A 19-year-old man who was admitted from the emergency department with a firearm (hunting gun) after an autolysis attempt (disability of impact less than one meter).
He presented a wound of the lower third lateral region with significant bone loss of region from first left premolar to left mandibular angle.
Cutaneous plaque-mucosal imported from the left jugular region and left cheek.
Initially proceeded to the realization of laparotomy, debridement of devitalized tissues, dental ferulization, intermaxillary block and placement of a mandibular reconstruction plate.
In this first surgical time, direct intraoral closure and cutaneous closure with a cervicofacial advancement flap were performed.
In the immediate postoperative period there is suffering and loss of the cutaneous flap of cervicofacial advancement that leaves an important area of left facial granuloma.
Electrical retraction produces a large limitation of oral opening (0.8 cm).
Orofacial communications and salivary fistulas are manifested.
A secondary intervention was performed using a non-dominant left arm scapular-parascapular osteomiocutaneous flap, but with a history of recurrent dislocation.
The intervention begins with a newotomy and preparation of the recipient vessels: facial artery and branch of the thyrolingual-facial venous trunk.
It is necessary to remove a large amount of tissue level I and III.
Then, the scapular-parascapular osteocutaneous flap was dissected and the donor site was closed, leaving aspiration drainage and immobilizing the left upper limb with a sling.
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The bone part of the flap is then adapted to the mandibular defect with ostosyntesis using the reconstruction plate placed in the initial intervention.
The cutaneous part of the flap is folded as if from a book it was treated, leaving one of the cutaneous lobules intraoral and another extraoral (cervical facial).
The back of the supposed book is deepithelialized and sutured to the remaining lower lip.
The intraoral part removes the entire buccal mucosa to the anterior pillar of the palate velum.
The external part presents the cutaneous zone mandibular and submandibular left.
The superior region of the skin defect remains for dermoepidermal graft.
The block and dental splint were removed and the mouth was left "open".
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Flap adaptation requires submaxillectomy and removal of part of the subcutaneous tissue of the lower zone.
Anastomosis was performed at the end-to-end of the circumflected scapular artery to the facial artery; and from the largest of the circumflected scapular veins to the thyrolingual-facial trunk.
The duration of the intervention was 14 hours, with an ischemia time of 2.45 hours.
Dissatisfaction regarding the vitality of the scapular flap.
Local complications: parotid salivary fistula in upper zone due to loss of the dermoepidermic injector on the masseteric region.
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Complications in donor site detachment of the long arm of the triceps and wound dehiscence.
For treating this condition, the patient underwent surgery, performing a local transposition flap.
Postural involvement: paralysis of the radial nerve of the contralateral side (right).
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The patient follows rehabilitation treatment to recover mobility of the left arm.
