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Bilateral Vascularized Second Metatarsophalangeal Flaps for Severe Mandibular Hypoplasia

2024; Wolters Kluwer; Volume: 12; Issue: 1S1 Linguagem: Inglês

10.1097/01.gox.0001005964.25678.f9

2169-7574

Lee W. T. Alkureishi, Chad A. Purnell, Walton L. Robert,

Cleft Lip and Palate Research

Background: We present a novel approach using bilateral vascularized second metatarsophalangeal flaps to reconstruct the mandibular rami and temporomandibular joints in two patients with severe mandibular hypoplasia in Pierre-Robin Sequence. Both patients had multiple prior failed reconstructions, and presented with nonfunctional TMJs and severe malocclusion. After discussion with patient/family, the decision was made to proceed with staged reconstruction using the second metatarsophalangeal flap donor site. Methods: Staged reconstruction was performed in both patients. In one patient, the first surgery involved removal of infected and malpositioned bilateral alloplastic ramus/TMJ implants, and placement of cranial-based "chickenfoot" distractors to improve soft tissue compliance. Following this, an ipsilateral vascularized second metatarsophalangeal flap incorporating the MTP joint was reversed and transferred to the mandible, with fixation of the phalanx to the temporal bone and the metatarsal to the mandibular body. The contralateral side was performed 3-5 months later, and external distractors removed 2 months after the second side. Results: Mean duration of treatment was 18 months, and mean follow-up was 24 months. One patient developed surgical site infections at the left temporal fossa and left foot, requiring operative debridement. In both patients, corrected occlusal relationship has been maintained, and mean mandibular range of motion is 2.5cm. Patient 2 is planned to undergo tracheostomy decannulation and begin orthodontic treatment in the near future. Both patients remain very happy with the donor site. Discussion: The vascularized second metatarsal flap has found utility in the hand surgery literature, where the reversed proximal metatarsal can be used to replace articular surfaces around the wrist. A similarly designed flap has also been described in the treatment of temporomandibular joint ankylosis, with nonvascularized graft of the metatarsal base used to reconstruct the glenoid portion of the TMJ. To our knowledge, this is the first report of a composite metatarsophalangeal flap incorporating the MTP joint, used for salvage reconstruction of the bilateral TMJs and mandibular rami in patients with severe mandibular hypoplasia and multiple prior failed reconstructions. Conclusion: The second metatarsophalangeal flap provides an alternative option for free flap reconstruction of the mandibular ramus and TMJ, potentially avoiding the visible donor site of options such as the fibula flap. Our results are promising, and we plan to continue exploring this flap's utility going forward.