Facial Reconstruction With Radial Forearm-Fascia Lata Flaps

Abstract and Introduction

Abstract

Background: Primary explosion injuries with fireworks can lead to devastating and geometrically complex facial traumas that present a challenge to the reconstructive surgeon. Our patient, a woman in her early thirties, was hit directly in her chin by a large artillery shell firework. This caused complete soft tissue loss of the lower lip and chin beyond the oral commissures, complicated further by a comminuted mandible fracture.

Methods: After external fixation, our patient underwent a 2-stage reconstruction with a novel composite flap arrangement. Soft tissue coverage and lip reconstruction were performed with opposing bilateral radial forearm free flaps. The outer flap constituted the soft tissue of the new chin and outer lower lip, whereas the inner flap composed the intraoral lining. In the second stage, portions of the inner upper lip mucosa and superior orbicularis oris muscle were flipped down as a bipedicle, axial pattern "bucket-handle" type flap to the lower lip to reconstruct the vermilion. A graft of fascia lata was attached to the modioli of the orbicularis oris and interpositioned beneath the vermilion flap and the radial forearms to restore static and some dynamic sphincter control. One month later, the mandibular fractures underwent open reduction and internal fixation.

Results: Two months after soft tissue reconstruction with no complications, our patient had satisfactory aesthetic outcomes, oral competence, and speech.

Conclusions: This case has shown that use of bilateral, fascia lata-reinforced radial forearm flaps may be an effective choice for soft tissue reconstruction and oral competence restoration in cases of severe facial explosion trauma.

Introduction

Direct explosion facial injuries create a unique clinical challenge for the reconstructive surgeon as these types of injuries can result in both large, full thickness soft tissue defects, as well as comminuted open fractures. Aesthetic restoration of the face can be challenging when the lip is involved, but greater considerations are necessary to restore oral competence to help give the patient a greater quality of life after injury. The fasciocutaneous radial forearm free flap (RFFF) has become a standard reconstructive option for large, full thickness facial traumatic wounds and postresective defects where local and regional flaps would otherwise result in significant aesthetic and functional deficits (such as microstomia).^[1–2] In recent years, its usage in composite tendinofasciocutaneous flaps has created avenues for improved oral competence after oral reconstruction.^[3–6]

In this case, we present a 2-stage reconstruction of the lower face following unconventional trauma from a direct hit with a large artillery shell/mortar type firework. Bilateral RFFFs were combined with a fascia lata graft and an axial pattern bipedicle flap of upper lip oral mucosa. These were used to reconstruct and restore functionality of the chin, lip, and oral mucosa. To the authors' knowledge, the use of bilateral fascia lata to reinforce RFFFs in this manner for a dramatic 2-stage facial reconstruction has not previously been described.