Chapter 43

Floor of the Mouth Resection

G Spriano, G Cristalli, V Terenzi, P Marchesi, V Manciocco

INTRODUCTION In case of T4a tumors with massive adjacent tissue

involvement, a demolitive resection with segmental mandi­
The standard treatment of floor of the mouth (FOM) is bulectomy en bloc with neck dissection(s) is mandatory.
surgery. The type of surgical resection in patients with
carcinoma of the FOM is related to the size and depth of the
tumor, its relationship with the mandible and the presence
or absence of cervical lymph node metastasis.
TREATMENT PLANNING
Single transoral resection, possibly associated with Treatment depends on tumor characteristics and patient-
Thiersch graft reconstruction is the treatment of choice related factors as illustrated in Table 1.
in case of small tumors (T1/2) without deep infiltration,
providing low morbidity (deep invasion of more than 3 mm
is considered as a risk for metastatic disease in neck). PREOPERATIVE ASSESSMENT
Marginal mandibulectomy is best suited for tumors;
encroaching on, adherent to or superficially invading the Preoperative examination includes anamnesis and physical
mandibular cortex, where it is possible to get an adequate examination. It is important to evaluate the patient’s general
3-D margin regardless of the dentition or history of previous condition to plan an adequate surgical treatment (possibility
radiotherapy. Segmental jaw resection is reserved for tumors to perform the surgical resection under local anesthesia, in
extensively invading the mandibular medullary cavity, when case of small lesion in patients with bad general conditions).
In case of extensive tumors with risk of bleeding or when
the mandible channel is infiltrated (lymphatic infiltration of
there are contraindications to orotracheal intubation, it is
V3) or when the mandible is thin and atrophic, and marginal
useful to perform a tracheotomy under local anesthesia.
resection would not leave an adequate rim of bone.
The resection of the primary tumor and metastatic
lymph nodes is considered by most authors, the classic Table 1: Tumor factors and patient-related factors
surgical approach to cancer. The “pull-through” operation
is the gold standard treatment in case of tumor invading Tumor factors Patient factors
the floor of the mouth. The operation consists of the tumor Site and subsite of origin General medical condition
resection from submandibular route avoiding the resection T and N stage Performance status
of the mandibular arch. Mandibular invasion Occupation
Otherwise, in case of tumors involving the posterior FOM, Grading Lifestyle (smoking/drinking)
to achieve an adequate exposure and adequate locoregional Depth of infiltration Socioeconomic considera­tions
control, a conservative transmandibular approach with a Previous treatment
lip-splitting incision has to be performed. (surgery/radiotherapy)
2 Atlas of Head and Neck Surgery
Diagnostic assessment consisting of local physical
examination and imaging helps to plan adequate resection
type, principally evaluating the proximity, the relationship
between the tumor and the mandible (even if the final
decision about mandibulectomy is taken intraoperatively)
and the tumor extension to adjacent sites. It is important
to evaluate the site and the extent of the surgical defect for
planning an appropriate reconstruction.
To assess tumor stage, radiological investigations required
are:
• Neck ultrasound to investigate cervical node involvement
• Head and neck computed tomography (CT) scan (Fig. 1)
and/or magnetic resonance imaging (MRI) to evaluate
tumor extension (Fig. 2), eventual bone invasion and
cervical node involvement
• Orthopantomogram (Fig. 3) to plan marginal or seg­
mental mandibulotomy, if required and to investigate
general status of dentature
• Thorax spiral CT scan to investigate the presence of lung
metastasis or secondary tumor
SURGICAL TECHNIQUES
Transoral Excision
Indications
T1-2, N0 tumors with limited deep infiltration (depth less
than 3 mm)
Fig. 1: Computed tomography scan shows the
involvement of mylohyoid plane bilaterally
Contraindication
Clinically node positive (cN+) tumors
Complications
• Dehiscence of the oral suture
• Infections
• Bleeding
• Tongue anchylosis
Patient is supine on the operatory table and a folder blan-
ket is placed under the shoulders to extend the neck (if tra-
cheotomy has to be performed). General endotra­cheal anes-
thesia is induced. Antibiotic is administered intra­operatively
(ampicillin and clavulanic acid 2.2 g). In case of tumor in-
volving the posterior FOM or when partial glossec­tomy is
required, temporary tracheotomy is recommended. If the
tumor extends to the oropharynx (base of the tongue), tra-
cheotomy conducted by local anesthesia is preferred. The pa-
tient is then prepared and draped including, the site to har-
vest the Thiersch graft (inguinal cutis can be used). An oral
mouth gag (Molt or Denhart 12–14 cm) is placed in the oral
cavity. A suture is placed in the midline of tip of the tongue
to expose the FOM.
The line of incision is marked by dots using pick-shaped
electrocautery tip. The margin of resection must extend
at least 1 cm from the normal tissue. Sublingual gland
represents the deep margin of resection. Lingual artery can
be identified in the neck and ligated to reduce bleeding. The
lingual nerve too can be identified and preserved, if there is
Fig. 2: Magnetic resonance imaging demonstrating cancer of
floor of the mouth close to the mandible not invading cortical
bone

Fig. 3: Preoperative orthopantomogram to evaluate
mandibular high according to Cawood-Howell 1988
no suspect of infiltration. If Wharton’s duct involvement is
present, it is necessary to marsupialize the duct and not to
cover it with the skin graft.
If a marginal mandibulectomy is planned and once, a
mandibular subperiosteal plane is clearly identified, it is
possible to perform the osteotomy using a drill or a straight
osteotome. Attention has to be paid to regularize osteotomy
margins using a drill. Local flap can be harvested and
positioned to cover the defect.
Margins are checked by frozen section. If they show
infiltration (R1) or margins appear close or with dysplasia, a
wired excision is required.
Suture can be achieved directly and if this is not possible,
a Thiersch graft may be harvested from the inguinal region
and positioned in place using a 3-0 or 4-0 absorbable stiches.
Postoperative Treatment
Nasogastric tube feeding is maintained usually for 4–5 days.
Tracheostomy is closed 3–4 days after surgery. Antibiotic
therapy is administered for 7 days after surgery (the use of
ampicillin and clavulanic acid is recommended at the dose
of 2.2 g × 2 intravenously. for the first 2 days and 1 g × 2 per
os for the remaining 5 days).
Pull-Through
This procedure consists of “en bloc” excision of the tumor
and neck dissection(s) through a combined transcervical
and transoral approach preserving mandibular continuity.
Indications
• T34a tumors independently to N stage (in case of T4
tumors, no massive bone infiltration has to be present so
that a marginal mandibulectomy can be performed)
• T1-T2 tumors (Fig. 4) with deep invasion (more than
3 mm) or cN+
Floor of the Mouth Resection 3
Fig. 4: Squamous cell carcinoma of the anterolateral floor of
the mouth pT2N2bM0
Source: Image courtesy; American Joint Committee on Cancer
(AJCC), 2002
Contraindications
• Bulky tumors
• Infiltration of mandible (in which segmental mandi­
bulectomy is required)
Complications
• Orocervical fistula
• Bleeding
• Infection
• Complications related to neck dissection
• Tongue anchylosis
Surgical Technique
The position of the patient is the same as that described
previously. Tracheotomy is mandatory and is performed
at the beginning of the operation according to the same
indication and contraindication of transoral resections
(Fig. 5). Preparation using bacteriostatic solutions (Beta­
dine) should extend from a line joining the tragus to the ala
of the nose, down to the nipples. Depending on the type of
reconstruction, specific surgical field has to be prepared.
The first step is neck dissection. Skin incision (two or
three limbs) depends on dissection type. In case of bilateral
neck dissection, a visor flap can be harvested. Platysmal
flap is dissected until inferior margins of the mandible.
Neck dissection is performed eventually ligating the lingual
4 Atlas of Head and Neck Surgery
Fig. 5: Transoral resection
artery to avoid bleeding if hemiglossectomy is planned,
and taking care to preserve vessels in case of microsurgical
reconstruction. The flap is elevated in the subperiosteal
plane so that the oral cavity is entered through the lateral
gingivobuccal sulcus.
Intraoral step: The line of resection must be at least
1 cm from the safety margins and is dotted before for
electrocautery as described for transoral resection. The
incision proceeds anteriorly, laterally and circumferentially
until a mandibular subperiosteal plane is clearly identified.
Posteriorly, the mucosa of lingual fold is incised avoiding the
step of sectioning the muscle plane.
If possible, it is better to preserve the anterior digastric
muscles. Following a subperiosteal plane (Fig. 6), the man­
dibular insertions of mylohyoid muscle and the geniohyoid
muscle are sectioned. At this point, it is possible to connect
the intraoral and extraoral incision and to pull the anterior
FOM in continuity with the neck dissection down through
the mandibular arch (Figs 7 and 8). Dissection proceeds
by sectioning the geniohyoid, mylohyoid muscles and the
digastric muscles laterally, beyond the insertion of masseter
muscle and inferiorly over the hyoid bone. The tumor is now
removed “en bloc” with neck dissection as in Figure 11.
Postoperative Management
The patient is kept on nasogastric tube feeding till soft
tissue healing allows feeding restoration. It usually occurs in
10 days period. In order to identify an orocervical fistula, a
methylene blue diluted solution can be administered orally
so that it can be detected in the neck drainage (within
24 hours) or through a cervical dehiscence. Tracheotomy
Fig. 6: Subperiosteal detachment of floor of
the mouth to the inner face of the mandible
is closed on 3rd–4th day or when there is no reasonable
risk of surgical revision. Chewing of solid food should be
postponed until approximately the sixth postoperative week.
To avoid infection, in addition to penicillin and clavulanic
acid, adjunctive intravenous metronidazole (500 mg × 2) can
be administered.
Blood pressure must be monitored after free flap. Skin
paddle of the flap is monitored by the nurse every 1 hour and
at the same time, the vacuum of the suction drains must be
evaluated.
Conservative Transmandibular Resection
Indications
Tumors with posterior extension to tongue base, lateral
oropharynx
Contraindications
• Associated disease of the mandible (osteoradionecrosis
post-radiation, previous bisphosphonate therapy)
• Mandibular infiltration (cT4a bone)
Complications
• Orocervical fistula
• Bleeding
• Infection
• Complications related to neck dissection
• Tongue anchylosis
• Malocclusion
• Teeth lesions
• Pseudarthrosis

Fig. 7: The tumor is tractioned through the mandibular arch
from the neck (pull-through operation)
Fig. 9
Figs 9 and 10: Detachment of oral floor allows a wide transit between the oral cavity and neck by preserving mandibular arch
Surgical Technique
Skin incision depends on the type of neck dissection as
described for pull-through operation and is continued
superiorly from the mid-submental crease using a straight
midline chin contour incision that extends through the lip
Floor of the Mouth Resection 5
Fig. 8: Pull-through resection allows to respect the continuity
between the tumor bed and the neck dissection
Fig. 10
and into the depth of the labial alveolar sulcus. It is advisable
to preserve an adequate cuff of alveolar mucosa to facilitate
incisional closure. The mucosal incision is then extended
within the labial alveolar sulcus to the region of the mandible
corresponding to the site of mandibular osteotomy. Once neck
6 Atlas of Head and Neck Surgery
Fig. 11: Surgical specimen shows “en bloc”
resection of tumor and neck dissection
dissection has been performed, the periosteum is elevated in
the region of placing the mandibular plate (preplating) before
making the osteotomy. The incision must be extended over
the alveolar ridge into the lingual sulcus. Mental nerve must
be preserved. Periosteum of the inner face of the mandible
is detached to insert a malleable retractor to protect soft
tissues during the osteotomy. The osteotomy is performed
avoiding excessive loss of bone by a slim sagittal saw or a gigli
saw through an oblique line conducted between the second
incisor and the canine. Dissection is continued through
the submucosal tissues and mylohyoid muscle to swing the
mandible laterally. The hypoglossal nerve is preserved while
the lingual nerve is usually sectioned.
Mandibular contention is then obtained using two
titanium miniplates and monocortical 7–11 mm screws.
Closure of lingual soft tissues is performed in multiple layers
using a microvascular free flap, such as, lateral thigh or
forearm flap. Moreover, a pectoralis major pedicled flap can
be used.
Anterior Composite Resection (Demolitive
Resection, Commando Operation)
The aim of the operation is to resect the mandible, the FOM
and neck nodes en block.
Indications
T4 tumors (Fig. 12) with extension to mandible, tongue and
soft tissues
Fig. 12: Squamous cell carcinoma of the anterior floor of the
mouth pT4aN2cM0
Source: Image courtesy; American Joint Committee on Cancer
(AJCC), 2002
Contraindication
• Bad general conditions
• Metastatic disease
Complications
• Orocervical fistula
• Bleeding
• Infection
• Complications related to neck dissection
• Tongue anchylosis
• Malocclusion
• Teeth lesions
• Pseudarthrosis
Surgical Technique
Patient preparation is the same as described for trans­
mandibular conservative resection. Tracheotomy is per­
formed eventually under local anesthesia, if endotracheal
intubation is not possible (risk of bleeding, trismus, bulky
mass). Dental extraction may be performed at the beginning
of the procedure or at the time of tumor excision. According
to the type of neck dissection, a two or three limbs skin
incision is performed or a visor flap is harvested. If possible,
the surgeon making the visor flap has to preserve one
mandibular nerve. The section of both mandibular nerve
allows a wide exposition of the mandibular arch and of the
neck without scars on lips and chin. In other cases (lateral
extension), it is better to use a labial split incision and a cheek
flap to expose the mandibular arch. In this way, even if the
esthetic results are less satisfying, it may be possible to preserve
one of the two mandibular nerve and the reconstructive
 Floor of the Mouth Resection 7

time is easier. A modification of this approach is necessary,

when the cancer infiltrates the floor of the mouth and the
mandible up to the skin of the chin. In this case, the skin of
the chin is excised en bloc with the mandible. The first step
is neck dissection.

Mandibulotomy
Mandibular arch is exposed by sectioning tissues of alveolar
ridge preserving the periosteum of the outer side of mandible.
Facial vein and artery are preserved as recipient vessels for
microvascular anastomosis. Marginal branch of facial nerve
is identified and preserved (if possible). The periosteum is
incised inferior to the attachment of the masseter muscle,
which is then elevated from the angle of mandible depending
on the extent of the cancer lateral to the mandible. A suture
that is placed in the tip of the tongue assists in stretching out
the mucosa.
By electrocautery, the resection continues along the
oral floor to the ventral surface of the tongue leaving safety
margins of 2 cm. The neck incision is then connected with
the intraoral incision. Care must be taken not to compromise
the resection margins. In case of approach by visor flap,
two Penrose drains must be passed through the oral cavity,
brought out through the neck incision and used for traction
of the flap.
A reconstruction plate is shaped and positioned by
screws. The anterior position of the mandibular osteotomy
is then marked on the mandible.
Osteotomy is planned according to the extension of tumor
with at least 2 cm safety margins. Line of osteotomy is generally
straight. The osteotomy can be facilitated by removal of a
tooth from the line of planned excision. During osteotomy,
care should be taken to ensure that adequate bone is left
around any remaining dentition. Most of these patients have
poor dentition and all the remaining teeth, if compromised
by cavity must be removed before the reconstruction time.
Lateral retraction of mandibular segment is limited by the
presence of an intact temporomandibular joint.
Depending on the extent of the cancer, this may be
performed either below the notch of the mandible or through
the notch with section of the coronoid process and portion
of tendon of the temporalis muscle, by disarticulation
of the mandible from the glenoid fossa or vertically with
preservation of the angle and posterior aspect of the ramus.
The latter chance requires mandibular channel intraoperative
frozen section to look for eventual lymphatic infiltration.
When both osteotomies have been completed, the
mucosal incision can be easily made around the tumor in
the oral cavity. The “Andy Gump” effect must be avoided to
prevent tearing of the specimen and at this time, the lingual
nerve is sectioned, if involved, or if it is proximal to the safety
margin.
Fig. 13: Surgical specimen including the floor of the mouth
and segmental mandibulectomy
By sectioning the mylohyoid muscles and geniohyoid
muscles of both sides and respecting the continuity with
neck dissection, the dissection is completed.
At this time, it is possible to separate the specimen
(Fig. 13) from the hyoid bone attachment by sectioning
inferiorly the geniohyoid muscle and hyoglossus muscle.
Frozen section may be taken and may be accurately
registered and labeled. Bone margins cannot be evaluated
intraoperatively.
Special Preoperative Considerations
• Evaluate the dentature state of the patient, eventually
planning teeth extraction
• Insert the nasogastric feeding tube after administering
anesthesia
• Use prophylactic antibiotic treatment to reduce infection
Special Intraoperative Considerations
• Cases in which a partial glossectomy is performed, the
suture can be performed between the mucosal margins and
the tongue intrinsic muscles to avoid tongue anchylosis
covering the deep plane of resection.
• In case of marginal mandibulectomy (Figs 14 to 17), it is
important to preserve at least 10 mm of inferior border
of mandible that accounts for almost 50% of the cross
sectional area of the mandible, since this usually provides
enough structural integrity to withstand the loading
forces related to mastication.
• In case of conservative mandibulotomy, a simple trans­
verse osteotomy minimizes bone loss and is the simpler
and more rapid method of avoiding stair stepped
osteotomy
8 Atlas of Head and Neck Surgery

Fig. 14: Squamous cell carcinoma of the anterior floor of the Fig. 15: Surgical field after tumor excision
mouth pT2N0M0 (proximal to the mandible) with marginal mandibulectomy
Source: Image courtesy; American Joint Committee on Cancer
(AJCC), 2002

Fig. 17: Postoperative panorex X-ray

Reconstruction (Figs 20 to 22) of composite defect can

Fig. 16: Surgical specimen be achieved with a fibula (Fig. 23) iliac crest or scapular free
flap.

Special Postoperative Considerations

• Do not start oral feeding before suture stabilization HIGHLIGHTS
• It is important to clean the oral cavity
I. Indications
• Transoral excision
– T1-2, N0 tumors with limited deep infiltration
RECONSTRUCTION (depth <3 mm)
It depends on the surgical defect. In case of isolated soft • Pull-through
tissue surgical defect, reconstruction can be achieved by – T3-4a tumors independently to N stage (in case
fasciocutaneous free flap (Figs 18 and 19), such as, radial of T4 tumors, no massive bone infiltration has to
forearm or anterolateral thigh free flap. Cases in which be present so that a marginal mandibulectomy
glossectomy is performed, a rectus abdominis free flap can can be performed)
be harvested. If it is impossible to use a free flap, a pectoralis – T1-T2 tumors with deep invasion (more than
major pedicled flap can be harvested. 3 mm) or cN+
 Floor of the Mouth Resection 9

Fig. 19: Postoperative picture 8 months after surgery (pull-

through resection). Reconstruction is performed by ante­
brachial fasciocutaneous microvascular flap

Fig. 18: Postoperative picture 8 months after surgery (marginal
mandibulectomy). Reconstruction is performed by antebrachial
fasciocutaneous microvascular flap
III. Special Preoperative Considerations
Fig. 20: Postoperative view of the floor
of the mouth 3 months later
IV. Special Intraoperative Considerations
• Conservative transmandibular resection
– Tumors with posterior extension to the tongue
base, lateral oropharynx
• Anterior composite resection (demolitive resection,
commando operation)
– T4 tumors with extension to mandible, tongue
and soft tissues.
II. Contraindications
• Transoral excision
– cN+ tumors
• Pull-through
– Bulky tumors
– Infiltration of mandible (in which segmental
mandibulectomy is required)
• Conservative transmandibular resection
– Associated disease of the mandible (osteoradio­
necrosis post radiation, previous biphosphonate
therapy)
– Mandibular infiltration (cT4a-bone)
• Anterior composite resection (demolitive resection,
commando operation)
– Bad general conditions
– Metastatic disease.
• Anterior composite resection (demolitive resection,
commando operation)
– Evaluate the dentature state of the patient,
eventually planning teeth extraction
– Insert the nasogastric feeding tube after admi­
nistering anesthesia
– Use prophylactic antibiotic treatment to reduce
infection.
• Anterior composite resection (demolitive resection,
commando operation)
– In case of partial glossectomy, suture can be
performed between the mucosal margins and
tongue intrinsic muscles to avoid tongue anchy­
losis.
– In case of marginal mandibulectomy, preserve
10 mm of inferior border of the mandible as it
provides integrity while mastication.
10 Atlas of Head and Neck Surgery
Fig. 21: Postoperative 3-D reconstruction CT scan
ADDITIONAL READING
Fig. 23: Osteocutaneous fibula free flap
designed with the skin perforator
– In case of conservative mandibulotomy, simple
transverse osteotomy minimizes bone loss and is
preferred to stair step osteotomy.
V. Special Postoperative Considerations
• Anterior composite resection (demolitive resection,
commando operation)
– Do not start oral feeding before suture stabi­
lization
– It is important to clean the oral cavity.
VI. Complications
• Transoral excision
– Dehiscence of the oral suture
– Infection, bleeding, tongue anchylosis
• Pull-through
– Orocervical fistula, bleeding, infections, com­
plications related to neck dissection, tongue
anchylosis
Fig. 22: Postoperative picture 3 months
after surgery pull-through operation
• Conservative transmandibular resection
– Orocervical fistula, bleeding, infections, com­
plications related to neck dissection, tongue
anchylosis
– Malocclusions, teeth lesions, pseudarthrosis
• Anterior composite resection (demolitive resection,
commando operation)
– Orocervical fistula, bleeding, infections, com­
plications related to neck dissection, tongue
anchylosis
– Malocclusions, teeth lesions, pseudarthrosis.
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