Long-term facial symmetry after pediatric mandibular reconstruction using the vascularized fibula free flap: A photogrammetric analysis.

BACKGROUND: The fibula free flap is the standard of care in the reconstruction of large mandibular defects in pediatric patients, enabling adequate restoration of the facial contour. However, the unpredictable growth potential of the reconstructed mandible could influence the preservation of the initially restored symmetry over time. Being mindful of the importance of facial appearance during developmental stages, this study aimed to evaluate the long-term facial symmetry after mandible reconstruction using this technique in growing patients. PATIENTS AND METHODS: A photogrammetric analysis of facial symmetry using the "Asymmetry Index" (AI) was performed from preoperative and postoperative frontal photographs in 17 pediatric patients (9 males and 8 females) who underwent mandibular reconstruction with the vascularized fibula free flap and had a minimum follow-up of 5 years. Comparisons between preoperative and postoperative measurements-as well as postoperative comparisons between condyle-reconstructed and condyle-preserved patients-were conducted. RESULTS: The mean follow-up was 76.9 (± 19.0) months (range, 60-120). The average age at intervention was 9.23 (± 3.8) years. Mean AI was 15.31 (± 1.81) preoperatively and 3.59 (± 0.97) postoperatively. Differences between preoperative and postoperative measurements were statistically significant in all the assessed parameters (p<0.001). Postoperative differences between the condyle-reconstructed and the condyle-preserved groups were not significant (p>0.05). No secondary procedures were required to enhance symmetry in the late postoperative period. CONCLUSIONS: Mandibular reconstruction using the vascularized fibula free flap provides adequate restoration of facial symmetry that could be predictably maintained throughout the developmental period in children and adolescents, regardless of the need for condylar reconstruction.

Speech and swallowing function following microsurgical reconstruction of palatal defects in a series of six pediatric patients.

BACKGROUND: Reconstruction of extensive palatal defects in growing patients aims to restore speech intelligibility and swallowing function while avoiding excessive scarring formation that may cause growth disturbances in the palate and midface region. Free flaps transfer healthy, well-vascularized tissue to the defect area, and their combination with pharyngeal flaps allow for restoration of the velopharyngeal function. We examined speech and swallowing after microsurgical palate reconstruction in a series of six pediatric patients. METHODS: Radial forearm free flaps were used in all cases, in combination with a superiorly based pharyngeal flap in five cases. Mean age at surgery was 10.7 years. Etiologies included recurrent oronasal fistula due to failed primary cleft palate repair (n = 4), embryonal rhabdomyosarcoma of the maxilla (n = 1), and inflammatory fibrous hyperplasia (n = 1). Speech evaluations (with the Hirose standard and listener ratings) and swallowing assessments (based on videofluoroscopy swallowing studies and patient-reported swallowing and diet) were performed in average 44 months postoperatively. RESULTS: All flaps survived without major postoperative complications. Speech intelligibility was graded as "excellent" in four patients and "moderate" in two. Hypernasality and nasal obstruction were each judged as "none/minimal" in five cases and "moderate" in one case. All patients tolerated oral diet without significant nasal regurgitation. In five of six patients, the swallowing assessment showed good motion and velopharyngeal closure. CONCLUSION: Microsurgical reconstruction of extensive palatal defects using radial forearm free flap, with or without a superiorly based pharyngeal flap, is a reliable technique that can deliver substantial improvement of speech and swallowing in pediatric patients.

Pediatric Mandibular Reconstruction Using the Vascularized Fibula Free Flap: Functional Outcomes in 34 Consecutive Patients.

BACKGROUND: The vascularized fibula free flap is a workhorse flap in pediatric mandibular reconstruction. This study aimed to address functional outcomes, complications, and morbidity associated with the fibula resection in a consecutive series of mandibular reconstruction using this technique in skeletally immature patients. METHODS: Functional outcomes in terms of maximal mouth opening capacity, patient-reported eating ability, occlusion, and gait were retrospectively reviewed in 34 consecutive pediatric patients (18 males, 16 females) who underwent mandibular reconstruction using the vascularized free fibula flap. Data regarding donor and recipient site complications were also retrieved. RESULTS: The mean follow-up period was 50.6 months (range, 12-108 months). The average age was 10.3 years (range, 2-15 years). Underlying pathologies included ossifying fibroma, ameloblastoma, mandibular arteriovenous malformation, fibrous dysplasia, Goldenhar syndrome, dentigerous cyst, mandibular lymphoma, odontogenic fibroma, adenomatoid odontogenic tumor, aneurysmal bone cyst, neurogenic sarcoma, and central giant cell granuloma. Defect length ranged from 8 to 17 cm. Mean return to normal ambulation was achieved 12 days postoperatively. All patients reported ability to eat solids and liquids, with 29 of 34 achieving normal mouth opening. Normal or minimally disturbed occlusion was maintained postoperatively in most patients. Temporomandibular joint ankylosis and condylar displacement were each developed in one patient. Two patients reported gait disturbances that receded after physical therapy. No other major donor site complications, including flexion contracture of the great toe, were identified. CONCLUSIONS: The vascularized fibula free flap is reaffirmed to be the criterion standard for mandible reconstruction in pediatric patients, providing satisfactory functional results and adequate adaptation to the growing facial skeleton with minimal sequelae. Complications regarding hallux function may be prevented by assessing the vascularity of the flexor hallucis longus intraoperatively and ensuring tension-free closure of the donor site.