Supermicrosurgery and Head and Neck Reconstruction in Children Departments of Plastic and Reconstructive Surgery* Otolaryngology, Neurosurgery* Pediatrics

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(1)∞. of Plastic and Reconstructive Surgery* C O Departments Otolaryngology, Neurosurgery* Pediatrics llabolation. Supermicrosurgery and Head and Neck Reconstruction in Children. Takuya Iida1, Makoto Mihara1, Takahiro Asakage2, Kensuke Kawai3 1:Department of Plastic and Reconstructive Surgery, The University of Tokyo, Japan 2:Department of Otolaryngology, The University of Tokyo Hospital, Japan 3:Department of Neurosurgery, The University of Tokyo Hospital, Japan received 2011.9.1. accepted 2011.10.10. Abstract Malignancies in the head and neck region requires multidisciplinary treatment and collaboration among head and neck surgery, neurosurgery, and plastic and reconstructive surgery, as well as oral surgery, pediatrics, rehabilitation, and psychiatry. Head and neck reconstruction in children with the use of a free flap is characterized by small, short blood vessels, a relatively large head, and the need for consideration of disruption of growth disturbance at the donor site of the flap. The perforator flap has less donor site morbidity and is very useful in children. However, children have smaller vessels than adults, requiring supermicrosurgical techniques. Learning of supermicrosurgical techniques should have an important role in increasing the options in free flap transfer in children. Keywords. Supermicrosurgery, head and neck reconstruction, free flap, skull base surgery, anterolateral thigh flap. Introduction Recent advances in. ntroduction. the breakthrough that allows the use of perforator flaps in children. Here, we present two cases of reconstruction of. microsurgical techniques. the head and neck in children and explore the feasibility.. allowed surgeons to perform. Case1. free flap transfer in children. A 10-year-old girl with. more safely than before.. Pierre-Robin syndrome. However, the vascular pedicle of. The patient was spontaneously. the perforator flap is small even in adults, and its transfer. born at a gestational age of 40. in children requires even more sophisticated techniques. In children, the risk of growth disturbance at the donor. ase. weeks and weighed 1973 g. At birth, micrognathia,. site of the flap should be considered, and the use of a. temporomandibular joint ankylosis, oropharyngeal atresia,. perforator flap, which has less donor site morbidity, is. and complete visceral inversion were observed and. very advantageous. Supermicrosurgical techniques may be. diagnosed as Pierre-Robin syndrome.. Correspondence: Department of Plastic Surgery and Reconstructive Surgery, The University of Tokyo, Japan Takuya Iida 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655 JAPAN E-mail: [email protected] Tel: 03-3815-5411, ext 30497. 5-1-9.

(2) ACSC She underwent tracheostomy, mandibulotomy with. After midline incision in the mandible and opening of the. distraction osteogenesis 3 times, oropharyngeal opening 3. oral cavity and oropharynx, an anterolateral thigh flap was. times, mobilization of temporomandibular joints, and. elevated from the left thigh and sutured to the defect in. cheiloplasty by oral surgeons. However, The. the mandible and oral cavity (Figure 2,3,4). The vascular. oropharyngeal passage closed soon after each of the. pedicle of the anterolateral thigh flap was anastomosed to. previous 3 procedures for the oropharyngeal opening,. the right superior thyroid artery, external jugular vein,. which precluded oral intake and vocalization (Figure 1).. and internal jugular vein with 10-0 nylon. The. To reopen the oropharyngeal passage, and cover the soft. postoperative course was uneventful, and the flap survived. tissue defects in the mandible and oral floor, we performed. completely (Figure 5). The patient is now receiving. oropharyngeal opening and free anterolateral thigh flap. swallowing rehabilitation, and we plan to perform flap. transfer.. reduction and rigid reconstruction with a free fibula flap.. Figure 1. Preoperative CT showed micrognathia, tongue defect, and atresia of the oral cavity and oropharynx.. Figure 2. A midline incision in the mandible was made to open the oral cavity and oropharynx. An anterolateral thigh flap was sutured to the defect in the oral cavity and the mandible . Figure 3. Elevated anterolateral thigh flap.. 5 - 1 - 10.

(3) Figure 4. Sutured flap.. Figure 5. CT at 3 months after surgery showed the free anterolateral thigh flap sutured to the opening of oropharyngeal passage to maintain the patency. Flap reduction and rigid reconstruction are planned.. Case2. large skull base defect and previous radiation, the full. A 7-year-old girl with left orbital osteosarcoma. length of the rectus abdominis muscle was harvested to. The patient was diagnosed as bilateral retinoblastoma at. cover the exposed dura with muscle (Figure 7,8,9). The. 4 months of age. The right eye was enucleated, and the. inferior epigastric artery and vein were anastomosed to. left eye was treated with ophthalmic artery infusion. the left superficial temporal artery and vein. Skin island. chemotherapy and radiotherapy (46 Gy), leading to. was de-epithelialized except for part of the eye socket.. remission. The patient was followed up thereafter. At the. Since priority was given to infection control, rigid. age of 7 years 5 months, hyperemia of the left eyelid and. reconstruction was not performed at this time and but. bulbar conjunctiva occurred together with proptosis.. scheduled later.. Computed tomography showed a bone tumor extending. The postoperative course was uneventful, and the flap. from the lateral wall of the orbit to the temporal fossa, and. survived completely. Meningitis and other infections did. a biopsy led to the diagnosis of osteosarcoma. Systemic. not occur, and chemotherapy was resumed on. chemotherapy and selective arterial infusion. postoperative day 14. Tumor recurrence, abdominal. chemotherapy were performed, followed by resection of. incisional hernia, and scoliosis did not occur during a. the left orbital osteosarcoma, brain lobectomy, and free fat. postoperative period of 2 years 2 months. We now plan to. graft. Despite repeated chemotherapy, osteosarcoma. perform rigid reconstruction and correction of the eye. recurred in the retro-orbital region, resulting in loss of. socket for cosmetic improvement.. vision. Because of resistance to chemotherapy, we decided to perform wide resection and free flap reconstruction (Figure 6). After gamma knife irradiation near the cavernous sinus where tumor invasion was suspected, extensive tumor resection and a free rectus abdominis muscle flap transfer were performed in cooperation with the departments of Neurosurgeons and Head and Neck surgeons. After a coronal incision was made, frontotemporal craniotomy and wide resection, including the orbital content and orbital floor, were performed together with dural reconstruction by fascia lata grafting, skull base closure by free rectus. Figure 6. Preoperative MRI showed sphenoid osteosarcoma extending from the left orbit to the intracranial compartment (arrow).. abdominis muscle flap transfer. With consideration of the. 5 - 1 - 11.

(4) ACSC. Figure 7. Intraoperative View after tumor resection. The nasal cavity communicated with the intracranial contents, which was later separated by the rectus abdominis muscle flap (arrow). The dura mater was reconstructed with the fascia lata.. Figure 8. Elevated rectus abdominis muscle flap with a vascular pedicle thinner and shorter than in adults (arrow).. Discussion Compared with adults, free flap transfer in children has the following features.1,2). iscussion. -Thin, short vascular pedicle -Elastic vessels with no. age-related changes such as arteriosclerosis -No history of alcohol intake or smoking -Failure to rest after surgery -Potential growth disturbance at the donor site of the flap (such as scoliosis associated with rectus abdominis muscle and latissimus dorsi muscle flaps) In addition, physicians should take into consideration the physical characteristics of children undergoing reconstruction of the head and neck, specifically a relatively large head and small, short extremities. Physicians should be aware that the maximum size of the. 5 - 1 - 12. Figure 9. Sutured rectus abdominis muscle flap. (arrow) Vascular anastomosis.. rectus abdominis muscle flap or latissimus dorsi muscle flap may be required to cover a defect in a relative large head. The degree of necessity and urgency of surgery is the major difference between cases 1 and 2, leading to the selection of different flaps. In case 1 (elective surgery), a perforator flap was used to minimize donor site morbidity. In case 2 (malignant disease), administration of chemotherapy soon after surgery is important to increase curability, and thus a rectus abdominis muscle flap was used for fewer postoperative complications, despite the risk of a growth disturbance. We weighed the risks and benefits (prognosis) when selecting the flap. Growth disturbances associated with flap harvest may be justified when the safety of surgery is given first priority in a life-threatening, serious disease. The perforator flap allows for preservation of muscle tissue and reduces the risk of a growth disturbance at the.

(5) donor site of the flap. Because of these advantages, the. Issue 1: Selection of free flaps. perforator flap is very useful in selected patients. Some. An appropriate flap should be selected with consideration. clinicians reported that vascular anastomosis is not very. of the size of the defect, conditions of the recipient bed,. difficult because children have relatively large vessels. length of the vascular pedicle, and others in individual. compared to flap size and healthy vessels. However,. patients.. vessels in perforator flaps are thin even in adults, and thus supermicrosurgical techniques are essential in children.. Issue 2: Technical difficulty in perforator flaps in. Our experience shows that it is relatively safe and easy to. children. perform anastomosis using 11-0 nylon and. Perforator flaps have established benefits but require. supermicrosurgical techniques, and we believe that. advanced techniques. Efforts to ensure the safety of. supermicrosurgical techniques are essential for increasing. surgery are needed in the use of technically demanding. flap options in children.. flaps.. Conclution We report two cases of head and neck reconstruction with free flaps in children. Supermicrosurgical techniques. onclution. are essential for the safe transfer of perforator flaps in children.. Growth disturbances at the donor site may be reduced by learning the techniques.. Reference. Acknowledgements. 1) Upton J, Guo L. Pediatric free tissue transfer:. This study was supported by grants from the following. a 29-year experience with 433 transfers. Plast Reconstr Surg. 2008 May;121(5):1725-37. 2) Yildirim S, Calikapan GT, Akoz T. Reconstructive microsurgery in pediatric population-a series of 25 patients. Microsurgery. 2008;28(2):99-107.. organizations. The authors would like to thank them all: ・Princess Takamatsu Cancer Research Fund ・Japan Funding Program for Next Generation World-Leading Researchers (Next Program) ・ New Energy and Industrial Technology Development Organization. (NEDO) ・ KAKENHI (23792039) ・ Japan Interaction in Science and Technology Forum Foundation ・ Leave a nest Grant (Leave a Nest Grant) ・ Children’s Cancer Association of Japan ・ Foundation for Promotion of Cancer Research ・ Mitsui Life Social Welfare Foundation ・ The JIST Foundation ・ Overseas Research scholoarship ・ Fukuoka University, School of Medicine Alumni, Eboshikai. 5 - 1 - 13.

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