⚠️ Teaching Case Note: This case has been de-identified and reconstructed for educational purposes. Clinical details reflect real surgical decision-making and outcomes. Patient identity is fully protected.
From "Afraid to Look in the Mirror" to Back at the Lectern
For a language teacher, the voice is everything. So is the face. When a 54-year-old Chinese middle school teacher noticed progressive swelling on the right side of his jaw — followed by restricted mouth opening, then bleeding — he knew something was seriously wrong. What he didn't know was that five months later, he would be standing in front of a classroom again, jaw rebuilt, voice restored, and cancer-free.
His diagnosis: locally advanced oral squamous cell carcinoma, staged cT4aN1M0. The tumor had invaded his jawbone, the masticator space, and measured 6.5 × 4.2 × 3.8 cm. A regional lymph node was already involved. Surgery would require removing part of his jaw, cheek muscle, oral lining, and overlying skin — then rebuilding all of it at once.
The team at Shanghai Ninth People's Hospital, led by Professor Li Qingfeng, Director of Plastic and Reconstructive Surgery, accepted the case.
The Diagnosis: Advanced but Operable
Enhanced MRI and CT confirmed the extent of invasion. Biopsy returned moderately differentiated squamous cell carcinoma — HPV-negative, p16-negative, PD-L1 CPS 15. His mouth opening was just 1.5 cm. Swallowing was mildly impaired. Nutritional risk was elevated (NRS-2002 score: 4).
A full multidisciplinary team convened: head and neck surgery, reconstructive surgery, radiology, pathology, radiation oncology, rehabilitation, and nutrition. Their consensus was clear — wide resection including segmental mandibulectomy, followed by immediate composite free flap reconstruction. No delay. No staged approach.
The defect would span bone, muscle, oral mucosa, and external skin simultaneously. This is among the most complex reconstructive challenges in head and neck surgery.
The Surgery: Precision Planning, Seamless Execution
Professor Li's team began weeks before the operation. Using high-resolution CT and MRI data processed through Mimics and 3-matic software, they performed virtual osteotomy and flap shaping simulations. A patient-specific titanium plate was pre-bent to match the exact curvature of his mandible. Recipient vessels — the facial artery and external jugular branches — were mapped in advance.
On the day of surgery, two teams worked in parallel.
The head and neck surgery team performed wide local excision with margins ≥1 cm, confirmed by intraoperative frozen section, plus modified radical neck dissection of levels II–IV. No internal jugular vein involvement was found.
Simultaneously, the reconstructive team harvested a right fibula osteocutaneous free flap: an 8 cm bone segment with a 6 × 4 cm skin paddle to reconstruct both the oral lining and external cheek surface. Under 10–16× magnification, end-to-side microvascular anastomoses were completed — two arteries, two veins. Indocyanine green (ICG) fluorescence imaging confirmed full perfusion throughout the flap with no venous congestion or arterial spasm.
The patient-specific titanium plate was fixed precisely to restore occlusion and facial contour. The flap was inset to reconstruct the oral cavity lining and external skin continuity. Total operative time: 5.6 hours. Blood loss: approximately 320 mL. No transfusion required.
Recovery: Faster Than Expected
Within 24–72 hours, flap monitoring confirmed no vascular crisis. Multimodal analgesia, low-molecular-weight heparin, and early enteral nutrition via nasojejunal tube were initiated per the ERAS protocol.
By day 7, the flap had 100% survival. A speech therapist began oral motor training. Mouth opening had already improved to 2.5 cm.
At three months, CT confirmed solid bony union between the fibula and native mandible, with the titanium plate in stable position. Adjuvant radiotherapy (60 Gy in 30 fractions) was completed. Mouth opening reached 3.5 cm. The patient could eat soft food. Speech recognition threshold (SRT) had recovered to 82%.
At twelve months: facial symmetry was significantly improved. Bite force had recovered to 70% of the contralateral side. He had returned to full-time teaching. No radiation-induced osteonecrosis. No late flap atrophy.
His own words: "From being afraid to look in the mirror, to standing at the lectern again — what was rebuilt wasn't just tissue. It was the foundation of my life."
About Professor Li Qingfeng
Professor Li Qingfeng is Chief Physician and Director of Plastic and Reconstructive Surgery at Shanghai Ninth People's Hospital, affiliated with Shanghai Jiao Tong University School of Medicine. He is nationally recognized for craniofacial reconstruction, microsurgery, and post-oncologic facial restoration, and is a recipient of multiple national science and technology awards. His department is one of China's leading centers for composite free flap reconstruction in head and neck cancer.
How CMCS Supported This Patient
China Medical Concierge – Shanghai (CMCS) coordinated every step of this patient's journey: initial case review and hospital matching, MDT appointment scheduling, pre-operative imaging logistics, on-site Mandarin-English interpretation throughout the surgical consultation and consent process, accommodation near Shanghai Ninth People's Hospital, and post-treatment follow-up coordination including radiotherapy scheduling and rehabilitation referrals.
For international patients facing complex oncologic or reconstructive surgery in China, CMCS provides end-to-end support — from first inquiry to final follow-up.
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