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Semin Plast Surg 2025; 39(01): 019-027
DOI: 10.1055/s-0044-1801409
Review Article

Presentation and Management of Self-Inflicted Gunshot Wounds to the Face

Rebecca Gardella
1   Division of Plastic & Reconstructive Surgery, Department of Surgery, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
,
Alyssa D. Reese
1   Division of Plastic & Reconstructive Surgery, Department of Surgery, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
,
Jhobani Torres-Gomez
2   School of Medicine, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
,
Phavon Sage
2   School of Medicine, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
,
Rena Atayeva
2   School of Medicine, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
,
Kerry P. Latham
3   Division of Plastic Surgery, Department of Surgery, Uniformed Services University of the Health Sciences School of Medicine, Bethesda, Maryland
,
Richard Tyrell
2   School of Medicine, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
4   Center for Plastic Surgery, Sentara Health, Norfolk, Virginia
› Author Affiliations Funding None.
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Abstract

Self-inflicted gunshot wounds (SI-GSW) to the head and face are associated with significant morbidity and mortality. Patients who do survive their injuries often face life-altering disfigurement and disability. To effectively care for these patients, providers must not only detect and address the immediate life-threatening injuries, but also plan for long-term definitive reconstruction. This review provides an overview of presentation and management of SI-GSW to the face, including initial stabilization and workup, assembly of a multidisciplinary care team, surgical reconstruction of soft tissue and bony defects, and long-term management to address aesthetic and functional goals. Emphasis is placed on the role of plastic and reconstructive surgeons in SI-GSW reconstruction; however, a better understanding of these complex injuries and their management can help all health care providers better optimize care for this high-risk population.

Keywords

ballistics - firearms - gunshot - self-inflicted - suicide - craniofacial - facial trauma - reconstruction


Publication History

Article published online:
26 March 2025

© 2025. Thieme. All rights reserved.

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  • References

  • 1 Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 2018–2022 on CDC WONDER Online Database, . released in 2024 . Data are from the Multiple Cause of Death Files, 2018–2022, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/ucd-icd10-expanded.html
    PubMedSearch in Google Scholar
  • 2 Foote CW, Doan XL, Vanier C, Cruz B, Sarani B, Palacio CH. Suicide versus homicide firearm injury patterns on trauma systems in a study of the National Trauma Data Bank (NTDB). Sci Rep 2022; 12 (01) 15672
    CrossrefPubMedSearch in Google Scholar
  • 3 Quenzer F, Givner A, Dirks R, Coyne CJ, Ercoli F, Townsend R. Self-Inflicted gun shot wounds: a retrospective, observational study of U.S. trauma centers. West J Emerg Med 2021; 22 (03) 518-524
    CrossrefPubMedSearch in Google Scholar
  • 4 Menezes JM, Batra K, Zhitny VP. A nationwide analysis of gunshot wounds of the head and neck: morbidity, mortality, and cost. J Craniofac Surg 2023; 34 (06) 1655-1660
    PubMedSearch in Google Scholar
  • 5 Tholpady SS, DeMoss P, Murage KP, Havlik RJ, Flores RL. Epidemiology, demographics, and outcomes of craniomaxillofacial gunshot wounds in a level I trauma center. J Craniomaxillofac Surg 2014; 42 (05) 403-411
    CrossrefPubMedSearch in Google Scholar
  • 6 Tran Z, Bonnick K, Byun J, Cho NY, Benharash P, Mukherjee K. An ounce of prevention is the only cure: nationwide clinical and financial outcomes of self-inflicted firearm injuries. Am Surg 2023; 89 (10) 4084-4088
    CrossrefPubMedSearch in Google Scholar
  • 7 Bukur M, Inaba K, Barmparas G. et al. Self-inflicted penetrating injuries at a level I trauma center. Injury 2011; 42 (05) 474-477
    CrossrefPubMedSearch in Google Scholar
  • 8 Palines PA, Park SY, Loo RJ. et al. Facial reconstruction following self-inflicted gunshot wounds: predictors, complications, and acceptable outcomes. Trauma Care 2022; 2 (02) 211-225
    CrossrefPubMedSearch in Google Scholar
  • 9 Lee KC, Wu BW, Chuang SK. Are facial gunshot wounds more fatal when they are self-inflicted or other-inflicted?. Craniomaxillofac Trauma Reconstr 2022; 15 (04) 275-281
    CrossrefPubMedSearch in Google Scholar
  • 10 Hussein MA, Nallani R, Jenkins PM. et al. The role of trauma services in intentional self-harm at a regional level 1 trauma center. Injury 2023; 54 (10) 110981
    CrossrefPubMedSearch in Google Scholar
  • 11 Wasicek PJ, Kantar RS, Yoon J, Elegbede A, Nam AJ. Survival following self-inflicted gunshot injuries to the face using the national trauma data bank. J Craniofac Surg 2021; 32 (06) 2064-2067
    CrossrefPubMedSearch in Google Scholar
  • 12 Schoen N, Matichak D, Armstrong V. et al. The cost of gunshot wounds to the head: an unevenly distributed burden. World Neurosurg 2023; 172: e201-e211
    CrossrefPubMedSearch in Google Scholar
  • 13 Weyh A, Gomez J, Kashat K, Fernandes R, Bunnell A. Self-inflicted craniomaxillofacial gunshot wounds: management, reconstruction, and outcomes. Int J Oral Maxillofac Implants 2023; 52 (03) 334-342
    CrossrefPubMedSearch in Google Scholar
  • 14 Johnson J, Markiewicz MR, Bell RB, Potter BE, Dierks EJ. Gun orientation in self-inflicted craniomaxillofacial gunshot wounds: risk factors associated with fatality. Int J Oral Maxillofac Implants 2012; 41 (08) 895-901
    CrossrefPubMedSearch in Google Scholar
  • 15 ATLS Subcommittee. American College of Surgeons' Committee on Trauma. International ATLS Working Group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg 2013; 74 (05) 1363-1366
    CrossrefPubMedSearch in Google Scholar
  • 16 Blessing MM, Lin PT. Suicide by shotgun in Southeastern Minnesota. J Forensic Sci 2016; 61 (Suppl. 01) S159-S162
    PubMedSearch in Google Scholar
  • 17 Hafertepen SC, Davis JW, Townsend RN, Sue LP, Kaups KL, Cagle KM. Myths and misinformation about gunshot wounds may adversely affect proper treatment. World J Surg 2015; 39 (07) 1840-1847
    CrossrefPubMedSearch in Google Scholar
  • 18 Schellenberg M, Inaba K, Heindel P. et al. The diagnostic dilemma of shotgun injuries. Eur J Trauma Emerg Surg 2020; 46 (06) 1351-1356
    CrossrefPubMedSearch in Google Scholar
  • 19 Stanbouly D, Chuang SK. Self-inflicted craniomaxillofacial gunshot wounds by handguns are more deadly than those by shotguns: an NIS study. Oral Maxillofac Surg 2023; 27 (01) 79-87
    CrossrefPubMedSearch in Google Scholar
  • 20 Bovio NR, Brooks JK, Prahlow JA. Suicide by gunshot wound to the posterior head and neck: a retrospective case series and review of the literature. Am J Forensic Med Pathol 2024; 45 (03) 248-253
    CrossrefPubMedSearch in Google Scholar
  • 21 Kriet JD, Stanley Jr RB, Grady MS. Self-inflicted submental and transoral gunshot wounds that produce nonfatal brain injuries: management and prognosis. J Neurosurg 2005; 102 (06) 1029-1032
    CrossrefPubMedSearch in Google Scholar
  • 22 Carpenter P, McCrary HC, Aylward A. et al. Penetrating Trauma Rapid Estimated Disability scale: assessing facial self-inflicted gunshot wounds. Facial Plast Surg Aesthet Med 2021; 23 (06) 455-459
    CrossrefPubMedSearch in Google Scholar
  • 23 Offiah C, Hall E. Imaging assessment of penetrating injury of the neck and face. Insights Imaging 2012; 3 (05) 419-431
    CrossrefPubMedSearch in Google Scholar
  • 24 Chattha A, Lee JC, Johnson PK, Patel A. An algorithmic approach to the management of ballistic facial trauma in the civilian population. J Craniofac Surg 2018; 29 (08) 2010-2016
    CrossrefPubMedSearch in Google Scholar
  • 25 Alvis-Miranda HRM, MRubiano A, Agrawal A. et al. Craniocerebral gunshot injuries; a review of the current literature. Bull Emerg Trauma 2016; 4 (02) 65-74
    CrossrefPubMedSearch in Google Scholar
  • 26 ACS TQIP Best Practice Guidelines in Imaging. October 2018 . Accessed December 9, 2024 at: https://www.facs.org/media/oxdjw5zj/imaging_guidelines.pdf
    PubMed
  • 27 Yoon J, Gebran S, Elegbede A. et al. Blunt cerebrovascular injury-like injury observed in patients with craniofacial self-inflicted gunshot wounds. J Craniofac Surg 2022; 33 (04) 1046-1050
    CrossrefPubMedSearch in Google Scholar
  • 28 Lustenberger T, Inaba K, Schnüriger B. Gunshot injuries in the elderly: patterns and outcomes. A national trauma databank analysis. World J Surg 2011; 35 (03) 528-534
    CrossrefPubMedSearch in Google Scholar
  • 29 Hatchimonji JS, Swendiman RA, Goldshore MA. et al. Pediatric firearm mortality in the United States, 2010 to 2016: a National Trauma Data Bank analysis. J Trauma Acute Care Surg 2020; 88 (03) 402-407
    CrossrefPubMedSearch in Google Scholar
  • 30 Martin WS, Gussack GS. Pediatric penetrating head and neck trauma. Laryngoscope 1990; 100 (12) 1288-1291
    CrossrefPubMedSearch in Google Scholar
  • 31 Shackford SR, Kahl JE, Calvo RY. et al. Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality: results of an 11-year multi-institutional study of 720 patients. J Trauma Acute Care Surg 2014; 76 (02) 347-352
    CrossrefPubMedSearch in Google Scholar
  • 32 Froehlich M, McNickle AG, Fraser DR. Airway management in self-inflicted gunshot wounds to the face. Surg Pract Sci 2022; 10: 100118
    CrossrefPubMedSearch in Google Scholar
  • 33 Holevar M, Dunham JCM, Brautigan R. et al. Practice management guidelines for timing of tracheostomy: the EAST Practice Management Guidelines Work Group. J Trauma 2009; 67 (04) 870-874
    PubMedSearch in Google Scholar
  • 34 Hawryluk GWJ, Selph S, Lumba-Brown A. et al. Rationale and methods for updated guidelines for the management of penetrating traumatic brain injury. Neurotrauma Rep 2022; 3 (01) 240-247
    CrossrefPubMedSearch in Google Scholar
  • 35 Rutman AM, Vranic JE, Mossa-Basha M. Imaging and management of blunt cerebrovascular injury. Radiographics 2018; 38 (02) 542-563
    CrossrefPubMedSearch in Google Scholar
  • 36 Alao T, Waseem M. Neck trauma. In: StatPearls [Internet]. Treasure Island, FL:: StatPearls Publishing;; 2024. . Accessed October 27, 2024 at: http://www.ncbi.nlm.nih.gov/books/NBK470422/
    Search in Google Scholar
  • 37 Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl 2018; 100 (01) 6-11
    CrossrefPubMedSearch in Google Scholar
  • 38 Kiwanuka H, Aycart MA, Gitlin DF. et al. The role of face transplantation in the self-inflicted gunshot wound. J Plast Reconstr Aesthet Surg 2016; 69 (12) 1636-1647
    CrossrefPubMedSearch in Google Scholar
  • 39 Jazayeri HE, Khavanin N, Yu JW. et al. Does early repair of orbital fractures result in superior patient outcomes? A systematic review and meta-analysis. J Oral Maxillofac Surg 2020; 78 (04) 568-577
    CrossrefPubMedSearch in Google Scholar
  • 40 Weiss R, He C, Gise R, Parsikia A, Mbekeani JN. Patterns of pediatric firearm-related ocular trauma in the United States. JAMA Ophthalmol 2019; 137 (12) 1363-1370
    CrossrefPubMedSearch in Google Scholar
  • 41 Qaisi M, Martin S, Al Azzawi T, Aldelayme R, Bokhari F, Murphy J. Is maxillofacial gunshot wound location associated with operative intervention?. J Oral Maxillofac Surg 2023; 81 (04) 434-440
    CrossrefPubMedSearch in Google Scholar
  • 42 McClay MM, O'Connor SS, Groh BN. et al. Denial of suicide attempt among hospitalized survivors of a self-inflicted gunshot wound. Psychiatr Serv 2018; 69 (06) 657-663
    CrossrefPubMedSearch in Google Scholar
  • 43 Doupnik SK, Rudd B, Schmutte T. et al. Association of suicide prevention interventions with subsequent suicide attempts, linkage to follow-up care, and depression symptoms for acute care settings: a systematic review and meta-analysis. JAMA Psychiatry 2020; 77 (10) 1021-1030
    CrossrefPubMedSearch in Google Scholar
  • 44 Leung AC, Nahmias JT, Roman KM, Kirby KA, Qazi AS, Joe VC. Unnecessary early gastrostomy for trauma patients. Am Surg 2023; 89 (12) 6338-6341
    CrossrefPubMedSearch in Google Scholar
  • 45 Mundinger GS, Borsuk DE, Okhah Z. et al. Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice. Craniomaxillofac Trauma Reconstr 2015; 8 (01) 64-78
    CrossrefPubMedSearch in Google Scholar
  • 46 Appelbaum RD, Farrell MS, Gelbard RB. et al. Antibiotic prophylaxis in injury: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma Surg Acute Care Open 2024; 9 (01) e001304
    CrossrefPubMedSearch in Google Scholar
  • 47 Baum GR, Baum JT, Hayward D, MacKay BJ. Gunshot wounds: ballistics, pathology, and treatment recommendations, with a focus on retained bullets. Orthop Res Rev 2022; 14: 293-317
    PubMedSearch in Google Scholar
  • 48 Stefanopoulos PK, Soupiou OT, Pazarakiotis VC, Filippakis K. Wound ballistics of firearm-related injuries–part 2: mechanisms of skeletal injury and characteristics of maxillofacial ballistic trauma. Int J Oral Maxillofac Implants 2015; 44 (01) 67-78
    CrossrefPubMedSearch in Google Scholar
  • 49 Yuksel F, Celikoz B, Ergun O, Peker F, Açikel C, Ebrinc S. Management of maxillofacial problems in self-inflicted rifle wounds. Ann Plast Surg 2004; 53 (02) 111-117
    CrossrefPubMedSearch in Google Scholar
  • 50 Murphy JA, McWilliams SR, Lee M, Warburton G. Management of self-inflicted gunshot wounds to the face: retrospective review from a single tertiary care trauma centre. Br J Oral Maxillofac Surg 2018; 56 (03) 173-176
    CrossrefPubMedSearch in Google Scholar
  • 51 Chaiyasate K, Gupta R, Boudiab EM. et al. Comprehensive treatment and reconstructive algorithm for functional restoration after ballistic facial injury. Plast Reconstr Surg Glob Open 2022; 10 (07) e4453
    CrossrefPubMedSearch in Google Scholar
  • 52 Khatib B, Cuddy K, Cheng A. et al. Functional anatomic computer engineered surgery protocol for the management of self-inflicted gunshot wounds to the maxillofacial skeleton. J Oral Maxillofac Surg 2018; 76 (03) 580-594
    CrossrefPubMedSearch in Google Scholar
  • 53 Zeiderman MR, Pu LLQ. Contemporary reconstruction after complex facial trauma. Burns Trauma 2020; 8: tkaa003
    CrossrefPubMedSearch in Google Scholar
  • 54 Palines PA, Ferrer JR, Yoo A, St Hilaire H, Stalder MW. Simplifying bony midface reconstruction with patient-specific titanium plates. Plast Reconstr Surg Glob Open 2021; 9 (04) e3555
    CrossrefPubMedSearch in Google Scholar
  • 55 Nandra B, Fattahi T, Martin T, Praveen P, Fernandes R, Parmar S. Free bone grafts for mandibular reconstruction in patients who have not received radiotherapy: the 6-cm rule-myth or reality?. Craniomaxillofac Trauma Reconstr 2017; 10 (02) 117-122
    CrossrefPubMedSearch in Google Scholar
  • 56 Sri Surya TP, Jaggannagari S, Danam RP, Colvenkar S, Alwala AM. Management of comminuted fracture of mandible using titanium mesh. Cureus 2023; 15 (03) e35799
    PubMedSearch in Google Scholar
  • 57 Dai J, Shen G, Yuan H, Zhang W, Shen S, Shi J. Titanium mesh shaping and fixation for the treatment of comminuted mandibular fractures. J Oral Maxillofac Surg 2016; 74 (02) 337.e1-337.e11
    CrossrefPubMedSearch in Google Scholar
  • 58 Biglioli F, Zago M, Allevi F. et al. Reanimation of the paralyzed lids by cross-face nerve graft and platysma transfer. J Craniomaxillofac Surg 2018; 46 (03) 521-526
    CrossrefPubMedSearch in Google Scholar
  • 59 Hart J, Gupta R, Chaiyasate K. Eyelid reanimation with free platysma graft: final stage of reconstruction after gunshot wound to face. Plast Reconstr Surg Glob Open 2022; 10 (06) e4372
    CrossrefPubMedSearch in Google Scholar
  • 60 Roy M, Corkum JP, Shah PS. et al. Effectiveness and safety of the use of gracilis muscle for dynamic smile restoration in facial paralysis: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2019; 72 (08) 1254-1264
    CrossrefPubMedSearch in Google Scholar
  • 61 Homsy P, Huelsboemer L, Barret JP. et al. An update on the survival of the first 50 face transplants worldwide. JAMA Surg 2024; 159 (12) 1339-1345
    CrossrefPubMedSearch in Google Scholar
  • 62 Vyas K, Suchyta M, Gibreel W. et al. Virtual surgical planning and 3D-printed surgical guides in facial allotransplantation. Semin Plast Surg 2022; 36 (03) 199-208
    Thieme ConnectPubMedSearch in Google Scholar
  • 63 Diep GK, Berman ZP, Alfonso AR. et al. The 2020 facial transplantation update: a 15-year compendium. Plast Reconstr Surg Glob Open 2021; 9 (05) e3586
    CrossrefPubMedSearch in Google Scholar
  • 64 Hughes BD, Cummins CB, Shan Y, Mehta HB, Radhakrishnan RS, Bowen-Jallow KA. Pediatric firearm injuries: Racial disparities and predictors of healthcare outcomes. J Pediatr Surg 2020; 55 (08) 1596-1603
    CrossrefPubMedSearch in Google Scholar
  • 65 Lemogne C, Bellivier F, Fakra E. et al. Psychological and psychiatric aspects of face transplantation: lessons learned from the long-term follow-up of six patients. J Psychosom Res 2019; 119: 42-49
    CrossrefPubMedSearch in Google Scholar