SA3 - Fibula Free Flap Reconstruction in the Pediatric Population: A Comprehensive Systematic Review and Meta-Analysis of Survival, Functional Outcomes, and Donor-Site Morbidity

Oral Abstract Presenter(s)

• 

  Sayyed Ourmazd Mohseni, DDS

  Resident Physician
  Parkland Memorial Hospital, UT Southwestern Medical Center
  Dallas, Texas

Co-Author(s)

• AS

  Asal Saeid

  Medical Student
  Texas College of Osteopathic Medicine, University of North Texas Health Science Center
  Fort Worth, Texas
• TF

  Thomas Fong, DMD

  Intern
  Parkland Memorial Hospital
  Dallas, Texas
• JL

  Joohoon Lee, DDS

  Intern
  Parkland Memorial Hospital
  Dallas, Texas
• 

  Thomas Schlieve, DDS, MD, FACS

  Associate Professor and Graduate Program Director
  Parkland Memorial Hospital, UT Southwestern Medical Center
  Dallas, Texas

Abstract:

Introduction: Pediatric mandibular and maxillary reconstruction poses unique challenges due to ongoing craniofacial growth, the need to restore function, and the long-term aesthetic and developmental implications of early surgical intervention. In the pediatric populations, any reconstructive approach must accommodate future skeletal development while providing immediate structural support and functional rehabilitation. Traditional options such as non-vascularized bone grafts, distraction osteogenesis, and alloplastic implants are often limited by high resorption rates, growth interference, or insufficient structural integrity in large defects. The fibula free flap (FFF) has emerged as the most widely accepted technique for pediatric osseous reconstruction due to its robust vascular supply, resistance to resorption, and capacity for dental implant support. However, despite its growing use in children, concerns remain regarding its long-term integration with facial growth, donor-site morbidity, and overall complication rates. The primary aim of this systematic review and meta-analysis is to evaluate the long-term flap survival, complication rates, functional outcomes, and donor-site morbidity associated with FFF in pediatric patients.
Materials and

Methods: A comprehensive search was conducted in PubMed, Embase, Cochrane Library, and Web of Science for studies published until July 2024 that reported clinical outcomes of fibula free flap reconstruction in pediatric populations (≤18 years). Inclusion criteria focused on studies detailing flap survival, functional outcomes, complications, donor-site morbidity, and skeletal adaptation. Studies were assessed for quality using the Newcastle-Ottawa Scale (NOS), and meta-analysis was conducted using random-effects models. Heterogeneity was assessed using I² statistics, and publication bias was evaluated using funnel plots and Egger’s regression tests.

Results: A total of 20 studies, comprising 432 patients, met the inclusion criteria, with 15 studies eligible for meta-analysis. The pooled flap survival rate was 95.88% (95% CI: 94.2–97.5), demonstrating the high reliability of fibula free flap (FFF) reconstruction in pediatric patients. The overall complication rate was 8.85% (95% CI: 6.2–11.3), indicating a low incidence of surgical and postoperative complications. Donor-site morbidity was reported at a pooled rate of 5.15% (95% CI: 3.8–6.9), suggesting that harvesting the fibula does not significantly impact long-term limb function. Heterogeneity across studies was low (I² = 5%), reflecting the consistency of findings across multiple independent cohorts. Funnel plot analysis did not reveal significant publication bias, indicating that the results of this meta-analysis provide an unbiased and comprehensive assessment of FFF outcomes in pediatric patients.
Outcomes Data and

Conclusion: The findings of this systematic review and meta-analysis confirm that fibula free flap (FFF) reconstruction is a highly effective and reliable approach for pediatric mandibular and maxillary reconstruction, demonstrating excellent long-term survival rates and minimal morbidity. The pooled flap survival rate of 95.88% reinforces the predictability of FFF in pediatric patients, with low rates of vascular compromise and surgical failure. The overall complication rate of 8.85% and donor-site morbidity of 5.15% further highlight the safety of this technique, making it a viable first-line option for extensive craniofacial reconstructions in children. Although a small subset of patients ( < 7%) exhibited minor skeletal asymmetries, these were not functionally significant, and timing of reconstruction may influence the need for secondary adjustments later in life. Additionally, functional outcomes, including speech, mastication, and airway stability, were highly favorable, with over 94% of patients retaining intelligible speech and full masticatory function within two years postoperatively. Despite initial concerns about donor-site morbidity, findings indicate that FFF harvesting does not significantly impair lower limb function, provided that at least 6 cm of the distal fibula is preserved. The absence of major gait disturbances or musculoskeletal complications further supports the safety of FFF in pediatric patients. These results strongly validate the continued use of FFF as the gold standard for pediatric mandibular and maxillary reconstruction.
Table 1. PRISMA Diagram Table 2. Pooled Summary of Studies Table 3. Cochrane Risk of Bias Assessment