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The
patient is a
known hypertensive with polycythemia with
history of stoke left ICA 5 years ago and renal
failure and hypothyroidism for 2 months, taking
L-thyroxin 50 microgram daily. |
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The patient
progressed squamous cell carcinoma the last 5
years, which progressed in size in the
midparietal region and was under the observation
of dermatologist and he was seen by the team
recently with infected and fungating nature with
necrotic center with diameter more than 14 cm. |
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On examination: the
patient was alert and during several days
investigation was performed to rule out
metastases or involvement of the intracranial
structures. Correction of his homeostasis was
performed during several days and his anemia was
corrected and 5 units of blood with 4 units FFP
were ready before surgery. |
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In the prone position with the neck slightly
extended, the tumor was resected in one piece
with 15 mm in the safe margin, including one
daughter located anteriorly and sent for
histological verification and the result was
that, the edges of the skin are free of tumor
cells. The defect now is more than 20 cm in the
AP and around 18 cm in the frontal plane. A long
incision was carried out, down to the C7 spinous
process. 2 lateral incision were performed down
to the ears. The whole scalp was dissected off
the skull down to the orbital ridges and lateral
to the external acoustic meati and the scalp was
dissected of the nuchal line lateral to the
mastoids, preserving during that the underlying
muscles and respecting the anatomy of the blood
supply. |
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The galia aponeurotica was was incised with a
lot of incisions to make the skin more
expandable. It was necessary to make rotational
flap from the right side to cover the defect of
the tumor bed. Another rotational flap was
created from the left side to cover the 1/6th of
the upper remaining huge skin defect located in
the previous half of the removed tumor.
The defect now is in the posterior aspect of the
neck with 7X20 cm dimensions. |
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A skin graft with these dimensions was harvested
from the right suprascapular area trying during
that to preserve the blood supply and was
migrated under tunnel to the neck area, trying
to avoid kinking of the pedicle. The transferred
graft could cove most of the skin defect,
but there was some tension in the right side. |
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To avoid tension of the flap another rotational
flaps were created in the right side of the neck
and the skin defect was solely closed. The color
of the flaps was acceptable during the end of
the procedure which lasted 8 hours and the
patient received during that 3 units blood and 4
units FFP. |
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The wounds were dressed without tension. |
