Conservative management of traumatic pneumocephalus and primary reconstruction following a self-inflicted midfacial gunshot wound: A case report

Introduction: Gunshot wounds to the midface represent a profound surgical challenge integrating acute life-threatening pathophysiology with complex reconstruction. We report the multidisciplinary care of a 52-year-old man who sustained a self-inflicted gunshot injury to the midface, resulting in an extensive panfacial laceration, a dentoalveolar fracture, and minor traumatic pneumocephalus. Case Report: Immediate care followed Advanced Trauma Life Support (ATLS) principles, prioritizing airway security and hemodynamic resuscitation. Computed tomography (CT) neuroimaging identified frontal lobe pneumocephalus in the absence of tension physiology, prompting a conservative neurosurgical strategy of watchful observation, short-course seizure prophylaxis, and targeted antimicrobial coverage. Operative management comprised thorough wound debridement with high-volume saline irrigation, followed by anatomically layered primary closure using absorbable deep sutures and interrupted non-absorbable monofilament skin sutures. Repeat CT at 24 hours demonstrated near-complete clearance of the intracranial air. Conclusion: The patient achieved full recovery without neurological sequelae or wound infection, with satisfactory healing evident at the initial postoperative review. This case demonstrates that a structured, protocol-driven approach combining trauma resuscitation, selective non-operative management of intracranial complications, and precise soft tissue reconstruction yields favorable outcomes in high-energy craniofacial ballistic trauma.