The evaluation of flap growth and long‐term results of pediatric mandible reconstructions using free fibular flaps

Abstract

Currently, the free fibular flap is well accepted as the first choice for mandibular reconstruction. Achieving functional results in pediatric patients requires a different approach than that employed for mature patients. Because the pediatric craniofacial skeleton continues to grow, reconstruction is more challenging, and the long-term results can be different from those of adult patients. In this study, we sought to measure flap growth objectively in our series. Ten pediatric patients who underwent reconstruction with free fibular flaps were retrospectively reviewed. Flap growth was evaluated by comparing the intraoperative photographs with photographs of the control panoramic mandibular radiographs taken using photo-anthropometric techniques. The measurements were converted to proportionality indices (PI), and these indices were compared. Subsequent complications and functional results were also evaluated. The mean patient age was 11.8 years, and the mean follow up was 57.7 months. The mean preoperative PI value was 10.74 ± 2.47. The mean postoperative PI value was 12.52 ± 2.34. The mean difference between the preoperative and postoperative PI values was -1.78 ± 0.53. These photo-anthropometric data clearly illustrated the growth of the fibular flaps (P = 0.001). None of these patients exhibited nonunion of the fractures; however, one patient experienced a delayed union, one had chronic temporomandibular joint pain, and one had chronic temporomandibular joint luxation. In two patients, the inter-incisive measurements were below the third percentile, and two additional patients had grade 2 eating abilities, which can be regarded as poor. All of the patients had symmetric mandibular contours. Free fibular flaps continue to grow in pediatric patients. This flap is a "workhorse" flap in children because it adapts to the craniofacial skeleton via its ability to grow, and this ability results in subsequent good cosmetic and functional results.

Free Flap Transfer for Pediatric Head and Neck Reconstruction: What Factors Influence Flap Survival?

“…As a result, some patients eventually required orthognathic surgery or the transfer of new flaps for surgical correction as they grew. On the contrary, most series on pediatric head and neck reconstruction have reported that free flaps seem to grow commensurately with surrounding structures . We reviewed a series of 51 patients < 18 years of age who underwent mandibular reconstruction with vascularized fibula flaps from 15 articles; we found that the number of patients with preserved growth potential was greater than those with no growth potential and concluded that the growth potential of the fibula was related to age, condylar preservation, tumor pathology, and postoperative radiotherapy.…”

“…On the contrary, most series on pediatric head and neck reconstruction have reported that free flaps seem to grow commensurately with surrounding structures. 4,19,22,47,48 We reviewed a series of 51 patients < 18 years of age who underwent mandibular reconstruction with vascularized fibula flaps from 15 articles; we found that the number of patients with preserved growth potential was greater than those with no growth potential and concluded that the growth potential of the fibula was related to age, condylar preservation, tumor pathology, and postoperative radiotherapy. This systematic review showed that whereas reconstruction after benign lesion resection, reconstruction between 8 and 12 years of age (which was termed the rapid growth stage), and condylar preservation facilitate postoperative mandibular growth, postoperative radiotherapy inhibits the same.…”

Use of three-dimensional, CAD/CAM-assisted, virtual surgical simulation and planning in the pediatric craniofacial population

“…Despite the continuous growth of the fibula and mandible, free fibula flap reconstruction of the mandible in pediatric patients has been shown to be effective, with minimal postoperative cross bite complications [6]. In adults, the use of 3D CAD/CAM technology in free fibula flap reconstructions have decreased operative time and increased accuracy [3e5, 20,21].…”

Bone Allograft Segment Covered with a Vascularized Fibular Periosteal Flap: A New Technique for Pediatric Mandibular Reconstruction

“…Moreover, the use of the FVFG in children has progressively gained popularity for mandibular reconstructions of large oncological resections and severe facial deformities of the lower jaw. 1,2,5 Despite its advantages, the FVFG handicaps result from the reduced height of the fibula ($10 mm), which is suboptimal for achieving a simultaneous reconstruction of the facial contour and alveolar height. 4 Several technical modifications and secondary procedures have been described to overcome the limitations of the FVFG in terms of bone height such as double-barrel designs and vertical distraction, among others.…”

“…Several authors have reported on the use of FVFGs for pediatric mandibular reconstruction without associated ankle morbidity. 1,2,5 However, most of these remain short series of patients with limited follow-up. Moreover, Sulaiman et al evaluated the long-term effects on the foot and ankle following FVFGs in children and concluded that resecting the fibula, even with preservation of a 6-cm distal fibular stump, may lead to abnormal growth in children younger than 6 years old.…”