North Texas Dentistry Volume 8 Issue 3 2018 ISSUE 3 DE - Page 29

Procedure The first stage of the surgery was completed without difficulty. The necrotic tissues were debrided until healthy tissues were found. The maxilla, malar, and or- bital rim were reconstructed in the traditional fashion using titanium implants to reduce the fractures. The avulsive defects were then packed and we returned to the OR a few days later to complete the reconstruction. A fibular free flap was harvested to reconstruct his mandible, and the soft tissue skin paddle from the leg was used to reconstruct his floor of mouth and ventral tongue. Simultaneously, a second free flap was taken, and the radial forearm free flap was used to reconstruct the avulsed soft tissues of his neck and chin. Both free flaps were anastomosed to an artery and vein in the neck measuring 2-3mm in size, using a microscope and 9-0 nylon sutures to supply these large tissue flaps with their own blood supply. At this point, the patient’s initial surgeries were completed. His wounds were closed and he was stable. He was able to eat and talk, however, he would require additional surgeries. He was returned to the OR several times over the past 3 years to reconstruct the remainder of his face. His right maxillary defect was initially attempted to be re- constructed using non vascularized iliac crest, how- ever, this bone graft failed, ultimately requiring another fibular free flap for reconstruction of his anterior and right maxilla. This was successful in reconstructing his maxilla and prepared him well for dental implants. In addition, a serial excision technique was used to ad- vance the cervical soft tissues to replace the trans- planted tissues with native tissue to create better symmetry. In addition, his lower lip was reconstructed using mucosal advancement flaps. Results With the ability to reconstruct patients using microvascular free tissue transfer, even large defects that in the past were unimaginable, can be reconstructed with excellent results. Although this patient was financially unable to complete dental rec onstruction, his quality of life has returned to a very high level. He can eat nearly anything he wants, and can speak, and truly appear normal to those that do not know what he has been through. AFTER DEBRIDEMENT AFTER BONE REDUCTION IMMEDIATE POST-OP ONE YEAR POST-OP 3 YEARS POST-OP 3 YEARS POST-OP Fibula flap using peroneal artery Head and Neck Surgery of North Texas PLLC 1411 North Beckley Avenue Pavilion III, Suite 152, Dallas, TX 75203 Microvascular anastomosis 2-3mm vessels (469) 713-2038 | NORTH TEXAS DENTISTRY 29