Surgical correction of residual facial deformity following conservative excision of a giant maxillary ossifying fibroma

by medihelp

Zhuoxia Wu, MD,a Yunlong Xing, MD,a Xin Liu, PhD,b Wanying Chen, MD,a Jiao Kong, MD,a Ronghui Wu, MD,a and Lianbo Zhang, PhDa,∗

2. Case report

A 44-year-old female patient presented to our department in November 2013 with a chief complaint of a giant swelling on the right side of her face that had gradually increased in size over 30 years. She experienced no related pain, paresthesia, or tenderness. On examination, the swelling in the right maxillary region measured 15 × 15 × 10 cm in size and had normal skin appearance. Additional findings included apparent drooping of the upper lip with a widened philtrum, distorted appearance of the nose and external nares, disappearance of the right alar groove, exposed right palate, and partially exposed teeth on the right side. There was no associated temperature or color change and no tenderness, but the skin surface was thickened. Inside the oral cavity, the maxillary lesion occluded the right buccal and labial vestibules, and the right buccal vestibule and palate were expanded with a normal mouth opening and shifted maxillary teeth with redundant oral mucosa (Figs.1 and ​2).

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Figure 1
A patient with a giant swelling on the right side of her face that had gradually increased in size over 30 years.
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Figure 2
Frontal view of three-dimensional reconstruction.

Computed tomography scan and 3-dimensional reconstruction revealed a 13 × 13 × 9 cm expansile lesion arising from the right maxilla with defined anterior margin and rough surface. Superiorly, the lesion was eroding the right inferior orbital wall and posterosuperiorly, the lesion had displaced the maxillary sinus, which appeared shrunken. The lesion involved the right os nasal medially and the right alveolar bone distally, and appeared as a solitary radiolucent cyst-like mass with irregular radiodensity. The cortex and medulla were not clearly separated (Figs.3 and 4).

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Figure 3
(A, B) Bone and soft tissue window of computed tomography axial view shows a well-defined lesion with radiolucent and radio-opaque foci.
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Figure 4
Three-dimensional reconstruction in different directions.

Because of the size of the maxillary tumor, reconstruction was necessary after complete resection to maintain the function of adjacent organs that had been invaded by the tumor. However, the patient refused bone or metal grafting for financial reasons and was treated with conservative excision after exposing the tumor using the Weber–Fergusson approach. We removed as much tumor tissue as possible while maintaining functional bone tissue and excised the excess skin and oral mucosa (Fig. ​5). Histopathologically, the lesion appeared as trabecular bone surrounded by osteoblasts scattered within proliferative fibrous tissue. Trabecular bone was thickened and arranged in parallel sheets with surrounding calcification, which confirmed the diagnosis of OF (Fig. 6).

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Figure 5
Preoperative labeling of primary excision.

Two years postoperatively, in November 2015, the patient complained of conspicuous scars and drooping of the upper lip on the right side with no visible tumor swelling (Fig. ​7). To improve her facial appearance, we performed a second surgery using the same approach to excise scar tissue and partial residual tumor, correcting the droop in the right upper lip. During recovery, local infection caused by bone wax rejection leads to subcutaneous adhesion of the right lower eyelid, which finally resulted in right lower eyelid ectropion through scar contracture (Fig.8). In February 2017, with no obvious increase in volume of the tumor, the patient underwent corrective surgery for the valgus deformity in the right lower eyelid. We separated the subcutaneous tissue to relax the constricted scar and implanted a crescent-shaped silicone prosthesis to avoid recurrence of subcutaneous adhesions and scar contracture (Fig. 9). Following this third surgery in January 2018, the ectropion deformity in the right lower eyelid improved dramatically and no obvious swelling of tumor was found (Fig. ​10); however, the patient was still followed for complications and tumor recurrence regularly.

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Figure 7
Two years after the primary excision, the patient complained of conspicuous scars and drooping of the upper lip on the right side with no visible increase in volume of the tumor.
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Figure 8
Fifteen months after the second surgery, local infection caused by bone wax rejection leads to subcutaneous adhesion of the right lower eyelid, which finally resulted in right lower eyelid ectropion through scar contracture.
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Figure 9
Postoperative photograph of the third surgery.
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Figure 10
Eleven months after the third surgery.
This article is intended for educational purposes. All credit to the authors.

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