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Semin Plast Surg 2023; 37(04): 231-239
DOI: 10.1055/s-0043-1776698
Review Article

Pediatric Microsurgery and Free-Tissue Transfer

Heather R. Burns
1   Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
2   Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
,
Anna J. Skochdopole
1   Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
2   Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
,
Richardo Alfaro Zeledon
1   Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
2   Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
,
William C. Pederson
1   Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
2   Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
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Abstract

Advancements in microsurgery, along with increased microsurgical experience in pediatric patients, have made free-tissue transfer a reliable modality for pediatric bone and soft tissue reconstruction today. Free-tissue transfer is most commonly used in children for the coverage of large or complex defects resulting from traumatic, oncologic, or congenital etiologies. While flap success and complication rates between pediatric and adult populations are similar, special considerations must be taken into account within the pediatric population. In this article, we will describe common indications, technical nuances, and clinical considerations for the management of the pediatric free-tissue transfer patient.

Keywords

pediatric plastic surgery - pediatric microsurgery - free-tissue transfer


Publication History

Article published online:
16 November 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Harii K, Ohmori K. Free groin flaps in children. Plast Reconstr Surg 1975; 55 (05) 588-592
    CrossrefPubMedGoogle Scholar
  • 2 Gilbert A. Reconstruction of congenital hand defects with microvascular toe transfers. Hand Clin 1985; 1 (02) 351-360
    CrossrefPubMedGoogle Scholar
  • 3 Shapiro J, Akbarnia BA, Hanel DP. Free tissue transfer in children. J Pediatr Orthop 1989; 9 (05) 590-595
    CrossrefPubMedGoogle Scholar
  • 4 Canales F, Lineaweaver WC, Furnas H. et al. Microvascular tissue transfer in paediatric patients: analysis of 106 cases. Br J Plast Surg 1991; 44 (06) 423-427
    CrossrefPubMedGoogle Scholar
  • 5 Devaraj VS, Kay SP, Batchelor AG, Yates A. Microvascular surgery in children. Br J Plast Surg 1991; 44 (04) 276-280
    CrossrefPubMedGoogle Scholar
  • 6 Aboelatta YA, Aly HM. Free tissue transfer and replantation in pediatric patients: technical feasibility and outcome in a series of 28 patients. J Hand Microsurg 2013; 5 (02) 74-80
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Upton J, Guo L. Pediatric free tissue transfer: a 29-year experience with 433 transfers. Plast Reconstr Surg 2008; 121 (05) 1725-1737
    CrossrefPubMedGoogle Scholar
  • 8 Spoerl S, Schoedel S, Spanier G. et al. A decade of reconstructive surgery: outcome and perspectives of free tissue transfer in the head and neck. Experience of a single center institution. Oral Maxillofac Surg 2020; 24 (02) 173-179
    CrossrefPubMedGoogle Scholar
  • 9 Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007; 119 (07) 2092-2100
    CrossrefPubMedGoogle Scholar
  • 10 Nakatsuka T, Harii K, Asato H. et al. Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection. J Reconstr Microsurg 2003; 19 (06) 363-368 , discussion 369
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Khouri RK, Cooley BC, Kunselman AR. et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102 (03) 711-721
    CrossrefPubMedGoogle Scholar
  • 12 Pires GR, Moss WD, Memmott S. et al. Analysis of readmissions and reoperations in pediatric microvascular reconstruction. J Reconstr Microsurg 2023; 39 (05) 343-349
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Dempsey RF, Chelius Jr DC, Pederson WC. et al. Pediatric craniomaxillofacial oncologic reconstruction. Clin Plast Surg 2019; 46 (02) 261-273
    CrossrefPubMedGoogle Scholar
  • 14 Rashid HU, Rashid M, Rehman IU. et al. Comparison of microvascular free tissue transfer in adult and pediatric patients. J Ayub Med Coll Abbottabad 2019; 31 (02) 156-161
    PubMedGoogle Scholar
  • 15 Liu S, Zhang WB, Yu Y. et al. Free flap transfer for pediatric head and neck reconstruction: what factors influence flap survival?. Laryngoscope 2019; 129 (08) 1915-1921
    CrossrefPubMedGoogle Scholar
  • 16 Alkureishi LWT, Purnell CA, Park P, Bauer BS, Fine NA, Sisco M. Long-term outcomes after pediatric free flap reconstruction. Ann Plast Surg 2018; 81 (04) 449-455
    CrossrefPubMedGoogle Scholar
  • 17 Jacob LM, Dong W, Chang DW. Outcomes of reconstructive surgery in pediatric oncology patients: review of 10-year experience. Ann Surg Oncol 2010; 17 (10) 2563-2569
    CrossrefPubMedGoogle Scholar
  • 18 Starnes-Roubaud MJ, Hanasono MM, Kupferman ME, Liu J, Chang EI. Microsurgical reconstruction following oncologic resection in pediatric patients: a 15-year experience. Ann Surg Oncol 2017; 24 (13) 4009-4016
    CrossrefPubMedGoogle Scholar
  • 19 Izadpanah A, Moran SL. Pediatric microsurgery: a global overview. Clin Plast Surg 2017; 44 (02) 313-324
    CrossrefPubMedGoogle Scholar
  • 20 Bentz M, Bauer BS, Zuker RM. Principles & Practice of Pediatric Plastic Surgery. Vol 1. Quality Medical Publishing, Inc.; 2008
    Google Scholar
  • 21 Morales-Chávez M, Ortiz-Rincones MA, Suárez-Gorrin F. Surgical techniques for smile restoration in patients with Möbius syndrome. J Clin Exp Dent 2013; 5 (04) e203-e207
    CrossrefPubMedGoogle Scholar
  • 22 Amer TA. A single hypoglossal nerve for bilateral smile reconstruction in Möbius syndrome. J Craniofac Surg 2010; 21 (06) 1926-1927
    CrossrefPubMedGoogle Scholar
  • 23 Serletti JM, Schingo Jr VA, Deuber MA, Carras AJ, Herrera HR, Reale VF. Free tissue transfer in pediatric patients. Ann Plast Surg 1996; 36 (06) 561-568
    CrossrefPubMedGoogle Scholar
  • 24 Coombs CJ, Ek EW, Wu T, Cleland H, Leung MK. Masseteric-facial nerve coaptation: an alternative technique for facial nerve reinnervation. J Plast Reconstr Aesthet Surg 2009; 62 (12) 1580-1588 DOI: 10.1016/j.bjps.2008.05.046. . PMID: 18842469.
    CrossrefPubMedGoogle Scholar
  • 25 Abi-Rafeh J, Jaberi M, Cattelan L, Aljerian A, Gilardino MS. Soft-tissue reconstruction in progressive hemifacial atrophy: current evidence and future directions. Plast Reconstr Surg 2022; 150 (03) 607-617
    CrossrefPubMedGoogle Scholar
  • 26 Schultz KP, Dong E, Truong TA, Maricevich RS. Parry Romberg syndrome. Clin Plast Surg 2019; 46 (02) 231-237
    CrossrefPubMedGoogle Scholar
  • 27 Slack GC, Tabit CJ, Allam KA, Kawamoto HK, Bradley JP. Parry-Romberg reconstruction: optimal timing for hard and soft tissue procedures. J Craniofac Surg 2012; 23 (7, Suppl 1): 1969-1973
    CrossrefPubMedGoogle Scholar
  • 28 Baek R, Heo C, Kim BK. Use of various free flaps in progressive hemifacial atrophy. J Craniofac Surg 2011; 22 (06) 2268-2271
    CrossrefPubMedGoogle Scholar
  • 29 Colen DL, Lin IC, Levin LS, Chang B. Radial longitudinal deficiency: recent developments, controversies, and an evidence-based guide to treatment. J Hand Surg Am 2017; 42 (07) 546-563
    CrossrefPubMedGoogle Scholar
  • 30 Vilkki SK. Vascularized metatarsophalangeal joint transfer for radial hypoplasia. Semin Plast Surg 2008; 22 (03) 195-212
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Vilkki SK, Paavilainen P. Vascularized second metatarsophalangeal joint transfer for radial deficiency—an update. J Hand Surg Eur Vol 2018; 43 (09) 907-918
    CrossrefPubMedGoogle Scholar
  • 32 Pike JM, Manske PR, Steffen JA, Goldfarb CA. Ulnocarpal epiphyseal arthrodesis for recurrent deformity after centralization for radial longitudinal deficiency. J Hand Surg Am 2010; 35 (11) 1755-1761
    CrossrefPubMedGoogle Scholar
  • 33 Kobayashi K, Nakao K, Kishishita S. et al. Vascular malformations of the head and neck. Auris Nasus Larynx 2013; 40 (01) 89-92
    CrossrefPubMedGoogle Scholar
  • 34 Nair SC, Spencer NJ, Nayak KP, Balasubramaniam K. Surgical management of vascular lesions of the head and neck: a review of 115 cases. Int J Oral Maxillofac Implants 2011; 40 (06) 577-583
    CrossrefPubMedGoogle Scholar
  • 35 Madani H, Farrant J, Chhaya N. et al. Peripheral limb vascular malformations: an update of appropriate imaging and treatment options of a challenging condition. Br J Radiol 2015; 88 (1047): 20140406
    CrossrefPubMedGoogle Scholar
  • 36 Shimizu F, Kato A, Uehara M, Oatari M. Successful reconstruction after radical resection of arteriovenous malformation of the finger and toe using microsurgery. JPRAS Open 2015; 5: 34-40
    CrossrefPubMedGoogle Scholar
  • 37 Lickstein LH, Bentz ML. Reconstruction of pediatric foot and ankle trauma. J Craniofac Surg 2003; 14 (04) 559-565
    CrossrefPubMedGoogle Scholar
  • 38 Rinker B, Valerio IL, Stewart DH, Pu LLQ, Vasconez HC. Microvascular free flap reconstruction in pediatric lower extremity trauma: a 10-year review. Plast Reconstr Surg 2005; 115 (06) 1618-1624
    CrossrefPubMedGoogle Scholar
  • 39 Abdelrahman H, Khan NA, El-Menyar A. et al. All-terrain vehicle (ATV)-related injuries among different age groups: insights from a 9-year observational study. Eur J Trauma Emerg Surg 2022; 48 (06) 4971-4981
    CrossrefPubMedGoogle Scholar
  • 40 Boyd LC, Bond GA, Hamidian Jahromi A, Kozusko SD, Kokkalis Z, Konofaos P. Microvascular reconstruction of pediatric lower extremity trauma using free tissue transfer. Eur J Orthop Surg Traumatol 2019; 29 (02) 285-293
    CrossrefPubMedGoogle Scholar
  • 41 Taran SJ, Taran R, Malipatil NB. Pediatric osteosarcoma: an updated review. Indian J Med Paediatr Oncol 2017; 38 (01) 33-43
    Article in Thieme ConnectPubMedGoogle Scholar
  • 42 Pederson WC, Person DW. Long bone reconstruction with vascularized bone grafts. Orthop Clin North Am 2007; 38 (01) 23-35 , v
    CrossrefPubMedGoogle Scholar
  • 43 Kurlander DE, Shue S, Schwarz GS, Ghaznavi AM. Vascularized fibula epiphysis transfer for pediatric extremity reconstruction: a systematic review and meta-analysis. Ann Plast Surg 2019; 82 (03) 344-351
    CrossrefPubMedGoogle Scholar
  • 44 Shammas RL, Avashia YJ, Farjat AE. et al. Vascularized fibula-based physis transfer: a follow-up study of longitudinal bone growth and complications. Plast Reconstr Surg Glob Open 2017; 5 (05) e1352
    CrossrefPubMedGoogle Scholar
  • 45 Zelenski N, Brigman BE, Levin LS, Erdmann D, Eward WC. The vascularized fibular graft in the pediatric upper extremity: a durable, biological solution to large oncologic defects. Sarcoma 2013; 2013: 321201
    CrossrefPubMedGoogle Scholar
  • 46 Wolf R, Ringel B, Zissman S. et al. Free flap transfers for head and neck and skull base reconstruction in children and adolescents—early and late outcomes. Int J Pediatr Otorhinolaryngol 2020; 138: 110299
    CrossrefPubMedGoogle Scholar
  • 47 Allam O, Shah R, Cadwell JB. et al. Evaluation of complication rates of free flap reconstruction in pediatric patients. J Indian Assoc Pediatr Surg 2022; 27 (04) 428-434
    PubMedGoogle Scholar
  • 48 Claes KE, Roche NA, Opsomer D, De Wolf EJ, Sommeling CE, Van Landuyt K. Free flaps for lower limb soft tissue reconstruction in children: systematic review. J Plast Reconstr Aesthet Surg 2019; 72 (05) 711-728
    CrossrefPubMedGoogle Scholar
  • 49 Pederson WC. Upper extremity microsurgery. Plast Reconstr Surg 2001; 107 (06) 1524-1537 , discussion 1538–1539, 1540–1543
    CrossrefPubMedGoogle Scholar
  • 50 Du W, Zhou W, Zhou L. et al. Donor-site morbidity of free fibula flap in pediatric patients: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2023; 83: 207-214
    CrossrefPubMedGoogle Scholar
  • 51 Azoury SC, Shammas RL, Othman S. et al. Outcomes following free fibula physeal transfer for pediatric proximal humerus reconstruction: an international multi-institutional study. Plast Reconstr Surg 2023; 151 (04) 805-813
    CrossrefPubMedGoogle Scholar
  • 52 Cho AM, Lopez J, Teven CM. et al. Outcomes in pediatric maxillofacial reconstruction with vascularized fibular flaps: a systematic review. J Craniofac Surg 2022; 33 (05) 1346-1351
    CrossrefPubMedGoogle Scholar
  • 53 Hubert DM, Low DW, Serletti JM, Chang B, Dormans JP. Fibula free flap reconstruction of the pelvis in children after limb-sparing internal hemipelvectomy for bone sarcoma. Plast Reconstr Surg 2010; 125 (01) 195-200
    CrossrefPubMedGoogle Scholar
  • 54 Brambrink AM, Evers AS, Avidan MS. et al. Isoflurane-induced neuroapoptosis in the neonatal rhesus macaque brain. Anesthesiology 2010; 112 (04) 834-841
    CrossrefPubMedGoogle Scholar
  • 55 Paule MG, Li M, Allen RR. et al. Ketamine anesthesia during the first week of life can cause long-lasting cognitive deficits in rhesus monkeys. Neurotoxicol Teratol 2011; 33 (02) 220-230
    CrossrefPubMedGoogle Scholar
  • 56 Bong CL, Allen JC, Kim JTS. The effects of exposure to general anesthesia in infancy on academic performance at age 12. Anesth Analg 2013; 117 (06) 1419-1428
    CrossrefPubMedGoogle Scholar
  • 57 Ing C, DiMaggio C, Whitehouse A. et al. Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics 2012; 130 (03) e476-e485
    CrossrefPubMedGoogle Scholar
  • 58 DiMaggio C, Sun LS, Li G. Early childhood exposure to anesthesia and risk of developmental and behavioral disorders in a sibling birth cohort. Anesth Analg 2011; 113 (05) 1143-1151
    CrossrefPubMedGoogle Scholar
  • 59 U.S. Food & Drug Administration. FDA Drug Safety Communication: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. Published online March 8, 2018. Accessed October 12, 2023 at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-review-results-new-warnings-about-using-general-anesthetics-and
    PubMed
  • 60 Parry SW, Toth BA, Elliott LF. Microvascular free-tissue transfer in children. Plast Reconstr Surg 1988; 81 (06) 838-840
    CrossrefPubMedGoogle Scholar
  • 61 Chiang YC, Jeng SF, Yeh MC, Liu YT, Chen HT, Wei FC. Free tissue transfer for leg reconstruction in children. Br J Plast Surg 1997; 50 (05) 335-342
    CrossrefPubMedGoogle Scholar
  • 62 El-Gammal TA, El-Sayed A, Kotb MM. et al. Dorsal foot resurfacing using free anterolateral thigh (ALT) flap in children. Microsurgery 2013; 33 (04) 259-264
    CrossrefPubMedGoogle Scholar
  • 63 Ngaage LM, Messner F, McGlone KL. et al. A multidisciplinary technique for concurrent panniculectomy-living donor renal transplantation. Ann Plast Surg 2020; 84 (04) 455-462
    CrossrefPubMedGoogle Scholar
  • 64 Taghinia AH. Pediatric replantation and revascularization. Hand Clin 2019; 35 (02) 155-178
    CrossrefPubMedGoogle Scholar
  • 65 Upton J, Guo L, Labow BI. Pediatric free-tissue transfer. Plast Reconstr Surg 2009; 124 (6, Suppl): e313-e326
    CrossrefPubMedGoogle Scholar
  • 66 Arnold DJ, Wax MK. Microvascular Committee of the American Academy of Otolaryngology–Head and Neck Surgery. Pediatric microvascular reconstruction: a report from the Microvascular Committee. Otolaryngol Head Neck Surg 2007; 136 (05) 848-851
    CrossrefPubMedGoogle Scholar
  • 67 Volk AS, Riad SSH, Kania KE. et al. Quantifying free fibula flap growth after pediatric mandibular reconstruction. J Craniofac Surg 2020; 31 (07) e710-e714
    CrossrefPubMedGoogle Scholar
  • 68 Yim NH, Montgomery A, Upadhyaya RM, Buchanan EP. Long-term update: free fibula flap growth after pediatric mandibular reconstruction. J Craniofac Surg 2023; 34 (03) 1027-1030
    CrossrefPubMedGoogle Scholar
  • 69 Innocenti M, Ceruso M, Manfrini M. et al. Free vascularized growth-plate transfer after bone tumor resection in children. J Reconstr Microsurg 1998; 14 (02) 137-143
    Article in Thieme ConnectPubMedGoogle Scholar
  • 70 Chen LE, Seaber AV, Urbaniak JR. Microvascular anastomoses in growing vessels: a long-term evaluation of nonabsorbable suture materials. J Reconstr Microsurg 1993; 9 (03) 183-189
    Article in Thieme ConnectPubMedGoogle Scholar
  • 71 Dort JC, Farwell DG, Findlay M. et al. Optimal perioperative care in major head and neck cancer surgery with free flap reconstruction: a consensus review and recommendations from the Enhanced Recovery After Surgery Society. JAMA Otolaryngol Head Neck Surg 2017; 143 (03) 292-303
    CrossrefPubMedGoogle Scholar
  • 72 McCauley P, Moore M, Duggan E. Anaesthesia for reconstructive free flap surgery for head and neck cancer. Br J Hosp Med (Lond) 2022; 83 (05) 1-9
    CrossrefPubMedGoogle Scholar
  • 73 Ashjian P, Chen CM, Pusic A, Disa JJ, Cordeiro PG, Mehrara BJ. The effect of postoperative anticoagulation on microvascular thrombosis. Ann Plast Surg 2007; 59 (01) 36-39 , discussion 39–40
    CrossrefPubMedGoogle Scholar
  • 74 Chen KT, Mardini S, Chuang DCC. et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120 (01) 187-195
    CrossrefPubMedGoogle Scholar
  • 75 van Gijn DR, D'Souza J, King W, Bater M. Free flap head and neck reconstruction with an emphasis on postoperative care. Facial Plast Surg 2018; 34 (06) 597-604
    Article in Thieme ConnectPubMedGoogle Scholar
  • 76 Torres Fuentes CE, Rodríguez Mantilla IE, Cáceres DNG, Camargo Gonzalez DF. Red blood cell transfusion and its relationship with pedicle thrombosis in microvascular free flaps. J Reconstr Microsurg 2022; 38 (05) 402-408
    Article in Thieme ConnectPubMedGoogle Scholar
  • 77 Geis S, Prantl L, Dolderer J, Lamby P, Mueller S, Jung EM. Postoperative monitoring of local and free flaps with contrast-enhanced ultrasound (CEUS)—analysis of 112 patients. Ultraschall Med 2013; 34 (06) 550-558
    Article in Thieme ConnectPubMedGoogle Scholar
  • 78 Rozen WM, Chubb D, Whitaker IS, Acosta R. The efficacy of postoperative monitoring: a single surgeon comparison of clinical monitoring and the implantable Doppler probe in 547 consecutive free flaps. Microsurgery 2010; 30 (02) 105-110
    CrossrefPubMedGoogle Scholar
  • 79 Schmulder A, Gur E, Zaretski A. Eight-year experience of the Cook-Swartz Doppler in free-flap operations: microsurgical and reexploration results with regard to a wide spectrum of surgeries. Microsurgery 2011; 31 (01) 1-6
    CrossrefPubMedGoogle Scholar
  • 80 Paprottka FJ, Klimas D, Krezdorn N, Schlarb D, Trevatt AEJ, Hebebrand D. Cook-Swartz Doppler probe surveillance for free flaps-defining pros and cons. Surg J (NY) 2020; 6 (01) e42-e46
    Article in Thieme ConnectPubMedGoogle Scholar
  • 81 Cameron M, Corner A, Diba A, Hankins M. Development of a tracheostomy scoring system to guide airway management after major head and neck surgery. Int J Oral Maxillofac Implants 2009; 38 (08) 846-849
    CrossrefPubMedGoogle Scholar
  • 82 Kremer B, Botos-Kremer AI, Eckel HE, Schlöndorff G. Indications, complications, and surgical techniques for pediatric tracheostomies—an update. J Pediatr Surg 2002; 37 (11) 1556-1562
    CrossrefPubMedGoogle Scholar
  • 83 Pederson WC, Grome L. Microsurgical reconstruction of the lower extremity. Semin Plast Surg 2019; 33 (01) 54-58
    Article in Thieme ConnectPubMedGoogle Scholar