Cranial Vault Defects and Deformities Resulting from Combat-Related Gunshot, Blast and Splinter Injuries: How Best to Deal with Them.

Combat-related gunshot and blast injuries of the craniomaxillofacial region present a unique and challenging situation for the maxillofacial and reconstructive surgeon. The devastating cosmetic deformities and severe functional debility ensuing as a result of extensive hard and soft tissue disruption caused by these highly complex injuries, can have disastrous consequences, unless managed in a swift and efficient manner, by a multidisciplinary team approach. Large calvarial defects and deformities are frequent sequelae of these injuries and could result from shattering of the cranial vault by the force of an exploding shell, mine or improvised explosive device, or due to penetration of the skull by the projectile, such as a bullet, flying splinters or shrapnel. It could also result from the decompressive craniectomy carried out in these patients as a neurosurgical procedure to deal with the traumatic brain injury sustained. Management of such injuries is significantly different from that of other craniomaxillofacial injuries, owing to the quantum and severity of hard and soft tissue destruction encountered in the former and also the need to deal with aspects such as splinters from the projectile deeply embedded within vital structures such as the delicate brain tissue and meninges. Further, restoration of the lost structural and functional integrity of the cranial vault using the most suitable cranioplasty material, is imperative to provide protection to the vulnerable and vital cranial contents. Correction of the cranial deformity is also essential from an esthetic and psychosocial standpoint, to restore the morale of the patient. The present study elaborates the immediate/primary management as well as the secondary/definitive management of blast and ballistic head injury patients. Comprehensive treatment and rehabilitation of these patients, including reconstruction of extensive calvarial defects and deformities, resulting either directly or indirectly from combat injuries, have been described in detail. This study also aims to analyze, review and reassess the currently accepted management perspectives and treatment protocols of combat-related cranial injuries and proposes a useful algorithm to best manage them.