Gleneagles Global Hospitals, part of Parkway Pantai, successfully performed Fibula osteo septocutaneous free flap for total mandible reconstruction on a 26-year-old Iraqi citizen for a gunshot injury. The mandible is the lower jawbone that holds the lower teeth in place. It is the only movable bone in the skull. It is the strongest and most massive bone in the face. The mandible plays a vital role in many common tasks, including chewing, speech, and facial expression.
In 2015, Ibrahim Mankhi suffered from a gunshot injury on the left side of his face. The bullet entered the left body of the mandible and exited through the right mandible, thereby shattering the whole mandible and soft tissue. He underwent 3 subsequent surgeries in Iraq and Iran. While these surgeries aimed at improving his post ballistic traumatic status, they were not completely successful. Ibrahim suffered from chronic sinus with discharge and dull pain.
In 2018, the patient approached Gleneagles Global Hospitals at Richmond Road for a consultation. The doctor found the patient to have a chronic suppurative osteomyelitis of the mandible due to a gunshot injury. Osteomyelitis is an inflammatory disease of the bone. It develops in the jaws after a chronic odontogenic infection or for a variety of other reasons such as trauma, inadequate treatment of fracture, or irradiation to the mandible. Functionally, Ibrahim’s speech and simple tasks like swallowing had been affected. Additionally, the shape and form of his face had been altered. The patient’s main request was improved functionality and aesthetic enhancement.
The surgery was planned for late February. A complete work up was carried out prior to the surgery. There were multiple challenges including an existing chronic infection, changes in the fibrotic subcutaneous plane due to previous surgeries and the missing mandible. In the workup to surgery, the team of doctors prepared a Rapid Prototype Model which was developed using his previous pre injury photos using simulation technique.
Plate pre-bending for additional stability and osteotomy or the surgical cutting of the bone for realignment were planned and executed. The complex surgery took nearly 10 hours. The patient was admitted for a total of 10 days to ensure smooth recovery.
With this approach, the surgical work flow was easier resulting in a near normal and accurate reconstruction. Immediate post op recovery was seen in 10 days. Ibrahim is also free of the chronic infection he first presented with. The speech, form and shape improvement was seen from 10 days to 3 weeks. The patient has been placed on a liquid/soft food diet from 3 weeks – 6 months. Once osteointegrated implant rehab is completed, that is, 6-12 months from post op, patient can return to a normal diet.
While segmental defects are treated regularly at Gleneagles Global Hospitals, Richmond Road, a total mandible defect is a rare entity.
The team of doctors from Gleneagles Global Hospitals that worked on this unique case comprised of Dr Prashanth Kesari, Lead Plastic Surgeon, Dr Manjunath Subramanyam, Craniomaxillofacial (CMF), Head and reconstructive Microsurgeon, Dr Subramanya Rao ENT / Head and Neck Oncologist, Dr Babu, ENT Surgeon and Dr Rajeev, Chief Anaesthesiologist.
Dr Manjunath Subramanyam, CMF, Head and Reconstructive Microsurgeon, Gleneagles Global Hospitals, Richmond Road, commented on the case, “A challenging case like a total mandible reconstruction with so many complexities is rare. In such cases, detailed planning is critical. We have technology and infrastructure aligned with global standards that are available at our disposal along with the expertise of a dedicated team of medical professionals at GGH. This allows us to successfully handle complex surgeries such as these.
