Microvascular Free Tissue Transfer for Head and Neck Reconstruction in Children: Part I

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.

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.

The Impact of Benign Jawbone Tumors on the Temporomandibular Joint and Occlusion in Children: A Ten-Year Follow-Up Study

This study aimed to provide a complex analysis of the modifications in craniofacial skeleton development that may arise following the diagnosis of pediatric benign jaw tumors. A prospective study was undertaken involving 53 patients younger than 18 years of age, who presented for treatment at the Department of Maxillo-Facial Surgery, University of Medicine and Pharmacy, Cluj-Napoca, with a primary benign jaw lesion between 2012 and 2022. A total of 28 odontogenic cysts (OCs), 14 odontogenic tumors (OTs), and 11 non-OTs were identified. At follow-up, dental anomalies were identified in 26 patients, and overjet changes were found in 33 children; lateral crossbite, midline shift, and edge-to-edge bite were found in 49 cases; deep or open bite were found in 23 patients. Temporomandibular disorders (TMDs) were found in 51 children, with unilateral TMJ changes identified in 7 cases and bilateral modifications found in 44 patients. Degenerative changes in the TMJ were also diagnosed in 22 pediatric patients. Although benign lesions could be associated with dental malocclusions, a direct etiological factor could be not identified. The presence of jaw tumors or their surgical treatment could, however, be linked to a change of the occlusal relationships or the onset of a TMD.

Pediatric Mandibular Reconstruction With Free Serratus Anterior-Rib Composite Flap: A Case Report

ABSTRACT

Reconstruction of children's mandibles after mandibular resection for benign or malignant tumors is challenging. Microvascular flap reconstruction is a common treatment option for restoring mandibular continuity after the resection of oral cavity neoplasms.We presented 2 cases of childhood mandibular reconstruction after tumor wide excision and segmental mandibulectomy, one for malignant cancer and one for benign ossifying fibroma, with serratus-rib composite free flap. All 2 patients had a favorable facial profile, functional outcome, and dental occlusion at the last follow-up. The development of children's mandible and donor site needs to be considered compared with adult's mandibular reconstruction. Given its reliability and utility, this flap can be an alternative for pediatric mandibular reconstruction compared with the free fibular flap and other candidates.

"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.

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.

Alloplastic Temporomandibular Joint Reconstruction Following Recurrent Ameloblastoma Resection

ABSTRACT

Ameloblastomas are benign tumors that most commonly affecting the mandible. The current standard of treatment for ameloblastomas is resection followed by reconstruction that has historically been accomplished through the use of a microsurgical vascularized flaps taken from the iliac crest or fibula. Alloplastic reconstruction methods have gained popularity over recent years with success reported in the reconstruction of many pathologies, including ankylosis, condylar fracture, neoplasia involving extensive resection, severe inflammatory/degenerative temporomandibular joint (TMJ) disease, and congenital TMJ abnormalities. The authors present a patient who successfully underwent ameloblastoma resection and TMJ reconstruction with a custom TMJ Concepts alloplastic implant. The authors also present a review of the literature on alloplastic TMJ reconstruction following ameloblastoma resection. To our knowledge, this is the second report in the literature on the use of a TMJ Concepts implant after ameloblastoma resection.

Free Flap Reconstruction of Extremity Defects in Pediatric Patients

BACKGROUND

Microsurgical reconstruction of extremity defects with free flaps has been carried out for many years. The aim of this retrospective study is to characterize free flap surgery on children of 1 to 7 years old by evaluating a series of 20 cases of free flap surgeries that have been performed in pediatric patients.

METHODS

From February 2014 to January 2018, 20 patients, 10 boys and 10 girls aged from 1 to 7 years (average, 4.6 years), were engaged in this study. Several types of free flaps were used, including anterolateral thigh flaps (ALT), inferior ulnar collateral artery flap, latissimus dorsi flap, medial plantar flap, fibular osteocutaneous flap and hallux toenail flap. After operations, follow-up period was at least for 2 years and the average follow-up period was 48.5 months. The long-term outcomes were estimated by questionnaires derived from the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI).

RESULTS

A total of 21free-flap reconstructions were performed on 20patients, including 15 ALT, 3 composite flaps, and 3 other cutaneous flaps. The size of the tissue flap ranged from 1.5 to 280 cm2 (average, 74.1cm2). The diameter of the anastomosed artery of the flap ranged from 0.7 to 1.2 mm. Among the 21 flaps, 20 survived and the success rate was about 95 %. Contour adaption was achieved in all flaps. Fifteen children received a secondary operation for debulking or functional improvement. Secondary deformity was present in 3 children, among which ankle joint valgus was seen in two children and a flexion deformity of injured toe occurred in one child. The mean global functioning score of PODCI was 94 (ranging from 81 to 98, maximum 100).

CONCLUSION

The success rate of free-flap surgery in pediatric patients was comparable to that achieved in adults. Post-operative caring for pediatric patients was easier than expected. For pediatric patients, the final outcomes were not varied remarkably from different types of free tissue transfer.

A conceptual framework for treating jaw deformities in patients with abnormal condyles: preservation versus replacement of the glenoid fossa-disc-condyle-ramus

This article outlines a conceptual approach to the reconstruction of jaw deformities associated with abnormalities in the mandibular condyle. The authors describe a hierarchy of reconstruction, emphasizing use of the least invasive and progressing to the most complex and invasive techniques, depending on the nature and severity of the underlying deformity, prior operations, patient age, and stage of growth. Consider joint preservation orthognathic surgical correction, followed by biological techniques for replacement of the condyle, and avoid replacing a functional temporomandibular joint based only on radiographic remodeling and concerns about potential future flare-ups of disease based on anecdotal data.

Tissue-engineered vascularized patient-specific temporomandibular joint reconstruction in a Yucatan pig model

PURPOSE

Current pediatric temporomandibular joint (TMJ) reconstruction options are limited. The aim of this project was to develop a proof-of-principle porcine model for a load-bearing, customized, 3D-printed and bone morphogenic protein 2 (BMP-2)-coated scaffold implanted in a pedicled (temporal) flap as a regenerative approach to pediatric TMJ mandibular condyle reconstruction.

MATERIALS AND METHODS

Scaffolds were customized, 3D-printed based on porcine computed tomography, and coated with BMP-2. Two operations occurred: (1) implantation of the scaffold in temporalis muscle to establish vascularity and, (2) 6 weeks later, unilateral condylectomy and rotation of the vascularized scaffold (with preservation of superficial temporal artery) onto the defect. Six months later, pigs were sacrified. The experimental side (muscle-scaffold) and control side (unoperated condyle) were individually evaluated by clinical, mechanical, radiographic, and histologic methods.

RESULTS

Scaffolds maintained physical properties similar in appearance to unoperated condyles. Vascularized scaffolds had new bone formation. Condyle height on the reconstructed side was 68% and 78% of the control side. Reconstructed condyle stiffness was between 20% and 45% of the control side.

CONCLUSION

In our porcine model, customized 3D-printed TMJ scaffolds coated with BMP-2 and implanted in vascularized temporalis muscle have the ability to (1) reconstruct a TMJ, (2) maintain appropriate condylar height, and (3) generate new bone, without impacting functional outcomes.

Locoregional Control and Survival in Children, Adolescents, and Young Adults With Localized Head and Neck Alveolar Rhabdomyosarcoma-The French Experience

INTRODUCTION

The head and neck (HN) are the most frequent sites of pediatric rhabdomyosarcoma (RMS). Alveolar RMS (ARMS) represents ~20% of all RMS cases and frequently spread to lymph nodes (LNs). The aim was to report locoregional control, event-free survival (EFS), and overall survival (OS), according to clinical and pathological features, LN staging, and treatment modalities.

METHODS

The study included all patients prospectively enrolled in EpSSG RMS 2005 study under 21 years of age with localized HN ARMS and diagnosed between 2005 and 2016 in France. Medical data including imaging, surgical report, and radiation therapy planes were analyzed.

RESULTS

Forty-eight patients (median age 6 years; range 4 months-21 years), corresponding to 30 parameningeal and 18 non-parameningeal ARMS, were included. There were 33 boys (69%). Tumor locations included the following: orbit (n = 7) among which four cases had bone erosion, paranasal sinuses and nasal cavity (n = 16), deep facial spaces (n = 10), nasolabial fold (n = 8), and other non-parameningeal HN sites (n = 7). A fusion transcript of PAX3-FOXO1 or PAX7-FOXO1 was expressed in 33 of the 45 cases (73%) with molecular analysis. At diagnosis, 10 patients had primary resection of the primary tumor (PRPT) (none with microscopic complete resection) and 9 had LN staging. After induction chemotherapy, 26 patients (54%) had secondary resection of the primary tumor (SRPT) and 13 patients (27%) had cervical LN dissection. A total of 43 patients (90%) were treated with radiation therapy.With a median follow-up of 7 years (range 2-13 years), 5-year OS and EFS were 78% (95% CI, 63-88%) and 66% (95% CI, 51-78%), respectively. We observed 16 events (10 deaths): 4 local, 4 regional, 1 local and regional, and 7 metastatic. In univariate analysis, OS was only superior for patients under 10 years of age (p = 0.002), while FOXO1-negative ARMS, SRPT for parameningeal ARMS, and LN surgery were associated with significantly better EFS.

CONCLUSION

Our study confirms a better outcome for fusion-negative ARMS and ARMS in children under 10 years. Moreover, LN surgery and SRPT of parameningeal tumor may improve EFS of ARMS. Larger studies are needed to confirm our findings.

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.

A Protocol for Resection and Immediate Reconstruction of Pediatric Mandibles Using Microvascular Free Fibula Flaps

PURPOSE

The use of a vascularized free fibula graft (FFF) for the reconstruction of a mandible in a child with a mandibular tumor is infrequent. The purpose of this study is to report our protocol for resection of mandibular jaw tumors and immediate reconstruction using FFF in pediatric patients.

METHODS

This was a retrospective case series of children with a mandibular tumor, which was resected and immediately reconstructed with FFF. All patients were treated via the same staged protocol: 1) presurgical digital planning, 2) surgical intervention (resection and immediate reconstruction), 3) postoperative care in the pediatric intensive unit, and 4) prosthodontic dental rehabilitation. Outcomes were complications and recurrence. Medical records were reviewed to document demographic information, tumor details, surgical interventions, postoperative course, and prosthodontic rehabilitation.

RESULTS

Fifteen patients (10 males, average age of 13.7 years) met inclusion criteria. Ten patients had mandibular ameloblastoma. All patients were treated by a dedicated pediatric team and followed the same protocol. The average tumor size was 4.87 × 3.22 × 2.03 cm. Most fibulas (n = 12) had one osteotomy to reestablish mandibular continuity and create appropriate contour. The most common microvascular anastomosis was with a facial artery (n = 13) and the external jugular vein (n = 9). At an average follow-up of 15.5 months, there were only 3 minor donor site complications. Eight implants were placed without complications. No tumors recurred.

CONCLUSIONS

The results of this study suggest that pediatric mandibular tumors can be successfully treated using a specific protocol involving resection and immediate reconstruction using FFF with minimal complications and without recurrence.

Microsurgical Reconstruction Following Oncologic Resection in Pediatric Patients: A 15-Year Experience

BACKGROUND

Free tissue transfer in the pediatric population is a challenging endeavor, even for experienced microsurgeons. Some surgeons argue these cases can be limited by vessel size and spasticity and should be undertaken only when absolutely necessary. We present a 15-year experience examining outcomes of free tissue transfer in pediatric oncologic patients.

METHODS

All free flaps performed at a single institution in pediatric patients (age range 3-17) between January 2000 and December 2014 were reviewed.

RESULTS

Overall, 102 patients (mean age 12.1 ± 4.0 years) were identified who underwent 109 free flaps. The most common flaps were the fibula free flap (46%) and the anterolateral thigh free flap (27%). 81 cases (74%) had malignant disease with 70 cases (64%) involving the head and neck region. 21 cases (19%) had preoperative radiation and 58 cases (53%) had preoperative chemotherapy. 5 cases had total flap loss (4.6%) and 17 cases (15.6%) had immediate post-operative complications, with wound infection (4.6%) being most common. 17 cases (15.6%) had long-term complications with delayed or non-union (4.6%) being most common. Survival rate was 91.7% at 1 year and 78.9% at 5 years.

CONCLUSIONS

Free tissue transfer is a reliable and appropriate choice in pediatric patients requiring soft tissue or bony reconstruction. Even in pediatric oncologic patients with preoperative chemotherapy or radiation, flap survival and outcomes are comparable to the adult population. Pediatric free tissue transfer should not be avoided but instead considered the gold standard for patients with complex defects, just as it is in the adult population.