An approach to reconstruction of complex lower face injuries

Abstract

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.