Acs0205 Oral Cavity Procedures


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Acs0205 Oral Cavity Procedures

  1. 1. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 2 HEAD AND NECK 5 ORAL CAVITY PROCEDURES — 1 5 ORAL CAVITY PROCEDURES Carol R. Bradford, M.D., F.A.C.S., and Mark E. Prince, M.D., F.R.C.S.(C) Preoperative Evaluation sues and result in a significant functional disturbance. In such Oral cavity procedures are commonly performed to treat malig- cases, a flap reconstruction must be considered. In select cases, nancies. Tumors should be assessed preoperatively to allow accu- pedicled flaps may be appropriate. Often, particularly with larger rate staging of the disease and to facilitate planning of definitive or more complicated defects, free flaps provide the best recon- treatment. In most cases, an examination under anesthesia with structive result. Free tissue reconstruction has the advantage of endoscopy and biopsy is required to stage the primary tumor and allowing the surgeon to reconstruct the defect with the exact tis- to look for synchronous second primary tumors. Except in the sue components that were excised, including bone and skin. In case of very superficial lesions, computed tomography plays an addition, free flaps can be reinnervated to achieve a sensate important role in preoperative planning. In selected cases, plain reconstruction. radiographs (e.g., Panorex views) may be useful in evaluating the If the planned surgical procedure involves resection of part of mandible.When the lesion is located in the tongue, magnetic res- the maxilla or the mandible, appropriate dental consultation onance imaging may provide additional information about the should be obtained. If a postoperative splint, obturator, or dental extent of the primary tumor. prosthesis is to be placed, it is critical that dental impressions be Wide surgical margins are necessary for adequate treatment of obtained before operation. Thyroid function should be tested in primary squamous cell carcinoma of the head and neck. A mar- all patients who have a history of radiation therapy to the neck to gin of 1 to 2 cm should be achieved whenever possible, ideally confirm that they are euthyroid. with frozen-section control. Current evidence clearly indicates In cooperative patients, small primary lesions of the oral cavi- that overall patient outcome improves when clear margins are ty can sometimes be excised with local anesthesia; however, gen- obtained. eral anesthesia with adequate relaxation is required in the major- Nodal metastases are common with oral cavity tumors. Accord- ity of cases.The route of intubation must be carefully considered ingly, patients should be assessed for cervical adenopathy both for each patient. When the planned resection is extensive and clinically and radiographically. A chest x-ray should be obtained in when significant postoperative edema is anticipated, a tracheos- all cases. CT or MRI can provide valuable information regarding tomy should be performed. Patients with bulky lesions should the nodal status of the neck. In patients with advanced disease, a undergo tracheostomy under local anesthesia before general more extensive search for distant metastases should be conducted, anesthesia is induced.When a tracheostomy is not planned, naso- including a CT scan of the chest. In some circumstances, com- tracheal intubation is often desirable. bining CT with positron emission tomography (PET) may be When the excision is limited to the oral cavity, perioperative useful. antibiotics are generally unnecessary. When a graft, a flap, or packing is employed, however, perioperative I.V. administration of antibiotics is advisable. In all cases in which the neck is Operative Planning entered, perioperative antibiotics are recommended. The oral Surgical management of the neck is an evolving field. In gen- cavity can be prepared preoperatively with chlorhexidine and a eral, if the risk of occult metastasis is greater than 20% to 25%, a toothbrush. selective neck dissection [see 2:7 Neck Dissection] is recommend- A nasogastric feeding tube should be inserted whenever it is ed, particularly if postoperative radiation therapy is not planned. believed that the patient may have a problem maintaining oral Whenever there is clinical evidence of nodal disease, treatment of nutrition postoperatively. Patients who undergo primary closure the neck must be included in operative planning. or split-thickness skin grafting or whose surgical wound is allow- The oral cavity is a major component of a number of impor- ed to heal by secondary intention may be allowed clear liquids tant functions, including speech and swallowing. Reconstruction in 24 to 48 hours and a pureed diet by postoperative day 3; of the anticipated surgical defect must be carefully planned to they can often tolerate a soft diet within 1 week. Patients who achieve the best results. Several basic considerations must be kept undergo flap reconstruction will have to be fed via a nasogastric in mind. Tongue mobility and sensation must be maintained to tube until they have healed to the point where they can resume the extent possible. Maintenance of mandibular continuity (espe- oral intake. cially in the anterior segment of the mandible) is vital for ensur- Patients should be advised to maintain oral hygiene postoper- ing postoperative oral competence. Separation of the nasal cavity atively by means of frequent irrigation and rinses with either nor- from the oral cavity is critical for the oral phase of swallowing and mal saline or half-strength hydrogen peroxide.Teeth may be gent- speech. Maintenance of the gingivobuccal and gingivolabial sul- ly cleaned with a soft toothbrush until healing has occurred. cus is important for oral function and the fitting of dentures. As a rule, oral cavity defects should be closed primarily when- ever possible. Primary closure has the advantage of using sensate Anterior Glossectomy tissue similar in form to the tissue that was excised. With experi- OPERATIVE PLANNING ence and careful judgment, the surgeon can usually determine when a defect is too large for primary closure or when primary Either orotracheal or nasotracheal intubation may be appro- closure is likely to cause distortion and tethering of adjacent tis- priate, depending on the surgical approach and the extent of the
  2. 2. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 2 HEAD AND NECK 5 ORAL CAVITY PROCEDURES — 2 planned resection. A tracheostomy should be performed when- ever significant postoperative swelling or airway compromise is anticipated. The depth of the excision and the size of the anticipated defect determine the optimal reconstructive approach. Defects that connect to the neck, unless they are small and can easily be closed primarily, usually necessitate creation of a flap for optimal reconstruction. When the excision extends down to the underly- ing musculature but there is no connection to the neck, a skin graft may be used. If a postoperative dental splint is planned to hold a skin graft in place, a dental consultation must be obtained before operation. The patient should be supine in a 20° reverse Trendelenburg position. Turning the table 180° may facilitate access and posi- tioning for the surgeon. OPERATIVE TECHNIQUE Step 1: Surgical Approach Small anterior lesions up to 2 cm in diameter may be approached transorally, as may certain carefully selected larger Figure 1 Anterior glossectomy. A lip-splitting incision is made that extends downward straight through the mentum. lesions. Exposure of the tongue is usually achieved with the help of an appropriately sized bite block; alternatively, a specialized retractor (e.g., a Molt retractor) may be used. Retraction of the tongue is facilitated by the use of a piercing towel clip or a heavy Palpation of the lesion is critical for obtaining adequate deep sur- silk suture placed through the tip of the tongue. gical margins. Access to posterior lesions and most larger lesions is obtained by Resection may be performed with a monopolar electrocautery, performing a mandibulotomy through a lip-splitting incision [see with the cutting current used to incise the mucosa and the coag- Figure 1]. A stair-step incision is made in the lip and extended ulation current used to cut the muscle. Alternatively, resection downward straight through the mentum, and a Z-plasty is done at may be performed with a scalpel and a scissors. Hemostasis is the mental crease. Alternatively, the incision may be carried around achieved with a monopolar or bipolar electrocautery. Larger ves- the mental subunit. sels are ligated with chromic catgut or Vicryl ties. The mandibular periosteum is elevated and a plate contoured to Lesions of the lateral tongue should be wedge-excised in a the mandible before the mandible is divided; this measure ensures transverse (rather than horizontal) fashion to facilitate closure exact realignment of the cut ends of the mandible.When possible, and enhance postoperative function. With larger lesions, for the mandibulotomy should be made anterior to the mental fora- which either flap reconstruction or healing by secondary inten- men to preserve sensation throughout the distribution of the men- tion is typically indicated, the shape of the defect is contoured so tal nerve. Repair of the mandibulotomy is greatly facilitated by as to obtain wide margins around the lesion, and the flap is making a stair-step or chevron-type mandibulotomy [see Figure 2]. designed to fill the contoured defect. A paralingual mucosal incision is made to allow retraction of the mandible and exposure of the posterior oral cavity. Step 3: Reconstruction As an alternative, a visor flap may be created [see Figure 3]. Such After negative margins are confirmed by frozen section examina- a flap allows the surgeon to avoid making a lip-splitting incision and tion, repair of the surgical defect is initiated. Careful preoperative provides adequate exposure of small lesions of the anterior oral cav- assessment of the anticipated defect lays the groundwork for opti- ity; however, it is inadequate for exposure of lesions posterior to the mal reconstruction. Many defects can be either repaired primarily middle third of the tongue or in the area of the retromolar trigone. or allowed to heal by secondary intention. Free tissue transfer is an Furthermore, creation of a visor flap results in anesthesia of the excellent reconstructive option in many cases, allowing the mainte- lower lip because of the necessity of dividing both mental nerves. nance of tongue mobility and the separation of the tongue from the To create a visor flap, an incision is made from mastoid to mandible and making sensate reconstruction possible. mastoid along a skin crease in the neck, with care taken to remain In many patients with wedge-excised lateral tongue lesions, pri- below the marginal mandibular nerves. The skin flap is elevated mary closure of the defect yields good results.The deep muscle is in the subplatysmal plane to the level of the mandible. The mar- carefully reapproximated with long-lasting absorbable sutures.The ginal mandibular nerves are preserved. The flap is elevated from mucosa is also closed with absorbable sutures. Care should be tak- the lateral surface of the mandible, and the two mental nerves are en not to strangulate tissues by making the sutures too tight.When divided. An incision is made in the oral cavity mucosa along the complete primary closure is not possible or desirable, the tongue gingivolabial sulcus and continued so that it connects to the skin may be allowed to granulate and heal by secondary intention. Split- incision. The flap is then retracted superiorly to expose the ante- thickness skin grafts, though useful for relining the floor of the rior mandible and the oral cavity. mouth, generally do not take well on the tongue. For large defects of the tongue and those involving the floor of Step 2: Resection the mouth, flap reconstruction is appropriate. Defects that con- The excision should include a generous mucosal margin nect to the neck, unless they are small and can be closed primar- around the visible lesion. A significant amount of the tongue ily, should also be closed with a flap. Free tissue transfer is fre- musculature surrounding the lesion should be resected as well. quently the optimal reconstructive approach. Free fasciocuta-
  3. 3. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 2 HEAD AND NECK 5 ORAL CAVITY PROCEDURES — 3 after 7 to 10 days. Patients with skin grafts should stay on a soft diet for 2 weeks. If a tracheotomy was performed, the patient may be decannulated when postoperative edema has settled. Meticulous and frequent oral hygiene is essential. Mouth rins- es and irrigation with normal saline or half-strength hydrogen peroxide should be done at least four times a day and after every meal. Teeth may be gently cleaned with a soft toothbrush. COMPLICATIONS The main complications of anterior glossectomy are as follows: 1. Injury to the lingual nerve, which causes numbness and loss of the sense of taste in the ipsilateral tongue. 2. Injury to the submandibular and sublingual gland ducts, which causes obstruction of the glands, pain and swelling, and pos- sibly ranula formation. 3. Injury to the hypoglossal nerve, portions of which are resect- ed with the lesion. Injury to the main trunk of this nerve leads to paralysis and atrophy of the remaining ipsilateral tongue. 4. Tethering and scarring of the tongue, which can lead to diffi- culties with speech and swallowing.This problem can usually be avoided by careful preoperative planning of reconstruction. Figure 2 Anterior glossectomy. A stair-step mandibulotomy is made. neous flaps from the radial forearm, the anterior lateral thigh, or the lateral arm are well suited to reconstruction in this area. Pedicled flaps (e.g., myocutaneous flaps from the pectoral mus- cle) are also used in this setting, but they are bulkier and harder to contour to the defects. If a mandibulotomy was made, it is repaired with the previ- ously contoured plate. The lip-splitting incision is closed in three layers (mucosa, muscle, and skin). Great care must be taken to ensure accurate realignment of the vermilion border and the orbicularis oris muscle. Alternative Procedure: Laser Vaporization Very superficial and premalignant lesions of the tongue may be vaporized by using a CO2 laser. The desired depth of tissue destruction for leukoplakia is approximately 1 to 2 mm. TROUBLESHOOTING Larger excisions may lead to airway edema.Whenever this pos- sibility is a concern, a tracheostomy should be performed. A sin- gle intraoperative dose of steroids may reduce postoperative tongue edema without adversely affecting wound healing. Using a stair-step incision for the lip-splitting incision facilitates accu- rate reapproximation of the vermilion border. Excessive tongue movement may result in dehiscence of the closure. Voice rest for 3 to 5 days after operation may be beneficial. POSTOPERATIVE CARE Patients who undergo primary closure of the tongue may begin a fluid diet on the day after operation; they should remain on a liquid diet for 7 to 10 days. Patients who undergo skin grafting may also begin a liquid diet on postoperative day 1. If a flap was used to close the defect or if there is some question whether the patient will be ca- pable of adequate oral intake, a nasogastric feeding tube should be Figure 3 Anterior glossectomy. As an alternative to a lip-split- inserted and maintained until the suture lines heal. ting incision with mandibulotomy, a visor flap may be employed Bolster dressings may be removed and skin grafts inspected for exposure.
  4. 4. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 2 HEAD AND NECK 5 ORAL CAVITY PROCEDURES — 4 Excision of Floor-of-Mouth Lesions POSTOPERATIVE CARE Postoperative care of patients undergoing excision of floor-of- OPERATIVE PLANNING mouth lesions is virtually identical to that of patients undergoing Planning for excision of a lesion from the floor of the mouth is anterior glossectomy [see Anterior Glossectomy, Postoperative essentially the same as that for anterior glossectomy [see Anterior Care, above]. Glossectomy, Operative Planning, above]. If either or both of Wharton’s ducts are to be transected without excision of the sub- COMPLICATIONS mandibular glands, consideration must be given to the manage- Excision of floor-of-mouth lesions is associated with the same ment of these glands. complications as anterior glossectomy [see Anterior Glossectomy, Complications, above]. OPERATIVE TECHNIQUE Step 1: Surgical Approach Excision of Superficial or Plunging Ranulas The surgical approach is the same as that described for glossecto- my [see Anterior Glossectomy, Operative Technique, Step 1, above]. OPERATIVE PLANNING Planning for excision of a superficial or plunging ranula resem- Step 2: Resection bles that for glossectomy. A Ring-Adair-Elwyn (RAE) tube is in- The area to be excised, including adequate margins, is marked. serted orally and taped to the contralateral cheek. Cervical explo- The lesion is then excised with a monopolar electrocautery; as in ration is usually unnecessary, because the cervical component of a glossectomy, the cutting current is used to cut the mucosa, the the ranula resolves after removal of the ipsilateral sublingual gland. coagulation current to cut the deeper tissues. Palpation is impor- In select cases, especially those involving disease recurrence after a tant for obtaining adequate deep surgical margins. previous attempt at excision, a transcervical approach should be If the excision cuts across Wharton’s duct, the duct should be considered. identified and transected obliquely so as to create a wider open- ing. The transected stump is held with a 4-0 chromic catgut OPERATIVE TECHNIQUE suture. Once the resection is complete, the duct is transposed posteriorly to the cut edge of the mucosa of the floor of the mouth Step 1: Surgical Approach and sutured in place with two or three 4-0 chromic sutures. Ranulas are resected via the transoral approach. A bite block or During subsequent reconstruction, care should be taken not to a Molt retractor is used to gain exposure. obstruct the orifice of the duct. Step 2: Resection Step 3: Reconstruction A local anesthetic preparation with epinephrine is infiltrated After clean surgical margins have been verified by frozen sec- into the area of the mucosal incisions. A small superficial ranula tion examination, repair of the surgical defect is initiated. Small may be marsupialized and packed with gauze.The ranula is wide- superficial defects of the floor of the mouth may be allowed to ly unroofed and the contents removed with suction.The margins heal by secondary intention. of the cyst are sutured to the mucosa with 4-0 chromic sutures, For small defects that do not connect to the neck, reconstruc- and the cavity is packed with iodoform strip gauze. The gauze tion with a 0.014 to 0.016 in.–thick split-thickness skin graft is may be removed in 5 to 7 days. appropriate.The graft is cut to size and sutured in place with 4-0 A plunging ranula is treated with complete surgical excision of chromic sutures. Several perforations should be made in the graft the cyst and the sublingual gland [see Figure 4]. A mucosal inci- to allow the egress of blood and serum. A Xeroform gauze bol- sion is made directly over the cyst. Careful dissection is carried ster is fashioned to fit over the skin graft and sutured in place with out around the cyst and the associated gland. Hemostasis is 2-0 silk tie-over bolster stitches; alternatively, it may be held in achieved with a bipolar electrocautery, with care taken not to place by a prefabricated dental prosthesis. injure the adjacent lingual nerve. The submandibular gland duct For larger defects, particularly those involving the tongue, a flap is cannulated with a lacrimal probe to help guard against inad- reconstruction typically yields the best functional results. In select vertent injury to this structure. The incision is closed with 4-0 cases, a platysma flap may be used for reconstruction of defects in chromic suture. the floor of the mouth. Other regional flaps tend to be bulky and difficult to shape to the contours of the defect. Free tissue transfer TROUBLESHOOTING frequently provides the most suitable reconstructive tissue charac- Efforts should be made to identify the lingual nerve and artery teristics and the most favorable postoperative results. A free fascio- so as to prevent inadvertent division of these structures. Metic- cutaneous radial forearm flap is usually the optimal choice for re- ulous hemostasis should be obtained in all cases. If the subman- construction of floor-of-mouth defects when a flap is required. dibular gland duct is injured, it should be transected and the cut end sutured to the adjacent floor-of-mouth mucosa TROUBLESHOOTING (sialodochoplasty). Special care should be taken to identify the lingual nerve and artery so that these structures are not inadvertently divided. COMPLICATIONS Meticulous hemostasis should be obtained in all cases. Any skin The three main complications of the procedure for excising a grafts used should be adequately sized and should not “tent up.” ranula are among those that are also associated with anterior glos- Generally, skin grafting and bolsters do not work well on mobile sectomy and excision of floor-of-mouth lesions: injury to the lin- structures. Quilting grafts to the underlying tissues with multiple gual nerve, injury to the submandibular gland duct, and injury absorbable sutures can eliminate the need for a bolster and result to the hypoglossal nerve [see Anterior Glossectomy, Complica- in acceptable graft take. tions, above].
  5. 5. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 2 HEAD AND NECK 5 ORAL CAVITY PROCEDURES — 5 TROUBLESHOOTING Careful dissection directly onto the duct and stone usually serves to prevent inadvertent injury to the lingual nerve. COMPLICATIONS The main complications of the procedure are as follows: 1. Injury to the lingual nerve, resulting in numbness and loss of the sense of taste to the ipsilateral tongue. 2. Stricture of the submandibular gland duct.This is an unusu- al complication that can be corrected by transecting the duct posterior to the stricture and suturing it to the mucosa of the floor of the mouth. Resection of Hard Palate OPERATIVE PLANNING Careful evaluation is required to determine whether resection of part of the hard palate will suffice or whether a more extensive dissection (e.g., maxillectomy) will be required. If it is anticipat- Cyst ed that a dental prosthesis will be required, a dental consultation should be obtained before operation. When the lesion to be Gland resected is superficial or only a limited amount of the bony hard palate must be resected, the procedure may be performed via the transoral approach. OPERATIVE TECHNIQUE Figure 4 Excision of plunging ranula. A mucosal incision is made over the cyst, dissection is done around the cyst and the Step 1: Surgical Approach associated sublingual gland, and cyst and gland are completely excised. The patient is supine, with the bed turned 180º to facilitate the surgeons’ access to the operative site. An oral RAE tube is insert- ed and taped in the midline. The lesion is approached transoral- ly, and a Dingman or Crowe-Davis retractor is used to obtain Removal of Submandibular Gland Duct Stones exposure. OPERATIVE PLANNING Step 2: Resection When a submandibular gland duct stone is readily palpable in An incision is made around the periphery of the lesion in such the floor of the mouth, a transoral approach is appropriate.When a way as to maintain adequate margins; a monopolar electro- the stone is within the hilum of the gland, however, it generally cautery with a needle tip is ideal for this purpose.The periosteum cannot be removed transorally and often must be treated by is elevated away from the underlying bone, and the lesion is excising the submandibular gland. removed [see Figure 5]. OPERATIVE TECHNIQUE When bone must be resected, the periosteum is elevated away from the incision site. A high-speed oscillating saw or an osteo- Step 1: Surgical Approach tome is used to make the cuts in the bone, after which the speci- men is rocked free and removed. The procedure is easily accomplished with local anesthesia in a cooperative patient. The patient is seated upright in the Step 3: Reconstruction examining chair, and a topical anesthetic is applied to the oral cavity. After surgical margins have been verified by frozen-section review, repair of the surgical defect is initiated. Small mucosal Step 2: Resection defects may be allowed to heal by secondary intention. Small A local anesthetic preparation with epinephrine is infiltrated through-and-through resections may be closed by placing relax- into the floor of the mouth and around the duct in which the ing incisions laterally and advancing the mucosa to permit pri- stone is palpated. A 2-0 silk suture may be placed around the duct mary closure. Larger defects may be closed with palatal mucosal behind the stone to prevent it from migrating back into the hilum flaps. Many through-and-through defects can be closed quite sat- of the gland. isfactorily with a dental obturator. A lacrimal probe is inserted into the duct and advanced to the POSTOPERATIVE CARE stone in a retrograde manner. A mucosal incision is then made directly over the stone and extended downward to the duct, with The patient should be maintained on a soft diet postoperative- the stone and the lacrimal probe serving as guides. The duct is ly. Meticulous oral hygiene is important. Oral rinses and flushes incised and the stone delivered. As a rule, repair of the duct is not with normal saline or half-strength hydrogen peroxide should be required. performed at least four times daily and after meals.
  6. 6. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 2 HEAD AND NECK 5 ORAL CAVITY PROCEDURES — 6 OPERATIVE TECHNIQUE Step 1: Surgical Approach Lesion In addition to the transoral approach, maxillectomy usually requires exposure of the anterior face of the maxilla. There are several options for achieving such exposure, including a Weber- Ferguson incision and midface degloving. Midface degloving has the advantage of eliminating the need for visible facial incisions, but it yields limited exposure in the ethmoid region. The choice of surgical approach is determined by the extent of the planned resection and by the preferences of the patient and the surgeon. In the Weber-Ferguson approach, the first step is to mark the path of the incision, which begins in the midline of the upper lip; extends through the philtrum; curves around the nasal vestibule and the ala; continues upward along the lateral nasal wall, just medial to the junction of the nasal sidewall and the cheek; and ends near the medial canthus. For added exposure in the ethmoid region, a Lynch extension, in which the incision is continued superiorly up to the medial eyebrow, may be performed. Alter- natively, the Weber-Ferguson incision may be continued laterally in the subciliary crease along the inferior eyelid to the lateral can- thus of the eye; this extension yields added exposure of the pos- terolateral aspect of the maxilla. The skin incisions should initially be made with a scalpel and then continued with an electrocautery. The upper lip is divided through its full thickness, and the incision is continued in the gin- givolabial sulcus laterally until the posterolateral aspect of the sinus is exposed. When possible, the infraorbital nerve is identi- fied and preserved. The soft tissues are elevated from the anteri- or wall of the maxillary sinus; if access to the pterygomaxillary fis- sure is desired, elevation should be continued up to the zygoma. In a midface degloving, the skin of the lower face and nose is Figure 5 Resection of hard palate. An incision is made around mobilized and retracted superiorly. A standard transfixion inci- the lesion, with adequate margins maintained, the periosteum is sion is made, transecting the membranous septum. Intercarti- lifted off the bone, and the lesion is removed. laginous incisions are then made bilaterally and connected to the transfixion incision.The incision is then continued laterally along COMPLICATIONS the cephalic border of the lower lateral cartilage and across the The most significant potential complication of hard palate resec- floor of the nose. To prevent stenosis, a small Z-plasty [see 3:7 tion is oral antral or oronasal fistula; careful tissue reconstruction Surface Reconstruction Procedures] or triangle is incised medially and the use of an obturator can prevent this complication. just before the transfixion incision is joined. The soft tissues are elevated over the nasal dorsum and the nasal tip with Joseph scis- sors. An incision is made in the gingivolabial sulcus with the Maxillectomy monopolar cautery, and this incision is connected to the floor-of- nose incisions by means of gentle dissection. The soft tissues are OPERATIVE PLANNING then elevated from the anterior maxilla as far as the infraorbital General anesthesia with muscle relaxation is essential for all types rims and laterally as far as the zygoma. of maxillectomy. Either orotracheal or nasotracheal intubation may be appropriate, depending on the surgical approach. Skin incisions Step 2: Resection should be marked before the endotracheal tube is taped in place to A Molt retractor is placed on the side opposite the side of the avoid distortion of facial structures and skin lines. The patient planned excision and opened as wide as possible to expose the should be supine in a 20° reverse Trendelenburg position.The eyes hard palate and the alveolus. should be protected carefully (e.g., with a corneal shield or a tem- The infraorbital rim should be preserved if it is possible to do porary nylon tarsorrhaphy suture). so safely. Often, a thin strip of the rim can be preserved even when Radiographic evaluation plays a vital role in planning the sur- the rest of the bone must be resected. If the orbital floor must be gical approach and determining the extent of resection required resected but the orbital contents can be preserved, the periorbita [see Figure 6]. Lesions of the infrastructure of the maxilla can be can be dissected away from the bone of the orbital floor and pre- excised by means of partial maxillectomy via the transoral route. served. If the orbital contents are involved, an orbital exenteration More extensive lesions usually must be accessed via facial inci- must be performed in conjunction with the maxillectomy. sions in conjunction with the transoral approach. The cut along the infraorbital rim and superior anterior max- In all cases, a dental consultation should be obtained preoper- illary wall is made with a high-speed oscillating saw with a fine atively so that a dental impression can be taken and an obturator blade. The level at which this superior cut is made is determined fashioned for intraoperative use. Antibiotics should be given peri- by the extent of the resection. Lesions that are confined to the operatively and continued until nasal packing is removed. alveolus or the palate and do not invade the maxilla typically can
  7. 7. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 2 HEAD AND NECK 5 ORAL CAVITY PROCEDURES — 7 be removed by excising the infrastructure of the maxilla.The line sal flap that is wrapped over the cut bony edge of the palate. The of transection is continued through the nasal process of the max- mucosal cut is connected around the maxillary tuberosity to the illa medially and downward through the piriform aperture. Later- gingivolabial sulcus incision that was made earlier. ally, the cut extends to the zygomatic process of the maxilla and The hard palate is then cut with a power saw. Once all the bone around the posterolateral aspect of the sinus. cuts are complete, an osteotome may be used to connect them if If the pterygoid plates are to be preserved, they are cut free by necessary.The remaining soft tissue attachments are divided along placing a curved osteotome along the posterior wall of the sinus and the posterior hard palate with curved Mayo scissors. The surgical sharply dividing the plates from the sinus wall. If the pterygoid defect is packed to control bleeding. Bleeding from the internal plates, part of the pterygoid musculature, or both are to be resected, maxillary artery is controlled by ligatures or ligating clips. the soft tissue attachments are cut sharply with curved Mayo scis- sors once the entire maxillary specimen has been mobilized. Step 3: Reconstruction The line of transection in the maxillary alveolus can run All sharp spicules of bone are debrided.The flap of hard palate between two teeth if a suitable gap is evident. In the majority of mucosa is brought up over the cut bony edge of the palate and held cases, however, it is advisable to extract a tooth and make the cut in place with several Vicryl sutures.The anterior and posterior cut through the extraction site. A power saw is used, and the cut is edges of the soft palate are reapproximated with absorbable sutures. connected to the transection line through the nasal process of the A split-thickness skin graft, 0.014 to 0.016 in. thick, is har- maxilla and the piriform aperture. The hard palate mucosa is vested and used to line the raw undersurface of the cheek flap. then incised lateral to the proposed cut in the hard palate bone to The skin graft is sutured to the mucosal edge of the cheek flap preserve a flap of mucosa that can be used to cover the raw cut with 3-0 chromic sutures. Superiorly, the graft is not sutured but bony edge of the palate. This incision is made with a needle-tip draped into position and retained by a layer of Xeroform packing electrocautery and carried down to the bone of the hard palate. and strip gauze coated with antibiotic ointment. Gentle pressure It should extend from the maxillary tuberosity posteriorly to the is applied to the packing so that it conforms to the defect. The cut bone in the maxillary alveolus anteriorly, with care taken to previously fabricated dental obturator is placed to support the obtain adequate mucosal margins. The mucosa is elevated for a packing and to close the oral cavity from the nasal cavity. In a short distance over the hard palate bone to create a short muco- dentulous patient, the obturator may be wired to the remaining a b c Figure 6 Maxillectomy. Radiographic assessment helps determine the required extent of resection. Depicted are (a) medial maxillectomy, (b) subtotal maxillectomy without orbital exenteration, and (c) total maxillectomy with orbital exenteration.
  8. 8. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 2 HEAD AND NECK 5 ORAL CAVITY PROCEDURES — 8 Figure 7 Mandibulectomy. A cheek flap is created by making a lip-splitting incision and extending it down to the level of the thyrohyoid membrane, then laterally to the mastoid along a skin crease. teeth; in an edentulous patient, it may be temporarily fixed in mucosa area. The graft is sutured to the cut edge of the buccal place with two screws placed in the remaining hard palate. mucosa with 4-0 chromic catgut. Xeroform and strip gauze coat- The skin incisions are closed in two layers, with interrupted ed with antibiotic ointment are gently packed into the defect to absorbable sutures used for the deep layers and nonabsorbable secure the skin graft. The previously fabricated dental obturator monofilament sutures for the skin. If a lip-splitting incision was is wired to the remaining teeth to hold the packing in place. made, care must be taken to ensure exact reapproximation of the TROUBLESHOOTING orbicularis oris and the vermilion border. If the infraorbital rim was resected, it should be reconstructed to If a lip-splitting incision is planned, lip contraction can be re- yield good aesthetic results. A split calvarial bone graft may be used duced and vermilion border realignment improved by employing a for this purpose when there is adequate soft tissue coverage for the stair-step lip incision and a Z-plasty. A single intraoperative steroid bone grafts available.When soft tissue coverage is inadequate or the dose reduces facial edema without compromising wound healing. orbital floor must be reconstructed, an osteocutaneous radial fore- Retention of the obturator is aided by the band of scar tissue that arm or scapular flap may be employed with excellent results. forms at the junction of the mucosa and the skin graft. Covering the cut edge of the hard palate bone with mucosa eliminates pain Alternative Procedure: Peroral Partial Maxillectomy caused by pressure from the obturator on thinly covered bone. The oral cavity is exposed with cheek retractors. An incision is If more than a small area of the floor of the orbit is resected, it made in the gingivobuccal sulcus and the mucosa of the hard should be repaired to prevent enophthalmos. Epiphoria is un- palate, with care taken to maintain adequate margins; a monopo- common; when it occurs, it is related to scarring of the nasolac- lar electrocautery, set to use the cutting current, is suitable for this rimal duct. Identifying the duct and transecting it obliquely should purpose. Incisions are made circumferentially through all the soft reduce the incidence of this complication. tissues up to the anterior wall of the maxilla and the hard palate. POSTOPERATIVE CARE The infraorbital nerve should be preserved if it is not involved with the disease process. A nasogastric tube is placed at the end of the procedure. Many The cut in the hard palate mucosa should be made lateral to patients are able to begin a liquid diet and advance to a soft diet the planned cuts in the hard palate bone to create a mucosal flap, within a few days after operation. A soft diet should be continued which will be used to cover the cut bony edge of the hard palate. for at least 2 weeks. Oral rinses and flushes with normal saline or If necessary, teeth may be extracted to allow the surgeon to make half-strength hydrogen peroxide should be performed at least bone cuts through tooth sockets while preserving adjacent teeth. four times daily and after meals. The bone is cut with a high-speed power saw, and an osteotome The obturator and the packing may be removed from the cav- is used to divide any remaining bony attachments and deliver the ity in 7 to 10 days. The obturator should be replaced to maintain specimen. If the mucosa remaining in the maxillary antrum is not oral competence. The prosthodontist makes a final obturator diseased, it need not be removed. once healing is complete and the cavity has stabilized. Facial inci- A split-thickness skin graft, 0.014 to 0.016 in. thick, is harvest- sions are cleaned twice daily and coated with antibiotic ointment. ed from the anterolateral thigh and used to reline the raw buccal Facial sutures are removed 5 to 7 days after operation.
  9. 9. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 2 HEAD AND NECK 5 ORAL CAVITY PROCEDURES — 9 COMPLICATIONS the retromolar trigone, and it may lead to anesthesia of the lower The main complications of maxillectomy are as follows: lip as a consequence of the need to divide both mental nerves. 1. Enophthalmos and hypophthalmos, which create a cosmet- Technical aspects of visor flap creation are summarized elsewhere ic deformity. [see Anterior Glossectomy, Operative Technique, Step 1, above]. 2. Infraorbital nerve injury, which results in anesthesia or pares- thesia of the ipsilateral cheek and upper lip. On occasion, the Step 2: Resection infraorbital nerve may have to be sacrificed as part of the If a plate is to be used in the reconstruction of the mandible, a planned resection. template and a reconstruction plate are shaped and conformed to 3. Epiphoria, caused by scarring of the nasolacrimal duct. the mandible before resection. The segment of mandible to be 4. Difficult retention of the dental prosthesis, which can usually resected is marked. The plate is applied to the buccal cortex of be prevented by careful preoperative evaluation and appropri- the mandible, and screw holes are predrilled in the mandible for ate choice of reconstructive method. In select cases, free tissue gauging of depth. The plate is then set aside until needed for reconstruction without a dental prosthesis may be optimal. reconstruction. Mucosal incisions are made around the lesion with the electro- cautery, with care taken to maintain adequate surgical margins.The Mandibulectomy mandibular segment to be removed is cut with a high-speed sagittal OPERATIVE PLANNING saw.The lingual nerve and the hypoglossal nerve are preserved if pos- sible. Muscle attachments to the resected mandibular segment are General anesthesia with muscle relaxation is essential for all sharply divided, allowing the surgical specimen to be delivered [see types of mandibulectomy. Either orotracheal or nasotracheal intu- Figure 8]. bation is appropriate, depending on the surgical approach and the extent of the planned resection. A tracheostomy should be per- formed whenever significant postoperative swelling or airway compromise is anticipated. Skin incisions should be marked before the endotracheal tube is taped in place. Preoperative radiographic evaluation is essential for planning the surgical approach and determining the extent of the proposed resection. For lesions without radiographic or clinical evidence of bone invasion, a marginal mandibulectomy is often appropriate. This procedure may also be performed to obtain adequate surgi- cal margins for lesions that are in close proximity to the mandible. When the lesion is small, it is occasionally possible to perform marginal mandibulectomy via the transoral route. For more ex- tensive lesions and those that show evidence of bone invasion, a segmental mandibulectomy is required. The patient should be supine in a 20° reverse Trendelenburg position. Perioperative antibiotics should be administered. OPERATIVE TECHNIQUE Step 1: Exposure Wide exposure for access to primary tumors of the oral cavity and the mandible may be achieved by means of either a lower- cheek flap or a visor flap.The former is often preferable, in that it allows resection of the primary and ipsilateral lymph nodes. To create a lower-cheek flap, a lip-splitting incision is made through the full thickness of the lower lip and carried down through the chin tissues to the periosteum of the anterior mandible [see Figure 7].This incision may be made straight through the mental subunit with a Z-plasty placed at the mental crease; alternatively, it may be made around the mental subunit.The incision is continued vertically to approximately the level of the thyrohyoid membrane, then extend- ed laterally to the mastoid along a skin crease.The transverse compo- nent of the incision should be made at least two fingerbreadths below the mandible to prevent injury to the marginal mandibular nerve. The cheek flap is fully developed by incising the oral mucosa along the gingivolabial sulcus while maintaining adequate surgical margins around the lesion.The periosteum of the mandible is then elevated and the cheek flap retracted to expose the mandible. A visor flap [see Figure 3] has the advantage of not requiring a Figure 8 Mandibulectomy. The segment to be removed is cut lip-splitting incision, and it provides adequate exposure for lesions with a high-speed saw, with care taken to preserve the lingual of the anterior oral cavity. However, it is inadequate for exposing and hypoglossal nerves if possible, and the muscle attachments lesions posterior to the middle third of the tongue or in the area of to the segment are sharply divided to free the surgical specimen.
  10. 10. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 2 HEAD AND NECK 5 ORAL CAVITY PROCEDURES — 10 In some cases, only a marginal mandibulectomy of the lingual or most patients will need to be fed through this tube until their inci- alveolar cortex of the mandible is necessary.The bone is cut with a sions are healed. A soft diet should be continued for 6 weeks. Oral high-speed saw in such a way that the cuts are rounded off and lack rinses and flushes with normal saline or half-strength hydrogen per- sharp angles, which are prone to fracturing. Once the bone cuts are oxide should be performed at least four times a day and after meals. made, an osteotome may be used to free the specimen. Facial incisions are cleaned twice a day and coated with anti- biotic ointment. Facial sutures are removed 5 to 7 days after Step 3: Reconstruction operation. When a marginal mandibulectomy has been performed, a plate is sometimes needed to support the mandible.This is especially likely TROUBLESHOOTING to be the case for a patient with a thin edentulous mandible, in which Contouring the reconstruction plate to the mandible before the remaining bone cannot withstand the forces of mastication. resecting the mandibular segment will prevent malocclusion and When the anterior mandible has been resected, it must be recon- enhance cosmetic results. Preserving the lingual nerve and the structed with vascularized bone. Any of several free flaps may be hypoglossal nerve, when possible, will improve postoperative employed, depending on the tissue requirements for the planned re- swallowing and speech. The marginal mandibular nerve should construction. Free tissue flaps from the fibula, the scapula, or the il- be identified and protected as well. If a lip-splitting incision is iac crest can provide bone that is suitable for mandibular recon- used, performing a stair-step lip incision and a Z-plasty reduces struction, as well as soft tissue that is suitable for reconstruction of lip contraction and improves vermilion border realignment. accompanying mucosal and cutaneous defects. After lateral mandibular resections, good results can be achieved COMPLICATIONS by using mandibular reconstruction plates with suitable soft tissue The main complications of mandibulectomy are as follows: reconstruction.There is a significant risk of plate failure, however, especially in dentulous patients. In many cases, replacing the resect- 1. Malocclusion, caused by inaccurate repair of the resected ed portion of the mandible with vascularized bone—especially if the mandibular segment. defect is longer than a few centimeters—yields better long-term re- 2. Plate failure or fracture, which can be reduced by recon- sults than using a reconstruction plate alone. structing bony defects larger than 1 to 2 cm with revascular- ized bone. POSTOPERATIVE CARE 3. Oral incompetence, caused by inadequate reconstruction of A nasogastric tube is placed at the end of the surgical procedure; anterior mandibular defects. Selected Readings Baurmash H: Submandibular salivary stones: current Johnson JT, Leipzig B, Cummings CW: Management Spiro RH, Gerold FP, Strong EW: Mandibular management modalities. J Oral Maxillofac Surg 62:369, of T1 carcinoma of the anterior aspect of the tongue. “swing” approach for oral and oropharyngeal tumors. 2004 Arch Otolaryngol 106:249, 1980 Head Neck 3:371, 1981 Brown JD:The midface degloving procedure for nasal, Lanier DM: Carcinoma of the hard palate. Surgery of Stern SJ, Geopfert H, Clayman G, et al: Squamous cell sinus and nasopharyngeal tumors. Otolaryngol Clin the Oral Cavity. Bailey BJ, Ed. Year Book Medical carcinoma of the maxillary sinus. Arch Otolaryngol North Am 34:1095, 2001 Publishers, Chicago, 1989, p 163 Head Neck Surg 119:964, 1993 Brown JS, Kalavrezos N, D’Sousa J, et al: Factors that Leipzig B, Cummings CW, Chung CT, et al: Carcinoma Wald RM, Calcaterra TC: Lower alveolar carcinoma: influence the method of mandibular resection in the segmental v. marginal resection. Arch Otolaryngol of the anterior tongue. Ann Otol Rhinol Laryngol management of oral squamous cell carcinoma. Br J 109:578, 1983 Oral Maxillofac Surg 40:275, 2002 91:94, 1982 Galloway RH, Gross PD, Thompson SH, et al: Patho- Osguthorpe JD, Weisman RA: “Medial maxillectomy” genesis and treatment of ranula: report of three cases. J for lateral nasal neoplasms. Arch Otolaryngol Head Oral Maxillofac Surg 47:299, 1989 Neck Surg 117:751, 1991 Hussain A, Hilmi OJ, Murray DP: Lateral rhinotomy Schramm VL, Myers EN, Sigler BA: Surgical manage- Acknowledgment through nasal aesthetic subunits: improved cosmetic ment of early epidermoid carcinoma of the anterior outcome. J Laryngol Otol 116:703, 2002 floor of the mouth. Laryngoscope 90:207, 1980 Figures 1 through 8 Alice Y. Chen.