15
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 99
Damaged tissue cannot resist microbial invasion It is the author rsquos
practice to close intraoral wound with interrupted sutures and
isolate the wound from the oral cavity and saliva Skin grafts are
occasionally employed to allow closure of the mucosa Often
a surgeon adopts wait-and-see position and starts to use drugs
therapy on suppurating wounds or wounds covered with necrotic
tissue which is erroneous Surgical debridement of a wound must
always performed irrespective of clinical condition or the length of
time lapsed since the injury was sustained It is necessary to
remember that wound debridement ful1047297ls two functions (1)
prevention of wound infection and (2) management of established
infection Microbes and toxins are removed from the wound and
tissue regeneration is promoted by removal of suppurative and
necrotic tissues Wound debridement the 1047297rst step and conserva-
tive treatment is a second
5 Conclusion
The treatment of facial gunshot injuries is performed in accor-
dance with the following principles
1) Evaluation of the woundedrsquos general clinical condition
2) Detailed examination of the wound by means of inspection
palpation and probing probe Within the 1047297rst few hours it may
be done without of any anaesthesia because tissue loses
sensitivity to pain due to local shock
3) Radical excision of wound borders to the point of active
capillary bleeding
4) Prevention of infection
5) Flap preparation if necessary
6) Primary closure of wounds with sutures and drainage
7) Application of button sutures if necessary
8) Physiotherapy
9) Massage
10) Therapeutic physical training
Ethics statements
This work has been approved by the appropriate ethical
committees related to the military hospital of Afghanistan in
1981e1985 where it wasperformed Subjects gave informed consent
Funding source
None
Con1047298ict of interest
None
References
Alexandrov NM Surgical debridement of modern gunshot wounds In Clinicaloperative maxillo-facial surgery L 1985 431e433 1985
Al-Shawi A Experience in the treatment of missile injuries of the maxillofacialregion in Iraq Brit J Oral Surg 24 244e250 1986
Berchenko GN Shaposhnikov JG Rudakov BJ Morphological characteristics of experimental wound treatment with collagen sponge In Study reparativeprocess and method them corrections Moscow Collection of Scienti1047297c Works 1MMI 81e84 1985
Berkutov AN Progress and management of traumatic and gunshot wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection MoscowMedicina 628e662 1990
Berkutov AN Modern gunshot wound Bulletin of AMS USSR 1 40e47 1975Callender GK Franch RW Wound ballistics studies in mechanism of wound
production by ri1047298e bullets Mil Surgeon 77 177e201 1935ChartesZ AC Charters AC Wounding mechanism of very high velocity projectiles
J Trauma 16 464e470 1976Davydovski IV Gunshot wounds in men M AMS USSR 1 360e362 1952Deriabin II Lytkin MI Basic principles of gunshot wound treatment Bulletin of
AMS USSR 3 52e56 1979Holt GR Kostohryz G Gunshot injuries to the head and neck Arch Otolaringol 109
313e318 1983Kostuchonok BM Karlov VA Clinic of woundsrsquo process In Kusin MI
Kostuchonok BM (eds) Wound and wound infection Moscow Medicina264e324 1990
Kousin MI Kostuchonok BM Karlov VA Treatment of suppurating wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection Moscow
Medicina 324e
484 1981Krizek T Robson M Evaluation of quantitative bacteriology in wound management
Am J Surg 130 579e584 1975Lukianenko AV Handbook of facial gunshot wound treatment Perm CLR The
Printerrsquos ldquoAsterrdquo 160 2010Marshall WG An analysis of 1047297rearm injuries to the head and face in Belfast Brit J
Oral Surg 24 233e243 1986Mechnikov II Pages of memoris vol 4 Moscow Medicina 137e161 1955OrsquoBrein DD Missile wounds Belfast 1971 Proc Roy Soc Med 66 292e294 1973Owen-Smith M Wounds caused by the weapons of war In Westby S (ed) Wound
care London W Heinemann 110e120 1985Pirogov NI General sources of military medicine vol 1 M -L Medgis 156 1941Reis ND Zinman C Besser MIB Shifrin LZ Rosen H A philosophy of limb salvage in
war use of external 1047297xator Milit Med 156 505e520 1991Rich NM Vietnam missile wounds evaluated in 750 patients Milit Med 133 9e22
1968Rybeck B Missile wounding and hemodynamic effects of energy absorption Acta
Chir Scand 450(Suppl) 1e32 1974Rudakov BJ Wounding mechanism of injuring projectiles In Shaposhnikov JG
(ed) Wound diagnostics and treatment 1984 21e
59 1984Shaposhnikov JG Rudakov BJ Gunshot wound pathogenesis and principles of their
surgical treatment Surgery 6 7e13 1986Shvyrkov MB Burenkov GI Demenkov VR Gunshot wounds of the face ENT
organs and neck In Manual for physicians vol 400 Moscow MeditsinaPublishers 15 2001
Shvyrkov MB Demenkov VR Microbial contamination of facial and neck gunshotwound Milit Med J 1 54e60 2003
Smoliannikov AB Pathological anatomy of gunshot trauma M Voenisdat p340e345 1960
Struchkov VI Modern aspects of in1047298ammation In International congress of surgeons 24-th M 1972 40e50 1972
Zbarge JP Gunshot wound of the mandible In Entin DA (ed) ) Experience of Soviet medicine in Great Patriotic war 1941e1945 ye vol 6 M Medgis163e165 1951
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e16
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 39
At 12e15 days 821 of the wounds were infected but suppuration
occurred in only 43 At 15 days after injury bacterial 1047298ora was not
found in 426 of the wounds and suppurating infection occurred
in 415 It was assumed that microbial growth into a wound from
the skin requires a few days Skin around wounds was smeared
with a 2 iodine solution Microbial growth in the wound was not
found up to end of wound healing It is clear microbes need a few
days to grow from skin to wound
Smoliannikov (1960) measured the temperature of bullets shot
from a ri1047298e barrel It was 137e156 C As far as 600 m its temper-
ature decreased to 92e126 C Bullets travel at 600 m and in non-
penetrating unclothed facial wounds the wound is sterile
21 Primary debridement of the facial gunshot wound
A 1047298ying bullet presses air in front of itself forming a ldquofront
percussion waverdquo The bullet enters in soft tissue as a piston drives
forward the air tearing and separating the tissue A conical fountain
of ground and disintegrated tissue 1047298ies out in front of and behind
the bullet through the entrance and exit (Fig12) Thus microbes do
not remain in a wound Microbial cells on the skin surface and
tissue cells are killed by contact with bullet at high temperatures
Non-perforated and perforated soft tissues wounds which werenot in contact with a primary infected cavity (mouth nose and
accessory sinuses of nose) without bleeding and haematoma were
treated without incision of the canal These wounds were 1047297lled
with gauze saturated with proteolytic enzymes for 4e5 h with the
purpose of digesting of necrotic tissues and then 1047297lled with anti-
septic or antibiotic ointment Gauze with liniment balm Vishnevski
may be changed every 2e3 days with other medicines e once or
twice daily
In penetrating wounds there always are few non-perforated
canals created by foreign objects (splinters of bone teeth and
wounding projectiles) which are situated inside the canal These
canals must be cut and opened and the foreign object removed
Small wound infection (up to 106 microbes per gramme of tissue)
may be successfully liquidated with leucocytes but as was noted byMechnikov in 1883 (1955) a foreign body will divert part of
leucocytes toitselfIn areas of the face tissues where use of a scalpel
is contraindicated or it is impossible to incise canals without harm
for wounded (for example penetrating wound of neck lengthwise
or across of face etc) (Figs 3 and 4)
In the case enzymatic debridement is recommended Ribbon
gauze with proteoclastic enzymes in buffered solution (for diges-
tion of killed tissues) antibiotics or antiseptics must be inserted
into wound and canals in turns These medicines may be injected
around the wound For 4e5 following days it is necessary to
alternate gauze with enzymes for 3e5 h with gauze with liniment
balm Vishnevski or antiseptic liniment Usually the1047297rst granulation
tissue emerges on the 6th day and the wound may be closed with
delayed primary sutures If granulation tissues grow slowly lini-ment balm Vishnevski is poured into the wound without gauze
because it oppresses granulation tissues with its pressure After
2e3 days a canal is 1047297lled with granulation tissue and the wound is
ready for closure
Primary debridement of wound (PD) which is initially per-
formed by maxillofacial surgeon right after wounding should be
distinguished from a secondary (repeated) debridement (SD) per-
formed some time after PD was done if necessary Primary
debridement is subdivided into early PD which is performed up to
24 h after injury postponed PD e is carried out between 24 and
48 h and late PD performed 48 h or more after wounding Wound
closure was performed with continuous sutures on the tongue and
interruptedsutures in wounds in the sublingual region This may be
done through external wounds especially after splinting
Interrupted sutures were used for closure of oral cavity wound lips
ensuring continuity of the vermilion border muscles fat and skin
Wounds must be drained Local 1047298aps were utilised as necessary to
achieve primary closure (Fig 5ab Fig 6ae
c Fig 7ab Fig 8ab
Fig 3 Perforating missile wound of left cheek and mastoid process Wound entrance
is very small exit e about 4 cm diameter It should not to cut and open this canal
because crumbly tamponade with same medicines gives good result
Fig 4 Perforating missile wound from left maxilla to parotid notch (exit) with rupture
of soft palate How to cut and open this canal
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e10
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 49
Fig 9ab) Primary and secondary sutures are distinguished
depending on term wound stitching after PD Early primary suture
used in layers immediately after PD Late PD is an easier process
than early PD because 2e4 days later vital and non-vital tissue is
demarcated with a pink line on skin which can lead the surgeon toexcise non-vital tissue without damaging healing potential Post-
poned primary closure was performed 3e4 days after wound
debridement in the following cases (1) following debridement of
very contaminated wound (2) in suppurative in1047298ammation of
wound edges (3) in the absence of complete excision of necrotic
tissues These wounds were prepared with hypertonic solution
sodium chloride enzymes antiseptics antibiotics ointment lini-
ment balm Vishnevski and physical therapy (Fig 10)
Delayed primary suture was used every 6e7 days after PD in
slow cleaning wound and 1047297nally is covered with granulation
tissues Treatment of these wounds was the same
Early secondary closure after 8e16 days after PD was performed
if (1) the wound was covered with healthy granulation tissue
(2) pus debris and necrotic tissue were absent from the woundSoft unscarred tissue is mobile and easily manipulated Sometimes
only 1e2 mm of skin excision is required for good aesthetic scar
formation
Late secondaryclosurewas used rarelythat is17e31days afterPD
when (1) in1047298ammation is 1047297nished (2) granulation tissue has grown
(3) necrotic tissues separation has occurred very slowly (4) wound
borders start scarring and became tough with little mobility Soft
tissues must be mobilised with a scalpel before late closure Wound
size can be diminished with button sutures in (1) large defects of soft
tissues (2) large and heavy 1047298ap formation or (3) festering wound
edges These are either approximation (approaching) relaxation
(retention) or directive button suture used in accordance with wound
morphology Rubber stopper from antibiotics bottles lavsan thread is
used which is more comfortable than wire and buckshot In all cases
horizontal mattress sutures were used thrusting a needle into skin
2 cm away from wound border with stoppers on both sides of the
wound Approximation (approaching) button suture is used to bring
woundedgescloser gradually It is used in big wide wound or wounds
with in1047297ltrated borders when stitching is impossible (Fig 10) Afterstitching the surgeon brings wound edges together closure by hand
and the assistant knots the all threads ends together minimising the
woundbut it does remain open therefore it hasto be1047297lled with gauze
saturatedwith antisepticointmentor liniment balmVishnevski Every
2e4 days the surgeon brings wound edges closer and repositions the
suture knots Gauze with liniment balm Vishnevski may be changed
every the third day and with antiseptics or antibiotics e daily
Relaxation button sutures are applied to decrease skin tension
after wound stitching the thread ends are knotted together After
the procedure skin tension must be eliminated between button
sutures around of stitched up wound and skin tension may be
checked by 1047297nger
A directive suture is required after large 1047298ap repositioning
Intermittent wound lavage with solution antiseptic or antibioticthrough thin tubing gives good results Thirty-40 drops are infused
into wound hourly except for 6 h at night Two or three aspirating
needles are placed aroundthe wound for permanent drops infusion
of antibiotics solution or dioxidin solution
Radical primary surgical debridement of gunshot wounds is in
fact sparing debridement because dead tissue is removed and all
intact tissue is spared and retained free of purulent in1047298ammation
3 Results
In the 2-nd World War primary sutures were used in 130e150
of the wounded after sparing debridement The sutures destroyed
tissues and wound edges splayed in 500e770 patients (Zbarge
1951) Suppurative in1047298
ammation increases treatment time is
Fig 5 a e The old wound is bullet exit tangentional fracture of the mandible which was 1047297xed by device Rudko Tissuesrsquo 1047298aps were 1047297xed with two button sutures b e soft tissues
were cut off and defect was closed with bipolar scalp 1047298ap
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e11
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 59
accompanied with mental and physical trauma serious breach of
microcirculation system unsightly scarring and facial deformity
Radical PSD reduced wound infection by a factor of ten
compared to sapring debridement147 of the patients needed
local 1047298ap reconstruction during radical PSD (primarily operation) or
delayed plastic from remote area of patientrsquos body (bipolar scalp
1047298ap rope 1047298ap etc) 07 of the patients wounded were demobilised
from the army due to facial muscle paralysis ocular destruction and
impregnation of facial skin with gunpowder particles (Fig 11ab)
4 Discussion
Treatment of facial gunshot injuries especially wound debride-
ment is controversial There are two opposing approaches proposed
Some recommend economical cautious soft tissue excision with
planned secondary debridement (Alexandrov 1985 Berkutov 1975
Shaposhnikov and Rudakov 1986 Deriabin and Lytkin 1979 Owen-
Smith 1985 Rich 1968 Reis et al 1991) Others excise all necrotic
and soft tissue of dubious viability together with foreign bodies and
Fig 6 a e Wounded after mine explosion Apparatus Rudko 1047297xed the mandible fractured button sutures brought wound borders closer Neck skin was damaged too therefore it
could not be used for cheek restoration b e wounds are clean and 1047297lled with good succulent granulation c e monopolar pedicle 1047298ap from left humerus closes cheek wound d e
the same patient after 2 months
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e12
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 69
microbes to preventing in1047298ammation and toxaemia (OrsquoBrein 1973
Al-Shawi 1986 Shvyrkov et al2001) Only vital soft tissue should be
left in wound to withstand bacterial invasion Those in the1047297rst group
hold that it is impossible to distinguish dead from live tissue
However a microcirculation system supports tissue metabolism
This means that if there is active capillary bleeding after tissue
excision the tissue is alive Leaving necrotic tissue in wounds ignores
established surgical principles
However a certain relaxation in rigid attitude of military
doctorsrsquo 1047297
rst group sometimes is useful to meet Alexandrov (1985)
has written about delayed wound management ldquoRemoving
damaged tissues from the wound must be more extensive (does not
spare as require beforee MSh) those tissues which could be used
fordefect closure lose their vitality gradually and cannotbe used for
wound closurerdquo According to histopathological examination and
my experience these tissues lose their vitality at the time of injury
not 2e3 days later Histological alteration increases gradually and
necrosis becomes visible only after 2e3 days when a line of
demarcation appears The author disagrees with the position of
leading military doctors who excise tissue after necrosis has been
Fig 7 Z-plastic a e gunshot defect of lower lip b e defect liquidated with Z-plastic by Limberg
Fig 8 Wounded after perforating missile wound of the maxilla a e subtotal gunshot defect of nose b e bipolar tube 1047298ap sutured to a skin frontonasal notch c e after operation
1047297rst stage
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e13
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 79
Fig 9 a - Wounded with gunshot upper lip defect on right side due to gutter wounding b - local plastic of upper lip triangular musculocutaneous pedicle 1047298ap is cut out from lower
lip and moved to a defect of upper lip
Fig10 a e Old avulsive penetrating deep wound as a result of gutter wounding with in1047297ltrated borders b e after medical treatment wound become clean and closed with 1047297brin
ce wound borders were brought closer gradually by two approximation button sutures wound was 1047297lled with granulation tissue de thin narrow strip of skin (about 1 mm) was
cut off from wound borders (for borders refreshes) and wound closed with cooptation sutures
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e14
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 89
diagnosed The authorcontendsthat indirect lateral blow with high
velocity projectile inevitably causes tissue necrosis and considers
that cautious debridement leads to avoidable purulent in1047298amma-tion and unnecessary resource expenditure Reis et al (1991) rec-
ommended ldquo primary radical wound excision repeated every
48 h The wound is always left openrdquo This debridement cannot be
termed radical because this type of debridement requires multiple
surgical interventions
Differing from Berchenko et al (1985) and Shaposhnikov and
Rudakov 1986 the author has identi1047297ed three zones of gunshot
tissue damages a zone of primary necrosis where soft and bony
tissues are destroyed at the time of initial injury (4) a zone of
delayed necrosis where cell metabolism stops and cells perish the
day after initial injury (3) a zone of parabiosis where cells metab-
olism ceases to a great extent with cell death occurring 2e3 days
later the zone at which a line of demarcation arises (2) and 1047297nally
a zoneof healthy tissue(1) (Fig1) Dead anddyingtissues inevitably
remain in cautious debridement becoming an in1047298ammatory focus
suppuration starts These tissues became heterogeneous substance
for patientrsquos organism which tries to remove them by in1047298amma-
tion Leukocytes macrophages and tissues enzymes attack them A
bacterial 1047298ora develops lysing dead tissue and contributing to
wound cleaning Davydovski (1952) attached great importance to
microscopic1047298ora asa ldquobiological cleanerrdquo However acute purulent
in1047298ammation does not always happen Bleeding and local traumareduce tissue resistance creating favourable conditions for the
development of wound infection Kostuchonok and Karlov (1990)
stated ldquo purulent infection development is possibly only in
substrate availability for vital functions of microbes e tissues
necrosis haematoma etc Such situation happens more often in
inadequate wound debridementrdquo Acute in1047298ammation increases
tissue acidity collagen 1047297laments expand and weaken sutures start
to tear tissue wound edges diverge and the wound opens
The in1047298ammatory process is very expensive for a wounded
organism The mobilisation of leucocytes macrophages and oste-
oclasts expends much energy to demolish damaged tissue instead
of preserving this for healing The organism will reject the non-
viable tissues if they were not incised again expending energy
The appearance of a scar is also compromised by inadequatedebridement of the initial wound
The examination of the microbial growth con1047297rms the introduc-
tion of infection as a result of ingrowth of microbes from theskin not
as a result of their penetration with a bullet Most surgeons consider
all gunshot wounds to be infected This assumption is probably
correct if shreds of clothing have been incorporated in the wound
which less frequently occurs with facial wounds Shell-splinters are
hotter because explosion of the projectile occurs at higher temper-
atures In such penetrating wounds on the face ribbon gauze with
proteolytic enzymes is packed into the wound for 4e5 days the skin
is smeared with 2 iodine solution and covered with sterile gauze
Foreign object are thus encapsulated and healing occurs
Microbes take several days to grow from skin into a wound
When saliva 1047298ows into wound contamination occurs immediately
Fig 12 Conical fountain of ground and disintegrated tissues 1047298ies out in front and
behind of the bullet through entrance hole and outlet
Fig 11 a e Wounded after mine explosion with wounds burn and impregnation face and neck skin b e the same wounded there are a few granulated wounds on face and neck
and skin impregnation with burnt gunpowder both eyes were damaged
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e15
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 99
Damaged tissue cannot resist microbial invasion It is the author rsquos
practice to close intraoral wound with interrupted sutures and
isolate the wound from the oral cavity and saliva Skin grafts are
occasionally employed to allow closure of the mucosa Often
a surgeon adopts wait-and-see position and starts to use drugs
therapy on suppurating wounds or wounds covered with necrotic
tissue which is erroneous Surgical debridement of a wound must
always performed irrespective of clinical condition or the length of
time lapsed since the injury was sustained It is necessary to
remember that wound debridement ful1047297ls two functions (1)
prevention of wound infection and (2) management of established
infection Microbes and toxins are removed from the wound and
tissue regeneration is promoted by removal of suppurative and
necrotic tissues Wound debridement the 1047297rst step and conserva-
tive treatment is a second
5 Conclusion
The treatment of facial gunshot injuries is performed in accor-
dance with the following principles
1) Evaluation of the woundedrsquos general clinical condition
2) Detailed examination of the wound by means of inspection
palpation and probing probe Within the 1047297rst few hours it may
be done without of any anaesthesia because tissue loses
sensitivity to pain due to local shock
3) Radical excision of wound borders to the point of active
capillary bleeding
4) Prevention of infection
5) Flap preparation if necessary
6) Primary closure of wounds with sutures and drainage
7) Application of button sutures if necessary
8) Physiotherapy
9) Massage
10) Therapeutic physical training
Ethics statements
This work has been approved by the appropriate ethical
committees related to the military hospital of Afghanistan in
1981e1985 where it wasperformed Subjects gave informed consent
Funding source
None
Con1047298ict of interest
None
References
Alexandrov NM Surgical debridement of modern gunshot wounds In Clinicaloperative maxillo-facial surgery L 1985 431e433 1985
Al-Shawi A Experience in the treatment of missile injuries of the maxillofacialregion in Iraq Brit J Oral Surg 24 244e250 1986
Berchenko GN Shaposhnikov JG Rudakov BJ Morphological characteristics of experimental wound treatment with collagen sponge In Study reparativeprocess and method them corrections Moscow Collection of Scienti1047297c Works 1MMI 81e84 1985
Berkutov AN Progress and management of traumatic and gunshot wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection MoscowMedicina 628e662 1990
Berkutov AN Modern gunshot wound Bulletin of AMS USSR 1 40e47 1975Callender GK Franch RW Wound ballistics studies in mechanism of wound
production by ri1047298e bullets Mil Surgeon 77 177e201 1935ChartesZ AC Charters AC Wounding mechanism of very high velocity projectiles
J Trauma 16 464e470 1976Davydovski IV Gunshot wounds in men M AMS USSR 1 360e362 1952Deriabin II Lytkin MI Basic principles of gunshot wound treatment Bulletin of
AMS USSR 3 52e56 1979Holt GR Kostohryz G Gunshot injuries to the head and neck Arch Otolaringol 109
313e318 1983Kostuchonok BM Karlov VA Clinic of woundsrsquo process In Kusin MI
Kostuchonok BM (eds) Wound and wound infection Moscow Medicina264e324 1990
Kousin MI Kostuchonok BM Karlov VA Treatment of suppurating wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection Moscow
Medicina 324e
484 1981Krizek T Robson M Evaluation of quantitative bacteriology in wound management
Am J Surg 130 579e584 1975Lukianenko AV Handbook of facial gunshot wound treatment Perm CLR The
Printerrsquos ldquoAsterrdquo 160 2010Marshall WG An analysis of 1047297rearm injuries to the head and face in Belfast Brit J
Oral Surg 24 233e243 1986Mechnikov II Pages of memoris vol 4 Moscow Medicina 137e161 1955OrsquoBrein DD Missile wounds Belfast 1971 Proc Roy Soc Med 66 292e294 1973Owen-Smith M Wounds caused by the weapons of war In Westby S (ed) Wound
care London W Heinemann 110e120 1985Pirogov NI General sources of military medicine vol 1 M -L Medgis 156 1941Reis ND Zinman C Besser MIB Shifrin LZ Rosen H A philosophy of limb salvage in
war use of external 1047297xator Milit Med 156 505e520 1991Rich NM Vietnam missile wounds evaluated in 750 patients Milit Med 133 9e22
1968Rybeck B Missile wounding and hemodynamic effects of energy absorption Acta
Chir Scand 450(Suppl) 1e32 1974Rudakov BJ Wounding mechanism of injuring projectiles In Shaposhnikov JG
(ed) Wound diagnostics and treatment 1984 21e
59 1984Shaposhnikov JG Rudakov BJ Gunshot wound pathogenesis and principles of their
surgical treatment Surgery 6 7e13 1986Shvyrkov MB Burenkov GI Demenkov VR Gunshot wounds of the face ENT
organs and neck In Manual for physicians vol 400 Moscow MeditsinaPublishers 15 2001
Shvyrkov MB Demenkov VR Microbial contamination of facial and neck gunshotwound Milit Med J 1 54e60 2003
Smoliannikov AB Pathological anatomy of gunshot trauma M Voenisdat p340e345 1960
Struchkov VI Modern aspects of in1047298ammation In International congress of surgeons 24-th M 1972 40e50 1972
Zbarge JP Gunshot wound of the mandible In Entin DA (ed) ) Experience of Soviet medicine in Great Patriotic war 1941e1945 ye vol 6 M Medgis163e165 1951
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e16
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 49
Fig 9ab) Primary and secondary sutures are distinguished
depending on term wound stitching after PD Early primary suture
used in layers immediately after PD Late PD is an easier process
than early PD because 2e4 days later vital and non-vital tissue is
demarcated with a pink line on skin which can lead the surgeon toexcise non-vital tissue without damaging healing potential Post-
poned primary closure was performed 3e4 days after wound
debridement in the following cases (1) following debridement of
very contaminated wound (2) in suppurative in1047298ammation of
wound edges (3) in the absence of complete excision of necrotic
tissues These wounds were prepared with hypertonic solution
sodium chloride enzymes antiseptics antibiotics ointment lini-
ment balm Vishnevski and physical therapy (Fig 10)
Delayed primary suture was used every 6e7 days after PD in
slow cleaning wound and 1047297nally is covered with granulation
tissues Treatment of these wounds was the same
Early secondary closure after 8e16 days after PD was performed
if (1) the wound was covered with healthy granulation tissue
(2) pus debris and necrotic tissue were absent from the woundSoft unscarred tissue is mobile and easily manipulated Sometimes
only 1e2 mm of skin excision is required for good aesthetic scar
formation
Late secondaryclosurewas used rarelythat is17e31days afterPD
when (1) in1047298ammation is 1047297nished (2) granulation tissue has grown
(3) necrotic tissues separation has occurred very slowly (4) wound
borders start scarring and became tough with little mobility Soft
tissues must be mobilised with a scalpel before late closure Wound
size can be diminished with button sutures in (1) large defects of soft
tissues (2) large and heavy 1047298ap formation or (3) festering wound
edges These are either approximation (approaching) relaxation
(retention) or directive button suture used in accordance with wound
morphology Rubber stopper from antibiotics bottles lavsan thread is
used which is more comfortable than wire and buckshot In all cases
horizontal mattress sutures were used thrusting a needle into skin
2 cm away from wound border with stoppers on both sides of the
wound Approximation (approaching) button suture is used to bring
woundedgescloser gradually It is used in big wide wound or wounds
with in1047297ltrated borders when stitching is impossible (Fig 10) Afterstitching the surgeon brings wound edges together closure by hand
and the assistant knots the all threads ends together minimising the
woundbut it does remain open therefore it hasto be1047297lled with gauze
saturatedwith antisepticointmentor liniment balmVishnevski Every
2e4 days the surgeon brings wound edges closer and repositions the
suture knots Gauze with liniment balm Vishnevski may be changed
every the third day and with antiseptics or antibiotics e daily
Relaxation button sutures are applied to decrease skin tension
after wound stitching the thread ends are knotted together After
the procedure skin tension must be eliminated between button
sutures around of stitched up wound and skin tension may be
checked by 1047297nger
A directive suture is required after large 1047298ap repositioning
Intermittent wound lavage with solution antiseptic or antibioticthrough thin tubing gives good results Thirty-40 drops are infused
into wound hourly except for 6 h at night Two or three aspirating
needles are placed aroundthe wound for permanent drops infusion
of antibiotics solution or dioxidin solution
Radical primary surgical debridement of gunshot wounds is in
fact sparing debridement because dead tissue is removed and all
intact tissue is spared and retained free of purulent in1047298ammation
3 Results
In the 2-nd World War primary sutures were used in 130e150
of the wounded after sparing debridement The sutures destroyed
tissues and wound edges splayed in 500e770 patients (Zbarge
1951) Suppurative in1047298
ammation increases treatment time is
Fig 5 a e The old wound is bullet exit tangentional fracture of the mandible which was 1047297xed by device Rudko Tissuesrsquo 1047298aps were 1047297xed with two button sutures b e soft tissues
were cut off and defect was closed with bipolar scalp 1047298ap
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e11
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 59
accompanied with mental and physical trauma serious breach of
microcirculation system unsightly scarring and facial deformity
Radical PSD reduced wound infection by a factor of ten
compared to sapring debridement147 of the patients needed
local 1047298ap reconstruction during radical PSD (primarily operation) or
delayed plastic from remote area of patientrsquos body (bipolar scalp
1047298ap rope 1047298ap etc) 07 of the patients wounded were demobilised
from the army due to facial muscle paralysis ocular destruction and
impregnation of facial skin with gunpowder particles (Fig 11ab)
4 Discussion
Treatment of facial gunshot injuries especially wound debride-
ment is controversial There are two opposing approaches proposed
Some recommend economical cautious soft tissue excision with
planned secondary debridement (Alexandrov 1985 Berkutov 1975
Shaposhnikov and Rudakov 1986 Deriabin and Lytkin 1979 Owen-
Smith 1985 Rich 1968 Reis et al 1991) Others excise all necrotic
and soft tissue of dubious viability together with foreign bodies and
Fig 6 a e Wounded after mine explosion Apparatus Rudko 1047297xed the mandible fractured button sutures brought wound borders closer Neck skin was damaged too therefore it
could not be used for cheek restoration b e wounds are clean and 1047297lled with good succulent granulation c e monopolar pedicle 1047298ap from left humerus closes cheek wound d e
the same patient after 2 months
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e12
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 69
microbes to preventing in1047298ammation and toxaemia (OrsquoBrein 1973
Al-Shawi 1986 Shvyrkov et al2001) Only vital soft tissue should be
left in wound to withstand bacterial invasion Those in the1047297rst group
hold that it is impossible to distinguish dead from live tissue
However a microcirculation system supports tissue metabolism
This means that if there is active capillary bleeding after tissue
excision the tissue is alive Leaving necrotic tissue in wounds ignores
established surgical principles
However a certain relaxation in rigid attitude of military
doctorsrsquo 1047297
rst group sometimes is useful to meet Alexandrov (1985)
has written about delayed wound management ldquoRemoving
damaged tissues from the wound must be more extensive (does not
spare as require beforee MSh) those tissues which could be used
fordefect closure lose their vitality gradually and cannotbe used for
wound closurerdquo According to histopathological examination and
my experience these tissues lose their vitality at the time of injury
not 2e3 days later Histological alteration increases gradually and
necrosis becomes visible only after 2e3 days when a line of
demarcation appears The author disagrees with the position of
leading military doctors who excise tissue after necrosis has been
Fig 7 Z-plastic a e gunshot defect of lower lip b e defect liquidated with Z-plastic by Limberg
Fig 8 Wounded after perforating missile wound of the maxilla a e subtotal gunshot defect of nose b e bipolar tube 1047298ap sutured to a skin frontonasal notch c e after operation
1047297rst stage
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e13
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 79
Fig 9 a - Wounded with gunshot upper lip defect on right side due to gutter wounding b - local plastic of upper lip triangular musculocutaneous pedicle 1047298ap is cut out from lower
lip and moved to a defect of upper lip
Fig10 a e Old avulsive penetrating deep wound as a result of gutter wounding with in1047297ltrated borders b e after medical treatment wound become clean and closed with 1047297brin
ce wound borders were brought closer gradually by two approximation button sutures wound was 1047297lled with granulation tissue de thin narrow strip of skin (about 1 mm) was
cut off from wound borders (for borders refreshes) and wound closed with cooptation sutures
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e14
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 89
diagnosed The authorcontendsthat indirect lateral blow with high
velocity projectile inevitably causes tissue necrosis and considers
that cautious debridement leads to avoidable purulent in1047298amma-tion and unnecessary resource expenditure Reis et al (1991) rec-
ommended ldquo primary radical wound excision repeated every
48 h The wound is always left openrdquo This debridement cannot be
termed radical because this type of debridement requires multiple
surgical interventions
Differing from Berchenko et al (1985) and Shaposhnikov and
Rudakov 1986 the author has identi1047297ed three zones of gunshot
tissue damages a zone of primary necrosis where soft and bony
tissues are destroyed at the time of initial injury (4) a zone of
delayed necrosis where cell metabolism stops and cells perish the
day after initial injury (3) a zone of parabiosis where cells metab-
olism ceases to a great extent with cell death occurring 2e3 days
later the zone at which a line of demarcation arises (2) and 1047297nally
a zoneof healthy tissue(1) (Fig1) Dead anddyingtissues inevitably
remain in cautious debridement becoming an in1047298ammatory focus
suppuration starts These tissues became heterogeneous substance
for patientrsquos organism which tries to remove them by in1047298amma-
tion Leukocytes macrophages and tissues enzymes attack them A
bacterial 1047298ora develops lysing dead tissue and contributing to
wound cleaning Davydovski (1952) attached great importance to
microscopic1047298ora asa ldquobiological cleanerrdquo However acute purulent
in1047298ammation does not always happen Bleeding and local traumareduce tissue resistance creating favourable conditions for the
development of wound infection Kostuchonok and Karlov (1990)
stated ldquo purulent infection development is possibly only in
substrate availability for vital functions of microbes e tissues
necrosis haematoma etc Such situation happens more often in
inadequate wound debridementrdquo Acute in1047298ammation increases
tissue acidity collagen 1047297laments expand and weaken sutures start
to tear tissue wound edges diverge and the wound opens
The in1047298ammatory process is very expensive for a wounded
organism The mobilisation of leucocytes macrophages and oste-
oclasts expends much energy to demolish damaged tissue instead
of preserving this for healing The organism will reject the non-
viable tissues if they were not incised again expending energy
The appearance of a scar is also compromised by inadequatedebridement of the initial wound
The examination of the microbial growth con1047297rms the introduc-
tion of infection as a result of ingrowth of microbes from theskin not
as a result of their penetration with a bullet Most surgeons consider
all gunshot wounds to be infected This assumption is probably
correct if shreds of clothing have been incorporated in the wound
which less frequently occurs with facial wounds Shell-splinters are
hotter because explosion of the projectile occurs at higher temper-
atures In such penetrating wounds on the face ribbon gauze with
proteolytic enzymes is packed into the wound for 4e5 days the skin
is smeared with 2 iodine solution and covered with sterile gauze
Foreign object are thus encapsulated and healing occurs
Microbes take several days to grow from skin into a wound
When saliva 1047298ows into wound contamination occurs immediately
Fig 12 Conical fountain of ground and disintegrated tissues 1047298ies out in front and
behind of the bullet through entrance hole and outlet
Fig 11 a e Wounded after mine explosion with wounds burn and impregnation face and neck skin b e the same wounded there are a few granulated wounds on face and neck
and skin impregnation with burnt gunpowder both eyes were damaged
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e15
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 99
Damaged tissue cannot resist microbial invasion It is the author rsquos
practice to close intraoral wound with interrupted sutures and
isolate the wound from the oral cavity and saliva Skin grafts are
occasionally employed to allow closure of the mucosa Often
a surgeon adopts wait-and-see position and starts to use drugs
therapy on suppurating wounds or wounds covered with necrotic
tissue which is erroneous Surgical debridement of a wound must
always performed irrespective of clinical condition or the length of
time lapsed since the injury was sustained It is necessary to
remember that wound debridement ful1047297ls two functions (1)
prevention of wound infection and (2) management of established
infection Microbes and toxins are removed from the wound and
tissue regeneration is promoted by removal of suppurative and
necrotic tissues Wound debridement the 1047297rst step and conserva-
tive treatment is a second
5 Conclusion
The treatment of facial gunshot injuries is performed in accor-
dance with the following principles
1) Evaluation of the woundedrsquos general clinical condition
2) Detailed examination of the wound by means of inspection
palpation and probing probe Within the 1047297rst few hours it may
be done without of any anaesthesia because tissue loses
sensitivity to pain due to local shock
3) Radical excision of wound borders to the point of active
capillary bleeding
4) Prevention of infection
5) Flap preparation if necessary
6) Primary closure of wounds with sutures and drainage
7) Application of button sutures if necessary
8) Physiotherapy
9) Massage
10) Therapeutic physical training
Ethics statements
This work has been approved by the appropriate ethical
committees related to the military hospital of Afghanistan in
1981e1985 where it wasperformed Subjects gave informed consent
Funding source
None
Con1047298ict of interest
None
References
Alexandrov NM Surgical debridement of modern gunshot wounds In Clinicaloperative maxillo-facial surgery L 1985 431e433 1985
Al-Shawi A Experience in the treatment of missile injuries of the maxillofacialregion in Iraq Brit J Oral Surg 24 244e250 1986
Berchenko GN Shaposhnikov JG Rudakov BJ Morphological characteristics of experimental wound treatment with collagen sponge In Study reparativeprocess and method them corrections Moscow Collection of Scienti1047297c Works 1MMI 81e84 1985
Berkutov AN Progress and management of traumatic and gunshot wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection MoscowMedicina 628e662 1990
Berkutov AN Modern gunshot wound Bulletin of AMS USSR 1 40e47 1975Callender GK Franch RW Wound ballistics studies in mechanism of wound
production by ri1047298e bullets Mil Surgeon 77 177e201 1935ChartesZ AC Charters AC Wounding mechanism of very high velocity projectiles
J Trauma 16 464e470 1976Davydovski IV Gunshot wounds in men M AMS USSR 1 360e362 1952Deriabin II Lytkin MI Basic principles of gunshot wound treatment Bulletin of
AMS USSR 3 52e56 1979Holt GR Kostohryz G Gunshot injuries to the head and neck Arch Otolaringol 109
313e318 1983Kostuchonok BM Karlov VA Clinic of woundsrsquo process In Kusin MI
Kostuchonok BM (eds) Wound and wound infection Moscow Medicina264e324 1990
Kousin MI Kostuchonok BM Karlov VA Treatment of suppurating wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection Moscow
Medicina 324e
484 1981Krizek T Robson M Evaluation of quantitative bacteriology in wound management
Am J Surg 130 579e584 1975Lukianenko AV Handbook of facial gunshot wound treatment Perm CLR The
Printerrsquos ldquoAsterrdquo 160 2010Marshall WG An analysis of 1047297rearm injuries to the head and face in Belfast Brit J
Oral Surg 24 233e243 1986Mechnikov II Pages of memoris vol 4 Moscow Medicina 137e161 1955OrsquoBrein DD Missile wounds Belfast 1971 Proc Roy Soc Med 66 292e294 1973Owen-Smith M Wounds caused by the weapons of war In Westby S (ed) Wound
care London W Heinemann 110e120 1985Pirogov NI General sources of military medicine vol 1 M -L Medgis 156 1941Reis ND Zinman C Besser MIB Shifrin LZ Rosen H A philosophy of limb salvage in
war use of external 1047297xator Milit Med 156 505e520 1991Rich NM Vietnam missile wounds evaluated in 750 patients Milit Med 133 9e22
1968Rybeck B Missile wounding and hemodynamic effects of energy absorption Acta
Chir Scand 450(Suppl) 1e32 1974Rudakov BJ Wounding mechanism of injuring projectiles In Shaposhnikov JG
(ed) Wound diagnostics and treatment 1984 21e
59 1984Shaposhnikov JG Rudakov BJ Gunshot wound pathogenesis and principles of their
surgical treatment Surgery 6 7e13 1986Shvyrkov MB Burenkov GI Demenkov VR Gunshot wounds of the face ENT
organs and neck In Manual for physicians vol 400 Moscow MeditsinaPublishers 15 2001
Shvyrkov MB Demenkov VR Microbial contamination of facial and neck gunshotwound Milit Med J 1 54e60 2003
Smoliannikov AB Pathological anatomy of gunshot trauma M Voenisdat p340e345 1960
Struchkov VI Modern aspects of in1047298ammation In International congress of surgeons 24-th M 1972 40e50 1972
Zbarge JP Gunshot wound of the mandible In Entin DA (ed) ) Experience of Soviet medicine in Great Patriotic war 1941e1945 ye vol 6 M Medgis163e165 1951
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e16
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 59
accompanied with mental and physical trauma serious breach of
microcirculation system unsightly scarring and facial deformity
Radical PSD reduced wound infection by a factor of ten
compared to sapring debridement147 of the patients needed
local 1047298ap reconstruction during radical PSD (primarily operation) or
delayed plastic from remote area of patientrsquos body (bipolar scalp
1047298ap rope 1047298ap etc) 07 of the patients wounded were demobilised
from the army due to facial muscle paralysis ocular destruction and
impregnation of facial skin with gunpowder particles (Fig 11ab)
4 Discussion
Treatment of facial gunshot injuries especially wound debride-
ment is controversial There are two opposing approaches proposed
Some recommend economical cautious soft tissue excision with
planned secondary debridement (Alexandrov 1985 Berkutov 1975
Shaposhnikov and Rudakov 1986 Deriabin and Lytkin 1979 Owen-
Smith 1985 Rich 1968 Reis et al 1991) Others excise all necrotic
and soft tissue of dubious viability together with foreign bodies and
Fig 6 a e Wounded after mine explosion Apparatus Rudko 1047297xed the mandible fractured button sutures brought wound borders closer Neck skin was damaged too therefore it
could not be used for cheek restoration b e wounds are clean and 1047297lled with good succulent granulation c e monopolar pedicle 1047298ap from left humerus closes cheek wound d e
the same patient after 2 months
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e12
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 69
microbes to preventing in1047298ammation and toxaemia (OrsquoBrein 1973
Al-Shawi 1986 Shvyrkov et al2001) Only vital soft tissue should be
left in wound to withstand bacterial invasion Those in the1047297rst group
hold that it is impossible to distinguish dead from live tissue
However a microcirculation system supports tissue metabolism
This means that if there is active capillary bleeding after tissue
excision the tissue is alive Leaving necrotic tissue in wounds ignores
established surgical principles
However a certain relaxation in rigid attitude of military
doctorsrsquo 1047297
rst group sometimes is useful to meet Alexandrov (1985)
has written about delayed wound management ldquoRemoving
damaged tissues from the wound must be more extensive (does not
spare as require beforee MSh) those tissues which could be used
fordefect closure lose their vitality gradually and cannotbe used for
wound closurerdquo According to histopathological examination and
my experience these tissues lose their vitality at the time of injury
not 2e3 days later Histological alteration increases gradually and
necrosis becomes visible only after 2e3 days when a line of
demarcation appears The author disagrees with the position of
leading military doctors who excise tissue after necrosis has been
Fig 7 Z-plastic a e gunshot defect of lower lip b e defect liquidated with Z-plastic by Limberg
Fig 8 Wounded after perforating missile wound of the maxilla a e subtotal gunshot defect of nose b e bipolar tube 1047298ap sutured to a skin frontonasal notch c e after operation
1047297rst stage
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e13
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 79
Fig 9 a - Wounded with gunshot upper lip defect on right side due to gutter wounding b - local plastic of upper lip triangular musculocutaneous pedicle 1047298ap is cut out from lower
lip and moved to a defect of upper lip
Fig10 a e Old avulsive penetrating deep wound as a result of gutter wounding with in1047297ltrated borders b e after medical treatment wound become clean and closed with 1047297brin
ce wound borders were brought closer gradually by two approximation button sutures wound was 1047297lled with granulation tissue de thin narrow strip of skin (about 1 mm) was
cut off from wound borders (for borders refreshes) and wound closed with cooptation sutures
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e14
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 89
diagnosed The authorcontendsthat indirect lateral blow with high
velocity projectile inevitably causes tissue necrosis and considers
that cautious debridement leads to avoidable purulent in1047298amma-tion and unnecessary resource expenditure Reis et al (1991) rec-
ommended ldquo primary radical wound excision repeated every
48 h The wound is always left openrdquo This debridement cannot be
termed radical because this type of debridement requires multiple
surgical interventions
Differing from Berchenko et al (1985) and Shaposhnikov and
Rudakov 1986 the author has identi1047297ed three zones of gunshot
tissue damages a zone of primary necrosis where soft and bony
tissues are destroyed at the time of initial injury (4) a zone of
delayed necrosis where cell metabolism stops and cells perish the
day after initial injury (3) a zone of parabiosis where cells metab-
olism ceases to a great extent with cell death occurring 2e3 days
later the zone at which a line of demarcation arises (2) and 1047297nally
a zoneof healthy tissue(1) (Fig1) Dead anddyingtissues inevitably
remain in cautious debridement becoming an in1047298ammatory focus
suppuration starts These tissues became heterogeneous substance
for patientrsquos organism which tries to remove them by in1047298amma-
tion Leukocytes macrophages and tissues enzymes attack them A
bacterial 1047298ora develops lysing dead tissue and contributing to
wound cleaning Davydovski (1952) attached great importance to
microscopic1047298ora asa ldquobiological cleanerrdquo However acute purulent
in1047298ammation does not always happen Bleeding and local traumareduce tissue resistance creating favourable conditions for the
development of wound infection Kostuchonok and Karlov (1990)
stated ldquo purulent infection development is possibly only in
substrate availability for vital functions of microbes e tissues
necrosis haematoma etc Such situation happens more often in
inadequate wound debridementrdquo Acute in1047298ammation increases
tissue acidity collagen 1047297laments expand and weaken sutures start
to tear tissue wound edges diverge and the wound opens
The in1047298ammatory process is very expensive for a wounded
organism The mobilisation of leucocytes macrophages and oste-
oclasts expends much energy to demolish damaged tissue instead
of preserving this for healing The organism will reject the non-
viable tissues if they were not incised again expending energy
The appearance of a scar is also compromised by inadequatedebridement of the initial wound
The examination of the microbial growth con1047297rms the introduc-
tion of infection as a result of ingrowth of microbes from theskin not
as a result of their penetration with a bullet Most surgeons consider
all gunshot wounds to be infected This assumption is probably
correct if shreds of clothing have been incorporated in the wound
which less frequently occurs with facial wounds Shell-splinters are
hotter because explosion of the projectile occurs at higher temper-
atures In such penetrating wounds on the face ribbon gauze with
proteolytic enzymes is packed into the wound for 4e5 days the skin
is smeared with 2 iodine solution and covered with sterile gauze
Foreign object are thus encapsulated and healing occurs
Microbes take several days to grow from skin into a wound
When saliva 1047298ows into wound contamination occurs immediately
Fig 12 Conical fountain of ground and disintegrated tissues 1047298ies out in front and
behind of the bullet through entrance hole and outlet
Fig 11 a e Wounded after mine explosion with wounds burn and impregnation face and neck skin b e the same wounded there are a few granulated wounds on face and neck
and skin impregnation with burnt gunpowder both eyes were damaged
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e15
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 99
Damaged tissue cannot resist microbial invasion It is the author rsquos
practice to close intraoral wound with interrupted sutures and
isolate the wound from the oral cavity and saliva Skin grafts are
occasionally employed to allow closure of the mucosa Often
a surgeon adopts wait-and-see position and starts to use drugs
therapy on suppurating wounds or wounds covered with necrotic
tissue which is erroneous Surgical debridement of a wound must
always performed irrespective of clinical condition or the length of
time lapsed since the injury was sustained It is necessary to
remember that wound debridement ful1047297ls two functions (1)
prevention of wound infection and (2) management of established
infection Microbes and toxins are removed from the wound and
tissue regeneration is promoted by removal of suppurative and
necrotic tissues Wound debridement the 1047297rst step and conserva-
tive treatment is a second
5 Conclusion
The treatment of facial gunshot injuries is performed in accor-
dance with the following principles
1) Evaluation of the woundedrsquos general clinical condition
2) Detailed examination of the wound by means of inspection
palpation and probing probe Within the 1047297rst few hours it may
be done without of any anaesthesia because tissue loses
sensitivity to pain due to local shock
3) Radical excision of wound borders to the point of active
capillary bleeding
4) Prevention of infection
5) Flap preparation if necessary
6) Primary closure of wounds with sutures and drainage
7) Application of button sutures if necessary
8) Physiotherapy
9) Massage
10) Therapeutic physical training
Ethics statements
This work has been approved by the appropriate ethical
committees related to the military hospital of Afghanistan in
1981e1985 where it wasperformed Subjects gave informed consent
Funding source
None
Con1047298ict of interest
None
References
Alexandrov NM Surgical debridement of modern gunshot wounds In Clinicaloperative maxillo-facial surgery L 1985 431e433 1985
Al-Shawi A Experience in the treatment of missile injuries of the maxillofacialregion in Iraq Brit J Oral Surg 24 244e250 1986
Berchenko GN Shaposhnikov JG Rudakov BJ Morphological characteristics of experimental wound treatment with collagen sponge In Study reparativeprocess and method them corrections Moscow Collection of Scienti1047297c Works 1MMI 81e84 1985
Berkutov AN Progress and management of traumatic and gunshot wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection MoscowMedicina 628e662 1990
Berkutov AN Modern gunshot wound Bulletin of AMS USSR 1 40e47 1975Callender GK Franch RW Wound ballistics studies in mechanism of wound
production by ri1047298e bullets Mil Surgeon 77 177e201 1935ChartesZ AC Charters AC Wounding mechanism of very high velocity projectiles
J Trauma 16 464e470 1976Davydovski IV Gunshot wounds in men M AMS USSR 1 360e362 1952Deriabin II Lytkin MI Basic principles of gunshot wound treatment Bulletin of
AMS USSR 3 52e56 1979Holt GR Kostohryz G Gunshot injuries to the head and neck Arch Otolaringol 109
313e318 1983Kostuchonok BM Karlov VA Clinic of woundsrsquo process In Kusin MI
Kostuchonok BM (eds) Wound and wound infection Moscow Medicina264e324 1990
Kousin MI Kostuchonok BM Karlov VA Treatment of suppurating wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection Moscow
Medicina 324e
484 1981Krizek T Robson M Evaluation of quantitative bacteriology in wound management
Am J Surg 130 579e584 1975Lukianenko AV Handbook of facial gunshot wound treatment Perm CLR The
Printerrsquos ldquoAsterrdquo 160 2010Marshall WG An analysis of 1047297rearm injuries to the head and face in Belfast Brit J
Oral Surg 24 233e243 1986Mechnikov II Pages of memoris vol 4 Moscow Medicina 137e161 1955OrsquoBrein DD Missile wounds Belfast 1971 Proc Roy Soc Med 66 292e294 1973Owen-Smith M Wounds caused by the weapons of war In Westby S (ed) Wound
care London W Heinemann 110e120 1985Pirogov NI General sources of military medicine vol 1 M -L Medgis 156 1941Reis ND Zinman C Besser MIB Shifrin LZ Rosen H A philosophy of limb salvage in
war use of external 1047297xator Milit Med 156 505e520 1991Rich NM Vietnam missile wounds evaluated in 750 patients Milit Med 133 9e22
1968Rybeck B Missile wounding and hemodynamic effects of energy absorption Acta
Chir Scand 450(Suppl) 1e32 1974Rudakov BJ Wounding mechanism of injuring projectiles In Shaposhnikov JG
(ed) Wound diagnostics and treatment 1984 21e
59 1984Shaposhnikov JG Rudakov BJ Gunshot wound pathogenesis and principles of their
surgical treatment Surgery 6 7e13 1986Shvyrkov MB Burenkov GI Demenkov VR Gunshot wounds of the face ENT
organs and neck In Manual for physicians vol 400 Moscow MeditsinaPublishers 15 2001
Shvyrkov MB Demenkov VR Microbial contamination of facial and neck gunshotwound Milit Med J 1 54e60 2003
Smoliannikov AB Pathological anatomy of gunshot trauma M Voenisdat p340e345 1960
Struchkov VI Modern aspects of in1047298ammation In International congress of surgeons 24-th M 1972 40e50 1972
Zbarge JP Gunshot wound of the mandible In Entin DA (ed) ) Experience of Soviet medicine in Great Patriotic war 1941e1945 ye vol 6 M Medgis163e165 1951
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e16
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 69
microbes to preventing in1047298ammation and toxaemia (OrsquoBrein 1973
Al-Shawi 1986 Shvyrkov et al2001) Only vital soft tissue should be
left in wound to withstand bacterial invasion Those in the1047297rst group
hold that it is impossible to distinguish dead from live tissue
However a microcirculation system supports tissue metabolism
This means that if there is active capillary bleeding after tissue
excision the tissue is alive Leaving necrotic tissue in wounds ignores
established surgical principles
However a certain relaxation in rigid attitude of military
doctorsrsquo 1047297
rst group sometimes is useful to meet Alexandrov (1985)
has written about delayed wound management ldquoRemoving
damaged tissues from the wound must be more extensive (does not
spare as require beforee MSh) those tissues which could be used
fordefect closure lose their vitality gradually and cannotbe used for
wound closurerdquo According to histopathological examination and
my experience these tissues lose their vitality at the time of injury
not 2e3 days later Histological alteration increases gradually and
necrosis becomes visible only after 2e3 days when a line of
demarcation appears The author disagrees with the position of
leading military doctors who excise tissue after necrosis has been
Fig 7 Z-plastic a e gunshot defect of lower lip b e defect liquidated with Z-plastic by Limberg
Fig 8 Wounded after perforating missile wound of the maxilla a e subtotal gunshot defect of nose b e bipolar tube 1047298ap sutured to a skin frontonasal notch c e after operation
1047297rst stage
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e13
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 79
Fig 9 a - Wounded with gunshot upper lip defect on right side due to gutter wounding b - local plastic of upper lip triangular musculocutaneous pedicle 1047298ap is cut out from lower
lip and moved to a defect of upper lip
Fig10 a e Old avulsive penetrating deep wound as a result of gutter wounding with in1047297ltrated borders b e after medical treatment wound become clean and closed with 1047297brin
ce wound borders were brought closer gradually by two approximation button sutures wound was 1047297lled with granulation tissue de thin narrow strip of skin (about 1 mm) was
cut off from wound borders (for borders refreshes) and wound closed with cooptation sutures
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e14
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 89
diagnosed The authorcontendsthat indirect lateral blow with high
velocity projectile inevitably causes tissue necrosis and considers
that cautious debridement leads to avoidable purulent in1047298amma-tion and unnecessary resource expenditure Reis et al (1991) rec-
ommended ldquo primary radical wound excision repeated every
48 h The wound is always left openrdquo This debridement cannot be
termed radical because this type of debridement requires multiple
surgical interventions
Differing from Berchenko et al (1985) and Shaposhnikov and
Rudakov 1986 the author has identi1047297ed three zones of gunshot
tissue damages a zone of primary necrosis where soft and bony
tissues are destroyed at the time of initial injury (4) a zone of
delayed necrosis where cell metabolism stops and cells perish the
day after initial injury (3) a zone of parabiosis where cells metab-
olism ceases to a great extent with cell death occurring 2e3 days
later the zone at which a line of demarcation arises (2) and 1047297nally
a zoneof healthy tissue(1) (Fig1) Dead anddyingtissues inevitably
remain in cautious debridement becoming an in1047298ammatory focus
suppuration starts These tissues became heterogeneous substance
for patientrsquos organism which tries to remove them by in1047298amma-
tion Leukocytes macrophages and tissues enzymes attack them A
bacterial 1047298ora develops lysing dead tissue and contributing to
wound cleaning Davydovski (1952) attached great importance to
microscopic1047298ora asa ldquobiological cleanerrdquo However acute purulent
in1047298ammation does not always happen Bleeding and local traumareduce tissue resistance creating favourable conditions for the
development of wound infection Kostuchonok and Karlov (1990)
stated ldquo purulent infection development is possibly only in
substrate availability for vital functions of microbes e tissues
necrosis haematoma etc Such situation happens more often in
inadequate wound debridementrdquo Acute in1047298ammation increases
tissue acidity collagen 1047297laments expand and weaken sutures start
to tear tissue wound edges diverge and the wound opens
The in1047298ammatory process is very expensive for a wounded
organism The mobilisation of leucocytes macrophages and oste-
oclasts expends much energy to demolish damaged tissue instead
of preserving this for healing The organism will reject the non-
viable tissues if they were not incised again expending energy
The appearance of a scar is also compromised by inadequatedebridement of the initial wound
The examination of the microbial growth con1047297rms the introduc-
tion of infection as a result of ingrowth of microbes from theskin not
as a result of their penetration with a bullet Most surgeons consider
all gunshot wounds to be infected This assumption is probably
correct if shreds of clothing have been incorporated in the wound
which less frequently occurs with facial wounds Shell-splinters are
hotter because explosion of the projectile occurs at higher temper-
atures In such penetrating wounds on the face ribbon gauze with
proteolytic enzymes is packed into the wound for 4e5 days the skin
is smeared with 2 iodine solution and covered with sterile gauze
Foreign object are thus encapsulated and healing occurs
Microbes take several days to grow from skin into a wound
When saliva 1047298ows into wound contamination occurs immediately
Fig 12 Conical fountain of ground and disintegrated tissues 1047298ies out in front and
behind of the bullet through entrance hole and outlet
Fig 11 a e Wounded after mine explosion with wounds burn and impregnation face and neck skin b e the same wounded there are a few granulated wounds on face and neck
and skin impregnation with burnt gunpowder both eyes were damaged
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e15
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 99
Damaged tissue cannot resist microbial invasion It is the author rsquos
practice to close intraoral wound with interrupted sutures and
isolate the wound from the oral cavity and saliva Skin grafts are
occasionally employed to allow closure of the mucosa Often
a surgeon adopts wait-and-see position and starts to use drugs
therapy on suppurating wounds or wounds covered with necrotic
tissue which is erroneous Surgical debridement of a wound must
always performed irrespective of clinical condition or the length of
time lapsed since the injury was sustained It is necessary to
remember that wound debridement ful1047297ls two functions (1)
prevention of wound infection and (2) management of established
infection Microbes and toxins are removed from the wound and
tissue regeneration is promoted by removal of suppurative and
necrotic tissues Wound debridement the 1047297rst step and conserva-
tive treatment is a second
5 Conclusion
The treatment of facial gunshot injuries is performed in accor-
dance with the following principles
1) Evaluation of the woundedrsquos general clinical condition
2) Detailed examination of the wound by means of inspection
palpation and probing probe Within the 1047297rst few hours it may
be done without of any anaesthesia because tissue loses
sensitivity to pain due to local shock
3) Radical excision of wound borders to the point of active
capillary bleeding
4) Prevention of infection
5) Flap preparation if necessary
6) Primary closure of wounds with sutures and drainage
7) Application of button sutures if necessary
8) Physiotherapy
9) Massage
10) Therapeutic physical training
Ethics statements
This work has been approved by the appropriate ethical
committees related to the military hospital of Afghanistan in
1981e1985 where it wasperformed Subjects gave informed consent
Funding source
None
Con1047298ict of interest
None
References
Alexandrov NM Surgical debridement of modern gunshot wounds In Clinicaloperative maxillo-facial surgery L 1985 431e433 1985
Al-Shawi A Experience in the treatment of missile injuries of the maxillofacialregion in Iraq Brit J Oral Surg 24 244e250 1986
Berchenko GN Shaposhnikov JG Rudakov BJ Morphological characteristics of experimental wound treatment with collagen sponge In Study reparativeprocess and method them corrections Moscow Collection of Scienti1047297c Works 1MMI 81e84 1985
Berkutov AN Progress and management of traumatic and gunshot wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection MoscowMedicina 628e662 1990
Berkutov AN Modern gunshot wound Bulletin of AMS USSR 1 40e47 1975Callender GK Franch RW Wound ballistics studies in mechanism of wound
production by ri1047298e bullets Mil Surgeon 77 177e201 1935ChartesZ AC Charters AC Wounding mechanism of very high velocity projectiles
J Trauma 16 464e470 1976Davydovski IV Gunshot wounds in men M AMS USSR 1 360e362 1952Deriabin II Lytkin MI Basic principles of gunshot wound treatment Bulletin of
AMS USSR 3 52e56 1979Holt GR Kostohryz G Gunshot injuries to the head and neck Arch Otolaringol 109
313e318 1983Kostuchonok BM Karlov VA Clinic of woundsrsquo process In Kusin MI
Kostuchonok BM (eds) Wound and wound infection Moscow Medicina264e324 1990
Kousin MI Kostuchonok BM Karlov VA Treatment of suppurating wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection Moscow
Medicina 324e
484 1981Krizek T Robson M Evaluation of quantitative bacteriology in wound management
Am J Surg 130 579e584 1975Lukianenko AV Handbook of facial gunshot wound treatment Perm CLR The
Printerrsquos ldquoAsterrdquo 160 2010Marshall WG An analysis of 1047297rearm injuries to the head and face in Belfast Brit J
Oral Surg 24 233e243 1986Mechnikov II Pages of memoris vol 4 Moscow Medicina 137e161 1955OrsquoBrein DD Missile wounds Belfast 1971 Proc Roy Soc Med 66 292e294 1973Owen-Smith M Wounds caused by the weapons of war In Westby S (ed) Wound
care London W Heinemann 110e120 1985Pirogov NI General sources of military medicine vol 1 M -L Medgis 156 1941Reis ND Zinman C Besser MIB Shifrin LZ Rosen H A philosophy of limb salvage in
war use of external 1047297xator Milit Med 156 505e520 1991Rich NM Vietnam missile wounds evaluated in 750 patients Milit Med 133 9e22
1968Rybeck B Missile wounding and hemodynamic effects of energy absorption Acta
Chir Scand 450(Suppl) 1e32 1974Rudakov BJ Wounding mechanism of injuring projectiles In Shaposhnikov JG
(ed) Wound diagnostics and treatment 1984 21e
59 1984Shaposhnikov JG Rudakov BJ Gunshot wound pathogenesis and principles of their
surgical treatment Surgery 6 7e13 1986Shvyrkov MB Burenkov GI Demenkov VR Gunshot wounds of the face ENT
organs and neck In Manual for physicians vol 400 Moscow MeditsinaPublishers 15 2001
Shvyrkov MB Demenkov VR Microbial contamination of facial and neck gunshotwound Milit Med J 1 54e60 2003
Smoliannikov AB Pathological anatomy of gunshot trauma M Voenisdat p340e345 1960
Struchkov VI Modern aspects of in1047298ammation In International congress of surgeons 24-th M 1972 40e50 1972
Zbarge JP Gunshot wound of the mandible In Entin DA (ed) ) Experience of Soviet medicine in Great Patriotic war 1941e1945 ye vol 6 M Medgis163e165 1951
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e16
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 79
Fig 9 a - Wounded with gunshot upper lip defect on right side due to gutter wounding b - local plastic of upper lip triangular musculocutaneous pedicle 1047298ap is cut out from lower
lip and moved to a defect of upper lip
Fig10 a e Old avulsive penetrating deep wound as a result of gutter wounding with in1047297ltrated borders b e after medical treatment wound become clean and closed with 1047297brin
ce wound borders were brought closer gradually by two approximation button sutures wound was 1047297lled with granulation tissue de thin narrow strip of skin (about 1 mm) was
cut off from wound borders (for borders refreshes) and wound closed with cooptation sutures
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e14
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 89
diagnosed The authorcontendsthat indirect lateral blow with high
velocity projectile inevitably causes tissue necrosis and considers
that cautious debridement leads to avoidable purulent in1047298amma-tion and unnecessary resource expenditure Reis et al (1991) rec-
ommended ldquo primary radical wound excision repeated every
48 h The wound is always left openrdquo This debridement cannot be
termed radical because this type of debridement requires multiple
surgical interventions
Differing from Berchenko et al (1985) and Shaposhnikov and
Rudakov 1986 the author has identi1047297ed three zones of gunshot
tissue damages a zone of primary necrosis where soft and bony
tissues are destroyed at the time of initial injury (4) a zone of
delayed necrosis where cell metabolism stops and cells perish the
day after initial injury (3) a zone of parabiosis where cells metab-
olism ceases to a great extent with cell death occurring 2e3 days
later the zone at which a line of demarcation arises (2) and 1047297nally
a zoneof healthy tissue(1) (Fig1) Dead anddyingtissues inevitably
remain in cautious debridement becoming an in1047298ammatory focus
suppuration starts These tissues became heterogeneous substance
for patientrsquos organism which tries to remove them by in1047298amma-
tion Leukocytes macrophages and tissues enzymes attack them A
bacterial 1047298ora develops lysing dead tissue and contributing to
wound cleaning Davydovski (1952) attached great importance to
microscopic1047298ora asa ldquobiological cleanerrdquo However acute purulent
in1047298ammation does not always happen Bleeding and local traumareduce tissue resistance creating favourable conditions for the
development of wound infection Kostuchonok and Karlov (1990)
stated ldquo purulent infection development is possibly only in
substrate availability for vital functions of microbes e tissues
necrosis haematoma etc Such situation happens more often in
inadequate wound debridementrdquo Acute in1047298ammation increases
tissue acidity collagen 1047297laments expand and weaken sutures start
to tear tissue wound edges diverge and the wound opens
The in1047298ammatory process is very expensive for a wounded
organism The mobilisation of leucocytes macrophages and oste-
oclasts expends much energy to demolish damaged tissue instead
of preserving this for healing The organism will reject the non-
viable tissues if they were not incised again expending energy
The appearance of a scar is also compromised by inadequatedebridement of the initial wound
The examination of the microbial growth con1047297rms the introduc-
tion of infection as a result of ingrowth of microbes from theskin not
as a result of their penetration with a bullet Most surgeons consider
all gunshot wounds to be infected This assumption is probably
correct if shreds of clothing have been incorporated in the wound
which less frequently occurs with facial wounds Shell-splinters are
hotter because explosion of the projectile occurs at higher temper-
atures In such penetrating wounds on the face ribbon gauze with
proteolytic enzymes is packed into the wound for 4e5 days the skin
is smeared with 2 iodine solution and covered with sterile gauze
Foreign object are thus encapsulated and healing occurs
Microbes take several days to grow from skin into a wound
When saliva 1047298ows into wound contamination occurs immediately
Fig 12 Conical fountain of ground and disintegrated tissues 1047298ies out in front and
behind of the bullet through entrance hole and outlet
Fig 11 a e Wounded after mine explosion with wounds burn and impregnation face and neck skin b e the same wounded there are a few granulated wounds on face and neck
and skin impregnation with burnt gunpowder both eyes were damaged
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e15
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 99
Damaged tissue cannot resist microbial invasion It is the author rsquos
practice to close intraoral wound with interrupted sutures and
isolate the wound from the oral cavity and saliva Skin grafts are
occasionally employed to allow closure of the mucosa Often
a surgeon adopts wait-and-see position and starts to use drugs
therapy on suppurating wounds or wounds covered with necrotic
tissue which is erroneous Surgical debridement of a wound must
always performed irrespective of clinical condition or the length of
time lapsed since the injury was sustained It is necessary to
remember that wound debridement ful1047297ls two functions (1)
prevention of wound infection and (2) management of established
infection Microbes and toxins are removed from the wound and
tissue regeneration is promoted by removal of suppurative and
necrotic tissues Wound debridement the 1047297rst step and conserva-
tive treatment is a second
5 Conclusion
The treatment of facial gunshot injuries is performed in accor-
dance with the following principles
1) Evaluation of the woundedrsquos general clinical condition
2) Detailed examination of the wound by means of inspection
palpation and probing probe Within the 1047297rst few hours it may
be done without of any anaesthesia because tissue loses
sensitivity to pain due to local shock
3) Radical excision of wound borders to the point of active
capillary bleeding
4) Prevention of infection
5) Flap preparation if necessary
6) Primary closure of wounds with sutures and drainage
7) Application of button sutures if necessary
8) Physiotherapy
9) Massage
10) Therapeutic physical training
Ethics statements
This work has been approved by the appropriate ethical
committees related to the military hospital of Afghanistan in
1981e1985 where it wasperformed Subjects gave informed consent
Funding source
None
Con1047298ict of interest
None
References
Alexandrov NM Surgical debridement of modern gunshot wounds In Clinicaloperative maxillo-facial surgery L 1985 431e433 1985
Al-Shawi A Experience in the treatment of missile injuries of the maxillofacialregion in Iraq Brit J Oral Surg 24 244e250 1986
Berchenko GN Shaposhnikov JG Rudakov BJ Morphological characteristics of experimental wound treatment with collagen sponge In Study reparativeprocess and method them corrections Moscow Collection of Scienti1047297c Works 1MMI 81e84 1985
Berkutov AN Progress and management of traumatic and gunshot wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection MoscowMedicina 628e662 1990
Berkutov AN Modern gunshot wound Bulletin of AMS USSR 1 40e47 1975Callender GK Franch RW Wound ballistics studies in mechanism of wound
production by ri1047298e bullets Mil Surgeon 77 177e201 1935ChartesZ AC Charters AC Wounding mechanism of very high velocity projectiles
J Trauma 16 464e470 1976Davydovski IV Gunshot wounds in men M AMS USSR 1 360e362 1952Deriabin II Lytkin MI Basic principles of gunshot wound treatment Bulletin of
AMS USSR 3 52e56 1979Holt GR Kostohryz G Gunshot injuries to the head and neck Arch Otolaringol 109
313e318 1983Kostuchonok BM Karlov VA Clinic of woundsrsquo process In Kusin MI
Kostuchonok BM (eds) Wound and wound infection Moscow Medicina264e324 1990
Kousin MI Kostuchonok BM Karlov VA Treatment of suppurating wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection Moscow
Medicina 324e
484 1981Krizek T Robson M Evaluation of quantitative bacteriology in wound management
Am J Surg 130 579e584 1975Lukianenko AV Handbook of facial gunshot wound treatment Perm CLR The
Printerrsquos ldquoAsterrdquo 160 2010Marshall WG An analysis of 1047297rearm injuries to the head and face in Belfast Brit J
Oral Surg 24 233e243 1986Mechnikov II Pages of memoris vol 4 Moscow Medicina 137e161 1955OrsquoBrein DD Missile wounds Belfast 1971 Proc Roy Soc Med 66 292e294 1973Owen-Smith M Wounds caused by the weapons of war In Westby S (ed) Wound
care London W Heinemann 110e120 1985Pirogov NI General sources of military medicine vol 1 M -L Medgis 156 1941Reis ND Zinman C Besser MIB Shifrin LZ Rosen H A philosophy of limb salvage in
war use of external 1047297xator Milit Med 156 505e520 1991Rich NM Vietnam missile wounds evaluated in 750 patients Milit Med 133 9e22
1968Rybeck B Missile wounding and hemodynamic effects of energy absorption Acta
Chir Scand 450(Suppl) 1e32 1974Rudakov BJ Wounding mechanism of injuring projectiles In Shaposhnikov JG
(ed) Wound diagnostics and treatment 1984 21e
59 1984Shaposhnikov JG Rudakov BJ Gunshot wound pathogenesis and principles of their
surgical treatment Surgery 6 7e13 1986Shvyrkov MB Burenkov GI Demenkov VR Gunshot wounds of the face ENT
organs and neck In Manual for physicians vol 400 Moscow MeditsinaPublishers 15 2001
Shvyrkov MB Demenkov VR Microbial contamination of facial and neck gunshotwound Milit Med J 1 54e60 2003
Smoliannikov AB Pathological anatomy of gunshot trauma M Voenisdat p340e345 1960
Struchkov VI Modern aspects of in1047298ammation In International congress of surgeons 24-th M 1972 40e50 1972
Zbarge JP Gunshot wound of the mandible In Entin DA (ed) ) Experience of Soviet medicine in Great Patriotic war 1941e1945 ye vol 6 M Medgis163e165 1951
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e16
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 89
diagnosed The authorcontendsthat indirect lateral blow with high
velocity projectile inevitably causes tissue necrosis and considers
that cautious debridement leads to avoidable purulent in1047298amma-tion and unnecessary resource expenditure Reis et al (1991) rec-
ommended ldquo primary radical wound excision repeated every
48 h The wound is always left openrdquo This debridement cannot be
termed radical because this type of debridement requires multiple
surgical interventions
Differing from Berchenko et al (1985) and Shaposhnikov and
Rudakov 1986 the author has identi1047297ed three zones of gunshot
tissue damages a zone of primary necrosis where soft and bony
tissues are destroyed at the time of initial injury (4) a zone of
delayed necrosis where cell metabolism stops and cells perish the
day after initial injury (3) a zone of parabiosis where cells metab-
olism ceases to a great extent with cell death occurring 2e3 days
later the zone at which a line of demarcation arises (2) and 1047297nally
a zoneof healthy tissue(1) (Fig1) Dead anddyingtissues inevitably
remain in cautious debridement becoming an in1047298ammatory focus
suppuration starts These tissues became heterogeneous substance
for patientrsquos organism which tries to remove them by in1047298amma-
tion Leukocytes macrophages and tissues enzymes attack them A
bacterial 1047298ora develops lysing dead tissue and contributing to
wound cleaning Davydovski (1952) attached great importance to
microscopic1047298ora asa ldquobiological cleanerrdquo However acute purulent
in1047298ammation does not always happen Bleeding and local traumareduce tissue resistance creating favourable conditions for the
development of wound infection Kostuchonok and Karlov (1990)
stated ldquo purulent infection development is possibly only in
substrate availability for vital functions of microbes e tissues
necrosis haematoma etc Such situation happens more often in
inadequate wound debridementrdquo Acute in1047298ammation increases
tissue acidity collagen 1047297laments expand and weaken sutures start
to tear tissue wound edges diverge and the wound opens
The in1047298ammatory process is very expensive for a wounded
organism The mobilisation of leucocytes macrophages and oste-
oclasts expends much energy to demolish damaged tissue instead
of preserving this for healing The organism will reject the non-
viable tissues if they were not incised again expending energy
The appearance of a scar is also compromised by inadequatedebridement of the initial wound
The examination of the microbial growth con1047297rms the introduc-
tion of infection as a result of ingrowth of microbes from theskin not
as a result of their penetration with a bullet Most surgeons consider
all gunshot wounds to be infected This assumption is probably
correct if shreds of clothing have been incorporated in the wound
which less frequently occurs with facial wounds Shell-splinters are
hotter because explosion of the projectile occurs at higher temper-
atures In such penetrating wounds on the face ribbon gauze with
proteolytic enzymes is packed into the wound for 4e5 days the skin
is smeared with 2 iodine solution and covered with sterile gauze
Foreign object are thus encapsulated and healing occurs
Microbes take several days to grow from skin into a wound
When saliva 1047298ows into wound contamination occurs immediately
Fig 12 Conical fountain of ground and disintegrated tissues 1047298ies out in front and
behind of the bullet through entrance hole and outlet
Fig 11 a e Wounded after mine explosion with wounds burn and impregnation face and neck skin b e the same wounded there are a few granulated wounds on face and neck
and skin impregnation with burnt gunpowder both eyes were damaged
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e15
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 99
Damaged tissue cannot resist microbial invasion It is the author rsquos
practice to close intraoral wound with interrupted sutures and
isolate the wound from the oral cavity and saliva Skin grafts are
occasionally employed to allow closure of the mucosa Often
a surgeon adopts wait-and-see position and starts to use drugs
therapy on suppurating wounds or wounds covered with necrotic
tissue which is erroneous Surgical debridement of a wound must
always performed irrespective of clinical condition or the length of
time lapsed since the injury was sustained It is necessary to
remember that wound debridement ful1047297ls two functions (1)
prevention of wound infection and (2) management of established
infection Microbes and toxins are removed from the wound and
tissue regeneration is promoted by removal of suppurative and
necrotic tissues Wound debridement the 1047297rst step and conserva-
tive treatment is a second
5 Conclusion
The treatment of facial gunshot injuries is performed in accor-
dance with the following principles
1) Evaluation of the woundedrsquos general clinical condition
2) Detailed examination of the wound by means of inspection
palpation and probing probe Within the 1047297rst few hours it may
be done without of any anaesthesia because tissue loses
sensitivity to pain due to local shock
3) Radical excision of wound borders to the point of active
capillary bleeding
4) Prevention of infection
5) Flap preparation if necessary
6) Primary closure of wounds with sutures and drainage
7) Application of button sutures if necessary
8) Physiotherapy
9) Massage
10) Therapeutic physical training
Ethics statements
This work has been approved by the appropriate ethical
committees related to the military hospital of Afghanistan in
1981e1985 where it wasperformed Subjects gave informed consent
Funding source
None
Con1047298ict of interest
None
References
Alexandrov NM Surgical debridement of modern gunshot wounds In Clinicaloperative maxillo-facial surgery L 1985 431e433 1985
Al-Shawi A Experience in the treatment of missile injuries of the maxillofacialregion in Iraq Brit J Oral Surg 24 244e250 1986
Berchenko GN Shaposhnikov JG Rudakov BJ Morphological characteristics of experimental wound treatment with collagen sponge In Study reparativeprocess and method them corrections Moscow Collection of Scienti1047297c Works 1MMI 81e84 1985
Berkutov AN Progress and management of traumatic and gunshot wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection MoscowMedicina 628e662 1990
Berkutov AN Modern gunshot wound Bulletin of AMS USSR 1 40e47 1975Callender GK Franch RW Wound ballistics studies in mechanism of wound
production by ri1047298e bullets Mil Surgeon 77 177e201 1935ChartesZ AC Charters AC Wounding mechanism of very high velocity projectiles
J Trauma 16 464e470 1976Davydovski IV Gunshot wounds in men M AMS USSR 1 360e362 1952Deriabin II Lytkin MI Basic principles of gunshot wound treatment Bulletin of
AMS USSR 3 52e56 1979Holt GR Kostohryz G Gunshot injuries to the head and neck Arch Otolaringol 109
313e318 1983Kostuchonok BM Karlov VA Clinic of woundsrsquo process In Kusin MI
Kostuchonok BM (eds) Wound and wound infection Moscow Medicina264e324 1990
Kousin MI Kostuchonok BM Karlov VA Treatment of suppurating wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection Moscow
Medicina 324e
484 1981Krizek T Robson M Evaluation of quantitative bacteriology in wound management
Am J Surg 130 579e584 1975Lukianenko AV Handbook of facial gunshot wound treatment Perm CLR The
Printerrsquos ldquoAsterrdquo 160 2010Marshall WG An analysis of 1047297rearm injuries to the head and face in Belfast Brit J
Oral Surg 24 233e243 1986Mechnikov II Pages of memoris vol 4 Moscow Medicina 137e161 1955OrsquoBrein DD Missile wounds Belfast 1971 Proc Roy Soc Med 66 292e294 1973Owen-Smith M Wounds caused by the weapons of war In Westby S (ed) Wound
care London W Heinemann 110e120 1985Pirogov NI General sources of military medicine vol 1 M -L Medgis 156 1941Reis ND Zinman C Besser MIB Shifrin LZ Rosen H A philosophy of limb salvage in
war use of external 1047297xator Milit Med 156 505e520 1991Rich NM Vietnam missile wounds evaluated in 750 patients Milit Med 133 9e22
1968Rybeck B Missile wounding and hemodynamic effects of energy absorption Acta
Chir Scand 450(Suppl) 1e32 1974Rudakov BJ Wounding mechanism of injuring projectiles In Shaposhnikov JG
(ed) Wound diagnostics and treatment 1984 21e
59 1984Shaposhnikov JG Rudakov BJ Gunshot wound pathogenesis and principles of their
surgical treatment Surgery 6 7e13 1986Shvyrkov MB Burenkov GI Demenkov VR Gunshot wounds of the face ENT
organs and neck In Manual for physicians vol 400 Moscow MeditsinaPublishers 15 2001
Shvyrkov MB Demenkov VR Microbial contamination of facial and neck gunshotwound Milit Med J 1 54e60 2003
Smoliannikov AB Pathological anatomy of gunshot trauma M Voenisdat p340e345 1960
Struchkov VI Modern aspects of in1047298ammation In International congress of surgeons 24-th M 1972 40e50 1972
Zbarge JP Gunshot wound of the mandible In Entin DA (ed) ) Experience of Soviet medicine in Great Patriotic war 1941e1945 ye vol 6 M Medgis163e165 1951
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e16
8132019 Facial Gunshot
httpslidepdfcomreaderfullfacial-gunshot 99
Damaged tissue cannot resist microbial invasion It is the author rsquos
practice to close intraoral wound with interrupted sutures and
isolate the wound from the oral cavity and saliva Skin grafts are
occasionally employed to allow closure of the mucosa Often
a surgeon adopts wait-and-see position and starts to use drugs
therapy on suppurating wounds or wounds covered with necrotic
tissue which is erroneous Surgical debridement of a wound must
always performed irrespective of clinical condition or the length of
time lapsed since the injury was sustained It is necessary to
remember that wound debridement ful1047297ls two functions (1)
prevention of wound infection and (2) management of established
infection Microbes and toxins are removed from the wound and
tissue regeneration is promoted by removal of suppurative and
necrotic tissues Wound debridement the 1047297rst step and conserva-
tive treatment is a second
5 Conclusion
The treatment of facial gunshot injuries is performed in accor-
dance with the following principles
1) Evaluation of the woundedrsquos general clinical condition
2) Detailed examination of the wound by means of inspection
palpation and probing probe Within the 1047297rst few hours it may
be done without of any anaesthesia because tissue loses
sensitivity to pain due to local shock
3) Radical excision of wound borders to the point of active
capillary bleeding
4) Prevention of infection
5) Flap preparation if necessary
6) Primary closure of wounds with sutures and drainage
7) Application of button sutures if necessary
8) Physiotherapy
9) Massage
10) Therapeutic physical training
Ethics statements
This work has been approved by the appropriate ethical
committees related to the military hospital of Afghanistan in
1981e1985 where it wasperformed Subjects gave informed consent
Funding source
None
Con1047298ict of interest
None
References
Alexandrov NM Surgical debridement of modern gunshot wounds In Clinicaloperative maxillo-facial surgery L 1985 431e433 1985
Al-Shawi A Experience in the treatment of missile injuries of the maxillofacialregion in Iraq Brit J Oral Surg 24 244e250 1986
Berchenko GN Shaposhnikov JG Rudakov BJ Morphological characteristics of experimental wound treatment with collagen sponge In Study reparativeprocess and method them corrections Moscow Collection of Scienti1047297c Works 1MMI 81e84 1985
Berkutov AN Progress and management of traumatic and gunshot wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection MoscowMedicina 628e662 1990
Berkutov AN Modern gunshot wound Bulletin of AMS USSR 1 40e47 1975Callender GK Franch RW Wound ballistics studies in mechanism of wound
production by ri1047298e bullets Mil Surgeon 77 177e201 1935ChartesZ AC Charters AC Wounding mechanism of very high velocity projectiles
J Trauma 16 464e470 1976Davydovski IV Gunshot wounds in men M AMS USSR 1 360e362 1952Deriabin II Lytkin MI Basic principles of gunshot wound treatment Bulletin of
AMS USSR 3 52e56 1979Holt GR Kostohryz G Gunshot injuries to the head and neck Arch Otolaringol 109
313e318 1983Kostuchonok BM Karlov VA Clinic of woundsrsquo process In Kusin MI
Kostuchonok BM (eds) Wound and wound infection Moscow Medicina264e324 1990
Kousin MI Kostuchonok BM Karlov VA Treatment of suppurating wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection Moscow
Medicina 324e
484 1981Krizek T Robson M Evaluation of quantitative bacteriology in wound management
Am J Surg 130 579e584 1975Lukianenko AV Handbook of facial gunshot wound treatment Perm CLR The
Printerrsquos ldquoAsterrdquo 160 2010Marshall WG An analysis of 1047297rearm injuries to the head and face in Belfast Brit J
Oral Surg 24 233e243 1986Mechnikov II Pages of memoris vol 4 Moscow Medicina 137e161 1955OrsquoBrein DD Missile wounds Belfast 1971 Proc Roy Soc Med 66 292e294 1973Owen-Smith M Wounds caused by the weapons of war In Westby S (ed) Wound
care London W Heinemann 110e120 1985Pirogov NI General sources of military medicine vol 1 M -L Medgis 156 1941Reis ND Zinman C Besser MIB Shifrin LZ Rosen H A philosophy of limb salvage in
war use of external 1047297xator Milit Med 156 505e520 1991Rich NM Vietnam missile wounds evaluated in 750 patients Milit Med 133 9e22
1968Rybeck B Missile wounding and hemodynamic effects of energy absorption Acta
Chir Scand 450(Suppl) 1e32 1974Rudakov BJ Wounding mechanism of injuring projectiles In Shaposhnikov JG
(ed) Wound diagnostics and treatment 1984 21e
59 1984Shaposhnikov JG Rudakov BJ Gunshot wound pathogenesis and principles of their
surgical treatment Surgery 6 7e13 1986Shvyrkov MB Burenkov GI Demenkov VR Gunshot wounds of the face ENT
organs and neck In Manual for physicians vol 400 Moscow MeditsinaPublishers 15 2001
Shvyrkov MB Demenkov VR Microbial contamination of facial and neck gunshotwound Milit Med J 1 54e60 2003
Smoliannikov AB Pathological anatomy of gunshot trauma M Voenisdat p340e345 1960
Struchkov VI Modern aspects of in1047298ammation In International congress of surgeons 24-th M 1972 40e50 1972
Zbarge JP Gunshot wound of the mandible In Entin DA (ed) ) Experience of Soviet medicine in Great Patriotic war 1941e1945 ye vol 6 M Medgis163e165 1951
MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e16