Tumour removal and reconstruction of a two-year-old’s lower jaw

Brave little Annelie is on her way to a much-improved future after intricate procedure

Tuesday, October 25 2022

“A person’s face is crucial for human interaction and communicating, both verbally and nonverbally. Your entire personality is expressed in your face. When we meet someone for the first time, we immediately unconsciously try to read their facial expressions and their speech for clues about them and, rightly or wrongly, whether we can trust the person.”

“Facial reconstruction is therefore so much more than merely cosmetic. Restoring the form and function of the face is absolutely fundamental to overall wellbeing and development, particularly where such a young child is concerned,” says Dr Sunil Aniruth, a maxillofacial and oral surgeon practising at Netcare Blaauwberg Hospital.

Just over two years ago, Annelie*’s parents noticed a swelling on the right side of their daughter’s face and took her to the general practitioner thinking that it could have been mumps or a similar common childhood illness. When the medicine prescribed for a gland infection failed to resolve the problem, the doctor referred the family to paediatrician Dr Zakiyya Omarjee who ordered the tests needed for a diagnosis.

Image Two years ago, a little girl underwent a procedure to remove a highly aggressive tumour from her lower jaw and fill the space left in its place. A portion of the child’s fibula, the smaller bone of the lower leg that is not necessary for stability, was used to reconstruct her jawbone. At a recent follow up, it was confirmed that the bone graft has fused onto the jaw and remained stable and functional.
(Left to right) Microsurgeon, plastic and reconstructive surgeon Dr Alexander Zühlke, paediatric surgeon Professor Daniel Sidler, and maxillofacial and oral surgeons Dr Ebrahim Parker and Dr Sunil Aniruth, performed the intricate and complex procedure on the two-year-old girl at Netcare Blaauwberg Hospita


“I was so emotional at the time, it is hard seeing your child being poked with needles and undergoing so many tests. I knew it was necessary, but I just wanted it to stop. At this time, the doctor still couldn’t advise what was wrong with my daughter, but at least she was not in pain,” Annelie's mother recalls.

Dr Omarjee and the family consulted paediatric surgeon Professor Daniel Sidler, who also practises at Netcare Blaauwberg Hospital and a CT scan, MRI scan and surgical biopsy were performed.

A rare, highly aggressive tumour
“We discovered the child had a very rare kind of highly aggressive fibrous tumour, one of only a handful identified and all affecting young children. The tumour was in one side of the child’s jaw, and it would require a highly complex surgery involving a multidisciplinary team,” Prof Sidler says.  

“Prof Sidler advised us that even though the tumour was not cancerous, she would have to have a major operation because the tumour was essentially eating into her right jawbone. We were extremely worried and just trying to take in all the information about her diagnosis and what this actually meant for our daughter,” her father says.

“We were so overwhelmed and emotional thinking about our child, smiling and playing just like any other two year old, unaware of the big operation and recovery ahead of her. To be honest, as her parents we also did not know quite what we were heading into. No parent is prepared for this and we were advised there are risks involved, but we just had to think of our daughter and what would be best for her.”

Team assembled for a complex procedure
Dr Aniruth and Prof Sidler assembled an expert team with the necessary skills to perform the highly complicated operation to not only remove the tumour, but also to fill the space left in its place with a functional replacement for the young child’s jawbone.

Dr Aniruth, assisted by Prof Sidler and Dr Ebrahim Parker, performed the resection of the tumour which involved soft tissue and bone resection. The 3-D pre-surgical planning was coordinated by Stacey Du Plessis of Selective Surgical, while anaesthetist Dr Cath Jackson ensured the child was safely and appropriately managed under the general anaesthetic.

“To help reduce the risk of the tumour recurring, we needed to remove some of the surrounding healthy tissue, and then in a single procedure also rebuild the child’s jaw so that she would have a complete face,” Prof Sidler says.

Dr Alexander Zühlke, a microsurgeon, plastic and reconstructive surgeon was asked to join the multidisciplinary team and was responsible for restoring the missing section of bone from the child’s chin to the angle of her jaw at the back.

Painstaking reconstruction
“It is crucial to provide new, vascularized bone to reconstruct the lower jaw because if there is instability, the person will not be able to chew on that side. The central portion of the fibula was utilised, which is the smaller bone of the lower leg that is not necessary for leg stability. This bone has similar thickness and strength to the jawbone,” Dr Zühlke says.

The fibula was removed from the child’s leg, as well as the artery and veins that are needed to supply the bone with oxygen and nutrients because the bone cannot survive without proper blood supply. The fibula was cut to fit the required space and doubled up to increase the height and stability of the newly fashioned jawbone, which was held in place with specially made surgical plates.

Under a microscope, Dr Zühlke meticulously connected the artery and vein of the fibula, which are less than 2mm in diameter in such a small child, to an artery and vein in the neck. This delicate and intricate work therefore required very fine suture, size 9/0.

“Seeing our daughter for the first time coming out of surgery was very emotional for both of us. Once she woke up, she wanted us to hold and comfort her but she couldn’t move much because of all the tubes and drips. We let her know Mommy and Daddy are here and asked her ‘How much do you love us?’, to which she responded showing 10 fingers, meaning she loves us the most, 10 out of 10,” the child’s mother remembers, now two years after the procedure.

Recovery of a strong, confident child
At her two-year clinical and CT scans follow up with maxillofacial and oral surgeon Dr Ebrahim Parker, it was confirmed that the bone graft has fused onto the jaw and remained stable and functional. A second operation was performed by Dr Aniruth assisted by Dr Parker to remove the plates to prevent them from restricting the growth as the child grows. Future follow ups will be required as the child grows.

“She is amazing, such a brave and strong little girl, our little girl. Each day she got better, climbing out of bed on the third day. Seeing her walk was a miracle on its own, and seeing her smile was so heart-warming, we are full of love for her and grateful to the whole team who assisted our daughter. The doctors and nurses, kitchen staff and everyone involved at the hospital made her feel so comfortable and special,” Annelie’s parents say.

“She is once more her loving, happy old self. Seeing our daughter embracing herself and showing remarkable self-confidence with anything she puts her mind to has made us very proud parents.”


Editor’s note

***Please be aware that the name of the child has been changed to protect the privacy of the child and her family.***

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