Salvage Reconstruction of Composite Defects of the Anterior Mandible, Floor of Mouth, and Lip

Abstract

Anterior mandible defects result in loss of support for the tongue, floor of the mouth and lower lip, resulting in impairment of airway, feeding, and speech. We treated four patients with these "Andy Gump" deformities. Reconstruction was performed with two free flaps: a fibula osteocutaneous flap for the anterior mandible and floor of the mouth, and a soft tissue free flap for the lip, chin, and anterior neck. The lower lip was suspended cranially with fascia or tendon grafts ± mini-temporalis turndown flaps. All flaps survived completely. All patients were tube feed-dependent before surgery; they all resumed an oral diet. All tracheostomies were decannulated. Lip competence was restored as evidenced by cessation of drooling. Speech improved from unintelligible to intelligible with frequent repetitions. Objective assessment was performed with the functional intraoral Glasgow scale; the mean FIGS score improved from 3.25 (range 3-4) to 11 (range 9-13). We conclude that composite anterior mandible and tongue defects have large tissue requirements that require multiple free flaps. Reconstruction leads to significant improvement in function.

Keywords: Andy Gump; anterior mandible; free flap; functional intraoral Glasgow scale; lip suspension.

Fig. 1

Schematic of the reconstruction. A fibula osteocutaneous flap was used for reconstruction of the mandible, overlying soft tissue, and anterior floor of the mouth. A second soft tissue free flap was used for the reconstruction of the lip, chin, and central neck. The lower lip is suspended cranially with fascia or tendon slings ± mini-temporalis turndown flaps.

Fig. 2

A 26-year-old female who sustained a gunshot wound to the face at the age of 5 years. Previous failed reconstructive attempts included pedicled pectoralis major and supraclavicular flaps and two anterolateral thigh free flaps with a reconstruction plate. Anteroposterior and lateral views showing an Andy Gump deformity.

Fig. 3

CT scan showing cranial rotation of the mandibular rami.

Fig. 4

Reconstruction with a fibula osteocutaneous flap and a vertical rectus abdominus musculocutaneous flap.

Fig. 5

Final result after flap liposuction and vestibuloplasty.

Fig. 6

Pre- and postprocedure pictures of a 30-year-old female with through and through anterior mandible loss. Previous attempts at outside institutions included free fibula flap and pedicled pectoralis major flap with reconstruction plate. Definitive reconstruction was performed with fibula osteocutaneous and anteromedial thigh free flaps.

Fig. 7

Pre- and postprocedure pictures of a 29-year-old male with through and through anterior mandible loss due to a gunshot wound. He underwent reconstruction at an outside hospital with a pedicled pectoralis major flap and reconstruction bar which was complicated by plate extrusion. Definitive reconstruction performed with fibula osteocutaneous and anterolateral thigh free flaps.

Fig. 8

Pre- and postprocedure pictures of a 22-year-old male who sustained a gunshot wound to the mandible, which was temporized at an outside hospital with debridement and primary closure. He presented to our unit 3 months later. Definitive reconstruction was performed with fibula osteocutaneous and anterolateral thigh free flaps.