Advances in Oral and Maxillofacial Surgery 8 (2022) 100332

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Advances in Oral and Maxillofacial Surgery

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The use of pulling sutures for surgical excision of soft palatal

epithelial-myoepithelial carcinoma
Ciro Emiliano Boschetti, Emilio Canet López *, Nicola Cornacchini, Gianpaolo Tartaro,
Giuseppe Colella
Department of Multidisciplinary Medical, Surgical and Dental Specialties, University of Campania “Luigi Vanvitelli”, via del Sole, 80138, Naples, Italy

Epithelial-myoepithelial carcinoma also named malignant myoepi­
thelioma, is formed by tumor cells with myoepithelial differentation [1].
It constitutes the 0.4 to 0.6 among all salivary gland tumors and on
recent studies represents the 1.2% to 1.5% among all salivary gland
carcinomas, palatal site is one of the main affected regions [2,3]. The
average age in affected patients is 55 years with the same incidence
among both genders. Myoepithelioma carcinoma can appear as a pri­
mary tumor in major salivary glands or it can appear as a secondary
carcinoma from a preexisting lesion as pleomorphic adenoma [4,5].
A CT scan is required in order to identify the surrounding structures
involved by the tumour and have an approximate idea of the tumour
type, which will be only confirmed by the histopathological examination
of the excised lesion.
In April 2022 a 67 year old Caucasian female patient came to the
attention of our Maxillofacial Surgery Unit of the regional hospital of
Naples (Naples, Italy). The patient presented a 4 × 3 cm multinodular
non-ulcerated mass, firmly attached on the right side of the soft palate,
causing eating and breathing problems to the patient (Fig. 1). CT images,
the clinical examination and its slow growing behaviour during the last
18 months since it was noticed for the first time, were indicative of a
benign lesion (Fig. 2). Later, a FNA biopsy was performed identifying the
lesion as a potential epithelial-myoepithelial carcinoma [5].
The patient underwent surgery under general anaesthesia. The
endotracheal intubation was performed trough left nostril. Local
anaesthesia was infiltrated around the mass in order to reduce bleeding
and facilitate the dissection process. A transversal incision along both
sides of the mass was done, then the dissection was carried out to set up
two soft palatal flaps, one at each side of the mass. With a 2–0 vicryl
suture placed on the bottom part of each palatal flap we anchored the
mobile part of the palate (Fig. 3). This technique allows a pull action
force from the base of both sides of the mass and permits an easier
dissection. These sutures act also as efficient retractors giving the op­
erators a better grasp on palatal flaps and a wider view of the surgical
field, helping as well to block the bending movement of the soft palate
due to the pressure while the dissection is performed (Fig. 4). Surgical
dissection was completed removing as well the periosteum and under­
lying mucosa. A 4–0 vicryl suture was finally performed for closing the
surgical access (Fig. 5). The histopathological examination of the
excised lesion confirmed the diagnosis of epithelial-myoepithelial car­
cinoma. The patient did not present any breathing, swallowing or speech
problem after surgery. The patient is under follow-up periodically every
3 months and no recurrence have been observed yet. The main purpose
of our study was to describe a new way to perform the dissection process
for removing a soft palate tumor and this technique substantially
simplified the procedure and abbreviated the surgical times representing
a valid alternative also for less experienced surgeons.
Human and animal rights
No animals were used in this research. All research procedures were
in accordance with the Helsinki Declaration of 1975, as revised in 2008.
Consent for publication
The study has been approved by Institutional Ethical Committee.
Informed consent for publication was obtained from the patient
included for publication of patients’ pictures.
Disclosures
None.
Funding
None.

* Corresponding author.
E-mail address: emilio.canetlopez@unicampania.it (E.C. López).

https://doi.org/10.1016/j.adoms.2022.100332
Received 19 July 2022; Accepted 21 July 2022
Available online 10 August 2022
2667-1476/© 2022 The Authors. Published by Elsevier Ltd on behalf of British Association of Oral and Maxillofacial Surgeons. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
C.E. Boschetti et al. Advances in Oral and Maxillofacial Surgery 8 (2022) 100332

Fig. 1. Picture showing palatal swelling on hard and soft palate junction. Fig. 3. Picture showing the lesion with the placement of sutures before
applying pulling action.

Fig. 4. Picture showing the lesion pulled out by the sutures previously placed.

Fig. 2. CT scan showing the extension of the lesion.

2
C.E. Boschetti et al. Advances in Oral and Maxillofacial Surgery 8 (2022) 100332

Declaration of competing interest

The authors declare that they have no known competing financial

interests or personal relationships that could have appeared to influence
the work reported in this paper.

References

[1] Barnes L, Eveson JW, Reichart P. Sidransky. In: World Health Organization
classification of tumours. Pathology and genetics of tumours of the head and neck, 9.
Lyon: IARC Press; 2005.
[2] Jones AV, Craig GT, Speight PM, Franklin CD. The range and demographics of
salivary gland tumours diagnosed in a UK population. Oral Oncol 2008;44:407–17.
[3] Subhashraj K. Salivary gland tumors a single institution experience in India. Br J
Oral Maxillofac Surg 2008;46:635–8.
[4] Boschetti CE, Lo Giudice G, Spuntarelli C, Apice C, Rauso R, Santagata M, Tartaro G,
Colella G. Kabat rehabilitation in facial nerve palsy after parotid gland tumor
surgery: a case-control study. Diagnostics 2022;12(3):565.
[5] Colella G, Rauso R, De Cicco D, Boschetti CE, Iorio B, Spuntarelli C, Franco R,
Tartaro G. Clinical management of squamous cell carcinoma of the tongue: patients
not eligible for free flaps, a systematic review of the literature. Expet Rev Anticancer
Ther 2021;21(1):9–22.
Fig. 5. Closure of surgical defect.