Reconstruction of a Combined Maxillectomy and Segmental Mandibulectomy Defect in a Seven-Year-Old with a Single Free Fibula Osteocutaneous Flap

Abstract

Vascularized bone flaps form an integral part of head and neck reconstruction. Nevertheless, the best results in complex head and neck defects are far from optimal. A combined defect involving the maxilla and mandible may ideally require two bone flaps for reconstruction. The purpose of this article is to report a case of single-stage bony reconstruction of a combined maxilla and mandible defect after a benign tumor excision in a 7-year-old girl, using a free fibula flap. This case is unique in many aspects such as the age of the patient, the defect created by an arteriovenous malformation, and the case being a failure of a previous bony reconstruction with a vessel-depleted neck. Case ReportA 7-year-old girl, a case of arteriovenous malformation of left maxilla region, with a history of prior left total maxillectomy, presented with a recurrent lesion involving the ramus of the mandible. The reconstruction was first attempted with a free fibula flap, which failed, and then with an anterolateral thigh (ALT) flap which was successful. The orbital floor reconstruction was done with a titanium mesh. The computed tomographic (CT) scan at presentation showed residual arteriovenous malformation involving ramus and coronoid process of left mandible with cortical destruction (►Figs. 1 and 2). There was no evidence of recurrence at previous operated site. A carotid angiogram showed feeders from left external carotid artery with draining veins to both internal jugular veins.She underwent wide excision of the lesion with segmental mandibulectomy through a midline lip split with chin sparing incision and cheek flap approach. Bone resection involved segmental mandibulectomy from first premolar tooth on the left side to the ascending ramus and coronoid, preserving the condyle. The upper alveolus defect of the previous surgery was also considered. This was previously reconstructed with a soft-tissue flap only (►Fig. 3). A 2-mm titanium plate was pre bent using three-dimensional, CT-based contouring. This Keywords ► combined maxilla and mandible defect ► maxillary reconstruction ► mandibular reconstruction ► pediatric patient ► fibula flap AbstractCombined upper alveolectomy and segmental mandibulectomy are complex defects. Reconstruction of these defects is usually suboptimal. We describe the case of a pediatric patient with vessel-depleted neck with recurrent vascular malformation involving the ramus and coronoid process of mandible and a previous history of maxillectomy and a reconstruction with anterolateral thigh flap. The patient underwent wide resection. The defects involving the upper alveolus and mandible were simultaneously reconstructed with a single free fibula flap.

Outcomes in Pediatric Maxillofacial Reconstruction With Vascularized Fibular Flaps: A Systematic Review

“…Among reported cases during the follow-up period, 3 patients (2.8%) with benignindications and 2 patients (5.9%) with malignant indications exhibited disease recurrence (Supplementary Digital Content, Table 5, http://links.lww.com/SCS/D797). All studies reviewed are shown in Supplementary Digital Content, Table 6, 17-61 http://links.lww.com/SCS/D798.…”

Post‐operative Outcomes in Pediatric Patients Following Facial Reconstruction With Fibula Free Flaps

“…Fibula free flaps are the workhorse for composite reconstructive defects as they provide osseous and soft tissue components, with the fibula providing ample bony length to reconstruct multi-component defects of the midface and lower facial skeleton. 1,7 Additionally, the bone of fibula free flaps can facilitate dental rehabilitation with implants. 6 The outcomes of fibula free flaps for the reconstruction of large facial defects in the adult population have welldefined functional and cosmetic outcomes.…”

“…The paradigm for treatment in the adult population is well‐defined with autologous composite free tissue transfer that replaces the composite tissue defect. Fibula free flaps are the workhorse for composite reconstructive defects as they provide osseous and soft tissue components, with the fibula providing ample bony length to reconstruct multi‐component defects of the midface and lower facial skeleton 1,7 . Additionally, the bone of fibula free flaps can facilitate dental rehabilitation with implants 6 …”

Fibula Musculo-Osteocutaneous Flap with Full Thickness of Flexor Hallucis Longus Muscle

“… 2 The fibula osteo-cutaneous flap is used for reconstruction of many anatomical defects. They are used in reconstruction of mandible, maxilla, 3 clavicle, 4 long bones (humerus, radius, ulna, femur, tibia), 5 vertebrae, calcaneum, 6 etc. The length of the bone that can be harvested, presence of muscle, and large skin paddle that can be harvested have added to the advantages of using fibula flap for reconstruction purposes.…”