Free flap reconstruction in paediatric patients with head and neck cancer: clinical considerations for comprehensive care

Pediatric Free Flaps: Indications, Considerations, and Follow-up

Free tissue transfer is a very effective reconstructive technique for challenging defects of the head and neck and in many cases the gold standard for congenital facial paralyses and composite defects. Although its use in the pediatric population is not new and the success rates are comparable to those in adults, there is still a lack of information about its applications in children. This study aims to review the indications for use and discuss the anatomic considerations that may influence surgical complexity and long-term outcomes in the developing craniofacial skeleton.

Airway management in pediatric patients undergoing microvascular free tissue transfer reconstruction after mandibulectomy

OBJECTIVES

Microvascular free tissue transfer (MVFTT) for head and neck reconstruction is infrequently performed in pediatric patients. There is a paucity of data on perioperative airway management in pediatric MVFTT, such as the need for tracheostomy, which can pose higher morbidity to young patients due to potential long-term effects on the softer, more pliable laryngotracheal cartilage. Our objective was to report airway outcomes on pediatric patients undergoing MVFTT after segmental mandibulectomy with or without tracheostomy.

METHODS

Retrospective chart review of pediatric patients who underwent MVFTT reconstruction after segmental mandibulectomy at a tertiary care center from 2014 to 2023. Demographic variables, surgical characteristics, and hospital clinical outcomes were recorded. Statistical analyses were performed with JMP Pro, Version 16.0.0 (2021) SAS Institute Inc., Cary, NC, 1989-2021.

RESULTS

Ten patients (median age 11.5 years old, IQR: 9.0-13.3) underwent fibular free flap reconstruction. Mandibular pathologies included 3 ameloblastoma, 2 mesenchymal chondrosarcoma, 2 desmoplastic fibroma, 1 Ewing sarcoma, 1 chondroblastic osteosarcoma, and 1 desmoid tumor. Two patients received upfront tracheostomy at time of initial surgery for a subtotal mandibulectomy and a sub-hemimandibulectomy, respectively. Both patients were decannulated within 1 week after surgery and prior to discharge. The median ICU and hospital length of stay for patients who underwent tracheostomy was 3.5 days [IQR: 3.0-4.0] and 8.5 days [IQR: 8.0-9.0] respectively. Of the remaining 8 patients without tracheostomy, surgical defects were hemimandibulectomy and anterior subtotal mandibulectomy. Median intubation duration was 1.0 day [IQR: 1.0-2.5]. The median ICU and hospital length of stay for these patients were 3.0 days [IQR: 2.0-6.3] and 8.5 days [IQR: 7.3-13.0], respectively. No patient had to be reintubated for respiratory failure following extubation or had long-term airway complications during the follow-up period.

CONCLUSIONS

Fibular free flap reconstruction without tracheostomy can be feasible in pediatric patients with mandibular defects, which can potentially reduce hospital resources required for fresh tracheostomy care needs and avoid additional surgical morbidity. Further studies in larger populations and prospective approaches are warranted.

Maxillofacial Microvascular Free-Flap Reconstructions in Pediatric and Young Adult Patients-Outcomes and Potential Factors Influencing Success Rate

Background: Maxillofacial microvascular free-flap reconstructions are significant interventions in the management of congenital defects, traumatic injuries, malignancies, and iatrogenic complications in pediatric and young adult patients. Craniofacial disorders within this demographic can result in profound functional, cosmetic, and psychosocial impairments, highlighting the critical need for thorough investigation into factors that may influence procedural success and postoperative quality of life. This retrospective chart review aims to examine the outcomes and potential influencing factors, aiming to offer valuable insights into optimizing the effectiveness of these reconstructions and improving patient outcomes. Methods: A single head and neck surgical team performed all the included 136 procedures. Demographic and surgical patient data were recorded. Type of transfer performed in each recipient site and major complications were analyzed. Relevant influencing factors, such as age, gender, and etiology of defect were determined using the ANOVA test and χ2 test of independence. Results: The results indicate a 90% success rate. No significant relationship was found between the incidence of total flap loss and patient age, etiology, or graft source. The maxillary reconstructions showed a higher incidence of total flap loss compared to mandibular reconstructions (11 vs. 3 cases). Conclusions: Despite the high success rate, the findings underline the necessity for further research to validate these observations and enhance surgical methods for pediatric and young adult patients.

Donor-site morbidity of free fibula flap in pediatric patients: A systematic review and meta-analysis

The morbidity of free fibula flap (FFF) in pediatric patients has gained attention. Thus, we aimed to evaluate donor-site morbidity after FFF harvesting in pediatric patients and its relationship with age. A systematic literature search of databases for cross-sectional studies related to pediatric donor-site morbidity after FFF harvesting was performed. Two independent reviewers evaluated relevant article titles and abstracts to extract data regarding donor-site morbidity from each article. Fifteen studies were included in the meta-analysis that evaluated the rate of complications. Individual cases of ankle instability were divided into the 0-13- and 13-17-year-old groups. The Chi-square test was used to compare ankle instability between both groups. A logistic regression model was created to analyze the relationships between age and ankle instability/claw toe. Sixteen English articles published between 2007 and 2021 were included in the systematic review. Information on morbidities of 294 cases in which FFF was used was collected. The mean incidence rate of complications, instability, claw toe, and nerve injury were 19.3%, 12.9%, 5.9%, and 5.1%, respectively. Bivariate analysis showed that age was significantly correlated with the incidence of ankle instability but not with the incidence of claw toe. The Chi-square test showed that the incidence rate of ankle instability between the age groups was significantly different. Therefore, we recommend 14 years of age as a new predictive factor for ankle instability. Nevertheless, there is limited evidence in this field, and more pediatric research is needed to clarify these findings.

Comparison between an Operating Surgical Microscope and High Magnification Surgical Loupes in Microvascular Reconstruction of Head and Neck Defects in a Tertiary Healthcare Centre

Introduction and Objective

Microvascular free tissue transfers have become an important method of reconstruction following head & neck oncological resection. The objective of this study was to evaluate the efficacy of surgical loupes against surgical operating microscope, which is the gold standard for microvascular anastomosis and also to explore the possibility of surgical loupes as an essential cost-effective armamentarium in head and neck reconstruction.

Materials and Methods

This prospective randomized study included 40 patients diagnosed with head and neck malignancies, requiring microvascular free flap reconstruction. A total of 20 patients who underwent free flap reconstruction following oncologic/maxillofacial defects using high magnification surgical loupes & the other 20 patients were subjected to reconstruction under an operating surgical microscope. The efficacy was assessed based on the following parameters. 1. Total operating time taken for completing anastomosis. 2. Overall fatigue. 3. Free flap failure rate.

Results

The microscope group took an overall mean time of 34.26 min considering its limited degree of freedom in adjusting intraoperatively whereas the loupes group had a shorter mean anastomosis time 33.29 min considering its ease of operator adjustability. Overall, fatigue was compared using Mann-Whitney Test and found to be statistically significant with P value of 0.17, the loupe group was found to be better with mean score of 6.90 in 21 patients than microscope with mean score of 6.21in 19 patients. Flap survival rate in the loupe group had two cases of venous obstruction at 24 h follow-up and microscope group had 1 case of venous.obstruction.

Conclusion

The success with loupe only free tissue transfer can be attributable considering expertise with the microscope and the loupes can be a cost-effective alternative to microscope.