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Article

Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review

by
Sean A. Knudson
1,
Kristopher M. Day
1,2,3,*,
Patrick Kelley
1,2,3,
Pablo Padilla
4,
Ian X. Collier
3,
Steven Henry
2,3,
Raymond Harshbarger
1,2,3 and
Patrick Combs
1,2,3
1
Division of Craniofacial and Pediatric Plastic Surgery, Dell Children’s Medical Center, The University of Texas at Austin, 1361 Wildcat Lane, Iowa City, IA 52246, USA
2
Department of Plastic Surgery, Dell Seton Medical Center, The University of Texas at Austin, Austin, TX, USA
3
Dell Medical School, The University of Texas at Austin, Austin, TX, USA
4
Department of Plastic Surgery, University of Texas Medical Branch at Galveston, Galveston, TX, USA
*
Author to whom correspondence should be addressed.
Craniomaxillofac. Trauma Reconstr. 2022, 15(3), 206-218; https://doi.org/10.1177/19433875211026432
Submission received: 1 November 2020 / Revised: 1 December 2020 / Accepted: 1 January 2021 / Published: 21 June 2021
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Abstract

:
Study Design: Retrospective case series; systematic review. Objective: It is unknown whether the use of virtual surgical planning (VSP) to facilitate same-admission microsurgical reconstruction of the mandible following acute maxillofacial ballistic trauma (MBT) is sufficient to achieve definitive reconstruction and functional occlusion. Methods: A single-center retrospective analysis was conducted for patients who underwent microsurgical reconstruction of the mandible using VSP after acute MBT. The PubMed/MEDLINE, Embase, ScienceDirect, and Scopus databases were systematically reviewed using blinded screening. Studies were evaluated via thematic analysis. Results: Five patients were treated by same-admission and microsurgical reconstruction of the mandible using VSP. We observed an average of 16.4 ± 9.1 days between initial presentation and reconstruction, an average length of stay of 51.6 ± 17.9 days, 6.2 ± 2.8 operations, and 1.6 ± 0.9 free flaps per patient. Four types and 8 total flaps were employed, most commonly the anterior lateral thigh flap (37.5%). Care yielded complete flap survival. Each patient experienced at least 1 minor complication. All patients achieved centric occlusion, oral nutrition, and an approximation of their baseline facial aesthetic. Follow up was 191.0 ± 183.9 weeks. Systematic review produced 8 articles that adhered to inclusion criteria. Consensus themes in the literature were found for clinical goal and function of VSP when practicing MBT reconstruction, yet disagreement was found surrounding optimal treatment timeline. Conclusions: Same-admission microsurgical reconstruction after MBT is safe and effective to re-establish mandibular form and function. VSP did not delay reconstruction, given the need for preparation prior to definitive reconstruction.

Introduction

High-energy ballistic trauma can cause severe composite tissue defects, requiring complex reconstruction. Upwards of 64,000 non-lethal firearm injuries are treated in the United States with 10-12% of these cases involving the head and neck.[1] Intracranial injury and skull fracture comprise the 2 most common causes of fatality in craniomaxillofacial ballistic trauma, but mortality from maxillofacial ballistic trauma (MBT) in the absence of cranial involvement is relatively low at 2-3%.[2] Ballistic mandible injuries cause aesthetic disfigurement and malocclusion, which impairs mastication, nutrition, speech, and social interaction.[3,4,5,6,7,8,9] While treatment algorithms exist,[10,11] there is lack of consensus for the: timing of reconstruction, definition of the clinical goal, role for microvascular free flaps, or function of virtual surgical planning (VSP) for MBT trauma reconstruction.
Most reviews of MBT demonstrate optimal outcomes through the sequential execution of various goals of care, including: patient stabilization, thorough primary zone of injury debridement, temporary structural stabilization, secondary zone of injury debridement and refinement of tissue stabilization, delayed definitive reconstruction, and subsequent revision, as needed.[12,13,14,15,16,17,18,19,20,21] Advanced trauma life support and the military experience inform the primary management of MBT, such as: initial triage, airway management, bleeding control, and the primary salvage of critical structures of the head and neck.[22,23,24,25,26,27,28] Clinical studies have improved our understanding of the unique aspects of high-energy ballistic trauma pathophysiology, such as: shock wave trauma, an extended field of injury, delayed tissue necrosis, and the importance of serial surgical intervention.[29,30]
While such concepts have advanced clinical care, the value of more recent innovations, such as sameadmission microsurgical reconstruction and the use of VSP, is not yet known.[10,16] The goals of mandible reconstruction—restoration of baseline speech, mastication and facial aesthetics—have traditionally been achieved in a delayed fashion. Some clinical scenarios may require free tissue transfer for definitive reconstruction, which may paradoxically enable fewer surgical stages.[31,32] Studies comparing delayed versus immediate reconstruction in MBT suggest that immediate reconstruction may decrease infection, soft tissue contraction, secondary psychological trauma, and the number of patients lost to follow-up.[10,16,33,34] Multiple studies also suggest that VSP may compel preoperative planning, expedite intraoperative surgical care, improve surgical precision, and perhaps improve outcomes.[35,36,37,38,39] This case series and systematic review details the use of VSP to facilitate same-admission microsurgical mandible reconstruction after acute MBT.

Materials and Methods

Case Series

We performed an institution review board-approved retrospective case series of all cases of acute MBT using microsurgical reconstruction performed at a tertiary referral, level I trauma center. The authors adhered to the Declaration of Helsinki at all times. The electronic medical records of all patients with diagnosis of facial gunshot wound were reviewed. Relevant epidemiologic data and clinical course details from the initial phase of inpatient admission were collected, including: length of stay (LOS), number of operations, number of flaps, timeline between procedures, and complications. Minor complications were defined as any surgical condition that required a return to the operating room for revision of flap contour, wound care, partial debridement, or other procedural optimization. We then tabulated this data and calculated descriptive statistics to depict our results. All patients underwent care and reconstruction for maxillofacial ballistic trauma using VSP planning (KLS Martin; Jacksonville, FL) and hardware manufacturing (3D Systems, Inc.; Littleton, CO).

Systematic Review

The PubMed/MEDLINE, Embase, ScienceDirect, and Scopus databases were searched from inception to October 13, 2020, for studies that evaluated maxillofacial ballistic trauma reconstruction using VSP by 2 reviewers (S.K. and K.D.). The search strategy is provided in the supplement (Online Supplement 1). The inclusion criteria were as follows: studies must include maxillofacial reconstruction using VSP or computer planning; studies must solely discuss prompt and definitive reconstruction following maxillofacial ballistic trauma by firearm, blast, or high velocity shrapnel; studies must include at least 1 of our case series topics: same-admission, microvascular reconstruction, or mandibular involvement; and studies must be from a peer reviewed journal. Article inclusion was not restricted by language or year of publication.
Once the database search was completed, all citations were compiled and uploaded to Rayyan (QCRI; Doha, Qatar) for blinded title and abstract screening. Once initial screening was completed, the reviewers un-blinded and settled article inclusion disputes through discussion. Full text screening was conducted by a single reviewer (S.K.) to certify inclusion criteria adherence. At this point, a database was created to track article variables for descriptive data analysis. Variables recorded were: year of publication, article type, level of evidence (LOE), number of patients (if applicable), practice of same-admission, mandibular inclusion, microvascular free-flap inclusion, population of interest, mode of injury, function of VSP, and definition of clinical goal. Quantitative variables were evaluated using rates and percentages, while qualitative variables were evaluated via thematic analysis. The heterogeneity of article type and limited primary patient data prohibited valuable meta-analysis.

Results

Case Series

Five patients were treated by free flap reconstruction to the head and neck region after acute MBT. All mechanisms were close-range assault or self-inflicted MBT affecting the mandible, and all reconstructions employed VSP. As outlined in Table 1, our patients were 100% male with an average age of 28.4 ± 8.9 years, ranging from 18 to 42 years old. There was an average of 16.4 ± 9.1 days between initial presentation and microsurgical reconstruction and an average total length of stay of 51.6 ± 17.8 days. Patients underwent an average of 6.2 ± 2.9 operations while inpatient with an average of 1.6 ± 0.9 free flaps employed while inpatient. (Table 1).
Table 2 outlines the 4 types of flaps utilized in our patients’ initial admission. The free anterior lateral thigh flap was the most prevalent (Table 2). Flap selection was determined by the primary surgeon’s judgment of best replacement of the defect by size and tissue components involved. Osteocutaneous, vascularized osseous, and fasciocutaneous options were all utilized as befitting the missing tissue. Three patients (60.0%) were reconstructed with a single flap, while 2 patients (40.0%) required multiple flaps. There was 1 patient with dual flaps (20.0%) and 1 patient with triple flaps (20.0%). Multiple flap reconstruction was planned in the vast majority of cases after our patients’ first phase of inpatient care.
Minor complications were experienced in all cases, with 4 (80.0%) patients requiring procedural intervention. Minor complications included: sialocele formation requiring drainage, wound dehiscence without ischemia corrected by debridement and primary closure, donor site abscess requiring drainage, and flexor hallucis longus contracture requiring release. Overall flap survival was 100%. No patients suffered major systemic morbidity or mortality.
The VSP planning sessions were performed using craniomaxillofacial thin-cut protocol computerized tomography scans that were obtained after each patient’s final bony debridement. Custom-milled plates, custom cutting guides, or other physical clinical translation tools requiring off-site manufacturing required between 5-7 days for production and shipment. All custom plates were pre-milled. All osseous flaps were harvested using custom cutting guides on the donor site coupled with custom cutting guides at the recipient site to ensure precise bone-to-bone apposition. All guides were designed to remove significantly traumatized tissues to achieve precise fit. There were no device malfunctions and no delays in reconstruction due to VSP planning. The time interval between final preparatory debridement and definitive reconstruction averaged 9.4 ± 4.3 days, which occurred on average post-trauma day 16.4 ± 9.1.
Patients were followed up with for an average of 191.0 ± 183.9 weeks and suffered no additional postoperative complications. All patients achieved a functional occlusion that enabled oral-only nutritional support with aid from a speech-language pathologist. Frequent aesthetic complications handled after the initial stage of sameadmission were poor nose projection and form, asymmetry of the orbits, and imbalance in facial contouring due to inconsistencies in bone and soft tissue underlay post flap reconstruction. Aesthetic deficiencies were handled at later outpatient follow-up.

Case Presentations

Patient 1. Following a suicide attempt with a 9 mm pistol, a 25-year-old male presented to our hospital with massive destruction of the mandible, roof of the mouth, and orbits. During same-admission, our surgeons utilized a single double barrel osteocutaneous free fibula flap for his reconstruction. He was inpatient for 50 days.
Immediately upon hospital arrival, our patient was taken directly to the operating room for tracheostomy, debridement of open fractures of the face, including removal of foreign body, devitalized mucosa, and devitalized bone. Further repair of complex skin and intraoral lacerations was also completed. Four days post trauma, split cranial bone graft was harvested for nasal reconstruction and Le Fort II repair. A Medpor Titan implant (Stryker, Kalamazoo, MI) was also used for bilateral reconstruction of orbital blowout fractures.
Two weeks following ballistic trauma in coordination with VSP, our patient underwent reconstruction of segmental mandibular defect with free fibula osteocutaneous flap (double barreled design with 4 segments), multiple-segment osteotomy of the mandible, closed reduction of right hemi Le Fort I fracture, and open reduction and internal fixation (ORIF) of complex mandibular fracture. VSP aided definitive reconstruction by assisting in the planning of complex free flap placement and precise bone on bone apposition for mandibular reconstruction. The patient stayed an additional 5 weeks due to need for long-term enteral nutrition and treatment of complications such as: sialocele formation and flexor hallucis longus contracture.
Patient 2. Following a suicide attempt with a 12-gauge shotgun, an 18-year-old male presented to our hospital with massive bone and soft tissue trauma; and complete loss of nose, upper lip, and mid-face structures. During sameadmission, our surgeons utilized a single anterior lateral thigh flap for the patient’s reconstruction. He was inpatient for 48 days.
Upon arrival to the hospital, our patient underwent immediate tracheostomy and debridement of extensive facial and oral wounds associated with open fractures of the face and mandible. The following day, the patient had bilateral inferior turbinectomies, bilateral anterior partial ethmoidectomies, and further closure of complex oral wounds. Over a week following trauma and in coordination with VSP, our patient underwent craniotomy for acquisition of adequate bone graft for complex craniofacial reconstruction, ORIF of left zygoma fracture, bilateral canthopexies, bilateral orbital reconstruction (medial walls and floors with split cranial autogenous bone graft), ORIF of Le Fort II comminuted fracture with autogenous bone grafting, debridement of maxilla, zygomas, and orbit, and debridement of mandibular wound with removal of bone fragments and bullet fragments. Additionally, using VSP, our patient underwent reconstruction of mandible with large plate, and placement of anterior lateral thigh free flap to oral cavity, floor of mouth, and nasal cavity. Due to the amount of traumatized tissue, VSP guided the removal of devitalized structures prior to definitive reconstruction in order to achieve a precise fit. We further utilized VSP following same-admission for our patients to alleviate persistent deformity and defects of the mandible and nasal cavity.
Patient 3. Following a close-range gunshot, a 26-year-old male presented to our hospital with massive blowout to the left face, severe jaw deformity, and loss of left globe (Figure 1). During same-admission, our surgeons utilized 3 microvascular free flaps for his reconstruction: radial forearm flap, anterior lateral thigh flap, and free fibula osteocutaneous flap. The man was inpatient for 54 days.
Upon hospital arrival, our patient underwent tracheostomy for stabilization, debridement, and primary closure of facial wounds. The skull base was explored due to dural defect and cerebrospinal fluid leakage. Three days later, the patient underwent bifrontal craniotomy, hematoma evacuation, repair of bifrontal anterior cranial fossa dural defect with free pericranial autograft, and ORIF of the left hemiorbital bandeau and left orbital roof.
Our patient tolerated dural defect repair well and was able to undergo maxilla and mid-face reconstruction within 2 weeks of the traumatic injury using VSP planning (Figure 2A and B). Post bifrontal craniotomy, the patient underwent ORIF of the palate and floor of mouth reconstruction using free radial forearm flap, Lefort II with bone graft, Lefort I with ORIF; and fixation of his right nasal maxillary fracture and closed nasal reduction reconstruction. Two weeks later, after additional debridement and with further assistance from VSP, anterior lateral thigh flap and free osteocutaneous flap were used to rebuild the left maxilla. The patient was discharged from same-admission with oral nutrition and centric occlusion aided by the precision of VSP (Figure 3). Revision operations were also done using VSP following same-admission inpatient care (Figure 4A and B). Seven months following same-admission, the patient had well-positioned mandibular reconstruction and a stable craniofacial skeleton (Figure 5).
Patient 4. Following a suicide attempt, a 42-year-old male presented with destruction of the right face, mandible, maxilla, and orbit. During same-admission, 2 microvascular free flaps were utilized for his reconstruction: anterior lateral thigh and radial forearm free flaps, and was inpatient for 78 days.
The first day at the hospital our patient underwent tracheostomy for stabilization, initial debridement, primary closure of oral wounds, and placement of multiplanar external fixation device for mandibular fixation. Five days later he underwent additional debridement and packing of open wounds. In delayed fashion, 10 days after the initial trauma, our patient underwent definitive reconstruction of the mandible and chin defect using anterior lateral thigh flap. VSP provided operative efficiency for our surgeons when utilizing the pre-milled plate and guide for the mandible. Similarly 15 days later, he underwent placement of a mandibular reconstruction bar and radial forearm free flap to reconstruct the floor of the mouth, lip, and chin resulting in occlusion.
Following these procedures, he spent an additional 52 days in the hospital after definitive reconstruction. Patient 4 had the longest LOS. This can be attributed to complications such as: flap dehiscence, palate defect, and acute ischemia of the right foot. The interventions required to treat these complications needed to be handled before our patient could safely leave the hospital and this resulted in his lengthened stay.
Patient 5. A 31-year-old male found down in a night club parking lot following gunfire, presented with severely comminuted right mandible fracture (Figure 5A), right zygomaticomaxillary fracture, and right orbital fracture. The bullet entered through the right pre-commissure area and then through the retromolar trigone region. Immediately upon hospital arrival, the patient underwent tracheotomy, debridement, and cerebral angiogram due to bullet lodged in the right posterior neck. No evidence of carotid or vertebral artery dissection was found. During same admission, 1 free fibula flap was used for reconstruction and the patient stayed for 28 days.
Ten days following trauma and in coordination with VSP, the patient underwent reconstruction of right mandible with free fibula osteocutaneous flap, osteotomy of mandible for reconstruction and re-creation of mandibular angle, open reduction of condylar fracture dislocation, right submandibular gland resection, and right parotidectomy. VSP was helpful here because it gave our surgeons an accurate evaluation of centric spacing of the temporomandibular joint to best recreate the mandibular angle. Due to the large amount of swelling, internal fixation of the right zygomaticomaxillary complex was not possible and future surgery was planned following same-admission.
Two weeks after definitive reconstruction, the patient was discharged. His care is the shortest in our series due to anatomic isolation of traumatic injury and development of only 1 minor complication.

Systematic Review

Our database search resulted in 305 articles from PubMed/ MEDLINE, 309 articles from Embase, 653 articles from ScienceDirect, and 115 articles from Scopus, which totaled 1382 articles. Following duplicate detection in Rayyan, 1070 articles remained. After title and abstract screening, 48 articles remained. Full text screening and article attrition yielded 8 articles for final inclusion and analysis (Figure 6). The 8 articles that adhered to our inclusion criteria are listed and described in Table 3.
Our article cohort included 5 expert opinions (62.5%), 2 case series (25%), and 1 case report (12.5%). In terms of LOE, our cohort included 2 level IV articles (25%) and 6 level V articles (75%). Four articles included sameadmission (50%), 6 articles included microvascular freeflap reconstruction (75%) and all articles included mandibular reconstruction (100%). In terms of mode of injury, 6 articles discussed gunshot trauma (75%) while 2 articles discussed ballistic/blast related trauma (25%). There were only 3 studies in our article cohort that included primary patient data. In the 3 studies, 13 civilians with MBT with mandibular involvement are presented in total.
Additionally, the publication rate of articles that adhered to our inclusion criteria has increased in recent years. Following a decade (2006-2015) of 1 publication per every 5 years (0.2 publications/year), the last 5 years (2016-2020) yielded a publication rate of 1.2 publications/year. Although publication rate has increased, LOE of MBT studies have not progressed passed levels IV or V in the evidence hierarchy.
Thematic analysis of the articles offered insight into clinical goal, same-admission, and function of VSP. The articles reveal that the clinical goal of care following MBT should be, “functional occlusion,” “[establishment] of bony continuity,” “[mitigation of] less predictable results and future functional deformities,” and “patient stabilization.” A consensus theme of same-admission was characterized as: “[completion of] as much of the skeletal and soft tissue reconstruction as possible during the initial hospitalization” and “[understand] that revisions will certainly occur later.” Disagreement in same-admission treatment timeline can be characterized by “phased approach and delayed reconstruction,” versus “early bony reconstruction.” Analysis of themes of function of VSP revealed that plastic surgeons use this technology primarily to, “decrease operative time,” “increase integrity of plates,” “help determine treatment sequence,” “help produce more predictable outcomes,” and “increase accuracy of surgical repair.”

Discussion

We present a case series of acute MBT cases that were reconstructed during the same-admission as their original post-traumatic presentation with microsurgical techniques using VSP. The minor complication rate was high, requiring revision procedures in a majority of cases, though the reconstructive goals were achieved with these revisions. The use of VSP facilitated preoperative planning, allowing for accurate and individualized mandibular reconstruction for complex maxillofacial ballistic trauma defects. It enforced advanced pre-operative planning, using computerized tools to enable more efficient surgical execution, and greater reconstructive precision.
We selected to used custom pre-milled plates in association with VSP to ensure precise match to custom cutting guides and to optimize plate rigidity by avoiding stock plate bending to fit the reconstruction. Similarities between milled, laser melted, or pre-bent plates allow for a personalized approach to each patient’s mandibular reconstruction using VSP. Yet, pre-milled and laser melted plates are more exact due to their computerized origin as compared to pre-bent plates which are milled by hand using custom cutting guides. A downside to laser melted plates are that they run more expensive than pre-bent and pre-milled plates.
Our systematic review revealed consensus themes that VSP function was to help produce more predictable outcomes and the clinical goal post MBT should be stabilization, functional occlusion, and mitigation of future deformities. Although functional occlusion was achieved in all of our patients with the precision of surgical planning, other functional complications such as dysphagia and proper speech are common to ballistic facial trauma. An advantage of same-admission is swallow rehabilitation from speech-language pathologists, so patients can slowly regain independent oral nutrition prior to leaving the hospital or being lost to follow-up.
Other persistent issues following same-admission such as patient aesthetic complications of poor nose projection and form, orbital asymmetry, and facial contour imbalance were not dealt with during same-admission. These complications should not be placed as high of a priority as proper reduction and fixation for stable osteosynthesis. We found it best to handle these issues in an out-patient fashion.
It can be noted that our study displays a high variance in same-admission LOS with a standard deviation of 17.8 days. Factors related to variance in LOS in our patient cohort can be attributed to severity of injury and number of complications. Severe mid-face, orbital, and maxilla blast injuries, as seen in Patients 3 and 4, led to longer hospital stays (54 and 78 days) as compared to the shorter hospital stay (28 days) and less severe and isolated ballistic trauma to the mandible experienced by Patient 5. The isolated mandibular injury experienced by Patient 5 resulted in the lowest amount of operations during same-admission in our cohort as well as less complications compared to the remaining cohort.
Our systematic review and patient cohort reveals that microvascular reconstruction is necessary after highenergy MBT, especially for the mandible. However, there is controversy as to the timing of definitive reconstruction, which was revealed in our systematic review thematic analysis. Surgical management is typically partitioned into 3 phases: initial operative debridement and temporary stabilization, definitive soft tissue and/or bony reconstruction, and possible subsequent aesthetic refinement (Figure 7).[2,10,13,19,24] Most authors fall into 2 camps: those that favor early intervention and those that advocate for delayed reconstruction. Early reconstruction authors suggest optimization of the soft tissue envelope, patient capture without loss to follow-up, and superior functional and aesthetic outcome. Delayed reconstruction authors suggest the beneficial interval between initial operative debridement and temporary stabilization has been used to ensure that necrotic tissue or contamination not be incorporated into the definitive reconstruction, which may be associated with fewer complications.[2,10,17,21,29,30] Reviews by Vaca et al., Jose et al., and Gurunluoglu et al., in particular, offer detailed early definitive microsurgical reconstruction algorithms in order to optimize outcomes.[10,16,45] We demonstrate that same-admission MBT microsurgical reconstruction may be performed with reasonably high fidelity using VSP.
In contrast to the MBT, the traditional dogma for breast, lower extremity, and head and neck post-oncologic reconstruction promotes early reconstruction.[33,34] Shock-wave trauma yields a field of injury beyond the defect proper at the time of MBT. Adjuvant radiation, which also creates a field effect, however, is usually given after a period of postoperative healing. This explains the tendency for minor complications following same-admission MBT reconstruction. The trade-off for delayed reconstruction raises additional questions about cost-efficacy, the risk-benefit between complications and long-term outcomes, and patient satisfaction. One could argue that non-compliant patients, who may not participate with risk-reduction strategies after MBT, may also not follow-up for delayed reconstruction, thereby excluding themselves from prior analyses. We believe future studies may demonstrate a higher potential outcome after early reconstruction with the trade-off of an increased re-intervention rate, given that recently-traumatized tissues tend to demonstrate greater rates of postoperative wound complication.
The use of VSP for early reconstruction requires timing and coordination to obtain physical clinical transfer tools without a prohibitive manufacturing and shipping time lag. A study by Kokosis et al. reported the use of VSP for mandibular trauma with decreased time from initial evaluation to surgical intervention.[37] Patients with MBT typically require other interventions prior to definitive reconstruction, such as tracheostomy, gastrostomy, or neurosurgical intervention. This time interval may be dual-utilized by the craniofacial surgeon for the declaration of viability of threatened penumbral tissue and simultaneously as time for manufacturing and shipment of clinical transfer tools. We observed that the early employment of VSP facilitated same-admission definitive microsurgical MBT reconstruction.
The limitations of our study include a small sample size and lack of a comparison group, as well as its retrospective nature. Our institution’s standard practice for maxillofacial ballistic trauma reconstruction is during the initial admission, which precluded a patient match comparison group. Our systematic review revealed no studies greater than levels IV and V of evidence revealing there are practical difficulties in implementing comparative trials in the field. Our study did not analyze procedures where VSP was not used, nor the economic implications of VSP. Additional studies are needed to analyze the impact of VSP on occlusion, precision of bone apposition, and patient-reported outcomes. The impact of early versus delayed reconstruction on chronic complications, such as wound contracture, infection rates, bite strength, occlusal accuracy, and psychological impact is also not investigated. Ultimately, comparison studies of early versus delayed definitive microsurgical jaw reconstruction after MBT would be required to better understand the relative value of these approaches.

Conclusion

Same-admission microsurgical reconstruction after MBT using VSP is safe and effective to re-establish lower jaw form and function. Further investigations are required to determine the impact on patient satisfaction, optimization of outcomes, and cost-efficacy.

Supplementary Materials

Supplemental material for this article is available online.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Conflicts of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Considerations

The work in this manuscript was approved by the University of Texas at Austin institutional review board (UT IRB # 2018-08-0088). The authors adhered to the Declaration of Helsinki through the entire research process.

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Figure 1. Patient 3 computed tomography scan immediately following close range maxillofacial ballistic trauma.
Figure 1. Patient 3 computed tomography scan immediately following close range maxillofacial ballistic trauma.
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Figure 2. A, Patient 3 VSP preoperative anatomy 10 days post MBT. B, Patient 3 virtual surgical planning simulated postoperative anatomy following reduction of pan-facial fractures.
Figure 2. A, Patient 3 VSP preoperative anatomy 10 days post MBT. B, Patient 3 virtual surgical planning simulated postoperative anatomy following reduction of pan-facial fractures.
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Figure 3. Patient 3 computed tomography scan following same-admission course of care.
Figure 3. Patient 3 computed tomography scan following same-admission course of care.
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Figure 4. A, Patient 3 virtual surgical planning preoperative anatomy 7 months post MBT and 5 months following same-admission. B, Patient 3 virtual surgical planning simulated postoperative anatomy following Le Fort I, maxilla, and mandible reconstruction using fibula free flap.
Figure 4. A, Patient 3 virtual surgical planning preoperative anatomy 7 months post MBT and 5 months following same-admission. B, Patient 3 virtual surgical planning simulated postoperative anatomy following Le Fort I, maxilla, and mandible reconstruction using fibula free flap.
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Figure 5. Patient 3 computed tomography scan 7 months following same-admission demonstrating stable craniofacial reconstruction and anatomy.
Figure 5. Patient 3 computed tomography scan 7 months following same-admission demonstrating stable craniofacial reconstruction and anatomy.
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Figure 6. Systematic review article attrition.
Figure 6. Systematic review article attrition.
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Figure 7. Average clinical timeline. Maxillofacial ballistic trauma surgical management is typically partitioned into 3 phases: initial operative debridement and temporary stabilization, definitive soft tissue and/or bony reconstruction, and possible subsequent aesthetic refinement.
Figure 7. Average clinical timeline. Maxillofacial ballistic trauma surgical management is typically partitioned into 3 phases: initial operative debridement and temporary stabilization, definitive soft tissue and/or bony reconstruction, and possible subsequent aesthetic refinement.
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Table 1. Patient Demographics.
Table 1. Patient Demographics.
PatientAgeGenderDays to
Flap		Number of Flaps
(Inpatient)		Operations
(Inpatient)		Days
Inpatient		Complications (Inpatient)Weeks
Follow-Up
MinorMajor
125M1614504049
218M6164850307
326M243105410138
442M27287840449
531M913281011
Mean28.4M: 100%16.41.66.251.63.00.0191.0
Standard Deviation8.9—9.10.92.917.81.90.0183.9
Table 2. Same-Admission Microvascular Free Flap Usage.
Table 2. Same-Admission Microvascular Free Flap Usage.
FlapOverall UsageFrequency
Anterior lateral thigh33/8 (37.5%)
Osteocutaneous free fibula22/8 (25.0%)
Radial forearm22/8 (25.0.2%)
Free rectus11/8 (12.5%)
Total88/8 (100.0%)
Table 3. Systematic Review: Ballistic Maxillofacial Trauma Using Virtual Surgical Planning.
Table 3. Systematic Review: Ballistic Maxillofacial Trauma Using Virtual Surgical Planning.
StudyTypePerspectiveLOEnPopulationMandibleMicrosurgerySame Admission
Stuehmer et al. 2008[40]Case ReportRetrospectiveV1CivilianYesYesNo
Harris and Laughlin 2013[41]ReviewExpert OpinionVN/aN/aYesYesYes
Benateau et al. 2016[35]Case SeriesRetrospectiveIV2CivilianYesNoNo
Khatib et al. 2017[36]ReviewExpert OpinionVN/aN/aYesYesNo
Kupfer et al. 2017[42]ReviewExpert OpinionVN/aN/aYesYesNo
Khatib et al. 2018[43]Case SeriesRetrospectiveIV10CivilianYesYesYes
Volk et al. 2019[18]ReviewExpert OpinionVN/aN/aYesYesYes
Breeze and Powers 2020[44]ReviewExpert OpinionVN/aN/aYesNoYes
Totals———13—100%75%50%
Knudson et al. (Current study)Case SeriesRetrospectiveIV5CivilianYesYesYes
Abbreviations: N/a, not applicable; LOE, level of evidence; n, sample size.

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MDPI and ACS Style

Knudson, S.A.; Day, K.M.; Kelley, P.; Padilla, P.; Collier, I.X.; Henry, S.; Harshbarger, R.; Combs, P. Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review. Craniomaxillofac. Trauma Reconstr. 2022, 15, 206-218. https://doi.org/10.1177/19433875211026432

AMA Style

Knudson SA, Day KM, Kelley P, Padilla P, Collier IX, Henry S, Harshbarger R, Combs P. Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review. Craniomaxillofacial Trauma & Reconstruction. 2022; 15(3):206-218. https://doi.org/10.1177/19433875211026432

Chicago/Turabian Style

Knudson, Sean A., Kristopher M. Day, Patrick Kelley, Pablo Padilla, Ian X. Collier, Steven Henry, Raymond Harshbarger, and Patrick Combs. 2022. "Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review" Craniomaxillofacial Trauma & Reconstruction 15, no. 3: 206-218. https://doi.org/10.1177/19433875211026432

APA Style

Knudson, S. A., Day, K. M., Kelley, P., Padilla, P., Collier, I. X., Henry, S., Harshbarger, R., & Combs, P. (2022). Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review. Craniomaxillofacial Trauma & Reconstruction, 15(3), 206-218. https://doi.org/10.1177/19433875211026432

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