Self-inflicted midline facial gunshot wounds: the case for a combined craniofacial and microvascular team approach.

Self-inflicted gunshot wounds to the face are extremely complex and difficult to manage. In the past, these patients have been treated by debridement, hemostasis, and soft tissue closure with reconstruction deferred to a later time. This approach consigned the patient to significant facial contracture and scarring, which is impossible to adequately correct secondarily. As a result of this traditional approach, patients had substantial disfigurement as well as dysfunction. At the Medical College of Wisconsin, we have begun an aggressive multispecialty team approach in which the maximum possible reconstruction is performed acutely. This has resulted in superior aesthetic and functional results, and in a substantially lower number of hospitalizations, surgical procedures, and hospital days. This approach includes the spectrum of current plastic surgical techniques including the craniofacial approach using open reduction with accurate miniplate reconstruction and acute bone grafting as well as soft tissue reconstruction and replacement using composite multiple-stacked free tissue transfer. We believe the overall approach provides a superior result and we will continue a program of aggressive and acute intervention.