Excision of two thirds of the mid face and prosthetic replacement

Abstract

A 71-YEAR-OLD FARMER had for at least 5 years an enlarging malignant ulcer on the right lateral aspect of his nose for which he consistently refused treatment. Eventually he was admitted as an emergency because of massive haemorrhage from the lesion; his haemoglobin was 40 per cent and his haematocrit 20 per cent. The tumour infiltrated all of the nose as far as the left naso-labial fold, all the upper lip and all the right cheek; the right eye was blind because of invasion of the right orbital cavity (Fig. 1). Intra-orally there was invasion of the alveolar process of two-thirds of the maxilla and infiltration of the palatal and vestibular mucosa. X-rays showed bony resorption of the maxilla, complete opacity of the maxillary antrum and shadows in the right ethmoidal cells and the right side of the frontal sinus. Biopsy revealed a highly differentiated spindle cell carcinoma. After correction of the hypovolaemia and after a full discussion with the patient and his complete agreement, an extensive excision of two-thirds of the mid-face was carried out, including all of the maxilla, the right orbit and bilaterally the ethmoidal cells and the frontal sinus. Immediate pathological examination revealed invasion of the roof of the right orbit and in the region of the cribriform plate. Bone was resected until the dura was exposed over an area of 4 x 6 cm. A small patch of dura was also resected but showed no microscopic invasion (Figs. 2-4). After complete haemostasis the exposed dura was covered with a pedicle flap of the epicranial aponeurosis. The whole defect was then covered with split-thickness skin grafts with a firm tie-over dressing for immobilisation. A gastric feeding tube was inserted. No tracheostomy was necessary. The postoperative course was uneventful and the take of all skin grafts was good, even on the pedicled epicranial flap covering the dura (Fig. 5). We planned to reconstruct the upper lip and the palatal region with a pedicle flap of the sternomastoid muscle and its covering skin (Owens, 1955) with a secondary anastomosis of the accessory nerve to the trunk of the resected facial nerve. This flap was delayed twice and was ready for transfer when, about 8 weeks after the excision, the patient had several attacks of cardiac insufficiency and further surgery was abandoned.