Referimo-nos ao caso de um paciente masculino de setenta e cinco anos de idade, com um carcinoma espinocelular (SCC), que se originou na parte exterior da orelha direita há quatro anos. Sofreu uma remoção cirúrgica da parte lesionada combinada com dissecção modificada do pescoço e reconstrução com o uso de retalho peitoral maior. Além disso, teve radioterapia com 6000 rads na região temporal direita. Há dois meses o paciente mostrou urna recorrência expansiva no que diz respeito ao músculo temporal e ao osso, o osso litóide, os músculos masseter e os músculos pterigóideos, a parte direita da mandíbula, a glândula da parótida com o nervo facial, e o bulbo superior da veia jugular interna. Sofreu uma remoção cirúrgica da lesão afetada até as extremidades saudáveis e reconstrução estética e funcional com a utilização combinada de uma prótese de metal fixa do côndilo e da mandíbula direita e o uso de músculo-cutâneo trapezious flap. Apresentamos o relato de um caso sobre as opções de reconstrução que nós temos em nossos dias para proporcionar qualidade de vida a doentes que sofrem de cancro.We report a case of a seventy-five years old male patient with a squamous cell carcinoma (SCC) originated from the right external ear four years ago. He was undergone surgical removal of the lesion with a combination of modified neck dissection and reconstruction with the use of pectoralis major flap. Furthermore, he had radiotherapy with 6000 rads of the right temporal region. Two months ago the patient showed an extended recurrence concerning the temporal muscle and bone, the lithoid bone, the maseter and the pterygoids muscles, the right part of the mandible, the parotid gland with the facial nerve, and the superior bulb of the internal jugular vein. He had a surgical removal of the lesion in extended healthy margins and functional and esthetic reconstruction of the defect with a combination of metal fixed prosthesis of the condyle and the right mandible and the use of myocutaneous trapezious flap. This is a case report of the reconstruction options we have nowadays to provide quality of life in cancer patients

Alexopoulou, Maria Miranda

Antonopoulos, Dimitrios

Goumas, Panagiotis

Papadas, Theodoros

Papakyriakos, Ioannis

Papavasiliou, Dimitrios

Brazilian Journal of Otorhinolaryngology

SummaryWe report a case of a seventy-five years old male patient with a squamous cell carcinoma (SCC) originated from the right external ear four years ago. He was undergone surgical removal of the lesion with a combination of modified neck dissection and reconstruction with the use of pectoralis major flap. Furthermore, he had radiotherapy with 6000 rads of the right temporal region. Two months ago the patient showed an extended recurrence concerning the temporal muscle and bone, the lithoid bone, the maseter and the pterygoids muscles, the right part of the mandible, the parotid gland with the facial nerve, and the superior bulb of the internal jugular vein. He had a surgical removal of the lesion in extended healthy margins and functional and esthetic reconstruction of the defect with a combination of metal fixed prosthesis of the condyle and the right mandible and the use of myocutaneous trapezious fla p. This is a case report of the reconstruction options we have nowadays to provide quality of life in cancer patients

Elsevier - Publisher Connector 

Cancer patients with large defects. Reconstructional options: A case study 

Scientific Electronic Library Online - Brazil

Cancer patients with large defects. Reconstructional options: a case study

87
REVISTA BRASILEIRA DE OTORRINOLARINGOLOGIA 71 (1) PART 1 JANUARY/FEBRUARY 2005
http://www.rborl.org.br  /  e-mail: revista@aborlccf.org.br
Cancer patients with large
defects. Reconstructional
options: A case study
Summary
Theodor os Papada s1, Panagiotis Goumas1, Ma r ia
Mir anda  Alexopoulou2, Ioannis Papakyr iakos2,
Dimitr ios Papavasiliou2,Dimitr ios Antonopoulos 3
1Department of Otorhinolaryngology, University Hospital of Patras.
2Department of Oral Maxillofaciall Surgery, University Hospital of Patras.
3 Plastic Surgery Clinic, Saint Andrews Hospital of Patras
Adapted for presentation at XVIIth IFOS World Congress. Cairo, Egypt, 28 Sep. – 3 Oct., 2002
Address for correspondence and reprint requests: Theodoros Papadas MD, PhD –
Stefanou Granitsa 24 – 264 43 Patras Greece.
Tel: (0030-61) 42-5564 Fax: (0030) 61-993986 – E-mail: PGOUMAS@ med.upatras.gr
Article submited on March 17, 2004. Article accepted on April 11, 2004.
We report a case of a seventy-five years old male
patient with a squamous cell carcinoma (SCC) originated
from the right external ear four years ago. He was
undergone surgical removal of the lesion with a
combination of modified neck dissection and reconstruction
with the use of pectoralis major flap. Furthermore, he
had radiotherapy with 6000 rads of the right temporal
region. Two months ago the patient showed an extended
recurrence concerning the temporal muscle and bone,
the lithoid bone, the maseter and the pterygoids muscles,
the right part of the mandible, the parotid gland with the
facial nerve, and the superior bulb of the internal jugular
vein. He had a surgical removal of the lesion in extended
healthy margins and functional and esthetic reconstruction
of the defect with a combination of metal fixed prosthesis
of the condyle and the right mandible and the use of
myocutaneous trapezious flap. This is a case report of
the reconstruction options we have nowadays to provide
quality of life in cancer patients.
Rev Bras Otorrinolaringol.
V.71, n.1, 87-90, jan./feb. 2005
CASE REPORT
ARTIGO ORIGINAL
Key words: squamous cell carcinoma, esthetical and
functional rehabilitation, metal fixed prosthesis,
myocutaneous trapezious flap.
88
REVISTA BRASILEIRA DE OTORRINOLARINGOLOGIA 71 (1) PART 1 JANUARY/FEBRUARY 2005
http://www.rborl.org.br  /  e-mail: revista@aborlccf.org.br
INTRODUCTION
Squamous cell carcinoma (SCC) is a malignant tumor
of the face affecting soft tissues as well as bone structures
with high frequency of metastases. Cancer patients with SCC
of the skull and the facial skeleton have undergone extended
surgeries with combination of preoperative or postoperative
chemo and radiotherapy with very good results and high
rates of survival.
Sometimes lesions are very extended due to topical
recurrence or because of negligence, leaving large defects
after the surgical removal, and skin invasion is often present.
The main problem is the functional and esthetical
rehabilitation of these patients, providing them with a quality
of life. Nowadays the options we have are numerous, using
combinations of flaps with fixed prosthesis and bone grafts.
There are several reports in the literature on the
therapeutic results after surgical removal of malignant tumors
of the region1-3 and also reports which review reconstructive
results using flaps such as pectoralis major, trapezious,
latissimus dorsi or free flaps4-6 but very few reports concerning
the reconstruction defects of the parotid area5-8.
The aim of this paper is to describe our experience
of the use of myocutaneous flaps and combination of them
with reconstructive plates for covering large defects.
CASE REPORT
A 75-year-old man showed in our clinic four years
ago with a lesion of the right auricle. After X-rays, C/T
examinations and biopsy of the lesion he  underwent a
surgical removal of the lesion concerning the whole right
external ear, with combination of modified neck dissection.
The ear defect was covered with the use of the right
pectoralis major flap, and the histological results showed a
SCC carcinoma of medium differiation. A year after, during
the regular follow-up examination, a recurrence of the 1cm
x 0,5cm lesion was revealed.
Under general anesthesia, a modified right
mastoidectomy was performed, and postoperatively the
patient had a course of 6000 rads of radiotherapy in the
right temporal region.
There were no complications postoperatively and he
had a two-year uneventful follow-up. Eight months ago, and
while the patient had not showed up for a year, he came
back complaining of severe trismus, otorrhea, pus of the
external auditory canal and the right temporal bone, bone
necrosis due to radiotherapy and right facial palsy.
The clinical examination revealed a large defect
(Figure 1), and after C/T examination, he underwent radical
mastoidectomy, lateral temporal bone resection, total
parotidectomy with resection of the right facial nerve and
right partial mandibulectomy.
The skin in the area was invased concerning also the
pectoralis major flap that has been previously used. The
margins of the defect extended from the mastoid part of
the temporal bone, the tip of the lithoid bone, the
hypotymbanon, revealing beneath the superior bulb of the
internal jugular vein. The descending part of the facial nerve,
the whole parotid gland, the maseter muscle, the exterior
and interior pterygoid muscles were also invaded. The
temporomandibular joint, the right condyle and coronoid
process, the ramus and the body of the right mandible were
included in the dissection.
The resulting defect was very large and can be
characterized as hemifacial.
A pedicled myocutaneous lower island trapezius flap
(Figure 2) was used to cover the defect and the right
temporalis muscle was transferred to cover the facial palsy.
Metal right condyle prosthesis with combination of titanium
reconstructive plate was used for the mandible (Figure 3).
The postoperative course was uneventful and the patient
returned home fifteen days after the operation.
Ten months after the last operation he was fully
rehabilitated (Figure 4), with normal chewing function,
speaking function and acceptable esthetic results of the face
and donor site (Figure 5). The panoramic X-ray (Figure 6)
showed the metal prosthesis in place and the 3D C/T
examination postoperatively showed the physical contour
of the right mandible (Figure 7)
DISCUSSION
Malignant tumors of the external ear and the parotid
glad sometimes cause extensive damage to adjacent
structures, such as temporal bone, lithoid bone, facial nerve,
malar bone, maseter muscles, temporomandibular joint,
mandible. Very often these tumors invase the skin and so
the challenge the surgeon comes up concerning the
reconstruction of these cases is huge.
Radiotherapy and neglected cases or careless
surgeries make the problem even bigger.
The main concern is the better quality of life in these
patients providing them functional and esthetic results.
Local and regional flaps have been used for closure
of such defects but when there is quite a loss of soft tissue
these flaps are of no use9,5.
Usually a pectoralis major flap is used to close massive
defects concerning large amounts of soft tissue9,5 as the main
problem is the loss of soft tissue bulk.
If the mandible is also resected, reconstructive plate
or bone grafts had to be used to provide substance and
profile and also mastication, deglutition, phonation10,11.
There are several reports in the literature on the
therapeutic results after the use of pectoralis major flap4,5,12
and its advantages are numerous, but when it is not indicated
or cannot be used as in our case because we already used it
in the first surgery and now it was invaded, lattisimus dorsi
89
REVISTA BRASILEIRA DE OTORRINOLARINGOLOGIA 71 (1) PART 1 JANUARY/FEBRUARY 2005
http://www.rborl.org.br  /  e-mail: revista@aborlccf.org.br
Figure 1. Clinical view of the defect at the right external auditory canal Figure 2. The pedicled myocutaneus lower island trapezious flap
Figure 3. Intraoperative view. The metal condyle prosthesis for the mandible Figure 4. The patient, ten months postoperatively
Figure 5. Clinical view of the donor site Figure 6. Panoramic X-ray, ten months postoperatively
myocutaneous flap or a trapezious one are in our opinion
the second best choice. We used the lower island of the
trapezious flap as it offers enough skin and muscle to enable
large head and neck defects9,5 and it’s easy to raise. The
esthetical result is acceptable concerning the skin colors,
and it can be improve by skin tattooing5.
This flap sometimes needs debulking, although the
muscle flap atrophies over a period time.
The trapezious myocutaneous flap is very useful
because it can fill up the oral cavity, nasopharynx, middle
ear, an open temporomandibular joint or other contaminated
cavities. The better use is with micovascular anastomosis
but the requiring time is a disadvantage especially in older
patients. Although pedicled flap, because of the repositioning
90
REVISTA BRASILEIRA DE OTORRINOLARINGOLOGIA 71 (1) PART 1 JANUARY/FEBRUARY 2005
http://www.rborl.org.br  /  e-mail: revista@aborlccf.org.br
of the patients is not preferred by some authors5, we thing
that it can be of a great use, giving solutions in complicated
cases.
When the therapeutic treatment includes a partial
mandibulectomy, a bone graft especially a rib costochondral
graft is suggested in the literature, but because of the need
of two teams of surgeons, expanded surgery time and
possible complications, we preferred the use of Martin
titanium reconstructive plates and metal condyle prosthesis
properly adjusted for the patient. The results from the use
of titanium reconstructive plates are very encouraging in
large series of patients10,11,13,14. Koch and co authors in a
retrospective review of 40 patients promote the titanium
reconstructive plate as a permanent method of mandibular
reconstruction.
These plates maintain jaw contour and occlusal
relationships of residual teeth. The acceptable results rates
of 73% to 93%10,13,14 and there is failure rate of 33,3%10.
Complications related to the use of flaps and plates
in oromandibular reconstruction are usually, infection, intraoral
exposure of the plate, (that needs plate removal, or local
flap coverage). Also external exposure or bar fracture can
be detected10,13,14.
Our patient eight months postoperatively showed an
infection in the temporal region, which after antibiotic
treatment with ciproxin for two months had been eliminated.
Figure 7. 3D C/T view, ten months postoperatively
In conclusion, a number of reconstructive options are
available for large defects of temporal bone and parotid area,
which needs large amounts of tissue. The use of trapezious
flap with combination of temporal muscle and reconstructive
titanium plate for the mandible gives acceptable results and
quality of life in cancer patients.
REFERENCES
1. Byrne M, Spector J. Parotid masses: evaluation analysis and current
management Laryngoscope 1988 98; 99-105.
2. Casler J, Couley J. Surgical management of adenoid cystic
carcinoma of the parotid gland. Otolaryngol Head Neck Surg
1992; 106: 332-8.
3. Pedersen D, Overgaard J, Sogaard H, Elbrond O, Overgaard M.
Malignant parotid tumors in 110 consecutive patients: treatment,
results and prognosis. Laryngoscope 1992; 102: 1064-9.
4. Ioannides Ch, Fossion E, Boeckx W. Reconstruction of external
cervicofacial defects Br J Surg 1993; 80: 84-5.
5. Ioannides Ch, Fossion E. Reconstruction of extensive defects of
the parotid region: experience with the pectoralis major and free
latissimus dorsi flaps. Cranio Maxillofacial Surg 1997; 25: 57-62.
6. Urken L, Turk J, Weinberg H, Vickery C, Filler H. The rectus
abdominis free flap in head and neck reconstruction Otolaryngol.
Head and Neck Surg 1991; 117: 857-66.
7. Asko-Seljavaara S, Latheenmaki T, Waris T, Sundell B. Comparison
of latissimus dorsi and rectus abdominis free flaps. Br J Plast Surg.
1987; 40: 620-8.
8. Kinney S, Wood B. Malignancies of the external ear canal and
temporal bone: Surgical technique and results. Laryngoscope 1987
97; 158-63.
9. Gal T, Kerschner J, Futran N, Bartels L, Farrior J, Ridley M, Klotch
D, Endicott J. Reconstruction after temporal bone resection
Laryngoscope 1998; 108: 476-81.
10. Boyd J, Mullholand R, Davidson J, Gullane P, Rotstein L, Brown
D, Freeman J, Irish J. The free flap and plate in oromandibular
reconstruction: long – term review and indications. Plast Reconst
Surg 95, 1995; 1018-28.
11. Eufinger H, Wehmoller M, Machtens E. Individual prostheses and
resection templates for mandibular resection and reconstruction.
1997 35; 413-8.
12. Russell R, Feller A, Franklin Elliot L, Kucan J, Zook E. The extended
pectoralis major myocutaneous flap: uses and indications Plast
Reconstr Surg 1991; 88: 814-23.
13. Koch W, Yoo F, Goodstein M, Eisele D, Richtsmeier W, Price J.
Advantages of mandibular reconstruction with the titanium hollow
screw osseointegrating reconstruction plate (THORP).
Laryngoscope 1994; 104: 545-52.
14. Spencer K, Sizeland A, Taylor G, Wiesenfeld D. The use of titanium
mandibular reconstructions plates in patients with oral cancer Int
J Oral Maxillofac Surg 1999; 28: 288-90.


http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-72992005000100015&lng=en&tlng=en

Cancer patients with large defects. Reconstructional options: a case study

Abstract

Similar works

Full text

Available Versions

Elsevier - Publisher Connector

Scientific Electronic Library Online - Brazil

Elsevier - Publisher Connector