We present a 7 year old boy with a right cheek defect . The boy was brought to the hospital by the mother. Both are HIV/AIDS patients who were previously on ARVs but had stopped several months ago. Child developed swollen right cheek as a result of tooth ache. Mother sought to the use of herbal medicine. The cheek swelling progressed till abscess formed and burst through the skin. Mother resorted to dressing the resulting wound at home. Mother is a single parent with serious financial difficulties including food shortages at home.Child had lost weight considerably. His appetite for food was excellent. Both had been coughing for several months prior to admission
Pale ,afebrile, anicteric, withdrawn
The boy was wasted , malnourished as shown by light thin easily pluckable hair. There was prominence of cheek and rib bones . He was ill looking but stable
Chest examination revealed. Bilateral crepitations and wheezes all over lung zones
Abdomen was soft. No masses palpable
Oral examination: several carious teeth in upper and lower rows. Huge 6×6 defect seen on right cheek with intraoral communication. There was a piece of cotton saoked in herbs and offensive salive on the right cheek.This was removed to examine the defect. Lateral border of tongue could be seen through defect. The dry and darkened root of right lower premolar also visualised
1. Right orocutaneous cheek defect secondary to dental abscess
2. Bronchopneumonia to rule out pulmonary tuberculosis
Full blood counts
Patient was given nutritional assessment and counselling.Mother was counselled on how to properly clean the teeth of the child. They received cash and food donations from sympathisers within the facility. One visitor donated cash to help them out.
The defect with its associated discharge of saliva was a big physical and psychological stress to mother and child.
Decision was taken to improve nutritional state, treat the chest infection and close the cheek defect.
Defect closure was planned based on pectoralis major flap
Mild sedation with ketamine and skin infiltration with 1% xylocaine
Flap length was measured with neck rotated to the left. The cheek ,neck, chest and upper abdomen prepared routinely and draped.
An inferiomedial incision running from lateral 1/3 of right clavicle made and extended below the nipple. Island of skin corresponding to defect size was dissected with the pectoralis major muscle.Dissection carried down proximal to pectoral branches of thoracoacromial artery.
A subcutaneous tunnel made on the neck to bring flap to the cheek. Minimal debridement of scarred tissue made at defect site.
Pectorais muscle flap anchored to surrounding buccinator muscles using vicryl 2/0 interrupted suturing. Skin flap sutured to surrounding skin . Edges of primary wound dissected to aid in tension free closure. Passive drain introduced into previous pectoralis muscle bed and routine wound closure done
Duration of surgery was 2hours
Skin patch observed to had become due to detachment from cutaneous branches of intercostal vessels. It failed to take , became gangrenous and was excised on the ward. There was slight retraction of the muscle leading to a small defect in the upper part of the cheek wound . Defect coverage was about 90 percent.
Decision taken to allow child’s nutrition and bulk to improve pending a revision surgery
Dr Richard Ametih
St Benito Menni Hospital