Management Protocol for Ballistic and Other High-Energy Avulsive Facial Injuries—An Update for the 21st Century

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.