Surgery two weeks ago

I am two weeks post-op. Amazingly, the tumor that was on the floor of my mouth extending onto the side of my tonsillar pillar was basically “dead” and no cancer or dysplasia was found anywhere in this extremely extensive free flap reconstruction surgery. While I am glad I made the decision to go through this procedure, which provided invaluable information I would not have gotten if I had gone the radiation-chemo route, it was (and continues to be) very brutal and much more difficult than I ever imagined. I will elaborate in the future.

The pain in the ICU was primarily gastroparesis, colitis, and brief period of ileus. Unfortunately, the pain and swelling in the submandibular space, pharynx, and neck dissection area emerged only a week ago and was worse than ever last night. I had expected to be on the mend by now, so I am pretty darn frustrated. I see oncologists and speech therapist on Monday so hopefully I will get some reassurance.

This is what I went through:

WIDE LOCAL RESECTION RIGHT ORAL CAVITY( TONGUE) 41153
RIGHT NECK DISSECTION 38724
Excision right submandibular gland 42440
Limited Pharyngectomy 42890
PHARYNGOPLASTY 42950
LEFT RADIAL FOREARM Free Flap 15757
Skin Graft (split thickness) 15100
ROBOT ASSISTED MICROSURGERY 69990
Use of an operating microscope 69990

PROCEDURE DETAILS: The patient was wheeled to the operating room placed upon the operating table. After adequate general tracheal anesthesia was established via nasal intubation the patient was cleaned prepped and draped in the standard surgical fashion. At this time we examined the oral cavity tumor on the right. The floor mouth/lateral tongue and retromolar trigone lesion had significantly reduced in size there is a lot of scar tissue in the area. We performed a wide local resection of the floor mouth right lateral tongue including a piece of piece of the right base of tongue and the right lateral pharyngeal wall and anterior tonsillar pillar. We took some generous margins in all directions. We took frozen sections in all directions as well which were negative for persistent tumor. We passed this off the table specimen. We had a complex defect which involved the right lateral pharyngeal wall right anterior tonsillar pillar right retromolar trigone soft tissue and floor of mouth and oral and base of tongue. We preserve the lingual nerve. At the at this point we proceeded with a right neck dissection. We made a horizontal incision in the right neck through skin crease. Skin flaps raised inferiorly and superiorly in the subplatysmal plane exposing the contents of the right neck. We skeletonized the sternocleidomastoid muscle from the anterior the posterior border. We skeletonized the posterior belly of the digastric muscle. We found the accessory nerve and skeletonized it. We then elevated the lymph nodes off the floor the neck preserving the accessory nerve the cervical rootlets the phrenic nerve and the vagus nerve. We sharply entered into the carotid sheath and elevated the fascia and the lymph nodes off the carotid artery vagus nerve and internal jugular vein. We passed levels 2 3 and 4 for the table specimen. We passed level 2B off separately.

At this time we removed the right submandibular gland using a clamp and tweak technique we elevated the fascia off the submandibular and in the facial artery and vein. We preserve the marginal mandibular nerve. We dissected the soft tissue off of the gland preserving the lingual nerve and the submandibular ganglion. We isolated ligated and divided this as well as the submandibular duct. We passed the right submandibular and off table specimen. We prepared the facial artery and vein for the microvascular portion of the procedure. We created a tunnel through the submandibular space along the parapharyngeal space into the floor mouth.

We went to the left forearm and drew out a skin paddle that was 6 x 4 cm over the radial artery. I made incisions around it brought the incision up to the antecubital fossa. Raised skin flaps laterally medially exposing the flexor carpi radialis and brachioradialis muscles. We harbored harvested the deep venous system and the superficial venous system of this flap. We did have a separate skin paddle as a monitor which was more proximal. We elevated the fascia off the brachioradialis and flexor carpi radialis muscles. We isolated ligated and divided the radial artery and vena comitans distally. We preserve the superficial portion of the radial nerve and all its branches. We elevated the flap from distal to proximal until it was entirely pedicled off the radial artery and 2 venous systems both the deep and the superficial. We released the tourniquet allowed to perfuse a perfused appropriately. We isolated ligated and divided the pedicle proximally and brought the flap up to the head of the bed. We pulled it through the parapharyngeal tunnel into the right neck. Leaving the skin paddle in the floor mouth and pharynx. We inset the skin paddle with 2-0 Vicryl sutures in this complex defect. We recreated the right lateral pharyngeal wall the floor mouth right base of tongue and oral tongue and right retromolar trigone with all of this tissue. We then inset the skin paddle in the neck as a skin monitor. We performed a microvascular anastomosis using 8-0 nylon sutures under microscopic visualization between the radial artery and facial artery. We then performed a venous anastomosis between the cephalic vein and the facial vein using 8-0 nylon sutures. We then used the Simoni robot to perform a second venous anastomosis between the deep venous system and a branch off the facial vein. This was also done with 8-0 nylon sutures. The flap perfused appropriate at this time. 2 Penrose drains were left in the neck for postop drainage. The neck was closed in 3 layer fashion.

We went back down to the forearm donor site. We lavaged the wound with normal saline. Hemostasis was achieved the bipolar cautery. The skin flaps were closed in 3 layered fashion. A split-thickness skin graft was harvested from the thigh that was over over 150 cm² and inset into the defect where the skin paddle was harvested from with 4-0 chromic sutures. A wound VAC was placed over the skin graft. A clean surgical site was placed over the arm. A clean sterile dressing was placed on the donor site for the skin graft. A clean surgical site was placed on the neck.

FINDINGS:
Negative margins in all directions