Hemifacial microsomia is the second most PEDIATRIC/CRANIOFACIAL. Mandibular Microsurgical Reconstruction in Patients with Hemifacial Microsomia

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1 PEDIATRIC/CRANIOFACIAL Mandibular Microsurgical Reconstruction in Patients with Hemifacial Microsomia Eric Santamaría, M.D. Christian Morales, M.D. Jesse Adam Taylor, M.D. Alejandra Hay, M.D. Fernando Ortiz-Monasterio, M.D. Mexico City, Mexico Background: Although hemifacial microsomia is a relatively common craniofacial malformation, there is some debate regarding the ideal treatment of severe mandibular hypoplasia. Traditionally, patients with severe mandibular deficits have been treated with iliac or costochondral bone grafts followed by distraction osteogenesis, with mixed results. The authors present their experience with the use of the fibula osteocutaneous free flap for mandibular reconstruction in severe hemifacial microsomia patients. Methods: From 1999 to 2006, 10 patients aged 3 to 10 years (mean, 7.2 years) underwent 10 free flap reconstructions. Of the 10 patients, six were girls and four were boys. Data were collected retrospectively from the patients records, photographs, and radiographs. The authors report the surgical technique used, complications, and long-term outcome. Results: Nine of 10 flaps were successful, for a flap survival rate of 90 percent. Donor bone length was 5 to 10 cm, with a mean of 6.3 cm. Skin paddles ranged from 8 to 36 cm 2, with a mean size of 18.7 cm 2. Mean operation time was 412 minutes and mean follow-up was 45.4 months (range, 12 to 94 months). Two patients underwent successful distraction osteogenesis subsequent to their free flap mandible reconstruction. All patients demonstrated stable bony union of the free flap by physical and radiographic examination. One major complication (a failed free flap) and two minor complications were observed. Conclusion: The free flap is safe and effective, and should be considered as a first choice in mandibular reconstruction in severe cases of hemifacial microsomia where distraction osteogenesis is not possible. (Plast. Reconstr. Surg. 122: 1839, 2008.) Hemifacial microsomia is the second most common craniofacial malformation after cleft lip cleft palate. 1,2 The treatment of the hemifacial microsomia mandible has been revolutionized by the advent of craniofacial distraction osteogenesis, with the technique s application in animals published by Snyder et al. and in humans by McCarthy et al., and cultivated in our unit. 3 7 Mandibular distraction osteogenesis engineers new bone while elongating the overlying soft tissues without additional donor sites. However, mandibular distraction osteogenesis requires sufficient bone stock in both the proximal and distal bony segments such that they can From the Department of Plastic and Reconstructive Surgery and the Postgraduate Division of the Medical School, Universidad Nacional Autónoma de México, Hospital General Dr. Manuel Gea González. Received for publication July 28, 2007; accepted March 26, Copyright 2008 by the American Society of Plastic Surgeons DOI: /PRS.0b013e31818cc349 be fixated with a distraction device without devascularizing either segment. Mandible alterations in hemifacial microsomia have been classified by Pruzansky as grades I, II, and III. This classification was expanded by Kaban et al., who subdivided grade II into grade IIA and IIB. Grade IIA features a small condyle and glenoid fossa, which are anatomically oriented, and grade IIB features a nonaligned condyle-ramus with displacement of the ramus from the glenoid fossa. In grade III, ramus, condyle, and coronoid process are absent. 8,9 In the last group of patients, distraction osteogenesis has been unsuccessful because there is insufficient bone stock in the mandibular segment to create an entire neoramus Other methods of mandible reconstruction that have been published previously in- Disclosure: None of the authors has any financial interests to disclosure

2 Plastic and Reconstructive Surgery December 2008 clude iliac and costochondral bone grafts The results using such nonvascularized bone grafts had been disappointing because of variable resorption rates ranging from 30 to 80 percent and unpredictable growth rates Graft failure has been attributed to poor vascularity of the recipient bed, 18 a frequent finding in Pruzansky grade III and IIB mandibles. Those grafts that had survived had been poor candidates for distraction osteogenesis, with complication rates far higher than those in nongrafted patients. 14,19 Microvascular mandibular reconstruction in hemifacial microsomia using a scapular or fibular free flap has been published previously We have settled on the free flap as our workhorse in mandibular reconstruction because of its abundant bone stock, ease of dissection, ability to facilitate simultaneous dissection of the recipient and donor sites, low donor-site morbidity, and track record for successful distraction osteogenesis. 23,28 32 This retrospective study reviews our experience with using the free flap to reconstruct the mandible in patients with hemifacial microsomia. PATIENTS AND METHODS All free flap mandibular reconstructions at the Hospital General Dr. Manuel Gea González from 1999 to 2006 in patients with hemifacial microsomia were reviewed. A total of 10 patients aged 3 to 10 years (mean, 7.2 years) were included. All patients had unilateral hemifacial microsomia, and two of them presented the expanded spectrum known as Goldenhar syndrome. Previous operations included eight failed bone grafts in five patients, six iliac crests and two costochondral. Two patients had previously undergone closure of clefts of the lip and palate. Patient data are summarized in Table 1. Associated malformations and Pruzansky grade are listed in Table 2. Telephone interviews were conducted with patients and their families, with satisfaction graded from 1 to 5 as follows: 1, not satisfied; 2, slightly satisfied; 3, moderately satisfied; 4, satisfied; and 5, totally satisfied. Preoperative, postoperative, and long-term follow-up frontal photographs were analyzed for menton deviation, bigonial cant obliqueness, occlusal cant obliqueness, and lateral canthus to oral commissure distance related to normal side. Results were recorded as follows: worsening, no change, partial improvement, and total correction. Data are summarized in Table 3. Preoperative Evaluation Surgical planning and therapy were individualized to the patient s deformity. Based on static and dynamic soft-tissue and bony relationships, clinical examination, and study of the dental models and cephalograms, skeletal and soft-tissue correction was planned. All patients underwent preoperative and postoperative frontal and lateral cephalometry and Panorex radiographs. A three-dimensional computed tomographic scan was obtained preoperatively in four patients. Lower extremity examination included neurosensory testing, gait monitoring, and Doppler examination of all ankle signals. Operative Technique The operations were performed with the patient in supine position under general anesthesia by means of nasotracheal intubation. Dissection of the recipient and donor site occurred simulta- Table 1. Patient Data* Patient Age (yr) Sex Follow-Up (mo) DO (mm) Complication Flap Bone Length/Skin Paddle (cm) Recipient Vessels Satisfaction Rate 1 9 F /5 3 FA, FV F 84 7/5 3 FA, FV M /7 3 LA, LV F 50 Venous thrombosis 10/4 2 ECA, EJV F 45 6/4 6 STA, FV M 40 5/5 3 ECA, EJV M 23 Partial dehiscence 6/6 6 ECA, FV 3 of donor site 8 5 F 19 5/5 4 FA, LV M 13 Partial skin 7/7 3 FA, FV 4 paddle necrosis 10 7 F 12 5/4 3 ECA, EJV 4 DO, distraction osteogenesis; FA, facial artery; FV, facial vein; LA, lingual artery; LV, lingual vein; ECA, external carotid artery; EJV, external jugular vein; STA, superior thyroid artery. *All patients have severe hemifacial microsomia. Three complications were observed. Distraction osteogenesis was performed in two cases. Vessel anastomoses were performed to the recipient vessels. The satisfaction rate is provided (see text for details). 1840

3 Volume 122, Number 6 Hemifacial Microsomia Table 2. Severity of Mandible Alteration and Other Malformations* Patient Pruzansky Grade Other Alterations 1 III 2 III Macrostomia, microtia 3 III Microtia 4 III 5 III Facial nerve deficit 6 III Unilateral cleft lip cleft palate, macrostomia, microtia 7 IIB Bulbar dermoids, vertebral abnormalities, microtia 8 III Bulbar dermoids, vertebral abnormalities, microtia 9 III Bilateral cleft lip cleft palate, microtia 10 III *The severity of mandible alteration is expressed as Pruzansky grade. Standard therapy for associated malformations had been initiated according to our unit protocols. neously. The mandible region was approached through a submandibular or preauricular incision, releasing previous scar tissue and preventing damage to possible flaps for auricular reconstruction. Recipient arteries and veins were chosen on the basis of availability and inspection and are summarized in Table 1. No intermaxillary fixation was applied intraoperatively or postoperatively. A combined anteroposterior approach was used in dissecting the free flap. Skin paddles were designed over the distal third of the fibula so as to capture one or more septocutaneous perforators, and all skin paddles allowed for primary closure of the donor site. Bony osteotomies in the fibula were tailored to the patient s ramus and body defects, and no overcorrection was planned. Peroneal arteries and veins were not ligated until the recipient site and vessel dissections were completed. Additional fibular osteotomies and angular fixation with 2.0-mm titanium plates and 7-mm screws were performed before pedicle section. The free fibula was fixed to the native mandible with 2.0-mm titanium plates and unicortical 7-mm screws (Stryker Leibinger, Freiburg, Germany). The free flap was inset such that fibular bone recreated the deficient mandibular ramus and body as needed. The skin paddle was oriented to increase cheek volume and allow for tension-free closure of the skin. In addition to increasing softtissue volume, the skin paddle also acted as a monitor for flap viability. Postoperative Care Two patients were admitted to our intensive care unit and the remainder were monitored in our inpatient unit. Flap checks, consisting of inspection, palpation, and Doppler examination for both arterial and venous flow, were performed hourly for 24 hours and every 4 hours for the duration of hospitalization. The anticoagulation regimen consisted of low-molecular-weight dextran for 5 days and aspirin for 21 days. All patients were maintained in a posterior-based leg splint for 14 days and allowed to ambulate thereafter. Patients were not placed in maxillomandibular fixation during the operation and were allowed to freely range the mandible immediately postoperatively. They were placed in an intensive postoperative physical therapy regimen consisting of range-of-motion exercises multiple times each day and maintained on a soft diet for 4 weeks. RESULTS Ten patients with hemifacial microsomia underwent mandible reconstruction using free flaps. Table 3. Photographic Analysis* Patient Menton Deviation Occlusal Obliqueness Bigonial Obliqueness Lateral Canthus Commissure Distance 1 PI/PI PI/TC PI/NC PI/PI 2 TC/NC PI/NC PI/NC PI/NC 3 PI/PI PI/PI PI/PI PI/PI 4 NA NA NA NA 5 NA/NC NA/NC NA/NC NA/NC 6 PI/W PI/W PI/W PI/W 7 PI/W TC/NC TC/TC PI/NC 8 PI/W PI/W TC/W PI/NC 9 PI/NC PI/NC PI/NC PI/NC 10 TC/NC TC/NC PI/NC PI/NC W, worsening; NC, no change; PI, partial improvement; TC, total correction; NA, not available because of flap loss or no preoperative photograph available. *Analysis of clinically relevant characteristics, obtained from frontal photographs. Postoperative/longer term follow-up (follow-up time as noted in Table 1). Postoperative analysis was performed in relation to preoperative photograph, and follow-up analysis was performed in relation to the postoperative photograph. This patient had distraction osteogenesis at long-term follow-up. Cleft lip cleft palate patient. 1841

4 Plastic and Reconstructive Surgery December 2008 Concomitant malformations included bilateral and unilateral cleft lip cleft palate, microtia, facial nerve palsy, macrostomia, dermoid cyst, and vertebral abnormalities (Table 2). Nine of 10 flaps were successful, for a flap success rate of 90 percent. One failed because of a pedicle venous thrombosis that could not be resolved in time to save the flap. Thus, the failure rate was 10 percent and our salvage rate was 0 percent. Donor bone length was 5 to 10 cm, with a mean of 6.3 cm. Skin paddles ranged from 8 to 36 cm 2, with a mean of 18.7 cm 2. Five cases required only ramus reconstruction, and thus no fibulofibular osteotomies were necessary. Five cases required reconstruction of the ascending ramus and a portion of the mandibular body, and thus one fibular osteotomy was made to provide an angled configuration. Operative times ranged from 320 to 525 minutes, with a mean of 412 minutes. Mean hospital stay was 8 days, and all patients were discharged before postoperative day 10. Mean follow-up was 45.4 months (range, 12 to 94 months). Between 6 and 9 months postoperatively, bone integration and healing was confirmed clinically and radiographically (Fig. 1). Bony integration and healing was 100 percent in all cases where the flap was successful, and there was no evidence of bony resorption. Physical examination also demonstrated improved facial symmetry (Figs. 2 through 5) and improved masticatory mechanics. In one case of mouth opening impairment because of soft-tissue contraction and fibrosis, the free flap allowed for near-normal interincisal opening. Satisfaction obtained with this surgery was rated high in all but one patient who had a failed flap. Fig. 1. (Above) One-year postoperative Panorex image of patient 6 at age 4 years, with a Pruzansky grade III left hemimandible. The flap is placed in the inferior border of the native mandible to protect the tooth buds, and a fibular osteotomy is made to recreate the contour of the mandibular angle. The free flap is placed in proximity to the temporal bone region to recreate a temporomandibular joint. Ipsilateral cleft lip cleft palate is present. (Below) One-year postoperative three-dimensional computed tomographic scan of patient 9 at age 6 years. Note the improvement in bony symmetry. Evidence of bilateral cleft lip cleft palate is present. 1842

5 Volume 122, Number 6 Hemifacial Microsomia Fig. 2. (Above, left) Preoperative view of patient 3 at age 8 years with a left Pruzansky grade III hemimandible who underwent previous ramus reconstruction with a nonvascularized iliac crest bone graft. (Above, right) Preoperative Panorex image demonstrating iliac bone graft fixed with screws. (Center, left) Unfortunately, the iliac bone graft underwent resorption, and this is an intraoperative image demonstrating resorbed iliac bone (yellow arrow), with a spiculated appearance. Prior screw positions (yellow arrowhead) can be observed. (Center, right) Two years later, the patient underwent a free fibula and subsequent distraction osteogenesis for 21 mm with an oblique vector. Bone callus can be observed in the distracted area. When fibular contact with infratemporal region was achieved (green arrowhead), distraction was stopped. A posterior open bite was created. (Below, left) Clinical appearance 4 years after distraction osteogenesis. Menton deviation and occlusal obliquity are partially corrected. (Below, right) Image obtained 7 years after free fibula flap surgery. Neoramus height is similar to the contralateral, normal side. The fibular bone is healthy and has suffered no resorption (white arrowhead). The spiculated iliac bone graft can still be appreciated (white arrow). The posterior open bite was corrected with dental eruption, orthodontics, and maxillary downgrowth. Three patients have required additional mandibular operations, and this has given us an opportunity to observe bony reconstructions. One patient required reorientation of the fibular segment to direct the proximal segment into the infratemporal region. Two cases required mandibular distraction osteogenesis because of lack of growth of the free flap and growth of the maxilla and contralateral mandible that increased menton deviation and occlusal obliquity. In all three 1843

6 Plastic and Reconstructive Surgery December 2008 Fig. 3. (Above, left) Photograph of patient 1 at age 9 years, with hemifacial microsomia and a Pruzansky grade III hemimandible. Note deviation of the occlusal plane and severe facial asymmetry. (Below, left) Clinical appearance after 7-year follow-up of free flap reconstruction and subsequent distraction osteogenesis. Note the improvement in facial symmetry and occlusal plane. Menton deviation is partially improved. (Above, right) Panorex image obtained immediately after free flap surgery. Fibular contact with infratemporal region was not achieved. Previous costochondral nonvascularized bone graft is almost fully resorbed (arrow), adopting a spiculated appearance. (Center, right) One year after undergoing free flap mandibular reconstruction, the patient underwent mandibular distraction osteogenesis. This is a Panorex image obtained immediately after distractor placement. She subsequently underwent mandibular distraction osteogenesis with an oblique vector for a distance of 31 mm. Distraction osteogenesis was stopped when occlusal obliquity was corrected. (Below, right) Panorex image obtained 7 years postoperatively. Note improvement in bony symmetry. reoperated cases, bicortical, well-integrated bone was observed. In the two cases requiring mandibular distraction osteogenesis, we distracted the bone for distances of 21 and 31 mm, respectively (Figs. 2, 4, and 5). Latency, distraction, and consolidation phases were performed as previously described, 4,10 and no complications were incurred during or after distraction osteogenesis. Follow-up radiographs confirmed the presence of calcified bone of good quality and quantity (Figs. 2 and 3). Neither of the two patients has required a second distraction osteogenesis. Postoperative photographic analysis was performed in eight of nine patients, as we could not find an adequate preoperative photograph of our 10-year-old girl. Long-term follow-up was achieved in nine patients. Partial improvement in menton deviation in six patients and total correction in two patients with free flaps were observed. Two patients experienced further improvement after dis- 1844

7 Volume 122, Number 6 Hemifacial Microsomia Fig. 4. (Above, left) Preoperative anteroposterior view of patient 7 at age 5 years with a severe Pruzansky grade IIB hemimandible. (Above, right) Preoperative lateral view demonstrates hypoplastic mandibular angle, lack of posterior facial height, and severe lack of cheek soft-tissue volume. (Below, left) Anteroposterior view 2 years after free flap reconstruction. Transplanted bone and soft tissue have improved the facial contour and symmetry. Menton deviation is partially corrected. (Below, right) Two-year postoperative lateral view demonstrates improvements in mandibular angle, posterior facial height, and cheek soft-tissue volume. The creation of a mandibular angle is not possible with unidirectional distraction osteogenesis. Also, note the location of the fibular flap skin paddle and incisions that preserve possible flaps for ear reconstruction. traction osteogenesis. Six patients had partial improvement with free flaps and two had total correction of occlusal obliqueness. Partial improvement was observed in lateral canthus to commissure distance in all patients. Bigonial obliqueness was improved in six patients and totally corrected in two. Interestingly, some clinical characteristics worsened in three patients operated on at 3 and 5years;inparticular,mentondeviationafter follow-up longer than 19 months. One major complication was a complete venous thrombosis of the flap that could not be 1845

8 Plastic and Reconstructive Surgery December 2008 Fig. 5. (Above) Preoperative Panorex image demonstrating severe hypoplasia of the left ramus. Incisal and molar relationships are abnormal, and the occlusal plane is oblique. (Center) In this 9-month postoperative Panorex image, the free flap is oriented toward the infratemporal region. Improvement in first molar and incisal relationships is observed in the left hemimandible. (Below)Panoreximageobtained2yearspostoperatively.Dental eruption is evident, occlusion is level, and the free flap is healthy with no evidence of resorption. Right ramus growth is also evident. salvaged. Two minor complications were a partial dehiscence of the fibular donor site and a partial skin paddle necrosis. Both minor complications resolved with wound care conservative therapy. No patient has developed gait disturbances, ankle stiffness, or lower extremity weakness. DISCUSSION Distraction osteogenesis has revolutionized the treatment of Pruzansky grade I, IIA, and most IIB mandibles. It is our treatment of choice in those cases where there is sufficient bone stock for fixation of distraction pins without devascularization of the bony segments. Unfortunately, in severe cases of hemifacial microsomia, all grade III and some grade IIB, distraction osteogenesis is not possible because of lack of bone stock. 14,19 Although we have not been successful in distracting these mandibles, others have attempted it with moderate success. Cavaliere and Buchman 33 have described two patients for whom distraction was performed in Pruzansky grade III mandibles with reasonable results. Despite the fact that these patients had technically successful outcomes, the authors admit that the mandibular remnant posterior to the molars (i.e., the proximal segment) is small and prone to necrosis because of inadequate blood supply. 33 Nonvascularized bone grafts, both costochondral and iliac, have had high failure rates in our hands and in others, likely because of the lack of a well-vascularized recipient bed. Such grafts have demonstrated high resorption rates and unpredictable growth patterns. 14,15,19 Five of 10 patients in our cohort had failed nonvascularized grafts before undergoing free flap surgery. In addition to a poorly vascularized recipient bed, these patients had hypoplastic soft-tissue envelopes, with compression forces contrary to those of the graft. High graft failure in hemifacial microsomia is a natural consequence of this hypoplastic envelope. Distraction osteogenesis of costochondral grafts has a high complication rate of up to 68 percent, as described by Corcoran et al. in an eight-patient series. 14 Complications included hardware failure, fibrous pseudoarthrosis, temporomandibular joint ankylosis, and lack of consolidation. 14,19,34 Höening et al. reported a modified osteotomy to improve osteogenesis in costochondral grafts in five patients. 35 However, according to Stelnicki et al., distraction of costochondral grafts is prone to fail when the distraction advancement to bone width ratio is more than 1.5:1. 19 This distraction advancement is less than is needed in the majority of patients. According to Li et al., 18 free flaps have a low rate of resorption compared with nonvascularized bone grafts and are felt to be stable over time. We no longer consider nonvascularized bone grafts as the best option in this group of patients, and in our last five cases, no attempt at bone grafting was made before free flap surgery. Microvascular mandibular reconstruction in hemifacial microsomia has been published previously with a variety of donor flaps. Polley et al. reported a case of simultaneous mandibular distraction osteogenesis of a parascapular flap

9 Volume 122, Number 6 Hemifacial Microsomia Longaker and Siebert 20 and Warren et al. 22 reported two cases of hemifacial microsomia reconstructed with parascapular flaps, with harvest of both soft tissue and bone performed to restore facial symmetry. The free flap is our workhorse in mandibular reconstruction because of its abundant bone stock, ease of dissection, ability to facilitate simultaneous dissection of the recipient and donor sites, low donor-site morbidity, and track record for successful distraction osteogenesis. 23,28 32 Additional benefits are the ability to perform multiple osteotomies without compromising blood supply and the use of septocutaneous perforators to obtain soft tissue to remodel facial contour. In two patients for whom distraction osteogenesis was necessary to mimic contralateral facial growth, we performed a transverse corticotomy in the fibular segment. After finishing the consolidation phase, a close to normal native bone was observed. Cho 23 shared a similar experience when distracting a free fibular segment of a mandible in an adult with hemifacial microsomia. In contrast to our results in children, he had to perform maxillomandibular distraction to obtain a stable occlusion. 36 It is our philosophy to prevent the need for maxillomandibular distraction osteogenesis by performing free flap surgery before maxillary growth has finished so that the maxillary alveolus has the opportunity to descend on its own to meet the neomandible. In addition to its bony benefits, distraction osteogenesis greatly improves the symmetry of the overlying soft tissues as noted by improved parity between the distance from the commissure to the lateral canthus and occlusal obliqueness (Figs. 2 and 3). We used clinical criteria to decide when to stop distracting the patient in Figure 3. Despite the fact that the free flap was not in close proximity to the temporal bone, occlusal obliqueness was corrected, interincisal opening was adequate, and occlusion was stable. In the patient depicted in Figure 2, a posterior open bite was created with distraction osteogenesis, and this was corrected with orthodontics and maxillary downgrowth. In less severe cases of hemifacial microsomia, our trend has been toward earlier distraction osteogenesis of the mandible because it has allowed us to achieve our best results from both functional and aesthetic standpoints. 10 We believe the same may be true in these drastic cases. Early in this series, we performed free flap reconstruction at approximately age 10, after the use of nonvascularized bone grafts. As our experience grew, we noticed that we could transfer free flaps earlier instead of nonvascularized grafts. Thus, we are transferring the free flap earlier, at approximately age 6, before the period of mixed dentition. We subsequently manage these patients as group I or IIa patients as reported previously by our team and others. 6,10 The downside to this approach is the need for distraction osteogenesis of the free flap in selected cases because of contralateral mandibular growth. The upside to this approach is the free flap s ability to unlock maxillary growth, allowing a vertically deficient maxilla to catch up to its contralateral counterpart as observed in sequential Panorex images in patients in Figures 2, 4, and 5. Further follow-up is needed to observe this benefit as skeletal maturity is reached, but at this moment, results are promising. It is possible that the deformity is progressive in hemifacial microsomia as demonstrated by Kearns et al. 37 If that is the case, many of our patients may require subsequent distraction osteogenesis. Our cases involving patients approximately 6 years old sustain this hypothesis. As we gain experience, we will be able to better establish the optimal timing of microvascular mandibular reconstruction. However, at this time, we believe that the ideal age for reconstruction of the mandible using the free flap is between 5 and 7years.Atthisage,maxillarygrowthis unlocked, harvesting the fibula does not increase morbidity on the leg, and the microsurgical procedure is easier in terms of size/technique demands. We are including growth follow-up of two patients with cleft lip cleft palate. These patients have different growth issues involved that will be investigated further. Possibly the major advantage of using the free flap is the capability of reproducible distraction osteogenesis thereafter with its associated benefits. Currently, we are evaluating the possibility for mandibular distraction osteogenesis in three additional patients in this series, as contralateral growth has exceeded that of our free flap reconstruction, as can be observed in molar relation in the long term (Fig. 5). Vertical maxillary growth and dental eruption have been observed, and the distal free flap bone has moved away from the temporal bone as the contralateral vertical ramus has grown. We are now treating this patient with an orthodontic spacer. 10,38 We currently do not overcorrect our neomandibles in any dimension during free flap placement. The main reason for this is that we want to prevent any undue stress on the normal, contralateral temporomandibular joint as described previously by Murray et al. 38 and confirmed by previous experience of the senior author (F.O.M.). 1847

10 Plastic and Reconstructive Surgery December 2008 We do not include the epiphyseal portion of the fibula, which some might argue would form a neo temporomandibular joint and would likely contain a growth center. Because there is no glenoid fossa, the addition of a cartilaginous fibular head would still fall short of creating a neo temporomandibular joint. Furthermore, including the proximal epiphysis would compromise knee stability, a risk we are not willing to take. We have not observed growth or resorption of the free flap, but we have noted remodeling of the distal flap in the zone of the temporal bone. Direct bone contact between fibula and temporal bones could theoretically induce bone consolidation, another risk that we will not take. However, we have observed adequate interincisal opening in all cases despite the absence of a temporomandibular joint. Patients and their parents are satisfied with the results of the surgery, as demonstrated by the high satisfaction rating. In some cases, patients have undergone further operations that have improved overall results, and this could have influenced their responses. Future areas of investigation are whether and by how much to overcorrect, and molecular strategies to improve bony healing. CONCLUSIONS The free flap is a safe, effective procedure for mandibular reconstruction in children with Pruzansky grade III and severe grade IIB mandibles. We propose this procedure as the first choice for mandibular reconstruction in patients where distraction osteogenesis is not feasible. REFERENCES Eric Santamaría, M.D. Calz. De Tlalpan 4800 Ciudad de Mexico D.F., C.P , Mexico ericsanta@prodigy.net.mx 1. McCarthy, J. G., Grayson, B. H., Coccaro, P. J., and Wood-Smith, D. Craniofacial microsomia. In J. G. McCarthy (Ed.), Plastic Surgery, Vol. 4. Philadelphia: Saunders, Pp McCarthy, J. G., Hopper, R. A., and Grayson, B. H. Craniofacial microsomia. In S. J. Mathes (Ed.), Plastic Surgery, Vol. 4. 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11 Volume 122, Number 6 Hemifacial Microsomia 29. Hellner, D., Schmelzle, R., Friedrich, R. E., and Delling, G. Callus distraction in irradiated human mandible after free microvascular bone transplants: First results. Presented at the 18th Congress of the International Association for Maxillofacial Surgery, Leuven, Belgium, July 29 31, Siciliano, S., Lengele, B., and Reychler, H. Distraction osteogenesis of a fibula free flap used for mandibular reconstruction: Preliminary report. J. Craniomaxillofac. Surg. 26: 286, Eski, M., Turegun, M., Deveci, M., Suat, H. G., and Sengezer, M. Vertical distraction osteogenesis of fibular bone flap in reconstructed mandible. Ann. Plast. Surg. 57: 631, Ortakoglu, K., Tolga, B. S., Ozyigit, A., Ozen, T., and Sencimen, M. Vertical distraction osteogenesis of fibula transplant for mandibular reconstruction: A case report. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 102: e8, Cavaliere, C. M., and Buchman, S. R. Mandibular distraction in the absence of an ascending ramus and condyle. J. Craniofac. Surg. 13: 527, Thomas, D. J., and Rees, M. J. Fibrous ankylosis after distraction osteogenesis of a costochondral neomandible in a patient with grade III hemifacial microsomia. J. Craniofac. Surg. 2: 469, Höening, J. F., Grohmann, U. A., and Merten, H. A. Dove tail osteotomy in distraction osteogenesis of costochondral bone grafts in the mandible: A new concept. J. Craniofac. Surg. 16: 330, Ortiz-Monasterio, F., Molina, F., Andrade, L., Rodriguez, C., and Arregui, J. S. Simultaneous mandibular and maxillary distraction in hemifacial microsomia in adults: Avoiding occlusal diasters. Plast. Reconstr. Surg. 100: 852, Kearns, G. J., Padwa, B. L., Mulliken, J. B., and Kaban, L. B. Progression of facial asymmetry in hemifacial microsomia. Plast. Reconstr. Surg. 105: 492, Murray, J. E., Kaban, L. B., and Mulliken, J. B. Analysis and treatment of hemifacial microsomia. Plast. Reconstr. Surg. 74: 186, Contribute to Plastic Surgery History The Journal seeks to publish historical photographs that pertain to plastic and reconstructive surgery. We are interested in the following subject areas: Departmental photographs Key historical people Meetings/gatherings of plastic surgeons Photographs of operations/early surgical procedures Early surgical instruments and devices Please send your high-resolution photographs, along with a brief picture caption, via to the Journal Editorial Office (ds_prs@plasticsurgery.org). Photographs will be chosen and published at the Editor-in- Chief s discretion. 1849