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Lech D, Matysek J, Maksymowicz R, Strączek C, Marguła R, Krakowczyk Ł, Kozakiewicz M, Dowgierd K. Maxillofacial Microvascular Free-Flap Reconstructions in Pediatric and Young Adult Patients-Outcomes and Potential Factors Influencing Success Rate. J Clin Med 2024; 13:2015. [PMID: 38610780 PMCID: PMC11012962 DOI: 10.3390/jcm13072015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/16/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Maxillofacial microvascular free-flap reconstructions are significant interventions in the management of congenital defects, traumatic injuries, malignancies, and iatrogenic complications in pediatric and young adult patients. Craniofacial disorders within this demographic can result in profound functional, cosmetic, and psychosocial impairments, highlighting the critical need for thorough investigation into factors that may influence procedural success and postoperative quality of life. This retrospective chart review aims to examine the outcomes and potential influencing factors, aiming to offer valuable insights into optimizing the effectiveness of these reconstructions and improving patient outcomes. Methods: A single head and neck surgical team performed all the included 136 procedures. Demographic and surgical patient data were recorded. Type of transfer performed in each recipient site and major complications were analyzed. Relevant influencing factors, such as age, gender, and etiology of defect were determined using the ANOVA test and χ2 test of independence. Results: The results indicate a 90% success rate. No significant relationship was found between the incidence of total flap loss and patient age, etiology, or graft source. The maxillary reconstructions showed a higher incidence of total flap loss compared to mandibular reconstructions (11 vs. 3 cases). Conclusions: Despite the high success rate, the findings underline the necessity for further research to validate these observations and enhance surgical methods for pediatric and young adult patients.
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Affiliation(s)
- Dominika Lech
- Department of Clinical Pediatrics, Head and Neck Surgery Clinic for Children and Young Adults, University of Warmia and Mazury, Żołnierska 18a Street, 10-561 Olsztyn, Poland; (D.L.); (J.M.); (R.M.); (C.S.); (R.M.)
| | - Jeremi Matysek
- Department of Clinical Pediatrics, Head and Neck Surgery Clinic for Children and Young Adults, University of Warmia and Mazury, Żołnierska 18a Street, 10-561 Olsztyn, Poland; (D.L.); (J.M.); (R.M.); (C.S.); (R.M.)
| | - Robert Maksymowicz
- Department of Clinical Pediatrics, Head and Neck Surgery Clinic for Children and Young Adults, University of Warmia and Mazury, Żołnierska 18a Street, 10-561 Olsztyn, Poland; (D.L.); (J.M.); (R.M.); (C.S.); (R.M.)
| | - Cyprian Strączek
- Department of Clinical Pediatrics, Head and Neck Surgery Clinic for Children and Young Adults, University of Warmia and Mazury, Żołnierska 18a Street, 10-561 Olsztyn, Poland; (D.L.); (J.M.); (R.M.); (C.S.); (R.M.)
| | - Robert Marguła
- Department of Clinical Pediatrics, Head and Neck Surgery Clinic for Children and Young Adults, University of Warmia and Mazury, Żołnierska 18a Street, 10-561 Olsztyn, Poland; (D.L.); (J.M.); (R.M.); (C.S.); (R.M.)
| | - Łukasz Krakowczyk
- Oncological and Reconstructive Surgery Clinic, Branch of National Oncological Institute in Gliwice, Maria Sklodowska-Curie Institute—Oncology Centre (MSCI), Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Marcin Kozakiewicz
- Department of Maxillofacial Surgery, Medical Univeristy of Lodz, 113 Żeromskiego Str., 90-549 Lodz, Poland;
| | - Krzysztof Dowgierd
- Department of Clinical Pediatrics, Head and Neck Surgery Clinic for Children and Young Adults, University of Warmia and Mazury, Żołnierska 18a Street, 10-561 Olsztyn, Poland; (D.L.); (J.M.); (R.M.); (C.S.); (R.M.)
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Lam T, Levi E, Shen J, Wilks D, Alexander W. Radial forearm free flap reconstruction in a 3-month-old patient with undifferentiated pharyngeal sarcoma. Microsurgery 2024; 44:e31149. [PMID: 38363100 DOI: 10.1002/micr.31149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/01/2023] [Accepted: 01/16/2024] [Indexed: 02/17/2024]
Abstract
There is minimal information regarding free tissue transfers in very young infants, especially those less than a year old. It is often thought that that age remains a limit to free tissue transfers, with younger patients having smaller vessels, making the operation technically challenging. In this case report, we discuss the youngest and smallest recorded case of a free flap reconstruction. A 3-month-old patient with a malignant parapharyngeal undifferentiated round cell sarcoma underwent a resection and reconstruction with a radial forearm free flap (RFFF). The defect was 35 by 20 by 15 mm, and required a pharyngeal "patch," as opposed to a "tube," reconstruction. The defect was templated, and the RFFF then raised in a standard subfascial fashion, and inset with resorbable sutures. The patient was observed in the ICU postoperatively. The patient was subsequently diagnosed with Stage IV primary undifferentiated sarcoma with regional metastasis and received adjuvant chemotherapy. Fifteen-month follow up revealed no signs of recurrence, full oral intake, a well-reconstructed pharynx on nasoendoscopic examination, and minimal donor site morbidity. This report illustrates several unique adaptations of free flap transfer in infants and adds to the emerging body of evidence that age is not a contraindication for head and neck reconstruction.
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Affiliation(s)
- Theodore Lam
- Department of Plastics and Reconstructive Surgery, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Eric Levi
- Department of Otolaryngology, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Jacson Shen
- Department of Plastics and Reconstructive Surgery, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Daniel Wilks
- Department of Plastics and Reconstructive Surgery, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - William Alexander
- Department of Plastics and Reconstructive Surgery, The Royal Children's Hospital Melbourne, Melbourne, Australia
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Liu S, Zhang WB, Wang Y, Mao C, Yu GY, Peng X. Long-Term Outcomes after Pediatric Mandibular Reconstruction Using Vascularized Free Fibula Flap. Plast Reconstr Surg 2024; 153:397e-406e. [PMID: 37053458 DOI: 10.1097/prs.0000000000010529] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the long-term outcomes of mandibular reconstruction with vascularized free fibula flap in pediatric patients. METHODS Consecutive cases of mandibular reconstruction with vascularized free fibula flaps in pediatric patients at Peking University School and Hospital of Stomatology between 1999 and 2019 were reviewed. Postoperative computed tomography (CT) data of all patients were collected at each postoperative follow-up point, and after the age of 18 years. The length and height of the grafted fibula and the length of the remaining mandible were evaluated by measuring the three-dimensional CT data using ProPlan CMF 3.0 software. Lower limb function was evaluated using the Enneking evaluation scale. Facial symmetry was self-evaluated and scored. Statistical analysis was performed on the data obtained. RESULTS Fourteen patients were included in this study. All flaps were successful. The CT measurement results showed growth in the length of the grafted fibula that reconstructed the mandibular ramus and the residual mandible ( P < 0.05). The height of the grafted fibula remained stable ( P > 0.05). Eight patients were followed up until they were older than 18 years, and the CT measurement results after 18 years showed an essentially symmetric mandible profile ( P > 0.05). All patients were satisfied with their postoperative facial symmetry. Enneking evaluation scores showed good recovery of lower limb functions. CONCLUSIONS The vascularized free fibula flap for mandibular reconstruction in pediatric patients is safe and reliable. It also provides good cosmetic and functional outcomes, as it demonstrated positive growth. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Shuo Liu
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology; National Center of Stomatology; National Clinical Research Center for Oral Diseases; and National Engineering Laboratory for Digital and Material Technology of Stomatology
| | - Wen-Bo Zhang
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology; National Center of Stomatology; National Clinical Research Center for Oral Diseases; and National Engineering Laboratory for Digital and Material Technology of Stomatology
| | - Yang Wang
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology; National Center of Stomatology; National Clinical Research Center for Oral Diseases; and National Engineering Laboratory for Digital and Material Technology of Stomatology
| | - Chi Mao
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology; National Center of Stomatology; National Clinical Research Center for Oral Diseases; and National Engineering Laboratory for Digital and Material Technology of Stomatology
| | - Guang-Yan Yu
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology; National Center of Stomatology; National Clinical Research Center for Oral Diseases; and National Engineering Laboratory for Digital and Material Technology of Stomatology
| | - Xin Peng
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology; National Center of Stomatology; National Clinical Research Center for Oral Diseases; and National Engineering Laboratory for Digital and Material Technology of Stomatology
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Wang JH, Zheng B, Lv L, Cai ZG, Liu XJ, Zhang L, Peng X, Mao C, Yu GY, Su JZ. Characteristics and management of vascular compromise after an organ transplantation surgery of the head and neck region: Analysis of 220 submandibular glands with autologous transplantation. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 124:101566. [PMID: 37490996 DOI: 10.1016/j.jormas.2023.101566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/12/2023] [Accepted: 07/16/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Microvascular submandibular gland transplantation (SMGT) for severe dry eye disease (DED) has rarely been reported in the literature. The aim of this study was to report a case series of SMGT with the special focus on monitoring and management of postoperative vascular compromise. METHODS Using a retrospective single-cohort study design, the investigators enrolled a sample of DED patients undergoing SMGT in a Chinese university hospital during 1999 and 2021. The main outcomes were baseline and surgical data, post-operative manifestations, and surgical results. Descriptive, uni- and bivariate statistics were computed with the significant P < 0.05. RESULTS During the study period, 220 DED patients (55.9% female) with a mean age of 32.66±14.47 years underwent SMGT. Vascular compromises occurred in 27 grafted glands (12.3%; 22 venous compromises and 5 arterial compromises) at a median of 27 h(range, 3.3 to 288 h) after surgery. Harden texture and swelling of the covering skin flap of the donor indicated venous compromises, while some specific sign was absent for arterial compromise. The accompanying vein of the facial artery (FAV) as a donor's vein was associated with less vascular compromise compared to the anterior facial vein (AFV). Timely reexploration was performed in 25 glands (92.6%), with a salvaged rate of 48%, and more venous compromises were salvaged compared to artery compromises (54.6% vs. 0%, P = 0.047). Temporary hypersecretion on postoperative 2-5 days was noticed in the grafted glands with no or salvaged vascular compromise (Schirmer's test, 35 mm/5 min and 37 mm/5 min, respectively, P = 0.749), while they were absent for the 15 surgically failed grands (Schirmer's test 0 mm/5 min, P<0.001). CONCLUSIONS Vascular compromise appears to be a common complication of SMGT. Postoperative hypersecretion of the grafted glands may indicate good circulation, and the use of FAV as the donor's vein could help to decrease the risk of vascular compromise.
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Affiliation(s)
- Jing-Han Wang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing 100081, PR China
| | - Bang Zheng
- Peking University School of Public Health, Beijing, 100191, China; Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Lan Lv
- Department of Ophthalmology, Affiliated Beijing Tong Ren Hospital, Capital University of Medical Science, Beijing, 100730, China
| | - Zhi-Gang Cai
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing 100081, PR China
| | - Xiao-Jing Liu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing 100081, PR China
| | - Lei Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing 100081, PR China
| | - Xin Peng
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing 100081, PR China
| | - Chi Mao
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing 100081, PR China
| | - Guang-Yan Yu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing 100081, PR China.
| | - Jia-Zeng Su
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing 100081, PR China.
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Burns HR, Skochdopole AJ, Alfaro Zeledon R, Pederson WC. Pediatric Microsurgery and Free-Tissue Transfer. Semin Plast Surg 2023; 37:231-239. [PMID: 38098684 PMCID: PMC10718656 DOI: 10.1055/s-0043-1776698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Advancements in microsurgery, along with increased microsurgical experience in pediatric patients, have made free-tissue transfer a reliable modality for pediatric bone and soft tissue reconstruction today. Free-tissue transfer is most commonly used in children for the coverage of large or complex defects resulting from traumatic, oncologic, or congenital etiologies. While flap success and complication rates between pediatric and adult populations are similar, special considerations must be taken into account within the pediatric population. In this article, we will describe common indications, technical nuances, and clinical considerations for the management of the pediatric free-tissue transfer patient.
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Affiliation(s)
- Heather R. Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Anna J. Skochdopole
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Richardo Alfaro Zeledon
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - William C. Pederson
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
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Slijepcevic AA, Wax MK, Hanasono M, Ducic Y, Petrisor D, Thomas CM, Shnayder Y, Kakarala K, Pipkorn P, Puram SV, Rich J, Rezaee R, Pittman A, Troob S. Post-operative Outcomes in Pediatric Patients Following Facial Reconstruction With Fibula Free Flaps. Laryngoscope 2023; 133:302-306. [PMID: 35656557 DOI: 10.1002/lary.30219] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/16/2022] [Accepted: 05/03/2022] [Indexed: 01/20/2023]
Abstract
EDUCATIONAL OBJECTIVE Assess outcomes of pediatric facial reconstruction with fibula free flaps. OBJECTIVES Free flap reconstruction of complex maxillofacial defects in pediatric patients is rare. Post-operative complications, donor site morbidity, impact on craniofacial growth, and oro-dental rehabilitation are unknown. Our study assesses the outcomes of pediatric maxillofacial reconstruction with composite fibula free flaps. STUDY DESIGN Retrospective chart review. METHODS Multi-institutional retrospective chart review from 2000 to 2020 on pediatric patients undergoing maxillomandibular reconstruction with fibula free flaps. RESULTS Eighty-seven patients underwent 89 surgeries; 5 maxillary and 84 mandibular defects. Median age: 12 years. Defects were acquired following resection of sarcoma/carcinoma 44% or benign tumors 50%. 73% of cases had immediate free flap reconstruction. Closing osteotomies were reported in 74%; 1 in 40%, 2 in 27%, and more than 2 in 6.7%. Hardware was used in 98% and removed in 25%. 9.2% demonstrated long-term hardware exposure, greater than 3 months following reconstruction. Short-term complications: wound infection 6.7%, flap salvage/failure 2.2%, fistula 1.1%, and compromised craniofacial growth: 23%. Two patients developed trismus. Long-term fibula donor site complications: hypertrophic scarring: 3.4%, dysesthesia: 1.1%, and long-term gait abnormality: 1.1%. Dental rehabilitation was performed in 33%. Post-operative speech outcomes showed 94% with fully intelligible speech. CONCLUSION Pediatric maxillary and mandible defects repaired with fibula free flaps demonstrated complication rates comparable to the adult free flap population. Long-term follow-up did not demonstrate adverse outcomes for craniofacial growth. Hardware for flap retention was utilized and remained in place with minimal exposure. Post-operative gait abnormality is rare. LEVEL OF EVIDENCE 3 Laryngoscope, 133:302-306, 2023.
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Affiliation(s)
- Allison A Slijepcevic
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Matthew Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas, USA
| | - Daniel Petrisor
- Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Carissa M Thomas
- Department of Otolaryngology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Yelizaveta Shnayder
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Kiran Kakarala
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jason Rich
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Rod Rezaee
- Ear, Nose and Throat Institute-University Hospital and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Amy Pittman
- Department of Otolaryngology-Head and Neck Surgery, Loyola Medicine, Maywood, Illinois, USA
| | - Scott Troob
- Department of Otolaryngology-Head and Neck Surgery, Columbia University, New York, New York, USA
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Complex Head and Neck Resection, Reconstruction, and Rehabilitation in Children. Otolaryngol Clin North Am 2022; 55:1205-1214. [DOI: 10.1016/j.otc.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Vascularized Composite Parietal Bone Flap for Immediate Reconstruction of a Hemi-Maxillectomy Defect in an Infant. J Craniofac Surg 2021; 31:2334-2338. [PMID: 33136885 DOI: 10.1097/scs.0000000000006786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Surgical resection of maxillary tumors can result in defects that can be difficult to reconstruct by conventional means due to the complex functional and anatomic nature of the midface and lack of regional bone flap options in the head and neck. Many reconstructive methods have been used to repair maxillary defects, but the ideal technique for the reconstruction of hemi-maxillectomy defects in growing pediatric patients has yet to be determined. METHODS The authors present a rare pediatric patient with melanotic neuroectodermal tumor of infancy resulting in a hemi-maxillectomy defect after resection that was reconstructed using a pedicled vascularized composite flap consisting of temporalis muscle, pericranium, and parietal bone. RESULTS The patient achieved successful long-term bony reconstruction of his right maxilla with this flap. Stable skeletal fixation with adequate orbital support was maintained over a >3-year follow-up period. CONCLUSION A vascularized composite parietal bone flap is a reliable reconstructive option for reconstruction of large maxillectomy defects providing low donor-site morbidity, adequate globe support, excellent long-term skeletal stability, and malar symmetry in rapidly growing pediatric patients. Successful reconstruction for a rare patient with maxillary melanotic neuroectodermal tumor of infancy requiring hemi-maxillectomy was demonstrated with >3-year follow-up.
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