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Reconstruction of the Pediatric Midface Following Oncologic Resection
Matthew Doscher, M.D., Ali Charafeddine, M.D., Oren Tepper, M.D., Satyen Undavia, M.D., Jonathan Gill, M.D., Richard Gorlick, M.D., Richard Smith, M.D., Evan Garfein, M.D..
Montefiore Medical Center - Albert Einstein College of Medicine, Bronx, NY, USA.
Background: Management of midface tumors in the pediatric population presents myriad challenges. The challenges of resection and reconstruction are exaggerated in pediatric patients due to both typical tumor biology and the anatomic constraints of the region. These factors often lead to the choice of radiation therapy rather than surgical management for primary treatment. This series describes the feasibility and efficacy of midface reconstruction in the pediatric population.
Methods: After obtaining IRB approval a retrospective review was performed. Records of all pediatric patients who underwent midface resection and reconstruction at Montefiore Medical Center between 2008 and 2012 were reviewed. Seven patients who underwent resection and reconstruction for maxillary sarcomas were identified and included in this review.
Results: Seven patients underwent eight midface/orbit reconstructions. These patients ranged in age from 8 months to 20 years. Five patients were reconstructed with six microvascular free flaps. Two patients received pedicled flaps. Follow-up ranged from 1 to 4 years. Reconstructive, oncological, and functional outcomes were analyzed. All 7 patients had resection for sarcomas of the maxilla (Cordeiro classifications- II-1, IIIa-4, and IV-1, orbit only - 1). Flaps utilized included four vertical rectus abdominis myocutaneous flaps, one anterolateral thigh flap, one fibula flap and two temporoparietal flaps. One flap developed a venous thrombosis but was successfully salvaged after thrombectomy and revision of the venous anastomosis using a vein graft. One patient developed recurrence after initial flap placement and required salvage resection and a second free flap. Six patients had good facial symmetry and were able to tolerate a regular oral diet with near-normal dental occlusion. Two patients succumbed to metastatic disease.
Conclusions: Standard therapy for treatment of sarcomas of the maxilla in the pediatric population consists of non-surgical management. Surgical resection and reconstruction in pediatric patients are utilized at lower frequencies than in the adult population secondary to concerns over technical feasibility of resection and reconstruction and an unfavorable morbidity profile. Not only is microsurgical reconstruction of the pediatric midface safe and effective, but primary surgical management preserves radiation as a salvage modality of treatment. Complications of free tissue transfer occur at a low frequency and acceptable functional and cosmetic outcomes are the norm. Surgical resection and immediate microsurgical reconstruction should be considered first-line treatment of midface malignancies in children.
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