Survival and infection rates of microvascular free flaps in pediatric mandibular reconstruction: A systematic review and meta-analysis

BACKGROUND

Vascularized free tissue transfer has been established as an effective method in the reconstruction of mandibular defects. However, a limited understanding of its efficacy in pediatric patients persists due to its infrequent presentation. The aim of this study is to systematically consolidate the survival and infection rates of free flaps in pediatric mandibular reconstruction.

METHODS

A systematic literature search was conducted on Ovid Medline, Embase, and Cochrane Library for studies published up to January 2024. We included peer-reviewed studies reporting on survival and infection outcomes associated with free flap mandibular reconstruction in pediatric patients (<18 years). We performed a random-effects meta-analysis with the inverse-variance weighted approach to estimate survival and infection rates. Heterogeneity was assessed by I2, and publication bias was examined using Egger's test.

RESULTS

A total of 26 studies, reporting on 463 free flaps and 439 pediatric patients with a mean age of 10.7 years, were included in our study. Most free flaps originated from the fibula (n = 392/463, 84.7%) and benign tumors were the most common cause for mandibular reconstruction (n = 179/463, 38.7%). The pooled estimate for survival of flaps was 96% (95% CI: 93-97, I2 = 0%), and recipient-site infections were estimated to occur in 9% (95% CI: 6-13, I2 = 0%) of cases. The most common reported complications within the study timeframe were early malocclusion (n = 28/123, 21.4%) and bite abnormalities (18/131, 13.7%).

CONCLUSION

Free tissue transfer for mandibular reconstruction in pediatric patients is effective and safe. Further research is required to explore functionality following mandibular reconstruction in diverse pediatric populations.

Does Free Fibular Flap Reconstruction Affect the Quality of Life in Pediatric Patients With Various Extend of Mandible Defects?

BACKGROUND

The long-term outcomes in pediatric patients with various extents of mandible defects have not been well-documented.

METHODS

A retrospective case series in which this study looked at pediatric patients under the age of 13 who had mandibular reconstruction with free fibular flap and had not received another operation in the previous 6 months. The eating, swallowing, speech function, and quality of life are evaluated with EORTC QLQ-H&N35 after the mandible growth spurt has occurred.

RESULTS

A total of 7 patients were included in this study with operation ages ranging from 6 years 1 month to 12 years 2 months. The etiology of malignant tumors was found in 2 patients and benign tumors in 5 patients. The mandibular defect distribution consists of 1 class Ic, 1 class II, 2 class IIc, 2 class III, and 1 class IVc. All patients reported no swallowing or speech difficulties. However, transient eating trouble was seen in 1 patient due to the extensive defect size that causes tooth loss. Only 1 patient received dental rehabilitation. The patients displayed an overall good quality of life with an average score of 2.857.

CONCLUSIONS

Free fibular flap for mandibular reconstruction in children who have not reached their mandibular growth peak have a satisfying outcome, both in their function and quality of life.

Long-Term Outcomes after Pediatric Mandibular Reconstruction Using Vascularized Free Fibula Flap

BACKGROUND

The purpose of this study was to evaluate the long-term outcomes of mandibular reconstruction with vascularized free fibula flap in pediatric patients.

METHODS

Consecutive cases of mandibular reconstruction with vascularized free fibula flaps in pediatric patients at Peking University School and Hospital of Stomatology between 1999 and 2019 were reviewed. Postoperative computed tomography (CT) data of all patients were collected at each postoperative follow-up point, and after the age of 18 years. The length and height of the grafted fibula and the length of the remaining mandible were evaluated by measuring the three-dimensional CT data using ProPlan CMF 3.0 software. Lower limb function was evaluated using the Enneking evaluation scale. Facial symmetry was self-evaluated and scored. Statistical analysis was performed on the data obtained.

RESULTS

Fourteen patients were included in this study. All flaps were successful. The CT measurement results showed growth in the length of the grafted fibula that reconstructed the mandibular ramus and the residual mandible ( P < 0.05). The height of the grafted fibula remained stable ( P > 0.05). Eight patients were followed up until they were older than 18 years, and the CT measurement results after 18 years showed an essentially symmetric mandible profile ( P > 0.05). All patients were satisfied with their postoperative facial symmetry. Enneking evaluation scores showed good recovery of lower limb functions.

CONCLUSIONS

The vascularized free fibula flap for mandibular reconstruction in pediatric patients is safe and reliable. It also provides good cosmetic and functional outcomes, as it demonstrated positive growth.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Symmetrical Midfacial Growth After Pediatric Mandibular Reconstruction With Free Fibula Flap

BACKGROUND

Free fibula is the workhorse flap for mandibular reconstruction and is increasingly being used in pediatric patients. However, craniomaxillofacial growth and development involve interdependent processes, and it remains unknown whether mandibular reconstruction with free fibula allows symmetric growth of the midface.

PURPOSE

The study evaluated midfacial symmetry after pediatric mandibular defect reconstruction.

STUDY DESIGN, SETTING, SAMPLE

This retrospective cohort study included pediatric patients aged ≤14 years who underwent mandibular reconstruction with free fibula flap. Postoperative computed tomography data were obtained at predefined follow-up time points. Midfacial symmetry was evaluated based on 3-dimensional (3D) cephalometry.

PREDICTOR VARIABLE

The predictor variable was the side of the midface (affected or healthy side relative to the mandibular defect).

MAIN OUTCOME VARIABLES

The primary outcome variable was postoperative midfacial symmetry (at 1 week, 6 months, 1 year, 2 years, and >3 years, or after the age of 18 years), assessed in horizontal, vertical, and anteroposterior dimensions using 3D cephalometry. Another outcome variable was patient satisfaction based on a self-evaluation using visual analog scoring.

COVARIATES

Sex, age, diagnosis, and type of denture restoration.

ANALYSES

Paired t tests were performed to assess the relationship between the predictor and outcome variables, with the significance level of P < .05.

RESULTS

A total of 13 patients were included in this study (9 males and 4 females; mean age: 12.23 ± 2.39 years). The average distance from upper first molar point (U6) to the horizontal plane on the affected side became greater than on the healthy side (difference: 0.7 ± 0.5 mm to 1.6 ± 1.4 mm, P < .05), while the average distance from pterygomaxillary fissure to coronal plane on affected side became shorter than that on the healthy side (difference: 0.6 ± 0.6 mm to 1.2 ± 1.1 mm, P < .05) from 1 year after the surgery. There were no statistically significant differences in the remaining measurements between the 2 sides (P > .05). All the patients were satisfied with their postoperative facial symmetry.

CONCLUSIONS AND RELEVANCE

There were no severe midface deformities after pediatric mandibular reconstruction with free fibula flap. Meanwhile, pediatric mandibular reconstruction and proper occlusion could promote midfacial growth and symmetry.

Pediatric Craniofacial Tumor Reconstruction

Effective management of pediatric craniofacial tumors requires coordinated input from medical, oncologic, and surgical specialties. Reconstructive algorithms must consider limitations in pediatric donor tissue and account for future growth and development. Immediate reconstruction is often focused on filling dead space, protecting underlying structures, and ensuring skeletal symmetry. Staged reconstruction occurs after the patient has reached skeletal maturity and is focused on restoring permanent dentition. Reconstructive options vary depending on the location, size, and composition of resected tissue. Virtual surgical planning (VSP) reduces the complexity of pediatric craniofacial reconstruction and ensures more predictable outcomes.

Flow through fibula and fasciocutaneous free flaps in oromandibular reconstruction

INTRODUCTION

The osteocutaneous fibula is a workhorse flap for oromandibular reconstruction. Skin paddles not only perform soft tissue reconstruction but also serve as a monitor for the fibula. In cases where the skin paddle cannot be harvested as desired due to variations, two challenges arise, such as fibula follow-up and the need for a second free flap so recipient. Moreover, there may not be enough recipient vessels for the double flaps in the neck. This report aimed to address the difficulties mentioned above with the use of flow-through free flaps in composite oromandibular reconstructions.

PATIENTS AND METHODS

Between 2019 and 2021, five (three Female, two Male) patients underwent flow-through technique as free fibula and fasciocutaneous flaps due to variations in fibular skin paddle or insufficiency of recipient vessels in the neck. Ages of patients were between 45 and 75 years. Four patients underwent surgery for tumor and one patient for the result of radionecrosis. ALT, chimeric ALT, and RFFF were selected as second free flaps.

RESULTS

The size of the fasciocutaneous flaps ranged from 6 × 4 cm to 14 × 11 cm. Mandibular defects ranged from 6 to 16 cm. 1 venous occlusion occurred post-op 1st day and was salvaged. One hematoma and one wound dehiscence occurred postoperatively and were salvaged successfully. One Partial tongue necrosis occurred due to previous radiotherapy and additional tumor surgery. No additional complication occurred. All flaps survived. Follow-up period was between 3 months and 2 years. Patient who had tongue necrosis experienced swallowing and speech difficulty and Percutaneous endoscopic gastrostomy tube was placed post-operative 2 months. Functional finale outcomes were successful for other patients.

CONCLUSION

Flow-through technique provides fibula monitoring with avoiding to find second recipient. Customizing free flaps under more favorable conditions as on the operation table before fixation of the bone can be a useful approach.

Post-operative Outcomes in Pediatric Patients Following Facial Reconstruction With Fibula Free Flaps

EDUCATIONAL OBJECTIVE

Assess outcomes of pediatric facial reconstruction with fibula free flaps.

OBJECTIVES

Free flap reconstruction of complex maxillofacial defects in pediatric patients is rare. Post-operative complications, donor site morbidity, impact on craniofacial growth, and oro-dental rehabilitation are unknown. Our study assesses the outcomes of pediatric maxillofacial reconstruction with composite fibula free flaps.

STUDY DESIGN

Retrospective chart review.

METHODS

Multi-institutional retrospective chart review from 2000 to 2020 on pediatric patients undergoing maxillomandibular reconstruction with fibula free flaps.

RESULTS

Eighty-seven patients underwent 89 surgeries; 5 maxillary and 84 mandibular defects. Median age: 12 years. Defects were acquired following resection of sarcoma/carcinoma 44% or benign tumors 50%. 73% of cases had immediate free flap reconstruction. Closing osteotomies were reported in 74%; 1 in 40%, 2 in 27%, and more than 2 in 6.7%. Hardware was used in 98% and removed in 25%. 9.2% demonstrated long-term hardware exposure, greater than 3 months following reconstruction. Short-term complications: wound infection 6.7%, flap salvage/failure 2.2%, fistula 1.1%, and compromised craniofacial growth: 23%. Two patients developed trismus. Long-term fibula donor site complications: hypertrophic scarring: 3.4%, dysesthesia: 1.1%, and long-term gait abnormality: 1.1%. Dental rehabilitation was performed in 33%. Post-operative speech outcomes showed 94% with fully intelligible speech.

CONCLUSION

Pediatric maxillary and mandible defects repaired with fibula free flaps demonstrated complication rates comparable to the adult free flap population. Long-term follow-up did not demonstrate adverse outcomes for craniofacial growth. Hardware for flap retention was utilized and remained in place with minimal exposure. Post-operative gait abnormality is rare.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:302-306, 2023.

Use of a Fibula Free Flap for Mandibular Reconstruction in Severe Craniofacial Microsomia in Children with Obstructive Sleep Apnea

This is a retrospective study describing a multi-stage protocol for the management of severe mandibular hypoplasia in craniofacial microsomia (CFM) with accompanying obstructive sleep apnea (OSA). Patients with severe mandibular hypoplasia require reconstruction functionality and esthetical features. In the cohort, reconstructions based on free fibular flaps (FFF) may be the most effective way. Patients aged 4-17 years with severe mandibular hypoplasia were treated with FFF, which initially improved the respiratory function assessed on polysomnography (AHI). In the next stages of treatment of cases with respiratory deterioration, it was indicated to perform distraction osteogenesis (DO) of the mandible and the structures reconstructed with FFF. All surgeries were planned in accordance with virtual surgery planning VSP. The aim of the study was to prospectively assess the effectiveness of multi-stage mandibular reconstruction in craniofacial microsomia with the use of a free fibula flap in terms of improving respiratory failure due to obstructive sleep apnea (OSA). The FFF reconstruction method, performed with virtual surgical planning (VSP), is proving to be an effective alternative to traditional methods of mandibular reconstruction in patients with severe CFM with OSA.

Long-Term Update: Free Fibula Flap Growth After Pediatric Mandibular Reconstruction

A free fibular flap is commonly used in adult mandibular reconstruction; however, its use in the pediatric population is not strongly supported. The authors are reporting the long-term update of a case of a pediatric patient who underwent a mandibular reconstruction using a free fibular flap after a resection of mandibular desmoid fibromatosis. Greatest growth was objectively measured and demonstrated at the condyle using a 3-dimensional model generated from Materialise software. This is 1 case and subsequent studies should be observed to further elucidate the full growth potential of the mandible in pediatric patients undergoing mandibular reconstruction.

Long-term Growth, Functional, and Aesthetic Outcomes after Fibula Free Flap Reconstruction for Mandibulectomy Performed in Children

Background:

The long-term outcome of mandible reconstruction when performed in children has not been well documented.

Methods:

This is a retrospective case series of patients who underwent immediate oncologic mandible reconstruction with a fibula free flap at younger than 18 years of age over a 20-year period, by a single surgeon, who had long-term follow-up.

Results:

A total of 10 patients met inclusion criteria. Patient age ranged from 3 years and 8 months to 17 years and 9 months (mean 11 years). The etiology was malignant tumors in seven patients and benign locally aggressive tumors in three patients. All fibula flaps survived. All donor sites were closed primarily. The mean follow-up duration was 10 years and 5 months (range 3–20 years). The mean patient age at follow-up was 21 years and 10 months (range 8 years and 9 months to 30 years and 9 months). All patients achieved a regular diet and normal speech. Final occlusion was normal in seven of 10 patients. The aesthetic outcome, as evaluated by clinical examination, was a symmetric mandible in eight patients (in the other two the aesthetic asymmetry and malocclusion was minor and did not require operative intervention). Dental implants were ultimately placed in three patients. Leg function was normal in eight patients. Achilles lengthening and tendon transfer was required in one patient, and one patient developed ankle pain associated with running.

Conclusion:

Mandible reconstruction in children with the fibula free flap provides excellent aesthetic and functional outcomes that are durable over time.

"Systematic Review and Guidelines for Perioperative Management of Pediatric Patients Undergoing Major Plastic Surgery Procedures, With a Focus on Free Tissue Transfer."

BACKGROUND

Microsurgical free tissue transfer has been successfully implemented for various reconstructive applications in children. The goal of this study was to identify the best available evidence on perioperative management of pediatric patients undergoing free tissue transfer, and use it to develop evidence-based care guidelines.

METHODS

A systematic review was conducted in Pubmed, Embase, Scopus, and Cochrane Library databases. Since a preliminary search of the pediatric microsurgical literature yielded scant data with low level of evidence (LOE), pediatric anesthesia guidelines for healthy children undergoing major surgeries were also included. Exclusion criteria included: vague descriptions of perioperative care, case reports, and studies of syndromic or chronically ill children.

RESULTS

204 articles were identified, and 53 met inclusion criteria. Management approaches specific to the pediatric population were used to formulate recommendations. High quality data was found for anesthesia, analgesia, fluid administration / blood transfusion, and anticoagulation (LOE 1). Lower quality evidence was identified for patient temperature (LOE 3) and vasodilator use (LOE 4). Key recommendations include: administering sevoflurane for general anesthesia, implementing a multimodal analgesia strategy, limiting preoperative fasting, restricting blood transfusions until hemoglobin < 7 g/dl unless patient is symptomatic, and reserving chemical venous thromboembolism prophylaxis for high risk patients.

CONCLUSIONS

Pediatric-specific guidelines are important as they acknowledge physiologic differences in children, which may be overlooked when extrapolating from adult studies. These evidence-based recommendations are a key first step toward standardization of perioperative care of pediatric patients undergoing plastic surgical procedures, including free tissue transfer, to improve outcomes and minimize complications.

Outcomes in Pediatric Maxillofacial Reconstruction With Vascularized Fibular Flaps: A Systematic Review

BACKGROUND

The purpose of this study was to examine the complications and outcomes after maxillofacial reconstruction using the free fibular flap in the pediatric population.

METHODS

A systematic review and descriptive analysis were conducted using data variables, including study characteristics; patient characteristics; postoperative complications (major and minor); surgical revision; and dental rehabilitation.

RESULTS

The systematic review resulted in 1622 articles, 55 of which met inclusion criteria for this study. The 55 articles consisted of 17 case series and 38 case reports with level III/IV and level V of evidence, respectively. Of the 155 identified pediatric patients, the rate of major complications was 13.5% and minor complications was 24.5%. The most common complication was mild growth distortion (n = 7) at the recipient site. Complications at the donor site were less common. During follow-up, 29 patients (18.7%) underwent or awaited surgical revision, and 43 patients (27.7%) underwent or awaited dental rehabilitation.

CONCLUSIONS

Our study suggests that the free fibular flap for pediatric maxillofacial reconstruction is safe and reliable. Additionally, surgical revision to correct the functional impairments resulting from primary reconstruction using the free fibular flap is relatively common.

Pediatric Mandibular Reconstruction Using the Vascularized Fibula Free Flap: Functional Outcomes in 34 Consecutive Patients

BACKGROUND

The vascularized fibula free flap is a workhorse flap in pediatric mandibular reconstruction. This study aimed to address functional outcomes, complications, and morbidity associated with the fibula resection in a consecutive series of mandibular reconstruction using this technique in skeletally immature patients.

METHODS

Functional outcomes in terms of maximal mouth opening capacity, patient-reported eating ability, occlusion, and gait were retrospectively reviewed in 34 consecutive pediatric patients (18 males, 16 females) who underwent mandibular reconstruction using the vascularized free fibula flap. Data regarding donor and recipient site complications were also retrieved.

RESULTS

The mean follow-up period was 50.6 months (range, 12-108 months). The average age was 10.3 years (range, 2-15 years). Underlying pathologies included ossifying fibroma, ameloblastoma, mandibular arteriovenous malformation, fibrous dysplasia, Goldenhar syndrome, dentigerous cyst, mandibular lymphoma, odontogenic fibroma, adenomatoid odontogenic tumor, aneurysmal bone cyst, neurogenic sarcoma, and central giant cell granuloma. Defect length ranged from 8 to 17 cm. Mean return to normal ambulation was achieved 12 days postoperatively. All patients reported ability to eat solids and liquids, with 29 of 34 achieving normal mouth opening. Normal or minimally disturbed occlusion was maintained postoperatively in most patients. Temporomandibular joint ankylosis and condylar displacement were each developed in one patient. Two patients reported gait disturbances that receded after physical therapy. No other major donor site complications, including flexion contracture of the great toe, were identified.

CONCLUSIONS

The vascularized fibula free flap is reaffirmed to be the criterion standard for mandible reconstruction in pediatric patients, providing satisfactory functional results and adequate adaptation to the growing facial skeleton with minimal sequelae. Complications regarding hallux function may be prevented by assessing the vascularity of the flexor hallucis longus intraoperatively and ensuring tension-free closure of the donor site.

Unique Techniques Utilizing Rib Grafts for Mandibular Reconstruction in the Pediatric Population

INTRODUCTION

Pediatric mandibular reconstruction requires a grafted segment of sufficient height and stability to support dental implant placement. Double barreling and mandibular distraction osteogenesis (MDO) after reconstruction are two techniques to achieve this, but they have only been reported with fibular grafts. Rib grafts not only have a lower donor site morbidity than fibular grafts, but they also provide adequate defect coverage in children. As such, we propose their use with either a double barrel technique or with MDO.

METHODS

Three pediatric patients underwent mandibular resection and reconstruction using rib grafting. One patient underwent single rib graft placement with subsequent vertical rib distraction. In the remaining two patients, a double-barreled rib technique was used, stacked horizontally in one patient and vertically in the other.

RESULTS

From March 2018 to May 2019, three patients with an average age of 11 underwent resection of mandibular tumors or tumor-like lesions followed by immediate reconstruction with rib graft. Due to postoperative wound complications, the graft was completely removed in one patient. The remaining two patients had an uneventful recovery with dental implants planned for one and fully osseointegrated in the other. None of the patients experienced donor-site complications.

CONCLUSION

This case series supports the utility and versatility of autogenous rib grafts as a reconstructive option in children. Not only is rib an excellent bone source with low donor site morbidity, but its height can be augmented through MDO or double barreling, facilitating the successful placement of implants and oral rehabilitation in pediatric patients.

Objectifying growth of vascularized bone transfers after mandibular reconstruction in the pediatric population

BACKGROUND

Autologous vascularized bone transfer is the preferred strategy for the reconstruction of mandibular defects in a pediatric population. The principal argument is the theoretical postoperative growth potential of the neomandible, which uses vascularized donor tissues.

OBJECTIVES

The purpose of this study was to objectify the veritable growth potential of vascularized bone transfers in children.

METHODS

A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, revealing 57 patients younger than or equal to 18 years who had undergone a mandibular reconstruction with a vascularized free flap. Only studies using postoperative imaging were included. Outcomes regarding growth and postoperative corrections and complications were analyzed.

RESULTS

Neomandibular growth was observed in 63.2% of all included patients. The proportion of growth was higher in patients with condylar preservation (95.7%) than that of patients with condylar involvement (41.2%). Reconstruction of the condyle by a free flap, which includes an epiphyseal growth plate or cartilage increased postoperative growth potential (77.8%) but did not reduce the need for later orthognathic surgery.

CONCLUSION

After mandibular reconstruction with a vascularized bone transfer, the majority of pediatric patients shows neomandibular growth. Condylar preservation, the inclusion of epiphyseal growth plates or cartilage, and the patients age at the time of reconstruction are essential defining parameters.

[Dental rehabilitation in the complex treatment of children and adolescents with maxillofacial neoplasms]

THE PURPOSE

Of the study was to improve algorithms and methods of complex dental rehabilitation of children and adolescents with maxillofacial neoplasms.

MATERIALS AND METHODS

Sixty-seven patients aged from 2 to 17 years (average age 10.43±4.56; 30 boys, 37 girls) underwent complex rehabilitation as a part of neoplasm treatment (40 benign, 27 malignant). Patients were divided into 3 groups: group 1 aged 2 to 7 years; group 2 aged 8 to 12 years; group 3 aged 13 to 17 years.

RESULTS

Structural integrity of upper and lower jaws was reconstructed using vascularized bone flaps (27 cases), non-vascularized bone flaps (5 cases), titanium reconstructive plates (11 cases) or individual titanium endoprostheses of the temporomandibular joint (2 cases). Orthodontic, orthopedic and surgical dental treatment was performed at all stages of rehabilitation of patients and had its own characteristics depending on the group affiliation.

CONCLUSION

Algorithms for dental rehabilitation of children and adolescents with maxillofacial neoplasms have been improved on the base of performed treatment.

Pediatric Mandible Reconstruction: Controversies and Considerations

Mandibular reconstruction in pediatric patients has some unique considerations. The method of reconstruction has to factor in the growth potential of the neo-mandible, the native mandible, and the donor site. The condyle is considered the main growth center of the mandible. Current literature indicates that fibula, iliac crest, and scapula osseous flaps do not have the ability to grow. Costochondral grafts exhibit growth because of the costal cartilage component, although the growth is unpredictable. Preservation of the mandibular periosteum can result in spontaneous bone regeneration. Fibula bone harvest in a child mandates close follow-up till skeletal maturity, to monitor for ankle instability and valgus deformity. Dental rehabilitation maintains occlusal relationships, which promotes normal maxillary development. Elective hardware removal should be considered to facilitate future dental implant placement and possible revision procedures. After completion of growth, if occlusion or symmetry is not satisfactory, secondary procedures can be performed, including distraction osteogenesis, orthognathic-type bone sliding operations, and segmental ostectomy.

Outcomes following Microvascular Mandibular Reconstruction in Pediatric Patients and Young Adults

Background:

The etiology and treatment of complex mandibular defects in children differ markedly from those of adults, although treatment with free bone flaps is historical in both groups. While adult outcomes and complication rates are well known, few pediatric data exist, especially for patients with congenital deficiencies. This study reports early and late outcomes from a cohort of young, primarily syndromic patients undergoing microvascular mandibular reconstruction.

Methods:

This is a retrospective case series of patients who underwent microvascular mandibular reconstruction between 1995 and 2016.

Results:

Thirteen patients received a total of 13 fibula transfers and 1 medial femoral condyle transfer. Most patients carried a congenital diagnosis (77%), and the average age during surgery was 11.7 ± 5.7 years. The median (interquartile range) [IQR] length of follow-up was 6.3 (5.7) years. There was a 100% flap survival rate, although 86% of all patients experienced at least one complication. Half of all procedures resulted in an early complication. Nine patients (69%) developed late complications, of which temporal mandibular joint ankylosis was the most common (n = 5; 38%).

Conclusions:

This study is one of few detailing outcomes following mandibular reconstruction by free flap transfer in pediatric patients. These patients were primarily syndromic with appreciable complication rates higher than in other adult and pediatric studies. Some complications are manageable or self-resolving, but others lead to functional problems that may require late operative interventions to correct. Microsurgical treatment should be reserved for children with large, complex mandibular defects when other options are unavailable or have been exhausted.

Free flap transfers for head and neck and skull base reconstruction in children and adolescents - Early and late outcomes

OBJECTIVES

Reconstruction of surgical defects by free tissue transfer following resection of head and neck tumors in children are sparse. This study aims to assess the feasibility and safety of free flap reconstruction following surgical ablation of head and neck and skull base tumors in children based on our experience and the recent literature.

METHODS

Data from medical files of all children and adolescents <18 years of age who underwent free flap reconstruction following resection of head and neck and skull base tumors at our tertiary center between 2000 and 2018 were retrospectively reviewed. Data on early and late complications at the primary and donor sites, functional and aesthetic outcome, and tumor control were analyzed.

RESULTS

Twenty-four children (mean age 11.3 ± 5.1 years) were enrolled. Early complications occurred in 14 (56%) and late complications occurred in 8 (32%) of the procedures, with surgical intervention required in 4 (16%). Prior chemoradiation, sarcoma, non-reanimation procedures, and the use of rectus abdominis free flaps were associated with higher complication rates. The final functional and cosmetic outcomes, including mastication, deglutition, and speech, were satisfactory in all patients with one exception.

CONCLUSIONS

Free flap transfer is a safe and feasible technique for reconstructing head and neck and skull base defects following surgical excision of tumors in children. Early identification and precautionary measures against the effects of potential causes of complications may improve outcome. Larger international cohort studies are warranted.

Quantifying Free Fibula Flap Growth After Pediatric Mandibular Reconstruction

INTRODUCTION

The free fibula flap (FFF) is a preferred option for adult mandibular reconstruction. Due to skeletal immaturity, its routine use in pediatric patients remains in question. Inconsistencies regarding the ability of the FFF to grow in concordance with the patients' natural growth currently exist in the literature. The purpose of this report is to quantify mandibular growth in a young patient undergoing partial hemi-mandibular reconstruction with a FFF utilizing advanced three-dimensional software.

METHODS

A 2-year old underwent left hemi-mandibular reconstruction with a FFF following resection of a desmoid tumor. The condyle was preserved. Using 3D software, changes in mandibular growth and morphology were evaluated based on preoperative (2.1 years old) and postoperative (2.5 years and 5.2 years old) computed tomography imaging.

RESULTS

Mandibular growth occurred throughout the mandible in both postoperative evaluations. Greatest growth was seen in the ramus height. Fibula growth was also seen when comparing measurements to the virtual surgical planning guide. A novel parts comparison analysis revealed the greatest growth potential occurred at the condyle.

CONCLUSION

Providing an objective evaluation using 3D software, we have demonstrated growth throughout the reconstructed mandible, with greatest growth occurring at the preserved condyle. Despite scientific limitations of our study, the potential for mandibular growth appears to remain after FFF reconstruction, offering successful functional and cosmetic outcomes.

Temporomandibular disorders in head and neck cancers: Overview of specific mechanisms and management

Diagnosis classification system of Temporomandibular disorders (TMD) is based on the biopsychosocial model of pain. The pathogenesis is poorly understood, leading to difficulties in treating these multifactorial conditions. The predisposing factors are pathophysiological, psychological or structural processes that alter the masticatory system and lead to an increase in the risk of development of TMD. The purpose of this integrative review was then to point out the specific mechanisms of TMD in the oral oncologic context to optimize the TMJ functional results in the management of patients with oral oncologic conditions. We explored in this paper the role of Axis II assessment of the biopsychosocial model of pain, the involvement of mechanical concepts such as dental occlusion, mandibular condyle positioning and related-structures reconstruction, and the stomatognathic changes induced by radiation.

Considerations for Mandibular Reconstruction in the Pediatric Patient Following Resection of Malignant Tumors

We recently achieved favorable results in 3 pediatric patients with mandibular osteosarcomas that were treated at our hospital, including with immediate reconstructive surgery performed after tumor resection. Based on a literature review and practical investigation, we discuss the considerations for mandibular reconstruction after malignant lesions are removed from the mandible in children. Mandibular reconstruction for pediatric patients requires an understanding of the changes in bone and soft-tissue architecture due to growth and development at both the donor and recipient sites. Immediate mandibular reconstruction with a free flap can be considered a reasonable option even for young children who require extensive mandibular surgery. However, the variables affecting decisions about treatment planning vary between the different conditions in individual patients, and moreover, these cases are not common in the pediatric population. Therefore, long-term follow-up treatment and further investigations are required for the optimized diagnosis, treatment, and prognosis of pediatric mandibular malignancies.

Mandibular Reconstruction for Pediatric Patients

: Mandibular reconstruction in pediatric patients is controversial. The scant pediatric experience and the infrequent occurrence of this type of pathology in children complicate therapeutic decisions. The literature contains different treatment protocols and describes the bone graft alternatives to be used.

MATERIALS AND METHOD

This is a retrospective review of patients under the age of 15 who were subjected to resection and reconstruction.

RESULTS

A total of 18 patients were included in the study: 8 women and 10 men. The age on the date of diagnosis ranged from 2 years to 13 years and the average was 7 years. Five patients underwent resective surgery for a malign pathology, 7 for a benign pathology, 4 for aggressive lesions of odontogenic origin, and 1for the effects of a fracture that was complicated by osteomyelitis.

CONCLUSIONS

In conclusion, treating pediatric patients with tumor pathology requires an experience pediatric team to get good outcomes. Surgeons must consider that pediatric patients are in constant growth and development but that must not be an issue in resection and reconstruction decisions. Literature review shows that, as in adults, free flaps seem to be the criterion standard for big resections in mandibles defects, and are safe to use in pediatric patients.

Free flaps for head and neck cancer in paediatric and neonatal patients

PURPOSE OF REVIEW

To review recent literature on the subject of free tissue transfer options in paediatric head and neck surgery, with a particular emphasis on highlighting the advantages and disadvantages of different reconstructions in the paediatric patient.

RECENT FINDINGS

Free tissue transfer in paediatric patients is predictable and applicable for a wide range of congenital and acquired defects in the head and neck. The free fibula flap is a mainstay of mandibular reconstruction and allows excellent implant-supported prosthodontic rehabilitation and growth potential at the recipient site with little or no donor site morbidity. Other less commonly explored options include the deep circumflex iliac artery flap, scapula flap and medial femoral condyle flap. The gracilis mucle remains the mainstay for facial reanimation with other options including pectoralis minor, rectus abdominis, extensor digitorum brevis and latissimus dorsi. There are compelling arguments for centralization of services and creative strategies in postoperative rehabilitation (e.g. play therapy).

SUMMARY

Free flaps in paediatric patients are a viable option and may even have advantages relative to adults because of the absence of atherosclerosis, purported lower risk of vasospasm and proportionally larger vessel size. Transfer earlier in life maximizes functional potential and 'normalizes' treatment.

Temporomandibular Joint Reconstruction in the Growing Child

Indications and considerations for reconstruction of the temporomandibular joint (TMJ) differ between growing and skeletally mature patients. Osteoarthritis, which is the most common cause of TMJ destruction in adults, is comparatively rare in children. The most common indications in young patients are congenital deformities, pathology, ankylosis and progressive resorptive processes. Options for reconstruction include distraction osteogenesis, autologous reconstruction (ie, costochondral graft, free fibula flap), and total alloplastic joint replacement. The choice of the ideal reconstruction is based on multiple factors, which include extent and laterality of the deformity, patient age, jaw growth pattern, and potential for progressive destruction.

Use of three-dimensional, CAD/CAM-assisted, virtual surgical simulation and planning in the pediatric craniofacial population

OBJECTIVE

Virtual Surgical Planning (VSP) and computer-aided design/computer-aided manufacturing (CAD/CAM) have recently helped improve efficiency and accuracy in many different craniofacial surgeries. Research has mainly focused on the use in the adult population with the exception of the use for mandibular distractions and cranial vault remodeling in the pediatric population. This study aims to elucidate the role of VSP and CAD/CAM in complex pediatric craniofacial cases by exploring its use in the correction of midface hypoplasia, orbital dystopia, mandibular reconstruction, and posterior cranial vault expansion.

METHOD/DESCRIPTION

A retrospective analysis of thirteen patients who underwent 3d, CAD/CAM- assisted preoperative surgical planning between 2012 and 2016 was performed. All CAD/CAM assisted surgical planning was done in conjunction with a third party vendor (either 3D Systems or Materialise). Cutting and positioning guides as well as models were produced based on the virtual plan. Surgeries included free fibula mandible reconstruction (n = 4), lefort I osteotomy and distraction (n = 2), lefort II osteotomy with monobloc distraction (n = 1), expansion of the posterior vault for correction of chiari malformation (n = 3), and secondary orbital and midface reconstruction for facial trauma (n = 3). The patient's age, diagnosis, previous surgeries, length of operating time, complications, and post-surgery satisfaction were determined.

RESULTS

In all cases we found presurgical planning was helpful to improve accuracy and significantly decrease intra-operative time. In cases where distraction was used, the planned and actual vectors were found to be accurate with excellent clinical outcomes. There were no complications except for one patient who experienced a wound infection post-operatively which did not alter the ultimate reconstruction. All patients experienced high satisfaction with their outcomes and excellent subjective aesthetic results were achieved.

CONCLUSIONS

Preoperative planning using CAD/CAM and VSP allows for safe and precise craniofacial reconstruction in complex pediatric cases with a reduction of operative time.

Simultaneous Autologus Mandible and Temporomandibular Joint Reconstruction

Ablative surgery of mandible often necessitates combined reconstruction of the mandible and the temporomandibular joint. Fibula-free flaps with gap arthroplasty or osseochondral grafts are common procedures in the authors' practice. In search for a better reconstructive option free fibula flap is used together with a metatarsal bone flap for the vascular reconstruction of the mandibular body and the condyle at the same time. The 2 osseous-free flaps have been fused and used as a combined flow through double-free flap. The literature has been reviewed for other reconstructive options, but no alternatives providing autologous reconstruction of both the mandible and the condyle with vascular tissue have been found. This is a preliminary report of this new technique which the authors humbly think is very promising.

Bone Allograft Segment Covered with a Vascularized Fibular Periosteal Flap: A New Technique for Pediatric Mandibular Reconstruction

The free vascularized fibular graft is nowadays the preferred technique for pediatric mandibular reconstruction. Despite the versatility and proven efficacy for restoring the facial appearance and maxillomandibular function, those mandibular reconstructions with free vascularized fibula associate difficulties for a simultaneous restoration of the alveolar height and facial contour, which are derived from the height discrepancy between the fibula and the native mandible. In addition, the donor-site growth and morbidity are of special concern in the pediatric patient. We report a novel technique for pediatric mandibular reconstruction, in an 11-year-old girl, using a combination of a bone allograft segment with a vascularized fibular periosteal flap (VFPF), after resection of an Ewing sarcoma located at the right body of the mandible. The patient has showed optimal cosmetic, functional, and radiological outcomes, which have been maintained for 2.5 years, without detecting donor-site complications. Through this original technique, and based on the powerful osteogenic and vasculogenic properties of the pediatric VFPFs, we could effectively reconstruct a large mandibular defect providing a functional and aesthetic reconstruction, while avoiding the potential morbidity associated with the fibula resection.

[Complex carcinological head and neck reconstruction in pediatric surgery]

Head and neck reconstruction in pediatric oncology, even if it is based on adult experience, presents important characteristics including age-related growth, the type of tumor and donor sites features. Indications of free flaps are rare but required care that should be codified, taking into account the details specific to context, and not giving place for improvisation as it is important that surgical outcomes must be as simple as possible. The objective of this article is not to present the technical details of free flaps harvesting in children because it is what is certainly the least different with adults. The aim is to share our experience of the specificities and singularities of pediatric head and neck reconstruction in order to focus attention to everything that makes this surgery demanding. We present the most common indications, the types of free flaps used for reconstruction, facial location modalities of reconstruction and the perioperative management.

Evaluation of the Effects of Bile on the Arterial Tonus in a Rabbit Model

Background:

Hepatic artery anastomosis is an essential part of live-donor liver transplantation, and during this anastomosis, an unusual contact between bile and vessel ends is observed. In this study, the effects of this nonphysiological contact in a rabbit model were evaluated.

Methods:

The study was designed in 2 steps—in vitro and in vivo. Three groups were established for the in vitro study. In the first group, vessels were incubated in Krebs solution with 5% bile for 1 minute. In the second group, vessels were kept in Krebs solution with 5% bile for 5 minutes. Vessels in the control group were kept in Krebs solution without bile. All groups were examined for responses to vasodilator and vasoconstrictor agents in organ bath system. The specimens were evaluated immunohistochemically and histopathologically. In the in vivo step, microvascular anastomosis was performed bilaterally. Right carotid artery was anastomosed during bile contamination as study group, and left carotid artery was anastomosed without bile contamination as control group. Blood flow indexes were measured.

Results:

The results of the in vitro study revealed decreased responses to contractile and relaxing agents in the first study group compared with that of the control group (P < 0.0001). There was no response obtained in the second study group. The Doppler ultrasound results revealed no difference between preoperative and postoperative flow indexes (P > 0.05). There was no postoperative spasm in the study group. However, there was significant vasospasm in the control group (P < 0.05).

Conclusions:

Vessels exposed to bile have decreased contractile and relaxing responses, and this effect increases with exposure duration.