reconstruction surgery

1
Case presentation
reconstruction surgery
Kai-feng Hung
Taipei VGH
???
2
personal data (case presentation)
personal data / chief complaint
renal
chief complaint (case presentation)
Name ??? Age 80 y/o Sex male Chart No 8855525
Marital status married
Mass lesion over Lt retromolar trigone with pain
sensation for 3 months.
evaluation
classification
reversible tx
surgery
3
case presentation reconstruction surgery
gt clinical examination
gt history
gt
radiologic investigations
gt joint clinic
gt
treatment plan
gt surgical procedures
4
physical examination (systemic)
physical examination
renal
General appearance moderate looking
appearance Vital sign BP138/64mmHg, PR 72/min,
RR 22/min, BT35.2 Head scar(), trauma(-),
bony mass(-) Neck palpable mass(), Lt
submandibular region, 1.5cm Eye protruded
eyes(-), pupils equal round reactive to
light() Ear ear drum, otorrhea(-) Nose
rihnorrhea(-), sinus tenderness(-), nasal
bleeding(-) Throat ulceration over mucosa(-),
tonsil enlargement(-)
gt
gt
gt
gt
gt
gt
gt
gt
evaluation
classification
reversible tx
surgery
5
physical examination (systemic)
physical examination
renal
Chest Lung percussion normal auscultation
wheezing (-), rales (-) rhonchi(-), stridor
(-) Heart regular heart beat, murmus
(/-) Abdomen soft and flat, splenomegaly(-)
hepatomegaly (-) Extremities joint
stiffness(-), pitting edema(-)
gt
gt
gt
gt
evaluation
classification
reversible tx
surgery
6
clinical examination (intraoral and extraoral)
renal
intraorally
Ulcerative mass lesion over left buccal mucosa,
extend to lt retromolar trigone region, and
close to lt tuberosity. The size was about 4x3cm.
extraorally
A palpable LN was noted over Lt level
Ib which size about 1.5x1.5cm.
evaluation
classification
reversible tx
surgery
7
case presentation reconstruction surgery
gt clinical examination
gt history
gt
radiological investigations
gt joint clinic

gt treatment plan
gt oral manifestation and dental
management

8
radiological study
renal
CT scan
Increased soft tissue density over lt buccal
mucosa, retromolar region Multiple
lymphadenopathy with central hypodensity, level Ib
evaluation
classification
reversible tx
surgery
9
radiological study
renal
whole body scan
No obvious uptake over maxilla and mandible
abdomen sono
No focal lesions in liver parenchyma, mild fatty
liver Kidney, prostate gland
within normal size
evaluation
classification
reversible tx
surgery
10
case presentation reconstruction surgery
gt clinical examination
gt history
gt
radiological investigations
gt joint clinic

gt clinical diagnosis treatment plan
gt oral
manifestation and dental management

11
clinical diagnosis treatment plan
TMJ
Primary lesion
left buccal mucosa, retromolar trigone

• wide excision
• marginal resection of mandible
• partial maxillectomy

Clinical diagnosis and staging
squamous cell carcinoma over left buccal mucosa
extend close to retromolar trigone, cT3N2bM0,
stage IV
evaluation
classification
reversible tx
surgery
12
clinical diagnosis treatment plan
TMJ
Neck mass
central hypodensity LN over level Ib, 1.5cm in
size

• left side modified radical neck dissection, type
  II
• right side suprahyoid neck dissection

Clinical diagnosis and staging
squamous cell carcinoma over left buccal mucosa
extend close to retromolar trigone, cT3N2bM0,
stage IV
evaluation
classification
reversible tx
surgery
13
clinical diagnosis treatment plan
TMJ
Reconstruction
hard tissue defect mandible
soft tissue defect mucosa of
buccal side, retromolar trigone
Clinical diagnosis and staging
squamous cell carcinoma over left buccal mucosa
extend close to retromolar trigone, cT3N2bM0,
stage IV

• posterior based tongue flap (combined with
  S.T.S.G)
• pectoralis major myocutaneous flap
• free forearm flap

evaluation
classification
reversible tx
surgery
14
clinical diagnosis treatment plan
TMJ
Airway management

• tracheotomy

Clinical diagnosis and staging
squamous cell carcinoma over left buccal mucosa
extend close to retromolar trigone, cT3N2bM0,
stage IV
evaluation
classification
reversible tx
surgery
15
case presentation reconstruction surgery
gt clinical examination
gt history
gt
radiological investigations
gt joint clinic

gt clinical diagnosis treatment plan
gt surgical
procedures
16
neck dissection
the
surgical procedures
renal
Single Y incision. Lower submandibular incision
was below mandible lower border 23cm, vertical
limb was placed posterior to carotid bifucation
to clavicle (back of blade for cross-hatchings)
Tracheotomy
evaluation
classification
reversible tx
surgery
17
neck dissection
the
surgical procedures
renal
Skin flap (ant border strap muscle, post border
trapezius m, lower border clavicle) in
subplatysmal level / ext jugular vein,
sternocleidomastoid m. / omohyoid m / phrenic n,
brachial plexus, TCA, sup thyroid a, hypoglossal
n / carotid sheath, / common carotid a, int
jugular vein, and vagus n / small portion of
lower pole of parotid tail
evaluation
classification
reversible tx
surgery
18
primary lesion surgery
the
surgical procedures
renal
Lip-splitting procedures with elevation of lower
cheek flap / incision of buccal and retromolar
mucosa forming lateral margin of resection) /
Incision of medial gingival mucosa forming medial
margin of resection / Ramus is exposed
subperiosteally
evaluation
classification
reversible tx
surgery
19
primary lesion surgery
the
surgical procedures
renal
/ extraction of 32, incision and elevation of
mucosa of soft tissue anterior margin /
extraction of 26, incision and elevation of
mucosa of soft tissue posterior upper margin /
marginal resection of posterior mandible toward
medially / partial maxillectomy of tuberosity /
whole specimen with neck mass was resected in
continuity
evaluation
classification
reversible tx
surgery
20
primary lesion surgery
the
surgical procedures
renal
/ whole specimen with neck mass was resected in
continuity
evaluation
classification
reversible tx
surgery
21
reconstruction surgery
the
surgical procedures
renal
/ should tip to xiphoid / right angle line from
middle of clavicle until meets this line
evaluation
classification
reversible tx
surgery
22
reconstruction surgery
the
surgical procedures
renal
/ stay 2 cm lateral to sternum / elevation from
lower upward / tunnel in the neck with stay
suture traction
evaluation
classification
reversible tx
surgery
23
reconstruction surgery
the
surgical procedures
renal
/ final intraoral closure, lip-splitting closure,
neck closure with two exudrain
evaluation
classification
reversible tx
surgery
24
Thanks for your attention.