[Surgical treatment of complications after irradiation for malignant facial neoplasms].
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The majority of malignant tumors of the skin on the head are found in the upper two thirds of the face. The oral surgeon who is active in the plastic surgery field is therefore frequently confronted with surgical problems exceeding the limited area of the jaws. In this respect nose and ear are regions presenting special problems with regard to esthetics and function.
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The glomus tumor is a benign, vascular, hamartomatous derivative of the glomus body, a normal intradermal arteriovenous anastomosis. Most glomus tumors are solitary, tender lesions of the nail bed and are found only rarely on the eyelid. Occasionally, glomus tumors assume a multiple form, wherein they are nontender. I report a unique case of multiple glomus tumors involving the face, palate, eyelid, and anterior orbit.
A 37-year old woman had received multiple radiation treatments between the ages of 6 months and 15 years for an extensive cavernous hemangioma of the left side of the face. At the age of 27 years, a biopsy specimen from a lesion of the left buccal commissure disclosed squamous cell carcinoma arising in chronic radiodermatitis. Multiple cutaneous lesions were excised surgically, and extensive skin grafting of the left side of the face was performed. At the age of 35, she developed a tumor of the left upper and lower eyelids that extended into the orbit, which proved to be a sebaceous gland carcinoma. Following left orbital exenteration, the tumor promptly recurred in the socket. The patient died with widespread metastatic lesions nine months after exenteration. This case, which, to our knowledge, represents the fourth example of postradiation sebaceous gland carcinoma of the eyelids, differs from the previously reported cases in that the radiation therapy had been given for a benign cutaneous condition.
An unusual case of mucinous adenocarcinoma of the sweat glands originating from the right axilla is described. Despite complete control of the primary tumor after local excision, diffuse metastatic lesions continued to appear in the scalp, face, upper and lower extremities, sacral and pelvic bones, and left posterior iliac bone marrow space. The tumors were radioresistant. Multiple trials of various chemotherapeutic regimens, including alkylating agents, antifolates, antipyrimidines, vinca alkaloids, and antineoplastic antibiotics, were ineffective. The cutaneous neoplasms were grossly round, smooth, red, glistening, and cystic and were filled with a gelatinous mucinous material. Microscopic and ultrastructural findings are described.
A series of 11 sebaceous carcinomas is reported. None of the tumours recurred or metastasized. Two growth patterns were observed: basal-cell carcinomas with sebaceous differentiation, and pure sebaceous carcinomas. Since both these types may occur together they are considered to be merely variants of a single tumour entity. The clinical and histological characteristics of sebaceous carcinomas of our series are compared with those recorded in the literature. It is concluded that sebaceous carcinomas originate in the epidermis, in the skin appendages, or in both.
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We advise an aggressive approach in ablating basal cell carcinomas which have originated in the region of the medial canthus. Extirpation of the entire tumor under accurate histological control, whether it includes skin only or the entire orbital contents and ethmoid air cells--and reconstruction with one of the described procedures--gives the surgeon an effective armamentarium to successfully treat these potentially lethal lesions.
The hypoglossal-facial nerve crossover is a valuable surgical procedure for the treatment of certain types of facial paralysis. It is most effective when used as an integral part of a primary ablative operation for the treatment of cancer in this region. In the treatment of long-standing facial paralysis, its application requires an intact peripheral facial nerve system and some functioning mimetic muscles with an obliterated proximal facial nerve segment. It is recognized that other procedures are available for repair in patients who meet essentially these same criteria. The disadvantages are minimal intraoral crippling, mass movements of the face and, in some instances, hypertonia of the face. The advantages are improved facial tone, protection of the eye, intentional facial movements controlled by the tongue, and movements associated with physiological functions of the tongue.
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Chemosurgery by Mohs' fresh-tissue technique lends itself readily to plastic repair of the defects. The advantages and disadvantages of this approach and the various techniques that have been used successfully are discussed.
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