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22-JULY-2010  HADY ABBAS AL-KHALISY  69 YEARS  SQUAMOUS CELL CARCINOMA OF THE SCALP IN THE MIDPARIETAL REGION.

Please! wait for 3-5 min till the video start to load. It depends upon the internet connection.

 

Anamnesis

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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.


Comments

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This case a challenging one. Scalp expander cannot be used because, there is no place to put it and infection will cause further problems.

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The skin graft harvested with pedicle from the suprascapular area cannot reach the tumor site

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The only solution remains, what we did during such situation.

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The dressing in the next day showed good condition of the grafts.


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Notice: Head injuries and very urgent surgeries are also escaped from the plan .

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