18. Ozek C, Celik N, Bilkay U, Akalin T, Erdem O, Cagdas A:Marjolin’s ulcer of the scalp: Report of 5 cases and review ofthe literature. J Burn Care Rehabil 22:65, 2001

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20. Copcu E, Aktas A, Sisman N, Oztan Y: Thirty-one cases ofMarjolin’s ulcer. Clin Exp Dermatol 28:138, 2003

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J Oral Maxillofac Surg65:2105-2107, 2007

Unusual Ballistic Trauma of the Face Witha Less-Lethal Launcher

Ivan Dojcinovic, MD, DMD,* Martin Broome, MD, DMD,†

Max Hugentobler, MD, DMD,‡ and Michel Richter, MD, DMD§

We present an unusual case of ballistic trauma of theface from a “less-lethal” launcher. Projectiles fromthese weapons are supposed to fragment on impact,without causing penetrating injuries. Our case provesthe contrary. These projectiles can cause serious oreven potentially lethal injuries, depending on the or-gan targeted and the distance fired.

Report of a Case

A 44-year-old woman received a paint-filled projectile in theface during a demonstration. On admission to the emergencydepartment of our hospital (Hôpitaux Universitaires de Ge-nève, Genève, Switzerland), the patient presented a deep woundbehind the right cheek measuring 2 cm, with irregular margins,stained pink (Fig 1). No nerve deficiencies or difficulties in open-ing the mouth were noted. X-rays showed multiple small radio-opaque particles as well as a bifocal fracture of the zygomatic arch(Figs 2, 3). Treatment consisted of a simple revision of the woundunder local anesthesia and extraction of the foreign bodies wherepossible (Fig 4). The deep particles were left in place toprevent the risk of an iatrogenic lesion on the zygomaticbranch of the facial nerve. The fracture needed no treatmentbecause it was only slightly displaced and had no functional oresthetic repercussions. Computed tomography was per-formed after revision of the wound, confirming some remain-ing radio-opaque particles (Fig 5). The wound was rinsed dailywith chlorhexidine and healed by secondary intention.

Discussion

Paintball is a warfare simulation game invented inNew Hampshire in 1981.1 On contact with the tar-

Received from the Clinic of Maxillofacial and Oral Surgery, Depart-

ment of Surgery, University Hospital of Geneva, Geneva, Switzerland.

*Senior Resident.

†Junior Resident.

‡Fellow.

§Professor and Chairman.

Address correspondence and reprint requests to Dr Dojcinovic:

Clinic of Maxillofacial and Oral Surgery, Hôpitaux Universitaires de

Genève, 24 Micheli-du Crest, 1211 Genève 14, Switzerland; e-mail:

ivan.dojcinovic@hcuge.ch

© 2007 American Association of Oral and Maxillofacial Surgeons

0278-2391/07/6510-0035$32.00/0

doi:10.1016/j.joms.2006.06.258

DOJCINOVIC ET AL 2105

get, the projectiles burst harmlessly, releasing thecolorant and marking the target. The potential ofthis type of missile for law enforcement purposeswas recognized, and several manufacturers havesince developed reduced vulnerability weapons in-spired by the paintball game. These allow policeforces to deter, for example, increasing violence instreet demonstrations by shooting a missile that deliv-ers both a dissuasive kinetic impact shock while at the

same time marking troublemakers with paint. Theseare promoted by the manufacturers as having beendeveloped around a “reduced lethality” concept,given the frequency and severity of other ballistictraumas to the face, explicable both by the exposure ofthe face and the difficulties in protecting cephalic ex-tremities. Ballistic traumas vary according to the type ofweapon and follow the principles first outlined by Wil-son in 1927.2 The determining factors are: distance,projectile velocity (quantity of energy transmitted to thetissue), direction of transmitted energy, and tissue den-sity as well as the size, shape, and hardness of theprojectile itself. The lesion is contingent on the absorp-tion of the kinetic energy released by the projectile atthe point of impact. The kinetic energy (or woundingcapacity) can be calculated using the formula:

KE � MV�2�/2,

where KE is kinetic energy measured in J, M is mass(kg), and V is velocity (meter/second).3 Firearms can

FIGURE 1. Facial wound.

Dojcinovic et al. Unusual Ballistic Trauma of the Face. J OralMaxillofac Surg 2007.

FIGURE 2. X-ray showing multiple small radio-opaque particles.

Dojcinovic et al. Unusual Ballistic Trauma of the Face. J OralMaxillofac Surg 2007.

FIGURE 3. X-ray showing a bifocal fracture of the zygomatic arch.

Dojcinovic et al. Unusual Ballistic Trauma of the Face. J OralMaxillofac Surg 2007.

FIGURE 4. Removed particles.

Dojcinovic et al. Unusual Ballistic Trauma of the Face. J OralMaxillofac Surg 2007.

2106 UNUSUAL BALLISTIC TRAUMA OF THE FACE

be divided into 2 categories depending on the initialprojectile speed; infrasonic and supersonic. Infra-sonic firearms, which have an initial projectile speedinferior to 660 meters per second (m/s) and super-sonic firearms, superior to 660 m/s. The gun used in ourcase was the FN303 developed by the firm FN Herstal(Herstal, Belgium).4 Initial velocity of projectiles firedfrom these guns is 85 to 90 m/s, placing them wellwithin the infrasonic group, and they develop kineticenergy of 33 J. They are semiautomatic compressed airguns with a 0.68-inch (17.3 mm) caliber. The projectile(weighing 8.5 g) used in our case is made from a domed,polystyrene body designed to break on impact (Fig 6).The forward payload contains nontoxic bismuth grains.The posterior part of this particular type of projectilecontains a pink, washable fluorescent pigment in a non-toxic glycol base. Projectiles launched by the FN303have a kinetic energy of 26 J (79 m/s) at 30 m and 21 J(70 m/s) at 50 m. This puts it in the mid-range ofallegedly nonpenetrating weapons, falling as it does be-tween true “game style” paintballs at the lower end of

the range (under 20 J) and beanbags and plastic bulletsat the other. Theoretically then, paint-containing mis-siles should have a low risk of causing a penetratinginjury, which is confirmed in the manufacturer’s man-ual.4 To date, we have found no other reports of pene-trating wounds made by the FN303. In our case, how-ever, the projectile did have adequate kinetic energy topenetrate the skin, causing a comminute fracture of thezygomatic arch.

References1. Thach AB, Ward TP, Hollifield RD, et al: Ocular injuries from

paintball pellets. Ophthalmology 106:533, 19992. Wilson LB: The Medical Department of the United States Army

in the World War. Washington, DC, US Government PrintingOffice 2, 1927

3. Shelton DW, Albright CR: Study in wound ballistics. J Oral Surg25:341, 1967

4. FN Herstal website: Available at: http://www.fnherstal.com/html/Index.htm

FIGURE 5. Computed tomography scan showing the remainingparticles.

Dojcinovic et al. Unusual Ballistic Trauma of the Face. J OralMaxillofac Surg 2007.

FIGURE 6. Projectile launched by the FN303.

Dojcinovic et al. Unusual Ballistic Trauma of the Face. J OralMaxillofac Surg 2007.

DOJCINOVIC ET AL 2107