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 demon- strated 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- ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 126, MAR 2000 WWW.ARCHOTO.COM 293 ©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.