Primary Repair of Full Thickness Excision of the Cheek* BENJAMIN F. RUSH, JR.,M.D. AND LOREN HUMPHREY, M.D., Lexington,
From the Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky.
entire buccal area can be resurfaced mucosa in this fashion.
distressing problem in operations on the oral cavity is the lesion which leaves large mucocutaneous defects after excision. Until the defect is closed, the patient must suffer the continual problems of an unesthetic salivary fistula. Speech and eating are severely impaired or impossible, tube feedings are required, and multiple operations are needed to close the defect. We are proposing a technic to close such defects at the original procedure, thus avoiding the problems of delayed closure.
CASE I. The patient (2. L., No. 03-86-59 9), a fifty-nine year old white, retired engineer, was admitted to the University of Kentucky Hospital on April 5, 1966 with recurrent carcinoma and severe radionecrosis of the left buccal mucosa. Two years previously the original lesion was treated elsewhere with heavy external irradiation. The entire buccal area, including the mucosa, skin, and intervening tissue, was involved in a dense heavy scar, inflexible and woody throughout. In the center of this area was a 1 by 1 cm. mucosal ulceration. The gingival ridge was denuded with exposed bone over a 2 cm. area. A through and through incision was made around the entire area of previous radiation, sacrificing the overlying skin, intermediate muscle, and underlying mucosa. The specimen measured 6 by 5 by 3 cm. and contained an area of well differentiated recurrent squamous cell carcinoma. To repair the buccal defect (Fig. 2A) a hockey stick incision was made in the neck, the resulting neck flap was undermined, and the skin advanced from the neck to fill the defect in the face. The buccal lining of this flap was obtained by undermining mucosa from the tonsillar pillars and bringing this forward to the angle of the mouth. (Fig. 2B.) The postoperative course was uneventful and the patient was discharged on the seventh postoperative day.
OPERATIVE TECHNIC After the through and through excision of the cheek lesion with a generous margin, the extent and position of the hole in the cheek are assessed. (Fig. 1A.) A hockey stick incision is made in the neck, as previously described [I]. A radical neck dissection performed through the neck incision may proceed or follow the primary excision if needed. The skin of the neck is freed, forming a
bucket handle flap below the cheek defect. (Fig. 1B.) This flap is advanced onto the cheek, providing a liberal amount of skin to fill the defect. This maneuver will cause a large “dogear” to appear at the anterior portion of the flap (Fig. 1C) and this is excised (Fig. 1D). Mucosa to line the inner raw surface of the flap is obtained from the area posterior to the cheek defect. Undermining of the mucosa proceeds through the tonsillar fossa into the lateral pharyngeal wall. The elasticity of this tissue as it is freed allows it to be advanced as far forward as the corner of the mouth. (Fig. 1B.) The
CASE II. The patient (C. R., No. 06-63-58 3), a sixty-three year old white housewife, was admitted to the University Tumor Clinic on September 21, 1966, complaining of pain, swelling, and trismus of the left jaw of two months’ duration. The patient had chewed tobacco for fifty-seven years since the age of six.
* Presented at the Thirteenth Annual Meeting of the Society of Head and Neck Surgeons, New York, New York, April 17-19, 1967. 592
AmericanJournal of Surgery
Primary Repair of Cheek There was a large ulcerating lesion over the left buccal mucosa extending from the retromolar triangle and anterior tonsillar pillar to a point opposite the first molar tooth. In the vertical plane the lesion spread from the inferior gingivobuccal gutter almost to the superior gingivobuccal gutter and invaded the cheek puckering the overlying skin. A 1 by 1 cm. movable lymph node was present at the angle of the left mandible. Biopsy indicated the oral lesion to be squamous cell carcinoma. Integrated therapy with irradiation followed by operation was elected as the treatment of choice. A total dose of 6,012 rads of cobalt 60 to the tumor was given in forty days. Operation six weeks later consisted of incision of the entire buccal mucosa with an overlying elipse of skin measuring 6 by 6 cm. The horizontal ramus, a portion of the ascending ramus of the mandible, and the contents of the left part of the neck were removed with the specimen in the cheek. The pathology report showed residual carcinoma in the gingivobuccal gutter and in one of twenty cervical nodes. The defect was closed by the described technic. The postoperative course was uncomplicated and the patient was discharged on the eleventh postoperative day. CASE III. The patient (H. C., No. 06-42-12 4), an eighty-six year old retired white man, came to the University Tumor Clinic with an eight year history of a sore on the left oral commissure. Attempts to excise this five years and one year previously had failed, The patient smoked a pipe for forty-five years, always holding it in the left side of the mouth. The lesion, involving the angle of the mouth, included about 1 cm. of both the upper and lower lips and extended deeply into the cheek covering an area of 4 by 4 cm. of buccal mucosa. On September 15, 1966 the anterior two thirds of the cheek and the superior and inferior 2 cm. of the left angle of the mouth were excised. A hockey stick incision was made in the neck, a large
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FIG. 1. The extent of the area of cheek to be excised is outlined (A). A hockey stick shaped incision in the neck plus the through and through excision of the cheek form together a bipedicled flap (B). The flap is advanced into the defect forming a long “dogear” at the anterior margin (C). The dogear is excised and the defect sutured. The vertical line of the closure falls into the nasolabial fold. The horizontal line of closure crosses the upper part of the cheek (D). The defect in the neck is closed by advancing skin from the posterior neck.
flap was freed up, and the skin of the neck advanced to cover the defect in the cheek. The mucosa of the cheek was reconstructed by unfolding additional tissue from the tonsillar pillars. Histologically, the lesion was a squamous cell carcinoma, grade II; the margins were free of tumor. The postoperative course was uncomplicated and the patient was sent home on the fifth postoperative day. Four months later a recurrence was noted in the original scar. A second excision was performed on January 18, 19G7. Again, a wide excision was carried but sacrificing the entire reconstructed buccal
Rush and Humphrey
FIG. 3. CASE III. A, the extent of the second excision of the cheek which was performed excision in the same area. B, closure of the defect in one stage. mucosa. (Fig. 3A.) The original Rap in the neck was again elevated and once more advanced to cover the
defect in the cheek. This was successfully accomplished, but no additional mucosa was available to line this flap. Therefore, the flap was left uncovered and the lower margin sutured as securely as possible to the edge of the gingiva. (Fig. 3B.) Atelectasis of the left lower lobe developed on the first postoperative day. This cleared after treatment and the patient was discharged on the tenth postoperative day. The nodule of recurrent tumor removed measured 2 cm. and the overlying skin meaured 4.5 by 3 cm. The greatest dimensions of skin in the first specimen were 5.5 by 3.5 cm, so maximum skin removed at the two procedures totaled 10 by 6.5 cm. CASE IV. The patient (V. M., No. 0649-39 2), a sixty-two year old white housewife, was seen on September 16, 1966 with an oral ulcer of three months’ duration; she had also lost 17 pounds. The patient had been a “snuff dipper”* for forty years. Centered in the right gingivobuccal gutter, a large ulcer spread over the gutter and the retromolar triangle. Biopsy showed the lesion to be a well differentiated squamous cell carcinoma. Cervical nodes were not palpable. The decision was made to use combined radiation and operation. Cobalt 60 teleotherapy through a single port was begun on the day of her first visit and a total dose of 6,012 rads to the tumor was given in forty days. Six weeks later left radical neck dissection with excision of the left hemimandible, buccal mucosa, and overlying skin was carried out. At operation it appeared that the lesion had increased in size during or after radiation, although this may have been due to the sloughing away of radiated tumor. The measurements of the * Appalachian snuff ‘dippers’ are usually women. They place the snuff in the lower gingivobuccal gutter.
four months after a previous
surgical specimen indicated that a 4.5 by 5 cm. area of buccal mucosa was removed with a 6 cm. segment of the horizontal ramus and a 5 by 3 cm. segment of overlying skin, The tumor measured 2 by 1 cm. and penetrated the marrow of the mandible; margins of the resection were tumor-free. The defect in the mucosa was closed by unfolding mucosa from the posterior areas above the tonsillar pillar and the skin defect was closed by shifting a skin flap from the neck. The patient’s postoperative course was unremarkable except for transient atelectasis of the left lower lobe which responded readily to treatment. The patient was discharged on the sixteenth postoperative day. CASEv. The patient  (M. S., No. 03-86-03 7), a forty-six year old housewife, noted a lump on the left cheek approximately one year prior to admission. This gradually increased to the size of a “hen’s egg,” became ulcerated, and drained. Concurrently, an ulcer developed on the inside of the cheek opposite the cutaneous lesion. There had been no previous treatment. The patient did not drink and smoked two to three cigarettes a day. The buccal mucosa presented a 2 by 2 cm. ulcerated lesion at about its mid-point. The overlying skin of the cheek was puckered and scarred but no gross fistula was present. Biopsy revealed the lesion to be mucoepidermoid carcinoma. On April 30, 1965, through and through excision of almost the entire left cheek was performed. The skin surface of the specimen measured 7 by 4 by 2 cm. and the carcinoma was seen to involve the entire thickness of the cheek in the center of the block of tissue, extending from the buccal mucosa to the skin over a 2 cm. area. All margins were clear. The lesion was closed by the described technic. A rather large advancement of the skin flap was required since the upper edge of the cheek incision Amevicon Journal of Suvgery
was parallel with the zygoma.
However, this was accomplished easily and the neck incision could be closed primarily without requiring skin grafting. The patient did well and was discharged on the eleventh postoperative day. She was last seen two years postoperatively and was doing well without recurrence of the tumor. CASE VI. The patient  (B. H., No. 02-93-89), a forty-two year old white man with alcoholism. was admitted to the hospital with a history of progressive ulceration of the buccal mucosa beginning at the right commissure eight months prior to admission. The tumor gradually extended back along the mucosa toward the back of the mouth and out to the lower lip. Four months prior to admission a node was reported as squamous cell carcinoma. The patient chose to ignore his physician’s advice concerning treatment until pain and progressive tumor growth forced him to seek help. At this time the oral lesion had extended back along the buccal mucosa to the ascending ramus and involved the gingival buccal gutter, submaxillary gland, mandible, and the node in the angle of the mandible in one large mass, A course of integrated therapy was adopted beginning with 6,000 rads of cobalt therapy. This markedly reduced the size of the original tumor but resulted in a 2 by 2 cm. fistula directly through the substance of the mandible at the mid-point of the horizontal ramus. Six weeks after radiotherapy, a large area of skin was removed in the vicinity of the fistula extending from the angle of the mouth to below the submaxillary gland and above to a point at the level of the upper lip. Skin removed measured 6 by 7 cm. After hemimandibulectomy and bilateral neck di: section, closure was achieved by the methods described. The patient had difficulty with facial edema for some time postoperatively, which kept him in the hospital for six weeks before discharge. Local rel.!urrence developed six months after operation and he died one year postoperatively of recurrent carcinoma. The flap remained intact throughout this period.
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Garrett, Giblin, and Hoffman  have dethe use of skin from the neck and pectoral area to resurface defects in the face. Our technic accomplishes the same result more simply and less extensively. As long as the posterior limb of the hockey stick incision is slanted far enough posteriorly, the skin lying between the cheek and neck incisions represents a bipedicle flap with a generous blood supply. We have never encountered a loss of any part of this flap and its color has always remained good. No subsequent fistula developed and all wounds healed per primum. With this technic available there is no need to stage the closure of cheek defects. All interim problems of feeding, speech, salivary drooling, and psychic depression can be avoided. scribed
A technic for one stage closure of large mucocutaneous defects of the cheek at the time of primary excision of tumors in this area is described and six patients treated with this method are reported upon. REFERENCES 1. RUSH, B. F., JR. A standard
technique for in-continuity incisions of the head and neck. Surg. Gynec. 6 Obst., 121: 353, 1965.
2. RUSH, B. F., JR. Combined procedures in the treatment of oral carcinoma. In: Current Problems in Surgery. Chicago, 1966. Year Book Publishers, Inc. 3. GARRETT, W. S., GIBLIN, T. R., and HOFFMAN, G. W. Closure of skin defects of the face and neck by cervicopectoral flaps. Plast. 6 Reconstruct. Surg., 38: 342, 1966.