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

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.

Comparing Fibula Flap Insetting Techniques for Pediatric Oncologic Extremity Reconstruction

BACKGROUND

Extremity reconstruction in skeletally immature patients presents unique challenges in terms of operative technique, bone healing, and limb function. A variety of insetting techniques have been described, with no clearly superior option. The authors hypothesized that vascularized fibula flaps placed in the intramedullary space are associated with shorter union times and better functionality compared with onlay flaps.

METHODS

In a cohort study, the authors retrospectively reviewed the medical records of all pediatric patients who underwent fibula flap extremity reconstruction at a single center from 2001 through 2018. Comorbidities, complications, and outcomes were analyzed. Complete fibula union was based on radiographic evidence of significant cortical bridging.

RESULTS

Thirty-three patients (mean age, 13.6 years; range, 2 to 18 years) underwent pedicled ( n = 7) or free ( n = 26) fibula flap reconstructions in 12 upper extremities and 21 lower extremities. Median follow-up was 69.5 months (interquartile range, 16.3 to 114.6 months). Onlay and intramedullary fibula position compared with intercalary placement (median, 13.5 and 14.6 months versus 3.4 months; P = 0.002) were associated with longer time to complete bone union. Complications including allograft fracture ( P = 0.02) and hardware removal ( P = 0.018) were also associated with longer time to complete union and eventual conversion to megaprosthesis ( P = 0.02, P = 0.038). Thirty-two patients (97%) achieved full union and a functional reconstruction.

CONCLUSIONS

Fibula flap reconstruction is safe and effective for pediatric long-bone reconstruction. Longer fibula union times were associated with onlay and intramedullary fibula placement, allograft fracture, and hardware removal.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The evolution of pediatric soft-tissue free flap reconstruction of the lower extremity after oncologic resection: A 30 year experience

INTRODUCTION

Limb salvage has become the standard of care for lower extremity tumors because of improvements in adjuvant treatments and reconstructive techniques. While there is literature assessing pediatric lower extremity free flap reconstruction in the setting of trauma, there is a paucity of literature that analyzes oncologic free flap reconstruction in this patient population. We report our long-term experience and evolution of care for lower extremity oncologic free flap reconstruction in pediatric patients.

METHODS

This is a retrospective case series of all patients ≤18 years of age who underwent oncologic soft-tissue microvascular reconstruction of the lower extremity, from 1992 to 2021. Data were collected for patient demographics, oncologic treatment, operative details, and post-operative outcomes. Functional outcomes were assessed by weight bearing status, ambulation, and participation in activities-of-daily-living (ADLs), and musculoskeletal tumor society (MSTS) scores.

RESULTS

Over the 30-year study period, inclusion criteria were met by 19 patients (11 males, 8 females) with a mean age of 13.8 years and a mean follow-up of 5.3 years. At last follow-up, 13 patients (68.5%) were alive. The most common pathology was osteogenic sarcoma (13 patients, 68.5%). Sites of reconstruction were the hip (n = 1), thigh (n = 5), knee (n = 4), leg (n = 7), and the foot (n = 2). The most commonly used flaps were latissimus dorsi (n = 8), gracilis (n = 4), and anterolateral thigh ± vastus (n = 4). Postoperative complications occurred in nine patients (43%). Overall flap success rate was 95%. At latest follow-up, ambulation without assistive device was obtained in 11 patients (58%), full weight bearing was achieved by 13 patients (68.5%), and ADLs could be performed independently by 13 patients (68.5%). Mean MSTS score was 23.1/30.

CONCLUSION

Microvascular reconstruction for oncological lower extremity defects in the pediatric population has high limb salvage rates and good functional outcomes.

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.

Expanding horizons of reconstructive microsurgery in Lebanon: Reconstruction of complex traumatic wounds with anterolateral thigh perforator flaps in paediatrics patients less than 10 years of age

Paediatric complex wounds pose a challenge to the reconstructive surgeon due to the intricacy of reconstructive options required. Developments in microsurgery and microsurgical technique have brought free tissue transfer ever closer to the comfort zone of the reconstructive surgeon for reconstruction of paediatric traumatic complex wounds. We present our experience of microsurgical reconstruction in Lebanon for complex traumatic wounds in paediatric patients under the age of 10 years using the free anterolateral thigh (ALT) flap. The ALT flap has proven its value as a safe, adaptable, and aesthetically acceptable reconstructive option in paediatric complex trauma.

"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.

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.

Novel Design of the Chimeric Deep Inferior Epigastric Artery Perforator Flap that Provides for Three-Dimensional Reconstruction of Composite Tissue Defects of the Heel in Children

Objective

The aim of the present study was to report a novel design of the chimeric deep inferior epigastric artery perforator flap (DIEP) to achieve dead space filling, Achilles tendon bridging, and skin resurfacing simultaneously with minimal donor‐site morbidity.

Methods

From September 2012 to May 2016, a retrospective study was carried out on six pediatric patients with composite soft tissue defects of the heel that were repaired with the chimeric DIEP flap. The chimeric flap design included a flap of the anterior sheath of the rectus, a block of rectus muscle, and a large skin paddle. All the parts were supplied by a common artery. After harvesting the flap, all element parts were inserted at the corresponding sites in a tension‐free manner. With one set of vessel anastomoses at the recipient site, accurate repair with tendon reconstruction, dead space elimination, and wound covering were accomplished. The donor site incisions were closed initially. Data on patient age, medical history, injury severity, defect size, flap dimensions, recipient vessels, donor site closure, complications, and follow‐up were collected and reviewed.

Results

Five of the six chimeric DIEP flaps survived without complications. The remaining one case experienced partial necrosis of the skin paddle caused by venous congestion, which healed after routine dressing changes. Primary donor site closure was accomplished in all cases. The mean follow‐up was 18.6 months (range, 10–36 months). Five patients had satisfactory aesthetic and functional outcomes; one patient needed a secondary debulking procedure. Compared to the unaffected side, the affected side showed no obvious difference for ankle movement, tiptoe function, and patient gait during the follow‐up period. Good ankle function was observed in all patients. There was no donor site breakdown, with only a slightly noticeable linear scar.

Conclusion

The chimeric DIEP flap reduced the operative time, solved the problem of deficiency of recipient vessels, and attained satisfactory functional and aesthetic outcomes with low donor site morbidity. Therefore, it is a promising option for three‐dimensional reconstruction of composite defects with dead space and Achilles tendon defects as well as skin loss in children.

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.

Venous Coupler in Pediatric Free Tissue Transfer: Case Series and Literature Review

Background

Venous couplers have gained widespread acceptance as an effective, safe, and time-efficient alternative for hand-sewn anastomosis in microsurgical reconstruction. The literature on venous couplers use in pediatric free tissue transfer is scant. The purpose of this study is to present our experience with coupler-assisted venous anastomosis in young pediatric free flap reconstruction.

Methods

This is a retrospective single-center review of all children younger than 10 years old who underwent free flap reconstruction over 36-month period. The primary objective was to assess flap survival rate at 30-day postoperative period. The rate of venous thrombosis, flap take back, flap salvage, and the mean coupling time were also assessed.

Results

Four girls and 1 boy with a mean age of 7.3 ± 2.7 years (range 4-10 years) underwent 6 free flap transfers for head and neck, upper limb, and lower limb reconstructions. Microvascular anastomotic coupler system was used for 8 out of 9 performed venous anastomoses with a size ranging from 1.5 to 2.5 mm. Primary flap survival rate was 100%. None of the flaps in our series developed venous thrombosis or required flap take back for microvascular compromise (mean follow-up of 14.4 months). The mean coupling time was 7.1 minutes.

Conclusions

In the current study, venous couplers were safe and reliable in free tissue transfer in children younger than 10 years old. Future studies with larger sample size are needed to further examine the safety and efficacy of venous couplers in pediatric microsurgical anastomosis.