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