Subtotal midfacial/total nasal reconstruction following shotgun blast to the face employing composite microvascular serratus anterior rib, muscle, and scapular tip

A 40-year-old man presented with near-complete mid and lower facial destruction from a shotgun blast to the face. His midface was reconstructed with a serratus anterior muscle composite flap employing rib for nasal reconstruction and scapular tip for palate. Surfacing was done with split-thickness skin grafts. A temporoparietal scalp flap completed the upper lip reconstruction, and tubed, thick, split-thickness grafts supplemented with full-thickness grafts allowed airway reconstruction. Successful restoration of form and modest function were achieved with several surgeries. Our paper discusses the controversies and difficulties encountered in achieving autogenous tissue reconstruction of this devastating injury.