|Year : 2020 | Volume
| Issue : 1 | Page : 12-16
Microvascular reconstruction for tumors of the head and neck in the pediatric population
Deepak Balasubramanian1, Narayana Subramaniam1, Janarthanan Ramu2, Ridhi Sood1, Mohit Sharma2, Jimmy Mathew2, Krishnakumar Thankappan1, Pramod Subhash3, Arjun Krishnadas3, Subramania Iyer4
1 Department of Head and Neck Oncology and Reconstructive Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
2 Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
3 Department of Craniomaxillofacial Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
4 Department of Head and Neck Oncology and Reconstructive Surgery; Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
|Date of Submission||13-Dec-2019|
|Date of Decision||23-Jan-2020|
|Date of Acceptance||14-May-2020|
|Date of Web Publication||18-Jun-2020|
Department of Head and Neck Oncology and Reconstructive Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Ponnekkara, Kochi - 682 041, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: Microsurgical tissue transfer in the pediatric population is challenging for several reasons– small vessel diameter, flap size, difficulties with postoperative flap monitoring, and difficulty in anticipating tissue growth and remodeling. In addition, head-and-neck reconstruction is uniquely difficult due to the functional deficits after ablative surgery. We present our series of microvascular reconstruction for tumors of the head and neck in the pediatric population. Materials and Methods: Retrospective review of microvascular reconstruction performed in our institution for benign and malignant tumors of the head and neck for patients aged <10 years of age between 2004 and 2016. Demographic and treatment details were analyzed, and descriptive statistics were performed. Results: The flaps used for reconstruction were anterolateral thigh flap (n = 5), fibula free flap (n = 4), scapular free flap (n = 2), radial forearm free flap (n = 1), and sixth rib with serratus anterior and latissimus dorsi (growth center transfer) (n = 1). Rapid prototyping models and inverse planning were used for bony reconstruction in seven cases. The flap success rate was 100%. The average operating time was 130 min. There were no major intraoperative or postoperative complications. Conclusion: Microvascular reconstruction for head-and-neck tumors in the pediatric age group is safe and is associated with good functional and esthetic outcomes. The anterolateral thigh flap and the fibula flap are the flaps of choice in a majority of cases. Preoperative planning, especially in complex bony reconstruction, is important to maximize outcomes and minimize the operative time. Multidisciplinary care is essential to ensure rapid rehabilitation in the postoperative period.
Keywords: Head, microvascular reconstruction, neck tumors, pediatric
|How to cite this article:|
Balasubramanian D, Subramaniam N, Ramu J, Sood R, Sharma M, Mathew J, Thankappan K, Subhash P, Krishnadas A, Iyer S. Microvascular reconstruction for tumors of the head and neck in the pediatric population. J Head Neck Physicians Surg 2020;8:12-6
|How to cite this URL:|
Balasubramanian D, Subramaniam N, Ramu J, Sood R, Sharma M, Mathew J, Thankappan K, Subhash P, Krishnadas A, Iyer S. Microvascular reconstruction for tumors of the head and neck in the pediatric population. J Head Neck Physicians Surg [serial online] 2020 [cited 2020 Jul 10];8:12-6. Available from: http://www.jhnps.org/text.asp?2020/8/1/12/287155
| Introduction|| |
The pediatric population accounts for an estimated 10%–15% of tumors occurring in the head and neck., Of these, lymphoreticular malignancies and central nervous system tumors are most common, along with tumors of the oral cavity, facial skeleton, and paranasal sinus. A significant proportion of these patients would require surgical tumor extirpation. For patients with substantial defects, the microvascular free flap is the reconstructive technique of choice. Lack of significant tissue volume in the regional flaps and unavailability of reliable pedicled bone flaps necessitate free flap reconstruction. Anatomically, the reconstruction must account for future growth of the craniofacial skeleton. Donor site morbidity is a significant concern in the growing child. Technical challenges include small flap size and vessel diameter, difficulties in postoperative flap monitoring, and patient compliance.
Data on microvascular reconstruction for tumors in the head and neck in the pediatric population are sparse. The aim of this article was to review our experience of head-and-neck microvascular reconstruction for tumors in patients aged <10 years of age.
| Materials and Methods|| |
This was a retrospective study, which included patients 10 years of age or less who underwent resection and microvascular reconstruction for tumors of the head and neck at our center between 2004 and 2016. Relevant medical records of these patients were extracted, including demographic details, clinical, surgical, and pathological details. Details of intra-operative and postoperative courses were collected from medical charts. Follow-up data were assessed for late complications, dental rehabilitation, donor site morbidity, and other relevant details.
| Results|| |
A total of thirteen free flap reconstructions were performed for either benign or malignant tumors of the head and neck in eleven patients aged 10 years of age or less; two patients had recurrences requiring reconstruction with a second free flap. The mean age of patients was 6 (range 2–9) years. Median follow-up was 15 (range 6–24) months.
The patient characteristics and nature of defects are shown in [Table 1]. Half of the patients were male, and the other half were female. The tumor pathology was mucoepidermoid carcinoma (n = 2), desmoplastic fibroma (n = 2), pseudotumor of mandible (n = 1), mesenchymal chondrosarcoma (n = 1), arteriovenous malformation (n = 1), ossifying fibroma (n = 1), recurrent infantile fibromatosis of the skull base (n = 1), and primary mesenchymal mixed tumor (n = 1). Majority of patients were treated with surgery alone. One patient received neoadjuvant chemotherapy, and one received adjuvant radiotherapy.
The flaps used for reconstruction were anterolateral thigh flap (n = 5), fibula free flap (n = 4), scapular free flap (n = 2), radial forearm free flap (n = 1) and sixth rib with serratus anterior and latissimus dorsi (growth center transfer) on a single vascular pedicle (n = 1). The donor vessels used for microvascular anastomosis were the facial vessels (n = 7), superior thyroid vessels (n = 3), lingual vessels (n = 1), and superficial temporal vessels (n = 1). The sutures used were 9-0 and 10-0 nylon. The average flap harvest time was 92 (range 60–110) min. In children who underwent fibula free flap reconstruction, the proximal and distal 6 cm of the bone were spared to avoid common peroneal nerve injury and ankle instability. The average time to perform both the arterial and venous anastomosis was 44 (range 28–64) min. All cases had only one vein anastomosis. The total duration of reconstructive surgery, including the contouring and inset, was 110 (range 88–184) min. The average postoperative stay in the hospital was 12 (range 6–47) days.
The overall complication rate was 20% (2/10). The patient of pseudotumor mandible had multiple episodes of heavy bleeding in view of underlying hemophilia. However, this was managed successfully with repeated factor VIII injections, factor eight inhibiting binding antigen injections and transfusions. The flap survived with no compromise. The patient of mucoepidermoid carcinoma of the parotid was re-explored on the second postoperative day, and the venous anastomosis was redone. There was partial skin paddle loss that was managed by split skin grafting.
|Figure 1: Patient 1, showing (a) clinical appearance (b) radiological appearance on computed tomography and (c) intraoperative appearance for a fibula free flap reconstruction for a central arch segmental mandibulectomy defect following excision of a primitive myxoid mesenchymal tumour of infancy|
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|Figure 2: Patient 5, showing (a) radiological appearance on computed tomography (b) intraoperative defect photograph and (c) postreconstruction with anterolateral thigh free flap for a mesenchymal chondrosarcoma of the right maxilla|
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There were no donor site complications. Patients were able to resume normal physical activity without any restrictions within a four-week period. Those who underwent fibula transfer were noted to have a normal gait and ankle range of motion. Functional and cosmetic outcomes were satisfactory. No patients had delayed healing or wound breakdown. All patients were able to tolerate a soft diet and had satisfactory speech intelligibility. Twelve out of thirteen patients were alive and disease-free at follow-up. Although it was of significant interest to assess the serratus anterior-rib growth center transfer postoperatively, this could not be performed as the patient was unavailable for review imaging.
| Discussion|| |
Free flaps have been established as the standard of care in head and neck reconstruction. However, experience in the pediatric age group is limited; given the rarity of head-and-neck tumors in this age group. A lack of multidisciplinary care has resulted in several patients receiving sub-optimal nonsurgical treatment.,
There were several challenges unique to this patient demographic. The availability of large volumes of skin, soft tissue, and bone in local and pedicled flaps is a concern. Harvest of local and pedicel flaps often result in scars that cannot be concealed. When attempting microsurgery in these patients, the donor and recipient vessels used are of small caliber. Some of the commonly performed flaps in adults, like the radial forearm free flap, are seldom sufficient to provide soft-tissue cover in children. The fibula flap does not provide for a growth center transfer for mandible during routine harvest. The postoperative monitoring in this age group is difficult and can lead to delay in identifying problems with the anastomosis. Tracheostomy and nasogastric tube care are also difficult, necessitating intensive postoperative rehabilitation to ensure early decannulation.
In this series, all patients had rapidly growing aggressive tumors that required wide resections. Some of the vascular tumors resulted in potentially life-threatening bleeding. Of our cases described, only two (15%) had previous therapy; one received prior radiotherapy, while one received prior chemotherapy. Both of these have been shown to impact healing after surgery;, however neither of these patients had any issues with postoperative healing. This is in accordance with previously published literature, which has shown satisfactory outcomes in similarly treated patients.,
Regarding the choice of flap, the anterolateral thigh flap is our flap of choice for soft tissue reconstruction. The large volume of tissue, ability to contour and thin the flap, concealed donor site, and insignificant impact on function make it an ideal flap for children. Multiple components can be harvested, and the vastus lateralis can be used to obliterate dead spaces in the skull base when compartment excisions are to be performed. The radial forearm is not preferred because of the small donor area size, unsightly scar, and functional morbidity, which results from the harvest. When bone reconstruction is to be considered, there are three choices. The fibula flap is ideal for a majority of maxillary and mandibular reconstructions. The long bone, ease of contouring good pedicle length, and ability to use dental implants make it the flap of choice. Rigid fixation of the bone in the recipient site with low profile plates is preferred. These children also need early dental rehabilitation as occlusal loading helps in bone union and further increase the native mandibular growth. One concern is whether the presence of the rigid plates would hinder the growth of the native mandible. It is our observation that the native facial skeleton grows even in the presence of these plates, and once sufficient tissue healing has been achieved, the plates can be removed, although with difficulty. Donor site morbidity in the fibula is generally low; however, it is noted that in children, 45% can develop ankle valgus after free fibula harvest, up to a quarter of which are severe and require surgical intervention. We did not note this complication in any of the children in our series.
The scapula angle free flap is our second flap of choice, especially for infrastructure maxillectomy defects. The scapula angle natively offers the shape of the palate, and the teres major muscle can be used to reconstruct the soft palate as well. The pedicle length is long and allows for reach into the neck. However, the bone is thin and does not accept dental implants. Furthermore, there is a need to reposition the patients before flap harvest. In one of our cases, we attempted a growth center transfer base on the attachments of the serratus anterior to the rib. The patient should excellent growth of the rib in the mandibular defect. This is not commonly performed, and the resultant reconstructed mandible may not have sufficient bone stock to accept dental implants. We recommend the use of computer-aided planning for all bony reconstructions in the pediatric population. The use of inverse planning, rapid prototyping, and stereolithographic models allow for accurately contouring the reconstruction plate to ensure occlusion and reduce surgical time. It is also helpful in secondary maxillomandibular reconstruction, especially when growth and remodeling occur.
It is our belief that pediatric microvascular reconstruction should be offered to all children with large defects in the head and neck. To the best of our knowledge, this is the first series from the subcontinent that has reported the outcomes in this patient group.
| Conclusion|| |
Microvascular reconstruction for head-and-neck tumors in the pediatric age group is safe and is associated with good functional and esthetic outcomes. The anterolateral thigh flap and the fibula flap are the flaps of choice in a majority of cases. Preoperative planning, especially in complex bony reconstruction, is important to maximize outcomes and minimize the operative time. Multidisciplinary care is essential to ensure rapid rehabilitation in the postoperative period.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
This material has never been published and is not currently under evaluation in any other peer reviewed publication.
The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
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[Figure 1], [Figure 2]