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PREOPERATIVE DIAGNOSIS: Left buccal mucosal verrucous squamous cell carcinoma.

POSTOPERATIVE DIAGNOSIS: Left buccal mucosal verrucous squamous cell carcinoma.

PROCEDURE PERFORMED:
1. Wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region.
2. Adjacent tissue transfer closure of the left supraclavicular grafting site.

ESTIMATED BLOOD LOSS: Less than 30 cc.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a 16-year-old Caucasian female with a history of left verrucous squamous cell carcinoma of the buccal mucosa, present for a number of months that was diagnosed in the office after two biopsies. After risks, complications, consequences, and questions were addressed with the patient, medical clearance was obtained with the patient and a written consent was obtained.

PROCEDURE: The patient was brought to operative suite by Anesthesia. The patient was placed on the operative table in supine position. After this, the patient was then placed under general endotracheal intubation anesthesia. The operating bed was then turned 90 degrees away from anesthesia. A shoulder roll was then placed followed by the patient's oral lesion being localized with 1% lidocaine with epinephrine 1:1000 approximately 5 cc total. After this the patient was then prepped and draped in the usual sterile fashion including the left shoulder region.

After this sweetheart retractor along with a Minnesota retractor were utilized to lift the upper and lower lips along with tongue to gain access to this oral cavity lesion. A #15 Bard Parker was then utilized to make an incision circumferentially around this lesion or mass with approximately a 1 cm margin. The lesion was then grasped with a DeBakey forceps and grasped through in order to dissect this from the buccal mucosal sites with a #15 blade along with a curved sharp Joseph scissors. After this the 12, 6, and 3 o'clock positions were marked with marking suture and the specimen was finally passed off the field. It was sent to the frozen section's Pathology. Hemostasis was maintained with bipolar cauterization. Pathology called back into the room and verified that the regions from 12 to 3 and from 6 to 12 were still involved. A second margin was obtained from the 6 o'clock position all the way to the 3 o'clock position with sutures again placed in the 12, 6, and 3 o'clock regions. This was cut utilizing the #15 Bard-Parker and grasped with the DeBakey forceps. It was passed off the field and sent to Pathology. Pathology then called back into the room and verified that margins were clear. After this the bipolar cauterization was then utilized to control a further bleeding. After this the superior and inferior aspects of the defect were reapproximated with approximately one #4-0 Vicryl suture. After this the left shoulder that was prepped previously was unveiled. Surgical gloves were all changed and a 3 x 4 cm elliptical skin graft was taken from the left supraclavicular region. First a #15 Bard-Parker was utilized to make an incision in the skin in elliptical fashion. After this the skin was then grasped and a full thickness graft was taken with undermining performed by the #15 Bard-Parker. After this the underlying subcutaneous tissue was then hemostatically controlled with bipolar cauterization. After this the tissue was then reapproximated in multiple interrupted #4-0 undyed Vicryl followed by reapproximation of the skin with a #5-0 Prolene. After this the skin graft was then defatted with a curved Joseph scissors. It was then placed in the oral defect. Circumferentially it was sutured down to the edge of the buccal mucosa with multiple interrupted #4-0 undyed Vicryl sutures. It was then ________ with a #15 Bard-Parker and sutured in from the midportion of the multiple areas with multiple interrupted #4-0 undyed Vicryl. After this the patient was then thoroughly cleaned and Mastisol Steri-Strips were then placed on the left shoulder defect along with the sterile dressing. The patient was then turned back to the Anesthesia, extubated in the operating room and transferred to recovery room in stable condition. The patient tolerated the procedure well and will be admitted to hospital for observation.

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