reconstruction surgery

1. Casepresentation reconstruction surgery Kai-feng Hung Taipei VGH 洪凱風

2. personal data (case presentation) personal data / chief complaint renal chief complaint (case presentation) Name: 黃霜清 Age: 80 y/o Sex: male Chart No: 8855525 Marital status: married Mass lesion over L’t retromolar trigone with pain sensation for 3 months. evaluation classification reversible tx surgery

3. case presentation reconstruction surgery > clinical examination > history > radiologic investigations > joint clinic > treatment plan > surgical procedures

4. physical examination (systemic) physical examination renal General appearance: moderate looking appearance Vital sign: BP:138/64mmHg, PR: 72/min, RR: 22/min, BT:35.2 Head: scar(+), trauma(-), bony mass(-) Neck: palpable mass(+), L’t 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(-) > > > > > > > > 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(-) > > > > evaluation classification reversible tx surgery

6. clinical examination (intraoral and extraoral) renal intraorally 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. extraorally A palpable LN was noted over L’t level Ib which size about 1.5x1.5cm. evaluation classification reversible tx surgery

7. case presentation reconstruction surgery > clinical examination > history > radiological investigations > joint clinic > treatment plan > oral manifestation and dental management

8. radiological study renal CT scan Increased soft tissue density over l’t 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 > clinical examination > history > radiological investigations > joint clinic > clinical diagnosis & treatment plan > 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 > clinical examination > history > radiological investigations > joint clinic > clinical diagnosis & treatment plan> surgical procedures

16. neck dissection the surgical procedures renal Tracheotomy 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) evaluation classification reversible tx surgery

17. neck dissection the surgical procedures renal Skin flap (antborder: 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

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