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Page 2 of 11 Pang et al. Plast Aesthet Res 2021;8:49 https://dx.doi.org/10.20517/2347-9264.2021.42

after which attention may then be turned towards questions regarding the nature of the injury itself and the
ideal plan for restoration of form and function. Facial trauma represents a substantial burden on the
medical system with estimated costs of around $1 billion annually, with a subset of this cost related to the
[1]
care of patients with massive facial trauma . Although not technically defined, massive facial trauma can be
understood as a facial injury, more often due to ballistic or avulsive forces, that result in significant soft-
tissue and bone loss necessitating substitution of missing components through a variety of surgical
practices . Technological advances in the last century, however, have not only given surgeons new
[2]
techniques for improved reconstruction but have also contributed to changes in the pattern of injury over
time.

TRENDS IN PATTERNS OF INJURY
There is a paucity of large-scale studies regarding the epidemiology and treatment of massive facial trauma
patients; however, inferences can be made by combining related trends in the literature with anecdotal and
institutional experience. Mechanisms typically capable of producing such injuries are gunshot injuries or,
less likely, high-speed motor-vehicle accidents. Although motor-vehicle usage has become widespread
throughout the 20th century, advanced safety measures such as seatbelts, airbags, and vehicle design have
led to decreased incidence of associated facial injuries in several studies . Ballistic injuries to the face are
[3,4]
much more likely to produce injuries classifiable as massive facial trauma, and the United States continues
to suffer from an epidemic of gun violence, as evidenced by the roughly eight times higher death rate due to
firearms than other high-income nations . More recent evidence alarmingly shows an increase in age-
[5,6]
adjusted rates of firearm mortality in the United States from 2014 to 2017 after having been stable for nearly
a decade prior . Among the roughly 329 daily injuries related to firearms, two-thirds of patients will survive
[7]
and go on to live with the functional ramifications of their injuries .
[8]
TRENDS IN RECONSTRUCTIVE PRACTICE
Mechanisms capable of generating massive facial trauma wounds impart a number of locoregional tissue
changes that create challenges for definitive primary repair, including evolving tissue loss, distortion of
normal landmarks, muscular attachment disruption, and an overall deficit of tissue bulk, both soft tissue
and bone [2,9-11] . Prior to the implementation of free tissue transfer, non-vascularized bone grafts were the
primary technique used in order to restore the rigid facial structure on top of which soft tissues could be
manipulated. These efforts were met with significant issues, among which were resorption and relative the
[12]
inability to reconstruct larger defects due to their lack of vascularity . Throughout the period surrounding
World War I and II, attempts were made to incorporate bone grafts into random pattern neck skin flaps as a
method of enhancing reconstructive efforts . This would eventually give way to the use of pedicled
[13]
myocutaneous flaps in the head and neck; however, limitations due to the reach of the flap and the sub-
[14]
optimal transfer of bone were still problematic . Ultimately, the fibula free flap would be described as the
first free vascularized bone flap in 1975 and was readily incorporated into the reconstruction of the head
and neck after that . Numerous other osseus flaps have since been described and added to the
[15]
armamentarium of the modern microvascular surgeon. This has led to a shift in the paradigm of
management for massive facial trauma patients from delayed to more definitive primary reconstructive
efforts. As will be described in this paper, modern approaches aim to overcome the pitfalls of delayed
management by decreasing wound contracture and scarring before they can further distort the complexities
of the facial anatomy.