reconstruction surgeryCase presentation
洪凱風 Kai-feng Hung Taipei VGH
personal data / chief complaint
evaluation classification reversible tx surgery
renal
personal data (case presentation)
Name: 黃霜清Age: 80 y/oSex: maleChart No: 8855525 Marital status: married
chief complaint (case presentation)
Mass lesion over L’t retromolar trigone with pain sensation for 3 months.
case presentation reconstruction surgery
> clinical examination > history > radiologic investigations > joint clinic > treatment plan > surgical procedures
physical examination
evaluation classification reversible tx surgery
renal
physical examination (systemic)
General appearance: moderate looking appearanceVital sign: BP:138/64mmHg, PR: 72/min, RR: 22/min, BT:35.2Head: scar(+), trauma(-), bony mass(-)Neck: palpable mass(+), L’t submandibular region, 1.5cmEye: protruded eyes(-), pupils equal round reactive to
light(+)Ear: ear drum, otorrhea(-)Nose: rihnorrhea(-), sinus tenderness(-), nasal bleeding(-)Throat: ulceration over mucosa(-), tonsil enlargement(-)
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physical examination
evaluation classification reversible tx surgery
renal
physical examination (systemic)
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(-)
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clinical examination (intraoral and extraoral)
evaluation classification reversible tx surgery
renal
Ulcerative mass lesion over left buccal mucosa, extend to l’t retromolar trigone region, and close to l’t tuberosity. The size was about 4x3cm.
intraorally
extraorally
A palpable LN was noted over L’t level Ib which size about 1.5x1.5cm.
> clinical examination > history > radiological investigations > joint clinic > treatment plan > oral manifestation and dental management
case presentation reconstruction surgery
radiological study
evaluation classification reversible tx surgery
renal
Increased soft tissue density over l’t buccal mucosa, retromolar region
Multiple lymphadenopathy with central hypodensity, level Ib
CT scan
radiological study
evaluation classification reversible tx surgery
renal
No obvious uptake over maxilla and mandible
whole body scan
No focal lesions in liver parenchyma, mild fatty liver Kidney, prostate gland: within normal size
abdomen sono
> clinical examination > history > radiological investigations > joint clinic > clinical diagnosis & treatment plan > oral manifestation and dental management
case presentation reconstruction surgery
evaluation classification reversible tx surgery
TMJ clinical diagnosis & treatment plan
[ left buccal mucosa, retromolar trigone ]
Primary lesion
- 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
TMJ
[ central hypodensity LN over level Ib, 1.5cm in size ]
Neck mass
- 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
clinical diagnosis & treatment plan
evaluation classification reversible tx surgery
TMJ
[ hard tissue defect: mandible ]
Reconstruction
- posterior based tongue flap (combined with S.T.S.G)
- pectoralis major myocutaneous flap
- free forearm flap
Clinical diagnosis and staging: squamous cell carcinoma over left buccal mucosa extend close to retromolar trigone, cT3N2bM0, stage IV
clinical diagnosis & treatment plan
[ soft tissue defect: mucosa of buccal side, retromolar trigone ]
evaluation classification reversible tx surgery
TMJ
Airway management
- tracheotomy
Clinical diagnosis and staging: squamous cell carcinoma over left buccal mucosa extend close to retromolar trigone, cT3N2bM0, stage IV
clinical diagnosis & treatment plan
> clinical examination > history > radiological investigations > joint clinic > clinical diagnosis & treatment plan > surgical procedures
case presentation reconstruction surgery
surgical procedures
evaluation classification reversible tx surgery
renal
the neck dissection
Single Y incision. Lower submandibular incision was below mandible lower border 2~3cm, vertical limb was placed posterior to carotid bifucation to clavicle (back of blade for cross-hatchings)
Tracheotomy
surgical procedures
evaluation classification reversible tx surgery
renal
the neck dissection
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
surgical procedures
evaluation classification reversible tx surgery
renal
the primary lesion surgery
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
surgical procedures
evaluation classification reversible tx surgery
renal
the primary lesion surgery
/ 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
surgical procedures
evaluation classification reversible tx surgery
renal
the primary lesion surgery
/ whole specimen with neck mass was resected in continuity
surgical procedures
evaluation classification reversible tx surgery
renal
the reconstruction surgery
/ should tip to xiphoid
/ right angle line from middle of clavicle until meets this line
surgical procedures
evaluation classification reversible tx surgery
renal
the reconstruction surgery
/ stay 2 cm lateral to sternum
/ elevation from lower upward
/ tunnel in the neck with stay suture traction
surgical procedures
evaluation classification reversible tx surgery
renal
the reconstruction surgery
/ final intraoral closure, lip-splitting closure, neck closure with two exudrain
Thanks for your attention….