Ameloblastoma (Oral Tumor) Surgery & Microvascular Reconstruction by Dr Abdullah Masud -English Sub
Welcome everyone! I am Dr ABdullah Al Masud Assistant Professor of Oral & Maxillofacial Sugery, Dhaka Dental College. I am gonna tell you about a tumor, which is called Ameloblastoma & Ameloblastoma is an oral Tumor, Which is not cancerous,but grows rapidly & is called 'Locally Malignant', Which effects its surrounding structures rapidly. We are now looking at a patient who was suffering from Ameloblastoma, ...Who got his surgery done three times in a row...
But it didnt get cured completely. We know, if some part of the tissue of a Ameloblastic lesion remains after surgery It can recur again & can destroy the whole structure So, we are beginning our Surgery right now, & our main purpose is to remove the tumor completely, & as his lower jaw is involved here , We will remove the whole affected mass, ...with some healthy margin And will replace the lost stucture by taking bones & tissues from his leg .. Which is called Fibula Microvascular Free Flap Which has been started very recently in Bangladesh In Developed nations, its pretty familiar though & Its such a great news that, we can now reconstruct Jaws completely We can see, a portion of the mandible is being resected from the right side , ...with the help of osteotome & bur And the inferior alveolar neurovascular bundle is being clipped with artery foecep, & then resected with diathermy As this tumor has spread in all direction, both externally & internally and under the tongue, ..It needs to be excised from all sites. Here the facial artery, which is located over submandibular gland of the right side, ..is being separated nicely. And we are using Liga-clip here to prevent excess use of diathermy, Because, Facial artery needs to be preserved for the microvascular free flap later, ...for the anastomosis with peroneal artery. One end of the tumor has already been separated.
...now mylohyoid muscle is being separated. We can see some steel plates used in previous surgeries. Some affected soft tissues from the left side of the mouth is being removed gradually.
We are trying to keep this surgical field as bloodless as possible in every step , ...as its a huge tumor. I am grateful to all the doctors who assisted me in this surgery for their enormous help. Now we are approaching to the coronoid & condyler area Now the facial artery in the left submandiular gland is being seerated precisely & Vessel preservation is very important in this surgery for microvascular anastomosis and the anastomosis will be done with very fine suturing. 9-0 proline will be used here for microvascular anastomosis Facial artery is kept ligated foe now for further use. Some part of masseter & mylohyoid muscle is being excised here with the lesion. We preserved a very small portion of bony structure on both end, ...for the proper placement of the reconstruction plate during microvascular surgery.
To ensure normal mastication & prevent disfigurement of the face of the patient. At this stage excision is being done with diathermy on the retromolar area of the left side Temporalis muscle fibers are is being excised here gradually from the coronoid process We will expose the condyle of the mandible after some time... Point to be noted here that, the inferior alveolar neurovascular bundle of the left side should be clipped before... The condyle of the left side pf the mandible is being shaped with bur... Advantage of keeping the condyle intact is, it keeps the facial structure normal, ...thus maintaining normal facial appearance & masticatory function The whole tumor mass has been removed & its a huge one! Now the patient doesn't have any lower jaw Facial Artery & common facial vein... ..and External jugular vein have been kept preserved & prepared... For the anastomosis with peroneal artery & vena comitans of fibula.
That's the whole excised tumor mass. And we will take a huge skin Island from the leg. ..because, We will need a huge amount of mass to replace the lost structure & close the facial defect.
So, What we are gonna do is, take a huge skin paddle with fibula flap after separating the peroneal muscle... ...Which is called 'Fibula Osteocutaneous Free Flap' .... ...Soleus muscle is nicely being separated here.. We know, this skin paddle should be taken from the area between.. ...Peroneus longus muscle & Soleus muscle .. ..it should go through the anterior inter mascular septum situated here..
And the fibula flap has been raised nicely.. We will separate the raised fibula into three parts by osteotomy to adapt the reconstruction plate... ...and during osteotomy the periosteum should be reflected nicely.. So that,the blood supply of the bone remains good. & Keeping the blood supply intact we will divide this fibula in three parts.. ...shape it like mandible & fix it with reconstruction plate by screws... & then anastomosis shoud be done with the vessels of fibula, Peroneal vessels ..
Now, we can see, defect of the leg is being closed layer by layer... ...and fibula is being fixed with the reconstruction plate gradually. The shaping is very beautifully done, I think. This beautifully shaped fibula is fixed with plates ...and the reconstruction plate is being fixed with srcews with the remaining portion of the both condyle. ...We used three screws each in the both sides & after fixing this, what we are gonna do is, ...attaching the Masseter, Suprahyoid & Mylohyoid muscle......after bringing them to their original position... ...to the newly formed lower jaw.
Then, we are gonna do Microvascular Anastomosis.. ....which is already being started here..... Usually We do the anastomosis of the vein first, then the artery... ..We used 9-0 proline in both arteries and veins Because of this Microvascular surgery , now we can replace huge structures.. ..which has been resected due to cancer or tumor ... Or whatever diseases where resection of huge structures is necessary ... We can see now, anastomosis has been completed as as the vessels are pulsating now, Few weeks later, as we can see in the OPG Xray, healing is done nicely... ...And the patient's jaw is fully functioning...
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