Case 1: Cheek rotation flap
Authors: Magnus Balslev Avnstorp, MD and Frederik Gulmark Hansen, med.stud.
A 78-year old male admitted to the dept. of Plastic Surgery with an aggressive Merkel cell tumor on the right cheek growing rapidly through 4 months. A suspected local skin metastasis is found on the lower right cheek. Pre-operative PET-CT scan found no signs of distant metastases.
Before and after
Patient examination
Patient in good condition. On central right cheek a necrotic tumor measuring 6×5 cm, infiltrating the underlying tissue. On lower cheek a local skin metastasis measuring 2,5×2,5 cm. No palpable pathologic lymphnodes in the head and neck regions.
Pre-Operative Considerations
Merkel cell tumor is a highly aggressive tumor that must be radically excised in at least 1 cm margin to the fascia in the facial region (recommended 2cm in other regions)(1). Pre-operative PET-CT scan and sentinel lymph node dissection are advised (1).
- Plan: Radical excision of the primary tumor and the local metastasis in 1 cm margin to fascia. Perform sentinel node excision on the right neck in level 2 through the defect on lower cheek. Reconstruction of the defect with a cheek rotation flap using the excess skin from the lateral, lower cheek and the right side of the neck. See Cheek Rotation Flap Design.
- Patient information: Risk of facial nerve lesion to obtain free surgical margins, drag in lower right eyelid, flap necrosis and post-operative infection.
Step 1: Pre-operative examination
Large aggressive Merkel cell tumor on central cheek measuring 6×5 cm, and a local skin metastasis on lower cheek measuring 2,5×2,5 cm. The sentinel lymph node location found on SPECT scintigraphia on the neck is marked with an X.
Step 2: Excision
The primary tumor and local metatasis were radically excised in 1 cm margin including deep subdermal tissues and the facial nerve brances to the eye, nose and cheek. The Sentinel lymphnode was dissected through the defect on the cheek.
- Notice: The tumor is covered by Tegaderm to avoid contamination of necrotic tissue, tumor cells and bacteria from the necrotic center.
Step 3: Further Excision
Notice the depth of the excision including subdermal tissues, nerves, vessel and in some locations muscle to obtain radical free margins.
Step 4: Drawing for cheek rotation flap
Notice the height of the rotation arch stretching superior to the zygomatic arch and up to the temple region.
Step 5: Flap raised
The cheek rotation flap is raised in the SMAS plane and found with adequate blood supply.
- Notice the drain is placed passing through the area of lymph node neck dissection.
Step 6: Closure
The flap was closed in two layers using vicryl and nylon.
Step 7: Post-operative
Taper strips placed.
- Notice the written “%TRYK” means: “No pressure” (in danish) in the area of the pedicle – to avoid flap necrosis
Step 8: Follow-up (1 month)
Healed cheek rotation flap. Complete right side facial paralysis to eye, nose and cheek – as the nerve was excised to obtain radical margins. A minor defect of 5×5 mm was found on the tip of the flap, which healed secondarily over the following two weeks.
Post-Operative Plan
The histologic assessment found radical excised Merkel Cell tumors on the central and lower right cheek. The sentinel lymph node was found with infiltrating metastases of Merkel cell tumor cells. The patient was admitted to the Dept of Oncology for adjuvant treatment and follow-up with PET-CT scans every 3 months.
References
- Naseri S, Steiniche T, Ladekarl M, Bønnelykke-Behrndtz ML, Hölmich LR, Langer SW, Venzo A, Tabaksblat E, Klausen S, Skaarup Larsen M, Junker N, Chakera AH. “Management Recommendations for Merkel Cell Carcinoma-A Danish Perspective.” Cancers (Basel). 2020 Feb 28;12(3):554. doi: 10.3390/cancers12030554. PMID: 32121063; PMCID: PMC7139291.