The Forgotten Flap: The Pedicled Trapezius Flap's Utility in Pediatric Head and Neck Reconstruction-A Systematic Review

BACKGROUND

 When free tissue transfer is precluded or undesired, the pedicled trapezius flap is a viable alternative for adults requiring complex head and neck (H&N) defect reconstruction. However, the application of this flap in pediatric reconstruction is underexplored. This systematic review aimed to describe the use of the pedicled trapezius flap and investigate its efficacy in pediatric H&N reconstruction.

METHODS

 A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing the trapezius flap for H&N reconstruction in pediatric patients were included. Patient demographics, surgical indications, wound characteristics, flap characteristics, complications, and functional outcomes were abstracted.

RESULTS

 A systematic review identified 22 articles for inclusion. Studies mainly consisted of case reports (n = 11) and case series (n = 8). In total, 67 pedicled trapezius flaps were successfully performed for H&N reconstruction in 63 patients. The most common surgical indications included burn scar contractures (n = 46, 73.0%) and chronic wounds secondary to H&N masses (n = 9, 14.3%). Defects were most commonly located in the neck (n = 28, 41.8%). The mean flap area and arc of rotation were 326.4 ± 241.7 cm2 and 157.6 ± 33.2 degrees, respectively. Most flaps were myocutaneous (n = 48, 71.6%) and based on the dorsal scapular artery (n = 32, 47.8%). Complications occurred in 10 (14.9%) flaps. The flap's survival rate was 100% (n = 67). No instances of functional donor site morbidity were reported. The mean follow-up was 2.2 ± 1.8 years.

CONCLUSION

 This systematic review demonstrated the reliability of the pedicled trapezius flap in pediatric H&N reconstruction, with a low complication rate, no reports of functional donor site morbidity, and a 100% flap survival rate. The flap's substantial surface area, bulk, and arc of rotation contribute to its efficacy in covering soft tissue defects ranging from the proximal neck to the vertex of the scalp. The pedicled trapezius flap is a viable option for pediatric H&N reconstruction.

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 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.

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.

Maxillo-Mandibular Reconstruction in Pediatric Patients: How To Do It?

Maxillo-mandibular reconstruction in pediatric patients involves particular functional and cosmetic implications. Attention is required for the craniofacial growth over time, involvement of the permanent dentition, facial symmetry, and donor site morbidity. Our aim is to identify the best reconstructive options for maxilla-mandibular defects in children (<18 years) based on our experience with 25 pediatric patients. We believe that reconstruction has to be performed at the same time as resection in pediatric patients. Local flaps should be reserved for cases of maxillary defects because of malignant neoplasms, which ultimately have poor prognosis. In cases of large mandibular defects, radiotherapy is eventually required. When the condition of the soft tissues is poor (because of previous surgery, etc), free flaps potentially represent the best options. Nevertheless, in patients younger than 5 years old (with no damaged tissues), reconstruction with rib grafts should be performed, and the use of titanium plates should be reserved for very select cases (such as temporary reconstruction in toddlers).

Thoraco dorsal artery perforator flap for trismus release in a young girl

Trismus is a frequent complication occurring after treatment of tumors of the pterygomaxillary fossa. Local flaps and full-thickness skin grafts fail to release it because they usually lead to scar contracture in previously irradiated tissues. We propose to release it with a thoracodorsal artery perforator flap, which is feasible in children like other perforator flaps. It is interesting because it is thinner than the anterolateral thigh flap and its scar may be less disgraceful and easier to hide.