MANDIBULAR RECONSTRUCTION WITH A FIBULAR OSTEOCUTANEOUS FREE FLAP IN AN 8-MONTH-OLD GIRL WITH A 12-YEAR FOLLOW-UP JOS  E C.M. FARIA M.D., PH.D., 1 * BERNARDO N. BATISTA M.D., 1 LUIZ U. SENNES M.D., PH.D., 2 MARCO V.L. LONGO M.D., 1 ARTHUR H. DANILA, 3 and MARCUS C. FERREIRA, M.D. PH.D. 1 The purpose of this article is to describe a case of an 8-month-old girl who was diagnosed with a melanotic neuroectodermal tumor and was submitted to a right hemimandibulectomy and immediate reconstruction with a fibular osteocutaneous free flap. At 12-year follow-up, the longest reported in a patient this young, the transferred bone had grown much like the native mandible, and the patient had adequate mandibular contour and function. No revisions were needed, although orthopedic surgery was performed to correct an ankle valgus devia- tion on the donor leg. It is the opinion of the authors that microsurgical mandible reconstruction in very young patients is efficient and that the surrounding structures contribute to the remodeling of the bone segment to achieve characteristics similar to those of the native man- dible. V C 2013 Wiley Periodicals, Inc. Microsurgery 34:51–53, 2014. Head and neck reconstruction has evolved dramatically with flap anatomy studies and microsurgical techniques. In our institution, the fibular osteocutaneous free flap is the preferred reconstructive option for mandible defects needing vascularized bone. 1 Pediatric tumors that require wide excision and complex reconstruction are rare and challenging. The purpose of this article is to report the successful mandibular reconstruction in an 8-month-old girl with a fibular osteocutaneous free flap with a 12-year follow-up. CASE REPORT An 8-month-old girl presented to our hospital with a large solid blue mass on her right mandible (Fig. 1). The mass had appeared a few months after birth and grew rapidly. Preoperative biopsy showed that the lesion was a melanotic neuroectodermal tumor, also referred to as melanotic progonoma. Because of the size and biological behavior of the tu- mor, the head and neck team decided to perform a right hemimandibulectomy, including the condyle and part of the central left mandible, with removal of the mucosa covering the lesion (Fig. 2). A right fibular osteocutaneous free flap was harvested to reconstruct the mandible (Figs. 3 and 4). As much of the fibula was harvested as possible so as to preserve the growth centers, and portions thought to be sufficient to maintain joint stability were left proximally and distally.The length of the fibular segment was 8.9 cm and the dimensions of the corresponding skin paddle were 4.5 3 2.1 cm 2 . The facial vessels were used as recipient vessels with end-to-end microsurgical anastomosis. A single green- stick osteotomy was performed to reproduce the jaw angle. The authors decided not to perform more osteoto- mies due to the risk of losing skeletal stability, jeopardiz- ing vascularization of the flap and damaging the growth centers. The fibula was then secured to the native mandi- ble with interosseous wiring. The other end of the fibula was positioned in the direction of the glenoid fossa with a 3–0 vicryl stitch. The skin paddle was used to replace the mucosal defect. The donor site was treated with a full-thickness skin graft and occlusive dressing. The patient had a satisfactory recovery. The patient developed a valgus deformity of her right ankle and a corrective procedure was performed at age 7. She otherwise had normal growth and development of the right leg. No recurrence was found at 12-year follow- up. Although slight contour asymmetry persists, the bone flap has grown much like the native mandible and the patient has no trismus or difficulties with mastication (Figs. 5A–5C). DISCUSSION Melanotic neuroectodermal tumor is a rare entity, with sporadic case reports and series in the literature. Less than 400 cases have been reported to date. First described in 1918, 90% of the cases are seen in the head and neck region, with the maxilla being the most affected (68.8%). It is accepted to be of neuroectodermal origin, and as a melanin producing tumor, it produces a blue or black, solid, rapidly growing mass, firmly 1 Department of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo, Brazil 2 Department of Otolaryngology, Hospital das Clinicas, University of Sao Paulo, Brazil 3 Medical Student, School of Medicine, University of Sao Paulo, Brazil *Correspondence to: Jos e Carlos Marques de Faria, M.D., Ph.D., Rua Mae- stro Cardim, 377 Cjs: 85/86, 01323-000 S~ ao Paulo, Brazil. E-mail: microcirurgia@terra.com.br Received 31 January 2013; Revised 6 April 2013; Revision Accepted 29 April 2013 Published online 29 July 2013 in Wiley Online Library (wileyonlinelibrary. com). DOI: 10.1002/micr.22136 Ó 2013 Wiley Periodicals, Inc.