Functional reconstruction of total lower lip defects using innervated gracilis flap in the setting of high-energy ballistic injury to the lower face: preliminary report.
BACKGROUND
Reconstruction of total full-thickness lower lip defects combined with extensive composite mandibular defects particularly in the setting of close-range high-energy ballistic injury presents a formidable challenge for the reconstructive plastic surgeon. While the fibular flap has been widely accepted for its usefulness in the reconstruction of composite mandibular defects, to date, there is no definitive widely established method of total lower lip reconstruction. The article presents authors' approach using innervated gracilis muscle flap for total lower lip reconstruction in the setting of high-energy gunshot injuries to the face.


METHODS
Three patients underwent composite mandibular defect reconstruction using fibular osteocutaneous flap and functional lower lip reconstruction using innervated gracilis muscle flap. Lip lining was reconstructed using the skin paddle of the fibular flap. The external surface of the gracilis muscle was skin-grafted. Facial artery myomucosal flap provided vermilion reconstruction in two patients.


RESULTS
All fibular (n=3) and gracilis flap transfers (n=3) were viable. An electromyographic study at 1 year postoperatively demonstrated successful re-innervation of the gracilis muscle. Starting at about 10 weeks postoperatively, patients exhibited voluntary lip movements and oral competence. In addition, all patients achieved near-normal speech, evidence of recovered protective sensitivity and satisfactory appearance. The mean follow-up was 16.1 months.


CONCLUSIONS
Our preliminary report in three patients demonstrated that innervated gracilis muscle transfer combined with fibular flap provides a successful reconstruction of extensive composite mandibular and total lower lip defects resulting from gunshot injuries to the face. Oral continence was achieved by combination of regained tonicity and voluntary movement of the gracilis muscle following re-innervation and assistance of the cheek muscles on the gracilis muscle. The described technique was reliable and the results were promising.
Department of Plastic and Reconstructive Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center, 777 Bannock Street, Denver, CO 80204, USA. raffi.gurunluoglu@dhha.org
Raffi
R
Gurunluoglu
Mark
M
Glasgow
Susan A
SA
Williams
Aslin
A
Gurunluoglu
Jarod
J
Antrobus
Vincent
V
Eusterman
D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D005151:Facial Injuries / Q000209:etiology / Q000601:surgery*; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D015601:Injury Severity Score; D008046:Lip / Q000293:injuries / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D052097:Quadriceps Muscle / Q000601:surgery* / Q000637:transplantation; D019651:Plastic Surgery Procedures / Q000379:methods*; D020127:Recovery of Function; D012189:Retrospective Studies; D018570:Risk Assessment; D013524:Surgical Flaps / Q000098:blood supply / Q000294:innervation*; D013997:Time Factors; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology; D014948:Wounds, Gunshot / Q000150:complications / Q000601:surgery*