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  • The entire length of the iliac crest, from the anterior-superior to the posterior-superior iliac spines, is composed of cartilage at birth. Growth occurs in an epiphyseal fashion in several areas of the pelvic girdle, including the acetabulum and the iliac crest, which grow until the second decade of life (Figure 10). The mechanical demands applied to the pelvis by both its upper and lower muscular attachments play an active role in pelvic remodeling, which occurs into young adulthood. Like the lateral scapular border, the crest serves as a traction epiphysis where the dynamic interaction between the iliac crest and its muscle attachments plays a crucial role in acetabular development, and hence gait stability. Disturbance of gait after iliac crest free flap harvest in the adult population has been documented in up to 11% of patients. Boyd described only minimal donor site morbidity in his series of iliac crest free flaps on young adults. However, his population ranged in age from 16 to 27. The probability of profound gait disturbance in a younger age group has discouraged surgeons from using this donor site for reconstruction, and as a result, there are no reported series of iliac crest free flap reconstructions in the pediatric population. We performed 1 case of mandibular reconstruction using the iliac crest free flap; however, this patient was not available for long-term follow-up. During the immediate postoperative course, this patient was ambulatory and actively participating in physical therapy. Figure 10. The iliac ramus serves as a major ossification center in the pediatric ilium (darkened area). Disturbance of growth in this region may have profound effects on the development of normal gait stability. Although fibular and scapular grafts have been used quite extensively by plastic surgeons for the reconstruction of acquired and congenital limb abnormalities, there is little reported on the long-term growth of the transferred bone after mandibular and maxillary reconstruction in the pediatric population. There is good evidence to support the preservation of osteocyte viability after the transfer of nonepiphyseal-containing vascularized bone, but the bone growth may be unpredictable. While experimental evidence supports the hypothesis that vascularized membranous bone grafts transferred to the mandible and zygomaticomaxillary defects in immature animals contribute to normal craniofacial development in a more predictable fashion than nonvascularized bone grafts, there is little evidence to support this clinically. Similarly, it has been suggested that a linear relationship between bone stress and bone growth may be responsible for symmetrical growth of the transplanted bone, but again, this relationship remains only speculative. In our patients, gross symmetrical maxillary and mandibular growth has occurred in reconstructions with both scapular and fibular free flaps. The advantage of primary bone-containing free flap reconstruction is borne out by the preservation of normal occlusal relationships throughout the patient's development. As discussed earlier, failure to reestablish maxillomandibular occlusion will lead to abnormal maxillofacial growth and malocclusion. This was not apparent in our series of patients, but we have not performed serial radiological evaluations and standard cephalometrics, an evaluative process that is necessary to draw a conclusion regarding donor bone growth and craniofacial development. Finally, long-term follow-up of 3 pediatric patients undergoing reconstruction with a single fibular and 2 scapular free flaps demonstrates that there is no evidence of physical developmental abnormalities as a result of the free tissue harvest. A larger series with serial radiographic assessment of the reconstructed site is necessary to derive a conclusion regarding the growth of transplanted bone and its effect on maxillofacial development. A Keszler MB Guliemotti F Dominguez Oral pathology in children: frequency, distribution, and clinical significance. Acta Odontol Latinoam. 1990;5:39-48. H Wanebo J Koness J MacFarlane Head and neck sarcoma: report of the head and neck sarcoma registry. Head Neck. 1992;14:1-7. M Fromm P Littman RB Raney Late effects after treatment of twenty children with soft tissue sarcomas of the head and neck: experience at a single institution and review of the literature. Cancer. 1986;57:2070-2076. N Jaffe B Toth R Hoar Dental and maxillofacial abnormalities in the long-term survivors of childhood cancer: effects of treatment with chemotherapy and radiation to the head and neck. Pediatrics. 1984;73:816-823. ML Urken D Buchbinder PD Costintino Oromandibular reconstruction using microvascular composite flaps: report of 201 cases. Arch Otolaryngol Head Neck Surg. 1998;124:46-55. K Horiuchi A Hattori I Inada Mandibular reconstruction using the double barrel fibular graft. Microsurgery. 1995;16:450-454. B Thilander Basic mechanisms in craniofacial growth. Acta Odontol Scand. 1995;53:144-151. S Kiliaridis A Bresin J Holm Effects of masticatory muscle function on bone mass in the mandible of the growing rat. Acta Anat (Basel). 1996;155:200-205. JW Prichett Growth and growth prediction of the fibula. Clin Orthop. 1997;334:251-256. AJ Weiland TW Phillips MA Randolph Bone grafts: a radiologic, histologic, and biomechanical model comparing autografts, allografts, and free vascularized bone grafts. Plast Reconstr Surg. 1984;74:368-379. PK Donski GR Carwell LA Sharzer Growth in revascularized bone grafts in young puppies. Plast Reconstr Surg. 1979;64:239-243. S Mizumoto S Tamai J Goshima Experimental study of vascularized tibiofibula graft in inbred rats: a preliminary report. J Reconstr Microsurg. 1986;3:1-11. S Tamai Experimental vascularized bone transplantations. Microsurgery. 1995;16:179-185. L Teot JP Bosse A Gilbert GR Tremblay Pedicle graft epiphysis transplantation. Clin Orthop. 1983;180:206-218. S Omokawa S Tamai Y Takakura H Yajima K Kawanishi A long-term study of the donor-site ankle after vascularized fibula grafts in children. Microsurgery. 1996;17:162-166. LF Teot J Souyris P Bosse Pedicle scapular apophysis transplantation in congenital limb malformations. Ann Plast Surg. 1992;29:332-340. JF Moscoso J Keller E Genden Vascularized bone flaps in oromandibular reconstruction: a comparative anatomic study of bone stock from various donor sites to assess suitability for enosseous dental implants. Arch Otolaryngol Head Neck Surg. 1994;120:36-43. C Forrest B Boyd R Manktelow R Zuker V Bowen The free vascularised iliac crest tissue transfer: donor site complications associated with eighty-two cases. Br J Plast Surg. 1992;45:89-93. JC Beirne HJ Barry FA Brady VB Morris Donor site morbidity of the anterior iliac crest following cancellous bone harvest. Int J Oral Maxillofac Surg. 1996;25:268-271. JB Boyd Mandibular reconstruction in the young adult using free vascularized iliac crest. Microsurgery. 1988;9:141-149. O Antonyshyn RG Colcleugh C Anderson Growth potential in suture bone inlay grafts: a comparison of vascularized and free calvarial bone grafts. Plast Reconstr Surg. 1987;79:1-11. Accepted for publication January 3, 2000. Presented at the annual meeting of the American Head and Neck Society, Palm Desert, Calif, April 24, 1999. Reprints: Eric M. Genden, MD, Mount Sinai School of Medicine, Department of OtolaryngologyHead and Neck Surgery, Box 1189, 1 Gustave Levy Pl, New York, NY 10029 (e-mail: eric_genden@smtplink.mssm.edu).
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  • JAMA
  • License Rights Holder:
  • Copyright 2000 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
  • Asset Type:
  • Image
  • Asset Subtype:
  • Figure
  • Image Orientation:
  • Portrait
  • Image Dimensions:
  • 590 x 809
  • Image File Size:
  • 56 KB
  • Creator:
  • Eric M. Genden MD, Daniel Buchbinder DMD, MD, John M. Chaplin MBChB, Edgar Lueg MD, Gerry F. Funk MD, Mark L. Urken MD
  • Credit:
  • Genden, E. M., Buchbinder, D., Chaplin, J. M., Lueg, E., Funk, G. F., & Urken, M. L. (2000). Reconstruction of the Pediatric Maxilla and Mandible. Arch Otolaryngol Head Neck Surg, 126(3), 293-300. https://doi.org/10.1001/archotol.126.3.293.
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  • No
  • Model Release:
  • No
  • Purchasable:
  • Yes
  • Sensitive Materials:
  • No
  • Article Authors:
  • Eric M. Genden MD, Daniel Buchbinder DMD, MD, John M. Chaplin MBChB, Edgar Lueg MD, Gerry F. Funk MD, Mark L. Urken MD
  • Article Copyright Year:
  • 2000
  • Publication Volume:
  • 126
  • Publication Issue:
  • 3
  • Publication Date:
  • 03/01/2000
  • DOI:
  • https://doi.org/10.1001/archotol.126.3.293

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