Scalp cancer repeatedly ulcerated for 5 years Xiangya multidisciplinary experts 18 hours surgery to help the woman regain her life 2015/10/17 19:20:09 Party Branch: Third Party Branch Department: Party Committee Propaganda Office Oral Medicine Center Author: Wang Jie Correspondent Li Wenlong Clicks: 2032 Xiangya Hospital of Central South University Neurosurgery Li Xuejun “Xiangya doctors are really so helpful, thank you! for your life-saving grace!” Recently, Ms. Wang excitedly held the hand of Associate Professor Guo Feng of the Department of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, on the occasion of her discharge from the hospital. For five years, Ms. Wang had suffered from scalp cancer, and half of her head had repeatedly festered and flowed with pus. Fortunately, the team of Associate Professor Guo Feng, together with Professor Li Xuejun from the Department of Neurosurgery, Professor Wang E and Professor Wang Yunjiao from the Department of Anesthesiology, and with the cooperation of the operating room and the central ICU, overcame many difficulties and finally gave Ms. Wang a new lease on life after 18 hours of struggle. Associate Professor Guo Feng examined Ms. Wang’s recovery. 5 years of repeated ulceration and pus flow, “eroding” the skull and meninges Ms. Wang from Huaihua found a lump on her scalp 5 years ago, and pus flowed. She went to a local hospital and found that she unfortunately had squamous cell carcinoma of the scalp. However, 2 years after the surgery, Ms. Wang’s tumor unfortunately recurred and she had to undergo another surgery. At the end of last year, misfortune struck again and Ms. Wang found a soy-sized lump on the top of her head, which turned out to be a recurrence of scalp cancer, and the situation was getting worse. Her scalp began to slowly flow pus and ulcerate, the wound gradually expanded to the whole top of her head, and she even experienced dizziness. “What’s more dangerous is that the cancer cells had eroded into the skull during the second recurrence, and a small piece of the skull was cut off during the surgery. And this recurrence is even more serious, as the cancer cells ‘drove straight in’ through the defective skull to invade the meninges and sagittal sinus, which may cause damage to brain tissue and nerves and serious consequences such as intracranial infection if not treated early.” Associate Professor Guo Feng of the Department of Oral and Maxillofacial Surgery at Xiangya Hospital said. The only way was to surgically remove the 17×350px lesion on Ms. Wang’s scalp and skull, meninges and sagittal sinus. However, after the removal, how to “reconstruct” a piece of scalp for Ms. Wang to repair such a large missing part? According to Associate Professor Guo Feng, since Ms. Wang had already undergone two surgeries, there was not much scalp left and the adjacent tissues were not enough to repair the defect left by the enlarged tumor. However, for such a large defect, the flap would be difficult to survive and would require a second surgery for skin grafting if traditional methods were used. In addition, the appearance of the flap is also bulky and affects the aesthetics. As the first participant of the “Master Training Course on Threading Flaps” organized by Professor Tang Juyu, a “famous Xiangya doctor,” Associate Professor Guo Feng intends to use the new technique of threading flaps as a good way to successfully repair this defect. “The most important feature of the through-branch flap technique is the ability to dissect the very complete vascular tip of the through-branch without incidental other tissues. The space between the flap and the skull is very small, and only with this technique can we ensure that the blood vessels on the flap remain open in such a narrow space, thus ensuring that the flap will survive.” Associate Professor Guo Feng said. The “problem” of the scalp was solved, but the dural defect was still a danger. After a consultation, Associate Professor Li Xuejun of the Department of Neurosurgery pointed out that only by repairing the dural defect and forming a barrier for the brain tissue could the cerebrospinal fluid leak be prevented or external bacteria cause intracranial infection. After 18 hours of overnight work, the scalp was reconstructed with a flap technique. At the end of September, after thorough preoperative preparation, a team of eight doctors, including Associate Professor Guo Feng, Dr. Huang Long and Professor Li Xuejun, operated on Ms. Wang in a “two-pronged” manner. During the operation, after cleaning the lesion on the scalp, Associate Professor Guo Feng’s team started to make the flap. At the same time, Prof. Li Xuejun’s team started to remove the intracranial tumor and the involved dura mater, and repaired the defective dura mater with a 5×125px broad fascia of the thigh. Since the scalp defect was too large and round, in order to minimize the damage to the donor area, Associate Professor Guo Feng decided to remove a 28×212.5px long flap from Ms. Wang’s thigh, then cut it into two flaps and spliced them into the shape of the scalp defect. In this way, the need for defect repair could be met and the thigh donor area could be closed in one stage. Everything was proceeding in an orderly manner according to the preoperative design, however, the accident came unexpectedly. The three perforators prepared according to the preoperative exploration did not converge to the common trunk, and each merged into three different source vessels, making the planned combination of lobed flaps to repair the scalp defect challenging. Associate Professor Guo Feng, who has extensive experience in the technique of threading flaps, decided to use the descending branch of the lateral rotor femoral artery as the vessel tip to anastomose with the recipient vessel as the proximal flap, and to anastomose the distal flap threading vessel with the distal end of the descending branch of the lateral rotor femoral artery to form a “relay” flap. To ensure the blood supply to the proximal flap, another penetrating artery of the proximal flap is anastomosed with a very small branch of the descending branch of the lateral rotor femoral artery, creating an “internal pressurization” of the flap. “In this way, a flap that originally needed to anastomose only two vessels was increased to six vessels, creating almost a new ‘vascular network’ beneath the flap.” Associate Professor Guo Feng said that in order to prevent the blood vessels in the flap from pressing too much on the skull and affecting the blood flow, they also made special efforts to thin the flap, which is only 25px thick and matches the residual scalp very well. However, Ms. Wang’s anatomical variation once again posed a challenge to the surgery. A normal person would have superficial temporal arteries and veins on the left and right sides of the head, and only these two vessels would need to be connected to the vessels of the flap to form complete blood circulation. However, Ms. Wang’s anterior temporal veins on both sides were missing, so how to find a blood vessel for the flap to return blood flow? This posed a big problem for the surgeon. After 2 hours of careful exploration, Associate Professor Guo Feng’s team finally found 2 unnamed veins in Ms. Wang’s right parotid gland, the thinnest of which had an outer diameter of only 0.6 mm, and the blood in the two large flaps flowed back through these 2 small vessels. “Anastomosis of the vessels requires the most care and patience, any problem with the anastomosis and the 2 flaps may be at risk of necrosis.” Associate Professor Guo Feng introduced that the intraoperative anastomosis took about 6 hours continuously, requiring constant attention to the microscope and no relaxation at all. After 18 hours of overnight surgery, starting at noon on September 22, the operation was completed. The next morning at 6:30 a.m., Ms. Wang’s surgery was finally completed successfully. A week later, her new “scalp” survived well, and Ms. Wang has now been discharged from the hospital.