Optimizing outcomes in pediatric microvascular mandibular reconstruction: A 23-year institutional experience

The vascularized free fibula flap (VFFF) is a well-established technique for addressing critical-sized mandibular defects, including those in pediatric patients. However, surgical risk factors and impact on growth potential are not well understood, particularly in skeletally immature patients, nor are the methods to optimize growth and outcomes.

We retrospectively reviewed children who underwent mandibular reconstruction using VFFF between 2001 and 2024 at our institution. Complications were classified using the Clavien-Dindo scale. Data were analyzed using Pearson's r correlation, Fisher's exact tests, and chi-squared analysis.

Twenty-nine patients underwent 31 mandibular reconstructions using VFFFs at a median age of 14 years old (range: 3.5-18.9 years), most commonly after ameloblastoma resection (n=10, 32%). Twenty-nine (94%) flaps were successful, and 17 complication events transpired among 13 (42%) operations, most commonly hardware exposure (n=4, 24%). Complications decreased with increased institutional experience (after 2016, p=0.011) and with the use of two rather than one venous anastomosis (p=0.002). Recipient site complications were more common in patients under 12 years of age (p=0.026). Although flap viability was high; two flap failures occurred with single venous anastomosis, and none with two venous anastomoses. Hardware removal was planned on an average 15.7 months after nine operations (29%) to maintain growth potential; subsequent corrective orthognathic surgery was performed following four flaps (13%).

Pediatric mandibular reconstruction using VFFF is safe and effective, with the majority maintaining functional occlusion with growth. Complication rates are comparable to those in the adult population and may be mitigated via multiple vein anastomoses and institutional experience.