Reconstruction of the Pediatric Maxilla and Mandible

ORIGINAL ARTICLE Reconstruction of the Pediatric Maxilla and Mandible

Eric M. Genden, MD; Daniel Buchbinder, DMD, MD; John M. Chaplin, MBChB; Edgar Lueg, MD; Gerry F. Funk, MD; Mark L. Urken, MD

Background: The creation of osseous defects in the up- Results: Two patients were lost to follow-up, and 1 per and lower jaws in children is an uncommon occur- died secondary to complications related to distant meta- rence. It is therefore likely that a head and neck recon- static disease. Three of 6 patients were observed for 2 structive surgeon will accumulate only limited experience years 6 months, 4 years, and 4 years 2 months, respec- in restoring such defects. We have reviewed 7 pediatric tively. Two of the 3 patients who were observed long bone-containing microvascular free flap reconstruc- term have undergone full dental rehabilitation and cur- tions in 6 patients for reconstruction of the upper or lower rently maintain a regular diet and deny pain with masti- jaws. Three patients were available for long-term fol- cation or deglutition. One patient did not require dental low-up to evaluate the effect of osseous free flap recon- rehabilitation. All 3 patients demonstrate gross facial struction on function and growth and development of symmetry and normal dental occlusion. Assessment of the donor site. the fibular donor site demonstrated normal limb length and circumference. The patients denied pain or restric- Design: Retrospective review. tion to recreational activity. Scapular donor sites demonstrated normal range of motion, strength, and shoulder Setting: Academic tertiary referral center for otolaryn- stability. gology. Conclusions: Free flap reconstruction of the pediatric Patients and Methods: Six pediatric patients rang- maxilla and mandible requires harvesting bone from ac- ing in age from 8 to 16 years underwent 2 fibular, 4 scapu- tively growing donor sites. We have found no evidence lar, and 1 iliac free flap procedure for restoration of 2 max- of functional deficit after bone harvest from the fibular illary and 5 mandibular defects from 1992 to 1997. Three or scapular donor sites. Patients demonstrate normal of the 6 patients were available for long-term follow-up growth at the donor sites, and symmetry of the man- to assess the postoperative donor site function in an ef- dible and maxilla is preserved. fort to determine the effect of this surgery on long-term donor site morbidity and development. Arch Otolaryngol Head Neck Surg. 2000;126:293-300

ANDIBULAR and maxil- nor site and the mandibulofacial com- lary reconstruction in plex as a result of growth and develop- children is uncom- ment. mon. When faced with While many factors must be consid- this challenge, how- ered when choosing a donor site, there are Mever, it is essential that special consider- several issues that are unique to the devel- ation be given to issues related to the grow- oping child. The commonly used donor ing child to achieve optimal restoration of sites, including fibula, iliac, and scapula, all mastication, deglutition, and cosmesis. possess epiphyseal growth centers. An un- Similar to reconstruction of the adult man- derstanding of the anatomic location of dible, bone stock, soft tissue, and skin these growth centers and their role in nor- From the Departments of paddle design are important factors in ad- mal development is essential to prevent- Otolaryngology–Head and dressing the specific reconstructive re- ing long-term functional deficits. Simi- Neck Surgery, Mount Sinai quirements of the patient. In contrast to larly, the process of craniofacial School of Medicine, New York, NY (Drs Genden, Buchbinder, the adult patient, however, the pediatric development is a dynamic one where man- Lueg, and Urken and patient is growing. Surgical reconstruc- dibular, maxillary, and basicranial growth Mr Chaplin) and the University tion of the upper and lower jaws requires are intimately interrelated. The disrup- of Iowa College of Medicine, an understanding of the changes in bone tion of these relationships, as occurs with Iowa City (Dr Funk). and soft tissue architecture at both the do- a mandibular or maxillary resection, can re-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 PATIENTS, MATERIALS, shoulder rotation, pronation and supination, and a series of biceps, triceps, and shoulder strength exercises. Lower AND METHODS extremity iliac crest and fibula donor sites were evaluated with a full range of hip, knee, and ankle exercises. Limb The following is a retrospective review of 6 pediatric pa- length and circumference were assessed by an orthopedic tients who underwent mandibular or maxillary reconstruc- surgeon using standard limb measurement techniques. tion following ablative treatment for either benign or ma- Strength was not assessed. lignant disease from June 1992 until October 1997 at Mount Each of the 3 patients was asked the following ques- Sinai Medical Center, New York, NY. Patients were in- tions: (1) Do you presently have pain at the donor site dur- cluded in the review if they were aged 16 years or younger ing rest? (2) Do you have pain at the donor site during physi- and had undergone reconstruction of the maxilla or man- cal activity? (3) Is your participation in recreational activities/ dible with osteocutaneous free tissue transfers. Over a 5-year sports limited as a result of pain or restriction at the donor period, 6 pediatric patients underwent free flap reconstruc- site? (4) Does the scar at your donor site disturb you or tion of the maxilla or the mandible. Three of the 6 pa- affect your activity? and (5) Do you favor donor site arm/ tients were available for long-term follow-up. leg during physical activity? All 5 questions were admin- The surgical records of all 6 patients were reviewed istered to each of the 3 patients available for long-term fol- for factors pertaining to donor site selection, technical low-up. considerations, and reconstructive approach. The 3 Fibula donor sites were treated with a posterior plas- patients who were available for long-term follow-up were ter splint applied in the operating room and worn for 10 evaluated for donor site function, respectively, 4 years and days, after which the patient entered full weight-bearing 2 months, 4 years, and 2 years and 6 months postopera- physical rehabilitation. Closure of the scapular donor sites tively. Donor site strength and range of motion were were performed by reattaching the teres major and teres determined for the scapular donors by a physical thera- minor muscles to the cut edge of the lateral border of the pist, and for the fibula donor, by an orthopedic surgeon. scapula using nonabsorbable sutures. Scapular donor sites Range of motion, strength, and flexibility tasks were per- were treated by placing the donor site arm in a crossbody formed on the donor side and compared with the unaf- sling for 10 days. Mandibular and maxillary reconstruc- fected (control) side in all patients. This aspect of the tions were fixed with a titanium plating system and tita- evaluation included full shoulder and elbow adduction, nium screws. All patients had fixation hardware removed full shoulder and elbow abduction, medial and lateral between 12 and 18 months postoperatively.

sult in abnormal development of the midface, mandible, the defect but also the patient’s comorbidities,5 the and skull base, leading to profound long-term functional pediatric patient is usually healthy and in good nutri- consequences. Restoration of these relationships with free tional status. Issues related to long-term development at flap reconstruction, however, can reestablish mandibulo- the reconstructed site and at the donor site are the cen- maxillary occlusion and condylar-basicranial articula- tral concern. We have reviewed 7 microvascular recon- tion, thereby preventing abnormal craniofacial develop- structions of the upper or lower jaws in 6 pediatric ment. patients in an effort to elucidate factors such as donor In contrast to those of adults, most diseases affect- site selection, reconstructive approach, technical con- ing the upper and lower jaws of pediatric patients are be- siderations, and the role of osseointegrated implants, nign,1 requiring only narrow margins and in turn neces- which are unique to this population. We have also sitating minimal soft tissue reconstruction. In these cases, obtained long-term follow-up on 3 patients in the series options for reconstructing the jaw include vascularized of 6 to examine the long-term effects of free flap harvest composite flaps and nonvascularized bone grafts. Sarco- on donor site function. mas are the most common malignancies to involve the 2 mandible in this age group. While surgical resection plays RESULTS an important role in the treatment of this disease, in many cases these patients have been previously treated with che- The average age of our 6-patient cohort was 13.2 years, motherapy, radiation, or a combination of both. As a re- with a range of 8 to 16 years (Table). Five patients were sult, the recipient bed is often compromised with re- boys and 1 was a girl. All 6 patients were surgically gard to healing,3,4 thus limiting the application of adjacent treated and underwent reconstruction primarily at tissue transfer or bone grafts. While strategies to mini- Mount Sinai Medical Center except for patient 6, who mize the effect of chemotherapy and radiation on the heal- presented for a secondary reconstruction after receiving ing of soft tissue and growth of the craniofacial skeleton chemotherapy and external beam irradiation followed by have been investigated,3 under these circumstances free surgical resection for rhabdomyosarcoma at an outside vascularized tissue remains the most reliable source of hospital. Two patients were lost to follow-up (patients 1 bone and soft tissue. The selection of a reconstructive tech- and 3), and 1 (patient 2) died of complications related to nique that supplies adequate bone stock for the place- distant metastases. Patients 4, 5, and 6 were contacted ment of osseointegrated implants must be weighed against and evaluated postoperatively at 4 years 2 months, 4 the potential for donor site morbidity. years, and 2 years 6 months, respectively. Primary dis- In contrast to the adult patient, where the selection ease processes of the patients reviewed included rhabdo- of a donor site is based not only on the requirements of myosarcoma (1), osteogenic sarcoma (2), aggressive

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Patient No./Sex/Age, y Follow-up Diagnosis Resection Reconstruction, 10/20 Donor Site Dental Implant 1/M/15 4y6mo Osteogenic sarcoma Hemimaxillectomy 10 Scapula Yes, 10 2/M/16 NA Osteogenic sarcoma Hemimandible 10 Iliac/RFF No Scapula 3/F/11 1y6mo Fibrous dysplasia Hemimandible 10 Fibula Yes, 20 4/M/8† 4y2mo Aggressive juvenile fibromatosis Hemimandible 10 Fibula Yes, 20 5/M/15† 4 y Ossifying fibroma Hemimaxillectomy 10 Scapula Yes, 20 6/M/15† 2y6mo Rhabdomyosarcoma Hemimandible 20 Scapula No

*RFF indicates radial forearm free flap; NA, not available. †Patient was available for follow-up.

juvenile fibromatosis (1), ossifying fibroma (1), and operative course. One month postoperatively, he had no fibrous dysplasia (1). The 3 patients diagnosed with gait deficit or pain associated with the harvest site. malignant sarcoma had all received chemotherapy and Patients 4, 5, and 6 denied pain at rest or with physi- external beam irradiation prior to surgical reconstruc- cal activity at the donor site. None of the 3 patients fa- tion. vored the donor limb, and all felt the donor site scar did Two patients underwent reconstruction for maxil- not restrict their activity, nor was it cosmetically dis- lectomy defects using scapular osteocutaneous free flaps pleasing. Patient 4 related “discomfort and stiffness” in (patients 1 and 5) (Table). The remaining 4 patients were his ankle for nearly 2 years after the fibula harvest. How- treated for mandibular defects using fibular (patients 3 ever, he has become progressively more active and pres- and 4), scapular (patient 2 and 6), or iliac (patient 2) free ently reports “no limitations to recreation.” Patients 5 and flaps. Patient 2 was originally treated with an iliac os- 6, who underwent scapular reconstructions, denied shoul- teocutaneous free flap and a radial forearm free flap af- der pain or stiffness, and both demonstrated normal shoul- ter resection of a primary osteogenic sarcoma of the man- der strength, mobility, and range of motion. All 3 pa- dibular body. Resection of a large segment of skin of the tients are currently active in recreational and school- mentum and anterior neck resulted in a larger-than- related sports, and all report being satisfied with their expected soft tissue defect. Although a large iliac skin current state of rehabilitation. All 3 patients observed long- paddle was harvested, a radial forearm free flap was re- term maintain a full diet without restrictions. All deny quired to prevent contracture and malposition of the lower pain or discomfort with mastication or swallowing. lip. A recurrence adjacent to the posterior osteotomy in the ascending ramus 18 months postoperatively re- CASE 1 quired a second resection and reconstruction with an osteocutaneous scapular free flap. No patient experienced Patient 4 was 8 years old at the time of resection of an an intraoperative or postoperative head and neck or do- aggressive juvenile fibromatosis lesion involving the left nor site complication. hemimandible (Figure 1). The resection involved ab- Dental implants were placed primarily in patient 1 lation of the ramus, body, and hemisymphyseal por- and secondarily in patients 3, 4, and 5. Implants were tions of the mandible. The lingual and hypoglossal nerves successfully secured without bone augmentation in pa- were preserved; however, the mental branch of the tri- tients 4 and 5; however, patient 3 was an 11-year-old girl geminal nerve was resected with the specimen. A pri- with a small-diameter fibula requiring a “double barrel- mary nerve graft was performed using a greater auricu- ing” technique.6 To perform this technique, one third of lar nerve graft. Reconstruction of the defect was performed the circumferential cortical bone was removed from the with a contralateral fibular free flap and osseointegrated fibula and a midpoint transverse osteotomy was per- implants were placed primarily (Figure 2). A panorex formed in which the fibula was folded on itself and se- radiograph taken 6 months postoperatively demon- cured with lag screws. This roughly doubled the area of strated bony union (Figure 3). A photograph of the pa- bone stock, allowing for the secure placement of osseo- tient taken 4 years postoperatively demonstrated sym- integrated implants. metrical growth of the lower third of the face (Figure 4). The scapular bone used for palatomaxillary recon- Mandibular reconstruction plates were removed 18 struction in patient 1 required onlay iliac bone grafts to months postoperatively. augment the bone stock and successfully secure osseointegrated implants. These nonvascularized onlay grafts CASE 2 were harvested through a separate incision adjacent to the anterior-superior iliac crest. Patient 5 was 15 years old at the time of resection of an All 6 patients had unremarkable immediate post- ossifying fibroma of the left hemipalate and maxilla operative recoveries with well-controlled pain manage- (Figure 5). A scapular osteocutaneous free flap was used ment and physical therapy instituted by postoperative day to reconstruct this defect. The proximal lateral scapular 7. Patient 2, who was the only patient to undergo an iliac border was used as a vertical buttress, and the distal scapu- crest free flap reconstruction, had an unremarkable post- lar tip, based on the angular artery, was used to recon-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Figure 3. Panorex radiograph taken 4 years postoperatively, demonstrating symmetrical mandibular development in patient 4 (case 1).

Figure 1. Axial computed tomographic scan of patient 4 (case 1), demonstrating a destructive lesion involving the left hemimandible (aggressive juvenile fibromatosis).

Figure 4. Postoperative photograph taken 4 years and 2 months after fibular reconstruction of the left mandible, demonstrating facial symmetry in patient 4 (case 1).

tion (Figure 6). Four years postoperatively, the patient demonstrated symmetrical facial growth (Figure 7). There is minimal donor site scar contracture and the patient has no restriction in shoulder mobility.

COMMENT Normal craniofacial development is dependent on the relationships between the mandible and maxilla. A disruption in this relationship prior to mandibulofacial epiphyseal fusion, which occurs between the ages of 13 and 18 years, can result in profound midface deformity. Osseous reconstruction of maxillary and mandibular postablative defects may prevent developmental facial deformity; however, one must carefully consider the risk of harvesting bone Figure 2. Intraoperative photograph of patient 4 (case 1), demonstrating the fibula reconstruction of the left mandible with osseointegrated implants from a growing child. Essential in choosing a donor site in place. for pediatric maxillary or mandibular reconstruction is an understanding of the growth centers and the morbidity associated with each of the donor site options. struct the palate. A bilobed scapular/parascapular skin Mesenchymal in origin, bone is a living tissue mak- paddle was designed such that one skin paddle was used ing up the majority of the human skeleton. The cranio- to reline the intraoral palatal defect, and the other to re- facial skeleton, including the mandible, grows through line the nasal cavity. Osseointegrated implants were placed 2 mechanisms: epiphyseal proliferation and remodel- secondarily to permit functional prosthetic rehabilita- ing. Epiphyseal proliferation is largely responsible for in-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Figure 6. Reconstructed maxilla of patient 5 (case 2) after placement of osseointegrated implants.

mal craniofacial development, such that unrecon- structed defects of the pediatric maxilla can lead to substantial disturbances in facial growth. Normal max- Figure 5. Intraoperative photograph of palatomaxillary defect in patient 5 illary width occurs as a result of bony accretion at the (case 2) after resecting an ossifying fibroma. suture lines and resorption at the lateral nasal wall. Ver- tical growth of the midface is the combined result of down- creases in bone length and projection, a process that is ward displacement of the maxilla and remodeling at the dominant during the first 18 years of life. After age 18, bone surfaces. Fusion between the palatine processes oc- the epiphyseal plate, located in the proximal zone of the curs at age 18 years, and there are no endochondral growth conical subcondylar ridge, fuses. Prior to fusion, it ex- plates in the maxilla because all growth occurs as a re- ists as a 3-dimensional structure that, under the influ- sult of osteogenic activity at the suture lines. Girls com- ence of the surrounding soft tissues, is essential to nor- plete vertical growth at about age 14 years and boys reach mal mandibular projection. The epiphysis adapts the maturity 2 years thereafter. intercondylar distance to the widening cartilaginous syn- Fibular growth, which has been studied quite ex- chondrosis of the cranial base, highlighting the ever- tensively, occurs in a classic endochondral pattern be- important relationship between normal mandibular cause the 3 ossification centers, 1 in the shaft and 1 in growth and normal basicranial development. The role of each of the distal and proximal epiphyses, are respon- epiphyseal growth, particularly in the prepubescent pe- sible for proportionate growth. The growth plates lie diatric patient, cannot be overemphasized. within 1 to 2 cm of each end of the bone, proximal and However, bone remodeling plays an equally impor- distal to where a harvesting osteotomy should be made. tant part in mandibular contour and symmetry. In con- Most growth occurs in the proximal epiphyseal plate, trast to epiphyseal growth, remodeling is a process that which fuses by age 15 for girls and age 17 for boys.9 Simi- occurs throughout adulthood. Downward and forward lar to the adult’s, the pediatric patient’s fibula offers the projection of the mandible occurs through deposition of longest segment of bone of the 3 donor sites; however, bone at the posterior margin of the ramus and corre- the stock of bone, particularly in patients under the age sponding resorption at the anterior margin (Figure 8). of 13, may lack the height appropriate to stabilize osseo- Likewise, mandibular contour and width occur as a func- integrated implants. As demonstrated in case 1, a por- tion of buccal bone deposition and concomitant lingual tion of the cortex of the fibula can be cut away at the sur- resorption (Figure 8). The 2 processes of epiphyseal face and the fibula can be double barreled6 by creating a growth and bone remodeling occur in different areas midpoint osteotomy and folding the bone on itself. This within the same bone simultaneously, and there is no his- results in an increase in the bone height and a more stable tological difference in new bone created by either pro- foundation for osseointegrated implants. The double- cess. While epiphyseal fusion occurs in early adoles- barreled fibula can be secured on itself by placing a ver- cence, remodeling continues throughout adult life largely tical lag screw or circumosseous wires at each end of the in response to the mechanical stress applied by the muscles complex. While the epiphyseal plates were not trans- of mastication.7,8 Understanding these principles is im- ferred in the cases reported herein, the fibula will con- portant to surgical reconstruction because disruption of tinue to grow with the adjacent native mandible,10-13 which the mandible prior to epiphyseal fusion may result in a allows for reliable healing and volume retention. It has different long-term developmental defect than a similar been shown experimentally11,14 that transferred epiphy- surgical disruption after epiphyseal fusion. It is also im- seal plates retain the potential for growth. Although it portant to recognize that girls reach mature mandibular has not been reported clinically, this may serve as a po- height and depth at a mean age of 13 on average, 2 to 5 tential source for condylar reconstruction in the prepu- years earlier than boys. bescent pediatric patient. Finally, the occlusal interaction between the max- Harvesting the fibula from a growing limb has raised illa and the mandible is of paramount importance for nor- concerns among reconstructive surgeons; however, there

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Figure 7. Left, Frontal view of patient 5 (case 2) 4 years after palatomaxillary reconstruction with scapular free flap demonstrating normal facial symmetry. Right, Oblique view of the same patient 4 years after palatomaxillary reconstruction with scapular free flap, demonstrating normal facial contour.

pain or restriction in the donor limb at the time of follow-up and reported no difficulties during activities of recreation or daily living. Furthermore, the patient denied any restriction in his ability to participate in sports (ie, running and jumping). Unlike the fibula, the scapula is a flat membranous bone. The lateral scapular border and scapular tip develop from a large osteocartilaginous epiphyseal plate. At birth, the inferior 7 to 8 cm is composed entirely of hya- line cartilage. Ossification proceeds in a superior to inferior pattern until approximately age 10, when the scapula is roughly 12 cm long and the distal epiphysis has de- creased to 4 cm (Figure 9). A smaller but equally important growth plate exists superiorly, adjacent to the glenoid fossa.16 Mainly responsible for vertical scapular growth, the superior growth plate lies outside the range of harvested bone, and therefore should not be directly affected. Both superior and inferior growth plates fuse at age 20 re- Figure 8. Growth of the pediatric mandible. Downward and anterior sulting in a disruption of the normal scapular develop- projection of the mandible results from growth at the epiphyseal plates ment by harvesting bone from the lateral border of the located within the condylar neck. Lingual bone resorption (black arrows) and scapula in the pediatric patient. The lateral border of the buccal bone deposition (small white arrows) are responsible for contour and width. Large white arrows indicate the axis of condylar epiphyseal growth. scapula serves as a traction epiphysis, growing in response to pull of the teres and triceps muscle groups.14 Teot et al16 found that harvesting bone from this area for con- is little clinical evidence suggesting that long-term limb genital limb reconstruction resulted in a moderate scapu- growth is adversely affected. Experimental evidence in lar size discrepancy, but no appreciable functional deficit. rats demonstrates that the fibula exerts a restrictive ef- They concluded that the upper growth plate compensates fect on tibial growth such that removal of the fibula leads for disruption of the lateral scapular border, although there to longitudinal tibial overgrowth.13 However, clinically, is no objective data to support this claim. Similarly, our pa- leg length discrepancy has not been demonstrated and tients demonstrated no functional deficit with regard to ob- did not occur in our patient. The most substantial de- jective measurements in strength and/or range of motion. layed complication associated with fibula harvest, par- When asked about activity, they described no restrictions ticularly in children younger than 9 years, is a valgus de- or pain. When asked to compare the affected side with the formity at the donor ankle.15 While our patient did not contralateral shoulder, they related little or no difference demonstrate this complication, Omokawa et al15 have during activities of recreation (ie, throwing a ball, lifting a found that performing a synostosis at the time of the har- heavy object) or daily living. vest prevented valgus deformity in 90% of patients While the adult scapula has been shown to accom- younger than 8 years. The patient in our series denied modate osseointegrated implants,17 the pediatric scapula

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Figure 9. Ossification centers of the scapula are located at the medial scapular border and the glenoid fossa (darkened areas). The lateral border serves as a traction epiphysis.

may be quite thin and limit the stability of implants. To facilitate implant stability, iliac crest bone onlay grafts were used in patient 1 to augment the scapular bone dur- Figure 10. The iliac ramus serves as a major ossification center in the ing the secondary placement of osseointegrated im- pediatric ilium (darkened area). Disturbance of growth in this region may plants. Both patients underwent successful implants and have profound effects on the development of normal gait stability. maintain an unrestricted regular diet. The entire length of the iliac crest, from the anterior- superior to the posterior-superior iliac spines, is composed of cartilage at birth. Growth occurs in an epiphy- tion of acquired and congenital limb abnormalities, there seal fashion in several areas of the pelvic girdle, including is little reported on the long-term growth of the trans- the acetabulum and the iliac crest, which grow until the ferred bone after mandibular and maxillary reconstruc- second decade of life (Figure 10). The mechanical de- tion in the pediatric population. There is good evidence mands applied to the pelvis by both its upper and lower to support the preservation of osteocyte viability after the muscular attachments play an active role in pelvic re- transfer of non–epiphyseal-containing vascularized modeling, which occurs into young adulthood. Like the bone,10-13 but the bone growth may be unpredictable. lateral scapular border, the crest serves as a traction While experimental evidence supports the hypothesis that epiphysis where the dynamic interaction between the iliac vascularized membranous bone grafts transferred to the crest and its muscle attachments plays a crucial role in mandible and zygomaticomaxillary defects in immature acetabular development, and hence gait stability. Dis- animals contribute to normal craniofacial development turbance of gait after iliac crest free flap harvest in the in a more predictable fashion than nonvascularized bone adult population has been documented in up to 11% of grafts,21 there is little evidence to support this clinically. patients.18,19 Boyd20 described only minimal donor site Similarly, it has been suggested that a linear relation- morbidity in his series of iliac crest free flaps on young ship between bone stress and bone growth8 may be re- adults. However, his population ranged in age from 16 sponsible for symmetrical growth of the transplanted bone, to 27. The probability of profound gait disturbance in a but again, this relationship remains only speculative. In younger age group has discouraged surgeons from us- our patients, gross symmetrical maxillary and mandibu- ing this donor site for reconstruction, and as a result, there lar growth has occurred in reconstructions with both are no reported series of iliac crest free flap reconstruc- scapular and fibular free flaps. The advantage of pri- tions in the pediatric population. We performed 1 case mary bone-containing free flap reconstruction is borne of mandibular reconstruction using the iliac crest free flap; out by the preservation of normal occlusal relationships however, this patient was not available for long-term fol- throughout the patient’s development. As discussed ear- low-up. During the immediate postoperative course, this lier, failure to reestablish maxillomandibular occlusion patient was ambulatory and actively participating in physi- will lead to abnormal maxillofacial growth and maloc- cal therapy. clusion. This was not apparent in our series of patients, Although fibular and scapular grafts have been used but we have not performed serial radiological evalua- quite extensively by plastic surgeons for the reconstructions and standard cephalometrics, an evaluative pro-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 cess that is necessary to draw a conclusion regarding do- 6. Horiuchi K, Hattori A, Inada I, et al. Mandibular reconstruction using the double nor bone growth and craniofacial development. barrel fibular graft. Microsurgery. 1995;16:450-454. 7. Thilander B. Basic mechanisms in craniofacial growth. Acta Odontol Scand. 1995; Finally, long-term follow-up of 3 pediatric patients 53:144-151. undergoing reconstruction with a single fibular and 2 8. Kiliaridis S, Bresin A, Holm J, et al. Effects of masticatory muscle function on bone scapular free flaps demonstrates that there is no evidence mass in the mandible of the growing rat. Acta Anat (Basel). 1996;155:200-205. of physical developmental abnormalities as a result of the 9. Prichett JW. Growth and growth prediction of the fibula. Clin Orthop. 1997;334: free tissue harvest. A larger series with serial radio- 251-256. 10. Weiland AJ, TW Phillips, Randolph MA. Bone grafts: a radiologic, histologic, and graphic assessment of the reconstructed site is necessary biomechanical model comparing autografts, allografts, and free vascularized bone to derive a conclusion regarding the growth of trans- grafts. Plast Reconstr Surg. 1984;74:368-379. planted bone and its effect on maxillofacial development. 11. Donski PK, GR Carwell, LA Sharzer. Growth in revascularized bone grafts in young puppies. Plast Reconstr Surg. 1979;64:239-243. Accepted for publication January 3, 2000. 12. Mizumoto S, Tamai S, Goshima J, et al. Experimental study of vascularized tibio- fibula graft in inbred rats: a preliminary report. J Reconstr Microsurg. 1986;3:1-11. Presented at the annual meeting of the American Head 13. Tamai S. Experimental vascularized bone transplantations. Microsurgery. 1995; and Neck Society, Palm Desert, Calif, April 24, 1999. 16:179-185. Reprints: Eric M. Genden, MD, Mount Sinai School of 14. Teot L, Bosse JP, Gilbert A, Tremblay GR. Pedicle graft epiphysis transplanta- Medicine, Department of Otolaryngology–Head and Neck tion. Clin Orthop. 1983;180:206-218. Surgery, Box 1189, 1 Gustave Levy Pl, New York, NY 10029 15. Omokawa S, Tamai S, Takakura Y, Yajima H, Kawanishi K. A long-term study of the donor-site ankle after vascularized fibula grafts in children. Microsurgery. (e-mail: [email protected]). 1996;17:162-166. 16. Teot LF. Souyris J, Bosse P. Pedicle scapular apophysis transplantation in con- REFERENCES genital limb malformations. Ann Plast Surg. 1992;29:332-340. 17. Moscoso JF, Keller J, Genden E, et al. Vascularized bone flaps in oromandibular reconstruction: a comparative anatomic study of bone stock from various do- 1. Keszler A, Guliemotti MB, Dominguez F. Oral pathology in children: frequency, nor sites to assess suitability for enosseous dental implants. Arch Otolaryngol distribution, and clinical significance. Acta Odontol Latinoam. 1990;5:39-48. Head Neck Surg. 1994;120:36-43. 2. Wanebo H, Koness J, MacFarlane J, et al. Head and neck sarcoma: report of the 18. Forrest C, Boyd B, Manktelow R, Zuker R, Bowen V. The free vascularised iliac head and neck sarcoma registry. Head Neck. 1992;14:1-7. crest tissue transfer: donor site complications associated with eighty-two cases. 3. Fromm M, Littman P, Raney RB, et al. Late effects after treatment of twenty chil- Br J Plast Surg. 1992;45:89-93. dren with soft tissue sarcomas of the head and neck: experience at a single in- 19. Beirne JC, Barry HJ, Brady FA, Morris VB. Donor site morbidity of the anterior stitution and review of the literature. Cancer. 1986;57:2070-2076. iliac crest following cancellous bone harvest. Int J Oral Maxillofac Surg. 1996; 4. Jaffe N, Toth B, Hoar R, et al. Dental and maxillofacial abnormalities in the long- 25:268-271. term survivors of childhood cancer: effects of treatment with chemotherapy and 20. Boyd JB. Mandibular reconstruction in the young adult using free vascularized radiation to the head and neck. Pediatrics. 1984;73:816-823. iliac crest. Microsurgery. 1988;9:141-149. 5. Urken ML, Buchbinder D, Costintino PD, et al. Oromandibular reconstruction us- 21. Antonyshyn O, Colcleugh RG, Anderson C. Growth potential in suture bone inlay ing microvascular composite flaps: report of 201 cases. Arch Otolaryngol Head grafts: a comparison of vascularized and free calvarial bone grafts. Plast Recon- Neck Surg. 1998;124:46-55. str Surg. 1987;79:1-11.

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