Use of bilateral folded radial forearm free flaps for reconstruction of a midface gunshot wound.

Optimal treatment of midfacial gunshot wounds includes early definitive reconstruction of the bony scaffold to prevent soft tissue contraction. When this is not possible, secondary reconstruction is more difficult. The authors present a case of delayed reconstruction of a midface gunshot wound. Two months following a self-inflicted, submental gunshot wound and eventual rigid fixation of the remaining midfacial bony anatomy, two simultaneous radial forearm free flaps were utilized in the reconstruction. The first flap was folded onto itself to recreate the hard palate in conjunction with a split rib graft; the second flap filled the remaining soft-tissue defect and simultaneously provided lining for an eventual staged nasal reconstruction. The second stage of the nasal reconstruction was completed 5 weeks later with a calvarial bone graft and forehead flap. This dual microsurgical approach allowed for one-step reconstruction of both surfaces of the hard palate, resulting in separate oral and nasal cavities, and optimizing the patient's ability to speak and eat. Extensive soft-tissue contraction encountered in late reconstructions underscores the importance of an early, definitive, surgical approach in these difficult wounds.