Multistage composite midface reconstruction after gunshot injury: A case report

Abstract

Introduction and importance

Severe facial trauma from firearm injuries poses significant reconstructive challenges. This case report highlights the use of advanced reconstructive techniques, including patient-specific 3D implants, radial forearm flaps, costochondral grafts, and prosthodontic rehabilitation, in the restoration of midfacial contour and function following a gunshot-induced deformity.

Presentation of case

A 54-year-old male was admitted with a history of a gunshot injury sustained seven months ago to the left orbit and skull base causing severe facial deformities. Physical examination revealed a depressed midface, collapsed nasal bridge, scarred left upper eyelid, displaced right zygoma, missing left maxilla, and an oroantral communication on the right. A multi-staged reconstructive approach was used, including patient-specific 3D implants, a radial forearm flap, a costochondral graft, and prosthodontic rehabilitation, resulting in significant functional and aesthetic improvements.

Clinical discussion

This case demonstrates the successful integration of advanced surgical techniques to address severe trauma-induced deformities. Patient-specific 3D planning and implants restored facial contours, while the radial forearm flap provided vital soft tissue coverage. The costochondral graft reconstructed the missing maxilla, and prosthodontic rehabilitation restored oral function. This multi-disciplinary approach enabled the restoration of both form and function.

Conclusion

The combination of 3D implants, radial forearm flaps, costochondral grafts, and prosthodontic rehabilitation provides an effective, staged strategy for managing gunshot-induced facial deformities. This case emphasizes the importance of individualized, multi-staged approaches to achieve optimal outcomes in complex trauma. Further refinement of these techniques may improve future surgical protocols.

Highlights

• •Multi-stage reconstruction restored midface form and function after gunshot injury.
• •Patient-specific 3D-printed implant enabled precise anatomical facial restoration.
• •Radial forearm flap provided vital soft tissue coverage for midface reconstruction.
• •Costochondral graft reconstructed bony structures of the missing maxilla.
• •Customized prosthodontic denture restored oral aesthetics and functional capacity.

1. Introduction

Facial trauma resulting from firearm injuries often leads to significant deformities that present both functional and aesthetic challenges. Severe cases, such as the one described here, necessitate complex, multidisciplinary care. Reconstructive surgery in these cases involves the restoration of both facial form and function, requiring a combination of advanced surgical techniques and materials [1,2].

For extensive midfacial deformities, strategies such as the use of patient-specific 3D implants, vascularized flaps, bone grafting, and prosthodontic rehabilitation offer effective solutions. Patient-specific 3D implants enable precise restoration of facial contours, while radial forearm flaps provide essential soft tissue coverage [3]. Costochondral grafts play a key role in reconstructing missing bone structures, and prosthodontic rehabilitation is crucial in restoring oral function. These multi-staged, individualized interventions have proven successful in the management of complex facial trauma, allowing for both aesthetic and functional recovery [4].

This case report presents a multi-staged reconstructive approach following a gunshot injury to the left orbit and skull base, as depicted in Fig. 1 showing pre and intra-operative image of the patient with implant placement with a focus on restoring midfacial contour and function [5]. The sequence of surgical and rehabilitative interventions was systematically planned and executed in accordance with the SCARE (Surgical Case Report) guidelines [6].

Fig. 1.

Preoperative and intraoperative views of facial reconstruction in a post-gunshot injury patient. (A) Preoperative image showing the side view of patient with a depressed midface, collapsed nasal bridge, missing left maxilla, and significant left periorbital scarring with soft tissue atrophy. The patient also exhibited a displaced right zygoma, mild trismus, and an oroantral communication on the right side. (B) Intraoperative image following the placement of a customized 3D-printed implant aimed at restoring midfacial contour and function. The implant was positioned to support the maxilla and nasal structure, aiding in the correction of facial asymmetry and structural deficits.

The integration of cutting-edge techniques, including 3D implants and vascularized flaps, was instrumental in achieving optimal outcomes [7]. This case underscores the importance of personalized treatment plans and multidisciplinary collaboration in managing severe facial trauma, highlighting the need for continued refinement of surgical protocols in complex trauma cases [8].

2. Patient information

A 54-year-old male was admitted with a history of a gunshot injury sustained seven months ago to the midface, involving the zygomatic arch and the anterior floor on the left side. He presented with severe facial deformities, including a collapsed nasal bridge and absence of maxilla. His medical history revealed no significant comorbidities except for a high HbA1c value of 15.7, indicating poorly controlled diabetes. Upon physical examination, the patient exhibited a depressed midface and nasal bridge, a collapsed nose, and a missing left maxilla. A left periorbital scar with significant atrophy was also noted, alongside a displaced right zygoma and mild restriction in mouth opening. Additionally, there was an oroantral communication on the right side. No history of smoking or alcohol use was mentioned.

2.1. Diagnostic assessment

The patient underwent volumetric scanning of maxillofacial region and head done using 128 slices Multidetector computed tomography (MDCT) scanner to assess the extent of the facial trauma. The plain CT scan of the face as in Fig. 2 revealed significant imaging degradation due to the presence of metallic foreign bodies, consistent with the gunshot injury. The scan showed enucleation of the left orbit, subluxation of the right eye lens, and fractures involving the right zygomatic arch, right maxilla, right inferior orbital margin, and nasal bone. The left inferior orbital margin, left maxilla, and upper alveolar process were not visualized, likely due to the post-surgical status. Severe deformities of the pterygoid plates bilaterally, along with significant deformities in the nose, face, and nasopharynx, were also noted, suggesting extensive facial trauma. The presence of bilateral mastoiditis and post-tracheostomy status were observed [9]. A separate brain CT scan as depicted in Fig. 2 revealed mild cerebral atrophy but no signs of intracranial hemorrhage or midline shift.

Fig. 2.

(A)&(B) Non-contrast axial computed tomography (CT) scan of the face and brain in a patient with a gunshot injury before stage 1 surgery of debridement and open reduction and internal fixation (ORIF) surgery. The image demonstrates traumatic injuries consistent with ballistic trauma, including comminuted fractures of facial bones, bullet fragments & soft tissue disruption. (C) 3D CT reconstruction from CT after stage 1 surgery of debridement and ORIF surgery.

A follow-up CT scan of the face, performed 5 months post-operative Stage I surgery as in Fig. 2, showed changes consistent with the implantation of metallic devices in the right periorbital region. The imaging quality was again degraded by the presence of metallic foreign bodies. The scan revealed similar findings as the initial scan, including fractures in the facial structures, severe deformities in the nasal region, and absence of the left maxilla and upper alveolar process [10]. Severe deformities in the pterygoid plates and evidence of bilateral mastoiditis persisted.

These diagnostic findings confirmed the extensive nature of the facial trauma and played a crucial role in planning the multi-staged reconstructive approach.

3. Material and methods

3.1. Therapeutic interventions

The study is single center retrospective case report. The patient underwent a meticulously planned multi-stage facial reconstruction, utilizing advanced 3D design software (Materialise 3-matic Medical) to guide implant fabrication and stage-wise restoration of facial contour and function, as illustrated in Fig. 3, Fig. 4. Stage 1 involved exploration and debridement of fractured and malunited segments, followed by open reduction and internal fixation (ORIF), along with soft tissue reconstruction using a lateral forehead flap to cover the left periorbital scar area. In Stage 2, midface reconstruction with piriform aperture support was achieved using a custom-designed 3D-printed implant fabricated from rigid titanium alloy Ti-6Al-4 V (Titanium alloyed with 6 % Aluminum and 4 % Vanadium) with the thickness of 2.5 mm. The implant was created using CAD/CAM technology with Materialise 3-matic medical software and manufactured through Direct Metal Laser Sintering (DMLS) on an EOS M290 printer. The implant design incorporated a solid structure without intentional porosity, considering the extensive soft tissue scarring and the need for maximum structural rigidity. Fixation was achieved using long titanium cortical screws (2 mm × 12 mm, 8 screws per side), ensuring optimal stability. While direct osteointegration was not the primary goal due to the implant's alloplastic nature, the PSI was designed to integrate with surrounding soft tissues to minimize micromovement and potential exposure.

Fig. 3.

Preoperative 3D reconstruction image of the craniofacial skeleton. The facial image (A) front view, (B) right view & (C) left view shows complex facial fractures with highlighted regions indicating the planned implant placement sites. The 3D design was used to guide surgical reconstruction, aiming to restore facial contour and function in a patient with post-traumatic deformities following a gunshot injury.

Fig. 4.

3D implant planning for facial reconstruction. The facial image (A) front view, (B) right view & (C) left view demonstrates the placement of a customized 3D-printed implant on the solid bony contours of the face to restore structural support and enhance the function of the maxilla. The implant was designed to conform to the patient's unique anatomy, aiding in the restoration of midfacial projection and symmetry.

Stage 3 addressed contour deformities, periorbital reconstruction, and dental rehabilitation [9]. The procedure was performed under general anesthesia with careful flap monitoring to ensure graft survival. The surgical team, consisting of experienced facial reconstructive surgeons and prosthodontists, managed the complex facial trauma with a multi-disciplinary approach to achieve optimal outcomes [1]. This work has been reported in line with the SCARE criteria [6].

The patient underwent a multi-stage surgical approach, with careful management of their HbA1c levels [11]. In Stage 1, after controlling the HbA1c to 5.5, the patient underwent exploration and debridement of fractured and malunited segments. Open reduction and internal fixation (ORIF) were performed, and the left periorbital scar area was covered with a lateral forehead flap. A two-point fixation of the right zygomatic tripod was done with a continuous titanium plate, and an iliac crest bone graft was harvested for maxillofacial deformity repair. Intraoperative findings revealed excessive fibrosis. Stages 2 and 3 were performed 10 months later, following appropriate recovery time and continued control of HbA1c. In Stage 2, secondary reconstruction addressed midface deformities using a patient-specific implant, radial forearm flap, and costochondral cartilage. The radial forearm flap was carefully dissected, and a costochondral graft was harvested from the chest [10]. The patient-specific implant was inserted to restore the zygomatic arch, and the radial forearm flap was placed to cover the implant. Microvascular anastomosis was performed between the donor vessels and the recipient superior thyroid artery [12]. Table 1 outlines the chronological progression of treatment, from initial presentation to final stages of functional and aesthetic rehabilitation, reflecting a multidisciplinary and staged approach to complex midfacial reconstruction.

Table 1.

Chronological timeline of surgical and rehabilitative procedures.

Timeline	Procedure
0 months (presentation)	Patient admitted 7 months post-gunshot injury with severe midface deformity
Week 1	Stage 1: Debridement, ORIF, lateral forehead flap, iliac bone graft
Month 1–10	Recovery, diabetes control, pre-op planning for next stages
Month 10–11	Stage 2: Customized 3D-printed implant placement, radial forearm flap, costochondral graft
Month 11+	Stage 3: Periorbital contouring, dental rehabilitation with custom denture
Month 17	Functional and aesthetic recovery confirmed; follow-up ongoing

In addition to the reconstructive procedures, a customized denture was made to address the significant maxillary gap caused by the missing left maxilla and upper alveolar process. The denture was fabricated using the open tray technique to support the patient's remaining oral structures, enhancing oral function and improving the patient's ability to eat, speak, and smile. The defect was classified according to Brown's Classification of Maxillary Defects, wherein this case corresponds to a Class IIIb defect of a subtotal maxillectomy with orbital exenteration on the left side. The prosthetic rehabilitation plans emphasized achieving occlusal balance by utilizing an implant-supported obturator prosthesis. The design incorporated strategic implant positioning on the unaffected contralateral maxilla and the PSI-supported side to restore function, speech, and aesthetics. Fig. 5 shows the denture before and after placement in the patient's mouth [13]. The denture was designed to offer both functional and aesthetic benefits, ensuring comfort while helping restore the patient's oral appearance and function. The clinical evaluation phase included meticulous placement and visualization of the prosthetic denture to assess adaptation, retention, and stability. This step is essential to ensure optimal functional and aesthetic outcomes before final delivery. As shown in Fig. 6, the denture was carefully seated, and retention was checked intraorally to confirm accurate fit and alignment with the underlying oral structures [14,15].

Fig. 5.

Placement of customized denture for maxillary rehabilitation in a post-traumatic facial reconstruction patient. (A) Preplacement view showing the patient's oral cavity with a missing maxillary soft tissue segment and upper denture. (B) Customized denture designed to restore the maxillary structure and support oral functions. (C) Post completion of surgical restoration and placement of customized denture demonstrating significant recovery in maxillofacial form and function.

Fig. 6.

Intraoral clinical photograph showing placement and visualization of the prosthetic denture. The clinician is assessing the adaptation of the denture to the alveolar ridge, evaluating retention, stability, and overall fit. This step is crucial to ensure proper seating and function of the prosthesis before final adjustments and patient instructions are given.

4. Result

The patient successfully underwent all three stages of facial reconstruction without major complications. Postoperative monitoring showed stable vital signs, good flap viability, and controlled facial edema. HbA1c remained at 5.5, supporting effective healing. Ten months after the initial surgery, midfacial reconstruction using a patient-specific 3D-printed implant, radial forearm flap, and costochondral graft was completed with good anatomical integration. Customized denture placement restored oral function and aesthetics, enabling improved speech, mastication, and facial symmetry. The patient was able to tolerate oral feeds, and gradual progress was made in their rehabilitation [16]. Overall, the staged, multidisciplinary approach resulted in satisfactory functional and cosmetic outcomes.

5. Discussion

This case highlights the effective use of a multi-stage, multidisciplinary approach to manage severe facial trauma from a gunshot injury. Reconstruction involved radial forearm flaps, costochondral grafts, and custom 3D-printed implants to restore facial aesthetics and function. Combined soft tissue and bone reconstruction was key to correcting deformities and achieving a successful outcome.

While a vascularized free fibula flap (VFFF) is a reliable option for maxillary reconstruction and implant support, it was not feasible in this case due to extensive soft tissue fibrosis and inadequate osseous support in the maxillary region. The risk of graft exposure in a severely compromised bed, along with the patient's uncontrolled diabetes (HbA1c 15.7), made the procedure high-risk. A patient-specific implant (PSI) offered a more predictable and structurally stable alternative, enabling accurate fixation with long titanium screws (2 mm × 12 mm, 8 screws per side), and restoring midfacial contour effectively in this challenging anatomical scenario.

Moreover, metallic foreign bodies complicated imaging and injury assessment. Despite this, thorough preoperative planning and a skilled multidisciplinary team approach ensured smooth procedures. Patient-specific 3D-printed implants enabled precise reconstruction, with radial forearm flaps providing soft tissue coverage and costochondral grafts offering structural support.

In this case, the superior thyroid artery was selected for microvascular anastomosis due to specific anatomical and clinical considerations. Typically, vessels such as the maxillary artery, facial artery, and superficial temporal artery are used in maxillofacial reconstruction. However, the facial artery was deemed unsuitable in this patient because of compromised blood flow resulting from prior injury and scarring in the submandibular region. The superficial temporal artery, although considered, was found intraoperatively to have a small caliber and a tortuous course, which made it an unreliable choice for a tension-free anastomosis with the radial forearm free flap pedicle. The maxillary artery, while anatomically close to the defect, is located deep within the tissue and would have required more extensive dissection, thereby increasing intraoperative morbidity. As a result, it was ruled out in favor of a more accessible and dependable vessel.

The superior thyroid artery was chosen not only for its accessibility but also for its size compatibility with the radial artery used in the forearm flap. The radial artery typically measures 2.0–3.0 mm in diameter, while the superior thyroid artery ranges from 1.5 to 2.5 mm. In this case, both arteries had a diameter of approximately 2 mm, allowing for a well-matched, tension-free, and reliable end-to-end anastomosis without the need for inter-positional vein grafts.

Although the superior thyroid artery is located in the lower neck, necessitating a longer vascular pedicle, the radial forearm flap offers a generous pedicle length of 12–15 cm. This length was more than adequate to bridge the distance without tension or kinking. Careful routing of the pedicle under the platysma and along natural fascial planes ensured protection against compression or torsion, thereby contributing to a successful surgical outcome.

Postoperatively, the patient was monitored for flap viability, coagulation, and wound healing. Early intervention addressed hematoma and venous congestion, with timely drainage preserving vascular integrity. Mild coagulation issues were effectively managed with fresh frozen plasma (FFP) and packed red blood cells (PRBCs) transfusions, and supportive care. The patient's diabetes was closely monitored to ensure stable blood sugar levels, crucial for wound healing and recovery.

At discharge, the patient showed satisfactory improvement in facial appearance and function. The flap remained viable, the wound healed well, and lab results were normal. The patient was advised on diabetes management, oral hygiene, and avoiding activities that could strain the healing tissues. The sequence of surgical and rehabilitative interventions was systematically planned and executed in accordance with the SCARE (Surgical Case Report) guidelines.

5.1. Take-away lessons

• •Custom 3D-printed implants are effective in restoring midfacial structure when conventional bone grafting is limited due to anatomical or systemic constraints.
• •A staged surgical approach allows for systematic correction of deformities while reducing surgical risk in medically complex patients.
• •Radial forearm flaps continue to be a reliable method for soft tissue reconstruction in scarred or fibrotic beds.
• •Careful control of comorbidities (e.g., diabetes) is essential for postoperative healing and flap viability.
• •Prosthodontic rehabilitation with implant-supported obturators can provide significant improvements in oral function and facial aesthetics.

6. Conclusion

This case demonstrates that with a comprehensive, multi-disciplinary approach, severe facial deformities resulting from traumatic injuries can be successfully managed. The patient reported significant improvement in both the functionality and aesthetic appearance of his face post-surgery. The integration of advanced techniques such as 3D-printed implants, vascularized flaps, bone grafting, and prosthodontics has led to both functional and aesthetic restoration of the patient's face, offering valuable insights into the future of reconstructive surgery for traumatic facial injuries. The successful outcome underscores the importance of individualized, staged interventions and close post-operative monitoring.

Abbreviations

3D

Three-Dimensional

CT

Computed Tomography

MDCT

Multidetector Computed Tomography

ORIF

Open Reduction and Internal Fixation

HbA1c

Hemoglobin A1c (Glycated Hemoglobin)

DMLS

Direct Metal Laser Sintering

FFP

Fresh Frozen Plasma

PRBCs

Packed Red Blood Cells

SCARE

Surgical Case Report (guidelines)

Author contribution

Dr. Aashish Chaudhry: Conceptualization; Formal Analysis; Data curation; Visualization; Writing – review & editing original draft.

Dr. Shilpi Bhadani: Investigation; Conceptualization, Methodology, Surgical Support, Formal Analysis; Validation; Writing – review & editing.

Dr. Kaushal Charan Pahari: Project administration; Surgical Support, Resources; Writing – review & editing.

Dr. Tanvi Chawla: Software; Formal analysis; Visualization, 3D model and design support.

Dr. Mani Pandey: Formal analysis; Writing – original draft; Writing – review & editing.

Consent

Patient's Written informed consent was obtained from the patient for both treatment and the publication of clinical details and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval was exempt as it involves a retrospective review of a single patient's clinical management using standard treatment protocols. Custom shaped Implant and denture used with no experimental procedures, investigational devices or off label interventions were involved.

Guarantor

Dr. Aashish Chaudhry: Conceptualization; Formal Analysis; Data curation; Visualization; Writing – review & editing original draft.

Dr. Shilpi Bhadani: Investigation; Methodology, Surgical Support, Formal Analysis; Validation; Writing – review & editing.

Funding

No external funding was received for this case report. All expenses related to the surgical procedures, patient care, and subsequent follow-up were covered by the hospital's standard care provisions.

Conflict of interest statement

The authors declare that there are no conflicts of interest regarding this case report. There were no financial or personal relationships with any organizations or entities that could have influenced the research or outcomes presented.

Data availability

All relevant data, including the patient's clinical details, findings, and imaging results, are available and have been included within this case report. Strict adherence to non-disclosure of patient identification has been followed. Any additional data or tables required to support the findings can be provided upon request.