Loss of Facial Identification of the Survivor after Firearm Injury to the Head

Military Medicine, Mar 2004 by Baransel, Aysun, Dulger, H Ergin, Bayazit, Yildirim A

Firearm wounds to the head are often fatal and are routinely encountered in the practice of forensic medicine. Herein we presented a patient who was wounded with a military rifle. This condition is unique and interesting for forensic medicine because none of the vital structures or major vessels were injured although the patient had a firearm injury to his head. In contrast to many other cases, the vital signs of our patient were normal and he was conscious on admission. Although the patient was considered lucky because he was still alive, he now had an unrecognizable face.

Introduction

Firearm injuries are common in many countries and can result from a variety of factors. Accidents or suicidal attempts are among these factors, and the head is one of the most common sites of injury in these cases. Firearm wounds to the head are often fatal and are routinely encountered in the practice of forensic pathology. ' The anatomic site of the entrance wound is usually used to support or refute the manner of death.

A military rifle has high kinetic energy. It is supposed to cause death. Our case is interesting in that this suicidal attempt did not result in mortality, and the patient survived. It only caused a change in his facial appearance with a resultant inability to identify the patient, even by his relatives who knew him before his injury.

Case Report

A 21-year-old soldier was admitted to our Emergency Room due to a firearm wound. On initial physical examination, the midface structures including middle portion of the mandible, palatine bone, medial portions of the maxilla, and nose were absent. The nasopharynx, oropharynx, and tongue were the structures visible. It was impossible to identify the patient because of the severe anatomic disruption of his face. The patient was conscious, and vital signs (respiration, blood pressure, and hemodynamic status) were normal. An emergent tracheotomy was performed for any potential airway problem. History revealed that the soldier had attempted to commit suicide by a G3 military rifle (7.62 � 51 mm). He had armed and shot the rifle at his submental region.

The left orbit was in place, but the eye was blind. There was severe periorbital ecchymosis. There was a 6-cm-long wound in the forehead skin over the left eye brow. The nose was completely absent. The part of the mandible between the angles was absent.

On radiological assessment, a bullet was encountered under the frontal bone just lateral to the midline. Computed tomography revealed destruction throughout the bullet tract including the submandibular region where the bullet entered, maxillary bone, nose, and right orbit. There was minimal cerebral hematoma in the frontal lobe neighboring the bullet (Figs. 1 and 2).

The patient was operated on by the collaboration of otolaryngologists, ophthalmologists, and orthopedists, and three successive operations were performed. In the first operation, the debris was cleaned, mandibular angles were fixed with metal plates, and the wound edges were approximated primarily to close the defective sites of skin on the face. In the second operation, a free osteocutaneous flap prepared from the iliac bone was used to reconstruct the midline mandibular defect. In the third operation, a pediculated rotational flap prepared from forehead skin was used to reconstruct nose. Obturator prosthesis was used to reconstruct the defect in the hard palate and maxilla.

The patient had some symmetricity on his face. The orbits and globes were preserved, although the left eye was blind. A psychiatric consultation was not performed to understand the cause of the suicidal attempt because the patient underwent a series of operations in a short period of time. After these procedures, particularly after reconstruction of the oral cavity and maxilla, the patient could start to talk and communicate. At that time, as a formal procedure, the patient had to be referred to the hospital of Military Medicine Academy where he could get support for his psychological status and social acceptance. With his new face, the patient was doing well at the control visit 1 year after the surgery (Fig. 3).

Discussion

The face is important in identification of the individual. It is the part of the body that the majority of people first notice. That is, the face is rather important for the human being who lives in a social environment. Any scar tissue, discoloration, or some other extraordinary changes attract the attention of other people. According to the Penal Code of this country, it is illegal to change one's face. When the changes in the face lead to loss of identification of the subject, this will be one of the most heavily punished crimes in this country. In our case, in addition to the severe disruption in the bones and teeth, there were dramatic esthetic changes in the face that have made identification of the patient impossible.

It was suggested that the absence of fractures in the cranial fossae points to the use of small-caliber handguns (7.65 mm).2 Our patient was wounded with a 7.62-mm caliber gun but did not have a fracture in the cranial fossa or fragmentation of the skull. Therefore, the direction or contact site of the arm may affect the outcome of the injury. In our case, the rifle was in contact with the submental region and directed vertically and, most possibly, the bony structures (mandible, hard palate, maxilla, and nasal bones) caused deceleration of the bullet.