Quantifying Free Fibula Flap Growth After Pediatric Mandibular Reconstruction

The purpose of this report is to quantify mandibular growth in a young patient undergoing partial hemi-mandibular reconstruction with a free fibula flap (FFF) utilizing advanced three-dimensional software. A 2-year old underwent left hemi-mandibular reconstruction with a FFF following resection of a desmoid tumor. The condyle was preserved. Using 3D software, changes in mandibular growth and morphology were evaluated based on preoperative (2.1 years old) and postoperative (2.5 years and 5.2 years old) computed tomography imaging. Mandibular growth occurred throughout the mandible in both postoperative evaluations. Providing an objective evaluation using 3D software, we have demonstrated growth throughout the reconstructed mandible, with greatest growth occurring at the preserved condyle. Despite scientific limitations of our study, the potential for mandibular growth appears to remain after FFF reconstruction, offering successful functional and cosmetic outcomes.

A 53-year-old man was referred to our institution with an abdominal mass that was found incidentally on ultrasonography for prostate cancer screening. Multidetector computed tomography (MDCT) showed a cystic and solid mass with fat components in the ileal mesentery, measuring 25 cm in size. The mass was insinuating into the ileal vessels, invading the mesenteric side of jejunal loops, closely abutting the third portion of the duo-denum and uncinate procsess of the pancreas. The differential diagnosis included infiltrating liposarcoma, gastrointestinal stromal tumor (GIST), desmoid tumor (DT) and malignant peripheral nerve sheath tumor (MPNST) with entrapment of the mesneteric fat. Based on the imaging findings, surgical treatment of the en block resection of the mass was planned. A mesenteric mass excision with partial pancreatectomy, duodenectomy and small bowel segmental resection was performed. The mass encompassed duodenum, first jejunum loops and their mesentery. The resected specimen consisted of a large firm and white mesenteric mass, 24 × 11 cm, attached to the duodenum, small intestine and the uncinate process of the pancreas.

Benign soft tissue lesions are 300 times as common as soft tissue sarcomas; hence, the likelihood of confusion is high. Lesions that are larger than 5?cm, deep, show infiltrative growth, or recur despite benign histology are suspicious for soft tissue sarcoma. The biopsy incision must be carefully chosen; in large lipomas, atypical lipomatous tumor should be considered in the differential diagnosis. Lymphomas can be misdiagnosed and treated as undifferentiated soft tissue sarcoma. Vascular tumors and epithelioid lesions require more attention in histopathologic diagnostics and staging. Inflammatory lesions and aggressive fibromatosis (desmoid tumor) should also be borne in mind. In general, staging should be adapted to the underlying tumor biology. Neoadjuvant and adjuvant multimodal therapy must be discussed with the patient and used in a targeted manner. Superficial infiltrating sarcomas are prone to intralesional resection and may require intraoperative frozen section histology. If plastic reconstruction is necessary, a two-step procedure after proven tumor-free margins can be beneficial. Cavities and seromas, tight sutures, and closing the wound with clips are particularly critical. Wound drains at the thigh, pelvis, and groin should be left longer. Early revision in cases of hematoma or critical wound healing have proven beneficial. Adjuvant therapies are best planned before discharge from hospital. Overall, tumor-specific follow-up can significantly reduce the disadvantages of a recurrence resection.

Sixteen patients (18 desmoid tumors) were retrospectively evaluated. Initial surgery was performed in 13/18 tumors, with complete resection in 6 (one with free margin and five with microscopic residual disease); 10/13 had local relapse. Eleven patients with 13 tumors underwent treatment with methotrexate-vinblastine. The response rate to chemotherapy was 54%, and up to 81% if stable disease cases were included. The best response was partial remission. Only 2 had grade 4 toxicity. Twelve of 15 patients had sequelae. In 8 cases sequelae were directly related to the surgical intervention and 3 of them were severe. The 5-year progression-free survival and overall survival were 30% and 93.3%, respectively. Low dose chemotherapy achieved stable disease and even remission of the lesions with low toxicity. The high rate of sequelae is probably related to the initial surgery performed in the majority of patients and may be avoided by the use of neoadjuvant low dose chemotherapy.

We present a case of a young male with a sporadic 31 ? 25 ? 12 cm desmoid type fibromatosis (DTF) arising from the ileocolic mesentery that was complicated by mass effect on bowel and intra-abdominal organs requiring surgical intervention. The tumor biopsy confirmed the diagnosis of DTF. No evidence of familial adenomatous polyposis or Gardner syndrome was identified. The tumor was surgically excised and intimately associated with the bowel requiring ileocolonic resection with primary anastomosis. At 3-months follow up, surveillance MRI showed no residual or recurrent lesion. A multi-disciplinary approach to this patient’s diagnosis and treatment allowed for an accurate diagnosis, efficient treatment, and follow up plan.

We report a case of fibromatosis of cheek in an adult female that was managed successfully by surgical intervention and to discuss the review of literature on this subject.