Complete loss of lower lip in a one-year-old treated with delayed free tissue transfer: a case report and comprehensive review of the literature

Abstract

Pediatric lower lip reconstruction is rare and technically challenging due to small donor sites, ongoing facial growth, and functional demands, such as speech and oral competence. We present the case of a one-year-old male who sustained complete avulsion of the lower lip from a dog bite. Initial management included a Karapandzic advancement flap for coverage. Definitive reconstruction at 23 months involved a radial forearm free flap with palmaris longus tendon for static suspension, augmented by acellular dermal matrix. Postoperative dehiscence required revision vestibuloplasty with a split-thickness skin graft. The patient achieved adequate lip suspension, improved sialorrhea, and restoration of oral competence by the first postoperative visit. Free flap reconstruction of the lower lip in children under two is feasible and can yield functional and aesthetic outcomes when individualized planning and multidisciplinary care are employed.

Keywords: dog bite trauma; lower lip avulsion; oral competence; pediatric free flap reconstruction; radial forearm free flap; static suspension.

Figure 1

Initial presentation and local flap coverage. (a) Photograph upon initial presentation at 11 months of age to tertiary care facility demonstrating complete loss of lower lip with soft tissue defect exposing mandible. (b) Photograph following Karapandzic advancement flap coverage of mandible and resultant microstomia.

Figure 2

Preoperative evaluation and flap harvest. (a) Preoperative photograph (23 months of age) prior to definitive free flap reconstruction highlighting exposed mandibular dentition. (b) Intraoperative photo depicting harvest of the right RFFF.

Figure 3

Inset of RFFF. (a) Intraoperative photo demonstrating the harvested RFFF positioned over the soft tissue defect. (b) Front profile following RFFF reconstruction of lower lip with suspension sutures to zygoma periosteum. (c) Side profile following RFFF reconstruction of lower lip.

Figure 4

Postoperative outcome. (a) Postoperative photo demonstrating coverage of mandibular dentition following complex vestibuloplasty with split thickness skin graft and revision suspension of free flap to mandibular periosteum. (b) Patient photo from first postoperative check on POD 15 demonstrating mouth closure with lip opposition and restoration of oral competence.