contents introduction on lip anatomy types of malignancy\ various reconstructions techniques and other treatment modalities

1.  Presenter: Dr. Rickey Sam Abraham
 Moderator: Dr. S.M. Azeem Mohiyuddin

2. 1. Explaining the anatomy of lip
2. Types of lip malignancies
3. Various surgical techniques for
reconstruction

3.  Lips form anterior boundary of oral cavity
 Parts: 2 surface of lip, skin & mucosa become
continous with one another round & this
margin vermilion
 Vermilion border:
 Dry vermilion: pattern of wrinkles has clear
cut boundary line between it & skin proper

4.  Smooth wet vermilion: merges without
obvious surface change with mucosa lining of
lip.

5.  Epithelium:
Lip covered with non-keratinised stratified
squamous epithelium which is transparent &
contain no hair, sebaceous glands or pigments.
Hence, Red.
On vermilion border, distance between epithelium
& muscle is just 2mm.

6.  BLOOD SUPPLY
Small submental arteries branches
Inferior & superior labial arteries facial art.
supply lips

7. ◦ Motor Innervation
 Facial nerve VII
 Buccal
 Elevators of commissures and
orbicularis oris
 Marginal mandibular
 Lip depressors (depressor labii
inferioris)

8. ◦ Sensory innervation
 Trigeminal nerve
 Mental nerve terminal branch of
inferior alveolar nerve( mandibular br. )
 Lower lip
 Infraorbital nerve (maxillary br.)
 Upper lip

9.  LYMPHATIC DRAINAGE
 Upper lip: drains into preauricular,
infraparotid & submandibular nodes
 Lower lip:
Medial portion of lower lip submental
nodes
Lateral portion  submandibular nodes

11. ◦ Oral competence
◦ Deglutition
◦ Articulation
◦ Expression of emotion
◦ Symbol of beauty

12.  EPIDEMIOLOGY
 It is one of most common malignant tumor
affecting head & neck
 Squamous cell Carcinoma is most common in
India
 Factors affecting are:
1. Solar radiation
2. Tobacco smoking
3. Viruses

13.  Male:female ratio – 14:1
 Lower lip > upper lip (solar radiation)
 90% : lower lip
6%: oral commissure
4%: upper lip

14. Histologic types:
 Squamous cell carcinoma : commonest
 Basal cell carcinoma:
 Non squamous form of lip cancer: from
tumors of minor salivary gland (upper
lip>lower lip)

15.  Exophytic crusted lesion with variable
invasion into underlying muscle
 Adjacent lip often shows:
Actinic sun damage like crusting, color
change, thinning of lip & associated areas of
leukoplakia

16.  TX : Primary tumor cannot be assessed
 T0 : No evidence of primary tumor
 Tis : Carcinoma in situ
 T1 : Tumor 2cm or less in greatest
dimension
 T2 : Tumor more than 2cm but not more
than 4cm in greatest dimension
 T3 : Tumor more than 4cm in greatest
dimension
 T4 ; Tumor invades through cortical bone,
inferior alveolar nerve, floor of mouth or skin of
face ie, chin or nose

17.  Imaging in early stage not required
 USG Neck & parotid: rule out salivary gland
tumors/nodal metastasis
 CT Scan or MRI : advanced tumors of lip
involving mandible for complete staging &
treatment planning

18.  Early stage lip cancer:surgery/radiotherapy
 Surgical treatment survival rates of melanoma
T1 to T2 tumors: 75-80%
T3 & T4 tumors: 40-50%
 Presence of cervical nodes at presentation: poor
prognostic factor

19.  Small lesions: simple surgical excision &
primary closure / external beam radiotherapy
 Factors associated
1. Extent of lip resection, functional outcome
of repair (lip sensitivity & muscle function)
2. General physical, medical & psychological
condition of patient

20. 1. Lip should have sensation, motion, prevent
drooling, permit speech & resonable
cosmetic appearance.
2. Full thickness skin flaps used whenever
possible
3. It should provide sufficient mucosa
contiguous to commisure to avoid
contracture

21.  Indication:
Superficial field change lesions affecting the
central vermilion of lip (leukoplakia or actinic
keratosis)
Extensive premalignant changes: entire
vermilion surface of lip excised.
Post treatment: use sun block to lip to prevent
recurrence

22. Lower lip defect
Less than ½
Wedge,shield,
rectangle or ‘w’
excision

23. Lower lip defect
½ to 2/3 lip
does defect include commissure?
yes no
estlander abbe sabittini
flap flap

24. lower lip defect
Is defect midline or lateral?
midline lateral
Bernard burrow Gate flap
Webster flap

25.  Lesion up to ½ : excised & repaired primarily
with margin (0.5cm for SCC)
 First wedge excision lip: Louis (1768)
 As size of lesion increase- wedge  ‘W’
(avoid crossing submental groove to chin)
 Lesion involves close to one half of lip:
rectangular excision with advancement flap
done

26. FIGURE 2. Direct excision and repair of lower lip lesions. Lesions up to one half
of the lip can be excised and repair primarily.
Small lesions can be excised using the "V" excision, and can be angled to blend
into the chin-lip crease. Larger lesions can be
excised using a "W" pattern. The "W" avoids crossing the chin-lip crease and
retains an adequate margin of tissue around the
lesion inferiorly. The largest lesions can be excised as a rectangle and incisions
made in the chin-lip crease to allow advancement
of lateral lip tissue for closure.

27. FIGURE 3. Rectangular excision of
lower lip carcinoma. (A) Lower lip
defect after excision of carcinoma.
Proposed advancement incisions
outlined. (B) Final result.

28. FIGURE 4. Modification of classic
"V" excision to improve
vermilion-cutaneous matching. (A)
Classic "V" excision can result in a
noticeable "step off" in the
vermilion-cutaneous junction. (B)
Slight angulation of lateral incision
allows for precise matching of .
vermilion-cutaneous junction.

29.  Closure: strong precise anastomosis of ends
of orbicularis oris reconstitute the oral
sphincter
 Aligning mucocutaneous junction (white line)-
first step of skin closure.

30.  Defect >½ lower lip: cannot be closed primarily
due to undue wound tension
 Tissue borrowing from opposing lip – first
described by Sabattini (1838) known as Abbe
cross lip flap
 Flap width = ½ width of excised tissue
 2cm is maximum width size of flap which is
pedicled on labial artery. Pedicle divided 10-21
days later.

31.  Advantage:
1. Defect is repaired with like tissue
2. Flap eventually regain both sensory & motor
function
Type Initial return Near complete
return
Pain 2 months 12 months
Tactile 3 months 12 months
Cold 6 months 12 months
Hot 9 months 12+ months
Motor 6 months 12 months

32.  Disadvantage:
1. Need for 2 stages : risk of patient injuring
flap by opening mouth wide & relative
microstomia it creates.

33.  Similar to Abbe flap
 Involves rotating the upper lip tissue around lateral
edge of mouth
 Indication: defect involves oral commissure.
 Procedure:
Incision: placed in melolabial crease & flap
designed 1 to 2mm longer than defect, pedicle
divided at 2 weeks. Ankling & advancement of
mucosa of 2 lip segments. Commissure plasty at 3
months

34. FIGURE 6. Estlander cross lip flap. (A)
"V"-shaped incision diagramed around lower
lip lesion and proposed upper lip flap outlined.
(B) Lesion removed, flap rotated and sutured
into defect. Flap is designed with height 1 to 2
mm greater than defect to be reconstructed

35. FIGURE 6. Estlander cross lip flap. (A)
"V"-shaped incision diagramed around lower
lip lesion and proposed upper lip flap outlined.
(B) Lesion removed, flap rotated and sutured
into defect. Flap is designed with height 1 to 2
mm greater than defect to be reconstructed.

36.  First described by Von Bruns
 A complete lip is formed by rotating upper lip
& perioral tissue down & around.
 Incision made through skin & muscle down
to, but not through mucosa.
 During flap creation, nerves & blood vessels
are preserved.

37. Karapandzic flap, (A) Lower lip
defect after resection of
carcinoma. Proposed incisions
outlined. (B) Incisions made
through skin. Buccal branches of
facial nerve and labial artery
branches preserved to greatest
extent possible. (C) Tissue
advanced and defect closed.

38. Bernard burrow flap (Webster modification)
 Horizontal incision through skin from commissure
to melolabial fold created & triangle crescents of
skin & subcutaneous skin excised.
 Facial muscle not excised
 Triangle/crescent also excised lateral mental-labial
groove
 Intraoral mucosal advancement, flaps advanced &
sutured.

39. Bernard-Burow flap (Webster modification). (A) Complete lower lip defect following
resection of carcinoma.
Horizontal incisions through skin from the commissure to melolabial fold created and
triangles/crescents of skin and
subcutaneous tissue excised adjacent to melolabial fold. Facial muscle is not excised.
Triangles/crescents also excised lateral from
mental-labial groove as required. Intraoral mucosal advancement flaps created as noted
by broken lines. (B) Flaps advanced and
sutured. Small ellipse of skin removed from superior portion of flap and mucosa advanced
to create new lower lip vermillion.

40. Clinical example of unilateral Bernard-
Burow flap. (A) Squamous cell carcinoma of
left lower lip. (B) Proposed
excision and Bernard-Burow advancement
flap outlined. (C) Lesion excised, flap
advanced into place and sutured. (D) Early
postoperative result.

41. Indication:
Defect does not involve the entire lip & is
laterally located.
Large unilateral lower lip defects
Procedure:
Medial & lateral incisions are full thickness
Horizontal cutaneous incisions is not deep to
preserve blood supply.

42. "Gate" flap. (A) Complete lower lip defect with proposed flaps
outlined. Mucosal incisions represented by broken
lines. Medial incisions and most of lateral incisions are full
thickness. Horizontal cutaneous incision is not deep to
preserve
blood supply. (B) Flaps rotated and sutured. This technique is
especially useful for large, unilateral lower lip defects.

43.  A full thickness incision is made around the
commmissure extending onto upper lip at
nasolabial fold
 Incision is cut & extending almost of
vermilion border of upper lip
 Flap is now pedicled on labial vessels & can
be advanced & closed in layers
 Vermilion is reconstructed by mucosal
advancement of tongue mucosal flap which is
divided at 10 – 14 days

45. Upper lip defect
Less than ½
Wedge,shield,
rectangle or ‘w’
excision

46. Upper lip defect
½ to 2/3 lip
does defect include commissure?
yes no
estlander abbe sabittini/ reverse
flap parakandzic flap

47. Estlander flap. (A) Proposed
excision and repair
of large squamous carcinoma of
upper lip using Estlander
flap. (B) Carcinoma excised and
defect reconstructed with
Estlander flap.

48. 2/3 to complete lip
Diffenbach attachement flaps
+/- Abbe Sabattini flaps

49. Modified Burow Diffenbach technique
for upper lip reconstruction. (A)
Proposed excision of tumor and
perialar incisions. (B)
Lesion excised and perialar crescents
excised. (C) Closure of defect.

50.  The primary lymphatic drainage of lower lip is
to submental & submandibular level 1a & 1b
cervical lymph node
 Neck dissection generally not performed as
less than 5 percent of patients develop
recurrence in neck following treatment

51.  For small tumors, radiotherapy equivalent to
surgical management
 Disadvantage:
 Cosmetic results to lip may not be
satisfactory
 Burdensome for the patient than a relatively
mild surgery

52.  Lower lip: ideal sites for orthovoltage x-ray
therapy
 Using a single anterior field, a fractioned
course of 50 Gy in 15 fractions over 3 weeks.

53.  192- Iridium brachytherapy can be used in
treatment of lip cancer
 Patient treated twice a day for 4 – 5 days with
total radiation dose 40-45Gy in 8-10
fractions.
 The paris system is often used where needles
are placed horizontally and parallel to the
mucosa of the lip with 9mm spacing between
them.

54.  Photodynamic therapy can also be used to
treat primary cancer of the lip.
 Procedure: Photofrin (light sensitising drug)
given intravenously followed 4days later by a
single non thermal illumination of the tumour
using a light dose of 20J/cm with an
irradiance of 100mW/sq.cm.

55.  ADVANTAGES:
1. This treatment yields complete response
rates comparable to surgery or
radiotherapy.
2. Less scarring(cold photochemical process)
3. The treatment can be given on many
occasions as there is no tissue memory.

56.  TUMOR THICKNESS & SURVIVAL RATES
Tumor size(cm) Five year survival rate(%)
1cm 94
<2cm 84
<3cm 58
<4cm 67
>4cm 62