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PMC9646561_02
Case C (A) Abscess and multiple skin fistulas on the left paramandibular side due to cutaneous metastasis under IT. Photo taken during tumor aftercare from the left-hand side. (B) Salvage surgery. Tumor resection with hemimandibulectomy of the left side and partial resection of the left buccal region/maxilla. (C) Reconstruction with two microvascular grafts. Microvascular double flap reconstruction with anterior lateral thigh and latissimus dorsi flap.
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The patient's clinical condition progressively deteriorated, with abscess and multiple skin fistulas on the left paramandibular side due to cutaneous metastasis ( Figure 3A ). Tumor resection with hemimandibulectomy and partial resection of the left buccal region/maxilla was performed ( Figure 3B ) followed by microvascular flap reconstruction ( Figure 3C ).
PMC9646561_03
Case D (A) Recurrence of the outer skin with in-transit metastasis. Extensive recurrence of the outer skin located occipital-left and measuring 7 cm with arrosion of the skull calvaria and the dura mater as well as an in-transit metastasis. (B) Salvage surgery. Salvage surgery with palliative intent by radical tumor resection including resection of the calvarium and dura mater. (C) Reconstruction with microvascular graft. Defect coverage with a microvascular latissimus dorsi graft in collaboration with the Department of Neurosurgery. (D) Last follow-up in August-2021 - 2 months postoperative. No signs of tumor recurrence. Further follow-up care takes place near home at the patient's request. (E) For further information see 
Figure 4D
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A, NCT03291002). The administration took place from November 2019 to February 2020. After discontinuation of IT due to further progress, an extensive recurrence of the outer skin occipital-left measuring 7 cm with arrosion of the skull calvaria and the dura mater as well as an in-transit metastasis was diagnosed in May 2021 (  Figure 4A  ). Figures 4B, C  ). Last CT and tumor aftercare in August 2021 showed no signs of recurrence ( Figures 4D, E  ). Further aftercare takes place close to home according to patient's choice.
PMC9646561_04
PMC9646561_05