Advice on Upcoming Reconstruction Surgery

i had a gun shot injury in march 2011 with a lot of pellets scattered around my face. The emergency treatment didn't take out the plastic cartridge which i had in my face for 9months. When i went for first reconstruction in india, titanium plates were inserted and the infection before then was so strong my nose ran continuously and there was a foul smell. 2months after that surgery, i had a boil on the line the incision was made and it has since discharged pus and blood, it also resulted in ectropion. The foul smell and runny nose reduced but i feel a lot of pain from the plates and the movement of the pellets is quite uncomfortable. I'm meant to have another surgery at Johns Hopkins Next week and i'm kinda scared. I just completed a dose of Levofloxacin, it was prescribed after having a wound swab done. The doctor plans to use medpor implants to replace the titanium mesh to build my orbital floor. He says my right sinus is blocked and he'd have to do a sinus surgery to drain it to clear the infection and also help me breathe thru that nostril again, he also wants to use an implant for my cheek as i have lost my cheek bone. A scar revision for my cheek will be done too. He says all this can be achieved in 1 surgery. I dunno why i'm worried. Please docs, what do you think about this treatment plan? Thank you.  

Doctor Answers 2

Secondary Facial Reconstruction After Gunshot

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Every surgeon with experience in facial trauma reconstruction has slightly different approaches to each individual case...and each one is very different in some way. But there are basic principles involved and all that was mentioned can and should be done in a single procedure. I think the only debatable issue, given your history of chronic infection, is whether implants or bone grafts should be used for your reconstruction. With wide open exposure to the maxillary sinus, the use of implants may be associated with a slightly higher risk of infection but they do offer the avoidance of a bone graft harvest site and make the surgery easier to do, which in many cases could be worth the trade-off.

Different approaches to facial reconstruction

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Surgeons at different institutions may have different experiences guiding their reconstructive efforts.

At our institution, we would take a slightly different approach: as you have had a history of infections surrounding the hardware in your face, we would stage our surgical plan:  surgery 1 would be removal of all hardware and the sinus surgery to open up sinus drainage followed by a few weeks of antibiotics to clear the infection. Stage 2 [a couple months later] would involve reconstruction of the orbit and the cheek. For a this secondary reconstruction we prefer to use calvarial bone grafts [from your own skull] to reconstruct the orbit and cheek, as opposed to using implants again. This does make the surgery more complex and lengthy, but we feel decreases the chance of  postop infection [which you have experienced].

If you feel the infection is adequately addressed with preoperative antibiotics, stage 1 and stage 2 could be combined into one surgery. But that decision may need to be made on the table during the surgery.

And finally, there will likely need to be a 3rd surgery to adequately address the eyelid ectropion.

But as I said, the are many different approaches to surgical reconstruction and the surgeons at Johns Hopkins, are quite experienced, I'm sure.

A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 42 reviews

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