Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e145ee146

CASE REPORT

An explosion in the mouth caused by a firework

Giovanni Di Benedetto*, Luca Grassetti, William Forlini, Aldo Bertani

Department of Plastic and Reconstructive Surgery, Marche Polytechnic University Medical School, Ancona, Italy

Received 9 April 2008; accepted 4 June 2008

KEYWORDSFirework;Mouth explosion;Oral reconstruction

* Corresponding author. Departmentive Surgery, Marche Polytechnic UniAncona, Italy. Tel./fax: þ39 071 5963

E-mail address: dibenplast@hotma

1748-6815/$-seefrontmatterª2008Britdoi:10.1016/j.bjps.2008.06.074

Summary Explosion and gunshot mouth injuries represent a challenging problem with regardto restoring optimal oral function. These wounds exhibit a spectrum of complexity and mostlyinclude extensive soft tissue trauma complicated by burns, foreign bodies, fractures andconcomitant traumas.

To gain maximal restoration of oral function, the use of reconstructive techniques, togetherwith microsurgical techniques, such as grafting of nerves, vessels and soft tissue, as an acutefree flap to cover a large defect, are immediately necessary.

We report the case of a young Caucasian patient who destroyed the middle and lower thirdsof the face when a firecracker blasted in his mouth. His clinical history is unusual in terms ofthe modality of injury, i.e. a Russian roulette game, and the lesions suffered, in the recon-struction of which we used both surgical and microsurgical techniques.ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Publishedby Elsevier Ltd. All rights reserved.

Explosion and gunshot mouth injuries represent a chal-lenging problem with regard to restoring optimal oralfunction. These wounds exhibit, in fact, a spectrum ofcomplexity and mostly include extensive soft tissue traumacomplicated by burns, foreign bodies, fractures andconcomitant traumas.

To gain maximal restoration of oral function, the use ofreconstructive techniques, together with microsurgicaltechniques, such as grafting of nerves, vessels and softtissue, as an acute free flap to cover a large defect, areimmediately necessary.

t of Plastic and Reconstruc-versity, Via Conca 71, 60020486.il.com (G. Di Benedetto).

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We report the case of a patient who destroyed themiddle and lower thirds of the face when a firecrackerblasted in his mouth.

A 25-year-old Caucasian man was referred to ourdepartment on 31 December 2005 because of an explosionin his mouth. He was playing a kind of Russian roulette withsome friends, passing each other an explosive using theirteeth in succession, until the firework went off in hismouth.

The patient presented with multiple lesions of themiddle and lower thirds of the face, with laceration of thegums and dislocation of the inferior incisive tooth. Therewere multiple lacerations around the entire mouth, whichinvolved the lips and adjacent skin for a 12� 9 cm area.Blast-induced abrasion and contusion of the skin extendedfor an 18� 15 cm area (Figure 1). The nasal septum and

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 1 Left: Blast injury of the mouth, nose and surrounding tissues. Preoperative lateral view. Right: Intraoperative front viewafter initial debridement.

e146 G. Di Benedetto et al.

wing cartilages were torn too. Gunpowder tattooing causedby the explosion was present on the entire face.

An accurate exploration of the facial nerve showed itsbilateral interruption close to the mouth.

After an accurate debridement and removal of burnedtissues (Figure 1) and gums, reconstruction of the mouthvestibule was performed. The inferior incisive tooth wasextracted and an implant was put successively in its place.

The right facial nerve was exposed. Since it was trans-acted without a significant tissue loss and evident contu-sion, it was coapted by four to five 10/0 epineurialinterrupted sutures. On the contrary, the left facial nerveshowed a 2 cm long bruised tract, so it was microsurgicallytransected for a 2.8 cm length and a graft was taken fromthe anterior branch of the right medial antebrachial cuta-neous nerve and interposed between the proximal anddistal stumps to bridge the nerve gap.

We proceeded, then, to face reconstruction with rota-tion-advancement local flaps. Muscle and skin layers wereclosed primarily by means of 5/0 vicryl and nylon inter-rupted stitches, respectively.

A reconstructive rhinoplasty, paying special attention tothe tip, was then performed.

Figure 2 Follow up at 24 months. Postoperative front view.

The patient was discharged from our department on the8th postoperative day.

Follow up at 6, 12 and 24 months showed good results, interms of function and aesthetic appearance (Figure 2).

In the surgical literature, explosion and gunshot injuriesrepresent, in some cases, a reconstructive problem in termsof functional restoration. Hands (40%), eyes (20%), andhead and face (17%) are the areas most often involved.These wounds are complicated by burns, foreign bodies,fractures and concomitant traumas.

It is interesting to stress that primary mouth explosion isvery rare and only a few cases have been described in themedico legal literature, in cases of suicide.1e3

In our patient, the lesion was initially believed to berelated to a migration of firework fragments from the handto the mouth. Further investigation revealed the patienthad no other lesions on the body and that he used to playRussian roulette with other friends.

Facing these traumas, a wide debridement is mandatory,followed by immediate reconstructive procedures,4,5 withregard to fracture fixation, mucosa, gums, muscle and skinreconstruction.

In selected cases, acute nerve, and more rarely vesselreconstruction has to be performed.

In our experience, the use of local flaps after accuratedebridement is the first acute surgical step. Only in caseswith extensive tissue loss has the use of distant flaps, suchas the pectoralis major flap, the supraclavicular island flap,or free flaps such as the latissimus dorsi flap or the ante-rolateral thigh flap, been suggested.

References

1. Blanco-Pampın JM. Suicidal deaths using fireworks. J ForensicSci 2001 Mar;46:402e5.

2. Ladham S, Koehler SA, Woods P, et al. A case of a death byexplosives: the keys to a proper investigation. J Clin ForensicMed 2005 Apr;12:85e92.

3. Niemcunowicz-Janica A, Ptaszynska-Sarosiek I, Janica J. Suicideby detonation of an explosive placed in the oral cavity. ArchMed Sadowej Kryminol 2005 ApreJun;55:171e3.

4. Cvetinovic M. Reconstruction of a face destroyed by an explo-sion. Vojnosanit Pregl 1997 JuleAug;54:73e6.

5. Kohnlein HE, Seitz HD. Management of an explosion injury of theface. Langenbecks Arch Chir 1987;372:713e4.