Med. J. Malaysia Vol. 38. No. 1 March 1983.

PRIMARY EXCISION AND IMMEDIATERECONSTRUCTION FOR ADVANCED CANCEROF THE CHEEK

M. N. SUDHAKAR KRISHNANN. JANAKARAJAH

SUMMARYCarcinoma of the buccal mucosa is the

commonest intra-oral malignancy seen in Malaysia.The purpose of this paper is to present 12 patientswith carcinoma of the buccal mucosa who wereseen by the authors between January 1981 toSeptember 1981. The principal problems are thoseof late presentation and treatment, these aspectsare illustrated, with a view ofearly return to normallife.

INTRODUCTIONIndia, Sri Lanka and South East Asia have the

highest incidence of oral cancers. This is attributedto the habit of chewing of betel, peculiar to thisregion. The betel leaf is smeared with slaked limeand chewed together with tobacco and areca nut.(Fig. 1). This mixture is usually kept for prolongedperiods between the cheek and alveolus or the lipand alveolus. This habit compounded with

M. N. Sudhakar Krishnan, B.Sc, M.B.B.S, M.S., FRCS(Glasgow & Edin.)Dept. of Surgery,University Hospital,Kuala Lumpur.

N. Janakarajah, B.D.S. (Ceylon.) FDS.RCS (Edin).Dept of Oral Surgery,Dental Faculty,University Malaya,Kuala Lumpur.

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Fig. 1 Constituents of the betel quid: - betel leaf, tobacco,slaked lime and areca nut.

alcoholism, avitaminosis and sepsis stronglypredispose to cancer of the oral cavity. Carcinomaof the cheek mucosa is the predominant lesion ofthe oral cavity in Malaysians, I and also in our seriesat the University Hospital, Kuala Lumpur, (Fig. 2),whereas carcinoma of the tongue and floor of themouth are common in South Africa 2 and U.K. 'Among Malaysians the peak age incidence isbetween 51-70 years, while the male: female ratiofor the Indians and Malays is 1:1.1, and for Chinese3.5:1. I Most carcinomas of the cheek are detectedlate. By the time discomfort and pain attractattention the lesion has usually spread to the fullthickness ofthe cheek. (Fig. 3).

Fig. 2 Number of patients and sites of malignant oral lesionsseen at University Hospital, Kuala Lumpur, 1968 - 1979.

MATERIALS AND METHODBetween January 1981 to September 1981, 12

patients of carcinoma of the cheek mucosa wereseen. This paper deals with the management of 10of them, with wide excision of the lesion andimmediate reconstruction of the defect.

an extended hemimandibulectomy, 3 hadsegmental mandibulectomy and 6 had concurrentsuprahyoid block dissections. (Table I).

Fig. 11 Case No. 11 - Showing the oro-cutaneous fistula dueto extensive carcinoma of the cheek.

TONGUE ROOF OF ALVEOLUS FLOOR OFMOUTH MOUTH

CHEEKMUCOSA

160

140 133

120

cl) 100....

zUJ

~ eou.0

0:z 60

40

20

Two patients, unsuitable for surgery, were givenradiotherapy. Of the 12, 5 were males and 7females; while the racial distribution was 9 Indiansand 3 Malays, The age ranged between 48-82 years.The duration of symptoms ranged from 3 to 26months. Four patients were referred following poorresponse to radiotherapy, of these 3 had oro-cutaneous-fistulae. Four of the patients weresmokers. Two consumed alcohol regularly and 7were habitual betel chewers. Of the latter, 4normally included tobacco in their betel amalgam.In 5 patients, the submandibular lymph nodes felthard and mobile. The patients were staged on theT.N.M. classification based on the VICC 1978categories (Table I).

After improving the oral hygiene, ten patientsunderwent wide excision of the primary lesion.Eight patients underwent frozen sectionexamination of the surgical margins to ascertainadequate clearance of the tumour. One patient had

RECONSTRUCTION

Following surgical excision of the primary lesion inthe cheek, reconstruction involved 2 areas: theinner lining and external covering (Table I). Themain problem was the difficulty of providing anadequate epithelial cover for the buccal aspect. Forthe inner lining, tongue flaps were used in 5 casessupplemented by a split skin graft 'in 3, and palatalflaps in 2. Reversed forehead flaps were used in 2patients for the inner lining. In 3, the buccalmucosa was approximated by primary closure.

The external surface of the cheek defect wasreconstructed by raising a forehead flap in 5patients. Reversed forehead flaps were used in 2.The external surface of the latter two were coveredwith a split skin graft in one, and a pectoralmyocutaneous flap in the other.

Following surgery, the vital signs of the 8 patients

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TABLE IRECONSTRUCTION FOLLOWING EXCISION OF CARCINOMA CHEEK

Tumour stage on Assoc, SurgicalPatients TNM classification External Covering Procedures Inner Lining(DICC - 1978)

--

No. 1 M. - Male T 3 NO MO F.P Seg. Mandibulectomy T.F. + S.S.G.DXRTNo. 2 Y. - Male T 3Nl bMO F.P. S.HY.B.DlS. T.F + S.S.G.No. 3 1. - Male T 2 NO MO F.P T.F. + S,S.G.DXRTNo. 4 G.H. - Male T 4 NIb MO F.P. Myo. cut. (Delta I.F. + P.F

Pectoral) Flap forsub-mental defect

No. 5 M. - Female T 3 NIb MO F.P. S.H.Y.B. DlS. T.F. + P.F. + Infoldingof F.P.

No. 6 Mu. - Female T 4N l bMO Rev. F.P. + S.S.G. Ext. Hemimandibulec- Rev. F.P.DXRT tomy S.HY.B.DIS.No. 7 G.S. - Male T 4 NIb MO Rev. F.P. + Myo. cut Seg. Mendibulectomy Rev. F.P

Flap (D.P.) S.HY.B.DlS.No. 8 R. - Female T 4 NIb MO D. X. R. T. Bi!. Cheek and LipsNo. 9 H.B. - Female T 2 N l a MO D. X. Aortic Incompetence +

R. T. VDRL +veNo. 10 K. - Female T 2 NIb MO P.R. ClosureNo. 11 RI. - Female T 2 NIb MO S.HY.B.DlS. P.R. ClosureNo. 12 Rh - Female T 2 NO MO S.HY.B.DlS. P.R. Closure

F.PS.S.GT.F.

Forehead FlapSplit Skin GraftTongue Flap

P.F.S.HY.B.DlS.DXRT

Palatal NapSupra-Hyoid Block-DissectionRadiotherapy

were closely monitored in the intensive care unit forperiods ranging from 1 to 3 days.

RESULTSThe forehead flap 4.5 proved to be a relatively

easy and quick method for reconstructing facialdefects. The raw area over the forehead wascovered with a split skin graft. The deformity in theforehead was minor and well accepted. (Fig. 4).

In two patients moderate restriction to theopening of the mouth was satisfactorily relievedfollowing the release of bands. Swallowing andmasticating problems were overcome with self-motivation and re-education, but two of the olderpatients, aged 73 and 82 years required more thanthe average time to adapt to their new style ofeating.

The tongue flaps did not cause undue restrictionto its mobility and a staged division of the pediclewas done under local anaesthesia about 2 weekslater. The same applied to the palatal flaps.

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One patient, who had an extensive excision ofprimary carcinoma with an extendedhemimandibulectomy persistently drooled saliva. Atemporary prosthetic device was successfullyapplied. In another patient, the tumour recurred inthe form of satellite skin nodules two monthsfollowing the primary surgical procedure. This waswidely excised and skin cover obtained. Of thetwelve patients, one died on the 16th post operativeday: due to cerebral anoxia sustained on theevening of the operation.

All patients have been followed up for periodsranging from 5 to 14 months, Recurrence of thetumour was noted in two patients. In one,metastasis recurred to the ipsilateral cervicallyrnphnodes which was treated by a cervical blockdissection. In another recurrence of the tumouroccurred intraorally and was treated by cytotoxicchemotherapy.

CONCLUSIONA review of 12 patients with carcmoma of the

Fig. 4 Case No. 3 - After reconstruction using a foreheadflap and palatal flap for the inner lining.

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cheek was carried out. Ten of them were surgicallytreated with simple re-constructive procedures withminimal facial and functional deformity. Two hadrecurrence within eight months.

REFERENCES

I Ramanathan K and Lakshmi "Malignant oral tumours inPeninsular Malaysia. Preliminary report on 2,263 cases".Med.]. ofMalaysia. 63:4, 342-352June 1979.

2 Holman P et al "Cancer of the floor of the mouth: S. AfricanJournal ofSugery 13: 147, - 159, 1975.

S Stanley Lee E. and Wilson J S P "Carcinoma involving thelower alveolus". Brit.]. Surg. 60: 2, 85-107, 1973.

4 Mc Gregor 1 A "The temporal flap in intra-oral cancer, its usein repairing the post excisional defect". Brit. J. Plast. Surg.16,318-355, 1963.

5 Lewis M Band Remesnyder J P "Forehead flap forreconstruction after ablative surgery for oral and oro-pharyngeal malignancy". Plastic and Reconstructive Surgery.62(1), 59-65, July 1978.