[Microsurgery and ballistic traumatology of the face]

The use of free flaps to fill and repair facial defects due to suicidal gunshot wounds has considerably extended and refined the possibilities available to reconstructive surgeon. The objective is no longer to close the defect at any cost, or "fill a hole", but to replace missing tissue by an identical tissue, able to restore an identical cosmetic appearance, support equivalent constraints, and restore analogous function. Retrospective analysis of 56 cases of large facial defects due to gunshot wounds revealed a total of 66 free flaps for 32 cases. The vascular quality of the flaps allowed better integration in a sometimes hostile recipient site and markedly reduced the treatment time. Although the objective results obtained in the treatment of these severe defects remain poor, the first-line use of these multiple flaps, exclusively reserved for deep repair, as the basis for reconstruction, has modified our behaviour. A real medium-term treatment strategy, based on a decision flow-chart, can be proposed which, despite several inevitable failures, leaves less room for improvisation and piecemeal surgery. Free flaps are only the hidden part of the reconstruction, as surface cover uses local flaps and other conventional reconstructive surgery techniques. However, this humble, hidden role is nevertheless fundamental, in the strict sense of the term, and guides the general approach to this surgery.