Treatment of Squamous Cell Carcinoma from the Posterior Maxilla with Obturator Placement and Ipsilateral Neck Dissection

CHAPTER 1

This is Dr. Daniel Oreadi. I'm an oral maxillofacial surgeon and assistant professor here at Tufts University and Tufts Medical Center. Today, we'll be performing a surgery for the treatment of a squamous cell carcinoma of the right posterior maxilla. This comes in addition to a right supraomohyoid neck dissection on a female patient. The procedure essentially is two parts. We'll start with the removal of the lymph node-containing fibrofatty tissue from the right side of the neck. After that, we'll move forward with the wide local excision of the tumor of the maxilla. We will obtain frozen sections to make sure that all the cancer cells have been removed and also perform an advancement of the buccal fat pad and placement of a surgical obturator.

CHAPTER 2

So let's get a marking pen. We're going to identify some of the important landmarks of our first part of the procedure, which is the supraomohyoid neck dissection. We have the angle of the mandible. And we identify the inferior border of the mandible. That's another landmark. We have the suprasternal notch. We have the external jugular. And then, on a skin crease line, we'll mark our incision that will serve as the skin flap that we're going to raise to access the neck contents. All right, we have local already in. Let's get a 15 blade. Incision. I just stay perpendicular. The first part of this procedure consists of the elevation of the platysma flap, or subplatysmally, to access the lymph node-containing fibrofatty tissue. Mm hmm. And if you can go a little bit more here. And I'll take the double skin hooks. Good, I'll take the Bovie.

Mm hmm. Can we increase the Bovie to 30, please? Okay. I definitely have not easily identified platysma. And we'll have to identify a couple of anatomic structures here, such as the greater auricular nerve and the external jugular, which you can see, showing up there. Some of the vessels as well. You can see the greater auricular right there. Some of the platysma fibers there. And we do this until we start feeling relatively close to the inferior border of the mandible. Mm hmm. Can I have a McCabe for a second? Some hemostasis, let's take a look here. I just want to protect this. Greater auricular. And this too, here. Mm hmm. Let's see what's oozing. Bipolar please. Step on it. It's right under here. And one more time. Mm hmm. And one more time. Okay, Metz? This is a gland, so we have to go above the gland here. She didn't even have an easily identified platysma, which we know with age, you know, we tend to lose a little bit. Will do. Mm hmm. Okay, we're very close here. Let's just lift up a little bit more here. Mm hmm. Very good. Let's get some hemostasis here, and then let's reflect the flap inferiorly. I want to see what this is, that's oozing here. Step on the bipolar. Okay. Now we'll switch sides here. Just lift up there, very nicely. A 15 blade. Yeah, thank you. Keep twisting now. There you go. I'll borrow this. I'll get the McCabe. If you can get it with the Bovie? I just want to find the greater auricular.Make sure we stay above it. Okay, do you want to cut this? Go ahead. Right under the platysma. So this is where we want to be. There's a little vessel there. Mm hmm. We'll tie this one in a minute. Can I have another SNaP? Another mosquito? And let's get the Metz? Tie this. Okay. Let's get the skin hooks again. And I can take the McCabe. A little bit of platysma still attached to this. All this is neck contents that we're going to be removing. We need to go a little bit lower as well. A little bit of a… Mm hmm. We're going to tie. Let's tie this. We also need some medium and a small clips. But let's tie this one. I have small open. No, that's fine, that's fine. Okay, we'll tie this one. Let's get a couple of SNaPs. Metz? I'll take one. Do you mind holding this, here? Thank you. Go ahead and cut this. All right, let's get some lone stars. Okay, good, so we have identified some anatomy. You have the greater auricular, you have the EJ, and submandibular gland. So we have level 1A, 1B, 2B, 2A, and part of 3 that we're going to be dissecting off.

So, first thing, since we're not using any free flap reconstruction, we can sacrifice all these vessels. Okay, and we can just grab a… Two mosquitoes. Two SNaPs. Mm hmm. I would cut. Yep. Go ahead. And then we'll take this. This is a big vessel, so we have to do a double knot. So what we'll do is open that one. Mm hmm. Then McCabe. We're going to clamp this. With the Bovie.

We'll start dissecting off the fascia of the sternocleidomastoid muscle. And then I lift this off. You may have to go ahead and cut. And just cut here in between this. And we're going to tie this up a little bit more. You can use a small clip below me. Good, now Metz. Mm hmm, start here. Mm hmm. Go ahead and Bovie this. In here, we're going to try to find the superior belly of the supraomohyoid muscle. Let's have another lone star. Thank you. McCabe. Mm hmm. Go ahead and Bovie here. Can we have a couple of Babcocks, please? Mm hmm. And the McCabe. Bovie. Thank you. We'll probably need a little bit of bipolar here. I like to keep a bloodless field. Yeah. It allows for identification of the anatomic landmarks better. Go ahead. Mm hmm. Good. Okay. That's good, we can see the superior belly of omohyoid right there. Right here. e're going to continue our dissection superiorly until we can see the posterior edge of the SCM. Mm hmm. Which we can start seeing there. She doesn't have too much of fibrofatty tissue in this area here. And we're heading superiorly towards level 2B. Here's superior belly of omohyoid. Go ahead and buzz me here. Mm hmm. And with the bipolar we'll address this area here. Let's increase the bipolar to 12, please. And let's go superiorly here. Good. Now, I want to clean up this a little bit more. Here, we're going to bipolar all this. Grab your bipole. Go through that. We're still safe because we're low, inferior to the... Can I get a Metz please? Cranial nerve XI, or spinal accessory. All right. you want to cut this? Bipolar through this.

Let's get some bipolar oxygen here. Make sure you do it right. Yeah, good. Thank you. Okay, I can feel the angle of the mandible. I can feel the mastoid process there, where we're going to identify the posterior belly of the digastric. We need to see what this is here. This is a vessel, so just go ahead and grab it there. And let's get the nerve stimulator. I'll take an Army Navy, please. Bovie? Okay, here's the tissue that we want to get from levels 2A and 3, where we find branches of the brachial plexus. Go ahead. In this area, we can go arbitrarily. Her PET/CT was negative. Therefore, we don't have too much concern. However, we're worried about microscopic disease. And this is the reason why we do this procedure, and for most of the oral cancers. Okay. Now, let's move superiorly. Try to identify the spinal accessory nerve. Can I have the nerve stimulator? No, superiorly. Can I have the nerve stimulator? This is greater auricular, so it should be around this area here. Okay. Yeah, I saw some. It's over here, mm hmm. I think it's under this area here. Mm hmm. Mm hmm, yeah. Yeah, okay. I think I can find the… Right there. Yeah. Definitely. Go ahead and stimulate that. I think - mm hmm. Yep. That's it. Okay, all right. So she has a very small… Yeah. So, let's test all this, and we're going to bipolar through this because this is extra tissue. Mm hmm. Go ahead and bipolar that. Because this is part of our specimen from level 2B. Do we have a vessel loop? Do we have the blue ones? Yeah, the blue one. Let's see. So this a nerve here. We're going to get all this tissue here. Go ahead and bipolar that. Good. Now we can see it right there. Yeah. Test this. Oh, it was low. Okay, there we go. Mm hmm. Mm hmm. All right, let's get the vessel loop. Thank you. You can put a SNaP here if you like. There are some vessels that protect the nerve that can be annoying at times. Bovie? Okay, now, can you retract here? Actually, we'll do twice. Do we have a lady finger? So we'll retract this here. If you can, with your right hand, this, with your left hand, here. Now, the bipolar? Good. All right. Now we need to find the posterior belly of the digastric. Can I have the baby Metz? We can see there, posterior belly of the gastric. And there are limits here, the levator scapulae and this splenius capitis muscles. So we're dragging our level 2B specimen off of here. And we ought to pass it. Now I have the… We're going to pass this inferiorly. Lift this up, all this here, and then move it up. And try to bring all this tissue. And make sure here that we're careful, because this is the distal aspect of the IJ. Can I have a McCabe? Please? Which we have right here. Let's get the Bovie there. Now, I will finish this and bring the nerve superiorly. If you want to pull this? Yeah. Yeah. Like this. Mm hmm. So we'll bring this tissue here, like that. Can I have another Babcock, please? Careful like that. Okay, good. So we gotta be careful here because you see that XI splits in two, so if you're not careful there - you can go ahead and Bovie here - you can transect part of it. So there are many ways to start this procedure. Some people start from dissecting different levels separately. Some others start on level 1B. I always like to start from posterior to anterior, and from inferior to superior, depending on how you get used to it. Go ahead. So we'll start seeing some branches of a cervical plexus in a minute. And then, we can move our dissection to the perijugular lymph nodes. This here, it's a little bit arbitrarily because as we know, we can remove every single lymph node. Go ahead. You can see some other branches there. We'll leave those down. Okay, so now, we'll switch this Babcocks to here. Go ahead and… Okay.

All right, let's go here. Okay. Bovie here. Let's go here, Trager. You can let these here, and go here, here. And some… Mm hmm. And I want you to lift all three like this. Can I have a blade? Thank you. Bipolar. Let's see the McCabe. All right, go here. Give pressure there. Go ahead. Yeah, use the bipolar. We start seeing here, the contents of the carotid sheath. Mm hmm. You can use the Metz. I got… We have some of the small vessel here that we want to… Go ahead and buzz. Mm hmm. Up and down. There you go. Metz? Don't pull them. That's fine. We'll cut them. Good. It's a good plane here. Okay, let's take a look here because I want to leave some of this. Oh, careful there. Careful when you do that. Okay. Can I have the blade, please? Let's pull up on this. Pull up there. Mm hmm. Yeah, just grab that one there. And just keep pulling there. So we're dissecting the internal jugular until we start finding some of the branches. And this will contain all the perijugular lymph nodes. So we start seeing a branch that is coming up right there and then we can tie those off. Let me see some of the branches of ansa that we tried to preserve there. Let's see here superiorly. There you go. Okay. I'll give you this back. If you want to just switch this one to this area here. I don't know, this is probably one lymph node there. Okay, here. Good. I'll take the McCabe actually. So the carotid is right under it. And then, DeBakey? We'll include this in our specimen. And go ahead and Metz this. Metz? I'm trying to keep this one here. I want to stay close to inferior aspect. And you know, the superior belly of omohyoid, sometimes we can save, sometimes we'll sacrifice. In a negative neck by staging, I like to preserve it as possible.

Get a little bit of that ansa there. That's fine. That's the muscle, yeah. I try to stay on my side here, so we can maximize the use of this specimen. And now, we're going to clean it off the IJ. Now, regrab this. Let this go. Cut this. And I'll take the blade. And we'll go superior now to the ansa. Can I have a bipolar? Okay, I'll take the blade again. All right, good. So this is carotid under it. Under it. This is just a… Let's keep that there. Keep pulling up. See how the carotid gets pressed against it. So, that's the carotid. Mm hmm. McCabe? Keep pulling like that, if you don't mind. Yeah, grab it. That's a big node there. Yep. Mm hmm. There's a vessel here that we're going to tie off. All these vessels, I like to tie, because if you let go for a second, they become bigger, right? Can I have a 2-0 tie? Okay. Grab the Metz. Yeah. Yeah, this one, we're going to have to sacrifice. Here, cut right around there. Okay. Mm hmm. Metz. Let's make our turn here. So in this case, we're going to make the turn by cutting the superior belly of omohyoid. Let's go high up. Lady finger?

Okay, now come here. And just this much there. Okay. Can I have the blade? It's a fresh blade. Thank you. Okay, McCabe? We're going to tie this. Suction. Can I have another… Can I have a clip? Hold this, Trager. DeBakey to me. It's a long one. Suction there. Okay. Okay, let's clamp this. Clamp? Mm hmm. Another one? And let's Metz this. Okay. Now, let's see what we have here. Can you pull this a little bit? Mm hmm. Bipolar, please? Another Debakey. So these two ties are together. So cut in the middle. Mm hmm. Let's get the bipolar here. Okay, I can see it here. It's a big branch. Another DeBakey. Okay. Let's see, we got suction all around it. Let's clean it up. Deeper too. Can I have a hemostat? Mm hmm. Actually, can I have a tie please? Give me one tie. Now, hold this open. Keep it open like that. Good. Let's see, we want to do this here. And we get another tie in a minute. Would you prefer the long or short DeBakey when I give it? Hemostat? Mm hmm. All right, and I'll take the Metz. Okay, now we can cut the ties. That was a challenging one. All right, I'll take the DeBakeys again. So we're going to continue our dissection here. Now here, we can just leave that alone. Bipolar? Let's see where vagus is. Mm hmm. That's good. Go for it. Okay, let's drop this down. Let's get the Bovie. Retract with an instrument there.

I want to find the anterior belly of the digastric here. You can get a Kintner and help me out. Can I get a Kintner? Yeah, you can grab it there. I'm going to stay ipsilateral, so you don't need to go that… Go for it.

That's good for now. And this we just peel off from the strap muscles. I'm going to stay in the fascia maybe. Burn this. We may have to tie those off, like this one here. McCabe first. Mm hmm. Now, Bovie. Mm hmm. Actually, now let's see what's oozing here. Okay. Let's focus on… a McCabe? Do we have the nerve stimulator? We're going to need it. Still working on it. It will be a moment. Well in that case, let's Keep going here. Go ahead and cut this.

All right, let's keep that, and let's go to the level 1B. Okay, I'll get the McCabe. We got the mandible right there. Okay. All right, test this. All right, just the - make sure that you're checking the… Yeah. Okay, good. Yeah. Let's get the Metz. We'll use a Metz. Metz is up. Let's get the nerve stimulator here. Where's the light? So you have to turn it up for it to work. Mm hmm. For it to work. So look at the nerve now, then… Yep, looking, yep. Yep, okay, so I found it right there. It's right here. So this is the branch of the marginal mandibular. It's a branch of the facial nerve. We're going to move that superiorly and protect it at all cost. You gotta be careful here because some of the perifacial lymph nodes tend to harbor cancer. And in her case, she doesn't have too many here. You can cut there. Mm hmm. So we're going to have to tie this facial vessel that is part of the specimen, inferiorly, but I want to tie superiorly as well.Cut this. See if Lauren can retract a little bit more. Can I get an Army-Navy? Careful with the nerve there. I'm on the nerve, right? Mm hmm, yeah. Cut this. Scissors. Okay, there's a conglomerate of veins there. We're going to try to leave that up. We don't need to include those in the specimen. Okay, cut this. All right, so let's tie this here with 2-0 silk. So this one we're going to tie. I'm going to tie high, you tie low, okay? Sorry. What was that? A DeBakey. I've got plenty. Okay, now you can go ahead and tie this one low. Mm hmm. I'll guide you. No, not so much. Just make the knot, and I'll guide you. Okay. Good. Good? Yep. Okay, so now, you can retract here carefully, with the long one. Let me - just like that. Good. I'm going to continue peeling this off here. Let's get the - the bipolar. I think I'm on tendon, okay? Do we have another Babcock? Maybe we can borrow it from the specimen? Let's grab the gland slowly. Good. Part of the vein that it just crosses it. Kintner? And we're going to find the omohyoid, so we can identify open retraction of it, the lingual nerve. Going to use bipolar here? Keep it with you. Mm hmm. And that's the facial artery right under this. Cut it. I can see the facial artery, parts of facial vein, submandibular gland. Going to continue carefully dissecting to this. We're under the mandible now. Getting into the common tendon of the digastric. You can cut this. Mm hmm. I want to go anteriorly to identify the… A little higher. Okay. Okay, you can see it right there. So this one needs some bipolar here. Closer to the gland. Mm hmm. Okay, good. Yeah, keep retracting there. Okay. Let's tie this, or actually, use some bipolar there. That's fine. Okay, we have the stylohyoid right there. Right here. I'm going to keep going here with the bipolar. And now we're going to try to find… Can I have the Army-Navy for a second? I'm going to do this here. There you go. Okay, so by dissecting, by retracting, I'm sorry, the mylohyoid anteriorly, you can identify the lingual nerve. Okay? Comes right there. Now, Kintner to me. If we have another right angle retractor, that would be great for Dr. Trager, please. So you can see the lingual nerve right there. Yeah, lady finger works. Here you go. Dr. Trager, you can put it carefully right there, okay? All right, so we have some vessels that we have to address here. And before that, I'd like to get the Metz. Metz? Like that, good. Okay, good, good. Okay. Now, so you can see here, the lingual nerve making a curve here, okay? And then the submandibular ganglion right here. All right? So I'll take the McCabe and we're going to tie this off to almost completely separate the gland and include it on our specimen. Bleeding in this area, sometimes it's inevitable. As you can see, there's a large amount of a venous - blood vessels. And if you can tie this, because... Yeah. I'm a little short of hands. And we'll cut inferior to that knot. Good. Okay. You can cut here. All right, now let's see what we have. I'll take the bipolar. I'd like to get some hemostasis, being careful of not touching the lingual nerve. Go ahead and buzz me. Uh huh. Again. There you go. Okay, that will do it. All right, now we'll move anteriorly to finish off level 1A, and we'll join forces in the center. Go ahead and give me some Bovie. Mm hmm. Oh, you can use the Bovie. It's faster. Just go on the… Yeah. This and the submental triangle, I'm not too concerned. Mm hmm. Go ahead. DeBakey to me. Go ahead here. Mm hmm. That's the anterior belly of the digastric under me. Okay. You can go right on top of the common digastric tendon. Right here, you can do all that. Careful there. Okay. let's finish up here. DeBakey and the Bovie to me. Yeah, in there. Can I have a Babcock? Here, hold this. McCabe? Go ahead and give me some Bovie here. Let's wait now. I want to come back to this area here. And Trager, if you want to retract here superiorly. Don't pull too much - don't pull the specimen too much. Thank you. You're welcome. Okay, bipolar actually. Metz? Mm hmm, Metz? Okay, let's get the nerve stimulator. So this is hypoglossal, okay? You see it right there? Hypoglossal nerve. I want to find vagus, right there, okay? All right, so we can finish off with the McCabe. Can I have some Bovie? Some of the strap muscles. DeBakey? Bipolar here. Keep the hypoglossal down there. Okay, we're going to need two JP drains.

We need us a couple of clips. Small clips. I'll do it. Retract superiorly. Mm hmm. And before we put the drains, we'll now request a valsalva. I'm sorry. A valsalva? We'll tell you when. In a couple minutes, probably. Go ahead and bipolar this. Mm hmm. Okay. Let's get a tie. Tie under me. I'm going to put this on the back table for identification on orientation. All right, cut on top of that knot. Okay. You can hold it there.

And let's take a look. Let's do a valsalva in five seconds. Get a couple of Army-Navies. I'll get one. You can get it to 30. Okay, bipolar? We identified a bleeder right there. Again. That should do it. Irrigation, please? Would you like antibiotic solution with that? Sure, sure. Yeah. For closure, we're going to use 3-0 Vicryls on an SH. Pop-offs? Pop-offs are fine. And we're going to finish up with nylon, 4-0 nylon or prolene for the skin. No, that's good. That good? Yeah, that's good. We're good. 4.0 - or Prolene. Can I have the nerve stimulator? Silk. The nerve stimulator? Mm hmm.

Okay, so let's review the anatomy here. Take a look at her surgical field. We're going to check out first, the cranial nerve XI, which is right here. Okay. It's functioning. This is cranial nerve XII. Okay. We have phrenic nerve, and vagus is probably right there. Right there. Okay? And the facial nerve is right here. Yep, right there. Good. And lingual nerve, we saw it already.

So let's mark this one with a double suture, level 2B. Double suture, level 2B. This is the main specimen, right neck. Main specimen, right neck. Yes, ma'am. Level 3 is going to be short. And long is 1B. And cut it. We can cut it over here. Good.

I'll take a number 15 blade. And doctor, would you give me some… Yeah. Entrance? So one here, one there, but with an instrument, not your finger, please. Grab a McCabe, or… Yeah, he got it. Mm hmm. So we can go with one and go right here. Okay? Go ahead and come in. And stay open. Can I have the McCabe myself? No, stay open. Okay. No, you're gonna come from here. Okay. Right? Mm hmm. Otherwise - there you go. So this one would go here. Oh, we have a bleeder. Hold on. Can I have a - McCabe? A - It's right here. Yeah. No, that's fine. Thank you. It's right here. Yeah, yeah. No, grab the bipolar. All right. right there. Good. Okay, so this one is going to go here. Let's cut it at about here. Cut right there. Okay, that goes under. Good, okay. And then the other one. Let's get the blade again. Grab the… Is there oozing there? It might just be from where we stopped. Ah, okay. Yeah, it should be fine. Yeah. Blade down. SNaP. Mm hmm. Come out. Silk? Yeah, silk. This one would go… Can you cut here? Perfect, so platysma suture. Now, let's give you some sharps back. You're going to secure the drains with that. I'll take the - Vicryl. Adson? That's okay. And Vicryl? Mm hmm. And would you like an Adson or a DeBakey? Adson's fine.

CHAPTER 3

We're going to have to probably sacrifice the greater palatine on both sides. You think? Yeah. Definitely come into this. So we can leave this tooth. Take this one out. Put it on the specimen. Yeah. And here, we're going to come through here. Here. Here. Here, here. I don't like that - the way that looks Okay.

And I'll take the Bovie. Okay, you hold that. Wait, you were saying, we have to take bilateral GPs? Yeah, I mean, we're getting close. We may be able to save that when… I'd rather not take the other one, the contralateral one, but it's a margin. So we may be able to play it. So the plan is to excise the tumor and then we'll send for frozen sections. All right. That's all of it? Yeah, that's all.

We have to be careful if we… Once we do the resection, take a look at the tube. Let me include in this white area there. May I have the Gerald with teeth, please? Can I have a Kintner, please? All right, let's see if we can do this. Definitely want to find a bone on either side. We have to go subperiosteal. And on the x-ray, we noticed that the bone was involved, unfortunately. So we're going to have to do a maxillary resection as well. We can see the buccal fat pad is starting to show up. And we save that for later. Dimitri, would you mind getting a 2-0 silk? You can put it right through here. 2-0 silk, please? That will be the posterior border. So, you know, when you go from the soft palate, you have to be careful because you want to be split-thickness there. So we're going to approach it anteriorly. We get to the bone and we then bring it posteriorly, so we can identify the floor. You go from known to unknown. Got it. Mm hmm, and I'll grab it here, hold on. Mm hmm. Do we have the bigger bite block? Mm hmm. Let's switch it now. Is it the medium or large? Yeah, and let's get a scissors. So, get that there. Bite block, I think this will be less in the way. Yes. Okay. Good, and now you can retract the tongue. Perfect. And I'll get a periosteal elevator, please. Oh, this one here? Okay, this is what I think - oh, yes, so we have that one. This one is here.

So, we need to take out this tooth here. Let me see the straight elevators. This will allow us to approach the bone easily. And what number is this? This will be number 5. 5. Can I have the periosteal? Yeah, yeah, yeah, yeah. Yeah. Yes, thank you.

It's not where I left it. Yep. So we're definitely missing a lot of bone in that area there. Right here. Yeah. It doesn't look that bad in the middle. No. So the palate, I'm happy with it - for her not losing the hard palate. So this is the greater palatine right there, which we're going to actually, I don't know if we can bipole that. Let's get a McCabe. Actually, do we have a curved, like a Schmidt? Mm hmm. You maybe want to tie that honestly. Yeah, let's… Do we have a right angle by any chance? Be careful. Okay, grab a silk. Mm hmm. I see it right there. Now, we tie this. Did you tie it? Did you... Not yet. Okay. I can do it with this. Okay. Last one. We're not going to cut this. Grab the blade. Leave that tie just in case - we don't want to lose this vessel, and let it retract into the greater palatine foramen. So you can see here the pedicle that we use for reconstruction with path or flap. You're going to cut with the blade on top of it. And this is going to be our deep margin because I can feel getting into the tumor. Go ahead and cut. Yeah, right there. Some maybe tumor. Okay, good. A little bit more. Can I suction here? Can I have the blade? Keep going. Almost, grab here. Okay, good. Okay. Let's keep that there. Trager, if you don't mind just keeping the retraction? Like this. Periosteal? Mm hmm. Okay, I'll take the Bovie. And DeBakey. Mm hmm. And retract showing like that. Good. Thank you. Okay, I can see the bone here. Okay. And the periosteal now. Excellent. So that's the area of bone that is affected there. Okay, you can see it right here. Mm hmm. Right there. Okay? So that's what we have to take out, that part of bone. Could we have a curette by any chance? Mm hmm. Yeah, the bone feels okay, but the tumor is penetrating into it. Yeah. Yeah. This is greater… Yeah. Oh yeah, I see. Oh, yeah. So now, if I can just clean it from the soft tissue, then we can get our margin of bone. I mean, ideally, you want to do the wide local excision en bloc with the bone, but in this case, I was hesitant to do that because we have very little bone. So I want to preserve the integrity of the tumor - it's intact. Suction there. Now, let's get a Minnesota to Dr. Tragar - this one here. I'm learning the names of these, so thank you. No, that's okay. And let's just put you right there. Suction there. And a periosteal? Periosteal? Periosteal? The periosteal - the curved that you gave me before. Thank you. Okay. So we're getting closer to the hamular notch. All right, now I've gotta go here with the Bovie. And do a split-thickness fashion. Suction there. I want to make sure this is not the contralateral… Would it be? Kintner? Yeah, right? No, it's not. Do we have a Gerald with teeth? Margins are key in this case, so we need to make sure that we get them negative. Feels like a - I can feel the pterygoid plates there. Some of the fat protruding, which is good. This one, we can tie - we can cut, the one for the GP. Okay, now this… Can I have the periosteal again?

Okay, if they have the bone right there, all I need to do is just move the curved here. See the tensor palatini there? Mm hmm. Okay, this is coming up. All right, so let's put it right here on a towel because I'm going to orient this, and then we're going to get the - the frozens, and we're going to get the bone as well. So, this is the posterior. Okay, keep it there. I feel comfortable with the margins. Now, let's get some suction there. Yeah. Let's get some suction there. So we have - all this has to go. Now this bone, we're going to have to come to here. So the osteotomy, boss, is going to be… Can I have the Bovie? We're going to come… We're going to do this. Okay? Going to come through here. You have to be careful with the greater palatine. Yep. Okay? I'm going to come - I'm going to try to protect it, Push it medially, where you come with the drill here, okay? In this area. And just buzz it here for now. And then we're going to come here. We can do this with an osteotome. And then come around here. And with the retraction in this area, this is the maxillary prominence. We're going to come through here, okay? Mm hmm. All right. Now before we do that, let's orient this and get some frozens.

So, long posterior. Long posterior. This is going to be right posterior maxilla tumor. Frozen, correct? No, this is going to be a permanent, but this is a main specimen. I'm just going to give you the orientation for it. That's fine. And we have a long posterior suture and a short medial, and a double suture deep. So, I'm going to give you the deep margin first. Can I have sharp scissors? Let's have a double there. Mm hmm. Cut that? Mm hmm, that's good.

So this is the deep margin. We pass them and we send them all together. So this is the deep margin. Deep. Deep margin. Mm hmm. So I have a specimen. Deep margin. All right. I'll let you go here for the osteotomy, boss. Now, let me just retract here. I'm going to send some margins. So I sent the deep already. Okay. We probably know that the bone is involved. so we can do a posterior. And I want to see if I can get this area here. It's going to be posterior. P-O-S, posterior. Okay, posterior. We're going to call this one lateral. This is… We know that lateral is going to be all wall. Lateral. Lateral, okay. This is going to be… Oh, we can include the rest. Have another? Yes, medial. Medial. And the last margin is anterior. A-N-T, anterior. Thank you. Okay, so let's review the margins. You should have a deep, you should have a… Deep. Posterior, lateral, medial, and anterior. And anterior, okay. Deep margin, posterior, perfect.

All right, let's do the osteotomy. Let's get some irrigation. I'll go about a centimeter from the edge, right? Like somewhere here? So remember, you're going to come to here. Yeah. Okay, so you can start from the buccal and then just come here, and then we're going to complete it and make it, you know, by protecting the… The GPA. What I'll do is I'll protect the GPA. And you come anterior to it, okay? Okay, all right. Mm hmm. And try not to get the… [Speaking faintly.] You want to include this tooth in your osteotomy. Yeah. And if you cannot make a perfect curve, that's fine, we can always round it out at the end. And we use the osteotomes to finish it off if we need it. Okay. That's good. Don't go too deep in there - in that area because we can meet it. Again, try to stay superficial there because you don't want to perf into the nose, if you can. Mm hmm. Be mindful of the… So now, you're going to make the turn towards, yeah. Yeah, the turn towards GPA. In front of GPA. Uh huh. And go straight up to the back. Yep. You can keep going all the way around it, yeah, just protect the fat in there. Okay? Because you want to include all that if it's all bad bone. Okay, that's it. Because you're deep enough. Let's go on the buccal. And we can finish it up with the osteotome. We'll do it with the osteotome. All right. Buccal? Yep. You don't want to go too high on the buttress. Going to include all this bone. Okay. And remember, don't go too deep, don't go too deep. You're in the sinus already. In terms of depth… Yeah, you don't want to go too deep. In terms of height, like am I good? Yeah, right there. That's good. That's a good one. There's no way we can get margins from bones, so… Okay, so just go deep and we'll finish up with the osteotome. You want to go a little bit more. Yeah, thank you. Okay. All right, I can come under here. Do you want the smaller bite block. Then you'll be able to stretch it a little more? Yeah, let's do that. Well, we can do it without it. Take your hand out. I think we should be able to do that with osteotomes, boss. Yeah, because I'm going to get into this. Let's do this now. Okay, let me take a look here. Yeah. Okay, that's fine. Mm hmm. Yeah, you want to put it down and get down there? Yep. Try to do a straight there. Mm hmm. That's good. Coming out. Yep. All right. Now we're going to go posteriorly. Reflect the nasal mucosa. Yeah, yep. A Freer? A freer please. A curved freer? We're still stuck in the back. So hold it right there for now. Let me see where we are. Grab your osteotome and put it right there. Yeah. But let me just protect greater palatine. I have it right there, okay. Mm hmm. Good. That's the turbinates. Mm hmm. Okay. Can I get suction there. Okay, so we have some soft tissue here. And a big cyst there. Let's get all that mucosa there, just at the margin for the bone. Yep. Mm hmm. Can I get a… Now we have some of the pterygoids… So you need to pull, and I can just retract the base. Or get a Kocher. Okay, grab it. Pull it out. Now hold on one second. We're going to send all this. Yeah. It came out? Okay, that's fine.

So now, what I want you to do is… Undermine. You're going to undermine this a little bit, okay? And by doing that, we can bring… Yes, put a sweetheart there. Yep, slowly. You can pull it a little bit. So we can, you know, the one part that I like to really cover is the posterior palate, yep. Yep.

So if we can suture some here to this corner, okay? The rest falls here. We're never going to close it completely because that's not the idea. You want to also examine for any potential recurrences. All right. So, you know, if we put a couple of sutures from here to here... Can we do a hole? Yeah, you can put a hole there, yep. That's the suture there. And then you can… Irrigation? Use the curved freer first. Mm hmm. Good. All right, let's try some 3-0 Vicryl. Be careful when you tie because if you tie too tight, then… Just like an air knot. Yeah, sure. Why were you saying you'd rather cover to the posterior aspect more? Because that's where muscle is exposed. Oh, okay. So you want to give that extra coverage to the muscle. Okay. So it doesn't scar… Because we know that the bone is going to secondarily… And there's no point in covering the sinus because the fat is going to die. Right. Because you have a big hole. So you want to cover the areas that you know that you can attach to mucosa and maybe some of the contralateral palate that we exposed. Oh, okay. Okay. So now you can put, oops, you can bring this down right there, uh huh. And we have to be careful when we add the Coe-Soft, not to add it where the fat is. Oh yeah. Because then we're going to push it up and grip it, so… Make sure we don't lose that… Because when we put it in, we're going to have it be like that doughy part. Yeah, no. Not when it's liquidy? Yeah, it cannot be liquidy. It needs to be doughy. Yeah, okay. Perfect. Another one? Yeah, you can put a one here in the back. And then, you know, you can extend this a little bit just to cover the bone there. And now, this one here. Caribbean was wondering if you will rebiopsy your… Caribbean? Yeah, he was asking. If it doesn't show any evidence of clinical lesion, I wouldn't biopsy it. No, right? That's what I thought. Yeah. If he's concerned about that opening there, you know, yeah, if it looks inflamed and ulcerated… Get some additional time… Yeah. Careful, you're pulling it through. Okay.

CHAPTER 4

For permanence. Mm hmm. Irrigation? Okay. The back is kind of tight where we pulled the fat from. Do we want to try the other one just in case. Sure. Yeah, that's something that they do here with the dentures like this. I still don't get it. Is it too far back from the palate? This one may be a little bit better. You think? Yeah, I think that's the better one. Yeah, this one is better. Okay. So we don't need to put too many. I'll put one here, and this one here. Just so you know it doesn't… We need to make sure it's not… Okay, fine. Yeah. Let's get some irrigation. How do you want to protect the buccal fat from it getting in it. Oh, we're just going to pour it in the… Just in the anterior part? Yeah, mm hmm. So it goes into the sinus and that's how it's going to be retentive, and lets the mucosa heal. How do you get it out without it getting locked in though? Well, luck. Yeah, luck.

That's good. Let me just grab... Eh. Yeah. Not good? That's fine. Just take some because we're going to have to add more. Let's try. Yeah. Mm hmm. It's easy to remove once it's solid. Some saline. That's good. All right, let's try to take a look here. Open real big. Her tongue was in the way. Yeah. Mm hmm. That's good. Okay. That's fine, just let it sit now. We have it in the holes. We want it to get all solidified. Yeah. Going to treat it like an impression. Yeah, exactly. The wires will go through the… Suction in the back to see the flap. That is good. That's good. That's good. Even if it's not all the way flushed, we just want it to cover some. And you said you leave this for 48 hours? No, no, a week. A week. Oh, I thought. Yeah, we'll see her next week. Okay. The drains are usually - we try to remove earlier, but…

Hello? Hi, Monica, how are you? Yes, mm hmm. Yeah, that's what I thought. So, in addition to that, which, you know, the next oncologic margin will be the bone, which I'm sending. I did an alveolectomy, so you're going to get an entire segment of bone. Obviously, we won't be able to get anything else beyond that. I'm also, in addition to that, on the other side of the bone, I'm sending you a sinus mucosa, just to take a look too. Yeah, yeah, exactly. Everything will be - there's nothing else that I can send you even if you tell me that it's positive. So, yeah. Mm hmm, mm hmm. And the rest of the frozens? The rest of them looked negative. Oh, perfect. Okay. Excellent. Thank you so much. Bye-bye. All right, we're all set. All right. Only the deep margin that I sent from the table, which was the bone. Yeah, exactly. Okay. So, I can take those off the table now? Yes, yep. Mm hmm. And send them to her? Yep. And still as a permanent status, right? Yes, correct. Still fresh? Yeah, still fresh. It came out really easily. Yep. That's why you need to wire it down. Yeah. Let's take a look. Sorry, can we get alcohol wipes? Do you mind please? Thank you. Oh, wow. So we technically don't need this to hit the floor. We can trim this a little bit. Wow. It's like when you take an impression and you accidentally get all the way down. Yeah. You get a laryngeal impression. Yeah. Okay. So let's get a last irrigation and suction. And then, we'll secure this with wire.

You ready? Are we going to irrigate one more time? Good hemostasis? Okay. Good hemostasis. Thank you. If we can get a soft oropharyngeal tube, so we can suction her. You know those suction catheters? Or an OG - you can give me an OG tube. We can put it in the - we can put it through the nose. Yeah, yeah. Mm hmm. To suction out, so we avoid it. Well, you'll have to… No, we can use a real OG - no, so she's not nauseous after. Yeah, yeah. Now let's put the wire. I'll get the wires, please. Mm hmm. I'll give you this here, so he can see the wire on the canine. You can actually bring it from here to here and these two in the lateral, yeah. Oh, I didn't make them super long, sorry. It's okay. She has crowding of that tooth, so it may be a little challenging. You got her? Yeah.

CHAPTER 5

We just completed a surgical procedure on a patient with a stage two squamous cell carcinoma of the oral cavity. The procedure we performed was a neck dissection on the right side, essentially three levels: one, two, and three, to remove the fibrofatty lymph node-containing tissue in order to confirm the presence or absence of regional metastatic disease. We also performed the wide local excision of the tumor, which was located in this area, here, in the right posterior maxilla, involving the alveolar bone. We had to perform the wide local excision of the tumor in addition to a partial maxillectomy. And then, we advanced the fat from the area, anteriorly and medially to try to repair the defect, in addition to placement of a surgical obturator. The patient did well. And she, right now, is in the postanesthesia care unit. Thank you.