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Fibular flap Reconstruction Of Recurrent Squamous

by cancerhospitalindia

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Composite Resection And Free fibular flap Reconstruction Of Recurrent Squamous Cell Carcinoma Of Buccal Mucosa And Upper Alveolus

Cancer is a leading health problem in India, with approximately 1 million cases occurring each year.  The increasing number of head and neck cancer is a cause of major concern as it is associated with high morbidity and mortality. According to various studies, the prevalence of head and neck malignancies with respect to total body malignancies ranges from 9.8% to 42.7%. In India, head and neck cancer comprises about one-third of total body malignancies, primary reason for the high incidence being the indiscriminate use of tobacco in various forms.


A systematic approach is required for management of head and neck cancers. Surgery as a treatment modality is frequently used in most types of head and neck cancers, especially oral cancers. We, at DharamshilaHospital and Research Centre, recently conducted a workshop on head and neck oncology with live surgery. Following is the case summary of the patient who was operated during the same.


Case Summary


A 55 year old male patient, a chronic tobacco chewer, presented with complaint of growth left upper alveolus and buccal mucosa since one month. He was a known case of CA left buccal mucosa (T2N0M0), for which, wide local excision Buccal Mucosa and Supra-omohyoid neck dissection was done at a premier institute. Histopathology of the resected specimen was suggestive of Verrucous/Squamous Cell Carcinoma. 



Present day, examination revealed two separate lesions at left upper alveolus, hard palate (3x2cm) and buccal mucosa(2x2cm); N0 neck with scar of previous surgery present in the neck. Mouth opening was restricted to approximately one finger breadth.



Punch Biopsy revealed moderately differentiated squamous cell carcinoma. MRI face and neck showed large heterogenous mass (41mmx31mmx26mm) involving left cheek & left maxillary alveolus. Metastatic workup ruled out metastasis.



Thus a diagnosis of Well Differentiated Squamous Cell Carcinoma of left BM and upper alveolus (T4aNxM0) was made. Patient was planned for left composite resection with free fibular flap reconstruction.



A modified Crile’s incision was planned with the horizontal limb extending along the previous scar line. To complete the neck dissection, Left Modified neck dissection type II was done. Dissection was carried out in the sub-platysmal plane to raise the skin flaps. Level I to Level V nodes with sternocleidomastoid muscle was removed. Spinal accessory nerve and IJV were carefully dissected and preserved. This was followed by the resection where wide local excision of buccal mucosa, retromolar trigone, hard & soft palate was dine taking 1.5cm margin all around. Left hemimandibulectomy (distal to left canine) was and left upper partial alveolectomy (distal to first premolar) was done alongwith infratemporal fossa clearance. The specimen was removed enmass. The specimen was sent for frozen section, which confirmed that all the margins were free of tumor.


A thorough wash was given with normal saline for mechanical lavage and to remove any exfoliated tumor cells. Hemostasis secured.


For reconstruction, the requirements were 22x12cm for the skin paddle, and 6.5cm (body) x 4cm (ramus) bony requirement with one osteotomy. Free fibular flap was harvested with dimensions described above.


Anastomosis was done using two veins (Direct IJV, end to side, 8-0 ethilon, interrupted sutures; and Br. IJV, end to end, 8-0 ethilon, interrupted sutures) and one artery (left facial artery, end to end, 8-0 ethilon, interrupted sutures). Fibula fixation was done using 2mm mini plates and screws sizes 8 & 10. Donor site was covered with split thickness skin graft.


Post operatively, the patient was kept on ventilator support for 24 hours. He was managed according to the set protocol at DHRC. He responded well to the surgery.


Post operative Protocol:


1)    Ventilator support for 24 hours.

2)    Head tilt to the opposite side to avoid pressure on anastomosed site.

3)    Ryle’s tube feeding, Chest physiotherapy and sitting on bed every two-hourly from Day 2.

4)    Mouthwash from Day 3.

5)    1st graft donor site dressing on Day 5, followed by alternate day dressings (4-5 dressings)

6)    Head bandage to contour the operative site from Day 5.

7)    Ryle’s tube removal after two weeks. 


Histopathology of the resected specimen showed moderately differentiated squamous cell carcinoma with foci of surface ulceration; no lymphovascular invasion. All the margins of the resected specimen, underlying bone, as well as all of forty two dissected lymph nodes were free of tumor.


In the follow-up of last 1 month, the progress of patient is satisfactory. He is planned for post-operative radiotherapy.


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