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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4451_Библиотеки_им_академика_М_И_Перельмана
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Oral Cavity andNeck Dissection
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Fig. 35 Growth in the left buccal mucosa close to the
lower gingivobuccal sulcus and alveolus. Marginal mandibulectomy may be necessary to achieve adequate
margins
Fig. 37 Defect
following left buccal
mucosa composite
marginal
mandibulectomy
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Fig. 36 Growth in the right retromolar trigone
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Fig. 38 The oor of the
mouth can be advanced
laterally to close the
marginal
mandibulectomy
N. M. Nagarkar et al.
Fig. 39 Masseteric ap for the marginal mandibulectomy defect
Fig. 40 Marginal mandibulectomy defect closure with
the masseteric ap
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Fig. 41 Marginal
mandibulectomy defect
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Fig. 42 Marginal
mandibulectomy defect
closure with the lateral
oor of mouth
advancement
– Three types of marginal mandibulectomy
are described, i.e. horizontal, vertical and
oblique.
– As the lingual plate is weaker than the buc-
cal plate, an isolated buccal plate excision
may not withstand subsequent weight bearing, and the bone may fracture. Hence isolated buccal plate excision is risky in buccal
mucosa lesions.
– The theory of preferential route of tumour
entry through the inferior alveolar nerve
has been refuted by multiple studies; hence
it is no longer advocated to include the
inferior alveolar nerve up to the skull base
with a rim resection.
– Adequate exposure is achieved with a lower
cheek ap. Occasionally, a small anterior
lesion can be approached perorally.
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– The edges of the bone should be “canoe
shaped” to avoid sharp corners, and angled
cuts predispose to stress fractures and
hence are avoided. Inferiorly a bony bridge
of >1 cm in height should be retained to
avoid a stress fracture.
– The bone is cut with sharp bone-cutting
instruments. Finally the corresponding gingivolingual sulcus is divided to deliver the
specimen.
– With marginal mandibulectomy for retro-
molar trigone cancer, the anterior aspect of
the ascending ramus of the mandible is
excised in continuity with the coronoid
process, as releasing the attachment of the
temporalis muscle avoids postoperative
trismus.
• Segmental and hemimandibulectomy—This
is indicated when there is gross bone erosion,
either clinically or radiologically, for signicant paramandibular disease, for postradiotherapy recurrence due to the multiple routes
of tumour entry or with a pipe stem mandible
(inadequate bony remnant of <1cm in height)
(Figs.43, 44, 45, 46, 47 and 48):
N. M. Nagarkar et al.
Fig. 44 Defect of complex bite resection
Fig. 43 Skin marking for the complex composite seg-
mental mandibulectomy with skin excision and bilateral
neck dissection
Fig. 45 Specimen of bite composite segmental
mandibulectomy
Fig. 46 Composite middle segmental mandibulectomy
defect
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Fig. 47 Specimen of the central arch of the mandible
with the lower lip and skin
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3.2 Resecting thePrimary
• After incising the mucosa around and soft tissue using diathermy or a knife, bone cuts are
marked adjacent to the soft tissue.
• The posterior mucosal cut is made according
to the extent of tumour. Attention should be
paid mainly to the third dimension, i.e. deep
resection margin.
• This margin must contain at least one layer of
the normal tissue beyond the tumour. With this
in mind, it should contain the buccinator muscle with supercial lesions and the buccal fat
pad or the zygomaticus major muscle with
deeper lesions.
• With lesions deeper than that, e.g. adhering to
the skin or causing peau d’orange, the overlying skin is excised to achieve an adequate
margin.
Surgical specimen following buccal mucosa-
wide local excision with marginal mandibulectomy or bite resection is depicted in Figs.49, 50,
51, 52, 53 and 54.
The surgical steps of the modied Estlander
ap to reconstruct the angle of the mouth are
depicted in Figs.55, 56 and 57.
The surgical steps of buccal fat pad grafting
and split-thickness skin grafting are depicted in
Fig. 48 Nerve anastomosis with the lateral antebrachial
cutaneous nerve of the arm with greater auricular nerve
– Segmental mandibulectomy may encom-
pass the mandibular arch (mid-third segment) or may be arch-preserving (lateral
segment).
– Mandibulectomy that includes the entire
ascending ramus, condyle and coronoid
can either be a posterior segmental mandibulectomy (posterior to mental foramen)
or hemimandibulectomy.
Fig. 49 Specimen showing buccal mucosa composite
marginal mandibulectomy
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Fig. 50 Specimen of buccal mucosa composite marginal
mandibulectomy with the pin at the tumour
N. M. Nagarkar et al.
Fig. 53 Specimen of bite marginal resection. * upper jaw
and ** lower jaw
Fig. 51 Composite buccal mucosa with segmental mandibulectomy with oral commissure specimen
Fig. 52 Bite resection specimen (infrastructure maxillectomy with marginal mandibulectomy with intervening
buccal mucosa). * upper jaw and ** lower jaw
Fig. 54 Posterior segmental mandibulectomy with level
IB with the primary resection specimen; this ensures that
paramandibular disease is not cut through
Fig. 55 Modied Estlander ap harvesting
Figs. 58, 59, 60, 61, 62 and 63, and composite
buccal mucosa resections with segmental mandibulectomy are shown in Figs.43, 44, 45, 46, 47
and 48.
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127
Fig. 56 Estlander ap creating the oral commissure
Fig. 57 Following the ap inset
Fig. 59 Buccal fat pad after inset. A bolster may be
placed to secure the fat pad graft
Fig. 60 Buccal fat pad grafting for left buccal mucosa
defect
Fig. 58 Buccal fat pad can reconstruct small- to mediumsized buccal mucosa defects
The surgical steps of PMMC ap reconstruction of oral cavity defect are depicted in Figs.64,
65, 66, 67 and 68.
Fig. 61 Buccal mucosa composite defect (following
marginal mandibulectomy), reconstructed with the split
skin grafting and oor of mouth advancement
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Fig. 62 Floor mouth advancement to close the marginal
mandibulectomy defect
N. M. Nagarkar et al.
Fig. 63 Defect following complete closure
3.3 Bite Resection
• Also known as composite bialveolar resec-
tion, this entails excision of the superior and
inferior alveoli with the intervening interalve-
olar tissue (like a bite).
• It is indicated for lesions involving the retro-
molar trigone extending to the superior
alveolus.
Fig. 64 Marking for the PMMC ap
• The specimen consists of the inferior as well
as the superior alveolus in continuity with the
overlying retromolar trigone mucosa and soft
tissue formed by the pterygoid muscles.
3.4 Infratemporal Fossa
• If the lesion does not involve the ITF, then the
bone cut is made anterior to the pterygoid
plates. However, if the lesion involves the
medial pterygoid muscle, the pterygoid plate
is included in the specimen to ensure adequate
soft tissue resection that includes the pterygoid muscles.
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129
Fig. 66 Reconstruction with the bipaddle PMMC ap
Fig. 65 PMMC ap pedicle
• “Bite excision” with resection of the entire
medial pterygoid muscle is performed when
the lower ITF is involved. If resection of the
higher ITF is warranted, then “bite excision”
encompassing the pterygoid plates is
performed to include the entire medial and lateral pterygoid muscles.
• The temporalis muscle below the temporal
fossa is resected in continuity with the coronoid up to the roof of the ITF.
• The ITF is divided into infra-notch and supranotch at the level below and above the mandibular or sigmoid notch. The ITF is further
sub-compartmentalised as described by
Mahajan and colleagues [8].
Fig. 67 Intraoral view of PMMC reconstruction
Follow-up of various reconstructions of oral
cavity defects is shown in Figs.69, 70, 71, 72, 73,
74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86,
87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99,
100 and 101, and the complications following the
postoperative adjuvant radiotherapy are depicted
in Figs.102, 103, 104 and 105.
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Fig. 68 PMMC donor site closure
N. M. Nagarkar et al.
Fig. 70 Propeller nasolabial ap for the reconstruction of
commissure defect
Fig. 69 Bipaddle PMMC ap to close the defect
Fig. 71 Follow-up of nasolabial ap reconstruction for
the marginal mandibulectomy defect
Fig. 72 Contour of the PMMC ap after reconstruction
of posterior segmental mandibulectomy defect
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