A 60-year-old gentleman presented to the head and neck surgeon with a mass at the floor of his mouth.

 

A biopsy was done which showed a malignant squamous cell carcinoma.

He declined to be followed up and initially sought traditional treatments, but unfortunately, the tumour continued to grow. About three months later, he re-presented with bleeding from his mouth from the tumour which had grown even larger to involve his base of tongue and his anterior jaw (mandibular) bone.

 

With further scans, the tumour was found to have invaded the upper part of his throat as well as his mandibular bone, but had not spread to other parts of the body. He was then planned for surgery to resect the entire tumour, which would have removed the anterior 60% of his jaw, his entire tongue, and the upper part of his throat.

 

For this, he was referred to Dr Adrian for reconstruction of this complex, 3-dimensional defect involving multiple head and neck structures.

 

The goals were to restore a normal mandibular contour and swallowing tract. For his tongue and upper throat, a skin-only free flap was taken from his anterolateral thigh (ALT) to resurface these structures, and microvascular surgery was performed to restore the blood supply to this ALT flap. For the jaw, computer aided design (CAD) was done to create templates to reconstruct the jawbone, which was done using the fibula (small bone from the lower leg).

 

This CAD enabled precise and expedient surgery to be performed using this fibula free flap, which also required microvascular surgery to restore its blood supply.

In the initial post-operative period, he was fed through a nasogastric tube, while his reconstructions healed. He was able to walk without any restriction 1 week after surgery. 10 days after the procedure, seeing that healing was proceeding well, he was started on oral fluids, and his feeding tube was removed. This was built up to a soft diet by the 4th week after surgery.

 

He was able to receive post-operative radiotherapy at this point without any issues, and he continued to remain disease-free, able to eat a normal diet, and with a normal mandibular contour thereafter.