Mandibular Microsurgical Reconstruction in Patients with Hemifacial Microsomia:

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.

3D-CT measurements of facial symmetry in severe CFM patients: A comparative study between mandibular ascending ramus distraction osteogenesis and bone grafting

This study aims to compare the effects of mandibular distraction osteogenesis (MDO) and bone grafting on the facial symmetry of children with Pruzansky-Kaban type IIB and III craniofacial microsomia (CFM). Medical records and three-dimensional computed tomography (3D-CT) data of CFM patients who had primarily undergone MDO and bone grafting were collected. A retrospective analysis of pre-and post-operative 3D imaging data was conducted to compare the improvement rate in facial symmetry between the two groups based on occlusal cant, affected/unaffected ramus height ratio and chin point deviation. The data were tested for normality using the Shapiro-Wilk test. When the data followed a normal distribution, a paired sample t-test was employed for the comparison between preoperative and postoperative data. When the data did not follow a normal distribution, the Wilcoxon signed-rank test for paired samples was used for preoperative and postoperative comparison. The study included 18 children with type IIB and III CFM, 11 in the MDO group and 7 in the bone grafting group. In the MDO group, postoperative Gn-FH and Gn-Cor distances increased significantly, whereas the postoperative Gn-Mid distance decreased significantly. Occlusal cant decreased significantly and ramus height affected/unaffected ratio increased significantly after MDO. In the bone graft group, there was no statistically significant difference in the postoperative ratios of chin deviation, occlusal cant, and ramus height affected/unaffected compared to the preoperative values. Compared to bone grafting, MDO can significantly enhance ramus height ratio, level occlusal plane, and centralize the chin point among patients with CFM. Furthermore, MDO achieves superior enhancements in facial symmetry.

Visual Attention, Bias, and Social Dispositions Toward People With Facial Anomalies: A Prospective Study With Eye-Tracking Technology

BACKGROUND

Facial attractiveness influences our perceptions of others, with beautiful faces reaping societal rewards and anomalous faces encountering penalties. The purpose of this study was to determine associations of visual attention with bias and social dispositions toward people with facial anomalies.

METHODS

Sixty subjects completed tests evaluating implicit bias, explicit bias, and social dispositions before viewing publicly available images of preoperative and postoperative patients with hemifacial microsomia. Eye-tracking was used to register visual fixations.

RESULTS

Participants with higher implicit bias scores fixated significantly less on the cheek and ear region preoperatively (P = 0.004). Participants with higher scores in empathic concern and perspective taking fixated more on the forehead and orbit preoperatively (P = 0.045) and nose and lips (P = 0.027) preoperativel.

CONCLUSIONS

Participants with higher levels of implicit bias spent less visual attention on anomalous facial anatomy, whereas participants with higher levels of empathic concern and perspective taking spent more visual attention on normal facial anatomy. Levels of bias and social dispositions such as empathy may predict layperson gaze patterns toward those with facial anomalies and provide insights to neural mechanisms underlying the "anomalous is bad" paradigm.

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.

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.

Custom Alloplastic Temporomandibular Joint Reconstruction: Expanding Reconstructive Horizons

Custom alloplastic temporomandibular joint (TMJ) reconstruction has been well established for the management of end-stage TMJ disease. However, its use in congenital TMJ deformities is limited. Here, the authors present initial outcomes of skeletally mature patients who underwent custom alloplastic TMJ reconstruction and simultaneous orthognathic surgery.A retrospective case series of patients who underwent custom alloplastic TMJ reconstruction concurrent with orthognathic surgery between 2014 and 2019 was completed. Functional, aesthetic and orthodontic outcomes as well as complications were recorded.Seven TMJs in 5 skeletally mature patients (4 female, 1 male, ages 16-30) (2 bilateral, 3 unilateral) were replaced. All but 1 patient had previous attempts at reconstructive surgery with poor results. All cases were prepared using virtual surgical planning and underwent concomitant maxillomandibular orthognathic surgery. All patients demonstrated improved post-operative occlusions. Four of 5 patients achieved >30 millimeters of post-operative MIO. Complications included ear canal perforation and facial nerve dysfunction.There were no infections or other implant-related complications. Mean follow up was 2 years and 15 days. Alloplastic TMJ reconstruction at the time of skeletal maturity for patients with congenital mandibular TMJ defects is an alternative to existing management options. Further long-term prospective outcomes studies are ongoing.

Complication After Mandibular Reconstruction With Fibula Free Flap in a Patient With Hemifacial Microsomia

ABSTRACT

Hemifacial microsomia is the second most frequent pathology in craniofacial malformations. Clinical findings are broad, mainly affecting the mandible. Several classifications of mandibular compromise exist that guide the best treatment option in each patient. The authors present a case of an unusual complication following fibular free flap mandibular reconstruction in a patient with hemifacial microsomia prada type IV, who presented with ankylosis at the skull base and simultaneous fibula pseudoarthrosis at the union with the residual mandible. These dual findings allowed the patient to have a functional mouth aperture, which give us time to let him grow and wait for final management. Treatment options and follow up are discussed, knowing that there is no literature to support any protocol with this patient, so we present his evolution.

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.

Mandibular Reconstruction Following Central Giant Cell Granuloma Resection in Primary Dentition: A Case for the Use of a Costochondral Graft

Central giant cell granuloma is a benign, intraosseous lesion that may affect the pediatric craniofacial skeleton, particularly the mandible. When surgery is indicated, the role of the craniofacial surgeon is to ameliorate the sequelae of ablative surgery by restoring facial symmetry, ensuring appropriate postoperative occlusion, and allowing for adequate interincisal opening, all in the setting of a growing craniofacial skeleton. Herein, we report the case of a 3-year-old female presenting for reconstruction after resection of the right hemimandible proximal to the unerupted first permanent molar. We highlight the various reconstructive challenges associated with mandibular reconstruction during primary dentition and make a case for the use of a costochondral graft, with a successful outcome demonstrated at 2 years of follow-up.

Autologous Fat Graft for Soft Tissue Camouflage in Craniofacial Microsomia

INTRODUCTION

In India, a large majority of patients with craniofacial microsomia are unable to undergo complex reconstructions owing to unaffordability, lack of access to good craniofacial centers, or reluctance of parents to accept the surgical risk. There is also considerable social stigma attached to the resultant facial scars of surgery, especially in a girl child. Hence, we have explored autologous fat graft transfer as a "stand-alone" reconstructive option for soft tissue camouflage and aesthetic correction of facial deformity in unilateral craniofacial microsomia of Pruzansky-Kaban Grades I and II.

MATERIALS AND METHODS

Twelve patients who were seeking aesthetic correction of facial deformity in unilateral craniofacial microsomia of Pruzansky-Kaban Grades I and II, and who had adequate fat in the preferred donor sites of lower abdomen and antero-medial thighs, were selected. Patients with Grade III deformity, facial palsy, and previous skeletal surgeries were excluded. Autologous fat harvesting was done with the standardized Coleman's technique and injected after decantation. Volumetric augmentation was assessed by clinical comparison with normal side for facial symmetry, skin pinch thickness at four reference points, and by two-dimensional analysis of pre- and postoperative standardized photographs at periodic intervals.

RESULTS AND ANALYSIS

Eleven of our patients were female and one was a male (N = 12). In each session, 20-40mL (mean 28.75 ± standard deviation [SD] 5.69) fat was aspirated and 12-35mL (mean 23.67 ± SD 6.07) fat was injected. The average operating time was 35min (mean 32.91 ± SD 4.05). Majority of our patients needed three sessions (mean 2.8 ± SD 1.03) of serial fat injections to achieve bilateral facial symmetry. Increase in skin pinch thickness was 6.4167 ± 1.31 mm. The mean patient satisfaction score was 8.83 ± SD .717.

CONCLUSION

Based on our results, we conclude that autologous fat transfer, when used for soft tissue camouflage, is a versatile, easy, effective, and inexpensive method for obtaining consistent long-term aesthetic goals in mild to moderate cases of craniofacial microsomia.

Craniofacial Microsomia

Clinicians use different diagnostic terms for patients with underdevelopment of facial features arising from the embryonic first and second pharyngeal arches, including first and second branchial arch syndrome, otomandibular dysostosis, oculoauriculovertebral syndrome, and hemifacial microsomia. Craniofacial microsomia has become the preferred term. Although no diagnostic criteria for craniofacial microsomia exist, most patients have a degree of underdevelopment of the mandible, maxilla, ear, orbit, facial soft tissue, and/or facial nerve. These anomalies can affect feeding, compromise the airway, alter facial movement, disrupt hearing, and alter facial appearance.

Functional Temporomandibular Joint Reconstruction in Costochondral Grafting of Micrognathia

Rib bone and costochondral complex grafting has been used to treat micrognathia classified as Pruzansky type III. To acquire more physiological joint movement, we reconstructed a temporomandibular joint with the glenoid fossa in addition to the mandibular ramus. The patient underwent a tracheostomy to correct her airway obstruction at 2 months of age. After that, no further surgical treatments were performed on the micrognathia. When she was 6 years of age and during consultation at our department, micrognathia caused by Goldenhar syndrome was confirmed. A head and neck computed tomography scan showed hypoplasia and deficit of the mandible, severe glossoptosis and airway constriction. Initially, a bilateral mandibular body distraction was performed at 6 years of age, and 15 mm of elongation was obtained. Subsequently, reconstruction of the right ramus and right temporomandibular joint fossa was performed at 8 years of age to achieve extubation. Part of her sixth rib and costochondral complex graft was used for the ramus, and costochondral graft was used for the joint fossa. Some new ideas for temporomandibular joint reconstruction were added. Postoperatively, the open mouth range was increased and improvement of the airway space narrowing was observed in a computed tomography scan. The main points of this new method are prevention of ankylosis, skull cortex thinning, and reconstructed ramus’ dislocation. This method may become an effective new treatment for cases of micrognathia with a ramus classified as Pruzansky type III.

Reconstruction of Mandibular Segmental Detects Using Transport Disk Distraction Osteogenesis

BACKGROUND

Distraction osteogenesis (DO) has become an important alternative for bone defect reconstruction. The study aims to investigate the clinical feasibility and efficiency of transport disc DO (TDDO) for reconstruction of segmental defect of mandible and further dental implant treatment.

METHODS

A serial of 6 patients diagnosed with ameloblastoma or keratocystic odontogenic tumor were included in this study. Computed tomography (CT) scanning and panoramic radiograph were performed for preoperative evaluation and surgery planning. Transport disc DO was applied simultaneously with tumor resection for reconstruction of mandibular defects. The postoperative panoramic radiographs and CT scans were taken for evaluation of the ossification level. Then a second surgery was performed for removal of the distraction apparatus. Bone graft and rigid internal fixation were also used to fill the gap between the transport disc and the stump of the residual ramus. Further dental implant treatment was also finished or in progress.

RESULTS

All patients finished the whole treatment period, and no distraction device failure or tumor recurrence occurred. The distraction length ranged from 35 to 48 mm and the whole treatment period of TDDO ranged from 21 to 33 weeks. High degree of ossification was confirmed at the end of treatment by postoperative radiographs and intraoperative observation. Infection occurred in 1 of the 6 patients, and the symptom was controlled by surgical dressing change and flushing. Results of final facial profile in all patients were good. Three patients finished dental implant treatment with good occlusion.

CONCLUSION

Results in this study suggest the clinical feasibility and efficiency of TDDO for reconstruction of segmental defect of mandible and further dental implant treatment.

Goldenhar syndrome: current perspectives

BACKGROUND

Progress in medical branches that has taken place since the first child with Goldenhare syndrome (GS) had been described in 1952 by Maurice Goldenhar, facilitated better understanding of this congenital defect. It also gave new perspectives and the opportunity to achieve satisfactory treatment results, mainly due to development of surgical techniques.

DATA SOURCES

Based on the literature and own experience, we discussed the phenotype of presentation of GS, ethiopathogenesis, genetic counselling and treatment with particular emphasis on surgery correction of hemifacial microsomia.

RESULTS

The spectrum of GS abnormalities ranges from mild to severe ones and include patients with barely noticeable facial asymmetry to very pronounced facial defect with more or less severe abnormalities of internal organs and/or skeleton. It is characterized most commonly by impaired development of eyes, ears, lips, tongue, palate, mandible, maxilla, zygomatic and orbital structures and deformations of the teeth structures. Ethiopathogenesis is multifactorial and dependent on genetic and environmental factors but there are still many unknowns about the syndrome which should be revealed.

CONCLUSIONS

Patients with GS due to a large variety of abnormalities and different severity of symptoms pose a challenge for clinicians. All of this necessitate an individual approach to each single patient and involvement a team of specialists in treatment planning. It is a complex, long-lasting, multidisciplinary process and should be divided into stages, according to patient's age, as well as the extent and severity of observed abnormalities. Neonatologists and pediatricians are involved in care of these patients from the onset.

Desmoplastic Fibroma of the Mandible in a Pediatric Patient: A Case Report of Resection and Reconstruction With A Six-Year Follow-Up

Desmoplastic fibroma (DF) of bone is considered a benign but locally aggressive tumor of fibroblastic origin. DF is rare, representing less than 1% of all bone tumors. Approximately 84% of patients are younger than 30 years. DF has a slow but aggressive growth potential and can recur locally when it has not been completely excised. Complete resection is the treatment of choice to decrease recurrence and morbidity. Mandibular reconstruction is mandatory in pediatric patients to ensure correct craniofacial development. The present report describes the case of a pediatric patient with mandibular DF in whom complete resection and immediate reconstruction with a fibula flap proved a satisfactory treatment option, with low morbidity and excellent esthetic and functional results at 6-year follow-up.

Efficacy of Standard Costochondral Grafting in Patients With Bilateral Craniofacial Microsomia

Craniofacial microsomia remains the second most common craniofacial deformity after cleft lip and palate. Mandibular pathology has been classically scored from type I to type III by the modified Pruzansky-Kaban classification. The authors report a case of a 5-year-old patient with Goldenhar syndrome and bilateral type III craniofacial macrosomia. The patient had absence of bilateral glenoid fossas, condyles, coronoids, and rami as well as hypoplasia of the symphysis, parasymphysis, and mandibular body. Reconstruction was performed using 2 costochondral rib autografts to reconstruct a ramus and assist in the development of a neo-glenoid fossa at the cranial base. An additional portion of costal rib graft was used to augment the deficient symphysis. The patient was placed in class III occlusion postoperatively using maxillo-mandibular fixation screws and heavy elastics. The bone grafts healed without complications with no evidence of ankylosis, nonunion, or resorption to date. For the most severe forms of craniofacial microsomia, costochondral grafting remains an effective initial technique for lengthening the hypoplastic mandible and providing a foundation for future distraction.

Facial bone reconstruction with prefabricated vascularized calvarium flaps in children and young adults: Advantages and long-term results

INTRODUCTION

Reconstruction of facial bone defects in children is challenging. The use of well-vascularized bone is mandatory to obtain stable lasting results. This study reports our experience of facial bone reconstruction using prefabricated vascularized calvarium flaps.

METHODS

Retrospective case series of 50 patients who underwent 52 maxillary, malar, and mandibular reconstructions between 1988 and 2014 using prefabricated vascularized calvarium flaps. Forty-nine patients suffered from noma sequels; one patient had craniofacial cleft Tessier 3-11. Surgery consisted of a two-step procedure beginning with flap delay and prelamination with skin grafting on the galea. Flap harvest followed at least 2 weeks later (range, 2-16 weeks), including a full-thickness calvarium fragment, which was set into the facial defect.

RESULTS

Early complications concerned wound healing and infections requiring surgical revision in six patients at the recipient and six at the donor site. There was one flap loss. Clinical long-term assessment at 15-year median follow-up (range, 1-27 years) showed good results, assuring facial height and contour. Radiological long-term results demonstrated excellent integration of the flap to the adjacent facial skeleton of the growing child.

CONCLUSIONS

Prefabricated vascularized calvarium flaps are an effective, safe and lasting method for reconstruction of facial bone defects in children.

The use of computer-aided design/manufacturing (CAD/CAM) technology to aid in the reconstruction of congenitally deficient pediatric mandibles: A case series

BACKGROUND

Microvascular reconstruction of the pediatric mandible, particularly when necessitated by severe, congenital hypoplasia, presents a formidable challenge. Complex cases, however, may be simplified by computer-aided design/computer-aided manufacturing (CAD/CAM) assisted surgical planning. This series represents the senior authors' preliminary experiences with CAD/CAM assisted, microvascular reconstruction of the pediatric mandible.

METHODS

Presented are two patients with hemifacial/bifacial microsomia, both with profound mandibular hypoplasia, who underwent CAD/CAM assisted reconstruction of their mandibles with vascularized fibula flaps. Surgical techniques, CAD/CAM routines employed, complications, and long-term outcomes are reported.

RESULTS

Successful mandibular reconstructions were achieved in both patients with centralization of their native mandibles and augmentation of deficient mandibular subunits. No long-term complications were observed.

CONCLUSIONS

CAD/CAM technology can be utilized in pediatric mandibular reconstruction, and is particularly beneficial in cases of profound, congenital hypoplasia requiring extensive, multi-planar, bony reconstructions.

Orthognathic surgery in craniofacial microsomia: treatment algorithm

Craniofacial microsomia is a broad term that covers a variety of craniofacial malformation conditions that are caused by alterations in the derivatives of the first and second pharyngeal arches. In general terms, diverse therapeutic alternatives are proposed according to the growth stage and the severity of the alteration. When craniofacial growth has concluded, conventional orthognathic surgery (Le Fort I osteotomy, bilateral sagittal split osteotomy, and genioplasty) provides good alternatives for MI and MIIA type cases. Reconstruction of the mandibular ramus and temporomandibular joint before orthognathic surgery is the indicated treatment for cases MIIB and MIII. The goal of this article is to establish a surgical treatment algorithm for orthognathic surgery on patients with craniofacial microsomia, analyzing the points that allow the ideal treatment for each patient to be chosen.

Autogeneous coronoid process as free graft for reconstruction of mandibular condyle in patients with temporomandibular ankylosis

OBJECTIVE

This study was conducted to determine the efficacy of using the autogeneous coronoid process as free graft for reconstruction of mandibular condyle and to achieve structural, functional, as well as esthetic rehabilitation of patients with temporomandibular joint (TMJ) ankylosis.

MATERIALS AND METHODS

This article presents the clinical results of an evaluation of ten cases of TMJ ankylosis treated by using autogeneous coronoid process as free graft for reconstruction of mandibular condyle after resection of ankylotic mass.

RESULTS

Satisfactory mouth opening were obtained in all ten cases. No patient showed signs of re-ankylosis at 12 months follow-up. Preoperative mouth opening ranged from 0 to 15 mm with mean being 4.8 mm. As a result of successful procedure, the immediate postoperative mouth opening increased ranging from 24 to 31 mm (mean, 26.5 mm). Follow up of patients at the first and 12th month showed good results with increase in mouth opening from a range of 24 to 31 mm (mean, 27.8 mm ) to 26 to 36 mm (mean, 33.13 mm).

CONCLUSION

The results of this study suggest that the autogeneous coronoid process as free graft is a suitable graft material for reconstruction of mandibular condyle after resection of ankylotic mass.

Craniofacial microsomia

Craniofacial microsomia (CFM) is one of the most common congenital conditions treated in craniofacial centers worldwide. This condition is variably associated with anomalies of the jaws, ears, facial soft tissue, orbits, and facial nerve function and can be associated with extracranial anomalies. The cause of this condition is unknown, though CFM has been associated withprenatalexposures and genetic abnormalities. Diagnosis, treatment, and outcome assessment in CFM is challenging due to the wide phenotypic spectrum observed in this condition. Surgical treatment requires a coordinated team approach involving multiple specialties, which can include plastic surgery, craniofacial surgery, orthognathic surgery, and microsurgery. A wide variety of surgical options exist, and individual treatment plans should be based on the patient's needs. Although CFM can be challenging to treat, successful outcomes are rewarding. We provide a review of the common craniofacial surgical treatments for individuals with CFM.

The free osteofasciocutaneous fibula flap: clinical applications and surgical considerations

INTRODUCTION

The aim of this study was to investigate the intraoperative findings, postoperative complications, donor site morbidity and patients' Quality of Life in order to evaluate the usefulness of the free osteofasciocutaneous fibula flap in the reconstruction or construction of a mandibula, neophallus, lower leg or forearm.

MATERIALS AND METHODS

104 patients were treated with free osteofasciocutaneous fibula flaps in our clinic. 23 for mandible reconstruction, 66 for neophallus reconstruction, 9 for lower leg reconstruction and 6 for forearm reconstruction. These patients were asked to answer a questionnaire and to be present for a clinical and a radiological examination in our department. In addition, their previous records were evaluated retrospectively.

RESULTS

The dimension of the surface of the skin island was 178.6 cm(2) (72-352 cm(2)) in average and the average length of the fibular bony part was 15.4 cm (10-23 cm). The most frequent and severe complication was skin island edge necrosis (n=7); no total flap necrosis was found. Donor-site morbidity was low, since no joint instability could be reported. Quality of Life was improved according to the standardised FLZ(M) questionnaire.

CONCLUSION

Advantages of free osteofasciocutaneous fibula flaps were the wide cortical bone and the relative constant anatomy, the long pedicle, flat, uniform and sufficient large and pliable skin island, as well as the good blood circulation also by massive modelling of the skin and bone part. The skin island could be harvested large enough in order to reconstruct extended soft-tissue defects in the face and the extremities as well as to construct neophallus in its normal size without any restrictions. The lower leg donor-site morbidity was moderate and can be readily covered with a sock in patients' everyday life common activities. Finally, in our hands, the utilisation of the free osteofasciocutaneous fibula flap is the best possible therapy for these difficult composite reconstructions.

A New Classification Based on the Kaban's Modification for Surgical Management of Craniofacial Microsomia

In medicine, classifications are designed to describe accurately and reliably all anatomic and structural components, establish a prognosis, and guide a given treatment. Classifications should be useful in a universal way to facilitate communication between health professionals and to formulate management protocols. In many situations and particularly with craniofacial microsomia, there have been many different classifications that do not achieve this goal. In fact, when there are so many classifications, one can conclude that there is not a clear one that accomplishes all these ends and defines a treatment protocol. It is our intent to present a new classification based on the Pruzansky's classification, later modified by Kaban, to determine treatment protocols based on the degree of osseous deficiency present in the body, ramus, and temporomandibular joint. Different mandibular defects are presented in two patients with craniofacial microsomia type III and IV according to our classification with the corresponding management proposed for each type and adequate functional results.

Autogenous grafts for condylar reconstruction in treatment of TMJ ankylosis: current concepts and considerations for the future

Temporomandibular joint (TMJ) ankylosis is characterized by difficulty or inability to open the mouth due to fusion of the temporal and the mandible, resulting in facial symmetry/deformity, malocclusion and dental problems. The only treatment option for TMJ ankylosis is surgical with or without condylar reconstruction. Various autogenous grafts are available for condylar reconstruction after freeing the ankylotic mass such as costochondral, sternoclavicular, fibular, coronoid, and metatarsophalangeal. Costochondral graft is preferred by surgeons, but distraction osteogenesis is slowly gaining popularity and may ultimately become the standard procedure, providing a cost-effective approach with low morbidity and excellent functional outcomes. Tissue engineering is another budding field which has shown promising results in animal studies but has not been applied to humans. To date, there is no ideal autogenous graft for condylar reconstruction that satisfies the complex anatomy and the myriad of functions of a missing condyle.

Reconstruction of the premaxilla: an option for mutilated bilateral clefts

The loss of the maxilla is a severe mutilation resulting from inadequate surgery of bilateral clefts of the lip and palate. It is usually associated with palatal fistulae, collapse of the maxillary segments, and limited facial growth.Functional rehabilitation can be achieved by reconstruction of the premaxilla with osteomucosal fibula grafts. Mucosal grafts are fixed to the fibula in a preliminary stage. The composite graft is transplanted to the maxilla 10 to 12 weeks later. Osteointegrated implants are placed 3 months later.The procedure was used in 7 patients, 1 holoprosencephaly and 6 with sequelae of bilateral clefts; mean age, 17.28 years, with a follow-up of 14 to 70 months.The mucosal grafts integrated successfully to the fibula in all the patients. The osteocutaneous graft achieved a solid maxillary arch in all the patients. Normal mastication was achieved with a prosthesis fixed to the osteointegrated implants. Facial proportions were greatly improved.