PREOPERATIVE DIAGNOSIS: Desmoplastic malignant melanoma, submucosal, left

PREOPERATIVE DIAGNOSIS: Desmoplastic malignant melanoma, submucosal, left side of upper lip. POSTOPERATIVE DIAGNOSIS: Same. SURGICAL PROCEDURES: 1. Sentinel node biopsy, left submandibular region. 2. Wide V-excision (1 centimeter) of desmoplastic malignant melanoma, left side of upper lip with through-and-through excision and 1 centimeter margins on all sides. SURGEON: Brian Wilson, MD ANESTHESIA: General endotracheal with supplementary 2 cc of 1% Xylocaine and 1 : 800,000 epinephrine. SURGICAL FINDINGS: The patient had a scar of the upper lip and a 5-millimeter linear, pigmented lesion near the mucosal junction. There was one submandibular lymph node identified that appeared to be benign. No occipital or posterior submandibular lymph nodes were identified despite assiduous search. DESCRIPTION OF PROCEDURE: Following injection of radioactive dye in the radiology department, the patient was sent to the operating room where the face and neck were prepped with Betadine scrub and solution and draped in a routine sterile fashion. Sentinel node biopsy: The sites that had been identified in radiology were noted, and on the mastoid area, I detected 100 on the probe externally. I explored this, but when I got inside, I was unable to reproduce the external reading despite a vigorous exploration of the mastoid area and splitting of the sternocleidomastoid muscle over the site where most of the probe activity was evident. We made about a 3-centimeter incision in this area and explored it thoroughly in all areas indicated. I thought on occasion I palpated a lymph node, but upon deep dissection, it was noted that this was simply another fiber of the sternocleidomastoid muscle, and we abandoned this after a search of about 15 minutes. In the submandibular area, an incision was made, and activity was evident. The skin in the posterior mandibular area had a reading of 13 with an in vivo reading of 63. However, the ex vivo was only approximately 7 on the specimen itself. It may have been too small to have caused any reactivity. The background was 26 following removal of a small lymph node that was less than 1 centimeter in diameter. No anterior mandibular lymph node was ever identified. Also, it should be noted that at no time did I, other than the small lymph node we removed, palpate lymphadenopathy in the mesenteric muscle region nor in the region of the external maxillary artery that crossed the marginal mandibular nerve. Wide V-excision, left upper lip: I then marked out a margin of 1 centimeter around the previous scar, and in so doing, I noted that included within this resection was a 5-millimeter linear pigmented lesion. This was a wedge resection of the lip, and bleeding of the coronal arteries were clamped and ligated with 4-0 Vicryl. I then began closure of the mucosa, lining up the mucocutaneous junction and lining up the vermilion where it meets the white roll. After completion of the mucosal closure, the musculature was brought together. The orbicularis oculi musculature was brought together with 4-0 Vicryl suture, and interrupted 5-0 Prolene was used to reapproximate the skin. There was no evidence of residual tumor within the specimen submitted. A silk suture tagged the lip side of the specimen. Antibiotic ointment was applied, and 4 x 4 was used to cover the incision. The patient tolerated the procedure well and left the area in good condition. Pathology report later indicated: Melanocarcinoma. Procedure Key Terms: excision, biopsy, excision skin (lip) ICD-10-CM Key Terms: melanoma, lip, malignant

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