Management Protocol for Ballistic and Other High-Energy Avulsive Facial Injuries—An Update for the 21st Century
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<jats:p>High-energy ballistic and avulsive injuries to the face represent some of the most complex challenges in modern reconstructive surgery. Since Robertson and Manson’s 1999 management protocol, extensive military experience and technological advancements have transformed the treatment principles while preserving the core tenets of staged care. This updated review synthesizes evidence from 36 studies published since 2000, encompassing over two decades of global experience in both military and civilian trauma. Advances in damage-control resuscitation, wound decontamination, and early skeletal stabilization have improved survival and functional outcomes. Modern imaging—particularly intraoperative CT and navigation—enables the precise verification of the reduction and removal of retained fragments, while virtual surgical planning and patient-specific implants allow the accurate restoration of facial buttresses. Early vascularized tissue transfer has reduced contracture and infection rates. Adjuncts such as hyperbaric oxygen therapy, permissive hypotension, and advanced hemostatic agents further optimize recovery. The updated four-phase protocol—resuscitation, reconstitution, reconstruction, and rehabilitation—emphasizes early definitive repair, multidisciplinary collaboration, and the integration of digital planning. These refinements extend Robertson and Manson’s foundational principles into the era of precision surgery, achieving superior aesthetic and functional outcomes for patients with devastating facial injuries.</jats:p>
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Pepper, Thomas, Michele H Kim, Dane McMillan, Sarah Cantrell, Angel Scialdone, Angelina Nasthas, Ralph Erdmann, Paul N Manson, et al. (n.d.). Management Protocol for Ballistic and Other High-Energy Avulsive Facial Injuries—An Update for the 21st Century. Craniomaxillofacial Trauma & Reconstruction, 19(1). pp. 14–14. 10.3390/cmtr19010014 Retrieved from https://hdl.handle.net/10161/34270.
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Sarah Cantrell
Sarah Cantrell (she/her/hers) is the Associate Director for Research & Education at the Medical Center Library & Archives, and is responsible for developing, implementing, and evaluating the Library's research and education programs. She is also the liaison to the Graduate Medical Education programs. Sarah is currently on the steering committee of the Evidence-Based Practice for Health Sciences Librarians workshop, and co-director of the Evidence-Based Practice for the Medical Librarian course at the University of North Carolina at Chapel Hill School of Information and Library Science. Sarah served as a Co-Director of Duke's national Evidence-Based Practice (EBP) workshop for clinicians and librarians from 2019 to 2024. Before joining Duke, she worked at Walter Reed National Military Medical Center in Bethesda, MD, where she established a Clinical Librarian Program and joined inpatient care teams for teaching rounds, providing real-time evidence-based decision support and teaching at the point of care. Prior to WRNMMC, she was the Education Services Coordinator and Instruction Librarian at Georgetown University Medical Center's Dahlgren Memorial Library in Washington, DC.
- MLIS, Library & Information Studies, University of Wisconsin Madison
- BA, English Literature, University of Wisconsin Madison
David Bryan Powers
Dr. Powers currently serves as a Professor of Surgery, and Director of the Craniomaxillofacial Trauma Program, at Duke University Medical Center. Additionally, he is the Fellowship Director for the Craniomaxillofacial Trauma and Reconstructive Surgery fellowship within the Department of Surgery. His surgical experience in facial trauma was attained during a military career highlighted by the acute management of ballistic and other injuries of warfare, as well as performing secondary and tertiary facial reconstructive surgery during various staff assignments at Wilford Hall USAF Medical Center, the Walter Reed National Military Medical Center – Bethesda and the R Adams Cowley Shock Trauma Center in Baltimore, Maryland. He lectures and has published extensively on the management of ballistic and high-energy transfer injuries to the craniomaxillofacial skeleton, comprehensive reconstruction techniques for facial trauma, and the use of computer-aided surgical planning and patient-specific implants for anatomic rehabilitation after catastrophic craniomaxillofacial injuries.
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