Composite Microvascular Free Tissue Transfer for Congenital and Acquired Craniofacial Deformities in the Pediatric Population

Statement of Problem:

Traditionally, pediatric craniomaxillofacial reconstruction was driven by non vascularized bone grafts and then later distraction osteogenesis. Although  beneficial, these techniques were prone to problems, particularly relapse and graft resorption. Oftentimes, patients reconstructed primarily with costochondral grafts required multiple subsequent operations to reconstruct the mandible and temporomandibular joint secondary to near total graft resorption.  We propose the use of the free fibula flap in conjunction with adjunctive procedures (orthognathic surgery, temporomandibular joint reconstruction or maxillofacial prosthetics) to successfully treat young patients with complex craniofacial asymmetries who have failed previous operations.

Methods:

A retrospective chart review at NYU Langone Medical Center was completed to identify patients under 18 years of age who underwent free fibula flap reconstruction for congenital or acquired asymmetric craniofacial deformities from 2010-2013. All patients were previously treated with non-vascularized grafts prior to free tissue transfer.  A total of 7 patients were treated for hemifacial microsomia, Pruzansky III (HFM) (n=4), Treacher Collins syndrome (n=1), Ectodermal dysplasia (n=1), and orbital osteoradionecrosis (n=1). Computer aided design and virtual surgical planning was implemented in all cases. For the 4 patients with HFM, reconstruction of the hypoplastic mandible with the fibula flap was performed in conjunction with maxillary and/or mandibular orthognathic surgery. One of those patients also underwent concomitant total prosthetic replacement of the contralateral TMJ. 5 patients underwent concomitant dental implant placement into the fibula, while 1 patient received a post operative orbital prosthesis. Frameless stereotaxy was used in 3 cases to aid in placement of the proximal fibula. Post operative physical examination and computed tomography was used to evaluate flap position and correction of asymmetry.

Results:

All patients were reconstructed successfully with this method without any flap failures or complications. Patient age ranged from 11-18 with a mean age of 15. The longest follow up time was 34 months with a mean of 18 months. The four patients undergoing concomitant orthognathic surgery required pre and post operative orthodontics. All patients reported satisfaction in their reconstruction.  All patients had a stable and reproducible occlusion post operatively with 4 patients requiring 2-4 weeks of guiding elastic therapy. 4 patients required revision surgery for flap debulking, scar revision or hardware removal.

Conclusion:

The fibula flap can be implemented to successfully correct complex congenital and acquired craniofacial asymmetries and may be used in conjunction with orthognathic surgery, total joint replacement, dental implants. and/or maxillofacial prosthetics for definitive treatment of these defects. In this cohort, all patients had multiple failed operations prior to successful microsurgical reconstruction. In our experience, computer assisted design and virtual planning is essential in achieving the above described results while maintaining appropriate operative times.

Guo, L., N. F. Ferraro, et al. (2008). "Vascularized fibular graft for pediatric mandibular reconstruction." Plastic and Reconstructive Surgery 121(6): 2095-2105.

Warren, S. M., L. J. Borud, et al. (2007). "Microvascular reconstruction of the pediatric mandible." Plastic and Reconstructive Surgery 119(2): 649-661.