Introduction and Clinical Imperative 

Severe maxillofacial trauma resulting from firearm injuries is one of the most formidable challenges in reconstructive surgery, which often resulting in complex, multi-layered defects spanning bone, cartilage, and soft tissue. Its successful reconstruction demands not just the restoration of aesthetic facial contour but, critically, the re-establishment of vital functions such as mastication, deglutition, and visual acuity. Conventional methods frequently fall short in achieving precise anatomical restitution in these composite defects. This case report highlights an advanced, multi-disciplinary, multi-staged approach utilizing state-of-the-art reconstructive techniques, including patient specific implants and microsurgical flaps, to address a massive midfacial deformity following a high-velocity gunshot injury. The novelty of this approach lies in the orchestrated sequence of interventions designed to optimize both skeletal support and vascularized soft tissue coverage. 

Case Presentation and Initial Injury Assessment 

The patient is a 54-year-old male who presented to the surgical team seven months following a severe gunshot injury to the left side of his face, affecting the orbit and skull base regions. The initial ballistic trauma resulted in catastrophic destruction of the central midfacial complex. 

Upon presentation, the patient exhibited severe, chronic facial deformities, which included: 

• A profoundly depressed midface contour, causing significant aesthetic disfigurement. 

• A near-total collapse of the nasal bridge and adjoining structures. 

• A scarred left upper eyelid, indicating significant periorbital tissue loss and potential functional compromise. 

• A displaced right zygoma (cheekbone), disrupting the symmetry of the facial scaffold. 

• Total loss of the left maxilla (upper jawbone), leading to a massive bony defect. 

• A large oroantral communication on the right side, severely impairing oral competence, speech, and mastication. 

The seven-month delay between injury and definitive reconstructive surgery further complicated the case due to established scarring, contracture, and wound instability. The necessity for a composite, staged reconstruction—addressing bone, soft tissue, and function separately—was clear. 

Multi-Staged Reconstructive Strategy (Methods) 

The successful management of this complex case relied on a meticulously planned, multi-staged approach, integrating several specialized surgical and engineering disciplines. 

Stage 1: Virtual Surgery Planning and Custom Implant Fabrication 

The initial phase focused on restoring the foundational skeletal continuity and facial contour. Using high-resolution CT data, virtual surgical planning (VSP) was performed to accurately mirror the uninjured side and define the precise geometry of the missing osseous structures. Curewith3D fabricated a 3D printed custom titanium implant (PSI). This custom implant was designed to replace the large bony defects, especially in the orbital floor and zygomatic region, serving as the primary structural scaffold for the re-establishment of the correct facial projection and symmetry. 

Stage 2: Soft Tissue and Vascularized Lining 

Following the placement of the patient specific implant, the next crucial step was providing vascularized soft tissue coverage and a mucosal lining, particularly for the oroantral communication site. This was achieved using a radial forearm free flap (RFFF). The RFFF, known for its thin, pliable, and reliable vascularity, was harvested and transferred microsurgically to the midface defect. This provided the vital lining necessary to close the oroantral defect and stabilize the soft tissue envelope around the new skeletal construct. The flap ensured the longevity of the underlying patient specific implant and prevented secondary complications such as wound breakdown or implant exposure. 

Stage 3: Maxillary and Cartilaginous Reconstruction 

To address the critical deficit of the missing left maxilla and structural support for the nasal complex, a costochondral graft (rib cartilage and bone) was utilized. This autologous graft was shaped to reconstruct the load-bearing portion of the midface, providing living tissue with the potential for long-term integration and stability. This phase focused on rebuilding the alveolar ridge and providing structural support for the nasal bridge. 

Stage 4: Functional Restoration 

The final stage involved prosthodontic rehabilitation. Given the extensive loss of the maxilla and associated dentition, custom-made oral and dental prosthetics were fitted. This step was essential for restoring the patient’s ability to chew, speak clearly, and maintain oral hygiene, thereby ensuring the functional success of the entire surgical effort. 

Results and Clinical Discussion 

The composite reconstructive strategy achieved significant functional and aesthetic improvements. The 3D-printed patient specific implant was instrumental in providing an anatomically exact, stable base, successfully restoring the natural midfacial projection and symmetry, a result nearly impossible with standard plates and reconstruction bars. The successful radial forearm flap provided a durable, well-vascularized soft tissue coverage, leading to uneventful wound healing and closure of the persistent oroantral fistula. The integration of the costochondral graft contributed to the stability and bulk required for the missing maxilla, facilitating the final prosthodontic phase. 

At the final follow-up, the patient demonstrated: 

• A highly satisfactory aesthetic result with restored facial contour. 

• Resolution of the oroantral communication. 

• Re-established oral competence and significant improvement in mastication and speech, facilitated by the prosthodontic rehabilitation. 

This case serves as a powerful testament to the necessity of an individualized, multi-disciplinary approach in complex facial trauma. It validates the critical role of custom additive manufacturing (3D printing) in optimizing surgical outcomes by enabling precision and anatomical restoration that traditional reconstructive methods cannot match. The synergistic use of patient specific technology, vascularized soft tissue transfer, and autologous bone grafting provided a pathway to restoring both the form and function of the severely compromised maxillofacial complex. 

Conclusion 

The combined use of 3D printed patient-specific implants, radial forearm flaps, costochondral grafts, and sequential prosthodontic rehabilitation represents an effective, comprehensive, and phased strategy for managing massive gunshot-induced facial deformities. This case underscores the importance of technological integration and multi-disciplinary collaboration in achieving optimal long-term functional and aesthetic outcomes in complex trauma reconstruction. Further refinement of these digital planning and custom manufacturing techniques will undoubtedly guide future surgical protocols in the field of maxillofacial surgery.