Combat Ballistic Injuries to the Face

Abstract

Combat ballistic injuries to the face present complex challenges for military medical personnel, often involving multiple traumas that require immediate intervention to preserve life and function. This review explores the mechanisms of ballistic trauma, highlighting the unique injury patterns seen in modern conflicts like those in Iraq, Afghanistan, Syria, and Ukraine. Advances in protective gear have altered injury profiles, increasing the incidence of head, neck, and facial injuries. Early evacuation and definitive care are critical, though prolonged field care settings may require adapted surgical techniques due to resource constraints. The goals of surgical management focus on restoring form and function, with treatment strategies influenced by the severity of injuries and available medical resources. This article also discusses the long-term complications, such as infections, nerve injuries, and posttraumatic stress disorder, emphasizing the need for a multidisciplinary approach. The evolving nature of combat injuries underscores the importance of continuous surgical innovation and timely intervention to improve outcomes for soldiers suffering from ballistic facial trauma.

Introduction to Combat Ballistic Injuries

Combat ballistic injuries are wounds inflicted by projectiles such as bullets and shrapnel during military conflicts. These injuries result from various forms of ballistic trauma, including high-velocity gunshot wounds and explosive-related shrapnel injuries. Due to their prevalence and complexity, these injuries present significant challenges for military medical personnel. They often result in severe and multifaceted traumas, requiring advanced and immediate medical interventions.

This article aims to provide a comprehensive understanding of combat ballistic injuries by examining their historical development, treatment evolution, and outcomes. It will also compare military and civilian injuries to highlight differences in injury mechanisms, medical responses, and patient prognosis. By understanding these differences, medical professionals can better tailor treatment approaches to improve outcomes for injured soldiers.

Combat ballistic injuries have become increasingly relevant in military medicine, particularly in the context of modern warfare, where the use of advanced weaponry has led to more complex injury patterns. The nature of these injuries often involves a combination of penetrating, blunt, and burn trauma, which adds additional complexity to their management.

Historical Context and Advancements

In ancient and medieval warfare, ballistic injuries were primarily caused by arrows and other projectiles. Even as weapons continued to progress until World War I (WWI), treatments were rudimentary, focusing on immediate survival rather than long-term recovery. Significant advancements in treating ballistic injuries occurred during WWI and World War II (WWII). Sir Harold Gillies pioneered facial reconstruction surgery, developing techniques such as the pedicle tube and skin grafts to address the severe facial injuries caused by trench warfare. He established a dedicated ward for facial repairs at Queen's Hospital in Sidcup, England, 1917, which became a pivotal center for the development of modern plastic surgery. ¹

Recent conflicts, such as Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), have seen further developments in treating combat ballistic injuries. These conflicts have led to changes in injury patterns and medical responses, including improved field medical systems and rapid medical evacuation, significantly reducing mortality rates. The enforced use of flak jackets and advanced body armor has changed the profile of wounds, with a decrease in chest, stomach, and pelvic injuries and an increase in arm and leg injuries. ²

Analysis of combat casualties has shown a significant decline in the number of deaths from wounds over the years, dropping from 8% in WWI to 2.1% in Desert Storm. However, the number increased to 6.4% in the urban combat scenario of Somalia. ³ A comprehensive study of injuries during OIF and OEF reveals an evolving landscape of combat casualties characterized by complex injury profiles that often combine various types of trauma, such as blast injuries and gunshot wounds. ⁴ The United States has achieved unprecedented survival rates, as high as 98%, for casualties arriving alive at combat hospitals. ⁵ Despite this, up to 25% of battlefield deaths are potentially preventable, occurring mainly in the prehospital setting. ⁶ Among the injuries sustained, head and neck injuries remain one of the critical sources of morbidity and mortality. During WWII, the Korean War, and the Vietnam War, head, face, and neck wounds accounted for more than 40% of deaths, more than any other body region, among U.S. armed forces. ⁷

Conflict-Specific Injury Patterns

Historically, war has catalyzed medical innovation to meet the pace of modern weapons engineering. With each conflict, a new set of combat-specific injury patterns arises. We will review important considerations from previous conflicts, the impacts of modern warfare, and important considerations for managing head and neck trauma, including possible areas for future surgical advancement.

Operation Enduring Freedom/Operation Iraqi Freedom

Head, facial, and neck injuries were prevalent during sustained conflict during OEF/OIF. Improvised explosive devices (IEDs) were the most common battle-related source of head, facial, and neck injury, while motor vehicle crashes were the most common nonbattle mechanism. ⁸ Universally, the advent and utilization of Kevlar helmets and vests reduced rates of head and penetrating chest trauma; however, this left the face and neck vulnerable to injury. With the improvements in body and neck Kevlar, the great vessels such as the aorta, subclavian, carotids, iliac, and proximal femoral arteries are protected. The face and extremities remain vulnerable as soldiers must walk, run, shoot, talk, turn their heads, and see well. Therefore, the extremities and the face remain vulnerable even with greatly improved body armor.

An extensive retrospective review of casualties from the joint trauma registry showed that 28% of injuries sustained involved the head/neck, and explosive injury represented the most common mechanism of injury (74%), which was significantly higher than gunshot wounds. Comparatively, the proportion of head and neck wounds was considerably higher than the proportion experienced in WWII, Korean, and Vietnam wars. The reported percentage of explosive mechanisms was the highest in any large-scale conflict. ⁸ The most common injuries were soft tissue and facial fractures; of the soft tissue injuries, the face/cheek was most common, followed by the neck/larynx/trachea. The most common facial fractures were of the orbit and maxilla/zygoma in relatively equal distribution. ⁹ Notably, one-third of patients presented with multiple wounds to the head, face, and neck. ⁸

Modern Warfare—Conflicts in Syria and Ukraine

In many ways, modern warfare continues to demonstrate similar injury patterns to that seen in Iraq and Afghanistan resulting from explosive and ballistic techniques. A retrospective review of injuries sustained in the Syrian war revealed approximately 80% of injuries were related to explosions, with gunshot wounds being the second most common mechanism. ¹⁰ Similarly, in the conflicts in Ukraine, blast injury remained the most common mechanism of injury. Blast-related injury constellations identified in Ukraine included intracranial hemorrhage, intracranial deep hemorrhage, spinal injury, and facial injury. ¹¹

Blast injury commonly results in multiple traumas. In recent conflicts, these include a higher proportion of high-velocity multifragmented facial fractures and extensive soft tissue injury. Among these injuries include large avulsive injuries of bone and surrounding soft tissue resulting from large explosive fragments. In a survey of physicians practicing in nearby hospitals during the Ukrainian conflict, 80% of respondent providers performed osteosynthesis for the treatment of these fractures within the first year of conflict. With the rise of these large soft tissue defects, the demand for advanced surgical reconstructive techniques has increased precipitously. A survey of 97 physicians in nearby hospitals in conflict areas showed that 38% could perform microsurgical reconstruction. ¹² In response, some Ukrainian medical centers have emphasized implementation and training in advanced reconstructive techniques, including microvascular anastomosis and free and pedicled flaps. There is a strong emphasis on improving surgical training in microvascular techniques and enhanced collaboration with international experts. ¹³

Timing of Definitive Care

Timely, definitive care is crucial in managing combat ballistic injuries to minimize complications and improve outcomes. Severe craniomaxillofacial (CMF) trauma can result in substantial hemorrhage and airway compromise, which are immediately life-threatening and must be addressed expeditiously. Delays in treatment due to remote locations can worsen these conditions and impact patient survival. ¹⁴ In a 2006 analysis of facial trauma outcomes in OIF casualties, 33% of patients received delayed treatment. The immediate fixation group had a complication rate of 7%, while the delayed treatment group had a significantly higher complication rate of 57%. Infectious complications were observed in 7% of the immediate fixation group, compared to 43% in the delayed treatment group, with many requiring reoperation. ¹⁵

Mechanisms of Trauma, Associated Injuries, and Sequela

Ballistic Injury

Ballistic trauma is the primary form of injury in modern conflict. Overall, ballistics are categorized by velocity into low- and high-velocity projectiles. Low-velocity projectiles include handguns and shotguns, while high-velocity projectiles encompass IEDs and other military-grade weapons. The ultimate injury pattern is determined by the degree of energy transfer, which is ultimately determined by (1) projectile caliber, design, and composite materials; (2) velocity; (3) kinetic energy of the projectile at the time of impact; (4) distance traveled before bodily impact and after penetration; (5) entrance profile and path of travel through the body, and (6) biologic characteristics of the penetrated tissue. ¹⁶ As previously mentioned, the prevalence of high-velocity projectiles in the form of blast injury has steadily increased through OEF/OIF and remained high during modern conflicts. Blast injury is the most common injury mechanism in conflicts of this century due to the widespread use of explosives, confirmed by recent conflicts such as Ukraine. ¹¹ Ultimately, the extent of injury is determined by the extent of temporary and permanent cavitation events. For low-energy projectiles, temporary cavitation is limited; the permanent cavitation event typically results in local tissue destruction proportional to the size of the projectile itself.

In contrast, high-energy projectiles cause more widespread destruction related to the dissemination of forces into surrounding tissue during temporary cavitation. These forces result in stretching, shearing, thermal, and crush injuries. ¹⁶ Ultimately, these forces result in composite tissue disruption and, in some instances, significant soft tissue losses, posing unique challenges for surgical reconstruction. Injuries to the head and neck also pose multiple important considerations for essential nearby structures, including the eye/orbital injury, skull, neck, and airway, which often require a multidisciplinary approach for optimal repair. Commonly, these injuries may lead to distortion of critical anatomic planes due to composite soft tissue loss hemorrhage, which can have devastating esthetic and functional consequences and require a carefully phased and staged management protocol. ¹⁷ Significant injury can also mask the presence of a retained foreign body, increasing the risk of infection, dehiscence, and possible exposure of underlying hardware in the case of facial fractures.

Thermal Injury

The importance of understanding thermal injury should not be underestimated. Overall, most burn injuries are sustained to the hands and face. In times of war, thermal injury occurs at a rate of 5 to 20%, with a mortality rate of 4%. ¹⁸ The rate of thermal injury has also increased in association with increasing blast trauma, as previously discussed. Burns are usually associated with polytrauma because more than half of these injuries are blast-related, based on data from previous conflicts. ¹⁸ Burns to the head and neck are highly associated with eye pathology, the need for mechanical ventilation, intensive care unit admission, traumatic brain injury, and psychosocial sequelae. ¹⁸ The percentage of combat-related facial burns was significantly higher than noncombat-related facial burns (73 vs. 54%, p  < 0.001). ¹⁹ During conflicts in Iraq and Afghanistan, the pediatric case fatality rate for burn was significantly higher than all other diagnoses aside from head injury (15.9% for burn vs. 3.8% for all other diagnoses, p  < 0.01). ²⁰ Burns to the face can result in disfiguring scars that require careful reconstructive planning. They also involve essential structures that commonly require rehabilitation for functional recovery, the most common complications being microstomia and eyelid ectropion. ²¹

Infection

It is evident that combat-related soft tissue injury to the face is complex and is often best approached through a multi-disciplinary approach. In the setting of facial trauma, often, an intraoral approach to trauma or concomitant injury leaves the head and neck susceptible to bacteria-laden oral flora if the mucosal lining is disrupted or dehiscent. Large-volume tissue loss can also predispose to infection with inadequate tissue for closer and/or coverage. Successful care for these patients frequently requires consideration of the impacts of the environment and trauma care system, including transportation and sequelae/associated injuries.

Infection is an essential consideration for combat ballistic trauma. In a retrospective study from Vietnam, despite rapid evacuation and antibiotics, 42% of patients with severe maxillofacial trauma developed infections during treatment. ²² A similarly high rate of infection from the Iraq–Iran conflict showed most patients with severe facial injuries were infected upon arrival at hospitals. Notably, factors that have been shown to prevent infection in the setting of maxillofacial trauma reliably include debridement, irrigation, early repair of hard and soft tissues, and initiation of broad-spectrum antibiotics as soon as possible. ²² Evidence supports early debridement, closed reduction, irrigation, and removal of foreign body and bone fragments followed by delayed reconstruction, which boasts a near 1.15 infection rate. ²² Antimicrobial resistance (AMR) has been a growing trend, with spiking rates observed in the Middle East, particularly in gram-negative pathogens such as Acinetobacter baumannii , Pseudomonas aeruginosa , and Klebsiella pneumoniae . This increase is at least partly due to the role of wars and conflicts in driving the emergence of resistant pathogens. The armed conflict involving ISIS in Iraq in 2014 not only caused civilian casualties and displacement but also further weakened the already fragile health care infrastructure, potentially contributing to the spread of AMR. ²³ In these combat zones, highly resistant bacteria necessitated multiple washouts and debridements as debris and foreign bodies worked their way to the surface and areas of compromised tissue became apparent.

Foreign Body

Facial trauma is commonly associated with embedded foreign bodies. Approximately one-third of foreign bodies are estimated to be missed during the initial examination. ²⁴ Retained foreign bodies often result in various complications ranging from wound dehiscence, infection, granuloma formation, and superficial skin tattooing. Detection of embedded foreign bodies requires careful examination, intraoperative exploration, irrigation, and debridement. Diagnosis of retained foreign body is best achieved with thorough physical examination and radiographic evaluation. Plain radiography is inexpensive and widely accessible, including in early roles of care in combat zones; it is helpful for the detection of radiopaque materials such as metal and glass. However, it cannot detect radiolucent vegetative materials. ²⁵ Although computed tomography may increase the ability to visualize foreign bodies obscured by bone, it is not typically utilized for initial evaluation given radiation exposure, low sensitivity for detecting radiolucent material, and cost. ²⁵ However, in the setting of suspected facial trauma, computed tomography is typically already available for the detection of facial fractures and surgical planning. An additional consideration is ultrasonography, which is widely accessible and cost-effective. It also offers an advantage over computed tomography and radiography in detecting radiolucent materials. ²⁵ The limitation of ultrasonography in detecting foreign bodies is that the quality of assessment is operator-dependent and limited by bone shadowing. Timely evaluation and management of foreign bodies are critically important because of their impact on surrounding tissue, as previously discussed. Traumatic tattooing is a unique consideration for foreign bodies, which are frequently attributed to blast and projectile injuries. Tattooing results from graphite, asphalt, or gunpowder deposited into the superficial skin ²⁵ ; if these objects are not removed before epithelialization, tissue tattooing occurs.

Goals of Definitive Care

Restoring function in military trauma surgery is paramount before addressing aesthetic considerations. Several key factors, such as the early closure of defects, play a crucial role in restoring function. ²⁶ Clear and concise transfer of patient data, medical history, and ongoing care requirements is essential to ensure patients receive the necessary care. This communication occurs between different levels of medical care providers, such as combat medics and field surgeons, who relay a comprehensive history to the trauma surgeon responsible for the final restoration of function. ²⁷

In military settings, injuries are often complex and multifaceted, involving severe tissue damage and environmental contamination. When aesthetic considerations are addressed, primary reconstruction becomes a central management aspect. ²⁸ Primary reconstruction involves immediate surgical intervention to repair and reconstruct damaged tissues, aiming to restore function and appearance. This approach is crucial in military trauma due to the nature of injuries, which often include high-velocity projectiles and blast injuries resulting in extensive tissue loss.

The surgeon's most important responsibility is to convert a contaminated wound into a clean one. ²⁸ This involves thorough debridement to remove all necrotic and contaminated tissue, thereby reducing the risk of infection and preparing the wound for reconstruction. Following debridement, the surgeon performs reconstruction using techniques such as skin grafts, flaps, and bone reconstruction to restore the form and function of the affected area. These procedures aim to achieve optimal healing and minimize further damage and complications.

Primary reconstruction and preventing complications in the military often require a multidisciplinary approach involving infectious disease experts, orthopaedic surgeons, and plastic surgeons. ²⁹ This team-based approach ensures comprehensive care for the injured soldier, addressing all aspects of the injury and maximizing recovery. Postoperative rehabilitation focuses on physical and mental recovery. Physical rehab restores mobility, strength, and function, while mental health support, including psychiatrists, addresses the psychological impact of trauma. ³⁰ This holistic approach ensures soldiers receive the necessary support to fully recover, enhancing their overall well-being and quality of life.

Additional Considerations and Systemic Factors

Transportation

Modern warfare has also provided the advantage of rapid evacuation from the battlefield. This has globally increased the number of previously nonsurvivable injuries that can make it to tertiary care centers. In Afghanistan, a “golden hour” policy was implemented, requiring transportation of casualties within 60 minutes. The percentage killed in action before the mandate was 16.0% and it decreased significantly to 9.9% after the mandate. In contrast, the percentage died of wounds, or late deaths occurring after military treatment facility arrival, was 4.1% before the mandate and remained relatively unchanged at 4.3% after the mandate. ³¹ This is particularly relevant for head injuries that would previously be considered fatal and their associated fracture patterns and soft tissue injuries to the head and neck.

U.S. Joint (JP4-10 2006) and U.S. ARMY (FM4-02.2 May 2007) doctrine describes precedence for casualty evacuation as within 1 hour for urgent and urgent surgical missions, within 4 hours for priority cases, and within 24 hours for routine cases. ³² With airway control and bleeding control, definitive treatment of soft tissue and facial fractures can often wait until injured soldiers are transported to major receiving trauma centers, as seen in OEF/OIF, where patients could be transported to Germany or the contiguous United States in under 72 hours. A secure airway is critical during transport. Nasal intubation or maxillary mandibular fixation is not preferred.

Definitive care of a patient with a ballistic facial injury may be treated in theater in reverse triage settings. This may be necessary if the injuries are minor and the soldier can return to combat or duty in the combat zone. In that case, definitive care may be appropriate and safe without increasing the risk of complications or infection.

Typically, patients with ballistic facial injuries suffer from multiple injuries and are unlikely to return to battle quickly. Ideally, polytrauma patients should be evacuated to a medical center outside the war zone for definitive care. In prolonged field care settings, surgical techniques may change when timely evacuation is impossible and resource constraints exist. When patients cannot be evacuated, resupply of resources cannot occur. This may occur in settings without air superiority. Patient-specific plates and guides would not be available. Plates and screws may be scarce, and the use of external fixators and wire-based surgery may be indicated. Avoiding soft tissue retraction and loss of facial width, height, and projection is important in the early management of ballistic facial injuries, regardless of available resources and techniques. The goals of surgery and care are to restore form and function. The timing and type of fixation to achieve those goals are influenced by the location of service or ability to get to higher care and the resources available. As shown in Table 1 , different medical teams contribute varying degrees of lifesaving care depending on their capabilities.

Table 1. Roles of care and capabilities.

Roles of care	Description	Personnel	Capabilities
Role I Battalion aid station	Immediate lifesaving measures	Self-aid/buddy aid Combat lifesaver Combat medic	Limited point-of-care interventions
Role II Forward surgical team	Life and limb saving surgical care First level of surgery available	Small highly mobile surgical team	Basic labs, X-ray
Role III Combat surgical hospital	High-volume trauma center within an area of military operations or combat	Primary care Dental Physical therapy Mental health Surgical services	Full range of surgical, medical, laboratory, and radiological capabilities
Role IV Military treatment facility	Definitive medical and surgical care outside military operations. Either within or outside of the continental United States.	Fully equipped complement of medical services/providers	Full range of surgical, medical, laboratory, and radiological capabilities

Source: Modified from Lane et al. ³²

Long-Term Impact of Injuries

Facial reconstructive surgery following ballistic injuries frequently results in complications due to the extensive damage typically involved. Common complications include infections, nonunion of bone fractures, and the necessity for multiple surgeries to achieve complete reconstruction. Notably, up to 68.2% of patients experience at least one major complication during their recovery. ³³ Additional complications associated with CMF trauma include trigeminal and facial nerve injuries, as well as blindness. In a study of 188 patients with facial trauma, 36% suffered from functional limitations, and 17% developed posttraumatic stress disorder (PTSD). Furthermore, 34.3% of patients reported being bothered by their injury scars, and 49.4% found their injuries emotionally challenging. ³⁴ Another retrospective study of 378 patients treated for CMF trauma over a 5-year period found that 31% demonstrated a positive diagnosis of PTSD. ³⁵

Conclusion

The history and evolution of injury patterns in combat ballistic soft tissue injuries have continued to evolve. It is largely influenced by trends and technological advances in ballistic weaponry, and understanding these mechanisms of injury is essential for providing holistic and comprehensive care to these patients. Modern injury patterns are characterized by large-volume soft tissue injuries frequently requiring knowledge and training in microvascular techniques for definitive management. It is important to recognize that with improved survival rates, more patients with previously nonsurvivable head and neck injuries are presenting to military care facilities for definitive management. Multiple short- and long-term-associated sequelae must be considered when caring for these patients.

Funding Statement

Funding None.