Cole Anderson, DMDJonathan S. Bailey, DMD, MD, FACS
INTRODUCTION
Lip cancer comprises 30% of all head and neck malignancies and is second only to cutaneous malignan-cies.1,2 The oral and maxillofacial surgeon (OMS) has a unique opportunity to participate in the diagnoses and management of these patients. General dental practitioners often identify premalignant and malignant lesions and have traditional referral pattern to their surgical colleagues and traditionally the OMS is greatly involved in the management of lip cancer.3,4,5 While the prognosis for early stage lip cancer is generally good,1 up to 20% of the patients can develop nodal metastasis. Those cancers with nodal metastasis are noted to be of larger size (greater than 2 cm) or higher histologic grade. Elective cervical lymphadenectomy can be justified for lip cancers that are very poorly differentiated or undifferentiated and for locally recur-rent lip cancers when the initial tumor size is greater than 2 cm. High grade histologic tumors have been found to present with regional metastasis more frequently regardless of T stage.6
The incidence of lip cancer is approximately 10–12 cases per 100,000 persons in the United States,2 and sun exposure is one of the most common risk factors. The Sun Belt region in the south and southwest of the United States has been identified as having a greater prevalence of lip cancer. Other risk factors include smoking, particularly cigar and pipe smoking.7 Men represent 95% of all diagnosed cases8 and this is pre-sumed to be due to traditional gender roles such as labor activities in the sun. Additionally, women may decrease their risk due to the use of lipstick or lip coverage.9 Generally, most patients are 53–66 years of age, likely due to a cumulative effect of chronic sun exposure. Squamous cell carcinoma is the most common histological variant reported at 90%,10 melanoma, basal cell carcinoma, and minor salivary malig-nancies represent the minority of lesions.8
DIAGNOSIS/STAGING
Lip cancer lesions are typically diagnosed early given the fact that the lesion is in a conspicuous area, which prompts individuals to seek treatment. These lesions may present with a variety of clinical features. A persistent ulcerative wound on the vermilion, and endophytic or exophytic variants are typical (Figs. 12.1, 12.2, and 12.3). Early lesions can present as a limited leukoplakia to advanced lesions being obviously malignant, invading the adjacent anatomic structures. The lower lip is most often affected and accounts for 89% of lesions. The upper lip and oral commissure represent 7% and 4% of lesions, respectively (Figs. 12.4, 12.5, 12.6).
The American Joint Committee on Cancer has established the tumor, node, metastasis (TNM) classifica-tion for staging lip cancer, which is also used in staging of oral cancer11,12 (Table 12.1). Seventy percent of
Fig. 12.1. Frontal view of an 84-year-old male with an endophytic T2N0M0 squamous cell carcinoma of the lower lip. (Miloro M. 2004. Peterson’s Principles in Oral and Maxillofacial Surgery, 2nd ed., BC Decker Inc., Hamilton, Ontario, Canada.)
Fig. 12.2. Frontal view of a 76-year-old male with an exophytic T2N0M0 squamous cell carcinoma of the left lower lip. (Miloro M. 2004. Peterson’s Principles in Oral and Maxillofacial Surgery, 2nd ed., BC Decker Inc., Hamilton, Ontario, Canada.)
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Fig. 12.3. Close-up view of the umbilicated exophytic T2 lesion. (Miloro M. 2004. Peterson’s Principles in Oral and Maxil-lofacial Surgery, 2nd ed., BC Decker Inc., Hamilton, Ontario, Canada.)
Fig. 12.4. Frontal view of a 73-year-old female with a T1N0M0 squamous cell carcinoma of the upper lip.
Fig. 12.5. Frontal view of a 78-year-old male with a T1N0M0 squamous cell carcinoma of the right oral commissure.
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Fig. 12.6. Intraoral view of the right oral commissure squamous cell carcinoma.
Table 12.1. American Joint Committee on Cancer TNM (Tumor, Node, Metastasis) Classification
Primary Tumor (T)
TX Primary tumor cannot be assessedT0 No evidence of primary tumorTis Carcinoma in situT1 Tumor 2 cm or less in greatest dimensionT2 Tumor more than 2 cm but not more than 4 cm in greatest dimensionT3 Tumor more than 4 cm in greatest dimensionT4a Moderately advanced local disease; superficial erosion alone of bone/tooth socket by gingival primary is not
sufficient to classify a tumor as T4(Lip) Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face, that is chin or nose(Oral cavity) Tumor invades adjacent structures only [e.g.. through cortical bone (mandible or maxilla) into deep extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), maxillary sinus, skin of face]
T4b Very advanced local diseaseTumor invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimensionN2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or
in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N2a Metastasis in single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimensionN2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimensionN2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimensionN3 Metastasis in a lymph node more than 6 cm in greatest dimension
Distant Metastasis (M)
M0 No distant metastasisM1 Distant metastasis
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Anatomic Stage/Prognostic Groups for Lip and Oral Cavity
Stage 0 Tis N0 M0Stage I T1 N0 M0Stage II T2 N0 M0Stage III T3 N0 M0
all lip cancers present as stage I while stages II, III, and IV comprise 16%, 10%, and 4%, respectively.8 Diagnostic tools include a incisional biopsy, thorough history and clinical evaluation for cervical lymph-adenopathy, and imaging of the neck most commonly via computed tomography (CT) with contrast or magnetic resonance imaging (MRI) when indicated.
The mainstay in treatment modalities for lip cancer is surgical excision7,13 or radiation therapy. The surgical defect and the undesirable side effects of radiation contribute to the morbidity of treating lip cancer. Surgical margins for resection may vary with a 5-mm margin in lesions smaller than 10 mm in diameter and up to a 20-mm margin for larger lesions.14,15,16 Preoperative planning of the anticipated surgi-cal defect is paramount. Maintaining the facial aesthetics, speech, and oral competence are the pivotal reconstructive goals.
Many proposed techniques have been utilized for lip reconstruction following ablative surgery. Options include primary closure, local tissue rearrangement and microvascular free tissue transfer. A simple approach when considering reconstruction is to estimate the size of the defect. T1 lesions may be managed with a wedge resection and primary closure due to elasticity of the perioral tissue. Vermilionectomy should be included with the wedge resection when indicated. For larger defects that are one-third to two-thirds of the lip, horizontal advancement flaps may be employed. For defects greater than two-thirds of the lip, a number of differing local tissue rearrangement techniques have been proposed (e.g., nasolabial flaps and fan flaps),17,18 (Figs. 12.7–12.12). Free flaps can also be employed for large defects [Figs. 12.13(a)–(e); Table 12.2). No matter which reconstructive option is utilized, many of the complications associated with the treatment of lip cancer revolve around the challenges to restore the premorbid function, anatomy, and aesthetics.
COMPLICATIONS ASSOCIATED WITH LIP RECONSTRUCTION
Wound DehiscenceWound dehiscence is a common complication related to lip cancer surgery. Compromised wound healing and dehiscence of the reconstruction are the cause of these complications. This can be attributed to two main issues: limitations of the chosen reconstructive option and comorbid health conditions.
Fig. 12.7. Frontal view of an 86-year-old male with a large fungating T4N0M0 squamous cell carcinoma of the lower lip.
Fig. 12.9. Intraoperative intraoral view of planned excision margins.
Fig. 12.10. Intraoperative view of defect and planned reconstruction with Bernard flaps.
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Fig. 12.11. Immediate postoperative view of the lower lip reconstruction using the Bernard’s flaps technique. Note the wound tension and venous congestion.
Fig. 12.12. Dehiscence of a reconstructed lower lip. Secondary healing is occurring at the midline where the wound margins have broken down.
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Fig. 12.13. Intraoperative view of planned resection and reconstruction with the Karapandzic Flaps. (a), (b). The figure presents the Karapandzic flap reconstruction technique for excision of a lower lip lesion that comprises greater than one-third of the lower lip. (c) The two-staged Abbé flap. The opposing vermillion is interpolated to the opposing lip. Approxi-mately 3 weeks following the initial procedure, the pedicle is divided and primary closure of the harvest site and reconstruction site occurs. (d) The Estlander flap with advancement of the upper lip to the defect of the lower lip. Note the rounding of the commissure. (e) The Bernard flap is useful for reconstruction of defects that comprise nearly the entirety of the lip. (Edge SE, Byrd DR, Compton CC, eds. 2010. AJCC Cancer Staging Manual, 7th ed. New York, NY: Springer.)
(a) (b)
(c) (d) (e)
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A common contributor of wound break down is marginal ischemia as a result of tension (Fig. 12.11). Reconstructing the perioral anatomy is influenced by functional limits, such as the desired dimensions of the stoma and available tissue. If the flap design does not provide for a tension-free closure or if the pedicled flap is not passive, tissue ischemia and wound dehiscence may occur. The microenvironment of the acute surgical wound inherently has reduced oxygenation of the tissues from a direct surgical disruption of the blood supply. Tension created by rearrangement of local tissue can further compromise the vascular supply. Initial signs of tissue ischemia include venous congestion with tissue edema, suggestive of venous insuf-ficiency (Fig. 12.12). Other signs include poor capillary refill and pale color of the tissue that indicate arterial compromise.
Many patients who suffer from lip cancer have comorbidities that may compromise the success of the reconstruction. Common conditions include metabolic conditions (diabetes and renal failure), respiratory [chronic obstructive pulmonary disease (COPD)] or cardiovascular [congestive heart failure (CHF)] disease, immunosuppression, and/or malnutrition. Optimization of these medical conditions can increase success of treatment and reduce the risk of poor wound healing and breakdown of the reconstructed wounds. Preoperative consultation with the primary care physician to optimize these conditions may be indicated.
Due to the robust vascularity of the head and neck, most wound problems are somewhat limited. Management usually includes simple wound care and minimal debridement. Other interventions include identification and treatment of infection, dressings to absorb excessive exudates and maintain open and clean wound margins (Table 12.3).19
Table 12.2. Lip Reconstruction Techniques
V ExcisionVermilionectomy with mucosal advancementV-Y mucosal advancement flapsTongue flapTranspositional flapsAbbé–Estlander flapKarapandzic flapBernard flapStair step flapCircumoral advancement flapsCheek advancement flapGillies fan flapsMcGregor flapsMicrovascular free flap
Table 12.3. Wound Care
Debridement of necrotic tissueKeep wound moistWet to wet dressingsPack dead spaceControl oral secretionsTreat infectionsProtect from mechanical injuryOptimize nutritional and medical status
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Fig. 12.14. Intraoperative view of an 82-year-old female with a rapidly growing T3N0M0 squamous cell carcinoma of the lower lip.
Hyperbaric oxygen (HBO) therapy has been utilized to improve wound healing. Many studies have demonstrated that HBO therapy has been very successful in the salvage of flaps in situations of hypoxia and decreased perfusion. HBO maximizes tissue viability reducing the need for repeat procedures.20,21 This is due to the physiologic effects of HBO that include control of infection by the potentiation of neutrophils’ ability to kill bacteria, angiogenesis to improve oxygenation of ischemic tissue, and epithelial migration of the wound edge.22
MicrostomiaLarge T3 and T4 lip cancers that require surgical excision present a difficult reconstructive challenge to avoid microstomia. Microstomia may result in speech articulation errors, loss of oral competence, difficul-ties with oral intake, and for patients with removable dental prosthesis, the inability to use their prosthesis (Figs. 12.14–12.17).23
For example, following the Karapandzic flap technique for lip reconstruction, up to 24% of patients require surgical revision for microstomia.24 Several revision techniques, variations of commissuroplasty, to increase the size of the oral stoma can be employed. Regardless of the technique used, reconstruction of the oral sphincter is essential. Oral competence and control of secretions depend on the restoration of this anatomic feature.25
A nonsurgical option for managing microstomia is the use of a graduated lip expander or semidynamic acrylic splints. Consultation with a maxillofacial prosthodontist would be essential in designing the expander appropriately. The device is designed with two opposing arms that are placed at each of the oral commissures and an expanding mechanism is at midline to incrementally increase the oral stoma over a number of weeks to achieve a greater opening. A combination of commissuroplasty and tissue-expanding therapy can optimize the correction of microstomia and reduce relapse.26
Consultation with a speech pathology therapist directed toward swallowing, speech articulation, and intelligibility may also be helpful.27
Poor tolerance for use of removable dental prosthesis is another associated complication related to microstomia, as mentioned earlier. The patient with microstomia can find it very challenging to insert and
Fig. 12.15. Intraoperative view of reconstruction of lower lip. Note microstomia and potential trauma to lower lip due to the presence of the remaining dentition.
Fig. 12.16. Contracture and thinning of the lower lip status post (s/p) resection and reconstruction of advanced lower lip cancer.
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remove the prosthesis through a small oral stoma. Furthermore, loss of the normal oral vestibule, in cases of vermilionectomy when mucosa advancement is used for reconstruction, retention of a complete denture may be compromised. This is more problematic for patients with significant mandibular alveolar ridge resorption and shallow vestibules. A possible alternative to labial mucosa advancement for recon-struction of the vermilion in these cases is a tongue flap, as it allows for preservation of the labial vestibule depth.
Prosthetic dental rehabilitation of the lip cancer patient may require the assistance of a maxillofacial prosthodontic specialist. Sectional impression techniques may be required and have been utilized in patients with microstomia for denture fabrication. Flexible dentures have also been used for delivery into and out of the small stoma. These methods use a number of segments of impressions that can be passed through the stoma and later assembled to create the prosthesis.28,29
Patients with advanced stage lip cancer often require postoperative radiation therapy. Xerostomia in conjunction with microstomia creates a difficult problem in providing dental care. The development of chronic periodontal disease, dental caries, and dental abscesses are real and significant problems for these patients.30 Lip cancer patients at stages T3 and T4 may require dental extractions at the time of the ablative surgery to limit radiation caries, the need for future extractions, and the potential risk for osteoradione-crosis. Additionally, the presence of the anterior mandibular teeth needs to be considered when planning the reconstruction of the lower lip since some flaps (such as tongue flaps) may not be possible to utilize without modifications.
Neurologic InjuryAblative surgery for lip cancer can result in altered sensation to the lower lip and chin. The mental nerve branch of the inferior alveolar nerve supplies sensation of the lower lip and chin. Injury to this nerve can result in paresthesia, which is abnormal sensation often characterized as decreased sensation, or dysesthesia, which is abnormal painful sensation. Patients with decreased sensation often accommodate well without a significant impact on their quality of life. However, patients with neuropathic pain have a significant impact on their quality of life and may require medical treatment with a neurologist. There are a number of pharmacological agents to treat nerve pain that include carbamezepine, oxcarbazepine, baclofen, lamotrigine, pimozide, gabapentin, and phenytoin. Neurology consultation is also useful in long-term management.31
Scarring and Poor Cosmetic OutcomeThere are a number of notable unfavorable outcomes related to the aesthetic aspect of reconstruction. Scarring, asymmetry, unbalanced facial proportions, inconsistent tissue color and texture, and discontinu-ity of the defined anatomy of the lips are some of the related complications.
Contracture of the lower or upper lip can result in thinning of the lips (Fig. 12.17). Vermilion reconstruction is most often reconstructed with mucosal advancement flaps. The vermilion is a
Fig. 12.17. Profile view of patient with contracture and inward rotation of lower lip.
280 Management of Complications in Oral and Maxillofacial Surgery
modified mucosal tissue and thus oral mucosa presents as a good alternative for reconstruction. Mucosal advancement may result in thinning of the visible vermilion and inward rotation of the lip. The latter in male patients can cause irritation of the upper lip from the facial hair of the lower lip. Shaving may also be more troublesome for these patients (Fig. 12.18). Although this may represent a minor complication, patients will often note this change. At the time of reconstruction, generous dissection of the mucosal flap to the depth of the vestibule to allow for adequate advancement may improve the outcome.31,32
Appropriate preoperative planning for flap reconstruction is also imperative to maximize the cosmetic outcome. Placing incisions in the relaxed skin tension lines and natural skin creases such as nasolabial, labiomandibular, submental, melolabial, and rhytids of the lips will aid in hiding incisions for improved aesthetic outcomes.33,34
COMPLICATIONS RELATED TO RADIATION THERAPY
Radiotherapy is used either as an adjunct to surgery for advanced lip cancers or as a primary modality for treatment of small lesions. The common problems encountered with use of radiotherapy in the head and neck, such as dermatitis, mucositis, poor wound healing, and poor saliva production, will occur when treating for lip cancer. Symptomatic management of mucositis during treatments, and fundamental prin-ciples of wound care post surgery should be used as indicated. Long-term management of the fragile radi-ated facial skin in the chin, lip area (or neck if included in fields of radiation) is based on prevention of further injury. Skin protection from environmental elements includes relief from cold, wind, and sunlight that along with meticulous hygiene may minimize problems.35
The complications related to mucositis are based on the ability to eat and swallow. For minor symptoms, sialogogues, oral hydration, and palliative oral rinses (i.e., viscous lidocaine and sedative medicaments) can be beneficial. If symptoms become so severe that the patient is unable obtain adequate oral intake, con-sideration should be given to provide nutritional support via feeding tubes that bypass the oral cavity. Encouragement to return to oral intake and swallowing, though, is paramount to preventing long-term swallowing difficulties from the radiation. Poor nutrition compounds the healing ability related to radia-tion therapy and may result in wound breakdown and associated sequelae.
Fig. 12.18. Patient with lip inversion and shaving irritation.
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CONCLUSIONS
In summary, the surgical treatment of lip cancer can be a challenging and rewarding aspect in the practice of oral and maxillofacial surgery. The treating surgeon and patient can often be hopeful of an optimistic outcome. However, potential complications may result in a significant alteration on the patient’s quality of life. It is incumbent upon the surgeon to proactively identify and navigate the potential complications that can arise with treating lip cancer. Adherence to the fundamental principles of surgery is essential in minimizing complications. Accurate diagnosis, planning, appropriate medical management, and meticu-lous surgical technique are at the center of successful management of the lip cancer patient.
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