Vascularized Fibular Graft for Facial Reconstruction in Pediatric Patients

Although vascularized bone grafts have become well-accepted in adults, especially following ablative head and neck procedures, there are few long-term reports in the pediatric patient. In this study, the authors analyzed the outcomes of 12 free bone grafts in 11 patients, whose records contained complete documentation and recent follow-up examinations.

Seven patients had cancer-related defects (resection alone, n =ߙ3; resection + XRT, n =ߙ4), four had congenital malformations (hemifacial microsomia, n =ߙ3; Najar syndrome, n =ߙ1), and one had a trauma-related defect. All congenital malformations had been followed since birth, and the others from the time of their original cancer diagnosis or injury. The most severe deformities were seen in those with cancer resections and radiation therapy. Most defects were hemimandibular, one total mandibular (a child with Ewing's sarcoma), and one maxillary. All but two of these children had one or more previous non-vascularized bone grafts. Three of these free transfers contained fibula in one or more segments, and nine included additional soft tissue components. All free tissue transfers were successful. There were no vascular problems. All transfers contained one arterial and two venous anastomoses. There was one return trip to the OR for a hematoma. The mean follow-up time is 5 years. The only donor site problem was transitory weakness of the FPL in three patients.

A number of lessons have been learned from a careful analysis of this unique group of patients, who continue to be followed through adolescence and adulthood. Vascularized fibular grafts are predictable and an excellent option following failed non-vascularized grafts. Radiated recipient vessels in the upper neck can be used. The fibula can be separated into one or more separate segments with or without soft tissue components. Double layered grafts should be used with osteointegrated implants for dental restoration. Longitudinal and vertical growth of these grafts does not occur. These grafts can be subsequently split or advanced. Fibular donor site problems are minimal. Postoperative morbidity is low due to the lack of associated medical problems or malformations in other organ systems.

Vascularized fibular bone grafts with or without accompanying soft tissue components can be safely and predictably performed for facial (re)construction in the pediatric patient. Preoperative emphasis should be placed on precise planning and technical execution. The outcomes of these procedures are often remarkable.