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Figure 1: (A) Contrast enhanced CT of the head and neck showed a heterogeneously enhancing lesion in the previous surgical bed with a central area of necrosis. The lesion was located deep to the previous free flap reconstruction and involved the right pinna, superficial and deep parotid lobes, the stylomandibular tunnel and masticator space. It abuts the mandible and masseter anteriorly. The dotted-line wedge shows the extent of resection required (B) Another cross sectional image showing the extent of petrous temporal bone that needs to be resected in order to ensure adequate oncological clearance; without a temporal bone resection the posterior margin cannot be adequate in tumours such as these. The dotted-line wedge shows the extent of temporal bone resection required to get margin adequacy
Figure 2: Pre-operative image shows extent of tumour (inner dashed line) and planned extent of resection (outer solid line) with a linear extent to expose the neck vessels
Figure 3: Final en-bloc resection specimen showing (A) superficial view with pinna, skin, external auditory canal, zygoma and mandible (B) deep view showing deep lobe of parotid gland and masticator space and facial nerve stump marked with a prolene stitch. Deep margin of parapharyngeal space fat as seen in gross (C) and microscopy (D)
Figure 4: Final resection bed showing (A) pinna remnant (B) temporal bone remnant (C) zygoma remnant (D) facial nerve distant stumps marked with prolene sutures (E) mandible margin (F) skin flap (G) common carotid artery (H) internal jugular vein (I) sternocleidomastoid muscle (J) parapharyngeal fat which serves as deep margin