Figure legend
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