ORAL AND MAXILLOFACIAL SURGERY

1. LIP CANCER (EVIDENCE BASED
MANAGEMENT)
DR SAQBA
ALAM
(ORAL AND
MAXILLOFACIAL SURGERY)

2. INTRODUCTION
INCIDENCE----1.8 IN 100,000 M>F
Shares features of both oral and skin cancers. Complex tasks like
articulation of speech, facial expression and oral deglutition.
Median age 68-73 yrs
90%SCC=lower lip, BCC=more prevalent in upper lip
SCC 95%lower lip,1%commisure
87%SCC,2%adenocarcinoma
BCC arises from skin of upper lip adjacent to the mucocutaneous
lesion hence not included in the mucosal lip category of
carcinoma.(Early diagnosis/good prognosis)

3. ETIOLOGY
UV light
50 +yrs
White skinned
Population working under the sun mostly in fields in rural areas.
Pipe /cigar smoking
HPV
Chronic wounds and immune suppression
Chemical carcinogens
Tobacco chewing in synergy with alcohol consumption
LOWER LIP 93% epithelial cancers. Upper lip only 7% (Ref Jatin Shah)

4. COMPOSITION
Skin 2 parts:
Mucosa (Dry vermillion covered by keratinized sq
epithelium)
Minor salivary glands and
Muscles (Wet vermillion or mucosal lip containing minor
salivary glands)
Neurovascular structures
BLOOD SUPPLY
Superior labial,inferior
Labial and branches of facial
artery

5. NECK DISEASE
T1=7% CHANCE OF NECK METS
T2-T4=16%
A/c to size <1cm--------2% chance of occult Mets
4cm--------8% chance of occult Mets
(Ref Werning Oral Cancer)
Lower lip is formed by fusion of two lateral mandibular processes,
this puts lip carcinomas at increased risk of contralateral neck
metastasis.

6. WORK UP
After a good clinical history and examination, the radiographic work
up of early stage Lip Ca is usually not required.10% patients can
present with clinically palpable neck nodes.
Suspected bony invasion(tooth mobility) or neurovascular(numbness)
invasion needs CT/MRI in advanced cases T2-T4.MRI-Normal fatty
signal replaced by grayish tumor infiltration/ID nerve enhancement.

7. FACTORS AFFECTING CHOICE OF
THERAPY
TUMOR FACTORS
T size
Histology
Depth of infiltration of labial musculature and involvement of commisure
Extent of lip resection necessary
Availability of local tissue for reconstruction
Anticipated outcome of surgery
PATIENT FACTORS
Age
Medical condition
Compliance
Cost

8. MANAGEMENT OF NECK DISEASE

9. LOWER LIP CA N0
Management depends on tumor size and stage.
T1=occults mets less than 20% (options include close neck
ultrasound surveillance and no neck dissection)
T2/T3 N0 =involved lip resection with 1cm safe margin,END 1a,1b,II
and III.
T4 or advanced tumors involving commissure=involved mucosal or
skin resection with mandibulectomy (marginal/segmental),superficial
parotidectomy
The inferior parotid nodes are most commonly involved, and patients
generally have substantial associated cervical metastases. When
treating patients who have oral or oropharyngeal cancer with
substantial cervical metastasis, physicians should consider removing

10. N0 DISEASE
Suprahyoid neck dissection results in reduced morbidity related to
radiotherapy and radical neck dissection. This surgical procedure
removes nodal levels I (submandibular), II (high cervical) and III
(midcervical). If the nodes removed are negative, then observation is
recommended because of the possibility of positive nodes in level IV
and V is very low. In positive cases, modified neck dissection is
indicated.Radiotherapy should be added if further examination reveals
multiple node metastasis or extracapsular invasion.

11. LOWER LIP CA N+
Submental and submandibular lymph nodes (level I) display the
earliest involvement as a basis for tumour advancement. 5-year
survival rate for patients with cervical metastasis is reported to be
between 30% and 70%, with an average of 50%
With regards to the first parameter, in the case of T1 tumours, lymph
node engagement ranges from 3.4% to 7%. For T2 tumours,
engagement ranges from 11.2% to 35%, and for T3 tumours,
engagement ranges from 26.4% to 63%. Similarly, well-differentiated
tumours are characterised by a 7% incidence of lymphnode metastasis
compared with the 21% in the case of non-differentiated tumors.

12. PROGNOSIS
Tumours of the lip are relatively common lesions and are not adequately acknowledged as
potentially fatal.
Well-controlled surgical excision of primary SCC achieves 5 years cure rate of 92% with overall
recurrence rate of 8%
 In cases of local lymph node involvement, the five-year mortality is approximately 50%.
Recurrence rate varies according to size, location, previous treatment and histology
The risk of metastasis increases for tumors larger than 2 cm and deeper than 4 cm, recurrent
tumors, bone invasion, perineural and perivascular involvement [13]. Approximately 95% of
metastases are detected within 2 years and the reported 5-year survival for metastatic SCC is 25%
The overall curability of patients with metastasised lower lip tumours approaches 50% [1,2,3]. The
incidence of lip tumour metastasis to cervical lymph nodes ranges from 5% to 20%, with level I
metastases being the most common

13. N+ DISEASE
Selective neck dissection I-IV as no drainage in level 5.
Contralateral neck dissection for tumors involving FOM or
approaching midline(adjuvant radiotherapy is another option)
Some authors recommend MRND for N+disease.
In patients with a cN+ contralateral neck, a contralateral neck
dissection should be performed. In patients with a cN0 contralateral
neck, an elective contralateral neck dissection may be offered in
patients with a tumor of the oral tongue and/or floor of the mouth
that is T3 or T4, or approaches midline (ASCO 2019)

14. N+
An ipsilateral therapeutic selective neck dissection for
a cN+ neck should include nodal levels Ia, Ib, IIa, IIb,
III, and IV. An adequate dissection should include at
least 18 lymph nodes. Dissection of level V may be
offered in patients with multistation disease (Type:
evidence based; Evidence quality: intermediate, benefit
outweighs harm; Strength of recommendation:
moderate).

15. GOALS OF LIP RECONSTRUCTION
FUNCTIONAL GOALS AESTHETIC
GOALS
Water tight seal Symmetric
appearance at
Restoration of orbicularis oris sphincter rest and
dynamically
Preservation of lip sensation
Preservation of stability to support dentures Ideal
scar/Flat/narrow
Prevent drooling
levelled/colourmatch

16. SIZE AND SITE SIGNIFICANCE
T1=Upto 2cm(less than 1/3rd)
T2=2-4cm (between 1/3rd to 2/3rd)
T3=>4cm (more than 2/3rd of lip)
Advanced Cancers (T4) involves jaw bone, vessel and neural invasion

17. Surgical removal is the treatment of choice for squamous
cell carcinoma of the lower lip, although radiotherapy or
brachytherapy can be used to treat small lesions; tissue
loss is treated using a variety of techniques, depending on
the extent and location (median or lateral) of the defect,

18. RECONSTRUCTION A/C TO SIZE

19. SYNERGISTIC ABBE AND STAIRCASE FLAP
STAIRCASE FLAP

20. WAVE TECHNIQUE
The wave technique22 uses the “steps” of the staircase flap, with
retention of dimensions and extensions, but transforms straight lines
into curves to achieve better esthetic results. The original Burow's
triangle is now rounded, allowing the flap to readily slide to cover lost
tissue

22. PRIMARY CLOSURE
WEDGE EXCISION AND PRIMARY
CLOSURE
VY ADVANCEMENT FOR VERMILLION
RECONSTRUCTION

23. ABBE FLAP
Central Abbe flap with bilateral upper lip advancement flaps and
excision of perialar crescents (B). Inset (C). Final result (D).

24. KARAPANDZIC FLAP (CLINICAL
CASE WITH ND)

26. HARVESTING
ANTERIOLATER
AL THIGH FLAP

28. CLINICAL CASE DISCUSSIONS

29. CASE -1

30. T2N0M0
WLE WITH 1CM SAFE
MARGIN
NECK DISSECTION
LEVEL I,II,III (SOMND)

31. CASE 2 T1N2CM0
WLE WITH 1CM SAFE
MARGIN
NECK DISSECTION LEVELS
LEVEL1-IV BILATERALLY

32. CASE 3 ADVANCED STAGE 4

33. LIP SUPPORT VIA FASCIA LATA