Plastic Surgery Service, Walter Reed General Hospital, Washington, D.C., 20012

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Joella Dickerson
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1 British Journal of Plastic Surgery (x 97z), 25, z3-z8 AN APPROACH TO RECONSTRUCTION OF COMPLEX LOWER FACE INJURIES ROBERT W. PARSONS, M.D., F.A.C.S., Colonel, U.S. Army, and HARLAN R. THERING, M.D., F.A.C.S., Lt.-Colonel, U.S. Army Plastic Surgery Service, Walter Reed General Hospital, Washington, D.C., TIrE war in Vietnam has resulted in relatively few U.S. casualties with severely crippling facial deformity. There have been fewer serious avulsive losses than in other wars, and superb early care has sharply reduced the amount of reconstructive surgery needed for many patients. The severe facial wounds which have occurred still present major problems to the reconstructive surgeons in our Army hospitals, however. Massive injuries of the lower face'with partial or complete loss of lips, chin, jaw and floor of mouth are especially difficult to manage. Each wound is unique, there are no routine methods, and no meaningful statistical analysis of our experience is possible. On our service at Walter Reed General Hospital, a basic approach to these deformities has been developed. This will be demonstrated by the presentation of a single case, chosen particularly because it presents nearly all facets of the problem. This soldier was 23 years old when he was injured by multiple fragments from a rocket-propelled grenade in Vietnam. His wounds involved the face, neck, shoulders and chest. His initial treatment included tracheostomy, debridement, reduction of facial fractures with direct wiring, and primary closure of the facial wounds in as nearly normal relationship as possible. His post-injury course was stormy, complicated by both Candida albicans and Pseudomonas pseudomallei septicaemia. Some IO months elapsed before his general condition was satisfactory for major surgery. This long period of debilitation is distinctly unusual in our experience. The reconstructive problems facing us at this point were : (I) bilateral paralysis of the 7th cranial nerve ; (2) loss of the right eye ; (3) complete loss of the lower lip ; (4) partial loss of the floor of mouth and tongue ; (5) loss of the soft tissue of the chin ; (6) avulsion of a portion of the left ramus and body of the mandible. The severe comminution of the remainder of the body of the mandible had consolidated during the long period of medical management. The patient's most consistent and significant complaint from the very beginning was drooling, which forced him to carry a towel against his mouth at all times. He could swallow his saliva only when recumbent, and this was also the only position in which he could manage to eat or drink. His other complaints were his inability to chew and the totally blank facial stare caused by loss of one eye and bilateral facial paralysis. Surprisingly, his emotional outlook at the beginning of reconstruction was only moderately depressed, although he seemed fully aware of the fact that he would have permanent residual disfigurement. Our first efforts were directed towards the facial nerves. Electromyography indicated possible early recovery on the left. The proximal trunk of the facial nerve was explored on the right and a nerve graft done to no avail. Unfortunately the muscle potentials on the extensively damaged left side progressively disappeared. It was our judgement that further attempts at direct nerve grafting or repair would be fruitless. Therefore we decided to defer further attempts to overcome this loss until the mouth was restored to continence. 2~

2 24 B R I T I S H JOURNAL OF PLASTIC SURGERY FIG. I FIG. 2 FIG. 3 FIG. 4 FIGS I-4.--Early photos showing bilateral 7th nerve paralysis: loss of right eye: loss of lower lip, soft tissue of chin and floor of mouth, with neck skin advanced for closure.

3 RECONSTRUCTION OF COMPLEX LOWER FACE INJURIES 2 5 Tissue replacement began from the inside out and from foundation to super- Structure. A cervical tube was used to reconstitute the floor of the mouth, free the anterior tongue, release the medially displaced mandible, and provide additional soft tissue for the chin. In another case we might be more inclined to use a Bakamjian delto-pectoral flap (Bakamjian, 1967) for this purpose. In principle, we begin by following Gillies' precept of putting what is normal in normal position and keeping it there, with addition of tissue as needed. FIG. 6 FIG. 5 FIE. 7 FIG. 5.--Cervical tube used to release tongue and augment soft tissue of floor of mouth and chin. (Note spontaneous improvement in facial tattooing.) FIGS 6-7.JExtensive comminution of mandible seen in Figure 6 consolidated during early management. Figure 7 shows appearance of iliac bone graft to portion of body and ramus of left mandible 3 months post-operative. The foundation of the reconstruction was further established by an iliac bone graft to the left side of the mandible. In this instance a Gunning-type splint was used, held by circummandibular wires. In other patients we have found the use of the acrylic biphasic appliance valuable for this immobilisation. With satisfactory healing of the graft, we were ready to begin construction of the lip itself. From the patient's point of view, however, a long period of hospitalisation and multiple operations had produced no significant improvement in either his appearance or his major complaint of drooling. He felt unable to face the world outside the Plastic Surgery ward and his own apartment. He had marital problems, and his wife had left him. His increased depression led him to speak openly of suicide. Psychiatric consultation was of little help, although he had seen therapists on a number of occasions during this time. It is our experience that young patients who have suffered a major insult to their body image are oriented toward surgical rehabilitation, sometimes excessively so. They

Static fascial slings and McLaughlin tarsorrhaphies were done at this time to improve patient's morale. FIGS 9- i I.

4 26 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 8 FIG. 9 FIG. IO FIG. I I FIG. 8.--Nasolabial flaps delayed because they are based on scar. Hairless portion of cervical tube for lining of lip has also been delayed. Static fascial slings and McLaughlin tarsorrhaphies were done at this time to improve patient's morale. FIGS 9- i I. - - P r e s e n t appearance of patient. T h e simulation of vermilion border on lower lip results from contrast between the quality of cervical skin and nasolabial skin.

RECOI~STRUC'rlOlq OF CO~VLEX LOWER FACE I~JURIES 27 are initially unable to accept the idea that part of their difficulties may be overcome through emotional acceptance of permanent deformity.

5 RECOI~STRUC'rlOlq OF CO~VLEX LOWER FACE I~JURIES 27 are initially unable to accept the idea that part of their difficulties may be overcome through emotional acceptance of permanent deformity. This seems to develop slowly over a period of time, and our patients are helped most by a realistically optimistic attitude on the part of the surgeons coupled with spontaneous or planned group therapy support of other patients. This patient clearly was in desperate need of some concrete visible improvement. We had concentrated our planning on the surgical challenge, and minimised the early relief of his principal complaints. We now decided to use Wilkie's technique (Wilkie, ~97 o) for diversion of the parotid secretions to the pharynx, despite the heavy scarring in the left cheek and buccal mucosa. The marked diminution in drooling produced dramatic improvement in morale. We would now employ this technique at a much earlier stage in any similar ca~e. The reconstruction of the lower lip itself is always difficult. As a basic precept we feel that the lower lip should not be formed in continuity from the same flap as the floor of mouth and chin. Rather the chin, floor of mouth, and the bony arch of the mandible should be established as a foundation upon which the lower lip is independently reconstructed. Thus the lip is not required to suspend the skin of the chin and upper neck against gravity. In this case the problem was compounded because no support for the lip could be developed from the paralysed cheek muscles. We elected to use bilateral nasolabial flaps, attempting to place the pivot points so that some skin support would result. Excess skin in the cervical flap at the chin was turned up to provide lining and, incidentally, a lip border. This plan was successful in providing a continent mouth, although the anaesthesia of the lower lip required that the patient make a conscious effort to keep the lips dosed. The vermilion-like appearance of the skin flap used for lining and lip border is a happy secondary benefit which we have observed in several other patients when the scar falls along a line simulating the junction of vermilion and skin. For other cases in which both lips are significantly damaged, and the remaining tissue is innervated, we use the tissue from the upper lip to provide a good lower lip, preferring total reconstruction of a curtain-like upper lip to a lower lip which is difficult to support in proper position. With total loss or near total loss of the lower lip alone, we frequently prefer the forehead as a donor site. During the reconstruction of the lip proper another procedure was done for morale purposes. Static fascial slings were used to support the lower eyelids. In general, we prefer the temporalis muscle transfer for this, but we were deterred in this man by the possibility of later use of these muscles for lip support, and by our uncertainty as to the adequacy of function of the muscle on the left. The static support will be replaced, if possible, when the muscle transfer is done to support the lip. After the basic tissue requirements were met, we proceeded to the refinements needed for rehabilitation. The appearance about the eyes was improved by release of the earlier lid adhesion on the left, creation of McLaughlin tarsorrhaphies bilaterally (McLaughlin, 1953) and implantation of glass beads beneath the periosteum of the roof of the right orbit to improve the enophthalmic appearance of the prosthetic eye. The chin and lip flaps were thinned and a procedure done to create a sulcus anterior to the mandible for a denture. There remains now only the muscle transfer operation, further thinning of the lower lip, and possible further minor adjustments. The patient has now adapted to his deformity reasonably well and is in school making up deficiencies in his educational background so that he can pursue a skilled trade.

28 BRITISH JOURNAL OF PLASTIC SURGERY SUMMARY Our approach can be summarised in a series of maxims, some of which are paraphrased from Sir Harold Gillies, James Barrett Brown, and other early leaders

6 28 BRITISH JOURNAL OF PLASTIC SURGERY SUMMARY Our approach can be summarised in a series of maxims, some of which are paraphrased from Sir Harold Gillies, James Barrett Brown, and other early leaders in the reconstruction of war injuries. Diagnosis precedes treatment. An adequate analysis of the entire problem is essential so that ill-advised early steps will not compromise later operations. The patient has the problem. The surgeon faces only a technical challenge in helping the patient to overcome his problem. Therefore the patient's complaints and wishes must be given due weight in deciding priorities of treatment. In this case the alleviation of drooling by redirection of the parotid secretions could have helped the patient at an early stage. In planning, first things come first. A good foundation is essential to a good result. In the lower face we work from the inside out and from the bottom up. The lower lip is best reconstructed independent of and subsequent to the establishment of the foundation of floor of mouth, chin and mandibular arch. Routine methods are for routine cases. In lower face reconstruction one should avoid the temptation to make the case fit a favourite technique. The best results come from opportune use of the whole spectrum of plastic surgical methods. Deformity is often best measured with~a ruler. With due consideration for the patient's priorities, concentrate on the measures which will produce maximal reduction of overall disfigurement before proceeding to refinements which make the photographs more appealing. An operation which reduces the visibility of disfigurement from 20 feet to 4 feet is very important functionally. One which makes a scar look better without reducing the footage may be worth while as a touch-up, but does not have high initial priority. The best psychotherapy is definite progress toward normality. During the patient's adjustment of his body image to incorporate permanent deformity, the sympathetic support of an honest, realistically optimistic surgeon is essential. But he also needs visible reassurance that his disfigurement is decreasing. The reconstruction of the severely disfigured lower face and jaw is a challenge which requires all of the ingenuity, technical skill and perseverance the surgeon can command. He must constantly strive for perfection in spite of the sure knowledge that he cannot achieve it. At the same time, he must never lose sight of the fact that his goal is a rehabilitated patient functioning in society, and not a photogenic technical result. REFERENCES BAKAMJIAN, V. Y., CULV, N. K. and BALES, H. W. (x967). Versatility of the deltopectoral flap in reconstruction following head and neck cancer surgery. "Transactions of the Fourth International Congress of Plastic and Reconstructive Surgery", pp. 8o8-8r 5. Amsterdam: Excerpta Medica. MCLAUGrmXN, C. R. (I953). Surgical support in permanent facial paralysis. Plastic and Reconstructive Surgery, xi, 3o WILKm, T. F. (I97O). The surgical treatment of drooling. Plastic and Reconstructive Surgery, 45,

SURGICAL TREATMENT OF SEVENTH NERVE PARALYSIS. By B. GRUNDT, M.D. Oslo, Norway

SURGICAL TREATMENT OF SEVENTH NERVE PARALYSIS By B. GRUNDT, M.D. Oslo, Norway WE are all familiar with the patient who has paralysis of the facial nerve. The oblique mouth and the corresponding oblique