Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16

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Journal of Cranio-Maxillo-Facial Surgery

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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 1981e1985 the author treated 1486 patients with facial gunshot wounds sustained in combat in Afghanistan. In the last quarter of 20th century, more powerful and destructive weapons such as M-16 ries, 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 authors experience was that tissue sparing lead to a high rate of complications (47.6%). 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 0.7% patients required discharge from the army due to facial muscle paralysis and/or 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 haemorrhage, 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 gunshot wound debridement. There are many wound debridement concepts described. The shortest belongs to Pirogov (1941) . to convert a crushed wound into incised wound. Based on my experience, contused, crushed, dead and dying wound edges must be excised to the point of active capillary bleeding then the wound becomes an incised wound. The wound can then be drained and sutured, allowing wound
* Corresponding author. Tel.: 7 499 261 93 75, 8 905 537 77 28. E-mail addresses: mbshvyrkov@gmail.com, mbshvyrkov@rambler.ru (M.B. Shvyrkov). 1 Present address: 7 495 Moscow, 105005 Pleteshkovskii pereulok hous 8, korp 1, at 17, Russia.

closure without suppuration, rejection, disintegration and suture breakage. Struchkov (1972) and Berkutov recommended excising wound edges and depths with the removal of all damaged, contaminated and blood saturated tissues. After debridement wound edges should be well perfused and resistant to bacterial invasion to ensure rapid healing. In military maxillo-facial surgery the basic principles of maxillo-facial gunshot wound debridement 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 projectiles and changes in wound characteristics with combined wound quantity (wound and burn) are not taken into consideration (Callender and Franch, 1935, Chartes and Charters,1976, Berkutov, 1981; Holt and Kostohryz, 1983; Alexandrov, 1985, Marshall,1986). Combined wound (wound 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 2/3 of facial injuries were soft

1010-5182/$ e see front matter 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. doi:http://dx.doi.org/10.1016/j.jcms.2012.04.001

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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 rst 12 h after injury. Wounds were not infected in 58.6e64.4% of the wounded within 3 days after injury (Table 1). Purulent inammation was found in 8 of 21 infected wounds on the rst day only. At 4e6 days after injury, 70.7% of the wounded were infected while suppuration happened in 56.1% 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 nally zone of healthy tissues. Upper channel from old bullet, down e from modern high velocity bullet.

tissues wounds and 1/3 fractures of the facial skeleton. In Afghanistan these proportions were reversed. In my rst manuscript I would like to consider debridement of isolated gunshot wounds of the face soft tissues of 502 (33, 8%) wounded. In my rst 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 interventions and prolonged duration of treatment. I performed radical primary surgical debridement (RPSD) of gunshot wounds, meaning excision of soft tissue wound 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 inammation develops (Krizek and Robson, 1975). Soft tissues excision together with microbes decreases microbial load in a wound (Kousin et al., 1981).

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 ora availability in the face gunshot wound depending on period (term) of wounding. Time after injury Patients quantity/% from total number in the line Bacterial ora is absent 38/64, 4% 34/58, 6% 17/29, 3% 3/16, 7% 3/21, 4% 5/17, 9% 100/42, 6% Bacterial ora is present 21/35, 6% 24/41, 4% 41/70, 7% 15/83, 3% 11/78, 6% 23/82, 1% 135/57, 4% Altogether patients 59 58 58 18 14 28 235 Quantity of suppuration from infected wounds 8/38, 1% 15/62, 5% 23/56, 1% 7/46, 7% 2/18, 2% 1/4, 3% 56/23, 8%

Up to 24 h 2e3 days 4e6 days 7e9 days 10e12 days 12e15 days Altogether

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At 12e15 days 82.1% of the wounds were infected but suppuration occurred in only 4.3%. At 15 days after injury bacterial ora was not found in 42.6% of the wounds, and suppurating infection occurred in 41.5%. 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 rie barrel. It was 137e156  C. As far as 600 m its temperature decreased to 92e126  C. Bullets travel at 600 m and in nonpenetrating unclothed facial wounds the wound is sterile. 2.1. Primary debridement of the facial gunshot wound A ying bullet presses air in front of itself forming a front percussion wave. 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 ies out in front of and behind the bullet through the entrance and exit (Fig. 12). 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 were not 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 lled with gauze saturated with proteolytic enzymes for 4e5 h with the purpose of digesting of necrotic tissues and then lled with antiseptic 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 by Mechnikov in 1883 (1955) a foreign body will divert part of leucocytes to itself. In 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 digestion 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 the rst granulation tissue emerges on the 6th day and the wound may be closed with delayed primary sutures. If granulation tissues grow slowly, liniment balm Vishnevski is poured into the wound without gauze because it oppresses granulation tissues with its pressure. After 2e3 days a canal is lled with granulation tissue and the wound is ready for closure. Primary debridement of wound (PD) which is initially performed by maxillofacial surgeon right after wounding should be distinguished from a secondary (repeated) debridement (SD) performed 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 interrupted sutures in wounds in the sublingual region. This may be done through external wounds especially after splinting.

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?

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 aps were utilised as necessary to achieve primary closure (Fig. 5a,b; Fig. 6aec; Fig. 7a,b; Fig. 8a,b;

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Fig. 5. a e The old wound is bullet exit, tangentional fracture of the mandible which was xed by device Rudko. Tissues aps were xed with two button sutures; b e soft tissues were cut off and defect was closed with bipolar scalp ap.

Fig. 9a,b). 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 to excise non-vital tissue without damaging healing potential. Postponed primary closure was performed 3e4 days after wound debridement in the following cases: (1) following debridement of very contaminated wound, (2) in suppurative inammation 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, liniment balm Vishnevski and physical therapy (Fig. 10). Delayed primary suture was used every 6e7 days after PD in slow cleaning wound and, nally, 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 wound. Soft, unscarred tissue is mobile and easily manipulated. Sometimes only 1e2 mm of skin excision is required for good aesthetic scar formation. Late secondary closure was used rarely, that is,17e31 days after PD when (1) inammation is nished, (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 ap 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 wound edges closer gradually. It is used in big wide wound or wounds with inltrated borders when stitching is impossible (Fig. 10). After stitching the surgeon brings wound edges together closure by hand and the assistant knots the all threads ends together minimising the wound but it does remain open, therefore it has to be lled with gauze saturated with antiseptic ointment or liniment balm Vishnevski. 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 nger. A directive suture is required after large ap repositioning. Intermittent wound lavage with solution antiseptic or antibiotic through 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 around the 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 inammation. 3. Results In the 2-nd World War primary sutures were used in 13.0e15.0% of the wounded after sparing debridement. The sutures destroyed tissues and wound edges splayed in 50.0e77.0% patients (Zbarge, 1951). Suppurative inammation increases treatment time, is

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Fig. 6. a e Wounded after mine explosion. Apparatus Rudko xed 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 lled with good succulent granulation; c e monopolar pedicle ap from left humerus closes cheek wound; d e the same patient after 2 months.

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 debridement.14.7% of the patients needed local ap reconstruction during radical PSD (primarily operation) or delayed plastic from remote area of patients body (bipolar scalp ap, rope ap etc.). 0.7% 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. 11a,b).

4. Discussion Treatment of facial gunshot injuries especially wound debridement 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; OwenSmith, 1985; Rich, 1968; Reis et al., 1991). Others excise all necrotic and soft tissue of dubious viability together with foreign bodies and

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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 ap sutured to a skin frontonasal notch; c e after operation, rst stage.

microbes to preventing inammation and toxaemia (OBrein, 1973; Al-Shawi, 1986; Shvyrkov et al., 2001). Only vital soft tissue should be left in wound to withstand bacterial invasion. Those in the rst 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 doctors rst group sometimes is useful to meet Alexandrov (1985)

has written about delayed wound management: Removing damaged tissues from the wound must be more extensive (does not spare, as require before e M.Sh.): those tissues which could be used for defect closure lose their vitality gradually and cannot be used for wound closure. 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

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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 ap is cut out from lower lip and moved to a defect of upper lip.

Fig. 10. a e Old avulsive penetrating deep wound as a result of gutter wounding with inltrated borders; b e after medical treatment wound become clean and closed with brin. ce wound borders were brought closer gradually by two approximation button sutures, wound was lled 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.

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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.

Fig. 12. Conical fountain of ground and disintegrated tissues ies out in front and behind of the bullet through entrance hole and outlet.

diagnosed. The author contends that indirect lateral blow with high velocity projectile inevitably causes tissue necrosis and considers that cautious debridement leads to avoidable purulent inammation and unnecessary resource expenditure. Reis et al. (1991) recommended . primary radical wound excision, repeated every 48 h. The wound is always left open. 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 identied 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 metabolism ceases to a great extent with cell death occurring 2e3 days later, the zone at which a line of demarcation arises (2), and nally a zone of healthy tissue (1) (Fig. 1). Dead and dying tissues inevitably

remain in cautious debridement becoming an inammatory focus, suppuration starts. These tissues became heterogeneous substance for patients organism, which tries to remove them by inammation. Leukocytes, macrophages and tissues enzymes attack them. A bacterial ora develops lysing dead tissue and contributing to wound cleaning. Davydovski (1952) attached great importance to microscopic ora as a biological cleaner. However, acute purulent inammation does not always happen. Bleeding and local trauma reduce tissue resistance creating favourable conditions for the development of wound infection. Kostuchonok and Karlov (1990) stated . 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 debridement. Acute inammation increases tissue acidity, collagen laments expand and weaken, sutures start to tear tissue, wound edges diverge, and the wound opens. The inammatory process is very expensive for a wounded organism. The mobilisation of leucocytes, macrophages, and osteoclasts expends much energy to demolish damaged tissue instead of preserving this for healing. The organism will reject the nonviable tissues if they were not incised again expending energy. The appearance of a scar is also compromised by inadequate debridement of the initial wound. The examination of the microbial growth conrms the introduction of infection as a result of ingrowth of microbes from the skin 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 temperatures. 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 ows into wound contamination occurs immediately.

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Damaged tissue cannot resist microbial invasion It is the authors 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 fulls 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 rst step and conservative treatment is a second. 5. Conclusion The treatment of facial gunshot injuries is performed in accordance with the following principles: 1) Evaluation of the woundeds general clinical condition; 2) Detailed examination of the wound by means of inspection, palpation and probing probe. Within the rst 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.

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Ethics statements This work has been approved by the appropriate ethical committees related to the military hospital of Afghanistan in 1981e1985 where it was performed. Subjects gave informed consent. Funding source None Conict of interest None