63

Chap.

我们毕业啦
Lip Cancer—Ablative and
Reconstructive Surger y
其实是答辩的标题地方

Repoter R1陳楊麟

Time 2019.01.31
 Introduction

Etiopathodgenesis
&Causative factors

Pathologic anatomy

Diagnostic studies

Tr e a t m e n t &
Reconstructive goals
CO N TA N T S
Specific treatment
and technique

Po sto per ative care

Introduction
Introduction

1 Lip cancer is one of the most curable

--->ability to be detected in the early stages.

2
In most report
5-year survival statistics
90%

3
Some lip cancers had exhibit aggressive
behavior, with recurrence or mortality noted in
up to 15% of cases.
Introduction

1 Lip cancer is one of the most curable

--->ability to be detected in the early stages.

2
In most report
5-year survival statistics
90%

3
Some lip cancers had exhibit aggressive
behavior, with recurrence or mortality noted in
up to 15% of cases.
Introduction

1 Lip cancer is one of the most curable

--->ability to be detected in the early stages.

2
In most report
5-year survival statistics
90%

3
Some lip cancers had exhibit aggressive
behavior, with recurrence or mortality noted
in up to 15% of cases.
Introduction

4
Lymph node metastases seem to occur in
5% ~20% of patients, and the overall
incidence is quoted at 10%.

5
Similar to skin cancer rather than oral
mucosal cancer in terms of behavior,
survival and lymph node metastases.
Introduction

4
Lymph node metastases seem to occur in
5% ~20% of patients, and the overall
incidence is quoted at 10%.

5
Similar to skin cancer rather than oral
mucosal cancer in terms of behavior,
survival and lymph node metastases.
Introduction

Upper lip Lower lip

Carcinogen Ultraviolet radiation(most)

Cancer type Basal cell Squamous cell

(most) carcinoma. carcinoma

Occur rate 7% 90%

(remainder located at
the commissure. )

Minor salivary gland neoplasms are most commonly

seen in upper lip, and the majority of these tumors
are benign.
Introduction

Range at diagnosis
95% is 54 to 65 years

50
Men Age

But… sometimes occur in patients younger than 30 years.

Etiopathogenesis
&Causative factors
Etiopathogenesis&Causative factors

1 1/3 patient excessive sun exposure

in patients with outdoor occupations

2 Originate on the exposed vermilion of the

lower lip. (much prominence )

3
Commonly with second primary skin
malignancies. Like other head and
neck skin cancers,.
Etiopathogenesis&Causative factors

1 1/3 patient excessive sun exposure

in patients with outdoor occupations

2 Originate on the exposed vermilion of

the lower lip. (much prominence )

3
Commonly with second primary skin
malignancies. Like other head and
neck skin cancers,.
Etiopathogenesis&Causative factors

1 1/3 patient excessive sun exposure

in patients with outdoor occupations

2 Originate on the exposed vermilion of the

lower lip. (much prominence )

3
Commonly with second primary skin
malignancies. Like other head and
neck skin cancers,.
Etiopathogenesis&Causative factors

freckles blue eyes,

light complexions f a i r- c o l o r e d h a i r

10 times higher in whites skin people ,

it is ver y rare in black people .
Etiopathogenesis&Causative factors

Cumulative sun exposure a s t h e m o s t

significant carcinogen involved in the
d e v e l o p m e n t o f melanoma and non-melanoma.

Other risk factors :

Cigarette and pipe smoking
Lip trauma
Immunosuppression
Pathologic anatomy
Diagnostic studies

Frontonasal
process

Maxillary
processes

Mandibular
processes

Lower lip cancers,are at higher risk for

contralateral metastasis.

The blood supply is derived from the

superior and inferior labial arteries.
Diagnostic studies

Ly m p h a t i c d r a i n a g e f o l l o w s a predictable course

Upper lip Lower lip

Preferentially Buccal, periparotid, Cervical lymph nodes of the

metastasize preauricular region. submental and submandibular
triangles of level I cervical
lymph nodes
Secondary Cervical lymph nodes Level II and III lymph nodes
metastases in the submandibular (level IV and V are rare)
triangle

Bilateral level I metastases are not uncommon.

Pathologic anatomy

Upper lip
Trigeminal nerve, maxillary divisions
Lower lip
Trigeminal nerve, mandibular divisions

(Fig. 63-1).

Screening pano to rule out mandibular involvement

by the cancer as a result of perineural spread
Diagnostic studies
Diagnostic studies

Physical examination

Non-healing crusted lesion of

the lip that persists for several
months.

Crusting and surrounding

induration or a mass.

(Fig. 63-2)
Diagnostic studies

Incisional biopsy

Performed within the

center of the lesion
Pano radiograph
investigate for a widened
mental foramen or erosion
(Fig. 63-1) of the mandible,
Diagnostic studies

Special imaging studies: CT,MRI, PET

1. When clinical neck examination does not reveal

suspicious adenopathy (N0).

not required to assist in ablative surgery

2. When the neck is classified as N+

particularly PET/CT, are indicated.

provide images of the contralateral
neck for lower lip cancer
Diagnostic studies

“ Distant metastases are identified in less than

2% of patients at the time of initial evaluation of
a previously untreated lip carcinoma.

”
Treatment&
Reconstructive goals
Tr e a t m e n t & R e c o n s t r u c t i v e g o a l s

Proper ablation Avoid microstomia

Management
of lip cancer

Immediate biologic Functionally

reconstruction esthetically acceptable
Tr e a t m e n t & R e c o n s t r u c t i v e g o a l s

According to blood supply for soft tissue flap

Random-pattern
Specific pedicles are not identified or necessarily
preserved within the flap.

Axial-pattern
Pedicle is identified and intentionally preserved
within the flap that is rotated into the recipient tissue bed
Tr e a t m e n t & R e c o n s t r u c t i v e g o a l s

Microvascular free flaps

Involve distant soft tissue transfers in which

arterial and venous anastomoses are required
for flap viability.

P.S.

Vascularization for Tissue Engineering and

Regenerative Medicine pp 1-34
Tr e a t m e n t & R e c o n s t r u c t i v e g o a l s

Discussion of pre-cancer for lip

Actinic keratosis(lower lip)

Damaged by ultraviolet radiation

White color of the vermilion
Dry in its appearance.
Ulcerations may be present.
(Fig. 63-4) A mass is not noted
Tr e a t m e n t & R e c o n s t r u c t i v e g o a l s

Discussion of pre-cancer for lip

Actinic keratosis
(Histologic)
Reveal signs of dysplasia or
carcinoma in situ.
Not require preoperative incisional
biopsy, but certainly necessitates
(Fig. 63-4)
histologic confirmation
Specific treatment
and technique
Specific treatment and technique

Vermilionectomy(lip shave) and mucosal

advancement flap
Indicated:
1 .actinic keratosis
with or without dysplasia
2. micro-invasive SCC.
(Frankly invasive is contraindication)

3. Performed from commissure to

commissure because of the diffuse
nature of lower lip actinic keratosis

(Fig. 63-5 )
Specific treatment and technique

Vermilionectomy(lip shave) and

mucosal advancement flap

4. Mucosal advancement flap is

enhanced by complete lower
lip mucosal reconstruction.

5. The mucosa is closed primarily in

single-layer fashion without undue
tension.

(Fig. 63-5 )
Specific treatment and technique

Wedge excision and primary closure

1. Full-thickness excision and

immediate reconstruction.

2. Commissure is preserved

3. Excision dimensions <1/2 of

the lip with linear primary closure.

4. Inferior aspect does not cross

the labiomental fold.

(Fig. 63-6 )
Specific treatment and technique

Wedge excision and primary closure

5. The laxity of the remaining

tissues is important factor. Ex:

-Older patient with greater

tissue redundancy

Primary closure for large defect

-Younger patient with less

tissue redundancy
Require local flap reconstruction

(Fig. 63-6 )
Specific treatment and technique

Block excision and Karapandzic flap reconstruction

1. 1/2 to 2/3 Central Lower lip

(excision crosses the midline )
2. Need for bilateral flaps
3. Incise skin and muscle but not
communicate oral cavity.
4. Preserve
– branches CN V & VII
– labial arteries
– muscles if possible

(Fig. 63-7 )
Specific treatment and technique

Block excision and Karapandzic flap reconstruction

5. Nasolabial folds are used for

development of the flaps.
6. Indicated:
unacceptable surrounding soft
tissue laxity to primary closure
7. Contraindicated:
when the commissure is
excised with the specimen.

(Fig. 63-7 )
Specific treatment and technique

Block excision and Karapandzic flap reconstruction

Upper lip cancer is excised, reverse Karapandzic flaps

(Fig. 63-8 )
Specific treatment and technique

Wedge excision with an Abbe flap or

Abbe-Estlander flap reconstruction

1. Two-staged procedure
2. A crosstransfer of full-thickness
tissue from one lip to the other
3. 1/4 of the lower lip is used to
reconstruct 1/3 of the upper lip
4. Height of the defect and the
flap must coincide
5. Pedicle noted in part D is cut at
2 ~ 3 weeks postoperatively
(Fig. 63-9 )
Specific treatment and technique

Wedge excision with an Abbe flap or

Abbe-Estlander flap reconstruction

6. Based on the labial artery in

the vermilion of the lip.
7. Advantage: acceptable skin
texture and color match with
the surrounding tissue
8. Originally designed for defects
near the oral commissure
9. The medial pedicle flap is used to
reconstruct the commissure
(Fig. 63-10 )
Specific treatment and technique

Block Excision with the Webster

Modification of Bernard Cheiloplasty.
While >2/3 of the lower lip may be reconstructed

(Fig. 63-11 )
(Cancer excision includes nearly the entire lower lip.)
Specific treatment and technique

Block Excision with the Webster

Modification of Bernard Cheiloplasty.

1. Requires the development of

Burow’s triangles.
2. Medial vertical limb is incorporated
into the nasolabial fold.
3. Width of the base distance from
the oral commissure to the lateral
portion (the base = ½ width of lip
tissue excised)

(Fig. 63-11 )
Specific treatment and technique

Block Excision with the Webster

Modification of Bernard Cheiloplasty.

4. Required to advance bilateral

cheek tissue.
5. Suitable for restoration when neck
dissection is not being performed
6. Particularly suite to reconstruction
of the oral commissure and should
be considered first.

(Fig. 63-11 )
Specific treatment and technique

Excision with free microvascular flap reconstruction

1. Indication:
- Excision of the entire lower lip and adjacent facial soft tissues
- Neck dissection is planned and the carotid artery and internal
jugular vein will be dissected and preserved,

(Fig. 63-12 )
Specific treatment and technique

Excision with free microvascular flap reconstruction

2 Used radial forearm free flap is a

fasciocutaneous flap based on the
radial artery and vein and the
venae comitantes.
3. The soft tissue is relatively thin and
well suited for full-thickness lower
lip defects when skin and mucosa
must be reconstructed.
Postoperative care
Postoperative care

“ 1. Suture line
Effective oral hygiene by the patient
2. Sutures and neck drains
Commonly removed 1week postoperatively
3. When perineural/intraneural is invasion present
Post-op RT is indicated initiated by 6 to 8 weeks
postoperatively.
Monitored indefinitely due to the high likelihood
of recurrent disease and poor prognosis. .

”
Pearls and pitfalls
 究结果 问题讨论
Rule of 90s
-90% of lip cancers are SCC
-90% on the lower lip
-5 year survival rate is 90%
1 -90% of lip cancers have no evidence of
nodal disease at the time of initial.

<10% cervical LNs metastasis

But,if present, these metastatic
2 deposits must be diagnosed and
treated.

Lower lip cancer surgery failure

3 Neurological dysfunction and perineural
spread. Preoperative panorex should
be obtained to rule out involvement of
the mandible.
 究结果 问题讨论

Prevent microstomia
when performing ablative and
reconstructive surgery for lip cancer.
4
Best method for lip cancer
Properly performed ablative and
reconstructive surgery
( RT may result in a cosmetically
5 compromised outcome.)

Poor prognostic indicators

-large primary tumors (>3 cm),
6 -cervical lymph node metastases,
-recurrent tumors,
-perineural invasion,
-poorly differentiated histology –
-mandibular invasion by the cancer
THANKS