Microvascular Reconstruction of Mandible Defects Due to Gunshot Injuries

Mandibular reconstruction presents a significant challenge for reconstructive surgeons. However, current advances in microvascular and maxillofacial surgical knowledge have provided a new dimension to overcome the difficulties in this area.

Between 1992 and 2003, 73 patients with mandibular gunshot injuries were treated in the Department of Plastic and Reconstructive Surgery at GMMA. In 23 cases, the bony defects were treated with free flap transfers. Of these 23 patients, 9 were treated with a free fibula flap transfer in the early period. For the other patients, bone plates were used to restore mandibular contour, so that subsequent soft tissue collapse could be prevented. Mandibular reconstruction was performed at 8 to 12 weeks following the complete recovery of oral mucosa and skin. Bone grafts were used if the mandibular defect was less than 4 cm, while larger defects were reconstructed by free flap transfers. Vascularized fibula flaps (in 15 patients) and DCIA flaps (in 2 cases) were used for definitive treatment of bone defects. Other cases were treated either by bone graft or distraction osteogenesis. Dental prosthetics were routinely employed.

Of the 73 patients, 56 were suffering from close-range gunshot injuries due to suicide attempts. The average bony defect was 6.7 cm (range: 4 to 9 cm). The defect was central in 15 patients and lateral in 8 patients. In 7 cases, the fibular flap was combined with another free flap (fibula or radial forearm) and in one case, three simultaneous free flaps were performed. The authors would have preferred to perform definitive treatment in early reconstruction, in order to improve the final outcome and reduce hospitalization time, but this was possible in only 9 cases. In 14 cases, late reconstructions were performed. A near-normal occlusion was obtained in all cases. In 3 patients, oral competence was achieved with additional operative procedures. Postoperative complications included loss of free fibula flaps (3 cases), loosening of plates (8 cases), nonunion (1 case), and plate fracture (1 case). A second free fibular flap was performed in those with free flap loss.

The authors recommended reconstruction of large bone defects by vascularized bone flaps either in the early or late periods. Early reconstruction of mandiblar gunshot injuries has several advantages, such as better functional and cosmetic outcomes, decreased hospitalization and cost. The defect should be bridged by use of a reconstruction plate, if early definitive treatment is not considered. They recommended the removal of reconstruction plates 6 months after the graft procedure. Dental prosthetics are generally required to achieve a good functional result.