Algorithm-Based Reconstruction for Pediatric Mandibular Desmoid Tumors: Two Decades From a Single Institution

Pediatric mandibular desmoid tumors are rare, locally aggressive lesions that can create composite defects in a growing craniofacial skeleton. We retrospectively reviewed biopsy-proven pediatric desmoid tumors involving the mandible region treated at a tertiary children's hospital (2004-2024) and mapped each case to an institutional, algorithm-based reconstructive pathway (A-D) incorporating a mandibular resection index (RI; threshold 32%) and 2 modifiers (modifier 1: systemic therapy/radiotherapy; modifier 2: staged bony reconstruction for inadequate bone stock). We summarized pathway assignments, transitions over time, and cumulative operative burden. Eight mandibular cases were included in the algorithm analysis. Initial pathway assignments were A (n=4), B (n=3), C (n=1), and D (n=0). Modifier 1 was applied in 2/8 (25%) and modifier 2 in 4/8 (50%). During follow-up, 4/8 patients escalated to a higher pathway (A→B→C, B→C, B→D, C→D). Among 7 operative patients, median age at index reconstructive surgery was 5.1 years (range: 0.9-11.9), with mean cumulative hospitalization of 25.1±21.8 days and mean cumulative operative time of 18.4±12.7 hours. Patients requiring pathway escalation had higher cumulative burden (hospitalization 34.0±21.8 days; operative time 26.5±10.6 hours; median 5 operations). Algorithm-based pathway assignment captures the longitudinal reconstructive reality of pediatric mandibular desmoid tumors. Early recognition of predictable failure modes (infection, hardware compromise, and inadequate bone stock) may help teams select definitive reconstruction earlier in select patients and reduce cumulative surgical burden.