SP13. Systematic Review of Surgical Approaches for Firework Soft Tissue Injuries to the Lower Face, and Case Report

BACKGROUND: Firework injuries to the craniofacial anatomy can cause severe soft tissue and bone defects requiring complex reconstruction. While the most common injury sites include the orbit, midface, and ears, lower facial injuries are rare, with few cases reported. We present a case of a 10-year-old female who experienced a firework injury to the lower half of the face, resulting in significant soft tissue damage and multiple open facial fractures. Given the limited literature on lower face firework injuries, this systematic review and case report aim to provide evidence-based recommendations for managing such injuries. Case: A 10-year-old female patient suffered a firework-in-mouth traumatic blast injury in 2022, leading to extensive lower face soft tissue loss requiring multiple bone reconstructions and preliminary soft tissue approximation. Definitive reconstruction began six months post-injury after scar maturation, when tissue loss and contracture resulted in a maximal incisal opening (MIO) of 2 mm. The initial stage included muscle and scar releases with local flaps, improving MIO to 20 mm. Later stages involved cheek expanders, early expander exposure curtailing expansion time, followed by commissuroplasties to improve oral competence. Continued follow-up over the past two years focused on comprehensive assessments including MIO measurements and aesthetic evaluations. METHODS: A systematic review adhering to PRISMA guidelines was conducted. A comprehensive search of PubMed, Web of Science, and Embase using the keywords “maxillofacial” and “firework” yielded 123 articles (52 duplicates). Inclusion criteria focused on studies reporting surgical management of firework injuries to the lower face, excluding abstracts, reviews, and articles lacking soft tissue injury data. Individual cases meeting the inclusion criteria within multi-case studies were analyzed for pooled descriptive statistics and chi-square analyses. RESULTS: Twelve relevant individual case studies were included, with an average patient age of 23.3 years (range: 3 to 59 years, SD 15.5). The gender distribution was 8 males and 4 females. Injuries primarily resulted from projectile firework explosions in the mouth (66%) and direct biting of explosives (33%). Mandibular fractures occurred in 58% of cases, maxillary fractures in 25%, and both in 16%. Only 16% required flaps for reconstruction; others underwent direct closure. Notably, 33% needed multiple surgeries, including commissuroplasty and rhinoplasty. The average follow-up for 11 cases was 10.07 months (range: 1 week to 36 months, SD 12.09). Two cases required bone allografts, four reported nerve damage, and one reported MIO. CONCLUSION: This case and systematic review highlight the lack of standardized protocols for managing severe firework-induced injuries to the lower face. Our review found few published cases, with one-third requiring multiple staged surgeries and 16% needing complex flap reconstructions. No significant relationships were observed between projectile location and fracture patterns, likely due to limited reports. In our case, muscle release improved MIO from 2mm to 20mm. While cheek tissue expansion was attempted, expander exposure led to premature removal and necessitated commissuroplasties. We were not able to find other descriptions of cheek tissue expansion following firework injuries. Further investigation is needed for these unique injuries, and we recommend monitoring MIO as a functional outcome measure.