Background:

Ballistic injuries to the maxillofacial region pose a major reconstructive challenge due to complex anatomy and the need to restore both aesthetic appearance and essential functions such as speech and swallowing. This study evaluates microvascular reconstruction strategies and associated complications in these injuries.
Methods:

A retrospective descriptive study was performed, including patients treated at a level I trauma center during a 10-year period. Inclusion criteria were (1) ballistic injury to the lower face or midface, (2) tissue loss requiring microvascular reconstruction, and (3) complete clinical and radiological documentation. Data collected included demographics, injury characteristics, reconstructive techniques, complications, and microbiological findings.
Results:

Nine patients underwent microvascular reconstruction between 2015 and 2025, with a total of 15 free flap procedures performed, including 10 fibula free flaps. One flap loss occurred due to infection 3 months postoperatively. Reconstruction was delayed in 7 cases. War-related injuries and delayed reconstruction were significantly associated with preoperative wound infection and detection of multidrug-resistant Gram-negative (MDRGN) organisms (P = 0.018 and P = 0.023, respectively). The presence of MDRGN organisms was significantly associated with the occurrence of surgical site infections (P = 0.016).
Conclusions:

Microvascular free flap reconstruction remains the gold standard for complex maxillofacial ballistic injuries, even under adverse conditions. War-related trauma and delayed reconstruction are strongly associated with infectious complications, particularly involving MDRGN, and should be carefully considered in perioperative management.