A 70-year-old male patient was admitted to the emergency department with severe facial intubation after an autolytic attempt with a gun.
Physical examination revealed a traumatic lesion in the middle and lower thirds of the face, with loss of bone and soft tissues (upper to total menton thickness of the lower lip, and perioral region).
A craniofacial computed tomography (CT) was performed, which ruled out brain damage and showed extensive loss of substance at the mandibular level, with multiple maxillary fractures, fracture of the orbital bones and fracture of the orbital floors.
The patient was transferred to the operating room where a regulated ostomy was performed, cleaning and hemostasis of facial wounds and removal of comminuted fragments and foreign bodies.
Bone defect was then bridged using a 2.5mm mandibular reconstruction plate and primary closure of blade tissues.
The stability of fractures was confirmed in the middle third, so an expectant attitude was adopted.
Closed nasal reduction was performed.
The patient remained in the intensive care unit for four days.
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Ten days later secondary reconstruction was performed, with removal of the mandibular reconstruction plate, carving of microvascularised osteofasciocutaneous flap of the left fibula and preformed in situ mandibular reconstruction at a level of mandibular remanent reconstruction.
The external coverage of the fibula was performed by means of its cutaneous pallet, arranged at the chin and submental level, and the internal coverage by detachment and advancement of the mucosa of the floor of the anterior mouth.
Finally, microanastomosis of peroneal vessels to facial vessels was performed.
Complete-thickness flaps were raised at the level of the remnant mental pedigree superior base to the modified Karapandzic flap mode, with facial preservation of neo and carved flap creation.
Both mucocutaneous flaps were rotated medially to their union at the central level, neoforming the lower lip of full thickness and creating the lower lip vestibule.
A left Webster flap was then used for reconstruction of the upper lip defect.
In addition to reconstruction of soft and bone tissues, in our case the patient had a constitutional macroglossia, so we performed a midline glossectomy (resecting the middle third of the free tongue) as a lip approach.
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During the postoperative period, the results were evaluated in terms of lip competence, speech, feeding and aesthetics.
Lip competence was optimal, without achieving hermetic closure of the lips, but without loss of fluid when drinking.
Speech was evaluated according to the intelligibility of the patient by telephone, which was positive.
As for the ability to eat, the patient has a normal diet (triturated by lack of teeth).
The aesthetic result was acceptable.
There were no complications during the 6 months of follow-up and the patient was under psychiatric follow-up and treatment.
In the near future there is a need for additional intervention (lip esthetic refinement, dental prosthetic rehabilitation, etc.).
