A 24-year-old female patient with no relevant clinical history presented with an 8-month history of left lower lip paresthesia.
Three months later, a 1.5 cm diameter tumor appeared in the mandibular alveolar region and floor of the mouth on the same side.
On physical examination we observed facial discomfort in the lower left third with increased volume in the submandibular region.
In the intraoral examination, we observed a lesion located in the mandibular alveolar ridge and floor of the mouth on the left side, of indurated consistency, whitish and red coloration, painful, with irregular edges.
Computed tomography (CT) of facial mass without contrast shows the presence of a heterogeneous tumor mass with central density and solid periphery, displacing the right geniohyoid, mylohyoid and genioglossal structures.
In addition, irregular bundle branch was found in the left mandibular cortical bone.
Magnetic resonance imaging (MRI) revealed the presence of a rounded hyperintense occupancy lesion of irregular edges with heterogeneous content of approximately 9 x 8 x 9 cm that displaces the structures of the left side of the mouth.
Incisional biopsy reported high-grade chondroblastic osteosarcoma. After the mandibular segment we discovered a defect with treatment to perform a hemimandibulectomy and immediate reconstruction of the defect with an osteocutaneous flap of the radial floor for reconstruction.
Previous surgery was performed for tumor resection.
The procedure was performed by two surgical teams who worked simultaneously.
The first was formed by Oncological Surgery and the second by Plastic Surgery and Maxillofacial Surgery.
The first team performs laparotomy, oncologic resection and preparation of the recipient vessels for the two free flaps: the right and left facial artery and vein.
The second team performed the dissection, lifting of the fibular free osteocutaneous flap, osteotomies on the peroneal flap, transport, adaptation of soft and hard tissues for the reconstruction of the radial covered anastomosis, lifting of the flap.
Oncological resection consisted of left side hemimandibulectomy, floor of mouth resection and modified radical neck dissection type III on the same side, leaving a large defect with dimensions of 9.5 cm in height in anteroposterior direction bl, 8 cm.
The lesion was sent for histopathological study.
Then, we raised a 10 cm fibula free osteocutaneous flap with a 13 x 17 cm skin island with vascular access.
We performed two osteotomies in the proximal part of the fibula, one for the symphysis and parasymphysis and another for reconstruction of the mandibular body.
We used 3 cm of bone for reconstruction of symphysis and parasymphysis and 5 cm for reconstruction of the mandibular body on the left side.
We fixed the segments with 2 plates of osteosyntesis of 4 orifices of 2.0 mm with jawbone gap 2.0 mm and 7 mm in length; and 1 plate of 4 orifices of 2.4 mm x 10 segments with mouthrn.
The peroneal artery was termino-terminally anastomosed to the left facial artery, and the peroneal vein was also termino-terminal to the thyrolinguopharyngofacial trunk.
We covered the donor site with a skin graft taken from the left thigh.
We raised a radial forearm free flap of the left arm after marking dimensions of 6 x 12 cm, which we used for reconstruction of the submandibular skin defect ranging from the midline to the mandibular angle.
We performed anastomosis of this flap end-to-end to the right artery and facial veins.
We performed the closure of the donor site of the radial forearm flap by covering with a partial thickness skin graft taken from the anterior thigh area, sutured and fixed with a Brown dressing.
Postoperative monitoring of the flap was performed every 2 hours, proving the correct perfusion and survival of the flaps.
After surgery, the patient was discharged from the intensive care unit (ICU) for 72 hours, of which he remained under deep sedation during the first 24 hours to avoid sudden movements of the anastomosis site, after being discharged from hospital for 72 hours.
We used enoxaparin 40 mg subcutaneously once daily for 14 days as an anticoagulant, and ampicillin + broad-spectrum beta-lactam antibiotics 1.5 mg every 7 days as an intravenous administration every 6 hours
During hospitalization, on the 6th postoperative day the patient began to receive clear liquids orally and soft diet on the 7th day by papillae and supplements, showing good nutritional status.
Walking began 15 days after surgery.
Once discharged from hospital, we performed periodic controls every 8 days during the first 2 months and from the third month, controls once a month.
The patient was referred for chemotherapy.
No intraoperative verification was performed.
2.7 Post-operative histopathological study reported high-grade chondroblastic osteosarcoma based on the resected surgical piece of dimensions 7 x 6 x 9.5 cm. These dimensions were covered by ellipse brown skin piece 5.5 x 6 x 9.5 cm.
The anterior edge distanced 2.5 cm from the tumor lesion.
At the posterior edge of the piece, an irregular segment of bone tissue covered by adipose and muscle tissue was identified, as well as 2 lobulated pinkishes measuring 3.5 x 2 x 1.4 cm and 1.5 x 1 cm.
On the lateral edges, an encapsulated lesion of white cartilaginous aspect naked in the center hard tissue with 5.3 cm in diameter was identified, and the internal and external borders distanced 0.5 cm and 0.3 cm, respectively.
We performed a postoperative follow-up radiograph 30 days after the surgical procedure, checking mandibular reconstruction.
After 6 months of evolution, the patient was asymptomatic solid foods with normal distribution on the unaffected side and there were no fistulas or exposure of bone or osteosyntesis material.
The occlusion was displaced approximately 2 mm to the right side, considering the lack of muscles on the affected side.
The defect was completely covered and the mandibular contour was returned.
No complications were observed in the donor sites of both flaps.
In the control performed 7 months after surgery, the patient came complaining of pain in the left mandibular region.
The intraoral clinical examination showed the presence of an ulcerous lesion in the mucosa of the left retromolar region. For this reason, we interconsulted the Head and Neck Service and a mandibular dislodgement CT in our hospital.
We performed a biopsy of this lesion resulting from high-grade chondroblastic osteosarcoma.
When recurrence occurs, new imaging studies determined unfavorable evolution due to rapid invasion of the lesion to the base of the skull with significant involvement of anatomical structures that prevented its resection.
The patient remained 9 months after detection of recurrence with palliative treatment and pain therapy, and unfortunately died 21 months after surgery.
