Case of the fortnight
Department of Plastic Surgery, Hand Surgery and Reconstructive Microsurgery
FOLDED RADIAL FOREARM FREE FLAP
FOR THROUGH & THROUGH CHEEK DEFECT
A 40 year old male, was referred by another hospital with complaints of malignancy of left cheek. He developed a proliferative lesion inside his left cheek which has steadily increased in size projecting into his face. The lesion was diagnosed to be squamous cell carcinoma of the cheek. He had no metastatic lymph nodes in the neck. clinically.
Examination :
He was alert, thin built and appeared cachexic.
He had an ulceroproliferative lump of 3.5 cms diameter in his left cheek just posterior to the left commissure (angle of the mouth).
The lesion was seen extending from the buccal mucosa inside the mouth onto the external skin. The lesion was indurated, tender and associated with a foul smell. His mouth opening was restricted to about 2cm. There was no gross cervical lymphadenopathy. He had a positive history for tobacco and pan chewing habit along with the tendency to keep the quid in his buccal mucosa.
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| Front view with cancer | Side view with cancer |
Treatment :
The patient had left supraomophyoid neck dissection, involving level I to III nodes. The cheek lesion was resected and it involved the entire thickness of the left cheek repairing the angle of the mouth along with the alveolar rim of the posterior mandible.
The reconstruction of the defect was done using a folded radial forearm free flap harvested with the radial artery and uphalic vein which were anastomosed to the facial artery and the external jugular vein respectively. The donor site in the left forearm was covered using a split thickness skin graft from the thigh.
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| Defect After Cancer Resection | Flap Harvested from Forearm (Radial forearm flap) |
Present status:
The patient is very comfortable with excellent function and good cosmesis. He has also completed 30 cycles of radiotherapy.
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| Post op Frontal View | Post op Side View | Post op Mouth Opening |
Discussion:
Reconstruction of post oncologic head & neck defects is quite complex and challenging. The advent of microsurgical reconstructive techniques has revolutionized head & neck reconstruction. The size and nature of the defect are not limiting factors as they are with conventional reconstructive techniques. Replacement of bone, soft tissue or both is possibly with microvascular flap reconstruction.The other advantages of microvascular tissue transfer include the ability to contour the tissue to the receipient site and better prosthodontic rehabilitation. These tissues also withstand the effects of radiotherapy better.