Long-term facial symmetry after pediatric mandibular reconstruction using the vascularized fibula free flap: A photogrammetric analysis



      The fibula free flap is the standard of care in the reconstruction of large mandibular defects in pediatric patients, enabling adequate restoration of the facial contour. However, the unpredictable growth potential of the reconstructed mandible could influence the preservation of the initially restored symmetry over time. Being mindful of the importance of facial appearance during developmental stages, this study aimed to evaluate the long-term facial symmetry after mandible reconstruction using this technique in growing patients.

      Patients and Methods

      A photogrammetric analysis of facial symmetry using the “Asymmetry Index” (AI) was performed from preoperative and postoperative frontal photographs in 17 pediatric patients (9 males and 8 females) who underwent mandibular reconstruction with the vascularized fibula free flap and had a minimum follow-up of 5 years. Comparisons between preoperative and postoperative measurements—as well as postoperative comparisons between condyle-reconstructed and condyle-preserved patients—were conducted.


      The mean follow-up was 76.9 (± 19.0) months (range, 60–120). The average age at intervention was 9.23 (± 3.8) years. Mean AI was 15.31 (± 1.81) preoperatively and 3.59 (± 0.97) postoperatively. Differences between preoperative and postoperative measurements were statistically significant in all the assessed parameters (p<0.001). Postoperative differences between the condyle-reconstructed and the condyle-preserved groups were not significant (p>0.05). No secondary procedures were required to enhance symmetry in the late postoperative period.


      Mandibular reconstruction using the vascularized fibula free flap provides adequate restoration of facial symmetry that could be predictably maintained throughout the developmental period in children and adolescents, regardless of the need for condylar reconstruction.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Iconomou T.G.
        • Zuker R.M.
        • Phillips J.H.
        Mandibular reconstruction in children using the vascularized fibula.
        J Reconstr Microsurg. 1999; 15: 83
        • Warren S.M.
        • Borud L.J.
        • Brecht L.E.
        • et al.
        Microvascular reconstruction of the pediatric mandible.
        Plast Reconstr Surg. 2007 Feb;; 119: 649-661
        • Crosby M.A.
        • Martin J.W.
        • Robb G.L.
        • et al.
        Pediatric mandibular reconstruction using a vascularized fibula flap.
        Head Neck. Mar 2008; 30: 311-319
        • Abramowicz S.
        • Goudy S.L.
        • Mitchell C.E.
        • et al.
        A protocol for resection and immediate reconstruction of pediatric mandibles using microvascular free fibula flaps.
        J Oral Maxillofac Surg. 2020 Aug 26; (S0278-2391(20)31085-5)
        • Cleveland E.C.
        • Zampell J.
        • Avraham T.
        • et al.
        Reconstruction of congenital mandibular hypoplasia with microvascular free fibula flaps in the pediatric population: a paradigm shift.
        J Craniofac Surg. Jan 2017; 28: 79-83
        • Zhang W.B.
        • Liang T.
        • Peng X.
        Mandibular growth after paediatric mandibular reconstruction with the vascularized free fibula flap: a systematic review.
        Int J Oral Maxillofac Surg. Apr 2016; 45: 440-447
        • Temiz G.
        • Bilkay U.
        • Tiftikçioğlu Y.Ö.
        • et al.
        The evaluation of flap growth and long-term results of pediatric mandible reconstructions using free fibular flaps.
        Microsurgery. May 2015; 35: 253-261
        • Donski P.K.
        • Carwell G.R.
        • Sharzer L.A.
        Growth in revascularized bone grafts in young puppies.
        Plast Reconstr Surg. 1979; 64: 239-243
        • Weiland A.J.
        • Phillips T.W.
        • Randolph M.A.
        Bone grafts: a radiologic, histologic, and biomechanical model comparing autografts, allografts, and free vascularized bone grafts.
        Plast Reconstr Surg. 1984; 74: 368
        • Tamai S.
        Experimental vascularized bone transplantations.
        Microsurgery. 1995; 16: 179
        • Budal J.
        The osteogenic capacity of the periosteum.
        Oral Surg Oral Med Oral Pathol. 1979; 47: 227-229
        • Farkas L.G.
        • Posnick J.C.
        • Hreczko T.M.
        Growth pattern of the face: a morphometric study.
        Cleft Palate Craniofac J. 1992; 39: 308-315
        • Nakamura T.
        • Okamoto K.
        • Maruyama T.
        Facial asymmetry in patients with cervicobrachial pain and headache.
        J Oral Rehabil. Nov 2001; 28: 1009-1014
        • Schellhas K.P.
        • Pollei S.R.
        • Wilkes C.H.
        Pediatric internal derangements of the temporomandibular joint: effect on facial development.
        Am J Orthod Dentofacial Orthop. Jul 1993; 104: 51-59
        • Smartt Jr, J.M.
        • Low D.W.
        • Bartlett S.P.
        The pediatric mandible: I. A primer on growth and development.
        Plast Reconstr Surg. 2005; 116: 14e-23e
        • Boyd J.B.
        • Gullane P.J.
        • Rotstein L.E.
        • Brown D.H.
        • Irish J.C.
        Classification of mandibular defects.
        Plast Reconstr Surg. Dec 1993; 92: 1266-1275
        • Penton-Voak I.
        • Perrett D.I.
        Consistency and individual differences in facial attractiveness judgements: an evolutionary perspective.
        Soc Res (New York). 2000; 67: 219-244
        • Rhodes G.
        The evolutionary psychology of facial beauty.
        Ann Rev. Psychol. 2006; 57: 199-226
        • Dion K.
        • Berscheid E.
        • Walster E.
        What is beautiful is good.
        J Pers Soc Psychol. 1972; 24: 285-290
        • Perkins D.F.
        • Lerner R.M.
        Single and multiple indicators of physical attractiveness and psychosocial behaviors among young adolescents.
        J Early Adolesc. 1995; 15: 269-298
        • Vingilis-Jaremko L.
        • Maurer D.
        The influence of symmetry on children's judgments of facial attractiveness.
        Perception. 2013; 42: 302-320
        • Wan Q.
        • Zwahlen R.A.
        • Cheng G.
        • Li Z.
        • Li Z.
        Influence of mandibular reconstruction on patients’ health-related quality of life.
        J Oral Maxillofac Surg. Jun 2011; 69: 1782-1791
        • Zavalishina L.
        • Karra N.
        • Zaid W.S.
        • El-Hakim M.
        Quality of life assessment in patients after mandibular resection and free fibula flap reconstruction.
        J Oral Maxillofac Surg. Aug 2014; 72: 1616-1626
        • Zhang X.
        • Li M.J.
        • Fang Q.G.
        • Li Z.N.
        • Li W.L.
        • Sun C.F.
        Free fibula flap: assessment of quality of life of patients with head and neck cancer who have had defects reconstructed.
        J Craniofac Surg. Nov 2013; 24: 2010-2013
        • Zavala A.
        • Al Deek N.F.
        • Chang Y.M.
        • Tsai C.Y.
        • Wei F.C
        Reconstruction of mandibular defects involving the central segment with fibula osteoseptocutaneous free flap following ameloblastoma resection: patient-reported outcomes.
        J Plast Reconstr Aesthet Surg. Nov 2021; 74: 3022-3030
        • Nahhas R.W.
        • Valiathan M.
        • Sherwood R.J.
        Variation in timing, duration, intensity, and direction of adolescent growth in the mandible, maxilla, and cranial base: the Fels longitudinal study.
        Anat Rec (Hoboken). 2014; 297: 1195-1207
        • Al Deek N.F.
        • Kao H.K.
        • Wei F.C
        The fibula osteoseptocutaneous flap: concise review goal-oriented surgical technique, and tips and tricks.
        Plast Reconstr Surg. 2018; 142: 913e-923e
        • Wei F.C.
        • Chen H.C.
        • Chuang C.C.
        • et al.
        Fibular osteoseptocutaneous flap: anatomic study and clinical application.
        Plast Reconstr Surg. 1986; 78: 191-200
        • Santamaría E.
        • Galaso-Trujillo J.R.
        • Palafox D.
        • Mainardi S.R.
        • García R.A.
        • Romero A.C.
        • Rangel W.A.T.
        Donor-site morbidity following free fibula flap harvest for mandibular or maxillary reconstruction in pediatric patients.
        J Craniofac Surg. 2021 Jul-Aug 01; 32: e464-e468
        • Zavala A.
        • Ore J.F.
        • Broggi A.
        • De Pawlikowski W.
        Pediatric mandibular reconstruction using the vascularized fibula free flap: functional outcomes in 34 consecutive patients.
        Ann Plast Surg. 2021 Dec 1; 87: 662-668
        • Guo L.
        • Ferraro N.F.
        • Padwa B.L.
        • Kaban L.B.
        • Upton J.
        Vascularized fibular graft for pediatric mandibular reconstruction.
        Plast Reconstr Surg. Jun 2008; 121: 2095-2105
        • Phillips J.H.
        • Rechner B.
        • Tompson B.D.
        Mandibular growth following reconstruction using a free fibula graft in the pediatric facial skeleton.
        Plast Reconstr Surg. Aug 2005; 116 (discussion 425-6): 419-424
        • Volk A.S.
        • Riad S.S.H.
        • Kania K.E.
        • Davies L.
        • Wirthlin J.O.
        • Pederson W.C.
        • Buchanan E.P.
        Quantifying free fibula flap growth after pediatric mandibular reconstruction.
        J Craniofac Surg. Oct 2020; 31: e710-e714
        • Tahiri Y.
        • Chang C.S.
        • Tuin J.
        • et al.
        Costochondral grafting in craniofacial microsomia.
        Plast Reconstr Surg. 2015; 135: 530-541
        • Yu Y.
        • Zhang W.B.
        • Liu X.J.
        • Guo C.B.
        • Yu G.Y.
        • Peng X.
        Regeneration of the neocondyle after free fibular flap reconstruction of the mandibular condyle.
        J Oral Maxillofac Surg. Mar 2020; 78: 479-487