Malignancy of lip
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Transcript of Malignancy of lip
Presenter: Dr. Rickey Sam Abraham Moderator: Dr. S.M. Azeem Mohiyuddin
MALIGNANCY OF LIP
1. Explaining the anatomy of lip2. Types of lip malignancies3. Various surgical techniques for
reconstruction
Objectives:
Lips form anterior boundary of oral cavity
Parts: 2 surface of lip, skin & mucosa become continous with one another round & this margin vermilion
Vermilion border:
Dry vermilion: pattern of wrinkles has clear cut boundary line between it & skin proper
Anatomy
Smooth wet vermilion: merges without obvious surface change with mucosa lining of lip.
Epithelium:
Lip covered with non-keratinised stratified
squamous epithelium which is transparent
& contain no hair, sebaceous glands or
pigments. Hence, Red.
On vermilion border, distance between
epithelium & muscle is just 2mm.
BLOOD SUPPLY Small submental arteries
branches Inferior & superior labial arteries facial art.
supply lips
◦Motor Innervation
Facial nerve VII Buccal Elevators of commissures and
orbicularis oris
Marginal mandibular Lip depressors (depressor labii
inferioris)
Innervation
◦Sensory innervation
Trigeminal nerve Mental nerve terminal branch of
inferior alveolar nerve( mandibular br. ) Lower lip
Infraorbital nerve (maxillary br.) Upper lip
LYMPHATIC DRAINAGE
Upper lip: drains into preauricular, infraparotid & submandibular nodes
Lower lip: Medial portion of lower lip submental
nodes Lateral portion submandibular nodes
Muscles
◦Oral competence◦Deglutition◦Articulation◦Expression of emotion◦Symbol of beauty
Lip Function
EPIDEMIOLOGY
It is one of most common malignant tumor affecting
head & neck
Squamous cell Carcinoma is most common in
India
Factors affecting are:
1. Solar radiation
2. Tobacco smoking
3. Viruses
LIP CANCER
Male:female ratio – 14:1
Lower lip > upper lip (solar radiation)
90% : lower lip
6%: oral commissure
4%: upper lip
Histologic types:
Squamous cell carcinoma : commonest
Basal cell carcinoma:
Non squamous form of lip cancer: from
tumors of minor salivary gland (upper
lip>lower lip)
Exophytic crusted lesion with variable invasion into underlying muscle
Adjacent lip often shows:
Actinic sun damage like crusting, color change, thinning of lip & associated areas of leukoplakia
Clinical features
TX : Primary tumor cannot be assessed T0 : No evidence of primary tumor Tis : Carcinoma in situ T1 : Tumor 2cm or less in greatest dimension T2 : Tumor more than 2cm but not more
than 4cm in greatest dimension T3 : Tumor more than 4cm in greatest
dimension T4 ; Tumor invades through cortical bone,
inferior alveolar nerve, floor of mouth or skin of face ie, chin or nose
TNM Staging of lip cancer
Imaging in early stage not required
USG Neck & parotid: rule out salivary gland tumors/nodal metastasis
CT Scan or MRI : advanced tumors of lip involving mandible for complete staging & treatment planning
INVESTIGATION
Early stage lip cancer:surgery/radiotherapy
Surgical treatment survival rates of melanoma T1 to T2 tumors: 75-80% T3 & T4 tumors: 40-50%
Presence of cervical nodes at presentation: poor prognostic factor
Treatment
Small lesions: simple surgical excision & primary closure / external beam radiotherapy
Factors associated1. Extent of lip resection, functional outcome
of repair (lip sensitivity & muscle function)2. General physical, medical & psychological
condition of patient
Choice of treatment
1. Lip should have sensation, motion, prevent drooling, permit speech & resonable cosmetic appearance.
2. Full thickness skin flaps used whenever possible
3. It should provide sufficient mucosa contiguous to commisure to avoid contracture
Principles of lip repair
Indication: Superficial field change lesions affecting the
central vermilion of lip (leukoplakia or actinic keratosis)
Extensive premalignant changes: entire vermilion surface of lip excised.
Post treatment: use sun block to lip to prevent recurrence
LIP SHAVE & MUCOSAL ADVANCEMNT
Lower lip defect
Less than ½
Wedge,shield, rectangle or ‘w’ excision
LOWER LIP DEFECT
Lower lip defect
½ to 2/3 lip
does defect include commissure?
yes no
estlander abbe sabittini flap flap
lower lip defect
Is defect midline or lateral?
midline lateral
Bernard burrow Gate flap Webster flap
Lesion up to ½ : excised & repaired primarily with margin (0.5cm for SCC)
First wedge excision lip: Louis (1768)
As size of lesion increase- wedge ‘W’ (avoid crossing submental groove to chin)
Lesion involves close to one half of lip: rectangular excision with advancement flap done
One half of lower lip
FIGURE 2. Direct excision and repair of lower lip lesions. Lesions up to one half of the lip can be excised and repair primarily.Small lesions can be excised using the "V" excision, and can be angled to blend into the chin-lip crease. Larger lesions can beexcised using a "W" pattern. The "W" avoids crossing the chin-lip crease and retains an adequate margin of tissue around thelesion inferiorly. The largest lesions can be excised as a rectangle and incisions made in the chin-lip crease to allow advancementof lateral lip tissue for closure.
FIGURE 3. Rectangular excision oflower lip carcinoma. (A) Lower lipdefect after excision of carcinoma.Proposed advancement incisionsoutlined. (B) Final result.
FIGURE 4. Modification of classic "V" excision to improvevermilion-cutaneous matching. (A)Classic "V" excision can result in anoticeable "step off" in thevermilion-cutaneous junction. (B)Slight angulation of lateral incisionallows for precise matching of .vermilion-cutaneous junction.
Closure: strong precise anastomosis of ends
of orbicularis oris reconstitute the oral
sphincter
Aligning mucocutaneous junction (white
line)- first step of skin closure.
Defect >½ lower lip: cannot be closed primarily due to undue wound tension
Tissue borrowing from opposing lip – first described by Sabattini (1838) known as Abbe cross lip flap
Flap width = ½ width of excised tissue
2cm is maximum width size of flap which is pedicled on labial artery. Pedicle divided 10-21 days later.
One half to two third of lower lip
Advantage:1. Defect is repaired with like tissue2. Flap eventually regain both sensory &
motor function
Type Initial return Near complete return
Pain 2 months 12 months
Tactile 3 months 12 months
Cold 6 months 12 months
Hot 9 months 12+ months
Motor 6 months 12 months
Disadvantage:1. Need for 2 stages : risk of patient injuring
flap by opening mouth wide & relative microstomia it creates.
Similar to Abbe flap Involves rotating the upper lip tissue around
lateral edge of mouth Indication: defect involves oral commissure.
Procedure: Incision: placed in melolabial crease & flap
designed 1 to 2mm longer than defect, pedicle divided at 2 weeks. Ankling & advancement of mucosa of 2 lip segments. Commissure plasty at 3 months
Estlander flap
FIGURE 6. Estlander cross lip flap. (A)"V"-shaped incision diagramed around lowerlip lesion and proposed upper lip flap outlined.(B) Lesion removed, flap rotated and suturedinto defect. Flap is designed with height 1 to 2mm greater than defect to be reconstructed
FIGURE 6. Estlander cross lip flap. (A)"V"-shaped incision diagramed around lowerlip lesion and proposed upper lip flap outlined.(B) Lesion removed, flap rotated and suturedinto defect. Flap is designed with height 1 to 2mm greater than defect to be reconstructed.
First described by Von Bruns
A complete lip is formed by rotating upper lip & perioral tissue down & around.
Incision made through skin & muscle down to, but not through mucosa.
During flap creation, nerves & blood vessels are preserved.
Karapandzic flap
Karapandzic flap, (A) Lower lip defect after resection of carcinoma. Proposed incisions outlined. (B) Incisions madethrough skin. Buccal branches of facial nerve and labial artery branches preserved to greatest extent possible. (C) Tissueadvanced and defect closed.
Bernard burrow flap (Webster modification)
Horizontal incision through skin from commissure to melolabial fold created & triangle crescents of skin & subcutaneous skin excised.
Facial muscle not excised Triangle/crescent also excised lateral mental-
labial groove Intraoral mucosal advancement, flaps advanced
& sutured.
2/3 to Complete lower lip
Bernard burrow flap
Bernard-Burow flap (Webster modification). (A) Complete lower lip defect following resection of carcinoma.Horizontal incisions through skin from the commissure to melolabial fold created and triangles/crescents of skin andsubcutaneous tissue excised adjacent to melolabial fold. Facial muscle is not excised. Triangles/crescents also excised lateral frommental-labial groove as required. Intraoral mucosal advancement flaps created as noted by broken lines. (B) Flaps advanced andsutured. Small ellipse of skin removed from superior portion of flap and mucosa advanced to create new lower lip vermillion.
Clinical example of unilateral Bernard-Burow flap. (A) Squamous cell carcinoma of left lower lip. (B) Proposedexcision and Bernard-Burow advancement flap outlined. (C) Lesion excised, flap advanced into place and sutured. (D) Earlypostoperative result.
Indication: Defect does not involve the entire lip & is
laterally located. Large unilateral lower lip defects
Procedure:Medial & lateral incisions are full thicknessHorizontal cutaneous incisions is not deep to
preserve blood supply.
Gate flap/Melolabial flap
Gate flap
"Gate" flap. (A) Complete lower lip defect with proposed flaps outlined. Mucosal incisions represented by brokenlines. Medial incisions and most of lateral incisions are full thickness. Horizontal cutaneous incision is not deep to preserveblood supply. (B) Flaps rotated and sutured. This technique is especially useful for large, unilateral lower lip defects.
A full thickness incision is made around the commmissure extending onto upper lip at nasolabial fold
Incision is cut & extending almost of vermilion border of upper lip
Flap is now pedicled on labial vessels & can be advanced & closed in layers
Vermilion is reconstructed by mucosal advancement of tongue mucosal flap which is divided at 10 – 14 days
Gillie’s fan flap
Upper lip defect
Less than ½
Wedge,shield, rectangle or ‘w’ excision
UPPER LIP DEFECT
Upper lip defect
½ to 2/3 lip
does defect include commissure?
yes no
estlander abbe sabittini/ reverse flap parakandzic flap
Estlander flap
Estlander flap. (A) Proposed excision and repairof large squamous carcinoma of upper lip using Estlanderflap. (B) Carcinoma excised and defect reconstructed withEstlander flap.
2/3 to complete lip
Diffenbach attachement flaps +/- Abbe Sabattini flaps
UPPER LIP DEFECTS
Modified Burow Diffenbach technique for upper lip reconstruction. (A) Proposed excision of tumor and perialar incisions. (B)Lesion excised and perialar crescents excised. (C) Closure of defect.
The primary lymphatic drainage of lower lip is to submental & submandibular level 1a & 1b cervical lymph node
Neck dissection generally not performed as less than 5 percent of patients develop recurrence in neck following treatment
NECK DISSECTION IN LIP CANCER
For small tumors, radiotherapy equivalent to surgical management
Disadvantage:
Cosmetic results to lip may not be satisfactory
Burdensome for the patient than a relatively mild surgery
RADIOTHERAPY TECHNIQUES
Lower lip: ideal sites for orthovoltage x-ray therapy
Using a single anterior field, a fractioned course of 50 Gy in 15 fractions over 3 weeks.
EXTERNAL BEAM THERAPY
192- Iridium brachytherapy can be used in treatment of lip cancer
Patient treated twice a day for 4 – 5 days with total radiation dose 40-45Gy in 8-10 fractions.
The paris system is often used where needles are placed horizontally and parallel to the mucosa of the lip with 9mm spacing between them.
BRACHYTHERAPY
Photodynamic therapy can also be used to treat primary cancer of the lip.
Procedure: Photofrin (light sensitising drug) given intravenously followed 4days later by a single non thermal illumination of the tumour using a light dose of 20J/cm with an irradiance of 100mW/sq.cm.
PHOTODYNAMIC THERAPY
ADVANTAGES:1. This treatment yields complete response
rates comparable to surgery or radiotherapy.
2. Less scarring(cold photochemical process)
3. The treatment can be given on many occasions as there is no tissue memory.
TUMOR THICKNESS & SURVIVAL RATES
Tumor size(cm) Five year survival rate(%)
1cm 94 <2cm 84 <3cm 58 <4cm 67 >4cm 62
Survival rates for lip cancer