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

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

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

4. physical examination evaluationclassificationreversible txsurgery renal physical examination (systemic) 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(-) > > > > > > > >

5. physical examination evaluationclassificationreversible txsurgery 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(-) > > > >

6. clinical examination (intraoral and extraoral) evaluationclassificationreversible txsurgery 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.

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

8. radiological study evaluationclassificationreversible txsurgery renal Increased soft tissue density over l’t buccal mucosa, retromolar region Multiple lymphadenopathy with central hypodensity, level Ib CT scan

9. radiological study evaluationclassificationreversible txsurgery 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

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

11. evaluationclassificationreversible txsurgery 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

12. evaluationclassificationreversible txsurgery 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

13. evaluationclassificationreversible txsurgery 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 ]

14. evaluationclassificationreversible txsurgery 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

15. > clinical examination > history > radiological investigations > joint clinic > clinical diagnosis & treatment plan > surgical procedures case presentation reconstruction surgery

16. surgical procedures evaluationclassificationreversible txsurgery 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

17. surgical procedures evaluationclassificationreversible txsurgery 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

18. surgical procedures evaluationclassificationreversible txsurgery 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

19. surgical procedures evaluationclassificationreversible txsurgery 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

20. surgical procedures evaluationclassificationreversible txsurgery renal the primary lesion surgery / whole specimen with neck mass was resected in continuity

21. surgical procedures evaluationclassificationreversible txsurgery renal the reconstruction surgery / should tip to xiphoid / right angle line from middle of clavicle until meets this line

22. surgical procedures evaluationclassificationreversible txsurgery renal the reconstruction surgery / stay 2 cm lateral to sternum / elevation from lower upward / tunnel in the neck with stay suture traction

23. surgical procedures evaluationclassificationreversible txsurgery renal the reconstruction surgery / final intraoral closure, lip-splitting closure, neck closure with two exudrain

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