Unintended Consequences: Combat-related injuries lead to advances in facial plastic and reconstructive surgery

Field experience has shown that early primary closure of these wounds will usually fail about five days post trauma due to tissue breakdown and necrosis, resulting in increased scarring and scar contracture which may negatively impact the success of reconstructive surgery (ADF Health. 2008;9(1):36-42). Therefore, even if patients appear asymptomatic, this type of high-velocity penetrating neck trauma mandates the consideration of neck exploration. In a 2006 study, COL Joseph Brennan, MD, from the Department of Otolaryngology/Head and Neck Surgery at Wilford Hall Medical Center, reported that the incidence of major intraoperative pathology found on exploration was 78 percent in patients with penetrating neck trauma (Otolaryngol Head Neck Surg. 2006;134(1):100-105). Relying only on imaging studies for neck exploration may result in a missed diagnosis.

Additionally, fragmentation wounds from IEDs are always contaminated because of the dirt, glass and metal found in them and require antibiotics such as cefazolin or clindamycin to combat Clostridium tetani and Bacteroides. Serial debridement and irrigation of these contaminants, as well as delayed wound closure, are crucial to preserving damaged soft tissue.

Based on the increasing number of HFNIs in OIF and OEF, the U.S. Army now has a wound management protocol in place for maxillofacial injuries that optimizes form and function outcomes for victims of IEDs, rocket propelled grenades, and high-velocity ballistics (ADF Health. 2008;9(1):36-42). “These advances include a better understanding of injury patterns from high velocity penetrating wounds, as well as an improved treatment algorithm,” Dr. Lopez said.

Bringing it Home

Dr. Holt acknowledged that deployed surgeons will someday be practicing in the civilian community after their military obligation is over and will bring their experiences to their communities and colleagues in otolaryngology.

“Since we are the ones deployed overseas to treat U.S. casualties, we can share directly with residents in training—the future leaders in military medicine,” said LCDR Robert M. Laughlin, DMD, interim director of Residency Training and staff surgeon in the Department of Oral Maxillofacial Surgery at Naval Medical Center in San Diego (NMCSD).

Physicians at NMCSD treat a broad range of combat-related head and neck wounds, including infections, airway management, nondisplaced facial fractures, lacerations and complex panfacial fractures, with and without significant avulsive tissue loss, often with loss of bony facial skeleton, as well as soft tissue injuries.

“We are applying our knowledge from head and neck cancer and large ablative surgeries to our wounded warriors with the application of free tissue transfers and large rotational flaps in order to restore form and function,” Dr. Laughlin said. “With these techniques, we are able to do a one stage versus multistage surgery, combining bony and soft tissue reconstruction. Although this technique is currently not done in theater, the surgeons on the front lines are cognizant of free tissue transfer and are preparing patients for this type of definitive care when they arrive stateside.”