Quantifying Free Fibula Flap Growth After Pediatric Mandibular Reconstruction

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.

Genetic determinants of periosteum-mediated craniofacial bone regeneration: a systematic review

BACKGROUND

Periosteum-mediated bone regeneration (PMBR) is a recognized method for mandibular reconstruction. Despite its unpredictable nature and the limited degree to which it is understood, it does not share the concerns of developmental changes to donor and recipient tissues that other treatment options do. The definitive role of the periosteum in bone regeneration in any mammal remains largely unexplored. The purpose of this study was to identify the genetic determinants of PMBR in mammals through a systematic review.

METHODS

Our search methodology was designed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. We conducted a quality assessment of each publication, and evaluated the differences in gene expression between days 7 and 15.

RESULTS

A total of four studies satisfied the inclusion criteria. The subjects and tissues examined in these studies were Wistar rat calvaria in two studies, mini-pigs in one study, and calves and mice in one study. Three out of the four studies achieved the necessary quality score of ≥ 3. Gene expression analysis showed increased activity of genes responsible for angiogenesis, cytokine activities, and immune-inflammatory responses on day 7. Additionally, genes related to skeletal development and signaling pathways were upregulated on day 15. Conclusions: The results suggest that skeletal morphogenesis is regulated by genes associated with skeletal development, and the gene expression patterns of PMBR may be characterized by specific pathways.

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 Microsurgery and Free-Tissue Transfer

Advancements in microsurgery, along with increased microsurgical experience in pediatric patients, have made free-tissue transfer a reliable modality for pediatric bone and soft tissue reconstruction today. Free-tissue transfer is most commonly used in children for the coverage of large or complex defects resulting from traumatic, oncologic, or congenital etiologies. While flap success and complication rates between pediatric and adult populations are similar, special considerations must be taken into account within the pediatric population. In this article, we will describe common indications, technical nuances, and clinical considerations for the management of the pediatric free-tissue transfer patient.

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.

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.

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.